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NHM 465/566

Case Study: Chronic Kidney Disease

Patient Name: Carlos Mendes

I. Understanding the Disease and Pathophysiology

1. Describe the 3 main physiological functions of the kidneys.


The primarily functions of the kidneys is to maintain fluid balance, acid-base balance,
bone health (through interaction of specific organs and hormones) and waste removal
(urea, vitamins/minerals, drugs and poisons). Normal kidneys are exposed to huge
fluctuations in sodium, water and solutes, yet efficiently maintain salt and water
homeostasis. The kidneys also regulate blood pressure via the renin-angiotensin system,
produces erythropoietin (a hormone) and active form of vitamin D (1,25-
dihydroxycholecalciferol).

2. Which of your patients pre-existing conditions can lead to chronic kidney disease and how?
Our patients pre-existing high blood pressure can lead to chronic kidney disease
(CKD). High blood pressure damages the small blood vessels in the kidneys responsible
for the filtration of blood. The result is inefficient filtration of blood, which makes
removal of waste from the body very difficult.

3. Does this patient have high blood pressure? If yes, how can this contribute to the onset of
CKD?
Yes, the patient has a blood pressure of 139/82 mmHg, which puts him in the
prehypertension category. High blood pressure damages the blood vessels throughout
the body thereby reducing blood supply to the kidneys. High blood pressure also
damages the filtration system of glomerulus in the kidneys. As a result, the removal
waste and extra fluid is inefficient. These series of events leads to the onset of CKD.

4. After reading your patients history and physical, what signs and symptoms of kidney disease
did he have? (give at least 3)
Signs and symptoms of kidney disease are:
Low eGFR, high BUN, high Creatinine, high UACR, and low serum albumin.

II. Nutrition Assessment

A. Evaluation of Weight/Body Composition

5. Calculate your patients BMI using the weight from their MNT referral form. (Use the metric
formula, round your final answer to 1 decimal place, and show your work to receive full
credit.)

BMI = wt (kg)/ht (m2)


= 92.272/3.161

= 29.2

6. If this patient developed edema, how would this factor affect your interpretation of their
weight?
Edema is the accumulation of fluid around the interstitial cell spaces. Extra fluid (via
edema) increases a patients weight and therefore overestimates BMI. Hence, for
individual with edema, dry (edema free) body weight must be taken into account or post
dialysate weight.

7. Interpret their BMI, how does this influence their health risk?

BMI category: Overweight

An overweight patient with CKD has greater chance of developing type 2 diabetes and
hypertension. Kidneys of overweight individual work harder filtering and have a
greater stress load on organs to correct any excess solutes in the body (phosphorus,
calcium, nitrogen, etc.), which increases the risk of developing CKD.

B. Calculation of Nutrient Requirements show all work to receive full credit

8. What are your patients current energy requirements? (Note use the appropriate energy
calculation for their diagnosis and BMI).
IBW = 106 (for 5) + 60 (for 10) = 166 lbs. or 75.5 kg

Pre-ESRD energy requirements: 30-35 kcal/kg/IBW

30 kcal/kg * 75.5 kg = 2265 kcal/day

35 kcal/kg * 75.5 kg = 2642.5 kcal/day

9. What are your patients current protein requirements?

Protein requirements for pre-ESRD are 0.6-1.0 g/kg/IBW.

0.6 * 75.5 = 45.3 g protein/day

1.0 * 75.5 = 75.5 g protein/day


10. Calculate what your patients energy needs will be if they progress to ESRD and need to
begin hemodialysis.
35 kcal/kg * 75.5 kg = 2642.5 kcal/day

11. Calculate what your patients protein needs will be if they progress to ESRD and need to
begin hemodialysis.

Patients protein needs for HD are 1.2 g/kg/IBW and are as follows:

1.2 g/kg * 75.5 = 90.6 g protein/day

C. Intake Domain

12. 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.

Animal proteins have all 9 essential amino acids and have more protein per gram than
plant protein; however animal protein sources (such as eggs, meat, etc.) are high in
saturated fats and cholesterol.

Plant protein on the other hand lack in one or more of the essential amino acids, but is
lower in fat and has no cholesterol. However, consuming 2 different types of plant
protein at the same time, such as rice and beans will provide all essential amino acids in
one meal. Even though per gram, plant sources generally provide less protein - beans,
nuts, and vegetables are good sources of protein with very little fat.

Eating a balanced diet of lean animal protein (ex. skinless chicken breast) together with
plant protein is the key for CKD patients to decrease the chance of developing CKD
risk factors of high cholesterol, high blood pressure, diabetes, and cardiovascular
diseases.

13. After reviewing your patients 24-hour recall, which foods does he consume that are high in
potassium? (list at least 5) Provide alternative options for each item. **Remember to pick
ethnically appropriate alternatives.
Foods high in potassium are refried beans, canned milk, cola, coffee, and fried beef.

Alternatives are grilled peppers and onions, roasted ears of corn, rice tortillas, half and
half, water, or club soda.
14. Referring to your patients 24-hour recall, what foods have the highest levels of phosphorus?
(list at least 5) Provide alternative options for each item. **Remember to pick ethnically
appropriate alternatives.
Foods highest in phosphorous are cola, beef, cheese, coffee and refried beans.

Alternatives are: water, chicken has 5mg less phosphorous than beef, almond milk, soy
milk, cottage cheese, club soda.

15. If a patient must follow a fluid restriction, what can be done to help reduce his or her thirst?
The patient can be given chilled or frozen fruit, candy to suck on, and limit salt in the
diet to reduce thirst.

D. Clinical Domain

16. Evaluate your patients original MNT referral lab report. What labs support their renal
disorder diagnosis?

1. Glomerular Filtration Rate (GFR): This blood test gives the best number to tell how
well our kidneys are functioning. It is measure in percentage of the functional capability
of kidneys. The patient has GFR -25, which means there is a severe decrease in the
function of the kidneys.

2. Creatinine: This blood test measures the waste products of the muscles that are
eliminated by the kidneys. When kidneys function lower, the creatinine number goes up
and waste products start building up in the blood. The patients original blood report
shows high creatinine level of 2.5 H, indicating diminished function of kidneys.

3. Blood Electrolyte tests: This is also known as blood chemistries. These substances
are normally filtered out of the blood by the kidneys, too high or too low levels may be
due to lower kidney function. Blood electrolyte test includes potassium, sodium,
phosphorous, calcium and magnesium levels. Looking at the blood levels of the patient,
the serum calcium levels seem low. This indicates that the substances are not properly
filtered out, further indicating a lower functional capability of the kidneys.

4. Albumin: Hypoalbuminemia is a deficit of albumin, which is a protein found in the


blood. Increased excretion (or loss) of albumin due to renal dysfunction may cause leak
of albumin in the urine, causing hypoalbuminemia. Since the patients serum albumin
levels are low in MNT referral lab report, he is mostly suffering from kidney
dysfunction.

5. UACR: For patients with type 1 diabetes for 5 years or more or with type 2 diabetes,
the American Diabetes Association and the National Kidney Disease Education
Program (NKDEP) recommend that health care professionals assess urine albumin
excretion yearly to diagnose and monitor kidney damage. Damaged kidneys leak
protein into the urine. This can be one of the earliest signs of kidney disease. To check
for protein in urine (called proteinuria), a Urinary albumin creatinine ratio (UACR)
test is done, which tells the doctor how much albumin is in the urine. A normal UACR is
< 30mg/g, but the patients level is 683 mg/g2, which is indicative of renal dysfunction.

17. Evaluate their current medications list on their initial referral sheet. Explain why the
following medications were prescribed by completing the table. (Do not include standard
multivitamin preparations.)

Medication Indications (why is Mechanism Nutritional concerns


it prescribed?) or interactions
(How does it work?)

Enalapril 10 Antihypertensive It is an angiotensin It causes severe


mg converting enzyme Hyperkalemia.
(ACE) inhibitor.

They agents are used


to relax blood vessels Potassium
and lower blood supplements and salt
pressure. They substitutes should be
prevent enzyme renin avoided.
to produce
angiotensin II, which
narrows blood vessels
and increases blood Licorice should be
pressure. avoided as it
antagonizes the
action of diuretics
and anti-
hypertensives.
Resultant
hypokalemia may
alter the action of
Medication Indications (why is Mechanism Nutritional concerns
it prescribed?) or interactions
(How does it work?)

some drugs.

Lovastatin 40 Antihyperlipidemic This is HMG CoA Grapefruit/related


gm Reductase citrus should be
Inhibitors/Statins, avoided. Grapefruit
which is a class of contains a chemical
cholesterol lowering that interferes with
drugs that inhibit the the bodys ability to
enzyme HMG-CoA break down or
reductase (plays a metabolize certain
central role in the statin medications
production of
cholesterol)

Furosemide 80 Antihypertensive This is a loop It


mg diuretic. Loop causes hyponatremia,
diuretics are diuretics hypochloremia
that act at the alkalosis,
ascending loop of hypokalemia,
Henley in the kidneys. hypomagnesemia or
The medicine is hypocalcemia
primarily used to
treat hypertension
and edema, often due
to congestive heart
failure or renal
insufficiency

Glipizide XL 10 Oral hypoglycemic It is used to keep Taking alcohol with


mg agent. blood sugar under glipizide can cause
control in adults with either hypo or hyper
Medication Indications (why is Mechanism Nutritional concerns
it prescribed?) or interactions
(How does it work?)

type 2 diabetes (also glycaemia.


known as noninsulin-
dependent diabetes or
adult-onset diabetes.
They are
sulpholyureas which
stimulates the release
of insulin from
pancreatic B-cells

(can only be used in


patients with some B-
cell function,

E. BehavioralEnvironmental Domain
18. What behaviors or environmental factors may be influencing this patients progress (for
better or for worse)? List at least 3 and explain how they are related to the patients health
changes.

High sodium intake: There is a co-relationship between hypertension and kidney


disease. Uncontrolled high blood pressure damages blood vessels, which can lead to
damage of the kidneys, conversely blood pressure often rises with chronic kidney
disease, which may further damage kidney function if the patient continues to indulge
in high sodium diet even after the diagnosis of CKD. Too much sodium in a person's
diet can be harmful because it causes blood to hold fluid. People with CKD need to be
careful not to let too much fluid buildup in their bodies. The extra fluid raises blood
pressure and puts a strain on the heart and kidneys. Looking at the higher intake of
sodium rich foods such asrefried lard beans, fast food tacos, fried beefs from 24 dietary
recall call, and his co-existing high blood pressure, we can predict that the patients
CKD condition might further worsen.

High potassium intake: His 24 hr recall highlighted his intake of apple, canned milk and
regular cola, which are rich sources of potassium. When kidneys fail they can no longer
remove excess potassium, so the level builds up in the body. High potassium in the blood
is called hyperkalemia, which may occur in people with advanced CKD. So people with
CKD should limit the dietary intake of potassium. Hence increased intake of potassium
rich foods will worsen the patients CKD conditions, since his serum potassium levels
are already high.

High fat intake: The important consequence of dyslipidemia is cardiovascular disease.


For patients with CKD, heart disease risk can be significantly increased with frequent
consumption of high fat and processed foods, which may raise serum lipid levels and
subsequent heart disease risk. So, Limiting high fat foods for heart protection becomes
even more important for CKD patients. Looking at the 24 hr. dietary recall, the patient
had high intake of refried beans with lard, fast food tacos, fried beef which have a
significant amount of cholesterol, saturated fats and Trans fats, and regular intake of
such high fat foods may worsen his CKD condition considering that his LDL levels are
already out of range.

IV. Nutrition Diagnosis

19. List all nutrition-related health concerns for this patient, and rank them in order of priority
(1= highest priority.) For each health concern, identify the appropriate AND IDNT nutrition
diagnostic term.

NTR-related Priority Nutrition diagnostic term


health concern ranking

CKD 1 Altered Nutrition-Related Laboratory Values


(UACE/eGFR/Albumin/Creatinine/BUN) (NC-2.2)

Hypoglycemia 2 Inconsistent Carbohydrate Intake (NI-5.8.4)

Overweight 3 Excessive Energy Intake (NI-1.3)

Hyperkalemia 4 Excessive Mineral Intake (Potassium) (NI-5.10.5)


20. Choose two of the high-priority nutrition problems and complete a PES statement for each.
Altered Nutrition-Related Laboratory Values (UACR/eGFR/Albumin/Creatinine/BUN)
(NC-2.2) related to chronic kidney disease and albuminuria as evidenced by laboratory
assessment in the CKD Diet Counseling MNT referral form which reveals high levels of
UACR at 484 mg/g versus the normal of < 30 mg/g, low eGFR at 20 mL/min versus the
normal of > 60 mL/min, low albumin at 2.5 g/dL versus the normal of 3.5-5 g/dL, high
creatinine at 3.1 mg/dL versus the normal of 0.6-1.5 mg/dL and high BUN at 43 mg/dL
versus the normal of 7-23 mg/dL.

Inconsistent carbohydrate intake (NI-5.8.4) related to chronic kidney disease and


hypoglycemia as evidenced by laboratory assessment in the CKD Diet Counseling MNT
referral form which reveals normal levels of blood glucose at 76 mg/dl, but inconsistent
dietary carbohydrate intake such as drinking of regular cola with meals to keep his
blood glucose levels normal.

V. Nutrition Intervention

21. For each of the PES statements you have written, establish an ideal goal (based on the signs
and symptoms) an appropriate nutrition-related intervention (based on the etiology), your
method for monitoring, and how you will evaluate the success of your intervention.

PES Statement Goal Intervention Monitoring Evaluation


Altered Nutrition- Short-term: Consume: Short-term: Short-term:
Related Laboratory Preserve renal 45.3-75.5 g/day Monitor food Patient
Values function by of protein. and nutrient consumes
(UACR/eGFR/Albumin/ reducing strain intake by recommended
Creatinine/BUN) (NC- on the kidneys. 2000-3000 evaluating food amounts of
2.2) related to chronic mg/day of dairy every 3-4 protein,
kidney disease and Long-term: potassium and weeks. potassium,
albuminuria as Delay sodium. sodium and
evidenced by laboratory progression to Monitor lab phosphorus as
assessment in the CKD ESRD and 800-1200 mg/kg values: UACR, indicated in
Diet Counseling MNT maintain healthy IBW/day of eGFR, food dairy.
referral form which kidney function. phosphorus. Albumin,
reveals high levels of Creatinine and Patient
UACR at 484 mg/g Discuss foods BUN every 3-5 chooses low
versus the normal of < choices that are months. protein foods
30 mg/g, low eGFR at 20 low in protein, over high
mL/min versus the phosphorus, Long-term: protein foods.
normal of > 60 mL/min, potassium and Continue
low albumin at 2.5 g/dL sodium. monitoring lab Long-term:
versus the normal of 3.5- values based on Patient
5 g/dL, high creatinine Educate on how progression of demonstrates
at 3.1 mg/dL versus the to maintain a disease to normal/stable
normal of 0.6-1.5 mg/dL food dairy. ESRD every 6 values of
and high BUN at 43 to 12 months. UACR, eGFR,
mg/dL versus the normal Albumin,
of 7-23 mg/dL. Creatinine
and BUN and
kidney
function does
now seem to
have
worsened.
Inconsistent Short term: Educate patient Short-term: Short-term:
carbohydrate intake Treat on CHO Monitor CHO Patient
(NI-5.8.4) related to hypoglycemia a counting to intake and follows CHO
chronic kidney disease by the education ensure that the glucose levels counting
and hypoglycemia as of carbohydrate patients by evaluating instructions
evidenced by laboratory counting to dietary CHO the food dairy and evenly
assessment in the CKD ensure that the intake is evenly every 2-3 distributes his
Diet Counseling MNT patients dietary distributed weeks. total CHO
referral form which carbohydrate throughout the intake per
reveals normal levels of intake is evenly day. Monitor HbA1c day.
blood glucose at 76 distributed levels every 3
mg/dl, but inconsistent throughout the Educate patient months. Long-term:
dietary carbohydrate day. on meal, snack Patient
intake such as drinking and fluid Long-term: demonstrates
of regular cola with Long term: choices to Continue consistent
meals to keep his blood Regulate normal ensure monitoring normal blood
glucose levels normal. blood glucose stabilization of glucose and glucose values
levels and blood glucose HbA1c levels and kidney
maintain healthy in-between based on functions do
kidney meals. progression of not seem to
functions. ESRD every 6 worsen.
Educate patient to 12 months.
on portion
control.

Educate patient
on how to use a
glucometer.

Educate patient
on how to
maintain a food
dairy.
22. Using the Supertracker Dietary Analysis program (available at
www.supertracker.usda.gov), design a 2 day hemodialysis-appropriate diet that meets or falls
within your patients estimated needs once they begin hemodialysis . (Note you have calculated
their energy and protein needs above, use your text or course notes to identify where the
remaining micronutrients should be.)
Attach printouts of your 2 days of diets, including foods and nutrient reports.

Diets will be evaluated for reasonability and thoroughness.

Nutrient Estimated needs (or range, when 2-day diet Notes


appropriate) average

Energy 2642.5 kcals/day 2631 kcals Average must be


within 50 kcal

Protein 90.6 g/day 89 g Within 5 g

Sodium 2000-3000 mg/day 2396.5 mg Within 50 mg

Potassium 2537 mg Within 50 mg


2000-3000 mg/day or

40 mg/kg IBW (3020 mg/day)

Phosphorus 1095.5 mg Within 50 mg


800-1200 mg/day or

< 17 mg/kg IBW (1208 mg/day)

V. Research Find one journal article published within the last 5 years from a peer-
reviewed health care journal that describe original clinical research related to nutrition and
chronic or end-stage renal disease management. A good resource of peer-reviewed research
is Pubmed at http://www.ncbi.nlm.nih.gov/pubmed/ . Make sure the article is an original
research study (not a review paper or a case study).

23. Give the article information (authors, article title, journal, date, volume, issue, page
numbers).
Caria, S., Cupisti, A., Sau, G., & Bolasco, P. (2014).
The incremental treatment of ESRD: a low-protein diet combined with weekly
hemodialysis may be beneficial for selected patients.
BMC nephrology, 15(1), 172.

24. After reading the article, write an original abstract of the article in your own words
describing the goals, subjects, methods, results, and conclusions of the research. It should
not be >250 words. Do not plagiarize the abstract the authors have already written!
The aim of this study is to observe the safety, benefits, and drawbacks of a
Combined Diet Dialysis Program (CDDP) compared to a standard thrice-a-week
hemodialysis (THD) in end stage renal disease (ESRD) patients. This study is a
multicenter, non-randomized, prospective controlled study that consists of 68
patients with a glomerular filtration rate of 5-10ml/min. The 68 patients were asked
to choose between either the low-protein (0.6g/kg/d), weekly dialysis CDDP schedule
(n = 38), or the THD free diet schedule (n = 30). The patients had blood and urine
samples taken at baseline, 6 and 12 months, with a survival and hospitalization rate
taken at 24 months. This study found that CDDP patients had lower levels of
phosphate (4.6mg/dl 0.8 vs 5.2mg/dl 1.1, p = 0.001), BUN (70mg/dl 17 vs
77mg/dl 22.9, p = 0.003), PTH (18pg/ml >300% vs 37.9pg/ml >300%, p = 0.01),
and higher albumin levels (4.1g/dl 0.4 vs 3.7g/dl 0.48, p = 0.01) at 12 months
compared to THD patients. Additionally, the hospitalization rates for the CDDP
patients were 11 days for 3 patients (3.7 1.5 days/patient) and 147 days for 24
patients (6.1 6.3 days/patient) among the THD patients. The survival rates showed
no significant difference between the CDDP and THD patients at 94.7% and 86.8%
respectively. These findings show that CPPD could be a beneficial choice in patients
with ESRD that can adhere to lower protein dietary modifications.

25. Make 2 clinical recommendations based on the results of the article. If you deem the
results valid (and if other studies also supported them) how could these results be translated
for use in clinical nutrition practice? (Note we are making an assumption here that they are
valid. In real practice, one would rarely make clinical recommendations based on the results
of one study.)
1. Keep protein intake at 0.6g/kg/d to preserve residual renal function which will
result in lower circulating phosphate, BUN, PTH, and higher albumin levels along
with reduced hospital stays and overall cost savings.
2. When planning menus for patients with CKD, omit dairy and processed foods to
reduce the amounts of sodium and phosphorus which are used in abundance as
preservatives.