Summer Martin

3/8/2016
Nutr. 409
Case Study #18
Chronic Kidney Disease Treated with Dialysis
1. What diseases/ conditions can lead to chronic kidney disease
(CKD)? Explain the relationship between diabetes and CKD.
Several diseases and conditions can lead to CKD. These include: type 1
or type 2 diabetes, high blood pressure, glomerulonephritis, interstitial
nephritis, polycystic kidney disease, enlarged prostate, kidney stones,
vesicoureteral reflux, (a condition that causes urine to back up into the
kidneys), urinary tract infections, certain cancers, hypertension, and
diabetes. CKD is caused by damage to the glomerular filtration rate,
which is further broken down into five stages of filtration rate.
Diabetes causes damage to many of the bodys organs including the
kidneys. The small blood vessels in the kidneys become damaged and
the kidneys cannot filter the blood properly. Diabetes also causes
damage to nerves, which effects bladder emptying and as a result,
urine backs up into the kidneys, which damages them. This leads to
retaining fluid, which leads to weight gain and edema. Filtration rate is
slowed due to changes in the nephrons and glomeruli which causes
larger amounts of protein to concentrate in the blood and urine.
2. Outline the stages of CKD including the distinguishing signs and
symptoms.
The five stages of CKD can be determined by the kidneys glomerular
filtration rate (GFR). In stage 1, GFR is between 90-130 mL/min, the
kidney is damaged, but kidney function is normal to increased. The
second stage has a GFR of 60-89 mL/min with a mild decrease in
kidney function. Stage 3 has a GFR of 30-59 mL/min with a moderate
decrease in kidney function. Stage 4 has a GFR of 15-29 mL/min with a
severe decrease in kidney function. Stage 5 has a GRF of less than 15
mL/min with kidney failure, also referred to as end-stage renal disease.
The final stage results in death unless a transplant or dialysis is used.
The symptoms associated with the disease include edema,
hypoalbuminemia, and hyperlipidemia.
3. What are the treatment options for Stage 5 CKD? Explain the
differences between hemodialysis and peritoneal dialysis.

Treatment options include dialysis or kidney transplant. There are two

types of dialysis treatments, hemodialysis or peritoneal dialysis.
Hemodialysis requires permanent access to the bloodstream through a
fistula created by surgery to connect an artery and a vein. Large
needles are inserted into the fistula and the hemodialysis fluid is
introduced into the body. Waste products and electrolytes move by
diffusion, ultrafiltration, and osmosis from the blood into the dialysate
and are removed. HD treatment can be done in an outpatient dialysis
facility or in a patients home with assistance from a care partner. A
dialysis machine removes a small amount of a patients 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.
Peritoneal dialysis, unlike hemodialysis, 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. It is done four times a day for 15-30
minute intervals. It makes use of the bodys own semipermeable
membrane, the peritoneum. A catheter is surgically implanted in the
abdomen and into the peritoneal cavity. Dialysate containing a highdextrose concentration is instilled into the peritoneum and diffusion
carries waste products from the blood through the peritoneal
membrane and into the dialysate. The fluid is then withdrawn and
discarded and new solution is added.
4. Explain the reasons for the following components of Mrs. Joaquins
medical nutrition therapy:
Nutrition Therapy
35 kcal/ kg

1.2 g protein/kg

Rationale
Adequate energy intake to prevent
catabolism and achieve optimal
nutritional status. Sufficient kcal from
carbohydrate and fat may help
prevent muscle and visceral protein
from being utilized as energy.
To ensure intake of essential amino
acids in order to maintain neutral or
positive nitrogen balance and lead to
improvement or maintenance of
visceral protein stores. Protein should
be restricted to 1.2g protein/kg/day in
order to decrease glomerular
pressure; increased glomerular
pressure can accelerate renal

2gK

1 g phosphorus

2 g Na

1000 mL fluid + urine output

damage.
Potassium was reduced because the
high CKD stage Mrs. Joaquin is in, at
this level, the kidney cannot filter all
the potassium digested. Limiting
potassium intake due to the increased
risk for hyperkalemia
Restrictions in P levels are related to
diminished functions of the kidneys to
remove the excess P from body
causing hyperphosphatemia,
overtime can cause pain and other
health issues due to the hardening of
the tissues. Phosphorus was limited to
help delay hyperparathyroidism.
Sodium was set to 2g a day to help
prevent hypotension and further
deterioration of renal functions. Na+
restriction is important for the control
of fluid intake, fluid retention and
control of high blood pressure.
Fluid restriction is tight when kidney
function fails. Edema is common and
leads to increased blood pressure, wt
gain and congestive heart failure. To
control fluid balance due to many
patients being oliguric during first 12
months of hemodialysis treatment.

5. Calculate and interpret Mrs. Joaquins BMI. How does edema affect
your interpretation?
Mrs. Joaquins BMI is 33.2, which is obese. She is also suffering from
edema, which is causing her BMI to be artificially higher, due to fluid
retention and swelling. Because her edema is causing her BMI to be
higher than normal, her BMI must be adjusted by calculating her
edema free weight.
6. What is edema free weight? Calculate Mrs. Joaquins edema free
weight.
Edema free weight is the weight of your actual body, minus the water
retention, due to edema. Edema free weight is used to accurately
figure out the nutrient needs of a patient

aBWef = BWef + [(SBW BWef) x 0.25}

aBWef = 165 + [(65-165) x 0.25}
aBWef = 63.6kg

7. What are the considerations for differences in protein requirements

among predialysis, hemodialysis, and peritoneal dialysis patients?
Dialysis is a drain on body protein and intake must be increased
accordingly. Protein losses of 20 to 30 g can occur during a 24-hour PD.
For predialysis, or impaired renal function, 0.6-1.0 g/kg IBW is required.
For hemodialysis 1.2 g/kg of IBW is required. For peritoneal dialysis 1.21.5 g/kg of BW is required.
8. Mrs. Joaquin has a PO4 restriction. Why? What foods have the
highest levels of phosphorus?
Mrs. Joaquin has a phosphorus restriction in order to prevent
hyperphosphatemia due to her chronic kidney disease. Phosphorus can
build up in the blood and worsen CKD. Her serum phosphate levels are
very high at 9.5; the normal range is 2.3-4.7. Foods with high levels of
phosphorus include: cheese, beans, oysters, sardines, colas, and whole
grain cereals.
9. 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? If a patient must follow a fluid
restriction, what can be done to help reduce his or her thirst?
Mrs. Joaquin should limit her sodium and liquid intake. The majority of
dialysis patients need to restrict sodium and fluid intake in order to
reduce hypertension. Foods considered fluids, are any foods that can
be liquid at room temperature. These include: soups, yogurt, ice
cream, custard, gelatin, and popsicles. She can eat foods with low
sodium in order to reduce her thirst, suck on ice chips, sour candies, or
cold sliced fruit.
10. Several biochemical indices are used to diagnose chronic kidney
disease. One is glomerular filtration rate (GFR)? What does GFR
measure? What is normal GFR? Mrs. Joaquins GFR is 28 mL/min.
Interpret her value.

CKD can be diagnosed by screening for serum creatinine and

testing the urine for proteinuria. Other indicators include: increased
BUN, potassium, phosphorus, and decreased calcium levels.
Normal GFR ranges from 90-120 mL/min. GFR is measured by the
blood creatinine level along with a persons age, body size, and
gender. Mrs. Joaquin is currently in Stage 4 of CKD with a GFR of
28 mL/min. She has a severe decrease in kidney function and she
must take all necessary precautions in order to not progress into
Stage 5 of CKD.

11. Evaluate Mrs. Joaquins chemistry report. What labs support the
diagnosis of Stage 5 CKD?
Elevated serum creatinine: 12.0 (normal: 0.6-1.2). Measures
the amount of creatinine in urine and blood, which
determines how well the kidneys are filtering it. High
creatinine is associated with muscle damage, catabolism, MI,
muscle dystrophy, ARF/CKD, excessive protein intake,
inadequate dialysis or transplant rejection.
Increased BUN: 69 (normal: 8-18). High blood urea nitrogen
indicates insufficient filtration in the kidneys. The BUN is
measured to detect elevated waste levels in the bloodstream,
which is an early sign of decreased kidney function.
Decreased Na+: 130 (normal: 136-145). Low sodium reflects
losses in urine or fluid retention. It can be caused by a
number of factors including nephritis, diabetic acidosis, and
hyperproteinemia, over hydration, hyperglycemia.
Increased Potassium: 5.8 (normal: 3.5-5.5). High serum
potassium indicates compromised filtration in the kidneys.
High potassium is associated with tissue destruction, shock,
acidosis, dehydration, hyperglycemia diuretics, excessive oral
intake, inadequate dialysis, and inappropriate dialysate K+.
Increase in Phosphorus: 9.5 (normal: 2.3-4.7). Healthy
kidneys filter extra amounts not needed in the body, but
unhealthy kidneys cannot remove phosphorus from the blood
and remove excess urine. High levels of phosphorus,
(hyperphosphatemia), in the blood can cause issues such as;
low blood Ca, which causes calcium to be taken from the
bones. Oral phosphate binders will often be necessary to
prevent GI absorption of dietary phosphorus.
Decreased Calcium: 8.2 (normal: 9-11.). Low serum Ca is
associated with CKD due to alterations in vitamin D

metabolism. Insufficient active vitamin D prevents calcium

re-absorption in the intestines, increased P, and decreased
uptake of Ca the in gut. Foods with Ca are restricted because
they often have high P. Low Ca is associated with insufficient
vitamin D, malabsorption, postparathyroidectomy,
hypoparathyroidism with low.
Cholesterol: 220 (normal: 120-199). Inflammation of the
glomerulus can cause altered lipid metabolism, causing high
levels of cholesterol and TG.
Increased LDL: <130 (normal: 135).
Decrease in HDL: 50 (normal: >55).
Increase in TG: 200 (normal: 35-135). HD & PD patients are
at increased risk for coronary artery disease and stroke. TGs
are especially increased in PD patients due to glucose uptake
in dialysate.
High pH: 7.9 normal: 5-7).
Positive protein balance: 2+ (normal: negative). Indicates
kidney damage. Damage to the tiny blood vessels in the
kidneys allow albumin to leak into the urine. Diabetes and
high blood pressure are two conditions that can damage
these vessels. If not managed properly, the damage can
accelerate over time.
High WBC count: 20 (normal: 0-5). Indicates damage.
Decreased urine output

12. Explain why the following medications were prescribed by

completing the following table.
Medication
Capoten/ captopril

Erythropoietin

Indications/
Mechanism
An angiotensinconverting enzyme
inhibitor (ACEI) used to
lower blood pressure and
may slow renal damage.
Prescribed to help
produce more red blood
cells. This will help with
some of the symptoms
associated with anemia,
such as fatigue and
weakness.

Nutritional Concerns
Can diminish taste
perception, increase
risk of hyperkalemia,
and can cause anemia.
May decrease iron, Vit
B12, and/or folate.

Sodium bicarbonate

Used as an alkalinizing
agent.

Renal caps

Prescribed for
malnutrition due to renal
failure.

Renvela

Prescribed to control
serum phosphorus
levels.
Prescribed to treat
hyperparathyroidism.
Prescribed to increase
the effects of her insulin
and to lower the glucose
absorbed by the GI.

Hectorol
Glucophage

May increase thirst and

weight from the body
retaining more fluid.
Contains Vitamin C,
Thiamin, Riboflavin,
Niacin, Vitamin B6,
Folate, Vitamin B12,
Biotin, and Pantothenic
Acid.
May decrease Vitamin
D, E, K, and folic acid
levels
Can cause patient to
develop hypocalcemia.
May decrease folate
and vitamin B12
absorption.

13. What health problems have been identified in the Pima Indians
through epidemiological data? Explain what is meant by the thrifty
gene theory. Are the Pima at higher risk for complications of
diabetes? Explain.
The Pima Indians have the highest reported prevalence of obesity
and non-insulin-dependent diabetes mellitus in the world. The Pima
Indians have had only cases of type 2 diabetes characterized by
obesity, insulin resistance, insulin secretory dysfunction, and
increased rates of endogenous glucose production. Thrifty gene
theory suggests that certain genes enable individuals to efficiently
collect and process foods to deposit fat during periods of food
abundance in order to pride for periods of food shortage. Because
Mrs. Joaquin has had type 2 diabetes since she was 13 years old,
she is at a higher risk for developing complications associated with
diabetes, such as kidney disease.

14. Why is it recommended for patients to have at least 50% of their

protein from sources that have high biological value?
Protein deemed to have a high biological value, is that which
contains the essential amino acids in proportion similar to that
required by humans. High biological protein foods are found in

animal sources and include, meat, poultry, eggs, milk, milk

products, fish, and seafood. During hemodialysis protein needs are
higher due to additional loss of proteins through the dialysis
membrane. Peritoneal dialysis reduces the amount of protein waste
in the body, but protein loss still occurs and needs are higher,
about 1.2-1.3 g/kg/day. The kidneys have to work harder to remove
unnecessary protein and high biological value proteins create less
waste to be removed.