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Case Study: Chronic Kidney Disease (CKD) treated with Dialysis Ashlee Schoch & Lusi Martin

October 6th, 2009 I. Understanding the Disease and Pathophysiology 1. Describe the physiological functions of the kidneys. Kidney function can be classified in three categories including, excretory, endocrine, and homeostasis. The kidneys form urine for excretion of waste products such as urea, uric acid, and creatinine. The kidneys secrete hormones including erythropoietin for red blood cell production and urodilation for natriuresis mediation, and convert vitamin D3 to its active form, 1, 25-dihydroxyvitamin D. The kidneys have several homeostatic functions including, acid-base balance, blood pressure, and plasma volume. In addition to these functions, the kidneys synthesize carnitine, maintain glucose homeostasis, and produce prostaglandin E2. (Escott-Stump, 2008) 2. What diseases/conditions can lead to chronic kidney disease (CKD)? Diabetes mellitus, hypertension, autoimmune diseases, systemic infections, urinary tract infections, kidney stones, cancer, family history of CKD, exposure to certain drugs, and low birth weight (Escott-Stump, 2008) 3. Explain how type 2 diabetes mellitus can lead to CKD. Glomeruli, clusters of blood vessels located in nephrons in the kidneys, filter waste from blood into urine for excretion. High levels of blood glucose from uncontrolled DM can lead to changes in the nephrons, starting with thickening of glomeruli to destruction. As the glomerulus is compromised, larger amounts of protein is allowed to pass from the blood into the urine for excretion. Initially, the amount of protein in the urine is small (microalbuminuria) but as the damage worsens, the amount of protein increases, developing into diabetic nephropathy. (Nelms, Sucher, Long, 2007)

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4. Outline the stages of CKD, including the distinguishing signs and symptoms.

Stage Signs & Symptoms

1 Kidney damage with normal or increased GFR of >90 mL/min Blood flow through the kidney increases (hyperfiltration) and the kidneys increase in size Usually no outward signs are present

2 Kidney damage with a mild decrease in GFR of 60-89 mL/min Albuminuria <30 mg/d Normal blood pressure

3 Kidney damage with a moderate decrease in GFR of 30-59 mL/min Microalbuminuria becomes constant Losses increase to 30-300 mg/d

4 Advanced kidney damage with GFR 15-29 mL/min Nephropathy Large amounts of protein in the urine Blood pressure increases New symptoms: nausea, taste changes, uremic breath, anorexia, difficulty concentrating, and numbness in fingers and toes

5 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) 5. From your reading of Mrs. Joaquin’s history and physical, what signs and symptoms did she have? Patient History:

Diagnosed with T2D at 13 yrs old

Non-compliant with prescribe treatment for diabetes

Ethnicity- Native American (Pima Indian tribe of southern Arizona)

Declining GFR over the years

Increasing creatinine and urea concentrations

Elevated serum phosphate

Physical Exam:

Muscle Weakness

3+ pitting edema to the knees

High blood pressure 6. What are the treatment options for Stage 5 CKD? At stage 5, renal replacement therapy become necessary and nutrition therapy is a crucial part of medical care. The treatment options are (Nelms, Sucher, Long, 2007):

Renal (kidney) transplantation (most preferred method): surgical transplantation of a donor kidney from a living related donor, living non-related donor or cadaver.

Intermittent dialysis therapy (hemodialysis or peritoneal dialysis): Dialysis is a renal replacement procedure that removes excessive and toxic by-products of metabolism from the blood, thus replacing the filtering function of healthy kidneys. Dialysis does not replace the kidneys, so its filtering function is not as effective.

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7. Describe the differences between hemodialysis and peritoneal dialysis.

Hemodialysis: a type of renal replacement therapy whereby wastes or uremic toxins are filtered from the blood by a semipermeable membrane and removed by the dialysis fluid. Typically, a patient on hemodialysis usually spends 3-4 hour per treatments (sometimes up to 5 hours for larger patients) given 3 times a week. There are 3 primary methods are used to gain access to the blood: an intravenous catheter, an arteriovenous (AV) fistula and a synthetic graft (Nelms, Sucher, Long, 2007).

Peritoneal dialysis: a type of renal replacement therapy during which the peritoneal cavity serves as the reservoir for the dialysate and the peritoneum acts as the semipermeable membrane across which excess body fluid and solutes are removed. The process uses the patient's peritoneum in the abdomen as a membrane across which fluids and dissolved substances (electrolytes, urea, glucose, albumin and other small molecules) are exchanged from the blood. Fluid is introduced through a permanent tube in the abdomen and flushed out either every night while the patient sleeps (automatic peritoneal dialysis) or via regular exchanges throughout the day (continuous ambulatory peritoneal dialysis) (Nelms, Sucher, Long, 2007).

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II. Understanding the Nutrition Therapy 8. Explain the reasons for the following component of Mrs. Joaquin’s medical nutrition therapy:

Nutrition Therapy

Rationale

35 kcal/g According to the National Kidney Foundation and Kidney Disease Outcomes and Quality Initiative guidelines, both nondialyzed and hemodialysis patients are to calculate energy intake of 35 kcal/kg/day for patients younger than 60 years of age. This provides adequate calories to prevent excessive protein loss through catabolism and malnutrition.

1.2g protein/kg

Restrictions in protein helps the kidneys work less thus delaying the progression of CKD by controlling uremia. However, during hemodialysis the patient loses some protein during dialysis and Provide patient with adequate protein to prevent protein energy malnutrition and to conserve serum protein.

2g K Restriction in dietary potassium is necessary because the kidneys are unable to remove potassium. High levels of potassium can cause abnormal heart rhythms.

1g Phos Restrictions in phosphorus levels are related to the diminished functions of the kidneys to remove the excess phosphorus from the body leading to hyperphosphatemia. Hyperphosphatemia overtime leads to heart and bone problems, low blood calcium (hypocalcemia), calcification or hardening of tissues when phosphorus and calcium form hard deposits in the heart, arteries, joints, skin or lungs that can be painful and lead to serious health problems, bone pain, itching.

2g Na Sodium restriction is important for controlling fluid intake, fluid retention and to control high blood pressure.

1,000 mL fluid + urine output

Fluid restriction is very important as the kidney function declines. The kidneys in CKD patients do not urinate often, thus fluid retention (edema) is common which leads to increase in blood pressure, some weight gains, and congestive heart failure.

III. Nutrition Assessment A. Evaluation of Weight/Body Composition 9. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your interpretation? Body Mass Index (BMI): body weight (lbs) / height (in2) x 704.5 = 170 /3600 x 704.5 = 33.26 Based on Mrs. Joaquin‟s BMI, she is considered to fall in the obese category. Edema (fluid retention) is the accumulation of fluid around the interstitial spaces surrounds cells. Mrs. Joaquin‟s reports having edema in her extremities, face and eyes. Due to the edema, Mrs. Joaquin‟s weight may be inflated thus her BMI may be overestimated as the BMI formula does not take into account confounding factors such as edema. BMI based on edema-free adjusted body weight of 140 lbs is 27.3.

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10. What is edema-free weight? The following equation can be used to calculate the edema-free adjusted body weight (aBWef):

aBWef = BWef + [ (SBW – BWef) x 0.25 ]

where BWef is the actual edema-free body weight and SBW is the standard body weight as determined from the NHANES II data. Calculate Mrs. Joaquin’s edema-free weight. Is this the same as dry weight? aBWef = 165 + [ (65 – 165) x 0.25] = 165 + [(-100) x 0.25] = 165 + (-25) = 140lbs or 63.6kg Edema free weight (also called dry weight or postdialysis weight) is your weight without the 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. B. Calculation of Nutrient Requirements 11. What are the energy requirements for CKD? According to the National Kidney Foundation (NFK) and Kidney Disease Outcomes and Quality Initiative (K/DOQI), energy intake recommendations for both nondialyzed and hemodialysis patients are 35 kcal/kg/day for patients younger than 60 years of age and 30 to 35 kcal/kg/d for those older than 60 years of age. The free adjusted body weight (aBWef) is recommended to be used to calculate energy and protein requirements for underweight and obese patients (NFK,K/DOQI, 2000) 12. Calculate what Mrs. Joaquin’s energy needs will be once she begins hemodialysis. Energy Requirement: 35 kcal / kg SBW 140lbs / 2.2 = 63.6kg Total Energy Needs: 63.6kg x 35 = 2,226 kcal 13. What are Mrs. Joaquin’s protein requirements when she begins hemodialysis? Protein Requirement: 1.2gm/kg SBW 140lbs / 2.2 = 63.6kg aBWef x 1.2gm/kg protein = 63.6kg x 1.2 = 76.32gm protein/day

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14. What is the rationale? How would these change if she were on peritoneal dialysis? The energy requirement for patients who are on hemodialysis and peritoneal dialysis are the same. The energy and protein requirement is set high enough for the patient to receive adequate calories to spare any unnecessary protein loss, ensure adequate intake of essential amino acids and to prevent malnutrition.

Factors relating to higher protein requirements include: 1. Losses of free amino acids 2. Altered albumin turnover 3. Metabolic acidosis with increases amino acid degradation 4. Inflammation 5. Infection

If Mrs. Joaquin were on peritoneal dialysis her protein requirement would be a little higher at 1.3gm/kg SBW because during episodes of peritonitis (inflammation of the peritoneum), even in mild cases, the dialysate protein losses increase by 50% to 100% to an average of 15 – 36 g/24 hours and have been reported to remain elevated for several weeks. C. Intake Domain 15. 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 such as milk, meats and eggs are high in protein and may also be high in fat. Since individuals with CKD are at risk for cardiovascular disease, choosing protein foods that are heart friendly (low fat) (such as lean chicken, fish, egg beaters, soy products) will be beneficial. Plant proteins will also be beneficial for patients with CKD as plant proteins are naturally be lower in fat, especially in saturated fat, but are generally lower in protein compared to animal sources. Thus, there may be some potential benefits to using plant proteins rather than animal protein in terms of a patient‟s lipid profile. Both animal and plant sources of protein vary in sodium, potassium, phosphorus, and fluid, all nutrients that may need restrictions with CKD, so it is important to check product labels for the specific nutrient content. 16. Mrs. Joaquin has a PO4 restriction. Why? Phosphorus is a mineral that builds up in the blood as kidney failure progresses. In early CKD, hyperphosphatemia is prevented by an adaptive increase in renal excretion and decreased phosphate reabsorption. Hyperphosphatemia is evident when the GFR falls between 20 and 30mL/min/1.73 m2 indicating diminished kidney function. Thus, Mrs. Joaquin‟s PO4 restriction is to prevent hyperhposphatemia which can cause more harm to kidneys and bone health (i.e. bone health- renal osteodysstrophy)

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17. What foods have the highest levels of phosphorus?

Beverages Dairy Products Protein Vegetables Other Foods

Ale Cheese Carp Dried beans & peas

Bran cereals

Beer Cottage Cheese Beef Liver Bakes Beans Caramels

Chocolate drinks Custard Oysters Kidney Beans Seeds

Cocoa Ice-cream Crayfish Limas Whole grain products

Drinks made with milk

Milk Chicken Liver Pork „n beans Brewer‟s yeast

Canned iced teas Pudding Organ Meats Soy beans Nuts

Dark Colas Creams Soups Sardines Black beans Wheat germ

Yogurts Fish roe Lentils

18. 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? Foods that are considered to be fluids are soups, popsicles, sherbet, ice cream, yogurt, custard and gelatin. Recommendations made include the following (Nelms, 2007): 1. Limit high-salt foods so you will have less thirst. 2. Use sour candy or sugar free gum to moisten your mouth. Try special thirst-quencher gums. 3. Use ice cubes instead of liquids. One cup of ice is equal to ½ cup of water/juice and

will last longer. 4. Freeze grapes and eat throughout the day as one of your fruit servings (servings is ½ cup). 5. Try frozen blueberries and pineapple tidbits, fruit cocktail, and other recommended fruits. 6. Remember fluids in fruits and to other foods that are considered liquids (i.e. yogurts, soups etc). 19. If a patient must follow a fluid restriction, what can be done to help reduce his or her thirst? The following can help reduce a CKD patients thirst (Nelms et al. 2007): 1. Drink from small glasses and cups 2. Drink only when you are thirsty. Reach for very cold beverages. Beverages that are

less sweet will quench your thirst. 3. Use sour candy or sugar free gum to moisten your mouth. Try special thirst-quencher gums. 4. Freeze grapes and eat throughout the day as one of your fruit servings (servings is ½ cup). 5. Try frozen blueberries and pineapple tidbits, fruit cocktail, and other recommended fruits. 6. Swish water around in the mouth to relieve thirst.

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20. Identify nutrition problems within the intake domain using the appropriate diagnostic term. Inadequate energy intake (NI-1.4) Inadequate oral food/beverage intake (NI-2.1) Excessive mineral intake (specify) (NI-55.2)

High potassium food choices

High phosphorus food choices

High sodium food choices D. Clinical Domain 21. Several biochemical indices are used to diagnose chronic kidney disease. One is glomerular filtration rate (GFR). What does GFR measure? Glomerular filtration rate measures the rate at which substances are cleared from the plasma by the glomeruli. GFR is used as an index of kidney function. (Nelms, Sucher, Long, 2007) 22. What test is usually done to estimate glomerular filtration rate? Creatinine clearance is used to estimate GFR. The current most widely used method is the Cockcroft-Gault equation which uses serum creatinine, adjusted by the effects of age, sex, and body weight to estimate creatinine clearance. (Nelms, Sucher, Long, 2007) 23. Mrs. Joaquin’s GFR is 28 mL/min. What does this tell you about her kidney function? Mrs. Joaquin‟s GFR of 28 mL/min indicates that she is in stage 4 of chronic kidney disease so her kidney function has severely diminished.

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24. Evaluate Mrs. Joaquin’s chemistry report. What labs support the diagnosis of Stage 4 CKD?

Lab Test NormalRange

PatientValue

Explanation

Albumin (g/dL)

3.5-5 3.7 Low albumin reflects protein losses in urine. While this value is in the normal range, her value at discharge is lower indicating a gradual decline.

Sodium (mEq/L)

136-145 130 L Low sodium reflects losses in urine or fluid retention, which dilutes the blood.

Potassium (mEq/L)

3.5-5.5 5.8 H High serum potassium indicates compromised filtration in the kidneys.

PO4 (mg/dL) 2.3-4.7 9.5 H High serum phosphate indicates compromised filtration in the kidneys.

Total CO2

(mEq/L) 23-30 20 L Low CO2 indicates compromised acid-base balance has

been used to assess malnutrition. Studies show that uremic acidosis causes an increase in protein degradation. Correction of acidosis is accompanied by a decrease in protein tissue breakdown.

Glucose (mg/dL)

70-110 282 H High blood glucose indicates uncontrolled DM, which leads to diabetic nephropathy.

BUN (mg/dL) 8-18 69 H High blood urea nitrogen indicates insufficient filtration in the kidneys.

Creatinine (mg/dL)

0.6-1.2 12.0 H High level of creatinine indicates impaired renal function. Creatinine clearance is used to estimate GFR, the primary diagnostic criteria.

Calcium (mg/dL)

9-11 8.2 L Low serum calcium reflects insufficient vitamin D, which is converted to the active form in the kidneys. Insufficient active vit D prevents calcium reabsorption in the intestines.

Cholesterol (mg/dL)

120-199 220 H Inflammation of the glomerulus can cause altered lipid metabolism, causing high levels of cholesterol and triacylglyerol.

TG (mg/dL) 35-135 200 H Inflammation of the glomerulus can cause altered lipid metabolism, causing high levels of cholesterol and triacylglyerol.

HbA1C

(%) 3.9-5.2 8.9 H HbA1C indicates long-term uncontrolled hyperglycemia,

indicating diabetic nephropathy as the likely cause of the patient‟s chronic kidney disease.

Protein urine (mg/dL)

Negative 2+ H High level of protein in urine indicates protein losses, a strong predictor of renal disease progression.

25. Examine the patient care summary sheet for hospital day 2. What was Mrs. Joaquin’s weight postdialysis? Why did it change? Mrs. Joaquin‟s postdialysis weight was 165 lbs, a decrease of 5 lbs from the previous day. Dialysis helped to filter the blood to remove excess fluid built up due to diminished kidney function.

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26. Which of Mrs. Joaquin’s other symptoms would you expect to begin to improve? Anorexia, nausea, and vomiting 27. Explain why the following medications were prescribed by completing the table.

Medication Indications/Mechanism Nutritional Concerns

Vasotec (ACE Inhibitor)

Antihypertensive to treat diabetic nephropathy

Insure adequate fluid intake, Na, Ca may be recommended, Avoid salt substitutes, caution with K supplementation, anorexia/weight loss

Erythropoietin (epoetin alfa)

Recombinant human erythropoietin, antianemic, stimulates RBC production to treat ESRD-induced anemia

May need Fe, Vit B 12, or folate supplements. ESRD diet compliance mandatory. May cause nausea, vomiting, and/or diarrhea.

Vitamin/mineral supplement

Supplement water-soluble vitamins (B vitamins, folic acid, vitamin C) due to increased fluid losses during dialysis, anorexia, low dietary intake Supplement Fe if needed.

Water-soluble vitamins: none at recommended doses Fe: Take with water or juice on empty stomach or with food to GI distress, take with vitamin C to absorption, take carbonate antacids separately; anorexia, nausea, vomiting, dyspepsia, bloating, constipation, diarrhea; limit alcohol

Calictriol Ca regulator/active vitamin D used to treat hypocalcemia in dialysis patients

Do not take with vitamin D or Mg supplements, with dialysis do not take with excessive Ca or low P, Ca absorption, anorexia, weight, thirst

Glucophage (metformin)

Antihyperglycemic agent, biguanide; Increases effect of insulin, lowers GI glucose absorption, decreases hepatic glucose production

Anorexia, weight stable or declines, decreases folate and vit B12 absorption; caution with severe renal function,

Sodium bicarbonate

Antacid, alkalinizing agent Consider Na content with Na diet; May thirst, weight (fluid); caution with severe renal function, HTN

Phos Lo (calcium acetate)

Phosphate binder for use in renal failure

Take with meals, avoid Ca supplements or antacids; Fe abs, anorexia, nausea, vomiting, constipation

28. Identify nutrition problems within the clinical domain using the appropriate diagnostic term.

Altered nutrition-related laboratory values including elevated potassium, phosphorus, creatinine and diminished GFR (NC-2.2)

Impaired nutrient utilization including glucose (NC-2.1)

Overweight/obesity (NC-3.3)

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E. Behavioral-Environmental Domain 29. What health problems have been identified in the Pima Indians epidemiological data? Pima Indians have high rates of obesity and diabetes, and many of the complications caused by diabetes, such as kidney disease, eye disease, and nerve damage, which often leads to amputations. In the adult population of Pima Indians, 50% have diabetes mellitus and among those with DM, 95% are overweight or obese. (National Institute of Diabetes and Digestive and Kidney, 2009) 30. Explain what is meant by the “thrifty gene” theory. The “thrifty gene” theory hypothesizes that, over many years, a genetic change occurred in Pima Indians. This change allowed the population to adapt to alternating periods of feast and famine that resulted from their reliance on farming, hunting, and fishing for food. Overtime, they developed a gene that was more efficient at storing fat during periods of excess, which was later used for energy during times of famine. As the Pima Indians adopted a Westernized way of life, with less physical activity and a continuous food supply, their once protective gene has predisposed them to developing chronic diseases. (National Institute of Diabetes and Digestive and Kidney, 2009) 31. How does nephropathy affect Pima Indians? As with other populations, nephropathy (diabetic kidney disease) is a complication of DM. The risk of developing nephropathy increases when blood glucose levels are not controlled, especially over longer periods of time. Pima Indians develop DM at a much younger age, 36 years, as compared to the Caucasian population, 60 years. This difference in age of onset gives the Pima Indian population many more years of living with their disease and increases their risk for developing complications. In the Pima Indian population, kidney disease is the leading cause of death from diabetes. (National Institute of Diabetes and Digestive and Kidney, 2009) IV. Nutrition Diagnosis 32. Choose two high-priority nutrition problems and complete a PES statement for each.

1. Altered nutrition-related laboratory values including elevated serum potassium (NC-2.2) as related to dietary choices high in potassium as evidenced by serum potassium of 5.8 mEq/L and self-reported potassium intake of 4.3 g.

2. Excessive sodium intake (NI-5.10.2) as related to fluid retention and usual intake of foods high in sodium as evidenced by reported intake of intake 3.3 g of Na+ and 3+ pitting edema to the knees.

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V. Nutrition Intervention 33. For each PES statement, establish an ideal goal (based on the signs and symptoms) and appropriate intervention (based on the etiology).

Goals Intervention

1) Lower serum potassium (K) to normal range of 3.5-5.5 mEq/L.

Modify distribution, type, or amount of food and nutrients within meals or at specified time (ND-1.2)

Limit dietary K to 2 g/day Deliver initial nutrition education on priority modifications (E-1.2)

Educate on health implications of consuming excess K.

Educate on foods high and low in K.

Provide sample meal plan to help aid in adherence to dietary goals.

Conduct nutrition counseling on strategies for self-monitoring (C-2.3)

Track dietary intake including K.

2) Reduce fluid retention to acceptable range (2-5% body weight) per dialysis treatment.

Modify distribution, type, or amount of food and nutrients within meals or at specified time (ND-1.2)

Limit dietary Na+ to 2 g/day

Limit fluid intake to 1000mL + output/ day Deliver initial nutrition education on priority modifications (E-1.2)

Educate on health implications of consuming excess Na+ and fluid.

Educate on foods high and low in Na+ and fluids.

Provide sample meal plan to help aid in adherence to dietary goals.

Conduct nutrition counseling on strategies for self-monitoring (C-2.3)

Track dietary intake including Na+ and fluids.

34. When Mrs. Joaquin begins dialysis, energy and protein recommendations will increase. Explain why. 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.

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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). 35. 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 (K/ KDOQI guidelines, 2008). 36. The MD ordered daily use of a multivitamin/mineral supplement containing B-complex, but not fat soluble vitamins. Why are these restrictions specified? Vitamins fall into two classes: fat soluble and water soluble. Water soluble vitamins do not build up in the body and must be replaced daily from the diet. CKD patients have greater requirements for some water soluble vitamins due to increased fluid losses through dialysis. Special renal vitamins are usually prescribed to kidney patients to provide the extra water soluble vitamins needed. Renal vitamins contain vitamins B1, B2, B6, B12, folic acid, niacin, pantothenic acid, biotin and a small dose of vitamin C.

The fat soluble vitamins (D, E, K and A) are more likely to build up in your body, so these are avoided unless prescribed by your kidney doctor. See table below for CKD recommendations:

Fat Soluble Vitamins in Chronic Kidney Disease**

Vitamin Role CKD Recommendations

Vitamin D Helps the body absorb calcium and phosphorus; deposits these minerals in bones and teeth; regulates parathyroid hormone (PTH)

The kidney doctor decides if a vitamin D supplement is needed based on blood tests that measure calcium, phosphorus and parathyroid hormone (PTH) levels. As CKD progresses, the kidney‟s ability to activate vitamin D is lost. A special activated vitamin D may be prescribed along with blood work to monitor calcium and PTH levels.

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Vitamin E Anti-oxidant; helps protect body cells from oxidation and free radicals to protect against illnesses like heart disease and some types of cancer

Supplementation for Vitamin E is rarely needed, but very high doses (800 mg) may increase blood clotting time, especially for people on blood thinners.

Vitamin K Helps make blood clotting proteins, important for healthy bone formation

Supplements generally not needed unless long term poor intake combined with antibiotic therapy. Supplements can cause increased blood clotting and interfere with blood thinners

Vitamin A Promotes the growth of body cells and tissues; helps protect against infection, essential for night vision.

Levels are usually elevated. No supplementation recommended as toxic levels may occur with daily supplements.

**Adapted from DaVita at http://www.davita.com/diet-and-nutrition/diet-basics/a/374. Accessed October 2, 2009. Other Nutrient of Concern: Vitamin C supplements are recommended in a 60 to 100 mg dose. There is concern that if you have CKD, taking very high doses of vitamin C can cause a buildup of oxalate, which can be deposited in the bones and soft tissues.

37. What resources would you use to teach Mrs. Joaquin about her diet? There are several resources that can be used to teach Mrs. Joaquin about her diet. The National Renal Diet has set standard dietary recommendations for patients with kidney disease and for those on dialysis. Information from the National Renal Diet can be used to set guidelines and menus for Mrs. Joaquin. Additional information on nutrition for individuals with kidney disease is available online at the National Kidney Foundation‟s website and can also be used. Another website that is user friendly and can be recommended to Mrs. Joaquin is DaVita (davita.com). Additional resources should be provided to Mrs. Joaquin to go home with for references and to help her adhere to the prescribed diet (i.e. sample menus and educational handouts).

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38. Using Mrs. Joaquin’s typical intake and the prescribed diet, write a sample menu. Make sure you can justify your changes and that it is consistent with her nutrition prescription.

Meal Diet PTA Sample Menu Justification

Breakfast Cold cereal,3/4 c Bread, 2 sl or Fried potatoes, ¾ c Fried egg, 1 (occasionally)

Corn flakes, 1 c Milk (1%), 1/2 c Bread (white), 1 slice Margarine, whipped, 2 t Scrambled egg, 1 lg Tangerine, 1 med Water, 2 fo

Corn flakes low in K, P Limit milk to ½ c Omit potatoes d/t high K Add 1 slice of bread with whipped margarine for energy Add scrambled egg, no fat for protein and energy Add limited fluids

Snack None Pita bread, white, 2 med Green bell pepper, ¼ c Margarine, whipped, unsalted 1 T Water, 2 fo

Added snack to increase energy Included foods low in K, P Low sodium bread would be helpful with sodium restriction Added limited fluids

Lunch Sandwich: White bread, 2 slices, Bologna, 2 slices, Mustard Potato chips, 1 oz Coke, 12 fo

Sandwich: Bread (white) 2 slices Deli turkey, low-sodium, fat-free, 3 oz Mustard 1 tsp Tortilla chips, unsalted, 1 oz Plum, med Root beer, 8 fo

Changed sandwich meat to low sodium, fat free turkey Limited mustard to small serving due to P content Replaced potato chips with tortilla chips to reduce K Added fruit for energy and balanced diet Replaced cola with root beer

Snack None Dried cranberries, 1.5 oz Added afternoon snack for energy

Dinner Chopped beef, 3 oz Fried potatoes, 1 c

Lean beef, 3 oz Rice, 1 c Green beans, 1 c Pita bread, 1 med Margarine, 1 T

Replaced chopped beef with a leaner beef Replaced potatoes with rice to lower K Added green beans for energy and diet balance Added pita bread with margarine for energy

Snack Saltine crackers, 6 Peanut butter, 2 T

Saltine crackers, low sodium, 6 Peanut butter, unsalted, 1 T Grapes, 1 c

Replaced regular saltine crackers with low sodium Change pnb to unsalted and reduced serving of pnb to 1 T Added grapes for energy, fluid and diet balance

Current Diet Recommended Diet Goals

Energy 2,537 kcal 2,215 kcal 2,226 kcal

Protein 77 g 79 g 76 g

Sodium 3,329 mg 2,013 mg 2,000 mg

Potassium 4,283 mg 1,952 mg 2,000 mg

Phosphorus 1,345 mg 945 mg 1,000 mg

Water 859 mL 1,327 mL 1,300 mL

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The goal of the recommended menu changes was to lower energy, potassium, phosphorus, and sodium and to maintain appropriate protein and fluid levels. The recommended changes were selected to meet Mrs. Joaquin‟s requirements while maintaining some of her usual eating patterns. For this reason, a few foods high in potassium, phosphorus and/or sodium remain in her diet. While water is the preferred beverage, her usual cola was changed to a smaller serving of root beer to help her embrace other dietary changes. Over time, as she makes dietary changes, additional changes can be recommended to further improve her diet. 39. Using the renal exchange list, plan a 1-day diet that complies with your diet order. Provide a nutrient analysis to assure consistency with all components of the prescription.

Energy(kcal)

Fat (%)

Protein (g)

Na (mg)

P (mg)

K (mg)

Water (mL)

Breakfast: Corn flakes, 1 oz 102 1.4 1.9 205 10 11 166 Milk 1%, 4 fo 51 20.3 4.1 54 116 183 110 White bread, 1 sl 67 10.8 1.9 170 25 25 9 Margarine, whipped, 2 tsp 45 99.4 0.0 2 0 1 1 Tangerine, 1 med 47 0.3 0.7 2 18 146 75 Water, 2 fo 0 0.0 0.0 2 0 0 59

Meal Total 312 21.1 8.6 435 169 378 255

Snack: Bagel, white, 1 small 177 5.7 6.9 309 60 52 25 Raspberries, ½ c 16 10.5 0.4 0 9 46 26 Light cream cheese, 1 T 35 67.0 1.6 44 22 25 10 Water, 2 fo 0 0.0 0.0 2 0 0 59

Meal Total 228 15.3 8.9 356 91 123 120

Lunch: Rotini, 2 oz 246 4.9 9.0 2 90 69 97 Olive oil, 1 T 119 100.0 0.0 0 0 0 0 Chicken breast, 2 oz 98 23.5 17.5 44 122 140 37 Broccoli, cauliflower, carrots w/ olive oil, 1 c

64 64.7 2.2 19 35 143 91

Plum, 1 med 30 5.1 0.5 0 11 104 58 Water, 2 fo 0 0.0 0.0 2 0 0 59

Meal Total 558 35.4 29.2 66 259 456 341

Snack: Popcorn, unsalted 1 oz 146 56.1 2.4 1 66 61 1 Margarine 67 99.4 0.0 3 0 2 2 Salt*, 1/8 tsp 0 0.0 0.0 295 0 0 0 Water, 2 fo 0 0 0 2 0 0 59

Meal Total 214 69.8 2.4 301 66 62 61

Dinner: Salmon, 3 oz 134 36.1 20.1 56 230 471 58 Rice, white, 1 c 205 1.8 4.3 2 68 55 108 Margarine, whipped, 1 T 67 99.4 0.1 0 0 2 2

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Green beans, canola oil, 1 c 78 54.0 2.0 1 39 215 123 Roll, white, 1 med 112 18.8 3.9 193 44 50 10 Margarine, whipped, 2 tsp 45 99.4 0.0 2 0 1 1 Water, 2 fo 0 0.0 0.0 2 0 0 59

Meal Total 641 35.3 30.3 259 382 794 362

Snack: Angel food cake, 1/10 169 0.7 4.2 447 12 123 30 Blueberries, ½ c 42 4.8 0.5 1 9 57 62 Water, 2 fo 0 0.0 0.0 2 0 0 59

Meal Total 211 1.6 4.8 450 21 180 151

Day Total 2,164 31.3 84.1 1,867 989 1,993 1,291

Dietary Goals 2,226 30.0 76.3 2,000 1,000 2,000 1,300

*Optional depending on diet adherence 40. Write an initial medical record note for your consultation with Mrs. Joaquin. A (Assessment) Mrs. Joaquin is a 24-yo obese Native American female (60”, 170#, BMI 33). Her BWEF is 165 lbs and her aBWEF was calculated as 140 lbs. She was diagnosed with T2DM at 13 years of age and with stage 3 CKD 2 yrs ago. Her kidney function has progressively declined and she was admitted to the hospital for preparation for kidney replacement therapy. She has elevated serum phosphorus, potassium, creatinine, and low GFR, which places her at stage 4 CKD. She reported a usual dietary intake high in potassium, phosphorus, sodium, and energy. Due to anorexia, n & v, her recent intake has been poor. D (Diagnosis)

1. Altered nutrition-related laboratory values including elevated serum potassium (NC-2.2) as related to dietary choices high in potassium as evidenced by serum potassium of 5.8 mEq/L and self-reported potassium intake of 4.3 g.

2. Excessive sodium intake (NI-55.2) as related to fluid retention and usual intake of foods high in sodium as evidenced by reported intake of 3.3 g of Na+ and 3+ pitting edema to the knees.

I (Intervention) Established the following goals with the client: Goal 1: Lower serum potassium (K) to normal range of 3.5-5.5 mEq/L.

Modify distribution, type, or amount of food and nutrients within meals or at specified time (ND-1.2)

o Limit dietary K to 2 g/day

Deliver initial nutrition education on priority modifications (E-1.2) o Educate on health implications of consuming excess K. o Educate on foods high and low in K. o Provide sample meal plan to help aid in adherence to dietary goals.

Conduct nutrition counseling on strategies for self-monitoring (C-2.3) o Track dietary intake including K.

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Goal 2: Reduce fluid retention gains to acceptable range (2-5% body weight) per dialysis treatment.

Modify distribution, type, or amount of food and nutrients within meals or at specified time (ND-1.2)

o Limit dietary Na+ to 2 g/day

Deliver initial nutrition education on priority modifications (E-1.2) o Educate on health implications of consuming excess Na+ and fluid intake. o Educate on foods high and low in Na+ and fluids. o Provide sample meal plan to help aid in adherence to dietary goals.

Conduct nutrition counseling on strategies for self-monitoring (C-2.3) o Track dietary intake including Na+ and fluids.

M & E (Monitoring & Evaluation) Behavior regarding self-reported adherence (BE-2.4.1) to dietary requirements Behavior regarding self-monitoring ability (BE-2.8.1) related to recording foods and beverages Mineral intake including potassium and sodium (FI-6.2) Oral fluid amounts (FI-2.1.1) Electrolyte and renal profile including, potassium (S-2.2.7) and sodium (S-2.2.5)