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

General InformationGeneral Information

Name of patient: JG

Ward No. 3

Age: 46

Date of Admission: July 14, 2008

Hospital: Philippine General Hospital (PGH)

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)

Medical HistoryMedical History

Present Illness: CKD stage 5 secondary to Hypertensive Nephrosclerosis

Anemia Hyperkalemia Metabolic Acidosis UGIB

Chief Complaint: Generalized weakness

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

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

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

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

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

EtiologyEtiologyMetabolic disorder like Diabetes

MellitusExcessive pressure against the

blood vessel walls or hypertension

Genetic factors

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

IncidenceIncidence

IncidenceIncidence

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

Meal PlanMeal PlanSalt Solution= 3000- 1431=

1569mg=1569/500=3.138 or 3T

Additional calcium= 1800-620.5=1179.5 mg 2 tablets