Natalie Meltzer November 4, 2013 NUTR 409 Case Study 18: Renal Disease 1.

Describe the physiological functions of the kidneys. Every day, a persons kidneys process about 200 quarts of blood to sift out about 2 quarts of waste products and extra water. The waste and extra water become urine, which flows to the bladder until urination. People with two healthy kidneys have 100% of their kidney function. Small or mild declines in kidney function would rarely be noticeable. Kidney function is calculated using a blood sample and formula to find the estimated glomerular filtration rate (eGFR). The eGFR corresponds with the percent of kidney function available. 2. What diseases/conditions can lead to chronic kidney disease (CKD? Explain the relationship between diabetes and CKD. Conditions that can damage the kidneys and cause chronic kidney disease are kidney diseases and infections, such as polycystic kidney disease, pyelonphritic, glomerulonephritis, or a kidney problem you were born with. Other conditions include having a narrowed or blocked renal artery and long-term use of medicines, for example, NSAIDs. People with diabetes often have kidney problems. Diabetes causes about 35% of all chronic kidney disease. High blood sugar levels caused by diabetes damage blood vessels in the kidneys; if a blood sugar levels remains high, this damage gradually reduces the function of the kidneys. 3. Outline the stages of CKD, including the distinguishing signs and symptoms. Stage 1: Normal kidney function but urine findings or structural abnormalities or genetic trait point to kidney disease; there are usually no symptoms to indicate the kidneys are damaged because kidneys do a good job even when theyre not functioning at 100% Stage 2: Mildly reduced kidney function, and other findings point to kidney disease; there are usually no symptoms to indicate the kidneys are damaged; same concept of stage 1 Stage 3: Moderately reduced kidney function; a person is more likely to develop complications of kidney disease such as high blood pressure, anemia, and/or early bone disease; some symptoms that may start to be present are: fatigue, swelling (edema), urination changes, kidney pain, and sleep problems. Stage 4: Severely reduced kidney function; likely this person will need dialysis or a kidney transplant in the near future. Symptoms include fatigue, swelling (edema), urination changes,

kidney pain, sleep problems, nausea, taste changes, uremic breath, loss of appetite, difficulty in concentrating, and nerve problems. Stage 5: Very severe, or end stage kidney failure, sometimes called established renal failure; kidneys have lost nearly all their ability to do their job effectively, and eventually dialysis or a kidney transplant is needed to live. Symptoms in this stage are loss of appetite, nausea or vomiting, headaches, fatigue, unable to concentrate, itching, making little or no urine, swelling around eyes and ankles, muscle cramps, tingling in hands or feet, changes in skin color, and increased skin pigmentation. 5. What are the treatment options for Stage 5 CKD? Explain the differences between hemodialysis and peritoneal dialysis. Treatment options for stage 5 CKD are hemodialysis, peritoneal dialysis, of a kidney transplant. Hemodialysis requires an access site be created to get blood from the body to a dialyzer (artificial kidney) so it can be clean and then go back into the body. A catheter would be temporarily placed for access, and if a person remains on hemodialysis, the person would get a fistula for permanent access. Another type of access site is a graft that uses artificial tubing to connect the artery and vein. Peritoneal dialysis uses catheter access that is placed in the abdomen. It is performed by running dialysate solution through the catheter into the peritoneum and then removing the solution after some time and replacing it with new dialysate. There are different methods of performing PD. It can be manually drained every 4 6 hours, an automated machine that works while a person sleeps with a manual exchange in the morning, or where PD is performed at night while sleeping. 6. Explain the reasons for the following components of Mrs. Joaquins medical nutrition therapy: Nutrition Therapy 35 kcal/kg Rationale These calories are important to maintain weight and level of energy. Since she must make changes in her diet, it may make it more difficult for her to get enough calories each day. She should follow this guideline to get enough calories and still eat healthy Low protein diets may be helpful before dialysis is started; once dialysis is started, a high protein diet is recommended to help replace muscle and other tissues that are lost Too much potassium can build up when the kidneys no longer function well. This is why a low potassium diet is recommended Low phosphorus is recommended because phosphorus levels in the blood can become too high in CKD. It may cause the body to pull calcium from the bones to make them break and

1.2 g protein/kg

2gK

1 g phosphorus

2 g Na

1000 mL fluid + urine output

itching Low sodium in the diet helps control high blood pressure and from being thirsty. It also prevents the body from holding onto extra fluid Fluid can build up in the body which is why it is important to monitor a low fluid intake.

7. Calculate and interpret Mrs. Joaquins BMI. How does edema affect your interpretations? Mrs. Joaquins BMI is 33.2. Based on her BMI, she is considered obese. Mrs. Joaquin has edema which affects the BMI interpretations to be overestimated. Her edema-free BMI is 27.3, which uses her adjusted body weight of 140 lbs. 8. What is edema-free weight? Calculate Mrs. Joaquins edema-free weight. aBWef = BWef + [(SBW BWef) x 0.25] 73.3 kg + [(60 kg 73.3 kg) x 0.25] 73.3 + (- 13.3 x 0.25) = 70 kg Edema-free weight is a calculated weight without the excess fluid buildup due to the edema. This weight is guideline as the lowest weight a person can safety reach while on dialysis. Edema-free weight for Mrs. Joaquin is 70 kg. 12. Calculate what Mrs. Joaquins energy needs will be once she begins hemodialysis. Mrs. Joaquins total energy needs are 2,226 kcal/day. This is based on 35 kcal per kg of adjusted body weight. 13. Mrs. Joaquin has PO4 restriction. Why? What foods have the highest levels of phosphorus? Phosphorus is a mineral that builds up in the blood as kidney failure progresses. If potassium reaches dangerous levels in the body, a person may feel weakness, numbness, and can cause an irregular heartbeat or a heart attack. Foods that have the highest levels of phosphorus include apricot, avocado, broccoli, milk, nuts and seeds, and legumes. 14. Mrs. Joaquin tells you that one 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 liquid restriction, what can be done to help reduce his or her thirst?

Foods that are considered fluids are fruit, yogurt, soups, gelatin, vegetables, ice cream, and custard. Recommendations I can make for Mrs. Joaquin include: limit high salt foods to feel less thirst, use thirst quencher candies or gum, use ice cubes inside of liquids, use frozen fruit as a liquid serving to feel greater quenching feeling. To reduce thirst for a patient following a liquid restricted diet, they can use the following tips to reduce thirst: drink from small glasses, drink only when thirst, drink cold beverages that are less sweet, use candies and gums to moisten the mouth, eat frozen fruit as a serving of liquid, and swish water around mouth to relieve thirst. 15. Several biochemical indices are used to diagnose chronic kidney disease. One is glomerular filtration rate (GFR). What does GFR measure? What is a normal GFR? Mrs. Joaquins GFR is 28 mL/min. Interpret her value. Glomerular filtration rate measures the rate at which substances are cleared from the plasma by the globmeruli. GFR is used as an index of kidney function. This test measures creatinine clearance. A normal GFR over 90 mls/min/1.73m2 is normal unless there is other evidence of kidney disease. Mrs. Joaquins GFR indicates that she is in stage 4 of chronic kidney disease. Her kidney function has severely diminished. 16. Evaluate Mrs. Joaquins chemistry report. What labs support the diagnosis of Stage 5 CKD? Albumin 3.7 g.dl: Low albumin levels reflect protein losses in her urine Sodium 130.0 mEo/L: Low sodium levels reflect losses in urine or fluid retention Potassium 9.5 mg/dL: High serum potassium indicate compromised filtration in the kidneys Total CO2 20.0 mEq/L: Low CO2 indicate compromised acid-base balance; malnutrition Glucose 282 mg/dl: High blood glucose indicates uncontrolled diabetes mellitus BUN 69.0 mg/dl: high blood urea nitrogen indicates insufficient filtration in the kidneys Creatinine 12.0 mg/dl: High level of creatinine indicates impaired kidney function Calcium 8.2 mg/dl: Low calcium reflects insufficient vitamin D Protein urine: 2+ mg/dl: High level of protein in urine indicates protein losses, a strong predictor of renal disease progression

18. Explain why the following medications were prescribed by completing the following table. Medication Capoten/captopril Indications/Mechanism Increases effect of insulin, lowers GI glucose absorption, decreases hepatic glucose production Stimulates red blood cell production to treat ESRDNutritional Concerns Do not take with vitamin D or Magnesium supplements, with dialysis do not take with excessive calcium or low potassium May need iron, vitamin B 12, or folate supplements; may

Erthropoietin

induced anemia Sodium bicarbonate Antacid

Renal caps

Combination of B vitamins to treat or prevent deficiency

Renvela Hectorol

Glucophage

Used to manage phosphorus levels Decreases PTH levels and increases calcium/phosphorus levels in the body May cause lactic acidosis

cause nausea, vomiting, and/or diarrhea Consider sodium content with low sodium diet; may increase thirst, increase fluid retention May experience mild upset stomach or flushing may occur; effects are usually temporary Hypophosphatemia, bowel obstruction; take with meals Should not take if she has a history of abnormal high calcium levels Check blood sugar regularly

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 of complications of diabetes? Explain. Pima Indians have high rates of obesity and diabetes. Health problems that are arisen due to their high rates of obesity and diabetes are kidney disease, eye disease, and nerve damage. Fifty percent of Pima Indians have diabetes mellitus and 95% of those with DM are overweight or obese. The thrifty gene is a theory that a genetic change has occurred over time in the Pima Indians. The change allowed the Pima Indians to survive during long periods of times of famine. As the Pima Indians adopted a Westernized life of less physical activity and a continuous food supply, the thrifty gene has predisposed them to developing chronic illnesses. The Pima are at higher risk of complications of diabetes. Pima Indian populations develop DM at around 30 years old, compared to Caucasian populations who develop DM around 60 years of age. 22. Why is it recommended for patients to have at least 50% of their protein from sources that have a high biological value? Biological value refers to how quickly the body can actually use protein. Body protein is conserved and minimizes urea generation when patients have at least 50% of their protein from sources high in biological value.