Mechanical AV and tricuspid repair, HD and CVA and the
nutritional implications of
Kidney Disease and Hungry Bone
Syndrome
Kari Ikemoto
Dietetic Intern
Keene State College
Name That Kidney
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Dartmouth Hitchcock Medical Center
• 225 acre facility located in
Lebanon, NH
• 396 bed facility
• Level 1 Trauma Center
• New Hampshire’s only
academic medical institution
• Norris Cotton Cancer Center
• Children’s Hospital at
Dartmouth
• Geisel School of Medicine at
Dartmouth
• Dartmouth Hitchcock
Advanced Response Team
Registered Dietitians at DHMC
• 20 Dietitians Total
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Director of Food and Nutrition Services
Inpatient
Nutrition Support
ICN/Pediatrics
Outpatient
 Diabetes, Renal, Bariatric, Oncology
• 3 Diet Technicians
Role of the RD at DHMC
Inpatient
Outpatient
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• Referral from physician
• Patient desire
• Follow up
Respond to clinician consult
Pulled by diagnosis
Pulled by unit (ICU/PICU)
Age
Diet order
Abnormal labs
PO checks
Nutrient drug interactions
Diet progression (off TPN/TF)
Hospital day 9
A Multi-Disciplinary Approach
• Inpatient
▫ Work independently
▫ ICU-TF & TPN
▫ Specialties
 GI, CF, Pedi, ICN, Pedi CF
• Clinics
▫ Team approach
 GI, GIM, CF, ALS, Pedi CF, OB, Stone
• Outpatient
▫ Infectious diseases, Endocrinology, Bariatrics,
Hem/Onc (pedi), NCCC
PES Statements & Charting
• DHMC does not follow a specific PES statement
in their documentation
▫ Some RDs will use the diagnosis for their own
reference
• Each RD has their own template that they use
▫ Typically SOAP style format
• Malnutrition recommendations
▫ DHMC guide, based on the ADA Manual of
Clinical Dietetics
DHMC Malnutrition Guidelines
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Kwashikor
Malnutrition of Mild Degree
Marasmus
Malnutrition of Moderate Degree
Severe Protein Calorie Malnutrition
Cachexia
Other Protein-Calorie Malnutrition
Unspecified Protein-Calorie Malnutrition
Patient Information
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Ms. B
Age: 64 years old
Occupation: Administrative Assistant at college
Family
▫ Single with 1 child and 2 grandchildren.
▫ Brother and sister-in-law are biggest support system
• Former smoker, quit at age 40
▫ Smoker for 20 years
• Anthropometric measurements
▫ Height: 175.3 cm
▫ Weight: 64.41
▫ BMI: 20.97
Pertinent Medical History
Previous Surgical History
Past Medical History
• Parathyroidectomy
▫ Related to persistent
hypercalcemia.
▫ Parathyroid gland inserted
into her right brachioradialis
muscle
• Tonsillectomy
• Left flank exploration surgery
that dx PKD
• ORIF of right finger
• Left upper extremity fistula for
HD access
• Intussusception repair during
infancy
• Polycystic Kidney Disease
▫ Hemodialysis-15 years
• Hypertension
• Hyperlipidemia
• Asymptomatic gallstone
• Anemia
• Severe aortic stenosis
Medications at Home
Medication
Sig
Function
Calcium Citrate 1,000 mg Tab
Take 1.5 tablets by mouth 6 times
daily.
Calcium supplementation
calcitRIOL (ROCALTROL) 0.5 mcg
capsule
Take 0.5 mcg by mouth 2 times daily. Vitamin D
ibuprofen (ADVIL;MOTRIN) 200 mg Take 200 mg by mouth as needed.
tablet
For migraines
B Complex-Vitamin C-Folic Acid
(NEPHROCAP) 1 mg capsule
Take 1 capsule by mouth daily.
Renal friendly MVI
ranitidine (ZANTAC) 150 mg tablet
Take 150 mg by mouth nightly.
H2 histamine blocker, heartburn
Carvedilol Phosphate (COREG CR) 10 Take 1 capsule by mouth every
mg CM24
morning.
Treat HBP and heart failure
lisinopril (PRINIVIL;ZESTRIL) 5 mg Take 1 tablet by mouth every morning. HBP, ACE inhibitor
tablet
History of Presentation
Symptoms experienced
Reason for visit
• MWF hemodialysis
• Presented with several months
(likely over a year) of severe
dyspnea on exertion with
routine activities
▫ Significantly decreased
exercise tolerance
• Bilateral lower extremity
edema x 2-3 months
• Aortic stenosis with chronic
LV systolic dysfunction (LVEF
25%) and pulmonary
hypertension with tricuspid
regurgitation
• Ultimately, after much
deliberation, she decided
upon a mechanical
prosthesis, related to high
probability of
calcification of valve
The Kidney
• Main functions
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Excretory
Acid base balance
Endocrine
Fluid and electrolyte balance
• Endocrine functions
▫ 1, 25-dihydroxy-vitamin d3
(calcitriol) is produced in
kidney and enhances calcium
absorption
▫ In healthy kidneys the
activation of Vitamin D and
excretion of excess phos help
to maintain healthy bones
Polycystic Kidney Disease
• Hereditary disorder where cysts form in the
kidneys, destroying kidney tissue and function.
• Two types
▫ Autosomal recessive-early childhood
▫ Autosomal dominant- later in life
• Typically treated with hemodialysis or kidney
transplant
• Note- Cerebral aneurysms are commonly found
in adults with PCKD; often screened with MRIs
of the brain
Parathyroid Metabolism
• The response of PTH to the kidney is to increase renal
calcium resorption and calcium excretion.
• In the kidney PTH blocks resorption of phosphate in the
proximal tubule while promoting calcium resportion in
the ascending loop of Henle, distal tubule, and collecting
tubule
• Promotes absorption of calcium from the bone in 2 ways
▫ Bind to receptors on bone cells to pump Ca ions from the
bone to the extracellular fluid (rapid)
▫ Activate osteoclasts to digest formed bone, followed by
proliferation of osteoclasts
• Converts 1, 25 hydroxy Vitamin D to its active form
▫ Primary function of active form is to promote gut
absorption of calcium.
Parathyroidectomy
• Indicated for patients with hyperparathyroidism
and elevated serum calcium
• Monitor calcium levels following surgery, they
should return to normal
• In some cases however, prolonged hypocalcemia
exists in a condition known as Hungry Bone
Syndrome
Hungry Bone Syndrome
• Rapid, profound, and prolonged hypocalcemia (>4
days post op) associated with hypophosphatemia
and hypomagnesemia, exacerbated by suppressed
PTH following parathyroidectomy.
• Believed to be due to the greatly increased skeletal
usage of calcium as a result of high circulating PTH
levels on bone
• Uncommon but serious adverse effect of
parathyroidectomy.
• Older age is a risk factor
Calcium, PTH and Kidney Disease
• Patients with CKD almost always develop secondary
hyperplasia of the parathyroid glands, resulting in elevated
blood levels of parathyroid hormone (PTH).
• This abnormality is due to the hypocalcemia that develops
during the course of kidney disease and/or to a deficiency of
1,25-dihydroxycholecalciferol that may directly affect the
function of the parathyroid glands.
• With progressive loss of kidney function, a decrease in the
number of vitamin D receptors (VDR) and calcium-sensing
receptors (CaR) in the parathyroid glands occurs, rendering
them more resistant to the action of vitamin D and calcium.
•
As stated by the K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic
Kidney Disease
Admission to DHMC for
procedure
October 11th- Hospital Day 1
10/11/13- Hospital Day 1
• Operative Findings: Large
pericardial effusion. Severely
calcified trileaflet aortic valve.
• Ensured that pt was not volume overloaded, HD
prior to surgery
• Consultation by nephrology, no urgent need for
RRT (renal replacement therapy)
• Taken to the CVCC in critical but stable
condition
• Intubated and on minimal pressors
Initial Nutrition Consult- Hospital Day 4
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Consulted s/p AVR
Diet order: DHMC, Low Phos, 2 gram K, 2 gram Na
PO: Not eating well, only able to tolerate liquids prn
Nutrition Needs estimated at: 1,530-1,830kcal, 92110 g protein.
• Nutrition Plan/Recommendations
▫ Continue diet as ordered
▫ Not appropriate for education for DHMC/Renal diet at
this time
▫ Will send liquid nutrition supplement drinks offered to
optimize PO
Hospital Day 6
• During HD, stroke alert for pt was made
• Nurse performed neuro assesment
▫ Sudden onset left sided weakness
• CT showed no hemorrhage
• CT Head w/o contrast showed no evidence of
intracranial hemorrhage, or large area of cortical
hypodensity. There is an area of increased density in
a right MCA sylvian branch.
• Consented to thrombectomy for clot removal
• Neurology reports that stroke most likely
cardioembolic (mechanical heart valve) or
atheroembolic.
Hospital Day 8- Nutrition Consult for
TF
• Pert. Meds: calcitriol, calcium citrate,
epinephrine, reglan, oxycodone, phenylephrine,
RBOs, vasopression @ 0.08 unit/min
• Current weight (kg): 70.6/Adm weight (kg):
61.3/IBW (kg): 65.9/Height (cm): 175.3/BMI:
20
• Nutrition needs 1800 calories and 92 gms
protein daily.
• Current TF of Nepro running at 15 ml/hr via
OGT. Patient on pressors.
Labs
Lab Results
Value
Sodium
136
Potassium
4.2
Chloride
99
CO2
25
BUN
22*
Creatinine
2.19*
Glucose Lvl
127
Calcium
6.9*
Phos
2.7
TF Recommendations
• Pt is on pressors which may increase risk for
gastrointestinal hypoperfusion with enteral feeds.
▫ Monitor for increasing abdominal distention,
constipation, elevated gastric residuals, or ileus.
• Suggest: Nepro at goal rate of 50 ml per hour plus 2
scoops of protein powder daily.
▫ This rate is calculated to compensate for unplanned
time off feedings due to potential procedures, etc.
▫ This will provide 1850 calories, 93 grams protein, 727
ml water from formula +100 ml water from protein
powder administration, 27.2 mEq of potassium, 720
mg of phos and 46.1
Hospital Day 10- MD Note
• Very deconditioned and poor nutritional status
likely contributed to development of ulcer. Will
monitor closely, increase TFs to goal to help with
healing.
• Pt also noted to be too critically ill for HD,
possible transition to CVVH
Wound Care RN Note
• Area of deep purple discoloration to coccyx/sacrum
is consistent with a suspected deep tissue injury.
This area may continue to evolve and breakdown
further into full thickness skin loss, there is no sign
of infection at this time. This is at least a stage II
pressure ulcer as there is partial thickness skin loss.
• Poor nutritional status-PAB level is 7, she is at high
risk for additional skin breakdown due to overall
status, pressor requirement and poor nutritional
status.
Hospital Day 10- Nutrition note
• Formula was changed to Replete
▫ No need for renal formual with CVVH, increased
protein needs on CVVH
• Small pressure ulcer reported.
• Nutrition needs assessed at: 1600 calories and
124 gms protein daily while on CVVH.
• While on CVVH, suggest: Replete rate of 75 per
hour plus 6 scoops of protein powder daily.
• When off CVVH, suggest TF goal of Nepro 250
mg Vit C suggested daily for wound healing.
Hospital Day 11-SLP
• Positive outward s/s of Sensory-Motor
Oropharyngeal Dysphagia and s/s Aspiration at
this time
• Recommendations:
▫ continue NPO; continue with alternative nutrition
at this time
▫ Further w/u with Modified Barium Swallow when
pt more stable if s/s aspiration presist
▫ Further speech, language, voice evaluation
• Note- Pt pulls out NG tube
Hospital Day 12- Nutrition NPO Note
• Tolerated CVVH, negative -500.
• Pt seen for tube feeding follow-up. She self d/c'd
her feeding tube and refused to have it replaced..
Therefore, she has essentially been NPO and/or
has received less than 500 calories/day over the
past week.
• Consider TPN if appropriate.
• Labs- PAB 7 (indicative of poor nutrition status)
Hospital Day 14- Nutrition Notes
• MD recommends Replete
▫ This formula not consistent with
recommendations when pt is on HD
• Suggest: Nutren 2.0 at goal rate of 37 ml per
hour plus 6 scoops of protein powder daily
Hospital Day 17- Nutrition Note
• TF order: Replete at 50 ml/hr plus 2 scoops protein powder
daily -> currently off for GI bleed, may restart later today
• Residuals WNL is
• Average TF intake 80% calorie requirements
• Suggested to change tube feedings to Nutren 2.0 which is
more appropriate for pt given hemodialysis.
▫ Nutren 2.0 at goal rate of 37 ml per hour plus 6 scoops of protein
powder daily
• Loose stools s/p rectal tube - pt receiving liquid tylenol and
neutraphos. Liquid tylenol contains sorbitol, a poorly
absorbable sugar alcohol that can cause diarrhea and
Neutraphos can cause diarrhea.
• Pt has not been getting calcitriol
Hospital Day 17 Labs
Recent Labs
Basename
10/28/13 0600
10/27/13 0550
10/26/13 0648
NA
133*
138
131*
K
4.3
4.2
4.2
CL
95*
98
95*
CO2
25
27
24
BUN
34*
24*
31*
CREATININE
2.54*
1.88*
2.42*
GLUCOSE
--
--
--
CALCIUM
5.7*
6.2*
5.9*
MAGNESIUM
0.71
0.72
0.78
PHOS
3.0
2.5
2.6
Hospital Day 18- Nutrition SupportMD/RD
• Reason for Consult: Seeing the patient at the request of
Dr. Y to evaluate for initiation of parenteral nutrition
support of malnutrition. I have reviewed the available
records and examined the patient.
• Indicators of Severe Malnutrition:
▫ Poor nutritional intake > 7days
• Additional Justification for Nutrition Support:
▫ Nasoenteric/Gastric Feeding not tolerated or
contraindicated
▫ TPN support is necessary when parenteral feeding is
indicated for longer than two weeks, peripheral venous
access is limited, nutrients needs are large or fluid
restriction is required and the benefits of TPN support
outweigh the risks.
TPN Recommendations
• Nutritional Needs:
▫ Kcal/day:1800
▫ Protein/AA/day(gm):90
• Nutrition Prescription:
▫ Parenteral:
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Calories:1490
Dextrose (grams/day):176 (8 units of insulin)
Amino Acids (grams/day): 90
Lipids (grams/day): 55
Hospital Day 20
• Limit TPN/TF volume for HD and fluid removal
▫ Challenging fluid management related to nutrition support
and antibiotics.
• Nutrition was re-consulted for TF
▫ Consulted for tube feedings that are high in protein without
protein powder, low volume, and high in calcium.
▫ Suggest Impact Peptide 1.5 at goal rate of 55 ml per hour to
provide 1650 kcal, 103 gm protein, 846 ml water from
formula, 100% of RDI's for vitamins and minerals.
▫ If Cipro is changed to enteral per tube administration, hold
tube feedings for 2 hrs before and 2 hrs after each dose of
Cipro to avoid potential TF and drug interaction, and
consult nutrition services for adjusted TF goal rate.
Hospital Day 21
• Nutrition
▫ Tolerating thus far at 35 ml/hr with plans to
increase by 10 ml/hr every 4 hrs to goal.
▫ If pt becomes hyperkalemic- change tube feedings
to Nepro
• Nephrology
▫ Hypokalemia and hypocalcemia
▫ Calcium supplementation
Hospital Day 27
• Nutrition
▫ Tolerating TF, stayed with same formula.
▫ Discussing PEG placement RT pt displacement of DHT
• Hospital Day 31
▫ The past 3 days pt has averaged 92% of goal for enteral
feeds. Note that pt is getting PEG placed. Resume
enteral feeds when able.
▫ Propofol at current rate is providing 275 kcal/d from
lipid. Depending on how long she is on propofol, may
want to consider periodically checking her TG levels.
Hospital Day 34
• Nutrition
▫ The past 3 days pt has averaged 52% of goal volume for enteral
feeds
▫ Feeds on hold for OR for trach placement.
▫ Stool output is over a 1 L in the past 24 hrs. Recommend checking
stool for toxins. If toxin negative, consider starting loperamide 26 mg up to QID. Consider changing pt to a crushable pill form of
tylenol rather than liquid.
• Hospital Day 35
▫ PEG placed
• Hospital Day 38
▫ Residuals minimal
▫ Achieving only 40% of goal
▫ Pt on HD w/ TF via PEG w/ low PAB and inadequate TFs past 4
days.
Hospital Day 42
▫ 2 day average is at goal (100%). Continue to
monitor for tolerance.
▫ Monitor BM. Per nursing, pt had loose stools over
the last 2 days.
▫ Of note, pt has wound that is being monitored.
Protein intake ~1.7 gm/kg; for wound healing is
consistent with recommendations. TF providing
adequate vitamin C for healing. If consistent with
goals of care addition of 220 mg of zinc daily x 10
days may benefit healing.
Hospital Day 45
• In the HD population, the serum PAB is spuriously
elevated due to abnormal metabolism of the
prealbumin-retinol binding protein complex.
▫ Its generally recommended that when prealbumin is
used to monitor the nutritional status/response to a
nutritional intervention in this population, the goal of
therapy should be a prealbumin level equal to or
greater than 29 mg/dl.
▫ Presently her levels are at 12.
▫ Continue to monitor weekly but also suggest drawing
CRP level on the same day as PAB level to see what
degree an APR is playing in depressing the PAB.
Hospital Day 47
• Residuals minimal
• Average daily TF intake (past 4 days):965 ml, daily
goal is 1100 ml - achieving 88%
• Asked to re-eval TF for 2 gr protein/kg dry wt.
▫ As pt is not achieing 100% of TFs on most days,
suggest add 3 scoops protein powder to provide 121 gr
protein daily.
▫ Suggest 220 mg zinc sulfate daily for wound healing
• Hospital Day 53
▫ 99% of TF goal
▫ Wound healing- Addition of 200 mg zinc sulfate for
wound healing
Hospital Day 57
• Ms. B’s K was greater than 5.0 four out of the
last five days. Suggest changing enteral
formulation to provide less K.
• Nutren 2.0 at 36 ml/hr plus 10 scoops protein
powder daily.
▫ TF will provide, at goal, 35 mEq of K daily rather
than 53 mEq daily with the impact peptide 1.5
Hospital Day 59-Wound Care Nurse
• Diet/Nutrition Prescription: NPO; tube feeding
▫ Diet/Feeding Assistance: total feed
▫ Diet/Feeding Tolerance: good
▫ Intake (%): 100%
• Fluids: adequate
▫ Fluids Requirement: TF/IVF
• Nutrition Risk Screen (every 4 days/sig change)
▫ Consult Dietitian if Indicator Present: tube feeding or parenteral
nutrition
• Nutrition Interventions: tube feeding ordered
• Metabolic/Electrolyte Imbalance Management: electrolyte
adjustment
• Promote Oral Intake (dysphagia diet restrictions)
▫ NPO pending swallowing screening/evaluation
• Promote Oral Nutrition
• Swallowing Techniques: Dysphagia: oral mucosa moistened
Hospital Days 60/64
• Day 60
▫ TF at goal, residuals WNL
• Day 64
▫ The past 3 days pt has averaged 100%+ of goal
volumes for enteral feeds. Getting all protein
powder.
▫ Recommend a nephrocap daily for wound healing.
▫ Recommend D/C zinc supplementation tomorrow
as over supplementation of zinc can induce a
copper deficiency and this is also needed for
adequate wound healing.
Hospital Day 65- DISCHARGED
Ms. B was discharged to a Acute
Long Term Care facility in
Massachusetts.
Medications
epoetin alfa
Anemia, given during dialysis
calcijex
Treats low blood calcium
lactobacillus
probiotic
potassium & sodium phosphates (Neutraphos)hypophosphatemia
acetaminophen (liquid)
Pain reliever
piperacillin-tazobactam
Abx
calcitRIOL
Vitamin D
esomeprazole
Heart burn
aspirin
Pain reliever
senna-docusate
Bowel med
Weight History
Date
Wt
Date
Wt
10/1/13
61.3 kg
11/11/13
89.9 kg
10/11/13 (admit)
59.8 kg
11/14/13
90.1 kg
10/14/14
65.4 kg
11/17/13
92.5 kg
10/21/13
73.5 kg
11/21/13
86.2 kg
10/25/13
75.7 kg
11/22/13
84.3 kg
10/28/13
77.4 kg
11/27/13
83.6 kg
10/31/13
78 kg
12/2/13
78.5 kg
11/2/13
79.6 kg
12/4/13
94.3 kg
11/7/13
90.6
12/6/13
84.1 kg
Diagnosis
• Inadequate enteral nutrition infusion related to
altered absorption or metabolism of nutrients as
evidenced by serum calcium consistently less
than 9.2.
• Swallowing difficulty related to motor causes
evidenced by SLP pathology assessment and
subsequent motor paralysis as a result of CVA.
• Impaired nutrient utilization related to impaired
renal function as evidenced by renal failure and
PTH dysfunction.
MNT Recommendations
• Nutrition Management in the Hemodialysis
Patient
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Protein: 1.2 g/kg protein of HBV
Energy: >60 yrs old 30-35 kcal/kg bodyweight
2-4 g sodium per day
1-1.5 L fluid
MNT Recommendations
• Enteral Nutrition in Kidney Disease
▫ Changes in pt condition and effectiveness of
dialysis may require adjusting electrolyte intake
during tx.
▫ Electrolyte contents vary amongst formulas
▫ Renal formulas available that are lower in
electrolytes
▫ Excessive restriction of electrolytes in pt w/risk
factors can result in hypophosphatemia,
hypokalemia, and hypomagnesemia (refeeding
syndrome)
MNT Recommendations
• Hypocalcemia and kidney disease
 In the case of Ms. B her hypocalcemia was related to
her parathyroidectomy to control hypercalcemia
related to higher calcium to control PTH.
 Repletion with IV calcium
▫ Dosage of up to 12 g Ca per day
 If can tolerate PO, calcium between meals for best
absorption
 Calcitriol given to stimulate calcium and phosphorus
absorption
 Monitor phosphorus, may need to replete
Interventions
• Optimize nutrition for wound healing
▫ Wound healing vitamins, increased protein needs
▫ Improvement in wound
• Enteral nutrition
▫ Ensure that pt needs are met. Pt is at significant
nutrition risk RT oral dysphagia. Ensure tolerance to
feeds with limited residuals
• Calcium/Lytes
▫ Monitor hypocalcemia and replete with IV caclium
▫ Phosphorus repletion if levels have decreased
▫ Monitor potassium-change enteral formula
Evaluation/Assessment
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Wounds
Enteral nutrition
Care
Multidisciplinary team
Questions?
Thank you.
Visit
http://www.kidney.org/professionals/KDOQI/g
uidelines_commentaries.cfm for the most recent
kidney care guidelines.
References
• Byham-Gray, L, Wiesen, K. A Clinical Guide to Nutrition Care in Kidney Disease. United
States of America: Library of Congress Cataloging-in-Publication. 2004
• Essig Jr, MD, G. Medscape. Parathyroid Physiology. Published 2011.
http://emedicine.medscape.com/article/874690-overview#aw2aab6b7 Accessed 12/18/13.
• National Kidney Foundation. KDOQI Guidelines for CKD Care. Published 2007.
http://www.kidney.org/professionals/KDOQI/guidelines_commentaries.cfm. Accessed on
January 4, 2013.
• National Kidney Foundation. Evaluation of Protein Energy Nutritional Status. Published
2000. http://www.kidney.org/professionals/kdoqi/guidelines_updates/nut_a04.html
Accessed January 3, 2013
• Venes, MD, D. Taber’s Cyclopedic Medical Dictionary. United States of America: Library
of Congress Cataloging in Publication Data. 2005.
• Witteveen, JE, Thiel, S van, Romijn, JA, Hamdy, NAT. Hungry bone syndrome: still a
challenge in the post-operative management of hyperparathyroidism: a systematic review
of literature. European Journal of Endocrinology. 2013. 168: R45-R53.