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MEDICAL NUTRITION THERAPY – NEPHROLOGY MODULE;Renal Module

Please answer questions with focus on nutritional implications.

1.    Discuss the following functions of the normal kidney
•    Excretory
•    Acid-base balance
•    Endocrine
•    Fluid-electrolyte balance
Explain how the kidney makes urine
Define Glomerular Filtration Rate (GFR)

2.    List the 5 stages of Chronic Kidney Disease (CKD) with the criteria used to define each.

3.    Explain the following causes of Chronic Kidney Disease (CKD):
a.    Glomerulonephritis
b.    Hypertension
c.    Polycystic kidney disease
d.    Diabetes mellitus (DM)

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.

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.

6.    Compare Acute Kidney Injury (AKI) to Chronic Kidney Disease (CKD). Include pathophysiology and clinical symptoms of each condition.

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
b)    Hemodialysis
c)    Peritoneal dialysis

9.    List and compare the daily recommended nutrient intake for an adult patient with Stage 5 CKD on HD and on PD.
•    Energy
•    Fluid
•    Phosphorus
•    Potassium
•    Protein
•    Sodium

10.    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+.

11.    Discuss dietary goals associated with kidney transplant: pre-surgery, immediately post- surgery (initial phase), and for the person who is post-transplant (chronic phase).

12.    Briefly explain the following medications.
Anemia management
Medication    Function
Epogen, Aranesp
FeSO4 or Venofer

Where is erythropoietin produced?
How CKD affects the production of erythropoietin?
How CKD affects the absorption of iron?
Mineral and bone management group
Medication    Function    Similarities          Differences
Calcium carbonate (Tums)
Calcium acetate (PhosLo)
Sevelamer HCl
(Renagel)
OR
Sevelamer Carbonate (Renvela)
Lanthanum carbonate (Fosrenol)
1,25 (OH)2 D3 (Calcitriol)
Analogs of calcitriol (Hectorol or Zemplar)
Cinacalcet (Sensipar)

Lipid management group
Medication    Function
Statin drugs (Atorvastatin, Simvastatin)

Post-transplant management group
Medication    Function
Similarities          Differences
Prednisone
Mycophenolic acid
Tacrolimus

13.    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 conc.

14.    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.

15.    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
b.    calcium
c.    calcium X phosphorus product
d.    phosphorus
e.    potassium

16.    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.
2.    Describe the patient’s nutritional problems.
3.    Identify the nutrition diagnosis and intervention(s).
4.    Describe your recommendations for diet and nutrition education.

Resources:

•    American Academy of Nutrition and Dietetics Evidence Analysis Library. Evidence-based Nutrition Practice Guideline on Chronic Kidney Disease Executive Summary of Recommendations-July 2010 at http://www.adaevi-dencelibrary.com/topic.cfm?cat=3927&library=EBG and copywrited by the Academy. accessed 09-2013
•    Byham-Gray L, Stover J, Wiesen, K. A Clinical Guide to Nutrition Care in Kidney Disease. 2nd ed. Chicago, IL: American Dietetic Association; 2013. ISBN: 9780880914703
•    Danovitch, GM, (Ed.) Handbook of Kidney Transplan¬tation, 5th edition. “Nutrition in the Kidney Transplant Recipient” by Susan Weil, RD, CSR Kidney Transplant Program – David Geffen School of Medicine at UCLA, Los Angeles, California. Philadelphia: Lippincott, Williams & Wilkins, a Wolters Kluwer business; 2010.
•    Knutsen, PG, ACNS, BC, CDE, presenter, “Transplant Dia¬betes & Glucose Management: How Sweet It Is” NATCO Seminar: Donation and Transplantation Academy A Multi-Disciplinary Approach. Tempe, Az October 10/2013
•    KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant. 2009 Nov;9 (Suppl 3):S1-155. at http://www.kdigo.org/clinical_practice_guide-lines/pdf/TxpGL_publVersion.pdf. accessed 08/2013
•    National Kidney Foundation. KDOQI Clinical Practice Guideline for Diabetes and CKD. at http://www.kidney.org/professionals/KDOQI/guidelines_diabetesUp/dia¬betes-ckd-update-2012.pdf. accessed 08/2013

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