Hello all,

I have a resident with ESRD on HD. He has an unstableable ulcer on his heel as well as an open wound on one of his toes. The toe now has necrotic tissue with bone probing. He is getting liquid prot shops twice a day. Also super cereal and double portion eggs at breakfast. He typically eats 100%. Just got his dialysis labs back and his alb is low (3.4) however it has steadily improved each month since admission in May. He meets his needs via P.O. route with the listed interventions. Has hx of refusing nepro. I’m unsure if I really need to increase his supplements. If a patient is meeting their needs via PO how can you determine if you need to further maximize PO intakes esp in a case where add’l supplementation is already in place? His BMI is normal (20) by the way. Thank you!

Hello all, I have a resident with ESRD on HD. He has an unstableable ulcer on his heel as well as an open wound on one of his toes. The toe now has necrotic tissue with bone probing. He is getting liquid prot shops twice a day. Also super cereal and double portion eggs at breakfast. He typically eats 100%. Just got his dialysis labs back and his alb is low (3.4) however it has steadily improved each month since admission in May. He meets his needs via P.O. route with the listed interventions. Has hx of refusing nepro. I’m unsure if I really need to increase his supplements. If a patient is meeting their needs via PO how can you determine if you need to further maximize PO intakes esp in a case where add’l supplementation is already in place? His BMI is normal (20) by the way. Thank you!

Good morning! I would increase the protein shots (ProStat/Liquacel) to TID, add Nephrovite (or whatever renal multi your facility uses), and give zinc sulfate 220 mg daily for 2 weeks. Zinc deficiency is common in dialysis patients and can hinder wound healing.

Good morning! I would increase the protein shots (ProStat/Liquacel) to TID, add Nephrovite (or whatever renal multi your facility uses), and give zinc sulfate 220 mg daily for 2 weeks. Zinc deficiency is common in dialysis patients and can hinder wound healing.

Great information, thank you! I ended up increasing the prostat to TID, I figured it would be good for the low alb and open wound. I wasn't aware of the zinc sulfate, but I did recommend a renal vitamin. Is there anywhere in particular that you get your renal guidelines from? Thanks again!

Great information, thank you! I ended up increasing the prostat to TID, I figured it would be good for the low alb and open wound. I wasn't aware of the zinc sulfate, but I did recommend a renal vitamin. Is there anywhere in particular that you get your renal guidelines from? Thanks again!

If the ulcers are diabetic ulcers, than additional protein is unlikely to help. High protein supplements are more beneficial for PUs. Also, if he is meeting 100% of his estimated PO needs, it is unlikely that the albumin status is nutrition related and more likely that it is 2/2 inflammation (ulcers, comorbids- especially if the pt is new to HD). As long as albumin is trending up, or at least stable, I wouldn't be too concerned. You can consider a daily renal MVI also, especially if he is on a highly restrictive HD diet or if the ulcers are pressure related.

If the ulcers are diabetic ulcers, than additional protein is unlikely to help. High protein supplements are more beneficial for PUs. Also, if he is meeting 100% of his estimated PO needs, it is unlikely that the albumin status is nutrition related and more likely that it is 2/2 inflammation (ulcers, comorbids- especially if the pt is new to HD). As long as albumin is trending up, or at least stable, I wouldn't be too concerned. You can consider a daily renal MVI also, especially if he is on a highly restrictive HD diet or if the ulcers are pressure related.
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