Jessica Salgado Nutrition 409 Case 18: Chronic Kidney Disease Treated with Dialysis #1, 2, 3, 5, 6, 7, 8, 12, 13,

14, 15, 16, 18, 19, 22 1.) The kidneys physiological function include excretion, the removal of organic waste from body fluids, Elimination of discharge of these waste into the outside. Homeostatic regulation of the volume and solutes of blood plasma. There are two kidneys, the organs that produce urine which is a fluid containing water, ions, and small soluble compounds. Kidneys have several other homeostatic functions like regulating blood volume and blood pressure, by adjusting the volume of water lost in urine, releasing erythropoietin, and releasing renin. Regulating plasma concentrations of sodium, potassium, chloride, and other ions. Controlling calcium ion levels through the synthesis of calcitriol. Helps stabilize blood pH, by controlling the loss of hydrogen ions and bicarbonate ions. Conserving valuable nutrients while excreting organic waste products, mainly nitrogenous wastes such as urea and uric acid. Assist the liver in detoxifying poisons. 2.) Some diseases and conditions that can lead to CKD are diabetes, high blood pressure, cardiovascular disease, congestive heart failure, lung disease, peripheral vascular disease, neurological problems, and malnutrition. Diabetes causes high blood sugar, which can damage small blood vessels. It is the most common disease that causes chronic kidney disease. It can lead to eye and heart disease, as well. High blood pressure or hypertension, if remained untreated can cause atherosclerosis, a hardening of the arteries. This can lead to heart attack, stroke and many other disorders as well as CKD. Hypertension is the second leading cause of chronic kidney disease. Cardiovascular disease is a condition that affects the heart and blood vessels. Symptoms can vary depending on the person but can include chest pain, an irregular heartbeat, shortness of breath, edema and pain and numbness in your arms and legs. Cardiovascular disease can lead to a heart attack or stroke if left untreated. Treatment includes lifestyle changes, medications, procedures such as angioplasty and surgery. Congestive heart failure is a condition where the heart is no longer able to pump enough blood to meet your bodys needs. Symptoms include shortness of breath and feeling tired. Congestion or fluid accumulation can happen in the ankles and legs, but also in the lungs and can cause CKD. This can be treated with medications, including heart medications, antihypertensive medications and diuretics. Lung disease is any disease that affects the lungs. Asthma, emphysema, chronic bronchitis, lung cancer and pulmonary arterial hypertension are lung diseases that can either come on slowly or suddenly. Lung disease such as pulmonary arterial hypertension can cause high blood pressure, which is a cause of kidney disease. Peripheral vascular disease is a condition where there is reduced blood circulation in the arteries. This can cause pain in the legs when walking and may lead to infections or even amputations if not treated. Major neurological problems are any condition that affects the nervous system and damages the nerves. Autonomic neuropathy, a type of peripheral neuropathy, can occur if you have diabetes or high blood pressure which can lead to CKD. Malnutrition is a common problem in chronic kidney patients due to poor dietary intake and

sometimes to chronic infections or other disease states. Having malnutrition can put you at risk for a variety of other medical problems. 3.) Stage 1 of CKD has normal kidney function but urine findings or structural irregularities or genetic trait point to kidney disease. Stage 2 shows mildly reduced kidney function, and other findings shown in stage one that point to kidney disease. CKD is mainly based on measured or estimated Glomerular Filtration Rate, a GFR 60-89mls/min/1.73m2 is shown in stage 2. Both of first two stages require other evidence of kidney disease, for example Proteinuria or haematuria, a genetic diagnosis of kidney disease also known to be have a disease such as polycystic kidney disease and evidence of structural abnormal kidneys such as reflux nephropathy, renal dysgenesis. In Stage 3 CKD GFR is approximately 30-60% and GFR 45-59 (3A) or 30-44 (3B). Creatinine and GFR in patients are usually quite stable. Deteriorating renal function needs rapid assessment. The aim in stage 3 is to identify individuals at risk of progressive renal disease, and reduce associated like Risk of cardiovascular events and death is substantially increased by the presence of CKD. Some patients need further investigation where there are indications that progression to end stage renal failure may be likely. Pointers to progression of renal disease are Proteinuria, Haematuria of renal origin, Declining GFR. Stage 4 CKD is severely reduced kidney function, 15-30% GFR 15-29ml/min/1.73m2. Stage 5 CKD is very severely reduced kidney function endstage or ESRF/ESRD, less than 15% GFR less than 15 ml/min. Creatinine and hyperkalaemia that is severe or not responsive to changes in therapy should lead to discussion or referral. Hemoglobin if low, exclude non-renal cause. Calcium and phosphate, Oral phosphate binders will often be necessary. Urinary protein for ACR or PCR. Blood pressure is 140/90 max (130-139/90), or 130/80 max (120-129/80) for patients with proteinuria: urinary ACR>30 or PCR>50. Cardiovascular risk, advice on smoking, exercise and lifestyle. Consider cholesterol lowering therapy if already have macrovascular disease, or if estimated 10 year risk of cardiovascular events. Immunization, influenza and pneumococcal, plus hepatitis B immunization if renal replacement therapy contemplated. Medication review, regular review of medication to minimize nephrotoxic drugs, particularly NSAIDs and ensure doses of others are appropriate to renal function. In osteoporosis/ low bone density, do not use bisphosphonates or other agents that reduce bone turnover without detailed assessment of possibility of renal osteodystrophy. 4.) Some of the signs and symptoms that this patient is experiencing that are correlated to CKD are high blood pressure, edema in extremities, face and eyes, increasing creatinine & urea concentrations, declining GFR, fatigue/ malaise, inability to urinate, anorexia, elevated phosphate, and normochromic, normocytic anemia. 5.) The treatments for stage 5 CKD includes kidney transplant, peritoneal dialysis (CAPD/ APD), hemodialysis, and no dialysis. Peritoneal dialysis removes waste products across the natural membrane which lines the inside of the abdomen. This lining is called the peritoneum. The membrane is bathed in a special fluid passed into the abdomen through a small plastic tube. After a few hours this fluid is drained away and replaced by new fluid. Automated Peritoneal Dialysis involves the use of a small simple machine. Most of dialysis happens over approximately 8-9 hours at night. And patient is attached to the machine for the duration of

treatment. Continuous Ambulatory Peritoneal Dialysis involves carrying out 4 fluid exchanges daily. They are usually 4-6 hours apart with a longer gap overnight. The time taken is usually 3040 minutes and can be timed to fit in with your daily activities. During hemodialysis the blood is treated by passing it through an artificial kidney. Plastic tubes connect you to the dialysis machine and, in order to provide a good blood flow, a fistula, or neckline, or other device will be necessary. The difference are hemodialysis uses a man-made membrane (dialyzer) to filter wastes and remove extra fluid from the blood. Peritoneal dialysis uses the lining of the abdominal cavity, the peritoneal membrane and a solution, dialysate to remove wastes and extra fluid from the body. 6.) 35kcal/kg to make sure the patient get sufficient energy and prevent malnutrition from catabolic disease and provide optimal nutrition. 1.2g/kg protein is needed to maintain positive nitrogen balance and to prevent patient to become malnourished due to catabolic disease. 2g K to prevent hyperkalemia, elevated blood potassium concentration. 1g phosphorus to prevent hyper-phosphatemia, elevated blood phosphate concentration. 2g Na to prevent edema and fluid retention. 1000mL fluid plus urine output to prevent fluid overload that can lead to edema, prevent shortness of breath, helps control high blood pressure, and risk of congestive heart failure. 7.) 50 170 lbs 77.1 kg 152.4 cm 77.1/ 1.522 = 33. 4 kg/m2 Mrs. Joaquins BMI is 33.4kg/m2 which means she is obese according to her BMI, the fluid retention affects her BMI because it makes it falsely obese. 8.) Edema free weight is the extra weight of the patient puts on due to with retained fluids, but the weight of the fluids is factored out of the total body weight. Mrs. Joaquins edema free weight is 140lbs. aBWef=165+[(65-165)x 0.25] =165 + [(-100) x 0.25] =165 +(-25) =140 lbs or 63.6 kg 12.) Predialysis- 0.6- 1.0 g/ kg IBW, Hemodialysis- 1.2 g/kg IBW, Peritoneal Dialysis- 1.2-1.5 g/kg IBW 13.) This patient has a PO4 restriction because it can cause elevated blood serum phosphorus at the same rate as GFR decreases. PO4 restriction can be beneficial to the patient to prevent done disease and delay hyperparathyroidism in the future. Some foods high in PO4 are beans, lentils, pork, beef, salmon, low fat dairy products and variety of cheeses.

14.) I would tell the patients that foods that are considered fluids are liquid at room temperature. And since this patients is one a fluid restriction she is limited in options and I would recommend her to prevent her thirst by eating cold fruits or veggies sliced into small pieces and sucking on ice, chewing gum or possibly telling her to brush her teeth when she get really thirsty. 15.) The GRF measure uses a calculation to determine the rate of blood filtration by the kidneys, normal GRF is 60ml/min or above, less that this can indicate kidney disease. This patients GRF is 28ml/min which means she is in stage 5 of CKD and her disease moderately advanced and severe, which means she has limited kidney function. 16.) Lab values that support her stage 5 diagnosis are her potassium being high and her sodium being low. Other values show stage 5 are BUN, creatinine, phosphate, and blood glucose, protein, and white blood cells which are all high. And lastly her urine PH is abnormally high which means she was ketoacidosis. 18.) Capoten or Captopril is using to treat hypertension and CHF. Patient would have to avoid salt substitutes, caffeine, foods high in arginine, and several types of hers. Erythropoietin is a hormone that increases the production of RBC in bone marrow. Patient would need to sufficient eat foods high in iron and protein intake and b12 and folate supplementation. Sodium Bicarbonate is an antacid that helps symptoms of heart burn and acid indigestion. Patient would not be able to use this drug on a salt restricted diet, decrease the usefulness of certain drugs that need stomach acid to function. Renal caps are used with B vitamins to help treat and prevent vitamin deficiency but can falsely change lab results and can interact with other drugs and medications. Renvela is a drug that lowers the level of phosphorus. Patient would not be able to take with alcohol, interacts with many other drugs, can cause nausea and vomiting, anorexia, and abdominal pain. Hectorol is used for the treatment of hyperparathyroidism, drug works most effectively on a low phosphate diet. Glucophage is used to treat Type II Diabetes but can cause patient mild nausea, vomiting, diarrhea, given with meals. 19.) Some of the health problems related to Pima Indians are hypertension, obesity, and type 2 diabetes. One of the theories for this is the thirty gene theory which means that for thousands of years ago these Native Americans were a costume to hunting and finding their own food supplies which made them experience times with less foods causing them to stave so they have not adapted these extreme changes high caloric intake needs which allows them to store more fat then other groups. So this groups of individuals have a higher risk of complications of diabetes because they are less likely to take corrective action to bettering their health needs, so their condition might worsen over time. 22.) These patients are recommended to have at least 50% of their protein from highly biological sources because if a source has a high biological value it is absorbed better by the body, and since CKD patients require more protein than the average person, it is essential that a portion of the protein consumed can be easily absorbed and used in the body. These protein sources should come from complete protein foods such as animal protein and soy products.