Educational Intervention in Chronic Kidney Disease

Presented by: Megan Lasko

NFS 562 Case Study Presentation

University of Rhode Island MS in Dietetics

February 18, 2017

Presentation Format and Abbreviations

Format

I. Introduction

II. NCP: Presentation of Clinical Case

III. Discussion

IV. Conclusion

Abbreviations

• NCP = Nutrition Care Process

• CKD = Chronic Kidney Disease

• K+ = Potassium

• GFR = Glomerular Filtration Rate

I. Introduction:

Nutritional Relevance of CKD?

• Protein

• Potassium*

• Sodium

• Phosphorus

• Fluid

*This presentation has a particular focus on dietary K+

Image Source: By OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30148548

The Nephron

II. NCP Step 1: Assessment

Patient: HJ Age: 73 Sex: M Wt: 72.7 kg (160 lb)

Ht: 1.68 m (5’6”)

Admit Dx: Near Syncopal Episode

Medical History:• CKD Stage III• T2DM• Aortic Stenosis and Atrial Fibrillation s/p aortic valve replacement (November

2016)• Other Active Problems: HTN, HLD, vitamin D deficiency

Surgical History: Aortic Valve Replacement and Ligation of Left Atrial Appendage in November 2016

• Near syncopal episode (secondary to diuretic medication changes)

• Complex Hx + Abnormal Labs=Hospital Admission

• Consults:• Cardiology• Nephrology• Nutrition Services: “Patient has been having difficulty w/ his diet given

cardiac, kidney, and diabetes diagnoses.”

II. NCP Step 1: Assessment

Present Medical Status:

II. NCP Step 1: Assessment

LABS

LAB VALUE INTERPRETATION

K+ 6.1 mmol/L - ↑(normal 3.5-5.3)

Diet?

BUN 22 mg/dL – WNL Dietary protein?

Creatinine 2.03 mg/dL – ↑ (normal: 0.6-1.3)

Acute reduction in renal blood flow?

Estimated GFR 32.4 mL/min/1.73m2

(desirable: >60)Stage III CKD1

MEDICATIONS

MEDICATION DRUG TYPE PATIENT INDICATION

Apixiban (Eliquis) Anti-coagulant A. fib

ASA Platelet aggregation inhibitor Hyperlipidemia

Atorvastatin (Lipitor) Anti-hyperlipidemic Hyperlipidemia

Bisoprolol (Zebeta) Anti-hypertensive Hypertension

Cholecalciferol (vitamin D) Supplement/Calcium regulator CKD/hx of D deficiency

Fenofibrate (Triglide) Anti-hyperlipidemic Hyperlipidemia

Furosemide (Lasix) Anti-hypertensive loop diuretic Hypertension

Amiodarone Anti-arrhythmic A. Fib

Potassium Chloride (K-dur) Electrolyte/mineral supplement K-depleting diuretics

Toresemide (Demadex) Anti-hypertensive loop diuretic Hypertension

II. NCP Step 1: Assessment

II. NCP Step 1: AssessmentSocial History

• Retired x 7 years

• Lives at home with wife

• Cardiac rehabilitation participant

Diet History

• Hx diet education w/ RD (DM & Cardiac)

• Compliant

Breakfast Lunch Dinner

Oatmeal w/ Splenda andCinnamon

Cranberry or Orange Juice

Turkey MedallionsFruit (banana, cantaloupe)

Yogurt

Chicken BreastBaked PotatoFresh veggies

Large side salad w/ tomatoes

Snacks: fruit (banana, cantaloupe), yogurt, unsalted potato chipsFluids: 6 bottles water/day with sugar-free Crystal Lite®

Estimated Daily Protein Intake: 73 g/day (estimated via SuperTracker2)

II. NCP Step 1: Assessment

Inpatient Diet History*

Diet Order: Pre-Renal (Non-Dialysis)

AND EAL Recs3

K: ~2 g K: <2.4 g

P: ~1500 mg P: 800-1000 mg

Protein: 70 g (represents 1 g/kg HJ’s body weight)

Protein: 0.6-0.8 g/kg body weight

Na: ~3 g Na: <2.4 g

*Patient reports good appetite, consuming 100% of meals. C/o small portions.

II. NCP Step 1: AssessmentEnergy Needs

AND EAL for CKD:3

23-35 kcal/kg body weight to prevent signs of malnutrition

Protein Needs

AND EAL for CKD:3

0.6-0.8 g/kg: patients w/o DM

*Doesn’t apply

0.8-0.9 g/kg: patients w/ DM nephropathy

*Doesn’t apply

K/DOQI:1

0.8 g/kg: CKD w/ DM – APPLIES!

25-30 kcal x 72.7 kg=1818-2181 kcalHJ’S Energy Needs

0.8 g protein x 72.7 kg=58 gHJ’s Protein Needs

“Food and nutrition-related knowledge deficit (NB-1.1)

related to

lack of previous renal diet education in patient with CKD stage III as evidenced by

patient reports no knowledge of the foods and nutrients that are pertinent to CKD diagnosis.”

II. NCP Step 2: Diagnosis

Tackling the Task of Renal Diet Education: What was my method?

• Review of Labs (P: not available, BUN: WNL, K: ELEVATED!)

• Diet History=Major Key!

II. NCP Step 3: Intervention

Breakfast Lunch Dinner

Oatmeal w/ Splenda andCinnamon

Cranberry or Orange Juice

Turkey MedallionsFruit (banana, cantaloupe)

Yogurt

Chicken BreastBaked PotatoFresh veggies

Large side salad w/ tomatoes

Snacks: fruit (banana, cantaloupe), yogurt, unsalted potato chipsFluids: 6 bottles water/day with sugar-free Crystal Lite®

Estimated Daily Protein Intake: 73 g/day (estimated via SuperTracker2)

Final Verdict: Focus on Potassium!

• The dietetic intern will provide nutrition education on: 1) sources of K+-rich foods, particularly those present in the patient’s current diet regimen, 2) recommendations for replacing, reducing, or removing them (E-1.5), and 3) individualized daily K+ intake recommendations with specific information on how to determine K+ intake levels (E-2.3).

• To more comprehensively meet the patient’s educational needs, the dietetic intern will refer the patient to the facility’s outpatient RD for additional MNT (RC-1.2).

II. NCP Step 3: Intervention

• Short-Term Goals: • The patient will be able to verbally state 3 K+-rich foods present in his current

diet (bananas, cantaloupe, potatoes, tomatoes) and 3 lower K+ foods to replace them (berries, pineapple, cooked carrots) by the 3-day nutrition review.

• To further meet diet education needs, the patient will schedule an appointment for MNT with the outpatient RD by the time of discharge.

• Long-term goals:• The patient will effectively reduce dietary K+ intake to <2.4 g/day (as

prescribed by the AND EAL for patients with hyperkalemia2) to facilitate normal serum K+ levels by 3 months post-discharge.

II. NCP Step 3: Intervention

• Short-term, inpatient M&E:• Monitor: Further education needs, Labs (but consider strict pre-renal diet)

• Evaluation: Verbal-teach back of education

• Long-term, outpatient M&E:• Monitor: Continued monitoring for education needs and lab values

• Evaluate: Hyperkalemia prevention, hospital readmissions

A note on prognosis in CKD:

Turin et al:4 ↓ GFR=↓ life expectancy

14.5-.16.5 year life expectancy w/ HJ’s GFR 32.4 ml/min/1.73 m2

II. NCP Step 4: Monitoring & Evaluation

III. Discussion Part 1: PathophysiologyPotassium Homeostasis: Cellular Levela

K+

K+K+

K+

K+

K+

K+K+

K+

K+

K+

K+K+

K+

K+

K+

K+

K+

K+

K+

K+

K+

K+

K+

K+

K+

K+

K+

K+K+K+

A Human Cell ↓

aInformation adapted from Kovesdy et al5

K+

Extracellular Space↓

This is a carefully-maintained intra- toextracellular K+ gradient!

K+

K+

K+

III. Discussion Part 1: Pathophysiologya

Sufficient tubular flow

Functional principal cells

URINARY EXCRETION of K+

ALDOSTERONEAdrenal Gland

Potassium in=

Potassium out

Potassium in: Dietary K+

aInformation adapted from Kovesdy et al5

Rationale for Hyperkalemia Prevention

III. Discussion Part 2: Intervention Rationale

Hughes-Austin et al6 2017(n=9,651)

Luo et al7 2016(n=55,266)*

Nakhoul et al8 2015(n=36,359)*

Serum K+ >5.0 mEq/L

↑All-case mortality*↑ CVD death*

↑ non-CVD death*

*All risks > in diuretic users

Serum K+ >6.0 mEq/L

↑ Mortality↑Major adverse

cardiovascular events↑Hospitalizations

Serum K+ >5.0 mmol/L

↑ Mortality

*Subjects w/ CKD

Rationale for Recommending Dietary K+ Restriction

III. Discussion Part 2: Intervention Rationale

AND EAL for CKD:3

<2.4 g K+ /day for comprehensive approach to ↓ hyperkalemia and related adverse cardiovascular outcomes

Kovesdy 2015:5

Goal of chronic hyperkalemia management: “To prevent the development of hyperkalemia by identifying and correcting the proximal defect(s) in potassium homeostasis. This typically starts by eliminating correctable causes, such as high potassium intake in diet or in supplements, hyperkalemia-inducing medications, or metabolic acidosis.”

Rationale for Educational Strategy and Content

III. Discussion Part 2: Intervention Rationale

Cuppari et al9 Recommendations HJ Case/Intervention

Nutritional counseling to lower dietary K+

when serum K+ approaches 5.0 mmol/LHJ’s serum K+ was 6.1 mmol/L on admission

Recs to inform about: Informed HJ about:

• Foods that contain a significant amount of K+

• Foods specific to HJ’s diet that contained significant amount of K+

(bananas, tomatoes, potatoes, etc.)

• How much of that they should consume

• Provided handout with specific K food serving sizes and respective K+

amounts. • Personalized daily K goal for HJ <2.4-3

g K+

III. Discussion Part 3: MedicationsSeveral Medications w/ K+-Alterting Effects!

• Torsemide (Demadex) + Furosemide (Lasix): • K-depleting Loop diuretics (anti-hypertensives)

• K-Dur:• Potassium chloride supplement (compensate for Loop-induced K+ loss)

• Bisoprolol (Zebeta):• Beta-blocker (anti-hypertensive): inhibits renin production – alters K+

homeostasis

• Effectiveness of Nutritional Care:• Verbal teach-back @ nutrition review: successful!

• Patient scheduled appointment w/ outpatient RD

• What would I do again? • Individualized approach to renal diet education

• What would I do differently?• More collaboration with interdisciplinary care team

• Future research: RCTs w/ high K+ vs. low K+ diet – effect on serum K+

• Next slide: Questions for my colleagues!

IV. Conclusions

Your Opinion is Wanted!• Was my diagnosis appropriate?

• Consideration of “Excessive potassium intake (NI-5.10.2.5)”

• Thoughts on the Pre-Renal (non-dialysis) hospital diet? (see slide 9)• Too restrictive for the inpatient setting?

• What does the research say?

• Critical analysis of my approach to renal diet education:• What do you do differently?

• Any tips for improvement?

IV. Conclusions

References1. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;32(2 Suppl 1): S1-266.

2. SuperTracker. United States Department of Agriculture website. https://www.supertracker.usda.gov/. Accessed February 13, 2017.

3. Chronic kidney disease (CKD) guideline (2010): CKD: Executive summary of recommendations. Academy of Nutrition and Dietetics Evidence Analysis Library website. https://www.andeal.org/topic.cfm?menu=5303&cat=3929. Accessed February 13, 2017.

4. Turin TC, Tonelli M, Manns BJ, Ravani P, Ahmed SB, Hemmelgarn BR. Chronic kidney disease and life expectancy. Nephrol Dial Transplant. 2012;27(8):3182-3186.

5. Kovesdy CP. Management of hyperkalemia: An update for the internist. Am J Med. 2015;128(12):1281-1287.

6. Hughes-Austin JM, Rifkin DE, Beben T, et al. The relation of serum potassium concentration with cardiovascular events and mortality in community-living individuals. Clin J Am Soc Nephrol. 2017;12(2):245-252.

7. Luo J, Brunelli SM, Jensen DE, Yang A. Association between serum potassium and outcomes in patients with reduced kidney function. Clin J Am Soc Nephrol. 2016;11(1):90-100.

8. Nakhoul GN, Huang H, Arrigain, et al. Serum potassium, end-stage renal disease, and mortality in chronic kidney disease. Am J Nephrol. 2015;41(6):456-463.

9. Cuppari L, Nerbass FB, Avesani CM, Kamimura MA. A practical approach to dietary interventions for nondialysis-dependent CKD patients: the experience of a reference nephrology enter in Brazil. BMC Nephrol. 2016;17(1):85.