Medical Nutrition Therapy: Nephrology Module - Essay Example

Medical Nutrition Therapy - Nephrology Module Discuss the following functions of the normal kidney Excretory This is concerned with the elimination of waste materials and excess water from the body that have been produced through the process of homeostasis. This function is aided by the production of the antidiuretic hormone (ADH). Again, the kidney would maintain a proper balance between body electrolytes and water (Byham-Gray, Burrowes & Chertow, 2008). Subsequently, through the secretion of hormones such as erythropoietin, renin, and calcitriol, the kidney regulates the endocrine system’s activities, red blood cells, and the blood pressure. Acid-base balance The kidney regulates the urine acidity through the filtration of the water and body fluids that passes through it. As such, to regulate the balance, the kidney generates and reclaims bicarbonates and secretes the excess acids through the processes of acidosis and alkalosis, respectively. During alkalosis process, more bicarbonate is excreted by the kidneys due to the decrease in the secretion of hydrogen, while in acidosis, more bicarbonates are reabsorbed by the kidneys; thus, leading to more NH3 being formed (Danovitch, 2010). Endocrine The kidney is responsible for the production of calcitriol, erythropoietin, and renin hormones that it uses to synthesize prostaglandins. Subsequently, through the endocrine function, the kidney degrades the parathyroid and insulin hormones (Korbet, Schwartz & Lewis, 2000). The endocrine system also stimulates increased production of red blood cells. Fluid-electrolyte balance Electrolytes are used for regulation of the muscle and nerve functions in the body and maintenance of the acid-base balance. The kidney plays this function through the maintenance of the concentrations of the electrolytes by filtering them from the blood (Hickson, Gera, Amer, Iqbal, Moore, Milliner & Griffin, 2009). Explain how the kidney makes urine The process of making urine by the kidney entails three main processes, namely, filtration, reabsorption, and secretion. In the filtration stage, soluble constituents like wastes and water are transferred from the glomerulus and blood. In the second stage, ions, molecules, and water essential to the body for the maintenance of homeostasis get reabsorbed into the blood from the glomerular. In the final stage of secretion, items like drugs, creatinine, and hydrogen ions are transferred to the collecting duct before being discharged through the urethra. Define Glomerular Filtration Rate (GFR) Relates to a test applied in testing the level of functionality of the kidney and the stage of a kidney disease through a description of the rate of flow of fluids that filters through it. 2. List the 5 stages of Chronic Kidney Disease (CKD) with the criteria used to define each. Damage to the kidney and protein detected in the urine. Criterion is a GFR greater than 90. Mild decrease in the GFR with damage to the kidney. The criterion is a GFR of 60 to 89 (Wiggins, 2004). Reduced kidney functions to moderate levels with the criterion of GFR of 30 to 59. Severe reduction in the functions of the kidney with the criterion being GFR of 15 to 29. End stage kidney failure (ESRD) with the measuring criterion being a GFR less than 15. 3. Explain the following causes of Chronic Kidney Disease (CKD): a. Glomerulonephritis: This disease causes injury to kidney’s glomeruli, which is liable for the purifying of the blood. Injury to the kidney prevents it from proper filtration of the blood for wastes; thus, likely to result in kidney failures should the condition persevere (Weir & Lerma, 2014). This cause of CKD may be of two forms: acute and chronic. The acute form is characterized by symptoms such as the manifestation of plasma in the urine, less urination, and puffiness of the face. However, often the condition has faded by its own, or to the least people seek medical attention. The chronic form, assumed to be genetic, is characterized by high blood pressure, hematuria, proteinuria, edema, and bubbly urine (Levey, Coresh, Balk, Kausz, Levin, Steffes & Eknoyan, 2003). b. Hypertension Being the second leading cause of CKD, hypertension can cause damage to the kidney blood vessels; thus, reduce their viability to function. This results from the excessive force caused by blood flow that also weakens and scars the blood vessels; hence, derailing their removal of extra fluid and other wastes from the blood. The high blood pressure of the vessels may result from the retention of the fluids (Locatelli, F., Aljama, P., Barany, P., Canaud, B., Carrera, F., Eckardt, K. U., & Cameron, 2004). However, no known symptoms of hypertension are known, the common ones are nausea, loss of appetite, increased urine volumes, reduced urine volumes, loss of appetite, vomiting, feeling drowsy, and insomnia (Posey, 2005). c. Polycystic kidney disease The result of this disease are cysts development in the kidney and may be hereditary. It develops slowly in a patient; hence, its symptoms may be hard to recognize until adulthood with the development of more cysts over time if not detected early. As a result, the normal kidney functions are affected to the extent that it becomes difficult for the kidney tissues to filter blood efficiently (American Academy of Nutrition and Dietetics, 2010). d. Diabetes mellitus (DM): This results from the over-accumulation of sugar in the blood; thus, hindering the filtering by the kidney. The extraneous work and stress that the kidneys are made to undergo makes them to leak over time, resulting in loss of essential body proteins to the urine. The result may be micro albuminuria (presence of small amounts of protein in the urine) and macro albuminuria (large amounts of proteins in the urine). Treatment should be best conducted at the micro stage so as to avert the alteration of the infection into ESRD (Beto & Bansal, 2004). 4. A.N.D. Evidence Analysis Library.  On the home page, click on the “Projects” tab and search for Chronic Kidney Disease. Click, scroll down and select first CKD: Nutrition Needs and Disease Progression (2008-2010) and then CKD: Energy Requirements (2009) Explain this question: What are the energy requirements in adult non-dialyzed patients with chronic kidney disease, diabetic nephropathy or kidney transplant? State the evidence’s grade and its meaning. An adult non-dialyzed patient with chronic kidney disease would require approximately 23-35 kcals per kilogram of energy as indicated by the 2001 to 2007 randomized control studies available in the library. This energy amount is used in maintaining their body-mass index’s (BMI) stability. For those with diabetic nephropathy, the energy requirement approximates 1800 kcals daily, as evidenced by three randomized control studies that suggested that decrease in the body weight of the overweight persons may be attained by consuming such high amounts of body energy. Finally, patients with a kidney transplant will require energy approximating 30 kcals in a day or less. This is so as to enable the reduction in the BMI of the patients, as indicated by the study involving two patients that had their diet restricted (Byham-Gray, Wiesen, Stover, Academy of Nutrition and Dietetics, & National Kidney Foundation, 2013). 5. A.N.D. Evidence Analysis Library On the home page, click on the “Projects” tab and search for Chronic Kidney Disease. Click, scroll down and select first CKD: Nutrition Needs and Disease Progression (2008-2010) and then CKD: Fish Oil Therapy (2010). Explain the second question: What are the effects of fish oil therapy on the outcomes of IgA nephropathy? State the evidence’s grade and its meaning. Fish oil therapy results in the slowing of the rate of development of the insufficiencies of the renal for the high-risk IgA nephropathy patients. In the selected project, no statistical significance is revealed from the meta-analysis conducted on the four trials. However, continued use of the oil can only be possible if other therapies are not excluded owing to the risk factors, as it may not be effective on its own (Hunt, Baker, Chin, Cinquegrani, Feldmanmd, Francis & Smith, 2001). 6. Compare Acute Kidney Injury (AKI) to Chronic Kidney Disease (CKD). Include pathophysiology and clinical symptoms of each condition. Acute Kidney Injury results from the malfunctioning of the kidney due to an event trigger such as the use of specific medication, dehydration of the body, and loss of blood out of a surgery. Often, it occurs in patients hospitalized for other medical conditions for longer durations, and the diagnosis is usually indicated by the sudden rise of creatinine during blood tests. This ailment is designated by signs such as headache, loss of appetite, nausea, queasiness and fatigue (Ash, Campbell, McLaughlin, McCoy, Chan, Anderson & Trotter, 2006). On the contrary, chronic kidney disease results from the damage to the kidney and reduction of their functions as a result of long-term illnesses like diabetes. It is characterized by additional technical conditions such as anemia and hyperphosphatemia (increased phosphate levels in the blood). The major symptoms of the disease include loss of appetite, edema, nausea, change in patient’s mental state, changed urine output, fatigue, and diabetes (Byham-Gray, Wiesen, American Dietetic Association & National Kidney Foundation, 2004). 7. What are the pros and cons of the following Renal Replacement Therapies (RRT)? What factors are considered to determine a patient’s candidacy for each therapy? a) Kidney transplant Pros: No need for dialysis treatments by a patient. Normal functionality of the transplanted kidney with no hitches; hence, patient works without worries of a dialysis, and feels healthier as kidney failure is treated. Lesser diet and fluid restrictions placed on the patient. Enhanced duration for living by the patient. More freedom to the patient. Cons: Major surgery required that may have related risks. Patient required to take anti-rejection drugs for the life of the kidney or for the rest of their life. High risk of infection or complications due to the drugs taken. Risk of rejection of a patient’s body of the kidney transplant, forcing one to return to dialysis. Need to wait for an extensive period for a matching kidney donor. To qualify for this therapy, a patient need: To be suffering from kidney failure or other serious kidney conditions. To be medically fit with no history for diseases such as hypertension and cancer. To have undergone an adequate transplant evaluation. b) Hemodialysis Pros: Wide availability of facilities nationally. Attendance at all times of a patient by trained professionals. Opportunity to know other patients. No need for storing equipment at home or having a partner to administer the therapy if in-center. Normal fluids and diet intake by a patient. Cons: There may be instances when the patient will require to travel multiple times to the treatment center (Danovitch, 2010). Time consuming during treatment. Strict diet and fluid requirements. Inconvenience caused by the scheduled appointments. Takes some hours for a patient to feel better after being treated. Possibility of feeling tired, nausea, and headache after treatment. c) Peritoneal dialysis Pros: Freedom to choose treatment time. No need for travels to a dialysis center to be treated as it can be done at home. No need for bulky machines if treatment is done at home. More travel freedom due to the portability of the equipment used. Fewer diet and fluids restrictions compared to hemodialysis. Disadvantages: Requires daily administration and help of a partner. There is a high and increased risk of developing peritonitis (peritoneum infection) (Wiggins, 2004). A reduction in body proteins due to the continued use of dialysis fluid. May lead to weight gain among patients. 8. List and compare the daily recommended nutrient intake for an adult patient with Stage 5 CKD on HD and on PD. Recommended Nutrient CKD on HD CKD on PD Phosphorus 800-1000mg daily 800-1000mg daily Potassium 2-3g daily 2-4g daily Energy 30-35 kcal per kg 30-35 kcal per kg Sodium 2-2.4 g per day < 4 g per day Protein 1.2-1.4 g per kg 1.4-1.6 g per kg Fluid Urine output + 1 liter 1.3 liters of fluid 9. Calculate your own estimated diet prescription on hemodialysis. Document a one-day food recall for yourself at the present time. Then adjust that menu, based upon your estimated nutritional needs on hemodialysis. Calculate a nutrient breakdown of the HD menu’s total calories, protein, % of total protein grams from HBV sources, total fluid intake, and give total mg/day for the following: Na, Phos, and K+. Current Weight = 66.8 kg 1.25 to 1.35 gm/kg = 65 to 85 grams daily 25 to 30 mL/kg = 1420 to 1704 mL daily 35 to 40 kcal/kg = 1804 to 2088 kcals daily 10. Discuss dietary goals associated with kidney transplant: pre-surgery, immediately post- surgery (initial phase), and for the person who is post-transplant (chronic phase). Pre-surgery: Dietary goals and nutrients’ intake vary from one patient to another. Immediately post-surgery: These patients may need to have an unrestricted intake of phosphorus and potassium, approximately 2.0 g/kg of protein, less than 3 g of sodium, no restrictions on fluids and energy amounts ranging 30 to 35 kcal/kg. Medication Function Calcium carbonate (Tums) Used as a dietary supplement if small amounts of calcium are taken. When combined with dietary phosphorus, it forms calcium phosphorus that is insoluble. Acts as an antacid; hence, commonly used to relieve stomach upsets, acid indigestion, and heartburn. Calcium acetate (PhosLo) When combined with dietary phosphorus, it forms calcium phosphorus that is insoluble. Sevelamer HCl (Renagel) OR Sevelamer Carbonate (Renvela) Both mix with phosphorus in the intestinal tract, are non-absorbable cationic polymers that bind phosphate through ion exchange (Wiggins, 2004). Lanthanum carbonate (Fosrenol) Both mix with phosphorus in the intestinal tract, are non-absorbable cationic polymers that bind phosphate through ion exchange. 1,25 (OH)2 D3 (Calcitriol) These are steroid hormones that are used to regulate the amount of phosphates and calcium that are contained in the blood. Analogs of calcitriol (Hectorol or Zemplar) This binds to the phosphates and calcium in the blood to aid in their transportation to the bones. Cinacalcet (Sensipar) Used to lower the levels of parathyroid hormone (PTH) in the blood. Post-transplant (chronic phase): Patients at this phase need to have no restriction sin their fluids, plenty or unrestricted potassium intake, proteins ranging 0.8-1.0 g/kg, DRI for phosphorus, and an adjustment of their energy requirements based on the BMI so as to maintain their IBW. 11. Briefly explain the following medications. Anemia management Medication Function Epogen, Aranesp Treatment of anemia caused by chemotherapy or kidney failure. Stimulation of red blood cells production. FeSO4 or Venofer Treatment of iron deficiency anemia in patients with kidney disease. Where is erythropoietin produced? Kidneys. How CKD affects the production of erythropoietin? Through decreasing the production of EPO due to slower filtration rate by the kidneys. How CKD affects the absorption of iron? Through decrease in the normal amount of red blood cells due to decreased EPO production. Less plasma implies that absorption of iron will be reduced (Posey, 2005). Lipid management group Medication Function Statin drugs (Atorvastatin, Simvastatin) Used to lower the level of cholesterol in the blood through the inhibition of the HMG-CoA reductase hormone. Hence, there is a reduction in the production of cholesterol by the liver. Post-transplant management group Medication Function Prednisone Acts as a steroid and as an immunosuppressive drug. Mycophenolic acid Acts as an antimetabolite and as an immunosuppressive drug. Tacrolimus Acts as a calcineurin inhibitor and as an immunosuppressive drug. 12. Calculate the number of kcals absorbed for the CAPD patient on the following PD formula: 10 liters with 4 equal exchanges (2.5 liters each) all with 2.5% dextrose concentration (100g + 170g) x 3.4 kcal/g x 0.6 – 0.7 = 550 to 643 kcal (CAPD). 13. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI ™) or just, KDOQI ™ (pronounced “kay-dokey”) provides evidence-based clinical practice guidelines for patients with CKD. What are the KDOQI target ranges (i.e. serum level goals) for patients with Stage 5 CKD (ESRD) on dialysis for the following? a. Albumin: ranging from 3.4 to 5 mg/dL b. Calcium: ranging from 8.4 to 9.5 mg/dL c. Calcium X Phosphorus Product which is less than 55 mg2/dL2 d. Phosphorus ranging from 3.5 to 5.5 mg/dL e. Potassium: ranging from 3.5 to 5.0 mg/dL. 14. Case study   Bill is a 74 year-old man who has a past medical history of hypertension and chronic renal insufficiency. Bill lives by himself, and orders out half of his meals. Upon admission to the hospital, his laboratory results are: BUN 80, creatinine 4.8, albumin 3.4, potassium 5.9, and phosphorus 3.2. He weighs 66 kg and his height is 68”. He reported unplanned weight loss of 5lbs, but says he has water in his legs. He has had poor appetite for 2 to 3 months. You receive a request for a nutrition consult from the nephrologist once Bill has been started on hemodialysis. Write a nutrition assessment using S.O.A.P. format: 1. Describe the patient’s nutritional requirements. Height: 6 ft 8” Weight: 66 kg BMI = 16.0, an indication of a underweight. This would imply that the patient’s energy need would range from 30 to 35 kcal/kg an approximation of 2300 kcal daily. The patient’s protein needs would be approximately 1.4 g/kg or 90 grams daily. 2. As a result, there is reduced production of Bill has nutritional problems such as poor intake of PO during treatment, unplanned loss of weight; approximately 5 pounds, low phosphorus and potassium levels in the body, poor food choices when eating out, and an elevation of BUN and creatinine levels in the body (Wiggins, 2004). 3. Identify the nutrition diagnosis and intervention(s). To remedy Bill’s nutritional condition, the following need to be considered: a. Eating of small amounts of food even when feeling loss of appetite. b. Encouraging high intake of protein-rich foods. Subsequently, foods in phosphorus and potassium need to be avoided. c. Reliance on home-made food and not the ordered food from outside. 4. Describe your recommendations for diet and nutrition education. a. Bill needs to follow a strict dietary plan that would ensure that most of his meals comprise of high contents of proteins, low potassium, and low phosphorus (Beto & Bansal, 2004). b. Intake of nepro-supplements in the even that persistent weight loss is witnessed. References American Academy of Nutrition and Dietetics (2010). Evidence-based Nutrition Practice Guideline on Chronic Kidney Disease. Evidence Analysis Library: Executive Summary of Recommendations-July 2010. Accessed at http://www.adaevidencelibrary.com/topic.cfm?cat=3927&library=EBG Ash, S., Campbell, K., McLaughlin, H., McCoy, E., Chan, M., Anderson, K., & Trotter, B. (2006). 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