How Fasting May Have Impacted a

Patient Who Developed

Amyloidosis
Presented by: LINDA NGUYEN

FAST IN COSTA
RICA- ONLY
$8,000-13K!!

WHY DO PEOPLE FAST?

Different situations call for
different things-Lady J.

In Literature:

Weight loss
Detoxification
Strengthened immune system
Feeling of rejuvenation and extended life
expectancy
Healthier cardiovascular system
Improved skeletal and muscular systems
Increased will power and self -control
More energy
Increased body sensitivity
Increased spiritual connection

As a means for political protest - Ghandi (14

occasions, 21 days x3)
Treatment for convulsion disorders
Therapy for Morbid Obesity:
Longest record fast was 27 y/o M
who fasted for 382 days and lost
125 kg (276 lbs)

THE EFFECTS OF FASTING:

Case Report + Review of Literature

Subject:
41-year-old nonobese man
40-day acaloric fast, medically supervised
PMHx: significant for occasional benign ventricular premature contractions and iron deficiency anemia.
Usual diet had been ovolactovegetarian for the preceding 24 years
Study Protocol
Complete physical exam, Labs: serum K, Cl, Ca, Phos, uric acid, creat, total protein, albumin, globulin, TGs, total lipids,
total bilirubin, direct bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, lactic
dehydrogenase, thyroxine, iron, blood urea nitrogen, glucose and a complete blood count, including a differential cell
count.
Fluid Intake: 2L/d x3 wks; 1L final week
Total intake: 60 calories
Total Days Fasted: 36

Metabolic Adaptation
of Fasting :

-Fuel Stores
-Glucose Homeostasis
As fasting progresses,
plasma glucose levels fall
significantly whereas the
level of glucagon rises.
The level of plasma glucose
level is greater in female
than male subjects.

SUMMARY: FASTING

RESULTS:

COMPLICATIONS:

INTRODUCTION OF THE SUBJECT

Admitted: 4/26/16
Lady J 63 year old woman
No past medical history
LE edema that started in her feet about 1 month ago and has steadily progressed to full
LE/abdomen distention. SOB over the last 3 or 4 days. Denies any cough/sputum
production/fever/chills/sweats/dysuria/diarrhea/recent sickness.

PATIENT HISTORY
Patient has not seen a doctor in ~30 years, since the birth of her daughter.
Not on any medications
Patients dad with Coronary Artery Disease; denies EtHO/tobacco/drug abuse.

NPO or.Fasting?

Intake: 0%

Pt with 0% intakes; refused trays but drank fluids: skim milk,

crystal light, H2O; noted pt and husband eats strictly organic only
diet

Anthropometric Measurements
Body Measurements
05/05/16
Height: 163.6 cm | 64.4 Inches
Weight:101.3 kg
IBW:
Current Daily Weight: 109 kg 05/18/16
Previous Daily Weight: 108.4 kg 05/17/16
Difference from Previous: 0.600
Weight for Calculation: 110.50 kg 05/17/16
BMI: 41.3 05/17/16
Estimated needs 1375-1650 Kcals, 66-90 g pro daily (based on IBW)
Wt - 108.4 Kg (5/17) ht - 163.6 cm

Nutrition-Focused Physical Findings:

Review of Systems
IV gtts include: norepi at 15
GEN: NAD, somnolent but arousable enough to follow simple commands
HEENT: o/p clear and dry, sclerae icteric
NECK: +JVD
CHEST: clear anteriolrly no rhonchi or wheezes
COR:: irreg, no rubs
ABD: obese, S, ND, mildly tender around her lap incisions
EXT:: 3+ pitting LE and UE edema w/ weeping
GU: Foley in place w/ dark yellow urine in the bag
NEURO: CNs II-XII intact and symmetrical bilat
Physical Examination
Vital Signs (most recent and range for last 24 hours)
Temp (CEL) 37.7 (35.4-37.7) Temp (FAHR) 99.9 (95.7-99.9), BP 94/36 (74-103)/(27-80), HR
87 (77-118), RR 16 (10-22), O2Sat 94 (92-94)

Biochemical Data, Medical Tests and Procedures:

05/18/16 04:23
130L(Na) 100(Cl) 43H(BUN)

AlkPhos AST ALT Bili Prot ALB

---|---|---<100H(Glu) ---|---|---|---|---|--4.5(K) 21L(CO2) 1.68H(Cr)

05/17/16 17:23:00
WBC 14.1
Hgb 8.8
Glucose SerPl QN 68

786H

48H#

16

6.7H

5.4L

NUTRITION DIAGNOSIS | PES

Severe protein-calorie malnutrition related to Social or Environmental Circumstances as

evidenced by Energy Intake <50% >=1 month, moderate muscle loss, Severe fluid
accumulation.

DIAGNOSIS:
4/26 Anasarca; RUQ US at Henry County Hospital - pericholecystic fluid
5/01 Amyloidosis involving the liver, support from liver biopsy
5/02---IUH Methododist. Dr. Abonour (Heme/Onc physician specializing in amyloidosis)
5/20 Nephrotic Syndrome, ESLD and ARF from Amyloidosis, Hematemesis/hypotension, liver
cirrhosis, Plasma cell neoplasia, Anasarca, Acute kidney injury, Troponin leak from demand
ischemia, New onset Atrial fibrillation, Metabolic acidosis, Volume overload; large volume
ascites
-Pt admitted for shock after presenting c/o severe abdominal pain x1 day, nausea and
vomitting (emesis: coffee ground) (pneumoperitoneum); remained on pressor meds and
intubated

AMYLOIDOSIS?
-What is Amyloidosis?
-What Are the Causes?
-Who gets it?
-What happens?
-Diagnosis?
-Prognosis?
-Treatment?

INTERVENTIONS @BALL MEMORIAL HOSPITAL:

Enoxaparin, Injection, 40 mg, Subcutaneous, Q24H
Furosemide (Lasix), Injection 40 mg, IV Push, BID
Paracentesis if Laxis not helping
Stric I/O
GI consult
NPO except ice/meds
LS diet
Provided Low Sodium Diet Education
ONS- Ensure Compact

Proposed Outcomes to Monitor and Evaluate:

Weight indicators

Percentage of ideal body weight

Unintentional weight change

Edema/Fluid status
Alimentation indicators

Decreased intake by mouth (per os)

Total parenteral nutrition, peripheral parenteral nutrition, tube feeding (new order, sudden discontinuation,
inappropriate composition/rate)
Biochemical indicators

Hypoalbuminemia

Trend upward or downward of electrolytes

Clinical indicators

Comorbid conditions and/or catabolic conditions

Gastrointestinal: Nausea, vomiting, anorexia

Skin breakdown/decubitus/nonhealing or delayed wound healing

Mode of renal replacement therapy

FOLLOW UP/CONCLUSION:
May 22, 2016 15:44
GI visit completed, care plan remains effective and appropriate with 2.5ml/h fentanyl gtt (25mcg/h) controlling
pain and maintaining comfort. Educated family on progression of disease process and edema causing orthopnea,
shunting to the core, scleral icterus, jaundice, petechia and bruising secondary to clotting factor deficiency and
other natural body responses. Pt. pitting edema increased to 4+ through all extremities, heart sounds- pronounced
murmur and regular; bruising present all extremities; pt. is now non-responsive to verbal stimuli and minimal
response to tactile stimuli.
Patient transitioned to hospice; Hospice measures were initiated and the patient passed away peacefully.
Time Of Death: 05/24/16 01:55:00.
Preliminary Cause of Death
AKI from Amyloidosis
liver failure 2/2 Amyloidosis
Plasma cell neoplasia

REFERENCES:
1.
2.
3.

4.

http://www.newhealthadvisor.com/Water-Fasting-Before-and-After-Pictures.html
Kerndt PR, Naughton JL, Driscoll CE, Loxterkamp DA. Fasting: the history, pathophysiology and
complications. West J Med. 1982 Nov;137(5):379-99.
T. Yamashita, M. Yazaki, M.D. Benson, J.J. Liepnieks, D.D. Martin, B. Kluve-Beckerman, B. Guenther and
K. Hamidi. Amyloid Research Group. Amyloidosis? Accessed 5 July 2016. http://www.iupui.
edu/~amyloid/amy_info.html
Academy Nutrition and Dietetics Nutrition Care Manual: Adult. 2016. Renal: Nephrotic Syndrome. https:
//www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_toc_id=22389