chronic kidney disease diet therapy
DESCRIPTION
Chronic Kidney disease Diet Therapy. Undergraduate Case defense. Bachelor of Science in NutritionTRANSCRIPT
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CHRONIC KIDNEY CHRONIC KIDNEY DISEASE STAGE 5 DISEASE STAGE 5
with;with;
AnemiaAnemiaHyperkalemiaHyperkalemia
Metabolic acidosis &Metabolic acidosis &Uppper Gastro-Intestinal Uppper Gastro-Intestinal
Bleeding Bleeding
Timothy M. Zagada
HNF 42 S2-2L
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General InformationGeneral Information
Name of patient: JG
Ward No. 3
Age: 46
Date of Admission: July 14, 2008
Hospital: Philippine General Hospital (PGH)
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Socio-Economic HistorySocio-Economic HistoryMarried with 5 childrenHigh school graduatePermanent residence in TaguigWorks as a security guard
◦Wakes up early and prefer foods that are easy to prepare (ex; noodles, canned goods, fried)
Smoker (quitted a year ago)Alcoholic for 28 years (17-45 yrs of age)
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Medical HistoryMedical History
Present Illness: CKD stage 5 secondary to Hypertensive Nephrosclerosis
Anemia Hyperkalemia Metabolic Acidosis UGIB
Chief Complaint: Generalized weakness
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Medical HistoryMedical HistoryPast Illness: known hypertensive for
more than 20 years.◦One month prior to admission
Gradual onset of on and off epigastric, burning in character.
Nausea Occasional vomiting of previously ingested food Progressive body weakness and myalgia
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Medical HistoryMedical History◦Two days Prior to Admission
Gradual onset of on and off epigastric, burning in character.
Vomiting (coffee-ground material) Epistaxis Increased sleeping time.
◦Past surgeries: None◦Allergies: None
◦Past Hospitalization: Yes
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Medical HistoryMedical HistoryPhysical State of Health
◦Loss of appetite PTA◦Gastric pain caused by UGIB (resolving)
◦No elimination/ excretion problem
Family Medical History◦The patient’s mother is hypertensive
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Theoretical considerationTheoretical considerationChronic Kidney disease
is a progressive and irreversible damage of the functioning unit of kidneys, the nephrons.
◦Function of Nephrons; Filtration Iso-osmotic reabsorption Osmotic concentrator Electrolyte reabsorption Water reabsorption
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EtiologyEtiologyImmunological, metabolic, renal
vascular. Primary tubular and congenital disorders.
Vascular lesions that can lead to renal ischemia and kidney tissue.
Chronic Glomerular disease, such as glomerulonephritis.
Chronic infections, such as chronic pyelonephritis
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EtiologyEtiologyMetabolic disorder like Diabetes
MellitusExcessive pressure against the
blood vessel walls or hypertension
Genetic factors
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Stages of CKDStages of CKDStage Description GFR, mL/min
per 1.73m2
Action
1 Kidney damage with normal or high GFR
>90 Diagnosis and treatment, slowing progression, CVD risk reduction
2 Kidney damage with mild decrease in GFR
60-89 Estimating progression
3 Moderate decrease GFR
30-59 Evaluating and treating complications
4 Severe decrease in GFR
15-29 Preparation for kidney replacement therapy
5 Kidney failure <15 or dialysis Kidney replacement (if uremia present)
The patients GFR is 2.9 thus, belongs to stage 5
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IncidenceIncidence
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IncidenceIncidence
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What is Dialysis?What is Dialysis?is a way of maintaining the patients’
regular excretion of the body’s waste products.
Works on the principles of the diffusion and osmosis of solutes and fluid across a semi-permeable membrane.
Examples are Hemodialysis and Peritoneal Dialysis
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HemodialysisHemodialysis
The patient's blood is shunted from the body through a machine for diffusion and ultrafiltration and then returned to the patient's circulation
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Assessment of Nutritional Assessment of Nutritional StatusStatus
Anthropometry◦% Standard weight= (69 kg/ 63 kg) x 100
=109.5%◦BMI= 69/ 1.702= 23.88◦% weight change= 1.5% less
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Assessment of Nutritional Assessment of Nutritional StatusStatus
Biochemical AssessmentLaboratory Results Normal Values Actual Values Variance Rationale for
VarianceBUN 2.60-6.48 mmol/L 94.13 mmol/L 87.65 mmol/L or
higherFailure in kidney functions
Creatinine 53.00-115.00 umol/L
3202 umol/L 3087 umol/L or higher
Failure in kidney functions
RBC 4.3-5.9 x 106/mm3 2.25 x 106/mm3 3.65 x 106/mm3 or less
Anemia (reduced EPO roduction)
Hemoglobin 13.6-17 g/L 6 g/L 11 g/L or lower Anemia (reduced EPO roduction)
Hematocrit 39-49% 19% 30% or lower Anemia (reduced EPO roduction)
GFR <greater than 130 mL/min per 1.73m2
2.9 mL/min per 1.73m2
127.1 L/min per 1.73m2
Renal Failure (CKD stage 5)
Potassium 3.8- 5 mmol/L 6.9 mmol/L 1.9 mmol/L or higher
Hyperkalemia
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Assessment of Nutritional Assessment of Nutritional StatusStatus
Clinical AssessmentBody parts Clinical sign Possible
Nutrient Deficiency
Others
Conjunctivae pale Vitamin A Low hemoglobin/RBC
Nailbeds pale Zinc Low hemoglobin/RBC
Tongue (posterior)
Blackish discoloration
Riboflavin/Niacin Presence of infection
Mouth Uremic Breathe
- Caused by uremia
Vascular system High blood pressure
- Caused by alcohol and smoking
Muscular system Weakness - Low hemoglobin/RBC
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Dietary AssessmentDietary AssessmentDBW= (170-100) -10%
= 70 - 7= 63 kg
TER= 63 x 35 (method II)= 2205 kcal or 2200 kcal
CPF distribution (60-15-25)CHO= 2200 x 0.6=1323/4= 330.75 g or 330 gPRO= 2200 x 0.15= 330/4= 82.5 or 85gFAT= 2200 x 0.25= 550/9= 61.1 or 60 g
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Dietary AssessmentDietary AssessmentPrior to Admission
◦Kcal=2240, CHO=334g, PRO=74g, FAT= 67.5g
• CHO % Adequacy= 334/330 x 100= 101.21%
• PRO % Adequacy= 74/85 x 100= 87.1%
• FAT % Adequacy= 67.5/60 x 100=112.5%
• Energy % Adequacy= 2240/2200 x 100= 101.18
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Dietary AssessmentDietary AssessmentDuring Confinement
◦Kcal=1900, CHO=334g, PRO=74g, FAT= 67.5g
TER= 63 x 30= 1900 kcalPRO= 63 x 1.1= 70 g
PRO kcal= 70 x 4= 280 kcalNon PRO kcal= 1900-280= 1620 kcalCHO: 1620 x 0.7= 1134 - 148 (dialysate)=
986/ 4=246.5 or 245 gFAT: 1620 x 0.3= 486/9= 55 g
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Dietary AssessmentDietary Assessment
CHO % adequacy= 164/245 x 100=66.94%
PRO % adequacy= 56/70 x 100 = 80%FAT % adequacy= 30/55 x 100
= 54.5%Calorie % adequacy= 946/1900 x 100
= 49.8%
During Confinement % adequacy
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Nutrient-Drug InteractionNutrient-Drug InteractionName of Drug Indication Possible Interactions
NaHCO3 Metabolic acidosis
Neutralizing gastric acid
Amlodipine Osteodystrophy
Inhibit the transport of calcium into myocardial and vascular smooth muscles
Clonidine Hypertension Inhibits cadioacceleration and vasoconstriction
Kalimate Hyperkalemia Exchanges sodium ions for potassium
Lactulose Q8 Uremia inhibits diffusion of ammonia from the colon , lowers pH
Furosemide Uremia Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tube.
Erythropoetin 4000 ‘u
Anemia Stimulates erythropoesis
Vitamin K tablets Hypokalemia Synthesis of blood coagulation factors
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Nutritional Care PlanNutritional Care PlanIdentification of Problem
Parameters Medical Problems Nutritional Problem
Anthropometry None None (Normal BMI)
Biochemical Accumulation of BUN and CreatinineAnemiaHyperkalemia
Uremic syndrome
Dietary Metabolic acidosis Gastric pain
Drug and Nutrient Interaction
Furosemide causes hypokalemia
Weakness
Others HypertensiveUGIB
Nausea, Vomiting
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Nutrient Implications and Nutrient Implications and ReccomendationsReccomendations
Should have enough energy and protein to maintain the patients DBW.
Two thirds of the protein must come from sources of High Biological Value (HBV) to assure the essential amino acid requirements.
Regular monitoring of lab results is essential to evaluate the patient’s condition while in hemodialysis
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Diet PrescriptionDiet Prescription
TER= 63 x 30= 1900 kcalPRO= 63 x 1.1= 70 g
PRO kcal= 70 x 4= 280 kcalNon PRO kcal= 1900-280= 1620 kcalCHO: 1620 x 0.7= 1134 - 148 (dialysate)=
986/ 4=246.5 or 245 gFAT: 1620 x 0.3= 486/9= 55 g
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Diet PrescriptionDiet Prescription
Diet Rx: 1900 Calorie CHO245 PRO70 FAT55
148 kcal from dialysate
1200 mg P3000 mg Na2000 mg K1800 mg Ca1500 ml Fluid
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Meal Plan
Food group
Ex Pro Na K Ca P Fluid CHO Fat Kcal
Milk A powd
1 8 160 400 360 250 0.6 12 10 170
Meat Grp A 3 24 90 600 45 210 93 - 1 105Lean MeatFish B.1 1/2 4 15 100 17.5 45 17.5 - 0.5 20.5Egg 1 8 110 95 50 115 45 - 6 86Total 44 375 1195 472.5 620 156.1 12 17.5 381.5
Food grp Ex Pro Na K Ca P Fluid CHO Fat KcalVeg grp A 2 1.2 4 120 30 30 60 3 - 16.8Rice -A -B 6 24 920 240 80 140 40 138 - 648Total 25.2 924 360 110 170 100 141 - 664.8Total 1+2 69.2 1299 1555 582.5 790 256.1 153 17.5 1046.3
1.) HBV Protein
2.) LBV Protein
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Meal PlanFood grp Ex Pro Na K Ca P Fluid CHO Fat Kcal
FruitsA 2 0.8 6 240 20 20 96 20 - 83.2B 3 0.6 6 180 15 15 126 30 - 122.4Sugar 8.5 - - - - - - 42.5 - 170Total 1.4 12 420 35 35 222 92.5 - 375.6Total 1+2+3 70.6 1311 1975 617.5 825 478.1 245.5 17.5 1421.9
3.) Fruit and sugar exchange
Food grp Ex Pro Na K Ca P Fluid CHO Fat KcalFat 3 0 120 6 3 3 3 - 15 135ABFree foods 5 - - - - - - - 25 225Total - 120 6 3 3 3 - 35 360Total 1+2+3+4
70.6 1431 1981 620.5 828 481.1 245.5 57.5 1781.9*
4.) Fat exchange
*Add 148 kcal from dialysate (1781.9+148= 1929 kcal)
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Meal PlanMeal PlanSalt Solution= 3000- 1431=
1569mg=1569/500=3.138 or 3T
Additional calcium= 1800-620.5=1179.5 mg 2 tablets