Chronic Kidney disease Diet Therapy. Undergraduate Case defense. Bachelor of Science in Nutrition

1. CHRONIC KIDNEYCHRONIC KIDNEY
DISEASE STAGE 5DISEASE STAGE 5
with;with;
AnemiaAnemia
HyperkalemiaHyperkalemia
Metabolic acidosis &Metabolic acidosis &
Uppper Gastro-IntestinalUppper Gastro-Intestinal
BleedingBleeding
Timothy M. Zagada
HNF 42 S2-2L

2. General InformationGeneral Information
Name of patient: JG
Ward No. 3
Age: 46
Date of Admission: July 14, 2008
Hospital: Philippine General Hospital (PGH)

3. Socio-Economic HistorySocio-Economic History
Married with 5 children
High school graduate
Permanent residence in Taguig
Works 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)

4. Medical HistoryMedical History
Present Illness: CKD stage 5
secondary to Hypertensive
Nephrosclerosis
 Anemia
 Hyperkalemia
 Metabolic Acidosis
 UGIB
Chief Complaint: Generalized weakness

5. Medical HistoryMedical History
Past 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

6. 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

7. Medical HistoryMedical History
Physical 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

8. Theoretical considerationTheoretical consideration
Chronic 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

9. EtiologyEtiology
Immunological, 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

10. EtiologyEtiology
Metabolic disorder like Diabetes Mellitus
Excessive pressure against the blood
vessel walls or hypertension
Genetic factors

11. Stages of CKDStages of CKD
Stage 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

12. IncidenceIncidence

13. IncidenceIncidence

14. 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

15. 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

16. Assessment of NutritionalAssessment 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

17. Assessment of NutritionalAssessment of Nutritional
StatusStatus
Biochemical Assessment
Laboratory Results Normal Values Actual Values Variance Rationale for
Variance
BUN 2.60-6.48 mmol/L 94.13 mmol/L 87.65 mmol/L or
higher
Failure 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

18. Assessment of NutritionalAssessment of Nutritional
StatusStatus
Clinical Assessment
Body 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

19. Dietary AssessmentDietary Assessment
DBW= (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 g
PRO= 2200 x 0.15= 330/4= 82.5 or 85g
FAT= 2200 x 0.25= 550/9= 61.1 or 60 g

20. Dietary AssessmentDietary Assessment
Prior 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

21. Dietary AssessmentDietary Assessment
During Confinement
◦ Kcal=1900, CHO=334g, PRO=74g, FAT=
67.5g
TER= 63 x 30= 1900 kcal
PRO= 63 x 1.1= 70 g
PRO kcal= 70 x 4= 280 kcal
Non PRO kcal= 1900-280= 1620 kcal
CHO: 1620 x 0.7= 1134 - 148 (dialysate)=
986/ 4=246.5 or 245 g
FAT: 1620 x 0.3= 486/9= 55 g

22. 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

23. Nutrient-Drug InteractionNutrient-Drug Interaction
Name 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

24. Nutritional Care PlanNutritional Care Plan
Identification of Problem
Parameters Medical Problems Nutritional Problem
Anthropometry None None (Normal BMI)
Biochemical Accumulation of BUN
and Creatinine
Anemia
Hyperkalemia
Uremic syndrome
Dietary Metabolic acidosis Gastric pain
Drug and Nutrient
Interaction
Furosemide causes
hypokalemia
Weakness
Others Hypertensive
UGIB
Nausea, Vomiting

25. Nutrient Implications andNutrient 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

26. Diet PrescriptionDiet Prescription
TER= 63 x 30= 1900 kcal
PRO= 63 x 1.1= 70 g
PRO kcal= 70 x 4= 280 kcal
Non PRO kcal= 1900-280= 1620 kcal
CHO: 1620 x 0.7= 1134 - 148 (dialysate)=
986/ 4=246.5 or 245 g
FAT: 1620 x 0.3= 486/9= 55 g

27. Diet PrescriptionDiet Prescription
Diet Rx: 1900 Calorie CHO245
PRO70 FAT55
148 kcal from dialysate
1200 mg P
3000 mg Na
2000 mg K
1800 mg Ca
1500 ml Fluid

28. 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 - 1 105
Lean Meat
Fish B.1 1/2 4 15 100 17.5 45 17.5 - 0.5 20.5
Egg 1 8 110 95 50 115 45 - 6 86
Total 44 375 1195 472.5 620 156.1 12 17.5 381.5
Food grp Ex Pro Na K Ca P Fluid CHO Fat Kcal
Veg grp A 2 1.2 4 120 30 30 60 3 - 16.8
Rice -
A -
B 6 24 920 240 80 140 40 138 - 648
Total 25.2 924 360 110 170 100 141 - 664.8
Total 1+2 69.2 1299 1555 582.5 790 256.1 153 17.5 1046.3
1.) HBV Protein
2.) LBV Protein

29. Meal Plan
Food grp Ex Pro Na K Ca P Fluid CHO Fat Kcal
Fruits
A 2 0.8 6 240 20 20 96 20 - 83.2
B 3 0.6 6 180 15 15 126 30 - 122.4
Sugar 8.5 - - - - - - 42.5 - 170
Total 1.4 12 420 35 35 222 92.5 - 375.6
Total 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 Kcal
Fat 3 0 120 6 3 3 3 - 15 135
A
B
Free foods 5 - - - - - - - 25 225
Total - 120 6 3 3 3 - 35 360
Total
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)

30. Meal PlanMeal Plan
Salt Solution= 3000- 1431= 1569mg
=1569/500
=3.138 or 3T
Additional calcium= 1800-620.5=1179.5
mg 2 tablets