Clinical Case Study
Rachel James
A Patient "ZZ" Admission
• 63 year old male
D • Admitted on 9/23/2019 at VA Hospital
• Pt came to ED after dialysis treatment due to odorous foot
• Pt worked up for sepsis 2/2 to dry gangrene due to
I peripheral artery disease
M/E
A
Anthropometrics
Height: 70in
Usual weight: 175-178 lbs (July 2019)
Admission weight: 156 lb
BMI: 22
% weight loss/gain: 13%
Current weight: 137 lb
BMI: 19.7
A
End-Stage Renal Failure
• Obesity, smoking, cardiovascular disease, aged 60, race (African-
American, Hispanic, Native-American)
• Diabetes, hypertension, glomerularnephritis, polycystic kidney
disease
• Management for diabetes, hypertension, hyperlipidemia; Renal
replacement therapy
• Protein-energy malnutrition
A
Past Present
• Secondary hyperparathyroidism • Dry gangrene of left foot
• Chronic kidney disease stage 5 • Amputation
• Diabetes mellitus with • Sepsis
neuropathy • Malnutrition
• Congestive heart failure
• Atrial fibrillation
• Secondary hypertension
A
Clinical data
Nutrition-Focused Physical Exam (NFPE): Mild temporal scooping,
moderate loss of fat in orbital region. Clavicle and acromion visible and
palpable, triceps with moderate losses. L>R LE edema noted.
Total calorie/Protein needs based on: ABW: 71 kg
Total estimated energy needs: 2130-2485 Calories(30-35 cal/kg)
Total estimated protein needs: 85-92 Gms Protein(1.2-1.3 Gms/kg)
Total estimated Fluid needs: 1L FR per pt
A Electrolytes
8.8
8.6
8.3 8.4
7.7 7.8
5.5
4.9
4.5 4.4
4 4
3.6 3.6 3.6
3.3
3 3
2.8 2.8
2.1 2.1 2.2 2.2 2.1 2
9/23/2019 9/24/2019 9/26/2019 9/27/2019 10/3/2019 10/4/2019 10/7/2019 10/9/2019 10/11/2019 10/18/2019 10/19/2019 10/22/2019
POTASSIUM PHOSPHORUS MAGNESIUM CALCIUM ALBUMIN
CBC
A
30.6
30
28.2 28.3 27.8 28.2
25.8
12.7 13.2
10.8 11
10
9.4 8.9 9.3 8.8 8.6 8.7 8.8
8.2 8.2
9/24/2019 9/27/2019 10/3/2019 10/7/2019 10/11/2019 10/14/2019 10/22/2019
HEMOGLOBIN HEMATOCRIT WBC
A
Diet
• Home diet: diabetic hemodialysis
• 9/23: Renal
• 9/26: Cardiac, diabetic
• 9/27: Renal
• 9/30: Cardiac, diabetic
• 10/11: Clear liquid
• 10/12: Full liquid
• 10/13: Renal
Weight (lbs) Wound size (cm)
175 10/4/2019
170
10/23/2019 10/7/2019
165
160 13.5
7
6.5
155
3.5 2.5
2
0.2
0.2 2
0.1
0.2
0.2
3
150 2 2 6.5
13
6 6.2
145 10/21/2019 10/10/2019
140
135
130
7/27/2019 8/24/2019 9/23/2019 10/3/2019 10/5/2019 10/11/2019 10/18/2019 10/18/2019 10/14/2019
Historial Admission
A B C
D
Nutrition Diagnosis
• PES:
Severe protein-calorie malnutrition related to decreased appetite,
poor PO intake, increased needs as evidenced by 24 lb weight loss
(13%) in 3 months and muscle/fat loss noted in NFPE.
I
Nutritional Intervention
• Pt drinks Nepro once daily at home
• 9/24: Nepro qd, Gelatein SF qd
• 9/27: Nepro BID, Gelatein SF qd
• 10/3: Nepro qd, Gelatein SF qd, Gelatein Plus qd
• Calorie count done 10/4-10/7
I
Calorie Count
Percentage Kcal Protein Supplement Kcal Protein
10/4 - Dinner 75% 631 kcal 33g
Nepro 425 kcal 19g
10/5 - Breakfast 0% 0 kcal 0g
Gelatein SF 90 kcal 20g
10/5 – Lunch 50% 222 kcal 11.9g
10/6 – Dinner 25% 142 kcal 9.4g Gelatein Plus 150 kcal 20g
10/6 – Breakfast 25% 159 kcal 9g
10/6 – Lunch 75% 442 kcal 29.5g
10/6 – Dinner 100% 793 kcal 45g
10/7 – Breakfast 25% 162 kcal 9g
10/7 - Lunch 75% 390 kcal 14g
10/7 – Dinner 100% 729 kcal 53g
M/E
Nutrition Monitoring and
Evaluation
• K, PO4, Mg, Ca, albumin drawn every few days
• CBGs checked ACHS
• Rounded on at least twice a week by intern
Intradialytic Oral Protein Supplementation and
Nutritional and Inflammation Outcomes in
Hemodialysis: A Randomized Controlled Trial1
• Objective: Evaluate efficacy of fermented whey beverage on
nutritional, oxidative, and inflammatory markers
• Study Design: Randomized, controlled, nonblinded, parallel trial
• Subjects:
• 17-65 years old
• Hemodialysis at Shahid Faghihi HD center
• No antioxidant supplements for 2 months prior to study
• No infection or hospitalization in 1 month prior to study
Intradialytic Oral Protein Supplementation and
Nutritional and Inflammation Outcomes in
Hemodialysis: A Randomized Controlled Trial1
• Methods:
• Random assignment to 4 groups:
• 3 bottles of vitamin E-fortified fermented whey beverage per week for 8 weeks (15g protein, 600
IU vitamin E)
• 3 bottles of fermented whey beverage per week for 8 weeks (15g protein)
• 3 capsules of vitamin E per week for 8 weeks (600 IU vitamin E)
• Control received no intervention
• Results:
• SGA scores and MISs decreased significantly in intervention groups
• BMI increased in treatment groups
• Serum albumin increased significantly in both whey beverage groups
• Conclusion:
• A fortified fermented whey beverage might prove beneficial as an additional therapy
for malnourished hemodialysis patients
Intradialytic parenteral nutrition in maintenance
hemodialysis patients suffering from protein-
energy wasting. Results of a multicenter, open,
prospective, randomized trial2
• Objective: Evaluate the effect of three times weekly IDPN on
prealbumin levels
• Study Design: Prospective, multicenter, randomized, open-label,
controlled, parallel-group Phase IV clinical trial
• Subjects:
• Maintenance hemodialysis (3x a week) for more than 6 months
• >18 years old men and women
• ESRD
• SGA score B or C
• 2/3: albumin <35g/L, prealbumin <250 mg/L, reduced body cell mass
Intradialytic parenteral nutrition in maintenance
hemodialysis patients suffering from protein-
energy wasting. Results of a multicenter, open,
prospective, randomized trial2
• Methods:
• All patients: standard nutrition counseling
• Intervention: IDPN for 16 weeks
• Results:
• Prealbumin: +26.31 mg/L (I), -1.84 (C)
• Conclusion:
• IDPN is a beneficial option in HD patients with PEW
Fresenius Kabi: Global medical supply company
Hindsight
• ASPEN: Does not recommend IDPN
• ESPEN: Does recommend IDPN
References
1. Sohrabi Z, Eftekhari M, Eskandari M, Rezaianzadeh A, Sagheb M.
Intradialytic Oral Protein Supplementation and Nutritional
and Inflammation Outcomes in Hemodialysis: A
Randomized Controlled Trial. American Journal of Kidney Diseases.
2016;68(1):122-130. doi:10.1053/j.ajkd.2016.02.050
2. Marsen, T., Beer, J. and Mann, H. (2017). Intradialytic parenteral
nutrition in maintenance hemodialysis patients suffering from
protein-energy wasting. Results of a multicenter, open, prospective,
randomized trial. Clinical Nutrition, 36(1), pp.107-117.
