Download Chronic Kidney Disease: Peritoneal Dialysis

Kevin Hernandez
October 21st, 2013
Case Study 2:
Chronic Kidney Disease: Peritoneal Dialysis
1. Describe the major exocrine and endocrine functions of the kidney.
The kidneys secrete two hormones: 1,25 dihydroxycholecalciferol, or calcitriol, and
erythropoietin. Calcitriol is an active form of vitamin D that increases the amount of
calcium in the blood. Erythropoietin stimulates red blood cell production in the bone
marrow. The kidneys also secrete an enzyme, renin, which affects blood pressure.
2. What is glomerulonephritis and how can it lead to kidney failure?
Glomerulonephritis is an inflammation of the glomeruli, the filtering units of the kidneys.
The damage caused by the inflammation can eventually cause the kidneys to lose their
basic function, the ability to filter blood, and cause waste to accumulate in the body.
3. What lab values or other tests support Mrs. Caldwell’s diagnosis of chronic kidney
disease? List all abnormal values and explain the likely cause for each abnormal
value.
Abnormal Lab Values
GFR
Sodium
Bicarbonate
BUN
Creatinine
Phosphate
Calcium
Low
Low
High
High
High
High
Low
Albumin
Hemoglobin
Total Protein
Low
Low
Low
Cause
A decreased filtration capacity.
Fluid accumulatioin.
Increasing metabolic acidosis.
Accumulation of waste products.
Accumulation of waste products.
Decreased ability to remove phosphorus.
Alterations in vitamin D metabolism; increased
phosphorus levels.
Possible malnutrition; protein loss in urine.
Decreased erythropoietin production.
May indicate protein leaking into urine.
4. This patient has had to 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?
Potential sources for a donor kidney include: deceased donors and living donors who
may or may not be related to the recipient. Rejection is controlled with
immunosuppressant medications. An acute rejection is defined as a rejection after
transplantation occurring in significantly less time than a more serious rejection.
5. Based on the admitting history and physical, what signs and symptoms does this
patient have that are consistent with the acute rejection of the transplant?
Acute rejection of the transplant will present itself as decreased organ function. Mrs.
Caldwell states she has a lot of fluid, her GFR is low, and her BUN and creatinine are
elevated.
6. Mrs. Caldwell has requested that she restart peritoneal dialysis. Describe the basic
concepts of the medical treatment and how it differs form hemodialysis.
Peritoneal dialysis consists of a dialysate filling the peritoneal cavity and using the
peritoneum as a semipermeable membrane to remove wastes from the plasma. Unlike
hemodialysis, peritoneal dialysis does not require a surgical an arteriovenous fistula or
graft to be created, or the removal of blood from the body. Patients who use peritoneal
dialysis have fewer restrictions than patients with hemodialysis.
7. This patient was prescribed the following diet in the hospital:
1500 kcal, 75 g protein, 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?
Although is recommended she receive 30-35 kcal/kg, she is obese, so her calories are
adequate. Her protein is about standard RDA due to the failing kidney. All other
components are normal for CKD patients. Once she begins PD, her energy intake might
stay about the same due to the dextrose in the dialysate, and her protein will increase to
1.3 g/kg. Potassium is usually unrestricted in PD patients because they can lose
potassium during dialysis. A sodium allowance of 2-4 grams, 2 L of fluid and 1000 mg of
phosphorus are usually recommended for PD patients.
8. Assess Mrs. Caldwell’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 Mrs. Caldwell’s adjusted body weight?
Mrs. Caldwell’s BMI is 31.1 kg/m2 (77.1 kg/ 1.574 m2). Her %UBW is 104.5%. Edema
would cause her weight to be higher than it really is so her BMI could possibly be slightly
lower, but still borderline obese. Her adjusted bodyweight is 73 kg.
9. Determine Mrs. Caldwell’s energy and protein requirements. Explain the rationale
for the method you used to calculate these requirements.
It is recommended PD patients receive 35 kcal/kg, so Mrs. Caldwell would require 2555
kcal/day. PD patients should receive 1.3 g Protein/day, so her requirement is 95 g
protein/day.
10. List all medications Mrs. Caldwell is receiving. Determine the action of each
medication and identify any drug-nutrient interactions that you should monitor for.
Medication
Procardia
Carvedilol
Catapres
Action
Antiangina,
antihypertensivie,
Calcium channel blocker
CHF treatment,
antihypertensive, nonselective beta blocker
Antihypertensive, analgesic
Nutrient Interactions
Avoid with grapefruit juice,
may need to lower Na
intake
Avoid with licorice, may
need to lower Na intake
Increased serum levels of K
and decreased serum
levels of Na.
May need to lower Na
intake, avoid licorice.
Reduced urinary levels of
Cellcept
Immunosuppressant
Fish oil
Lasix
Loop diuretic
Prednisone
Corticosteroid
Gengref
Immunosuppressant
Prinivil
Angiotensis converting
enzyme inhibitor –
antihypertensive
Antacid
Sodium Bicarbonate
Calcitriol
Renal caps
Renvela
Vitamin D for low calcium
levels
Specialized multivitamin
Phosphate binder
Na and Cl
Decrease serum levels of
K, P and Mg
Increase need for K, Mg
and avoid licorice
Decreased serum levels of
K, Mg, Na, Cl, Ca
Increased urinary levels of
K, Na, Cl, Mg, Ca
Decrease Na in diet;
increase Ca, vitamin D, and
protein. May need
additional K, P, and Vits A,
C
Increased serum levels of
Na; decreased serum levels
of K, Ca, Zn, vit C and A
Decrease urinary level of
Na; increased urinary levels
of K, Ca, N, Zn, vit C
Vit E may increase
absorption of drug
Increased serum level of K;
decreased serum level of
Mg
Decreased urinary level of
K; increased urinary level of
Mg
Increased serum levels of
K; decreased serum level of
Na
May need to lower Na
intake
Increased serum levels of
Na; decreased serum levels
of K, Ca
Monitor Ca and P levelsr
Low P in diet
Decreased serum levels of
P; increased serum levels
of Ca
Monitor P, Ca, Cl, bicarb
11. Mrs. Caldwell’s lab 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?
The kidneys produce erythropoietin, which causes the bone marrow to produce red blood
cells. When the kidneys fail, they lose all function, including erythropoietin production.
This is usually treated with erythropoiesis stimulating agents and iron supplementation.
12. What factors in Mrs. Caldwell’s history may affect her ability to eat? What are the
most likely causes of these symptoms? Can you expect that they will change?
Mrs. Caldwell claims she has a loss in appetite, shortness of breath, mild nausea, and
feels her food has a bad taste. Her SOB may be caused by fluid accumulation. Her
nausea and loss of appetite is caused by waste accumulation. Her alteration in her
sense of taste may occur in kidney disease. The symptoms should decrease once she
begins her dialysis treatment.
13. Evaluate Mrs. Caldwell/s diet history and 24-hour recall. Is her usual diet consistent
with her inpatient diet order?
According to her 24-hour recall, Mrs. Caldwell consumed 2100 kcals, 82 g protein, 2600
mg sodium, 2500 mg potassium. She is meeting her inpatient diet order but is consuming
calorically dense foods.
14. Identify the pertinent nutrition problems and the corresponding nutrition
diagnoses.
Obese/Overweight, inadequate energy intake, undesirable food choices, excessive fat
intake
15. Write a PES statement for each high priority nutrition problem.
Obese (NC-3.3) as related to a diet of energy dense food evidenced by BMI of 31.1.
Excessive fat intake (NI-5.6.2) as related to a diet of energy dense foods evidenced by
30% of calories from fat according to 24-hour recall.
Mrs. Caldwell 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 at 2500 mL). Total fill volume/24 hours: 10000 mL.
16. Determine the amount of energy that Mrs. Caldwell’s PD prescription will provide
each day. How will this affect your nutrition recommendations?
10 L x 2.5% solution = 250 g x 3.4 x 0.3-0.5 = 255-425 calories. This amount will have to
be subtracted from Mrs. Caldwell’s energy requirements.
17. Using the KDOQI adult guidelines for peritoneal dialysis patients, determine Mrs.
Caldwell’s nutrition prescription for outpatient use. (Include energy, protein,
phosphorus, calcium, potassium, sodium, and fluid).
2555 kcal, 95 g Protein, 950-1150 mg phosphorus, <2 g calcium, 3000-4000 mg
potassium, 2-4 g sodium, 2 L fluid.
18. Using the identified nutrition problems (and with the understanding that Mrs.
Caldwell 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?
Changing her diet from one that consists of energy-dense foods to one with nutrientdense foods.
Consuming less fat in her diet.
19. List factors that you would monitor to assess Mrs. Caldwell’s nutritional status
when she returns to the PD clinic.
Due to her dietary habits, I would monitor her blood lipid levels to make sure they were
still normal.
Additionally, I would monitor her BMI in hopes that it is lower at her next visit.
Her hematology values should be monitored in order to identify the presence of anemia
References:
National Kidney Foundation. KDOQI Clinical Practice Guidelines. Available at:
http://www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm
National Kidney Foundation: http://www.kidney.org
Nelms, M., Sucher, K., Lacey K., Roth, S. L. Nutrition Therapy and Pathophysiology. 2nd
ed. Belmont, CA: Wadsworth, Cengage Learning; 2011: 520-565
Forbes, L. (2004). Calculation of glucose absorption and caloric contribution during PD,
PDServe Connect, 8.
Navaneethan, S. D., Schold, J. D., Arrigain, S., Jolly, S. E., Wehbe, E., Raina, R., ... &
Nally, J. V. (2011). Serum bicarbonate and mortality in stage 3 and stage 4 chronic
kidney disease. Clinical Journal of the American Society of Nephrology, 6(10), 23952402.
UC Davis Health System Transplant Center. Sources of Donor Kidneys. Retrieved
October 15 2013 from :
http://www.ucdmc.ucdavis.edu/transplant/livingdonation/donor_kidney_sources.html
Tejani, A., & Sullivan, E. K. (2000). The impact of acute rejection on chronic rejection: a
Report of the North American Pediatric Renal Transplant Cooperative Study. Pediatric
transplantation, 4(2), 107-111.
Armstrong, J. E., Laing, D. G., Wilkes, F. J., & Kainer, G. (2010). Smell and taste
function in children with chronic kidney disease. Pediatric Nephrology,25(8), 1497-1504.