Download Renal Case Study - Blanca Castorena`s portfolio

Blanca Castorena
NUTR 409
Prof. Rupp
3 April 2015
Case Study 18: Chronic Kidney Disease (CKD) Treated with Dialysis
1. Describe the physiological function of the kidneys.
The kidneys filter metabolic wastes from the blood and helps maintain a stable blood composition.
Kidney filtration prevents the buildup of metabolic wastes, and maintains electrolyte balance in the
body makes. Another important function of the kidneys is the production of hormones. The kidneys
produce aldosterone which regulates blood pressure by stimulating sodium resorption. They also
secrete erythropoietin which stimulates the synthesis of red blood cells and they produce vitamin D
which is involved is the maintenance of bone health.
2. What disease condition can lead to CKD? Explain the relationship between diabetes mellitus and CKD.
Conditions that lead to CKD include diabetes (type I and type II) as well as high blood pressure, heart
disease, smoking, obesity, and high cholesterol. Some other risk factors include family history of kidney
disease, age of 65 or older and ethnic background of African, Native American, and Asian American
descent. Diabetic patients are at risk for developing kidney disease nephropathy. High blood sugar
levels increase pressure on the nephrons of the kidneys and damage capillary vessels which weaken and
begin to leak molecules which were once too big to be filtered by the kidneys such a protein and RBCs.
3. Outline the stages of CKD, including the distinguishing signs and symptoms.
Stage 1 with normal or high GFR (GFR > 90
mL/min)
Stage 2 Mild CKD (GFR = 60-89 mL/min)
Stage 3A Moderate CKD (GFR = 45-59 mL/min)
Stage 3B Moderate CKD (GFR = 30-44 mL/min)
High creatinine, and high urea in the blood
Blood or protein in the urine
Evidence of kidney damage examined through CT
scan, MRI, ultrasound, etc.
A family history of PKD (polycystic kidney disease)
High creatinine, and high urea in the blood
Blood or protein in the urine
Evidence of kidney damage examined through CT
scan, MRI, ultrasound, etc.
A family history of PKD (polycystic kidney disease)
Fatigue
Fluid retention, edema of extremities, and
shortness of breath.
Changes in color of appearance of urine such as
foamy, dark orange or red urine.
Urinating more or less
Pain in the lower back
Restless legs and issue sleeping due to muscle
cramps
Stage 4 Severe CKD (GFR = 15-29 mL/min)
Stage 5 End Stage CKD (GFR <15 mL/min)
Symptoms experienced in Stage 3, and in addition,
the following:
Nausea and vomiting
Metallic taste in the mouth
Bad breath because of urea buildup
Anorexia
Trouble concentrating
Neurological problems such as numbness or
tingling of the toes
Anorexia
Nausea, Vomiting
Fatigue
Headaches
Difficulty concentrating
Itching
Producing little to no urine
Tingling in hands or feet
Swelling around eyes and ankles
Muscle cramps
Changes in skin pigmentation and color
5. What are the treatment options for Stage 5 CKD? Explain the differences between hemodialysis and
peritoneal dialysis.
The treatment options for stage 5 CKD are limited. A patient can opt for a kidney transplant which often
requires years of waiting for a donor match and is expensive, unless the patient has a living donor
available such as a close relative. The second option is dialysis treatment. Dialysis is labor intensive and
requires a patient to visit a clinic and use a dialysis machine to filter blood several times a week. Another
option is peritoneal dialysis which uses a bag filled with fluid known as dialysate to filter wastes from the
peritoneum of the abdomen to the bag. This option allows the patient to do the treatment at home and
has more flexibility. However, both options have risks and complications attached to them. Both options
require careful monitoring of blood chemistry. Both options increase protein needs in patients.
7. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your interpretation?
Mrs. Joaquin’s BMI= 33.2 kg/m2 –calculated using her weight of 170 lbs. and her height of 5 feet –puts
her in the obese category. Mrs. Joaquin’s physical indicates she has 3+ pitting edema which may be the
reason she reports gaining 4 kilograms in the past two weeks. This information indicates her BMI may be
inflated and not representative. However, after calculating her BMI before the 4 kilogram weight gain,
Mrs. Joaquin’s BMI continues to indicate she is classified as obese.
6. Explain the reasons for the following components of Mrs. Joaquin’s medical nutrition therapy:
Nutrition Therapy
Rationale
35 Kcal/kg
A 35 Kcal/kg diet is prescribed to prevent the
development of malnutrition in Mrs. Joaquin.
Undernutrition in patients with renal failure is
linked with decreased patient survival.
1.2 g PRO/kg
Patients on hemodialysis have higher protein
needs because they lose 10-12 grams of protein
per treatment. Futhermore, Mrs. Joaquin has
anemia and therefore has increased protein needs
as well.
2gK
Patients with renal failure have a compromised
ability to excrete potassium. Mrs. Joaquin is on
hemodialysis which does not effectively rid the
body of potassium. High levels of potassium can
cause irregular heartbeats and lead to a heart
attack. Therefore, it is important to maintain
adequate potassium levels in the blood.
1 g Phosphorous
The kidneys regulate phosphorous in the blood.
Mrs. Joaquin has compromised kidney function,
and therefore, is a risk for accumulating
phosphorous in the blood which can lead to
calcium leeching out of the bones (reduced bone
density) as well as the creation of calcium deposits
in blood vessels and various parts of the body.
2 g Na
Mrs. Joaquin is on a sodium restricted diet
because she is hypertensive, but also, because she
suffers from edema and fluid retention. Her
kidneys are not properly excreting sodium;
therefore, it is important to restrict sodium in the
diet.
1000 mL fluid + urine output
A net I/O of 1000 mL + urine output is
recommended because Mrs. Joaquin had edema,
and a decreased ability to urinate. Therefore, it is
important to restrict fluid. A high volume of liquid
introduced into the body without excretion could
lead to congestive heart failure.
12. What are the considerations for differences in protein requirements among predialysis,
hemodialysis, and peritoneal dialysis patients?
Patients with CKD have different protein requirements depend on the stage of the disease as well as a
treatment. Pre-dialysis patients should consume on average .7-.8g of PRO/ kg of body weight /day.
Patients on hemodialysis will have increase needs of 1.2-1.5g of PRO/kg of body weight/day. This is due
to the loss of protein that occurs as part of treatment. Patients receiving peritoneal dialysis have the
highest needs at 1.3-1.5g of PRO/kg of body weight/day. The increased protein needs for peritoneal
dialysis are due to protein losses which occur each time a patient drains dialysate from their abdomen.
13. Mrs. Joaquin had a phosphate restriction. Why? What foods have the highest levels of phosphate?
Chronic Kidney Disease is characterized by a reduced ability to excrete phosphorous. Hemodialysis
removed only a small amount of phosphorous. High levels of phosphorous in the blood cause damage to
the body. Phosphorous levels can be managed by limiting foods high in phosphorous such as seeds,
cheeses such as parmesan or goat cheese, salmon, shellfish, brazil nuts, lean pork chop, lean beef, lean
veal, soy foods, beans, and lentils. However, a majority of the phosphorous in the typical American diet
comes from processed foods such as sugary, carbonated beverages, chocolate, candy, ice cream,
cookies and cakes from the supermarket, mayonnaise, processed cheese, frozen pizza, and processed
meats such as hot dogs.
14. What foods are considered to be fluids? What recommendations can you make for Mrs. Joaquin? If a
patient must follow a fluid restriction, what can be done to help reduce his or her thirst?
Some foods considered liquids include gelatin, soup, ice, ice cream, sherbet, frozen popsicles, shakes,
and pudding. I would recommend Mrs. Joaquin avoid salty and spicy foods because these will trigger a
thirst response. Drink only when you are thirsty. Consume kidney-friendly (find list on davita.com)
frozen or chilled fruits. Suck on lemon slices, or add them to iced water to help with dry mouth. Add
mint to dishes or chew on mint for a refreshing sensation. Suck away at an ice cube to help quench thirst
without too much liquid. Finally, suck on hard candies to stimulate saliva production and alleviate dry
mouth.
15. Several biochemical indices are used to diagnose chronic kidney disease. One is the glomerular
filtration rate (GFR). What does GFR measure? What is normal GFR? Mrs. Joaquin’s GFR is 28mL/min.
interpret her values.
The Glomerular Filtration Rate is a measure of kidney function. It measures the level of creatinine in the
blood, and inputs this information into a formula which gives a rate that indicates how well the kidneys
are functioning. A normal GFR is between 90mls/min to 120mls/min. Mrs. Joaquin’s GFR of 28ml/min
falls within the range of 15ml/min to 29 ml/min which defines stage 4, Chronic Kidney Disease.
16. Evaluate Mrs. Joaquin’s chemistry report. What labs support the diagnosis of Stage 5 CKD?
Mrs. Joaquin’s chemistry report indicates she has elevated BUN and creatinine in the blood which
indicates the kidneys are not filtering wastes effectively. Her urinalysis indicates high levels of protein
which are linked to kidney damage.
18. Explain why the following medications were prescribed by completing the following table.
Medication
Capoten/Captropril
Indications/Mechanism
ACE inhibitor, inhibits the
conversion of angiotensin I to
angiotensin II. Used to treat
hypertension, congestive heart
failure and kidneys problems due
to diabetes.
Erythropoietin
Sodium Bicarbonate
Renal Caps
Renvela
EPO stimulates RBC production.
Patients with CKD have a
reduced ability to produce EPO,
and therefore, can develop
anemia.
Antacid, alkalizing agent
Multivitamin made with a
combination of B vitamins used
to prevent deficiencies.
Phosphate binder
Hectorol
Lowers levels of parathyroid
hormone in patients with kidney
disease
Glugophage
Oral diabetes medicine
commonly known as Metformin.
Helps control blood sugar.
Nutritional Concerns
Patient should adhere to 2g
sodium restrictive diet and 1000
ml fluid intake, in order to
prevent a hypertensive state.
Patient should consume protein
of high biologic values, in order
to decrease the progression of
anemia.
With the progression of CKD,
follows a reduced ability to
regenerate sodium bicarbonate
which results in metabolic
acidosis, increased muscle
protein breakdown, reduced
albumin synthesis and can lead
to the development of renal
acidosis. To prevent this Mrs.
Joaquin’s serum bicarbonate
concentration must be closely
monitored.
Dialysis can increase excretion of
water soluble vitamins
Helps prevent hypercalcemia
cause by elevated phosphorous
in the blood.
Patient should not be on a
vitamin D supplement because it
is contraindicated for this
medication.
It’s important to control blood
sugar because it is linked to
increased inflammation and poor
prognosis in patients with kidney
disease. Furthermore,
monitoring diet can aid in
management as well.
19. What health problems have been identified in the Pima Indians through epidemiological data?
Explain what is meant by the “thrifty gene” theory. Are the Pima at higher risk for complication of
diabetes? Explain.
By studying Pima Indians, scientists were able to identify diabetes and create a treatment. They were
also able to establish a strong link between overweight and obesity as a risk factor for the development
of diabetes. About 50% of the adult Pima Indian population has diabetes, and 95% of Pima Indian
diabetics are overweight or obese (The National Institute of Diabetes and Digestive and Kidney
Diseases). NIDDK studies show Pima Indians are genetically predisposed to developing diabetes.
Furthermore, studies have established overweight and obesity is the single best predictor for type 2
Diabetes Mellitus. The Thrifty Gene Theory was proposed by geneticist James Neel in 1962 as a means
to explain high rates of diabetes among the Pima population. The theory postulates, populations that
depended on farming, hunting and fishing for food experienced periods of feast and famine due to
changing seasons and general food insecurity. Consequently, the Pima developed a gene which allowed
them to store fat more effectively when food was bountiful. In modern days caloric dense, processed
food are plentiful and available all-year-round. Thousands of years ago, the excess weight was useful to
survive during times of famine, but in the 21st century it is a risk factor for diabetes and comorbidities.
22. Why is it recommended for patients to have at least 50% of their protein from sources that have
high biological value?
It’s important for patient with CKD to have adequate intake of high biologic protein because they have a
reduced ability to produce EPO, and therefore, are at risk for developing anemia. Also, they have
increased needs because of the treatment (dialysis) which results in protein losses. Overall, CKD patients
are in a stressed and catabolic state which requires protein of high biologic value.