Kaila Raygoza
09.15.14
Nutr 409
Chronic Kidney Disease Case Study #18
#1, 2, 3, 5, 6, 7, 8, 12, 13, 14, 15, 16, 18, 19, 22
1. Describe the physiological functions of the kidneys. The kidneys are
two bean-shaped organs located in the rib cage. They filter about 120 to 150
quarts of urine, waste and excess fluid, which prevents a buildup of these
products in the body. The kidneys stabilize levels of electrolytes, such as
potassium, sodium, and phosphate. They are the place of synthesis of
hormones that help stimulate erythropoiesis, regulate blood pressure, and
maintain bone health. The kidneys are made up of about a million nephrons
that filter blood. Each nephron includes a filter called the glomerulus. The
glomerulus allows fluid and waste to pass through, but prevents blood cells
and any large molecules such as proteins from going through. The filtered
fluids pass through the tubule, where waste material can then be excreted as
urine and minerals are sent back into the bloodstream.
2. What diseases or conditions can lead to Chronic Kidney Disease (CKD)?
Explain the relationship between diabetes and CKD. The two leading causes of
CKD are diabetes and high blood pressure. They account for up to two-thirds of the
cases. When blood sugar levels are high in diabetics it causes damage to many
organs in the body, including the kidneys, heart, blood vessels, nerves, and eyes.
With high blood pressure, the pressure of the blood against the walls of the blood
vessels is increased. If it is not controlled, it leads to CKD, heart attacks and strokes.
CKD can also cause high blood pressure. There are many other conditions and
diseases that can result in CKD. Lupus and other diseases that affect the body’s
immune system can also lead to CKD. Repeated urinary infections and obstructions
from problems like kidney stones, tumors and enlarged prostate gland in men can
result in CKD. Another condition leading to CKD is Glomerulonephritis, a group of
disease that causes inflammation and damage to the kidney’s filtering units.
Inherited diseases such as polycystic kidney disease (PKD), which causes large cysts
to form in the kidneys and leads to damage of the surrounding tissue also leads to
CKD.
3. Outline the stages of CKD, including the distinguishing signs and symptoms.
Stage 1: normal or high GFR (GFR > 90 mL/min). It is distinguished by higher
than normal levels of creatinine or urea in the blood, blood or protein in the urine,
and evidence of kidney damage using an MRI, CT scan, or ultrasound.
Stage 2: Mind CKD (GFR = 60=89 mL/min). Stage 2 is classified by all of the
same symptoms as stage 1 CKD, but lower glomerular filtration rates.
Stage 3A: Moderate CKD (GFR = 45-59 mL/min). Stage 3B: Moderate CKD
(GFR = 30-44 mL/min). Stage 3 CKD is distinguished by fatigue, fluid retention,
edema of extremities, shortness of breath, and urination changes (frequency (less or
more), dark orange, brown, or red). Kidney pain and difficulty sleeping due to
muscle cramps or restless legs are also symptoms.
Stage 4: Severe CKD (GFR = 15-29 mL/min). Some of the symptoms of stage 4
in addition to the ones of the first three stages are nausea and vomiting, metallic
taste in mouth, bad breath due to urea buildup in the blood, difficulty concentrating,
loss of appetite, and never problems including tingling in toes and fingers.
Stage 5: End stage CKD (GFR = <15 mL/min). End stage CKD includes all the
symptoms of the first four stages of CKD as well as headaches, itching, little to no
urine production, swelling, especially around the eyes and ankles and increased skin
pigmentation.
5. What are the treatment options of stage 5 CKD? Explain the difference
between hemodialysis and peritoneal dialysis. One treatment option for stage 5
CKD is dialysis. Dialysis helps majority of patients start feeling much better, as it
starts removing toxins from the blood and medicine starts replacing the functions
the kidneys are no longer capable of performing. The first type of dialysis is
hemodialysis. This is where a dialysis machine removes a small amount of the
patient’s blood through a man-made membrane called a dialyzer, also known as an
artificial kidney. It filters the blood cleaning out the toxins that the kidneys are no
longer capable of removing and then returns the blood back to the body.
Hemodialysis may be done at home with the assistance of a care partner or in a
medical center. Peritoneal dialysis is a needle-free treatment that does not require a
care partner. The blood is filtered within the body, rather than through an outsize
dialyzer. The patient’s abdomen is filled with a solution called dialysate that assists
in removing waste and excess fluids from the blood. The abdomen lining takes the
place of the dialyzer in hemodialysis so needles are not required. Another option for
stage 5 CKD is kidney transplant. You can get on a waiting list for a cadaverous
kidney or find a living donor. Dialysis or kidney transplant is necessary for stage 5
CKD patients to continue living.
6. Explain the reasons for the following components of Mrs. Joaquin’s medical
nutrition therapy:
Nutrition Therapy
35 kcal/kg
Rationale
According to the National Kidney
Foundation, patients with CKD (on
dialysis or not) under the age of 60 are
to follow a diet of 35kcal/ kg body
weight. This provides an adequate
amount of calories to prevent excess
protein loss from through catabolism
and malnutrition.
1.2 g protein/kg
2gK
1 g phosphorus
2 g Na
1,000 mL fluid + urine output
CKD patients want to avoid excess
protein because it puts more strain on
the kidneys. However, dialysis causes
protein loss, so they must be given extra
protein to prevent PEM and to conserve
serum protein.
The impaired kidneys have a hard time
excreting potassium so consumption
must be kept at a minimum. Too much
potassium can cause irregular heartbeat,
slow pulse, and heart failure. A normal
level for a patient with the absence of
CKD is 3.5-4.5 mg/dL.
The recommended intake for patients
free of CKD is 800-1,00 mg / day. With
CKD, the kidneys cannot excrete excess
phosphorus, which can lead to
hypophosphatemia. This overtime leads
to heart and bone problems, and low
blood calcium that leads to hardened
deposits of phosphorus and calcium in
the heart, arteries, skin, joints, etc.
Restricted sodium intake is necessary
because excess sodium leads to fluid
retention and high blood pressure.
In CKD, the kidneys have a difficult time
producing urine, which leads to fluid
retention (edema) in patients. If fluids
are not kept at a minimum, it can lead to
edema, congestive heart failure, and high
blood pressure.
7. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your
interpretation?
BMI = body weight (lbs.) / height (in2) X 703
(5’5”) 60 X 60 = 3,600
170lbs. / 3,600 = 0.047 X 703 = 33.19 BMI
Mrs. Joaquin is considered to be obese based on of her BMI. Mrs. Joaquin has
reported edema in her extremities, face, and eyes and this could cause her BMI to be
falsely increased.
8. What is edema-free weight? Calculate Mrs. Joaquin’s edema-free weight.
Edema free weight, also known as dry weight, is a persons weight without excess
fluid buildup. It is the lowest weight a person can safely weight after dialysis.
Formula : edema-free adjusted body weight ( A BW er):
aBWer= BWer + [(SBW – Bwer) x 0.25]
BWer = actual edema-free body weight
BMW = standard body weight (NHANES II)
aBWef=165+[(65-165)x 0.25]
165 + [(-100) X 0.25)
=165 + (-25)
=140 lbs. (63.6 kg)
12. What are the considerations for differences in protein requirements
among predialysis, hemodialysis, and peritoneal dialysis patients? Predialysis
requires less protein than what is normally required. Protein requirements for
hemodialysis have to be set higher than normal to ensure the patient is receiving
adequate calories to make up for any unnecessary protein loss. When a patient is
receiving peritoneal dialysis their requirement is even higher than with
hemodialysis, around 1.3 g/kg because the dialysate protein losses increase by 50 to
100%. Dialysis can promote catabolism, leading to protein energy malnutrition so
protein intake must be adequate to avoid this.
13. Mrs. Joaquin has a PO4 restriction. Why? What foods have the highest
levels of phosphorus? Mrs. Joaquin has been put on a PO4 restriction because
phosphorus is a mineral that builds up in the blood as kidney function diminishes.
The less she consumes, the easier it will be on her already struggling kidneys. Some
of the foods highest in phosphorus are beer, chocolate drinks and dark colored
carbonated beverages, grains such as rice brain and wheat bran, vegetables like
broccoli, mushrooms, beans, and peas, meats such as chicken, liver, and spleen, and
dairy products like cheese, ice cream and pudding.
14. Mrs. Joaquin tells you that one of her friends can only drink 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 be made for Mrs.
Joaquin? If a patient has to follow a fluid restriction, what can be done to help
his or her thirst? Yes, this will also be the case for Mrs. Joaquin, as she has stage 3
CKD. Any food that is liquid at room temperate is counted towards the daily fluid
allowance for renal patients. Examples of these foods are soups, gelatin, and sherbet.
Fruits and vegetables are largely made up of water so consumption should be kept
to a minimum. People who are in the later stages of CKD should limit fluid intake
because the kidneys have lost their ability to excrete excess fluid. If a fluid
restriction is not followed it can lead to seriously complications for patients. Tips I
would give Mrs. Joaquin for controlling her fluid intake would be to avoid salty and
spicy foods that increase thirst, keep a journal of all fluid intake so you are less likely
to exceed your recommended amount, make ice cubes out of your favorite
beverages, and don’t allow your body to overheat. A few ways to conquer thirst are
brushing your teeth to make your mouth feel refreshed, chewing gum, sucking on
ice chips or lemon wedges, and suck on frozen fruit such as pineapples or grapes.
15. Several biochemical indices are used to diagnose CKD. One is glomerular
filtration rate (GFR). What does GFR measure? What is a normal GFR? Mrs.
Joaquin’s GFR is 28 ml/min. Interpret her value. Glomerular filtration rate is one
of the best tests to measure an individual’s level of kidney function and also
determine the stage of kidney disease. It is calculated using the results of serum
creatinine level, age, race, and gender. Creatinine is a waste product from muscle
activity. As kidney function declines, blood levels of creatinine will rise because they
are unable to remove the creatinine. Mrs. Joaquin’s GFR indicates that she has just
entered stage 4, severe CKD.
16. Evaluate Mrs. Joaquin’s chemistry report. What labs support the diagnosis
for stage 5 CKD?
 Sodium: 130 mEq/L (RR = 136-145 mEq/L) Low level of sodium indicates loses
in urine and fluid retention.
 Potassium: 5.8 mEq/L (RR = 3.5-5.0 mEq/L) A potassium level above 5.0 mEq/L
is indicative of compromised kidney filtration.
 Protein: 2+ mg/dL (RR = Neg) High protein in urine indicates that protein is
being lost in the urine which is a symptom of kidney disease.
 Albumin: 3.7 g/dL (RR = 3.5-5.0 g/dL) Same as in the case of protein; low
albumin indicates that protein is being excreted through the urine. High protein
catabolism is a symptom of CKD.
 Phosphorus: 9.5 mEq/L (RR = 2.3-4.7) High phosphorus levels in the blood show
that the kidneys are unable to filter to full capacity so excess phosphorus is being
built up in the body.
 Glucose: 282 mg/dL (RR = 70-110 mg/dL) Indicates that uncontrolled BG levels
lead to nephropathy that is likely to cause of chronic kidney disease.
18. Explain why the following medications were prescribed by completing the
following chart:
Medication
Capoten/Caporil
Erythropoietin
Indications/Mechanisms
Nutritional Concerns
Treats hypertension and
Should be taken on an
heart failure. Decreases
empty stomach for
chemicals that tighten the increased absorption. Do
blood vessels, allowing
not take if you have
blood to flow smoothly
diabetes or are taking
and the heart to pump
aliskiren drugs.
more efficiently.
A glycoprotein hormone
Increases risk of blood
that stimulates RBC
clots. Do not take while on
production to treat ESRDdrugs for myeloma
edema
including Revlimid,
Thalomid,
dezamethasone,
Sodium bicarbonate
Alkalizing agent / antacid.
Relieves heartburn and
acid indigestion.
Renal caps
Renal caps are used in the
case of CKD. They are soft
gels that provide watersoluble vitamins and are
used as a stress vitamin.
Renvela is a phosphate
binder that helps prevent
hypocalcaemia that is
caused by elevated
phosphorus levels. Used
for CKD patients on
dialysis.
Renvela
Hectorol
Adriamycin, and Doxil.
Take 1-2 hours after
meals with a full glass of
water. Do not take on an
overly full stomach.
The folic acid in them may
mask the symptoms of
pernicious anemia.
Do not take if you have a
history if stomach
problems, bowel
obstruction, or severe
constipation. Take 1-3
hours apart from other
medications as the
medicines can bind and
make each other less
effective.
Take about 3 times per
week with food while on
dialysis.
Used for CKD patients
with high levels of natural
substances such as PTH.
High PTH affects mineral
balance and leads to poor
bone health. This keeps
PTH down and
calcium/phosphorus up.
Glucophage (Metformin) Used to control elvated BG
Should be used in
in type 2 diabetics.
conjunction with a healthy
diet and exercise.
19. What health problems have been identified in the Pima Indians through
epidemiological data? Explain what it means by the “thrifty gene” theory. Are
the Pima at higher risk for diabetes? Explain why. Research on the Pima Indians
over the past 30 years indicates that half of all adult Pima Indians have diabetes and
95% of those with diabetes are overweight. The “thrifty gene” theory is a theory of
the prevalence of overweight in Pima Indians. It explains that for many years the
Indians survived on farming, fishing, and hunting for food and feast and famine did
not go hand-in-hand. Long periods of famine allowed them to adapt to this lifestyle
and promoted the storage of fat to survive these times. Their genes adapted which
was a huge advantage until they adopted a Western lifestyle high in fat and calories
and low in physical activity. The Pima are most definitely at higher risk for diabetes
Type 2 diabetes is strongly associated with overweight, low-active individuals.
Obesity is highly prevalent in Pima Indians, therefore putting them at high risk of
diabetes.
22. Why is it recommended for patients to have at least 50% of their protein
from sources that have high biological value? High biological proteins are
proteins that have a complete amino acid profile and are easily assimilated into the
body tissues. Examples of these proteins are eggs, meats, fish, and poultry. One of
the byproducts of protein metabolism is urea. Urea is a toxic byproduct and is highly
unfavorable for those with CKD because their kidneys cannot rid the waste
efficiently. The better quality the protein, the less havoc on the kidneys.