Kidney Disease Case Study - Medical Nutrition Therapy Manual

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Caitlin Mazurek
KNH 411
11/7/11
Chronic Kidney Disease Treated with Dialysis
1. Describe the physiological functions of the kidneys.
The functions of the kidney include maintenance of homeostasis through control of
fluid, pH, and electrolyte balance and blood pressure. The kidneys are also responsible
for the excretion of metabolic end-products and foreign substances. They are also the
producers of enzymes and hormones. Pg. 523
2. What diseases/conditions can lead to chronic kidney disease (CKD)?
Diabetic nephropathy is the most common condition that leads to CKD. This is due to
the kidney’s inability to make adequate erythropoietin which stimulates the production
of red blood cells. Pg. 526
3. Explain how type 2 diabetes mellitus can lead to CKD.
Type 2 diabetes mellitus can lead to CKD through the change in the thickening in the
glomerulus. The glomerulus is responsible for filtering the blood and the fluid that
eventually forms urine, as these glomeruler changes occur, the kidney may start
allowing more protein than normal to be released into the urine. Type 2 diabetes
patients who are insulin resistant have a difficult time controlling the amount of glucose
in their blood stream which in turn can put stress on the kidneys. Pg. 527
4. Outline the stages of CKD, including the distinguishing signs and symptoms.
Chronic kidney disease is a syndrome of a progressive and irreversible loss of the
excretory, endocrine, and metabolic functions of the kidney secondary to kidney
damage. Stage 1 of CKD is where the kidneys are damaged with normal or increased
glomerular filtration rate or GFR. Stage 2 is defined as kidney damage with normal or
increased GFR and kidney damage with mild decrease in GFR. At stage 3 there is
moderate decrease in GFR where the level is between 30-59 mL/min. In stage 4, there is
a severe decrese in GFR where the levels are between 15-29 mL/min and in stage 5,
there is kidney failure where GFR levels are under 15 mL/min and the patient would
need to be put on dialysis. The signs and symptoms for stage 5 include harmful wastes
build up in the blood, blood pressure rises, and excess fluid is retained. Pg. 526
5. From your reading of Mrs. Joaquin’s history and physical, what signs and symptoms did
she have?
The patient has diabetes as well as high blood pressure, which are two leading causes of
kidney failure. The patient has also had kidney/urinary problems and this is another
leading cause of kidney failure. Mrs. Joaquin is native American, and Native Americans
are nearly two times as likely to develop kidney failure. Pg. 526
6. What are the treatment options for Stage 5 CKD?
Treatment options for Stage 5 CKD include hemodialysis, peritoneal dialysis, and kidney
transplantation. Pg. 527
7. Describe the differences between hemodialysis and peritoneal dialysis.
Both hemodialysis and peritoneal dialysis are valid forms of dialysis that clean the
blood and or urine of any wastes. The biggest difference between the two is the way the
dialysis takes place or is connected to the body. Hemodialysis is the most common
method of treatment. The patients first need to go through a process so that they have
continual access to the bloodstream. In peritoneal dialysis, access to the patient’s blood
supply is gained using a catheter of silicone rubber and placed surgically into the
peritoneal cavity.
8. Explain the reasons for the following components of Mrs. Joaquin’s medical nutrition
therapy:
Nutrition Therapy
Rationale
35 kcal/kg
Sufficient nutrient requirement to give Mrs.
Joaquin enough energy to get past the
kidney replacement therapy
1.2 g protein/kg
Recommended protein intake for a person
on hemodialysis based off of the National
Kidney Foundation Pocket Guide to
Nutrition Assessment
2gK
Recommended potassium intake for a
person on hemodialysis based off of the NKF
pocket guide to nutrition assessment
1 g phosphorus
Phosphorus needs are based off of protein
intake and should be 10-12 mg/g protein so
when protein intake is around 100 g, there
should be 1 gram of phosphorus per day
based off of the NKF pocket guide to
nutrition assessment
2 g Na
Sodium intake is based off of NKF pocket
guide to nutrition assessment for a person
on hemodialysis
1,000 mL fluid + urine output
This is dependant upon the amount of fluid
released through urinary output and no
more than 1000 mL daily is recommended
for a patient on hemodialysis.
9. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your interpretation?
BMI = 77.3 kg / (1.52)2 m = 33.6 kg/ m2
It is believed that Mrs. Joaquin is suffering from edema in her extremities, face, and
eyes. Since she gained 4 kg in the past 2 weeks, it can be believed that her body weight
is not her adjusted body weight or edema free body weight.
10. What is edema-free weight? The following equation can be used to calculate the edemafree adjusted body weight (aBWef):
aBWef = BWef + [(SBW – BWef) x 0.25]
where BWef is the actual edema-free body weight and SBW is the standard body weight
as determined from the NHANES II data.
Calculate Mrs. Joaquin’s edema-free weight. Is this the same as dry weight?
Edema-free body weight is the weight adjusted for when the patient’s weight is < 95%
or > 115% of standard body weight.
Standard body weight should be about 60 kg where her actual body weight currently is
77.3 kg. Her adjusted edema free body weight then is around 73 kg. pg. 539
11. What are the energy requirements for CKD?
The energy requirements for CKD are 35 kcal/kg for anyone under 60 years of age such
as Mrs. Joaquin and 30-35 kcal/kg for anyone over 60 years of age. Pg. 536
12. Calculate what Mrs. Joaquin’s energy needs will be once she begins hemodialysis.
35 kcal/kg x 77.3 kg = 2704 kcal or 2700-2800 kcal/day
13. What are Mrs. Joaquin’s protein requirements when she begins hemodialysis?
1.2 g/kg x 77.3 kg = 92.8 g of Protein or about 370 kcal of protein daily.
14. What is the rationale? How would these change if she were on peritoneal dialysis?
For hemodialysis, it is necessary for the patient to receive at least 1.2 g of protein per
kilogram of body weight. If she were on peritoneal dialysis the protein intake would at
least between 1.2 and 1.3 g of protein per kilogram of body weight. Factors relating to
higher protein requirements include losing of approximately 10-12 grams free amino
acids per day and 5-15 grams per day of albumin. There is altered albumin takeover,
metabolic acidosis which increases amino acid degeneration and possibility of
inflammation and infection. It is necessary to increase protein intake then from the
usual 0.8 g/kg to 1.2 g/kg. pg. 536
15. Are there any potential benefits of using different types of protein, such as plant protein
rather than animal protein, in the diet for a patient with CKD? Explain.
It is said that at least half of the protein should be of high biological value. As long as the
protein intake is sufficient the form of protein is not so important. The National Renal
Diet provides with a food list that has serving sizes and provides sections on protein as
well as vegetarian eating to keep in mind. There is a table that provides the nutrition
composition of the various food lists. The tables should be used to plan meals and
amounts for serving sizes. The National Renal diet includes vegetarian protein as a food
for CKD patients. Pg. 537
16. Mrs. Joaquin has PO4 restriction. Why?
In CKD, hyperphosphatemia is prevented by an increase in renal output and lessening
of phosphate reabsorption. A dietary restriction of phosphorus is recommended for
patients on hemodialysis to help prevent the excess phosphorus levels in the blood and
urine.
17. What foods have the highest levels of phosphorus?
High phosphorus foods include the following: cheese, custard, milk, cream soups,
cottage cheese, ice cream, pudding, yogurt, carp, beef liver, fish roe, oysters, crayfish,
chicken liver, organ meats, sardines, dried beans and peas, soy beans, baked beans,
black beans, chick peas, garbanzo beans, kidney beans, lentils, limas, northern beans,
pork n beans, split peas, bran cereals, seeds, whole-grain products, brewer’s yeast, nuts,
and wheat germ.
18. 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?
Fluid consumption is on an individual basis based off of urinary output and type of
dialysis. Fluid intake can also be dependant on blood pressure, weight gain or loss
recently, and whether or not the patient has heart troubles. Pg. 538
19. If a patient must follow a fluid restriction, what can be done to help reduce his or her
thirst?
To control fluid intake, high salt foods should be limited, teeth can be brushed often,
pills should be taken at mealtime and fluids should be drank from small cups or glasses.
Pg. 537
20. Identify nutrition problems within the intake domain using the appropriate diagnostic
term.
Anorexia along with nausea and vomiting are two nutrition problems developed from
her stage 4 chronic kidney disease.
21. Several biochemical indices are used to diagnose chronic kidney disease. One is
glomerular filtration rate (GFR). What does GFR measure?
Kidney rate is measured by glomerular filtration rate, which is reflected in tests that
measure the rate at which substances are cleared from the plasma by the glomeruli.
Glomerular filtration is the nondiscriminant filtration of protein free plasma from the
glomerulus into Bowman’s capsule. Pg. 524
22. What test is usually done to estimate glomerular filtration rate?
There is a Cockroft-Gault equation that considers the effects of age, sex, and body
weight on creatinine generation which then adjusts the serum creatinine values to
accurately reflect creatinine clearance. GFR is measured approximately through
calculations. There is another more recent one, the Modification of Diet in Renal Disease
is most commonly used now. Pg. 524
23. Mrs. Joaquin’s GFR is 28 mL/min. What does this tell you about her kidney function?
With Mr.s Joaquin’s GFR at 28 mL/min, her CKD is at stage 4. She has severe decrease in
GFR and preparation for kidney replacement therapy should be put into action. Pg. 526
24. Evaluate Mrs. Joaquin’s chemistry report. What labs support the diagnosis of Stage 4
CKD?
Mrs. Joaquin has high potassium, phosphorus, BUN, creatinine, cholesterol and
triglycerides as well as low calcium levels. All of these fluctuations in the chemistry
report indicate stage 4 chronic kidney disease.
25. Examine the patient care summary sheet for hospital day 2. What was Mrs. Joaquin’s
weight postdialysis? Why did it change?
Mrs. Joaquin’s weight postdialysis on day 2 was 165 pounds which was 5 pounds less
than the day before. Her weight changed drastically due to her fluid loss within her first
day of hospital stay and her decrease in edema. The increased nutrition and dietary
intake can also lead to supportive weight loss. Pg. 539
26. Which of Mrs. Joaquin’s other symptoms would expect to begin to improve?
I would expect for Mrs. Joaquin’s high blood glucose to start to improve as her diet is
under control within the hospital setting. I would also hope that her metformin that she
may or may not be taking at home is being taken here at the hospital and therefore can
help regulate blood sugars. I would also expect to see better sodium, potassium,
chloride, phosphate, and calcium levels. While being in the hospital with a regulated
diet, I hope that these micronutrient levels can get back to normal after Mrs. Joaquin is
no longer having anorexic tendencies.
27. Explain why the following medications were prescribed by completing the table.
Medication
Indications/Mechanism
Nutritional Concerns
Vasotec
Ace-Inhibitor
This can possibly worsen
Vasodilators that reduce BP renal function, and produce
Erythropoietin
Vitamin/Mineral Supplement
Calcitriol
Glucophage
Sodium biocarbonate
Phos Lo
by decreasing peripheral
vascular resistance by
interfering with the
production of angiotensin II
from angiotensis I and
inhibiting degradation of
bradykinin
This is a glycoprotein
synthesized in the kidneys
that stimulates
erythropoiesis which is the
production of red blood cells
within the bone marrow
Help support the
malnutrition that was
caused due to her anorexia
and nausea and vomiting
This is a calcium regulator
for the body
Otherwise known as
metformin and is used to
regulate blood glucose levels
for type 2 diabetics
To regulate sodium levels in
the body
Calcium acetate is used as a
phosphate binder in an
attempt to aid in phosphate
levels
dysgeusia and causes dry
mouth and cough. Salt
substitutes should not be
taken with vasotec
No known available
Aid in the increase of
micronutrient levels as well
as keep the body healthy.
Helps aid in the regulation of
calcium since Mrs. Joaquin’s
calcium levels came in low
from poor dietary intake
Counting carbohydrate
intake is critical to managing
the type 2 diabetes
Helps aid in the regulation of
Mrs. Joaquin’s sodium levels
since she came in with low
sodium levels due to poor
dietary intake
Mrs. Joaquin came in with
extremely elevated
phosphate levels and
calcium acetate is there to
set an acid-base balance
28. Identify nutrition problems within the clinical domain using the appropriate diagnostic
term.
Impaired nutrient utilization including glucose NC 2.1, overweight/obesity NC 3.3
Behavioral- environmental domain
29. What health problems have been identified in the Pima Indians through epidemiological
data?
The Pima Indians are known to have the highest rate of reported incidence of diabetes.
Hypertension is also high among the Pima people.
30. Explain what is meant by the “thrifty gene” theory.
The thrifty gene theory is the ability to store excess nutrients against future famine. It is
the ability of the body to store fuel more efficiently to protect the body against food
shortages. (www.Yahoo.com/thrifty_gene_hypothesis)
31. How does nephropathy affect Pima Indians?
Genetics play into a huge role of nephropathy and the Pima Indians. Most deaths caused
from kidney problems are due to nephropathy.
32. Choose two high-priority nutrition problems and complete a PES statement for each.
- Excessive sodium intake related to fluid retention as evidenced by edema in the
extremities, face, and eyes.
- Increased blood glucose levels related to eating high carbohydrate foods as
evidenced by Mrs. Joaquin’s usual diet.
33. For each PES statement, establish an ideal goal (based on the signs and symptoms) and
appropriate intervention (based on etiology).
- Lower sodium intake to less than 2 g a day by not adding salt to foods, drinking
more water and educating Mrs. Joaquin about different salt substitutes.
- Educate Mrs. Joaquin on carbohydrate counting and how to better control her blood
glucose levels by testing her levels at least 4 times daily.
34. When Mrs. Joaquin begins dialysis, energy and protein recommendations will increase.
Explain why.
Protein and energy needs increase due to the amount of calories needed for dialysis to
happen. Dialysis is something that depletes the body of amino acids and therefore, these
will need to be replenished through increased protein intake. Pg. 543
35. Why is it recommended for patients to have at least 50% of their protein from sources
that have high biological value?
There is a high risk of losing essential amino acids through out the dialysis process.
Having proteins with high biological value will ensure that you are getting the amino
acids and retaining them as well. Pg. 543
36. The MD ordered daily use of a multivitamin/mineral supplement containing B-complex,
but not fat-soluble vitamins. Why are these restrictions specified?
During Mrs. Joaquin’s fluid loss in dialysis, the water-soluble vitamins are lost as well.
The fat-soluble vitamins therefore, build up in the blood due to the fact that they are not
lost during dialysis. These have a higher chance at building up in the body and can get
to unhealthy levels without being found in blood tests. Pg. 545
37. What resources would you use to teach Mrs. Joaquin about her diet?
I would show Mrs. Joaquin an example of the TLC diet as well as the MyPlate website
designed by the USDA. Overall, if her nutrition
38. Using Mrs. Joaquin’s typical intake and the prescribed diet, write a sample menu. Make
sure you can justify your changes and that it is consistent with her nutrition
prescription.
Diet PTA
Sample Menu
Breakfast: Cold cereal (3/4 c unsweentened) Special K cereal ½ c with ½ c skim milk
Bread (2 slices) or fried potatoes (1 med
1 slice of white bread toasted with two
potato)
sprays of butter
1 fried egg (occasionally)
1 cup scrambled egg whites with ground
pepper
Lunch: Bologna sandwich (2 slices white
bread, 2 slices bologna, mustard)
Potato Chips (1 oz)
1 can Coke
Dinner: chopped meat (3 oz beef)
Fried Potatoes (1 ½ medium)
HS Snack: Crackers (6 saltines) and peanut
butter (2 tbsp)
Turkey sandwich – 2 slices white bread, 3 oz
deli turkey meat, lettuce, tomato, light mayo
and mustard
½ c carrots and 2 T fat-free Ranch dressing
12 oz water with lemon wedge or mint
leaves
3 oz lean beef patty on white bun with one
slice cheddar cheese and lettuce, tomato,
mustard
½ cup cooked peas with pepper, pasta salad
with fat-free Italian dressing
5 low sodium saltine crackers, 2 T sugarfree jelly
39. Using the renal exchange list, plan a 1-day diet that complies with your diet order.
Provide a nutrient analysis to assure consistency with all components of prescription.
See attached sheet.
40. Write an initial medical record note for your consultation with Mrs. Joaquin.
A
24-yo female who is Native American, 77.3 kg, 1.52 m and a BMI calculated to
33 kg/m2, Diagnosed with type 2 diabetes at the age of 13 and stage 3 CKD 2
years ago
Currently has failing kidney function as GFR is decreasing and puts her in
Stage 4 CKD now Lab results show she has high potassium, phosphorus,
sodium and caloric levels
D
Excessive sodium intake related to fluid retention as evidenced by edema in
the extremities, face, and eyes.
Increased blood glucose levels related to eating high carbohydrate foods as
evidenced by Mrs. Joaquin’s usual diet.
I
Lower sodium intake to less than 2 g a day by not adding salt to foods,
drinking more water and educating Mrs. Joaquin about different salt
substitutes.
Educate Mrs. Joaquin on carbohydrate counting and how to better control
her blood glucose levels by testing her levels at least 4 times daily.
M/E
Monitor fluid intake and urine out put as well as daily weight check and
blood glucose levels. All micronutrient levels should also be checked while at
the hospital and intake records should be kept as well. There is a potential
issue with following a set diet, but it is important to inform Mrs. Joaquin of
the severity of her disease and the risks of not following the diet.
References
National Kidney Foundation. Web. 07 Nov. 2011. <http://www.kidney.org/>.
Nelms, Marcia Nahikian. Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA:
Wadsworth, 2011. Print.
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