Chronic Kidney Disease Stage 5Case 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 T

Surname 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 5’0 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 non–insulin 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 transplant—and 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 person’s stage of kidney disease. A math formula

using the person’s 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 Laboratory Results Normal Range Interpretation

BUN

(Blood Urea

Nitrogen)

69 mg/dL

M: 8-24 mg/dL

F: 6-21 mg/dL

↑ BUN: kidneys

aren’t working well

Creatinine 12 mg/dL

M: 0.7-1.2 mg/dL

F: 0.5-1.0 mg/dL

↑ creatinine: poor

clearance due to

impared kidneys

Glucose 200 mg/dL 82-110 mg/dL Patient is diabetic

HbA1c 8.9% mg/dL 3.5-5.5% mg/dL Patient is diabetic

Potassium 7mEq/L 3.5-5.5 mEq/L Hyperkalemia

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

kidney’s 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

viable—and perhaps superior—alternatives 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 One

—a portable hemodialysis machine for use in the home—between 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-benefit-

from-frequent-or-extended-dialysis-treatments-97937-1.htm#ixzz1o7eclTcV

V. Assessment of Nutritional Status

Anthropometry

Age: 26

Height:5’0 / 152.4cm

Weight:170lbs/ 77.5 kg

BMI:33.2 *(Obesity = BMI of 30 or greater)

 Based on patient’s G.T’s BMI, she is considered to fall in the obese category.

Biochemical Assessment

RESULTs INDICATIONs

BUN 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 12 mg/dL blood suggest

diseases or

conditions that affect

kidney function.

Glucose 200mg/dL impaired glucose

tolerance (pre-

diabetes)

HbA1c

8.9%

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 dietitian’s 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 kidney’s 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 patient’s diagnosis.

NORMAL

VALUES

RESULTs INDICATIONs

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

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.

HbA1c

 3.9-5.2 H

8.9% HbA1C indicates

long-term

uncontrolled

hyperglycemia, (%)

indicating diabetic

nephropathy as the

likely cause of the

patient‟s 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-or-

extended-dialysis-treatments-97937-1.htm#ixzz1o7eclTcV

www.lusimartin.blogspot.com

http://nursingdepartment.blogspot.com/2009/03/pathophysiology-of-diabetes-

milletus.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.