Julia Kaesberg Counseling Session KNH 413 February 27 th, 2014 Patient Description and Diagnosis: Sarah Jones is a 50-year-old female, 5 4, 131 pounds and her usual body weight is 125 pounds. Her %UBW is 104% (131/125 x 100). Sarah has been diagnosed with Stage 5 Kidney Disease and is beginning hemodialysis. Sarah s decline in kidney function is a result of her uncontrolled hypertension. Currently, Sarah is presenting with edema in her legs and feet. She has been asked by her physician to see a Registered Dietitian for instruction on a hemodialysis diet, including fluid restriction. Sarah s current urine output averages about 0.7 L per day and brought a 24- hour recall with her to this session. Etiology: The two leading causes of kidney failure in the United States are Type 2 Diabetes and high blood pressure. Effective treatment of these conditions can prevent or slow down kidney disease. End stage kidney disease occurs when 90% of kidney function has been lost and the patient may have symptoms such as nausea, vomiting, weakness, fatigue, confusion, difficulty concentration and loss of appetite ( Kidney disease: Causes, ). Diagnostic Measures: There are three simple diagnostic measures that are typically used to diagnosis kidney disease. The first is blood pressure. A blood pressure of 140/90 or higher is considered high blood pressure and with kidney disease 130/80 or less is recommended. The second diagnostic measure is urinalysis. Protein and blood in the urine may indicate kidney disease, especially in patients with diabetes. One test used to test for the presence of urine is the protein to creatinine ratio and a value of 200 mg/gm is
considered high. Another urine test is the albumin to creatinine ratio and a value of 30 mg/gm per day or higher can be a sign of early kidney disease. The third diagnostic test is the Glomerular filtration rate (GFR), which is estimated from the results of a serum creatinine test. This value indicates how well the kidneys are removing waste from the blood and a value of 60 or lower may indicate kidney disease ( Three simple tests, ). In addition to these simple diagnostic measures, physicians can also use renal ultrasounds to determine the size and shape of the kidney to see any abnormalities. A kidney biopsy can also be done to determine if cancerous or abnormal cells are present. Finally, a CAT scan can be used ( End stage renal, ). Medical Treatment: The first choice for medical treatment of End Stage Renal Disease (ESRD) is hemodialysis. Hemodialysis cleans and filters the blood through a machine that removes waste, extra salt and extra water. This helps to control blood pressure and keep the proper balance of chemicals such as potassium, sodium, calcium and bicarbonate in the body. Another choice is peritoneal dialysis, which also removes waste, chemicals and water from your body using the linin of your abdomen or belly. A third choice with ESRD is kidney transplantation where the donated kidney does the work that the patient s two failed kidneys used to do ( Kidney failure: Choosing, ). For Sarah, hemodialysis was chosen as the best choice of treatment for the current time. She will be receiving hemodialysis three times per week. Medical Nutrition Therapy: Sarah s protein needs are increased because of the hemodialysis and therefore requires 1.2 g pro/kg ( Chronic kidney disease, ). Sarah needs about 71 grams of protein per day.
Using the Harris Benedict equation, Sarah requires about 1,800 calories per day. Based on the Nutrition Care Manual from the Academy of Nutrition and Dietetics, Sarah must consume less than 2.4 g of sodium and potassium per day, between 800-1000 mg of phosphorus per day and less than 2 g from protein per day. Because the kidneys are not functioning properly, they cannot remove excess water from the body, so Sarah must restrict her fluid intake to her urine output plus 1,000 cc of fluid per day. Her current urine output is an average of 400 cc per day, so she can consume 1,400 cc of fluid in her diet daily ( Chronic kidney disease, ). Calculations: 1.2 g pro/kg (59.5 kg) = 71 g protein/day 71 g pro x 4 kcal/g= 284 calories from protein 71 g pro/7 grams per ounce= 10 ounces of meat Energy Requirements using Harris- Benedict equation: 655 + (9.56 x wt (kg)) + (1.85 x ht (cm)) (4.68 x age) 655 + (9.56 x 59.5) + (1.85 x 163 cm) (4.68 x 50) 655 + (569) + (302) 234 1,292 x (1.4 PAL) = 1,808 1,750-1,850 calories per day 1,800 calories- 284 calories from protein= 1,516 calories from carbohydrate and fat.
1,800 x 0.55 = 990 calories from carbohydrate/4 kcal/g= 247 g carbohydrate 1,800 total calories -990 (kcal from CHO) -284 (kcal from PRO) = 526 calories from fat/ 9 kcal/g= 58 g fat per day During the counseling session, the patient will be informed on the importance of restricting fluid, sodium, potassium, phosphorus and calcium. The patient s 24- hour recall will be reviewed and Sarah will be given tips on making food choices low in these minerals and higher in protein. The patient will also be given lists of foods that are low in potassium, sodium and phosphorous. In addition, Sarah will be educated on sodium and foods that have added salt, with the recommendation of choosing foods with 300 mg or less per serving. Website: The National Kidney Foundation www. Kidney.org Educational Material: http://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=157&actionx m=viewall
References: Chronic kidney disease (ckd) stage 5 dialysis. (n.d.). Retrieved from http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5537&l v2=255347&ncm_toc_id=255666&ncm_heading=nutrition Care End stage renal disease. (n.d.). Retrieved from http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_sy stem_disorders/end_stage_renal_disease_esrd_85,p01474/ Kidney disease: Causes. (n.d.). Retrieved from http://www.kidney.org/atoz/content/kidneydiscauses.cfm Kidney failure: Choosing a treatment that's right for you. (n.d.). Retrieved from http://kidney.niddk.nih.gov/kudiseases/pubs/choosingtreatment/ Three simple tests to check for kidney disease. (n.d.). Retrieved from http://www.kidney.org/kidneydisease/threesimpletests.cfm