Julia Kaesberg
Counseling Session
KNH 413
February 27th, 2014
Patient Description and Diagnosis: Sarah Jones is a 50-year-old female, 5’4”, 131
pounds and her usual body weight is 125 pounds. Her %UBW is 104% (131/125 x 100).
Sarah has been diagnosed with Stage 5 Kidney Disease and is beginning hemodialysis.
Sarah’s decline in kidney function is a result of her uncontrolled hypertension. Currently,
Sarah is presenting with edema in her legs and feet. She has been asked by her physician
to see a Registered Dietitian for instruction on a hemodialysis diet, including fluid
restriction. Sarah’s current urine output averages about 0.7 L per day and brought a 24hour recall with her to this session.
Etiology: The two leading causes of kidney failure in the United States are Type 2
Diabetes and high blood pressure. Effective treatment of these conditions can prevent or
slow down kidney disease. End stage kidney disease occurs when 90% of kidney
function has been lost and the patient may have symptoms such as nausea, vomiting,
weakness, fatigue, confusion, difficulty concentration and loss of appetite (“Kidney
disease: Causes,”).
Diagnostic Measures: There are three simple diagnostic measures that are typically used
to diagnosis kidney disease. The first is blood pressure. A blood pressure of 140/90 or
higher is considered high blood pressure and with kidney disease 130/80 or less is
recommended. The second diagnostic measure is urinalysis. Protein and blood in the
urine may indicate kidney disease, especially in patients with diabetes. One test used to
test for the presence of urine is the protein to creatinine ratio and a value of 200 mg/gm is
considered high. Another urine test is the albumin to creatinine ratio and a value of 30
mg/gm per day or higher can be a sign of early kidney disease. The third diagnostic test
is the Glomerular filtration rate (GFR), which is estimated from the results of a serum
creatinine test. This value indicates how well the kidneys are removing waste from the
blood and a value of 60 or lower may indicate kidney disease (“Three simple tests,”).
In addition to these simple diagnostic measures, physicians can also use renal ultrasounds
to determine the size and shape of the kidney to see any abnormalities. A kidney biopsy
can also be done to determine if cancerous or abnormal cells are present. Finally, a CAT
scan can be used (“End stage renal,”).
Medical Treatment: The first choice for medical treatment of End Stage Renal Disease
(ESRD) is hemodialysis. Hemodialysis cleans and filters the blood through a machine
that removes waste, extra salt and extra water. This helps to control blood pressure and
keep the proper balance of chemicals such as potassium, sodium, calcium and
bicarbonate in the body. Another choice is peritoneal dialysis, which also removes waste,
chemicals and water from your body using the linin of your abdomen or belly. A third
choice with ESRD is kidney transplantation where the donated kidney does the work that
the patient’s two failed kidneys used to do (“Kidney failure: Choosing,”). For Sarah,
hemodialysis was chosen as the best choice of treatment for the current time. She will be
receiving hemodialysis three times per week.
Medical Nutrition Therapy:
Sarah’s protein needs are increased because of the hemodialysis and therefore requires
1.2 g pro/kg (“Chronic kidney disease,”). Sarah needs about 71 grams of protein per day.
Using the Harris Benedict equation, Sarah requires about 1,800 calories per day. Based
on the Nutrition Care Manual from the Academy of Nutrition and Dietetics, Sarah must
consume less than 2.4 g of sodium and potassium per day, between 800-1000 mg of
phosphorus per day and less than 2 g from protein per day. Because the kidneys are not
functioning properly, they cannot remove excess water from the body, so Sarah must
restrict her fluid intake to her urine output plus 1,000 cc of fluid per day. Her current
urine output is an average of 400 cc per day, so she can consume 1,400 cc of fluid in her
diet daily (“Chronic kidney disease,”).
Calculations:
1.2 g pro/kg (59.5 kg) = 71 g protein/day
71 g pro x 4 kcal/g= 284 calories from protein
71 g pro/7 grams per ounce= 10 ounces of meat
Energy Requirements using Harris- Benedict equation:
655 + (9.56 x wt (kg)) + (1.85 x ht (cm)) – (4.68 x age)
655 + (9.56 x 59.5) + (1.85 x 163 cm) – (4.68 x 50)
655 + (569) + (302) – 234
1,292 x (1.4 PAL) = 1,808
1,750-1,850 calories per day
1,800 calories- 284 calories from protein= 1,516 calories from carbohydrate and fat.
1,800 x 0.55 = 990 calories from carbohydrate/4 kcal/g= 247 g carbohydrate
1,800 total calories -990 (kcal from CHO) -284 (kcal from PRO) = 526 calories from fat/
9 kcal/g= 58 g fat per day
During the counseling session, the patient will be informed on the importance of
restricting fluid, sodium, potassium, phosphorus and calcium. The patient’s 24- hour
recall will be reviewed and Sarah will be given tips on making food choices low in these
minerals and higher in protein. The patient will also be given lists of foods that are low
in potassium, sodium and phosphorous. In addition, Sarah will be educated on sodium
and foods that have added salt, with the recommendation of choosing foods with 300 mg
or less per serving.
Website:
The National Kidney Foundation
www. Kidney.org
Educational Material:
http://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=157&actionx
m=ViewAll
References:
Chronic kidney disease (ckd) stage 5 dialysis . (n.d.). Retrieved from
http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5537&l
v2=255347&ncm_toc_id=255666&ncm_heading=Nutrition Care
End stage renal disease. (n.d.). Retrieved from
http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_sy
stem_disorders/end_stage_renal_disease_esrd_85,P01474/
Kidney disease: Causes. (n.d.). Retrieved from
http://www.kidney.org/atoz/content/kidneydiscauses.cfm
Kidney failure: Choosing a treatment that's right for you. (n.d.). Retrieved from
http://kidney.niddk.nih.gov/kudiseases/pubs/choosingtreatment/
Three simple tests to check for kidney disease. (n.d.). Retrieved from
http://www.kidney.org/kidneydisease/threesimpletests.cfm