1. Case Study: Chronic Kidney Disease (CKD) treated with Dialysis
Ashlee Schoch & Lusi Martin
October 6th, 2009
I. Understanding the Disease and Pathophysiology
1. Describe the physiological functions of the kidneys.
Kidney function can be classified in three categories including, excretory, endocrine, and
homeostasis. The kidneys form urine for excretion of waste products such as urea, uric
acid, and creatinine. The kidneys secrete hormones including erythropoietin for red blood
cell production and urodilation for natriuresis mediation, and convert vitamin D3 to its active
form, 1, 25-dihydroxyvitamin D. The kidneys have several homeostatic functions including,
acid-base balance, blood pressure, and plasma volume. In addition to these functions, the
kidneys synthesize carnitine, maintain glucose homeostasis, and produce prostaglandin
E2. (Escott-Stump, 2008)
2. What diseases/conditions can lead to chronic kidney disease (CKD)?
Diabetes mellitus, hypertension, autoimmune diseases, systemic infections, urinary tract
infections, kidney stones, cancer, family history of CKD, exposure to certain drugs, and low
birth weight (Escott-Stump, 2008)
3. Explain how type 2 diabetes mellitus can lead to CKD.
Glomeruli, clusters of blood vessels located in nephrons in the kidneys, filter waste from
blood into urine for excretion. High levels of blood glucose from uncontrolled DM can lead
to changes in the nephrons, starting with thickening of glomeruli to destruction. As the
glomerulus is compromised, larger amounts of protein is allowed to pass from the blood
into the urine for excretion. Initially, the amount of protein in the urine is small
(microalbuminuria) but as the damage worsens, the amount of protein increases,
developing into diabetic nephropathy.
(Nelms, Sucher, Long, 2007)
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2. 4. Outline the stages of CKD, including the distinguishing signs and symptoms.
Stage Signs & Symptoms
1 Kidney damage with normal or increased GFR of >90 mL/min
Blood flow through the kidney increases (hyperfiltration) and the kidneys increase in size
Usually no outward signs are present
2 Kidney damage with a mild decrease in GFR of 60-89 mL/min
Albuminuria <30 mg/d
Normal blood pressure
3 Kidney damage with a moderate decrease in GFR of 30-59 mL/min
Microalbuminuria becomes constant
Losses increase to 30-300 mg/d
4 Advanced kidney damage with GFR 15-29 mL/min
Nephropathy
Large amounts of protein in the urine
Blood pressure increases
New symptoms: nausea, taste changes, uremic breath, anorexia, difficulty
concentrating, and numbness in fingers and toes
5 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)
5. From your reading of Mrs. Joaquin’s history and physical, what signs and
symptoms did she have?
Patient History:  Increasing creatinine and urea
 Diagnosed with T2D at 13 yrs old concentrations
 Non-compliant with prescribe  Elevated serum phosphate
treatment for diabetes
 Ethnicity- Native American (Pima Physical Exam:
Indian tribe of southern Arizona)  Muscle Weakness
 Declining GFR over the years  3+ pitting edema to the knees
 High blood pressure
6. What are the treatment options for Stage 5 CKD?
At stage 5, renal replacement therapy become necessary and nutrition therapy is a crucial
part of medical care. The treatment options are (Nelms, Sucher, Long, 2007):
 Renal (kidney) transplantation (most preferred method): surgical transplantation
of a donor kidney from a living related donor, living non-related donor or cadaver.
 Intermittent dialysis therapy (hemodialysis or peritoneal dialysis): Dialysis is a
renal replacement procedure that removes excessive and toxic by-products of
metabolism from the blood, thus replacing the filtering function of healthy kidneys.
Dialysis does not replace the kidneys, so its filtering function is not as effective.
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3. 7. Describe the differences between hemodialysis and peritoneal dialysis.
 Hemodialysis: a type of renal replacement therapy whereby wastes or uremic
toxins are filtered from the blood by a semipermeable membrane and removed by
the dialysis fluid. Typically, a patient on hemodialysis usually spends 3-4 hour per
treatments (sometimes up to 5 hours for larger patients) given 3 times a week.
There are 3 primary methods are used to gain access to the blood: an intravenous
catheter, an arteriovenous (AV) fistula and a synthetic graft (Nelms, Sucher, Long,
2007).
 Peritoneal dialysis: a type of renal replacement therapy during which the
peritoneal cavity serves as the reservoir for the dialysate and the peritoneum acts
as the semipermeable membrane across which excess body fluid and solutes are
removed. The process uses the patient's peritoneum in the abdomen as a
membrane across which fluids and dissolved substances (electrolytes, urea,
glucose, albumin and other small molecules) are exchanged from the blood. Fluid is
introduced through a permanent tube in the abdomen and flushed out either every
night while the patient sleeps (automatic peritoneal dialysis) or via regular
exchanges throughout the day (continuous ambulatory peritoneal dialysis) (Nelms,
Sucher, Long, 2007).
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4. II. Understanding the Nutrition Therapy
8. Explain the reasons for the following component of Mrs. Joaquin’s medical
nutrition therapy:
Nutrition Rationale
Therapy
35 kcal/g According to the National Kidney Foundation and Kidney Disease Outcomes and
Quality Initiative guidelines, both nondialyzed and hemodialysis patients are to
calculate energy intake of 35 kcal/kg/day for patients younger than 60 years of age.
This provides adequate calories to prevent excessive protein loss through catabolism
and malnutrition.
1.2g Restrictions in protein helps the kidneys work less thus delaying the progression of
protein/kg CKD by controlling uremia. However, during hemodialysis the patient loses some
protein during dialysis and Provide patient with adequate protein to prevent protein
energy malnutrition and to conserve serum protein.
2g K Restriction in dietary potassium is necessary because the kidneys are unable to
remove potassium. High levels of potassium can cause abnormal heart rhythms.
1g Phos Restrictions in phosphorus levels are related to the diminished functions of the
kidneys to remove the excess phosphorus from the body leading to
hyperphosphatemia. Hyperphosphatemia overtime leads to heart and bone
problems, low blood calcium (hypocalcemia), calcification or hardening of tissues
when phosphorus and calcium form hard deposits in the heart, arteries, joints, skin or
lungs that can be painful and lead to serious health problems, bone pain, itching.
2g Na Sodium restriction is important for controlling fluid intake, fluid retention and to control
high blood pressure.
1,000 mL Fluid restriction is very important as the kidney function declines. The kidneys in
fluid + urine CKD patients do not urinate often, thus fluid retention (edema) is common which
output leads to increase in blood pressure, some weight gains, and congestive heart failure.
III. Nutrition Assessment
A. Evaluation of Weight/Body Composition
9. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your
interpretation?
Body Mass Index (BMI): body weight (lbs) / height (in2) x 704.5
= 170 /3600 x 704.5
= 33.26
Based on Mrs. Joaquin‟s BMI, she is considered to fall in the obese category. Edema
(fluid retention) is the accumulation of fluid around the interstitial spaces surrounds cells.
Mrs. Joaquin‟s reports having edema in her extremities, face and eyes. Due to the edema,
Mrs. Joaquin‟s weight may be inflated thus her BMI may be overestimated as the BMI
formula does not take into account confounding factors such as edema. BMI based on
edema-free adjusted body weight of 140 lbs is 27.3.
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5. 10. What is edema-free weight? The following equation can be used to calculate the
edema-free adjusted body weight (aBWef):
aBWef = BWef + [ (SBW – BWef) x 0.25 ]
where BWef is the actual edema-free body weight and SBW is the standard body
weight as determined from the NHANES II data. Calculate Mrs. Joaquin’s edema-free
weight. Is this the same as dry weight?
aBW ef = 165 + [ (65 – 165) x 0.25]
= 165 + [(-100) x 0.25]
= 165 + (-25)
= 140lbs or 63.6kg
Edema free weight (also called dry weight or postdialysis weight) is your weight without the
excess fluid that builds up between dialysis treatments. This weight is similar to what a
person with normal kidney function would weigh after urinating. It is the lowest weight you
can safely reach after dialysis without developing symptoms of low blood pressure such as
cramping, which can occur when too much fluid is removed.
B. Calculation of Nutrient Requirements
11. What are the energy requirements for CKD?
According to the National Kidney Foundation (NFK) and Kidney Disease Outcomes and
Quality Initiative (K/DOQI), energy intake recommendations for both nondialyzed and
hemodialysis patients are 35 kcal/kg/day for patients younger than 60 years of age and 30
to 35 kcal/kg/d for those older than 60 years of age. The free adjusted body weight
(aBW ef) is recommended to be used to calculate energy and protein requirements for
underweight and obese patients (NFK,K/DOQI, 2000)
12. Calculate what Mrs. Joaquin’s energy needs will be once she begins
hemodialysis.
Energy Requirement: 35 kcal / kg SBW
140lbs / 2.2 = 63.6kg
Total Energy Needs: 63.6kg x 35 = 2,226 kcal
13. What are Mrs. Joaquin’s protein requirements when she begins hemodialysis?
Protein Requirement: 1.2gm/kg SBW
140lbs / 2.2 = 63.6kg
aBW ef x 1.2gm/kg protein = 63.6kg x 1.2 = 76.32gm protein/day
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6. 14. What is the rationale? How would these change if she were on peritoneal
dialysis?
The energy requirement for patients who are on hemodialysis and peritoneal dialysis are
the same. The energy and protein requirement is set high enough for the patient to
receive adequate calories to spare any unnecessary protein loss, ensure adequate intake
of essential amino acids and to prevent malnutrition.
Factors relating to higher protein requirements include:
1. Losses of free amino acids
2. Altered albumin turnover
3. Metabolic acidosis with increases amino acid degradation
4. Inflammation
5. Infection
If Mrs. Joaquin were on peritoneal dialysis her protein requirement would be a little higher
at 1.3gm/kg SBW because during episodes of peritonitis (inflammation of the peritoneum),
even in mild cases, the dialysate protein losses increase by 50% to 100% to an average of
15 – 36 g/24 hours and have been reported to remain elevated for several weeks.
C. Intake Domain
15. 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 such as milk, meats and eggs are high in protein and may also be high in
fat. Since individuals with CKD are at risk for cardiovascular disease, choosing protein
foods that are heart friendly (low fat) (such as lean chicken, fish, egg beaters, soy
products) will be beneficial. Plant proteins will also be beneficial for patients with CKD as
plant proteins are naturally be lower in fat, especially in saturated fat, but are generally
lower in protein compared to animal sources. Thus, there may be some potential benefits
to using plant proteins rather than animal protein in terms of a patient‟s lipid profile. Both
animal and plant sources of protein vary in sodium, potassium, phosphorus, and fluid, all
nutrients that may need restrictions with CKD, so it is important to check product labels for
the specific nutrient content.
16. Mrs. Joaquin has a PO4 restriction. Why?
Phosphorus is a mineral that builds up in the blood as kidney failure progresses. In early
CKD, hyperphosphatemia is prevented by an adaptive increase in renal excretion and
decreased phosphate reabsorption. Hyperphosphatemia is evident when the GFR falls
between 20 and 30mL/min/1.73 m2 indicating diminished kidney function. Thus, Mrs.
Joaquin‟s PO4 restriction is to prevent hyperhposphatemia which can cause more harm to
kidneys and bone health (i.e. bone health- renal osteodysstrophy)
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7. 17. What foods have the highest levels of phosphorus?
Dairy Products Protein Vegetables Other Foods
Beverages
Ale Cheese Carp Dried beans & Bran cereals
peas
Beer Cottage Cheese Beef Liver Bakes Beans Caramels
Chocolate drinks Custard Oysters Kidney Beans Seeds
Cocoa Ice-cream Crayfish Limas Whole grain
products
Drinks made with Milk Chicken Liver Pork „n beans Brewer‟s yeast
milk
Canned iced teas Pudding Organ Meats Soy beans Nuts
Dark Colas Creams Soups Sardines Black beans Wheat germ
Yogurts Fish roe Lentils
18. Mrs. Joaquin tells you that one of her friends can drink only 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 you make for Mrs. Joaquin?
Foods that are considered to be fluids are soups, popsicles, sherbet, ice cream, yogurt,
custard and gelatin. Recommendations made include the following (Nelms, 2007):
1. Limit high-salt foods so you will have less thirst.
2. Use sour candy or sugar free gum to moisten your mouth. Try special thirst-quencher
gums.
3. Use ice cubes instead of liquids. One cup of ice is equal to ½ cup of water/juice and
will last longer.
4. Freeze grapes and eat throughout the day as one of your fruit servings (servings is ½
cup).
5. Try frozen blueberries and pineapple tidbits, fruit cocktail, and other recommended
fruits.
6. Remember fluids in fruits and to other foods that are considered liquids (i.e. yogurts,
soups etc).
19. If a patient must follow a fluid restriction, what can be done to help reduce his
or her thirst?
The following can help reduce a CKD patients thirst (Nelms et al. 2007):
1. Drink from small glasses and cups
2. Drink only when you are thirsty. Reach for very cold beverages. Beverages that are
less sweet will quench your thirst.
3. Use sour candy or sugar free gum to moisten your mouth. Try special thirst-quencher
gums.
4. Freeze grapes and eat throughout the day as one of your fruit servings (servings is ½
cup).
5. Try frozen blueberries and pineapple tidbits, fruit cocktail, and other recommended
fruits.
6. Swish water around in the mouth to relieve thirst.
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8. 20. Identify nutrition problems within the intake domain using the appropriate
diagnostic term.
Inadequate energy intake (NI-1.4)
Inadequate oral food/beverage intake (NI-2.1)
Excessive mineral intake (specify) (NI-55.2)
 High potassium food choices
 High phosphorus food choices
 High sodium food choices
D. Clinical Domain
21. Several biochemical indices are used to diagnose chronic kidney disease. One is
glomerular filtration rate (GFR). What does GFR measure?
Glomerular filtration rate measures the rate at which substances are cleared from the
plasma by the glomeruli. GFR is used as an index of kidney function.
(Nelms, Sucher, Long, 2007)
22. What test is usually done to estimate glomerular filtration rate?
Creatinine clearance is used to estimate GFR. The current most widely used method is
the Cockcroft-Gault equation which uses serum creatinine, adjusted by the effects of age,
sex, and body weight to estimate creatinine clearance. (Nelms, Sucher, Long, 2007)
23. Mrs. Joaquin’s GFR is 28 mL/min. What does this tell you about her kidney
function?
Mrs. Joaquin‟s GFR of 28 mL/min indicates that she is in stage 4 of chronic kidney disease
so her kidney function has severely diminished.
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9. 24. Evaluate Mrs. Joaquin’s chemistry report. What labs support the diagnosis of
Stage 4 CKD?
Lab Test Normal Patient Explanation
Range Value
Albumin 3.5-5 3.7 Low albumin reflects protein losses in urine. While this value
(g/dL) is in the normal range, her value at discharge is lower
indicating a gradual decline.
Sodium 136-145 130 L Low sodium reflects losses in urine or fluid retention, which
(mEq/L) dilutes the blood.
Potassium 3.5-5.5 5.8 H High serum potassium indicates compromised filtration in the
(mEq/L) kidneys.
PO4 (mg/dL) 2.3-4.7 9.5 H High serum phosphate indicates compromised filtration in the
kidneys.
Total CO2 23-30 20 L Low CO2 indicates compromised acid-base balance has
(mEq/L) been used to assess malnutrition. Studies show that uremic
acidosis causes an increase in protein degradation.
Correction of acidosis is accompanied by a decrease in
protein tissue breakdown.
Glucose 70-110 282 H High blood glucose indicates uncontrolled DM, which leads to
(mg/dL) diabetic nephropathy.
BUN (mg/dL) 8-18 69 H High blood urea nitrogen indicates insufficient filtration in the
kidneys.
Creatinine 0.6-1.2 12.0 H High level of creatinine indicates impaired renal function.
(mg/dL) Creatinine clearance is used to estimate GFR, the primary
diagnostic criteria.
Calcium 9-11 8.2 L Low serum calcium reflects insufficient vitamin D, which is
(mg/dL) converted to the active form in the kidneys. Insufficient
active vit D prevents calcium reabsorption in the intestines.
Cholesterol 120-199 220 H Inflammation of the glomerulus can cause altered lipid
(mg/dL) metabolism, causing high levels of cholesterol and
triacylglyerol.
TG (mg/dL) 35-135 200 H Inflammation of the glomerulus can cause altered lipid
metabolism, causing high levels of cholesterol and
triacylglyerol.
HbA1C 3.9-5.2 8.9 H HbA1C indicates long-term uncontrolled hyperglycemia,
(%) indicating diabetic nephropathy as the likely cause of the
patient‟s chronic kidney disease.
Protein urine Negative 2+ H High level of protein in urine indicates protein losses, a
(mg/dL) strong predictor of renal disease progression.
25. Examine the patient care summary sheet for hospital day 2. What was Mrs.
Joaquin’s weight postdialysis? Why did it change?
Mrs. Joaquin‟s postdialysis weight was 165 lbs, a decrease of 5 lbs from the previous day.
Dialysis helped to filter the blood to remove excess fluid built up due to diminished kidney
function.
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10. 26. Which of Mrs. Joaquin’s other symptoms would you expect to begin to improve?
Anorexia, nausea, and vomiting
27. Explain why the following medications were prescribed by completing the table.
Medication Indications/Mechanism Nutritional Concerns
Vasotec (ACE Antihypertensive to treat Insure adequate fluid intake,  Na,  Ca may be
Inhibitor) diabetic nephropathy recommended, Avoid salt substitutes, caution with
K supplementation, anorexia/weight loss
Erythropoietin Recombinant human May need Fe, Vit B 12, or folate supplements.
(epoetin alfa) erythropoietin, antianemic, ESRD diet compliance mandatory. May cause
stimulates RBC production nausea, vomiting, and/or diarrhea.
to treat ESRD-induced
anemia
Vitamin/mineral Supplement water-soluble Water-soluble vitamins: none at recommended
supplement vitamins (B vitamins, folic doses
acid, vitamin C) due to Fe: Take with water or juice on empty stomach or
increased fluid losses with food to  GI distress, take with vitamin C to
during dialysis, anorexia,  absorption, take carbonate antacids separately;
low dietary intake anorexia, nausea, vomiting, dyspepsia, bloating,
Supplement Fe if needed. constipation, diarrhea; limit alcohol
Calictriol Ca regulator/active vitamin Do not take with vitamin D or Mg supplements,
D used to treat with dialysis do not take with excessive Ca or low
hypocalcemia in dialysis P,  Ca absorption, anorexia,  weight,  thirst
patients
Glucophage Antihyperglycemic agent, Anorexia, weight stable or declines, decreases
(metformin) biguanide; Increases effect folate and vit B12 absorption; caution with severe
of insulin, lowers GI glucose  renal function,
absorption, decreases
hepatic glucose production
Sodium Antacid, alkalinizing agent Consider Na content with  Na diet; May
bicarbonate thirst, weight (fluid); caution with severe 
renal function, HTN
Phos Lo Phosphate binder for use in Take with meals, avoid Ca supplements or
(calcium renal failure antacids;  Fe abs, anorexia, nausea, vomiting,
acetate) constipation
28. Identify nutrition problems within the clinical domain using the appropriate
diagnostic term.
 Altered nutrition-related laboratory values including elevated potassium, phosphorus,
creatinine and diminished GFR (NC-2.2)
 Impaired nutrient utilization including glucose (NC-2.1)
 Overweight/obesity (NC-3.3)
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11. E. Behavioral-Environmental Domain
29. What health problems have been identified in the Pima Indians epidemiological
data?
Pima Indians have high rates of obesity and diabetes, and many of the complications
caused by diabetes, such as kidney disease, eye disease, and nerve damage, which often
leads to amputations. In the adult population of Pima Indians, 50% have diabetes mellitus
and among those with DM, 95% are overweight or obese.
(National Institute of Diabetes and Digestive and Kidney, 2009)
30. Explain what is meant by the “thrifty gene” theory.
The “thrifty gene” theory hypothesizes that, over many years, a genetic change occurred in
Pima Indians. This change allowed the population to adapt to alternating periods of feast
and famine that resulted from their reliance on farming, hunting, and fishing for food.
Overtime, they developed a gene that was more efficient at storing fat during periods of
excess, which was later used for energy during times of famine. As the Pima Indians
adopted a Westernized way of life, with less physical activity and a continuous food supply,
their once protective gene has predisposed them to developing chronic diseases.
(National Institute of Diabetes and Digestive and Kidney, 2009)
31. How does nephropathy affect Pima Indians?
As with other populations, nephropathy (diabetic kidney disease) is a complication of DM.
The risk of developing nephropathy increases when blood glucose levels are not
controlled, especially over longer periods of time. Pima Indians develop DM at a much
younger age, 36 years, as compared to the Caucasian population, 60 years. This
difference in age of onset gives the Pima Indian population many more years of living with
their disease and increases their risk for developing complications. In the Pima Indian
population, kidney disease is the leading cause of death from diabetes.
(National Institute of Diabetes and Digestive and Kidney, 2009)
IV. Nutrition Diagnosis
32. Choose two high-priority nutrition problems and complete a PES statement for
each.
1. Altered nutrition-related laboratory values including elevated serum potassium (NC-
2.2) as related to dietary choices high in potassium as evidenced by serum
potassium of 5.8 mEq/L and self-reported potassium intake of 4.3 g.
2. Excessive sodium intake (NI-5.10.2) as related to fluid retention and usual intake of
foods high in sodium as evidenced by reported intake of intake 3.3 g of Na + and 3+
pitting edema to the knees.
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12. V. Nutrition Intervention
33. For each PES statement, establish an ideal goal (based on the signs and
symptoms) and appropriate intervention (based on the etiology).
Goals Intervention
1) Lower serum potassium (K) to normal Modify distribution, type, or amount of food and
range of 3.5-5.5 mEq/L. nutrients within meals or at specified time (ND-
1.2)
 Limit dietary K to 2 g/day
Deliver initial nutrition education on priority
modifications (E-1.2)
 Educate on health implications of
consuming excess K.
 Educate on foods high and low in K.
 Provide sample meal plan to help aid in
adherence to dietary goals.
Conduct nutrition counseling on strategies for self-
monitoring (C-2.3)
 Track dietary intake including K.
2) Reduce fluid retention to acceptable Modify distribution, type, or amount of food and
range (2-5% body weight) per dialysis nutrients within meals or at specified time (ND-
treatment. 1.2)
 Limit dietary Na+ to 2 g/day
 Limit fluid intake to 1000mL + output/ day
Deliver initial nutrition education on priority
modifications (E-1.2)
 Educate on health implications of
consuming excess Na+ and fluid.
 Educate on foods high and low in Na+ and
fluids.
 Provide sample meal plan to help aid in
adherence to dietary goals.
Conduct nutrition counseling on strategies for self-
monitoring (C-2.3)
 Track dietary intake including Na+ and
fluids.
34. When Mrs. Joaquin begins dialysis, energy and protein recommendations will
increase. Explain why.
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.
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13. 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).
35. 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 (K/ KDOQI
guidelines, 2008).
36. The MD ordered daily use of a multivitamin/mineral supplement containing B-
complex, but not fat soluble vitamins. Why are these restrictions specified?
Vitamins fall into two classes: fat soluble and water soluble.
Water soluble vitamins do not build up in the body and must be replaced daily from the
diet. CKD patients have greater requirements for some water soluble vitamins due to
increased fluid losses through dialysis. Special renal vitamins are usually prescribed to
kidney patients to provide the extra water soluble vitamins needed. Renal vitamins contain
vitamins B1, B2, B6, B12, folic acid, niacin, pantothenic acid, biotin and a small dose of
vitamin C.
The fat soluble vitamins (D, E, K and A) are more likely to build up in your body, so these
are avoided unless prescribed by your kidney doctor. See table below for CKD
recommendations:
Fat Soluble Vitamins in Chronic Kidney Disease**
Vitamin Role CKD Recommendations
Vitamin D Helps the body absorb calcium The kidney doctor decides if a vitamin D
and phosphorus; deposits these supplement is needed based on blood tests
minerals in bones and teeth; that measure calcium, phosphorus and
regulates parathyroid hormone parathyroid hormone (PTH) levels. As CKD
(PTH) progresses, the kidney‟s ability to activate
vitamin D is lost. A special activated vitamin
D may be prescribed along with blood work
to monitor calcium and PTH levels.
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14. Vitamin E Anti-oxidant; helps protect body Supplementation for Vitamin E is rarely
cells from oxidation and free needed, but very high doses (800 mg) may
radicals to protect against increase blood clotting time, especially for
illnesses like heart disease and people on blood thinners.
some types of cancer
Vitamin K Helps make blood clotting Supplements generally not needed unless
proteins, important for healthy long term poor intake combined with
bone formation antibiotic therapy. Supplements can cause
increased blood clotting and interfere with
blood thinners
Vitamin A Promotes the growth of body cells Levels are usually elevated. No
and tissues; helps protect against supplementation recommended as toxic
infection, essential for night levels may occur with daily supplements.
vision.
**Adapted from DaVita at http://www.davita.com/diet-and-nutrition/diet-basics/a/374.
Accessed October 2, 2009.
Other Nutrient of Concern:
Vitamin C supplements are recommended in a 60 to 100 mg dose. There is concern that if
you have CKD, taking very high doses of vitamin C can cause a buildup of oxalate, which
can be deposited in the bones and soft tissues.
37. What resources would you use to teach Mrs. Joaquin about her diet?
There are several resources that can be used to teach Mrs. Joaquin about her diet. The
National Renal Diet has set standard dietary recommendations for patients with kidney
disease and for those on dialysis. Information from the National Renal Diet can be used to
set guidelines and menus for Mrs. Joaquin. Additional information on nutrition for
individuals with kidney disease is available online at the National Kidney Foundation‟s
website and can also be used. Another website that is user friendly and can be
recommended to Mrs. Joaquin is DaVita (davita.com). Additional resources should be
provided to Mrs. Joaquin to go home with for references and to help her adhere to the
prescribed diet (i.e. sample menus and educational handouts).
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15. 38. Using Mrs. Joaquin’s typical intake and the prescribed diet, write a sample
menu. Make sure you can justify your changes and that it is consistent with her
nutrition prescription.
Meal Diet PTA Sample Menu Justification
Breakfast Cold cereal,3/4 c Corn flakes, 1 c Corn flakes low in K, P
Bread, 2 sl or Milk (1%), 1/2 c Limit milk to ½ c
Fried potatoes, ¾ c Bread (white), 1 slice Omit potatoes d/t high K
Fried egg, 1 Margarine, whipped, 2 t Add 1 slice of bread with
(occasionally) Scrambled egg, 1 lg whipped margarine for energy
Tangerine, 1 med Add scrambled egg, no fat for
Water, 2 fo protein and energy
Add limited fluids
Snack None Pita bread, white, 2 med Added snack to increase
Green bell pepper, ¼ c energy
Margarine, whipped, Included foods low in K, P
unsalted 1 T Low sodium bread would be
Water, 2 fo helpful with sodium restriction
Added limited fluids
Lunch Sandwich: Sandwich: Changed sandwich meat to
White bread, 2 Bread (white) 2 slices low sodium, fat free turkey
slices, Deli turkey, low-sodium, Limited mustard to small
Bologna, 2 slices, fat-free, 3 oz serving due to P content
Mustard Mustard 1 tsp Replaced potato chips with
Potato chips, 1 oz Tortilla chips, unsalted, 1 tortilla chips to reduce K
Coke, 12 fo oz Added fruit for energy and
Plum, med balanced diet
Root beer, 8 fo Replaced cola with root beer
Snack None Dried cranberries, 1.5 oz Added afternoon snack for
energy
Dinner Chopped beef, 3 oz Lean beef, 3 oz Replaced chopped beef with a
Fried potatoes, 1 c Rice, 1 c leaner beef
Green beans, 1 c Replaced potatoes with rice to
Pita bread, 1 med lower K
Margarine, 1 T Added green beans for energy
and diet balance
Added pita bread with
margarine for energy
Snack Saltine crackers, 6 Saltine crackers, low Replaced regular saltine
Peanut butter, 2 T sodium, 6 crackers with low sodium
Peanut butter, unsalted, 1 Change pnb to unsalted and
T reduced serving of pnb to 1 T
Grapes, 1 c Added grapes for energy, fluid
and diet balance
Current Diet Recommended Diet Goals
Energy 2,537 kcal 2,215 kcal 2,226 kcal
Protein 77 g 79 g 76 g
Sodium 3,329 mg 2,013 mg 2,000 mg
Potassium 4,283 mg 1,952 mg 2,000 mg
Phosphorus 1,345 mg 945 mg 1,000 mg
Water 859 mL 1,327 mL 1,300 mL
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16. The goal of the recommended menu changes was to lower energy, potassium,
phosphorus, and sodium and to maintain appropriate protein and fluid levels. The
recommended changes were selected to meet Mrs. Joaquin‟s requirements while
maintaining some of her usual eating patterns. For this reason, a few foods high in
potassium, phosphorus and/or sodium remain in her diet. While water is the preferred
beverage, her usual cola was changed to a smaller serving of root beer to help her
embrace other dietary changes. Over time, as she makes dietary changes, additional
changes can be recommended to further improve her diet.
39. Using the renal exchange list, plan a 1-day diet that complies with your diet
order. Provide a nutrient analysis to assure consistency with all components of the
prescription.
Energy Fat Protein Na P K Water
(kcal) (%) (g) (mg) (mg) (mg) (mL)
Breakfast:
Corn flakes, 1 oz 102 1.4 1.9 205 10 11 166
Milk 1%, 4 fo 51 20.3 4.1 54 116 183 110
White bread, 1 sl 67 10.8 1.9 170 25 25 9
Margarine, whipped, 2 tsp 45 99.4 0.0 2 0 1 1
Tangerine, 1 med 47 0.3 0.7 2 18 146 75
Water, 2 fo 0 0.0 0.0 2 0 0 59
Meal Total 312 21.1 8.6 435 169 378 255
Snack:
Bagel, white, 1 small 177 5.7 6.9 309 60 52 25
Raspberries, ½ c 16 10.5 0.4 0 9 46 26
Light cream cheese, 1 T 35 67.0 1.6 44 22 25 10
Water, 2 fo 0 0.0 0.0 2 0 0 59
Meal Total 228 15.3 8.9 356 91 123 120
Lunch:
Rotini, 2 oz 246 4.9 9.0 2 90 69 97
Olive oil, 1 T 119 100.0 0.0 0 0 0 0
Chicken breast, 2 oz 98 23.5 17.5 44 122 140 37
Broccoli, cauliflower, carrots 64 64.7 2.2 19 35 143 91
w/ olive oil, 1 c
Plum, 1 med 30 5.1 0.5 0 11 104 58
Water, 2 fo 0 0.0 0.0 2 0 0 59
Meal Total 558 35.4 29.2 66 259 456 341
Snack:
Popcorn, unsalted 1 oz 146 56.1 2.4 1 66 61 1
Margarine 67 99.4 0.0 3 0 2 2
Salt*, 1/8 tsp 0 0.0 0.0 295 0 0 0
Water, 2 fo 0 0 0 2 0 0 59
Meal Total 214 69.8 2.4 301 66 62 61
Dinner:
Salmon, 3 oz 134 36.1 20.1 56 230 471 58
Rice, white, 1 c 205 1.8 4.3 2 68 55 108
Margarine, whipped, 1 T 67 99.4 0.1 0 0 2 2
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17. Green beans, canola oil, 1 c 78 54.0 2.0 1 39 215 123
Roll, white, 1 med 112 18.8 3.9 193 44 50 10
Margarine, whipped, 2 tsp 45 99.4 0.0 2 0 1 1
Water, 2 fo 0 0.0 0.0 2 0 0 59
Meal Total 641 35.3 30.3 259 382 794 362
Snack:
Angel food cake, 1/10 169 0.7 4.2 447 12 123 30
Blueberries, ½ c 42 4.8 0.5 1 9 57 62
Water, 2 fo 0 0.0 0.0 2 0 0 59
Meal Total 211 1.6 4.8 450 21 180 151
Day Total 2,164 31.3 84.1 1,867 989 1,993 1,291
Dietary Goals 2,226 30.0 76.3 2,000 1,000 2,000 1,300
*Optional depending on diet adherence
40. Write an initial medical record note for your consultation with Mrs. Joaquin.
A (Assessment)
Mrs. Joaquin is a 24-yo obese Native American female (60”, 170#, BMI 33). Her BW EF is
165 lbs and her aBW EF was calculated as 140 lbs. She was diagnosed with T2DM at 13
years of age and with stage 3 CKD 2 yrs ago. Her kidney function has progressively
declined and she was admitted to the hospital for preparation for kidney replacement
therapy. She has elevated serum phosphorus, potassium, creatinine, and low GFR, which
places her at stage 4 CKD. She reported a usual dietary intake high in potassium,
phosphorus, sodium, and energy. Due to anorexia, n & v, her recent intake has been
poor.
D (Diagnosis)
1. Altered nutrition-related laboratory values including elevated serum potassium (NC-
2.2) as related to dietary choices high in potassium as evidenced by serum
potassium of 5.8 mEq/L and self-reported potassium intake of 4.3 g.
2. Excessive sodium intake (NI-55.2) as related to fluid retention and usual intake of
foods high in sodium as evidenced by reported intake of 3.3 g of Na+ and 3+ pitting
edema to the knees.
I (Intervention)
Established the following goals with the client:
Goal 1: Lower serum potassium (K) to normal range of 3.5-5.5 mEq/L.
 Modify distribution, type, or amount of food and nutrients within meals or at
specified time (ND-1.2)
o Limit dietary K to 2 g/day
 Deliver initial nutrition education on priority modifications (E-1.2)
o Educate on health implications of consuming excess K.
o Educate on foods high and low in K.
o Provide sample meal plan to help aid in adherence to dietary goals.
 Conduct nutrition counseling on strategies for self-monitoring (C-2.3)
o Track dietary intake including K.
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18. Goal 2: Reduce fluid retention gains to acceptable range (2-5% body weight) per dialysis
treatment.
 Modify distribution, type, or amount of food and nutrients within meals or at
specified time (ND-1.2)
o Limit dietary Na+ to 2 g/day
 Deliver initial nutrition education on priority modifications (E-1.2)
o Educate on health implications of consuming excess Na+ and fluid intake.
o Educate on foods high and low in Na+ and fluids.
o Provide sample meal plan to help aid in adherence to dietary goals.
 Conduct nutrition counseling on strategies for self-monitoring (C-2.3)
o Track dietary intake including Na+ and fluids.
M & E (Monitoring & Evaluation)
Behavior regarding self-reported adherence (BE-2.4.1) to dietary requirements
Behavior regarding self-monitoring ability (BE-2.8.1) related to recording foods and
beverages
Mineral intake including potassium and sodium (FI-6.2)
Oral fluid amounts (FI-2.1.1)
Electrolyte and renal profile including, potassium (S-2.2.7) and sodium (S-2.2.5)
18