ERSD: END STAGE RENAL DISEASE

Kathryn AtwaterPVAMU Intern 2012-2013

Patient Background

71 year old Hispanic, white female Middle Class Separated Lives with daughter 3 children History of tobacco use but no alcohol Stage 5 Renal Failure

General Health History Sleeps well Light physical activity

Limited due to walker Housework Tries to “walk” as much as possible

Lost 50 lb over past year Food intake varies based on daughter Alert with some memory loss

Recent Medical History First hospitalized 1/30/13 for:

Chronic CHF exacerbation Anemia

2/3/13 CVC placed in right chest High creatinine finalized decision (5.06

mg/dL) Started hemodialysis immediately

No previous dialysis Plans to get AVF as soon as possible

Past Medical History Diabetes Mellitus Hypertension Congestive Heart

Failure Coronary Artery

Disease Hypercholesterolemi

a Legally Blind Glaucoma

Anemia

Heart Attack Stroke

Family History Mother:

Heart Attack Diabetes Kidney Cancer Colon Cancer Hypertension

No known medical history for father Children in good health

Admission Values

Ht: 60” Wt: 54.4 kg Current Wt: 53.8 IBW: 54 kg %IBW: 99.6% BMI: 23.11 BP: 208/86 Minor Edema

Stable Weight Trend

No swallowing or GI problems

Lab Values Patient Normal Dialysis Rec.

Calcium (mg/dL)

7.6 (L) 12-16 8.4-10.2

Potassium (mEq/L)

4.2 3.5-5.0 3.5-5.5

Phosphorus (mg/dL)

5.2 (H) 2.5-4.5 3.0-5.5

Sodium (mEq/L) 138 135-145 135-145Hemoglobin (g/dL)

9.8 (L) 12-16 10-12

Ferretin (ng/mL) 1217 (H) 3-151 200-500PTH – Intact (pg/mL)

333 (H) 10-65 150-600

Albumin (g/dL) 3.4 (L) 3.5-5 Min: 3.5 Opt: 4.0

Hb A1c (%) 6.2 (H) 4.4-6.1 Less than 7.0Glucose (mg/dL)

172 (H) 70-105 80-180

URR (%) 76 - 65 or aboveCreatinine (mg/dL)

4.38 (H) 0.8-1.6 2-15

Medications

Oral: Acetaminophen Nifedipine Clonidine Pravastatin Docusate Escitalopram Lisinopril Tramadol Tums

IV Epogen Hectoral

Medication DescriptionsMedication Use Drug/Nutrient

InteractionsAcetaminophen

Pain Reliever/Fever reducer

BP medication, cholesterol medication, antibiotics, etc

Nifedipine Reduce BP/reduce angina grapefruit productsClonidine Reduce BP alcoholPrimvastatin HMG CoA reductase

inhibitor, or, statin, reduce LDL and increase HDL

Alcohol, grapefruit products, other statins, spironolactone,

Docusate Stool softener n/aEscitalopram Antidepressent Alcohol; Cold or

allergy medicine, narcotics, sleeping pills, muscle relaxers

Medications ContinuedMedication Use Drug/Nutrient

InteractionsLisinopril Ace-Inhibitor/reduce

BP/treat CHFAlcohol, salt substitutes, other bp medications, potassium supplements

Tramadol Pain reliever Alcohol, antidepressants

Clonidine Reduce BP alcoholTums Phosphate binder,

calcium supplement, indigestion

n/a

Epogen RBC production n/aHectoral Decrease PTH levels Magnesium

containing antacids, digoxin

General Diet History Good appetite Lost 50 lbs in past year Small portions Tries to “eat healthy, but

depends on my daughter” 3 meals a day 1 snack Says new renal diet is

“tricky” but she’s trying

24-hr Recall Breakfast: 2 eggs over easy, 1 piece of

white toast & 1 tsp butter Lunch: Pepper chicken with snap peas,

red peppers, and carrots, ½ cup white rice

Dinner: None (usually eats whatever daughter picks up after work)

Snack: 1 Mexican Cookie and a half of an apple

Dialysis Prescription

Type: Hemodialysis Days: M-W-F Treatment Length: 2.5 hr BFR: 350 mL/min Dialysate Flow Rate: 800 mL/min Access: CVC catheter – Jugular (Right) Average Fluid Gain: 1.6 kg EDW: 52 kg

Patient Estimated Needs

Kcal: 1550-1600 Protein: 60 g Sodium: 2000 mg Potassium: 2000 mg Phosphorus: 800 mg Fluid: 1000 mL

Diet Prescription Renal Diet

Low Potassium Low Phosphorus High Protein

Carbohydrate Controlled Low Fluid

Monitoring & Evaluation Start taking Tums as a phosphate

binder Start Hectoral to decrease PTH levels Increase Epogen to increase

hemoglobin Get fistula as soon as possible Patient eager to participate actively Prognosis:

GOOD!

ESRD: What is it? End Stage Renal Disease Stage 5 kidney disease

Kidneys stop working i.e. kidney failure <15% kidney function

PERMANENT Need a transplant or dialysis to live

No cure Goal of treatment: Slow progression

ESRD: Etiology & Pathophysiology

Progression of CKD Main causes:

Diabetes Hypertension

Kidney Failure=DEADLY

GFR <15 mL/min Dialysis or

Transplant required

ESRD: Diagnosis GFR rate calculation Urine Test Blood Test MRI Biopsy

ESRD: Signs & Symptoms

General “ill” feeling Itchy skin Dry skin Loss of appetite Nausea Edema Muscle-twitching &

cramps Headaches

Decreased urine output

Poor concentration

ESRD: Treatment Hemodialysis Peritoneal Dialysis Transplant

Not a cure Last about 5-10

years Strict guidelines

Treatment: Hemodialyis Hemodialysis

Filter blood Access Points Clinic Strict Diet

Treatment: Peritoneal Dialysis

Peritoneal Dialysis Filter through peritoneum Home Through abdomen Less Strict Diet

ESRD: Common Medicines

Binders Hectoral Sensipar Epogen Iron Calcitriol

Renal DietHemodialysis Peritoneal

DialysisEnergy (kcal/kg SBW) 30-35 30-35Protein (g/kg SBW) 1.2 1.2 & higherPhosphorus (mg/kg SBW) 800-1000 800-1000Potassium (mg/d) 2000-3000 3000-4000 Sodium (mg/d) 2000-3000 2000-3000Fluid (mL/d) 750-1000 2000

Protein Protein loss with

dialysis Affected by infection

& trauma Essential for:

Growth & development

Prevent infection Healing

Tissue Wound

HBV sources Meat Fish Poultry

Protein Supplement

Potassium Limit high

potassium foods Tomatoes Potatoes Bananas oranges

High Potassium Muscle weakness Bradycardia Cardiac arrest

Low Potassium Vomiting Diarrhea Hypotension

Phosphorus Poorly dialyzed Phosphate binders

Renvela PhosLo Tums

High phosorus Calciphylaxis Hardened arteries Weak bones

Avoid high phosphorus foods Cheese Dairy Beans Nuts cola

Fluid Fluid restriction Approx 48 oz. per day Based on:

Urine output Interdialytic weight gains

Excess fluid: Rapid weight gain High blood pressure Edema Poor appetite

Physical Activity Difficult for most Benefits

Stimulate appetite & circulation Improve cardiovascular risk factors

Hypertension Hyperlipidemia Diabetes Obesity

Enhance sense of well-being

PES Statement

Limited kidney function related to end stage renal disease as evidenced by low serum calcium, anemia, low serum protein, high serum phosphorus, high PTH, and high serum creatinine levels.

Follow-up Hemoglobin went up to 10.9, reduced

Epogen dose Fistula placed in left arm on March 14th

Understands disease & reason for treatment

Adjusting slowly but well As of 3/15 moved out of daughters home Patient says, “Will make it!”

Summary ESRD is DEADLY if not treated properly. Diet is the key component to keeping

person in optimal health Prognosis:

Good if sticks to plan

QUESTIONS?

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