Aliya​ ​Levy

October​ ​31,​ ​2017

Nutrition​ ​409​ ​-​ ​Fall​ ​2017

Case​ ​Study:​ ​Chronic​ ​Kidney​ ​Disease​ ​Treated​ ​with​ ​Dialysis

1. Describe​ ​the​ ​basic​ ​physiological​ ​functions​ ​of​ ​the​ ​kidneys.

The​ ​kidneys​ ​regulate​ ​the​ ​fluid​ ​and​ ​electrolyte​ ​balance,​ ​such​ ​as​ ​sodium​ ​and
potassium,​ ​of​ ​the​ ​body​ ​by​ ​continually​ ​filtering​ ​the​ ​blood.​ ​This​ ​is​ ​vital​ ​to​ ​maintain​ ​a
constant​ ​extracellular​ ​fluid​ ​volume​ ​and​ ​composition.​ ​Kidneys​ ​are​ ​able​ ​to​ ​excrete​ ​or
conserve​ ​salt​ ​and​ ​water,​ ​control​ ​body​ ​pH​ ​and​ ​free​ ​the​ ​body​ ​of​ ​waste​ ​products​ ​of​ ​the
metabolism.​ ​The​ ​Kidney​ ​also​ ​provides​ ​maintenance​ ​of​ ​acid-base​ ​balance,​ ​clearance​ ​of
toxins;​ ​absorption​ ​of​ ​glucose,​ ​amino​ ​acids​ ​and​ ​other​ ​small​ ​molecules,​ ​production​ ​of
various​ ​hormones,​ ​etc.
2. List​ ​the​ ​diseases/​ ​conditions​ ​that​ ​most​ ​commonly​ ​lead​ ​to​ ​chronic​ ​kidney
disease(CKD).​ ​Explain​ ​the​ ​role​ ​of​ ​diabetes​ ​in​ ​the​ ​development​ ​of​ ​CKD.
The​ ​cause​ ​of​ ​CKD​ ​isn’t​ ​always​ ​known​ ​but​ ​any​ ​condition​ ​or​ ​disease​ ​that​ ​damages
blood​ ​vessels​ ​or​ ​other​ ​structures​ ​in​ ​the​ ​kidneys​ ​can​ ​lead​ ​to​ ​kidney​ ​disease.​ ​High​ ​blood
sugar​ ​levels​ ​caused​ ​by​ ​diabetes​ ​damage​ ​blood​ ​vessels​ ​in​ ​the​ ​kidneys.​ ​If​ ​the​ ​blood​ ​sugar
level​ ​remains​ ​high​ ​over​ ​many​ ​years,​ ​this​ ​damage​ ​gradually​ ​reduces​ ​the​ ​function​ ​of​ ​the
kidneys.​ ​Uncontrolled​ ​hypertension​ ​damages​ ​blood​ ​vessels​ ​which​ ​can​ ​lead​ ​to​ ​damage​ ​in
the​ ​kidneys.​ ​Blood​ ​pressure​ ​often​ ​rises​ ​with​ ​CKD​ ​so​ ​high​ ​blood​ ​pressure​ ​may​ ​further
damage​ ​kidney​ ​function​ ​even​ ​when​ ​another​ ​medical​ ​condition​ ​initially​ ​caused​ ​the
disease.​ ​You​ ​can​ ​also​ ​get​ ​CKD​ ​after​ ​having​ ​polycystic​ ​kidney​ ​disease,​ ​pyelonephritis,
glomerulonephritis,​ ​and​ ​having​ ​a​ ​narrowed​ ​or​ ​blocked​ ​renal​ ​artery(the​ ​renal​ ​artery
carries​ ​blood​ ​to​ ​the​ ​kidneys).​ ​You​ ​can​ ​also​ ​develop​ ​CKD​ ​due​ ​to​ ​long​ ​term​ ​use​ ​of
medicines​ ​that​ ​damage​ ​the​ ​kidneys​ ​such​ ​as​ ​NSAIDs​ ​and​ ​certain​ ​antibiotics.
3. Outline​ ​the​ ​stages​ ​of​ ​CKD,​ ​including​ ​the​ ​distinguishing​ ​signs​ ​and​ ​symptoms.
Stage​ ​1:​​ ​Patient​ ​has​ ​kidney​ ​damage​ ​with​ ​glomerular​ ​filtration​ ​rate(GFR)​ ​at​ ​a​ ​normal​ ​or
high​ ​level​ ​greater​ ​than​ ​90​ ​ml/min.​ ​Usually​ ​no​ ​symptoms​ ​to​ ​indicate​ ​the​ ​kidneys​ ​are
damaged​ ​because​ ​although​ ​they​ ​are​ ​not​ ​at​ ​100%​ ​they​ ​are​ ​still​ ​doing​ ​a​ ​good​ ​job.​ ​Some
symptoms​ ​you​ ​might​ ​find​ ​is​ ​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.
Stage​ ​2​:​ ​Patient​ ​has​ ​kidney​ ​damage​ ​with​ ​a​ ​mild​ ​decrease​ ​in​ ​GFR​ ​of​ ​60-89​ ​ml/min.​ ​There
are​ ​usually​ ​no​ ​symptoms​ ​to​ ​indicate​ ​the​ ​kidneys​ ​are​ ​damaged.​ ​Some​ ​symptoms​ ​you
might​ ​find​ ​will​ ​be​ ​the​ ​same​ ​as​ ​stage​ ​1.
Stage​ ​3:​​ ​Patient​ ​has​ ​moderate​ ​kidney​ ​damage.​ ​This​ ​stage​ ​is​ ​broken​ ​into​ ​two:​ ​a
decrease​ ​in​ ​GFR​ ​for​ ​3A​ ​is​ ​45-59​ ​ml/min​ ​and​ ​a​ ​decrease​ ​in​ ​GFR​ ​3B​ ​is​ ​30-44​ ​ml/min.​ ​As
kidney​ ​function​ ​declines​ ​waste​ ​products​ ​can​ ​build​ ​up​ ​in​ ​the​ ​blood​ ​causing​ ​a​ ​condition
known​ ​as​ ​“uremia”.​ ​In​ ​stage​ ​3​ ​a​ ​person​ ​is​ ​more​ ​likely​ ​to​ ​develop​ ​complications​ ​of​ ​kidney
disease​ ​such​ ​as​ ​high​ ​blood​ ​pressure,​ ​anemia​ ​and/or​ ​early​ ​bone​ ​disease.​ ​Symptoms
include​ ​fatigue,​ ​fluid​ ​retention,​ ​swelling​ ​(edema)​ ​or​ ​extremities​ ​and​ ​shortness​ ​of​ ​breath,
 urination​ ​changes(foamy;​ ​dark​ ​orange,​ ​brown,​ ​tea​ ​colored​ ​or​ ​red​ ​if​ ​it​ ​contains​ ​blood),
kidney​ ​pain​ ​felt​ ​in​ ​the​ ​back​ ​or​ ​sleep​ ​problems​ ​due​ ​to​ ​muscle​ ​cramps​ ​or​ ​restless​ ​legs.
Stage​ ​4​:​ ​Patient​ ​has​ ​advanced​ ​kidney​ ​damage​ ​with​ ​a​ ​severe​ ​decrease​ ​in​ ​the​ ​GFR​ ​to
15-30​ ​ml/min.​ ​It​ ​is​ ​likely​ ​patient​ ​with​ ​Stage​ ​4​ ​CKD​ ​will​ ​need​ ​dialysis​ ​or​ ​a​ ​kidney
transplant​ ​in​ ​the​ ​near​ ​future.​ ​Will​ ​develop​ ​uremia.​ ​More​ ​likely​ ​to​ ​have​ ​complications​ ​such
as​ ​high​ ​blood​ ​pressure,​ ​anemia,​ ​bone​ ​disease,​ ​heart​ ​disease​ ​and​ ​other​ ​cardiovascular
diseases.​ ​Symptoms​ ​include​ ​fatigue,​ ​fluid​ ​retention,​ ​urination​ ​changes,​ ​kidney​ ​pain​ ​felt​ ​in
the​ ​back,​ ​sleep​ ​problems​ ​due​ ​to​ ​muscle​ ​cramps​ ​or​ ​restless​ ​legs,​ ​nausea​ ​and/or
vomiting,​ ​taste​ ​changes​ ​such​ ​as​ ​metallic​ ​taste​ ​in​ ​the​ ​mouth,​ ​bad​ ​breath​ ​due​ ​to​ ​urea
buildup​ ​in​ ​the​ ​blood,​ ​loss​ ​of​ ​appetite,​ ​difficulty​ ​in​ ​concentrating,​ ​and​ ​nerve​ ​problems.
Stage​ ​5​:​ ​Patient​ ​has​ ​end​ ​stage​ ​renal​ ​disease(ESRD)​ ​with​ ​GFR​ ​of​ ​15​ ​ml/min​ ​or​ ​less.​ ​At
this​ ​stage,​ ​kidneys​ ​have​ ​lost​ ​nearly​ ​all​ ​their​ ​ability​ ​to​ ​do​ ​their​ ​job​ ​effectively​ ​and
eventually​ ​dialysis​ ​or​ ​a​ ​kidney​ ​transplant​ ​is​ ​needed​ ​to​ ​live.​ ​Symptoms​ ​include:​ ​loss​ ​of
appetite,​ ​nausea​ ​or​ ​vomiting,​ ​headaches,​ ​being​ ​tired,​ ​being​ ​unable​ ​to​ ​concentrate,
itching,​ ​making​ ​little​ ​or​ ​no​ ​urine,​ ​swelling,​ ​muscle​ ​cramps,​ ​tingling​ ​in​ ​hands​ ​or​ ​feet,
changes​ ​in​ ​skin​ ​color,​ ​increased​ ​skin​ ​pigmentation.
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?
Patient​ ​complained​ ​of​ ​anorexia,​ ​weight​ ​gain(due​ ​to​ ​fluid​ ​retention),​ ​edema​ ​in​ ​the
face​ ​and​ ​extremities(due​ ​to​ ​fluid​ ​retention),​ ​malaise(a​ ​general​ ​feeling​ ​of​ ​discomfort,
illness,​ ​or​ ​uneasiness​ ​whose​ ​exact​ ​cause​ ​is​ ​difficult​ ​to​ ​identify),​ ​progressive​ ​SOB
(shortness​ ​of​ ​breath)​ ​with​ ​3​ ​pillow​ ​orthopnea(difficult​ ​to​ ​breathe​ ​when​ ​lying​ ​down)​ ​-
symptom​ ​of​ ​heart​ ​failure​ ​and​ ​she​ ​chose​ ​not​ ​to​ ​pick​ ​up​ ​her​ ​hypertensive​ ​meds,​ ​pruritus,
muscle​ ​cramps​ ​and​ ​inability​ ​to​ ​urinate.​ ​These​ ​symptoms​ ​and​ ​signs​ ​all​ ​started​ ​a​ ​few
weeks​ ​ago​ ​even​ ​though​ ​she​ ​was​ ​diagnosed​ ​2​ ​years​ ​ago.
5. What​ ​are​ ​the​ ​three​ ​treatment​ ​options​ ​for​ ​Stage​ ​5​ ​CKD?​ ​Explain​ ​the​ ​differences
between​ ​hemodialysis​ ​and​ ​peritoneal​ ​dialysis.
1.​ ​Kidney​ ​Transplant
2.​ ​Hemodialysis:​ ​treatment​ ​can​ ​be​ ​done​ ​in​ ​a​ ​center​ ​or​ ​in​ ​patients​ ​home​ ​with​ ​assistance
from​ ​a​ ​care​ ​partner.​ ​A​ ​dialysis​ ​machine​ ​removes​ ​a​ ​small​ ​amount​ ​of​ ​a​ ​patient's​ ​blood
through​ ​a​ ​man​ ​made​ ​membrane​ ​called​ ​a​ ​dialyzer,​ ​or​ ​artificial​ ​kidney,​ ​to​ ​clean​ ​out​ ​toxins
that​ ​the​ ​kidneys​ ​can​ ​no​ ​longer​ ​remove.​ ​The​ ​filtered​ ​blood​ ​is​ ​then​ ​returned​ ​to​ ​the​ ​body.
3.​ ​Peritoneal​ ​dialysis​ ​(PD):​ ​Unlike​ ​hemodialysis,​ ​PD​ ​is​ ​a​ ​needle-free​ ​treatment​ ​and​ ​a
care​ ​partner​ ​is​ ​not​ ​required​ ​to​ ​help​ ​assist​ ​during​ ​treatment.​ ​PD​ ​can​ ​be​ ​performed​ ​at
home​ ​or​ ​at​ ​work.
6. Explain​ ​the​ ​reasons​ ​for​ ​the​ ​following​ ​components​ ​of​ ​Mrs.​ ​Joaquin’s​ ​medical
nutrition​ ​therapy:
35​ ​kcal/kg:​ ​Patient​ ​needs​ ​to​ ​maintain​ ​current​ ​weight​ ​as​ ​she​ ​is​ ​about​ ​to​ ​have​ ​surgery​ ​and
should​ ​not​ ​be​ ​in​ ​a​ ​deficit.
1.2​ ​g​ ​protein/kg:​ ​Want​ ​to​ ​make​ ​sure​ ​all​ ​patients​ ​are​ ​getting​ ​enough​ ​protein​ ​to​ ​keep​ ​the
kidneys​ ​functioning​ ​properly.
2​ ​g​ ​K:​ ​ ​to​ ​keep​ ​nerves​ ​and​ ​muscles​ ​working​ ​correctly​ ​lower​ ​potassium​ ​levels.​ ​Avoid​ ​salt
substitutes​ ​as​ ​they​ ​can​ ​be​ ​high​ ​in​ ​potassium.
 1​ ​g​ ​phosphorus:​ ​To​ ​protect​ ​bones​ ​and​ ​blood​ ​vessels,​ ​keep​ ​phosphorus​ ​intake​ ​to​ ​a
minimum.​ ​When​ ​phosphorus​ ​levels​ ​are​ ​high​ ​in​ ​the​ ​blood,​ ​calcium​ ​will​ ​be​ ​leached​ ​from
the​ ​bones.
2​ ​g​ ​Na:​ ​Eating​ ​less​ ​sodium​ ​helps​ ​lower​ ​blood​ ​pressure​ ​and​ ​may​ ​slow​ ​down​ ​CKD.​ ​Try​ ​to
keep​ ​your​ ​blood​ ​pressure​ ​below​ ​140/90​ ​mmHg.​ ​One​ ​of​ ​the​ ​kidneys’​ ​important​ ​jobs​ ​is​ ​to
filter​ ​sodium​ ​out​ ​of​ ​the​ ​body​ ​and​ ​into​ ​the​ ​urine.​ ​Damaged​ ​kidneys​ ​cannot​ ​filter​ ​as​ ​well​ ​as
healthy​ ​kidneys​ ​can.​ ​This​ ​can​ ​cause​ ​sodium​ ​to​ ​stay​ ​in​ ​your​ ​body​ ​and​ ​make​ ​your​ ​blood
pressure​ ​go​ ​up
1000​ ​mL​ ​fluid​ ​+​ ​urine​ ​output:​ ​in​ ​the​ ​days​ ​between​ ​your​ ​dialysis​ ​treatments,​ ​your​ ​body
holds​ ​on​ ​to​ ​excess​ ​fluid​ ​and​ ​waste​ ​your​ ​kidneys​ ​cannot​ ​remove.
7. Calculate​ ​and​ ​interpret​ ​MRs.​ ​Joaquin’s​ ​BMI.​ ​How​ ​does​ ​edema​ ​affect​ ​your
interpretation?
Height:​ ​5’0”(1.52​ ​m);​ ​Weight:​ ​170​ ​lbs​ ​(77.27​ ​kg)
BMI:​ ​33.4(Obese)​ ​-​ ​this​ ​might​ ​be​ ​high​ ​because​ ​of​ ​the​ ​edema​ ​and​ ​extra​ ​weight
caused​ ​by​ ​the​ ​excess​ ​water​ ​being​ ​carried.
8. What​ ​is​ ​edema-free​ ​weight?​ ​Calculate​ ​Mrs.​ ​Joaquin’s​ ​edema-free​ ​weight.
Edema​ ​free​ ​weight(also​ ​called​ ​dry​ ​weight​ ​or​ ​post​ ​dialysis​ ​weight)​ ​is​ ​your​ ​weight
without​ ​excess​ ​fluid​ ​that​ ​builds​ ​up​ ​between​ ​dialysis​ ​treatments.​ ​This​ ​weight​ ​is​ ​similar​ ​to
what​ ​a​ ​person​ ​with​ ​normal​ ​kidney​ ​function​ ​would​ ​weigh​ ​after​ ​urinating.​ ​It​ ​is​ ​the​ ​lowest
weight​ ​you​ ​can​ ​safely​ ​reach​ ​after​ ​dialysis​ ​without​ ​developing​ ​symptoms​ ​of​ ​low​ ​blood
pressure​ ​such​ ​as​ ​cramping,​ ​which​ ​can​ ​occur​ ​when​ ​too​ ​much​ ​fluid​ ​is​ ​removed.
Mrs.​ ​Joaquin’s​ ​edema-free​ ​weight:​ ​BW(edema​ ​free)=BW​ ​+[(Standard​ ​Body
weight(as​ ​determined​ ​from​ ​the​ ​NHANES​ ​II​ ​data)-BW(edema​ ​free)​ ​x​ ​0.25)]
165​ ​+​ ​[(65-165)​ ​x​ ​0.25]
165+​ ​(-25)
140lbs​ ​(63.6​ ​kg)
9. What​ ​are​ ​the​ ​energy​ ​requirements​ ​for​ ​CKD?
If​ ​a​ ​patient​ ​is​ ​less​ ​than​ ​60​ ​years​ ​of​ ​age​ ​the​ ​National​ ​Kidney​ ​Foundation
recommends​ ​35​ ​kcal/kg/day,​ ​if​ ​the​ ​patient​ ​is​ ​over​ ​60​ ​years​ ​of​ ​age​ ​then​ ​it​ ​is
recommended​ ​to​ ​use​ ​30-35​ ​kcal/kg/day.
10. X
11. What​ ​are​ ​the​ ​differences​ ​in​ ​protein​ ​requirements​ ​among​ ​stages​ ​1​ ​and​ ​2​ ​CKD,
stages​ ​3​ ​and​ ​4​ ​CKD,​ ​hemodialysis​ ​and​ ​peritoneal​ ​dialysis​ ​patients?​ ​What​ ​is​ ​the
rationale​ ​for​ ​these​ ​differences?
When​ ​a​ ​patient​ ​is​ ​on​ ​dialysis​ ​there​ ​are​ ​losses​ ​of​ ​free​ ​amino​ ​acids,​ ​altered
albumin​ ​turnover,​ ​metabolic​ ​acidosis​ ​with​ ​increased​ ​amino​ ​acid​ ​degradation,
inflammation​ ​and​ ​infection​ ​which​ ​would​ ​increase​ ​a​ ​patient's​ ​needs​ ​to​ ​protein.
12. Mrs.​ ​Joaquin​ ​has​ ​a​ ​PO4​ ​restriction.​ ​Why?​ ​List​ ​the​ ​foods​ ​that​ ​have​ ​the​ ​highest
levels​ ​of​ ​phosphorus.
When​ ​someone's​ ​kidneys​ ​are​ ​functioning​ ​normally​ ​they​ ​can​ ​remove​ ​the​ ​extra
phosphorus​ ​in​ ​the​ ​blood.​ ​When​ ​a​ ​patient​ ​has​ ​chronic​ ​kidney​ ​disease​ ​their​ ​kidney​ ​cannot
remove​ ​the​ ​phosphorus​ ​very​ ​well,​ ​leaving​ ​high​ ​levels​ ​of​ ​phosphorus​ ​in​ ​the​ ​blood.​ ​These
high​ ​phosphorus​ ​levels​ ​can​ ​cause​ ​damage​ ​to​ ​the​ ​body​ ​by​ ​pulling​ ​calcium​ ​out​ ​of​ ​the
 bones​ ​which​ ​makes​ ​them​ ​weak.
Phosphorus​ ​is​ ​naturally​ ​found​ ​in​ ​protein-rich​ ​foods​ ​such​ ​as​ ​meats,​ ​poultry,​ ​fish,
nuts,​ ​beans​ ​and​ ​dairy​ ​products.​ ​Phosphorus​ ​found​ ​in​ ​animal​ ​foods​ ​is​ ​absorbed​ ​more
easily​ ​than​ ​phosphorus​ ​found​ ​in​ ​plant​ ​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
assure​ ​adherence​ ​and​ ​reduce​ ​his​ ​or​ ​her​ ​thirst?
Because​ ​she​ ​is​ ​on​ ​dialysis​ ​she​ ​should​ ​have​ ​restricted​ ​intake​ ​between​ ​dialysis
treatments​ ​because​ ​her​ ​body​ ​cannot​ ​get​ ​rid​ ​of​ ​all​ ​of​ ​the​ ​liquid​ ​and​ ​therefore​ ​waste
because​ ​the​ ​kidneys​ ​are​ ​damaged.​ ​Since​ ​she​ ​is​ ​still​ ​urinating​ ​she​ ​can​ ​be​ ​more​ ​liberal
with​ ​her​ ​fluid​ ​intake,​ ​if​ ​she​ ​was​ ​not​ ​they​ ​would​ ​limit​ ​her​ ​to​ ​1000​ ​mL​ ​of​ ​water​ ​each​ ​day.
Typically​ ​even​ ​with​ ​this​ ​low​ ​amount​ ​of​ ​water​ ​each​ ​patient​ ​will​ ​gain​ ​1kg​ ​each​ ​day​ ​due​ ​to
that​ ​water.​ ​To​ ​help​ ​adhere​ ​to​ ​a​ ​fluid​ ​restricted​ ​diet​ ​it​ ​is​ ​recommended​ ​to​ ​eat​ ​foods​ ​that
have​ ​low​ ​water​ ​content.​ ​Foods​ ​high​ ​in​ ​water​ ​content​ ​are​ ​watermelon,​ ​cucumber,​ ​mixed
greens,​ ​cantaloupe,​ ​zucchini,​ ​apple​ ​sauce​ ​and​ ​soups.
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​ ​-​ ​glomerular​ ​filtration​ ​rate​ ​is​ ​the​ ​best​ ​test​ ​to​ ​measure​ ​your​ ​level​ ​of​ ​kidney
function​ ​and​ ​determine​ ​your​ ​stage​ ​of​ ​kidney​ ​disease.​ ​Your​ ​doctor​ ​can​ ​calculate​ ​it​ ​from
the​ ​results​ ​of​ ​your​ ​blood​ ​creatinine​ ​test,​ ​your​ ​age,​ ​body​ ​size​ ​and​ ​gender.​ ​A​ ​GFR​ ​of​ ​60​ ​or
higher​ ​is​ ​in​ ​the​ ​normal​ ​range.​ ​A​ ​GFR​ ​below​ ​60​ ​may​ ​mean​ ​you​ ​have​ ​kidney​ ​disease.​ ​Mrs.
Joaquin’s​ ​GFR​ ​is​ ​4​ ​which​ ​is​ ​way​ ​below​ ​the​ ​normal​ ​range.
15. Evaluate​ ​Mrs.​ ​Joaquin’s​ ​chemistry​ ​report.​ ​What​ ​labs​ ​are​ ​altered​ ​due​ ​to​ ​her
diagnosis​ ​of​ ​Stage​ ​5​ ​CKD?
Electrolyte​ ​Imbalance:
Sodium(136-145)​ ​-​ ​130
Potassium(3.5-5)​ ​-​ ​5.8
Chloride(98-107)​ ​-​ ​91
CO2(23-29)​ ​-​ ​32
BiCarbonate(23-28)​ ​-​ ​22
BUN(6-20)​ ​-​ ​69
Creatinine(0.6-1.1)​ ​-​ ​12
Glucose(70-99)​ ​-​ ​282
Osmolality(275-295)​ ​-​ ​300.3
Protein(6-7.8)​ ​-​ ​5.9
Albumin(3.5-5.5)​ ​-​ ​3.3
HbA1C(<5.7)​ ​-​ ​9.2
16. X
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.
Capoten/​ ​captopril:​ ​It​ ​is​ ​an​ ​ACE(Angiotensin​ ​converting​ ​enzyme)​ ​inhibitor.​ ​ACE
inhibitors​ ​are​ ​used​ ​for​ ​treating​ ​high​ ​blood​ ​pressure,​ ​heart​ ​failure​ ​as​ ​well​ ​as​ ​being​ ​used​ ​to
prevent​ ​kidney​ ​failure​ ​due​ ​to​ ​high​ ​blood​ ​pressure​ ​and​ ​diabetes.​ ​This​ ​would​ ​be
prescribed​ ​for​ ​Mrs.​ ​Joaquin​ ​since​ ​her​ ​primary​ ​cause​ ​of​ ​CKD​ ​is​ ​from​ ​her​ ​diabetes
mellitus.​ ​Capoten​ ​can​ ​decrease​ ​levels​ ​of​ ​Zinc(slower​ ​wound​ ​healing,​ ​lower​ ​immunity,
loss​ ​of​ ​sense​ ​of​ ​smell)​ ​and​ ​Sodium(replacement​ ​not​ ​recommended)​ ​and​ ​can​ ​increase
potassium​ ​levels(especially​ ​if​ ​using​ ​salt​ ​substitutes).
Erythropoietin:​​ ​When​ ​the​ ​kidneys​ ​are​ ​diseased​ ​or​ ​damaged,​ ​they​ ​do​ ​not​ ​make​ ​enough
erythropoietin(EPO).​ ​As​ ​a​ ​result​ ​the​ ​bone​ ​marrow​ ​makes​ ​fewer​ ​red​ ​blood​ ​cells,​ ​causing
anemia.​ ​Many​ ​patients​ ​might​ ​also​ ​have​ ​anemia​ ​because​ ​of​ ​blood​ ​loss​ ​during
hemodialysis​ ​and​ ​low​ ​levels​ ​of​ ​iron​ ​in​ ​their​ ​diet.
Sodium​ ​Bicarbonate:​​ ​Metabolic​ ​Acidosis,​ ​generally​ ​perceived​ ​by​ ​clinicians​ ​as​ ​a​ ​low
plasma​ ​bicarbonate​ ​(HCO3-),​ ​is​ ​a​ ​common​ ​complication​ ​in​ ​patients​ ​with​ ​advanced​ ​CKD,
particularly​ ​when​ ​GFR​ ​falls​ ​below​ ​30​ ​ml/min.​ ​In​ ​this​ ​case​ ​patients​ ​will​ ​be​ ​prescribed​ ​a
Bicarbonate​ ​supplement.​ ​Bicarbonate​ ​can​ ​react​ ​adversely​ ​with​ ​stomach​ ​acid.
Renal​ ​Caps:​ ​Provide​ ​water​ ​soluble​ ​vitamins,​ ​the​ ​softgel​ ​contains​ ​Vitamin​ ​C,​ ​Thiamin,
Riboflavin,​ ​Niacin,​ ​Vitamin​ ​B6(pyridoxine),​ ​Folate,​ ​B12,​ ​Biotin​ ​and​ ​Pantothenic​ ​acid.
Renal​ ​caps​ ​are​ ​used​ ​when​ ​there​ ​is​ ​chronic​ ​renal​ ​failure.​ ​It​ ​is​ ​warned​ ​that​ ​folic​ ​acid​ ​can
mask​ ​the​ ​symptoms​ ​of​ ​pernicious​ ​anemia.
Renvela:​ ​Renvela​ ​is​ ​used​ ​to​ ​control​ ​phosphorus​ ​levels​ ​in​ ​people​ ​with​ ​CKD​ ​who​ ​are​ ​on
dialysis.​ ​It​ ​can​ ​help​ ​prevent​ ​hypocalcemia​ ​which​ ​can​ ​be​ ​caused​ ​by​ ​elevated​ ​phosphorus
Hectorol:​ ​It​ ​is​ ​used​ ​to​ ​maintain​ ​healthy​ ​blood​ ​levels​ ​of​ ​calcium​ ​and​ ​intact​ ​parathyroid
hormone​ ​(iPTH)​ ​in​ ​people​ ​with​ ​chronic​ ​kidney​ ​disease​ ​who​ ​may​ ​also​ ​be​ ​on​ ​dialysis.​ ​It​ ​is
also​ ​known​ ​as​ ​Doxercalciferol.​ ​Inactive​ ​vitamin​ ​D​ ​provided​ ​by​ ​Hectorol​ ​(doxercalciferol)
is​ ​activated​ ​by​ ​the​ ​liver,​ ​without​ ​the​ ​need​ ​for​ ​activation​ ​by​ ​the​ ​kidneys,​ ​to​ ​form​ ​active
vitamin​ ​D.​ ​Do​ ​not​ ​take​ ​other​ ​vitamin​ ​D​ ​related​ ​drugs​ ​if​ ​you​ ​are​ ​currently​ ​taking​ ​Hectorol.
Your​ ​doctor​ ​should​ ​monitor​ ​your​ ​calcium,​ ​phosphorus​ ​and​ ​PTH​ ​levels.
Glucophage:​​ ​(aka​ ​Metformin)​ ​It​ ​is​ ​an​ ​oral​ ​diabetes​ ​medicine​ ​that​ ​helps​ ​control​ ​blood
sugar​ ​levels.​ ​This​ ​is​ ​indicated​ ​because​ ​Mrs.​ ​Joaquin​ ​presented​ ​with​ ​Type​ ​2​ ​Diabetes
Mellitus.
18. List​ ​the​ ​nutrition​ ​related​ ​health​ ​problems​ ​that​ ​have​ ​been​ ​identified​ ​in​ ​the​ ​Pima
Indians​ ​through​ ​epidemiological​ ​data.​ ​Are​ ​the​ ​Pima​ ​at​ ​higher​ ​risk​ ​for
complications​ ​of​ ​diabetes?​ ​Explain.​ ​What​ ​is​ ​meant​ ​by​ ​the​ ​“thrifty​ ​gene”​ ​theory?
Pima​ ​Indians​ ​have​ ​high​ ​rates​ ​of​ ​obesity​ ​and​ ​diabetes,​ ​kidney​ ​disease,​ ​eye
disease,​ ​and​ ​nerve​ ​damage​ ​which​ ​often​ ​leads​ ​to​ ​amputations.​ ​In​ ​the​ ​adult​ ​population,
50%​ ​have​ ​diabetes​ ​mellitus​ ​and​ ​among​ ​those​ ​95%​ ​are​ ​overweight​ ​or​ ​obese.​ ​The​ ​“thrifty
gene”​ ​theory​ ​hypothesizes​ ​that​ ​there​ ​was​ ​a​ ​genetic​ ​change​ ​that​ ​happened​ ​in​ ​the​ ​Pima
Indians​ ​over​ ​many​ ​years.​ ​Over​ ​time​ ​they​ ​developed​ ​a​ ​gene​ ​that​ ​was​ ​more​ ​efficient​ ​at
storing​ ​fat​ ​during​ ​periods​ ​of​ ​excess,​ ​which​ ​was​ ​used​ ​when​ ​they​ ​were​ ​in​ ​times​ ​of​ ​famine.
19. X
20. X
21. Why​ ​is​ ​it​ ​recommended​ ​that​ ​patients​ ​obtain​ ​at​ ​least​ ​50%​ ​of​ ​their​ ​protein​ ​from
sources​ ​that​ ​have​ ​high​ ​biological​ ​value?
This​ ​is​ ​to​ ​help​ ​the​ ​patient​ ​maintain​ ​a​ ​positive​ ​or​ ​neutral​ ​nitrogen​ ​balance.​ ​It​ ​also
helps​ ​to​ ​maintain​ ​or​ ​even​ ​improve​ ​visceral​ ​protein​ ​stores​ ​for​ ​most​ ​patients​ ​on
hemodialysis.​ ​High​ ​biological​ ​sources​ ​of​ ​protein​ ​are​ ​complete​ ​proteins​ ​such​ ​as​ ​eggs,
meat,​ ​fish,​ ​poultry,​ ​cheese,​ ​milk​ ​and​ ​some​ ​soy​ ​products.
Notes:

- Primary​ ​cause​ ​of​ ​CKD​ ​is​ ​diabetes​ ​mellitus

- Second​ ​leading​ ​cause​ ​of​ ​CKD​ ​is​ ​hypertension
- Incidence​ ​in​ ​African​ ​Americans​ ​is​ ​3x​ ​the​ ​rate​ ​seen​ ​in​ ​Caucasians.
- CKD​ ​caused​ ​by​ ​diabetes​ ​mellitus​ ​is​ ​anywhere​ ​from​ ​10​ ​to​ ​75​ ​times​ ​more​ ​prevalent​ ​in
Native​ ​Americans​ ​than​ ​in​ ​caucasians;​ ​50%​ ​of​ ​Pima​ ​Indians​ ​age​ ​35+​ ​have​ ​type​ ​2
diabetes​ ​mellitus​ ​-​ ​the​ ​highest​ ​rate​ ​in​ ​the​ ​world
- 24​ ​year​ ​old​ ​Pima​ ​Indian,​ ​type​ ​2​ ​diabetes​ ​mellitus​ ​since​ ​13​ ​y.o.​ ​;​ ​has​ ​experienced
glomerular​ ​filtration​ ​rate​ ​for​ ​2​ ​years​ ​;​ ​admitted​ ​in​ ​preparation​ ​for​ ​kidney​ ​replacement
therapy
- Has​ ​been​ ​poorly​ ​compliant​ ​with​ ​prescribed​ ​treatment
- Diagnosed​ ​with​ ​stage​ ​3​ ​CKD​ ​2​ ​years​ ​ago,​ ​acute​ ​systems​ ​over​ ​last​ ​2​ ​weeks
- Stopped​ ​taking​ ​hypoglycemic​ ​agent​ ​and​ ​she​ ​has​ ​never​ ​filled​ ​her​ ​prescription​ ​for​ ​anti
hypertensive​ ​medication
- Decompensation​ ​of​ ​kidney​ ​function​ ​has​ ​been​ ​documented​ ​by​ ​declining​ ​GFR,​ ​increasing
creatinine​ ​and​ ​urea​ ​concentrations,​ ​elevated​ ​serum​ ​phosphate​ ​and​ ​normochromic,
normocytic​ ​anemia
- Glucophage(metformin):​ ​Oral​ ​Diabetes​ ​medication;​ ​do​ ​not​ ​use​ ​if​ ​have​ ​severe​ ​kidney
disease,​ ​do​ ​not​ ​take​ ​with​ ​alcohol(both​ ​hypoglycemic)
- Pt​ ​complains​ ​of​ ​anorexia,​ ​N/V,​ ​4​ ​kg​ ​weight​ ​gain,​ ​emena​ ​in​ ​extremities,​ ​face​ ​and​ ​eyes;
malaise(a​ ​general​ ​feeling​ ​of​ ​discomfort,​ ​illness,​ ​or​ ​uneasiness​ ​whose​ ​exact​ ​cause​ ​is
difficult​ ​to​ ​identify.),​ ​progressive​ ​SOB​ ​with​ ​3-pillow​ ​orthopnea(shortness​ ​of​ ​breath​ ​when
lying​ ​flat;​ ​three​ ​pillow​ ​means​ ​you​ ​have​ ​less​ ​tolerance​ ​for​ ​laying​ ​flat);​ ​pruritus(itch);
muscle​ ​cramps​ ​and​ ​inability​ ​to​ ​urinate(to​ ​do​ ​with​ ​kidney​ ​disease)
- Lethargic
-