CLIENT RECORDS

Erica is a 20 year old college student, a junior majoring in computer science. Her first two years of college were completed at a junior college in her hometown. This is Erica's first year living away from home.

 

The following information gives Erica's social, health, nutritional, and medical background. The latter, along with the nutritional assessment, laboratory values and metabolic information are necessary when assisting persons to develop and plan a nutritionally adequate diet when they have kidney disease requiring dialysis or organ transplant.

 

Presenting Problem

Erica went to Florida during the spring break with several girlfriends. While in Florida, Erica noticed a "rash" across the bridge of her nose following a day in the sun. Prior to this trip, she had also been troubled with severe headaches. Following her return from Florida, she visited the University Student Health Service where physical examination indicated hypertension (180/110). Urinalysis indicated azotemia and further medical assessment revealed systemic lupus erythromatosus (SLE).

Psycho-social Background

Erica had always been a physically active young woman. She had been horseback riding on a regular basis since age seven and had played soccer and softball throughout her middle and high school years. Erica maintained an A/B grade average through high school and at junior college. Her social life had been very limited while living at home, dating occasionally and spending free time with girlfriends and siblings. At college she became more sociable, spending weekends "partying and drinking".

Family Background

Erica is the oldest child in a large extended family. She has three younger siblings, two brothers and one sister. Erica has four maternal aunts and three uncles and two aunts on her father's side of the family. Both sets of grandparents are alive and well. There is no family history on either side of SLE.

Health History

Erica was a relatively healthy person until symptoms appeared during the fall term of her junior year in college. These symptoms are described in the Presenting Problem section. Initial medical examination findings and those of the nephrologist are described below under Initial Assessment Findings section.

Erica faithfully took her medications, followed the diet, and kept her return visits until summer break. While at home, Erica ran out of medication, but felt so much better, that she did not have her prescriptions refilled. She also stopped following her diet.

In August, prior to returning to school, Erica began having problems with headaches and general malaise. Her nephrologist at school was contacted who referred her to a nephrologist in her home town. An appointment was made for the following day. All previous medical history was faxed to her new nephrologist, who ordered new blood work along with a urinalysis. Results from the tests and nutritional care plans are given in the Predialysis section.

Erica's kidney function was rapidly deteriorating. After a discussion with the nephrologist on her dialysis options, either hemodialysis or peritoneal dialysis, Erica and her mother saw a social worker who helped Erica decide on the type of dialysis. They were also given a tour of both dialysis units. Erica's choice was continuous ambulatory peritoneal dialysis (CAPD) and her nephrologist was notified of her choice. An appointment was made to have a peritoneal catheter placed. Erica felt this type of dialysis, along with the diet, would give her more flexibility at school. Two weeks after the catheter was inserted, it was ready for use. Erica was scheduled for peritoneal dialysis training and to see the renal dietitian. Results of the tests and nutritional care plans are given in the CAPD section.

Erica did well with her CAPD, medication, and classes. She returned home for the summer. However, during the summer, she developed a severe problem with peritonitis which necessitated a change to hemodialysis.

Changing to hemodialysis required placement of an A-V fistula, a double lumen central line and a change in dietary prescription. Results of the tests and corresponding changes in nutrition care plans are given in the Hemodialysis section.

Two months after Erica started hemodialysis, she presented to the emergency room on a Sunday evening with a 10 pound weight gain, SOB and feeling lethargic. Her blood pressure was 150/80.

Erica stated that she had been to a party with friends the previous night. She was depressed about her life on dialysis and had too much to eat and drink. Potassium levels drawn indicated a level of 6.7 mg/dl. She was given Kayexalate to bring down the potassium. Since the medication has a foul taste, one of the staff offered her orange juice. Erica informed them that this juice was a poor choice as it was very high in potassium and would defeat the purpose of the medication. She asked for punch instead. Kayexalate is also administered rectally in some health care institutions. It can, however, cause fecal impaction, especially when sorbitol is not added. Sorbitol is given to induce diarrhea thus removing potassium rapidly. Since fecal impaction may result in bowel surgery, Kayexalate is only given orally at the UMHS.

Erica was admitted to the hospital overnight and monitored closely. On call dialysis staff was called to dialyze her on an emergency basis. She was released the following day. Erica's dialysis schedule was 3 times per week, MWF, 6-9:30 p.m. which she found very difficult. She was exhausted after each treatment, dietary compliance was difficult, and there was no time or energy left for homework and a social life.

Erica decided she wanted a transplant. Both parents volunteered to donate as the cadaver list required at least a two-year wait. Following a medical evaluation of both parents, Erica's father was found to be the best match. She was scheduled for surgery 2 months later during the summer break.

Transplant surgery was successful. Erica was hospitalized for a total of 3 days. Prior to discharge, she attended classes for transplant clients, was instructed in self-medication, and in her new diet. Laboratory findings and nutrition care plans are given in the Transplant section.

 

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Initial Assessment Findings:

Anthropometrics and Vitals

BP 140/80

Erica was seen by the renal dietitian during her first visit to the nephrologist. Physical examination by the dietitian revealed a slender, medium frame, young woman of 5'6" with a body weight of 130 lbs. (IBW = 130 lbs). Erica stated she would like to lose weight although she had not done any serious dieting while at school.

Laboratory findings at initial encounter with the nephrologist:

Urinalysis - Protein 25 mg/dl protein (<31 mg/dl per 24 hrs)

		Blood Test Results	Normal Values
	BUN	41.0 mg/dl	8-20
	Cr	4.0 mg/dl	0.6-1.0
	Na	136.0 mEq/L	136-146
	K	4.1 mEq/L	3.5-5.0
	Protein	7.2 g/dl	6.0-8.3
	Alb	3.6 g/dl	3.5-4.9
	P	7.1 mg/dl	2.5-4.9
	Ca	8.0	8.6-10.2
	Hct	28%	35.0-48.0

Medication for hypertension started.

Renal biopsy indicated Erica had systemic lupus erythematosus or SLE. She was started on corticosteriods for the SLE; blood pressure medication was continued.

Dietary Assessment Findings:

A 24-hour recall by the renal dietitian indicated the following dietary intake:

Breakfast

Usually skipped but did drink 1 glass (8 oz) 2% milk

Lunch

Reuben sandwich

	2 slices rye bread
	3 ounces corned beef
	1 slice Swiss cheese
	1/4 cup sauerkraut
	1 Tbsp French dressing

1 bag potato chips
1 medium pickle
1 large diet cola

Dinner

3 ounces hamburger
1 bun
1 med tossed salad
2 Tbsp low calorie dressing
1/8 piece of apple pie
1 glass (8 oz) 2% milk

Snack in evening

1 large diet cola
3 cups of salted popcorn

Erica stated that she liberally salts her food at all meals. Also, she usually has a luncheon meat type sandwich with chips or pizza almost every day for lunch.

Findings of 24-hr dietary analysis revealed Erica consumed approximately:

Calories	2000
Protein	90 gm
Na	5420 mg
K	2260 mg
P	1230 mg

On weekends, Erica usually has approximately six lite beers with pretzels and potato chips. Dietary analysis of these:

Calories	1070
Carbohydrates	87 gm
Protein	16 gm
Fat	22 gm
Na	1434 mg
K	810 mg
P	167 mg

Erica decided she would need to make other food and drink choices for the weekends. She chose clear uncola beverage and unsalted pretzels. Although beer is not forbidden for clients with ESRD, it is suggested that they limit their intake, especially, if fluid is restricted. In addition, they must check with their doctor or pharmacist to determine if alcohol interferes with any of their medications.

The dietary guidelines for a person with chronic renal failure, but not undergoing dialysis treatment are:

Protein	.6-.8 gm/kg/d with 65% HBV
Calories	> 35 kcal/kg/d
Na	1-3 gm/d when fluid retention is present
K	< 2800 mg/d if serum is elevated
P	8-12 mg/kg/d (1000 mg minimum amount recommended by UMHS)

All other minerals and vitamins are supplemented with medication as needed.

Based on Erica's elevated BUN, CR, phosphorus, and blood pressure, the diet recommended for Erica was:

Protein	50-60 gm
Na	3 gm
P	1000 mg phosphorus (minimum amount recommended by UMHS)

A fluid restriction was not considered necessary at this time as Erica still had good urine output. Potassium is not restricted but needs to be monitored at this time, especially when taking ACE inhibitors (for HTN). Captopril can cause potassium retention and will then require a restriction in dietary prescription.

Using Erica's food preferences, the dietitian helped Erica plan a diet within her dietary restrictions

	Na (mg)	K (mg)	PRO (gm)	P (mg)	CALORIES
BREAKFAST 1/2 c apple juice 1/2 c 2% milk 3/4 c dry cereal (corn flakes)	80 250	150 185 35	.5 4.0 2.0	15 110 35	70 80 90
LUNCH Lg tossed salad plus 2 oz meat 4 T low cal vinegar dressing 1 sl white bread or small roll 1 t margarine 1 red apple	95 500 80 55	350 20 35 10 300	16.0 2.0 1.0	230 10 35 5 30	170 45 90 45 140
DINNER 3 oz meat 1/2 c canned green beans 1/2 c mashed potatoes 1 sl white bread (or small roll) 3 t margarine 1/2 c canned peaches	75 250 15 80 165	300 100 250 35 30 150	21.0 1.0 1.0 2.0 .5	195 20 30 35 5 15	195 25 70 90 135 70
SNACK 3 c unsalted popcorn 2 t unsalted "marg" spray	160	70	4.0	70	180
TOTAL ALLOWED	1860 3000	2020 2800	55.0 50.0	840 800	1495 2068

 

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Predialysis

(visit with home-town nephrologist after discontinuing meds and diet)

Physical Findings

Weight	140 lbs
Temp	100° F
BP	180/110
Edema	3+

One week symptoms:
dyspnea
non-productive cough
pleural effusion
extremities - edematous
headaches
general malaise
poor p.o. intake

Urinalysis -Protein 35 mg/dl Normal: <31 mg/dl/24 hr

		Blood Analysis	Normal Values
	BUN	120 mg/dl	8-20 mg/dl
	Cr	8.3 mg/dl	0.6-1.0 mg/dl
	Na	130 mEq/dl	136-146 mEq/L
	K	6.2 mEq/dl	3.5-5.0 mEq/L
	Pro	5.2 g/dl	6.0-8.3 g/dl
	Alb	3.1 g/dl	3.5-4.9 g/dl
	P	8.2 mg/dl	2.5-4.9 mg/dl
	Ca	7.9 mg/dl	8.6-10.2 mg.dl

Medication was restarted. A phosphorus binder and a vitamin supplement, specifically for ESRD persons, were added to her medications.

Nutrition

Based on blood values and stage of disease, the diet was reviewed and revised to:

	Protein	50 gm
	Na	2 gm
	K	1600 mg
	P	800 mg

Continuous Ambulatory Peritoneal Dialysis (CAPD)

		Blood Analysis	Normal Values
	BUN	140 mg/dl	8-20 mg/dl
	Cr	9.4 mg/dl	0.6-1.0 mg/dl
	Na	130 mEq/L	136-146 mEq/L
	K	5.0 mEq/L	3.5-5.0 mEq/L
	Pro	5.0 mg/dl	6.0-8.3 g/dl
	Alb	3.0 mg/dl	3.5-4.9 g/dl
	P	6.1 mg/dl	2.5-4.9 mg/dl

BP 130/70 with medication

Nutrition

The dietary guidelines for peritoneal dialysis are the most liberal of the dialysis diets.

	Protein is increased 1.2-1.5 gm/kg
	Calories 25-35 kcal/kg/d
	Na 3-4 gm/d
	K unrestricted, except for very high K fruits/vegetables unless serum level is increased
	P 1000 mg UMHS
	Fluid unrestricted if weight, and blood pressure are controlled.

A secondary source of calories for a person on CAPD is glucose in the dialysate. As the concentration of glucose in the solution increases, calories also increase.

Erica's protocol required 4 exchanges per day using the following:

2 exchanges 1.5% solutions 1 1/2 L/exchange
2 exchanges 4.25% solutions 1 1/2 L/exchange

To prevent weight gain, Erica's calorie prescription would need to be decreased by 394 or 400 calories per day. Protein is lost in the dialysate, so she must not decrease her protein intake. Based on the above information Erica's diet was changed to:

	Protein	No restriction 70-90 gm/day
	Na	4 gm
	P	1000 mg
	K	Restriction minimal

The dietitian liberalized her diet by increasing the protein to 8 ounces meat per day, allowing potatoes, tomatoes, citrus fruit, and increasing the starches in her diet. Phosphorus still remains a problem so dairy and dairy products were still restricted to:

	1/2 cup milk per day
	1 oz cheese or 1/2 c yogurt/day
	Cola beverages were restricted since they are high in phosphorus.

 

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Hemodialysis

		Blood Analysis	Normal Values
	BUN	68 mg/dl	8-20 mg/dl
	Cr	4.8 mg/dl	0.6-1.0 mg/dl
	Na	136 mEq/L	136-146 mEq/L
	K	3.8 mEq/L	3.5-5.0 mEq/L
	Pro	5.9 mg/dl	6.0-8.3 g/dl
	Alb	2.0 mg/dl	3.5-4.9 g/dl
	P	5.6 mg/dl	2.5-4.9 mg/dl

The renal dietitian reviewed the results with Erica and based her diet on this information.

Dietary guidelines for a hemodialysis client are:

	Protein	1.1-1.4 gm/kg
	Calories	30-35 kcal/kg/d
	Na	2-3 gm
	K	1.5-3.0 gm (38-75 mEq)
	P	12-17 mg/kg

Erica's diet was individualized to meet her needs and food preferences. Her dietary prescription was changed to:

	Protein	no restriction, give 7 oz meat per day
	Calories	35 kcal/d
	Na	3 gm
	K	2400 mg (60 mEq)
	P	1000 mg
	Fluids	1 liter/day (output + 500 cc)

 

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Transplant

BP 130/70 with medication

		Blood Analysis (10 days post transplant)	Normal Values
	BUN	19.0 mg/dl	8-20 mg/dl
	Cr	1.0 mg/dl	0.6-1.0 mg/dl
	P	2.0 mg/dl 2	.5-4.9 mg/dl
	K	5.2 mEq/L	3.5-5.0 mEq/L
	Na	135 mEq/L	136-146 mEq/L
	Protein	5.6 g/dl	6.0-8.3 g/dl
	Alb	3.2 g/dl	3.5-4.9 g/dl

Nutrition

Transplant diet modifies several nutrients, depending on individual needs.

	Protein	1.3-2.0 gm/kg IBW
	Calories	30-35 kcal/kg IBW
	Carbohydrates	limited or restricted if weight or glucose increase
	Fat	moderate low cholesterol (hypercholesterolemia induced by cyclosporine)
	Na	2-4 gm
	K	2400-3000 mg/d if hyperkalemic
	P	may need supplementation until serum levels normalize

Erica's dietary restrictions were based on her serum blood levels and blood pressure:

	NAS	No Added Salt or 4 gm Na
	Protein	no restriction; 8 ounces of meat per day
	Fat	modified low cholesterol
	K	2000-4000 mg; modify as needed
	P	supplemented with medication if it remains low

One of Erica's early medical problems was HTN. She still had that problem following a successful transplant. Also, one of the side effects of the transplant medication, prednisone, is sodium retention. Another transplant medication, cyclosporine, causes elevated levels of sodium and potassium. Until the levels of this medication are reduced, clients need to modify their potassium intake.

Because cola beverages are high in phosphorus, Erica could drink any of these products to supplement her phosphorus intake.

One week following transplant, Erica was readmitted to the hospital with decreased urine output, elevated Cr and potassium. She was treated for organ rejection with medication. Her diet remained at 4 gm Na but a potassium restriction was added. The renal dietitian reviewed high potassium foods she would need to temporarily eliminate from her diet. High potassium foods are milk, orange juice, grapefruit juice (also interferes with cyclosporine absorption), potatoes, tomatoes, spinach, bananas, and greens.

Erica's Cr returned to 1.2 mg/dl and she was released from the hospital. She was scheduled to return to the out-patient clinic on a weekly basis. By the 4th week, Erica's blood values were:

		Blood Analysis	Normal Values
	BUN	16 mg/dl	8-20 mg/dl
	Cr	1.0 mg/dl	0.6-1.0 mg/dl
	Pro	6.5 g/dl	6.0-8.3 g/dl
	Alb	3.8 g/dl	3.5-4.9 g/dl
	Na	135 mEq/L	136-146 mEq/L
	K	4.2 mEq/L	3.5-5.0 mEq/L
	P	3.0 mg/dl	2.5-4.9 mg/dl
	Chol	179 mg/dl	140-200 mg/dl

Erica's diet was liberalized by the dietitian. She remained on the NAS, moderate low cholesterol diet, but was allowed to discontinue the potassium restriction. (Another side effect of cyclosporine is elevated cholesterol levels, thus diets are moderately restricted in cholesterol).

 

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Epilogue

In spite of Erica's many health problems, she graduated with her classmates. Being the oldest sibling in the family, Erica felt college was important and successfully attained her goal to complete and receive her baccalaureate degree. She learned how SLE affected her body and after two hospitalizations she readily took charge of her health care plan.

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