Dominga Cuevas
NUTR.409
17 March 2014
Case 18: Chronic kidney disease treated with dialysis
1. Describe the physiological functions of the kidneys?

The functions of the liver are:
o Filtering blood
o Maintaining fluid, solute, electrolyte balance
o Regulating blood pressure and osmotic water pressure
o Production of EPO
o Activating vitamin D to its active form (calcitriol)
2. What disease/conditions can lead to chronic kidney diseases (CKD). Explain the relationship
between diabetes and CKD?
 The diseases and conditions that can lead to chronic kidney diseases are diabetes, high
blood pressure, inflammation of the kidney, infection from the narrowing of urine flow,
and malignancy (tumors, cancers..), diseases that affect the immune system, lupus,
kidney stones, polycystic kidney diseases.
 The relationship between diabetes and CKD is that diabetes increases the pressure for
GFR increasing the risk factor for CKD.
3. Outline the stages of CKD, including the distinguishing signs and symptoms.
Stages
Stage 1
Function of Kidney
Kidney Damage, normal
to increase function (GFR
>90 ml/min)
Symptoms
Stage 2
Mild Decrease in Kidney
function
(GFR=60-89 mL/min)
No Sx
o higher than normal Cr/BUN
levels
o blood/protein in urine
Stage 3
Moderate decrease in
kidney function
(GFR =30-59 mL/min)
o Fatigue caused by
anemia
o Edema in legs,
hands, around eyes
o Changes in urine
(foamy, dark orange,
bown, tea, blood)
o Back pain due to
o
o
o
o
No Sx
Signs
o higher than normal Cr/BUN
levels
o blood/protein in urine
High blood pressure
Anemia
Bone disease
Uremia
kidney pain
o Sleeping problems
Stage 4
Severe decrease in kidney
function
(GFR=15-29 mL/min)
o
o
o
o
o
o
Stage 5
Kidney failure, treatment
necessary required
(end renal stage disease)
o
o
o
o
o
Same as stage 3 plus
Nausea
Altered taste
Uremic breath
Loss of appetite
Difficulty
concentrating
o Nerve problems
o
o
o
o
o
o
o
Loss of appetite
N/V
Headaches
Fatigue
Unable to
concentrate
Itching
Little/no urine
Edema
Muscle cramps
Tingling in
hands/feet
Skin color changes
Increase skin
pigmentation

Same as stage 3 plus:
o Heart disease
o CVD
Loss of kidney function
5. What are the treatment options for stage 5 CKD? Explain the differences between
hemodialysis and peritoneal dialysis.

The treatment options for stage 5 CKD are:
o Statins is given to correct hyperlipemia, low sodium diets, and diuretics
o Adequate protein and energy is required in order to have positive nitrogen
balance, plasma albumin and to decrease edema.

Hemodialysis (HD): treatment required 3-5 hours for 3 times a week, waste products and
electrolytes move by diffusion, ultrafiltration and osmosis from the blood by the dialysis
form which is them removed from the kidneys

Peritoneal dialysis (PD): catheter surgically implanted in the abdominal to the peritoneal
cavity, waste products carried from the blood through the peritoneal membrane to the
dialysis form in which water moves by osmosis
6. Explain the reasons for the following components of Mrs. Joaquins medical nutrition therapy:

This is are the requirements for hemodialysis therapy.
Nutrition therapy
35 kcal/kg
1.2 g protein/kg
2gK
1 g phosphorous
2 g Na
1000 mL fluid + urine output
Rationale
High Kcal is needed to spare protein because
having low intake of kcals will cause the body
to use the protein as energy.
Higher amounts is recommended because
protein is lost during dialysis and also because
Mrs. Joaquin is losing high amounts of protein
in the urine.
Low amounts is required since the kidney is
not functioning properly to excrete it in the
urine and can build up in the blood. Mrs.
Joaquin has high amounts of K in the blood
which can heart rhythms that can lead to death.
Mrs. Joaquin has elevated Ph levels, due to her
condition she needs to have low amounts
because her kidneys would not be able to
excrete excess amounts and can lead to low Ca
in the blood causing extraction Ca from the
bones.
Low amount is recommended to prevent fluid
retention in the body (edema). High sodium
can increase thirst that can contribute to edema.
Fluid should be limited, excess fluid can cause
fluid retention (edema). Monitoring fluid
intake is important and necessary in order for
the patient to not gain more than 4% weight
grain from fluids. Fluid output needs to be
taken in consideration because it tells how
much insensible fluid loses will be lost during
the different stages of kidney diseases and will
be need to be replaced.
10. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your interpretation?
 BMI: 33.2 kg/m2, obese
 Edema can increase the weight because the body retains the water in the body affecting
her BMI status.
12. What are the considerations for difference in protein requirements among predialysis,
hemodialysis and peritoneal dialysis patients?

Predialysis protein: 0.6-1.0 g/kg BW

Hemodialys protein:1.2 g/kg BW

Peritoneal dialysis protein: 1.2-1.5 g/kg BW
13. Mrs. Joaquin has PO4 restriction. Why? What foods have the highest level of phosphorous?

PO4 restriction is due to prevent the buildup of waste products.

The foods that have the highest phosphorous are: chocolate, dairy products, legumes,
nuts, seafood, fish, organ meats,
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?

The foods that are considered to be fluids are ice, gelatin, sherbet, water, shakes, juice,
and soups, anything at room temperature.

She can suck on ice chips, lollipops, cold sliced fruits, sour candies, or take artificial
saliva.
15. Several biochemical indices are used to diagnose chronic kidney disease. One is Glomerulus
Filtration Rate (GFR) what does GFR measure? What is a normal GFR? Mrs. Joaquin’s GFR is
28 mL/min. Interpret her value.

Glomerulus filtration rate (GFR) measures the function of the kidney through the amount
of blood passing through the glomeruli.

Normal GFR is 90-120 mL/min

Mrs. Joaquins lab value indicates that she has Stage 4 chronic disease and is progressing
to stage 5 chronic diseases.
16. Evaluate Mrs. Joaquin’s chemistry medication. What labs support the diagnosis of stage 5
CKD?

The lab values that support Mrs. Joaquins diagnosis are
o BUN: 69 mg/dL, high (8-18 mg/dL)
o Creatine serum: 12.0 mg/dL, high (.6-1.2 mg/dL)
o Sodium: 130 mEg/L, low (136-145 mEg/L)
o Potassium: 5.8 mEg/L, high (3.5-5.5 mEg/L)
o Glucose: 282 mg/dL, high (70-110 mg/dL)
o Phosphate: 9.5 mg/dL, high (2.3-4.7 mg/dL)
o Calcium: 8.2 mg/dL, low (9-11 mg/dL)
o pH: 7.9, high (5-7)
o Protein: 2+, high (negative)
18. Explain why the following medications were prescribed by completing the following table
Medication
Capoten/captopril
Indications/mechanism
Treats high blood pressure,
congestive heart failure and
kidney problems caused by
diabetes
Erythropoietin
Glycoprotein hormone that
controls RBC production
Releives heartburn and acid Increase Na production
ingestion,
also
makes Increase thirst
blood/urine less acid
Stomach cramps
Gas
Used in wasting syndrome of Needs Fe
chronic renal failure, uremia
and impaired metabolism
function of the kidney
Prevent vitamin deficiency
Sodium bicarbonate
Renal caps
Renvela
Hectorol
Glucophage (Metformin)
Lowers phosphorous amount
in the blood in dialysis
patients. (Phosphate binder)
Lowers high levels of PTH in
dialysis patients
Is a form of vitamin D
Nutritional concerns
Mineral imbalance ((K, Na)
Dehydration
V/N
Loss of appetite
Interferes with Ca and mineral
supplements
Metallic taste
Loss of appetite
Weight loss
N/V
Control blood sugar in type 2 Increase appetite
diabetes
Cramping
N/V
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.
 The health problems that have been identified in Pima Indians are overweight, obese and
increasing the chances of developing diabetes.
 Thrifty gene means that in order for the body to obtain energy reserve when there is
shortages of food, the body will need to store enough fat for later use as energy when
there is lack of access to food.

Pima Indians are at higher risk for diabetes because their diet consists of high in fat,
calories, refined carbohydrates, high starch and high in processed foods.
22. Why is it recommended for patients to have at least 50% of their protein from sources that
have a high biological value (HBV).
 It is recommended to consume 50% protein from HBV found in animal sources (meat,
fish, and poultry) to help prevent malnutrition and protein deficiency.