Karina Jaime Carbajal

818193279

Professor Rupp

February 20, 2018

Case Study 19: Chronic Kidney Disease Treated with Dialysis

1. Kidneys primarily function to filter the blood, remove waste products from blood (i.e.

BUN and Cr), make urine, regulate blood pressure, make erythropoietin, activate vitamin

D, balance electrolytes, and balance fluid levels.

2. Chronic Kidney Disease is characterized by when there is high amounts of albumin in the

urine and high amounts of BUN and Cr in the blood. Hypertension and diabetes can both

cause this disease. In hypertension, the kidneys are being bombarded with an increased

blood flow that damages the arteries around the kidneys and causes them to work faster.

In diabetes, the increased blood glucose can damage the vessels around the kidneys

causing them and the kidneys to not work as well.

3. CKD has five stages. The stages are broken down by the glomerular filtration rate (GFR),

age, sex, race, and serum creatinine levels. In the first stage, the GFR is still above 90

mL/min, the kidneys are damaged, but there is normal function. In stage two, the GFR

drops down to 60-89 mL/min and there is a milk decrease in kidney function that isn’t

noticeable to people yet. In stage three, the GFR decreases to 30-59 mL/min and there is

a moderate decrease in kidney function that people still don’t notice. In stage four, the

GFR decreases to 15-29 mL/min; there is a severe drop in kidney function; and the

patient may start to feel fatigue, fluid retention, shortness of breath, changes in their

urine, pain around their kidneys, and muscle cramps. In stage five, the GFR drops to 15
 mL/min and the patient starts to feel a loss of appetite, N/V, headaches, fatigue, difficulty

concentrating, itching, decreased urine output, swelling, muscle cramps, tingling in the

extremities, and skin color changes.

4. Mrs. Joaquin has uncontrolled hypertension (medical history shows she hasn’t filled her

prescription), a declined GFR, increased Cr and urea concentrations, elevated serum

phosphate, anorexia, rapid weight gain, edema, muscle cramps, N/V, blood pressure of

220/80, and the inability to urinate.

5. With Stage 5 CKD, the patient could get hemodialysis, peritoneal dialysis, or a kidney

transplant. Hemodialysis is when a machine with a special filter clean a patient’s blood

for them. In peritoneal dialysis, a cleaning fluid is used in the abdominal cavity; this fluid

picks up the waste products from the blood and discards them outside the body.

6. Mrs. Joaquin needs 35 kcal/kg because we want to spare the protein to only be used for

muscle building and protein needs as opposed to for any energy needs. Her protein needs

are 1.2 g/day because she has started HD and protein is lost in the dialysate. She needs to

restrict potassium, phosphorus, and sodium to avoid fluid overload, bone breakdown,

hypertension, and other side effects of high intake. Finally, she needs 1000 mL of fluid to

stay hydrated without increasing the edema.

7. Since Mrs. Joaquin is 1.5 meters (60 inches/39.37 inch/meter) and 77 kg (170 lb/2.2

lb/kg), her BMI is 34 kg/m2. Her edema, however, increases this value.

8. Since she had a 4 kg weight gain recently and has edema, her dry weight would be

approximately 73 kg which would make her BMI 32 kg/m2.

9. CKD patients’ energy requirements change depending on their stage of CDK as well as if

they are on dialysis or not. Typically, however, it ranges from 30-35 kcal/kg/day.
11. In stages 1-3 of CKD, a patient needs between 0.6 and 1.0 g/kg of protein. In

hemodialysis and peritoneal dialysis a patient needs 1.2-1.5 g/kg of protein. The rationale

being that you don’t want to overload the kidneys with protein if you’re in stages 1-4, but

if you are having dialysis then a machine is doing the filtering and is filtering out a good

bit so you can up the intake.

12. The patient has a phosphorus restriction because the kidneys are typically what filter

phosphorus out of the blood. However, if the kidneys aren’t working, then the extra

phosphorus can be very harmful for the patient’s bones. Foods high in phosphorus

include soda, meats, poultry, fish, nuts, beans, processed foods, whole grains, and dairy.

13. She does need to watch her fluid intake because of the dialysis. Foods considered liquids

include water, custard, pudding, sorbet, ice pops, juices, soup broth, etc. Patients on

hemodialysis are usually limited to 1000 mL a day. During hemodialysis you typically

want to keep weight gain about 1 kg a day or less than 4% of body weight.

14. GFR is the rate (speed) at which the glomeruli in the kidneys filter the blood. A normal

GFR is between 90-120 mL/min. The patient has a GFR of 4 mL/min which is far below

normal.

15. She has altered levels of sodium, potassium, chloride, BUN, Cr, GFR, glucose,

phosphate, calcium, osmolality, protein, albumin, RBC, hemoglobin, hematocrit, and

ketones.

17. She was prescribed: (why prescribed, nutritional concerns, dietary recommendations)

a. Capoten: this helps with hypertension by blocking the ACE from converting

angiotensin 1 into angiotensin 2. It significantly decreases absorption of food so it

 should be taken an hour- two hours before meals. Diet should avoid salt

substitutes and other high potassium foods.

b. Erythropoietin: this helps create new red blood cells. It should be taken with iron

and vitamin C.

c. Sodium bicarbonate: this helps release bicarbonate ions into the stomach to

neutralize the gastric acids and resulting in more alkaline urine. There is no food-

drug interactions. Requires a sodium-restricted diet.

d. Renal caps: this is a water soluble vitamin supplement. It contains all of the B

vitamins that are typically deficient in patients with renal diseases. There is no

food-drug interaction.

e. Renvela: this is a phosphate binder that helps remove excess phosphate from the

body that the kidneys can’t take care of. It attaches to phosphate and prevents the

absorption. It’s need to be able to still eat a healthy diet without getting too much

phosphate. It has no food-drug interactions but it should be taken with a

phosphate-controlled diet.

f. Hectorol: this helps treat hyperparathyroidism in patients going through dialysis

or in stages 3 and 4 of CKD. It helps create the active form of vitamin D,

promotes the absorption of calcium, and decreases PTH concentrations. If

consumed with a high calcium meal it could lead to hypercalcemia.

g. Glucophage: this helps treat diabetes mellitus by decreasing hepatic glucose

production, decreasing intestinal glucose absorption, and increasing the sensitivity

to insulin. It doesn’t have any food-drug interactions.

18. Pima Indians are known for having high rates of obesity. The “thrifty gene” theory

proposes that these people have a history of having food abundances followed by periods

of famine. After time, they stopped having the periods of famine and only had access to

food. The theory says that, since their bodies were used to saving up the food when they

had it to last through the times they didn’t, that they still store an excess in preparation

even though they now always have access to food which has made them obese.

21. These patients are recommended to have their protein from a high biological value

because it has all of the essential amino acids that their bodies need to recover from their

renal diseases.