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Questions for Medical Nutrition Therapy: A Case Study Approach 5th ed.Case 19 – Chronic Kidney Disease (CKD) Treated with Dialysis

Instructions: Answer the questions below and upload to your SharePoint folder.

1. Describe the basic physiological functions of the kidneys.Maintaining homeostasis (fluid control, pH and electrolyte balance, and blood pressure), excretion of waste, and enzyme and hormone production.

The kidneys regulate sodium levels through aldosterone, which in turn will assist in regulating potassium to maintain electrolyte balance. When serum sodium is elevated, potassium is exchanged to restore balance.

Vasopressin is responsible for stabilizing blood pressure by adjusting water absorption and managing fluid balance by controlling the concentration of urine.

Urine production by the kidneys is important in removing waste, drugs and environmental toxins.

Kidneys regulate serum sodium, phosphorous and potassium. Secretion of erythropoietin and urodilation and conversion of vitamin D to active form. Maintains pH by reabsorption of bicarbonate leading to secretion of hydrogen ions.

Nelms, M., Sucher, K. P., Lacey, K., 2016, pp. 667)

2. List the diseases/conditions that most commonly lead to chronic kidney disease (CKD)? Explain the role of diabetes in the development of CKD.

Diabetes (Type 1 or 2) – the glomeruli are destroyed by thickening (possibly caused by hyperglycemia), which decreases their function and requires an increase solute load cleared. Over time, the maximum that can be cleared is reached and an increase in body fluid concentration leads to uremia and azotemia (Nelms et al, 2016, pp. 527)

High blood pressure Glomerulonephritis Interstitial nephritis Polycystic kidney disease Prolonged obstruction of urinary tract Vesicoureteral Pyelonephritis Aging Family hx of CKD

(Mayo Clinic, 2016)

3. Outline the stages of CKD, including the distinguishing signs and symptoms. Stage 1: GFR > 90, evidence of kidney damage, proteinuria or haematuria, genetic dx of

the disease (dx of polycystic kidney disease), or abnormal kidney structure, typically asymptomatic

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Stage 2: GFR 60-89, evidence of kidney damage, proteinuria or haematuria, genetic dx of the disease (dx of polycystic kidney disease), or abnormal kidney structure, typically asymptomatic

Stage 3: GFR 30-59, symptoms can include fatigue, edema, shortness of breath, changes in urine color and frequency, kidney pain felt in the back, sleep problems

Stage 4: GFR 15-29, symptoms can include fatigue, edema, changes in urine color and frequency, kidney pain felt in the back, sleep problems, N/V, metallic taste in mouth, bad breath, appetite loss, difficulty concentrating, numbing or tingling in the fingers or toes

Stage 5: GFR <15, symptoms can include loss of appetite, N/V, fatigue, headaches, difficulty concentrating, little to no urine production, swelling around ankles and eyes, tingling in hands and feet, changes in skin color (increased pigmentation), muscle cramps

(Davita, n.d.)(National Kidney Center, n.d.)(Nelms et al, 2016, pp. 527)(The Renal Association, n.d.)

4. From your reading of Mrs. Joaquin’s history and physical, what signs and symptoms did she have that correlate with her chronic kidney disease? Declining GFR Increased creatinine and urea concentration Elevated serum phosphate Anemia Edema Weight gain Poor appetite (anorexia) HTN Pruritus Dry skin Difficulty breathing Muscle cramps Inability to urinate N/V Lethargy Malaise Previous diagnosis of stage 3 CKD T2DM

(Bronnert, J., 2007)(Mayo Clinic, 2016)

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5. What are the treatment options for Stage 5 CKD? Explain the differences between hemodialysis and peritoneal dialysis. Hemodialysis, peritoneal dialysis, and kidney transplant Hemodialysis (HD):

o Requires surgical creation of an arteriovenous fistula (AVF), which joins the radial artery and cephalic vein or a tunneled catheter and takes 4-6 weeks to become functional; OR

o Creation of an arteriovenous graft (AVG) that can be punctured repeatedly for treatment;

o Involves passing of dialysate around artificial membrane (electrolyte content is similar to normal plasma allowing this to occur) to filter blood via diffusion, ultrafiltration and osmosis (removes waste and electrolytes);

o Return of filtered blood through venous side;o Are 3-5 times per week for an average of 4 hours each treatment;o Covered by Medicare;o Option for home treatment for some, which would entail 5-7 sessions lasting 2-3

hours at a time OR a nocturnal option performed 3-6 nights per week during sleep.

Peritoneal Dialysis (PD):o Access to blood supply through a catheter placed in the peritoneal cavity;o Dialysate introduction through catheter to peritoneum;o Options of continuous ambulatory PD [CAPD] and continuous cycling PD

[CCPD];o Typically lasts 4-6 hours but an additional 30-40 minutes is required to replace

with fresh solution;o Solution changed at least 4 times per day and sleep with the solution in their

abdomens;o Requires a machine that fills and empties the abdomen 3-5 times per night;o One daily exchange in which dwell lasts the entire time;o More freedom in diet (can have more protein, sodium and potassium);o Would require extra sanitary precautions.

(Nelms et al, 2016, pp. 530)

6. Explain the reasons for the following components of Mrs. Joaquin’s medical nutrition therapy:

Nutrition Therapy Rationale35 kcal/kg Prevent catabolism and maintain optimal nutrition status,

prevention of visceral protein being used for energy and malnutrition, recommended sufficient kcals from CHO and fat

1.2 g protein/kg Maintain neutral or positive nitrogen balance, replace losses, prevent malnutrition

2 g K Maintain serum <5 to prevent hyperkalemia and/or arrhythmias1 g phosphorus Prevention of hyperphosphatemia2 g Na Prevent fluid overload

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1000 mL fluid + urine output

Maintain balance and prevent fluid overload

(Nelms et al, 2016, pg. 538-543)

7. Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your interpretation? Ht in cm: 5’0” = (60 in)2 = 3,600 (170/3600)* 703 = 33.2 (obese)

Edema will increase her weight, causing a misinterpretation of her BMI.

Her pre-weight-gain-BMI would be slightly lower: (4 kg)(2.2 #/kg) = 8.8#s 170#s – 8.8#s = 161.2#s (161/3600)* 703 = 31.4 (obese)

8. What is edema-free weight? Calculate Mrs. Joaquin’s edema-free weight.Edema-free body weight is a more accurate way of interpreting the patient’s weight by dismissing the edema weight that builds up between dialysis treatments.

aBWef = BWef + [(SBW - BWef) 0.25] aBWef = 73.3 kg + [(60 kg – 73.3 kg) 0.25] aBWef = 73.3 + [(-13.3) 0.25] aBWef = 73.3 – 3.325 = 69.975 kg or 70 kg

(National Kidney Foundation [NKF], Kidney Disease Outcomes and Quality Initiative [K/DOQI], 2000)

9. What are the energy requirements for CKD?

35 kcal/kg/day for pts younger than 60 y/o 30-35 kcal/kg/day for pts older than 60 y/o

(NKF, K/DOQI, 2000)

10. Calculate what Mrs. Joaquin’s energy needs will be once she begins hemodialysis. (35 kcal/kg)(68.3 kg) = 2,391 kcal

(NKF, K/DOQI, 2000)

11. What are the differences in protein requirements among stages 1 and 2 CKD, stage 3 and 4 CKD, hemodialysis, and peritoneal dialysis patients? What is the rationale for these differences?

PRO requirements: Stage 1 – 2: 0.8-1.4 g/kg/day Stage 3 – 4: 0.6 – 0.8 g/kg/day – decreased to slow GFR decline Stage 5 – higher to prevent PEM and to maintain positive or neutral nitrogen balance

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> 1.2 g/kg/SBW or ABW for HD 1.2-1.3 g/kg/day for stable pts, more for those w/ complications for PD. Inflammation

in the peritoneum can increase protein losses, thus requiring more to maintain homeostasis.

(Nelms et al, 2016, pp. 537-538)

12. Mrs. Joaquin has a PO4 restriction. Why? What foods have the highest levels of phosphorus?

Too much phosphorous can result in hyperphoshatemia and can also cause calcium to be pulled from the blood. If P stays elevated it stimulates PTH release to promote P excretion, but instead increases breakdown of bone and release of calcium, leading to several bone disorders.

Apricots Ale,beer Dark colas Canned iced teas Cocoa Dairy products Beans and lentils Whole-grain products, bran cereals, caramels, seeds, brewer’s yeast, nuts and wheat

germ

(Nelms et al, 2016, pp. 545)

13. 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 fluid restriction is generally recommended for someone on hemodialysis? Is there a standard guideline for maximum fluid gain between dialysis visits? If a patient must follow a fluid restriction, what can be done to help reduce his or her thirst? Anything liquid at room temperature is considered a fluid (water, tea, coffee,

smoothies/shakes, juice, soda, ice, sherbert, soup, etc).(Davita, n.d.)

No more than 1-1.5 L/daily when urine output is less than 1 L. If greater than 1L, 2L of fluid can be consumed.

Weight gain should not exceed 5% of BW. To reduce thirst: Limit sodium intake Take medicines with liquids at meals or pureed fruit Drink very cold beverages from smaller containers only when you are thirsty Weigh daily Try thirst-quencher gums, sugar free gum or sour candy Add lemon or ice to water Swish very cold water or low-alcohol mouthwash in the mouth Use lip balms to moisten lips Use ice cubes instead of liquids

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Eat frozen fruits(Nelms et al, 2016, pp. 543-544)

14. Several biochemical indices are used to diagnose chronic kidney disease. One is glomerular filtration rate (GFR). What does GFR measure? What is a normal GFR? Interpret her value.

GFR measures the rate at which the glomeruli filters substances from the plasma, which assists in assessing kidney function. A normal GFR is higher than 60. Hers is 4, indicating stage 5 CKD and preparation for renal replacement therapy (RRT).

(Nelms et al, 2016, pp. 526)

15. Evaluate Mrs. Joaquin’s chemistry report. What labs are altered due to her diagnosis of Stage 5 CKD?

Test Ref. Range Pt. Value SignificanceAlbumin (g/dL) 3.5-5.5 3.3 L Fluid overload, PEM,

nephrotic syndrome, inflammation, infection

BUN (mg/dL) 6-20 69 H Too much PRO intake, GI bleeding, dehydration, CHF, dialysis not adequate, overhydration

Calcium (mg/dL) 8.6-10.2 8.2 L Inadequate vitamin D, hypoparthyroidism (albumin is low, too)

CO2 (mEq/L) 23-29 32 H Metabolic alkalosisChloride (mEq/L) 98-107 91 L Diabetic acidosis,

potassium deficiency, GI losses, too much fluid, starvation, sweating in excess

Cholesterol (mg/dL) <200 220 H High fat diet, lipid metabolism disorder, nephrotic syndrome, use of glucocorticoid

Creatinine (mg/dL) 6-1.1 12 H Catabolism, damage to muscles, MI, inadequate dialysis

Glucose (mg/dL) 70-99 282 H DM, hyperparathyroidism, glucose intolerance, stress, hepatic disease

Hematocrit (%) 37-47 33% L Blood loss, anemia, CKD

Hemoglobin (g/dL) 12-16 10.5 L Overhydration,

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prolonged deficiency of iron, CKD, blood loss

A1C (%) <5.7 9.2% H Poorly controlled DM, hyperglycemia

Potassium (mEq/L) 3.5-5.1 5.8 H Dehydration, acidosis, destruction of tissue, inappropriate dialysate potassium, excessive oral intake

Phosphate (mg/dL) 2.2 – 4.6 6.4 H CKD, vitamin D intoxication, excessive intake

Protein (g/dL) 6-7.8 5.9 L Malnutrition, nephrotic syndrome, malabsorption, edema

RBC (x 106/mm3) 4.2-5.4 3.1 L Anemia, iron deficiencyTriglycerides (mg/dL)

35-135 182 H Alcohol abuse, pancreatitis, diabetes, nephrotic syndrome, PD

(Nelms et al, 2016, pp. 534-536)

16. Which of Mrs. Joaquin’s symptoms would you expect to begin to improve when she starts dialysis?

N/V, loss of appetite, fatigue, itching, cramps in the legs, anemia, weakness.

(National Kidney Foundation, n.d.)

17. The following medications were prescribed for Mrs. Joaquin. Explain why each was prescribed (the indications/mechanism) and describe any nutritional concerns and dietary recommendations related to the medication.

Medication Indications/Mechanism Nutritional ConcernsCapoten/ captopril 25 mg twice daily

Anti-hypertensive, ACE inhibitor, inhibits blood vessels tightening in order for heart to pump efficiently

Ensre adequate fluid intake, lower sodium and calcium recommended, avoid natural licorice, limit alcohol. Can cause N/V and/or diarrhea.

Erythropoietin 30 units/kg

Anti-anemic, initiates RBC formation

Supplementation of Fe, B12 or folate may be required. Mandatory diet compliance. Can cause N/V and/or diarrhea.

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Medication Indications/Mechanism Nutritional ConcernsSodium bicarbonate 2 g daily

Antacid, increases serum bicarbonate and buffers extra hydrogen concentration, which raises blood pH, reversing acidosis.

Lower sodium diet recommended. Take an iron supplement 1 hour before or 2 hours after taking NaHCO3. Caution with high calcium intake. Will increase thirst and weight. Can cause distention, cramps, and flatulence. Decreases renal function. Increases serum sodium and pH. Decreases serum potassium and calcium.

Renal caps 1 daily

Water-soluble vitamin supplement.

Take NaHCO3 separately after dialysis.

Renvela 3 times daily with each meal

Binds to phosphorous to prevent absorption

Take with each meal. Low phosphate diet recommended. Monitor serum phosphate, calcium, chloride and bicarbonate.

Hectorol 2.5 pg four times daily 3 times/week

Treats secondary hyperparathyroidism by assisting body in using more of the calcium consumed to regulate body’s production of parathyroid hormone [PTH]

Adequate hydration necessary. Anorexia and weight loss are common.

Glucophage 850 mg twice daily

Antihyperglycemic. Decreases amount of blood glucose absorbed from intake and liver production to lower serum glucose, increases response to insulin.

Take with meals. Diabetic diet recommended. Decrease calories if weight loss is necessary. Anorexia and weight loss are side effects. Decreases folate and B12 absorption.

(U.S. National Library of Medicine, n.d.)(Pronsky, Z., Elbe, D., Ayoob., K., 2015) 18. List the nutrition-related health problems that have been identified in the Pima Indians

through epidemiological data. Are the Pima at higher risk for complications of diabetes? Explain. What is meant by the "thrifty gene" theory? High prevalence of diabetes, obesity, and complications caused by the two (kidney and/or

eye disease, nerve damage) Pima Indians of Arizona have the world’s highest incidence of type 2 DM. One-half of adult Pima Indians have diabetes and 95% of those with diabetes are

overweight. The incidence of ESRD is 20 times higher in this group than the general U.S. population. Members of the Pima tribe have a prevalence of DM 2-5 times higher than Whites.

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Gestational DM increases risk of type 2 DM in childhood 10-fold and is the most important risk factor for development of type 2 DM in childhood.

Rates of type 2 DM in adolescent Pima have doubled in the past 30 years. The rate of new kidney failure in the Pima is 20 times higher than in other groups (90%

of new cases of kidney failure are caused

(Baier, L., Hanson, R., 2004, May) The “thrify gene” theory proposes the idea that since the Pima Indians relied on farming,

hunting and fishing for food for thousands of years that they adapted a gene that allowed them to store fat during periods of feast to prevent starvation during times of famine. It is thought that this protective gene contributed to their fat retention upon adoption of the Western lifestyle where calories are readily available and there’s less physical activity.

(Edberg, M., 2013)

19. Choose two high-priority nutrition problems and complete a PES statement for each.

Excessive sodium intake related to lack of compliancy to diet as evidenced by diet recall indicating usual sodium intake of 2,914 mg compared to diet prescription of 2000mg.

Altered nutrition related laboratory values related to altered kidney function and stage 5 dx of CKD as evidenced by elevated serum creatinine (12.0 mg/dL), elevated potassium (5.8 mEq/L), elevated phosphorous (6.4 mg/dL), and decreased GFR (4 mL/min/1.73 cm2).

20. For each PES statement, establish an ideal goal (based on the signs and symptoms) and appropriate intervention (based on the etiology).

Goal: Limit daily sodium intake to 2,000 mg.Intervention: Nutrition counseling on importance of adhering to a 2000 mg sodium restricted diet, other ways to enhance flavor, self-monitoring, how to interpret a nutrition facts label, and food sources high in sodium.

Goal: Maintain as close to normal ranges of serum creatinine, potassium, and phosphorous within 6 weeks through dietary changes:

Limiting potassium to 2g/day; Consuming recommended amount of protein and calories each day (2,391 calories and 88

– 95 g/PRO/day, 50% of PRO intake should come from high biological sources) to prevent or slow down catabolism;

Limiting phosphorous to 1 g/day.Intervention: Nutrition counseling on high potassium and phosphorous foods, high biological proteins, and self-monitoring. Education on not using salt subsitutes and low-sodium baking soda or powder.

21. Why is it recommended for patients to have at least 50% of their protein from sources that have high biological value?

To maintain or improve visceral protein stores and nitrogen balance and a high biological value makes for easily assimilation into body tissues.

(Nelms et al, 2016, pp. 538)

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22. What resources and counseling techniques would you use to teach Mrs. Joaquin about her diet?

Resources: The National Renal Diet, A Healthy Food Guide for People on Dialysis, Renal Exchange List, DaVita, information on menu planning and sample menus.Counseling technique: motivational interviewing and ongoing nutrition education activities as patient has demonstrated in the past she has a willingness to follow diet modifications (though very briefly), but ended up giving up because it was “too hard”. The ongoing education would help expand her knowledge of what she can eat and how to incorporate them into her daily food intake.

23. A. Based on Mrs. Joaquin's energy needs, calculate her carbohydrate, protein, and fat needs, Using the Renal Exchange list, plan a 1-day diet that meets her energy needs and complies with her diet orders (see question 6) Calories: 35 kcal/day * 73.3 kg = 2,391 kcal PRO:

o 1.2 * 73.3 kg = 88 g/PRO/dayo 1.3 * 73.3 kg = 95 g/PRO/dayo 88 – 95 g/PRO/day (50% from high biological sources)

Fat: 25 – 35%o 2,391 * .25 = 598 cals from fat = 66 go 2,391 * .35 = 837 cals from fat = 93 go 66 – 93 g fat

Carbs: 50 – 60%o 2,391 * .5 = 1,196 calories from CHO = 299 g/CHO/dayo 2,391 * .6 = 1,435 cals from CHO = 359 g/CHO/dayo 299 – 359 g/CHO/day

Using the higher range for each will put pt above calorie recommendations. Rather than further contributing to pts obese classification and co-morbid conditions, I would suggest mid-range for fat and calorie (30% fat or 80 g, 55% CHO or 329 g) intake and 1.3 g/PRO/day. –

Breakfast: Omelet w/ 2 eggs with yolks and 2 egg whites with ¼ c. onions and mushrooms –

280 calories,15 g fat, 22 g PRO, 480 mg potassium, 270 mg phosphorous, 642 mg sodium

½ c milk – 51 kcal, 2 g fat, 4.1 g PRO, 54 mg sodium, 116 mg phosphorous, 183 mg potassium

Total: 331 calories, 17 g fat, 26.1 g PRO, 584 mg potassium, 386 g phosphorous, 696 mg sodium

Lunch: 2 oz chicken with 2 oz pasta drizzled with 2 T olive oil – 604 calories, 15 g fat,

27.2 g PRO, 47 mg sodium, 224 mg phosphorous, 313 mg potassium Dinner:

3 oz salmon – 134 calories, 10 g fat, 20.1 g PRO, 56 mg sodium, 230 mg phosphorous, 471 mg potassium

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1 cup of white rice w/ 1 T margarine – 272 kcal, 10 g fat, 2 mg sodium, 68 mg phosphorous, 57 mg potassium

Green beans baked with canola oil – 78 calories, 15 g fat, 2 g PRO, 1 mg sodium, 39 mg phosphorous, 215 mg potassium

Total: 484 calories, 35 g fat, 22.1 g PRO, 59 g sodium, 337 mg phosphorous, 743 mg potassium

Snacks: Bagel w/ ½ c raspberries and 1 TB cream cheese – 228 calories, 10 g fat, 8.9 g

PRO, 256 mg sodium, 91 g phosphorous, 123 mg potassium Unsalted popcorn with margarine – 214 kcal, 10 g fat, 2.4 g PRO, 301 mg

sodium, 66 mg phosphorous, 62 mg potassium Angel food cake with ½ c. blueberries – 211 kcal, 1.6 g fat, 4.7 g PRO, 450 mg

sodium, 21 mg phosphorous, 180 mg potassium Total: 653 kcal, 21.6 g fat, 16 g PRO, 1,007 mg sodium, 178 mg phosphorous,

365 mg potassiumDay total:

2,072 kcal 88.6 g fat 95.7 g PRO 1,996 mg potassium 1,125 mg phosphorous 1,809 mg sodium

B. Using Mrs. Joaquin’s typical intake and the prescribed diet, write a sample menu. Justify your changes; why did you make the change to comply with her nutrition prescription.

Diet PTA Sample MenuBreakfast:Cold cereal (¾ c unsweetened)Bread (2 slices) or fried potatoes (1 med

potato)1 fried egg (occasionally)

Corn flakes - low in potassium and phosphorous

English muffin w/ margarine or butter – margarine or butter will provide extra calories and fat, potatoes are high in potassium

Incorporate more eggs into the diet to add protein and fat. Perhaps a 2 whole egg omelet with one egg white for extra protein of high biological value. Add in low potassium vegetables such as kale, mushrooms and onions.

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Diet PTA Sample MenuLunch:Bologna sandwich (2 slices white bread, 2

slices bologna, mustard)Potato chips (1 oz)1 can Coke

Sandwhich with 2 slices of low-sodium bread, 2-3 ounces of low-sodium cooked meat (chicken, turkey breast, etc) – lower in sodium and a better source of protein

Replace chips with unsalted pretzels to lower sodium but still give pt something crunchy

Replace coke with water, tea, sparkling water, or a light-colored soda to limit phosphorous intake.

Dinner:Chopped meat (3 oz beef)Fried potatoes (1 ½ medium)

To lower potassium and sodium, replace with chicken or shrimp

Replace potato for pasta tossed in garlic and olive oil with broccoli to decrease potassium and sodium intake

HS Snack: Crackers (6 saltines) and peanut butter (2 tbsp)

Replace saltines with a lower-sodium option and halve peanut butter by adding in a jelly or jam – decreasing peanut butter will decrease potassium intake

24. Write an initial ADIME note for your consultation with Mrs. Joaquin.Assessment:

24 y/o Native American female dx with T2DM @ 13 y/o and stage 3 CKD 2 years ago Height: 5’0”, wt: 170#s, BMI: 33.2 Languages: English and Akimel O’odham (Pima) Complains of N/V, anorexia, 4 kg wt gain in the past 2 weeks, edema, malaise, muscle

cramps, pruritus, and unable to urinate Medications: Glucophage – 850 mg twice daily 3+ pitting, warm skin temperature, lethargia Sodium 130 mEq/L, potassium 5.8 mEq/L, chloride 91 mEq/L, carbon dioxide 32

mEq/L, bicarbonate 22 mEq/L, BUN 29 mg/dL, creatinine serum 12.0 mg/dL, GFR 4 ml/min/1.73 m2, glucose 282 mg/dL, phosphate 6.4 mg/dL, calcium 8.2 mg/dL, osmolality 300.3 mmol/kg/H2O, protein 5.9 g/dL, albumin 3.3 g/dL, cholesterol 220 mg/dL, VLDL 36 mg/dL, triglycerides 182 mg/dL, A1c 9.2%, RBC 3.1, Hgb 10.5, Hct 33%, urine pH 7.9, +2 protein, +1 glucose and ketones, HCO3 20 mEq/L

Diagnosis

Excessive sodium intake related to lack of compliancy to diet as evidenced by diet recall indicating usual sodium intake of 2,914 mg as compared to recommended intake no greater than 2,000 mg.

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Altered nutrition related laboratory values related to altered kidney function and stage 5 dx of CKD as evidenced by elevated serum creatinine (12.0 mg/dL), elevated potassium (5.8 mEq/L), elevated phosphorous (6.4 mg/dL), and decreased GFR (4 mL/min/1.73 cm2).

Intervention:

Nutrition rx: 2,391 calories, 88-95 g PRO (50% from high biological value sources), 66-93 g fat, 299-359 g CHO

Nutrition counseling on importance of adhering to a 2000 mg sodium restricted diet, other ways to enhance flavor, self-monitoring, how to interpret a nutrition facts label, and food sources high in sodium.

Nutrition counseling on avoiding high potassium and phosphorous foods, high biological proteins, and self-monitoring. Education on not using salt subsitutes and low-sodium baking soda or powder.

Monitoring/Evaluating:

Monitor GFR, serum creatinine, sodium, potassium, glucose, BUN in a month. If results have improved, re-evaluate same labs in 3 months.

Measure cholesterol, triglycerides, VLDL, and A1C in 3 months. Urinalysis at visit in a month to check pH, protein, glucose and ketones. Monitor food journals and logs to check for compliancy in a month. Monitor weight status, hydration status, electrolytes (K, P, Na, Ca), glucose, and anemia

pertinent values (Hct, Hgb, RBC). Expressed desire to sustain changes over time and acknowledged that family is supportive of nutrition and medical care. Plan to see daily while in hospital and schedule outpatient within two weeks of discharge. Referral to dialysis RD once treatment scheduled.

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Reference List

Baier, L., Hanson., R. (2004, May). Genetic Studies of the Etiology of Type 2 Diabetes in Pima Indians. American Diabetes Association. Diabetes, 53(5):1181-1186. doi http://dx.doi.org/10.2337/diabetes.53.5.1181

Bronnert, J. (2007, June). Coding chronic kidney disease. Journal of American Health Information Management Association, 78(6):82-84.

DaVita (n.d.). Stage 2 of Chronic Kidney Disease. Retrieved October 25, 2016 from https://www.davita.com/kidney-disease/overview/stages-of-kidney-disease/stage-2-of-chronic-kidney-disease/e/4747

DaVita (n.d.). Stage 4 of Chronic Kidney Disease. Retrieved October 25, 2016 from https://www.davita.com/kidney-disease/overview/stages-of-kidney-disease/stage-4-of-chronic-kidney-disease/e/4751

DaVita (n.d.). Stage 5 of Chronic Kidney Disease. Retrieved October 25, 2016 from https://www.davita.com/kidney-disease/overview/stages-of-kidney-disease/stage-5-of-chronic-kidney-disease/e/4753

Edberg, M. C. (2013). Essentials of health, culture, and diversity: Understanding people, reducing disparities. Burlington, MA: Jones & Bartlett Learning. Pp. 122

Mayo Clinic (2016, August 9). Symptoms and causes – Chronic kidney disease. Retrieved October 25, 2016 from http://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/dxc-20207466

Multiple Myeloma Research Foundation (n.d.). What is erythropoietin? Retrieved October 27, 2016 from https://www.themmrf.org/multiple-myeloma-knowledge-center/myeloma-treatments-guide/growth-factors/erythropeietin/

National Kidney Center (n.d.). Stages 1 to 2. Retrieved October 25, 2016 from http://www.nationalkidneycenter.org/chronic-kidney-disease/stages/stages-1-to-2/

National Kidney Foundation (2000). KDOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. Retrieved October 27, 2016 from http://www2.kidney.org/professionals/KDOQI/guidelines_nutrition/nut_appx07a.html

National Kidney Foundation. Key Points: About Dialysis for Kidney Failure. Retrieved October 27, 2016 from https://www.kidney.org/patients/peers/dialysis

Nelms, M., Sucher, K. P., Lacey, K. (2016). Diseases of the Renal System. In Nutrition therapy & pathophysiology. 130). Belmont, CA: Cengage Learning.

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Pronsky, Z. M., Elbe, D., & Ayoob, K. (2015). Food medication interactions. Birchrunville, Penn.: Food-Medication Interactions.

The Renal Association (n.d.). Stages 1 and 2 CKD. Retrieved October 25, 2016 from http://www.renal.org/information-resources/the-uk-eckd-guide/stages-1-and-2-ckd

U.S. National Library of Medicine (n.d.). Medline Plus Drugs. Accessed October 27, 2016 from https://medlineplus.gov/druginformation.html