Case Study

Katie Haney
Dietetic Intern
Ball State University
Outline
Objectives
Introduction to the Problem
Introduction of the Subject
Patient History
Nutrition Diagnosis
Interventions
Proposed Outcomes to Monitor and Evaluate
Conclusion
 Objectives
1.) Identify the problem:
Identify and understand the potential nutritional ramifications for patients on CRRT/CVVH

2.) Develop a solution:

Analyze the development of individualized nutritional intervention for patients on CRRT/CVVH.

3.) Implement the solution:

Review up-to-date research on best practice/nutritional needs and interventions for patients on
CRRT/CVVH.

4.) Assess the impact:

Determine if the provided plan was effective in its goal for this patient and establish future
implementations for later cases.

***(LISTED IN RED THROUGHOUT THE SLIDES!)

 Introduction of the Problem
Acute Kidney Injury:
Three categories/causes:
Prerenal: Inadequate renal perfusion
Intrarenal: Diseases within the renal parenchyma
Postrental: Obstruction
Etiology:
Intrinsic (diseases within the renal parenchyma)
Toxic drug exposure
Allergic reaction to drugs
Progressive glomerulonephritis
Ischemic acute tubular necrosis
Pathophysiology:
Tissue destruction
Acidosis
Uremia
Hyperkalemia
(5,8)
 Introduction to the Problem
Acute Kidney Injury
Treatment:
Mild:
Drug withdraw
Severe
Dialysis
TPN
Electrolyte replacement
At Risk Populations:
Age
DM
Heart failure
Liver Failure
CKD
Hypotension
Sepsis (4)
 Continuous Veno-Venous
Hemofiltration (CVVH)
Defined as: A method of acute
renal failure management in
which an ultrafiltration
membrane, powered by the
patients own blood pressure or
a pump, produces an ultra
filtrate that can then be
removed and replaced by
parenteral nutrition fluids. (5)
VV-Veno-venous/vein to vein
 Nutritional Complications
Potential nutritional ramifications for patients w/AKI
Alters metabolism of macro/micronutrients
Reduced clearance of K+, Mg, and Ph
Hyperglycemia/hyperinsulinemia
^TG panel
~50% reduction in lipid clearance d/t altered lipolysis. (8)
Protein breakdown and catabolism
increase in protein breakdown because of compromised
transportation of amino acids across the cell membrane--
-AA can be cond essential in AKI d/t decrease in kidney
synthesis. (glutamine) (8)
Selenium, zinc, vitamin C and vitamin E deficiencies
Oxidative stress (8)
 Nutritional Complications
Potential nutritional ramifications for using CRRT/CVVH:
Weisen et al: Water soluble substances of low molecular weight
weakly bound to proteins will easily be filtered in proportion to
their plasma concentrations during convective as wall as diffusive
CRRT (pp 220)
Glucose:
dependent on dialysate composition and patients blood
glucose, can increase or decrease BG
Lipids:
Little loss during CRRT
Peptides and AA:
increases protein catabolism Producing O2 free radicals
Loss of electrolytes , trace elements, water soluble vitamins
Loss across membrane d/t molecular weight
(8)
(8)
 Nutritional Complications
Up-to-date research on best practice/nutritional needs and
interventions for patients on CRRT/CVVH:
Individualized nutritional intervention for patients on CRRT/CVVH:

ESPEN( 2006) Weisen et al (2011) ASPEN (2016)

(3) (8)
Calories 20-30kcal/kg BW/d 25-35kcal/kg/d 25-30kcal/kg/d
Protein <1.7g/kg BW/d 1.5-1.8g/kg/d <2.5g/kg BW/d
Introduction of the Subject
Patient: PD
Transferred from DuPont Hospital
Demographics:
Age 63
Female
White
Admitting Diagnosis:
Septic Shock
Abdominal abscess w/drain
AKI
ARF
Pleural effusions
Patient History
Medical History:
Seizure disorder
COPD
Pneumonia
Congestive Heart Disease
Coronary Artery Disease
Hypertension
Myocardial Infraction
Bowel resection
Gastroesophageal Reflux Disease
Irritable Bowel Syndrome
Arthritis
Type 2 Diabetes
Hyperlipidemia
Anemia
Anxiety
Depression
Patient History cont.
Surgical History:
Cholecystectomy
Bilateral arm surgeries
Spleenectomy
Right Heart Cath
Left wrist surgeries
Colostomy s/p reversal 3/2017
OR L&D abscess 4/2017
Right leg surgery
Right lymph nodes X2 removed
Family History:
Cancer: Brother
Social History:
Quit smoking 20 years ago
Lives in a trailer by herself
Does her own grocery shopping
 Anthropometrics
Height: 62
Weight: 182#
IBW: 110#
%IBW: 165%
BMI: 33.3: Obesity Grade 2
Date Weight (lbs) Edema
Prior to admit 147 -
4/12 182 No edema noted
4/14 177 Generalized 3+ pitting
4/18 195 Generalized 3+ pitting
BUE, BLE 3+4+ pitting
4/21 169 Generalized 2+ pitting,
BUE 3+4+ pitting, bilat
ankle and feet 1+ pitting
4/24 147 Generalized 1+2+,BLE
1+2+ pitting.
 Laboratory Values
LAB 4/12 4/14 4/18 4/19 4/21 4/24
Glucose 89-121 198 121-155 130 119 95-142

Albumin 1.3 (L) 1.1 (L) 1.2 (L) 1.8 (L) 1.8 (L) 2.1 (L)

BNP 566.7 (H) 553.9 (H) 553.9 (H)

BUN 25 (H) 52 (H) 65 (H) 90 (H) 109 (H)

Creatinine 2.2 (H) 2.3 (H) 2.4 (H) 2.6 (H) 2.1 (H)

GFR 21 (L) 25 (L) 23 (L) 20 (L) 19 (L) 24

Sodium 147 (H) 140 139 137 139 136

Chloride 118 (H) 111 (H) 100 99 95 (H) 93 (L)

Phosphorous 1.4 (L) 1.5 (L) 3 2.8 4.0 5.8 (H)

Magnesium 2.1 1.8 1.8 2.2

Potassium 3.2 (L) 3.4 (L) 4.0 4.1 5.4 (H)

Hemoglobin 9.1 (L) 10.0 (L) 10.5 (L) 8.4 (l0 8.6 (L) 7.8 (L)

Hematocrit 27.5 (L) 28.6 (L) 31.4 (L) 23.8 (L) 25 (L) 22.6 (L)

NRBC 7.4 (H) 0.8 (H) 0.6 (H) 0.0

HgbA1c N/A

WBC 17.6 (H) 19.3 (H) 18.5 (H) 10.9

 Medications
Medication Purpose
Antibiotics Treat infection/sepsis
Humulin R Patient history significant for Type 2 DM
Protonix Decreases stomach acid
Precedex Sedative
Fentanyl Pain Management
Kphos rider For renal function
Propofol (140kcal 4/17-4/19) Sedative
Proventil Bronchodilator
Lasix Drip (IVF) Diuretic
Norepinephrine infusion (IVF) Blood pressure support
Diprivan (IVF) Anesthetic
Nutritional Needs:
Individualized nutritional intervention for this patient on
CRRT/CVVH:
Calories:
25kcal/kg
1895kcal
Protein:
While on CVVH (4/12-4/14)
2.5g/kg IBW (50kg)
125g Pro
Not on CVVH (4/15-present)
1.5-2g/kg IBW (50kg)
75-100g Pro
Fluids:
Per MD
 Order of Events
October 2016:
Admitted to DuPont Hospital with a perforated diverticulum when a
segmental colectomy when colostomy was preformed.
March 2017:
Arrived to DH for an elective reversal of the colostomy, where she had an
elongated stay due to elevated troponin, hypoxemia, and COPD
exacerbation.
April 3rd:
Admits to DH anastomosis leak, pelvic perianastamotic abscess along with
nausea, abdominal bloating, orange stools and inability to urinate
Exploratory laparotomy and drain was completed, inevitability leading to
septic shock
April 11th:
Arrives via ambulance to Lutheran Hospital, vented and sedated
DX: Septic shock, respiratory failure, multiple system organ failure, fever,
anemia, oliguria AKI.
 Order of Event Continued
April 12th:
A preliminary round of CVVH started on April 12th, clotted off,
restarted, lasting until the 14th
April 14th:
TPN providing 1900kcal and 90grams Pro
Added Ca, Mg, KPh, Adult trace minerals, thiamin
Propofol @5.3ml/hr providing 140 kcal (d/c 4/18)
April 15th /16th
PD was finally without sepsis
16th: Extubated and was likely to advance to a liquid diet, still diuresing
due to fluid overload and third spacing, however her AKI was getting
worse.
April 17th:
Reintubated and sedated with Versed.
April 19th:
Started EN trickle feeds
Vital AF 1.2 @ 20ml/hr providing 576kcal, 36g Pro, 389mL free water
Order of Events Continued
April 20th
Began weaning TPN/ increasing EN
TPN providing 730kcal, 20g Pro
Vital AF 1.2 @40ml/hr providing 1152kcal, 72grams protein, and 779 ml free water
April 21st/22nd
Continue weaning TPN advancing EN
(Early morning/after TPN bag was finished):
Continuous EN via NG tube
Vital AF 1.2 @ 65ml/hr providing 1872kcal, 117g Pro, 1265ml free water.
5ml-10 ml residuals on 4/22
April 22nd:
chest tube has been removed and she was extubated w/NC.
April 24th:
Began Renal Diet Order
Typically eating 50-74%
Of intake, not nutrient dense/little PRO
Glucerna ordered TID w/meals
Plans for PT/OT
Transfer out of ICU
SW/CM following for..DISCHARGE!!!
Nutrition Diagnosis and PES
Statement
Increased nutrient needs related to physiological problems
impairing nutrient utilization as evidenced by NPO diet, TPN
orders, and use of CVVH.

Inadequate oral intake related to decreased appetite as

evidenced by estimated energy intakes from diet are currently
less than recommended levels indicating need for
supplementation with meals.
 Interventions
April 14th
TPN @ 43.4 (46)ml/hr w/Ca, Mg, KPh, Adult trace minerals, thiamin
1900kcal, 90grams Pro, Propofol @5.3ml/hr providing 140 kcal (d/c 4/18)
April 21st
Weaning TPN, beginning EN
(Early morning/after TPN bag was finished):
Continuous EN via NG tube
Vital AF 1.2 @ 65ml/hr providing 1872kcal, 117g Pro, 1265ml free water.
5ml-10 ml residuals on 4/22
Wean TF and advance oral diet as tolerated to a Renal diet
April 24th
Passed swallow study, began Renal Diet order
Educate patient on overall healthful nutrition and a Renal Diet
Monitor % intake at meals recorded by the RN
April 25th
Spoke with patient about her oral intake
Ordered Glucerna TID w/meals
Proposed Outcomes to Monitor
and Evaluate
Tolerate Nutrition Support/TF
Vital 1.2 @ 65ml/hr
Adequate nutrient intake
Meeting goal rate
Advance diet as tolerated
%oral intake
Adequate nutrient intake
Need for supplements?
Lab values to be within normal limits
GFR
Blood glucose
BUN
Creatinine
Albumin
Hemoglobin/Hematocrit
Potassium, magnesium, sodium, chloride, calcium, phosphorus
Input/output
Medication changes
Weight change
Was this plan effective in its goal for this patient , and how can we
establish future implementations for later cases?
 Conclusions
Identify and understand the potential nutritional ramifications for
patients on CRRT/CVVH:
Protein catabolism
Glucose: dependent on dialysate composition and patients blood glucose, can
increase or decrease BG
Lipids: Little loss during CRRT
Loss of electrolytes , trace elements, water soluble vitamins
Analyze the development of individualized nutritional intervention for
patients on CRRT/CVVH:
Severity of AKI
Length of time (days) on CVVH
TPN/EN
When EN is prescribed to the ICU patient, the underlying disease process, preexisting
comorbidities and current complications should be taken into account
How many mL to provided 100% RDI?
Review up-to-date research on best practice/nutritional needs and
interventions for patients on CRRT/CVVH:
ASPEN (2016):
25-30kcal/kg/d calories
<2.5g/kg/d protein
Determine if the provided plan was effective in its goal for this patient
and establish future implementations for later cases?
As per last slide
Citation
1. Brown R, Compher C, American Society for Parenteral and Enteral Nutrition Board of Dierectors. A.S.P.E.N. Clinical
Guidelines: Nutrition Support in Adult Acute and Chronic Renal Failure. Journal of Parenteral and Enteral Nutrition.
2010;34(4):366-377. doi:10.1177/0148607110374577.

2. Brown JR, Rezaee ME, Marshall EJ, Matheny ME. Hospital Mortality in the United States following Acute Kidney
Injury. BioMed Research International. 2016;2016:1-6. doi:10.1155/2016/4278579.

3. Cano N, Fiaccadori E, Tesinsky P, et al. ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure. Clinical Nutrition.
2006;25(2):295-310. doi:10.1016/j.clnu.2006.01.023.

4. Gambro. Continuous Renal Replacemet Therapy. Basic Therapy Principles. April 2017.

5. Mahan LK, Escott-Stump S. Krause's Food and Nutrition Therapy. 12th ed. Philadelphia, PA: Saunders Elsevier ;
2008.

6. McClave S, Taylor B, Martindale R, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy
in the Adult Critically Ill Patient (A.S.P.E.N). Journal of Parenteral and Enteral Nutrition. 2016;40(2):159-211.
http://pen.sagepub.com/content/40/2/159.full. Accessed April 20, 2017.

7. Schneeweiss, B., Graninger, W., Ferenci, P., Eichinger, S., Grimm, G., Schneider, B., ... & Kleinberger, G. (1990).
Energy metabolism in patients with acute and chronic liver disease. Hepatology, 11(3), 387-393.

8. Wiesen P, Overmeire LV, Delanaye P, Dubois B, Preiser J-C. Nutrition Disorders During Acute Renal Failure and Renal
Replacement Therapy. Journal of Parenteral and Enteral Nutrition. 2011;35(2):217-222.
doi:10.1177/0148607110377205.
Questions and Answers
Thank you!!!