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Renal Cell Carcinoma
Case Study
Presented by Erin McLean
Overview
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Patient information
Disease background
Nutrition care process
Conclusion
Review of key points
Personal impressions
Patient Profile
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Gender: Male
Age: 70
Ethnic background: Hispanic
Household situation: Lives with wife, has 2
grown children living elsewhere
Education: Not disclosed
Occupation: Retired heavy equipment operator
Religion: Not disclosed
Admit date, discharge date: 09/03/13, 09/14/13
Reason for Hospital Admission
• The patient was admitted to the hospital
for reparative surgery of a fractured right
hip due to a nonsyncopal fall.
• Shortly before the patient fractured his hip,
he was diagnosed with metastatic RCC.
• A x-ray exam found metastatic lesions in
the area of the fracture.
Medical/Health/Family History
• Past medical history:
– Stage IV RCC s/p 2 chemotherapy treatments
– Type 2 diabetes with neuropathy
– Hypertension
– Hyperlipidemia
– Peripheral vascular disease
– Benign prostatic hyperplasia
– Chronic kidney disease stage III
Medical/Health/Family History
• Home medications:
– Enalapril, Megace, metformin, Norco, Reglan,
iron, omeprazole, tamsulosin, fluoxetine
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Quit smoking 9 months prior to admission
No history of alcohol or illicit drug abuse
Poor appetite
Family history positive for type 2 diabetes
Medical Diagnosis
• Pathologic fracture in the right femoral
neck 2° metastatic RCC
• Pathologic fracture in the right proximal
humerus 2° metastatic RCC
• Acute-on-chronic renal failure
RCC Defined
• RCC:
– Most common form of kidney cancer
– 14th most common form of cancer in US
– Highly vascularized malignancies
– Originates in lining of proximal convoluted
tubules
– Termed metastatic RCC when its spreads
RCC Defined
Pathophysiology
• RCC consists of various tumor groups:
– Clear cell, 60-70%
– Papillary, 5-15%
– Chromophobe, 5-10%
– Oncocytic, 5-10%
– Collecting duct, <1%
Pathophysiology
• RCC affects calcium homeostasis:
Symptoms/Clinical Manifestations
• RCC often presents with symptoms
unrelated to renal cancer.
• The 3 classical RCC symptoms include:
– Abdominal pain, hematuria, palpable mass
• Metastatic RCC presents with:
– Bone pain, pulmonary issues, adenopathy, GI
bleeds
Etiology
• Risk factors for RCC:
– Tobacco smoking
– Obesity
– Hypertension
– Chemical exposure
– Analgesic drug use
– Hepatitis C infection
– End-stage renal disease
Hypertension and Risk of Renal Cell
Carcinoma Among White and Black Americans
• Purpose:
– To determine the association between high blood
pressure and RCC risk for black and white Americans
• Methods:
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358 black and 843 white case participants
519 black and 707 white control participants
HTN history and antihypertensive drugs reported
ORs and CI calculated utilizing unconditional logistic
regression
• Adjusted for smoking, BMI, family history of RCC,
demographic characteristics
(Colt et al., 2011, p. 1-4)
Hypertension and Risk of Renal Cell
Carcinoma Among White and Black Americans
• Results:
– In study population, HTN doubled risk of RCC
– Whites had lower incidence of developing
RCC (P=0.11)
– RCC risk ↑ with passing years after initial dx
of HTN with an OR of 4.1 (CI=2.3-7.4) for
blacks and an OR of 2.6 (CI=1.7-4.1) for
whites (P for trend <0.001)
(Colt et al., 2011, p. 1, p. 4-5)
Hypertension and Risk of Renal Cell
Carcinoma Among White and Black Americans
• Conclusion:
– Among blacks and whites, HTN is a risk factor
for RCC.
– Due to the increased prevalence of high blood
pressure in blacks than whites, HTN may
explain the racial disparity of RCC incidence
seen more commonly in the former rather
than the latter group.
(Colt et al., 2011, p. 1, p. 5-7)
Treatment
• Treatment depends on:
– Type of RCC
– Stage of RCC
– Tissue or organs affected
– Preexisting conditions or comorbidities
– Nutritional status
– Age
Treatment
• Surgical interventions:
– Nephron-sparing partial nephrectomy
– Radical nephrectomy
– Laparoscopic nephrectomy
Treatment
• Immunotherapy:
– Interleukin-2
– Interferon
• Tumor ablation therapy:
– Cryoablation
– Interstitial radio frequency
ablation
Treatment
• Targeted therapy:
– Sorafenib, pazopanib, sunitinib, everolimus
• Chemotherapy and radiotherapy
Treatment
• Treatment specific to patient:
– Repair of right femoral neck fracture
• Right hip long stem hemiarthroplasty with cement
– Repair of right proximal humerus fracture
• Intramedullary fixation
Treatment
• Medications:
– Amlodipine, cefazolin, enalapril, fluoxetine,
heparin, insulin, Megace, omeprazole,
pantoprazole
• Patient had received 2 chemotherapy
treatments prior to admission
Treatment
• Drug-nutrient interactions:
– Fluoxetine — if taken with tryptophan
supplements, can ↑ drug side effects
– Omeprazole — can ↓ calcium absorption by
61%; if taken with gingko and St. John’s wort,
can ↓ drug effectiveness
(Pronsky & Crowe, 2010, p. 140, p. 260).
Nutrition Intervention
• Interventions implemented to combat following
side effects associated with advanced cancer:
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Nausea/vomiting
Weight loss
Early satiety
Anorexia
Xerostomia
Altered taste
Bloating
Constipation
Dysphagia
Fruit, Vegetables, Fibre and Micronutrients
and Risk of US Renal Cell Carcinoma
• Purpose:
– To determine if an association existed
between the risk of RCC and the intake of
fruit, vegetables, fiber, and certain
micronutrients
• Methods:
– 323 case participants
– 1,827 control participants
– Questionnaires with dietary intake of
participants mailed to researchers for analysis
(Brock et al., 2011, p.1077-1078)
Fruit, Vegetables, Fibre and Micronutrients
and Risk of US Renal Cell Carcinoma
• Results:
– Intake of vegetables ↓ RCC risk
• (P for trend =0.002)
– Vegetable fiber associated with ↓ RCC risk
• (P<0.001)
– Grain and fruit fiber had no association with ↓
RCC risk
– β-cryptoxanthin ↓ RCC risk
• (P for trend =0.01)
– Lycopene nonsignificantly ↓ RCC risk
(Brock et al., 2011, p.1077, p.1079)
Fruit, Vegetables, Fibre and Micronutrients
and Risk of US Renal Cell Carcinoma
• Results cont.:
– Association between RCC risk and intake of
vegetable fiber and β-cryptoxanthin stronger in those
≥65 years of age
• (P for interaction =0.001)
– Nonsmokers with low intake of fruit fiber and
cruciferous vegetables had ↑ RCC risk
• (P for interaction =0.03)
• Conclusion:
– Further research necessary to identify additional
nutritional compounds that ↓ RCC risk
(Brock et al., 2011, p.1077, p. 1079, p.1082-1083)
Prognosis
• Prognosis dependent on cancer stage and
method of treatment
RCC Stage
5-Year Survival
Rate
Stage I
81%
Stage II
74%
Stage III
53%
Stage IV, metastatic
8%
Prognosis
• Survival predictors that indicate a ↓ life
expectancy include:
– ↑ serum calcium
– ↑ lactate dehydrogenase
– Anemia
– Stage IV RCC
– ↓ activities of daily living
– Systemic treatment <1 year after diagnosis
Preoperative Nutritional Status Is an Important
Predictor of Survival in Patients Undergoing
Surgery for Renal Cell Carcinoma
• Purpose:
– To determine whether nutritional deficiency is
a critical factor in determining survival after
surgery
• Methods:
– 369 patients who had either a partial or radial
nephrectomy
– 85 patients considered nutritionally deficient
preoperatively
(Morgan et al., 2011, p. 923-924)
Preoperative Nutritional Status Is an Important
Predictor of Survival in Patients Undergoing
Surgery for Renal Cell Carcinoma
• Methods cont.:
– Considered nutritionally deficient if:
• ≥5% body weight lost preoperatively
• BMI of <18.5 kg/m2
• Albumin <3.5 gm/dL
– Primary outcomes included overall mortality
and disease-specific mortality
(Morgan et al., 2011, p. 923-924)
Preoperative Nutritional Status Is an Important
Predictor of Survival in Patients Undergoing
Surgery for Renal Cell Carcinoma
• Results:
– 3-year overall survival was 58.5% and
disease-specific survival was 80.4% in
experimental group
– 3-year overall survival was 85.4% and
disease-specific survival was 94.7% in control
group
– (P<0.001)
(Morgan et al., 2011, p. 924-926)
Preoperative Nutritional Status Is an Important
Predictor of Survival in Patients Undergoing
Surgery for Renal Cell Carcinoma
• Conclusion:
– Addressing poor nutritional status in RCC
patients undergoing surgery is essential since
it remains a significant predictor of overall and
disease-specific mortality.
(Morgan et al., 2011, p. 923, p. 927)
Nutrition Care Process
Assessment
• Anthropometric data:
– Height: 5’11”
– Weight: 72.3 kg
– IBW: 78.2 kg ±10%
– BMI: 22.2 kg/m2, normal
Assessment
• Biochemical labs:
Renal Profile
Date
09/04
09/08
09/09
09/10
09/11
09/12
09/13
Glucose
(mg/dL)
119, High
177, High
Normal
112, High
Normal
134, High
139, High
BUN
(mg/dL)
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Creatinine
(mg/dL)
Normal
1.55, High
1.35, High
1.26, High
Normal
Normal
Normal
Potassium
(mEq/L)
Normal
Normal
3.1, Low
Normal
Normal
3.3, Low
Normal
Chloride
(mEq/L)
113, High
116, High
118, High
118, High
114, High
112, High
111,High
CO2
(mEq/L)
14, Low
12, Low
13, Low
16, Low
16, Low
17, Low
17, Low
Calcium
(mg/dL)
6.8, Low
6.8, Low
6.8, Low
6.6, Low
6.4, Low
6.3, Low
6.2, Low
Albumin
(gm/dL)
1.6, Low
1.5, Low
1.5, Low
1.5, Low
1.5, Low
1.4, Low
1.5, Low
Phosphorus
(mg/dL)
2.1, Low
2.1, Low
Normal
1.7, Low
2.0, Low
2.1, Low
2.0, Low
GFR
Normal
45, Low
52, Low
57, Low
Normal
Normal
Normal
(mL/min/1.73 m2)
Assessment
• Biochemical labs cont.:
Basic Metabolic Panel (BMP)
Date
09/05
09/06
09/07
09/08
Glucose
(mg/dL)
173, High
154, High
Normal
166, High
BUN
(mg/dL)
Normal
Normal
Normal
Normal
Creatinine
(mg/dL)
1.42, High
1.47, High
1.55, High
1.56, High
Sodium
(mEq/L)
135, Low
Normal
Normal
Normal
Potassium
(mEq/L)
3.4, Low
3.4, Low
3.0, Low
Normal
Chloride
(mEq/L)
114, High
119, High
121, High
120, High
CO2
(mEq/L)
14, Low
13, Low
15, Low
12, Low
Calcium
(mg/dL)
7.0, Low
6.9, Low
7.3, Low
6.9, Low
GFR
(mL/min/1.73 m2)
49, Low
47, Low
45, Low
44, Low
Assessment
• Biochemical labs cont.:
Comprehensive Metabolic Panel (CMP)
Date
09/14
Glucose
(mg/dL)
207, High
CO2
(mEq/L)
17, Low
Calcium
(mg/dL)
7.3, Low
Total Protein
(gm/dL)
5.9, Low
Albumin
(gm/dL)
1.8, Low
Assessment
• Biochemical labs cont.:
Complete Blood Count (CBC)
Date
09/04
09/05
09/07
09/08
09/09
09/10
09/11
09/12
09/13
09/14
Red Blood Cell
(m/ul)
3.70, Low
4.32, Low
4.33, Low
4.14, Low
4.09, Low
3.89, Low
3.90, Low
3.85, Low
4.04, Low
Normal
Hemoglobin
(gm/dL)
7.8, Low
9.9, Low
10.3, Low
10.0, Low
9.7, Low
9.2, Low
9.2, Low
9.1, Low
9.4, Low
10.5, Low
Hematocrit
(%)
25.0, Low
30.4, Low
30.9, Low
29.6, Low
29.4, Low
27.6, Low
27.8, Low
27.4, Low
28.5, Low
31.9, Low
Other Labs
Date
09/04
09/05
09/06
09/07
09/09
1.00, Low
0.98, Low
0.98, Low
1.06, Low
No lab drawn
PTH, Intact
(pg/mL)
No lab drawn
No lab drawn
No lab drawn
No lab drawn
101, High
Vit D, 25-OH
(nmol/L)
No lab drawn
No lab drawn
No lab drawn
No lab drawn
17, Low
Ionized Calcium
(mmol/L)
Assessment
• Diet history:
– Poor appetite
– General diet at home
– No swallowing difficulties
– No issues with digestion/elimination
Assessment
• Dietary consult #1:
– Sent by MD to address patient’s malnutrition
status before initial surgery
– Consult sent based on patient’s low albumin
labs (1.5-1.8 gm/dL throughout stay)
– Per daughter, patient consumed <50% of
each meal
Assessment
• Calculated needs:
– Calories
• 2170-2530 kcal (30-35 kcal/kg ABW)
– Protein
• 94-108 gm/day (1.3-1.5 gm/kg ABW)
– Fluid
• 2170-2530 ml/day
• Level 2 nutritional compromise:
– Limited PO intake (<50%)
– Unintentional weight loss PTA
Nutrition Diagnoses
• PES statements:
– Inadequate energy intake related to current
condition as evidenced by intake record.
– Increased nutrient needs related to metabolic
stressors as evidenced by albumin.
Nutrition Intervention
• Nutrition intervention:
– Glucerna Snack Shake TID (420 kcal)
– Mighty Shake TID (384 kcal)
– Encouraged to order from room service menu
– Request to MD to liberalize diet
– Continue Megace (400 mg BID) and calcium
gluconate
Monitoring & Evaluation
• Monitoring and evaluation:
– Patient’s serum albumin labs would trend
towards normal limits
– Patient would meet >75% of estimated
nutritional needs from oral food intake
– Lean body mass would remain intact
Assessment
• Dietary consult #2:
– Sent by MD to address increasing calcium in
the patient’s diet
– Consult sent based on patient’s low ionized
calcium labs (0.98-1.06 mmol/L)
– Per daughter, patient consumed ~50% of
each meal
Assessment
• Calculated needs remained the same
• Level 2 nutritional status remained the
same
• Nutrition diagnoses remained the same
Nutrition Intervention
• Nutrition intervention:
– Continue Glucerna Snack Shake TID
– Discontinue Mighty Shake TID
– Propass with mousse BID
– Request to MD for vitamin D and PTH labs
– Continue Megace (400 mg BID), calcium
gluconate, vitamin C (500 mg/day), and
multivitamin (1 tablet per day)
Monitoring & Evaluation
• Monitoring and evaluation:
– Patient’s ionized calcium labs would trend
towards normal limits
– Patient’s serum albumin labs would trend
towards normal limits
– Patient would meet >75% of estimated
nutritional needs from oral food intake
– Weight would remain stable
– Lean body mass would remain intact
– Promotion of surgical wound healing
Assessment
• Follow-up/reassessment:
– Patient reported improvement in appetite
– Per patient, consuming 50-75% of each meal
• Calculated needs remained the same
• Level 2 nutritional status remained the
same
• Nutrition diagnoses remained the same
Nutrition Intervention
• Nutrition intervention remained the same
but with two additions:
– Vitamin D supplementation
– Re-instate calcium supplementation
Monitoring & Evaluation
• Monitoring and evaluation remained the
same but with one addition:
– Patient’s vitamin D labs would trend towards
normal limits
Conclusion
• Patient admitted for surgical repair of right
hip fracture
• Additional fracture found in right proximal
humerus
• Patient developed AoCRF which resolved
upon discharge
• Medical diagnosis: Pathologic fractures
• Nutritional diagnoses: Inadequate energy
intake and increased nutrient needs
Conclusion
• Nutrition interventions:
– ↑ overall food intake
– Treating nutrient deficiencies
• Upon discharge, albumin increased
slightly
• Calcium supplementation not re-instated
• Vitamin D supplements ordered
• Weight could not be monitored after 2nd
consult
Review of Key Points
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RCC most common form of kidney cancer
Highly vascularized malignancies
Affects calcium homeostasis
Classic symptoms include:
– Abdominal pain
– Hematuria
– Palpable mass
Review of Key Points
• Most prominent risk factors include:
– Smoking
– Obesity
– Hypertension
• Many treatments available including:
– Surgical interventions
– Immunotherapy
– Tumor ablation therapy
– Targeted therapy
Review of Key Points
• Nutrition interventions typically combat
nutrition-related side effects
• Prognosis dependent on cancer stage and
method of treatment
Personal Impressions
References
About chronic kidney disease. (n.d.). The National Kidney Foundation:
Kidney Disease. Retrieved December 15, 2013, from http://www.
kidney.org/kidneydisease/aboutckd.cfm
[Anteroposterior radiograph of the right hip after hemiarthroplasty].
(n.d.). Retrieved January 14, 2014, from http://www.healio.com/
orthopedics/journals/ortho/%7B7aa2da59-ebe8-4ee3-a2df50e98f0ac058%7D/femoral-neck-fracture-following-hardwareremoval
[Anteroposterior radiograph three months after fixation of a three-part
proximal humeral fracture, with a broken distal locking screw and
backing-out of the PHILOS plate.]. (n.d.). Retrieved January 14,
2014, from http://www.bjj.boneandjoint.org.uk/content/89B/9/1206/F2
Brock, K. E., Ke, L., Gridley, G., Chiu, B. C., Ershow, A. G., Lynch, C.
F., ... Cantor, K. P. (2011). Fruit, vegetables, fibre and micronutrients
and risk of US renal cell carcinoma. British Journal of Nutrition,
108(6), 1077-1085. doi: http://dx.doi.org/10.1017/S000711
4511006489
[Calcium homeostasis]. (2012, December 14). Retrieved January 14,
2014. Image is from college notes.
Catchpole, G., Platzer, A., Weikert, C., Kempkensteffen, C., Johannsen,
M., Krause, H., ... Weikert, S. (2009). Metabolic profiling reveals key
metabolic features of renal cell carcinoma. Journal of Cellular and
Molecular Medicine, 15(1), 109-118. doi: 10.1111/j.15824934.2009.00939.x
Charney, P., & Malone, A. M. (2009). Albumin. In ADA pocket guide to
nutrition assessment (2nd ed., pp. 65-66). Chicago, IL: American
Dietetic Association.
Chittoria, N., & Rini, B. I. (2013, August). Renal cell carcinoma.
Cleveland Clinic Center for Continuing Education. Retrieved
December 15, 2013, from http://www.clevelandclinicmeded.com/
medicalpubs/diseasemanagement/nephrology/renal-cellcarcinoma/#top
Colt, J. S., Schwartz, K., Graubard, B. I., Davis, F., Ruterbusch, J.,
DiGaetano, R., ... Chow, W. (2011). Hypertension and risk of renal
cell carcinoma among white and black Americans. Epidemiology,
22(6), 1-16. doi: 10.1097/EDE.0b013e3182300720
Dugdale, D. C., & Lin, H. Y. (2012, September 5). Acute kidney failure:
MedlinePlus Medical Encyclopedia. U.S National Library of
Medicine. Retrieved December 15, 2013, from http://www.nlm.nih.
gov/medlineplus/ency/article/000501.htm
[Femoral neck fracture]. (n.d.). Retrieved January 14, 2014, from
http://imageradiology.blogspot.com/2012/07/types-of-hip-fracturesbasic.html
[Fracture of proximal humerus]. (n.d.). Retrieved January 14, 2014,
from http://www.mdguidelines.com/fracture-humerus-proximal
Graves, A., Hessamodini, H., Wong, G., & Lim, W. H. (2013). Metastatic
renal cell carcinoma: Update on epidemiology, genetics, and
therapeutic modalities. ImmunoTargets and Therapy, 2, 73-90. doi:
http://dx.doi.org/10.2147/ITT.S31426
Kidney cancer (adult) - renal cell carcinoma overview. (n.d.). American
Cancer Society. Retrieved December 15, 2013, from http://www.
cancer.org/acs/groups/cid/documents/webcontent/003052-pdf.pdf
[Kidney diagram with corresponding key]. (2001). Retrieved January
14, 2014, from http://science.howstuffworks.com/life/humanbiology/kidney1.htm
[Kidney with renal cell carcinoma]. (n.d.). Retrieved January 14, 2014,
from http://www.spacecoastmedicine.com/2009/10/incidence-ofkidney-cancer-increasing.html
Lee, J. E., Mannisto, S., Spiegelman, D., Hunter, D. J., Bernstein, L.,
Van den Brandt, P. A., ... Smith-Warner, S. A. (2009). Intakes of fruit,
vegetables, and carotenoids and renal cell cancer risk: A pooled
analysis of 13 prospective studies. Cancer Epidemiology
Biomarkers & Prevention, 18(6), 1730-1739. doi: 10.1158/10559965.EPI-09-0045
Mahan, L. K., Escott-Stump, S., Raymond, J. L., & Krause, M. V.
(2012). Calcium homeostasis. In Krause's food & the nutrition care
process (13th ed., pp. 532-533). St. Louis, MO: Elsevier/Saunders.
Morgan, T. M., Tang, D., Stratton, K. L., Barocas, D. A., Anderson, C.
B., Gregg, J. R., ... Clark, P. E. (2011). Preoperative nutritional status
is an important predictor of survival in patients undergoing surgery
for renal cell carcinoma. European Urology, 59(6), 923-928. doi:
10.1016/j.eururo.2011.01.034
Nutrition in cancer care. (n.d.). National Cancer Institute. Retrieved
December 15, 2013, from http://www.cancer.gov/cancertopics/pdq/
supportivecare/nutrition/HealthProfessional/page1/AllPages
[Partial nephrectomy surgical technique in a patient with localized
kidney cancer.]. (n.d.). Retrieved January 14, 2014, from
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanage
ment/nephrology/renal-cell-carcinoma/
Pronsky, Z. M., & Crowe, J. P. (2010). Proton pump inhibitors. In Food
medication interactions (16th ed., p. 260). Birchrunville, PA: FoodMedication Interactions.
[Renal cell carcinoma, clear cell type]. (2005, December 7). Retrieved
January 14, 2014, fromhttp://commons.wikimedia.org/wiki/File:Renal
_clear_cell_ca_(1)_Nephrectomy .jpg
[Renal cryoablation therapy]. (2012). Retrieved January 14, 2014, from
http://www.castlesurgical.com/cryo-ablation-therapy1.html
[Renal neoplasms]. (n.d.). Retrieved January 14, 2014, from http://
www.nature.com/modpathol/journal/v24/n6/fig_tab/modpathol20113f
2.html
[Stages of renal cell carcinoma]. (n.d.). Retrieved January 14, 2014,
from http://www.daviddarling.info/encyclopedia/K/kidney_cancer.
html
Survival rates for kidney cancer by TNM stage. (n.d.). Kidney Cancer
(Adult) Renal Cell Carcinoma Overview. Retrieved December 15,
2013, from http://www.cancer.org/cancer/kidneycancer/overview
guide/kidney-cancer--adult--renal-cell-carcinoma-overview-survivalrates
Treatment of kidney cancer. (n.d.). Kidney Cancer Treatment:
Continued... UCLA Urology. Retrieved December 15, 2013, from
http://urology.ucla.edu/body.cfm?id=444