CASE STUDYOluremi Famodu WVU Dietetic Intern

OUTLINE The Patient HIV (Background/Prevalence) HIV and Wasting Syndrome Nutrition and HIV Nutrition Assessment of Patient

Diagnosis Intervention Monitoring and Evaluation

PATIENT DEMOGRAPHICS 50 yo ♂ 52.7 kg (115.9 pounds) 5’11’’ (180.34 cm) BMI 16.2 – Protein/Energy Malnutrition Grade

II Ideal Wt: 75.3 kg (165.7 pounds) 70% IBW Former smoker and drinker

PATIENT MEDICAL HISTORYCurrent Medical Hx HIV positive Possible Tuberculosis

(TB) >110 pound weight loss

in 5 years Cachexia (Wasting

Syndrome) Weakness s/p PEG placement Pancytopenia Hyponatremia

Past Medical Hx HIV PEG tube placement Bilateral Hip

replacement

THE VIRUS

THE HUMAN IMMUNODEFICIENCY VIRUS (HIV) Zoonotic retrovirus (transfer between

species: monkey human) Rapid or severe loss of CD4+ T lymphocytes

Lentivirus (slow replicating) Causes Acquired Immunodeficiency

Syndrome (AIDS) Progressive failure of the immune system

allowing life-threatening opportunistic infections and cancers to thrive

No cure…but it can be controlled! Average life expectancy for untreated HIV= 10

years

HIV TIME COURSE

HIV/AIDS PANDEMIC Over one million

people living with HIV/AIDS in the United States (CDC)

1 in 5 people living with HIV are unaware of infection (~18% in the U.S.)

Having long-term controlled HIV infection shows ↑ risk of Cardiovascular disease and Osteoporosis/Osteopenia

HIV NUTRITION & COMPLICATIONSWasting Syndrome

WASTING SYNDROME/DISEASE Defined as

Involuntary weight loss (skeletal muscle and adipose tissue) greater than 10% from baseline OR

Chronic diarrhea OR Documented fever for more than 30 days AND associated weakness

In 2002, wasting incidence rates as high as 10.6/100 in HIV-infected women.

Nutrition for Healthy Living Cohort: 33.6% incidence rate in 2000.

WASTING SYNDROME CONT. ↑ rate of survival if overweight or obese Presence of opportunistic infection:

CLINICAL FINDINGS CONSISTENT WITH WASTING DISEASESubjective Lethargy Anorexia Food Insecurity Loose Fitting ClothingPhysical Function Difficulty or inability to stand w/o

assistanceVital Signs Unintentional weight loss

>10% >5% within 6 months

BMI <18.5 or marked decline from usual

BMI Mid-upper arm circumference

<10th NHANES percentile

Physical Findings Head

Temporal wasting, periocular edema or fat loss, prominent zygomatic process

Torso Subclavicular muscle loss, angular

shoulders, visible articulations of ribs at junction with sternum

Sacral edema (in bed rest/bound patient)

Extremities Diminished mass interosseous

dorsalis when pressing thumb to forefinger

Diminished mass quadriceps femoris and vastus medialis when leg bent at right angle

Delayed mid-upper arm skin fold return, loss of turgor

Lower extremity edema

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HIV AND NUTRITION Maintaining good nutrition may help:

Limit weight loss Reduce risk of infections Diarrhea Lipodystrophy (fat distribution syndrome) Limit nutrient deficiencies Help process medications and manage side

effects Keep immune system stronger

BASIC PRINCIPLES OF HIV AND NUTRITION General Healthy Diet

High in vegetables, fruits, whole grains and legumes Choosing lean, low-fat sources of protein Limiting sweets, soft drinks, and foods with added

sugar Balanced meals: protein + carbohydrate + little good

fat Multivitamin-Vitamin A, C, E, B Vitamins, Selenium and

Zinc High-Energy High-Protein

1.5 g/kg Mediterranean Diet? Physical Activity

NUTRITION ASSESSMENTDiagnosisInterventionMonitoring and Evaluation

INITIAL ASSESSMENT Assessing for:

Admitting diagnosis of HIVAlbumin <2.5,New Tube Feed

Braden Scale Score = 21; No skin breakdown IV Fluids: NS @ 100mL/hour Receiving folic acid Regular diet

INITIAL ASSESSMENT CONT. Sister and mom state concerns for pt’s

mental status and not able to take care of him

Conflicting reports of 110# weight loss over 8 months versus 5 years per H&P and MD notes

Per physician, pt on nightly tube feed regimen (unsure of formula)

NUTRITION ASSESSMENT: MEDICATIONS

Medication Pharmacologic ActionPrezista Antiretoviral (HIV/AIDS)Diflucan AntifungalIsentress Antiretoviral (HIV/AIDS)Zantac Antiulcer, AntiGERD, AntisecretoryZofran PRN Antiemetic, AntinauseantKlor-Con PRN Potassium SupplementSenokot-S PRN Stimulant Laxative; Stool SoftenerZithromax AntibioticDapsone AntibacterialNeupogen Colony Stimulating FactorZosyn Antibiotic Vancomysoin Antibiotic

NUTRITION ASSESSMENT: LAB VALUES

Constituent

Reference Admission Values

Cause/Significance

Glucose 70-99 mg/dL 92 mg/dL ---BUN 8-23 mg/dL 9 mg/dL ---Creatinine 0.6-1.2 mg/dL 0.5 mg/dL---L Decrease in muscle mass;

↓ protein intakeGFR 85-125 mL/min >60 mL/min ---Magnesium 1.8-2.6 mEq/L 1.5 mEq/L---L Malabsorption;

MalnutritionAlbumin 3.5-5 gm/dL 2.7 gm/dL---L Malabsorption;

Malnutrition; ↓ protein intake; acute illness/stress

WBC 3200-10,600/μL 1600/μL---L HIV/AIDSRBC 4.7-6.1

million/mm33.73 million/mm3---

LAnemia

Hb 14.6-17.5 g/dL 12.1 g/dL---L Anemia; HIV/AIDSHCT 41-51% 35.9% ---L Anemia; Blood loss

SUBJECTIVE: THE CALL (UNABLE TO VISIT 2° TO TB PRECAUTIONS) “Lost 110# in 2 years” Top weight 216#; ↓ after bit by a recluse

spider Reports good appetite and cooks for himself Has PEG tube for medication administration

2° to pill dysphagia “I put (pureed) Cornish hens, corn dogs, and

protein supplements down PEG tube” Unsure of home tube feeding formula

DIAGNOSISProblem = Underweight

Etiology = related to HIV

Symptoms = as evidenced by need for supplemental enteral nutrition

INTERVENTION Estimated Energy

35-40 kcal/kg: 1855-2120 kcal Estimated Protein

1.4-1.6 g/kg: 74-85 grams

Risk ScoreNutrition Support 6BMI <18.5 2Weight Loss 2Admitting Diagnosis 2

Total = 12 (High Risk)

INTERVENTION

Recommend initiating nightly tube feedingsBoost Plus 60mL/hour over 12 hours (20:00-8:00)

1080 calories, 42 grams of protein and 555 mL water Initiate Calorie Count x 3 days Monitor and encourage adequate po intake Monitor weight and labs Recommend education on proper PEG tube

feeding/care before discharge IPOC

Nutrition GoalsImprove protein statusImprove po intakeIntake of ≥ 50% Tolerate po diet

MONITOR & EVALUATE Po intake per RN note

Weight

Meal 11/4/2013 11/05/2013

11/08/2013

Breakfast 50-75% 75-100% 75-100%Lunch 25-50% 75-100% 0-25%Dinner --- --- ---

11/3/2013 11/05/2013 11/08/201352.7 kg 50.6 kg 53 kg

Bed Scale Standing Scale Standing Scale

MONITOR & EVALUATE Calorie Count and Tube Feeding

Estimated Calorie Needs

Estimated Protein Needs

(g)1855-2120 74-85

Date 11/06/2013

11/07/2013 11/08/2013

Daily Total Calories

1670 600 190

Daily Total Protein

67 17 7

% Estimated Calories Met

90 32 10

% Estimated Protein Met

91 23 9

Comment Tube feeding provided 1080 calories and 42 g protein.

No intake recorded for lunch or dinner. Tube feeding ran from 2000-2400 turned off d/t NPO. TF recorded under dinner slot.

No intake recorded for breakfast or dinner. Pt receiving TF from 2000-0800 but has been messing with pump. Pt changing rate throughout night.

MONITOR AND EVALUATE Calorie Count & Tube Feed Assessment

Average calorie intake = 44% 816 calories

Average protein intake = 41% 30 g protein

Estimated Calorie Needs

Estimated Protein Needs

(g)1855-2120 74-85

MONITOR AND EVALUATE Labs

Constituent Admission Values Discharge ValuesGlucose 92 mg/dL 74 mg/dLBUN 9 mg/dL 6 mg/dL---LCreatinine 0.5 mg/dL---L 0.5 mg/dL---LGFR >60 mL/min > 60 mL/minMagnesium 1.5 mEq/L---L ---Albumin 2.7 gm/dL---L ---WBC 1600/μL---L 1400/μL---LRBC 3.73 million/mm3---L 2.81 million/mm3---LHb 12.1 g/dL---L 9.1 g/dL---LHCT 35.9% ---L 27.6%---L

ENDING DIAGNOSIS Lung masses (two cavity) s/p bronchoscopy;

no hemoptysis or persistent coughing HIV/AIDS treatment Hyponatremia --- resolved Hypokalemia --- resolved Malnutrition with cachexia, 2° to mass & HIV Pancytopenia 2° to HIV Chronic pancreatitis

WHERE IS HE NOW? Key West?

OR

Camper in Clendenin?

To be continued…

REFERENCES Centers for Disease Control and Prevention:

http://www.cdc.gov/hiv http://www.webmd.com/hivaids www.aidsinfonet.org Fazia, A. (2012, October 01). Hiv and

nutrition. http://emedicine.medscape.com/article/2058483-overview

AND Nutrition Care Manual Mahan LK, Escott-Stump S. Krause’s Food

and Nutrition Therapy: 12th ed. 2008

QUESTIONS?