Question

A 55-year-old banker has developed chronic kidney disease as a result of hypertension. His condition was discovered several years ago, when routine laboratory tests revealed elevated serum creatinine and BUN levels. Since then, he has been taking antihypertensive medications and restricting dietary sodium; he reported difficulty following the low-protein diet that was also prescribed. The patient recently visited his doctor with complaints of low urine output and reduced sensation in his hands and feet. He also reported feeling drowsy at work and mentioned that he was bruising more than usual. The examination revealed a 9-pound weight gain since his last visit and swelling in his ankles and feet. Tests revealed that his GFR had fallen to 10 milliliters per minute. The patient is 5 feet 8 inches tall and normally weighs 160 pounds.

Review PES statement and an intervention plan addressing the patient’s condition. Respond to questions 1, 2, and 3 below!

PES statement and a plan addressing the patient’s condition.

1. Problem: Limited adherence to nutrition-related recommendations (NB-1.7)
2. Etiology: related to difficulty following previously prescribed low-protein diet
3. Symptom: as evidenced by edema, low urine output, elevated serum creatinine, and BUN levels, and reduced sensation in his hands and feet, drowsiness, and bruising.

Complete PES:

Limited adherence to nutrition-related recommendations (NB-1.7) related to difficulty following previously prescribed low-protein diet as evidenced by edema, low urine output, elevated serum creatinine, and BUN levels, and reduced sensation in his hands and feet, drowsiness, and bruising.

Plan: Low protein diet along with fluid restriction and electrolyte monitoring.

   Educate the patient on diet restrictions associated with CRF including restrictions related to    

    protein, sodium, potassium, and phosphorus intakes as well as fluids.

1. Explain how chronic kidney disease progresses. What happens to GFR, serum creatinine levels, and BUN as renal function declines?

2. Describe the clinical effects you would expect during the final stage of disease, when kidney failure develops. Explain the significance of each of the patient’s physical complaints.

3. Explain why a low-sodium, low-protein diet was prescribed for the patient at a former visit.

Answer 1

1. Explain how chronic kidney disease progresses. What happens to GFR, serum creatinine levels, and BUN as renal function declines?

DEFINITION

Chronic Kidney disease is a condition in which there is a gradual loss of kidney function evidenced by reduced GFR, Proteinuria or structural kidney gamage

Stages of Chronic KIdney disease progression

STAGE	GFR, mL/min	PATIENT'S Renal condition
I	More then 90	Normal kidney function but urine or other abnormalities point to kidney disease
II	60-89	Mildly reduced kidney function
III	30-59	Moderately reduced kidney function
IV	15-29	Severly reduced renal function
V	less than 15	Very severe, or endstage kidney failure

Kidney as a part of excretory system plays a vital role of removing all metabolic and tocix waste from body by filtering the blood.

Urea and creatinine are nitrogenous end products of metabolism. Urea is the primary metabolite derived from dietary protein and tissue protein turnover. Creatinine is the product of muscle creatine catabolism. BUN is a test to determine the amount of urea and nitrogen in blood.When a person's Kidney Function declines and GFR starts to fall urea creatinine level increases in the body because of improper filteration by damaged  nephrons following effects are found

GFR	Reduces
UREA	increases
CREATININE	increases
BUN	Increases

2.  clinical symptoms seen in final stage of kidney failure

• Nausea
• Vomiting
• Loss of appetite
• Fatigue and weakness
• Sleep problems
• Changes urine amount
• Decreased Alertness
• Muscle twitches and cramps
• Swelling of feet and ankles
• Persistent itching
• High blood pressure
• Swelling around feet and ankles

significance of each of the patient’s physical complaints.

1. Drowsiness- Fatigue and drowsiness is a common in patients with advanced kidney disease. Severe decrease in kidney funtion (GFR less than 10ml/min) leads to build up of waste and impurities in blood making patient more tired and drowsy.

2. Oedema- As the urine output is reduced in patient swelling has become evident due to water retention in body.

3. Low urine output- it is the result of reduced glomular filteration rate in patient

4. Bruising:- Along with aging Kidney disease can also causes reduction in skin elasticity due to increases urea creatinine level as a result patient bruise easily.

5. Weight gain- Weight gain in patient is seen because of fluid retention and edema.

3. Explain why a low-sodium, low-protein diet was prescribed for the patient at a former visit.

low protein diet- when protein is ingested nitrogenous waste (urea and creatinine) are produced as end product of metabolism which is filtered by the nephrons of the kidney in chronic kidney disease nephrons are not able  to remove protein waste and it accumulates in the blood increasing Urea, creatinine and BUN level. Hence low protein diet is prescribed for patient.

Low Sodium diet- Sodium maintains fluid balance in the body. But in CKD with severely reduced renal funtion kidney cannot filter excess sodium and fluid causing sodium and fluid retention in the body and leading to hypertension. Sodium restriction is recommended if blood pressure is high or fluid retention in more  a low-sodium diet help to control blood pressure and reduce fluid build up in body.