19-1 Kimberly LaBrecque NTR 404/504 Case Study No. 19 Case Questions for Medical Nutrition Therapy: A Case Study Approach 4th ed. Title: Case 19 – Chronic Kidney Disease: Peritoneal Dialysis Instructions: Answer the questions below. You may print your answers or e-mail them to your instructor. Questions: 1. Describe the major exocrine and endocrine functions of the kidney. The kidney’s primary exocrine function is the elimination of nitrogenous wastes from the body through the excretion of urine. The kidneys filter almost 1600 L of blood on a daily basis to produce ultrafiltrate. Most of the ultrafiltrate is reabsorbed by the kidneys’ tubules, which convert the remaining components to urine. Anywhere from 500 mL to 12 L of urine is excreted daily. The main hormone that regulates this process is vasopressin (or antidiuretic hormone). Inadequate amounts of water and increase in osmolality stimulates the release of vasopressin by the posterior pituitary. Vasopressin causes the kidneys to retain water (Mahan, Escott-Stump & Raymond, 2012, p. 800). As for endocrine functions, the kidneys regulate blood volume and red blood cell production through the renin angiotensin mechanism and synthesis of erythropoietin. When blood volume declines, this stimulates the glomerulus to release the enzyme renin. Renin catalyzes the formation and conversion of angiotensin I to angiotensin II. Angiotensin II stimulates the adrenal glands to release the hormone aldosterone, which in turn encourages sodium and water retention while constricting the vasculature to increase blood pressure. The function of the hormone erythropoietin is to stimulate red blood cell production in the bone marrow. The kidneys also play a role in calcium homeostasis by converting vitamin D into an active form, D-1, 25-dihydroxycholecalciferol. 1, 25-dihydroxycholecalciferol inhibits the parathyroid hormone from stimulating the osteoclasts to break down and resorb bone, and facilitates the absorption of calcium in the intestines (Mahan et al., 2012, pp. 800-801). 2. What is glomerulonephritis and how can it lead to kidney failure? Glomerulonephritis results in the inflammation and injury of the glomerulus. The glomerulus synthesizes the ultrafiltrate and consists of a membrane-bound network of capillaries within each nephron. Glomerulonephritis can be acute, or can lead to chronic kidney disease as well as end stage renal disease, and symptoms include hypertension, hematuria and decline in kidney filtration and function. Acute forms of glomerulonephritis may result from a streptococcal infection (Mahan et al., 2012, p. 813). © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-2 3. What laboratory values or other tests support Ms. C’s diagnosis of chronic kidney disease? List all abnormal values and explain the likely cause for each abnormal value. Lab Value Ms. C Normal Range Etiology Sodium 130 mEq/L 136 – 145 mEq/L Increased fluid retention may have resulted in mild hyponatremia. Bicarbonate 16 mEq/L 21-32 According to KDOQI guidelines, serum bicarbonate levels are reduced in patients with a GFR less than 60 mL/min/1.73 m2. The low levels may indicate acidemia and overall protein catabolic state. Low serum bicarbonate is often correlated with low albumin. BUN 124 mg/dL 12-18 mg/dL This value is high even for patients on dialysis. It indicates that Ms. C’s kidneys are not adequately eliminating nitrogenous wastes. Dialysis Patients: 50100 mg/dL Creatinine serum 6.8 mg/dL GFR (nonAfrican American) 6 mL/min/1.73 m2 61-589 mL/min/1.73 m2 GFR (AfricanAmerican patients) 8 mL/min/1.73 m2 61-714 mL/min/1.73 m2 Phosphate 11.9 mg/dL 2.3-4.7 mg/dL (inorganic) 0.6-1.2 mg/dL Dialysis: <15 mg/dL Dialysis: 3.0-5.5 mg/dL Most patients with chronic kidney disease have high creatinine levels. This results from muscle and protein catabolism. In addition, daily or frequent dialysis can lower creatinine levels. The GFR measures the quantity of filtrate produced by the nephrons and is indicative of end stage renal disease. Low GFR demonstrates that the kidneys are not able to filter and eliminate the waste products of metabolism. Phosphate levels increase as GFR declines so more phosphate remains in the bloodstream. A diet high in protein as well as processed foods will also be high in phosphorus. Ms. C’s consumption of an egg McMuffin, cheeseburger, cola and roast beef are contributing to higher phosphate levels. However, she does take Renvela, a phosphate binder. © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-3 Lab Value Ms. C Normal Range Etiology Calcium 8.3 mg/dL 9-11 mg/dL The kidneys are unable to convert to active Vitamin D, which aids in calcium absorption. The patient’s phosphate levels are high so calcium needs increase. The posterior pituitary continues to release parathyroid hormone, which stimulates the osteoclasts to break down resorb bone. The product of Ms. C’s phosphate and calcium is about 98.7, which puts her at risk for calciphylaxis. Dialysis: 8.5-10.2 mg/dL Anion Gap 22 mmol/L 10-20 mmol/L The higher value is indicative of metabolic acidosis caused by Ms. C’s potential uremia. As metabolic and nitrogenous wastes accumulate, the kidneys are unable to maintain an appropriate acidbase balance. Protein, total 5.9 g/dL 6-8 g/dL Although Ms. C’s protein lab value is not much lower than normal, it may indicate that she is in a catabolic state and her body is degrading protein faster than its rate of synthesis. Albumin 3.4 g/dL 3.0-5.5 g/dL Although this value is normal for patients without renal disease, Ms. C is returning to dialysis. KDOQI guidelines indicate that increased mortality is associated with renal patients who have albumin levels under 4 g/dL. Because albumin helps maintain osmotic pressure in the plasma, lower levels result in edema. Dialysis: >3.5 g/dL PT (sec) 12.4-14.4 (sec) 16.9 sec This value indicates and increased risk for blood clots. © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-4 Lab Value Ms. C Normal Range Etiology RBC 2.33 x 106/mm3 4.2-5.4 x 106/mm3 Ms. C’s red blood cell count is low due to reduced production of erythropoietin, which stimulates the bone marrow to synthesize red blood cells. Ms. C’s uremia may also cause destruction to existing red blood cells so both of these factors may be contributing to her reduced red blood cell count. Hemoglobin 6.6 g/dL 12-15 g/dL Ms. C has a reduced number of red blood cells as well as transferrin and ferritin (indicating low hepatic iron stores). Hemoglobin measures the amount of iron in red blood cells. Hematocrit 19.0 % 37-47 % Hematocrit reflects the overall percentage of red blood cells in Ms. C’s bloodstream. This is low due to Ms. C’s reduced erythropoietin and red blood cell production. Mean Cell Volume 65.3 µm3 80-96 µm3 Ms. C’s red blood cells are smaller than normal and may reflect a lack of or diminished amount of erythropoietin. Mean Cell Hgb 21.5 pg 26-32 pg Mean Cell Hgb Content 19.5 g/dL 31.5-36 g/dL These lower values may be caused by the reduced synthesis and number of red blood cells as well as erythropoietin. RBC Distribution 16.8 % 11.6-16.5 % Transferrin 219 mg/dL 250-380 mg/dL Transferrin carries iron to the bone marrow for hemoglobin synthesis. This value may decrease with inflammation and increase with low iron stores. Ferritin 5 mg/mL 20-120 mg/mL Low ferritin levels indicate low hepatic iron stores and reduced absorption of iron. Declining renal function leads to reduced erythropoietin, which stimulates red blood cell production. Since © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-5 Ms. C’s red blood cell count and hemoglobin values are low, she may require an infusion of iron. 4. This patient has had two previous kidney transplants. What are the potential sources for a donor kidney? How is rejection prevented after a kidney transplant? What does it mean when the physician states she is experiencing acute rejection? According to the National Kidney Foundation, kidneys are donated from either a deceased donor on a state registry as well as a living donor through the patient’s transplant center at a hospital. Family members, friends or strangers who are healthy and meet the established criteria of the transplant center are eligible to become donors. Kidney recipients take immunosuppressive medications to avoid rejecting the kidney (Mahan et al., 2012, p. 828). Some of these immunosuppressive medications include sirolimus, calcineurin inhibitors, corticosteroids, tacrolimus and azathioprine. Corticosteroids increase degradation of protein, increase sodium and fluid retention as well as increase excretion of calcium and potassium. This leads to an increased risk of developing osteoporosis with chronic corticosteroid use (Mahan et al., 2012, p. 216). Acute rejection occurs when the patient’s immune system treats the donated kidney as a foreign substance and mounts an immune response to it. Ms. C’s laboratory values and GFR indicate renal failure. In addition, she has dyspnea, nausea, and edema and appears to be uremic by reporting altered food taste and decline in appetite. 5. Based on the admitting history and physical, what signs and symptoms does this patient have that are consistent with acute rejection of the transplant? Ms. C’s laboratory values and GFR indicate renal failure. Specifically, her GFR indicates end stage renal disease since it is less than 15 mL/min/m2. In addition, the patient’s BUN is 124 mg/dL and creatinine is 6.8 mg/dL. Furthermore, Ms. C has dyspnea, edema and appears to be uremic by reporting altered food taste, nausea and an overall decline in appetite. Uremia occurs as nitrogenous wastes accumulate in the plasma and demonstrates end stage renal disease in that the kidneys are not able to maintain an appropriate acid-base balance and are unable to sufficiently excrete metabolic wastes. Additionally, Ms. C’s red blood cell count, hemoglobin and hematocrit are very low indicating her kidneys are not able to synthesize erythropoietin resulting in anemia related to chronic kidney disease. Acute rejection also reduces urine output, although Ms. C’s net intake is greater than her net output, which shows some decline in output although she is not oliguric (Mahan et al., 2012, p. 813). 6. Ms. C has requested that she restart peritoneal dialysis. Describe the basic concepts of this medical treatment and how it differs from hemodialysis. In peritoneal dialysis, a surgeon inserts a catheter into the patient’s peritoneum where a dialysis solution is inserted into the peritoneum. The differences in concentration cause wastes to diffuse out of the bloodstream and into the dialysate. The fluid is then removed and replaced with new dialysate (usually a concentrated dextrose solution). One form of peritoneal dialysis is CCPD, or continuous cycler assisted peritoneal dialysis, in which a © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-6 machine performs the dialysis at night while the patient may keep a long dwell or “single dialysate” during the day. Another form, CAPD, continuous ambulatory peritoneal dialysis, occurs when the dialysate is placed in the peritoneum up to five times a day and filtered by diffusion and gravity. Because peritoneal dialysis occurs more frequently, this provides more stability to serum metabolite fluctuations. However, the dextrose solution can lead to weight gain and the nature of the catheter insertion makes a patient more vulnerable to infections such as peritonitis (Mahan et al., 2012, p. 815). Peritoneal dialysis takes up to 40 minutes per exchange and is recommended up to four times daily. The amount of time the dialysate remains in the peritoneum can be anywhere from four to six hours. In CAPD, the patient is able to ambulate and continue with daily activities. Unlike peritoneal dialysis, hemodialysis is usually performed at an outpatient clinic three times a week. Each session lasts approximately three to five hours, or can occur for shorter time periods more frequently during the week, or while the patient is sleeping at home. In hemodialysis, a surgeon creates a fistula to join an artery and vein where the dialysis needle will be inserted. Wastes are removed from the blood by diffusion through a filter or dialyzer in a machine, and then the filtered blood is returned to the patient’s body (Mahan et al., 2012, p. 815). 7. This patient was prescribed the following diet in the hospital: 1500 kcal, 75 g pro, 3000 mg Na, 3500 mg K, 1000 mg P, 2000 cc fluid. Explain the rationale for each component of her nutrition therapy Rx. How might this change once she has started peritoneal dialysis? The prescribed energy needs reflect the decreased energy needs of a hospitalized patient with impaired kidney function. According to KDOQI guidelines, Ms. C’s energy needs would fall in the 35 kcal/kg range for patient’s under 60 (Mahan et al., 2012, p. 818). Ms. C’s ideal body weight for height is approximately 52.3 kg and multiplied by 30, this would equate to approximately 1569 kcal per day. KDOQI guidelines also indicate that protein needs for patients six weeks following a transplant is approximately 1 g per kg of body weight, which would range from 74 to 77.1 g of protein based on Ms. C’s usual and current body weights. In addition, recommended sodium levels for those with impaired kidneys ranges from 2 to 3 grams daily to reduce edema. Her potassium intake is slightly higher than the 2 to 3 gram recommended range for patients with impaired kidney function and but also reflects serum potassium levels, which were within normal limits, about 3.8 mg/dL. However, Ms. C has been taking a diuretic, Lasix, which promotes potassium excretion, and perhaps this amount is higher to replete the potassium lost from diuretics. According to KDOQI guidelines, patients who receive a transplant usually do not need to limit phosphorus as much as those with impaired function, but since Ms. C has kidney failure and acute rejection, the phosphorus levels reflect recommended amounts between 800 to 1000 mg per day. As for fluid, the amount may be a little higher than what some patients may receive with chronic kidney disease; however, Ms. C does not appear to be oliguric and she is not yet on dialysis (Mahan et al., 2012, pp. 817-819). Once Ms. C starts dialysis; however, her protein needs should increase to 1.2 to 1.3 g per kg of body weight as peritoneal dialysis promotes protein loss of up to 1 g per hour (Mahan et al., 2012, p. 822). In addition, per KDOQI guidelines, Ms. C’s energy needs should be increased to 35 kcal/kg in order to provide adequate energy to avoid protein sparing that can © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-7 occur in dialysis. Likewise, a proportion of calories will have to be deducted from the overall energy needs to compensate the absorption of glucose from the dialysate. 8. Assess Ms. C’s height and weight. Calculate her BMI and her % usual body weight. How would edema affect your interpretation of this information? Using the KDOQI guidelines, what is Ms. C’s adjusted body weight? Ms. C’s admission weight is 77.1 kg though her usual body weight is reported as about 74 kg. Using Ms. C’s current weight and height, her BMI is 31.1 [77.1kg/(1.574)2 ]. Ms. C’s BMI using her usual body weight is 29.9 [74/(1.574)2], and she would be classified as overweight. Ms. C’s ideal body weight is 52.3 kg (115 lbs) based on her height using the Hamwi equation. Her percent usual body weight would be approximately 104 percent (77.1kg /74 kg x 100 %). It appears that Ms. C has gained approximately 3 kg in body fluid. According to KDOQI guidelines, Ms. C’s adjusted body weight is 68.6 kg. aBWef=BWef + [(SBW-BWef) x 0.25] = 74 kg + [(52.3 kg-74kg) x 0.25]= 68.6 kg 9. Determine Ms. C’s energy and protein requirements. Explain the rationale for the method you used to calculate these requirements. Ms. C’s energy needs before dialysis, using the Mifflin St. Jeor formula for normal or overweight patients, are: 1453 kcal per day with a stress factor of 1.1 9.99 x 74 kg + 6.25 x 157.4 cm – 4.92 x 49-161= 1321 kcal x 1.1 stress factor = 1453 kcal An appropriate range might be anywhere from 1500 to 1600 kcal per day, using either a stress factor of either 1.1 or 1.2 since the patient is hospitalized and not ambulatory. As for protein requirements, KDOQI guidelines generally recommend one gram of protein per kilogram of body weight for post-transplant patients (beyond the initial six weeks of surgery). However, Ms. C is experiencing acute kidney rejection and renal failure so her protein needs, before dialysis, should be reduced in light of current labs and a GFR of 6 mL/min/m2. In addition, the patient’s protein requirements should be no more than 0.6 grams per kilogram of body weight. Given Ms. C’s fluid retention and weight gain, as well as BMI of 29.9, it would be appropriate to use the patient’s adjusted body weight, or 68.6 kg. Therefore, pre-dialysis, Ms. C’s protein needs would be about 41 grams per day. Once Ms. C starts peritoneal dialysis, the recommended energy intake according to KDOQI guidelines would be 35 kcal/kg of body weight for patients under 60. This would equate to approximately 2400 kcal per day using Ms. C’s adjusted body weight. It is more appropriate to use the patient’s adjusted body weight since she is retaining fluid and is overweight as evidenced by a BMI of 29.9. This seems high for someone who may not be very active. However, any form of dialysis requires adequate energy to avoid protein sparring since protein depletion occurs with dialysis treatments. Therefore, it is necessary to ensure the patient had adequate energy to avoid the muscle wasting that can occur with severe protein depletion (Mahan et al., 2012, p. 822). Likewise, Ms. C’s protein requirements on dialysis should increase to 1.2 to 1.3 g/kg of body weight to replete the protein lost from dialysis. Using Ms. C’s adjusted body weight, her protein needs would be anywhere from 82 to 89 grams per day. © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-8 10. List all medications that Ms. C is receiving. Determine the action of each medication and identify any drug–nutrient interactions that you should monitor for. Medication Function Drug-Nutrient Interaction Procardia Calcium channel blocker/antihypertensive Patient should avoid consuming grapefruit or related citrus fruits as well as alcohol. Medication should be taken on an empty stomach. Carvedilol Beta blocker/antihypertensive Patient should avoid any foods (dilates blood vessels) containing natural licorice (glycyrrhiza glabra). Medication Also used to treat heart may interfere with calcium failure in patients. absorption. May also cause sodium reabsorption as well as water retention. Catapres (clonidine) Antihypertensive/Alphaadrenergic agonist Patient should avoid any foods containing natural licorice. Patients should have adequate hydration and avoid alcohol while taking medication. CellCept Immunosuppressant (helps prevent kidney transplant rejection Patients should take medication on an empty stomach or two hours after eating. A magnesium supplement or antacid may be recommended (assuming adequate renal function). Lasix Loop diuretic Medication may increase excretion of potassium, magnesium, calcium and sodium. If renal function is adequate, then increased consumption of foods containing potassium, magnesium and calcium may be recommended. Prednisone Corticosteroid, antiinflammatory, immunosuppressant Medication accelerates protein degradation, and reduces calcium absorption. It also promotes fluid and sodium retention as well as increases excretion of potassium, calcium, zinc, vitamin C, and reduced calcium absorption. Supplementation of calcium and © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-9 vitamin D is often required. Medication should be taken with food and patient should limit caffeine to avoid GI disturbance as well as avoid alcohol. Gengraf (cyclosporine) Immunosuppressant Prinivil Antihypertensive, ACE inhibitor Medication may increase serum potassium. Patients should avoid natural licorice as well as salt substitutes. Patients should insure adequate hydration. This medication may be contraindicated in patients who require intravenous iron fusions. Sodium Bicarbonate Antacid, alkalizing agent Medication should be taken after meals, with one cup of water. Patient should use caution with calcium supplementation or high calcium intake. Decreasing sodium may also be recommended. Any iron supplements should be taken two hours after or one hour before taking medication. Calcitriol Calcium supplement used to treat hypocalcemia as well as secondary hyperparathyroidism Patient should avoid using vitamin D or magnesium supplements while taking this medication. For dialysis patients on parenteral IV, avoid high calcium and phosphorus diet. Renal Caps Supplement of B-complex and C vitamins mainly used for patients with chronic kidney disease and dialysis. No specific food or drug interactions. The supplement should be taken daily as prescribed by the patient’s physician. Renvela Phosphate binder Medication should be taken with foods and at mealtime, swallowed whole. Patients need to maintain a low phosphate diet and frequent monitoring of phosphate, calcium and bicarbonate. Medication is used to prevent kidney transplant rejection. Medication may increase sodium and potassium absorption while reducing magnesium levels. It may also increase triglycerides so fat, simple sugars and magnesium intake should be monitored. © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-10 Fish Oil Anti-hyperlipidemic, anticoagulant, antiinflammatory and antiarrhythmic, omega-3 supplement Supplement should be taken with food. Since the patient is allergic to fish, it might be beneficial to recommend a plant-based omega-3 supplement or encourage consumption of foods high in omega-3 fatty acids including flax or chia seeds. 11. Ms. C’s laboratory values that you discussed previously in this case indicate she has anemia. Why do renal patients suffer from anemia? How is this typically treated in dialysis patients? Renal patients often suffer from anemia because their kidneys are unable to synthesize enough of the hormone, erythropoietin. Erythropoietin (EPO) stimulates red blood cell synthesis in the bone marrow. Declining EPO means fewer red blood cells are produced, resulting in reduced hemoglobin. In addition to deficient EPO, dialysis and frequent blood draws may deplete red blood cells. Finally, the accumulation of metabolic wastes in the bloodstream from uremia can destroy existing red blood cells. Most renal dialysis patients take a synthetic form of EPO that can induce red blood cell production 2.5 times which leads to a rise in hematocrit. Often, the rise in red blood cell concentration requires an infusion of iron to meet the increased demand by red blood cells (Mahan et al., 2012, p.825). 12. What factors in Ms. C’s history may affect her ability to eat? What are the most likely causes of these symptoms? Can you expect that they will change? Ms. C has symptoms of uremia, which is typical of patients in end stage renal disease. As Ms. C’s kidneys are unable to eliminate nitrogenous wastes, metabolic wastes, such as ammonia and urea, accumulate in the bloodstream and can cause a patient to experience nausea, vomiting, neurological impairment and a metallic taste in foods (Mahan et al., 2012, p. 813). This may specifically result in food aversions, primarily to protein-containing foods. Some patients are unable to tolerate meat. Other sources of high quality protein may need to be provided such as eggs, tofu and poultry. Seasonings without salt and serving the protein foods cold might alter the taste. The goal is to make food attractive and palatable to encourage the patient to eat. However, once Ms. C begins peritoneal dialysis, her renal function and GFR should improve enough to eliminate her symptoms of uremia, and she should be able to tolerate foods better as her renal function improves (Mahan et al., 2012, p. 822). 13. Evaluate Ms. C’s diet history and 24-hour recall. Is her usual diet consistent with her inpatient diet order? According to Ms. C’s diet history, she consumes an excess of calories based on her energy needs. Her breakfast and lunch consist of fast food items which tend to be high in fat, sodium, energy and phosphate. Based on her diet and according to MyPlate’s SuperTracker, Ms. C is consuming about 1885 kcal per day on current diet. It is not clear if this is reduced © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-11 from what she normally eats, or if this was her typical diet before her symptoms of uremia started. The following chart shows Ms. C’s diet based on her 24-hour recall compared with what the physician’s admitting orders are: Ms. C’s Diet Protein Na 24-Hour Recall 71 g Admission 75 g Orders K P 2491 mg 2737 mg 919 mg Energy Fluid 1885 kcal 34 fl oz (1005 mL) 3000 mg 3500 mg 1000 mg 1500 kcal 2000 cc fluid (mL) Although Ms. C’s energy is higher, most of her nutrient and fluid needs are less than what was prescribed at admission. The nutrient, energy and fluid recommendations will change once Ms. C begins peritoneal dialysis. 14. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses. Based on her current laboratory values and history, Ms. C has the following nutrition-related problems: Altered nutrition-related laboratory values Impaired nutrient utilization Increased nutrient needs (protein, iron) Excessive Energy Intake Overweight/obesity The primary problems that need to be addressed immediately are the altered nutrition-related laboratory values and the impaired nutrient utilization. The other problems may be addressed over time when Ms. C’s condition becomes stable. 15. Write a PES statement for each high-priority nutrition problem. Altered nutrition-related laboratory values related to renal failure from glomerulonephritis and acute kidney rejection as evidenced by GFR of 6 mL/min/1.73 m2, serum phosphate of 11.9 mg/dL and serum albumin of 3.4 g/dL. Impaired nutrient utilization related to inability to metabolize urea, ammonia, nitrogen and other metabolic wastes as evidenced by GFR of 6 mL/min/1.73 m2, BUN of 124 mg/dL and serum creatinine of 6.8 mg/dL. Altered nutrition-related laboratory values related to renal dysfunction and hypertension as evidenced by GFR of 6 mL/min/1.73 m2 and blood pressure of 161/92. Increased nutrient needs related to anemia of chronic kidney disease as evidenced by hemoglobin of 6.6 g/dL, RBC of 2.33 x 106/mm3 and hematocrit of 19 percent. © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-12 16. Ms. C was discharged from the hospital and was prescribed the following regimen of peritoneal dialysis to begin at home: CCPD daily. Ca 2.50; Mg 0.5, Dextrose 2.5%. Total fills (or exchanges) = 3 (3 fills/cycle @2500 mL). Total fill volume/24 hours: 10000 mL. Determine the amount of energy that Ms. C’s PD prescription will provide each day. How will this affect your nutrition recommendations? If the total fill volume is 10000 mL per day, or 10 L, this would provide about 510 to 595 kcal per day. 10 L x 25 g/L = 250 g 250 g x 3.4 kcal/g = 850 kcal 850 kcal x 0.6 – 0.7 = 510 to 595 kcal At energy requirements of 2400 kcal per day (35 kcal/68.6 kg), Ms. C’s energy needs would be anywhere from 1800 to 1900 kcal per day subtracting 510 to 595 kcal from 2400. 17. Using the KDOQI adult guidelines for peritoneal dialysis patients, determine Ms. C’s nutrition prescription for outpatient use. (Include energy, protein, phosphorus, calcium, potassium, sodium, and fluid.) According to KDOQI guidelines, Ms. C’s energy needs should be approximately 35 kcal/kg of body weight. The guidelines recommend this energy intake for weight maintenance because low body weight is associated with higher mortality in chronic dialysis patients and protein energy malnutrition (KDOQI, p. 45-46). Since Ms. C is overweight (usual BMI of 29.9), it is appropriate to use her adjusted body weight of 68.6 kg. Her energy needs would be approximately 2400 kcal per day before subtracting the amount of energy from dextrose solution in peritoneal dialysate. Her energy needs would then be reduced to 1800 to 1900 kcal per day for weight maintenance. Moderate weight loss might be appropriate at a later point when Ms. C’s condition becomes more stable. As for protein, KDOQI guidelines recommend 1.2 to 1.3 g of protein per kg of body weight. Therefore, using Ms. C’s adjusted body weight, her protein requirements would be anywhere from 82 to 89 g of protein per day. The guidelines further stipulate that at least half the protein intake should come from high quality protein sources (high biological value) such as lean meat and eggs (animal sources). According to KDOQI guidelines, Ms. C’s micronutrients and fluid needs should be as follows: Phosphorus: 800 to 1000 mg/day(0.8-1.0 g/day) Sodium: 2000 mg/day (Ms. C has hypertension and should limit sodium as much as possible) Potassium: 2000-3000 mg/day (2 to 3 g/day) Calcium: 1000 mg/day not to exceed 2500 mg/day (this includes phosphate binders as well) © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-13 Fluid – Since Ms. C does not appear to be oliguric, then her fluid needs are at a minimum of 2000 mL/day 18. Using the identified nutrition problems (and with the understanding that Ms. C has received a significant amount of nutrition education in the past), what would you determine to be the most important topics for nutrition education when she returns to the PD clinic? Ms. C will have to readjust to a dialysis diet once again. There were fewer restrictions to her diet with respect to phosphorus, potassium, and fluid after transplant. As well, Ms. C’s protein needs will increase. Ms. C will have to readjust her diet to include high quality protein from lean meats and eggs. She should reduce her phosphorus intake to 800 to 1000 mg a day by limiting consumption of fast foods and other processed foods which tend to be high in phosphorus as well as sodium. The cola and coffee are also high in phosphorus and Ms. C should consider replacing the cola with seltzer, water or even Sprite (if she does not want to eliminate soda). Although she does not eat many fruits or vegetables, Ms. C will have to avoid consuming more than six servings of fruits and vegetables day (including fruit juice) (Mahan et al., 2012, p. 817-818). 19. List factors that you would monitor to assess Ms. C’s nutritional status when she returns to the PD clinic. A dietitian should plan to meet with Ms. C every month, and should monitor her weight, BMI, blood pressure (due to her history of hypertension) and diet as well as energy and protein intake through 24-hour recalls and/or food records. In addition, Ms. C’s laboratory values should be monitored every month by the dietitian, specifically her albumin, GFR, BUN, calcium, phosphate, potassium, sodium, creatinine, total protein, glucose, hemoglobin, iron saturation, urea reduction rate, parathyroid hormone levels as well as current medications and supplements. Coordination of care with Ms. C’s nephrologist, primary care physician, family, and dialysis nurse is crucial (Mahan et al., 2012, pp. 817-818). © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. 19-14 References Mahan, L. K., Escott-Stump, S. & Raymond, J. (2012). Krause’s Food & the Nutrition Care Process (13th edition). St. Louis, MO: Elsevier Saunders. National Kidney Foundation, KDOQI: http://www.kidney.org/index.cfm http://www.kidney.org/professionals/kdoqi/guidelines_pedbone/guide7.htm Pronsky, Z. (2010). Food and Medication Interactions. (17th edition). Birchrunville, PA: FoodMedication Interactions © 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.