Grand Round Case Study
CKD with Dialysis
Christine Valente & Venny Lalu
Patient Description
Name: EJ
Demographic: 24-year old, Native American, female
Anthropometrics: 50, 170 lbs. BMI= 33.3, IBW= 110 lbs, %IBW= 69%
UBW = 161.2 lb
Relevant medications: Glucophage (metformin) 850 mg twice daily.
History
Dietary history: Intake poor due to anorexia, N&V. Current diet: Low simple sugar,
0.8 g protein/kg, 2-3g Na. Purchases own groceries and prepares own food. No
vitamin/mineral supplement intake.
Medical history: Type 2 diabetes, declining GFR evidenced by increasing creatinine
and urea concentrations, elevated serum phosphate and anemia. Gravida 1/ para 1 7
years ago, Patient stopped taking prescribed hypoglycemia agent and has never filled
her prescription for antihypertensive medicine. No tobacco use. Drinks 12 oz. beer/d
History
Social history: Married and lives with husband and daughter. Works 8
hours/day as a secretary, speaks English and Pima Indian, high school
education.
Relevant family medical history: T2DM parents
Previous medical nutrition therapy: 2 years ago with pt dx of stage 3 CKD at
Reservation Health Service.
Disease Information
The patient has diagnosed Type 2 Diabetes Mellitus
Previously diagnosed stage 3 chronic kidney disease
Progressed to Stage 5
Evidenced by her physical symptoms and lab work
EJ is being evaluated for kidney replacement therapy.
Chronic Kidney Disease
Chronic kidney disease (CKD) is defined as progressive and irreversible loss
of the functions of the kidney which include excretion, endocrine and
metabolism.
CKD includes a glomerular filtration rate (GFR) of <60 mL/min/1.73m2 for
more than 3 months.
When GFR has dropped below 15, dialysis is initiated.
CKD Treatment: Dialysis
Dialysis is a treatment in which toxic by-products of metabolism are filtered
and excreted, ultimately replacing the function of the kidneys.
Dialysis can either be hemodialysis (HD) or peritoneal dialysis (PD).
Etiology
Diagnosis of T2DM
Her family history of DM.
T2DM- risk of CKD is higher in people with T2DM and especially in those
with uncontrolled blood sugar.
A1C values show EJs blood sugars are not well controlled.
Etiology
Native American
2x more likely than white Americans to develop CKD
Reservations are food deserts
Thrifty Gene Theory
Signs and Symptoms Upon Admission
Complaints of anorexia, nausea and vomiting.
Gained 4kg of weight in the past 2 weeks
despite her lack of appetite and lack of intake due to nausea and
vomiting.
Edema in extremities, face and eyes.
Diagnostic Testing
Her assessments identified muscle weakness, pitting edema to the knees,
mild asterixis, or a hand tremor when the hand is extended, and shortness of
breath.
Her laboratory values from blood and urine samples show indications of
acidosis and kidney failure.
Laboratory Findings
-Blood sodium, +blood potassium = acidosis from DM & decreased kidney
function
+Blood urea nitrogen (BUN) and + creatinine = decline in GFR
+Blood phosphorus levels and - blood calcium = calcium phosphate.
Calcification of CV system, + CVD risk, + of mortality of dialysis patients
+ A1C = hyperglycemia, poorly controlled T2DM
Protein in the urine = inability of kidneys to filter
PES Statements
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 3.3 g.
2. Excessive sodium intake (NI-55.2) as related to fluid retention and usual
intake of foods high in sodium as evidenced by self-reported intake of 3.9 g
of Na+ and 3+ pitting edema to the knees.
Patient Goals
1. Lower serum potassium (K) to normal range of 3.5-5.5 mEq/L.
2. Reduce fluid retention to acceptable range (2-5% body weight)
relative to dialysis treatment.
Interventions
1. Goal 1 Intervention
a. Modify distribution, type, or amount of food and nutrients within meals or at
specified time (ND-1.2).
i. Restrict dietary potassium intake to 2 g/d.
b. Deliver initial nutrition education on priority of modifications (E-1.2)
i. Health implications of excess dietary potassium consumption with impaired
renal functioning.
ii. Foods high and low in potassium
iii. Meal plan ideas
c. Conduct nutrition counseling on strategies for self monitoring (C-2.3)
i. How to track approximate potassium intake
Interventions
1. Goal 2 Intervention
a. Modify distribution, type, or amount of food and nutrients within meals or at
specified time (ND-1.2).
i. Restrict dietary sodium intake to 2 g/d.
b. Deliver initial nutrition education on priority of modifications (E-1.2)
i. Health implications of excess dietary sodium consumption and fluid intake.
ii. Foods high and low in sodium and adequate fluid intake
iii. Meal planning examples and ideas
c. Conduct nutrition counseling on strategies for self monitoring (C-2.3)
i. How to track approximate sodium intake
Nutrition Prescription
Prescription Rationale
a. 35 kcal/ kg a. Prevent catabolism and
malnutrition.
b. 1.2 g protein/kg
b. Maintain neutral/positive
c. 2 g Potassium nitrogen balance
d. 1 g Phosphorus c. Prevent hyperkalemia
e. 2 g Sodium d. Prevent hyperphosphatemia
e. Fluid retention and blood
f. 1000 mL fluid + Urine pressure
Output f. Fluid retention and blood
pressure
Patients Usual Intake
Dietary Analysis of Usual Intake
Recommended Usual Intake
2,350 kcal/day 1,990 kcal/day
80 g protein/ day 60 g protein/day
65-91 g fat/day 93 g fat/day
18.2 g saturated fat/day 17.6 g saturated fat/day
2 g Potassium and Sodium 3.3 g Potassium
1 g Phosphorus 4.0 g Sodium
Phosphorus not analyzed
Strengths and Weaknesses of Usual Intake
Weaknesses Strengths
Fruits and Vegetables Easily modified
Protein choices high in fat/ Adherence during
saturated fat
transition
Bologna, chopped meat
Foods high in potassium, sodium,
and phosphorus
Fried Potato
Chips
Mustard
Bologna
Peanut butter
Saltines
Dietary Changes
Potassium
Energy Intake
Potatoes exchanged for rice
Increase number of snacks
Potato chips replaced with baked
Fat Intake tortilla chips
Lean beef instead of chopped meat
Phosphorus
Sodium Eliminate Beer or reduce beer
Peanut butter unsalted Replace cola with root beer
Saltines Low sodium Reduce mustard serving size
Low sodium turkey breast Corn Flakes cereal
Micronutrients
Increase vegetable and fruit intake
Fluids
Add limited fluids
Dietary Instruction
1. Foods and beverages low/high in restricted minerals
2. Meal planning/modification
3. Health implications
References
Chodur, G. M., Shen, Y., Kodish, S., Oddo, V. M., Antiporta, D. A., Jock, B., Kang, S. S., Chang, J. W., & Park, Y. (2017). Nutritional Status Predicts 10-Year
& Jones-Smith, J.C. (2016). Food Environments around American Indian Mortality in Patients withEnd-Stage Renal Disease on Hemodialysis. Nutrients,
Reservations: A Mixed Methods Study. PLoS ONE, 11(8),e0161132. 9(4), 399. http://doi.org/10.3390/nu9040399
http://doi.org/10.1371/journal.pone.0161132
Kelley, A., Giroux, J., & Schulz, M. (2015).American-Indian diabetes mortality
Dialysis: It's a Lifesaver. (n.d.). Retrieved November 08, 2017, from in the Great Plains Region 20022010 BMJ Open Diabetes Research and Care
https://www.davita.com/kidney-disease/dialysis 2015;3:e000070. doi:10.1136/bmjdrc-2014-000070
ENCPT:Nutrition Terminology Reference Manual. (n.d.). Retrieved Nelms, M. N., Sucher, K.
November 09, 2017, From https://ncpt.webauthor.com/pubs/idnt-en/ P., & Lacey, K. (2015). Nutrition therapy and pathophysiology (3rd ed.). Boston,
MA:Cengage learning.
Genn-Bacon,
E. A. (2014). Thinking Evolutionarily About Obesity. The Yale Journal of Snelson, M., Clarke, R.
Biologyand Medicine, 87(2),99112. E., & Coughlan, M. T. (2017). Stirring the Pot: Can Dietary Modification
Alleviate the Burden of CKD? Nutrients, 9(3), 265.
Ikizler, T. A. (2013). A http://doi.org/10.3390/nu9030265
Patient with CKD and Poor Nutritional Status. Clinical Journal of the
American Society of Nephrology: CJASN, 8(12), 21742182.
http://doi.org/10.2215/CJN04630513
