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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.