March 6, 2014 12:00PM Christine Gilbert
S. Pt met with RD 2 years ago for sodium control and wt loss and lost 18#. He started diuretics and antihypertensive meds, but pt states he stopped taking them and went off his diet since he “felt fine” and lost wt. Although he didn’t know why, he reports he was getting bad headaches and gained wt 2 years later. Pt states his BP was 180/105 when he checked it at a local pharmacy, so pt called his doctor who referred him to a nephrologist.
O. 60YOAAM Dx: Stage 4 CKD (GFR 22mL/min), Stage II HTN
Diet Order: .8g pro/kg, 2g Na, 2g K, 1000mg Phos, no fluid restriction
Meds: Tums, Lasix, Kayexalate, Rocaltrol
Ht: 5’11” Wt: 225# BMI: 31.5 kg/m^2 (Obese I) IBW: 172#
%IBW: 130.8%
Labs:
Hgb: 12.8g/dL ↓ Hct: 40% ↓ MCV: 77 fL ↓
K+: 6.0mEq/L ↑ BUN: 48mg/dL ↑ Cr: 3.5 mg/dL ↑
Ca: 7.7mg/dL ↓ P: 5.7mg/dL ↑ Alb: 3.4 g/dL ↓
EER: 2580 kcal (30 kcal/kg IBW + 10%)
Est pro: 82g (13%kcal, .8g/kg)
Est CHO: 368g (57%kcal)
Est fat: 86g (30%kcal)
Est fluid: 2580mL (1mL/kcal)
Est Na: 2g, Est K: 2g, Est P: 1000mg
A. Excessive K and P intake r/to appropriate diet for CKD a/e/b hyperkalemia and hyperphosphatemia.
Pt has a severe decrease in GFR at 22 mL/min, showing pt has poor kidney function and should prepare for eventual dialysis. High lab levels of potassium, phosphorous, BUN, and creatine shows decreased reabsorption and filtration ability of kidneys. Pt has a priority for renal modification in diet and should follow dr’s appropriate diet order and prescriptions. Pt should prevent renal failure through diet by lowering protein intake and maintaining electrolyte balance through lower levels of Na, K, and P. Introduce pt to Davita website for menu ideas that reflect his restricted diet. Pt has no current fluid restriction, however when pt is on dialysis will have restriction of 1L of fluids.
Labs show low albumin levels, hgb, hct, and MCV, suggesting pt has microcytic anemia, a secondary complication accompanying kidney disease due to kidney’s inability to produce EPO. Should determine if pt has anemia and may need iron supplementation. After correcting for low albumin, pt still has low serum calcium, placing him at further risk for decreased heart function and renal bone disorders.
Risk factors contributing to CKD include HTN, ethnicity (African American), and obesity (Obese I and high %IBW), also placing pt at high risk for CVD. CVD is a co-morbid condition and main cause of mortality associated with CKD. Pt would benefit from wt and sodium reduction to reduce obesity and manage HTN.
Medication Lasix is a loop diuretic prescribed to manage HTN. Side effects include increased water and electrolyte depletion, wt loss, thirst, decreased appetite, N/V, and elevated TG and chol levels. Kayexalate has been prescribed to treat hyperkalemia, however side effects include N/V, increased thirst, uneven heartbeat, diarrhea and constipation, and loss of appetite. TUMS are a phosphate binder and calcium supplement that have are prescribed to prevent hyperparathyroidism attributed to CKD. TUMS may help pt reduce phosphate levels, however side effects include decreased appetite, N/V, dry mouth, and irreversible renal damage by forming renal calcium. Rocaltrol is a form of vitamin D prescribed to treat low blood calcium attributed to hyperparathyroidism and metabolic bone disease, however side effects include N/V, increased thirst, and uneven heart rate.
Pt does not seem very motivated to change his diet, however he mentioned he will take his meds and try to follow diet plan.
P. Reduce diet to 2g K, 1000mg P, and 2g Na with a 2580kcal/d diet (82g protein; 86g fat) by educating pt on CKD:
· Handout discussing foods sources high and low in select nutrients:
o Consume foods low in phosphorous, avoid high phosphorous foods
-High: nuts, wheat flour, lentils, peanuts, soy beans, yogurt, salmon
-Low: eggs, chicken thigh without skin, unsalted rice cakes, cream cheese
o Consume foods low in potassium, avoid foods high in potassium
-High: Milk, white beans, dried apricots, avocado, banana, dark leafy greens (spinach), potatoes with skin
-Low: Cranberry juice, carrots, cauliflower, grapes, apples
o Consume foods low in Na and avoid foods high in Na
-Educate pt on label reading
-High: canned and prepackaged foods
-Low: fresh, frozen, unprocessed foods
· Limit high protein foods to 4-6 oz a day
o Substitute rice milk with regular milk
o Have white flour instead of wheat
· Prevent renal bone disease through 1500 mg calcium:
o Food sources: Rice milk
o Medication: Calcium supplement and phosphate binders
-Tums, vitamin D supplement Rocaltrol
· Discuss medication interactions and side effects
· Consider taking renal supplement on empty stomach
o 15mg/d Zinc
o Vitamin C <100 mg
· Prevent anemia associated with CKD
o Have pt refer to doctor regarding EPO or high dose iron supplements
· Introduced Davita website for recipe ideas and meal plan for restricted diet
o Additional help with professional interest groups: National Kidney Foundation Council on Renal Nutrition, American Dietetic Association Renal Practice Group
Consider TLC diet and wt loss plan on next visit
Follow-up in 2 weeks with a 24 hr recall and lab results (K+, P, Ca, BUN, Cr, Alb, iron status, and Chem 7, lipid panel). Also, assess BP, urinary excretion, and wt change to determine knowledge, adherence and tolerance to new renal diet.
-Christine Gilbert, R.D. in training