Lauren Doherty Case study #18 CKD treated with Dialysis 11/02/2013 NUTR 409 CKD Treated with

Dialysis 1. Describe the physiological functions of the kidneys. The kidneys are responsible for making some enzymes and some hormones while maintaining fluid and electrolyte balance in the body. The kidneys regulate the excretion of waste product in the form of urea, nitrogen, creatinine, etc. in urine. The kidneys will retain urine and its components when necessary to maintain homeostasis or increase levels of excretion. 2. What disease/conditions can lead to chronic kidney disease (CKD)? Explain the relationship between diabetes and CKD. High blood pressure, Diabetes, kidney diseases and infections, such as polycystic kidney disease, pyelonephritis, and glomerulonephritis. A narrowed or blocked renal artery and medications such as NSAIDs and Celebrex. Any form of diabetes can cause CKD and is the most common cause of CKD. Diabetes will damage the blood vessels in the kidney which decreases the ability of the kidneys to filter blood and will increase the amount of protein allowed to pass from the blood and excreted through the urine. 3. Outline the stages of CKD, including the distinguishing signs & symptoms. Stage 1 with normal or high GFR (GFR > 90 ml/min) no physical signs or symptoms Higher than normal levels of creatinine or urea in the blood. blood or protein in the urine, evidence of kidney damage in an MRI, CT scan, ultrasound or contrast X-ray, or a family history of polycystic kidney disease (PKD) - usually being checked for another disease when discovered in stage 1. Stage 2 Mild CKD (GFR = 60-89 ml/min) - No physical signs or symptoms - Higher than normal levels of creatinine or urea in the blood. blood or protein in the urine, evidence of kidney damage in an MRI, CT scan, ultrasound or contrast X-ray, or a family history of polycystic kidney disease (PKD). - Usually being checked for another disease when discovered in stage 2. Stage 3 Moderate CKD (GFR = 30-59 ml/min) Fatigue, edema, urination changes including color change and may possibly be foamy, kidney pain, sleep problems, high BP , and anemia. Stage 4 Severe CKD (GFR = 15-29 ml/min) - Fatigue, edema, urination changes including color change and may possibly be foamy, kidney pain, sleep problems, high B , anemia, taste changes, nausea, anorexia, uremic (bad) breath, difficultly concentrating, nerve problems ES: numbness in toes. Stage 5 End Stage CKD (GFR <15 ml/min) - Anorexia, N/V, headaches, fatigue. unable to concentrate, Itching, making little or no urine, edema, especially around the eyes and ankles, muscle cramps, tingling in hands or feet, changes in skin color, and increased skin pigmentation

Lauren Doherty Case study #18 CKD treated with Dialysis 11/02/2013 NUTR 409

5. What are the treatment options for stage 5 CKD? Explain the difference between hemodialysis and peritoneal dialysis. Hemodialysis and peritoneal dialysis or kidney transplant are the treatment options remaining. Hemodialysis requires having a catheter places in a neck vein creating temporary access to the blood within the body and transporting it to the artificial kidney (dialyzer.) Peritoneal dialysis requires a catheter to be inserted into the abdomen along with dialysate which needs to be replaced every 4-6 hours. This acts as a membrane to remove the toxins from the blood. 6. Explain the reasons for the following components of Mrs. Joaquins MNT. 35kcal/kg patients on dialysis will lose protein and this is enough to help prevent the excessive loss of protein and malnutrition. 1.2g protein/kg Slightly more protein b/c of losses during dialysis prevents excessive loss of protein and malnutrition 2g K Limited b/c the body cannot remove excess K 1g phosphorus Attemtping to lower phosphorus levels in the blood high phos can result in bone loss and excessive strain on the kidneys 2g NA controlling fluid retention and high BP 1000mL fluid + urine output due to low urine outputs and the need for fluid balance. 7. Calculate and interpret Mrs. Joaquins BMI. How does edema affect your interpretation? BMI at current 170 wt. = 33.2; adjusted for 4kg weight gain over the last 2wks BMI = 31.6; although her BMI does lower, she is still obese + or the edema weight. 8. What is edema-free weight? Calculate Mrs. Joaquins edema-free weight.

12. What are the considerations for differences in protein requirements among predialysis, hemodialysis or peritoneal dialysis? Predialysis = will need the least protein due to overloading the kidneys Hemodialysis & Peritoneal dialysis = almost require the same amount of protein with peritoneal being slightly higher than hemodialysis. The higher amount of protein during dialysis is used to offset the amount of protein being lost. 13. Mrs. Joauqin has a PO4 restriction. Why? What foods have the highest levels of phosphorus? The patient already has high levels of phos. in her blood which is related to bone loss and excessive strain on the kidneys. Foods highest in phosphorus = Seeds, cheese, tofu, beans, lentils, fish, shellfish, nuts, pork, beef, low-fat dairy, and veal.

Lauren Doherty Case study #18 CKD treated with Dialysis 11/02/2013 NUTR 409 14. Mrs. Joaquin tells you one of her friends can only drink 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? If a patient must follow a fluid restriction, what can be done to help reduce his or her thirst? While the patient may have to limit her fluids as well, the restriction will likely vary from her friend because these limits are variable from person to person. Soups, popsicles, yogurts, custards, sherbets, gelatin, and ice cream are considered liquids. The patient should try to limit salt as salt induces thirst, try using ice cubes instead of water because it will last longer, try freezing fruits and eating them, etc. Patients in general with fluid restrictions should limit salt, try drinking from smaller cups, eat frozen fruit throughout the day, use ice cubes instead of water, etc. 15. Several biochemical indices are used to diagnose CKD. One is glomerular filtration rate. What does GFR measure? What is a normal GFR? Interpret Mrs. Joauqins value of 28mL/min. GFR used to calculate amount of kidney function . Normal GFR = 90 - 120 mL/min/1.73 m2. Older people will have lower normal GFR levels, because GFR decreases with age. 28mL/min is severe stage 4 CKD 16. Evaluate Mrs. Joaquins chemistry report. What labs support the diagnosis of stage 5 CKD High sodium, high potassium, high phosphorous, high creatinine, high BUN, and high hemoglobin AIC 19. What health problems have been identified in the Pima Indians through edidemiological data? Explain what is meant by the thrifty gene theory. Are the Pima at high risk for complications of diabetes? Explain. Pima Indians 50% have diabetes and 95% of those are overweight; historically are overweight. The thrify gene theory theorizes that due to periods of feast and famine in the past, some people are genetically predisposed to storing extra fat in case of a time of famine but today there generally are not periods of extreme famine which is resulting in obesity and diseases. 22. Why is it recommended for patients to have at least 50% of their protein from sources that have high biological value? HBV proteins will produce less of the byproduct urea. Urea is typically filtered by the kidney but in CKD patients, the kidneys cannot do so. Lower BV proteins such as those from plants produce more urea. Consuming more than 50% of proteins from those sources can result in toxic levels of urea for CKD patients.