Chronic Kidney Disease Stage 5

Case Study for Nutrition and Diet Therapy Schedule: 12:30pm-6:30pm

Submitted by:

Lazaro, Lorielyn Rochelle D. Soriano, Kristine Anne

II-BSN

Submitted to: Ms. Ma. Jenny Rose Pinpin

I.

General Information

Name:

G Surname

T Firstname

Age: 26-year-old Sex: Female Clinical Diagnosis: Stage 5 Chronic Kidney Disease Stage 5

II. Medical History PAST: A history of renal insufficiency hypertension and diabetes mellitus type 2. Current symptoms: anorexia, nausea and vomiting, edema, shortness of breath, and inability to urinate. MEDICINES: Captopril Vitamin/Mineral supplement Glucophage Erythropoietin Nutrition History She is 50 and weighs 170 lbs. usual body weight 162 lbs. Usual Intake Basically eats everything with no restrictions. No herbal dietary consumptions.

OVERVIEW of Past and Present Illness: Renal failure or kidney failure (formerly called renal insufficiency) describes a medical condition in which the kidneys fail to adequately filter toxins and waste products from the blood. The two forms are acute (acute kidney injury) and chronic (chronic kidney disease), a number of other diseases or health problems may cause either form of renal failure to occur. Renal failure is described as a decrease in glomerular filtration rate. Biochemically, renal failure is typically detected by an elevated serum creatinine level. Problems frequently encountered in kidney malfunction include abnormal fluid levels in the body, deranged acid levels, abnormal levels of potassium, calcium, phosphate, and (in the longer term) anemia as well as delayed healing in broken bones. Depending on the cause, hematuria (blood loss in the urine) and proteinuria (protein loss in the urine) may occur. Long-term kidney problems have significant repercussions on other diseases, such as cardiovascular disease. Hypertension or High Blood Pressure is a measurement of the force against the walls of your arteries as your heart pumps blood through your body. Blood pressure readings are usually given as two numbers -- for example, 120 over 80 (written as 120/80 mmHg). One or both of these numbers can be too high. The top number is called the systolic blood pressure, and the bottom number is called the diastolic blood pressure.

Normal blood pressure is when your blood pressure is lower than 120/80 mmHg most of the time.

High blood pressure (hypertension) is when your blood pressure is 140/90 mmHg or above most of the time.

If your blood pressure numbers are 120/80 or higher, but below 140/90, it is called pre-hypertension.

Causes, incidence, and risk factors Many factors can affect blood pressure, including:

How much water and salt you have in your body The condition of your kidneys, nervous system, or blood vessels Lifestyle Diet Type 2 diabetes mellitus comprises an array of dysfunctions resulting from the

combination of resistance to insulin action and inadequate insulin secretion. It is disorders are characterized by hyperglycemia and associated with microvascular (ie, retinal, renal, possibly neuropathic), macrovascular (ie, coronary, peripheral vascular), and neuropathic (ie, autonomic, peripheral) complications. Unlike patients with type 1 diabetes mellitus, patients with type 2 are not absolutely dependent upon insulin for life. This distinction was the basis for the older terms for types 1 and 2, insulin dependent and noninsulin dependent diabetes. However, many patients with type 2 diabetes are ultimately treated with insulin. Because they retain the ability to secrete some endogenous insulin, they are considered to require insulin but not to depend on insulin. Nevertheless, given the potential for confusion due to classification based on treatment rather than etiology, these terms have been abandoned. III. Discussion of Patients Diagnosis Chronic Kidney Disease Stage 5 A person with Stage 5 CKD has end stage renal disease (ESRD) with a GFR of 15 ml/min or less. At this advanced stage of kidney disease the kidneys have lost nearly all their ability to do their job effectively, and eventually dialysis or a kidney transplant is needed to live.

Symptoms that can occur in Stage 5 CKD include:

Loss of appetite Nausea or vomiting Headaches Being tired Being unable to concentrate Itching Making little or no urine Swelling, especially around the eyes and ankles Muscle cramps Tingling in hands or feet Changes in skin color Increased skin pigmentation

Because the kidneys are no longer able to remove waste and fluids from the body, toxins build up in the blood, causing an overall ill feeling. Kidneys also have other functions they are no longer able to perform such as regulating blood pressure, producing the hormone that helps make red blood cells and activating vitamin D for healthy bones. If diagnosed with stage 5 CKD, need to see a nephrologist immediately. This is a doctor who is trained in kidney disease, kidney dialysis and transplant. The doctor will help you decide which treatment is best for you hemodialysis, peritoneal dialysis (PD) or kidney transplantand will recommend an access for dialysis. Your nephrologist will develop your overall care plan and manage your healthcare team. Glomerular filtration rate (GFR) is the best measure of kidney function. The GFR is the number used to figure out a persons stage of kidney disease. A math formula using the persons age, race, gender and their serum creatinine is used to calculate a GFR. A doctor will order a blood test to measure the serum creatinine level. Creatinine is a waste product that comes from muscle activity. When kidneys are working well they

remove creatinine from the blood. As kidney function slows, blood levels of creatinine rise.

Laboratory Findings with Normal Values Laboratory Tests BUN (Blood Urea Nitrogen) M: 0.7-1.2 mg/dL Creatinine 12 mg/dL F: 0.5-1.0 mg/dL creatinine: poor clearance due to impared kidneys Glucose HbA1c Potassium 200 mg/dL 8.9% mg/dL 7mEq/L 82-110 mg/dL 3.5-5.5% mg/dL 3.5-5.5 mEq/L Patient is diabetic Patient is diabetic Hyperkalemia 69 mg/dL Laboratory Results Normal Range M: 8-24 mg/dL F: 6-21 mg/dL Interpretation BUN: kidneys arent working well

PATHOPHISIOLOGY

The underlying pathophysiology defect in type 2 diabetes is characterized by the following three disorders (1) peripheral resistance to insulin, especially in muscles cells:

(2) increased production of glucose by the liver, and (3) altered pancreatic secretion. Increased tissue resistance to insulin generally occurs first and eventually followed by impaired insulin secretions. The pancreas produces insulin, yet insulin resistance prevents its proper use at the cellular level. Glucose cannot enter target cells and accumulates in the blood streams, resulting in hyperglycemia. The high blood glucose levels often stimulate an increase in insulin production by the pancreas: thus. Type 2 diabetic individuals often have excessive insulin production (hyperinsulinemia). Insulin resistance refers to tissue sensitivity to insulin. Intracellular reaction are diminished, making insulin less effective at stimulating glucose uptake by the tissues and regulating glucose release by the liver. If blood glucose levels are elevated consistently for a significant period of time, the kidneys filtration mechanism is stressed, allowing blood proteins to leak into the urine. As a result, the pressure in the blood vessels of the kidney increases. It is thought that the elevated pressure serves as the stimulus the level of nephropathy. The earliest detectable change in the course of diabetic nephropathy is a thickening in the glomerulus. At this stage, the kidney may start allowing more albumin (protein) than normal in the urine, and this can be detected by sensitive tests for albumin. As diabetic nephropathy progresses, increasing numbers of glomeruli are destroyed. Now the amounts of albumin being excreted in the urine increases, and may be detected by ordinary urinalysis techniques. At this stage, a kidney biopsy clearly shows diabetic nephropathy and eventually leads to Chronic renal failure. End-stage renal disease (ESRD) with a GFR <15 mL/min Kidneys fail so toxins build up in the blood, causing an overall ill feeling New symptoms: anorexia, nausea or vomiting, headaches, fatigue, anuria, swelling around eyes and ankles, muscle cramps, tingling in hands or feet, and changing skin color and pigmentation (Escott-Stump, 2008) IV. Recent Literature updates to Kidney Failure Kidney Failure Patients Benefit From Frequent Or Extended Dialysis Treatments by VR Sreeraman on February 24, 2012 at 2:09 PM Organ Donation News

Patients suffering from kidney failure may benefit from frequent and longer dialysis treatments which may improve survival compared with conventional dialysis. The findings suggest that daily or nightly dialysis sessions at home or in the clinic are viableand perhaps superioralternatives for some patients with kidney failure. Most kidney failure patients who undergo dialysis receive treatments at outpatient facilities three times per week, for three to four hours per visit. Researchers suspect that more frequent and longer treatments might be more effective, but these would be inconvenient for most patients and would take up too much of their time. Therefore, nighttime dialysis while patients sleep (at home or in a clinic) or daily treatments at home might be good options. Several groups of researchers set out to test these alternatives. Their findings are summarized below. Eric Weinhandl (Minneapolis Medical Research Foundation) and his co-investigators compared survival of 1,873 daily home dialysis patients using the NxStage System Onea portable hemodialysis machine for use in the homebetween 2005 and 2008 with 9,365 thrice-weekly in-center hemodialysis patients. Over an average period of 1.7 to 1.8 years, daily home dialysis patients were 13% less likely to die than thrice-weekly clinic patients, and the survival benefit of daily home dialysis appeared to apply to all types of patients (different sexes, races, weights, etc.). "Whether these results apply to all hemodialysis patients needs further study because patients in our analysis were generally younger and less sick," said Weinhandl. GihadNesrallah, MD, Rita Suri, MD (University of Western Ontario, in London, Canada), and their team compared 338 patients who received intensive home hemodialysis (during the day or night) for an average of 4.8 sessions per week and an average treatment time of 7.4 hours per session with 1,388 patients who received conventional hemodialysis. After following patients for an average of 1.8 years, the researchers found that patients receiving intensive dialysis were 45% less likely to die than patients receiving conventional dialysis. "Whether this improvement in survival is due to

increased intensity of dialysis itself or due to the fact that the intensive dialysis patients performed their own dialysis treatments at home is not yet clear," said Dr. Suri. Eduardo Lacson, Jr., MD (Fresenius Medical Care North America) and his colleagues studied the health of 746 patients who received hemodialysis treatments at a clinic for three nights per week and for an average of eight hours per night, compared with 2,062 similar patients who received conventional hemodialysis treatments. During a two-year follow-up period, patients who received nighttime dialysis had a 25% reduced risk of dying compared with conventional dialysis. Nighttime dialysis patients also experienced improvements in certain measures such as lower weight, blood pressure, and blood phosphorous levels. "This comparison primarily evaluated the impact of the length of treatment time on hemodialysis because patients were all dialyzed in the center and at the same frequency of three times per week," said Dr. Lacson. "Longer treatment time allows for removal of fluid and waste products at a slower pace, but with the added benefit of potentially removing larger quantities from the body." Finally, John Daugirdas, MD (University of Illinois at Chicago) and his team analyzed data from two studies, the Frequent Hemodialysis Network Daily and Nocturnal Trials, which compared frequent (six times per week) treatments received during the day or at night, with conventional dialysis. Daugirdas and his colleagues looked to see if more frequent dialysis treatments could help lower patients' blood phosphorus levels. (Traditionally, dialysis patients often have high levels, which puts them at risk of developing various complications such as heart disease.) Compared with conventional dialysis treatments, daily or nightly dialysis treatments for 12 months lowered patients' phosphorus levels and reduced their need for phosphorus-lowering medications. The studies' findings indicate that additional research is warranted to determine if extended or more frequent dialysis treatments provide benefits for all dialysis patients and to determine the optimal treatment frequency and session length. Read more: Kidney Failure Patients Benefit From Frequent Or Extended Dialysis Treatments | MedIndiahttp://www.medindia.net/news/kidney-failure-patients-benefitfrom-frequent-or-extended-dialysis-treatments-97937-1.htm#ixzz1o7eclTcV

V. Assessment of Nutritional Status Anthropometry Age: 26 Height:50 / 152.4cm Weight:170lbs/ 77.5 kg BMI:33.2 *(Obesity = BMI of 30 or greater) Based on patients G.Ts BMI, she is considered to fall in the obese category. Biochemical Assessment RESULTs BUN 69mg/dL INDICATIONs a high blood urea nitrogen level means kidneys aren't working well can also be due to urinary tract obstruction, congestive heart failure or gastrointestinal bleeding Creatinine 12 mg/dL blood suggest diseases or conditions that affect kidney function. Glucose 200mg/dL impaired glucose tolerance (pre-

diabetes)

8.9% HbA1c High

Potassium

7 mEq/L

Acute or chronic kidn ey failure

Clinical Assessment A history of renal insufficiency hypertension and diabetes mellitus type 2. Current symptoms: anorexia, nausea and vomiting, edema, shortness of breath, and inability to urinate. Nutritional Diagnosis: Altered nutrition-related laboratory values including elevated serum potassium as related to dietary choices high in potassium as evidenced by serum potassium of 7 mEq/L .

Dietary Assessment It is based on observed food consumption Qualitative Method & Quantitative Method: can further observe in diet history in which patient GT eats everything with no restrictions (assuming from the food exchange list.) Diet History Basically eats everything with no restrictions VI. Nutrition Care Plan Patient G.T who basically eats everything with no restrictions is admitted with a diagnosis of Stage 5 Chronic Kidney Disease and presents a history of renal

insufficiency hypertension and diabetes mellitus type 2 her current symptoms include anorexia, nausea and vomiting, edema, shortness of breath, and inability to urinate and initiated with plan of having hemodialysis. People on hemodialysis generally need to increase their protein, and limit fluids, sodium, potassium and phosphorus, and in some cases, calcium. Those who choose PD usually need to increase their protein and limit phosphorus, but may have fewer limits on fluid and potassium. A healthy diet for stage 5 CKD may recommend: Including grains, fruits and vegetables, but limiting or avoiding whole grains and certain fruits and vegetables that are high in phosphorus or potassium A diet that is low in saturated fat and cholesterol and moderate in total fats, especially if cholesterol is high or if you have diabetes or heart disease Limiting intake of refined and processed foods high in sodium and prepare foods with less salt or high sodium ingredients Aiming for a healthy weight by consuming adequate calories and including physical activity each day within your ability Increasing protein intake to the level determined by the dietitians assessment of individual needs and to replace losses in the dialysis treatment Taking special renal vitamins high in water soluble B vitamins and limited to 100 mg of vitamin C Vitamin D and iron tailored to individual requirements Limiting phosphorus to1000 mg or based on individual requirements Limiting calcium to 2000 mg (no more than 1500 mg from calcium based phosphorus binders). Limiting potassium to 2000 to 3000 mg or bases on individual requirements

Short term Goals: Encourage intake. Promote blood pressure control. Maintain glucose, mineral, and electrolyte balance Long term Goals: Prevent chronic complications of immunosuppressive therapy: Excessive weight gain Hyperlipidemia Hypertension Corticosteroid-induced hyperglycemia and/or osteoporosis

VII.DEFINITION OF TERMS Chronic kidney disease (CKD) - also known as chronic renal disease, is a progressive loss in renal function over a period of months or years. The symptoms of worsening

kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. Obesity- is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems Diabetes mellitus type 2 formerly non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes is a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency. Hypertension (HTN) or high blood pressure, sometimes arterial hypertension- is a chronic medical condition in which the blood pressure in the arteries is elevated. Anorexia nervosa - is an eating disorder characterized by excessive weight loss, and irrational fear of gaining weight and distorted body self-perception. Edema (formerly known as dropsy or hydropsy)-, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling. Nausea- is an uneasiness of the stomach that often accompanies the urge to vomit, but doesn't always lead to vomiting. Vomiting- is the forcible voluntary or involuntary emptying ("throwing up") of stomach contents through the mouth. Urinary Retention- inability to urinate

VIII. QUESTIONS:

Explain how current symptoms are related to CKD. From the pathophisiology ,If blood glucose levels are elevated consistently for a significant period of time, the kidneys filtration mechanism is stressed, allowing blood

proteins to leak into the urine. As a result, the pressure in the blood vessels of the kidney increases. It is thought that the elevated pressure serves as the stimulus the level of nephropathy. The earliest detectable change in the course of diabetic nephropathy is a thickening in the glomerulus. At this stage, the kidney may start allowing more albumin (protein) than normal in the urine, and this can be detected by sensitive tests for albumin. As diabetic nephropathy progresses, increasing numbers of glomeruli are destroyed. Now the amounts of albumin being excreted in the urine increases, and may be detected by ordinary urinalysis techniques. At this stage, a kidney biopsy clearly shows diabetic nephropathy and eventually leads to Chronic renal failure. Correlate the laboratory with the patients diagnosis. NORMAL VALUES BUN 8-18 H 69mg/dL a high blood urea nitrogen level means kidneys aren't working well can also be due to urinary tract obstruction, congestive heart failure or gastrointestinal bleeding Creatinine 0.6-1.2 H 12 mg/dL High level of creatinine indicates impaired renal function. (mg/dL) Creatinine clearance RESULTs INDICATIONs

is used to estimate GFR, the primary diagnostic criteria Glucose 70-110 H 200mg/dL High blood glucose indicates uncontrolled DM, which leads to (mg/dL) diabetic nephropathy. 8.9% HbA1c 3.9-5.2 H HbA1C indicates long-term uncontrolled hyperglycemia, (%) indicating diabetic nephropathy as the likely cause of the patients chronic kidney disease. Potassium 3.5-5 H 7 mEq/L High serum potassium indicates compromised filtration in the (mEq/L) kidneys

Replace food exchange list with nurtion theraphy for CKD;include the nutrients that are usually controlled with CKD patients requiring dialysis plus the food source of each nutrient. FOOD EXCHANGE LIST

An imaginary typical intake of patient GT and the prescribed diet plus sample menu

When patient GT begins dialysis, energy and protein recommendations will increase.

Adequate energy intake is essential for protein to be used for growth and repair of lean tissue. In an absence of sufficient energy, protein is diverted from its important functions to supply energy (4 calories/gram). The dialysis procedure has been implicated as a potential catabolic factor predisposing the CKD patient to protein calorie malnutrition. Data demonstrates that dialysis is an overall catabolic event, decreasing the circulating amino acids, accelerating rates of whole body and muscle proteolysis, stimulating muscle release of amino acids, and elevating net whole body and muscle protein loss. Thus, the energy and protein requirement increase in dialysis are increased to prevent patient from experiencing malnutrition (Nelms, 2007). Why is it recommended for patients to have at least 50% of their protein from sources that have high biological value? Proteins sources that have high biological value are those that have complete essential amino acids required by the human body and are easily assimilated into body tissue are called proteins with High Biological Value (HBV). Proteins with HBV include such as meat, poultry, fish, eggs, milk, cheese and yogurt. Low biological value proteins are found in plants, legumes, grains, nuts, seeds and vegetables. One of the by-products of protein metabolism is urea (toxic) which is unfavorable to CKD patients as the kidneys are unable to remove this waste from the body efficiently. Thus, consuming at least 50% of protein from HBV protect and conserves body protein and minimizes urea generation

IX. REFERENCE: New England LMS (2007), (Escott-Stump, 2008) http://www.emedicinehealth.com/inability_to_urinate/article_em.htm http://www.medindia.net/news/kidney-failure-patients-benefit-from-frequent-orextended-dialysis-treatments-97937-1.htm#ixzz1o7eclTcV www.lusimartin.blogspot.com http://nursingdepartment.blogspot.com/2009/03/pathophysiology-of-diabetesmilletus.html American Dietetic Association. Guidelines for Nutrition Care of Renal Patients. Third edition. 2002. American Dietetic Association. Renal Care: Resources and Practical Application. 2004. Daugirdas, J., Blake, P., and Ing, T. Handbook of Dialysis. Third edition. Philadelphia: Lippencott Williams & Wilkins, 2001.