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Chronic Kidney Disease Secondary to Hypertensive Nephrosclerosis

with Type 2 Diabetes Mellitus 1​

Submitted by:

Marie Angelica T. Aday


Divina Gracia U. Sablan

HNF 42 T-2L

December 1, 2017

________________________________
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A case study submitted in partial fulfillment of the requirements in HNF 42: Medical Nutrition
Therapy II Laboratory under Ms. Zarah P. Garcia, 1​st​ semester, A.Y. 2017-2018.
I. INTRODUCTION
A. Medical Nutrition Therapy and the organ system concerned
Food and nutrition plays an important role in the well-being of an individual.
One’s maximum potentials and capabilities are greatly dependent on factors such as
the genes and the environment. However, genes are inflexible factors that are already
predetermined since an individual is born, thus making it difficult for health care
specialists to manipulate such. The environment, on the other hand, which includes
the food and nutrients people consume, is the aspect wherein the efforts for
prevention and treatment could be focused on to be able maximize and attain his or
her predetermined potentials dictated by genes. Accordingly, proper dietary
management is an essential thing for the attainment and maintenance of good health
of an individual.
There is the need for individuals to eat and consume food items to meet their
respective nutritional requirements and provide enough energy for metabolic
processes of the body. All parts of the body require energy and nutrients to function
appropriately and accordingly with other systems. Food taken through mouth passes
the gastrointestinal tract (GIT) where digestion and absorption of nutrients takes
place. The energy and nutrients obtained from food need to be transported to be able
to give supply of such to all parts of the body.

B. Significance of the Study


The case study was conducted in order to apply the principles and concepts
learned in HNF 42: Medical Nutrition Therapy II. The study was able to provide
students an avenue to enhance their understanding in the subject matter by having a
first-hand experience of collecting medical and nutritional data and information in
hospitals (through medical records and interviews) that may be deemed useful in
determining the causes and formulating interventions to the disease condition of the
patient. With this, the students conducted thorough research of related literatures to
supplement their current knowledge on how to improve the nutritional status,

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alleviate the clinical signs and symptoms, and prevent the complications of the
disease condition of the patient, specifically, Chronic Kidney Disease (CKD)
secondary to Hypertensive Nephrosclerosis with Type II Diabetes Mellitus, and on
how to improve the overall well-being of the patient.

C. Objectives
1. General
At the end of this case study, the students should be able to understand the
patient’s disease condition which includes its pathophysiology, risk factors,
and its corresponding signs and symptoms, so as to prevent possible
complications and serve as the basis for the recommended interventions.

2. Specific
The specific objectives are:
a. To describe the disease condition of a patient with Chronic Kidney
Disease (CKD) secondary to Hypertensive Nephrosclerosis with Type II
Diabetes Mellitus as to the definition, etiology, pathophysiology, and
clinical manifestations of each disease condition, including their
underlying mechanisms;
b. To identify the causative factors for the progression of the disease
condition based on the data gathered both from medical records and
interview;
c. To assess the current nutritional status of the patient using existing
anthropometric data;
d. To assess the patient’s laboratory and clinical findings and relate it to the
patient’s present condition;
e. To evaluate the patient’s diet during admission;
f. To describe the nutrient-drug interaction of each of the prescribed
medications and drugs for treatment;

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g. To formulate a nutritional care plan specific for the needs of the disease
condition of the patient;
h. To provide appropriate interventions individualized for the needs of the
patient to promote improvement of the patient’s condition; and
i. To prescribe a sample meal plan for the patient, including the basis and
rationale for recommending such.

D. Limitations of the Study


The case study and its content are limited only to the data gathered through the
medical records and interview to the patient. The diet before and upon admission was
only based on the 24-hour food recall conducted, thus, the reported dietary intakes
may be over or under estimated.

II. THEORETICAL CONSIDERATIONS


A. Disease Condition and Definition
The final diagnosis of the patient was chronic kidney disease (CKD) secondary to
hypertensive nephrosclerosis with type II diabetes mellitus. CKD is a
pathophysiologic process that results in the loss of nephrons and a decline in renal
function as determined by a measured or estimated decrease in the glomerular
filtration rate (GFR) that has persisted for more than three months (Porth, 2015).
Hypertensive nephrosclerosis, on the other hand, roots from hypertension.
Hypertensive nephrosclerosis happens when the vasculature of the kidney is damaged
with an increase in blood pressure.

Diabetic kidney disease (DKD), is a chronic kidney disease occurring from


diabetes or diabetic nephropathy. The term diabetes is derived from a Greek word
meaning “going through” and mellitus from the Latin word for “honey” or “sweet.”
Diabetes is a chronic disease resulting from an imbalance between insulin availability
and insulin need (Mahan & Raymond, 2017). Hyperglycaemia, or raised blood sugar,

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is a result of uncontrolled diabetes. This may further lead to serious damages in the
body’s system, especially in the nervous system.

B. Etiology
The two main causes of CKD are diabetes and high blood pressure, which are
responsible for up to two-thirds of the cases. CKD represents the end result of
conditions that greatly reduce renal function by destroying renal nephrons and
producing a marked decrease in the glomerular filtration rate (GFR).

Types of diabetes vary based on its root causes. For Type I diabetes, there is
destruction in the pancreatic beta cell due to autoimmune processes. This causes to
low production of insulin. On the other hand, Type II diabetes occurs due to insulin
resistance where the body ineffectively uses insulin. Most common risk factor of
diabetes is obesity and physical activity level.

C. Incidence/Prevalence
Recent research suggests that CKD prevalence in the country has worsened, from
the prevalence of 2.6 percent (2.6 out of 100 adult Filipinos) in 2003, its prevalence
has increased to 10 percent in 2013, affecting one in 10 adult Filipinos. According to
WHO, an estimated 1.6M deaths worldwide were directly caused by diabetes. The
2008 survey of the Philippines Diabetes Statistic stated that 1 out of 5 Filipinos have
diabetes, which is around 20% of the total population. Diabetes is also one of the
leading cause of kidney disease where 1 out of 4 adults with diabetes had kidney
disease.

D. Pathophysiology
The Philippine Renal Registry reports that among the leading cause of CKD is
diabetes and hypertension, both of which are also included in the medical history of
the patient. Chronic kidney disease (CKD) is a pathophysiologic process that results

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in the loss of nephrons and a decline in renal function as determined by a measured or
estimated decrease in the glomerular filtration rate (GFR) that has persisted for more
than three months (Porth, 2015). ​It can result from a number of conditions that cause
permanent loss of nephrons, including diabetes, glomerulonephritis, systemic lupus
erythematosus, and polycystic kidney disease (Levey, A., 2012). Regardless of cause,
all forms of CKD are characterized by a reduction in the GFR, reflecting a
corresponding reduction in the number of functioning nephrons. The rate of nephron
destruction differs from case to case, ranging from several months to many years. As
kidney structures are destroyed, the remaining nephrons undergo structural and
functional hypertrophy, each increasing its function as a means of compensating for
those that have been lost. In the process, each of the remaining nephrons must filter
more solute particles from the blood. It is only when the few remaining nephrons are
destroyed that the manifestations of kidney failure become evident.

Hypertensive nephrosclerosis, also known as hypertensive nephropathy, is


associated with a number of changes in the kidney structure and function. The
kidneys are smaller than normal and are usually affected bilaterally and can be
evidenced by a narrowing of the arterioles and small arteries, caused by thickening
and hyalinization of the vessel walls.

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Figure 1. Micrograph showing renal arterial hyalinosis.

As the vascular structures thicken and perfusion diminishes, blood flow to the
nephron decreases because the functional nephrons already have dilated tubules, often
with hyaline casts in the lumen (Figure 1). This causes patchy tubular atrophy,
interstitial fibrosis, and a variety of changes in glomerular structure and function.
Although uncomplicated hypertensive nephrosclerosis is not usually associated with
significant abnormalities in renal function, a few persons may progress to chronic
kidney disease.

Diabetes, resulting to hyperglycemia or high blood sugar, is a condition where


there is insufficient insulin production or resistance to insulin or both (Porth, 2015).
This study will be focusing on the second type of diabetes (T2DM) which insulin
resistance. The body’s main source of energy is from carbohydrates which is broken
down to its simplest form known as glucose. In order to utilize the energy from
glucose, it needs insulin so that it the glucose may enter the cell. In the surface of the
cell, there are insulin receptors where the glucose, together with the insulin, enters.
Some metabolic abnormalities occurs in T2DM. There can be impaired insulin
secretion, which can be caused by destruction of pancreatic beta cell. Peripheral

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insulin resistance is also evident. Lastly, there could be an increase in the production
of hepatic glucose. Uncontrolled glucose level in the blood may result to destruction
of body systems and progress to chronic diseases like CKD.

E. Clinical Signs and Symptoms


Common signs and symptoms of CKD are:
● Fatigue and less energy
● Having trouble in concentrating
● Having a poor appetite
● Having trouble sleeping
● Having muscle cramping at night
● Having swollen feet and ankles
● Having puffiness around your eyes, especially in the morning
● Having dry, itchy skin
● Needing to urinate more often, especially at night

F. Prognosis
Patients with CKD generally experience progressive loss of kidney function and
are at risk for end-stage renal disease (ESRD). The rate of progression depends on
age, the underlying diagnosis, the success of implementation of secondary preventive
measures, and the individual patient. Timely initiation of chronic renal replacement
therapy is imperative to prevent the uremic complications of CKD that can lead to
significant morbidity and death.

III. METHODOLOGY
Data Collection
Approved letters provided by the instructors, requesting for a patient were
submitted to different hospitals within Laguna. The researchers were accommodated in
Los Banos Doctors Hospital and Medical Center (LBDHMC) in Los Baños, Laguna on

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November 4, 2017, with the help of the dietitian. The dietitian handed the list of patients
with the diseases needed by the researchers. The interview of the patient followed two
days after. Consent for nutritional case report was signed by the patient prior to the
interview, afterwhich necessary data such as personal, medical, nutritional, and dietary
history were gathered. Anthropometric data was obtained through the medical chart and
actual measurement. Nurses were consulted regarding the disease and in identifying
terms and other information about the patient.

Data Analysis
Nutritional assessment was conducted after gathering necessary data for the study.
The nutritional status of the patient was evaluated using the body mass index, BMI =
weight (cm) / height (m2). The BMI was classified based on the WHO cut-off points. The
desirable body weight of the case patient was also computed using the Tannhauser’s
Method, where DBW = (height (cm) - 100) - 0.10 (height (cm) - 100). For the dietary
assessment, 24-hour food recall was used. This was evaluated based on the patient’s total
energy requirement. The 24-hour food recall of the patient was used as basis, to
determine the patient’s usual intake. The results of the biochemical test of the patient was
also evaluated to further understand her disease condition.

For the nutrition care plan, the total energy requirement (TER) of the patient was
calculated using Krause Method. The DBW of the patient was multiplied to the patient’s
physical activity factor. Following the energy deduction for elderly based on FAO, 7.3%
of the energy requirement was subtracted from the TER. All the patient’s diseases
conditions including CKD, hypertensive nephropathy, and diabetes were taken into
consideration in planning for the patient’s dietary management. All the steps in planning
for her diet was indicated in the study.

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IV. THE PATIENT
A. Personal Data
Mrs. Noeme M. Ledesma is a 64 year old female born on June 3, 1953 living in
Lalakay, Los Baños, Laguna. She was admitted to Los Baños Doctors Hospital and
Medical Center (LBDHMC) last November 4, 2017.

B. Socio-economic History
The patient is an employee in the School of Environmental Science and
Management (SESAM) in the University of the Philippines Los Baños. She lives with her
husband, Enriquito Ledesma, and their 12-year old son.

C. Present Illness and Chief Complaint


The patient was initially diagnosed with electrolyte imbalance, hypertension
(HPN), and type II diabetes mellitus (T2DM). She had an elevated blood pressure of
140/80 mmHg and experienced a generalized body weakness, persistent epigastric pain,
and recurring headache prior to confinement. She was under IVF and was given Vasalat,
Clopidogrel, Ketobest, Insuget N, Zoltax, Ketosteril, Fortifer FA, and Atenurix.

D. Past Illness and Surgery, Allergies, and Hospitalization


The patient has been diagnosed before with HPN and T2DM. No other history of
any other illnesses were recorded, nor any surgical operation was undergone by the
patient.

E. Family Medical History


The patient has no history of family disease.

F. Other Pertinent Data


The patient weighs 64 kilograms with a height of 5’5”. As for their food habits,
she is the one who usually prepares and cooks their food at home. Her usual meal pattern

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is three meals with two snacks in a day. According to her diet history, she has dietary
restrictions on salt, fat, and sugar, primarily because of her HPN and T2DM. She is fond
of eating fish and vegetables, which are among the food she prepares most often at home.

Upon admission, the patient was prescribed with a diet specifically for diabetes
mellitus by the physician, with which the hospital provided. The patient did not have any
eating difficulties during her confinement nor prior to her admission to the hospital.

V. RESULTS AND DISCUSSION


A. Anthropometric Assessment
The patient stands at 5’5” and weighs 64 kilograms. Using Tannhauser’s method,
her desirable body weight is 59 kilograms. Her nutritional status is classified as
normal based on the WHO cut-off points as evidenced by her BMI of 23.51 kg/m​2​.

B. Biochemical Assessment

Table 1. ​Complete blood count of the patient taken last November 4, 2017.

CBC RESULT UNIT NORMAL VALUES

Hemoglobin 11.17 (low) g/L 12 -15

Hematocrit 34.51 (normal) % 33 - 43

WBC 25.2 (high) 10​3​ / mm​3 4.5 - 10.5

RBC 3.57 (normal) 10​6​ / mm​3 3.5 - 5.0

Segmenters 63 (normal) % 55 - 65

Lymphocytes 29 (normal) % 25 - 35

Monocytes 8 (high) % 3-7

Platelet count 229 (normal) 10​3​ / mm​3 130 - 400

Mean Corpuscular 96.57 (high) µm​3 82 - 92


Volume (MCV)

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Mean Corpuscular 31.26 (normal) g/dL 27 - 32
Hemoglobin
(MCH)

The patient’s complete blood count was taken last November 4, 2017, same day
as her admission to the hospital. Results show that she has low hemoglobin levels at
11.12 mg/dL (N.V. 12 - 15 mg/dL), whereas elevated levels of WBC, monocytes, and
MCV were recorded, which may be indicative of an infection.

Table 2. ​Blood chemistry of the patient taken last November 4, 2017.

CHEMISTRY RESULTS UNIT NORMAL VALUES

Uric acid 7.1 (normal) mg/dL 2.6 - 7.2

Sodium 140 (normal) mmol/L 135 - 148

Potassium 2.79 (low) mmol/L 3.50 - 5.30

RBS 166 (high) mg/dL 80 - 140

Ionized Ca 4.48 (low) mg/dL 4.64 - 5.28

BUN 70 (high) mg/dL 7 - 18

Creatinine 4.20 (high) mg/dL 0.42 - 1.09

The patient’s blood chemistry showed low levels for potassium and ionized
calcium, which may be the primary reason for her initial diagnosis with electrolyte
imbalance. On the other hand, her BUN levels is significantly high at 70 mg/dL (N.V.
7 - 18 mg/dL), as well as her creatinine at 4.20 mg/dL (N.V. 0.42 - 1.09 mg/dL).
These elevated levels are manifestations of impaired kidney function at an advanced
stage. The patient’s RBS is elevated as well, at 166 mg/dL (n.v. 80 - 140 mg/dL).

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Table 3. ​Urinalysis of the patient taken last November 4, 2017.

URINALYSIS RESULTS UNIT NORMAL VALUES

pH 6.0 (normal) - 6.0 - 7.0

Specific gravity 1.020 (normal) - 1.002 - 1.030

Sugar Trace (normal) mmol/L 0 - 0.8

Albumin +1 - 0

The patient’s urinalysis tested for pH, specific gravity, sugar, and albumin.
Results show that the patient has albuminuria, or has albumin in her urine - this is
another sign of kidney damage.

C. Biophysical Assessment
The patient had a blood pressure of 140/80 mmHg upon admission, which is
above normal. This is a risk factor to the diagnosis of CKD as well as hypertensive
nephrosclerosis. Fortunately, the blood pressure of the patient was normalized to
110/80 upon confinement.

D. Clinical Assessment
The patient experienced a generalized body weakness, persistent headache, and
persistent epigastric pain prior to her admission. A feeling of fatigue was still evident
with the patient during her confinement in the hospital.

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E. Dietary Assessment
1. During confinement
Table 4. ​Quantitative evaluation of patient’s one-day food intake during
confinement.

Time / Menu HH Food Ex / CHO CHON Fat Energy


Measure Group (g) (g) (g) (kcal)

Breakfast:
Pork, ground 1 serv 2 LF Meat - 16 2 81
Oil - 2 Fat - - 10 90
Banana 1 piece 1 Fruit 10 - - 40
Rice ⅓ cup ⅔ Rice 15.3 1.3 - 66.7
Non-fat milk 1 cup 1 Milk, 12 8 Tr 80
Skimmed
Lunch:
Chicken 1 piece 1 LF Meat - 8 1 41
Sotanghon ½ cup 0.5 Rice 11.5 1 - 50
Rice ½ cup 1 Rice 23 2 - 100

PM Snack:
Suman sa ibos 2 pieces 2 Rice 46 4 - 200

Dinner:
Chicken 2 piece 1 LF Meat - 16 2 82
Sayote ¼ cup ¾ Veg B 2.3 0.8 - 12
Carrots ¼ cup
Rice ½ cup 1 Rice 23 2 - 100

TOTAL 143.1 g 59.1 g 15 g 943.7 kcal

The patient was prescribed with a DM diet during her confinement, with
which food items are listed above. According to the patient, all foods that
were provided were not modified in consistency, and thus seemed to be a
regular diet.

The adequacy of the food intake was computed based on the patient’s total
energy requirement. The patient’s total food intake showed that she consumed
57.19% of her daily energy requirements. Moreover, only 59.63% of
carbohydrate and 25.00% of fat requirement were met by her food intake. But,

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her protein intake was excessive by 47.75%, because her protein requirements
are restricted because of her CKD (see appendix for computations).

According to the patient, her food intake during confinement was


significantly decreased, due to loss of appetite and her food preferences. It can
be observed that the given food intake of the patient is inadequate, which can
cause even more weakness and fatigue from her. The prescribed diet, although
specific for patients with DM, is not appropriate for the patient’s final
diagnosis which is CKD, primarily because the protein restrictions specific for
the patient were not accounted for.

Table 5. ​Qualitative evaluation of the patient’s one-day food intake during


confinement.

Food groups Recommended Actual Intake Variance


amounts

Water 6 to 8 glasses 6 glasses As recommended

Rice and 4 ½ to 6 servings 5 servings As recommended


products

Fruits 2 servings 1 serving Deficient

Vegetables 3 servings 1 serving Deficient

Milk and 1 glass 1 As recommended


products

Egg 1 piece - Deficient

Meat, fish, 2 to 3 servings 4 servings Excessive


beans, and nuts

Sugars/Sweets 4 to 6 teaspoons - Deficient*

Fats and oils 2 to 5 teaspoons 3 teaspoons As recommended

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F. Drug and Nutrient Interaction
Table 5. ​Nutrient-drug interactions.

Nutrient-drug
Medication Indication interactions Dietary Strategies

Vasalat Management of Its active ingredient is -


hypertension and amlodipine which
prophylaxis of inhibits the cellular
angina. movement of calcium
ions across cell
membranes.

Clopidogrel Prevention of heart - -


attack and stroke for
persons with heart
disease (recent heart
attack), recent
stroke, or blood
circulation disease
(peripheral vascular
disease).

Ketobest Prevention of Hypercalcemia may Lessen intake of


therapy damages develop due to vitamin D
due to faulty or disturbed amino acid
deficient protein metabolism.
metabolism in
chronic renal
insufficiency.

Insuget N Treatment of Increase in appetite -


patients with which may result to
diabetes mellitus. weight gain.

Zoltax Treatment of - -
susceptible
infections.

Ketosteril Prevention and - -


therapy of damages
due to CKD until
GFR is 15 mL/min,
i.e. Stages II to IV
of CKD.

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Atenurix Treatment of - -
chronic
hyperuricemia in
conditions where
urate deposition has
already occurred.

Fortifer FA Treatment and Decreases absorption -


prevention of iron of iron with
deficiency and tetracycline and
nutritional anemia. antacids

VI. NUTRITION CARE PLAN


A. Nutrition and Non-Nutrition Related Problems
Table 6. ​Nutrition and non-nutrition related problems based on the nutrition
assessment.

Parameters Nutrition-related Problem Other Related


Problem/s

Anthropometry Has experienced weight loss n/a


for the past year due to DM

Biochemical Elevated levels of:


- WBC Infection, impaired
- Monocytes kidney function,
- MCV albuminuria, electrolyte
- BUN imbalance
- Creatinine
- Albumin (+ 1)
Low levels of:
- Hgb
- K
- Ionized Ca

Clinical Generalized body weakness, n/a


recurrent headache, and
persistent epigastric pain

Dietary Loss of appetite, difficulty in n/a


eating

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B. Analysis of Doctor’s Diet Prescription
Table 7. ​Analysis of the diet specific for diabetes mellitus prescribed by the physician
to the patient.

Nutrient Amount % Remarks Rationale


Distribution (Agree /
Disagree)

Calories 996 kcal - Disagree Inadequate for the energy


requirement of the patient
to attain optimal
nutritional status.

Macronutrient
a. CHO 161.8 g 64.98 % Disagree Inadequate

b. CHON 53.8 g 21.61 % Disagree Excessive since the


patient has CHON
restriction due to CKD

c. Fat 15 g 13.55 % Disagree Inadequate, should at least


have 55 g from Fat

Frequency of 3 times - Disagree The meals should be


meals evenly distributed in
small amounts throughout
the day, to avoid the onset
of hunger that can add to
weakening of the muscles
of the patient.

Consistency of Normal / - Disagree The diet should be of soft


meals regular consistency to facilitate
the chewing and
swallowing of the patient
and thus avoid choking.

Type of diet DM - Agree However, it should be


taken into consideration
that the patient is also
diagnosed with CKD.

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VII. RECOMMENDATIONS
A. Dietary Recommendations
Table 8. ​Dietary recommendations for the patient.

Short Term Long Term


Management
Recommendation Rationale Recommendation Rationale

Calories 1650 kcal To provide 1650 kcal To provide


adequate adequate
energy energy

Macronutrient
a. CHO 240 g To provide 240 g To provide
energy, to energy, to
maintain regulate blood
normal glucose glucose level
level

b. CHON 40 g GFR is 25 40 g GFR is 25

c. Fat 60g To control BP 60g To control BP

Micronutrients
a. Na 2000 mg To prevent 2000 mg To prevent
HPN, water HPN, water
retention, and retention, and
edema edema

b. K 1600 mg To prevent 1600 mg To prevent


hyperkalemia hyperkalemia

c. P 680 mg To prevent 680 mg To prevent


hyperphosphate hyperphosphate
mia mia

d. Ca 1500 mg To prevent 1500 mg To prevent


hyperphosphate hyperphosphate
mia and prevent mia and prevent
renal renal
osteodystrophy osteodystrophy

Frequency of CHO is is To regulate SFF To regulate


meals distributed glucose intake nutrient intake
equally for each and body
meals (⅓-⅓-⅓) wastes

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Consistency of Soft To facilitate the Regular -
meals chewing and
swallowing of
the patient

Type of diet Consistent- To help Consistent- To help


CHO, CHON- facilitate the CHO, CHON- facilitate the
restricted, management of restricted, management of
fat-controlled the disease fat-controlled the disease
condition condition

VIII. REFERENCES
● Levey, A.S. (2012). Chronic Kidney Disease. Lancet. 379:165-180.
● Mahan, L., & Raymond, J. (2017). Krause's Food & The Nutrition Care Process (14th
ed.). Canada: Elsevier Inc.
● Porth, C.M. (2015). Essentials of Pathophysiology Concepts of Altered Health States.
Lippincott Williams and Wilkins.
● Youdim, A. (n.d.). Nutrient-Drug Interactions. Retrieved November 20, 2017 from
http://www.merckmanuals.com/professional/nutritional-disorders/nutrition-general-co
nsiderations/nutrient-drug-interactions

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IX. APPENDICES
A. NCP using ADIME format
NUTRITIONAL ASSESSMENT:
Anthropometric: ​The patient is a 64 y/o female standing 5’5” and weighing 64 kg.
Using the Tannhauser’s method, her DBW is BMI is 23.51 kg/m​2​, which is classified
as normal based on the WHO BMI cut-off points.

Biochemical: ​The patient’s complete blood count show elevated levels of WBC at
25.2 x 10​3​/mm​3 (n.v. 4.5 - 10.5 x 10​3​/mm​3​), monocytes at 8.0 % (n.v. 3.0 - 7.0 %),
and MCV at 96.57 µm​3 (n.v. 82.0 - 92.0 µm​3​), while having below normal levels of
Hgb at 11.12 mg/dL (n.v. 12 - 15 mg/dL). For her blood chemistry, results show that
she has below normal levels for K at 2.79 mmol/L (n.v. 3.50 - 5.30 mmol/L) and
ionized Ca at 4.48 mg/dL (n.v. 4.64 - 5.28 mg/dL), while having elevated levels of
BUN at 70 mg/dL (n.v. 7 - 18 mg/dL), creatinine at 4.20 mg/dL (n.v. 0.42 - 1.09
mg/dL), and RBS at 166 mg/dL (n.v. 80 - 140 mg/dL).

Biophysical: ​The patient had a blood pressure of 140/80 mmHg which is above the
normal levels of 120/80 mmHg.

Clinical: ​The patient experienced a generalized body weakness, recurrent headache,


and persistent epigastric pain. The patient also feels fatigued even without vigorous
physical activity.

Dietary: ​The patient experienced loss of appetite.

Others: ​The patient was prescribed with Vasalat, Clopidogrel, Kerobest, Insuget N,
Zoltax, Ketosteril, Atenurix, and Fortifer FA

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NUTRITIONAL DIAGNOSIS:
1. Azotemia related to chronic kidney disease as evidenced by blood chemistry
results of elevated BUN at 70 mg/dL (n.v. 7 - 18 mg/dL).
2. Hypertension related to hypertensive nephrosclerosis as evidenced by elevated
blood pressure of 140/80 mmHg (n.v. 120/80 mmHg).
3. Hyperglycemia related to type 2 diabetes mellitus as evidenced by blood
chemistry results of elevated RBS at 166 mg/dL (n.v. 80 - 140 mg/dL).
4. Albuminuria related to chronic kidney disease as evidenced by urinalysis result of
+ 1 in albumin.
5. Leukocytosis related to ______ as evidenced by blood chemistry results of
elevated WBC monocytes, and MCV.
6. Risk of hypercalcemia related to disturbance in amino acid metabolism caused by
the intake of the prescribed medication, Ketobest.

NUTRITIONAL INTERVENTION
1. Short term interventions
Table 9. ​Short term interventions for the patient.

Objectives Interventions Monitoring and


Evaluation

Attain normal Provide CHON sources Ask the patient to keep a


biochemical levels of with ⅔ HBV and ⅓ LBV food record to be checked
BUN and albumin. for easy absorption and by the dietitian weekly;
essential AA to improve Monitor for clinical signs
BUN and albumin levels; and symptoms;
sodium and Monitor patient’s blood
potassium-restricted diet chemistry levels after one
(Na < 2000mg and K < month of compliance. If the
1600mg) to prevent HPN, patient’s blood chemistry
edema, hyperphosphatemia, levels normalize, then the
and hyperkalemia with Diet intervention is successful.
Rx of 1650 kcal CHO​240g Otherwise, reassess.
PRO​40g​ FAT​60g

Attain normal BP of Prescribe a fat-controlled, Monitor patient’s blood

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120/80 mmHg low-cholesterol (< 200 mg), pressure daily by asking her
and low sodium (< 2000 to visit nearby health center.
mg), diet Rx of 1650 kcal If the blood pressure is
CHO​240g​ PRO​40g​ FAT​60g within the normal range
(120/80), then the
intervention is successful.
Otherwise, reassess.

Attain normal RBS Prescribe Diet Rx: 1650 Let the patient have her
levels of 80 - 140 kcal CHO​240g​ PRO​40g​ FAT​60g RBS checked at least every
mg/dL That is consistent in week or teach the patient on
carbohydrate divided into SMBG. If the blood glucose
three meals and three is within the normal range,
snacks. then the intervention is
successful. Otherwise,
reassess.

Short term calculations:


BMI = weight (kg) / height (m​2​)
BMI = 64 kg / (1.65 m​2​)
BMI = 23.51 kg/m​2​ (Normal : WHO cut-off points)

DBW = (height (cm) - 100) - [10% (height in cm - 100)]


DBW = (165.1 cm - 100) - [10% (165.1 cm - 100)]
DBW = 65.1 - (0.10 x 65.1)
DBW = 59 kg

GFR = {[weight (kg) x 140 - age (yrs)] / (72 x serum creatinine)} x 0.85
GFR = {[64 kg x 140 - 64 yrs] / (72 x 4.20 mg/dL)} x 0.85
GFR = {8896 / 302.4} x 0.85
GFR = 25.01 mL/min

TER (Krause method) = DBW x P.A.


TER = 59 kg x 30

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TER = 1770 kcal - (7.3%)
TER = 1640.79 ~ 1650 kcal

CHON = 0.7g/kgDBW HBV (⅔) = ⅔ (40) = ​25 g HBV


CHON = 0.7g x 59kg LBV (⅓) = ⅓ (40) = ​15 g LBV
CHON = 41.3 ~ 40g

NPC = TER - kcal from CHON


NPC = 1650 kcal - 160 kcal from CHON
NPC = 1490 kcal

kcal CHO = 1490 x 0.65 = 968.5 kcal / 4 kcal per g = ​240 g CHO
kcal Fat = 1490 x 0.35 = 521.5 kcal / 9 kcal per g = ​60 g Fat
SFA = ​(1650 kcal x 0.07) / 9 kcal per g = < 13.0 mg
PUFA = ​(1650 kcal x 0.10) / 9 kcal per g = up to 18.0 mg
MUFA = ​(1650 kcal x 0.20) / 9 kcal per g = up to 37.0 mg

Diet Rx: ​1650 kcal CHO​240g​ PRO​40g​ FAT​60g


Cholesterol < 200 mg Na 2000 mg
SFA < 14.0 mg K 1600 mg
PUFA up to 18.0 mg P 680 mg
MUFA up to 37.0 mg Ca 1500 mg
Fiber up to 25 g Fluid 1500 mL

Table 10. ​One-day sample menu for the short-term interventions

MEAL FOOD NO. OF FOOD ITEM/S HH MEASURE


GROUP EX

BREAKFAST Rice 2 Rice, fried 1 cup


Fat 2 Coconut Oil 2 tsp
Tortang talong
Veg A 1 Egg plant ½ cup or 1 piece small

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Meat MF 1 Egg 1 piece
Fat 2 Coconut Oil 2 tsp
Fruit 1 Orange Juice 1 glass
Fat 1 Avocado ½ piece

AM SNACK Rice 1 Camote, Boiled 1 piece

LUNCH Rice 1 Spaghetti


Rice 0.5 Toasted bread 1 piece
Rice 0.5 Mashed potato
Fat 1 Butter 1 Tbsp
Buttered vegetables
Veg B 0.5 Carrots ¼ cup
Rice 0.5 Corn
Fat o.5 Butter ½ Tbsp

PM SNACK Clubhouse sandwhich


Rice 1 Loaf bread 2 slices
Veg A 1 Tomato, lettuce, ½ cup
Cucumber
Meat LF 1 Ham 1 slice
Fat 2 Mayonnaise 2 Tbsp

DINNER Rice 2 Rice 1 cup


Ginataang Kalabasa
Veg B 0.5 Squash, String beans ½ cup
Fat 1 Coconut Cream 1 Tbsp
Meat LF 1 Chicken strips 1 matchbox size
Fruit 2 Saba, boiled 2 pieces

MN SNACK Veg B 2 Pureed Carrot Juice 1 glass

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