Ministry Saint Josephs Hospital Clinical Case Study Presented
by: Jolene Sell, Keene State Dietetic Internship 2012-2013
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Founded more than 100 years ago The only major rural referral
medical center in Wisconsin providing health care to Wisconsin and
Upper Michigan 500+ bed tertiary care teaching institution 8
Regular Clinical Registered Dietitians, 4 DTRs
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Objectives Understand the physiology of the kidney Discuss the
pathophysiology of IgA nephropathy and Chronic Kidney Disease Stage
3 Determine medical diagnosis and treatment Case study patient
Nutrition Care Process MNT Recommendations
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Normal GFR over 90mls/min/1.73m2 Physiology of the Kidney
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Pathophysiology of IgA Nephropathy IgA Nephropathy (Bergers
disease) Most common lesion found to cause primary
glomerulonephritis throughout most developed countries. Autoimmune
renal disease arising from consequences of increased circulating
levels of IgA Initiating event is the mesangial deposition of IgA
Etiology Unknown-possibly dysregulation synthesis and metabolism of
IgA Environmental factors are a possibility Dietary antigens and
mucosal infections
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IgA Cont. Risk factors for developing this condition include:
Ethnicity: More common in Caucasians and Asians than in African
Americans Family history: Some cases IgA runs in families Diagnosed
Urine test Blood Test Kidney biopsy Complications High blood
pressure, high cholesterol, acute and chronic kidney failure,
nephrotic syndrome.
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IgA Cont. Treatment When kidneys are damaged they are not
repaired Focus is to slow the disease One complication is
hypertension ACE ARBs Lowering cholesterol may slow kidney damage
Statin therapy Omega-3s Vitamin E Corticosteroids (prednisone)
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Pathophysiology of CKD 3 Chronic Kidney Disease Slow gradual
loss of kidney function. Stage 3 CKD: There is a mild decrease in
GFR (30-59 mL/min) Microalbuminuria becomes consistent and can
range from 30-300mg/day starting out Uremia occurs as the kidneys
function decreases.
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CKD Stage 3 Cont. Etiology: Diabetes is the leading cause,
uncontrolled hypertension Complications: High blood pressure,
anemia and early bone disease. Risk Factors Proteinuria,
hypertension, dyslipidemia, anemia, oxidative stress, infections,
depression, hyperglycemia, bone disease, and obesity
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CKD Stage 3 Cont. Nutrition Status Patients are often
malnourished due to lack of energy and appetite due to uremia.
Edema occurs and can further decrease appetite Anemia occurs due to
the kidneys inability to make erythropoietin. Vitamin D and calcium
status decline
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MNT Consume adequate calories Nondialyzed patients >60 years
of age with GFR
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Case Study Patient Ms. KT Admitted July 22, 2013 with CKD stage
3, superimposed preeclampsia, gestational diabetes, intrauterine
pregnancy.
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1/23/13 Nephrology Follow-up appointment Proteinuria, elevated
serum creatitine, possible microscopic hematuria No evidence of
nephritic syndrome Renal biopsy in patients best interest Patient
has no plans of becoming pregnant No history of diabetes,
hypertension, or dyslipidemia
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4/08/13 Patient was referred to a registered dietitian with a
diagnosis of gestational diabetes Intervention Estimated nutrient
needs 1800 calories per day (25 kcal/kg pre-pregnancy ABW per day
plus 300 calories per day to meet pregnancy needs) Meal plan
Breakfast: 30gms CHO Lunch: 45 gms CHO Snack: 30 gms CHO Supper: 45
gms CHO Snack: 30 gms CHO
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5/09/13 Follow-up gestational diabetes visit with another RD It
does not seem that she has been measuring her foods, reading food
labels or complying with this meal plan. She also has not been
checking her blood sugar. At most she is checking twice per day.
Also not keeping a food log or journal. 5-day blood glucose levels.
All post-meal glucose levels are within normal limits. The two
available fasting levels are high.
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Nephrology Appointment 7/17/13 7/15/2013 Protein-Urine, 24 hr
4922 mg H Ms. KT was seen from Nephrology Blood pressure running
high 4.9 grams of protein in urine with in a 24 hour period Chronic
Renal Disease in third trimester Possibly IgA nephropathy At risk
for preeclampsia
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7/18/13 Perinatal Consultation Indication: CKD and possibly
developing superimposed preeclampsia Unable to have renal
biopsy
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Admission: 7/22 Day 1 34 year old female, pregnant 33 5/7 weeks
gestation, EDD 9/5/13 Admitted with CKD stage 3, superimposed
preeclampsia, gestational diabetes, intrauterine pregnancy. Gravid:
11 Para: 7; 6 full-term deliveries, 1 pre-term delivery, and 3
miscarriages Maternal Vital Signs: Blood Pressure: 110-155/63-89
TPAlb LDHALTASTeGFRBUNCreatUricAGluc 5.3 L2.6 L 246H4249 H46.6 L30
H1.3 H9.5 H98-123
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Past Medical History PMH includes : Iron deficiency anemia
Renal issues since 2000 Migraine headaches Anxiety, multifactorial
Obesity Seasonal allergies Food Allergies: Shrimp and crab
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Weight Trend Pre-pregnancy weight: 187 lbs., 85 kg Todays
weight 7/22/13: 197 lbs., 89.5 kg Computed pregnancy weight gain 10
lbs. Height: 61 inches Pre-gravid BMI: 35.4 Recommended weight gain
11-20lbs
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Social and Family History Social History: Works as a CNA at a
nursing home Marital Status: Single Support person: Boyfriend
Family History Denies and family members with intellectual
disabilities, recurrent pregnancy losses, chromosomal/genetic
disorders or birth defects. Denies smoking, alcohol or drug
use.
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Diet History Following Asian Diet: boiled chicken, white rice,
vegetables (broccoli, collard greens, cauliflower, zucchini)
Pre-pregnancy: One meal per day consisting of chicken/pork, white
rice, and vegetables Since pregnancy 2-3 meals per day, no
snacks
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Day 2 Chart 7/23 Nutrition Assessment Weight: 194 lbs., 88.2 Kg
(-2.9 lbs. from admission) Maternal Vital Signs Blood Pressure:
104/69-122/80 Labs TPAlbALTASTeGFRBUNCreatUricAGluc 5.0 L2.5
L353446.6 L37 H1.3 H9.1 H91-142
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Nutrition Diagnosis: Food-and Nutrition-related knowledge
deficit related diabetic carbohydrate controlled diet order as
evidenced by education patient on choosing adequate carbohydrates
choices for meals Nutrition Intervention Issued consistent
carbohydrate diet handout Issued carbohydrate snack list
Recommended calorie needs 1800-1900 Protein 71-82 grams Nutrition
Monitoring and Evaluation Monitor blood sugars and adjust
carbohydrate choices as needed, monitor pertinent labs and weight
trend
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Day 4 Chart 7/25 Weight: 84.9 Kg (-10.2 pounds from admission)
Maternal Vital Signs Blood Pressure 118/71-127/76 24 Hour
Protein-Urine Test 1265 H Creatitine Clearance 61.2 L
HgbAlbALTASTeGFRBUNCreatUricAGluc 6.8 LL_4044 H42.8 L30 H1.4
H_99-145
Nutrition Diagnosis: Inadequate oral food and beverage intake
related to weight loss as evidenced by patient consuming 900-1200
calories per day per CBORD. Nutrition Intervention Encouraged
appropriate carbohydrate snacks, increased protein and calorie
supplements Patient declined all Discussed family is able to bring
in meals Patient is taking PNV and Fe Nutrition Monitoring and
Evaluation Monitor blood sugars and adjust carbohydrate choices as
needed, monitor pertinent labs and weight trend
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Day 6 7/27 TPAlbALT /LDHASTeGFRBUNCreatUricAGLuc 5.3 L2.6 L87
H/229 H 101 H46.6 L27 H1.3 H10.5 H84-116 Monitor pertinent labs:
HELLP Syndrome H=hemolysis: breakdown of red blood cells, losing
blood in urine EL=elevated liver enzymes LP=low platelets
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Baby Girl Born 34 3/7 weeks Birth Admit to NICU: Premie Weight:
5 lbs. 4.2 ounces Length: 19 inches OFC: 31.5 centimeters
Appropriate Gestational Age (AGA)
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Discharge plans 7/30/13 Labs are stable Creatitine 1.2 ALT 112
AST 84 Will have post-partum follow up in 2 weeks Patient
encouraged to make follow up with nephrology Follow up with the RD
for Gestational DM Post Partum management.
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Questions/Co mments ???
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Thank You!
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References Escott-Stump, S. Nutrition and diagnosis-related
care. 7 th ed. Lippincott Williams & Wilkin; 2012. Barratt, J.
& Feehally, J. Pathogenesis of IgA nephropathy. In UpToDate,
2013. Hitoshi S, Kiryluk K, Novak J, et al. The pathophysiology of
IgA nephropathy. Journal of American Society of Nephrology. 2011:
1075-1803. Curtain WM, Weinstein L. A review of HELLP syndrome.
Journal of Perinatology. 1999: 138-143. Cheng YW, Caughey AB.
Gestational diabetes: diagnosis and management. Journal of
Perinatology. 2008:657-664.