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Questions for Medical Nutrition Therapy: A Case Study Approach 5th ed.
Case 19 – Chronic Kidney Disease (CKD) Treated with Dialysis
Name: __________________________________________________

Instructions: Type your answers to the questions below. Print and turn in on the day the case study
is due.

1. Describe the basic physiological functions of the kidneys.

The kidneys remove waste products and drugs, balance the body’s fluids, release hormones that regulate
blood pressure, produce an active form of vitamin D that promotes strong, healthy bones and control the
production of red blood cells.

2. List the diseases/conditions that most commonly lead to chronic kidney disease (CKD)? Explain the role of
diabetes in the development of CKD.
Diseases and conditions that lead to CKD are type 1 and type 2 diabetes, high blood pressure,
glomerulonephritis (inflammation of the kidney’s filtering units-glomeruli), interstitial nephritis
(inflammation of the kidney’s tubules and surrounding structures), polycystic kidney disease, prolonged
obstruction of the urinary tract (from conditions like enlarged prostate, kidney stones and some cancers),
vesicoureteral reflux (urine backing up into kidneys), and recurrent kidney infection (pyelonephritis).

When someone has diabetes, the small blood vessels in the body are injured. If blood vessels in the kidneys
are injured, blood cannot be cleaned properly. Your body will retain more water and salt than normal and
this can result in weight gain and edema. You may have protein in your urine or waste materials build up in
your blood. Diabetes can also damage nerves. This may cause issues emptying your bladder and pressure
from a full bladder may back up and injure the kidneys. If urine is not released from the bladder, bacteria
may rapidly grow and cause infection.

3. Outline the stages of CKD, including the distinguishing signs and symptoms.
Stage 1 includes mild kidney damage and usually no symptoms. If you have an eGFR (estimated
glomerular filtration rate) greater than 90, your kidneys are healthy. In stage 1, eGFR is normal but there
may be protein in your urine or physical damage to the kidneys.

Stage 2 also shows mild kidney damage and usually no symptoms. Stage 2 kidney disease is identified with
an eGFR between 60 and 89, which is normal. In Stage 2 there may also be protein in urine or physical
damage to kidneys.

Stage 3 kidney disease shows moderate damage and kidneys are not working as well as they should be.
There are two groups within Stage 3- Stage 3a and Stage 3b. Stage 3a shows an eGFR between 45 and 59
where as Stage 3b shows an eGFR between 30 and 44. Stage 3 is often asymptomatic but may include
swelling in the hands and feet, back pain and urinating more or less than is normal. Stage 3 is where health
complications tend to happen due to waste build up. This may include high blood pressure, anemia, and
bone disease.

Stage 4 means your kidneys are moderately to severely damaged and are not working properly. Stage 4
should be taken seriously because it is the last stage before kidney failure. Stage 4 shows an eGFR between
15 and 30. Symptoms are more common and include the same ones as Stage 3- swelling in the hands and
feet, back pain, and urinating more or less than normal. High blood pressure, anemia, and bone disease are
potential health complications here as well.

Stage 5 is characterized by an eGFR less than 15 and means kidneys are either failing or close to failing.
The symptoms in this stage are severe due to toxins and waste building up in your blood and making you
sick. Symptoms may include, itching, muscle cramps, nausea and vomiting, not feeling hungry, swelling in
the hands and feet, back pain, urinating more or less than normal, trouble breathing and trouble sleeping.
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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?
She has diabetes, was non-compliant with her diabetes treatments (high blood pressure) and is Native
American. Patient has declined kidney function shown by GFR, increased creatinine and urea
concentrations, elevated serum phosphate and normocytic, normocytic anemia.. Patient complains of
anorexia, nausea and vomiting. She has gained 4 kg in two weeks and shows edema in the face, eyes, and
extremities. She has shortness of breath, muscle cramps, pruritus (itching) and inability to urinate.

5. What are the treatment options for Stage 5 CKD? Explain the differences between hemodialysis and peritoneal
dialysis.

Treatment options for Stage 5 CKD include dialysis or a transplant.

Hemodialysis uses a machine to clean your blood. It does some of the work that your kidneys did when
they were healthy. Your blood travels through tubes from your body into the dialysis machine. While your
blood is in the machine, it is filtered in a dialyzer, which removes waste and extra fluid. Once it has been
cleaned, the blood travels back into your body from the machine.

Peritoneal dialysis uses the lining of your abdomen (peritoneum) and a solution called dialysate to clean
your blood. Dialysate absorbs waste and fluid from blood, using the peritoneum as a filter. This dialysis is
not done at a dialysis center so it grants more freedom to the patient.

6. Explain the reasons for the following components of Mrs. Joaquin’s medical nutrition therapy:

Nutrition Therapy Rationale

35 kcal/kg Provides adequate calories to prevent excessive protein loss through
catabolism and malnutrition
1.2 g protein/kg Protein restriction puts less stress on kidneys, leads to less protein waste
buildup. This is an adequate amount to insure patient is healthy and may lose
some protein during dialysis
2gK Kidneys are unable to remove potassium so restriction is necessary. High
levels may cause abnormal heart rhythms.
1 g phosphorus Kidneys are unable to remove excess phosphorus. High levels may lead to
heart and bone problems, hypocalcemia, calcification in the heart, arteries,
joins, skin, or lungs, that can lead to heart problems, bone pain, and itching.
2 g Na Controls fluid intake and retention as well as control BP
1000 mL fluid + urine output CKD patients lose ability to urinate so fluid restriction is essential to limit
edema.

7. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your interpretation?
Her BMI is 33.2 kg/m2. Edema may affect BMI because there is extra fluid around the interstitial spaces in
her body. The fluid retention is likely causing Mrs. Joaquin to have a higher weight and thus higher BMI
than usual.

8. What is edema-free weight? Calculate Mrs. Joaquin’s edema-free weight.

Edema-free weight is also called dry weight or your weight without excess fluid build up. Evidence
Analysis Library (EAL) states that subtracting 25% for obese CKD patients gives you the adjusted body
weight. Ms. Joaquin’s adjusted body weight would then be 127.5 lbs. Her new BMI would be 24.9.

9. What are the energy requirements for CKD?

EAL recommends intake between 23kcal to 35kcal per kg body weight is adequate to prevent signs of
malnutrition.
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11. What are the differences in protein requirements among stages 1 and 2 CKD, stage 3 and 4 CKD, hemodialysis,
and peritoneal dialysis patients? What is the rationale for these differences?
DaVita states that protein requirements in Stage 1, 2, and 3 should be limited to 12 to 15 percent of your
total calorie intake every day. In Stage 4, a dietitian may recommend protein intake be reduced to 10
percent of daily calorie intake. Unhealthy kidneys lose the ability to remove protein waste so as CKD
progresses, especially in Stage 4. Protein intake should not be excessive.

Protein requirements for hemodialysis are 1.2 grams per kg usual body weight. If Mrs. Joaquin was on
peritoneal dialysis, she would have a higher protein requirement (1.3 grams per kg usual body weight) due
to inflammation of peritoneum.

12. Mrs. Joaquin has a PO4 restriction. Why? What foods have the highest levels of phosphorus?
Unhealthy kidneys cannot remove extra phosphorus from your blood. Phosphorus can pull calcium out of
your bones, making them weak. This can also cause calcium deposits in blood vessels, lungs, eyes, and the
heart. The National Kidney Foundation reports that protein-rich foods such as meats, poultry, fish, nuts,
beans and dairy products have high levels of phosphorus. Phosphorus found in animal foods is absorbed
more easily than phosphorus from plant foods. Phosphorus may also be in food as an additive or
preservative and is found in fast foods, canned and bottled beverages and other processed foods.

13. 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 fluid restriction is generally recommended
for someone on hemodialysis? Is there a standard guideline for maximum fluid gain between dialysis visits? If a
patient must follow a fluid restriction, what can be done to help reduce his or her thirst?
DaVita states that the following foods are considered liquids: coffee, tea, gelatin, ice chips/cubes, ice
cream, juice, milk and milk substitutes, popsicles, sherbet, soup and sorbet. DaVita claims that a general
rule of liquids being limited 32 ounces or 1000 mL per day. If the patient can still urinate, more liquids may
be consumed but depend on how much the patient urinates. The National Kidney Foundation urges no more
than 1 kg or 2.2. lbs weight gain per day between dialysis treatments. To avoid excessive thirst, patients
should avoid salt and spicy foods, plan ahead and spread liquids throughout your day, stay cool and do not
overheat, drink cold beverages instead of hot ones, snack on cold kidney-friendly fruits and vegetables, eat
only the number of fruits and veggies in your meal plan, sip beverages and use smaller cups, make ice
cubes out of your favorite beverages, conquer dry mouth by brushing teeth, using mouth wash and sucking
on hard candy or a lemon wedge, take pills with very small sips of water or with applesauce, keep a daily
food and fluid journal that includes your weight and takes your prescribed water pills.

14. 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? Interpret her value.
GFR measures the level that your kidneys are functioning. It is equal to the total of the filtration rates of the
functioning nephrons in the kidney. Mrs. Joaquin’s GFR is >60 which states she is in Stage 2 CKD with
mild loss of kidney function (National Kidney Foundation.

15. Evaluate Mrs. Joaquin’s chemistry report. What labs are altered due to her diagnosis of Stage 5 CKD?
Sodium: diluted due to fluid retention, or lost in urine.
Potassium: kidneys not filtering properly
Chloride: kidneys not filtering properly
CO2: compromised acid-base balance used to assess malnutrition- causes increased protein degradation.
Bicarbonate: kidneys not filtering properly
BUN: kidneys not filtering properly
Creatinine: indicates impaired renal function. Used to estimate GFR.
BUN/crea ratio: kidneys not filtering properly
GFR: kidneys not filtering properly
Glucose: glucose metabolism may be impaired due to CKD but is likely due to diabetes.
Phosphate: kidneys not filtering properly
Calcium: reflects insufficient vitamin D (converted in kidneys), which prevents calcium reabsorption.
Osmolality: may indicate buildup of waste concentration
Protein: may be due to decreased protein needs for CKD
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Albumin: protein lost in urine

Cholesterol: When the glomerulus is inflamed, lipid metabolism may be altered (high)
TG: When the glomerulus is inflamed, lipid metabolism may be altered (high)
HbA1c: indicates uncontrolled hyperglycemia. Diabetes nephropathy (kidney damage) may have caused
kidney disease
RBC: anemia due to CKD
Hgb: anemia due to CKD
Hct: anemia due to CKD
pH: indicates kidney problem
Urine protein: protein lost in urine indicates renal disease progression

17. The following medications were prescribed for Mrs. Joaquin. Explain why each was prescribed (the
indications/mechanism) and describe any nutritional concerns and dietary recommendations related to the
medication.

Medication Indications/Mechanism Nutritional Concerns

Capoten/ Angiotensin Converting
captopril Enzyme (ACE) inhibitor-
widens blood vessels,
lowers BP.
Erythropoietin Growth factor produced in
kidneys that stimulate the
production of RBC. It
promotes the division &
differentiation of
committed erythroid
progenitors in bone
marrow. Treats anemia.
Sodium Antacid used to relieve
bicarbonate heartburn and acid
indigestion. Balance acidity
of blood due to
accumulation of waste
products.
Renal caps Combination of B vitamins
used to treat or prevent
vitamin deficiency due to
poor diet, certain illnesses,
alcoholism or pregnancy.
Renvela Controls phosphorus levels
in blood.
Doctor may limit salt while on medication. Can be taken with
or without food. Contains lactose. Loss of taste. Limit
alcohol.
May cause nausea. Take DRI for iron and consume foods that
help with iron absorption (vitamin C), and consume
adequate calories.
Increases sodium in body so check with doctor if on sodium
restricted diet. Can cause increased thirst, stomach
cramps, gas, nausea, vomiting, anorexia, and bloody,
black or tarry stools. Found in baked goods (baking soda)
and carbonated drinks.
May cause upset stomach, anorexia, taste problems, gas, and
N/V.
Can cause diarrhea, stomach upset, N/V, gas, and
constipation. May interfere with dialysis access site, cause
inability to have a bowel movement, and stomach/abdominal
pain or swelling.

Hectorol Manmade form of Vitamin May cause upset stomach, constipation, N/V, anorexia,
D that decreases increased thirst, increased urination, metallic taste in mouth
parathyroid hormone and unexplained weight gain/loss.
(PTH) and increases
calcium/phosphorus levels
in the body to prevent bone
weakness.
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Medication Indications/Mechanism Nutritional Concerns

Glucophage Treats diabetes by May cause N/V, upset stomach, diarrhea, metallic taste in
controlling blood sugar. mouth, and hypoglycemia.

21. Why is it recommended for patients to have at least 50% of their protein from sources that have high biological
value?
HBV proteins are foods that contain 50% or more protein and are readily absorbed. HBV proteins include
meat, fish, poultry, soy, and eggs. Urea is a byproduct of protein metabolism and patients with CKD are
unable to remove this waste efficiently. CKD patients should consume HBV proteins to minimize urea
production.