Download Case Study Write Up

Katherine Albus
PH 1231
Final Case Study: Chronic Kidney Disease
December 2, 2013
Patient summary: Mrs. Joaquin is a 24 year-old Native American woman. She was diagnosed
with Type 2 DM at age 13, and has been poorly compliant with prescribed medication and diet.
She was diagnosed with Stage 3 CKD two years ago. Acute symptoms have developed over the
last 3 weeks. Her occupation is sedentary. Patient is of Pima Indian ethnicity.
Medical history: Gravida 1/ para 1. Infant weighed 10# at birth, 7 years ago. Pt explains she
stopped taking oral hypoglycemic agent, and never started taking prescribed antihypertensive
medication. Declining GFR, increasing creatinine and urea concentration, elevated serum
phosphate, and normochromic, normocytic anemia are evidence of declining renal function.
She is being admitted to prepare for renal replacement therapy (RRT). Family history of T2DM
in both parents.
Physical findings: anorexia; nausea/vomiting; 4-kilogram weight gain over past 2 weeks;
anorexia; edema of face, extremities, eyes; malaise; shortness of breath; pruritus; muscle
cramps; inability to urinate. She is overweight, lethargic, has skin discoloration, and 3+ pitting
edema. These signs and symptoms are all consistent with progression of her CKD. Blood
pressure is 220/80.
Biochemical: Laboratory values show Mrs. Joaquin has elevated BUN and Creatinine, as well as
elevated potassium, phosphorus, glucose, cholesterol, LDL-C, triglycerides, and low sodium,
carbon dioxide, chloride, calcium, and HDL-C. Urinalysis is positive for protein (2+), and pH is 7.9
(range 5-7).
Given Mrs. Joaquin’s values, the current GFR is 4.58. This value is consistent with diagnosis of
Stage 5 CKD.
Medications were ordered for Mrs. Joaquin to manage her hypertension, anemia, acidosis,
diabetes, and secondary hyperparathyroidism. She was also given a prescription for a
phosphate-binding medication, as well as a water-soluble vitamin supplement. Mrs. Joaquin
will being renal replacement therapy. Nutrition therapy was prescribed using National Kidney
Foundation diet recommendations for hemodialysis patients. Mrs. Joaquin’s needs and
restrictions follow:
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Energy: 2550 kcal/day
Protein: 88 g/day, >44 g HBV
K: 2g/day



Phos: 1 g/day
Na: 2 g/day
Fluid: 1000mL + urine output
Nutrition Diagnosis:
1. Limited adherence to nutrition-related recommendations (NB-1.6) related to lack of skills
for following diets for CKD and T2DM evidenced by patient complaining of difficulty following
prior diet instructions and diet recall showing intake inconsistent with nutrition education for
T2DM and early stages of CKD.
2. Excessive mineral intake (sodium, potassium, phosphorous) (NI-5.10.2.5.6.7) related to
limited knowledge of stage 5 CKD diet restrictions evidenced by diet recall showing high
sodium, potassium, and phosphorous intake at each meal inconsistent with diet
recommendations for Stage 5 CKD.
Nutrition Intervention:
1. Nutrition prescription: Improve skills for managing Stage 5 CKD diet by reeducating
patient of diet guidelines and providing sample meal plans.
a. Nutrition education for skill development (E-2.2) in selecting appropriate
combination of foods for Stage 5 CKD management with concurrent diagnosis of
T2DM.
b. Strategy – Motivational interviewing (C-2.1) to resolve ambivalence to CKD and
T2DM diet plans by using patient-centered approach to elicit behavior change
goals from the patient and support self-efficacy for change.
c. Goal: Patient will be able to independently select combination of foods in
compliance with Stage 5 CKD diet restrictions while managing blood glucose
within 3 follow-up appointments.
2. Nutrition prescription: Reduce intake of sodium, potassium, and phosphorus to 2 g Na,
2 g K, 1 g Phosphorous (NKF K/DOQI recommendations for HD patient < 60 years).
a. Meals and snacks: Mineral-modified diet (ND-1.2.10) for sodium, potassium and
phosphorus meeting NKF K/DOQI recommendations for HD patient < 60 years.
b. Nutrition education: Priority modifications (E-1.2) are reducing sodium,
potassium, and phosphorus by any amount as soon as possible to reduce risk of
complications associated with hypernatremia, hyperkalemia, or
hyperphosphatemia.
c. Collaboration of nutrition care with other providers (RC-1.3) including
nephrologist, dialysis nurse, and dialysis technician to provide overall patient
care regarding dialysis modality and secondary disease management upon onset.
d. Goal: Patient will meet recommendations for sodium, potassium, and
phosphorus intake within 3 follow-up appointments according to daily food
diary.
See complete ADIME note in response to Question #26. Pocket card follows case study.
1. Describe the physiological functions of the kidneys.
The primary physiological functions of the kidneys include control of fluid, pH, electrolyte
balance, and blood pressure to maintain homeostasis; excretion of metabolic end-products and
foreign substances; and production of some enzymes and hormones, such as renin and
erythropoietin. The kidneys also synthesize 1,25-dihydroxycholecalciferol, the active form of
Vitamin D, allowing calcium to be absorbed. The formation of urine is an important component
of maintaining homeostasis, as its composition and volume vary depending on electrolyte
balance.1 Urine also serves as the route for excretion of waste products such as uric acid,
creatinine, urea, as well as drugs and environmental toxins.1
2. What diseases/conditions can lead to chronic kidney disease (CKD)? Explain the
relationship between diabetes and CKD.
The incidence of CKD is higher for individuals with diabetes mellitus, cardiovascular disease,
hypertension and glomerulonephritis than for other adults. 1 Additionally, the following factors
increase risk of CKD: ethnicity (African American, Native American, and Hispanic have higher
risk); family history of CKD; hereditary conditions such as polycystic kidney disease; physical
injury to kidneys; and prolonged intake of a combination of several over-the-counter painkiller
medications.1
Diabetic nephropathy is the most common cause of CKD in the U.S.2,3 Poorly controlled blood
glucose levels greatly increase the risk of developing nephropathy. The first change to be
detected is a thickening of the glomerulus, possibly due to prolonged hyperglycemia. As these
changes to the glomerulus occur, the kidney’s ability to filter blood and the fluid that will
eventually be urine is impaired. More albumin than normal will start to be excreted. As diabetic
nephropathy progresses, more glomeruli lose function, and consequently, more albumin is
excreted in the urine. 1 This is referred to as microalbuminuria, and it can be detected by
urinalysis. As nephrons begin to lose function, the remaining nephrons have to compensate by
clearing an increasing solute load. There is a limit to the amount of solute that can be cleared,
and once this level is reached, body fluid concentration increases, leading to azotemia
(accumulation of nitrogenous waste products in blood and body fluids) and uremia
(combination of symptoms including pruritus and fatigue). 1 This progression is slow, and the
body can partially adapt to the loss in function.
3. Outline the stages of CKD, including the distinguishing signs and symptoms.
The National Kidney Foundation has outlined five stages of CKD.4 “Kidney damage” is defined as
pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests,
or imaging studies. 1
Stage 1: Kidney damage with normal or increased glomerular filtration rate (GFR), >90
mL/min/1.73m2.
Stage 2: Kidney damage with mild decrease in GFR, 60-89 mL/min/1.73m2..
Stage 3: Moderate decrease in GFR, 30-59 mL/min/1.73m2.
Stage 4: Severe decrease in GFR, 15-29 mL/min/1.73m2.
Stage 5: Kidney function inadequate to sustain life (<15 mL/min/1.73m2.); renal
replacement therapy required.
Signs and symptoms are not part of the NKF-KDOQI guidelines for diagnosing stage of CKD.
Symptoms during the early stages of CKD are common symptoms for other illnesses, and may
be the only signs of kidney disease until the condition progresses. These include headaches,
pruritus, loss of appetite, fatigue, nausea, and unintended weight loss. 5
As kidney function worsens, the following symptoms may develop: 5









Skin discoloration (dark or light)
Neurological symptoms: drowsiness, confusion, inability to concentrate, peripheral
numbness, muscle twitching or cramping
Breath odor, shortness of breath
Polydipsia
Easy bruising, bleeding
Blood in stool
Vomiting
Edema
Insomnia, restless leg syndrome, obstructive sleep apnea
Additionally, hypertension is commonly present during all stages of CKD. Elevated BUN and
creatinine also indicate poor renal function.1 Urine abnormalities, such as albuminuria, are
tested with urinalysis and can assist in indicating level of kidney function along with GFR.
Electrolyte imbalances, as well as irregular levels of several vitamins and minerals in the blood,
will also worsen as CKD progresses.
4. From your reading of Mrs. Joaquin’s history and physical, what signs and symptoms
did she have that correlate with her chronic kidney disease?
Mrs. Joaquin’s diagnoses of hypertension and Type 2 diabetes, and the biochemical markers
associated with these (blood pressure and blood glucose) correlate with her CKD. Additionally,
other lab values consistent with her CKD diagnosis include declining GFR, increasing creatinine
and urea concentrations, elevated serum phosphate, and normochromic, normocytic anemia,
as well as electrolye and mineral imbalances. Mrs. Joaquin presents with many symptoms
associated with CKD: anorexia and loss of appetite, nausea, vomiting, pitting edema (3+),
malaise, shortness of breath, pruritis, muscle cramps, and inability to urinate, as well as
lethargy, pitting edema, and skin discoloration (yellow-brown). A respiratory exam reported
mild rhonchi with rales (breathing difficulty).
5. What are the treatment options for Stage 5 CKD? Explain the differences between
hemodialysis and peritoneal dialysis.
At Stage 5 CKD, or end-stage renal disease (ESRD), the body retains fluid, harmful wastes build
up in the blood, and blood pressure increases. The function of the kidneys has to be completely
replaced, and the options for this include hemodialysis, peritoneal dialysis, and kidney
transplantation. In general, dialysis is a procedure that removes toxic end-products of
metabolism from the blood, replacing the filtration function of the kidneys.1 Endocrine and
metabolic functions are not completely replaced, but dialysis can maintain life. Symptoms
indicating a definite need to initiate dialysis include pericarditis, fluid overload, pulmonary
edema, uncontrolled hyperkalemia, lethargy, and coma. Symptoms such as azotemia, nausea,
and vomiting are less severe and merit a subjective determination taking into account the
patient’s quality of life.
Hemodialysis is the most common method of renal replacement therapy. Patients first undergo
a procedure to allow continual access to the bloodstream through one of two forms of access
sites on the forearm. The preferred site is an arteriovenous fistula (AVF), which is a
subcutaneous joining of the radial artery and cephalic vein created surgically.6,7 Alternatively, if
a patient’s veins are not adequate for AVF, an arteriovenous graft (AVG) is created with
polytetrafluoroethylene (Teflon), which requires 4-6 weeks to become functional.7 The grafts
are punctured and blood travels through a needle to the dialyzer, an external machine, and
returns to the body after filtration. Hemodialysis treatments are usually needed three times per
week, lasting approximately four hours per treatment.8 There are options for home-based
hemodialysis and nocturnal home hemodialysis; however, this may not be appropriate for
every patient.
Peritoneal dialysis differs from hemodialysis by gaining access to the bloodstream via a catheter
surgically placed into the peritoneal cavity. 9 Dialysate, the fluid used to assist in removal of
wastes and toxins, enters the peritoneum via the catheter and the dialysis process occurs
within the patient’s abdomen. Solutes to be removed from the blood pass across the peritoneal
membrane into the dialysate, similar to the process that occurs in hemodialysis. The dialysate is
then removed from the body. There are two types of peritoneal dialysis: continuous
ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD). CAPD
requires no machine and can be done anywhere, usually lasting at least 4-6 hours, conducted at
least 4 times per day. CCPD requires a machine to fill and empty the abdomen 3-5 times during
the night, with another exchange during the day.9
To conduct a successful kidney transplant, the immunological characteristics of the donated
organ much match those of the recipient. 2 The United Network for Organ Sharing (UNOS)
provides information to coordinate matching of recipients with a potential donor.1 Patients
who undergo transplantation maintain a regimen of immunosuppressive medications to
prevent rejection.
6. Explain the reasons for the following components of Mrs. Joaquin’s medical nutrition
therapy:
Nutrition Therapy
35 kcal/kg
1.2 g protein/kg
2gK
1 g Phosphorous
2 g Na
1000 mL fluid +
urine output
Rationale
Meets NKF KDOQI recommendations for CKD pt <60 yrs on HD. HD pt’s have
higher energy needs than healthy individuals. Adequate energy is required to
prevent catabolism and malnutrition, and to achieve optimal nutritional status.
Meets NKF KDOQI recommendations for CKD pt <60 yrs on HD. HD pt’s have
increased protein needs due to high amino acid losses daily, altered albumin
turnover, increased amino acid degradation due to metabolic acidosis,
inflammation, and infection.1
Meets NKF KDOQI recommendations for CKD pt <60 yrs on HD. In ESRD,
kidneys are unable to excrete K. Severe hyperkalemia can result in cardiac
arrhythmias (Nelms).
Meets NKF KDOQI recommendations for CKD pt <60 yrs on HD. In ESRD,
kidneys are no longer able to excrete phosphate, so dietary restriction is
needed to avoid hyperphosphatemia. 1
Meets NKF KDOQI recommendations for CKD pt <60 yrs on HD. For this
patient, sodium is restricted to assist with fluid balance, and also blood
pressure. Controlling sodium will also assist in controlling fluid intake.1
Meets NKF KDOQI recommendations for CKD pt <60 yrs on HD. Fluid
restrictions are based on each pt’s urine output and method of dialysis. Blood
pressure and edema can be helped by monitoring fluid and sodium intake.
Fluid overload can lead to shortness of breath, hypertension, CHF, and edema.1
7. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your
interpretation?
Upon admission, the patient’s BMI is 33. However, with pitting edema (3+), the patient’s
weight is falsely high, resulting in an inaccurate BMI. However, according to this actual BMI,
Mrs. Joaquin is obese.
8. What is edema-free weight? Calculate Mrs. Joaquin’s edema-free weight.
Edema-free weight is used in nutrition assessment and prescription for patients whose
actual body weight is influenced by the presence of edema. Adjusted edema-free body
weight is recommended for underweight and obese patients.10 NKF-KDOQI Nutrition
Guidelines recommend adjusted edema-free body weight (aBWef) be based on National
Health Nutrition Evaluation Survey II (NHANES) data. 10 Guidelines call for clinical judgment
when assessing use of either actual body weight or adjusted edema-free body weight to
assessment or prescription of nutritional intake, due to the wide range in body weight and
body composition among dialysis patients.11 These guidelines include a statement that
aBWef is often difficult to ascertain and not precise. AND EAL states that the RD may use
published weight norms for assessment of CKD patients, but notes that each standard has
drawbacks and should be used with caution.12
Standard Body Weight (SBW) (NHANES II) = 60 kg
Actual Body Weight (ABW) = 77 kg
Adjusted edema-free body weight (for obese patients) = ABW + [(SBW-ABW) x .25]
= 77 + [(60-77) x .25]
aBWef = 73 kg
9. What are the energy requirements for CKD?
Adequate energy intake is important to prevent catabolism, provide neutral nitrogen balance,
and maintain serum albumin and anthropometric parameters. 1 Adequate kcal from
carbohydrates and fat may help prevent muscle and visceral protein from being utilized as
energy. Energy expenditure is similar to or slightly higher than that of healthy individuals. 1
K/DOQI guidelines are formulated based on this finding. Older persons with more sedentary
lifestyles may have lower energy needs. Those with higher energy levels, who are underweight,
or in a state of catabolism will have higher caloric requirements. For patients on peritoneal
dialysis (PD), the kcal absorbed from dialysate glucose must be considered, even though caloric
intake is typically low in this population.
NKF-K/DOQI give the following energy recommendations for renal conditions ranging from
acute renal dysfunction, through all stages of CKD, and for both hemodialysis and peritoneal
dialysis:10
Acute
Energy, kcal/kg
CKD
35-50 based on 30-35 >60 yrs
stress/nutrition
35 <60 yrs
status
Nephrotic
Syndrome
35 unless
obese
HD
PD
30-35 >60 yrs
30-35 >6 yrs
35 <60 yrs
35 <60 yrs,
include
dialysate
10. Calculate what Mrs. Joaquin’s energy needs will be once she begins hemodialysis.
Using adjusted edema-free body weight: (35)*(73) = 2555 kcal/day (NKF K/DOQI
recommendations)
11. What will Mrs. Joaquin’s protein requirements be when she begins hemodialysis?
What standard guidelines have you used to make these recommendations?
The NKF K/DOQI recommendations for hemodialysis patients are >1.2 gram/kg based on
standard or adjusted body weight, with >50% being high biological value (HBV). 10 Mrs.
Joaquin’s protein requirements will be:
(1.2)*(73) = 87.6 gram/day, or >88 grams per day with > 44 grams HBV.
12. What are the considerations for differences in protein requirements among predialysis,
hemodialysis, and peritoneal dialysis patients?
During CKD Stages 3 and 4, adequate protein is needed to maintain lean body mass and serum
protein levels. The most recent evidence indicates low-protein diets are associated with a
slowed progression of CKD and a delayed need for renal replacement therapy (RRT).10
Therefore, protein needs for predialysis patients range from 0.6-0.75 gm/kg/day, with at least
50% of protein being HBV. The ability of the kidneys to excrete end-products of protein
metabolism decreases as CKD progresses. Patients who reach Stage 5 and initiate RRT will need
to modify protein intake.
Patients who have begun hemodialysis (HD) or peritoneal dialysis have higher protein
requirements than those who are in predialysis.1 Factors influencing this higher need include 1)
estimated losses of 10-12 grams free amino acids per day and 5-15 grams albumin per day; 2)
altered albumin turnover; 3) metabolic acidosis leading to amino acid degradation; 4)
inflammation; 5) infection. For HD patients, the NKF K/DOQI guidelines recommend 1.2 grams
protein/kg body weight per day. At least 50% of protein should be HBV. This level is
recommended to ensure adequate intake of all essential amino acids, and to maintain neutral
or positive nitrogen balance and lead to an improvement or maintenance of visceral protein
stores.10 Higher protein levels are recommended for PD patients (1.2-1.3 g/kg with 50% HBV)
due to increased dialysate protein losses to an average of 15-35 grams per 24 hours, as well as
increased protein needs during times of peritonitis. 13
13. Mrs. Joaquin has a P04 restriction. Why? What foods have the highest levels of
phosphorous?
In a healthy individual, serum calcium and phosphorous levels are monitored by the
parathyroid gland (PTG). When low calcium is detected, parathyroid hormone (PTH) is
synthesized and secreted into the bloodstream. When the kidneys detect the PTH, three
processes are initiated: calcium reabsorption, phosphorous excretion, and vitamin D activation.
The vitamin D increases intestinal absorption of phosphorous and calcium. Additionally, PTH
results in bone reabsorption and the release of calcium and phosphorous into the bloodstream.
Once levels are normalized, the system relays feedback to the PTG and decrease PTH release.
However, in patients with CKD, this feedback mechanism is disabled. Damaged kidneys are not
able to reabsorb calcium and excrete phosphorous. Phosphorous is excreted primarily via urine.
Reabsorption of phosphorous in the renal tubules is the primary mechanism by which the body
maintains a constant level of phosphorous. The amount of phosphorous reabsorbed is
controlled mainly by PTH. High phosphorous levels trigger the release of PTH, which increases
urinary excretion of phosphorous. Over time, serum levels of PTH reach consistently high levels,
and the number of parathyroid cells increases and leads to secondary hyperparathyroidism and
renal bone disease. This condition impacts many other organ systems within the body. Elevated
serum phosphorus and PTH levels have been associated with increased morbidity and
mortality. 14 Levels above 6.5 mg/dL were associated with sudden death and death due to
coronary artery disease. 14 Target goals for serum phosphorous are 3.5 – 5.5 mg/dL.10
Mrs. Joaquin has a P04 restriction as recommended for all HD or PD patients to prevent
hyperphosphatemia. Additionally, phosphate binders are commonly required for RRT patients
to prevent gastrointestinal absorption of dietary phosphorous.1
Foods highest in P04 include the following: 10 cheese, milk, yogurt, and other dairy-based foods;
many varieties of dried beans and peas, especially lentils, chicken, all-bran cereal, tofu, ground
beef, soy milk, many nuts and seeds, peanut butter, and dark colas and beer. Many organ
meats are high in phosphorous, as well as oysters and sardines.
Additionally, Mrs. Joaquin will need to monitor phosphate additives in foods by checking the
Nutrition Facts label. In particular, foods high in phosphate additives include processed meats
(hot dogs, chicken nuggets), flavor-enhanced meats, processed cheeses, instant puddings and
sauces, refrigerated bakery products, seasonings, and many beverages. 10
14. Mrs. Joaquin tells you that some of her friends can drink only certain amounts of liquids
and wants to know if that is the case for her. 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 reduce his or her thirst?
Fluid recommendations are highly individualized for late-stage CKD patients differ between HD
and PD patients. Recommendations are also based on residual urine output, blood pressure
control, presence of edema, congestive heart failure, and interdialytic weight gain. 1 Fluid
recommendations are typically given in combination with a sodium recommendation, as
limiting dietary sodium intake is the best way to control fluid intake. Fluid overload can include
symptoms of shortness of breath, hypertension, congestive heart failure, and edema.
Mrs. Joaquin’s recommendations are for 2 grams sodium per day, and 1000 mL fluid plus urine
output per day. 1000 milliliters is approximately 34 fluid ounces.
To reduce her thirst, Mrs. Joaquin can limit her intake of high-sodium foods, and drink less
sweet beverages that will quench her thirst.10 To moisten her mouth, Mrs. Joaquin can use sour
candy or sugar-free gum. Alternatively, she can swish her mouth with very cold water or lowalcohol mouthwash when thirsty without swallowing the liquid. Ice cubes can also be helpful.
One cup of ice is equal to ½ cup water, and will last longer. Frozen fruit can also be used (within
a ½ cup serving size) by eating one serving throughout the day. Patients should brush teeth
often, and use lip balm to keep lips moist. Additionally, it will be important for Mrs. Joaquin to
weigh herself daily to ensure she is not exceeding the recommended amount of interdialytic
weight gain.
Some foods are considered to be fluids. These include soups, yogurt, custard, gelatin, ice cream,
sherbet, and frozen ice pops.
15. Several biochemical indices are used to diagnose CKD. One is GFR. What does GFR
measure? What is a normal GFR? Mrs. Joaquin’s GFR is 28 ml/min. Interpret her value.
The glomerular filtration rate (GFR) measures the rate at which substances are cleared from the
plasma by the glomeruli.1 It is used to evaluate kidney health, estimate the severity of disease,
and monitor CKD progression.6 The National Kidney Foundation uses GFR values as part of the
diagnostic criteria for distinguishing between the five stages of CKD. 10 Normal values for GFR
are 135-200 liters per day. Mrs. Joaquin’s value of 28 mL/min/1.73m2 indicates she is at Stage 4
of CKD, and action should be taken to prepare her for kidney replacement therapy.10
16. Evaluate Mrs. Joaquin’s chemistry report. What labs support the diagnosis of Stage 5
CKD?
Mrs. Joaquin presents with a GFR = 4.58, which meets K/DOQI criteria for Stage 5 kidney failure
(calculation using Modification of Diet in Renal Disease (MDRD) formula10, shown below). Her
laboratory values show elevated potassium, low sodium, chloride, and CO2, and elevated BUN,
creatinine, and phosphate. Additionally, the urinalysis shows elevated pH, and presence of
protein in the urine. Mrs. Joaquin’s blood glucose level was very high (282 mg/dL), and HgA 1c
was 8.9%, indicated uncontrolled diabetes. Finally, Mrs. Joaquin has hypertension, elevated
cholesterol, LDL-C, and triglycerides, as well as low HDL-C.
GFR = 170 x 12-.999 x 24-.176 x .762 x 69-.17 x 3.7-.32
GFR = 4.58
17. Which of Mrs. Joaquin’s other symptoms would you expect to begin to improve?
After RRT is initiated, Mrs. Joaquin’s lab values for the following should gradually improve:
potassium, sodium, chloride, phosphate, CO2, , and pH. Her BUN and creatinine will not be
within normal limits even with RRT. 10 Mrs. Joaquin’s appetite should return, and she will
hopefully lose some fluid contributing to her weight. The mental confusion, malaise, nausea,
and vomiting should lessen, and her ability to urinate should return. Mrs. Joaquin’s skin should
gradually return to normal coloration.
18. Explain why the following medications were prescribed by completing the following
table.15
Medication
Indications/Mechanism
Capoten/capt
opril
Antihypertensive (ACE inhibitor)
Erythropoietin
Antianemic
Sodium
bicarbonate
Antacid; alkalinizing agent
Renal caps
Water-soluble vitamin
supplement
Renvela
Phosphate binder (for use in
ESRD)
Hectorol
Hyperparathyroidism treatment
(in renal dialysis); used to treat
hypocalcemia in
hypoparathyroid or dialysis
patients, or to manage
hyperparathyroidism in
predialysis.
Glucophage
Antihyperglycemic agent
(potentiates the effect of
insulin, decreases glucose
Nutritional Concerns
Take on empty stomach, take oral Fe or Mg supplement
separately by at least 2 hours; adequate fluid/hydration
needed; anorexia and decreased weight have been
reported.
Diet compliance is mandatory; HTN must be controlled;
BP, Hb/HCT, electrolytes, GI function, and renal function
must be monitored. Caution use in pt with GI distress.
Low Na diet indicated; increased thirst and increased
weight related to edema indicated. Caution with severe
renal disease and HTN; monitor electrolytes, acid-base
balance, serum pH.
Indicated in end-stage renal disease and as stress
vitamin. If on dialysis, take after treatment.
Nausea/vomiting, GI distress. Folic acid may mask
symptoms of pernicious anemia.
Take with each meal and snack; swallow whole. Take 1
hour after or 3 hours before other medications. Low
phosphorous diet indicated. Nausea, diarrhea,
constipation side effects. Monitor P, Ca, Cl, Bicarb.
May mix with food or fruit juice. Avoid excessive
calcium; low phosphorous diet indicated. Side effects:
Increased calcium absorption; anorexia; weight loss;
increased thirst. Dry mouth, metallic taste, N/V,
diarrhea, and constipation. Some side effects are those
of vitamin D toxicity. Increased urinary calcium,
phosphorous, albumin expected; monitor serum Ca, P,
Mg, alk phos, renal function, PTH, and urinary Ca and P.
Take with meals; follow prescribed diabetic diet;
decrease caloric intake if weight loss indicated. Anorexia
indicated. Side effects: N/V, bloating, diarrhea. Caution
absorption, decreases hepatic
glucose production)
with renal failure and serum creatinine >1.4 females.
Monitor BG, HbA1c, renal function, B12, folate.
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
complications of diabetes? Explain.
Epidemiologic data shows Pima Indians have higher prevalence of overweight, obesity, and
diabetes, as well as other comorbidities.16 The prevalence of adolescent Type 2 diabetes in
Pima has doubled since 1980.16 The Pima are at higher risk for complications of diabetes,
including CKD often progressing to Stage 5. 16 The “thrifty gene” theory was proposed in 1962
by James Neel, a geneticist, as an explanation for why Pima Indians are disproportionately
overweight compared to other demographic groups.17 The theory is based on factual evidence
that for thousands of years, populations such as the Pima Indians, who relied on farming,
hunting, and fishing for food, experienced periods of both feast and famine. To adapt to these
alternating changes in caloric needs, people of these populations developed a “thrifty gene”
that enabled their bodies to store fat during times of “feast” to have a reserve and prevent
starvation during times of famine. 17 However, once these populations became Westernized,
they developed a lifestyle of less physical activity, higher fat diet, and reliable access to calories.
The “thrifty gene” continued to store calories in preparation for famine, yet that time period
never came. Many scientists believe this gene that once protected the Pima Indians from
starvation is now contributing to their unhealthy retention of fat and consequential high
prevalence of overweight, obesity, diabetes, and other comorbidities. 17
20. Choose two high-priority nutrition problems and complete a PES statement for each.
1. Limited adherence to nutrition-related recommendations (NB-1.6) related to lack of skills
for following diets for CKD and T2DM evidenced by patient complaining of difficulty following
prior diet instructions and diet recall showing intake inconsistent with nutrition education for
T2DM and early stages of CKD.
2. Excessive mineral intake (sodium, potassium, phosphorous) (NI-5.10.2.5.6.7) related to
limited knowledge of stage 5 CKD diet restrictions evidenced by diet recall showing high
sodium, potassium, and phosphorous intake at each meal inconsistent with diet
recommendations for Stage 5 CKD.
21. For each PES statement, establish an ideal goal (based on the signs and symptoms) and
appropriate intervention (based on the etiology).
3. Nutrition prescription: Improve skills for managing Stage 5 CKD diet by reeducating
patient of diet guidelines and providing sample meal plans.
a. Nutrition education for skill development (E-2.2) in selecting appropriate
combination of foods for Stage 5 CKD management with concurrent diagnosis of
T2DM.
b. Strategy – Motivational interviewing (C-2.1) to resolve ambivalence to CKD and
T2DM diet plans by using patient-centered approach to elicit behavior change
goals from the patient and support self-efficacy for change.
c. Goal: Patient will be able to independently select combination of foods in
compliance with Stage 5 CKD diet restrictions while managing blood glucose
within 3 follow-up appointments.
4. Nutrition prescription: Reduce intake of sodium, potassium, and phosphorus to 2 g Na,
2 g K, 1 g Phosphorous (NKF K/DOQI recommendations for HD patient < 60 years).
a. Meals and snacks: Mineral-modified diet (ND-1.2.10) for sodium, potassium and
phosphorus meeting NKF K/DOQI recommendations for HD patient < 60 years.
b. Nutrition education: Priority modifications (E-1.2) are reducing sodium,
potassium, and phosphorus by any amount as soon as possible to reduce risk of
complications associated with hypernatremia, hyperkalemia, or
hyperphosphatemia.
c. Collaboration of nutrition care with other providers (RC-1.3) including
nephrologist, dialysis nurse, and dialysis technician to provide overall patient
care regarding dialysis modality and secondary disease management upon onset.
d. Goal: Patient will meet recommendations for sodium, potassium, and
phosphorus intake within 3 follow-up appointments according to daily food
diary.
22. Why is it recommended for patients to have a least 50% of their protein from sources that
have high biological value?
Kidneys filter the by-products of protein digestion and metabolism.1 Additionally, when an
individual consumes more protein than is needed, the excess amino acids are removed as
waste. Urea is one example of these “waste” products that is removed through the kidneys and
excreted in the urine. More amino acids and waste products to be removed translate to harder
work for the kidneys, which can accelerate the decline in kidney function for patients with CKD.
However, a certain amount of protein is needed to prevent malnutrition. Therefore, patients
with CKD must minimize excess amino acids to spare kidney function. Proteins that have high
biologic value (HBV) create the least waste upon digestion, and are complete proteins, meaning
they provide all of the essential amino acids humans need.1 Sources of HBV proteins are animal
foods, such as eggs, meats, fish, and dairy products.
23. What resources would you use to teach Mrs. Joaquin about her diet?
Mrs. Joaquin will need lists of foods high/low in phosphorous, sodium, and potassium as well as
serving size amounts for these foods. She will also need guides for selecting and estimating
portion size of protein foods, and I would use a list of foods containing HBV protein to inform
Mrs. Joaquin of this special need. I would also use common water bottles or glasses to visualize
her fluid needs. Using food models will aid in teaching Mrs. Joaquin about her diet. I would also
use packages of food to teach and practice label reading, including Nutrition Facts and
Ingredients List. I would review all aspects diabetes management (blood glucose monitoring,
nutrition, etc.) with Mrs. Joaquin.
24. Using Mrs. Joaquin’s typical intake and the prescribed diet, write a sample menu. Make
sure you can justify your changes and that it is consistent with her nutrition prescription.
Diet PTA
Breakfast:
Cold cereal (3/4 c unsweetened)
Bread (2 slices) or
fried potatoes (1 medium potato)
1 fried egg (occasionally)
Lunch:
Bologna sandwich (2 slices white bread, 2 slices
bologna, mustard)
Potato chips (1 oz)
1 can Coke
Dinner:
Chopped meat (3 oz beef)
Fried potatoes (1 ½ medium)
HS Snack:
Sample Menu
Breakfast:
½ c. applesauce, no sugar added
½ English muffin, with 1 tsp margarine
2 egg whites, minimal cooking spray used
1 c. corn flakes, unsweetened
4 oz skim milk
8 oz water
Lunch:
Chicken sandwich: 2 slices white bread, 3 oz baked
chicken, alfalfa sprouts
½ c. carrots
1 medium apple
8 oz water
Dinner:
Tossed salad: kale, cabbage, carrot, water
chestnuts, red onion with Balsamic vinegar and 1
tsp olive oil
Beef tenderloin (3 oz), with garlic and 1 tsp
margarine
½ c. corn with low sodium, low potassium
seasoning
Asparagus (6) with 1 tsp olive oil, black pepper
1 White dinner roll
½ c. Baked peaches with cinnamon and nutmeg
8 oz water
HS Snack:
Crackers (6 Saltines) and peanut butter (2 Tbsp)
3 squares graham crackers
4 oz skim milk
Total kcal: 1770
Total protein: 77 gm
Fluid: 32 oz
While this meal plan provides fewer total calories than the recommended 2550 kcal/day.
However, considering patient’s history of noncompliance with Type 2 diabetes management
with diet, this meal plan was designed to allow for inaccuracies in serving sizes, particularly in
margarine and olive oil, that might add more calories than the serving sizes listed in the meal
plan. If follow-up shows Mrs. Joaquin is not meeting her calorie needs or is having difficulty
meeting portion size restrictions, an oral supplement such as Nepro can be initiated. This will
replace some of the protein in her meals and snacks, and will also make up 8 oz of her fluidrestricted diet.
25. After evaluating Mrs. Joaquin’s typical diet, what other recommendations can you make?
Mrs. Joaquin needs to incorporate more fruits and vegetables into her diet that comply with
her sodium, potassium, and phosphorus restriction. Her diet history shows that white potatoes
and high-sodium foods make up a large part of her caloric intake. I would recommend low
sodium alternatives to her, as well as low-sodium versions of foods she really likes (if meet
potassium and phosphorus restrictions). Mrs. Joaquin has previously been on a low protein
diet. After initiating RRT, she will have increased protein needs and will need to obtain the
additional protein while meeting the sodium, potassium, and phosphorus restrictions. Because
Mrs. Joaquin also has diabetes, she will need to become compliant with her hypoglycemic
medications and become more aware of her carbohydrate intake and portion sizes than her
history indicates. Mrs. Joaquin may also need to start taking a phosphate binder to prevent
hyperphosphatemia after observing her history of noncompliance with dietary restrictions.
26. Write an initial ADIME note for your consultation with Mrs. Joaquin.
ADIME Format
A(Assessment):
Food/Nutrition related history
Food Intake: Types of food/meals (FH-1.2.2.2) limited variety, energy-dense, nutrient-poor
Mineral Intake: Potassium (FH-1.6.2.5) Phosphorus (FH-1.6.2.6) Sodium (FH-1.6.2.7)
excessive for CKD restrictions Diet Experience: Previously prescribed diets (FH-2.1.2.1)
previous education for early stage CKD and T2DM management Beliefs and attitudes:
Motivation (FH-4.2.4) lacking for CKD and T2DM disease management
Anthropometric:
Height/weight/BMI (AD 1.1) Ht 5’0”; Wt 170# BMI 33
Biochemical
Sodium (BD-1.2.5) 130 mEq/L Potassium (BD-1.2.7) 5.8 mEq/L Chloride (BD-1.2.6) 91 mEq/L
CO2 (BD-1.1.3) 20 mEq/L BUN (BD-1.2.1) 69 mg/dL Creatinine serum (BD-1.2.2) 12.0 mg/dL
Glucose (BD-1.5.2) 282 mg/dL Phosphate (BD-1.2.11) 9.5 mg/dL Calcium (BD-1.2.9) 8.2
mEq/L Cholesterol (BD-1.7.1) 220 mg/dL Cholesterol-HDL (BD-1.7.2) 50 mg/dL CholesterolLDL (BD-1.7.3) 135 mg/dL Triglycerides (BD-1.7.7) 200 mg/dL HbA1c (BD-1.5.3) 8.9% Urine
test, protein (BD-1.12.5) 2+ md/dL Urine test, pH (BD-1.12.5) 7.9
Nutrition-focused physical findings
Body language (PD-1.1.12) malaise Skin (PD-1.1.8) yellow-brown coloration, dry Extremities
(PD-1.1.4) pitting edema – knees; muscle weakness
Client History
Age (CH-1.1.1) 24 years Race/Ethnicity (CH-1.1.3) Pima Indian Patient medical history,
endocrine (CH-2.1.3-P) T2DM age 13 Patient medical history, renal (CH-2.1.14-P) Stage 3
CKD age 22 Family health history, Endocrine (CH-2.1.3-F) Parents both T2DM
D (Diagnosis):
1. (P) Limited adherence to nutrition-related recommendations (NB-1.6) (E) related to lack of skills
for following diets for CKD and T2DM (S) evidenced by patient complaining of difficulty following prior
diet instructions and diet recall showing intake inconsistent with nutrition education for T2DM and
early stages of CKD.
2. (P) Excessive mineral intake (sodium, potassium, phosphorous) (NI-5.10.2.5.6.7) (E) related to
limited knowledge of stage 5 CKD diet restrictions (S) evidenced by diet recall showing high sodium,
potassium, and phosphorous intake at each meal inconsistent with diet recommendations for Stage 5
CKD.
I (Intervention):
1. Nutrition prescription: Improve skills for managing Stage 5 CKD diet by reeducating patient of
diet guidelines and providing sample meal plans.
a. Nutrition education for skill development (E-2.2) in selecting appropriate
combination of foods for Stage 5 CKD management with concurrent diagnosis of
T2DM.
b. Strategy – Motivational interviewing (C-2.1) to resolve ambivalence to CKD and
T2DM diet plans by using patient-centered approach to elicit behavior change goals
from the patient and support self-efficacy for change.
c. Goal: Patient will be able to independently select combination of foods in compliance
with Stage 5 CKD diet restrictions while managing blood glucose within 3 follow-up
appointments.
2. Nutrition prescription: Reduce intake of sodium, potassium, and phosphorus to 2 g Na, 2 g K,
1 g Phosphorous (NKF K/DOQI recommendations for HD patient < 60 years).
a. Meals and snacks: Mineral-modified diet (ND-1.2.10) for sodium, potassium and
phosphorus meeting NKF K/DOQI recommendations for HD patient < 60 years.
b. Nutrition education: Priority modifications (E-1.2) are reducing sodium, potassium,
and phosphorus by any amount as soon as possible to reduce risk of complications
associated with hypernatremia, hyperkalemia, or hyperphosphatemia.
c. Collaboration of nutrition care with other providers (RC-1.3) including nephrologist,
dialysis nurse, and dialysis technician to provide overall patient care regarding dialysis
modality and secondary disease management upon onset.
d. Goal: Patient will meet recommendations for sodium, potassium, and phosphorus
intake within 3 follow-up appointments according to daily food diary.
M&E (monitoring & evaluation):
Types of food/meals limited variety, energy-dense, nutrient-poor (based on diet recall).
Monitor at follow-up with food diary. Mineral Intake: Potassium, Phosphorus, Sodium
excessive for new HD restrictions (K/DOQI criteria). Will monitor change in Potassium,
sodium, phosphorus intake at follow-up. Diet Experience: Previously prescribed diets
previous education for early stage CKD and T2DM management. Will evaluate compliance
with T2DM and CKD diet at follow-up. Beliefs and attitudes: Motivation lacking for CKD and
T2DM disease management (patient interview). Will reevaluate motivation for compliance at
follow-up. Monitor all labs at follow-up: Sodium Current: 130 mEq/L; Goal: 136-145.
Potassium Current: 5.8 mEq/L; Goal:3.5-6.0. Chloride Current: 91 mEq/L; Goal:100-106. CO2
Current: 20 mEq/L; Goal:23-30, >22. BUN Current: 69 mg/dL; Goal:60-80. Creatinine Current:
12.0 mg/dL; Goal:2-15 Glucose Current: 282 mg/dL; Goal70-105 fasting, <200 nonfasting.
Phosphate Current: 9.5 mg/dL; Goal: 3.5-5.5. Calcium Current: 8.2 mEq/L; Goal:9.0-10.5.
Cholesterol Current: 220 mg/dL; Goal <200. Cholesterol-HDL Current: 50 mg/dL; Goal:>55.
Cholesterol-LDL Current: 135 mg/dL; Goal:<130. Triglycerides Current: 200 mg/dL; Goal:40160, <200. HbA1c Current: 8.9%; Goal:<7% Urine test, protein Current: 2+ md/dL; Neg. Urine
test, pH Current: 7.9; Goal: 5-7. Body language: Pt presents with malaise; energy should
increase upon RRT initiation (K/DOQI). Skin Current yellow-brown coloration and dry;
monitor color for return to normal upon RRT initiation. Extremities Current pitting edema –
knees and muscle weakness; monitor edema and muscle strength at follow-up after fluid
restriction and RRT initiated.
References
1. Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition therapy and pathophysiology. 2 ed.
Wadsworth. Cengage Learning, 2011.
2. National Institute of Diabetes and Digestive and Kidney Disease of the National Institute
of Health. Kidney and urologic disease statistics for the US. Available at
http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/index.htm#1
3. National Institutes of Health. National Kidney Disease Education Program (NKDEP).
Retrieved from http://nkdep.nih.gov/
4. K/DOQI. Chronic Kidney Disease: Evaluation, classification, and stratification. Guideline
1. Definition and stages of Chronic Kidney Disease. Pp.S7-S10. 2002.
5. National Institutes of Health (NIH). Chronic Kidney Disease. Medline Plus. 2011.
Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000471.htm
6. Daugirdas J, Van Stone J, Boag J. Hemodialysis apparatus. In: Daugirdas J, Blake P, Ing T,
eds. Handbook of dialysis. 3rd ed. PhiladelphiaL Lippincott Williams & Wilkins. 2001; 4666.
7. Besarab A, Raja R. Vascular access for hemodialysis. In: Daugirdas J, Blake P, Ing T, eds.
Handbook of dialysis. 3rd ed. PhiladelphiaL Lippincott Williams & Wilkins. 2001; 67-101.
8. Lindsay R. Daily hemodialysis: The time has come. Am J Kidney Dis. 2005;45:793-797.
9. Blake P, Daugirdas J. In: Daugirdas J, Blake P, Ing T, eds. Handbook of dialysis. 3 rd ed.
Philadelphia: Lippincott Williams & Wilkins. 2001; 281-296.
10. National Kidney Foundation. Pocket Guide to Nutrition Assessment of the Patient with
Chronic Kidney Disease (CKD). 4th ed. [Revised] Online, National New York: Kidney
Foundation. 2009.
11. National Kidney Foundation. Adult guidelines, Maintenance dialysis. 1. Evaluation of
protein-energy nutritional status. 2000. Retrieved from
http://www.kidney.org/professionals/kdoqi/guidelines_updates/nut_a12.html
12. Academy of Nutrition and Dietetics. Evidence Analysis Library. Chronic kidney disease
(CKD) anthropometric assessment options. Retrieved from
http://andevidencelibrary.com/template.cfm?key=2412&auth=1
13. Bannister DK, Acchiardo SR, Moore LW, et al. Nutritional effect of peritonitis in
continuous ambulatory peritoneal dialysis. J Am Diet Assoc. 1987;87:53-56
14. Block GA, Hulbert-Shearon TE, Levin NW, Port FK. Association of serum phosphorous
and calcium x phosphorus product with mortality risk in chronic hemodialysis patients: a
national study. Am J Kidney Dis. 1998;31:607-617.
15. Pronsky ZM, Crowe JP. Food medication interactions. 17th ed. Birchrunville, PA. 2012.
16. National Institute of Diabetes and Digestive and Kidney Diseases. The Pima Indians:
Pathfinders for health. 2002. Retrieved from
http://diabetes.niddk.nih.gov/dm/pubs/pima/index.htm.
17. Prevalence: Diabetes mellitus in the Pima Indians: Incidence, risk factors and
pathogenesis. Knowler WC, Pettitt DJ, Saad MF, Bennett PH. Article first published
online: 2009. Diabetes/Metabolism Reviews. Volume 6: 1: 1–27, February 1990. DOI:
10.1002/dmr.5610060101
CHRONIC
KIDNEY
DISEASE
Katherine Albus
October 28, 2013
Definition: Syndrome of progressive and irreversible loss of
excretory, endocrine, and metabolic functions of kidneys
secondary to kidney damage.1
Leading causes of renal failure2:
 Diabetes *most common cause in US
 Hypertension
 Glomerulonephritis
 CVD, HTN
 Ethnicity: African American, Native American, Hispanic
 Family history of CKD
 Hereditary conditions: Polycystic Kidney Disease
 Physical blow to either kidney
 Prolonged use of OTC painkillers (aspirin, acetaminophen,
ibuprofen)
Stages3:
Stage
1
3
Description
Kidney damage with
normal or increased GFR
Kidney damage with mild
decrease in GFR
Moderate decrease in GFR
4
Severe decrease in GFR
5
Kidney function
inadequate to sustain life
2
GFR
>90
mL/min/1.73m2
60-89
mL/min/1.73m2
30-59
mL/min/1.73m2
15-29
mL/min/1.73m2
<15
mL/min/1.73m2
Glomerular filtration rate (GFR): rate at which substances are
cleared from the plasma by glomeruli. 1
Calculation – Modification of Diet in Renal Disease (MDRD)
GFR = 170 x creatinine-.999 x age-.176 x (.762 if female) x (1.20 if
black race) x BUN-.17 x albumin-.32
Key lab values to monitor4
Test
BUN
Serum
Calcium
C02
Chloride
Cholesterol
Creatinine
Glucose
(fasting)
HbA1c
Phos
Potassium
Ref. Range
10-20 mg/dL
9.0-10.5 *may be
adjusted for low
albumin
23-30 mEq/L
100-106 mEq/L
<200 mg/dL
0.5-1.1 md/dL (fem)
0.6-1.2 mg/dL (male)
70-1-5 mg/dL
14-18 g/dL (male)
12-16 g/dL (fem)
3.0-4.5 mg/dL
3.5-5.0 mEq/L
Sodium
136-145 mEq/L
Triglycerides 40-160 mg/dL (male)
35-135 mg/dL (fem)
Signs and symptoms1:
Edema
Metabolic acidosis
Hyperkalemia,
hyperphosphatemia
Anemia
Uremia
Azotemia
Oliguria
Hypertension
Breath odor
CKD Range
60-80 mg/dL
WNL (low end)
WNL >22
WNL
WNL
2-15 mg/dL
WNL
<200 non-fasting
Variable,
10-12 g/dL
WNL
3.5-5.5 mg/dL
WNL
3.5-6.0 mEq/L
WNL
WNL
<200 mg/dL
Secondary hyperparathyroidism
Bone and mineral disorders
Skin discoloration
Drowsiness, confusion
Malaise, fatigue
Muscle cramping, numbness
Shortness of breath,
Nausea/vomiting
Insomnia
Urine abnormalities
Renal Replacement Therapy*:
 Hemodialysis
 Peritoneal dialysis
 Renal transplantation
*See NKF recommendations for detailed MNT per each RRT
Adjusted edema-free body weight (for obese)3:
aBWef = ABW + [(SBW-ABW) x .25]
(ABW = actual body weight (kg); SBW = standard body weight (kg)
according to NHANES II standards)
Nutrition recommendations4:
CKD
Protein, 0.6-0.75
g/day
> 50% HBV
Energy’, 30-35 > 60 yrs
kcal/day 35 < 60 yrs
Na+
Varies, 1-3 or “no added
salt”
+
K
Usually unrestricted
Phos,
800-1000 mg/day;
mg/day maintain WNL
Calcium, DRI
g/day
Fluid,
Usually unlimited
cc/day
HD
> 1.2
>50% HBV
30-35 > 60 yrs
35 < 60 yrs
2
2-3
800-1000 mg/day,
adjust to meet
needs^
< 2.0 including
binder load
Output + 1000 cc.
Limit interdialytic
weight gain
^Consider phosphate binder medication
‘Consider energy absorbed from dialysate in PD
High Biologic Value (HBV) protein1: complete proteins (i.e.
animal sources)
Collaboration with other healthcare providers1:
Nephrologist, Dialysis nurse, Dialysis Technician, Social Worker
Mineral
Foods to avoid
Phosphorous Dairy products, dried beans and peas, whole
grain products, nuts, beer/ale, dark colas,
chocolate, organ meats, some seafood
Potassium
Sodium
Fluid
Many fruits and vegetables, bran products,
chocolate, milk, nuts/seeds, salt substitutes,
chewing tobacco
Processed meats, brined meats, processed
cheese products, canned vegetables, pickled
foods, baked goods from mixes, seasoned
rice/noodle mixes, many sauces/condiments,
frozen dinners, convenience foods, mixes
Yogurts, popsicles, gelatin, ice cream, foods
liquid at room temperature
National Kidney Foundation
Common nutritional diagnoses in CKD:
• Inadequate energy intake
• Inadequate oral/food and beverage intake
• Excessive fluid intake
• Malnutriton
• Excessive protein intake
• Excessive mineral intake (K+, Na+, Phos)
• Altered GI function
• Altered nutrition-related laboratory values
• Food medication interaction
• Involuntary weight loss
• Involuntary weight gain
• Food and nutrition-related knowledge deficit
• Disordered eating pattern
• Limited adherence to nutrition-related
recommendations
• Undesirable food choices
• Impaired ability to prepare foods/meals
• Poor nutrition quality of life
• Limited access to food
References
1) Nahikian-Nelms M. Nutrition therapy and pathophysiology.
Belmont, Calif: Wadsworth, Cengage Learning; 2011.
2) National Institute of Diabetes and Digestive and Kidney
Disease of the National Institute of Health. Kidney and
urologic disease statistics for the US. Available at
http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/index.h
tm#1
3) K/DOQI Clinical Practice Guidelines for Chronic Kidney
Disease: Evaluation, Classification, and Stratification.
Guideline 1. Definition and stages of CKD. pp.S7-S10. 2002.
4) National Kidney Foundation. Pocket Guide to Nutrition
Assessment of the Patient with Chronic Kidney Disease (CKD).
4th ed. [Revised] Online, National New York: Kidney
Foundation. 2009.