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2. Which of your patients pre-existing conditions can lead to chronic kidney disease and how?
Our patients pre-existing high blood pressure can lead to chronic kidney disease
(CKD). High blood pressure damages the small blood vessels in the kidneys responsible
for the filtration of blood. The result is inefficient filtration of blood, which makes
removal of waste from the body very difficult.
3. Does this patient have high blood pressure? If yes, how can this contribute to the onset of
CKD?
Yes, the patient has a blood pressure of 139/82 mmHg, which puts him in the
prehypertension category. High blood pressure damages the blood vessels throughout
the body thereby reducing blood supply to the kidneys. High blood pressure also
damages the filtration system of glomerulus in the kidneys. As a result, the removal
waste and extra fluid is inefficient. These series of events leads to the onset of CKD.
4. After reading your patients history and physical, what signs and symptoms of kidney disease
did he have? (give at least 3)
Signs and symptoms of kidney disease are:
Low eGFR, high BUN, high Creatinine, high UACR, and low serum albumin.
5. Calculate your patients BMI using the weight from their MNT referral form. (Use the metric
formula, round your final answer to 1 decimal place, and show your work to receive full
credit.)
= 29.2
6. If this patient developed edema, how would this factor affect your interpretation of their
weight?
Edema is the accumulation of fluid around the interstitial cell spaces. Extra fluid (via
edema) increases a patients weight and therefore overestimates BMI. Hence, for
individual with edema, dry (edema free) body weight must be taken into account or post
dialysate weight.
7. Interpret their BMI, how does this influence their health risk?
An overweight patient with CKD has greater chance of developing type 2 diabetes and
hypertension. Kidneys of overweight individual work harder filtering and have a
greater stress load on organs to correct any excess solutes in the body (phosphorus,
calcium, nitrogen, etc.), which increases the risk of developing CKD.
8. What are your patients current energy requirements? (Note use the appropriate energy
calculation for their diagnosis and BMI).
IBW = 106 (for 5) + 60 (for 10) = 166 lbs. or 75.5 kg
11. Calculate what your patients protein needs will be if they progress to ESRD and need to
begin hemodialysis.
Patients protein needs for HD are 1.2 g/kg/IBW and are as follows:
C. Intake Domain
12. 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 have all 9 essential amino acids and have more protein per gram than
plant protein; however animal protein sources (such as eggs, meat, etc.) are high in
saturated fats and cholesterol.
Plant protein on the other hand lack in one or more of the essential amino acids, but is
lower in fat and has no cholesterol. However, consuming 2 different types of plant
protein at the same time, such as rice and beans will provide all essential amino acids in
one meal. Even though per gram, plant sources generally provide less protein - beans,
nuts, and vegetables are good sources of protein with very little fat.
Eating a balanced diet of lean animal protein (ex. skinless chicken breast) together with
plant protein is the key for CKD patients to decrease the chance of developing CKD
risk factors of high cholesterol, high blood pressure, diabetes, and cardiovascular
diseases.
13. After reviewing your patients 24-hour recall, which foods does he consume that are high in
potassium? (list at least 5) Provide alternative options for each item. **Remember to pick
ethnically appropriate alternatives.
Foods high in potassium are refried beans, canned milk, cola, coffee, and fried beef.
Alternatives are grilled peppers and onions, roasted ears of corn, rice tortillas, half and
half, water, or club soda.
14. Referring to your patients 24-hour recall, what foods have the highest levels of phosphorus?
(list at least 5) Provide alternative options for each item. **Remember to pick ethnically
appropriate alternatives.
Foods highest in phosphorous are cola, beef, cheese, coffee and refried beans.
Alternatives are: water, chicken has 5mg less phosphorous than beef, almond milk, soy
milk, cottage cheese, club soda.
15. If a patient must follow a fluid restriction, what can be done to help reduce his or her thirst?
The patient can be given chilled or frozen fruit, candy to suck on, and limit salt in the
diet to reduce thirst.
D. Clinical Domain
16. Evaluate your patients original MNT referral lab report. What labs support their renal
disorder diagnosis?
1. Glomerular Filtration Rate (GFR): This blood test gives the best number to tell how
well our kidneys are functioning. It is measure in percentage of the functional capability
of kidneys. The patient has GFR -25, which means there is a severe decrease in the
function of the kidneys.
2. Creatinine: This blood test measures the waste products of the muscles that are
eliminated by the kidneys. When kidneys function lower, the creatinine number goes up
and waste products start building up in the blood. The patients original blood report
shows high creatinine level of 2.5 H, indicating diminished function of kidneys.
3. Blood Electrolyte tests: This is also known as blood chemistries. These substances
are normally filtered out of the blood by the kidneys, too high or too low levels may be
due to lower kidney function. Blood electrolyte test includes potassium, sodium,
phosphorous, calcium and magnesium levels. Looking at the blood levels of the patient,
the serum calcium levels seem low. This indicates that the substances are not properly
filtered out, further indicating a lower functional capability of the kidneys.
5. UACR: For patients with type 1 diabetes for 5 years or more or with type 2 diabetes,
the American Diabetes Association and the National Kidney Disease Education
Program (NKDEP) recommend that health care professionals assess urine albumin
excretion yearly to diagnose and monitor kidney damage. Damaged kidneys leak
protein into the urine. This can be one of the earliest signs of kidney disease. To check
for protein in urine (called proteinuria), a Urinary albumin creatinine ratio (UACR)
test is done, which tells the doctor how much albumin is in the urine. A normal UACR is
< 30mg/g, but the patients level is 683 mg/g2, which is indicative of renal dysfunction.
17. Evaluate their current medications list on their initial referral sheet. Explain why the
following medications were prescribed by completing the table. (Do not include standard
multivitamin preparations.)
some drugs.
E. BehavioralEnvironmental Domain
18. What behaviors or environmental factors may be influencing this patients progress (for
better or for worse)? List at least 3 and explain how they are related to the patients health
changes.
High potassium intake: His 24 hr recall highlighted his intake of apple, canned milk and
regular cola, which are rich sources of potassium. When kidneys fail they can no longer
remove excess potassium, so the level builds up in the body. High potassium in the blood
is called hyperkalemia, which may occur in people with advanced CKD. So people with
CKD should limit the dietary intake of potassium. Hence increased intake of potassium
rich foods will worsen the patients CKD conditions, since his serum potassium levels
are already high.
19. List all nutrition-related health concerns for this patient, and rank them in order of priority
(1= highest priority.) For each health concern, identify the appropriate AND IDNT nutrition
diagnostic term.
V. Nutrition Intervention
21. For each of the PES statements you have written, establish an ideal goal (based on the signs
and symptoms) an appropriate nutrition-related intervention (based on the etiology), your
method for monitoring, and how you will evaluate the success of your intervention.
Educate patient
on how to use a
glucometer.
Educate patient
on how to
maintain a food
dairy.
22. Using the Supertracker Dietary Analysis program (available at
www.supertracker.usda.gov), design a 2 day hemodialysis-appropriate diet that meets or falls
within your patients estimated needs once they begin hemodialysis . (Note you have calculated
their energy and protein needs above, use your text or course notes to identify where the
remaining micronutrients should be.)
Attach printouts of your 2 days of diets, including foods and nutrient reports.
V. Research Find one journal article published within the last 5 years from a peer-
reviewed health care journal that describe original clinical research related to nutrition and
chronic or end-stage renal disease management. A good resource of peer-reviewed research
is Pubmed at http://www.ncbi.nlm.nih.gov/pubmed/ . Make sure the article is an original
research study (not a review paper or a case study).
23. Give the article information (authors, article title, journal, date, volume, issue, page
numbers).
Caria, S., Cupisti, A., Sau, G., & Bolasco, P. (2014).
The incremental treatment of ESRD: a low-protein diet combined with weekly
hemodialysis may be beneficial for selected patients.
BMC nephrology, 15(1), 172.
24. After reading the article, write an original abstract of the article in your own words
describing the goals, subjects, methods, results, and conclusions of the research. It should
not be >250 words. Do not plagiarize the abstract the authors have already written!
The aim of this study is to observe the safety, benefits, and drawbacks of a
Combined Diet Dialysis Program (CDDP) compared to a standard thrice-a-week
hemodialysis (THD) in end stage renal disease (ESRD) patients. This study is a
multicenter, non-randomized, prospective controlled study that consists of 68
patients with a glomerular filtration rate of 5-10ml/min. The 68 patients were asked
to choose between either the low-protein (0.6g/kg/d), weekly dialysis CDDP schedule
(n = 38), or the THD free diet schedule (n = 30). The patients had blood and urine
samples taken at baseline, 6 and 12 months, with a survival and hospitalization rate
taken at 24 months. This study found that CDDP patients had lower levels of
phosphate (4.6mg/dl 0.8 vs 5.2mg/dl 1.1, p = 0.001), BUN (70mg/dl 17 vs
77mg/dl 22.9, p = 0.003), PTH (18pg/ml >300% vs 37.9pg/ml >300%, p = 0.01),
and higher albumin levels (4.1g/dl 0.4 vs 3.7g/dl 0.48, p = 0.01) at 12 months
compared to THD patients. Additionally, the hospitalization rates for the CDDP
patients were 11 days for 3 patients (3.7 1.5 days/patient) and 147 days for 24
patients (6.1 6.3 days/patient) among the THD patients. The survival rates showed
no significant difference between the CDDP and THD patients at 94.7% and 86.8%
respectively. These findings show that CPPD could be a beneficial choice in patients
with ESRD that can adhere to lower protein dietary modifications.
25. Make 2 clinical recommendations based on the results of the article. If you deem the
results valid (and if other studies also supported them) how could these results be translated
for use in clinical nutrition practice? (Note we are making an assumption here that they are
valid. In real practice, one would rarely make clinical recommendations based on the results
of one study.)
1. Keep protein intake at 0.6g/kg/d to preserve residual renal function which will
result in lower circulating phosphate, BUN, PTH, and higher albumin levels along
with reduced hospital stays and overall cost savings.
2. When planning menus for patients with CKD, omit dairy and processed foods to
reduce the amounts of sodium and phosphorus which are used in abundance as
preservatives.