What is the appropriate management plan for a patient with normocytic anemia, protein-calorie malnutrition, post-fall pain, CKD stage 3, mild hypocalcemia, and essential hypertension?

Management of Normocytic Anemia, Protein-Calorie Malnutrition, Post-Fall Pain, CKD Stage 3, Mild Hypocalcemia, and Essential Hypertension

The assessment and plan outlined is appropriate and comprehensive, with the workup for normocytic anemia being correctly prioritized, nutritional support properly escalated, and blood pressure management optimized for CKD stage 3.

Normocytic Anemia Management

The diagnostic workup ordered (iron studies, reticulocyte count, peripheral smear, and stool guaiac) is the correct algorithmic approach to determine the etiology of new normocytic anemia in this clinical context. 1, 2

• The hemoglobin drop from 12.5 to 10.6 g/dL represents clinically significant anemia requiring investigation, particularly given the patient's CKD stage 3 and dual antiplatelet therapy. 1
• In CKD patients, normocytic anemia typically develops when GFR falls below 20-30 mL/min, but this patient's improved GFR of 64 mL/min makes relative erythropoietin deficiency less likely as the primary cause. 3, 4
• The ordered iron studies will identify absolute or functional iron deficiency, which is common in CKD and can impair erythropoietin efficacy. 3, 4
• Reticulocyte count will distinguish between inadequate bone marrow response (low reticulocyte count) and hemolysis or acute blood loss (elevated reticulocyte count). 1, 2
• Stool guaiac testing is essential given dual antiplatelet therapy, as occult gastrointestinal bleeding is a common cause of anemia in this setting. 2, 3
• Weekly CBC monitoring is appropriate to track progression and response to any interventions. 2

Protein-Calorie Malnutrition Management

The urgent dietitian consult with continued oral nutritional supplementation (Ensure and Pro-Stat) represents the correct first-line approach for hospitalized patients with CKD and malnutrition. 5

• The declining albumin (3.3 → 2.9 g/dL), total protein (6.0 → 5.2 g/dL), and low prealbumin (16 mg/dL) meet criteria for protein-calorie malnutrition requiring intervention. 5
• In malnourished non-critically ill hospitalized patients with CKD who can safely feed orally but cannot reach nutritional requirements with regular diet alone, oral nutritional supplements (ONS) shall be offered. 5
• ONS can add 10-12 kcal/kg and 0.3-0.5 g protein/kg daily over spontaneous intake when provided twice daily, facilitating achievement of nutritional targets. 5
• Evidence from large RCTs demonstrates that ONS improves nutritional status, preserves lean body mass, reduces complications, and decreases non-elective readmissions. 5
• If the patient fails to respond to or cannot tolerate ONS, escalation to enteral nutrition or parenteral nutrition should be considered. 5
• Weekly weights are appropriate for monitoring nutritional intervention effectiveness. 5
• Protein intake should be maintained at 0.8 g/kg/day in CKD stage 3, avoiding high protein intake (>1.3 g/kg/day) which may accelerate CKD progression. 5

Critical Caveat for Malnutrition in CKD

• Malnutrition itself can worsen renal function by decreasing glomerular filtration rate and renal plasma flow, creating a vicious cycle that must be interrupted with aggressive nutritional support. 6
• In older adults with frailty (which may apply given post-fall status), higher protein and calorie targets should be considered despite CKD. 5

Post-Fall Pain Management

The current PRN hydrocodone-acetaminophen regimen with required documentation of non-pharmacologic adjuncts is appropriate, but vigilance for opioid-related sedation is critical given concurrent benzodiazepine use. 5

• The combination of opioids and benzodiazepines significantly increases risk of respiratory depression and sedation. 5
• Non-pharmacologic pain management through therapy-guided mobility and transfer progression should be maximized to minimize opioid requirements. 5
• Acetaminophen dosing must be monitored carefully in the context of malnutrition and potential hepatic dysfunction. 5

CKD Stage 3 Management

The current management with losartan (ACE inhibitor/ARB class) and metoprolol is appropriate, with blood pressure targets of <140/90 mmHg for CKD stage 3. 5, 7, 8

• The improved GFR (43 → 64 mL/min) and normalized BUN indicate resolution of prerenal azotemia with successful hydration support. 7, 8
• Blood pressure target should be <140/90 mmHg for patients with CKD stage 3, though some guidelines recommend <130/80 mmHg for enhanced cardiovascular and renal protection. 5, 7, 8
• Losartan provides both blood pressure control and nephroprotection, particularly if proteinuria is present. 7, 8, 9
• The current blood pressure appears stable, and the regimen should be continued with weekly CMP monitoring. 7, 8
• Strict avoidance of NSAIDs and other nephrotoxins is essential to prevent acute kidney injury. 7, 8
• Dietary sodium restriction to <2 g/day (<90 mmol/day) should be reinforced to enhance blood pressure control and slow CKD progression. 5, 7, 8

Monitoring Strategy for CKD Stage 3

• Weekly CMP monitoring is appropriate during acute hospitalization, but should transition to every 3-6 months once stable. 7, 8
• Monitor serum creatinine, potassium, and bicarbonate 2-4 weeks after any medication changes. 7, 8
• CKD progression is defined as both a change in eGFR category AND ≥25% decline in eGFR. 7, 8

Mild Hypocalcemia Management

The albumin-corrected calcium of approximately 9.1 mg/dL is normal, and no supplementation is required at this time. 5

• Measured calcium of 8.2 mg/dL with albumin of 2.9 g/dL yields corrected calcium ≈ 9.1 mg/dL (using correction factor of +0.8 mg/dL for each 1 g/dL decrease in albumin below 4.0 g/dL). 5
• Adequate dietary calcium intake should be ensured through dietitian consultation. 5
• Weekly CMP monitoring will track calcium trends and detect any true hypocalcemia requiring intervention. 5
• In CKD stage 3, intact PTH levels should be monitored if calcium abnormalities persist, with target PTH >70 pg/mL for stage 3 CKD. 5

Essential Hypertension Management

The current antihypertensive regimen with losartan and metoprolol is appropriate, with clonidine PRN available for hypertensive urgency (SBP >160 mmHg). 5, 7, 8

• Blood pressure is stable without orthostasis, indicating adequate control. 5
• Losartan (an ARB) is first-line therapy for hypertension in CKD, providing both blood pressure reduction and renal protection. 5, 7, 8, 9
• The combination of losartan and metoprolol (ARB + beta-blocker) is appropriate and does not carry the risks associated with dual RAS blockade (ACE inhibitor + ARB). 5, 7, 8
• If blood pressure control becomes inadequate, adding a thiazide-type diuretic or calcium channel blocker would be the next step. 5, 7, 8

Blood Pressure Target Considerations

• JNC-8 guidelines recommend <140/90 mmHg for CKD patients of all ages. 5
• More recent guidelines (ACC/AHA) recommend <130/80 mmHg for all CKD patients based on SPRINT trial evidence showing cardiovascular and mortality benefits. 7
• Given this patient's age and clinical context, the <140/90 mmHg target is reasonable, but intensification to <130/80 mmHg could be considered if tolerated without adverse effects. 5, 7