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CKD-STAGE 3 & SEPSIS

AJEE’LON BOYD, KEENE STATE COLLEGE DIETETIC INTERNSHIP


Horizon Specialty Hospital
■ Located in Las Vegas, NV and Henderson, NV
■ 80 beds total (40 beds at each location)
■ Long term acute care
Role of The Clinical Dietitian at Horizon
Specialty Hospital
■ Clinical Dietitian
– Provides Medical Nutrition Therapy
– Provides Nutrition Education
– Assess nutritional needs based on the Standards of Care
– Active member of the interdisciplinary healthcare team
– Writes diet orders for oral diets and parenteral nutrition
– Makes recommendations for total parenteral nutrition
CKD Stage 3
■ Progressive loss of kidney function
– Characterized by a decline in GFR
■ MNT
– Elevated calorie needs to provide positive nitrogen balance under stressful conditions
■ 30-35 kcals/ kg BW
– Low protein needs
■ Protein needs can be increased as GFR improves (increases)
■ Dialysis pts have higher protein needs
– 1-1.5 g protein/kg BW
Risk Factors for CKD
■ Diabetes
■ HTN
■ Glomerulonephritis
– Diseases that cause inflammation
■ Third most common type of kidney disease.
– Damage the kidney's filtering units.
■ Polycystic kidney disease
– Inherited disease
– Large cysts form in the kidney
■ Damages the surrounding tissue.
■ Congenital malformations
– Leads to reflux nephropathy.
■ Diseases that affect the immune system
– Systemic lupus erythematosus
■ Obstructions caused by:
– Kidney stones, tumors, or an enlarged prostate gland in men.
■ Repeated UTI’s
Complications associated w/CKD
■ Protein-energy malnutrition
– Uremic state and increased protein catabolism
■ Altered Metabolism
– Ca, Phosphorus, Vitamin D
■ Leads to secondary hyperparathyroidism, causing mineral and bone disorder of
CKD,
– Cardiac and extra skeletal calcification
■ Electrolyte and fluid imbalances
– HTN, edema, CHF, severe hyperkalemia
■ Dyslipidemia and abnormal carbohydrate metabolism
– Increases risks for CVD
■ Anemia
– Impaired erythropoiesis and low iron stores
Sepsis
■ An infection triggers an inflammatory response that then leads to systemic response
– Symptoms:
■ Fever
■ Hypothermia
■ Tachycardia
■ Tachypnea
■ Leukocytosis
■ Leukopenia
■ Severe sepsis
– Dysfunction of one or more organ systems or unexplained metabolic acidosis
■ Inflammatory response
– Release of cytokines from neutrophils and macrophages
■ TNF a, Interleukins, & prostaglandins
– The cytokines then activate the extrinsic coagulation cascade
■ This inhibits fibrinolysis
– These processes lead to microvascular thrombosis
■ Which leads to organ dysfunction
■ Anti-inflammatory and inflammatory mediators have a significant role in sepsis
Risks Factors for Sepsis

■ Infection
– From the tiniest source (a hangnail) to the most severe (meningitis)
– Bacterial, viral, fungal, or parasitic
■ Infants and elderly patients are at the highest risks
■ Chronic illness
– Diabetes
– Cancer
– Impaired immune system
MNT for Sepsis

■ Immunosuppressive process that prevents adequate response to infection


■ Treatment is focused on treating the source of infection or trauma
■ Pt may be on vent, antibiotics, hemodynamic, renal, and metabolic support
■ Alterations in metabolism
■ Increased energy and protein needs
– 25-30 kcals/kg BW
– 1.2-2 g protein/kg BW
■ Altered GI function
J.D.
■ 65 yo Hispanic Male
■ Admitted 5/30/18 (124 lbs, BMI 21.2, 5’4”, IBW: 130 lbs, IBW Range: 117-143 lbs)
■ Medical Hx-
– Admitted to St Rose Hospital for fever, back pain, and altered mental status
– Hx of Parkinson’s, Lewy body dementia (functionally declining), Hep C, Cirrhosis, & Insomnia
– Wife denies previous hx of meningitis
– Hx of liver and renal transplant in 2009
– Appendectomy & Cholecystectomy
– Constipation
– Spinal fluid has significant pleocytosis
– Hx of cholecystectomy
■ Diet Hx-
■ Social Hx-
– Ambulating prior to hospital stay
– Pt lives at home with wife
– No hx of smoking, drinking alcohol, or illicit drug use
■ Family Hx-
– Pt has one son and is married
– No family hx of CKD
■ Pt Needs-
– 1692-1974 kcals/day method used 30-35kcals/kg IBW
– 56 g protein method used 1 g protein/kg IBW based on CKD and mild wounds
– 1692 mL H2Obased on 30 mL/kg IBW
Medications
■ Warfarin (Coumadin) ■ Omeprazole
■ .9% Sodium Chloride ■ Alprazolam (Xanax)
■ Magnesium ■ Loratadine (Claritin)
■ Menthol/Zinc Oxide (Calmoseptine) ■ Allopurinol (Zyloprim)
■ Tacrolimus (Prograf) ■ Calcitriol (Rocaltrol)
■ Carbidopa/Levodopa/Entacapone (Carbidopa- ■ Ferrous sulfate
Levodopa-Entacapone) ■ Fluconazole (Diflucan)
■ Rotigotine (Neupro) ■ Lacosamide (Vimpat)
■ Free Phenytoin (Dilantin 100) ■ potassium chloride
■ Magnesium, Aluminum Hydroxide (Maalox Tc) ■ Sodium Potassium Phos
■ Temazepam (Restoril) ■ Dulcolax
■ Prednisone ■ Clonidine Hcl
■ Sodium Bicarbonate ■ Ondasetron Hcl (Zofran)
■ Omeprazole ■ Ipratropium/albuterol sulfate
Nutrition Diagnosis

■ Altered nutrition related lab values R/T metabolic dysfunction AEB BUN 58 (altered
renal function)
■ Diet order-Nepro @ 50 cc/hr
■ Intervention-Initiate Jevity 1.2 @ 30 cc/hr increasing by 10 cc/hr every hour to goal
of 60 cc/hr (1,728 kcals, 80 g protein, 1162 mL H2O) FWF @ 30 cc/hr (1882 mL
H2O)
■ Monitor-EN tolerance, wt, labs, wounds
Day 3 (6/1)

Clinical Course
■ Current wt 124 lbs
■ BMI 21.2
■ IBW 130
■ IBW range 117-143 lbs
Day 1 (5/30) ■ Adjusted BW 122.5 lbs

■ Pt admitted ■ Parkinson's Disease, CKD stage 3, Lewy body dementia, liver and
kidney transplant, & cholecystectomy
■ Current wt 124 lbs ■ No edema present
■ Coccyx redness and bruising (no other wounds)
■ BMI 21.2
■ Nepro @ 50 cc/hr
■ NPO ■ Pt needs
– 1692-1974 kcals/day method used 30-35kcals/kg IBW
■ Nepro @ 50 cc/hr via PEG – 56 g protein method used 1 g protein/kg IBW based on CKD and
mild wounds
■ No FWF – 1692 mL H2Obased on 30 mL/kg IBW

■ No edema present ■ Altered nutrition related lab values R/T metabolic function AEB BUN of
58 (altered renal function)
■ Intervention
– 1. D/C Nepro @ 50 cc/hr
– 2. Initiate Jevity 1.2 @ 60 cc/hr (goal) (1,728 kcals, 80 g protein,
1,162 mL H2O)
– 3. FWF @ 30 mL/hr (1,882 mL H2O)
Labs on 6/1
Lab Value on 6/1 Normal Range
Glucose 123 (H) 65-99 mg/dL
BUN 58 (H) 7-25 mg/dL
Creatinine 1.24 (H) .70-1.18 mg/dL
GFR 61 >/= 60 mL/min
Na 142 135-146 mmol/L
K 4.2 3.5-5.3 mmol/L
Phosphorous 2.6 2.1-4.3 mg/dL
Ca 8.9 8.6-10.3 mg/dL
Albumin 2.8 (L) 3.6-5.1 g/dL
Hgb 8.5 (L) 13.2-17.1 g/dL
Hct 24.3 (L) 38.5-50 %
Clinical Course
Day 13 (6/11) ■ Previous note stated to D/C Nepro @ 50 cc/hr and Initiate
Jevity 1.2 @ 60 cc/hr
■ Diet- Regular, pureed & low potassium diet – Order was not implemented per MARS and nurse’s
– 0% PO note
– Per conversation w/ nurse, pt isn’t swallowing food
■ Nepro @ 50 cc/hr FWF @ 45 cc/hr via PEG and is pocketing food
– Tolerating ■ Potential choking hazard

■ Supplements: Ferrous SO4 ■ Altered nutrition related lab values R/T poor glycemic
control AEB consistently elevated blood glucose levels
■ Wt ■ Intervention
– 6/7 131.2 lbs – D/C Regular, pureed & low potassium diet
– 5/30 124 lbs – D/C Nepro @ 50 cc/hr
– Note 7lb wt gain in 1 week is likely an error – Initiate Glucerna 1.2 @ 60 cc/hr
with no dialysis or edema present ■ 1,728 kcals, 86 g protein, 1,166 mL H2O
■ No updated wound report ■ Pt likely to meet needs

■ No edema present ■ M/E- wt, labs, EN


Labs on 6/11
Lab Value on 6/11 Normal Range
Glucose 178 (H) 65-99 mg/dL
BUN 55 (H) 7-25 mg/dL
Creatinine 1.04 .70-1.18 mg/dL
GFR 75 >/= 60 mL/min
Na 140 135-146 mmol/L
K 4.3 3.5-5.3 mmol/L
Phosphorous 3 2.1-4.3 mg/dL
Ca 9 8.6-10.3 mg/dL
Albumin 2.6 (L) 3.6-5.1 g/dL
Hgb 9.8 (L) 13.2-17.1 g/dL
Hct 30 (L) 38.5-50 %
Clinical Course Lab Value on 6/18 Normal Range

Day 20 (6/18)
Glucose 193 (H) 65-99 mg/dL
■ Glucerna 1.2 @ 60 cc/hr via PEG BUN 46 (H) 7-25 mg/dL
– tolerating
Creatinine 1.14 .70-1.18
■ FWF @ 45 cc/hr per nurse’s note
mg/dL
– Tolerating
■ Wt GFR 67 >/= 60
– 5/31 124 lbs mL/min
– 6/7 131.2 lbs (likely a wt error/discrepancy)
Na 135 135-146
– 6/18 124 lbs
mmol/L
■ No edema present
■ No updated wound report
K 5.9 3.5-5.3
mmol/L
■ Altered nutrition related lab values R/T impaired
renal function AEB lab value K=5.9 (H)
Ca 8.9 8.6-10.3
■ Intervention mg/dL
– D/C Glucerna 1.2 @ 60 cc/hr FWF @ 45
cc/hr via PEG Albumin 2.8 (L) 3.6-5.1 g/dL
– Initiate Nepro @ 45 cc/hr FWF @ 40 cc/hr
via PEG Hgb 11.1 (L) 13.2-17.1 g/dL
■ M/E-wt, labs, EN tolerance
Hct 33.6 (L) 38.5-50 %
Clinical Course Lab Value on 6/24 Normal Range
Glucose 120 (H) 65-99 mg/dL
Day 26 (6/25) BUN 57 (H) 7-25 mg/dL
■ Nepro @ 60 cc/hr FWF @ 45 cc/hr via Creatinine 1.14 .70-1.18
NG Tube
mg/dL
– Tolerating
GFR 67 >/= 60
■ Wt
mL/min
– 6/22 119.2 lbs BMI 20
– 6/18 124 lbs Na 138 135-146
■ No edema present mmol/L
■ No updated wound report K 4.2 3.5-5.3
mmol/L
■ Unplanned wt loss R/T unknown cause
AEB 3.9 % wt loss in 4 days Ca 9.2 8.6-10.3
■ Intervention mg/dL
– Continue POC Albumin 3 (L) 3.6-5.1 g/dL
– Pt receiving above needs
Hgb 10.5 (L) 13.2-17.1 g/dL
■ M/E-wt, wounds, labs
Hct 31.5 (L) 38.5-50 %
Clinical Course

Day 28 (6/26)
■ Quick note
– Pts diet texture has been upgraded to pureed texture per ST eval
– Pts tube feeding will be reduced to a nocturnal feed
– Upon interview w/ pt and family, pt is eating very well and family is bringing pureed food from
home
■ Excessive EN infusion R/T upgraded diet texture AEB current PO intake and EN exceeding pt needs
■ Intervention
– Reduce tube feed frequency of Nepro @ 60 cc/hr FWF @ 45 cc/hr for 12 hrs (6 pm-6 am)
nocturnal feed
– Initiate 1:1 feeder
■ M/E- wt, labs, PO, EN tolerance, wounds
Clinical Course Lab Value on 7/2 Normal Range
Glucose 226 (H) 65-99 mg/dL
Day 33 (7/2) BUN 46 (H) 7-25 mg/dL
■ Pureed diet
Creatinine 1.17 .70-1.18
– 50-75% PO
mg/dL
■ Nocturnal feed-Nepro @ 60 cc/hr FWF @
45 cc/hr (6pm-6am) GFR 65 >/= 60
– Tolerating mL/min
■ Wounds Na 136 135-146
– New pressure ulcer found and mmol/L
improving per wound report
K 4.4 3.5-5.3
■ No new DX
mmol/L
■ Continue POC
– Pt has a low BMI
Ca 9.1 8.6-10.3
■ Nocturnal feed to provided added mg/dL
kcals and protein to meet pt needs
and supplement PO intake Albumin 3 (L) 3.6-5.1 g/dL
■ M/E- wt, labs, wounds, PO intake, EN Hgb 10.4 (L) 13.2-17.1 g/dL
tolerance
Hct 31.3 (L) 38.5-50 %
Clinical Course
Day 37 (7/6) Lab Value on 7/6 Normal Range
■ Regular pureed diet
– Variable PO
Glucose 109 (H) 65-99 mg/dL
■ 25-100%PO BUN 54 (H) 7-25 mg/dL
■ Nocturnal feed Nepro @ 60 cc/hr FWF @ 45 cc/hr (6pm-6am)
Creatinine 1.04 .70-1.18
– Tolerating
mg/dL
■ Stage 1 pressure ulcer
– Improving per wound report GFR 75 >/= 60
■ Wt mL/min
– 7/6 116.6 lbs BMI 20
Na 137 135-146
■ No edema present mmol/L
■ Upon interview with pt’s wife, pt is not eating well anymore
and has difficulty swallowing. Wife state concern that pt is K 4.1 3.5-5.3
dehydrated despite his FWF
mmol/L
■ Inadequate oral intake R/T altered mental status AEB variable
PO 25-100% Ca 8.9 8.6-10.3
■ Intervention mg/dL
– D/C nocturnal feed of Nepro @ 60 cc/hr FWF @ 45
cc/hr (6pm-6am) Albumin 3 (L) 3.6-5.1 g/dL
– Initiate Nepro @ 45 cc/hr for 24 hrs
■ 1,944 kcals, 87 g protein, 788 mL H2O
Hgb 10.4 (L) 13.2-17.1 g/dL
– Initiate FWF @ 30 cc/hr Hct 31.4 (L) 38.5-50 %
■ 720 mL H2O

■ M/E-wt, labs, PO, EN tolerance, hydration


Clinical Course

Day 38 (7/7)
■ Discharged to St. Rose Hospital for CT scan of the head for altered mental status
– No acute intracranial abnormality
■ MRI of brain w/o contrast
– No acute findings
■ Spinal tap
– Pending results
■ Pt was found to have phenytoin toxicity
■ Pt was discharged from Horizon Specialty Hospital to continue treatment at St. Rose Hospital
Clinical Course

Day 1 (7/9)
■ Pt readmitted
– Altered mental status, HTN, liver & kidney transplant, Parkinson’s disease (pt
medical diagnosis is the same as in the first admission note)
■ Pts mental status is improving
– Pt today is talking in short sentences
■ Pts son reports fluctuating Prograf levels over the past few months.
Clinical Course
Day 2 (7/10) Lab Value on 7/10 Normal Range
■ Nepro @ 50 cc/hr (2,160 kcals, 99 g protein, 876 Glucose 135 (H) 65-99 mg/dL
mL H2O) FWF @ 30 cc/hr (720 mL H2O)
– tolerating BUN 33 (H) 7-25 mg/dL
■ Wt Creatinine .92 .70-1.18
– 7/10 117.5 lbs BMI 20.2 IBW range 117- mg/dL
143
GFR 87 >/= 60
■ No edema present
mL/min
■ No new wounds
– Old surgical site wounds present (not Na 146 135-146
pertinent) mmol/L
■ Pt needs K 4.2 3.5-5.3
– 1731-2019.5 kcals/day method used 30- mmol/L
35kcals/kg ABW
– 57.7-69.2 g protein method used 1-1.2 g Ca 8.9 8.6-10.3
protein/kg ABW mg/dL
– 1731 mL H2Obased on 30 mL/kg IBW
Albumin 3.1 (L) 3.6-5.1 g/dL
■ Altered nutrition related lab values R/T metabolic
dysfunction AEB BUN of 33 (H) Phosphorus 2.2 2.1-4.3 mg/dL
■ Intervention
– Continue POC (pt meeting needs)
■ M/E-wt, labs, EN tolerance
Clinical Course
Day 5 (7/13)
Lab Value on 7/13 Normal Range
■ Nepro @ 50 cc/hr (2,160 kcals, 99 g protein, 876 mL H2O) FWF @ 300
mL Q4(1800 mL H2O)
– tolerating
Glucose 102 (H) 65-99 mg/dL
■ Wt BUN 50 (H) 7-25 mg/dL
– 7/10 117.5 lbs BMI 20.2
Creatinine .96 .70-1.18
■ No edema present
mg/dL
■ No updated wounds
■ ST eval/swallow study conducted GFR 83 >/= 60
– Pt cleared for pureed diet w/ thin liquids mL/min
– Nocturnal feed recommended for additional support to meet pt
needs Na 139 135-146
■ No new dx mmol/L
■ Pts wife was observed providing pt with ground chicken and rice
– Family was educated on appropriate diet texture and the risks
K 3.8 3.5-5.3
associated with food textures she was providing mmol/L
■ Wife did not seem compliant. Nursing and kitchen staff was
notified of incident and risks.
Ca 8.9 8.6-10.3
■ Intervention
– Initiate Regular pureed diet w/ thin liquids
mg/dL
– Initiate nocturnal feed (6pm-6am) of Nepro @ 65 cc/hr & FWF @
10 cc/hr
Albumin 2.7 (L) 3.6-5.1 g/dL
■ 1,404 kcals, 63 g protein, 1378 mL H2O
Phosphorus 2.7 2.1-4.3 mg/dL
■ M/E-wt, labs, EN tolerance, PO
– If pts PO intake improves D/C or decrease nocturnal tube feed
Clinical Course
Day 8 (7/16) Lab Value on 7/16 Normal Range
■ Quick note
Glucose 111 (H) 65-99 mg/dL
– Upon pt interview, son reports that he fed pt
pancaked and eggs w/ a biscuit for BUN 42 (H) 7-25 mg/dL
breakfast
■ Pts diet texture is pureed Creatinine .92 .70-1.18
■ Family was educated for a second time on mg/dL
appropriate diet texture and risks associated
with food texture pt was given for breakfast Na 137 135-146
and that ST has to upgrade pt diet texture
– Son seems compliant mmol/L
– Pts labs reflect that the pt is hydrated K 5 3.5-5.3
■ FWF is likely appropriate and likely to meet mmol/L
pt needs
■ Upon interview w/ pt and son, son reports pt Ca 9.4 8.6-10.3
is drinking about 2 L of fluids/day
mg/dL
■ Inadequate oral intake R/T difficulty swallowing
AEB continued need for nocturnal feed to Albumin 2.9 (L) 3.6-5.1 g/dL
supplement PO intake
Phosphorus 3 2.1-4.3 mg/dL
■ Intervention
– Request ST eval
– Continue POC
■ M/E-wt, labs, EN tolerance, PO intake
Clinical Course
Day 15 (7/23) Lab Value on 7/23 Normal Range
■ Regular pureed diet w/ thin liquids Glucose 124 (H) 65-99 mg/dL
– 25-75% PO BUN 34 (H) 7-25 mg/dL
■ Nepro @ 65 mL/hr & FWF @ 70 mL/hr Creatinine 1.05 .70-1.18
(1200A-1200P) mg/dL
– Tolerating GFR 74 >/= 60
mL/min
■ Wt
– 7/15 116.5 lbs BMI 20 Na 136 135-146
mmol/L
– 7/10 117.5 lbs
K 4.2 3.5-5.3
■ No edema present mmol/L
■ No updated wound report Ca 8.8 8.6-10.3
mg/dL
■ No new Dx
Albumin 2.5 (L) 3.6-5.1 g/dL
■ Continue POC
Phosphorus 3 2.1-4.3 mg/dL
■ M/E-wt, labs, wound PO intake, EN
tolerance Hgb 10 (L) 13.2-17.1 g/dL
Hct 29.5 (L) 38.5-50 %
Evaluation/Reassessment
■ Pt is still receiving treatment at Horizon Specialty Hospital
– Based on previous hx, expect needs to continue to be met
■ Pt needs were met throughout both stays
– Concerned about family’s ability to adhere to pts appropriate diet texture
■ Phenytoin toxicity discovered upon previous discharge to St. Rose hospital
– Can be caused by
■ Excessive self-medication
■ Misunderstanding of prescription order
■ Drug interactions
– Symptoms
■ Unsteady gait
■ Dizziness
■ Vertigo
■ Nausea
■ General weakness
■ Drowsiness
■ Vomiting
References

■ Nutrition and Sepsis. NCBI. https://www.ncbi.nlm.nih.gov/pubmed/23075593. Accessed


July 25, 2018.
■ US Commentary on the 2012 KDIGO Clinical Practice Guideline for the Evaluation and
Management of CKD. Official Journal of the National Kidney Foundation.
https://www.ajkd.org/article/S0272-6386(14)00491-0/fulltext. Accessed July 24, 2018.
■ Chronic Kidney Disease. Nutrition Care Manual.
https://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=267740. Accessed July 24,
2018.
■ Chronic Kidney Disease, Sepsis. Nelms. Nutrition Therapy and Pathophysiology. Accessed
July 25, 2018.
■ Sepsis. Sepsis.org. https://www.sepsis.org/faq/ Accessed July 25, 2018