Caitlin Mazurek KNH 411 11/7/11 Chronic Kidney Disease Treated with Dialysis 1. Describe the physiological functions of the kidneys. The functions of the kidney include maintenance of homeostasis through control of fluid, pH, and electrolyte balance and blood pressure. The kidneys are also responsible for the excretion of metabolic end-products and foreign substances. They are also the producers of enzymes and hormones. Pg. 523 2. What diseases/conditions can lead to chronic kidney disease (CKD)? Diabetic nephropathy is the most common condition that leads to CKD. This is due to the kidney’s inability to make adequate erythropoietin which stimulates the production of red blood cells. Pg. 526 3. Explain how type 2 diabetes mellitus can lead to CKD. Type 2 diabetes mellitus can lead to CKD through the change in the thickening in the glomerulus. The glomerulus is responsible for filtering the blood and the fluid that eventually forms urine, as these glomeruler changes occur, the kidney may start allowing more protein than normal to be released into the urine. Type 2 diabetes patients who are insulin resistant have a difficult time controlling the amount of glucose in their blood stream which in turn can put stress on the kidneys. Pg. 527 4. Outline the stages of CKD, including the distinguishing signs and symptoms. Chronic kidney disease is a syndrome of a progressive and irreversible loss of the excretory, endocrine, and metabolic functions of the kidney secondary to kidney damage. Stage 1 of CKD is where the kidneys are damaged with normal or increased glomerular filtration rate or GFR. Stage 2 is defined as kidney damage with normal or increased GFR and kidney damage with mild decrease in GFR. At stage 3 there is moderate decrease in GFR where the level is between 30-59 mL/min. In stage 4, there is a severe decrese in GFR where the levels are between 15-29 mL/min and in stage 5, there is kidney failure where GFR levels are under 15 mL/min and the patient would need to be put on dialysis. The signs and symptoms for stage 5 include harmful wastes build up in the blood, blood pressure rises, and excess fluid is retained. Pg. 526 5. From your reading of Mrs. Joaquin’s history and physical, what signs and symptoms did she have? The patient has diabetes as well as high blood pressure, which are two leading causes of kidney failure. The patient has also had kidney/urinary problems and this is another leading cause of kidney failure. Mrs. Joaquin is native American, and Native Americans are nearly two times as likely to develop kidney failure. Pg. 526 6. What are the treatment options for Stage 5 CKD? Treatment options for Stage 5 CKD include hemodialysis, peritoneal dialysis, and kidney transplantation. Pg. 527 7. Describe the differences between hemodialysis and peritoneal dialysis. Both hemodialysis and peritoneal dialysis are valid forms of dialysis that clean the blood and or urine of any wastes. The biggest difference between the two is the way the dialysis takes place or is connected to the body. Hemodialysis is the most common method of treatment. The patients first need to go through a process so that they have continual access to the bloodstream. In peritoneal dialysis, access to the patient’s blood supply is gained using a catheter of silicone rubber and placed surgically into the peritoneal cavity. 8. Explain the reasons for the following components of Mrs. Joaquin’s medical nutrition therapy: Nutrition Therapy Rationale 35 kcal/kg Sufficient nutrient requirement to give Mrs. Joaquin enough energy to get past the kidney replacement therapy 1.2 g protein/kg Recommended protein intake for a person on hemodialysis based off of the National Kidney Foundation Pocket Guide to Nutrition Assessment 2gK Recommended potassium intake for a person on hemodialysis based off of the NKF pocket guide to nutrition assessment 1 g phosphorus Phosphorus needs are based off of protein intake and should be 10-12 mg/g protein so when protein intake is around 100 g, there should be 1 gram of phosphorus per day based off of the NKF pocket guide to nutrition assessment 2 g Na Sodium intake is based off of NKF pocket guide to nutrition assessment for a person on hemodialysis 1,000 mL fluid + urine output This is dependant upon the amount of fluid released through urinary output and no more than 1000 mL daily is recommended for a patient on hemodialysis. 9. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your interpretation? BMI = 77.3 kg / (1.52)2 m = 33.6 kg/ m2 It is believed that Mrs. Joaquin is suffering from edema in her extremities, face, and eyes. Since she gained 4 kg in the past 2 weeks, it can be believed that her body weight is not her adjusted body weight or edema free body weight. 10. What is edema-free weight? The following equation can be used to calculate the edemafree adjusted body weight (aBWef): aBWef = BWef + [(SBW – BWef) x 0.25] where BWef is the actual edema-free body weight and SBW is the standard body weight as determined from the NHANES II data. Calculate Mrs. Joaquin’s edema-free weight. Is this the same as dry weight? Edema-free body weight is the weight adjusted for when the patient’s weight is < 95% or > 115% of standard body weight. Standard body weight should be about 60 kg where her actual body weight currently is 77.3 kg. Her adjusted edema free body weight then is around 73 kg. pg. 539 11. What are the energy requirements for CKD? The energy requirements for CKD are 35 kcal/kg for anyone under 60 years of age such as Mrs. Joaquin and 30-35 kcal/kg for anyone over 60 years of age. Pg. 536 12. Calculate what Mrs. Joaquin’s energy needs will be once she begins hemodialysis. 35 kcal/kg x 77.3 kg = 2704 kcal or 2700-2800 kcal/day 13. What are Mrs. Joaquin’s protein requirements when she begins hemodialysis? 1.2 g/kg x 77.3 kg = 92.8 g of Protein or about 370 kcal of protein daily. 14. What is the rationale? How would these change if she were on peritoneal dialysis? For hemodialysis, it is necessary for the patient to receive at least 1.2 g of protein per kilogram of body weight. If she were on peritoneal dialysis the protein intake would at least between 1.2 and 1.3 g of protein per kilogram of body weight. Factors relating to higher protein requirements include losing of approximately 10-12 grams free amino acids per day and 5-15 grams per day of albumin. There is altered albumin takeover, metabolic acidosis which increases amino acid degeneration and possibility of inflammation and infection. It is necessary to increase protein intake then from the usual 0.8 g/kg to 1.2 g/kg. pg. 536 15. Are there any potential benefits of using different types of protein, such as plant protein rather than animal protein, in the diet for a patient with CKD? Explain. It is said that at least half of the protein should be of high biological value. As long as the protein intake is sufficient the form of protein is not so important. The National Renal Diet provides with a food list that has serving sizes and provides sections on protein as well as vegetarian eating to keep in mind. There is a table that provides the nutrition composition of the various food lists. The tables should be used to plan meals and amounts for serving sizes. The National Renal diet includes vegetarian protein as a food for CKD patients. Pg. 537 16. Mrs. Joaquin has PO4 restriction. Why? In CKD, hyperphosphatemia is prevented by an increase in renal output and lessening of phosphate reabsorption. A dietary restriction of phosphorus is recommended for patients on hemodialysis to help prevent the excess phosphorus levels in the blood and urine. 17. What foods have the highest levels of phosphorus? High phosphorus foods include the following: cheese, custard, milk, cream soups, cottage cheese, ice cream, pudding, yogurt, carp, beef liver, fish roe, oysters, crayfish, chicken liver, organ meats, sardines, dried beans and peas, soy beans, baked beans, black beans, chick peas, garbanzo beans, kidney beans, lentils, limas, northern beans, pork n beans, split peas, bran cereals, seeds, whole-grain products, brewer’s yeast, nuts, and wheat germ. 18. 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? Fluid consumption is on an individual basis based off of urinary output and type of dialysis. Fluid intake can also be dependant on blood pressure, weight gain or loss recently, and whether or not the patient has heart troubles. Pg. 538 19. If a patient must follow a fluid restriction, what can be done to help reduce his or her thirst? To control fluid intake, high salt foods should be limited, teeth can be brushed often, pills should be taken at mealtime and fluids should be drank from small cups or glasses. Pg. 537 20. Identify nutrition problems within the intake domain using the appropriate diagnostic term. Anorexia along with nausea and vomiting are two nutrition problems developed from her stage 4 chronic kidney disease. 21. Several biochemical indices are used to diagnose chronic kidney disease. One is glomerular filtration rate (GFR). What does GFR measure? Kidney rate is measured by glomerular filtration rate, which is reflected in tests that measure the rate at which substances are cleared from the plasma by the glomeruli. Glomerular filtration is the nondiscriminant filtration of protein free plasma from the glomerulus into Bowman’s capsule. Pg. 524 22. What test is usually done to estimate glomerular filtration rate? There is a Cockroft-Gault equation that considers the effects of age, sex, and body weight on creatinine generation which then adjusts the serum creatinine values to accurately reflect creatinine clearance. GFR is measured approximately through calculations. There is another more recent one, the Modification of Diet in Renal Disease is most commonly used now. Pg. 524 23. Mrs. Joaquin’s GFR is 28 mL/min. What does this tell you about her kidney function? With Mr.s Joaquin’s GFR at 28 mL/min, her CKD is at stage 4. She has severe decrease in GFR and preparation for kidney replacement therapy should be put into action. Pg. 526 24. Evaluate Mrs. Joaquin’s chemistry report. What labs support the diagnosis of Stage 4 CKD? Mrs. Joaquin has high potassium, phosphorus, BUN, creatinine, cholesterol and triglycerides as well as low calcium levels. All of these fluctuations in the chemistry report indicate stage 4 chronic kidney disease. 25. Examine the patient care summary sheet for hospital day 2. What was Mrs. Joaquin’s weight postdialysis? Why did it change? Mrs. Joaquin’s weight postdialysis on day 2 was 165 pounds which was 5 pounds less than the day before. Her weight changed drastically due to her fluid loss within her first day of hospital stay and her decrease in edema. The increased nutrition and dietary intake can also lead to supportive weight loss. Pg. 539 26. Which of Mrs. Joaquin’s other symptoms would expect to begin to improve? I would expect for Mrs. Joaquin’s high blood glucose to start to improve as her diet is under control within the hospital setting. I would also hope that her metformin that she may or may not be taking at home is being taken here at the hospital and therefore can help regulate blood sugars. I would also expect to see better sodium, potassium, chloride, phosphate, and calcium levels. While being in the hospital with a regulated diet, I hope that these micronutrient levels can get back to normal after Mrs. Joaquin is no longer having anorexic tendencies. 27. Explain why the following medications were prescribed by completing the table. Medication Indications/Mechanism Nutritional Concerns Vasotec Ace-Inhibitor This can possibly worsen Vasodilators that reduce BP renal function, and produce Erythropoietin Vitamin/Mineral Supplement Calcitriol Glucophage Sodium biocarbonate Phos Lo by decreasing peripheral vascular resistance by interfering with the production of angiotensin II from angiotensis I and inhibiting degradation of bradykinin This is a glycoprotein synthesized in the kidneys that stimulates erythropoiesis which is the production of red blood cells within the bone marrow Help support the malnutrition that was caused due to her anorexia and nausea and vomiting This is a calcium regulator for the body Otherwise known as metformin and is used to regulate blood glucose levels for type 2 diabetics To regulate sodium levels in the body Calcium acetate is used as a phosphate binder in an attempt to aid in phosphate levels dysgeusia and causes dry mouth and cough. Salt substitutes should not be taken with vasotec No known available Aid in the increase of micronutrient levels as well as keep the body healthy. Helps aid in the regulation of calcium since Mrs. Joaquin’s calcium levels came in low from poor dietary intake Counting carbohydrate intake is critical to managing the type 2 diabetes Helps aid in the regulation of Mrs. Joaquin’s sodium levels since she came in with low sodium levels due to poor dietary intake Mrs. Joaquin came in with extremely elevated phosphate levels and calcium acetate is there to set an acid-base balance 28. Identify nutrition problems within the clinical domain using the appropriate diagnostic term. Impaired nutrient utilization including glucose NC 2.1, overweight/obesity NC 3.3 Behavioral- environmental domain 29. What health problems have been identified in the Pima Indians through epidemiological data? The Pima Indians are known to have the highest rate of reported incidence of diabetes. Hypertension is also high among the Pima people. 30. Explain what is meant by the “thrifty gene” theory. The thrifty gene theory is the ability to store excess nutrients against future famine. It is the ability of the body to store fuel more efficiently to protect the body against food shortages. (www.Yahoo.com/thrifty_gene_hypothesis) 31. How does nephropathy affect Pima Indians? Genetics play into a huge role of nephropathy and the Pima Indians. Most deaths caused from kidney problems are due to nephropathy. 32. Choose two high-priority nutrition problems and complete a PES statement for each. - Excessive sodium intake related to fluid retention as evidenced by edema in the extremities, face, and eyes. - Increased blood glucose levels related to eating high carbohydrate foods as evidenced by Mrs. Joaquin’s usual diet. 33. For each PES statement, establish an ideal goal (based on the signs and symptoms) and appropriate intervention (based on etiology). - Lower sodium intake to less than 2 g a day by not adding salt to foods, drinking more water and educating Mrs. Joaquin about different salt substitutes. - Educate Mrs. Joaquin on carbohydrate counting and how to better control her blood glucose levels by testing her levels at least 4 times daily. 34. When Mrs. Joaquin begins dialysis, energy and protein recommendations will increase. Explain why. Protein and energy needs increase due to the amount of calories needed for dialysis to happen. Dialysis is something that depletes the body of amino acids and therefore, these will need to be replenished through increased protein intake. Pg. 543 35. Why is it recommended for patients to have at least 50% of their protein from sources that have high biological value? There is a high risk of losing essential amino acids through out the dialysis process. Having proteins with high biological value will ensure that you are getting the amino acids and retaining them as well. Pg. 543 36. The MD ordered daily use of a multivitamin/mineral supplement containing B-complex, but not fat-soluble vitamins. Why are these restrictions specified? During Mrs. Joaquin’s fluid loss in dialysis, the water-soluble vitamins are lost as well. The fat-soluble vitamins therefore, build up in the blood due to the fact that they are not lost during dialysis. These have a higher chance at building up in the body and can get to unhealthy levels without being found in blood tests. Pg. 545 37. What resources would you use to teach Mrs. Joaquin about her diet? I would show Mrs. Joaquin an example of the TLC diet as well as the MyPlate website designed by the USDA. Overall, if her nutrition 38. 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 Sample Menu Breakfast: Cold cereal (3/4 c unsweentened) Special K cereal ½ c with ½ c skim milk Bread (2 slices) or fried potatoes (1 med 1 slice of white bread toasted with two potato) sprays of butter 1 fried egg (occasionally) 1 cup scrambled egg whites with ground pepper 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: Crackers (6 saltines) and peanut butter (2 tbsp) Turkey sandwich – 2 slices white bread, 3 oz deli turkey meat, lettuce, tomato, light mayo and mustard ½ c carrots and 2 T fat-free Ranch dressing 12 oz water with lemon wedge or mint leaves 3 oz lean beef patty on white bun with one slice cheddar cheese and lettuce, tomato, mustard ½ cup cooked peas with pepper, pasta salad with fat-free Italian dressing 5 low sodium saltine crackers, 2 T sugarfree jelly 39. Using the renal exchange list, plan a 1-day diet that complies with your diet order. Provide a nutrient analysis to assure consistency with all components of prescription. See attached sheet. 40. Write an initial medical record note for your consultation with Mrs. Joaquin. A 24-yo female who is Native American, 77.3 kg, 1.52 m and a BMI calculated to 33 kg/m2, Diagnosed with type 2 diabetes at the age of 13 and stage 3 CKD 2 years ago Currently has failing kidney function as GFR is decreasing and puts her in Stage 4 CKD now Lab results show she has high potassium, phosphorus, sodium and caloric levels D Excessive sodium intake related to fluid retention as evidenced by edema in the extremities, face, and eyes. Increased blood glucose levels related to eating high carbohydrate foods as evidenced by Mrs. Joaquin’s usual diet. I Lower sodium intake to less than 2 g a day by not adding salt to foods, drinking more water and educating Mrs. Joaquin about different salt substitutes. Educate Mrs. Joaquin on carbohydrate counting and how to better control her blood glucose levels by testing her levels at least 4 times daily. M/E Monitor fluid intake and urine out put as well as daily weight check and blood glucose levels. All micronutrient levels should also be checked while at the hospital and intake records should be kept as well. There is a potential issue with following a set diet, but it is important to inform Mrs. Joaquin of the severity of her disease and the risks of not following the diet. References National Kidney Foundation. Web. 07 Nov. 2011. <http://www.kidney.org/>. Nelms, Marcia Nahikian. Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA: Wadsworth, 2011. Print.