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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

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Day 5 Chart 7/26 Nutrition Assessment Follow-up Maternal Vital Signs Blood Pressure: 100/66-116/73 Labs HgbTP/AlbALTASTeGFRBUNCreatUricAGluc 8.5 L5.0L/2.5 L4551 H42.8 L28H1.4 H10.2 H83-142

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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.