Case Study: Chronic Kidney Disease

Qn. 1 What percentage of the U.S population suffers from chronic kidney disease and what percentage of these cases results from hypertension?

CKD is most common among adults in the United States. According to The Center for Disease Control and Prevention“National Chronic Kidney Disease Fact Sheet, 2014”, it estimates that more than 10 percent of adults in the United States may be suffering from CKD of varying levels of seriousness. The report adds that the chances for a person having CKD increases with age. It increases after age 50 and is most prevalent among adults older than 70 years.

Adults with diabetes or high blood pressure, or both have been identified to have a higher than average predisposition of developing CKD than those without these diseases (Center for Disease Control and Prevention; National Chronic Kidney Disease Fact Sheet, 2014). Approximately 1 of 3 (34 percent) adults with diabetes and 1 of 5 (20 percent) adults with high blood pressure has CKD. It is worth noting that men with CKD are 50 percent more probable to than women to develop kidney failure.

Qn.2 Explain how chronic disease progresses, what happens to GFR, serum creatinine levels, and BUN as renal function deteriorates?

In the early stages of chronic kidney disease the patient will have symptoms such as anorexia, exercise intolerance, fatigue and headache. He will also experience hyper-coagulation and hypertension as well as proteinuria/ hematuria (blood in urine).In the advanced stages of CKD, symptoms such as anemia and bleeding tendency, cardiovascular disease, confusion and mental impairments, as well as electrolyte imbalances will be exhibited. The patient will also experience fluid retention and edema, hormonal abnormalities, itching, metabolic acidosis, nausea and vomiting, peripheral neuropathy, protein-energy malnutrition and reduced immunity in addition to renal osteodystrophy.

Some of the key indicators that can be used to diagnose CKD is through the use of GFR, serum creatinine levels and BUN.As the renal functions deteriorate:

  1. BUN increases from its normal value of less than 20 mg/dL (7.1 mmol/L) to approximately 80-100 (35 mmol/L);
  2. Creatinine increases from its normal value of less than 1.0 mg/dL (88 mmol/L) to approximately 10 (884 mmol/L); and
  3. GFR falls to less than 10-15 ml/1.73 m2

Qn. 3 Describe the clinical effects commonly observed during the final stages of disease, when kidney failure develops. Explain the significance of each of Mr. Jefferson’s physical complaints and the swelling in his extremities.

Kidney failure occurs when the kidneys can no longer remove waste from the blood. It is also called End-Stage Renal Disease (ESRD) or Stage 5 CKD. When a patient has developed this, he will need dialysis or a kidney transplant to survive. All CKD patients have fixed proteinuria, and an elevated BUN or serum creatinine concentration.Progression of CKD is predicted in most cases by the degree of proteinuria. Patients with nephritic-range proteinuria (> 3 g/24 h or urine protein/creatinine > 3) usually have a poorer prognosis and progress to renal failure more rapidly. Progression may ensueeven if the underlying disorder is not active. In patients with urine protein < 1.5 g/24 h, progression usually occurs slowlyif at all. Hypertension, hyperparathyroidism, and acidosis are associated with more rapid progression as well.

During the final stages of the disease, patients usually exhibitProgressive metabolic acidosis, Hypertension develops due to the retention ofNaCl, acute cardiovascular events especially stroke and myocardial infarction, heart failure is also common due to sodium and water retention and anorexia and morning vomiting in the gastrointestinal tract isalso common

Loss of appetite, nausea and vomiting, metallic taste in the mouth, ammonia-like odor to the breath, severe fatigue, and inability to stay awake and to concentrate, swelling of the legs, arms, and face, shortness of breath, itching and Muscle twitching are usually the common symptoms of advance kidney failure and ESRD. These symptoms are consistent with the symptoms that Mr. Jefferson was experiencing.

Mr. Jefferson complained of swelling of the ankles and feet, drowsiness, reduced sensation in the hands and feet, and examination revealed a 9 pound weight gain.The swelling of the ankles and feet is one of the health problems resulting from CKD. This occurs when the body holds in too much or excess fluid, which leads to the swelling of the arms and legs. This can also explain the increased body weight as the retention of excess fluids means the body is holding more than normal levels of fluid.The reduced sensation in the hands and feet could be as a result of Myopathy which affects the proximal upper and lower extremities resulting to functional disabilities. This is because of increased levels of PTH, reducedlevels of vitamin D andphosphate, as well asdisproportionateaccumulation of aluminum. The drowsiness he was experiencing at work could be a result of anemia. This is because the number of red blood cells was decreasing, making the Mr. Jefferson feel tired and weak.

Qn. 4 Explain why a low sodium, low protein diet was prescribed to Mr. Jefferson at a former visit. What specific amounts of dietary energy Kcals and protein per day were probably recommended at that time? Show your calculations?

In people with diabetes, excessiveintake of protein may be haveharmful effects on the body. Experts advocatethat patients with kidney disease of diabetes consume the recommended dietary allowance for protein, but avoid high-protein diets. The doctor most probably diagnosed him with a reduced kidney function and therefore, recommended the diet containing reduced amounts of protein to help delay the onset of kidney failure.

The minimum daily dietary protein intake for patients with stage 4-5 CKD and not in dialysis is 0.75 g/kg IBW/day.Mr. Jefferson had a body weight of 160 pounds (72.57kg) and 5 feet 8 inches (173cm) tall. The ideal weigh for someone with the height 173cm is between55.37 and 74.79 Kgs.  Therefore, his weight of 72.57kg was within the ideal body weight.

Based on the recommended minimum daily dietary protein intake for patients with stage 4-5 CKD and not in dialysis as 0.75 g/kg IBW/day. His protein intake per day would therefore, be:

0.75 g/kg IBW/dayX72.57kg=54.42g

The recommended daily energy intake is 30-35 kcal/kg IBW/day is recommended for patients, depending also on age and physical activities. Therefore, his energy Kcals intake would be:

35 kcal/kg IBW/dayX72.57= 2539.95Kcal

Qn. 5 The physician determines that Mr. Jefferson kidney disease has reached the final stage and prescribes hemodialysis. How will dialysis alter Mr.Jefferson’s diet? Calculate his new protein recommendation, and compare it to the amount prescribed prior to dialysis.

As kidney functions worsen, it may be necessary to alter diet to reduce the problems caused by these substances accumulating.The nutrition needs for Mr. Jefferson will be dependent on the type of dialysis treatment he chooses, his blood test results and any other medical conditions that he may have, such as diabetes or heart disease.

Eating foods that are rich in protein is important because when he will be undergoing dialysis he can lose up to 1-2 ounces of protein through treatment. This implies that his protein requirements would increase. A general guideline to follow would be 7-10 ounces of protein per day.Salt and Sodium will also be an important part of the meal to consider in the diet. It is the mineral that helps control the level of fluids in the body, but in excess it will result to the body holding more water which can cause swelling of the hands and legs. This extra fluid gain can also lead to increased weight and longer dialysis time. Therefore it would be advisable to use less salt and eat fewer salty foods.

Fluid control will also be an important aspect when undergoing dialysis. It would be advisable to take fluids but resist the urge ti drink a lot of water. Foods containing Potassium and phosphorus are also other nutrients that would be under monitor. If the level is too high, serious heart problems may arise and also bone loss can occur.

During dialysis, theminimum dailyrecommended dietary protein intake for patients ondialysis is 0.8-1 g/kg IBW/day. Therefor during dialysis, Mr. Jefferson daily protein would be:

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