Case 17

Chronic Kidney Disease Treated with Dialysis

Mary Felipe (Acoma Pueblo) is a 24-year-old American Indian who has had type 2 diabetes mellitus
since age 16. Mrs. Felipe has experienced a declining glomerular filtration rate for the past two years.
She is being admitted in preparation for kidney replacement therapy.

Objectives
After completing this case, the student will be 7. Determine nutrition diagnoses and write
able to: appropriate PES statements.
1. Describe the pathophysiology of chronic 8. Develop a nutrition care plan—with appro-
kidney disease (CKD). priate measurable goals, interventions, and
2. Describe the stages of CKD. strategies for monitoring and evaluation—
3. Differentiate between the mechanisms of that addresses the nutrition diagnoses of
peritoneal dialysis and hemodialysis. this case.
4. Identify and explain common nutritional 9. Integrate sociocultural and ethnic food
problems associated with CKD. consumption issues within a nutrition care
5. Interpret laboratory parameters for nutri- plan.
tional implications and significance. 10. Make appropriate documentation in the
6. Analyze nutrition assessment data to evalu- medical record.
ate nutritional status and identify specific
nutrition problems.

197

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198 Unit Seven Nutrition Therapy for Renal Disorders

Felipe, Mary Female, 24 y.o.

Allergies: NKA Code: FULL Isolation: None
Pt. Location: RM 207 Physician: L. Nila Admit Date: 3/5

Patient Summary: Mrs. Felipe (Acoma Pueblo) is a 24-year-old female who

was diagnosed with type 2 DM when she was 16 years old and has been
iStock.com/Alina555

poorly compliant with prescribed treatment.

History:
Onset of disease: Diagnosed with Stage 3 chronic kidney disease 2 years ago.
Her acute symptoms have developed over the last 2 weeks.
Medical history: Gravida 1/ para 1. Infant weighed 10 lbs at birth 7 years ago. Pt admits she recently
stopped taking a prescribed hypoglycemic agent, and she has never filled her prescription for anti-
hypertensive medication. Progressive decompensation of kidney function has been documented by
declining GFR, increasing creatinine and urea concentrations, elevated serum phosphate, and normo-
chromic, normocytic anemia. She is being admitted for preparation for kidney-replacement therapy.
Surgical history: No surgeries
Medications at home: Glucophage (metformin), 850 mg twice daily
Tobacco use: No
Alcohol use: Yes, 1–2 12-oz beers daily
Family history: What? T2DM. Who? Parents.

Demographics:
Marital status: Married—lives with husband and daughter; Spouse name: Eddie
Number of children: 1
Years education: Associate’s degree
Language: English
Occupation: Program coordinator at community college
Hours of work: 9–5
Ethnicity: American Indian
Religious affiliation: Catholic

Admitting History/Physical:
Chief complaint: Pt complains of anorexia; N/V; 4-kg weight gain in the past 2 weeks; edema in
extremities, face, and eyes; malaise; progressive SOB with 3-pillow orthopnea; pruritus; muscle
cramps; and inability to urinate
General appearance: Overweight female who appears her age; lethargic; complaining of N/V.
HEENT: Head: normocephalic and atraumatic
Eyes: anicteric sclera, noninjected conjunctiva
Mouth: oral mucosa pink, dentition in good repair
Throat: pharynx pink without exudates
Neck: soft, supple, no palpable masses. No lymphadenopathy.
Cardiac: S4, S1, and S2, regular rate and rhythm. I/VI systolic ejection murmur, upper-left sternal border.
Pulmonary/Chest: Generalized rhonchi with rales that are mild at the bases (Pt breathes with poor effort).
Abdominal: Abdomen soft, mildly tender, with normoactive bowel sounds in all four quadrants. No
masses, no organomegaly. No guarding, rebound, or CVA tenderness.
Extremities: Normal range of motion in all four extremities. Muscle weakness; 3+ pitting edema to
the knees, no cyanosis.

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 Case 17 Chronic Kidney Disease Treated with Dialysis 199

Felipe, Mary Female, 24 y.o.

Allergies: NKA Code: FULL Isolation: None
Pt. Location: RM 207 Physician: L. Nila Admit Date: 3/5

Neurological: Conscious, alert, and oriented. Cranial nerves II through XII are intact grossly and
symmetrically. Mild asterixis.
Skin: Skin is warm and dry, yellow-tinged. Not diaphoretic. No rashes or ulcerations noted.
Psychiatric: Appropriate mood and affect for clinical situation.

Vital Signs: Temp: 98.6°F Pulse: 86 Resp rate: 25

BP: 220/80 Height: 5'0" Weight: 170 lbs

Nursing Assessment 3/5

Abdominal appearance (concave, flat, rounded, obese, distended) rounded, obese
Palpation of abdomen (soft, rigid, firm, masses, tense) soft
Bowel function (continent, incontinent, flatulence, no stool) continent
Bowel sounds (P=present, AB=absent, hypo, hyper)
RUQ P
LUQ P
RLQ P
LLQ P
Stool color brown
Stool consistency formed
Tubes/ostomies N/A
Genitourinary
Urinary continence N/A
Urine source N/A
Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria, orange, N/A
blue, tea)
Integumentary
Skin color light brown
Skin temperature (DI=diaphoretic, W=warm, dry, CL=cool, CLM=clammy, W
CD+=cold, M=moist, H=hot)
Skin turgor (good, fair, poor, TENT=tenting) good
Skin condition (intact, EC=ecchymosis, A=abrasions, P=petechiae, intact, A
R=rash, W=weeping, S=sloughing, D=dryness, EX=excoriated, T=tears,
SE=subcutaneous emphysema, B=blisters, V=vesicles, N=necrosis)
Mucous membranes (intact, EC=ecchymosis, A=abrasions, P=petechiae, intact
R=rash, W=weeping, S=sloughing, D=dryness, EX=excoriated, T=tears,
SE=subcutaneous emphysema, B=blisters, V=vesicles, N= necrosis)
Other components of Braden score: special bed, sensory pressure, activity, 16
moisture, activity, friction/shear (>18 = no risk, 15–16 = low risk,
13–14 = moderate risk, <12 = high risk)

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200 Unit Seven Nutrition Therapy for Renal Disorders

Felipe, Mary Female, 24 y.o.

Allergies: NKA Code: FULL Isolation: None
Pt. Location: RM 207 Physician: L. Nila Admit Date: 3/5

Orders:
Evaluate for kidney replacement therapy
Captopril 25 mg twice daily
Erythropoietin (r-HuEPO) 30 units/kg
Sodium bicarbonate 2 g daily
Renal caps—1 daily
Sevelamer carbonate—three times daily with each meal
Doxercalciferol 2.5 pg four times daily 3 times/week
Metformin 850 mg twice daily
35 kcal/kg, 1.2 g protein/kg, 2 g K, 1 g phosphorus, 2 g Na, 1000 mL fluid + urine output per day
CBC, metabolic panel
Stool softener
Occult fecal blood
Nutrition consult

Nutrition:
History: Intake has been poor due to anorexia, N/V. Patient states that she tried to follow the diet
that she was taught two years ago. “It went pretty well for a while, but it was hard to keep up with.
Basically, I tried to stay away from sweets and salty foods.”

Usual dietary intake:

Breakfast: Cold cereal
Bread or fried potatoes
Fried egg (occasionally)
Bacon or other meat 2–3× per week
Coffee
Lunch: Bologna or sub sandwich
Potato chips
Coke
Dinner: Chili con carne
Fry bread
Coke
Snacks: Crackers and peanut butter

Food allergies/intolerances/aversions: None

Previous nutrition therapy? Yes. If yes, when: 2 years ago when Pt Dx with Stage 3 chronic kidney
disease. Where? Indian Health Center—Acoma Service Unit
Current diet: Low simple sugar, 0.8 g protein/kg, 2–3 g Na
Food purchase/preparation: Self
Vit/min intake: None

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 Case 17 Chronic Kidney Disease Treated with Dialysis 201

Felipe, Mary Female, 24 y.o.

Allergies: NKA Code: FULL Isolation: None
Pt. Location: RM 207 Physician: L. Nila Admit Date: 3/5

Intake/Output
Date 3/5 0701–3/6 0700 3/6 0701–3/7 0700
Time 0701– 1501– 2301– Daily 0701– 1501– 2301– Daily
1500 2300 0700 total 1500 2300 0700 total
IN P.O. 0 50 0 50 NPO NPO NPO NPO
I.V.
(mL/kg/hr)
I.V.
piggyback
PN
Total 0 50 0 50 0 0 0 0
intake
(mL/kg) (0) (0.65) (0) (0.65) (0) (0) (0) (0)
OUT Urine 0 100 0 100 200 800 0 1000
(mL/kg/hr) (0) (0.16) (0) (0.05) (0.32) (1.29) (0) (0.54)
Emesis 0 50 0 50 0 100 50 150
output
Other
Stool ×1
Total 0 150 0 150 200 900 50 1150
output
(mL/kg) (0) (1.94) (0) (1.94) (2.59) (11.65) (0.65) (14.88)
Net I/O 0 2100 0 2100 2200 2900 250 21150
Net since admission 0 2100 2100 2100 2300 21200 21250 21250
(3/5)

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202 Unit Seven Nutrition Therapy for Renal Disorders

Felipe, Mary Female, 24 y.o.

Allergies: NKA Code: FULL Isolation: None
Pt. Location: RM 207 Physician: L. Nila Admit Date: 3/5

Laboratory Results
Ref. Range 3/5 0700
Chemistry
Sodium (mEq/L) 136–145 130 !
Potassium (mEq/L) 3.5–5.1 5.8 !
Chloride (mEq/L) 98–107 91 !
Carbon dioxide (mEq/L) 23–29 32 !
Bicarbonate (mEq/L) 23–28 22 !
BUN (mg/dL) 6–20 69 !
Creatinine serum (mg/dL) 0.6–1.1 F 12.0 !
0.9–1.3 M
BUN/Crea ratio 10.0–20.0 5.75 !
Uric acid (mg/dL) 2.8–8.8 F 5.1
4.0–9.0 M
Est GFR, non-Afr Amer >60 4 !
(mL/min/1.73 m2)
Glucose (mg/dL) 70–99 282 !
Phosphate, inorganic (mg/dL) 2.2–4.6 6.4 !
Magnesium (mg/dL) 1.5–2.4 2.1
Calcium (mg/dL) 8.6–10.2 8.2 !
Anion gap (mmol/L) 10–20 17
Osmolality (mmol/kg/H2O) 275–295 300.3 !
Bilirubin, total (mg/dL) ≤1.2 0.9
Bilirubin, direct (mg/dL) <0.3 0.2
Protein, total (g/dL) 6–7.8 5.9 !
Albumin (g/dL) 3.5–5.5 3.3 !
Prealbumin (mg/dL) 18–35 27
Ammonia (µg/L) 6–47 8
Alkaline phosphatase (U/L) 30–120 44
ALT (U/L) 4–36 21
AST (U/L) 0–35 16
CPK (U/L) 30–135 F 119
55–170 M
Lactate dehydrogenase (U/L) 208–378 265
Cholesterol (mg/dL) <200 220 !

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 Case 17 Chronic Kidney Disease Treated with Dialysis 203

Felipe, Mary Female, 24 y.o.

Allergies: NKA Code: FULL Isolation: None
Pt. Location: RM 207 Physician: L. Nila Admit Date: 3/5

Laboratory Results (Continued)

Ref. Range 3/5 0700
HDL-C (mg/dL) >50 F, >40 M 72
VLDL (mg/dL) 7–32 36 !
LDL (mg/dL) 0–99 111
LDL/HDL ratio <4.5 1.54
Triglycerides (mg/dL) <150 182 !
T4 (µg/dL) 5–12 6.1
T3 (µg/dL) 75–98 81
HbA1C (%) <5.7 9.2 !
Coagulation (Coag)
PT (sec) 11–13 12.1
INR 0.9–1.1 0.95
PTT (sec) 24–34 27
Hematology
WBC (× 103/mm3) 3.9–10.7 4.1
RBC (× 106/mm3) 4.2–5.4 F 3.1 !
4.5–6.2 M
Hemoglobin (Hgb, g/dL) 12–16 F 10.5 !
14–17 M
Hematocrit (Hct, %) 37–47 F 33 !
41–51 M
Urinalysis
Collection method — Random
specimen
Color — Straw
Appearance — Hazy
Specific gravity 1.001–1.035 1.001
pH 5–7 7.9 !
Protein (mg/dL) Neg +2 !
Glucose (mg/dL) Neg +1 !
(Continued)

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204 Unit Seven Nutrition Therapy for Renal Disorders

Felipe, Mary Female, 24 y.o.

Allergies: NKA Code: FULL Isolation: None
Pt. Location: RM 207 Physician: L. Nila Admit Date: 3/5

Laboratory Results (Continued)

Ref. Range 3/5 0700
Ketones Neg +1 !
Blood Neg Neg
Bilirubin Neg Neg
Nitrites Neg Neg
Urobilinogen (EU/dL) <1.0 0.03
Leukocyte esterase Neg Neg
Prot chk Neg +2 !
WBCs (/HPF) 0–5 1
RBCs (/HPF) 0–2 1
Bact 0 0
Mucus 0 0
Crys 0 0
Casts (/LPF) 0 0
Yeast 0 0
Arterial Blood Gases (ABGs)
pH 7.35–7.45 7.44
pCO2 (mm Hg) 35–45 33 !
SO2 (%) ≥95 97
CO2 content (mmol/L) 25–30 29
O2 content (%) 15–22 21
pO2 (mm Hg) ≥80 91
HCO3 (mEq/L) − 21–28 20 !

Note: Values and units of measurement listed in these tables are derived from several
resources. Substantial variation exists in the ranges quoted as “normal” and these may
vary depending on the assay used by different laboratories.

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 Case 17 Chronic Kidney Disease Treated with Dialysis 205

Case Questions
I. Understanding the Disease and Pathophysiology
1. Describe the basic normal physiological functions of the kidneys.

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

3. Outline the stages of CKD, including the distinguishing signs and symptoms.

4. From your reading of Mrs. Felipe’s history and physical, what signs and symptoms did she
have that correlate with her chronic kidney disease?

5. What are the three treatment options for Stage 5 CKD? Explain the differences between
hemodialysis and peritoneal dialysis.

II. Understanding the Nutrition Therapy

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

35 kcal/kg:

1.2 g protein/kg:

2 g K:

1 g phosphorus:

2 g Na:

1000 mL fluid + urine output:

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206 Unit Seven Nutrition Therapy for Renal Disorders

7. Calculate and interpret Mrs. Felipe’s BMI. How does edema affect your interpretation?

8. What is edema-free weight? Calculate Mrs. Felipe’s edema-free weight.

9. What are the energy requirements for CKD?

10. Calculate what Mrs. Felipe’s energy and protein needs will be once she begins
hemodialysis.

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

12. In question 6, you explained why Mrs. Felipe has a PO4 restriction. List the foods that have
the highest levels of phosphorus.

13. Mrs. Felipe 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 assure adherence and reduce his or
her thirst?

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 Mrs. Felipe's value.

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

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 Case 17 Chronic Kidney Disease Treated with Dialysis 207

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

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

Captopril:

Erythropoietin:

Sodium bicarbonate:

Renal caps:

Sevelamer carbonate:

Doxercalciferol:

Metformin:

18. Difference in the prevalence of disease can be linked to lifestyle as well as genetic
differences.

a. What do we know about the risk of diabetes and chronic kidney disease in the Ameri-
can Indian populations?

b. Diabetes, obesity, and CKD are described as polygenic diseases. Define polygenic.

c. Research has identified numerous single-nucleotide polymorphisms (SNPs) linked to

both diabetes and CKD in many American Indian populations. What is a polymor-
phism? How does a polymorphism potentially occur?

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208 Unit Seven Nutrition Therapy for Renal Disorders

III. Nutrition Diagnosis

19. Select two nutrition problems and complete the PES statement for each.

IV. Nutrition Intervention

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

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

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

23. A. Based on Mrs. Felipe’s energy needs and the fact that she will be starting hemodialysis,
plan a 1-day diet using the Renal Exchange List that complies with her diet orders (see
question 6).

B. Using Mrs. Felipe’s typical intake and the prescribed meal plan above, write a sample
menu. Justify your changes—why did you make the change to comply with her nutri-
tion prescription?

Diet PTA Sample Menu

Breakfast: Cold cereal (2 c unsweetened)
Bread (2 slices) or fried potatoes
(1 medium potato)
1 fried egg (occasionally)
2 cups coffee
Lunch: Bologna sandwich (2 slices white bread,
2 slices bologna, mustard)
Potato chips (1 oz)
1 can Coke

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 Case 17 Chronic Kidney Disease Treated with Dialysis 209

(Continued)
Diet PTA Sample Menu
Dinner: Chili con carne (3 oz beef)
Fry bread (1 slice, 6" diameter)
Iced tea with sugar (16 oz)
HS Snack: Crackers (6 saltines) and peanut
butter (2 tbsp)

24. Write an initial ADIME note for your consultation with Mrs. Felipe.

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210 Unit Seven Nutrition Therapy for Renal Disorders

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Internet Resources National Institute of Diabetes and Digestive and Kidney

Diseases (NIDDK): http://www2.niddk.nih.gov/
American Association of Kidney Patients: http://www National Kidney Foundation Council on Renal Nutrition:
.aakp.org/ http://www.kidney.org/
Cook’s Thesaurus: http://www.foodsubs.com/ National Kidney Foundation KDOQI Guidelines: https://
Culinary Kidney Cooks: http://www.culinarykidneycooks www.kidney.org/professionals/guidelines
.com/ Nephron Information Center: http://www.nephron.com/
eMedicineHealth: http://www.emedicinehealth.com Office of Minority Health. US Department of Health and
/chronic_kidney_disease/article_em.htm Human Services: https://minorityhealth.hhs.gov/
Indian Health Service. US Department of Health and Renal Web: http://www.renalweb.com/
Human Services: https://www.ihs.gov/ United States Renal Data System (USRDS): http://www
Kidney School: http://kidneyschool.org/ .usrds.org/

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