Ivette Navarro
16 September 2014
NUTR 409
Case 18: Chronic Kidney Disease (CKD)
Case Questions
Grade: 29/30
I. Understanding the Disease and Pathophysiology
1. Describe the physiological functions of the kidneys.
One of the main functions of the kidney is to maintain the balance of fluids, electrolytes,
and organic solutes. This is accomplished by the continuous filtration of blood with
alterations in secretion and reabsorption of this filtered fluid. In other words, the kidneys
are important because they keep the composition, or makeup, of the blood stable, which
lets the body function properly. Each kidney is made up of about a million filtering units
called nephrons. The nephron includes a filter, called the glomerulus, and a tubule. The
nephrons work through a two-step process. The glomerulus lets fluid and waste
products pass through it; however, it prevents blood cells and large molecules, mostly
proteins, from passing. The filtered fluid then passes through the tubule, which sends
needed minerals back to the bloodstream and removes wastes. The kidneys are also
involved in the control of blood pressure through the rennin-angiotensin mechanism.
Through this mechanism, the kidneys can act as a vasoconstrictor, which can cause
sodium and fluids to be reabsorbed, and blood pressure to be returned to normal. The
kidneys also produce the hormone erythropoietin (EPO), a critical determinant of
erythroid activity in the bone morrow. Furthermore, the kidney takes a role in the
production of the active form of vitamin D as well as elimination of calcium and
phosphorous.
Cited: pgs 799-80, Medical Nutrition Therapy: A Case Study Approach
2. What disease/conditions can lead to chronic kidney diseases (CKD)? Explain the
relationship between diabetes and CDK.
Diseases/conditions that can lead to chronic kidney diseases are kidney stones,
diabetes, hypertension, polycystic kidney disease, and glomerulonephritis, among
others. The relationship between diabetes and CDK is that high blood sugar levels
caused by diabetes can damage blood vessels in the kidneys. If the blood sugar level
remains high, this damage gradually reduces the function of the kidneys.
Cited: pgs 814, Medical Nutrition Therapy: A Case Study Approach
Cited: Kidney Health Australia
http://www.kidney.org.au/ForPatients/Management/DiabetesandCKD/tabid/704/Default.
aspx
3. Outline the stages of CDK, including the distinguishing signs and symptoms.
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Stage 1 – Signs of mild kidney disease but with normal or better GFR (greater
than 90% kidney function). Few or no physical symptoms that you can feel.
Stage 2 – Signs of mild kidney disease with reduced GFR (indicating 60% to
89% kidney function). Few or no physical symptoms that you can feel.
Stage 3 – Signs of moderate chronic renal insufficiency (where the GFR
indicates 40% to 59% kidney function). Symptoms may include; tiredness or
fatigue, puffiness or swelling, back pain, changes in appetite, changes in
urination, hypertension, and poor digestion.
Stage 4 – Signs of severe chronic renal insufficiency (where the GFR indicates
15% to 29% kidney function). Symptoms that may occur are the same as stage
3.
Stage 5 – Signs of end stage renal failure (where the GFR indicates less than
15% kidney function). Common symptoms include Anemia, bleeding and
bruising, headache, fatigue and drowsy feeling, weakness, mental
symptoms such as lowered mental alertness, trouble concentrating, confusion,
seizures, nausea, vomiting, and generally less desire to eat, thirst, muscle
cramps, muscle twitching, nocturnal (night-time urination), numb sensation in the
extremities, Skin color changes, swelling and puffiness, among others.
Cited: National Kidney Center
http://www.nationalkidneycenter.org/chronic-kidney-disease/stages/stage-5/
5. What are the treatment options for stage 5 CKD? Explain the differences between
hemodialysis and peritoneal dialysis.
Treatment options for stage 5 CKD include dialysis, transplantation, or medical
management progressing to death. In hemodialysis, fluid and electrolyte content is
similar to that of normal plasma. Waste products and electrolytes move by diffusion,
ultrafiltration, and osmosis. In peritoneal dialysis, it makes use of the body’s own
semipermeable membrane, the peritoneum. A catheter is surgically implanted in the
abdomen and into the peritoneal cavity.
Cited: pg 815, Medical Nutrition Therapy: A Case Study Approach
II. Understanding the Nutrition Therapy
6. Explain the reason for the following components of Mrs. Joaquin’s medical nutrition
therapy:
Nutrition Therapy
35 kcal/kg
1.2 g protein/kg
2gK
1 g phosphorous
2 g Na
1000 mL fluid + urine output
Rationale
To spare protein for tissue PRO synthesis
Required for patients receiving HD 3x/wk.
To prevent serum K+ elevation
To prevent retention is plasma
To prevent large intradialytic fluid gains
To maintain fluid balance
Cited: pgs 822-823, Medical Nutrition Therapy: A Case Study Approach
III. Nutrition Assessment
7. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your
interpretation?
Height: 5’0” Weight: 170#
BMI: 170 / (60)2 x 703= 33.2 (obese)
Edema can affect the interpretation because it is excess fluid in the tissues, which can
cause weight gain in the body. Her weight may be altered by the amount of fluid she
has on board.
Cited: pgs.166-167, Medical Nutrition Therapy: A Case Study Approach
8. What is edema-free weight? Calculate Mrs. Joaquin’s edema-free weight.
Edema-free weight is “Dry” or “target” body weight (which does not necessarily exclude
the presence of fluid excess) or minimal weight on progressive fluid depletion tolerated
without adverse effects.
Edema-free adjusted body weight (ABWer):
Where BW ef is the actual edema-free body weight and SBW is the standard body weight
as determined from the NHANES II data.
 aBWer= BWer + [(SBW – Bwer) x 0.25]
170 + [(68-170) x 0.25] = 144.5 lb
Cited: Management of the dialysis patient for the hospital physician
Postgrad. Med. J. 2009 85:376-381
Cited: Adjusted Body Weight From STD Tables
http://touchcalc.com/calculators/abw_calc
12. What are the considerations for the differences in protein requirements among
predialysis, hemodialysis, and peritoneal dialysis patients?
Dialysis is a drain on body protein, so protein intake must be increased accordingly.
Those receiving predialysis need at least 1.2 to 1.5 g/kg of body weight. At least 50%
should be HBV protein. Those receiving hemodialysis require daily protein intake of 1.2
g/kg of body weight. Those receiving peritoneal dialysis need at least 1.2 to1.3 g/kg of
body weight. Patients on dialysis who have low albumin levels have much higher
mortality rates, and weight should be monitored, and the diet should be adjusted
accordingly.
Cited: pg 822, Medical Nutrition Therapy: A Case Study Approach
13. Mrs. Joaquin has a PO4 restriction. Why? What foods have the highest levels of
phosphorous?
Mrs. Joaquin has a phosphorous restriction because it is a mineral that builds up in the
blood as kidneys begin to fail. This restriction is recommended to prevent
hyperphosphatemia, which can cause more harm to kidneys and bone health. Thus,
Mrs. Joaquin will need to limit the amount of dairy foods, because they contain large
amounts of phosphorous. This includes milk, yogurt, and cheese. Foods with the
highest levels of phosphorous include; carp, beef liver, black beans, chick peas, soy
beans, garbanzo beans, lentils, oysters, chicken liver, and sardines.
Cited: Medline Plus:
http://www.nlm.nih.gov/medlineplus/ency/article/002442.htm
National Kidney Foundation
http://www.kidney.org/atoz/content/phosphorus
14. Mrs. Joaquin tells you that one of her friends can drink only certain amounts of
liquids and wants to know is that is the case with 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?
Foods that are considered to be fluids include; soups, popsicles, sherbet ice cream,
yogurt, and gelatin are considered to be foods that are fluids. The following are some
recommendations for patients on how to deal with thirst without drinking include sucking
on ice chips, cold sliced fruit, sour candies or using artificial saliva are some alternative.
Furthermore, to control fluid intake, high salt foods should be limited.
Cited: pg 822, Medical Nutrition Therapy: A Case Study Approach
15. Several biochemical indices are used to diagnose chronic kidney disease. 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.
GFR measures the amount of filtrate per unit in the nephrons, the ability of the kidneys
to excrete the daily production of metabolic waste. Normal kidney function is a GFR of
about 100, over 90mls/min/1.73m2. In this case, Mrs. Joaquin’s GFR (28 mL/min) puts
her in the Stage 4 category. In this category, her kidney function has severely
diminished according to the CKD stage outline.
Cite: The Renal Association
http://www.renal.org/information-resources/the-uk-eckd-guide/normalgfr#sthash.MkTREYxE.dpbs
16. Evaluate Mrs. Joaquin’s chemistry report. What labs support the diagnosis of stage
5 CDK?
BUN: 69 mg/dL; high level indicates poor filtration; severely damaged kidneys.
Glucose: 282 mg/dL; high blood glucose indicated uncontrolled Diabetes Mellitus
Phosphate: 9.5 mg/dL; high level phosphorous indicates compromised filtration in the
kidneys
Cholesterol: 220 mg/dL; high level indicate glomerulus can be inflamed which causes
altered lipid metabolism
Protein: negative (2+); high levels of protein in urine indicates protein losses. This is an
indicator of renal disease progression.
Cited: pgs 808-809, 812, Medical Nutrition Therapy: A Case Study Approach
18. Explain why the following g medications were prescribed by completing the following
table.
Medication
Capoten/ captopril
Indications/Mechanism
Lowering high blood
pressure
Erythropoietin
This is a glycoprotein
synthesized in the kidneys
that stimulates
erythropoiesis which is the
production of red blood
cells within the bone
marrow
To regulate sodium levels
in the body
Sodium bicarbonate
Nutritional Concerns
Can produce dysgeusia
and causes dry mouth and
cough. Salt substitutes
should not be taken with
vasotec
Could not find.
aid in the regulation of Mrs.
Joaquin’s sodium levels
Renal caps
treat or prevent vitamin
deficiency due to poor diet
Renvela
To reduce the risk of
hyperphosphatemia
Hectorol
Lowers high levels of
parathyroid hormone in the
body
Also known as metformin
and is used to regulate
blood glucose levels for
type 2 diabetics
Glucophage
since she came in with low
sodium levels due to poor
dietary intake
Lack of fruits and
vegetables and whole grain
foods in diet.
Due to kidneys inability to
efficiently excrete/ filtrate
phosphorous.
Needed for patients who
are in kidney dialysis.
Counting carbohydrate
intake is critical to
managing the type 2
diabetes
Cite: Web MD
http://www.webmd.com/drugs/2/drug-4826/capoten-oral/details
Cite: Rx List
http://www.rxlist.com/renvela-drug/clinical-pharmacology.htm
Cite: pgs 801, Medical Nutrition Therapy: A Case Study Approach
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.
A health Problem that has been identified in the adult population of Pima Indians, 50%
have been diagnosed with Diabetes Mellitus. 95% of those who have DM are
considered to be overweight or obese. Because of the high prevalence of diabetes, they
are at risk for complications caused by diabetes, such as kidney disease, eye disease,
and nerve damage.
There is a hypothesis that states that, over many years ago, a genetic change occurred
in the Pima Indians. The change allowed the population to adapt to alternating period of
feast and famine. Overtime, they developed a gene that allowed them to become more
efficient at storing fat. Thus, this gene has now put Pima Indians at greater risk for
developing chronic diseases.
Cited: National Diabetes Information Clearing House. The Pima Indians: Pathfinders for
Health. http://diabetes.niddk.nih.gov/dm/pubs/pima/
Cited: National Diabetes Information Clearing House. The Pima Indians: Pathfinders for
Health. http://diabetes.niddk.nih.gov/dm/pubs/pima/
IV. Nutrition Diagnosis
22. Choose two high-priority nutrition problems and complete a PES statement for each.
1) Excessive calorie intake related to regular consumption of high-carb and high-fat
meals as evidenced by diet history and BMI 33.2 (obese)
2) High blood glucose levels related to poor compliant with prescribed medication
as evidenced by glucose levels 282 mg/dL