Carolina Arango MNTII- Chronic Kidney Disease

1. The primary functions of the kidney include maintenance of homeostasis through control of fluid, pH, and electrolyte balance and blood pressure (BP). They are responsible for excreting metabolic end-products and foreign substances, as well as the production of the Renin enzyme and the hormones 1,25-dihydroxycholecalciferol and erythropoietin (1). 2. Diabetes, hypertension and glomerulonephritis are the leading conditions that can lead to kidney failure (1,2). Other risk factors include autoimmune diseases, systemic infections, urinary stones or lower urinary tract obstruction, neoplasia, history of acute kidney injury, reduction in kidney mass, and low birth weight (2). Additional risk factors include ethnicity (African Americans, Asians, Pacific Islanders, and American Indians are at higher risk), hereditary factors, and prolonged consumption of over-the-counter painkillers such as aspirin, acetaminophen, and ibuprofen (1,2) low income and low education, age over 60, and the exposure to some chemical and environmental conditions (2). 3. Damage to the kidney due to diabetes is the most common cause of Chronic Kidney Disease (CKD) in the United States. Type 2 (and Type 1) diabetes can lead to CKD because the constant hyperglycemia causes the glomerulus to thicken. The glomerulus, which is normally responsible for filtering blood and fluids that form urine, is destroyed as the kidney starts allowing more of the albumin protein to be excreted in the urine. As the number of functioning nephrons decline, those that are left must clear more solute, until they reach a limit. At this point the concentration in body fluid increases, causing azotemia (a buildup of nitrogenous waste products such as urea in the blood and body fluids) and uremia (symptoms caused by disordered biochemical processes) (1). 4. There are 5 stages of CKD (1): 1. 2. 3. 4. 5. Kidney damage with normal or increased Glomerular Filtration Rate (GFR) ( 90) Kidney damage with mild decrease in GFR (60-89) Moderate decrease in GFR (30-59) Severe decrease in GFR (15-29) Kidney failure (GFR of >15); requires dialysis

GFR is defined as mL/min/1.73 m. Although not an official stage, those with a GFR of 60 are at increased risk for CKD. 5. Upon admission, Mrs. Joaquin had the following signs/symptoms: Hypertension: B/P of 220/80 High creatinine and BUN levels High Potassium and Phosphorus Anorexia Edema

 Progressive shortness of breath (SOB) with 3-pillow orthopnea Inability to urinate Malaise (feeling of unease) Muscle cramps Pruritus (itching) 6. Treatment options for patients with stage 5 CKD include hemodialysis and peritoneal dialysis. Along with these treatments, each patient must follow a strict nutrition therapy to meet nutritional requirements, prevent malnutrition, minimize uremia and other CKD complications, and maintain blood pressure and fluid status (1) Kidney transplant is also available when necessary. 7. Dialysis is a renal replacement procedure that replaces the filtering function of healthy kidneys by removing excessive and toxic by-products, wastes, and toxins in patients with CKD. Two types are hemodialysis (HD) and peritoneal dialysis (PD). Although both methods require a selective semipermeable membrane that allows passage of water and small- to middle-molecular weight molecules and ions, the selective membrane used in hemodialysis is a man-made dialyzer, while in peritoneal dialysis the lining of the peritoneal wall serves as the selective membrane. Waste and toxins are then removed by the fluid known as the dialysate (1). In addition, during peritoneal dialysis, glucose is infused into the peritoneum through a catheter with the purpose of the dextrose concentration creating an osmotic gradient to remove excess fluid and toxins (3). 8. Nutrition Therapy 35 kcal/kg Rationale Adequate energy intakes are needed to maintain a proper body composition, reduce the risk for malnutrition, and prevent catabolism (1,3) A higher protein intake is recommended to maintain a proper protein balance and body composition to reduce the risk for proteinenergy malnutrition (3) A low-potassium diet is needed to avoid hyperkalemia (3) Phosphorus intake should be decreased to avoid hyperphosphatemia (3) A sodium restriction is recommended to avoid large interdialytic weight gains, hypertension, edema, pleural effusion and congestive heart failure (3) A fluid restriction is recommended to avoid large interdialytic weight gains, hypertension, edema, pleural effusion and congestive heart failure (3)

1.2 g protein/kg

2gK 1 g phosphorus 2 g Na

1,000 mL fluid + urine output

9. BMI = (170/60 in) x 703 = 33.2; a person with a BMI of 33 or above is considered obese. However, Mrs. Joaquin has 3+ pitting edema, and has gained 4kg in the past two weeks, which means much of her current weight is water retention. 10. Edema-free weight is calculated from an equation derived from NHANES II data (1). It is used to get a better estimate of the patients actual weight minus the edema, and can be calculated as follows: aBWef = BWef + [(SBW BWef) x 0.25] 165lbs + (100lbs-165lbs) x 0.25 = 148.75lbs (67.6kg) 11. The energy requirements for CKD patients not on dialysis are 23 kcal/kg to 35 kcal/kg (2), while patients on hemodialysis require 35 kcal/kg/day (1). 12. Mrs. Joaquins energy needs once she is on hemodialysis will be, at 35 kcal/kg: 67.6kg x 35kcal/kg = 2,366 kcal/day 13. Mrs. Joaquins protein needs once she is on hemodialysis will be, at 1.2 g/kg: 67.6kg x 1.2 g/kg = 81 g protein/day 14. Protein needs are higher for patients on dialysis due to protein losses from the treatment. Currently, Mrs. Joaquins protein needs on hemodialysis are 1.2 kg/g of body weight. If she were on peritoneal dialysis (PD) they would be 1.2 to 1.3 g/kg (3). Her current calorie needs are at 35 kcal/kg of body weight. If she were on PD her needs would require the addition of any protein absorbed from the dialysate (3). 15. Vegetarian diets tend to be lower in protein, requiring that CKD patients on these diets monitor their protein status closely due to occurring losses during dialysis. Because plant proteins are a significant source of potassium and phosphorus, these minerals tend to be harder to control. Patients following a vegetarian diet may need phosphate binders to manage their phosphorus levels (3). 16. Currently, Mrs. Joaquins labs reveal elevated PO4 levels of 9.5 mg/dL. Phosphate is avoided to prevent hyperphosphatemia in patients with CKD (1,3). Too much of it stimulates the parathyroid hormone, breaking down bone and leading to bone disease and osteoporosis. 17. Foods high in phosphorus include beverages such as ales, drinks made with chocolate or milk, canned iced teas, cocoa, beer, and dark colas; dairy products such as cheese, custard, milk, cream soups, cottage cheese, ice cream, pudding, and yogurt; animal proteins such as carp, beef liver, fish roe, oysters, crayfish, chicken liver, organ meats and sardines; legumes; whole grain products, bran cereals, nuts and seeds. 18. Mrs. Joaquin, you will need to monitor your fluid intake from now on. Fluids include drinks and foods that are liquids at room temperature. These include (3): Clear or fruit-flavored drinks that have bubbles Coffee Fruit drinks Fruit or vegetable juice Ice cream, frozen yogurt, sherbet Milk, non-dairy creamers Popsicles, juice bars

 Soda pop Soup Tea Water Jell-O You should consume no more than 1 L of fluid a day. Also, keep track of your fluid output to replenish this amount on top of the 1 L. 19. The following tips are recommended for reducing thirst in patients who need to follow a diet with fluid restrictions (1): Limiting high-salt foods Drinking from small glasses and cups Drinking only when thirsty Use sour candy or sugar free gum to keep mouth moist Add lemon juice to water or ice Swish mouth with very cold water or low-alcohol mouthwash when thirsty Brush teeth often Keep lips moist Use ice cubes Freeze grapes and fruits to eat throughout the day Nutrition problems within the intake domain are (5): Inadequate energy intake NI-1.2 Malnutrition NI-5.2 Inadequate oral/food beverage intake NI-2.1 Excessive fluid intake NI-3.2 Excessive protein intake NI-5.7.1 Excessive mineral intake (potassium phosphorus, sodium) NI-5.10 The glomerulus is a network of thin-walled capillaries that filter a protein-free plasma into the tubular component. The glomerular filtrate is collected by the Bowmans capsule. The filtration ability of the glomerulus is known as the glomerular filtration rate (GFR), which has a normal value of 125 mL/min (1). GFR is measured through 24 hour urine collection and a blood test using serum creatinine level and age, weight, gender, and body size (6). Mrs. Joaquins GFR of 28 mL/min reveals a severe decreased GFR and that she is in level 4 CKD. The following labs (must be evaluated) support Mrs. Joaquins diagnosis of stage 4 CKD: Low albumin Low sodium High potassium Low chloride High PO4 High BUN High creatinine Upon admittance to the hospital, Mrs. Joaquin weighed 170 lbs. On her second day at the hospital, postdialysis, her weight dropped 5 lbs. due to vomiting and her dialysis treatment, which began to get rid of waste products and excess fluids she was retainingevidenced by her 3+ pitting edema upon admission (1).

20.

21.

22. 23. 24.

25.

26. Through the hemodialysis treatment, Mrs. Joaquins lab values will also improve. She will lower her potassium and phosphorus levels. Her appetite should improve, and feelings of N/V should diminish (7). Mrs. Joaquin will also get rid of much of the water retention she currently has, improving her current pitting edema. 27. Medication Indications/Mechanism Nutritional Concerns Vasotec (Enalapril) Antihypertensive (ACE Must insure adequate fluid inhibitor), to treat diabetic intake, low sodium and low nephropathy (8) calorie diet may be recommended. Avoid salt substitutes. Anorexia and weight loss have been reported (8) Erythropoietin Antianemic, stimulates RBC N/V, diarrhea. May need Fe, production (8) Vit B12 or Folate supplement (8) Vitamin/mineral supplement Vitamin and mineral Recommended due to high supplementation is water losses and low recommended due to high consumption of fruits, water losses and low vegetables, whole grains, and consumption of fruits, dairy (8) vegetables, whole grains, and dairy (8) Calcitriol Ca regulator, active Vit D3, Do not supplement Vit D or treats hypocalcemia in dialysis Mg. consume adequate Ca patients (8) and low P. Increases Ca absorption, may cause anorexia, weight loss, increased thirst, dry mouth, and a metallic taste (8) Glucophage Antihyperglycemic agent, Take with meals to lower GI potentiates the effect of distress. May cause anorexia, insulin, decreases glucose metallic taste, dyspepsia, absorption in GI and decreases N/V, bloating, diarrhea, hepatic glucose production (8) flatulence, constipation (8) Sodium bicarbonate Antacid, alkalinizing agent (8) Take Fe supplement separately, high Ca or milk may cause milk-alkali syndrome. May cause belching, gastric distention, cramps, flatulence (8) Phos Lo Phosphate-binder for use in Take drugs with meals, avoid renal failure (8) Cs supplement. May cause decreased Fe absorption, anorexia, N/V, constipation (8)

28. Nutrition problems within the intake domain are (5): Excessive mineral intake potassium, phosphorus, sodium NI-5.10.2 Inadequate protein-energy intake NI-5.3 29. The Pima Indians of Arizona have been diagnosed with the worlds highest incidence of type 2 DM. Half of adult Pima Indians have diabetes and 95% of those are overweight. End-stage renal disease (ESRD) is 20 times higher amongst the Pima than the entire US population (7). 30. The thrifty gene theory states that people have a genetic tendency to retain fat. Because certain populations experienced feasting and famine alternated, they developed a thrifty gene that allows them to store more fat to save them from starvation. Now, as they follow a Western diet and lifestyle of fatty foods and low exercise, the thrifty gene causes them to store more calories and gain weight (7). 31. Kidney failure amongst the Pima Indians is 20 times higher than in other groups (7). American Indians experience CKD 6 times more frequently than non-Hispanic whites (7), many believe as a cause of the thrifty gene. 32. Limited adherence to nutrition-related recommendations (NB-1.6) related to placing low importance to recommendations as evidenced by diet assessment reporting high intake of high sodium processed foods, high phosphate foods such as soda, and high potassium foods such as potatoes. Impaired nutrient utilization (NC-2.1) due to chronic kidney disease as evidenced lab values of sodium: 130mEq/L; chloride: 91mEq/L; potassium: 5.8mEq/L; PO4 9.5mg/dL. 33. Goals/intervention: Limited adherence to nutrition-related recommendations (NB-1.6): 1) aware patient on the importance of following nutrition-related recommendations for her DM and CKD. 2) Educate patient on foods allowed. 3) Help patient come up with ideas to incorporate allowed foods into her meals while avoiding undesirable foods for her condition. Impaired nutrient utilization (NC-2.1): 1) Aware patient of the importance of consuming foods that are appropriate for her DM and CKD. 2) Discuss with patient foods options she will enjoy out of the recommended foods. 3) Help patient find ways to incorporate adequate foods she will enjoy. 34. Patients on dialysis burn many calories and lose protein during each session. Patients need to consume adequate calories in order to prevent weight loss and malnutrition. They also need to maintain an adequate protein intake so the body does not begin to use protein as an energy source, inhibiting the important functions of protein in the body. 35. It is recommended that regardless of the amount of protein the patient consumes, 50-75% should be of high biological value, mainly from lean poultry, fish, and soy-and vegetable-based proteins. Because many amino acid losses occur, it is necessary for patients to obtain all necessary amino acids to create adequate amounts of protein in the body, and create less nitrogenous wastes (7). 36. Supplementation of the B-complex, water-soluble vitamins, is required for patients during dialysis due to increased losses, anorexia and poor dietary intake. However, fat soluble vitamins like vitamin A are not recommended as they can reach toxic levels. During HD and PD, serum vitamin A levels are elevated due to increased serum retinal-binding protein, decreased kidney metabolism, and failure of dialysis to remove vitamin A (1). 37. There are several resources available to teach Mrs. Joaquin about her diet. The National Kidney Disease Education Program a simple 5 step process to eating right. PDFs can be accessed at their website: http://nkdep.nih.gov/resources/eating-right.shtml. The National Kidney

Foundation also has a very informational website that details all foods to consume and avoid (http://www.kidney.org/atoz/atozTopic_KidneyDisease.cfm). These sources can be very beneficial as she familiarizes herself with her new diet. 38. During hemodialysis, Mrs. Joaquin requires: 2,366 kcal/day 81 g protein/day 2 g (2,000mg) Na/day 2-3g (2,000-3,000mg) K/day 850-1,020mg phosphorus/day <2g (2,000mg) Ca/day 1000 cc + output/day Diet PTA Breakfast: Cold cereal ( c unsweetened) Nutrition Adherence Make sure cereal is non-bran kind. Bran cereal has 90-160mg more of phosphorus per cup than non-bran cereal (6). Phosphorus should be limited in patients with CKD. Potatoes are high in potassium. If Mrs. Joaquin wants to continue her consumption of potatoes, she should leach them by peeling 1/8 inch thick, peeled wedges in 10 times the amount of warm water to the amount of vegetables for a minimum of 2 hours, then cooking in 5 times the amount water to the amount of vegetable (6). This procedure will help pull some of the potassium out of highpotassium foods. Patients with CKD are allowed protein as long as consumption is within recommended guidelines Bologna is high in sodium and fat Potatoes are high in potassium and chips are high in sodium and fat A can ofGinger Ale has 3mg of phosphorus vs. 55mg found in a can of coke (6). Phosphorus Sample Menu 1 cup of Corn flakes cereal

Bread (2 slices) or fried potatoes (1 med potato)

1 slice of white bread

1 fried egg

1 fried egg

Lunch: Bologna sandwich (2 slices of bread, 2 slices bologna, mustard) Potato chips (1 oz)

1 cup of pasta with 3 oz of chicken 4 Vanilla Wafer cookies

1 can coke

1 can of Ginger Ale

Dinner: Chopped meat (3 oz beef)

3 oz of beef are ok. Ct can also use another protein source such as chicken or lamb. Fried potatoes (1 medium) 1. Potatoes are high in potassium. 2. Leach potatoes before If Mrs. Joaquin wants to consuming. continue her consumption of potatoes, she should leach them by peeling 1/8 inch thick, peeled wedges in 10 times the amount of warm water to the amount of vegetables for a minimum of 2 hours, then cooking in 5 times the amount water to the amount of vegetable (6). This procedure will help pull some of the potassium out of highpotassium foods. HS Snack: Crackers (6 saltines) and peanut butter (2 tbsp) Peanut butter is high in potassium. Because Mrs. Joaquin has a potassium limit, she can replace this snack for one that of the recommended low-potassium foods. cup of unsweetened apple sauce and crackers.

should be limited in patients with CKD. Protein is ok for CKD patients as long as it is within recommended guidelines.

39. (9)

Date

Breakfast
1 large slice Bread, white

Lunch
1 medium (23/4" across) Apple, raw

Dinner
3 ounce(s) cooked, no bone Chicken, breast, boneless, skinless, roasted, grilled, or baked

Snacks
1 coffee cup (6 fl oz) Cafe con leche, with whole milk

03/06/13

1 cup Corn flakes cereal

4 medium Cookies, vanilla cream wafer

cup Kale, fresh, cooked (no salt or fat added)

4 medium Cookies, vanilla cream wafer

1 large egg(s) Egg, fried, with vegetable oil

3 ounce(s) cooked, no bone Lamb, loin chop, cooked, lean and fat eaten

cup, pieces or slices Mushrooms, raw

tablespoon Jelly, all flavors

1 cup, shredded or chopped Lettuce, mixed (mixed greens, salad mix, spring mix), raw

1 tablespoon Olive oil

1 small (2-1/2" across) Peach, raw

1 cup Rice, white, regular, cooked (no salt or fat added)

1 cup Pasta, (macaroni, rotini, ziti, shells, lasagna noodles), cooked (no salt or fat added)

cup (school carton) Whole milk

2 tablespoon Salad dressing, Italian, vinegar and oil

cup, diced Pineapple, raw

1 can (12 fl oz) Soft drink, ginger ale

1 mug (8 fl oz) Tea, herbal

(9)

Nutrients
Total Calories Protein (g)*** Protein (% Calories)*** Carbohydrate (g)*** Carbohydrate (% Calories)*** Dietary Fiber Total Fat Saturated Fat Monounsaturated Fat

Target
2000 Calories 46 g 10 - 35% Calories 130 g 45 - 65% Calories 25 g 20 - 35% Calories < 10% Calories No Daily Target or Limit No Daily Target or Limit 12 g 5 - 10% Calories 1.1 g 0.6 - 1.2% Calories No Daily Target or Limit No Daily Target or Limit < 300 mg

Average Eaten
2167 Calories 81 g 16% Calories 270 g 50% Calories 14 g 35% Calories 10% Calories 16% Calories

Status
Over OK OK OK OK Under OK Over No Daily Target or Limit No Daily Target or Limit OK OK OK OK No Daily Target or Limit No Daily Target or Limit Over

Polyunsaturated Fat

7% Calories

Linoleic Acid (g)*** Linoleic Acid (% Calories)*** -Linolenic Acid (g)*** -Linolenic Acid (% Calories)*** Omega 3 - EPA

15 g 6% Calories 1.9 g 0.8% Calories 10 mg

Omega 3 - DHA

35 mg

Cholesterol

391 mg

Minerals
Calcium Potassium Sodium** Copper Iron Magnesium Phosphorus Selenium Zinc

Target
1000 mg 4700 mg < 2300 mg 900 g 18 mg 310 mg 700 mg 55 g 8 mg

Average Eaten
561 mg 2084 mg 1973 mg 1235 g 21 mg 206 mg 1016 mg 129 g 8 mg

Status
Under Under OK OK OK Under OK OK OK

Vitamins
Vitamin A Vitamin B6 Vitamin B12 Vitamin C Vitamin D Vitamin E Vitamin K Folate Thiamin

Target
700 g RAE 1.3 mg 2.4 g 75 mg 15 g 15 mg AT 90 g 400 g DFE 1.1 mg

Average Eaten
945 g RAE 2.3 mg 6.6 g 94 mg 5 g 9 mg AT 687 g 783 g DFE 2.0 mg

Status
OK OK OK OK Under Under OK OK OK

Riboflavin Niacin Choline

1.1 mg 14 mg 425 mg

2.6 mg 36 mg 348 mg

OK OK Under

(9) 40. Initial medical record note after consultation: ADIME A: 24 y.o. woman with DM type II and BP 220/80. Pt was diagnosed with stage 3 kidney disease 2 yrs ago. Poorly compliant to diabetes treatment. Reports anorexia, N/V, 20 lb weight gain in the past 2 weeks, edema in extremities, face and eyes, malaise, shortness of breath with 3-pillow orthopnea, pruritus, muscle cramps and inability to urinate. Takes glucophage 850mg 2/d; vasotec 20mg 3/d. Ht: 50; Wt: 170lbs; BMI: 33.2 (obese); IBW: 110lbs; %IBW: 155%. 24-hour food recall reveals

mean average intake of 1833kcal (77% of needs) and 65g of protein (80% of needs). Labs: BUN: 69mg/dL; glucose: 282mg/dL; sodium: 130mEq/L; chloride: 91mEq/L; potassium: 5.8mEq/L;
PO4 9.5mg/dL.

Food record reveals usual intake of 1833kcal (77% of recommended) and 65g of protein (80% of recommended). Recommended (while on hemodialysis): 2366kcal/day; 81g protein/day
D: Limited adherence to nutrition-related recommendations (NB-1.6) related to placing low importance to recommendations as evidenced by diet assessment reporting high intake of high sodium processed foods, high phosphate foods such as soda, and high potassium foods such as potatoes. Impaired nutrient utilization (NC-2.1) due to chronic kidney disease as evidenced lab values of sodium: 130mEq/L; chloride: 91mEq/L; potassium: 5.8mEq/L; PO4 9.5mg/dL. I: Educate pt on: 1) Importance of adherence to nutrition-related recommendations 2) Renal diet food recommendations 3) Foods high in potassium, sodium, phosphorus that should be avoided 4) How to consume foods she enjoys while abiding to guidelines M/E: 1) Monitor patients lab values (K, Na, PO4) 2) Assess patients compliance to diet recommendations 3) Monitor patients weight SOAP

S : 24 y.o. woman with DM type II and BP 220/80 reports anorexia, N/V, 20 lb weight gain in the past 2 weeks, edema in extremities, face and eyes, malaise, shortness of breath with 3-pillow orthopnea, pruritus, muscle cramps and inability to urinate. Pt reports poor compliance to diabetes treatment. O: Pt was diagnosed with stage 3 kidney disease 2 yrs ago. Takes glucophage 850mg 2/d; vasotec 20mg 3/d. Ht: 50; Wt: 170lbs; BMI: 33.2 (obese); IBW: 110lbs; %IBW: 155%. 24-hour food recall reveals

mean average intake of 1833kcal (77% of needs) and 65g of protein (80% of needs). Labs: BUN: 69mg/dL; glucose: 282mg/dL; sodium: 130mEq/L; chloride: 91mEq/L; potassium: 5.8mEq/L;
PO4 9.5mg/dL.

Food record reveals usual intake of 1833kcal (77% of recommended) and 65g of protein (80% of recommended). Recommended (while on hemodialysis): 2366kcal/day; 81g protein/day
A: Limited adherence to nutrition-related recommendations (NB-1.6) related to placing low importance to recommendations as evidenced by diet assessment reporting high intake of high sodium processed foods, high phosphate foods such as soda, and high potassium foods such as potatoes. Impaired nutrient utilization (NC-2.1) due to chronic kidney disease as evidenced lab values of sodium: 130mEq/L; chloride: 91mEq/L; potassium: 5.8mEq/L; PO4 9.5mg/dL. P: 1) Educate pt on importance of adherence to nutrition-related recommendations 2) Teach renal diet food recommendations 3) Educate pt on foods high in potassium, sodium, phosphorus that should be avoided 4) Help pt understand how to consume foods she enjoys while abiding to guidelines 5) Monitor patients lab values (K, Na, PO4) 6) Assess patients compliance to diet recommendations 7) Monitor patients weight

Terms learned 1. 2. 3. 4. Pruritus: itching (10) Orthopnea: shortness of breath when the person is laying flat (10) Malaise: feeling of general discomfort or uneasiness (10) Sarcoidosis: a disease in which inflammation occurs in the lymph nodes, lungs, liver, eyes, skin, or other tissues (10) 5. Dialysate: the fluid and solutes in a dialysis process that flow through the dialyzer, dont pass through the membrane, and are then discarded along with removed toxic substances (1) 6. Dialyzer: the machine used to perform dialysis treatments (10) 7. Myeloma: a tumor composed of cells of the same type found in bone marrow (10)

8. Gravida/para: shorthand for: Gravida- number of times a woman has been pregnant; Paranumber of births >20 weeks births (10) 9. Asterixis: abnormal, involuntary movements that affect extremities (1) 10. Microalbuminuria: the leacing of small amounts of albumin into the urine by the kidneys nephritic syndrome (1) Nutrition Assessment Mrs. Joaquin is a 24 year old woman who was diagnosed with type 2 DM at the age of 13. She is from the Pima Indian tribe, which puts her at higher risk for DM. She has DM in her family from both her father and mother. Mrs. Joaquin has high BP as evidenced by a BP of 220/80 upon admittance to the hospital. She was also diagnosed with stage 3 kidney disease 2 years ago and is now complaining of gastric, abdominal pain, heartburn, anorexia, nausea, and vomiting. She has had a rapid weight gain of 20 lbs in the past 2 weeks, and reports to the hospital with edema (in extremities, face and eyes), malaise, shortness of breath with 3-pillow orthopnea, pruritus, muscle cramps and inability to urinate. Currently, she takes glucophage (850mg 2/d) for her diabetes. Upon admittance, she had abnormal labs of high BUN: 69mg/dL; high glucose: 282mg/dL; low sodium: 130mEq/L; low chloride: 91mEq/L; high potassium: 5.8mEq/L; high PO4 9.5mg/dL. Mrs. Joaquins anthropometrics are as follows: Ht: 50; Wt: 170lbs; BMI: (170lbs/60in) x 703 = 33.2 (obese) IBW: 100 + 5(0) = 100lbs; %IBW: (170/100) x 100 = 170%. Using her adjusted weight [165lbs + (100lbs-165lbs) x 0.25 = 148.75lbs (67.6kg)], her recommended needs are 2366kcal/day (67.6kg x 35kcal/kg) and 81g protein/day (67.6 x 1.2g/kg). Her 24-hour food recall reveals a mean average intake of 1833kcal (77% of needs) and 65g of protein (80% of needs). Food record reveals usual intake of 1833kcal (77% of recommended) and 65g of protein (80% of recommended). Her current recommended needs while on hemodialysis are 2366kcal/day and 81g protein/day, as well as 1000cc plus whatever amount she excretes.

24-hour food intake

Date

Breakfast
cup 100% Natural Cereal, plain

Lunch
1 sandwich Bologna sandwich, with margarine

Dinner
3 ounce(s) cooked, no bone Beef, steak, grilled or broiled, lean

Snacks
6 square Crackers, saltine

03/05/13

and fat eaten

1 large egg(s) Egg, fried, with vegetable oil

1 single serving bag (1 oz) Potato chips

1 portion (made from 1 medium potato) French fries, fresh, deep fried

2 tablespoon Peanut butter

1 medium (21/4" to 3" across) Potatoes, roasted (with salt, no fat added)

1 can (12 fl oz) Soft drink, cola (Pepsi, Coke)

Nutrients
Total Calories Protein (g)*** Protein (% Calories)*** Carbohydrate (g)***

Target
2000 Calories 46 g 10 - 35% Calories 130 g

Average Eaten
1833 Calories 65 g 14% Calories 212 g

Status
OK OK OK OK

Carbohydrate (% Calories)*** Dietary Fiber Total Fat Saturated Fat Monounsaturated Fat

45 - 65% Calories 25 g 20 - 35% Calories < 10% Calories No Daily Target or Limit No Daily Target or Limit 12 g 5 - 10% Calories 1.1 g 0.6 - 1.2% Calories No Daily Target or Limit No Daily Target or Limit < 300 mg

46% Calories 18 g 42% Calories 11% Calories 17% Calories

OK Under Over Over No Daily Target or Limit No Daily Target or Limit OK OK OK OK No Daily Target or Limit No Daily Target or Limit OK

Polyunsaturated Fat

11% Calories

Linoleic Acid (g)*** Linoleic Acid (% Calories)*** -Linolenic Acid (g)*** -Linolenic Acid (% Calories)*** Omega 3 - EPA

21 g 10% Calories 1.6 g 0.8% Calories 2 mg

Omega 3 - DHA

18 mg

Cholesterol

294 mg

Minerals
Calcium Potassium Sodium** Copper Iron

Target
1000 mg 4700 mg < 2300 mg 900 g 18 mg

Average Eaten
299 mg 3020 mg 1986 mg 1204 g 12 mg

Status
Under Under OK OK Under

Magnesium Phosphorus Selenium Zinc

310 mg 700 mg 55 g 8 mg

277 mg 1045 mg 65 g 11 mg

Under OK OK OK

Vitamins
Vitamin A Vitamin B6 Vitamin B12 Vitamin C Vitamin D Vitamin E Vitamin K Folate Thiamin Riboflavin Niacin Choline

Target
700 g RAE 1.3 mg 2.4 g 75 mg 15 g 15 mg AT 90 g 400 g DFE 1.1 mg 1.1 mg 14 mg 425 mg

Average Eaten
114 g RAE 2.2 mg 2.6 g 63 mg 1 g 10 mg AT 49 g 271 g DFE 1.0 mg 1.0 mg 20 mg 318 mg

Status
Under OK OK Under Under Under Under Under Under Under OK Under

References 1. Nelms M, Sucher KP, Lacey K. Roth, SL. Nutrition Therapy & Pathophysiology. 2nd ed. Belmont, CA: Wadsworth, Cengage Learning: 2011. 2. Nutrition Care Manual. Academy of Nutrition and Dietetics. 2012. Available at: http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=23081&ncm_heading=Risk%20 Screen. Accessed March 3, 2013. 3. Nutrition Care Manual. Academy of Nutrition and Dietetics. 2012. Available at: http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=255666&ncm_heading=Nutriti on%20Care. Accessed March 3, 2013. 4. Nutrition Care Manual. Academy of Nutrition and Dietetics. 2012. Available at: http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=23081&ncm_heading=Meal%2 0Plans. Accessed March 3, 2013. 5. International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. 4th ed. The American Dietetic Association, 2013. 6. Tests to measure kidney function, damage and detect abnormalities. National Kidney Foundation. 2013. http://www.kidney.org/atoz/content/kidneytests.cfm. Accessed March 3, 2013. 7. Schwartz V. Renal Disease. Available at: https://learn.dcollege.net/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2F webapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_26289_1% 26url%3D. Accessed March 1, 2013. 8. Pronsky ZM, Crowe, JP. Food Medication Interactions. 17th ed. Birchrunville, PA: Food Medication Interactions; 2012. 9. SuperTracker. United States Department of Agriculture website. Available at: https://www.supertracker.usda.gov/foodtracker.aspx.Updated2012. Accessed March 8, 2013. 10. The free dictionary by farlex. 2013. Available at: http://medicaldictionary.thefreedictionary.com/. Accessed March, 10, 2013.