Katie Enstad

10/10/15
Nutr409
Case Study 18
Chronic Kidney Disease Treated with Dialysis
1. Describe the physiological functions of the kidneys.
a. The kidneys filter blood to produce urine, which is composed of waste and
fluid. Urine flows from the kidneys to the bladder. The kidney prevent the
buildup of waste and fluid in the body, keep adequate levels of
electrolytes, and make hormones that regulate blood pressure/make red
blood cells/strengthen bones.
2. What diseases/conditions can lead to chronic kidney disease (CKD)? Explain the
relationship between diabetes and CKD.
a. Hypertension, which damages blood vessels, can result in damaging the
kidneys. Kidney diseases and infections like polycystic kidney disease,
pyelonephritis, and glomerulonephritis can also result in CKD. Blocked
renal arteries or long-term use of certain medicines can also damage the
kidneys, which can lead to CKD. Finally, diabetes can result in CKD
because of the high blood sugar levels, which damage blood vessels in the
kidneys, and if blood sugar levels are consistently high over multiple years
this can reduce the function of the kidneys.
3. Outline the stages of CKD, including the distinguishing signs and symptoms.
a. *GFR: glomerular filtration rate
b. Stage 1: GFR = 90+, Normal kidney functions but there are urine findings,
structural abnormalities, or genetic traits that point to kidney disease.
c. Stage 2: GFR = 60-89, Mildly reduced kidney function, and other findings
point to kidney disease.

d. Stage 3: GFR = 45-59 (A)/30-44 (B), A and B, moderately reduced kidney

function.
e. Stage 4: GFR = 15-29, Severely reduced kidney function.
f. Stage 5: GFR = <15 or on dialysis, Very severe/end-stage kidney failure
(established renal failure).
g. Symptoms of these stages include changes in urination, edema in the
feet/ankles/hands/face, fatigue/weakness, shortness of breath, ammonia
breath, back pain, itching, loss of appetite, nausea/vomiting, or
hypoglycemic episodes.
4. What are the treatment options for stage 5 CKD? Explain the differences between
hemodialysis and peritoneal dialysis.
a. Treatment options include hemodialysis, peritoneal dialysis, or kidney
transplant. Hemodialysis uses a dialyzer, which is a manmade membrane
that cleans out your blood; you are connected to the dialyzer by tubes that
are then attached to your blood vessels. This involves treatment about 3
days a week for 3-5 hours a day. Peritoneal dialysis involves a catheter
being placed in your belly, and uses the lining of your belly (peritoneal
membrane) to filter your blood, which is called exchange. There will
usually be 4-6 exchanges completed every day.
5. Explain the reasons for the following components for Mrs. Joaquins medical
nutrition therapy:
a.
Nutrition Therapy
35 kcal/kg
1.2 g protein/kg

Rational
There needs to be enough to energy intake
for protein synthesis and to prevent
malnutrition.
Requires adequate protein to maintain
muscle/body composition, and to maintain
protein balance. Also increased to make up
for dialysis, which depletes the bodys
protein.

2gK

Needs low levels of K to prevent

hyperkalemia (especially for hemodialysis).
1 g phosphorus
Phosphorus is monitored to avoid irritation
of the system that is posed by
hyperparathyroidism, phosphate retention,
and hypocalcaemia in renal failure. Increased
retention leads to low blood calcium,
calcification. May also preserve the existing
kidney function.
2 g Na
To avoid weight gain, Na and fluid
restriction should be monitored. Excess Na
could result in increased thirst, which could
lead to fluid gain.
1000 ml fluid + urine output
Restricted fluid intake to prevent edema.
Patients with CKD do not have regular urine
function so fluid retention is common.
6. Calculate and interpret Mrs. Joaquins BMI. How does edema affect your
interpretation?
a. BMI: 77 kg/2.31m = 33.3
b. Mrs. Joaquins BMI would indicate that she is obese. However, because
she is experiencing edema in her face/eyes and extremities her BMI is an
overestimation. BMI does not account for the extra fluid retention caused
by CKD.
7. What is edema-free weight? Calculate Mrs. Joaquins edema-free weight.
a. Edema-free weight is a patients weight after dialysis (dry weight). After
dialysis the excess fluid that builds up in between treatments is released.
b. aBMer = BWef + [(SBW BWef) x 0.25]
c. 75 + [(60-75) x 0.25] = 71.25 kg, 157 lb.
8. What are the considerations for differences in protein requirements among predialysis, hemodialysis, and peritoneal dialysis patients?
a. Patients who are on dialysis have increased need for protein. Patients on
peritoneal dialysis have higher protein requirements than hemodialysis.
50% of protein should come from high biological value (HBV).
9. Mrs. Joaquin has a PO4 restriction. Why? What foods have the highest levels of
phosphorus?

a. Mrs. Joaquin has a restriction on phosphate in order to avoid

hyperparathyroidism, phosphate retention, and hypocalcaemia. This can
also help avoid metastic calcification and metabolic bone disease/renal
osteodystrophy. In addition, restricting phosphorus may help preserve
existing renal function. Animal proteins have the highest levels of
phosphorus (milk, meat, fish, cheese, etc.). Whole grain/bran cereals, dried
beans/peas, and many other foods also contain high amounts of
phosphorus.
10. 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 fluid restriction, what can be done to help reduce his or her thirst?
a. The recommendation is 1000 ml/day + urine output. Fluids include drinks,
soups, popsicles, ice cream/sherbet, gelatin, yogurt, and custard; but all
liquids must be at room temperature. I would recommend that Mrs.
Joaquin adhere to a low sodium diet so there is not increased fluid
retention and so she is not always thirsty. Spicy foods may also cause the
same reactions so she should limit spicy foods as well. To help reduce
thirst Mrs. Joaquin may suck on ice, gargle water but dont swallow, dont
drink sweet beverages, and stay cool.
11. 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.
a. GFR is an indicator of kidney function; it measures the amount of
glomerular filtrate that is in the nephrons in both kidneys. A normal value

for GFR is 90-120 mL/min. Mrs. Joaquins GFR indicates she has severe
renal failure/stage 4 CKD.
12. Evaluate Mrs. Joaquins chemistry report. What labs support the diagnosis of
Stage 4 CKD?
a. Sodium 130 mEq/L (136-145 mEq/L): indicates edema, loss of sodium or
excess fluid intake.
b. Potassium 5.8 mEq/L (3.5-5.5 mEq/L): supports diagnosis because the
kidney function to filter is reduced.
c. Chloride 91 mEq/L (95-105 mEq/L): Indicates the body is struggling to
maintain the electrolyte balance, which is consistent with CKD.
d. Carbon dioxide 20 mEq/L (23-30 mEq/L): suggests body is having a
difficult time maintaining the acid-base balance due to fluid retention.
e. BUN 69 mg/dL (8-18 mg/dL): Impaired renal function/inadequate
filtration, which indicates stage 4 CKD.
f. Creatinine serum 12.0 mg/dL (0.6-1.2 mg/dL): increased levels are
consistent with renal disease/CKD because of the reduced blood flow to
the kidneys. Creatinine filtration is used to calculate GFR, which is the
primary diagnosis of CKD.
g. Glucose 282 mg/dL (70-110 mg/dL): increased blood glucose shows
diabetes mellitus, which is the cause of nephropathy.
h. Phosphate 9.5 mg/dL (2.3-4.7 mg/dL): increased phosphate retention
indicates impaired phosphate filtration; this can lead to organ damage.
i. Calcium 8.2 mg/dL (9-11 mg/dL): low calcium levels is an indicator of
stage 4 CKD.
j. Cholesterol 220 mg/dL (120-199 mg/dL): puts Mrs. Joaquin at heart
disease risk. Inflammation of the glomerulus can lead to increased
cholesterol and lipid metabolism.
k. HDL-C 50 mg/dL (>55 mg/dL): Indicate poor maintenance of type 2
diabetes, which can result in CKD.

l. LDL 135 mg/dL (<130 mg/dL): Indicate poor maintenance of type 2

diabetes, which can result in CKD.
m. Triglycerides 200 mg/dL (35-135 mg/dL): increased risk for heart disease
and are consistent with diabetes mellitus and kidney failure. Inflammation
of glomerulus can affect TG.
n. HbA1c 8.9% (3.9-5.2%): consistent with the poor management of her
diabetes, and is consistent with the diagnosis of CKD.
13.
Medication
Capoten/captopril

Erythropoietin

Indications/Mechanisms
Lowers high blood pressure,
helps prevent strokes, heart
attacks, and kidney problems.
Works by relaxing blood
vessels easy blood flow.
Stimulates the productions of
RBC.

Sodium bicarbonate

Antacid

Renal caps

Combination of B vitamins,
used to prevent vit deficiency.
Lowers high blood
phosphorus for patients on
dialysis.
Used to treat kidney disease
patients who have high levels
of parathyroid hormone,
which affect other minerals in
the body (calcium and
phosphorus).
Controls high blood sugar.
Restores bodys ability to
respond to insulin. Decreases
amount of sugar the liver
produces.

Renvela
Hectorol

Glucophage

Nutritional Concerns
Can cause high potassium
blood levels, which can
effect muscle
contractions/heartbeat.
Could cause
nausea/vomiting or diarrhea.
May need to supplement
iron, folate or B12
Control calcium intake, also
want to consider the drugs
sodium content if trying to
adhere to a low sodium diet.
Could cause
nausea/vomiting, diarrhea,
or constipation
Manmade form of Vit D.
Increases calcium and
phosphorus in the body. Can
cause nausea/vomiting,
diarrhea, or constipation.
Can cause nausea/vomiting
or diarrhea. Could cause
problems if patient has a
B12 deficiency.

14. 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.
a. The Pima Indians have been shown to have higher disease rates (diatbetes,
retinopathy, nephropathy, neuropathy, heart disease, hypertension, stroke,
and obesity). The thrifty gene theory suggests that genes predisposed to
diabetes used to be good because they are able to efficiently metabolize
food and store it as fat during times of abundance, which would mean the
fatter people could survive in times of famine. The Pima are at a higher
risk for nephropathy, and once they have nephropathy they have
accelerated rates of renal failure.
15. Why is it recommended for patients to have at least 50% of their protein from
sources that have high biological value?
a. Low albumin levels put dialysis patients at higher risk for mortality, so it
is important to get adequate protein. By consuming 50% of protein from
sources that have a high biological value it helps minimize the generation
of urea. By minimizing the generation of urea you minimize the byproduct
of protein breakdown that cannot be removed in patients with CKD.