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1. Initial assessment findings
Identify Erica's abnormal blood levels and explain how they relate to ESRD. Elaborate on decreased kidney function. Relate these findings to Erica's symptoms.
BUN, Cr, and phosphorus levels are elevated secondary to decreased kidney excretion, and consequent build up in the blood. Sodium is at the low normal level, secondary to increased fluid retention accompanying hypertension. Protein and albumin levels are within normal levels but continued kidney deterioration would lead to decreased levels secondary to urinary losses and to depleted stores. Hematocrit is low because of decreased erythropoietin biosynthesis.
Increased weight, edema and dyspnea indicate fluid overload. Headache is secondary to increased blood pressure. General malaise and poor dietary intake is secondary to decreased kidney function.
2. Initial findings - Determining ideal body weight (IBW)
Determine Erica's IBW. She is 5' 6". Given a medium body frame, is her weight within IBW? Show your calculations. (The Hamwi formula is commonly used by dietitians to quickly determine IBW. For males, allow 106 lb for the first 5 feet plus 6 lb for each inch over 5 ft. For females, start at 100 lb and add 5 lb for each inch over 5 ft. Deduct 10% for persons with small frame and add 10% for persons with large frame). She has indicated a desire to lose weight. Would you recommend it?
Her weight is within range of IBW.
5' = 100 lb
IBW = 100 + (6x5)
= 100 + 30
= 130 lb
It is not advisable for Erica to try to lose weight. It is very hard to maintain weight and adequate nutrition on a renal diet. As the disease progresses, anorexia and malnutrition, along with weight loss, are very common occurrences.
3. Initial findings - Determining energy requirements
Estimate Erica's energy needs. Her energy needs can be estimated by multiplying her IBW by 10, which is the rule of thumb for estimating her basal metabolic rate. Add calories for activity using the following as a guide: sedentary, 50%; moderate activity, 70%; and strenuous activity, 100%. Does her 24-hr diet meet her energy needs?
Her present diet meets her energy requirement.
1300 + (70% of 1300) = 1300 + 910 = 2210 calories
Another simple method of determining energy requirements uses the formula: IBW(kg) x 35 kcal. First convert Erica's weight from lb to kg by dividing it by 2.2 = 59 kg. 59 x 35 = 2068 calories
4. Predialysis - Meeting energy needs
Review the diet plan developed by the dietitian and check whether the recommended energy guidelines are met. How would you modify the diet to meet energy recommendations, without increasing her protein, potassium and phosphorus restrictions?
Calories are very low. To increase calories she should:
a. change salad dressing to regular
b. add jelly to bread.
c. add a dessert to dinner such as plain cookies, pie, or cake.
5. Predialysis - Dietary modification
Several nutrients need to be modified to meet decreased kidney function and correct abnormal blood levels. Go over the diet plan developed by the dietitian and check whether the amounts required for protein, sodium and potassium are met. Phosphorus needs to be restricted but this is a difficult nutrient to restrict in the diet. List foods that are high or moderate sources of phosphorus and should be avoided. How about calcium? Should she increase intake of foods rich in calcium?
Sixty-five percent of the protein in Erica's diet should be of high biologic value (33-39 gm HBV). Her diet contains adequate amounts of HBV.
Sodium is slightly low (no correction needed) and potassium is adequate. High phosphorus foods are milk, cheese, yogurt, meat, and cola beverages while moderately high phosphorus foods are corn, peas, mushrooms, some cereal, pancakes, waffles (baking powder contains calcium acid phosphate)
Phosphorus restriction followed at the UMHS is more liberal than the amounts recommended by the American Dietetic Association because of the following:
a. Protein needs must be met first
b. It is easier to maintain energy requirements with slightly higher phosphorus intakes.
c. It is more practical. Binders along with dietary modifications are used to control high phosphorus blood levels.Erica's calcium intake is low but high calcium containing foods are also high in phosphorus. To increase calcium in Erica's diet, she must take a calcium supplement.
6. Predialysis - Modifying adverse food habits: salt
Erica always adds salt to her food at meals and enjoys processed and salted snack foods. Can she continue with her high salt diet since she is on medication for hypertension? Can you think of foods that are high sources of salt and need to be avoided?
She cannot continue on her high salt intake! The more salt she takes, the more blood pressure medication she may need. If she decreases the salt in her diet, she may be able to decrease the amount of medication she is taking. Also, salt makes one thirsty. The following foods contain high amounts of sodium and should be avoided: processed meats, prepared boxed foods, regular soups, olives, sauerkraut, salted meats such as ham, bologna, regular salad dressings and seasonings such as garlic and celery salt, or other seasoned salt products.
7. Predialysis - Modifying adverse food choices: beer and snacks
On weekends, Erica usually has approximately six lite beers with pretzels and potato chips. Are these allowed in her diet?
Erica decided she would need to make other food and drink choices for the weekends. She chose clear uncola beverages and unsalted pretzels, which, she realized, she'd have to provide when she goes out with friends. Although beer is not forbidden for persons with ESRD, it is suggested they limit their intake,especially if fluid is restricted. Beer and other alcoholic beverages are "empty calories". Check that dietary intakes of protein and other nutrients are adequate. In addition, they must also check with their doctor or pharmacist to determine if alcohol interferes with any of their medications.
8. Predialysis - Translating nutrient needs to the Food Guide Pyramid
Review Erica's 24-hr dietary recall at the initial nutrition assessment. Does she meet the recommendations of the Food Guide Pyramid? How can Erica modify her diet to meet the predialysis diet prescription?
According to the Food Guide Pyramid, Erica's 24-hr dietary intake meets the recommendations for foods from the bread/cereal, meat and milk groups while her intake of vegetables needs to be increased. She did not eat any foods from the fruit group during the day of her diet recall. Here is what she could do to meet the predialysis diet prescription:
a. Decrease the meat in her diet to 4 oz per day to reduce protein.
b. Change potatoes to rice or noodles to reduce potassium.
c. Since fruits are high in potassium, she can have canned fruits, fruit drinks, or punch to reduce potassium and add calories to her diet.
d. Add desserts low in potassium and phosphorus to increase calories.
e. Refrain from adding salt to her food.
f. Encourage her to eat something in the early morning to "break her fast".
9. CAPD - Dietary modification
Describe the diet on CAPD. What restrictions are eliminated and what nutrient still has to be restricted. Explain why. Is a vegetarian diet appropriate in CAPD?
The dietitian liberalized Erica's diet considerably. Dialysis replaces most of the kidney functions especially in the elimination of metabolic products. Protein is not restricted since some are lost through the dialysate. Erica is allowed as much as 8 oz meat daily, twice what she was previously permitted. Potatoes, tomatoes, citrus fruit, and starches have been increased since potassium restriction is minimal. Phosphorus, however, still remains a problem which may require restricting milk and yogurt to 1/2c, and cheese to 1 oz daily. Thus, calcium supplements may be needed. Cola beverages are high in phosphorus and are also restricted. Dried peas and beans as protein sources in vegetarian diets are high in phosphorus and further do not supply the necessary HBV protein. Thus, vegetarian diets are not recommended in CAPD.
10.CAPD-Monitoring energy intake and weight
A secondary source of calories for a person on CAPD is glucose in the dialysate. Erica's dialysis schedule required 4 exchanges daily, two of each of the following:
1.5 L exchange with 1.5% solution
1.5 L exchange with 4.25% solution
Using the table below, determine the number of calories in Erica's daily dialysate.
Concentration of Solution
Calories Per Exchange*
1 L
1.5 L
2 L
2.5 L
3 L
1.5%
14
21
28
35
42
2.5%
52
78
104
130
156
4.25%
117
176
234
293
352
* For detailed calculation, see the American Dietetic Association National Renal Diet: Professional Guide p. 20, 1993.
What effect would these extra calories have on her weight? How would you adjust her dietary intake to maintain her weight?
1.5 L of 1.5% solution = 21 calories x 2 =
42
1.5 L of 4.25% solution =176 calories x 2 =
352
Total calories
934
The total calories absorbed from Erica's dialysate amounted to 400 kcal daily, over and above dietary sources. To prevent weight gain, her daily dietary intake should be decreased by 400 kcal. Since some protein is lost in the dialysate, additional protein foods must be added to her diet to make up for these losses. Therefore, calorie restriction needed for weight control should come from carbohydrates and fats.
11. CAPD or hemodialysis - Eating out
Prior to her illness, Erica frequented several of the fast food restaurants. May this pattern be continued on her diet?
Yes. Renal dietitians have listings of foods with the nutritional break down from the majority of the fast food restaurants. This information is always made available to all clients. This information is also available to the public from each restaurant.
12. CAPD or hemodialysis - Water-soluble vitamin supplements
A water-soluble vitamin supplement specific for ESRD persons is used to replace vitamin losses during dialysis. Is it needed by all persons on dialysis?
The routine use of water-soluble vitamin supplementation has been questioned. It is recommended for those with poor oral intake or those with uremia-related metabolic derangements. Supplemental ascorbic acid, folate and vitamin B12 do not appear necessary for persons who are considered stable and with adequate dietary intake. Supplemental pyridoxine participates in amino acid metabolism, particularly in heme synthesis, and is recommended for those receiving EPO.
13. Hemodialysis - Fluid restriction
Erica's urine output decreased to approximately 500 cc daily. What symptoms would you expect if her fluid intake is more than her output? How much weight gain is she allowed? Should her fluid intake be restricted? What are her dietary sources of fluid?
Persons on dialysis are allowed to gain only 2-4 pounds between dialysis treatments. (Weigh at the same time of day on the same scale). Larger weight gains secondary to fluid imbalance would result in pedal edema, fluid retention in the lungs causing shortness of breath and congestive heart failure. Erica's fluid intake should be restricted to 1 liter/day (output + 500cc). Any food that is liquid at room temperature is considered liquid, i.e. jello, sherbet, fruit ice, or even water from the water fountain. Although fruits are also high in water content, restricting them will require an overly complicated diet calculation.
14. Hemodialysis - Dietary sources of potassium
Many fresh fruits and vegetables, such as orange juice, banana, potatoes, tomatoes, spinach and greens are high in potassium and must be restricted. How can fruits and vegetables be used in a low potassium diet.
Canned peaches, pears, fruit cocktail, and applesauce may be used since potassium is leached during the canning process. When fresh vegetables are soaked or boiled in water, potassium also leaches out. (Both syrup and water should be discarded).
15. Transplant - Drug-nutrient-food interactions
After transplant, Erica is given cyclosporine as an immunosuppressive and prednisone as an anti-inflammatory agent. Review Erica's blood serum findings 10 days after transplant. Which levels are abnormal? Explain why.
Sodium levels are low and are related to excess fluid needed to keep the new kidney hydrated. Potassium levels tend to increase because of cyclosporine. Prednisone can cause elevation of blood pressure. Thus continued monitoring of blood pressure is necessary along with hypertensive medication. Until the levels of medication are reduced, dietary potassium and sodium need to be monitored and occasionally modified. Protein and albumin levels are decreased because of protein catabolism attributed to prednisone, dilution with intravenous fluid, or possibly to low p.o. intake.
Persons on cyclosporine anti-rejection medication are not allowed to take grapefruit juice since it interferes with its absorption. Another side effect of cyclosporine is elevated cholesterol levels. Diets are therefore moderately restricted in cholesterol as preventive nutrition.
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