A 55 year-old male on chronic ambulatory peritoneal dialysis (CAPD) for diabetic end-stage renal disease (ESRD) was admitted for peritonitis and septic shock. According to his wife the patient had gradually become weak and lethargic over the last few weeks, and his oral food intake had deteriorated. He took no vitamin supplements. His peritoneal fluid had become cloudy in the last week.
Subcutaneous insulin, ranitidine 150 mg qd, calcitriol 0.25
g qd, calcium carbonate 675 mg tid, FeSO
325 mg tid, and ZnSO
220 mg qd.
On admission, the patient was stuporous. His height was 5' 9" (175 cm) and his weight was 156 lb (71 kg). His pulse was 100, his BP 70/40, and his temperature 95
F. He had dry, flaky, hyperpigmented skin, a dry but normally papillated tongue and dry lips, easily pluckable hair, a sacral pressure sore, mild rales in both lung bases, a normal heart examination, and a tender but soft abdomen.
Laboratory values on admission
Na 130, K 4.0, Cl 105, bicarbonate 18, BUN 25, creatinine 4.3, glucose 89, Ca 6.7, Mg 1.3, phosphorus 4.0, albumin 1.1, Hct 32.2, MCV 95, WBC 5,500.
Question 1. What kind of malnutrition does the patient have, and what is the evidence for it?
Question 2. What is the nutritional impact of CAPD?
The patient was admitted to the ICU for broad-spectrum antibiotics and hemodialysis. His mental status improved somewhat and a 2200-kcal renal/diabetic diet was prescribed, but his p.o. intake remained poor (< 500 kcal/day). He developed a GI bleed and ileus, so TPN was started on the 9
hospital day, providing 2200 kcal/day with 19% of calories from protein, 60% from carbohydrate, and 21% from fat. 20 mEq potassium and 10 mmol phosphorus were included. No laboratory measurements were made on the day TPN was started.
Question 3. What complications may result from the planned nutritional support?
Question 4. What laboratory values are most important before starting TPN?
12 hours later the patient was very short of breath. Physical exam showed tachycardia and pronounced rales. His blood pressure dropped (74/50) and he required intubation. CXR showed pulmonary edema. Lab values included Na 130, K 2.9, Cl 96, bicarb 27, BUN 13, creatinine 2.0, glucose 445, Ca 7.4, phosphorus 0.9, and albumin 1.1.
Question 5. What has occurred and how should you address the problems?