Jeff Ha
NUTR 409
Case Study #18
Questions: 1-3, 5-8, 12-16, 18, 19, 22
1. The physiological functions of the kidneys involve electrolyte, fluid, and solute balance. Nitrogenous
waste (also referred to as Blood Urea Nitrogen) is filtered from the kidney and excreted within the urine.
The kidney can filter blood and regulate blood pressure. Production of the active form of vitamin D, red
blood cell production (erythropoietin), and the regulation of water homeostasis also takes place in the
kidney.
2. Hypertension, glomerulonephritis, PKD, diabetes, urinary tract being obstructed, recurrent kidney
infection, age, obesity, genetics, family history, smoking, high cholesterol, heart disease, are some risk
factors that can lead to CKD. The reason why diabetes can be linked to CKD is because it can damage the
kidneys. Small blood vessels in the body are damaged by diabetes, and due to this the blood may not
properly be filtered by the kidney, which can result to unnecessary build up in the blood. Nerves are also
affected by diabetes, nerves that are responsible for emptying the bladder. It is possible that the
pressure of a full bladder can possibly be backed up to the point where it can injure the kidney, and the
urine that stays in the bladder for an extremely long time can cause infection.
3.
STAGE 1:
 Glomerular filtration rate (GFR) is 90-130 ml/min
 Damage of the kidney, but normal to increased kidney function
 Findings in the urine or structural abnormalities
 BUN levels are higher than normal
Stage 2:
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Glomerular filtration rate (GFR) is 60- 89 ml/min
Disease is mild within kidney function
Enough evidence of kidney damage indicated by higher than normal levels of BUN
Stage 3:
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GFR is 30-59 ml/min
Moderate decrease in kidney functions
Fluid retention, edema within the extremities, fatigue
Change in urine (Dark orange, brown, foamy, bloody)
Change in the amount of urine (more or less than normal)
Sleep problem due to muscle cramps
Kidney pain
Stage 4:
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GFR is 15-29ml/min
Now severe decrease within kidney function
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Adding to the same symptoms of stage 3 is taste changes (everything having a metallic
taste), halitosis due to the buildup of urea in the blood, difficulty concentrating, nerve
problems causing numbness/tingling, and due to anorexia.
Stage 5:
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GFR is only 15 ml/min
End-stage renal disease with kidney failure and necessary treatment
Now adding on to the same symptoms of stage 4 are headaches, swelling of the eyes
and ankles, itching, little to no urine, changes in the pigment of the skin
5. Hemodialysis, Peritoneal dialysis, or a kidney transplant are options of treatment for Stage 5 CKD.
Hemodialysis – access is by an arteriovenous fistula, an artificial loop graft, or a possible subclavian
catheter. Fluid and electrolyte content is similar to normal plasma. Waste products and electrolytes
move by ultrafiltration, diffusion, and osmosis and is removed in the dialysate. The machine acts like an
artificial kidney that filers waste from the blood, then returns the blood back into the body. Outpatient
hemodialysis requires the patient to go into a clinic for 3-5 hours, 3 days a week. Some patients use it at
home and use it overnight.
Peritoneal Dialysis – A high-dextrose dialysate is instilled into the peritoneum, diffusion carries waste
product from the blood through the membrane and into the dialysate. This method practically uses the
body’s own peritoneum. CAPD, CCPD, and NIPD are 3 types of peritoneal dialysis. With peritoneal
dialysis, there is less fluctuation in blood chemistry, less equipment involved, and peritoneal dialysis
allows more of a flexible schedule to follow.
6.
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35 kcal/kg: higher in order to spare protein for energy
1.2 g pro/kg: Depends on GFR. But the needs for protein should be higher when the patient is on
dialysis in order to prevent muscle wasting and protein for energy needs.
2 g K: potassium is increased within the blood. Possible increase because dialysis does not filter
potassium or phosphorus and the body is unable to excrete excess potassium.
1 g P: phosphorus is increased in the blood because GFR decreases. 1:1 Calcium and Phosphorus
ratio is important for bone health.
2 g Na: Restricting sodium intake is important for avoiding fluid retention, edema, and
hyponatremia.
1000 ml + urine output – As it is important to stay hydrated, it is also important to avoid edema
or fluid retention.
7. Mrs. Joaquin’s BMI = 33.3 (Obese)
Edema affects the interpretation as it makes the patient weigh more due to the fluid retention. If
possible, measuring the dry weight is preferred and extremely important. The weight measure before
the 4 kg gain is 73.3kg; dropping her BMI to 31.5
8. Edema-free weight is considered to be the patient’s dry weight or the post-dialysis weight. This is
basically the weight excluding the excess fluid build-up from the patient. The NHANES II data is used to
assess the patient’s energy and protein needs, based off of the edema-free weight and standard body
weight:
aBWef= BWef + {(SBW- Bwef) x .25}
aBWef= 165+ {(65 - 165) x .25} = 140lbs or 63.6 kg
12. Predialysis - Lower protein recommended in order to prevent overworking the kidney.
Recommendation is based off of the GFR:
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.8 g/kg/d if GFR is greater than 55 ml/min
.6 g/kg/d if GFR is less than 55 ml/min
Hemodialysis - Protein losses results during hemodialysis since protein is not replaced when the
blood is filtered and returned. High mortality rates exists if albumin levels are too low.
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1.2 g/kg IBW
Peritoneal dialysis – 20-30% protein losses occurs. In order to spare lean body mass, higher protein
is recommended:
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1.2-1.5 g/kg/d IBW
13. The PO4 restriction is limited due to her hyperphosphatemia and inability to excrete excess
phosphorous through the kidneys. The foods with the highest levels of phosphorus are most commonly
found in processed foods as preservatives. Sodas have phosphoric acid. Phosphates are also naturally
found in dairy products, grains, nuts, and meats.
14. Foods considered to be fluids include ice cream, milk and milk substitutes, broth, coffee, tea, gelatin,
juice, popsicles and sherbet. Mrs. Joaquin’s current recommendation is 1000 ml + urine output. Foods
containing large amounts of water should be moderated (like watermelon). Some methods to reduce a
patient’s thirst are to keep the body cool, drink cold beverages instead of hot beverages, snack on
kidney-friendly fruits and veggies, avoid salty and spicy foods as they increase thirst, and possibly suck
on ice chips if they so desire.
15. GFR measures the amount of filtrate/unit in the nephrons of the kidney. This can measure the
amount of blood passing through the glomeruli per minute, ultimately indicating the kidney’s function
and status. A GFR over 90 ml/minute is considered normal. Mrs. Joaquin’s GFR of 28 ml/min indicates
that she is in stage 4 CKD. This tells us that she has a severe decrease in the function of her kidneys.
16. Her high serum phosphate and high serum potassium supports the diagnosis of stage 5 CKD. Because
the kidneys inability to excrete the excess amounts of potassium and phosphorous, there is high buildup
of these two macro minerals within the blood. The high creatinine and high BUN levels show up due to
the azotemia. The inflammation of the glomerulus alters lipid metabolism, which results in high
triglycerides and cholesterol levels. Low sodium reflects losses from the urine and dilution from the fluid
retention. The increase in glucose can be related to the patient’s type 2 Diabetes Mellitus. Low calcium
is related to the patient’s low levels of vitamin D, as the kidneys do convert the active form from the
kidneys. Her high proteinuria is related to her increased the protein losses in the urine.
18.
Capoten/ captopril:
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Indications/Mechanism – Treats high blood pressure. ACE inhibitor
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Nutritional concerns – Avoid high potassium intake and proteinuria. Avoid salt substitutes
or K supplements
Erythropoietin
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Indications/Mechanism – Hormone in kidney that regulates RBC production
Nutritional concerns – Iron supplementation needed to produce RBC
Sodium bicarbonate
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Indications/Mechanism – Antacid and alkalizing agent
Nutritional concerns – low sodium diet may cause edema/ water retention in the body
Renal caps
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Indications/Mechanism – Provide water-soluble nutrients
Nutritional concerns – May not provide necessary nutrients
Renvela
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Indications/Mechanism – Phosphate binder used to prevent hypocalcemia caused by
elevated phosphorus
Nutritional concerns – Must avoid if there are bowel obstruction or if allergic to sevelamer.
Renvela may bind to other meds to make them less effective. Unless indicated by Physician,
avoid Calcium or other mineral supplements. Possible vitamin D, E, K and folic acid
depletion.
Hectorol
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Indications/Mechanism –Contains Doxercalciferol (man- made vitamin D) and decreases
PTH levels and increases calcium and phosphorus levels in the body
Nutritional concerns – Monitor calcium and phosphorous balance.
Glucophage
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Indications/Mechanism – Controls blood glucose, increase insulin sensitivity, decreases
hepatic glucose production, decreases GI glucose absorption
Nutritional concerns – Decreases vitamin B12, folic acid, and causes lactic acidosis. Must
increase foods high in B12 and folic acid.
19. Being known as the population having the highest rate of diabetes of any population in the world,
the Pima Indians have very high rates of obesity and hypertension. The “thrifty gene” theory points out
the populations who relied on farming, hunting and fishing for food experienced alternating periods of
feast and famine within the past thousands of years, such as the Pima Indians. The theory continues to
explain that these populations developed a gene that allowed them to store fat during times of
adequate food, in order to not starve during famine. Being that the Pima Indians are already genetically
predisposed, they have a higher risk of developing diabetes. This tribe are known to have higher than
normal rates of obesity and hypertension, being closely associated with diabetes.
22. The body can utilize the protein more efficiently and reduce the amount of nitrogenous waste. The
kidneys need to work much harder if there is excess waste. HBV protein can deliver nutrients and
essential amino acids body needs and can help sustain lean muscle mass.