Question: CASE STUDY - Chronic Kidney Disease: A 58-year-old male was admitted to the hospital because of "chest tightness, and presence of blood in the urine for more than 10 days."

28 Nov 2023,1:16 AM

 

CASE STUDY - Chronic Kidney Disease

A 58-year-old male was admitted to the hospital because of "chest tightness, and presence of blood in the urine for more than 10 days." The patient had intermittent episodes of chest tightness and breathlessness without obvious triggers, which were aggravated after activity, accompanied by fatigue, palpitation, minor and bloody urination.

 

The patient was diagnosed with type 2 diabetes 10 years ago, had a history of hypertension for more than 10 years, coronary heart disease for 2 years, and chronic renal failure for 2 years. His father had also suffered from kidney disease. No allergies. He reports losing about 15 lbs over the past few months and now weighs 166 (UBW: 181); Height 67 inches. The patient walks for 30 minutes every day after dinner. The patient is Asian, graduated with a bachelor's degree, currently works in the finance department of a company, and has a medium income.

 

Medical History:

• Hypertension: Pt had a history of hypertension for over 10 years, which had been managed with antihypertensive medications.
• Coronary heart disease: for 2 years
• Chronic renal failure: for 2 years
• Type 2 Diabetes: He was diagnosed with type 2 diabetes 10 years ago and had been on oral medications to control his blood sugar.
• Family History: His father had also suffered from kidney disease.

 

Diagnosis: Pt was diagnosed with Chronic Kidney Disease (CKD) Stage 3 due to diabetic nephropathy. He was also diagnosed with hyperkalemia, metabolic acidosis, hemorrhoids, coronary heart disease, heart failure, and hypertension.

 

 

Medications:

• Metformin (Glucophage) for blood sugar control (800 mg, twice a day)
• Antihypertensive medications: Furosemid (40 mg, intravenously)
• Aspirin (81 mg, daily)
• 10% calcium gluconate (10 ml, IV)
• 5% sodium bicarbonate (100 ml, IV)

 

 

Lab Data:

White blood cells: 7.04×10^9/L (normal value: 4.5 to 11.0 × 10^9/L)

Hemoglobin: 71 g/L (normal value: 138 to 172 g/L)

Hematocrit: 38%  (normal value for men: 41% to 50%)

Platelets: 114×109/L (normal range: 150,000 to 450,000 platelets per microliter of blood)

Serum potassium: 7.38 mmol/L (normal value: 3.5 to 5.5 mEq/L)

Serum creatinine: 489.02 μmol/L (normal value: 61.9 to 114.9 µmol/L for men)

Blood calcium: 8.7 mg/dL (normal value: 8.5 to 10.5 mg/dL)

Serum phosphorus: 2.67 mmol/L (normal value: 3.4 to 4.5 mg/dl (1.12 to 1.45 mmol/L))

Carbon dioxide binding capacity: 7.0 mmol/L (normal value: 29 mmol/L).

Oxygen partial pressure: 182 mmHg (normal value:75 to 100 mm Hg))

Carbon dioxide partial pressure: 22.9 mmHg (normal range: between 35 to 45 mmHg, or 4.7 to 6.0 kPa.

Standard bicarbonate: 12.2 mmol/L (normal 22 to 32 mmol/L)

Actual alkali remaining: 11.6mmol/L

Lactic acid concentration: 1.9 mmol/L (normal 4.8 - 25.7 mg/dL)

B-type natriuretic peptide: 109.3 μg/L (normally less than 100 pg/mL)

Myoglobin: 1033.3 μg/L (normal 5 to 70 mcg/L)

High-sensitivity troponin: 0.025 μg/L (normal below 14ng/L)

GFR (glomerular filtration rate): 58 (normal value:>60) → CKD stage 3

C-reactive Protein: 1.6mg/dL (normal 0.3 to 1.0 mg/dL)

FBG: 127 mg/dl

HbA1c: 6.1% (normal below 5.7%)

 

 

Physical Examination:

Body temperature 36.4°C

Heart rate 84 beats/min

Regular breathing, 14 breaths/min

Blood pressure 182/62 mmHg

Swelling in his legs and feet → edema

Urinary color Doppler showed parenchymal damage in both kidneys, multiple cysts in both kidneys and prostatic hyperplasia with calcification.

 

 

Medical Treatment:

10% calcium gluconate 10 ml was injected slowly intravenously; furosemide 40 mg was injected intravenously; 100 ml 5% sodium bicarbonate was infused intravenously to correct acid substitution.

 

 

Dietary Recall:

Breakfast

1/2 cup acerola juice

2 medium slices Italian bread

2 T butter

1/2 cup brewed coffee

1/4 cup whole milk

Lunch

1/2 cup stewed rice

2 ounces baked pork tenderloin

1/3 cup green leaf lettuce

1 cup diet cola

Afternoon Snack:

1/2 cup brewed coffee

1/4 cup whole milk

Dinner

2 ounces sautéed beef cube steak with onions

1/2 cup brown rice

1 cup orange juice

Before Bedtime:

1 cup green tea

 

ADIME

 

Assessment

 

Pt is a 58 YO male.  He was admitted to the hospital because of chest tightness and presence of blood in the

urine for more than 10 days. Diagnosed with CKD Stage 3 due to diabetic nephropathy, hyperkalemia,

metabolic acidosis, hemorrhoids, coronary heart disease, heart failure, and hypertension.

 

Anthropometrics:

Ht: 5’7’’ (67 inches)

Current wt: 166 lbs (74.7 kg)

BMI: 26.0 (overweight)

% wt loss: 8.3 % (within 6 months)

UBW: 181 lbs

IBW: 148 lbs (66.6 kg)

% IBW: 112.2 %

 

Lab values:

White blood cells: 7.04×10^9/L (normal value: 4.5 to 11.0 × 10^9/L)

Hemoglobin: 71 g/L (normal value: 138 to 172 g/L)

Hematocrit: 38% (normal value for men: 41% to 50%)

GFR (glomerular filtration rate): 58 (normal value:>60)

HbA1c: 6.1% (normal below 5.7%)

Serum potassium: 7.38 mmol/L (normal value: 3.5 to 5.5 mEq/L)

Serum creatinine: 489.02 μmol/L (normal value: 61.9 to 114.9 µmol/L for males)

C-reactive Protein: 1.6mg/dL (normal 0.3 to 1.0 mg/dL)

FBG: 127 mg/dl (normal less than 100 mg/dL)

B-type natriuretic peptide: 109.3 μg/L (normally less than 100 pg/mL)

BUN: 3.7 mg/dl (normal value: 5-20 mg/dL)

 

PMH:

Type 2 Diabetes mellitus (for over 10 years)

Hypertension (for over 10 years)

Coronary artery disease

Heart failure

Edema

 

FH:

His father had also suffered from kidney disease.

 

Physical Examination:

Body temperature 36.4°C

Heart rate 84 beats/min

Regular breathing, 14 breaths/min

Blood pressure 182/62 mmHg

Swelling in his legs and feet → edema

Urinary color Doppler showed parenchymal damage in both kidneys, multiple cysts in both kidneys and prostatic hyperplasia with calcification.

 

Medications:

Metformin (Glucophage) for blood sugar control (800 mg, twice a day)

Antihypertensive medications: Furosemide (40 mg, intravenously)

Aspirin (81 mg daily)

10% calcium gluconate (10 ml, IV)

5% sodium bicarbonate (100 ml, IV)

 

Diet:

No allergies.

 

24hr Dietary Recall:

Breakfast

1/2 cup acerola juice

2 medium slices of Italian bread

2 T butter

1/2 cup brewed coffee

1/4 cup whole milk

Lunch

1/2 cup stewed rice

2 ounces baked pork tenderloin

1/3 cup green leaf lettuce

1 cup diet cola

Afternoon Snack:

1/2 cup brewed coffee

1/4 cup whole milk

Dinner

2 ounces sautéed beef cube steak with onions

1/2 cup brown rice

1 cup orange juice

Before Bedtime:

1 cup green tea

 

Estimated needs:

Energy: 1,998-2,331 kcal/d (30-35 kcal/kg IBW)

Protein:  40.0-66.6 g/d (0.6-1.0 g/kg IBW)

Fluids: 2,241 mL/d (30 mL/kg bw)

 

Diagnosis

 

1. Nutrition-related knowledge deficit related to lack of prior education on a renal diet (low sodium, low

potassium food) as evidenced by diet history indicating frequent consumption of high sodium and

high potassium foods (such as baked pork tenderloin and sautéed beef cube steak).

 

2. Inadequate oral intake related to recent unintentional weight loss as evidenced by a decrease in

body weight of 15 lbs over 6 months.

 

 

 

Intervention

 

1. Modify composition of meals/snacks: Pt will follow an individualized meal plan considering both CKD and diabetes management with emphasis on meeting estimated energy, protein, and fluid needs, CHO counting, and renal-friendly foods (2-3 g sodium per day, 700 mg phosphorus, potassium and fluid controlled).
2. Content-related nutrition education: Pt will receive education on diabetes and hypertension management, as well as on the importance of following a renal diet (sodium and potassium restriction).

 

 

Monitor/Evaluation

 

Schedule a follow-up appointment after 4 weeks. Monitor serum creatinine, GFR, BUN, blood glucose, and blood pressure at the next appointment. The patient will conduct a dietary recall to track CHO and protein intake, as well as sodium and potassium consumption.

 

 

Sample meal plan (3 days)

 

Calories (kcal) 2000.00

Protein (g) 65.00

Phosphorus (mg) 700.00

 

Day 1:

Breakfast:

2 large eggs, scrambled

1 T olive oil

1/2 cup lettuce

1/2 cup brown mushroom, cooked

2 medium slices of sourdough bread

1 medium apple

1 cup of herbal tea

 

Lunch:

2 oz chicken breast, grilled, skinless

1 T olive oil

½ cup sweet potatoes, cooked

½ cup steamed carrots

1 cup black coffee

½ cup oat milk

 

Snack 1:

1 rice cake

1 T honey

1 cup pineapple smoothie

1 T chia seeds, ground

 

Dinner:

2 oz salmon, baked

1 cup white rice, cooked

1 T olive oil

½ cup broccoli, boiled, chopped

½ cup blackberries, fresh

1 cup peppermint tea

 

Snack 2:

1 wheat tortilla (8’’ diameter)

1 cup baby carrots

2 tbsp hummus

 

Day 2:

Breakfast:

½ cup cream of wheat

1 small apple

1 tsp cinnamon

1 cup coffee

1 stevia packet

½ cup oat milk

 

Lunch:

2 oz lentils, drained, cooked

1 roll (plain, small, 1 oz)

1 cup spaghetti, cooked

2 T olive oil

1 T margarine

1 tsp minced garlic

1 handful of fresh herbs

 

Snack 1:

2 medium slices of wheat bread

1 T honey

1 cup apple juice

 

Dinner:

2 oz sweet and sour chicken

1 cup stirred vegetables, frozen

1 cup white rice, cooked

½ cup strawberries

 

Snack 2:

3 cups unsalted popcorn

 

Day 3:

Breakfast:

1 bagel, large

1 small apple

2 oz chicken breast, baked, skinless

1 T margarine

1 cup ginger tea, hot

 

Lunch:

2 oz salmon, baked

1 T olive oil

½ cup bell peppers, sautéed

½ cup sweet potatoes, cooked

¼ cup cucumber, diced

¼ cup cauliflower steamed 

2 tsp balsamic vinegar dressing

1 cup strawberry smoothie

 

Snack 1:

1 pita pocket (6 inches across)

2 oz grapes, red, small

1 cup black coffee

 

Dinner:

1 cup white rice, cooked

1/2 cup peas, green

1/2 cup lettuce, fresh

1/4 cup red bell pepper, fresh

1/4 cup onion, white, fresh

2 oz chicken breast, skinless, cooked

1 T olive oil

2 T salad dressing (regular)

1 cup apple juice

 

Snack 2:

1/2 cup pudding

1 cup green tea