Jang, Helen
DFM 458
3/18/15
Case Study #2: Case 18 (CKD Treated with Dialysis)
Answer the following questions:
1. Describe the physiological functions of the kidneys.
The kidneys regulates body homeostasis through pH balance, secretion of waste, blood
pressure and electrolyte balance, fluid balance, production of hormones and enzymes, and
maintenance of bone health.
1.
The kidneys maintains healthy pH levels by reabsorbing bicarbonate when
needed. The kidneys can reabsorb bicarbonate (HCO3) by secreting H+ ions to
form carbonic acid (H2CO3). Carbonic acid can later be dissolved to form CO2
and water. This allows for a constant reabsorption of bicarbonate.
2.
The kidneys are made up of tubules that regulate metabolic functions and is
crucial in removing waste through urine. The nephron contains a glomerulus
which works to filter waste from blood. The first step in urine formation is
filtration through the glomerulus, separating large proteins and blood cells to
produce ultrafiltrate. The urine is then reabsorbed in the second step of all amino
acids, glucose, minerals, and water. If water intake is low, the kidneys will
decrease urine filtration.
3.
Vasopressin directs the concentration of urine and helps with maintaining fluid
balance by directing plasma volume. Blood pressure is dependent on plasma
volume and vasopressin maintains it by increasing or decreasing the absorption of
water.Sodium levels are regulated by the kidneys through aldosterone. If sodium
levels are high, sodium is exchanged by potassium to provide homeostasis. The
filtration of urine allows for the excretion of by-products as well, such as
creatinine, uric acid, and urea.
4.
The kidneys also produces enzymes and hormones such as renin. The kidney’s
management of fluid balance is dependent on the renin-angiotensin based on
renin.
5.
The kidneys also synthesize the active form of vitamin D which can then be
hydroxylated in the liver. The kidneys also produce EPO which stimulates
production of red blood cells in the bone marrow.
2. What diseases/conditions can lead to chronic kidney disease (CKD)? Explain the
relationship between diabetes and CKD.
Chronic kidney disease is the progressive loss of kidney function based on the
glomerular filtration rate, which can be measured from the rate of which wastes
are filtered. The most common conditions that can lead to CKD are hypertension,
cardiovascular disease, and both type 1 and type 2 diabetes.
1.
For diabetes, the high concentration of glucose in the bloodstream will cause the
kidneys to increase secretion. In beginning stages of kidney disease, small
amounts of protein can be detected in the urine. This can be due to hyperglycemia
and detected by a thickened glomerulus. As this progresses, glomeruluses are
gradually destroyed and high levels of albumin can be detected in the urine
analysis. Any functioning glomerulus has to increase its solute load. Over time, a
2.
limit is reached on how much the kidneys can filter out waste leading to uremia
and azotemia. A kidney biopsy can be used to exhibit diabetic nephropathy.
High blood pressure, common with diabetes patients, can also damage the blood
vessels resulting to CKD. With damaged blood vessels, oxygen and energy are
not transported to cells. The combination of both HTN and DM accelerates the
damage of blood vessels in the kidneys and eventually lead to CKD.
3. Outline the stages of CKD, including the distinguishing signs and symptoms.
1.
Stage 1: The GFR will be equal to normal to greater than 90 mL/min.
Symptoms: Kidney damage with normal kidney function with normal GFR shown
by higher than normal levels of creatinine and urea in the blood, blood or protein
in urine, evidence of kidney disease in MRI, and family history of polycystic
kidney disease.
Stage 2: The GFR will be from 60-89 mL/min.
Symptoms: Kidney damage with minor loss of kidney function with mild
decrease GFR shown by higher than normal levels of creatinine and urea in the
blood, blood or protein in urine, evidence of kidney disease in MRI, and family
history of polycystic kidney disease.
Stage 3: The GFR will be from 30-59 mL/min.
Symptoms: Moderate loss of kidney function shown from fatigue, fluid retention,
edema, shortness of breath, urination changes (change in color: dark orange,
brown, red), decrease in urine, kidney pain in the back, sleep problems due to
muscle cramps.
Stage 4: The GFR will be from 15-29 mL/min.
Symptoms: Severe loss of kidney function shown by fatigue, fluid retention,
changes in urination, sleep problems due to muscle cramps, nausea and vomiting,
metallic taste in mouth, bad breath due to urea build up in the blood, poor
appetite, difficulty in concentration, and nerve problems.
Stage 5: The GFR will be less than 15 mL/min or dialysis
Symptoms: Kidney failure shown by loss of appetite, nausea and vomiting,
headaches, fatigue, inability to concentrate, itching, little to no urine output,
edema around eyes and ankles, muscle cramps, tingling in hands and feet, changes
in skin color, and increased skin pigmentation.
4. From your reading of Mrs. Joaquin’s history and physical, what signs and symptoms
did she have that correlate with her chronic kidney disease?
She has a history of Type 2 DM since she was thirteen, a history of HTN (her
blood pressure is 220/80), she is also of Native American descent (which is two
times as likely to develop kidney failure), and her family history includes DM.
She also has a hard time being compliant to the prescribed treatment for her DM.
Her admittance physical also show symptoms of edema in the her extremities,
weight gain, anorexia, complaints of nausea and vomiting, muscle cramps, and
inability to urinate which can be symptoms of chronic kidney disease.
5. What are the treatment options for Stage 5 CKD? Explain the differences between
hemodialysis and peritoneal dialysis.
At stage 5 CKD, harmful wastes builds up in the blood, excess fluids are retained,
blood pressure rises, and treatment is needed to replace the work of the kidneys. The
treatment options for CKD include dialysis such as hemodialysis and peritoneal dialysis,
and kidney transplant. The type of treatment options for CKD depends on the underlying
cause, CVD risk, age, family support, and proximity to a dialysis center.
1.
Hemodialysis (HD), the most common dialysis treatment, cleanses the blood
through a catheter done at a dialysis center about three to four times a week per
four hour sessions. In order for patients to do HD, an arteriovenous fistula (AVF)
needs to be made which is surgically joining of the radial artery and cephalic vein.
It usually takes four to six weeks to perform hemodialysis via AVF. If a patient is
unable to do the AVF, an arteriovenous graft (AVG) can be inserted instead
which is using an artificial tube to connect the two arteries. This access to the
fistula can be done after a few weeks and HD will be conducted through the
artificial tube. Blood travels through two needles, one inserted into the fistula into
a dialyzer membrane, an artificial kidney, which filters out the waste from the
blood due to its similarity of the electrolyte content to that of regular plasma
volume. The filtered waste such as urea and potassium is diffused into a “used
dialyzer solution” and the clean blood is filtered back into the vein through the
second needle through the process of diffusion, ultrafiltration, and osmosis.
2.
Peritoneal dialysis (PD) can be done daily at home using a peritoneal catheter to
filter waste from blood. The difference between an HD and a PD is the PD will
not remove blood from the body but rather filter out the waste via passive
movement into a collection bag. Before a PD, a procedure needs to be done to
insert a catheter into the peritoneum, membrane around abdomen. A dialysate
solution will then be infused into the peritoneal cavity via the catheter and the
filtered fluid will travel into the collection bag. There are two types of PD:
continuous ambulatory PD and continuous cycling PD. CAPD can be done
overnight, dialysate solution changing several times a day, does not require a
machine, and can range from four to six hours. With CCPD, it requires a machine,
a cycler, to empty and fill the peritoneum three to five times per night when
sleeping and a few times during the day.
If lucky enough, kidney transplants can be done with immunological matching but
can be difficult because there is a wait list of five years at most. The new kidney
will perform and function as a normal kidney but the complication can be kidney
rejection. Patient will be on immunosuppressive drugs to prevent rejection of the
kidney.
6. Explain the reasons for the following components of Mrs. Joaquin’s medical nutrition
therapy:
Nutrition Therapy Rationale
35 kcal/kg: Patients receiving dialysis most often times will have poor appetite and can
be hypermetabolic. The patient is also on the higher end of energy needs to decrease the
chance of any muscle loss. If a patient does not receive enough energy needs, body fat
and muscle can slowly decrease.
1.2g protein/kg: This is an adequate number to ensure adequate intake of protein. Her lab
values show secretion of high levels of protein in her urine. The 1.2g protein/kg will be a
good way to replenish her protein losses and create a neutral or positive nitrogen balance
to lead to a good maintenance for dialysis.
2g K: With kidney disease, the kidneys can only remove certain amounts of
phosphorus at a time so limiting potassium levels can help with potassium buildup.
Her lab values show increased potassium levels therefore a potassium restriction is
recommended to avoid hyperkalemia. Some complications of hyperkalemia are decreased
muscle movements, fatigue, and irregular heartbeats.
1g P: Her lab values show increased phosphate levels resulting in hyperphosphatemia.
Since the patient is at stage 3 CKD, a 1g phosphorus diet is recommended due to
hyperphosphatemia where the GFR is between 20 and 30 mL/min. Too much phosphate
in the blood can cause brittle bones and joint pain.
2g Na: This is a very typical sodium restriction. A low sodium diet will reduce the
thirst and amount of fluids she ingests and reduce blood pressure.
1000ml fluid + urine output: We want to limit the amount of fluid she is ingesting
because we do not want fluid to accumulate in her body. Her lab already shows edema in
her extremities, so we do not want her to exceed this 1000ml limit.
7. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your
interpretation?
Height: 5’0 or 60 inches = 152cm
Weight: 170lbs = 77kg
BMI: 170 / (60 x 60) x 703 = 33.2
Mrs. Joaquin’s BMI is at a 33 which falls under the obese category. Edema can
cause excess fluids to be retained; therefore, increasing her weight which BMI
does not account for.
8. What is Mrs. Joaquin’s estimated dry weight? (Hint: Weight gained in past 2 weeks is
related to fluid gains)
Her current weight is 170 lbs. She said she has gained 4kg (8.8lbs) due to edema
in the past 2 weeks, making her dry weight about 161 lbs.
9. Calculate what Mrs. Joaquin’s energy needs will be once she begins hemodialysis. Use
Mrs. Joaquin’s adjusted ideal body weight for your calculations:
(Current dry weight – IBW) x .25 + IBW
IBW: 100 lbs
(161 - 100 ) x .25 + 100 = 115.25 lbs or 52.4 kg
Kcals: 35 kcals/kg = 35 kcals x 52.4kg = 1833 kcals
Using her adjusted ideal body weight, Mrs. Joaquin will need about 1833 kcals
once she begins hemodialysis.
10. What are the considerations for differences in protein requirements among predialysis, hemodialysis, and peritoneal dialysis patients? Explain the rationale for each
recommendation.
a. For protein requirements, patients not on dialysis would need about 0.6-0.8g/kg.
This recommendation is due to recent evidence suggesting that low protein diets
slows down the progression of renal disease and delays the need for renal
replacement therapy.
b. For patients on hemodialysis, the protein requirements are 1.2g/kg or higher
depending on the patient. For patients on peritoneal dialysis, the protein
requirements are 1.2-1.3g/kg. These higher recommendations are to prevent
malnutrition and to provide adequate protein to preserve muscle mass and serum
protein during dialysis. It is used to treat vitamin abnormalities, mineral
absorption utilization, and to normalize blood lipids. Higher protein needs are
needed due to loss of approximately 10-12g of amino acids and 5-15g of albumin
per day, metabolic acidosis, altered albumin turnover rate, inflammation, and
infection. Of the 1.2g/kg protein recommendations, 50% of the protein should be
of high biological value to maintain neutral or positive nitrogen balance
ultimately leading to maintenance of protein storage.
11. Mrs. Joaquin has a PO4 restriction. Why? What foods have the highest levels of
phosphorus?
a. Normal kidneys can remove excess phosphorus but since Mrs. Joaquin has
chronic kidney disease, her body cannot excrete phosphorus as efficiently.
Therefore, she is on a phosphorus restricted diet to prevent her from developing
hyperphosphatemia. Symptoms of hyperphosphatemia include nausea, vomiting,
anorexia, and fatigue of which she has reported.
b. Foods that have the highest amounts of phosphorus includes dairy products
(milk, cheese, yogurt, cottage cheese, cream soups, ice cream), animal protein
(organ meats including beef and chicken), fish (sardines, oysters), beans, nuts,
bran cereals, oatmeals, whole grain products, beer, chocolate, and colas.
12. 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?
a. Fluid allowances depend on the patient's’ urine output and dialysis modality. For
Mrs. Joaquin, she is to be recommended to ingest no more than 1L of fluids.
Foods that can be considered fluids are coffee, tea, gelatin, ice chips, sherbet,
popsicles, soup, and juices.
b. A diet of low-sodium foods and no added sodium can reduce Mrs. Joaquin’s
thirst. When consuming fluid foods, it is best to spread it throughout the day and
consume it through sips rather than gulps. Sour candies and cold beverages also
tend to quench thirst rather than hot beverages. When taking medication, it is best
to take it with applesauce and other soft foods than fluids.
13. Evaluate Mrs. Joaquin’s chemistry report. What labs support the diagnosis of Stage 5
CKD?
Her Blood analysis: BUN and serum creatinine
 Her BUN is 69 (normal is 8 to 18mg/dL) which is very high suggesting high
amounts of urea in urine. BUN usually builds up during kidney disease but is not
a reliable factor in determining kidney disease.
 The measure of serum creatinine clearance is a good indicator of kidney function.
Her serum creatinine is 12 (normal is 0.6-1.2mg/dL) which is very high
suggesting kidney disease due to poor creatinine clearance from the kidneys.
 Using the web-based glomerular filtration rate equation on davita.com, Mrs’
Joaquin’s GFR is 4mL/min/1.73m2 which is less than 15min/1.73m2, indicating
stage 5 end stage renal disease.
Her Urine analysis: glucose, phosphate, potassium protein, pH
 Her glucose is 282 (normal is 70-110mg/dL) which is high due to Type 2 DM
which is a factor of ESRD.
 Her phosphate levels are 9.5 (normal is 2.3-4.7) which is high suggesting high
levels of phosphorus is being secreted, suggesting kidney disease.
 Her potassium levels are 5.8 (normal are 3.5-5.5mEg/L) which are slightly high
and can affect her heart if not lowered.
 Her protein is 2+ (normal is negative) which is high suggesting high levels of
protein are being secreted, suggesting kidney disease.
 Her pH is 7.9, (normal is 5-7) which is slightly high and can be used as a
diagnostic value.
14. Choose two high-priority nutrition problems and complete a PES statement for each.
a. Patient with excessive sodium intake related to fluid retention as evidenced by 8.8
lbs unintentional weight gain in two weeks.
b. Patient with knowledge deficit of the chronic kidney disease management related
to foods that exacerbates kidney disease as evidenced by elevated lab values of
creatinine (12mg/dL), BUN (69mg/dL), and a low GFR (<15min/1.73m2).
15. For each PES statement, establish an ideal goal (based on the signs and symptoms)
and appropriate intervention (based on the etiology).
a. The unintentional weight gain is due to the fluid retention from her CKD. Patient
will be recommended on the diet of fluid restriction and how to quench thirst with
fluid foods to dissuade any unintentional weight gain.
b. An established renal diet education need to be provided to patient such as dialysis
treatments, a high protein, low potassium, low phosphate, low salt, low fluid diet.
Explore motivational factors as to what prohibited the patient to not adhere to the
original diet.
16. Why is it recommended for patients to have at least 50% of their protein from sources
that have high biological value?
“High biological value” foods means it contains essential amino acids. “Low
biological value” protein foods contain less amino acids such as fruits, vegetables,
starches. Foods that contain high biological value are animal products such as
meat, poultry, fish, eggs, yogurt, milk, and cheese. HBV protein foods are
especially important in renal diets because of the low protein recommendations.
Consuming a food that has HBV makes controlling proteins level easier and does
not cause as much stress on the kidneys. This also causes less urea accumulation
in the blood.
17. Using Mrs. Joaquin’s typical intake and the prescribed diet, write a sample menu and
explain rationale for each change. Make sure you can justify your changes and that it is
consistent with her nutrition prescription.
Diet PTA
Sample Menu
Rationale
Breakfast: Cold cereal
(¾ c unsweetened)
Corn flakes with
almond milk
Limit dairy because of high P, some
almond milk brands contain very low
P levels, corn flakes are low K and P
Bread (2 slices) or fried
potatoes (1 med potato)
White bread with
margarine or SF
jelly
Avoid wheat starches, white breads are
both low in P and K, sugar free options
for her DM
1 fried egg (occasionally) Fruit cup (can be
strawberries,
blueberries, grapes,
peaches), egg
whites
Although fruits are LBV, it is a good
snack and can quench thirst, eggs
provide high protein, take out the yolk
because it is high in P
Lunch: Bologna
sandwich (2 slices white
bread, 2 slices bologna,
mustard)
Roast turkey with
cranberry sauce,
green beans, white
rice
Meats are HBV protein foods, opt for
chicken as it is leaner for her CVD,
cranberry sauce on the side because
certain gravies contain milk which is
high in P, if the vegetables can be
leached it will be lower in K
Potato chips (1 oz)
Applesauce and
unsalted pretzels
Chips are high in Na, try unsalted
pretzels for low Na but still packs
crunch, try a snack like applesauce to
quench thirst as well
1 can Coke
Diet cranberry juice
Cokes are high in P, opt for a diet or
sugar free juice like apple or diet
cranberry
Dinner: Chopped meat
(3 oz beef)
Lean fish, brussel
sprouts
Fish is a HBV protein foods, brussel
sprouts are one of the only vegetables
without P
Fried potatoes (1 ½
medium)
Couscous
Fried potatoes are high in saturated fat,
try couscous are low in P
HS Snack: Crackers (6
saltines) and peanut
butter (2 tbsp)
Cranberries,
Opt for foods low in Na, peanut butter
popcorn with no salt is high in K, the sweetness in the
or butter
cranberries and slight saltiness in the
popcorn should prove to be an
enjoyable snack