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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.