Danielle Kessler
Nutrition 409
March 10, 2015
Case Study #18 Chronic Kidney Disease w/ Dialysis
(1, 2, 3, 5, 6, 7, 8, 12, 13, 14, 15, 16, 18, 19, 22)
1. Describe the physiological functions of the kidneys?
To maintain fluid, electrolyte and solute balance, this is accomplished by the
continuous filtration of blood with alterations in secretion and reabsorption of this filtered
fluid. With that, the kidneys filter the blood. The glomerulus produces ultrafiltrate that
are reabsorbed by the tubules to produce urine. Kidneys also regulate water homeostasis
by stimulating vasopressin/ADH when there’s high osmolality. The kidneys regulate
blood pressure via the renin-angiotensin system. Decreased blood volume causes the cells
in the glomerulus to react by secreting renin, which stimulates the formation of
angiotensin, a vasoconstrictor. Angiotensin stimulates aldosterone to reabsorb sodium
and fluid to increase blood pressure. The kidneys produce erythropoietin, a critical
determinant of erythroid activity in the bone marrow. Kidneys also produce the active
form of Vitamin D, which suppresses PTH production, which is responsible for calcium
mobilization from the bones.
2. What disease/conditions can lead to chronic kidney disease (CKD)? Explain the
relationship between diabetes and CKD.
The risk factors of CKD include diabetes, hypertension and unhealthy aging, the
major two being diabetes and hypertension. The issue with diabetes is that it affects the
vessels from proper circulation, which puts pressure on the glomeruluses. Due to small
blood vessel injury, the kidneys cannot properly cleanse the body.
3. Outline the stages of CKD, including the distinguishing signs and symptoms.




Stage 1
 GFR: 90-130mL/min
 Kidney damage, but normal to increased kidney function. Usually, there
are no physical signs.
Stage 2
 60-89mL/min
 Mild decrease in kidney function. Blood pressure is still normal, but
there is a presence of proteinuria
Stage 3
 30-59 mL/min
 Moderate decrease in kidney function
Stage 4
 15-29 mL/min


Severe decrease in kidney function hemodialysis or kidney transplant.
Blood pressure increases and symptoms such as N/V, anorexia,
difficulty concentrating and taste changes occur.
Stage 5
 Less than 15 mL/min
 Kidney failure with treatment necessary, (defined as ESRD)
5. What are the treatment options for Stage 5 CKD? Explain the differences
between hemodialysis and peritoneal dialysis.
Options to treat Stage 5 CKD include transplantation, Hemodialysis and
peritoneal dialysis. Hemodialysis is when a fistula is implanted into a blood vessel, there
is an increase risk of infection because of an open wound. Treatment is usually for 3-5
hours three times a week. Peritoneal dialysis is when the catheter is implanted into the
stomach. This could include a continuous ambulatory peritoneal dialysis treatment.
Peritoneal dialysis is usually 20 minute exchanges given 4-5 times daily. This treatment
also has a lower protein need because the formula contains dextrose, decreases the
likelihood of the body using protein for energy.
6. Explain the reasons for the following components of Mrs. Joaquin’s medical nutrition
therapy:
Nutrition Therapy
35 kcal/kg
1.2 g protein/kg
2gK
1 g Phosphorus
2 g Na
1000 mL fluid + urine output
Rationale
Kidney patients require higher energy
requirements. This reduces the likelihood
of their body utilizing protein for energy.
Body needs high quality protein as well as
a higher amount to reduce the risk of
wasting. People with kidney issues also
have low serum albumin and Prealbumin
levels due to excessive levels in urine.
Potassium must be restricted, the kidneys
are not functioning properly and are
therefore not excreting excess Potassium. If
not limited, the patient could experience
hyperkalemia.
Like Potassium, the kidneys are not
properly excreting Phosphorus either. If
Phosphorus levels are too high, the rate of
Calcium resorption could increase, putting
the patient at risk for osteoporosis.
Cap Sodium intake to reduce the risk of
edema as well as controlling hypertension.
Prevents the patient from dehydration but
is capped to prevent the patient from
experiencing edema and fluid retention
7. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your
interpretation?
BMI = kg/m2
BMI = 77.27kg/1.5242
BMI= 33.2 kg/m2
A BMI of 33 is classified as obese, however because of her kidney disease causing
edema, this weight is most likely higher than her real weight. This would give her a
higher BMI.
8. What is edema-free weight? Calculate Mrs. Joaquin’s edema –free weight.
Edema-free weight would exclude the excessive fluid that is causing her high weight.
This weight is most similar to what her weight would be if she did not have edema.
abW = 165+ (65-165) x .25
165 – 25
=140lbs or 63.63kg
12. What are the considerations for differences in protein requirements among
predialysis, hemodialysis, and peritoneal dialysis patients?
Condition
Predialysis
Hemodialysis
Peritoneal Dialysis
Protein Requirements
0.6-1.0g (depends on
GFR) 0.6 < 55
1.2-1.5g
1.5-2.5 g
The more frequent the dialysis, the more protein the patient needs because the protein is
lost during the dialysis. Peritoneal dialysis is more frequent which drains protein more.
When predialysis, the patient is not having protein being drained.
13. Mrs. Joaquin has a PO4 restriction. Why? What foods have the highest levels
of phosphorus?
Phosphorus is built up in the body because the kidneys are incapable of excreting the
mineral. The body will accumulate phosphorus, which will cause an imbalance in the
body’s electrolytes. Foods with high phosphorus include processed foods, sodas, dairy,
grains, peanut butter, nuts, meats, sodium phosphate and calcium phosphate.
14. Mrs. Joaquin tells you that one of her friends can drink only certain amounts of
liquids and wants to know if that is the case for her. What foods are considered to
be fluids? What recommendations can you make for Mrs. Joaquin? If a patient
must follow a fluid restriction, what can be done to help reduce his or her thirst?
Foods that are considered liquids include soups, ice cream, yogurt, jello and frozen
desserts. To reduce thirst, she can reduce are intake of high-salt foods or chew gum to
stimulate saliva production. Also, drink liquids that aren’t high in sugar, so lean more
towards water than other beverages. Patients are recommended to freeze fruits to suck
on/eat and to use ice cubes, because they will last longer than drinking liquids.
15. Several biochemical indices are used to diagnose chronic kidney disease. One is
glomerular filtration rate (GFR). What does GFR measure? What is normal GFR?
Mrs. Joaquin’s GFR is 28 mL/min. Interpret her value.
GFr is calculated by age, gender, race and serum Cr levels. GFR measures the level of
kidney function by measuring how much blood passes through the glomeruluses each
minute. A normal GFR is 90mL/min. Mrs. Joaquin’s GFR is 28mL/min, which
categorizes her in Stage 4 of chronic Kidney Disease.
16. Evaluate Mrs. Joaquins chemistry report. What labs support the diagnosis of
Stage 5 CKD?
Lab Values
Explanation of results
Sodium 130mEq/L (low)
Sodium levels reflect kidneys inability to
regulate water/Sodium homeostasis. This
demonstrates water retention and edema
Potassium 5.8mEq/L (high)
High potassium levels indicate that the
kidneys are not properly filtering the
electrolytes, causing an imbalance in the
body.
BUN 69 mg/dL (high)
BUN levels are not normalized because the
kidneys cannot filter the body’s waste
products.
Cr Serum 12 mg/dL (high)
High serum Creatinine levels indicate that
the kidneys are not getting rid of the body’s
waste products. The blood is not being
filtered well.
Glucose 282mg/dL (high)
High glucose levels demonstrate
uncontrolled diabetes mellitus that
contributes to her continued CKD
progression.
Phosphate 9.5mg/dL (high)
High phosphate because the kidneys are
not regulating and excreting the
phosphorus.
Calcium 8.2mg/dL (low)
Low calcium levels are related to high
phosphorous levels, which competes with
absorption. This is directly related to the
body’s inability to filter and control the
electrolyte balance. This can also be
contributed to the kidney’s inability to
form the active form of Vitamin D.
18. Explain why the following medications were prescribed by completing the
following table.
Medication
Capoten/captopril
Erythropoietin
Sodium bicarbonate
Indications/Mechanisms
Treats high blood pressure
and treats kidney problems
stemmed by diabetes. ACE
inhibitor, relaxes blood
vessels.
Stimulating agents causes
bone marrow to produce
more red blood cells.
Decreases risk of anemia
Antacid, alkalinizing agent
Renal Caps
Combo of B vitamins that
prevents vitamin deficiency
Renvela
Phosphate binder
Hectorol
treatment for secondary
hyperparathyroidism caused
by late stages of CKD
Glucophage
Metformin. Regulates blood
glucose levels for diabetics.
Nutritional Concerns
May increase Potassium
levels, (monitor/check lab
values)
May need iron supplement,
B12, folate.
May increase sodium levels.
Alkalinizes pH , may
reduce iron and B12
absorption
Overdose symptoms include
stomach pain, N/V and GI
distress
Prevents low calcium
levels. May deplete
phosphate too much, check
lab values to determne
proper dosage
Do not take Vitamin D
related drugs. Watch Vit D
levels. Monitor calcium,
phosphorus and PTH levels.
Carbohydrate counting.
Decreases B12 absorption
and effectiveness of CoQ10
19. What health problems have been identified in the Pima Indians through
epidemiological data? Explain what is meant by the “thrifty gene” theory. Are the
Pima at higher risk for complications of diabetes? Explain.
Pima Indians are at a higher than average risk of developing diabetes due to
obesity. This is directly related to the development of kidney disease, nerve damage,
heart disease and eye problems. The thifty gene theory attempts to explain why some
people are more prone to diabetes. According to the theory, this gene is common in
hunter-gather populations because it allows for fat storage that allows them to survive
during times of scarcity. However, because there is not a huge risk for starvation in
modern times, this gene is more likely to cause obesity and other chronic health issues.
The Pima Indians are more likely to be prone to complications of diabetes because their
bodies are equipped to store fat more readily.
22. Why is it recommended for patients to have at least 50% of their protein from
sources that have high biological value?
During dialysis, the body is prone to loss protein. High biological value protein reduces
the risk of all essential amino acids being lost in the dialysis process. HBV proteins also
cause less waste that the body will most efficiently utilize.