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Kaila Raygoza09.15.14Nutr 409Chronic Kidney Disease Case Study #18#1, 2, 3, 5, 6, 7, 8, 12, 13, 14, 15, 16, 18, 19, 221. Describe the physiological functions of the kidneys. The kidneys are two bean-shaped organs located in the rib cage. They filter about 120 to 150 quarts of urine, waste and excess fluid, which prevents a buildup of these products in the body. The kidneys stabilize levels of electrolytes, such as potassium, sodium, and phosphate. They are the place of synthesis of hormones that help stimulate erythropoiesis, regulate blood pressure, and maintain bone health. The kidneys are made up of about a million nephrons that filter blood. Each nephron includes a filter called the glomerulus. The glomerulus allows fluid and waste to pass through, but prevents blood cells and any large molecules such as proteins from going through. The filtered fluids pass through the tubule, where waste material can then be excreted as urine and minerals are sent back into the bloodstream. 2. What diseases or conditions can lead to Chronic Kidney Disease (CKD)? Explain the relationship between diabetes and CKD. The two leading causes of CKD are diabetes and high blood pressure. They account for up to two-thirds of the cases. When blood sugar levels are high in diabetics it causes damage to many organs in the body, including the kidneys, heart, blood vessels, nerves, and eyes. With high blood pressure, the pressure of the blood against the walls of the blood vessels is increased. If it is not controlled, it leads to CKD, heart attacks and strokes. CKD can also cause high blood pressure. There are many other conditions and diseases that can result in CKD. Lupus and other diseases that affect the body’s immune system can also lead to CKD. Repeated urinary infections and obstructions from problems like kidney stones, tumors and enlarged prostate gland in men can result in CKD. Another condition leading to CKD is Glomerulonephritis, a group of disease that causes inflammation and damage to the kidney’s filtering units. Inherited diseases such as polycystic kidney disease (PKD), which causes large cysts to form in the kidneys and leads to damage of the surrounding tissue also leads to CKD. 3. Outline the stages of CKD, including the distinguishing signs and symptoms. Stage 1: normal or high GFR (GFR > 90 mL/min). It is distinguished by higher than normal levels of creatinine or urea in the blood, blood or protein in the urine, and evidence of kidney damage using an MRI, CT scan, or ultrasound. Stage 2: Mind CKD (GFR = 60=89 mL/min). Stage 2 is classified by all of the same symptoms as stage 1 CKD, but lower glomerular filtration rates. Stage 3A: Moderate CKD (GFR = 45-59 mL/min). Stage 3B: Moderate CKD (GFR = 30-44 mL/min). Stage 3 CKD is distinguished by fatigue, fluid retention, edema of extremities, shortness of breath, and urination changes (frequency (less or more), dark orange, brown, or red). Kidney pain and difficulty sleeping due to muscle cramps or restless legs are also symptoms. Stage 4: Severe CKD (GFR = 15-29 mL/min). Some of the symptoms of stage 4 in addition to the ones of the first three stages are nausea and vomiting, metallic taste in mouth, bad breath due to urea buildup in the blood, difficulty concentrating, loss of appetite, and never problems including tingling in toes and fingers. Stage 5: End stage CKD (GFR = <15 mL/min). End stage CKD includes all the symptoms of the first four stages of CKD as well as headaches, itching, little to no urine production, swelling, especially around the eyes and ankles and increased skin pigmentation. 5. What are the treatment options of stage 5 CKD? Explain the difference between hemodialysis and peritoneal dialysis. One treatment option for stage 5 CKD is dialysis. Dialysis helps majority of patients start feeling much better, as it starts removing toxins from the blood and medicine starts replacing the functions the kidneys are no longer capable of performing. The first type of dialysis is hemodialysis. This is where a dialysis machine removes a small amount of the patient’s blood through a man-made membrane called a dialyzer, also known as an artificial kidney. It filters the blood cleaning out the toxins that the kidneys are no longer capable of removing and then returns the blood back to the body. Hemodialysis may be done at home with the assistance of a care partner or in a medical center. Peritoneal dialysis is a needle-free treatment that does not require a care partner. The blood is filtered within the body, rather than through an outsize dialyzer. The patient’s abdomen is filled with a solution called dialysate that assists in removing waste and excess fluids from the blood. The abdomen lining takes the place of the dialyzer in hemodialysis so needles are not required. Another option for stage 5 CKD is kidney transplant. You can get on a waiting list for a cadaverous kidney or find a living donor. Dialysis or kidney transplant is necessary for stage 5 CKD patients to continue living. 6. Explain the reasons for the following components of Mrs. Joaquin’s medical nutrition therapy: Nutrition TherapyRationale 35 kcal/kgAccording to the National Kidney Foundation, patients with CKD (on dialysis or not) under the age of 60 are to follow a diet of 35kcal/ kg body weight. This provides an adequate amount of calories to prevent excess protein loss from through catabolism and malnutrition. 1.2 g protein/kgCKD patients want to avoid excess protein because it puts more strain on the kidneys. However, dialysis causes protein loss, so they must be given extra protein to prevent PEM and to conserve serum protein. 2 g KThe impaired kidneys have a hard time excreting potassium so consumption must be kept at a minimum. Too much potassium can cause irregular heartbeat, slow pulse, and heart failure. A normal level for a patient with the absence of CKD is 3.5-4.5 mg/dL. 1 g phosphorusThe recommended intake for patients free of CKD is 800-1,00 mg / day. With CKD, the kidneys cannot excrete excess phosphorus, which can lead to hypophosphatemia. This overtime leads to heart and bone problems, and low blood calcium that leads to hardened deposits of phosphorus and calcium in the heart, arteries, skin, joints, etc. 2 g NaRestricted sodium intake is necessary because excess sodium leads to fluid retention and high blood pressure. 1,000 mL fluid + urine outputIn CKD, the kidneys have a difficult time producing urine, which leads to fluid retention (edema) in patients. If fluids are not kept at a minimum, it can lead to edema, congestive heart failure, and high blood pressure. 7. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your interpretation? BMI = body weight (lbs.) / height (in2) X 703(5’5”) 60 X 60 = 3,600170lbs. / 3,600 = 0.047 X 703 = 33.19 BMIMrs. Joaquin is considered to be obese based on of her BMI. Mrs. Joaquin has reported edema in her extremities, face, and eyes and this could cause her BMI to be falsely increased. 8. What is edema-free weight? Calculate Mrs. Joaquin’s edema-free weight. Edema free weight, also known as dry weight, is a persons weight without excess fluid buildup. It is the lowest weight a person can safely weight after dialysis. Formula : edema-free adjusted body weight ( A BW er):aBWer= BWer + [(SBW – Bwer) x 0.25]BWer = actual edema-free body weightBMW = standard body weight (NHANES II)aBWef=165+[(65-165)x 0.25]165 + [(-100) X 0.25)=165 + (-25)=140 lbs. (63.6 kg)12. What are the considerations for differences in protein requirements among predialysis, hemodialysis, and peritoneal dialysis patients? Predialysis requires less protein than what is normally required. Protein requirements for hemodialysis have to be set higher than normal to ensure the patient is receiving adequate calories to make up for any unnecessary protein loss. When a patient is receiving peritoneal dialysis their requirement is even higher than with hemodialysis, around 1.3 g/kg because the dialysate protein losses increase by 50 to 100%. Dialysis can promote catabolism, leading to protein energy malnutrition so protein intake must be adequate to avoid this. 13. Mrs. Joaquin has a PO4 restriction. Why? What foods have the highest levels of phosphorus? Mrs. Joaquin has been put on a PO4 restriction because phosphorus is a mineral that builds up in the blood as kidney function diminishes. The less she consumes, the easier it will be on her already struggling kidneys. Some of the foods highest in phosphorus are beer, chocolate drinks and dark colored carbonated beverages, grains such as rice brain and wheat bran, vegetables like broccoli, mushrooms, beans, and peas, meats such as chicken, liver, and spleen, and dairy products like cheese, ice cream and pudding. 14. Mrs. Joaquin tells you that one of her friends can only drink 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 be made for Mrs. Joaquin? If a patient has to follow a fluid restriction, what can be done to help his or her thirst? Yes, this will also be the case for Mrs. Joaquin, as she has stage 3 CKD. Any food that is liquid at room temperate is counted towards the daily fluid allowance for renal patients. Examples of these foods are soups, gelatin, and sherbet. Fruits and vegetables are largely made up of water so consumption should be kept to a minimum. People who are in the later stages of CKD should limit fluid intake because the kidneys have lost their ability to excrete excess fluid. If a fluid restriction is not followed it can lead to seriously complications for patients. Tips I would give Mrs. Joaquin for controlling her fluid intake would be to avoid salty and spicy foods that increase thirst, keep a journal of all fluid intake so you are less likely to exceed your recommended amount, make ice cubes out of your favorite beverages, and don’t allow your body to overheat. A few ways to conquer thirst are brushing your teeth to make your mouth feel refreshed, chewing gum, sucking on ice chips or lemon wedges, and suck on frozen fruit such as pineapples or grapes. 15. Several biochemical indices are used to diagnose CKD. One is glomerular filtration rate (GFR). What does GFR measure? What is a normal GFR? Mrs. Joaquin’s GFR is 28 ml/min. Interpret her value. Glomerular filtration rate is one of the best tests to measure an individual’s level of kidney function and also determine the stage of kidney disease. It is calculated using the results of serum creatinine level, age, race, and gender. Creatinine is a waste product from muscle activity. As kidney function declines, blood levels of creatinine will rise because they are unable to remove the creatinine. Mrs. Joaquin’s GFR indicates that she has just entered stage 4, severe CKD. 16. Evaluate Mrs. Joaquin’s chemistry report. What labs support the diagnosis for stage 5 CKD? Sodium: 130 mEq/L (RR = 136-145 mEq/L) Low level of sodium indicates loses in urine and fluid retention. Potassium: 5.8 mEq/L (RR = 3.5-5.0 mEq/L) A potassium level above 5.0 mEq/L is indicative of compromised kidney filtration. Protein: 2+ mg/dL (RR = Neg) High protein in urine indicates that protein is being lost in the urine which is a symptom of kidney disease. Albumin: 3.7 g/dL (RR = 3.5-5.0 g/dL) Same as in the case of protein; low albumin indicates that protein is being excreted through the urine. High protein catabolism is a symptom of CKD. Phosphorus: 9.5 mEq/L (RR = 2.3-4.7) High phosphorus levels in the blood show that the kidneys are unable to filter to full capacity so excess phosphorus is being built up in the body. Glucose: 282 mg/dL (RR = 70-110 mg/dL) Indicates that uncontrolled BG levels lead to nephropathy that is likely to cause of chronic kidney disease. 18. Explain why the following medications were prescribed by completing the following chart: MedicationIndications/MechanismsNutritional ConcernsCapoten/CaporilTreats hypertension and heart failure. Decreases chemicals that tighten the blood vessels, allowing blood to flow smoothly and the heart to pump more efficiently. Should be taken on an empty stomach for increased absorption. Do not take if you have diabetes or are taking aliskiren drugs.ErythropoietinA glycoprotein hormone that stimulates RBC production to treat ESRD-edemaIncreases risk of blood clots. Do not take while on drugs for myeloma including Revlimid, Thalomid, dezamethasone, Adriamycin, and Doxil. Sodium bicarbonateAlkalizing agent / antacid. Relieves heartburn and acid indigestion.Take 1-2 hours after meals with a full glass of water. Do not take on an overly full stomach.Renal capsRenal caps are used in the case of CKD. They are soft gels that provide water-soluble vitamins and are used as a stress vitamin. The folic acid in them may mask the symptoms of pernicious anemia. RenvelaRenvela is a phosphate binder that helps prevent hypocalcaemia that is caused by elevated phosphorus levels. Used for CKD patients on dialysis.Do not take if you have a history if stomach problems, bowel obstruction, or severe constipation. Take 1-3 hours apart from other medications as the medicines can bind and make each other less effective. HectorolUsed for CKD patients with high levels of natural substances such as PTH. High PTH affects mineral balance and leads to poor bone health. This keeps PTH down and calcium/phosphorus up.Take about 3 times per week with food while on dialysis. Glucophage (Metformin)Used to control elvated BG in type 2 diabetics. Should be used in conjunction with a healthy diet and exercise. 19. What health problems have been identified in the Pima Indians through epidemiological data? Explain what it means by the “thrifty gene” theory. Are the Pima at higher risk for diabetes? Explain why. Research on the Pima Indians over the past 30 years indicates that half of all adult Pima Indians have diabetes and 95% of those with diabetes are overweight. The “thrifty gene” theory is a theory of the prevalence of overweight in Pima Indians. It explains that for many years the Indians survived on farming, fishing, and hunting for food and feast and famine did not go hand-in-hand. Long periods of famine allowed them to adapt to this lifestyle and promoted the storage of fat to survive these times. Their genes adapted which was a huge advantage until they adopted a Western lifestyle high in fat and calories and low in physical activity. The Pima are most definitely at higher risk for diabetes Type 2 diabetes is strongly associated with overweight, low-active individuals. Obesity is highly prevalent in Pima Indians, therefore putting them at high risk of diabetes. 22. Why is it recommended for patients to have at least 50% of their protein from sources that have high biological value? High biological proteins are proteins that have a complete amino acid profile and are easily assimilated into the body tissues. Examples of these proteins are eggs, meats, fish, and poultry. One of the byproducts of protein metabolism is urea. Urea is a toxic byproduct and is highly unfavorable for those with CKD because their kidneys cannot rid the waste efficiently. The better quality the protein, the less havoc on the kidneys. ................
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