Nicole Anschick Professor Rupp Nutr 409 17 March 2014 Nutr 409 Case Study #18 CKD 1.

Maintain fluid, electrolyte and solute balance

Majority of solutes: products of protein metabolism Glomerulus produces ultrafiltrate Tubules reabsorb part of the ultrafiltrate and produce urine Urine funneled into renal pelvis and ureters Vasopressin/ADH stimulated by high osmolality o ADH causes kidneys to retain H20

Filtration of blood

Regulation of water homeostasis

Regulation of blood pressure: renin-angiotensin system When blood volume decreases low blood pressure

Glomerulus secretes renin when blood volume decreases Renin stimulates formation of angiotensin (vasoconstrictor) Angiotensin stimulates aldosterone to reabsorb sodium and fluid and increase blood pressure Hormone that stimulates red blood cell synthesis

Production of erythropoietin (EPO)

Production of active form of vitamin D

2. Risk factors for CKD include diabetes, hypertension, aging, and certain ethnicities (American Indian and African American). Diabetes can cause chronic interstitial nephritis which primarily results in an inability to concentrate the urine and mild renal insufficiency. Diabetes also causes an increase in glomerular pressure which can lead to CKD.

3.

Stage 1: GFR is 90-130 mL/min; kidney damage but normal to increased kidney function Stage 2: GFR is 60-89 mL/min; mild decrease in kidney function (stages 1 and 2 have markers like proteinuria, hematuria, or anatomic issues) Stage 3: GFR is 30-59 mL/min; moderate decrease in kidney function Stage 4: GFR is 15-29 mL/min; severe decrease in kidney function (stages 3 and 4 are considered advanced stages) Stage 5: GFR is less than15 mL/min; kidney failure with treatment necessary, defined as end stage renal disease; results in death unless dialysis or transplantation is initiated

5. Treatment options for Stage 5 CKD or end-stage renal failure is either dialysis or transplantation. There are two different types of dialysis:

1. Hemodialysis- fluid and electrolyte content is similar to that of normal plasma. Waste products and electrolytes move by diffusion, ultrafiltration, and osmosis from the blood into dialysate and are removed. Majority of patients are on this, lifelong treatment w/o transplant, permanent access to the blood supply necessary (fistula or graft), typically less frequent than PD (3x/wk) 2. Peritoneal dialysis (PD)- makes use of the bodys own semipermeable membrane, the peritoneum. A catheter is surgically implanted in the abdomen and into the peritoneal cavity. Dialysate containing a high dextrose concentration is instilled into the peritoneum, where diffusion carries water products from the blood through the peritoneal membrane and into the dialysate; water moves by osmosis. This fluid is then withdrawn and discarded, and new solution is added. PD can be 24 hours or nocturnal

6. Nutrition Therapy 35 kcal/kg 1.2 g protein/kg 2gK 1 g phosphorus 2 g Na 1000 mL fluid + urine output Rationale MNT for chronic kidney disease; spare protein for tissue repair and maintenance Preparing for kidney replacement therapy No need to restrict any more during this stage of CKD Rises at the same rate GFR decreases Control edema and oncotic pressure Insufficient output; dehydration

7. BMI: 33.2 (obese); Edema may cause Mrs. Joaquins BMI to be falsely elevated due to the large amount of excess water she is holding on to.

8. Edema free weight (dry weight) is your weight without the excess fluid that builds up between dialysis treatments. This weight is normal to what a person may weigh with normal kidney function after urination. It is the lowest weight a person can safely reach after dialysis without developing symptoms of low blood pressure. aBWer= BWer + [(SBW Bwer) x 0.25] aBWef=165+[(65-165)x 0.25] o =165 + [(-100) x 0.25] o =165 +(-25)

=140 lbs or 63.6 kg

12. Protein recommendations for patients with CKD whose GFR > 55 is .8 g/kg/day, and .6 g/kg/day for CKD patients with a GFR < 55. Protein recommendations for patients undergoing dialysis is 1.2 -1.5 g/kg/day. For patients who are treated with hemodialysis, protein intake should range from 1.0-1.2 g/kg/day. Patients receiving peritoneal dialysis have higher protein limits ranging from 1.2-1.5 g/kg/day.

13. Phosphorus is a mineral that builds up in the system when the kidneys fail to excrete waste properly. Foods with high levels of phosphorus include processed foods, meat, dairy, legumes, nuts, and whole grains.

14. Before the patient began NPO, her net output on the first day of admission was 150 mL. It is recommended that CKD patients adhere to fluid intake of output plus an additional 750 mL/day. Foods with fluid include water, milk, beverages, soup, and ice cream to name a few. Methods of reducing thirst and managing a fluid restricted diet include only drinking when thirsty, avoiding foods high in fluids, swishing water around to moisten the mouth, and freezing fruits to suck on throughout the day.

15. GFR is a measurement of ability of the kidneys to filter waste products. GFR > 90 mLs/minute is a normal rate. A GFR of 28 mLs/minute indicates Stage 4 kidney failure and a severe decrease in kidney function.

16. Severely increased BUN ( 69 mg/dL), creatinine serum (12.0 mg/dL), potassium (5.8 mg/dL) and phosphate (9.5 mg/dL) indicate inability of the kidneys to excrete waste products from the body. Increased protein in the urine (2+) also indicates advanced stage kidney disease. 18. Medication Capoten/captopril Erythropoietin Sodium bicarbonate Renal caps Indications/Mechanism Treat kidney px caused by diabetes Controls RBC production Potassium balance, inability to regenerate bicarbonate, Acidosis Provide H20 soluble vitamins Nutritional Concerns Presence of food in GI decreases absorption, Increased excretion Iron supplementation Protein catabolism, increased BP from sodium Folic acid may mask pernicious anemia

Renvela Hectorol Glucophage

Lowers phosphorus in blood Lowers PTH Controls BG for Type II DM

N/V, constipation Metallic taste, anorexia, N/V, wt loss or wt gain N/V, increased hunger

19. In the adult population of Pima Indians, 50 percent have been diagnosed with Diabetes Mellitus. 95% of those who have DM are considered to be overweight or obese. Because of the high prevalence of diabetes, they are at risk for complications caused by diabetes, such as kidney disease, eye disease, and nerve damage. There is a hypothesis that states that, over many years ago, a genetic change occurred in the Pima Indians. The change allowed the population to adapt to alternating period of feast and famine. Overtime, they developed a gene that allowed them to become more efficient at storing fat. This gene has now put them at greater risk for developing chronic diseases. Nephropathy is a comp[lection with DM. The risk of developing it occurs when blood glucose levels are increased and not controlled. Pima Indians tend to develop DM much earlier in their lives, at around 35 years of age. This early onset gives Pima Indians a longer time to live with and endure their disease. This time long time period allows for more complications to arise because of it. In Pima Indians, kidney disease is the leading cause of death with diabetes patients. 22. Protein sources that have high biological value are those that have complete essential amino acids required by the human body. Proteins with high biological value are items such as, as meat, poultry and eggs. Protein with low biological value are items that include, nuts, seeds, and vegetables. One of the by-products of the metabolism of protein is toxic, and is difficult to remove form body for CKD patients. Therefore, consuming less than 50 % of protein from high biological value protect and conserve body protein.