End Stage Renal DiseaseInterstitial Nephritis

Major Case StudyKrista Blackwell

Sodexo Mid-Atlantic DIJanuary 28, 2014

Objectives

•Define Interstitial Nephritis•Identify etiology and pathophysiology of

Interstitial Nephritis•Discuss treatment and Medical Nutrition

Therapy for patients with ESRD

Functions of the Kidney

•Elimination of waste products

•BP regulation•Volume and fluid

maintenance•Electrolyte

balance•Acid-base

balance•Ca-phos

homeostasis

Interstitial Nephritis

• Inflammation of the spaces between the kidney tubules▫Acute or chronic

• Etiology▫Drug induced: Antibiotics, NSAIDS▫Autoimmune diseases and Systemic Diseases

Kawasaki’s Disease Sjogren syndrome Systemic Lupus Erythematosus

▫Infections: Bacteria, Viruses (HIV)

▫Idiopathic▫Chronic: Sickle cell disease, DM, vesicoureteral reflux

Interstitial Nephritis•Pathophysiology

▫Not completely known▫Depends on the original cause of the

disease▫Immune response

Inflammatory response Infiltrates: lymphocytes, macrophages,

eosinophils, plasma cells▫Decrease in renal function▫ESRD and Dialysis

Medical ManagementAcute Interstitial Nephritis

▫Removal of drug causing condition▫Steroids▫Cyclophosphamide and cyclosporineChronic Interstitial Nephritis ESRD: GFR <15

mL/min▫Immunosuppressive therapy▫Kidney transplant▫Dialysis▫Phosphate binders▫Calcium Supplements▫Epogen: Manage anemia▫MVI: B complex, Vit C

Do not need: Vit A, inactive Vit D

MNT in ESRD•Goal: Control edema and electrolyte

imbalances•Sodium: 2000 mg/day•Potassium: 2000-3000 mg/day•Phosphorus: 1000-2000 mg/day•Protein:

▫1.2-1.4 g/kg/day in HD▫GFR <50 without dialysis: 0.6-0.8 g/kg/day

•Fluid management ▫With HD: ~750ml + urine output

Nutrition in HIV and AIDS

• CD4 count <200 mm3= AIDS

• Change in body composition▫Loss of LBM and body

cell mass• Vit B12 deficiency• Wasting• Malabsorption• Increased metabolic rate:

Catabolic state• Lipoatrophy• Opportunistic Infections

▫TB, pneumonia, oral candidiasis

Nutrition Recommendations:

HIVKcal: 30-35 kcal/kg IBWProtein: 1-1.5 g/kg actual weight

AIDSKcal: 35-45 kcal/kg actual weightProtein: 1.2-1.8 g/kg actual weight

MVI with minerals

Case Study: Admission

•JB is a 41 year-old African American male

•Presented to the ED at SGAH on December 10th, 2013 with intractable nausea and vomiting

•Decreased urine output

•JB was admitted to SGAH for monitoring, evaluation, and treatment of renal failure

Medical Diagnoses

•Acute renal failure on chronic kidney disease

•Anemia•Hypocalcemia•Hyponatremia

Past Medical History

•Hypertension: Non compliant with medications

•HIV diagnosed in 1996

•CKD: Untreated

Past Medical History: Johns Hopkins

• February 19, 2008: “HIV 101”

• March 4, 2008: Follow-up

• May 10, 2012: Scheduled kidney biopsy

• June 4, 2012: Kidney biopsy, Cr 3.4

• October 22, 2012: Follow up with primary care physician.

BP 160/110, Cr 3.75

• April 16, 2013: Noncompliant with medications. Wt: 72.4 kg

• May 30, 2013: CD4 743, Cr 6.0

• Nov. 6, 2013: Moore Clinic

Social History

•Adopted•English speaking, Christian•Non-smoker, no history of smoking•No alcohol or drug use•Employment: JB works full-time at the

housing authority doing office work•Lives alone in a single level home in

Gaithersburg •Single, no children •Education level unknown, able to read and

write

Hospital Course and Consultations•Dec. 10: Admission•Dec. 11: Infectious Disease•Dec. 12: Retroperitoneal ultrasound, chest x-

ray, hemodialysis catheter placement•Dec. 11, 13, 14, 17, 20: Nutrition•Dec. 13, 14, 16, 17, 20: Case Management •Dec. 13: OT & PT•Dec. 17: Guided renal biopsy: Dx. Interstitial

Nephritis•Dec. 12, 13, 16, 18, 20: HD•Dec. 20: Discharge

Hospital Medications

Medications

Anthropometric Data• Ht: 177 cm, 69.69”

• Wt: ▫12/10: 62 kg, 136.4 lb▫12/17: 63.4 kg, 139.48 lb

• BMI: 19.79

• IBW: 75.5 kg, 166 lb

• %IBW: 83%

• Usual Body Weight: 74.1 kg, 163 lb

• % Wt change: 16.32% wt loss over 2-3 months

Initial Nutrition Assessment: Dec. 11th

•Risk level: High

•Diet: NPO for HD catheter placement

•Summary: JB reported a 30-35 lb wt loss over the past 2-3 months. Has not vomited in 2 days. Does not want HD. HD order in chart.

Laboratory Data

Nutrition Prescription

•Mifflin-St Jeor: REE= 1529 (1.1)(1.4)=

2355 kcal

▫38 kcal/kg

•Protein: 62-75 gm (1.0-1.2 g/kg)

▫Without HD 0.6-0.8 g/kg•Fluid:

▫1860 ml (500-1000 ml + urine output)

Nutrition Diagnoses

▫Diagnoses I: Malnutrition (severe) R/T HIV and renal failure AEB >7.5% wt loss in 3 months and <75% intake for >1 month

▫Diagnoses II: Altered nutrition-related laboratory values R/T renal failure AEB elevated BUN, Cr, and phos.

Nutrition Intervention Goals:

Pt to meet >75% of estimated needs within 3-4 days.

Pt to maintain wt throughout LOS Recommend Nepro BID Will monitor need for renal diet education

Monitoring and Evaluation Monitor food and beverage intake Monitor biochemical data: BUN, Creatinine,

electrolytes, and triglycerides Monitor weights

Nutrition Reassessment: Dec. 13th •Risk Level: High

•Diet: Renal Dialysis

•Summary: Pt extremely lethargic, minimal responses, vomited this morning. Pt had HD cath. placed and received HD yesterday, Dec.12th. Pt still has poor po intake. Consumed 0% of breakfast.

Laboratory Data: Dec. 13th

Nutrition Prescription

•Mifflin-St Jeor: REE= 1529 (1.1)(1.4)=

2355 kcal

▫38 kcal/kg

•Protein: 75-87 g

▫1.2-1.4 g/kg

•Fluid: 1860 mL

Nutrition Diagnoses

▫Diagnoses I: Malnutrition R/T HIV and renal failure AEB >7.5% wt loss in 3 months and <75% intake for >1 month

▫Diagnoses II: Altered nutrition-related laboratory values R/T renal failure AEB elevated BUN, Cr, and phos.

Nutrition Reassessment: Dec. 13th ▫Interventions:

Goals: Pt to meet >75% of estimated needs within 3-4

days: Not met, continue goal Pt to maintain wt throughout LOS: Progress

towards goal Rec. increasing Nepro to TID.

▫Monitoring and Evaluation: Monitor food and beverage intake Monitor biochemical data: BUN, Creatinine,

electrolytes, triglycerides Monitor weights Will monitor need for renal diet education

Nutrition Education: Dec. 14th • RD: AN• Pt has been drinking

Nepro, but not eating very much.

• Pt dislikes hospital food

• Provided renal diet education and printed materials from NCM

• Provided “All Time Favorites” list and reviewed Renal diet options

Nutrition Reassessment: Dec. 17th ▫Risk Level: High▫Diet: NPO for kidney biopsy▫Summary: N/V improved, pt still has fair po

intake because he dislikes food provided, consumed about 50% of meals yesterday

▫Diagnoses I: Malnutrition R/T HIV and renal failure AEB >7.5% wt loss in 3 months and <75% intake for >1 month

▫Diagnoses II: Altered nutrition-related laboratory values R/T renal failure AEB elevated BUN, Cr, and phos.

Laboratory Data

Nutrition Reassessment: Dec. 17th ▫Interventions:

Goals: Pt to meet >75% of estimated needs within 3-4 days: Not

met, progress towards goal Pt to maintain wt throughout LOS: Progress towards goal Pt’s renal labs WNL since starting dialysis

Recommend changing current diet to 2 gm Na restriction to increase po intake

▫Monitoring and Evaluation:

Monitor pt’s po intake Monitor renal labs: BUN, Cr, K, phos, Na Monitor triglycerides Monitor weight trends. Requested RN to take wt on pt

today since no new weights have been obtained since pt was admitted

Nutrition Reassessment: Dec. 20th ▫Risk Level: Moderate

▫Diet: Low Sodium: 2 gm

▫Summary: Nephrologist stated that he is not concerned with JB’s K levels, but that JB needs further phosphorus diet education. Pt denied N/V, able to consume regular diet and drinking Nepro. Pt to be d/c today with dialysis 3x per week

▫Education: Nephrologist requested pt receive low phosphorus diet Ed. Provided pt with verbal explanation and written material from

NCM Pt verbalized understanding of information provided. Estimated

compliance: High.

Laboratory Data

Laboratory Data

Nutrition Diagnoses

▫Diagnoses I: Malnutrition R/T HIV and renal failure AEB >7.5% wt loss in 3 months and <75% intake for >1 month

▫Diagnoses II: Altered nutrition-related laboratory values R/T renal failure AEB elevated BUN, Cr, and phos.

Nutrition Reassessment: Dec. 20th ▫Interventions:

Goals: Pt to meet >75% of estimated needs within 3-4

days: Met Pt to maintain wt throughout LOS: Met Pt’s renal labs WNL since starting dialysis: Met

Recommend continuing 2 gm Na restriction diet. Low phosphorus.

▫Monitoring and Evaluation: Monitor pt’s po intake Monitor renal labs: BUN, Cr, K, phos, Na Monitor triglycerides Monitor weight trends

Discharge Summary: Friday Dec. 20th

• Discharge Diagnoses:

▫Chronic Kidney Disease-dialysis initiated▫Anemia secondary to chronic kidney disease▫Hypertension▫ Interstitial nephritis on kidney biopsy: f/u at

Johns Hopkins Hospital▫AIDS on antiretroviral medications. • Discharge medications: • Calcitriol, PhosLo, Darunavir, Intelence, Ferrous

Sulfate, Lisinopril, Metoprolol, Raltegravir, and Norvir

• Scheduled for HD at Middletown DaVita M,W,F

References • Moore, Linda W. Implications for Nutrition Practice in the Mineral-Bone Disorder of Chronic Kidney Disease.

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• NKF K/ KDOQI Guidelines. Recommendations for Clinical Performance Measures. National Kidney Foundation. New York, NY. 2012. Web URL: www.kidney.org

• Huang, Yuli., Cai, Xiaoyan., Zhang, Jianyu., Mai, Weiyi., Wang, Sheng., Hu, Yunzhao., Ren, Hao., Xu, Dingi. Prehypertension and Incidence of ESRD: A systematic Review and Meta-analysis. American Journal of Kidney Diseases. National Kidney Foundation. September 2013.

• Mahan, K.., Escott-Stump, S, Raymond, J. Krause’s Food and the Nutrition Care Process. 3rd ed. Elsevier Saunders. 2012

Thank You!Questions?