Kerry Linne

2/14/18
Nutr 409
Case study #19

Chronic Kidney Disease Treated with Dialysis

1) The main function of the kidneys is to maintain the balance of fluids, electrolytes, and
organic solutes. The kidneys filter blood and produce ultra filtrate, and have the ability to
regulate water homeostasis. Additionally, they control blood pressure with the reninangiotensin
mechanism.

2) While there are several conditions and diseases that can lead to CKD, the most prevalent are diabetes and
hypertension. Glumerulonephritis, nephritic syndrome, and PKD are other conditions but not nearly as
prevalent as diabetes and hypertension .
The relationship between diabetes and CKD is related to blood sugar levels caused by diabetes damaging the
blood vessels in the kidneys. If blood sugar levels are high, the damage reduces the kidney’s functions.

3) Stage 1- GFR 90+ml/min: Normal kidney function however findings from urine, structural abnormalities, or
genetic traits are signs of kidney disease.
Typically there are no signs/symptoms indicating kidney damage but blood levels will indicate higher than
normal creatinine or urea in blood, blood or protein found in the urine, kidney damage discovered through
MRI, CT scan, ultrasounds, or contrast x-ray, or a family history of PKD.

Stage 2- GFR 60-89 ml/min: Mildly decreased kidney function and findings from stage 1 point to kidney
disease.
Typically no signs/symptoms of kidney damage but blood levels will indicate higher than normal creatinine or
urea in blood, blood or protein found in the urine, kidney damage discovered through MRI, CT scan,
ultrasounds, or contrast x-ray, or a family history of PKD.

Stage 3- GFR 30-59 ml/min: Moderately decreased kidney function

Symptoms include fatigue, a build up of fluid, shortness of breath, changes in urination, kidney pain, and
problems sleeping.

Stage 4- GFR 15-29 ml/min: Severely decreased kidney function

Symptoms include fatigue, a build up of fluid, changes in urination, kidney pain, problems sleeping, N/V,
changes in taste, loss of appetite, concentration problems, and nerve problems.

Stage 5- GFR <15 ml/min: Kidney failure with treatment, ESRD

Symptoms include loss of appetite, N/V, headaches, fatigue, itching, little to no urine output, swelling, muscle
cramping, tingling in hands/feet, changes in skin color, increased skin pigmentation.

4) Mrs. Joaquin’s history and physical showed a range of signs and symptoms that correlate with her chronic
kidney disease. Her patient history report included: diagnosed with T2D at 13 years old, non-compliant with
medications, Native American, declining GFR over time, increased creatinine and urea, elevated serum
 phosphate. Her physical exam showed muscle weakness, high blood pressure , and 3+ pitting edema to the
knees.

5) The treatment options for Stage 5 CKD include, hemodiaysis, periotoneal dialysis, or a kidney transplant.
Hemodialysis: Renal replacement therapy where wastes or uremic toxins are filtered from the blood by a
semipermeable membrane and removed by dialysis fluid. Treatment is usually 3-4 hours. There are three
methods to gain access to blood including intravenous catheter, arteriovenous fistula, and synthetic graft.

Peritoneal dialysis: The peritoneal cavity serves as the reservoir for the dialysate and peritoneum acts as the
semipermeable membrane across which excess body fluid and solutes are removed.

6)

Nutrition Therapy Rationale

35 kcal/kg Maintenance of adequate nutritional status and prevention of
excess protein loss through catabolism and malnutrition.
1.2 protein/kg Replacement of lost amino acids through dialysis.
2gK Too low or high leads to irregular heartbeats.
1 g phosphorus High amounts increases PTH, leads to calcium-phosphorus deposits
in heart, skin, lungs, organs, BVs, bone disease, red eyes, itching,
increased risk of death.
2 g Na Too much sodium can lead to high blood pressure resulting from
fluid retention.
1,000 mL fluid + urine output Too much fluid can lead to high blood pressure, low blood pressure,
and SOB, heart problems.

7) BMI= wt/(ht x ht) x 703

BMI= 170/(60x60) x 703
BMI= 33.2
Based on Mrs. J’s BMI, she falls within the range for being obese. However, her edema may affect her BMI
due to the excess fluids that she is retaining that add to her body weight.

8) Edema-free weight is the patient’s weight minus the fluid that was result of edema.
aBW ef = BW ef + [ (SBW – BW ef) x 0.25 ]
aBW ef = 165 + [ (65 – 165) x 0.25 ]
= 165 + [ (-100) x 0.25 ]
= 165 + (-25) = 140 lbs = 63.6kg12.

9) The recommended energy requirements for CKD for both nondialyzed and hemodialysis patients is 35
kcal/kg/day.

11) Predialysis = 0.75 g protein/kg

Hemodialysis = 1.2 g protein/kg
Peritoneal dialysis = at least 1.2 g protein/kg, if not more

The energy requirements for patients who are on hemodialysis and peritoneal dialysis are the same.
12) Too much PO4 can cause complications like hyperphosphatemia. Foods that have the highest levels of
phosphorus include beer, cheese, beans, beef/chicken liver, organs meats, bran cereal, whole grains, cocoa
and chocolate drinks, milk, dark colas, ice cream, custard, pudding, carp, oysters, sardines, nuts, seeds,
caramels, and wheat germ.

13) Fluid requirements are highly individualized between CKD patients. Mrs. Joaquin's requirements will
be based on her urine output, type of dialysis, as well as the status of her blood pressure, interdialytic
weight gains, presence of edema, and congestive heart failure. Foods that are fluids include anything
that is fluid at room temperature. This includes pudding, popsicles, ice cream, gravy, sauces, sherbet,
jello, ice, some fruit and all drinks. To reduce thirst, some recommendations are: drink small glasses,
drink only when thirsty, low sugar drinks, eat frozen berries, and swish water in mouth.

14) The GFR test screens for and detects kidney damage and is used to monitor the status of kidney function.
It is equal to the total of the filtration rates of the functioning nephrons within the kidneys and therefore
measures the clearance rate of substances from the plasma by the glomeruli. A normal GFR rate is 90-120
mL/.min. With a GFR of 28 mL/min, Mrs. J has stage 4 CKD. She has advanced kidney damage and will require
dialysis or a kidney transplant in the near future. In stage 4, Mrs. J is likely to develop complications
including, high blood pressure, anemia, bone disease, and possibly heart problems. In stage 4, patients
typically have symptoms such as, fatigue, edema, changes in urination, kidney pain, problems sleeping, N/V,
changes in taste, uremic breath, loss of appetite, concentration problems, and numbness or tingling in toes
or fingers.

15) Her high PO4 level, high glucose level, high BUN, high creatinine level.

17)
Capoten/captopril: Angiotensin- converting enzyme inhibitor used for treatment of blood pressure. Avoid or
limit caffeine and alcohol consumption. Be careful if kidneys are not producing enough on their own.

Eythropoietin: This is a glycoprotein synthesized in the kidneys that stimulates erythropoiesis which is
the production of red blood cells within the bone marrow

Sodium bicarbonate: To regulate sodium levels in the body, and controls levels of antacid bicarbonate in
the blood. It contains various side effects.

Renal caps: This is a combination of B vitamins used to treat or prevent water soluable vitamin deficiency.

Renvela: This is used to lower high blood phosphorus levels in patients who are on dialysis.

Hectorol: This is used to reduce PTH in the body, but do not take more than two grams of calcium per day
when taking this medicine

Glucophage: Otherwise known as metformin and is used to regulate blood glucose levels for type 2
diabetics and counting carbohydrate intake is critical to managing the type 2 diabetes.
18) Pima Indians have high rates of obesity and obesity is a major risk factor for diabetes. The “thrifty gene”
theory proposes that for thousands of years the Pima Indians would go through periods of an overabundance
of food and then periods of famine so they developed a gene that would retain fat for a fuel source when
there was a time of famine. However, as the Pima Indians developed a Western lifestyle, they had no bouts
of famine and always have had access to food. Since they always have access to food their body still actively
stores fat to save it for a famine, which will never come causing the majority of Pima’s to be obese.

21) Protein from sources of high biological value contain all essential amino acids and are better absorbed by
the body. CKD patients have a high recommended amount of protein so it is important that they get at least
50% from sources of high biological value.