P161
IMPROVEMENT IN NUTRITIONAL STATUS OF A HAEMODIALYSIS PATIENT
WITH SEVERE ANXIETY ACHIEVED BY EFFECTIVE MULTIDISCIPLINARY
TEAM WORKING – A CASE REPORT
King, M. Department of Nutrition and Dietetics, Salford Royal NHS Foundation Trust
Malnutrition is a common problem in end stage renal disease. The prevalence of malnutrition in
haemodialysis patients is estimated between 30-75% and is associated with poor clinical
outcomes and mortality. The main causes of malnutrition in haemodialysis patients include
inadequate dialysis dose, inflammation, dietary restrictions, nutrients lost via the dialysate and
the catabolic properties of dialysis. In this case report, severe anxiety leading to anticipatory
nausea also contributed to malnutrition.
A 30 year old women was referred to the dietetic department in September 2011 after “crash
landing” with an eGFR 6. She was diagnosed with Haemolytic Uraemic Syndrome and was
commenced on haemodialysis.
Nutritional assessment included monitoring of blood biochemistry, anthropometry (base weight,
Body Mass Index, percentage weight loss, hand grip strength, mid arm circumference, tricep
skinfold thicknesses), fluid balance and energy and protein intake.
There was a decline in daily dietary intake in the first three months after starting haemodialysis.
Food fortification and oral nutritional supplements were commenced and not tolerated and the
patient did not always consent to review. Due to further decline in nutritional status, the patient
was admitted to hospital in October 2012 for enteral tube feeding. Initially, dietary intake
improved but throughout admission it was variable depending upon anxiety levels. In addition
to oral diet, nasogastric feeding was commenced but only small flow rates were tolerated and
only 22% of energy and 26% of protein requirement could be provided by NG feeding. Several
NG tubes were dislodged and re-insertion of NG tubes were delayed due to anxiety attacks. It
was not deemed appropriate for insertion of a percutaneous endoscopic gastrostomy by the
Trust’s Nutrition Support Team.
Date
Base
BMI
% weight loss MAC
HGS TSF
weight
(kg/m2)
(cm)
(kg)
(mm)
(kg)
Sept 2011
72
24.0
Baseline
February 2012
60
20.0
16.7
October 2012
50.1
16.7
30.4
21
7.9
11.6
November 2012 44
14.7
38.9
19
11.7 9.7
January 2013
46
15.4
36.1
19.5
9.9
April 2013
53
17.7
26.4
19.5
10.6 4.8
December 2013 63
21.0
12.5
In November 2012, a multidisciplinary team meeting was held, with Consultant Nephrologist,
Advanced Nurse Practitioner, Consultant Psychologist, ward manager, Dietitian, patient and
husband. A frank discussion of the current situation was discussed and a nutritional care plan
was agreed ensuring good communication between all team members.
Subsequently, the patient began to focus upon increasing dietary intake and tolerated NG
feeding, allowing for the patient to be discharged home with overnight NG feeding for a six
month period leading to an improvement to nutritional status.
An improvement in nutritional status was achieved in a patient with severe anxiety through use
of effective team working and communication.