Mechanical AV and tricuspid repair, HD and CVA and the nutr - PowerPoint Presentation

Slide1

Mechanical AV and tricuspid repair, HD and CVA and the nutritional implications ofKidney Disease and Hungry Bone Syndrome

Kari

Ikemoto

Dietetic Intern

Keene State CollegeSlide2

Name That Kidney

1

2

3

4

5Slide3

Dartmouth Hitchcock Medical Center225 acre facility located in Lebanon, NH396 bed facility

Level 1 Trauma Center

New Hampshire’s only academic medical institution

Norris Cotton Cancer Center

Children’s Hospital at Dartmouth

Geisel School of Medicine at DartmouthDartmouth Hitchcock Advanced Response TeamSlide4

Registered Dietitians at DHMC20 Dietitians TotalDirector of Food and Nutrition ServicesInpatient

Nutrition Support

ICN/Pediatrics

Outpatient

Diabetes, Renal, Bariatric, Oncology

3 Diet TechniciansSlide5

Role of the RD at DHMCInpatient

Outpatient

Respond to clinician consult

Pulled by diagnosis

Pulled by unit (ICU/PICU)

AgeDiet order

Abnormal labsPO checksNutrient drug interactionsDiet progression (off TPN/TF)Hospital day 9

Referral from physicianPatient desireFollow upSlide6

A Multi-Disciplinary ApproachInpatientWork independently

ICU-TF & TPN

Specialties

GI, CF, Pedi, ICN, Pedi CF

Clinics

Team approachGI, GIM, CF, ALS, Pedi CF, OB, StoneOutpatientInfectious diseases, Endocrinology,

Bariatrics, Hem/Onc (pedi), NCCCSlide7

PES Statements & ChartingDHMC does not follow a specific PES statement in their documentationSome RDs

will use the diagnosis for their own reference

Each RD has their own template that they use

Typically SOAP style format

Malnutrition recommendations

DHMC guide, based on the ADA Manual of Clinical DieteticsSlide8

DHMC Malnutrition GuidelinesKwashikorMalnutrition of Mild DegreeMarasmus

Malnutrition of Moderate Degree

Severe Protein Calorie Malnutrition

Cachexia

Other Protein-Calorie Malnutrition

Unspecified Protein-Calorie Malnutrition Slide9

Patient InformationMs. BAge: 64 years oldOccupation: Administrative Assistant at college

Family

Single with 1 child and 2 grandchildren.

Brother and sister-in-law are biggest support system

Former smoker, quit at age 40

Smoker for 20 yearsAnthropometric measurementsHeight: 175.3 cm

Weight: 64.41BMI: 20.97Slide10

Pertinent Medical HistoryPrevious Surgical History

Past Medical History

Parathyroidectomy

Related to persistent

hypercalcemia

.Parathyroid gland inserted into her right brachioradialis muscleTonsillectomy

Left flank exploration surgery that dx PKDORIF of right fingerLeft upper extremity fistula for HD accessIntussusception repair during infancy

Polycystic Kidney Disease

Hemodialysis-15 yearsHypertensionHyperlipidemiaAsymptomatic gallstone

AnemiaSevere aortic stenosisSlide11

Medications at Home

Medication

Sig

Function

Calcium Citrate 1,000 mg Tab

Take 1.5 tablets by mouth 6 times daily.

Calcium supplementation

calcitRIOL (ROCALTROL) 0.5 mcg capsule

Take 0.5 mcg by mouth 2 times daily.

Vitamin D

ibuprofen (ADVIL;MOTRIN) 200 mg tablet

Take 200 mg by mouth as needed.

For

migraines

B Complex-Vitamin C-Folic Acid (NEPHROCAP) 1 mg capsule

Take 1 capsule by mouth daily.

Renal friendly

MVI

ranitidine (ZANTAC) 150 mg tablet

Take 150 mg by mouth nightly.

H2

histamine blocker, heartburn

Carvedilol

Phosphate (COREG CR) 10 mg CM24

Take 1 capsule by mouth every morning.

Treat

HBP and heart failure

lisinopril (PRINIVIL;ZESTRIL) 5 mg tablet

Take 1 tablet by mouth every morning.

HBP,

ACE inhibitorSlide12

History of PresentationSymptoms experienced

Reason

for visit

MWF

hemodialysis

Presented with several months (likely over a year) of severe

dyspnea on exertion with routine activities Significantly decreased exercise toleranceBilateral lower extremity edema x

2-3 monthsAortic stenosis

with chronic LV systolic dysfunction (LVEF 25%) and pulmonary hypertension with tricuspid regurgitationUltimately, after much deliberation, she decided upon a mechanical prosthesis, related to high probability of calcification of valveSlide13

The KidneyMain functionsExcretoryAcid base balance

Endocrine

Fluid and electrolyte balance

Endocrine functions

1, 25-dihydroxy-vitamin d3 (

calcitriol) is produced in kidney and enhances calcium absorptionIn healthy kidneys the activation of Vitamin D and excretion of excess

phos help to maintain healthy bonesSlide14

Polycystic Kidney DiseaseHereditary disorder where cysts form in the kidneys, destroying kidney tissue and function.Two types

Autosomal

recessive-early childhood

Autosomal

dominant- later in life

Typically treated with hemodialysis or kidney transplantNote- Cerebral aneurysms are commonly found in adults with PCKD; often screened with MRIs of the brainSlide15

Parathyroid MetabolismThe response of PTH to the kidney is to increase renal calcium resorption and calcium excretion.

In the kidney PTH blocks

resorption

of phosphate in the proximal tubule while promoting calcium

resportion

in the ascending loop of Henle, distal tubule, and collecting tubulePromotes absorption of calcium from the bone in 2 ways

Bind to receptors on bone cells to pump Ca ions from the bone to the extracellular fluid (rapid)Activate osteoclasts to digest formed bone, followed by proliferation of

osteoclastsConverts 1, 25 hydroxy Vitamin D to its active form Primary function of active form is to promote gut absorption of calcium.Slide16
Slide17

ParathyroidectomyIndicated for patients with hyperparathyroidism and elevated serum calciumMonitor calcium levels following surgery, they should return to normal

In some cases however, prolonged

hypocalcemia

exists in a condition known as Hungry Bone SyndromeSlide18

Hungry Bone SyndromeRapid, profound, and prolonged hypocalcemia (>4 days post op) associated with

hypophosphatemia

and

hypomagnesemia

, exacerbated by suppressed PTH following

parathyroidectomy.Believed to be due to the greatly increased skeletal usage of calcium as a result of high circulating PTH levels on boneUncommon but serious adverse effect of

parathyroidectomy.Older age is a risk factorSlide19

Calcium, PTH and Kidney DiseasePatients with CKD almost always develop secondary hyperplasia of the parathyroid glands, resulting in elevated blood levels of parathyroid hormone (PTH).

This abnormality is due to the

hypocalcemia

that develops during the course of kidney disease and/or to a deficiency of 1,25-dihydroxycholecalciferol that may directly affect the function of the parathyroid glands.

With progressive loss of kidney function, a decrease in the number of vitamin D receptors (VDR) and calcium-sensing receptors (

CaR) in the parathyroid glands occurs, rendering them more resistant to the action of vitamin D and calcium.

As stated by the

K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney DiseaseSlide20
Slide21

Admission to DHMC for procedureOctober 11th- Hospital Day 1Slide22

10/11/13- Hospital Day 1Operative Findings: Large pericardial effusion. Severely calcified trileaflet aortic valve.Slide23

Ensured that pt was not volume overloaded, HD prior to surgeryConsultation by nephrology, no urgent need for RRT (renal replacement therapy)Taken to the CVCC in critical but stable condition

Intubated

and on minimal

pressorsSlide24

Initial Nutrition Consult- Hospital Day 4Consulted s/p AVR

Diet order: DHMC, Low

Phos

, 2 gram K, 2 gram Na

PO: Not eating well, only able to tolerate liquids

prnNutrition Needs estimated at: 1,530-1,830kcal, 92-110 g protein.

Nutrition Plan/RecommendationsContinue diet as orderedNot appropriate for education for DHMC/Renal diet at this time

Will send liquid nutrition supplement drinks offered to optimize POSlide25

Hospital Day 6During HD, stroke alert for pt was madeNurse performed neuro

assesment

Sudden onset left sided weakness

CT showed no hemorrhage

CT Head w/o contrast showed no evidence of intracranial hemorrhage, or large area of cortical hypodensity. There is an area of increased density in a right MCA

sylvian branch. Consented to thrombectomy for clot removalNeurology reports that stroke most likely

cardioembolic (mechanical heart valve) or atheroembolic. Slide26

Hospital Day 8- Nutrition Consult for TFPert. Meds: calcitriol, calcium citrate, epinephrine,

reglan

,

oxycodone

,

phenylephrine, RBOs, vasopression @ 0.08 unit/min

Current weight (kg): 70.6/Adm weight (kg): 61.3/IBW (kg): 65.9/Height (cm): 175.3/BMI: 20 Nutrition needs 1800 calories and 92 gms protein daily.

Current TF of Nepro running at 15 ml/hr via OGT. Patient on pressors. Slide27

Labs

Lab Results

Value

Sodium

136

Potassium

4.2

Chloride

99

CO2

25

BUN

22*

Creatinine

2.19*

Glucose

Lvl

127

Calcium

6.9*

Phos

2.7 Slide28

TF RecommendationsPt is on pressors which may increase risk for gastrointestinal

hypoperfusion

with

enteral

feeds.

Monitor for increasing abdominal distention, constipation, elevated gastric residuals, or ileus. Suggest: Nepro

at goal rate of 50 ml per hour plus 2 scoops of protein powder daily. This rate is calculated to compensate for unplanned time off feedings due to potential procedures, etc.

This will provide 1850 calories, 93 grams protein, 727 ml water from formula +100 ml water from protein powder administration, 27.2 mEq of potassium, 720 mg of phos and 46.1 Slide29

Hospital Day 10- MD NoteVery deconditioned and poor nutritional status likely contributed to development of ulcer. Will monitor closely, increase

TFs

to goal to help with healing.

Pt also noted to be too critically ill for HD, possible transition to CVVHSlide30

Wound Care RN NoteArea of deep purple discoloration to coccyx/sacrum is consistent with a suspected deep tissue injury. This area may continue to evolve and breakdown further into full thickness skin loss, there is no sign of infection at this time. This is at least a stage II pressure ulcer as there is partial thickness skin loss.

Poor nutritional status-PAB level is 7, she is at high risk for additional skin breakdown due to overall status,

pressor

requirement and poor nutritional status. Slide31

Hospital Day 10- Nutrition noteFormula was changed to RepleteNo need for renal formual

with CVVH, increased protein needs on CVVH

Small pressure ulcer reported.

Nutrition needs assessed at: 1600 calories and 124

gms

protein daily while on CVVH. While on CVVH, suggest: Replete rate of 75 per hour plus 6 scoops of protein powder daily.

When off CVVH, suggest TF goal of Nepro 250 mg Vit C suggested daily for wound healing. Slide32

Hospital Day 11-SLPPositive outward s/s of Sensory-Motor

Oropharyngeal

Dysphagia

and

s/s Aspiration at this timeRecommendations: continue NPO; continue with alternative nutrition at this time Further

w/u with Modified Barium Swallow when pt more stable if s/s aspiration presist

Further speech, language, voice evaluationNote- Pt pulls out NG tubeSlide33

Hospital Day 12- Nutrition NPO NoteTolerated CVVH, negative -500. Pt seen for tube feeding follow-up. She self

d/c'd

her feeding tube and refused to have it replaced.. Therefore, she has essentially been NPO and/or has received less than 500 calories/day over the past week.

Consider TPN if appropriate.

Labs- PAB 7 (indicative of poor nutrition status)Slide34

Hospital Day 14- Nutrition NotesMD recommends RepleteThis formula not consistent with recommendations when pt is on HD

Suggest:

Nutren

2.0 at goal rate of 37 ml per hour plus 6 scoops of protein powder daily Slide35

Hospital Day 17- Nutrition NoteTF order: Replete at 50 ml/hr plus 2 scoops protein powder daily -> currently off for GI bleed, may restart later today Residuals WNL is

Average TF intake 80% calorie requirements

Suggested to change tube feedings to

Nutren

2.0 which is more appropriate for pt given

hemodialysis. Nutren

2.0 at goal rate of 37 ml per hour plus 6 scoops of protein powder daily Loose stools s/p rectal tube - pt receiving liquid tylenol

and neutraphos. Liquid tylenol contains sorbitol, a poorly absorbable sugar alcohol that can cause diarrhea and

Neutraphos can cause diarrhea. Pt has not been getting calcitriolSlide36

Hospital Day 17 Labs

Recent Labs

Basename

10/28/13 0600

10/27/13 0550

10/26/13 0648

NA

133*

138

131*

K

4.3

4.2

4.2

CL

95*

98

95*

CO2

25

27

24

BUN

34*

24*

31*

CREATININE

2.54*

1.88*

2.42*

GLUCOSE

--

--

--

CALCIUM

5.7*

6.2*

5.9*

MAGNESIUM

0.71

0.72

0.78

PHOS

3.0

2.5

2.6 Slide37

Hospital Day 18- Nutrition Support- MD/RDReason for Consult: Seeing the patient at the request of Dr. Y to evaluate for initiation of

parenteral

nutrition support of malnutrition. I have reviewed the available records and examined the patient.

Indicators of Severe Malnutrition:

Poor nutritional intake > 7days

Additional Justification for Nutrition Support: Nasoenteric/Gastric Feeding not tolerated or contraindicated

TPN support is necessary when parenteral feeding is indicated for longer than two weeks, peripheral venous access is limited, nutrients needs are large or fluid restriction is required and the benefits of TPN support outweigh the risks. Slide38

TPN RecommendationsNutritional Needs: Kcal/day:1800 Protein/AA/day(gm):90

Nutrition Prescription:

Parenteral

:

Calories:1490 Dextrose (grams/day):176 (8 units of insulin) Amino Acids (grams/day): 90 Lipids (grams/day): 55 Slide39

Hospital Day 20 Limit TPN/TF volume for HD and fluid removalChallenging fluid management related to nutrition support and antibiotics.

Nutrition was re-consulted for TF

Consulted for tube feedings that are high in protein without protein powder, low volume, and high in calcium.

Suggest Impact Peptide 1.5 at goal rate of 55 ml per hour to provide 1650 kcal, 103 gm protein, 846 ml water from formula, 100% of

RDI's

for vitamins and minerals.

If Cipro is changed to enteral per tube administration, hold tube feedings for 2 hrs before and 2 hrs after each dose of

Cipro to avoid potential TF and drug interaction, and consult nutrition services for adjusted TF goal rate. Slide40

Hospital Day 21NutritionTolerating thus far at 35 ml/hr with plans to increase by 10 ml/hr every 4 hrs to goal.

If

pt

becomes

hyperkalemic

- change tube feedings to Nepro NephrologyHypokalemia and

hypocalcemiaCalcium supplementationSlide41

Hospital Day 27NutritionTolerating TF, stayed with same formula. Discussing PEG placement RT pt displacement of DHT

Hospital Day 31

The past 3 days pt has averaged 92% of goal for

enteral

feeds. Note that pt is getting PEG placed. Resume

enteral feeds when able. Propofol

at current rate is providing 275 kcal/d from lipid. Depending on how long she is on propofol, may want to consider periodically checking her TG levels. Slide42

Hospital Day 34NutritionThe past 3 days pt has averaged 52% of goal volume for

enteral

feeds

Feeds on hold for OR for

trach

placement. Stool output is over a 1 L in the past 24 hrs. Recommend checking stool for toxins. If toxin negative, consider starting loperamide 2-6 mg up to QID. Consider changing pt to a crushable pill form of

tylenol rather than liquid.Hospital Day 35PEG placedHospital Day 38

Residuals minimal Achieving only 40% of goalPt on HD w

/ TF via PEG w/ low PAB and inadequate TFs past 4 days. Slide43

Hospital Day 422 day average is at goal (100%). Continue to monitor for tolerance. Monitor BM. Per nursing, pt had loose stools over the last 2 days.

Of note, pt has wound that is being monitored. Protein intake ~1.7 gm/kg; for wound healing is consistent with recommendations. TF providing adequate vitamin C for healing. If consistent with goals of care addition of 220 mg of zinc daily

x

10 days may benefit healing. Slide44

Hospital Day 45In the HD population, the serum PAB is spuriously elevated due to abnormal metabolism of the prealbumin

-retinol binding protein complex.

Its generally recommended that when

prealbumin

is used to monitor the nutritional status/response to a nutritional intervention in this population, the goal of therapy should be a

prealbumin level equal to or greater than 29 mg/dl.Presently her levels are at 12.

Continue to monitor weekly but also suggest drawing CRP level on the same day as PAB level to see what degree an APR is playing in depressing the PAB. Slide45

Hospital Day 47Residuals minimal Average daily TF intake (past 4 days):965 ml, daily goal is 1100 ml - achieving 88%

Asked to re-

eval

TF for 2

gr

protein/kg dry wt.As pt is not achieing 100% of TFs on most days, suggest add 3 scoops protein powder to provide 121

gr protein daily. Suggest 220 mg zinc sulfate daily for wound healing Hospital Day 53

99% of TF goalWound healing- Addition of 200 mg zinc sulfate for wound healingSlide46

Hospital Day 57Ms. B’s K was greater than 5.0 four out of the last five days. Suggest changing enteral formulation to provide less K.

Nutren

2.0 at 36 ml/hr plus 10 scoops protein powder daily.

TF will provide, at goal, 35

mEq

of K daily rather than 53 mEq daily with the impact peptide 1.5 Slide47

Hospital Day 59-Wound Care NurseDiet/Nutrition Prescription: NPO; tube feeding Diet/Feeding Assistance: total feed

Diet/Feeding Tolerance: good

Intake (%): 100%

Fluids: adequate

Fluids Requirement: TF/IVF

Nutrition Risk Screen (every 4 days/sig change) Consult Dietitian if Indicator Present: tube feeding or parenteral

nutrition Nutrition Interventions: tube feeding ordered Metabolic/Electrolyte Imbalance Management: electrolyte adjustment Promote Oral Intake (dysphagia

diet restrictions)NPO pending swallowing screening/evaluation Promote Oral NutritionSwallowing Techniques: Dysphagia

: oral mucosa moistenedSlide48

Hospital Days 60/64Day 60TF at goal, residuals WNLDay 64

The past 3 days pt has averaged 100%+ of goal volumes for

enteral

feeds. Getting all protein powder.

Recommend a

nephrocap daily for wound healing. Recommend D/C zinc supplementation tomorrow as over supplementation of zinc can induce a copper deficiency and this is also needed for adequate wound healing. Slide49

Hospital Day 65- DISCHARGEDMs. B was discharged to a Acute Long Term Care facility in Massachusetts.Slide50

Medications

epoetin

alfa

Anemia,

given during dialysis

calcijex

Treats low blood calcium

lactobacillus

probiotic

potassium & sodium phosphates

(

Neutraphos

)-

hypophosphatemia

acetaminophen

(liquid)

Pain

reliever

piperacillin-tazobactam

Abx

calcitRIOL

Vitamin

D

esomeprazole

Heart

burn

aspirin

Pain reliever

senna-docusate

Bowel medSlide51

Weight History

Date

Wt

Date

Wt

10/1/13

61.3 kg11/11/13

89.9 kg10/11/13 (admit)

59.8 kg11/14/1390.1 kg

10/14/1465.4

kg11/17/1392.5 kg

10/21/1373.5 kg

11/21/1386.2 kg10/25/13

75.7 kg11/22/13

84.3 kg

10/28/13

77.4 kg

11/27/13

83.6 kg

10/31/13

78 kg

12/2/13

78.5 kg

11/2/13

79.6

kg

12/4/13

94.3 kg

11/7/13

90.6

12/6/13

84.1

kgSlide52

DiagnosisInadequate enteral nutrition infusion related to altered absorption or metabolism of nutrients as evidenced by serum calcium consistently less than 9.2.

Swallowing difficulty related to motor causes evidenced by SLP pathology assessment and subsequent motor paralysis as a result of CVA.

Impaired nutrient utilization related to impaired renal function as evidenced by renal failure and PTH dysfunction.Slide53

MNT RecommendationsNutrition Management in the Hemodialysis PatientProtein: 1.2

g

/kg protein of HBV

Energy: >60 yrs old 30-35 kcal/kg bodyweight

2-4

g sodium per day1-1.5 L fluidSlide54

MNT RecommendationsEnteral Nutrition in Kidney DiseaseChanges in pt condition and effectiveness of dialysis may require adjusting electrolyte intake during

tx

.

Electrolyte contents vary amongst formulas

Renal formulas available that are lower in electrolytes

Excessive restriction of electrolytes in pt w/risk factors can result in

hypophosphatemia, hypokalemia, and hypomagnesemia (

refeeding syndrome)Slide55

MNT RecommendationsHypocalcemia and kidney diseaseIn the case of Ms. B her

hypocalcemia

was related to her

parathyroidectomy

to control

hypercalcemia related to higher calcium to control PTH.Repletion with IV calcium Dosage of up to 12 g

Ca per dayIf can tolerate PO, calcium between meals for best absorptionCalcitriol given to stimulate calcium and phosphorus absorption

Monitor phosphorus, may need to repleteSlide56

InterventionsOptimize nutrition for wound healingWound healing vitamins, increased protein needs

Improvement in wound

Enteral

nutrition

Ensure that pt needs are met. Pt is at significant nutrition risk RT oral

dysphagia. Ensure tolerance to feeds with limited residualsCalcium/Lytes

Monitor hypocalcemia and replete with IV cacliumPhosphorus repletion if levels have decreased

Monitor potassium-change enteral formulaSlide57

Evaluation/AssessmentWoundsEnteral nutritionCare

Multidisciplinary teamSlide58

Questions?Thank you.

Visit

http://www.kidney.org/professionals/KDOQI/guidelines_commentaries.cfm

for the most recent kidney care guidelines.Slide59

ReferencesByham-Gray, L, Wiesen

, K.

A Clinical Guide to Nutrition Care in Kidney Disease.

United States of America: Library of Congress Cataloging-in-Publication. 2004

Essig

Jr, MD, G. Medscape. Parathyroid Physiology. Published 2011.

http://emedicine.medscape.com/article/874690-overview#aw2aab6b7 Accessed 12/18/13.National Kidney Foundation. KDOQI Guidelines for CKD Care. Published 2007. http://www.kidney.org/professionals/KDOQI/guidelines_commentaries.cfm

. Accessed on January 4, 2013.National Kidney Foundation. Evaluation of Protein Energy Nutritional Status. Published 2000. http://www.kidney.org/professionals/kdoqi/guidelines_updates/nut_a04.html

Accessed January 3, 2013Venes, MD, D. Taber’s Cyclopedic

Medical Dictionary. United States of America: Library of Congress Cataloging in Publication Data. 2005.Witteveen

, JE, Thiel, S van, Romijn, JA, Hamdy, NAT. Hungry bone syndrome: still a challenge in the post-operative management of hyperparathyroidism: a systematic review of literature.

European Journal of Endocrinology. 2013. 168: R45-R53.