Case Study 19 – Chronic Kidney Disease Treated with Dialysis

Notes – Female, 24 yrs, African American. Diagnosed w/ T2D at age 13 Diagnosed with
stage 3 CKD 2 yrs ago. . Poorly compliant with prescribed treatment. Declining GFR,
increased creatinine and urea concentration, elevated serum phosphate, and normocytic
anemia. Admitted for kidney replacement therapy. T2DM runs in family. Complaints –
anorexia, N/V, weight gain, edema in extremities, 3-pillow orthopnea, muscle cramps,
and inability to urinate. Vitals - BP 220/80. Height 5’0. Weight 170 ibs. 3+ pitting edema
to knees. Nutrition – poor intake due to anorexia, N&V, current diet: low simple sugar,
0.8g protein/kg, 2-3g Na. Does not follow diet taught for CKD. No vit/sup intake. Lab
values- low Na, high K, high BUN, high Cr, extremely low GFR, high glucose, high P,
low protein, high cholesterol, high TG’s. Urine lab values – high pH, high protein,
glucose, ketones present

2. Diseases/conditions that can lead to CKD: Diabetes, hypertension, autoimmune

diseases, systemic infections, urinary tract infections, stones, cancer, family history of
CKD, and exposure to certain drugs.
Diabetes can lead to CKD – glomeruli filter waste filter waste from blood into urine for
excretion. High levels of blood glucose from uncontrolled DM can lead to changes in the
nephrons, by causing thickening of glomeruli. Due to the compromised glomerulus,
larger amounts of protein pass from the blood into the urine for excretion. At first the
amount of protein in the urine is small, but overtime, the damage worsens causing
diabetic nephropathy.

3.
Stage Signs & Symptoms
1 Kidney damage with normal or increased GFR of >90 mL/min. Blood flow through
kidney’s increases and kidneys increase in size. No signs present
2 Kidney damage with a mild decrease in GFR of 60-89 mL/min. Albuminuria <30 mg/d.
3 Kidney damage with a moderate decrease in GFR 30-59 mL/min. Microalbuminuria present.
Losses increase to 30-300 mg/d
4 Advanced kidney damage with GFR 15-29 mL/min. Nephropathy. Large amounts of protein
in urine. BP incr. New symptoms of taste change, anorexia, nausea, & difficulty
concentrating.
5 ESRD with GFR <15 mL/min. Kidneys fail so toxins build up in the blood. Symptoms –
anorexia, headaches, fatigue, muscle cramps, edema, nausea & vomiting.

4. Patient History: diagnosed with T2D at 13 yrs old. Non-compliant with prescribe
treatment. Declining GFR over the years. Increased creatinine and urea concentration.
Elevated serum phosphate. Physical exam: High BP. Muscle weakness. 3+ pitting edema
Symptoms: anorexia, muscle cramps, inability to urinate, and weigh gain.

5. If a patient reaches Stage 5, RRT becomes necessary and nutrition therapy is crucial.
Treatment options are kidney transplant or intermittent dialysis therapy (hemodialysis or PD).
Hemodialysis – a patient on hemodialysis spends 3-5 hours per treatment (machine)
given 3 times a week. There are 3 primary sites: an intravenous catheter, an arteriovenous
(AV) fistula, and a synthetic graft
Peritoneal Dialysis (PD) – With PD dialysate is instilled into the peritoneum and is used
to remove waste. This treatment is completed every day of the week. Fluid is introduced
through a permanent tube in the abdomen and flushed out either every night during sleep
(automatic PD) or via regular exchanges throughout the day (continuous ambulatory PD)

6.
Nutrition Therapy Reason
35 kcal/kg According to NKF patients need an energy intake of 35 kcal/kg/day
if younger than 60 years of age. This provided adequate calories to
prevent excessive protein loss from dialysis.
1.2 g protein/kg Restriction in protein helps kidneys work less, which helps delay
progression of CKD. However, patients on hemodialysis need more
protein due to the protein loss from dialysis. It is important to
provide adequate protein to prevent protein energy malnutrition and
to conserve serum protein.
2gK Restriction of dietary K is necessary because the kidneys are unable
to remove K. High K levels can cause abnormal heart rhythms.
1 g phosphorous Restriction in P levels is also related to kidneys being unable to
remove P. High levels of P can lead to hyperphosphatemia which
overtime can lead to hypocalcemia, hardening of tissues in heart,
arteries, etc. and can lead to serious health problems.
2 g Na Sodium restriction is important to control fluid intake, fluid
retention, and to control high blood pressure
1000 mL fluid + urine output Fluid restriction is very important to monitor as kidney function
declines. CKD patients do not urinate often, thus edema is common
which leads to increased BP, weight gain, and congestive HF.

10. Use IBW for patients with edema.

Energy Requirements: 35 kcal/kg - 59kg x 35kcal = 2065 kcal/day
Protein Requirements: 1.2g/day – 59kg x 1.2g = 71g protein/day

11. Protein needs in stage 1 and 2 protein needs are the standard 0.8/kg/day. Stage 3 and
4 need to be reduced to 0.6 g/kg/day, which help kidneys work less. PD requires more
protein (1.2 -1.5g/day) that hemodialysis (1.2g/day). This is because there is more protein
loss per session in PD.

14. The GFR measures the rate at which substances are cleared from the plasma by the
glomeruli. The GFR is used as an index of kidney function. Normal GFR is 90 – 120
mL/min. Anything lower than 90 mL/min indicates there is some kidney damage. Mrs.
J’s GFR is 4. This indicates she is in stage 5, kidney failure - severe destruction to
kidneys.
Case Study 20 – Chronic Kidney Disease (Peritoneal Dialysis)
Notes – Female, 49 yrs old. History – diagnosed w/ glomerulonephritis 15 yrs ago
resulting in ESRD. Kidney transplant X2. Admitted – transplant failure, shortness of
breath, fluid retention, and came for insertion of PD catheter. Medical history – allograft
transplant x2, hypertension, dyslipidemia, anemia of CKD. Tobacco use 1 pack per day
for 20 yrs, stopped 5-6 yrs ago. Vitals – BP 161/92, Height 157.4cm, Weight 77.1 kg,
UBW 74kg. No peripheral edema present. Urine- cloudy, amber. Diet: 1500 kcal, 75g
pro, 3000 mg Na, 35000 mg K, 1000mg P, 2000 cc fluid. Patient states mild nausea, no
vomiting, decreased appetite, food tastes bad, and has only been monitoring salt intake.
Lab values – low Na, high BUN, high Cr, low GFR, high K, low Ca, low protein &
albumin, low HDL, low ferritin, low Hgb, and Hct.

7. Once she starts dialysis her protein needs should increase to 1.2 to 1.5 g per kg of
body weight as peritoneal dialysis promotes protein loss of up to 1 g per hour. In
addition, per KDOQI guidelines, her energy needs should be increased to 35 kcal/kg in
order to provide adequate energy to avoid protein sparing that can occur in dialysis.
Diet Rationale Change after PD
To achieve and maintain IBW; restricted calories to Increase energy to 30-35
1500 kcal about 26 kcal per kg body weight kcal/kg ABW
77g/kg ABW or 68g/kg IBW for impaired renal
75g pro function 1.2-1.5g/kg IBW
3000 mg Na 2-3g/day for impaired renal function  2-4g sodium is needed
3500 mg K Increased to cover loss with diuretics 3-4 g potassium
1000 mg P 0.8-1.2g/day for impaired renal function  0.8-1.2g/day
2000 cc Minimum 2000 mL/day
fluid For fluid intake/output balance urine output

8. Ht – 157.4cm (61.97in) BMI: (169.96 x 703) / (61.97)2 = 31

Wt – 77.1kg (169.96ibs) %UBW: (100 x 169.96) / 163 = 104%
UBW = 74kg (163) IBW: 52kg (115ibs)
Adjusted body weight: .25(169.96-115)+115 = 129ibs

Edema increases water weight and amount of weight gained between dialyses. She
gained 3kg from body fluid.

11. Renal patients suffer from anemia because the kidney no longer produces EPO to
stimulate red blood cell production in the bone marrow. Usually, renal patients are treated
with EPO and most need IV iron supplementation. When serum ferritin falls below 100
ng/mL, IV iron is usually given.

Case Study 21 – Acute Kidney Injury (AKI)

Notes – Male, 67, Diagnosed w/ AKI postop day 7 (10/16). Admitted for surgery: CABG
10/9. S/P: surgery was successful. Recovery been complicated: respiratory distress,
subsequent intubation, and infection. Medical history – CAD, MI 15 years ago,
hyperlipidemia, and type 2 DM. Medications – lovastatin, Lasix, Lopressor. Allergies –
penicillin, sulfa. Tobacco use 2 packs per day for 20 years, stopped 1 year ago. Family
history – mother: diabetes & breast cancer, father: heart disease & lung cancer. Demo –
divorced, lives by himself. Progress note – POD#7 with decreased urine output, urine
appearance: cloudy, amber. Lab values – high potassium, high BUN, high creatinine
serum, low GFR, high glucose, low protein/prealbumin, high ALT, AST.

3. The major etiology of MR. Maddox AKI is age, history of heart problems, and type 2
diabetes.
Prerenal AKI – condition that reduces blood flow to kidneys. Cause: severe dehydration
Intrarenal AKI – condition that damages the glomeruli, interstitial tissue, or tubules.
Cause: acute glomerular nephritis, exposure to nephrotoxins, glomerulonephritis, tubular
necrosis
Postrenal – obstruction of urine flow. Cause: carcinoma and stones

Stage Serum Creatinine Urine Output

1 1.5 -1.9 x baseline or ≥ to 0.3 mg/dL <0.5 mL/kg/h for 6-12h
increase
2 2.0-2.9 x baseline <0.5 mL/kg/h for ≥ 12 h
3 3.0 x baseline or increase to ≥ 4.0 mg/dL <0.3 mL/kg/h for >24h or
anuria for ≥ 12h

4. It is well accepted that restriction of protein should not be a component of care for
AKI patients. Protein recommendations are 0.8-1.0 g/kg/day for non dialysis patients;
1.0-1.5 g/dg/day for patients on RRT. Adequate kcals need to be provided (30-
35kcal/kg). If patient is on dialysis, PD patients need less glucose than those on
hemodialysis. Energy, protein, and fluid requirements constantly need to be monitored in
patients with kidney disease because of constant changing of function. Since different
disease types and AKI stages can affect patients in a variety of ways, nutrition is best
tailored to individual needs, taking account clinical condition and treatment.

5.
High K due to tissue destruction, shock, acidosis, dehydration, and inadequate kidney
function
High BUN due to hypercatabolism and the acute assault to his kidneys
High Cr due to AKI. Creatinine can be produced as a result of the acute assault to the
kidney; there is also a lot of nitrogenous waste accumulation
Low GFR: the most common measurement of kidney function. This is low most likely
due to the low renal blood supply or damage from the infection causing the kidney
dysfunction.
High glucose due to the patient’s history of diabetes, as well as the acute infection and
recent events (MI, surgery) that cause systemic stress and decreased glucose utilization
High phosphorus is common with kidney disease because the kidneys cannot filter this
electrolyte as efficiently. Thus, phosphate and potassium are the most common
electrolyte imbalances. These electrolyte imbalances are probably not due to excessive
protein intake based on the low protein value and documented low PO intake.
Low prealbumin due to fluid overload (present edema), the inflammatory response from
the infection and protein losses due to kidney dysfunction

7. Nutrition therapy recommendation change when a patient is receiving CRRT is

protein. Protein can increase up to 1.5 - 2.0 g/kg/day. When not receiving any dialysis
protein levels range from 0.6 -1.0 g/kg/day depending on what stage AKI the patient is in.