Ali Rumsey HND 470 30 April 2013 Case #26 Chronic Kidney Disease 1.

Describe the physiological functions of the kidneys. The primary functions of the kidney include maintenance of homeostasis through control of fluid, pH, and electrolyte balance and blood pressure; excretion of metabolic endproducts and foreign substances; and the production of enzymes and hormones. Urine formation is a crucial component in the maintenance of homeostasis of the kidneys. 2. What diseases/conditions can lead to chronic kidney disease (CKD)? Diabetes, hypertension and glomerulonephritis are the leading causes of kidney failure however there are additional risk factors associated with the disease. Other risk factors include ethnicity; African-Americans are nearly four times as likely to develop kidney failure as white Americans, Native Americans are two limes as likely and Hispanic Americans have nearly twice the risk of non-Hispanic whites. Also, family history of CKD, hereditary factors such as polycystic kidney disease, a direct forceful blow the kidneys, and prolonged consumption of OTC pain killers that combine aspirin, acetaminophen, and other medicines such as ibuprofen. 3. Explain how type 2 diabetes mellitus can lead to CKD. Diabetic nephropathy is the most common cause of CKD in the U.S. People with Type 2 Diabetes are at increased risk when the blood glucose is not controlled. The earliest detectable change in the course of diabetic nephropathy is a thickening in the glomerulus, which may be caused by hyperglycemia and a change in the basement membrane of the tissue. The glomerulus is responsible for filtering the blood and the fluid eventually forms urine as the glomerular changes occur. The kidney may start allowing more protein (albumin) than normal to be excreted in the urine. As the diabetic nephropathy progresses an increasing number of glomeruli are distorted increasing the amount of albumin excreted which can be detected by a urinalysis. As the number of functioning nephrons declines each

nephron that remains must clear an increasing amount of solute. Eventually this leads to azotemia and uremia. The progression of this is slow and can take 5-10 years before other symptoms develop, so the body is able to adapt to the changes. At this point when the kidney is biopsied, it will show diabetic nephropathy. 4. Outline the stages of CKD, including the distinguishing signs and symptoms. Stage 1 of CKD: The kidney is enlarged, damaged with normal or increased levels of GFR. The level is > 90 mL/min. Usually there are no outward signs are present. Stage 2 of CKD: kidney damage with mild decrease in GFR, the level of GFR is 60-89. Blood pressure is still normal during this stage. Stage 3 of CKD: moderate decrease in GFR with levels of GFR being 30-59 mL/min. Microalbuminuria becomes constant. Stage 4 of CKD: severe decrease in GFR with levels of GFR being 15-29mL/min. Nephropathy occurs; large amounts of protein are present in the urine, blood pressure increases. New symptoms that may occur include: nausea, taste changes, uremic breath, anorexia, difficulty concentrating, and numbness in fingers and toes. Stage 5 of CKD: Kidney failure has occurred. The GFR levels are <15mL/min or the patient may be on dialysis. When the kidney fails toxins re build up in the blood which causes an ill feeling. Symptoms include: anorexia, nausea or vomiting, headaches, fatigue, anuria, swelling around eyes and ankles, muscle cramping, tingling in hands or feet, and changing skin color and pigmentation.

5. From your reading of Mrs. Joaquins history and physical, what signs and symptoms did she have? Mrs. Joaquin has the following symptoms: anorexia, inability to urinate, edema in extremities face and eyes, high blood pressure, heart burn, kidney and urinary problems, muscle cramps, purities, weakness and fatigue and a 4kg weight gain in the past two weeks. 6. What are the treatment options for Stage 5 CKD?

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Treatment options for stage 5 CKD are a kidney transplant or dialysis. There are two types of dialysis: hemodialysis and peritoneal dialysis. 7. Describe the differences between hemodialysis and peritoneal dialysis. Hemodialysis is the most common method of dialysis. Both methods require a selective semipermeable membrane that allows passage of water and small to middle-molecular weight molecules such as proteins. In hemodialysis the selective membrane is a man-made dialyzer sometimes referred to as an artificial kidney. Waste products and excess fluids are removed from the body through diffusion ultrafiltration and osmosis. During the process of removing these excess fluids from the body electrolyte balance must be maintained and this is accomplished by passing blood across the semipermeable membrane that is exposed to rinsing fluid (dialysate). Hemodialysis is usually done in a dialysis clinic although it may be done at home as well. Dialysis treatments are typically prescribed 3x per week on an average of 4 hours per treatment. Peritoneal dialysis accesses the patients blood supply through a catheter of silicone rubber or polyurethane placed surgically in the peritoneal catheter. Solutes from the plasma circulating in the vessels and capillaries perfusing the peritoneal wall pass across the peritoneal membrane into the dialysate which is subsequently removed and discarded. There are two types of peritoneal dialysis: continuous ambulatory peritoneal dialysis (CAPD) and cycling peritoneal dialysis (CCPD). CAPD requires no machine and can be done in any clean well lit location. The usual dwell time is 4-6 hours followed by the draining of used dialysate and its replacement with fresh solution required an additional 30-40 minutes. Most patients change at least for times a day and sleep with solution in their abdomens at night. CCPD does require a machine called a cycler to fill and empty the abdomen 3-5 times during the night. One exchange is done during the day with a dwell time that lasts the entire day with an addition of an added exchange for some patients.

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8. Explain the reasons for the following components of Mrs. Joaquins medical nutrition therapy: Nutrition Therapy 35kCal/kg 1.2 protein/kg Rationale To meet nutritional requirements and prevent malnutrition, minimize uremia and maintain blood pressure and fluid status. Adequate amounts of protein are essential because it reduces malnutrition, inflammation, edema and malabsorption. The body requires adequate amounts of protein to obtain neutral or positive nitrogen balance. Recommended because patient has high serum levels of potassium that can negatively impact the heart and muscles. Restriction is necessary to reduce high serum levels. Patient has high levels of phosphorus because of compromised kidney function. High levels of phosphorus in the blood can cause loss of calcium from bones. Consuming less phosphorus in the diet will lower blood phosphorus levels. To prevent patient becoming oliguric and anuric, which commonly develops within the first 12 months of hemodialysis. Also regulates hydration status. Proper intake of fluids that are based on urine output will help maintain positive fluid status. Also, essential for regulating extracellular fluid volume and plasma volume.

2gK

1 g phosphorus

2 g Na 1,000 mL fluid + urine output

9. Calculate and interpret Mrs. Joaquins BMI. How does edema affect your interpretation? Mrs. Joaquins calculated BMI is 33.2 which is considered to be obese. The edema affects this because she has gained 20lbs in the past two weeks so her BMI has gone up due to her weight increase. Water retention or edema has been found to cause an increase in body weight because of the excess fluid in the tissues. Prior to her weight gain, her BMI is calculated to be 29.3 and having this BMI would have her in the overweight range rather than the obese range. 10. What is edema-free weight? The following equation can be used to calculate the Edema-free adjusted body weight (aBWef): aBWef= BWef + [(SBW-BWef) x .25]

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Where BWef is s the actual edema-free body weight and SNW is the standard body weight as determined from the NHANES II data. Calculate Mrs. Joaquins edema-free weight. Is this the same as dry weight? aBWef= 165 + [(65-165) x 0.25] =165 + [(-100) x 0.25] =165 + (-25) =140lbs or 63.6 kg Edema free weight (also called dry weight or postdialysis weight) is the weight without excess fluid that builds up in the body between dialysis treatments. This is similar to the weight of a person with normal kidney function after urinating. It is also the lowest weight you can reach after dialysis treatments without developing symptoms such as low blood pressure, or cramping which occurs if too much fluid is removed from the body. 11. What are the energy requirements for CKD? The energy requirements for both non-dialyzed and hemodialysis CKD patients under the age of 60 is 35kCal/kg of body weight. For patients older than 60, 30-35kCals/kg of body weight is recommended. In order to calculate energy and protein needs it is recommended to use the free adjusted body weight for underweight and obese patients. 12. Calculate what Mrs. Joaquins energy needs will be once she begins hemodialysis. The patients energy needs are 35kCals/kg of edema-free adjusted body weight. 140lbs = 63.5kg (35) X (63.5) = 2222.5 kcals = ~2300kcals. 13. What are Mrs. Joaquins protein requirements when she begins hemodialysis? Protein requirements once Mrs. Joaquin begins hemodialysis are 1.2g/kg of body weight. (1.2)(77.1)= 92.52g of protein Mrs. Joaquin should be consuming ~93g of protein with at least 50% coming from high biological protein. These recommendations are based on the level of protein intake that

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will maintain neutral of positive nitrogen balance and lead to improvement or maintenance of visceral protein stores for the majority of hemodialysis patients. 14. What is the rationale? How would these change if she were on peritoneal dialysis? These recommendations for hemodialysis patients ensure adequate intake of essential amino acids. These are based on the level of protein intake that will maintain neutral or positive nitrogen balance and lead to an improvement or maintenance of visceral protein stores for the majority of hemodialysis patients. If Mrs. Joaquin was on peritoneal dialysis, the protein requirements are slightly higher because during episodes of peritonitis (inflammation of the peritoneum), even in mild cases, the dialysate protein losses increase by 50-100% to an average of 15-36g/24 hours and have been reported to remain elevated for several weeks. 15. Are there any potential benefits of using different types of protein, such as plant protein rather than animal protein, in the diet for a patient with CKD? Explain. There is not a significant benefit between eating plant based proteins or animal based proteins for patients with CKD. The only types or animal proteins that should be restricted organs meats, sardines, chicken liver, crayfish, oysters, fish roe, beef liver and carp. 16. Mrs. Joaquin has a PO4 restriction. Why? Phosphate is restricted in patients with CKD because in early CKD, hyperphosphatemia is prevented by an adaptive increase in renal excretion and decreased phosphate reabsorption. Hyperphosphatemia is evident when the GFR falls between 20 and 30 mL/min. Phosphorus restriction is 800-1000mg/day or <17mg/kg of IBW or standard body weight per day. 17. What foods have the highest levels of phosphorus? Foods with high phosphorus levels that should be restricted include the following: Beverages: Ale Dairy Products: Cheese Protein: Carp 6|Page

Chocolate Drinks Drinks made with milk Canned iced teas Beer Cocoa Dark Colas

Vegetables: Dried beans and peas Baked beans Chick peas Kidney beans Limas Pork n Beans

Custard Milk Cream Soups Cottage cheese Ice cream Pudding Yogurt Vegetables (Cont.). Soy beans Black beans Garbanzo beans Lentils Northern beans Split peas

Beef liver Fish roe Oysters Crayfish Chicken Liver Organ Meats Sardines Other Foods: Bran Cereals Caramels Seeds Whole-grain products Brewers yeast Nuts Yeast

18. Mrs. Joaquin tells you that one of her friends can drink only certain amounts of Liquids and wants to know if that is the case for her. What foods are considered to be fluids? What recommendations can you make for Mrs. Joaquin? Fluids are anything that is liquid at room temperature. Mrs. Joaquin should avoid foods that have a lot of water in them for example: soups, popsicles, sherbet, ice cream yogurt, custard, and gelatin. Also some fruits and vegetables have high water contents. These fruits/vegetables include: melons, tomatoes, celery, and cucumbers. 19. If a patient must follow a fluid restriction, what can be done to help reduce his or her thirst? There are a lot of things patients with fluid restriction can do in order to reduce their thirst they include: Having patient Limit high salt-foods so patient will have less thirst. Taking pills with mealtime liquids, applesauce or pureed fruits. Drinking only when thirsty. Reaching for cold beverages and beverages that are less sweet to quench thirst. Having the patient weigh themselves daily so they do not gain more than the prescribed amount of pounds per day. Using sour candy or sugar free gum to moisten the mouth, or special thirst quenching gums. Adding lemon juice to water or ice. The sour taste will help to quench thirst. Swishing cold water in the mouth, or low-alcohol mouth wash when thirsty but being sure not to swallow it! 7|Page

Brushing teeth often because good oral hygiene is essential. Keeping lips moist with lip balm/moisturized lipstick Using ice cubes instead of liquids. One cup of ice is equal to 1/3 cup of water/juice and will last longer. Freezing grapes to eat throughout the day as a fruit serving (serving= cup) Patients may also try frozen blueberries and pineapple tidbits, fruit cocktail and other recommended fruits. Limiting foods that are considered fluids (soups, popsicles, sherbet, ice cream, yogurt, custard, and gelatin).

20. Identify nutrition problems within the intake domain using the appropriate diagnostic term. Nutrition problems within the intake domain include the following: Inadequate protein and energy intake Inadequate fiber intake Inadequate vitamin C intake Inadequate potassium intake 21. Several biochemical indices are used to diagnose chronic kidney disease. One is Glomerular filtration rate (GFR). What does GFR measure? GFR is the filtration ability of the glomerulus; used as in index of kidney function. The normal value is approximately 125mL/min. GFR measures the rate at which substances are cleared from the plasma by the glomeruli. 22. What test is usually done to estimate glomerular filtration rate? In the clinical setting, endogenous creatinine clearance was once the gold standard which was used to approximate the actual GFR. Now it is though that approximation of GFR through calculations is the method of choice to evaluate an individuals kidney function. The National Kidney Foundation Guideline recommends using equations based on serum creatinine but adjusted for ethnicity, gender and age. The two most common equations used are the Modification of Diet in Renal Disease Study equation and the Cockcroft-Gault equation. 23. Mrs. Joaquins GFR is 28 mL/min. What does this tell you about her kidney function?

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With Mrs. Joaquins GFR being 28mL/min this tells us that she is in stage 4 of CKD. She has a severe decrease in her GFR and the next stage of CKD is kidney failure. 24. Evaluate Mrs. Joaquins chemistry report. What labs support the diagnosis of Stage 4 CKD? The labs that support the diagnosis of Stage 4 CKD include: low calcium level, increased sodium (resulting in edema), retaining of potassium, high levels of phosphorus, high BUN (indicating that she is retaining urea), and her total CO2 is low. 25. Examine the patient care summary sheet for hospital day 2. What was Mrs. Joaquins weight postdialysis? Why did it change? Mrs. Joaquins postdialysis weight was 165 pounds. She lost 5 pounds with dialysis, because the dialysis helped to filter her blood to remove excess fluids that build up from the kidney not being able to function properly. The dialysis treatment improved her ability to excrete fluids and metabolic products of protein. Also, on the second day of dialysis, Mrs. Joaquin lost weight because she did not drink at all during the day, and she vomited. 26. Which of Mrs. Joaquins other symptoms would you expect to begin to improve? The symptoms expected to improve would be the lack of appetite, nausea and vomiting because these were caused by the buildup of urea and other waste products in the blood. Once dialysis is done the blood is filtered so these should improve. Also, the inability to urinate, edema in the extremities, face and eyes are expected to improve because these were caused by the compromised kidney function and buildup of fluid in the body. Other symptoms expected to improve include muscle cramping, puritis, shortness of breath and serum electrolytes are expected to improve. 27. Explain why the following medications were prescribed by completing the table. Medication Vasotec Indication/Mechanism Antihypertensive to treat diabetic nephropathy. Recombinant human Nutritional Concerns Insure adequate fluid intake, decrease Na and Ca may be recommended. Avoid salt substitutes, caution with K supplementation, anorexia/weight loss May need Fe, Vit B12, or Folate supplements. 9|Page

Erythropoietin

Vitamin/ Mineral Supplement

erythropoietin, antianemic, stimulates RBC production to treat ESRD-induced anemia. Supplement water-soluble vitamins (B Vitamins, folic acid, Vitamin C) due to increased fluid losses during dialysis, anorexia, low dietary intake. Supplement Fe if needed.

ESRD diet compliance mandatory. May cause nausea, vomiting and/or diarrhea.

Calictriol

Glucophage

Sodium Bicarbonate Phos Lo

Water soluble vitamins: none at recommended doses. Fe: take with water or juice on an empty stomach or with food to decrease GI distress, take with vitamin C to increase absorption, take carbonate antacids separately. Anorexia, nausea, vomiting, dyspepsia, bloating, constipation, diarrhea. Alcohol should be limited. Ca regulator/active Do not take with vitamin D or Mg supplements, vitamin D used to treat with dialysis do not take with excessive Ca or low hypocalcaemia in dialysis P, increase Ca absorption, anorexia, decrease patients. weight and increased thirst. Anti-hyperglycemic agent, Anorexia, weight stable or declines, decreases biguanide; increases effect Folate and vitamin B12 absorption. Use caution of insulin, lowers GI with severe decreased renal function. glucose absorption, decreases hepatic glucose production. Antacid, alkalinizing Consider Na content with decreased Na diet; may agent. increase third and weight (fluid). Use caution with severe decreased rental function and HTN. Phosphate binder for use Take with meals, avoid calcium supplements or in renal failure. (has antacids; decreases Fe absorption, anorexia, calcium in it) nausea, vomiting and constipation.

28. Identify nutrition problems within the clinical domain using the appropriate diagnostic term. Nutrition problems within the clinical domain include: Altered nutrition related lab values Overweight 29. What health problems have been identified in the Pima Indians through epidemiological data? The Pima Indians in Arizona currently have the highest recorded prevalence of diabetes in the world. On average, American Indian and Alaska Native adults are 2.6 times more likely to have diabetes than non-Hispanic whites of similar age. They are 5 times more likely to

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have Type 2 Diabetes than whites. Also, ~50% their adult population has diabetes and ~95% of the population with Diabetes are overweight. 30. Explain what is meant by the thrifty gene theory. The thrifty gene theory was developed in 1962 by geneticist James Neel to help explain why many Pima Indians are overweight. Neels theory based on the fact that for thousands of years, populations who relied on farming, hunting and fishing for food such as the Pima Indians, experienced alternating periods of time of feast and famine. Neel proposed that to adapt to these extreme caloric changes these people developed a thrifty gene that allowed them to store fat during times of plenty so that they would not starve during the time of famine. The gene was originally helpful for the Pima Indians but once they developed a lifestyle with less physical activity, high fat in the diet and constant access to calories the gene began to work against them continuing to store calories for the time of famine. Since they were no longer facing these times of famine the gene was storing fat that did not have a use. Scientists believe that the thrifty gene once protected people from starvation but since starvation occurs in lesser amounts it help them to retain unhealthy amounts of fat. 31. How does nephropathy affect Pima Indians? Diabetic nephropathy is the leading cause of end-stage renal disease and is influenced by genetic and environmental factors. Research on the genome linkage analysis indicates that Pima Indians have a higher susceptibility for diabetic nephropathy on certain chromosomes. Also, Pima Indians have a much higher incidence of nephropathy due to type 2 diabetes than Caucasians and they also lose their renal function at an accelerated rate after they develop diabetic nephropathy. Pima Indians also develop diabetic nephropathy at a young age so more complications may occur. 32. Choose two high-priority nutrition problems and complete a PES statement for each. PES 1: Inadequate protein and energy intake related to recent poor intake and nausea and vomiting secondary to chronic kidney disease as evidenced by typical recent daily intake of

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~1300 kCals and 64g of protein compared to recommended 2100-2500kCals & 90g protein. PES2: Inappropriate intake of fats (cholesterol) related to intake of meats as evidenced by typical dietary intake cholesterol >300mg per day. 33. For each PES statement, establish an ideal goal (based on the signs and symptoms) and appropriate intervention (based on the etiology). PES 1: Goal: Increase protein and energy intake to recommended values. Intervention: Educate patient on recommended energy and protein values for patients with kidney disease and on dialysis. Provide patient with renal exchange list, renal food list, and national exchange list. Also provide patient with handouts that contain list of phosphorus foods that should be limited/avoided. PES 2: Goal: Reduce intake of processed meats and reduce dietary intake of fats (cholesterol). Intervention: Educate patient on recommended levels of fat which should be consumed in the diet. Provide patient with low fat options for foods she already enjoys. Educate patient on how fat is stored in the body and benefits of lower fat diet with CKD. 34. When Mrs. Joaquin begins dialysis, energy and protein recommendations will increase. Explain why. Adequate energy intake is important in order to prevent catabolism and achieve optimal nutritional status. Sufficient kcal from carbohydrates and fats may help to prevent muscle and visceral protein from being utilized as energy. The recommended energy expenditure is similar or slightly higher than that of a healthy person because it will supply the body with the proper energy and nutrients needed for the process. Patients with a good nutritional status are more stable and successful when on dialysis. Dialysis patients have an increase in protein requirements because amino acids are lost into dialysate and protein synthesis is reduced during treatment.

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35. Why is it recommended for patients to have at least 50% of their protein from sources that have high biological value? High biological value proteins such as eggs, chicken, beef are recommended because they are better absorbed in the body and easier for the body to digest. When patients are on dialysis it is recommended that they get ~50% of high biological protein and ~50 from plant-based proteins because balancing the two will help in maintaining a neutral or positive nitrogen balance and lead to a balanced diet that helps maintain adequate phosphorus and sodium levels. 36. The MD ordered daily use of a multivitamin/mineral supplement containing Bcomplex, but not fat-soluble vitamins. Why are these restrictions specified? The MD recommended the use of a B-complex vitamin because the B-complex is supplemented due to increased fluid losses during dialysis, anorexia, and poor dietary intake is typically indicated for hemodialysis and peritoneal dialysis patients. Other reasons include that a renal diet low in fresh fruits/vegetables, whole grains and dairy products may lead to altered metabolism, impaired synthesis, resistance to the actions of some vitamins and decreased intestinal absorption. Also, B-Vitamins aid in energy released from carbohydrates, fats and proteins. Fat-soluble vitamins are avoided because they buildup in the body. Serum vitamin A levels re elevated in both hemodialysis and peritoneal dialysis patients, so supplementation is not necessary. The reasons that vitamin A is increased include: serum retinal-binding protein, decreased kidney catabolism, and the failure of dialysis to remove vitamin A. 37. What resources would you use to teach Mrs. Joaquin about her diet? Resources that should be used to teach Mrs. Joaquin about her diet include: renal food list, renal exchange list and the national renal diet. These will help with educating her on the different options she will be able to eat as well as the foods that she should restrict in order to optimize her health and treat her CKD. 38. Using Mrs. Joaquins typical intake and the prescribed diet, write a sample menu. Make sure you can justify your changes and that it is consistent with her nutrition prescription. 13 | P a g e

Diet PTA Breakfast: Cold Cereal ( c unsweetened) Bread (2 slices) or fried potatoes (1 med) 1 fried egg (occasionally) Lunch: Bologna sandwich (2 slices white bread, 2 slices bologna, mustard) Potato Chips (1oz) 1 Can coke Dinner: Chopped meat (3oz beef) Fried Potatoes (1 medium) HS Snack: Crackers (6 saltines) and peanut butter (2 tbsp.)

Sample Menu Cereal is fine as long as it is not whole grain. Bread is fine as long as it is white. Potatoes should be limited because of the levels of K Egg whites are preferred over whole eggs. Eggs should not be fried. White bread is fine, substitute deli chicken or turkey for bologna. No mustard because of high levels of sodium substitute with low sodium/low fat mayonnaise. Due to high levels of sodium in potato chips should substitute with carrot sticks or an apple. Water with lemon (to add a sour taste) to quench thirst, limit fluids. Meat is fine, may substitute with lean chicken Limit potatoes to one meal per day, do not fry. Try grilling or steaming potatoes. Do not eat saltines and peanut butter because of high levels of Na and phosphorus. Eat popcorn instead.

39. Using the renal exchange list, plan a 1-day diet that complies with your diet order. Provide a nutrient analysis to assure consistency with all components of the prescription. Meal Breakfast Item 2 egg whites scrambled 2 slice white bread 1 Tbsp. margarine 1 medium apple cup nonfat milk 2 Tbsp. Jam cup frozen gapes Bagel 1oz light cream cheese 4 graham cracker squares 2 slices white bread 2oz oven roasted turkey 1 Tbsp. low fat mayonnaise 1oz lettuce cup 100% cranberry juice 1 orange 2oz baked chicken no skin 14 | P a g e

AM Snack

Lunch

Dinner

PM Snack

Total kCals= Protein= Phosphorus= Potassium= Sodium=

cup white rice 1 cup green beans 2 dinner roll 1 Tbsp. margarine 1 cup of water 2 Cups air popped popcorn 1 cup carrot sticks 3oz hard candy ~2200 kCals 99g 755mg 2125mg 2400mg

Kcals are a little under what we are aiming for and protein is a little bit higher, this is okay though because increased amount of proteins are excreted during dialysis. 40. Write an initial medical record note for your consultation with Mrs. Joaquin 4/29/13 1230 S: Chief complaint: anorexia, 4kg weight gain in 2 weeks, edema in extremities face and eyes, malaise. SOB, puritis, muscle cramps and inability to urinate. NKA. Has T2DM (11years). Takes Glucophage and Vasotec daily. O: 24yo female, 170#, UBW: 150#,ht: 50. EER: ~2300kCals EPR: ~92g. Dx: CKD stage 4. A: Inadequate protein and energy intake related to recent poor intake and nausea and vomiting secondary to chronic kidney disease as evidenced by typical recent daily intake of ~1300 kCals and 64g of protein compared to recommended 2100-2500kCals & 90g protein. P: Increase protein and energy intake to recommended values. Educate patient on recommended energy and protein values for patients with kidney disease and on dialysis. Provide patient with renal exchange list, renal food list, and national exchange list. Also provide patient with handouts that contain list of phosphorus foods that should be limited/avoided. Signature: ________________________________________________

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