1. End Stage Renal Disease Interstitial Nephritis
Major Case Study
Krista Blackwell
Sodexo Mid-Atlantic DI
January 28, 2014

2. Objectives Define Interstitial Nephritis
Identify etiology and pathophysiology of Interstitial Nephritis
Discuss treatment and Medical Nutrition Therapy for patients with ESRD

3. Functions of the Kidney
Elimination of waste products
BP regulation
Volume and fluid maintenance
Electrolyte balance
Acid-base balance
Ca-phos homeostasis

4. Interstitial Nephritis
Inflammation of the spaces between the kidney tubules
Acute or chronic
Etiology
Drug induced: Antibiotics, NSAIDS
Autoimmune diseases and Systemic Diseases
Kawasaki’s Disease
Sjogren syndrome
Systemic Lupus Erythematosus
Infections:
Bacteria, Viruses (HIV)
Idiopathic
Chronic: Sickle cell disease, DM, vesicoureteral reflux

5. Interstitial Nephritis
Pathophysiology
Not completely known
Depends on the original cause of the disease
Immune response
Inflammatory response
Infiltrates: lymphocytes, macrophages, eosinophils, plasma cells
Decrease in renal function
ESRD and Dialysis

6. Medical Management Acute Interstitial Nephritis
Removal of drug causing condition
Steroids
Cyclophosphamide and cyclosporine
Chronic Interstitial Nephritis ESRD: GFR <15 mL/min
Immunosuppressive therapy
Kidney transplant
Dialysis
Phosphate binders
Calcium Supplements
Epogen: Manage anemia
MVI: B complex, Vit C
Do not need: Vit A, inactive Vit D

7. MNT in ESRD Goal: Control edema and electrolyte imbalances
Sodium: 2000 mg/day
Potassium: mg/day
Phosphorus: mg/day
Protein:
g/kg/day in HD
GFR <50 without dialysis: g/kg/day
Fluid management
With HD: ~750ml + urine output

8. Nutrition in HIV and AIDS
CD4 count <200 mm3= AIDS
Change in body composition
Loss of LBM and body cell mass
Vit B12 deficiency
Wasting
Malabsorption
Increased metabolic rate: Catabolic state
Lipoatrophy
Opportunistic Infections
TB, pneumonia, oral candidiasis
Nutrition Recommendations:
HIV
Kcal: kcal/kg IBW
Protein: g/kg actual weight
AIDS
Kcal: kcal/kg actual weight
Protein: g/kg actual weight
MVI with minerals

9. Case Study: Admission JB is a 41 year-old African American male
Presented to the ED at SGAH on December 10th, with intractable nausea and vomiting
Decreased urine output
JB was admitted to SGAH for monitoring, evaluation, and treatment of renal failure

10. Medical Diagnoses Acute renal failure on chronic kidney disease Anemia
Hypocalcemia
Hyponatremia

11. Past Medical History Hypertension: Non compliant with medications
HIV diagnosed in 1996
CKD: Untreated

12. Past Medical History: Johns Hopkins
February 19, 2008: “HIV 101”
March 4, 2008: Follow-up
May 10, 2012: Scheduled kidney biopsy
June 4, 2012: Kidney biopsy, Cr 3.4
October 22, 2012: Follow up with primary care physician. BP 160/110, Cr 3.75
April 16, 2013: Noncompliant with medications. Wt: 72.4 kg
May 30, 2013: CD4 743, Cr 6.0
Nov. 6, 2013: Moore Clinic

13. Social History Adopted English speaking, Christian
Non-smoker, no history of smoking
No alcohol or drug use
Employment: JB works full-time at the housing authority doing office work
Lives alone in a single level home in Gaithersburg
Single, no children
Education level unknown, able to read and write

14. Hospital Course and Consultations
Dec. 10: Admission
Dec. 11: Infectious Disease
Dec. 12: Retroperitoneal ultrasound, chest x-ray, hemodialysis catheter placement
Dec. 11, 13, 14, 17, 20: Nutrition
Dec. 13, 14, 16, 17, 20: Case Management
Dec. 13: OT & PT
Dec. 17: Guided renal biopsy: Dx. Interstitial Nephritis
Dec. 12, 13, 16, 18, 20: HD
Dec. 20: Discharge

15. Hospital Medications

16. Medications

17. Anthropometric Data Ht: 177 cm, 69.69” Wt: BMI: 19.79
12/10: 62 kg, lb
12/17: 63.4 kg, lb
BMI: 19.79
IBW: 75.5 kg, 166 lb
%IBW: 83%
Usual Body Weight: 74.1 kg, 163 lb
% Wt change: 16.32% wt loss over 2-3 months

18. Initial Nutrition Assessment: Dec. 11th
Risk level: High
Diet: NPO for HD catheter placement
Summary: JB reported a lb wt loss over the past 2-3 months. Has not vomited in 2 days. Does not want HD. HD order in chart.

19. Laboratory Data

20. Nutrition Prescription
Mifflin-St Jeor: REE= 1529 (1.1)(1.4)= 2355 kcal
38 kcal/kg
Protein: gm ( g/kg)
Without HD g/kg
Fluid:
1860 ml ( ml + urine output)

21. Nutrition Diagnoses
Diagnoses I: Malnutrition (severe) R/T HIV and renal failure AEB >7.5% wt loss in 3 months and <75% intake for >1 month
Diagnoses II: Altered nutrition-related laboratory values R/T renal failure AEB elevated BUN, Cr, and phos.

22. Nutrition Intervention
Goals:
Pt to meet >75% of estimated needs within 3-4 days.
Pt to maintain wt throughout LOS
Recommend Nepro BID
Will monitor need for renal diet education

23. Monitoring and Evaluation
Monitor food and beverage intake
Monitor biochemical data: BUN, Creatinine, electrolytes, and triglycerides
Monitor weights

24. Nutrition Reassessment: Dec. 13th
Risk Level: High
Diet: Renal Dialysis
Summary: Pt extremely lethargic, minimal responses, vomited this morning. Pt had HD cath. placed and received HD yesterday, Dec.12th. Pt still has poor po intake. Consumed 0% of breakfast.

25. Laboratory Data: Dec. 13th

26. Nutrition Prescription
Mifflin-St Jeor: REE= 1529 (1.1)(1.4)= 2355 kcal
38 kcal/kg
Protein: g
g/kg
Fluid: 1860 mL

27. Nutrition Diagnoses
Diagnoses I: Malnutrition R/T HIV and renal failure AEB >7.5% wt loss in 3 months and <75% intake for >1 month
Diagnoses II: Altered nutrition-related laboratory values R/T renal failure AEB elevated BUN, Cr, and phos.

28. Nutrition Reassessment: Dec. 13th
Interventions:
Goals:
Pt to meet >75% of estimated needs within 3-4 days: Not met, continue goal
Pt to maintain wt throughout LOS: Progress towards goal
Rec. increasing Nepro to TID.
Monitoring and Evaluation:
Monitor food and beverage intake
Monitor biochemical data: BUN, Creatinine, electrolytes, triglycerides
Monitor weights
Will monitor need for renal diet education

29. Nutrition Education: Dec. 14th
RD: AN
Pt has been drinking Nepro, but not eating very much.
Pt dislikes hospital food
Provided renal diet education and printed materials from NCM
Provided “All Time Favorites” list and reviewed Renal diet options

30. Nutrition Reassessment: Dec. 17th
Risk Level: High
Diet: NPO for kidney biopsy
Summary: N/V improved, pt still has fair po intake because he dislikes food provided, consumed about 50% of meals yesterday
Diagnoses I: Malnutrition R/T HIV and renal failure AEB >7.5% wt loss in 3 months and <75% intake for >1 month
Diagnoses II: Altered nutrition-related laboratory values R/T renal failure AEB elevated BUN, Cr, and phos.

31. Laboratory Data

32. Nutrition Reassessment: Dec. 17th
Interventions:
Goals:
Pt to meet >75% of estimated needs within 3-4 days: Not met, progress towards goal
Pt to maintain wt throughout LOS: Progress towards goal
Pt’s renal labs WNL since starting dialysis
Recommend changing current diet to 2 gm Na restriction to increase po intake
Monitoring and Evaluation:
Monitor pt’s po intake
Monitor renal labs: BUN, Cr, K, phos, Na
Monitor triglycerides
Monitor weight trends. Requested RN to take wt on pt today since no new weights have been obtained since pt was admitted

33. Nutrition Reassessment: Dec. 20th
Risk Level: Moderate
Diet: Low Sodium: 2 gm
Summary: Nephrologist stated that he is not concerned with JB’s K levels, but that JB needs further phosphorus diet education. Pt denied N/V, able to consume regular diet and drinking Nepro. Pt to be d/c today with dialysis 3x per week
Education:
Nephrologist requested pt receive low phosphorus diet Ed.
Provided pt with verbal explanation and written material from NCM
Pt verbalized understanding of information provided. Estimated compliance: High.

34. Laboratory Data

35. Laboratory Data

36. Nutrition Diagnoses
Diagnoses I: Malnutrition R/T HIV and renal failure AEB >7.5% wt loss in 3 months and <75% intake for >1 month
Diagnoses II: Altered nutrition-related laboratory values R/T renal failure AEB elevated BUN, Cr, and phos.

37. Nutrition Reassessment: Dec. 20th
Interventions:
Goals:
Pt to meet >75% of estimated needs within 3-4 days: Met
Pt to maintain wt throughout LOS: Met
Pt’s renal labs WNL since starting dialysis: Met
Recommend continuing 2 gm Na restriction diet. Low phosphorus.
Monitoring and Evaluation:
Monitor pt’s po intake
Monitor renal labs: BUN, Cr, K, phos, Na
Monitor triglycerides
Monitor weight trends

38. Discharge Summary: Friday Dec. 20th
Discharge Diagnoses:
Chronic Kidney Disease-dialysis initiated
Anemia secondary to chronic kidney disease
Hypertension
Interstitial nephritis on kidney biopsy: f/u at Johns Hopkins Hospital
AIDS on antiretroviral medications.
Discharge medications:
Calcitriol, PhosLo, Darunavir, Intelence, Ferrous Sulfate, Lisinopril, Metoprolol, Raltegravir, and Norvir
Scheduled for HD at Middletown DaVita M,W,F

39. References
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PMID:
MedlinePlus. Interstitial Nephritis. U.S. National Library of Medicine NIH. September Web URL:
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British Dietetic Association. Renal Nutrition Group. Evidence Based Dietetic Guidelines Protein Requirements of Adults on Haemodialysis and Peritoneal Dialysis, BDA Renal Nutrition Group. June 2011.
Wright, Mark., Jones, Colin. Clinical Practice Guidelines. Nutrition in CKD. 5th ed. UK Renal Association
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40. Thank You! Questions?