Case 26 Chronic Kidney Disease Treated with Dialysis

Understanding the Disease and Path physiology1. (1 point) What are the 5 primary diseases/conditions that can lead to chronic kidney
disease (CKD)?
1. Diabetes Mellitus
2. Hypertension
3. Systemic Infections
4. UTI
5. Kidney Stones
2. (1point) In one paragraph, explain how Diabetes can lead to CKD [One Review article
from a Medical Journal required (SEE CALCULATION ASSIGNMENT AND CASE STUDY
GUIDELINES FOR NTR444 in Blackboard under the Case Study tab for details)].
Glomeruli, clusters of blood vessels located in nephrons in the kidneys, filter waste from
blood intro urine for excretion. High levels of blood glucose, due to uncontrolled DM can
lead to changes in the nephrons, starting with thickening of glomeruli to destruction. As
the glomerulus is compromised, larger amounts of protein pass from the blood into the
urine for excretion. Initially, the amount of protein in the urine is small (microalbuminuria)
but as the damage worsens, the amount of protein increases, developing into diabetic
nephropathy. (Nelms, Sucher, Long, 2007)
3. (2 points two paragraphs) Describe the differences between hemodialysis and peritoneal
dialysis.
In hemodialysis, wastes and toxins are filtered from the body by a semipermeable
membrane and removed by the dialysis fluid. This type of renal replacement therapy is
timely, and requires up to 5 hours per treatment, normally several times per week. There
are 3 primary routes used to access the blood stream; an intravenous catheter, an
arteriovenous fistula and a synthetic graft.
In peritoneal dialysis, the peritoneal cavity is the reservoir for the dialysate and acts as the
semipermeable membrane through which excess body fluid and solutes are filtered. The
dialysis fluid enters through a permanent tube in the abdomen and is flushed out every
night. PD removes more fluid and solutes than HD.
Understanding the Nutrition Therapy
4. (3 points) Explain the reasons for the following components of Mrs. Joaquins medical
nutrition therapy for HD:
Nutrition
Therapy
35 kcal/kg
1.2 g protein/kg
2gK

1 g phosphorus

Rationale
To provide adequate calories to prevent excessive protein
loss VIA catabolism and malnutrition.
Protein is lost through the dialysis process, placing patient at
a higher risk of protein energy malnutrition.
Restricted dietary potassium due to the kidneys inability to
remove potassium. High levels of potassium can lead to
abnormal heart rhythms.
The kidneys are not able to remove excess phosphorus,
leading to hyperphosphatemia, which overtime can lead to

2 g Na
1,000 ml fluid +
urine output

heart problems, low blood Ca, and calcification of tissues.

A sodium restriction is necessary to control for fluid retention
and consequently high blood pressure.
As kidney function decreases, the patient urinates less.
Edema is fairly common in the CKD patient, which leads to
increased blood pressure.

Nutrition Assessment
5.

(1 point) Calculate and interpret Mrs. Joaquins BMI. How does edema affect your
interpretation?
Body weight (lbs) / height (in2) x 704.5
170/3600x704.5 = 33.26
Mrs. Joaquins BMI falls in the obese category. However, due to the edema she is
experiencing, her weight may be currently inflated, leading to an overestimated BMI. BMI
calculations do not consider edema. Using the Adjusted Body weight formula [Adjusted
IBW: (EDW-IBW).25 + IBW + 10] her BMI based on her dry weight of 140 lbs is 27.3.

6. a. (1 point) Calculate what Mrs. Joaquins energy and protein needs will be once she
begins hemodialysis.
Energy Requirement: 35 kcal/kg
140 lbs/2.2 = 63.6 kg x 35 kcal/kg = 2,226 kcal/day
Protein Requirement: 1.2 g/kg
63.6kg x 1.2 g/kg = 76.32 g protein/day
b.

( 1 point) What is the rationale for her protein requirements? How would protein and
calorie requirements change if she were on peritoneal dialysis?
The protein requirements are set high to prevent protein catabolism and loss of lean
body mass. Not only does the dialysis pull protein from the bloodstream, but albumin
turnover rate is altered.
If Mrs.Joaquin was to switch to peritoneal dialysis, protein requirements would increase
to 1.4 g/kg because to increased protein losses due to inflammation of the peritoneum.
Her kcal needs do not change.

7. ( 2 points one short paragraph) Mrs. Joaquin has a PO 4 restriction. Why?

As kidney failure progresses, phosphorus levels build up in the blood. Hyperphosphatemia
manifests when GFR level decreases to 20-30 mL/min/1.73 m 2, symptomatic of diminished
kidney function. The phosphorus restriction is to protect against hyperphosphatemia,
which can lead to problems with kidney and bone health.
8. ( 2 points list the 5 categories that are the highest) What food categories have the
highest levels of phosphorus?
1. Vegetables
2. Dairy Products
3. Whole grains
4. Fruits
5. Meats & processed meats
9. ( 2-points - list 7) Evaluate Mrs. Joaquins chemistry report. What labs support the
diagnosis of Stage 4 CKD?

Abnormal
Lab
Sodium (130
mEq/L) low
Potassium (5.8
mEq/L) high
Phosphorus
(9.5 mg/dL)
high
TAG (200
mg/d/L) High
Glucose (282
mg/dL) High
BUN (69
mg/dL) High
Creatine (12
mg/dL) High

Rational
Sodium losses in urine or fluid retention, causing a dilution in the blood.
Decrease in filtration function of kidneys, leading to high potassium.
Decrease in filtration function of kidneys, leading to high phosphorus.

Glomerulus inflammation can cause altered lipid metabolism, leading to

an increase in cholesterol and TAG levels.
High serum glucose indicates uncontrolled diabetes, leading to diabetic
neuropathy.
Demonstrates decreased filtration in the kidneys.
Demonstrates impaired kidney function. Creatinine is used to estimate
GFR- primary diagnostic tool.

10.(2 points) Explain why the following medications were prescribed by completing the table.
Medication
Indications/Mechanism
Nutritional Concerns
Vasotec
Abtihypertensive used to treat
Adequate fluid intake,
diabetic neuropathy
decrease in dietary intake of
Na and Ca. Na substitutes to
be avoided. Caution with K
supplementation,
anorexia/weught loss.
Erythropoietin
Antianemic that stimulates RBC May require Fe, Vit B12 or
production to treat ESRDfolate supplements. ESRD diet
induced anemia
mandatory, May cause
nausea., vomiting and/or
diarrhea.
Vitamin/mineral supplement
Water-soluble Vitamin
Water-soluble vitamins: none
supplementation due to
with recommended doses
Fe: Take with food to decrease
increased fluid losses of
GI distress, for increased
dialysis, anorexia and low
absorption take with Vit C,
dietary intake. Fe supplement
take carbonate antacids
may be needed.
separately. May cause GI
distress. Limit alcohol.
Calcitriol
Ca regulator/active Vit D used
Not to be taken with Vit D or
to treat hypocalcemia in
Mg supplements, with dialysis
dialysis patients
do not take with excessive Ca
or low P, increases Ca
absorption, decreases weight
and increases thirst
Glucophage
Antihyperglycemic agent that
Anorexia, decline in weight,
increases effect of insulin,
decrease in folate and Vit B12
lowering GI absorption of
absorption, caution with
glucose, decreases hepatic
severe decrease in renal
glucose production
function

Sodium bicarbonate

Antacid, Alkalinizing Agent

Phos Lo

Phosphate binder for use in

renal failure

Consider content of Na while

following a Na restricted diet,
may increase thirst and weight
due to edema, caution with
severe decrease in rental
function, HTN
Take with meals, avoid Ca
supplements or antacids,
decrease Fe Absorption, may
cause GI symptoms- nausea,
vomiting, constipation

11.(2 points) Using Mrs. Joaquins typical intake and the prescribed diet, write a sample menu.
Make sure you can justify your changes and that it is consistent with her nutrition
prescription.
Diet Prior to Admission
(Including Beverages)

Breakfast: Cold Cereal c

Bread, 2 sl or fried potatoes
c, Fried Egg, 1 (occasionally)

Improved Sample Menu

Corn Flakes, 1 c
Milk (Fat Free), c
Bread (white), 1 slice
Margarine, 1 t, Jelly 1t
Tangerine, 1 med
Water, 1

Lunch: Sandwich: white bread, Sandwich: bread

2 slices, Bologna, 2 slices,
(white), 2 slices, roasted
mustard
turkey breast, skin off 3
oz, Mustard 1 tsp,
lettuce

Potato Chips, 1 oz

Tortilla Chips, unsalted,

1 oz

Coke, 12 Oz

8 oz lemonade

Dinner: Chopped beef, 3 oz

chicken, 3 oz

Fried Potatoes, 1 c

1/2 cup white rice, 1/2

Justification

Corn Flakes low in K, P

Omit Fried Potatoes,
which are high in K and
fat content.
Add 1 slice of bread
with margarine and jelly
to increase calories
Add scrambled egg, for
protein
Add limited fluids
Changed sandwich
ingredients to meet low
sodium, Bologna is
processed meat and
high in phosphorus,
limited mustard to small
serving due to P content
Replaced potato chips
with tortilla chips to
reduce K and lower
sodium due to fluid
retention
Omitted Coke beverage
due to high levels of
phosphorus
Replaced chopped beef
with chicken
Replaced potatoes with

cup steamed broccoli,

tossed salad with salad
dressing, a dinner roll
with margarine,

HS Snack/Beverages: Saltine
low sodium saltine
Crackers, 6, Peanut Butter, 2 T crackers 6, Choose lowpotassium fruits such as
applesauce or canned
pears, or low-potassium
vegetables such as
sliced cucumbers or
green peppers with
salad dressing

rice to lower K, Added

green salad and
broccoli, roll for calories
and balanced diet.

Replaced regular saltine

crackers with low
sodium to limit fluid
retention, Added lowpotassium fruits and
vegetables for snacks.

Write your Nutrition Care Form from the standpoint of an initial nutrition consult upon admission
to the hospital with diagnosis of ESRD secondary to DM.

Nutrition Care Form (10 points)

Age: ___24___ Gender: __F____ Height: __5______ Weight: __170 #__
Medical Diagnosis: _Stage 3 CKD____ Consult: _Preparation for Kidney replacement therapy,
nutrition consult by (nephrology) MD__
ASESSMENT
Weight History: _4 kg weight gain last 2 weeks__ Ideal Weight: __170_%
+/- 10#_

Ideal Weight: _100#

Activity Level: _Sedentary__ Medications: Glucophage, Vasotec, Erythopoietin, Vit/Min

supplement, Calcitriol, Sodium Bicarbonate and PhosLo. __
Past History: _T2DM (dx 13YO), declining glomerular filtration rate (past 2 yrs), HTN,
Kidney/urinary problems, gastric/Abd pn/Heartburn___
Lab Values: _3/6 ALB 3.4, Na 134, K 5.6, PO4 7.3, Glucose 200, BUN 55, Creatine 8.5, Ca 8.6,
urine pale yellow and slightly hazy_

Energy Needs: ___2227 kcal__ Protein Needs: __76g__ Fluid Needs: __1,000 mL + urine output per
day___
Energy Intake: __2318 kcal__ Protein Intake: _62 g___ Fluid Intake: __2L__
Current Diet Order: _30 kcal/kg, 0.8 PRO/kg, 8-12 mg PO4/kg, 2-3 g Na_ Education Needs: _Reestablish guidelines to healthy eating on renal diet and change diet to reflect 35 kcal/kg, 1.2 g
PRO/kg, 2g K, 1 g PO4, 2 g Na, 1000 mL fluid + urine output per day__
NUTRITION DIAGNOSIS:
Problem:_ Excessive Na, K and PO4 intake (NI-5.10.2), Poor nutrition quality of life (NB-2.5), SelfMonitoring Deficit (NB-1.4)__
Related To_Anorexia x 2 days, N & V, 4 kg in past 2 weeks of weight gain due to fluid retention
and poor eating habits prior to 2 days of anorexia. __
As Evidence by__Edema and diet recall of high Na, K and PO 4 foods progressive decline in
glomerular function and glucose labs at 282.. __
NUTRITION INTERVENTION:
_ Modify distribution, type, or amount of food and nutrients within meals or at specified times
(ND-1.2) priority modifications (E-1.2), Strategies for self-monitoring (C-2.3)
Goal: ___Control Intake of K (2-3 g/d),P (800-1000 mg/d), Fluids (1L + output) and Na (2g),
provide water soluble vitamins, Lower K to normal range, Educate on foods high and low in K,
provide sample meal plan to help in adhering to dietary goals, Limit dietary Na Intake, Educate
on foods high and low in Na and fluids, Track dietary intake including Na and Fluids. For HD,
increase kcal/d to 35 kcal/kg, PRO 1.2g/kg/d. Try to decrease blood glucose levels with controlled
diet.
NUTRITION MONITORING
_ Mineral intake Na and K (FH-1.6.1 and FH-1.6.2), oral fluid amounts (FH-1.2.1.1), Ability to
recall nutrition goals (FH-5.1.3), monitor BUN, creatine, GFR, potassium, phosphate, Triglycerides,
Na _
Goal: _Maintain at least 75% of dietary intake recommendation, monitor total caloric, fat and
protein intake to match appropriate protocols for HD patient. Maintain limit on Na and K. Assess
patients comprehension and ability to prepare and consume renal diet. If patient demonstrates
struggles, review government programs available for support of renal diet. Monitor glucose
levels, BUN, creatine, K, PO4, TG, Na and fluids.
RD Signature: _ Christina Talla Date: 03/26/2012___