|Year : 2020 | Volume
| Issue : 3 | Page : 64-69
Medical nutrition therapy in chronic renal disease: A case study
Department of Foods and Nutrition, Chief Dietitian, Shatabdi Superspeciality Hospital, Nasik Founder, Sattvanutricare, Panjab University, Chandigarh, India
|Date of Submission||04-Jan-2021|
|Date of Acceptance||06-Jan-2021|
|Date of Web Publication||13-Apr-2021|
Ms. Himani Puri
Department of Foods and Nutrition, Chief Dietitian, Shatabdi Superspeciality Hospital, Nasik, Founder, Sattvanutricare Panjab University, Chandigarh
Source of Support: None, Conflict of Interest: None
This article discusses the importance of nutrition intervention and management in clinical dietetic practice with the aid of nutrition care process (NCP) in a Stage 5 chronic renal failure, hypertensive outdoor patient. The objective was to provide medical nutrition therapy to the patient to delay the progression of the disease and improve the quality of life. Patient education was emphasized during every diet counseling session. The patient progressed through nutrition care as indicated in the plan of care, with improvement. NCP was used to document and manage nutrition care and involves four steps: nutrition assessment and reassessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation.
Keywords: Clinical dietetic practice, nutrition care process, malnutrition inflammation score
|How to cite this article:|
Puri H. Medical nutrition therapy in chronic renal disease: A case study. J Renal Nutr Metab 2020;6:64-9
| Introduction|| |
Diet plays a very vital role when the renal functioning is reduced. Researchers believe that the nutritional status, treatment, and diagnostic parameters of chronic renal failure (CRF) patients should target toward not only in improving the mortality outcome but also in improving the quality of life. Chronic kidney disease (CKD) is a disorder in which both the kidneys may lose their capacity to function and is a long-standing and progressive, irreversible condition. National Kidney Foundation defines CKD as “abnormalities of kidney structure or function, present for more than 3 months, with implications for health.” CKD is classified on the basis of glomerulus filtration rate (GFR), when GFR value lies <60 mL/min/1.73 m2 and/or albumin/creatinine ratio (ACR) ≥30 mg/g for 3 months or more. The dietary advice in CKD patients should account for personal factors, such as social environment, family, and psychological factors, and should help and guide them and the caretakers toward taking responsibility for their nutrition by setting targets goals.
| Patient Profile|| |
A case study of an 82-year-old female Mrs. SD who is nondiabetic, hypertensive patient with stage 5 CRF. The patient's chief complaints were lack of appetite, vomiting, weakness, frequent bowel movement, loss of weight, and decreased endurance during activities of daily living. The patient had been admitted in the hospital two times in the past with complaints of urinary tract infection (UTI), weakness, loss of appetite pain in the right shoulder intermittent bouts of diarrhea, and malaise. She was diagnosed with acute-on CRF and admitted on June 13, 2020, with increased renal function test and discharged on June 22 after feeling better. She was admitted again on July 4, 2020, with complaints of UTI, nausea, dry vomiting, body ache, and general weakness. She was tested for COVID-19 and found negative. She was treated for the symptoms and initiated with dialysis. After 4 days of admission and on feeling better took a voluntary discharge from the hospital, against the medical advice.
| Nutrition Intervention/Nutrition Care Process|| |
On September 20, 2020, she was referred to Sattva Nutricare for Outpatient Dietary Management. The patient had presented with her biochemical results showing persistent high renal function tests, slight abnormal serum electrolytes levels, low levels for complete blood count, and increased protein levels in urine. Her calculated GFR value was about 10.89 mL/min/1.73 m2, and on MHD since June. (MHD: maintenance hemodialysis).
NCP was implied and the procedures followed stepwise. NCP is a four-step model [Figure 1] involving nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition evaluation.
Nutrition assessment is the first in the NCP. During nutrition assessment, relevant patient data are collected, classified, and synthesized to identify nutrition-related problems and their causes. Nutrition assessment data come from two sources:
- Health record system: Laboratory data, medical diagnoses, epidemiological studies, and administrative reports
- Created during assessment, to be added to medical record: Nutritional intake, current anthropometric measures, and additional client history gathered in interview.
The data thus obtained by the patient were categorized into the following domains:
- Patient history – personal, family, and social: Mrs. SD is an 82-year-old pleasant female, homemaker, literate. She was completely alright till June 2020 when she started having complaints of vomiting, nausea, giddiness, and low appetite. On further investigation, she was found to have high creatinine level and was diagnosed to have CKD. She lives with her son, his wife, and two grandsons and a daughter who visits her often. The family takes good care of her health and is supportive and helpful by nature.
- Food- and nutrition-related history: The data were collected as a part of the interview or written assessment (food record) from the patient and included food and nutrient intake and administration, food allergy/intolerance, medication and complimentary/alternative medicine use, knowledge, beliefs, attitudes, behavioral factors effecting achievement of nutrition-related goals, and factors affecting access to food or food supplies. On discussion, it was found that Mrs. SD lacked knowledge about what to eat, she was confused, and had this misconception that if she ate well or according to her hunger, she would become obese. She thought that eating eggs would cause heat in her body and would aggravate the problem further, so she preferred to avoid them. She felt that, if she ate more, he would have difficulty in breathing. Further, she was told by some relatives that she is not supposed to eat proteins and so had stopped consuming dal at all and should avoid all vegetables and fruits having seeds. She loved to have tea and thought that it would improve her health. The nutrient intake was recommended based on the KDOQI guidelines [Table 1]
- Biochemical data, medical tests, and procedures: According to the information provided in [Table 2], the patient was deficient in blood hemoglobin and had exceeded levels of ACR, blood urea nitrogen, and creatinine and low sodium. These values were obtained from the biochemical analysis in laboratory reports of blood samples
Her other physical examinations were done [Table 3].
- Physical activity: Earlier, the patient was able to do his daily chores and go for walks in the evening. However, since June 2020, due to weakness, she found should it difficult to move around and was dependent on the family members for her day-to-day activities. The only movement was from the bed to bathroom
- Anthropometric measurements: Patient's height, weight, body mass index (BMI), and weight history were noted [Table 4] and [Table 5]. It was observed that the patient had lost 6 kg in the past 4 months
- Nutrition-related physical findings [Table 6].
|Table 6: Nutrition related Additional Physical examinations of the Patient|
Click here to view
The malnutrition inflammation score (MIS) has been used extensively to evaluate nutritional status. The MIS takes into account the relationship between malnutrition and inflammation in patients with CKD and was found to have greater utilization in predialysis CKD patients. Wang et al. in their study concluded that the MIS was strongly linked with indicators of nutrition. The MIS score for the patient was assessed and she was found to have mild malnutrition [Table 7].
On the basis of nutrition assessment results, nutritional diagnoses were made.
- Physical inactivity related to CKD Stage 5 that reduces physical activity as evidenced by observation of infrequent, low duration, physical activity, and client history of low muscle strength
- Not ready for change diet/life style
- Evident protein energy malnutrition (NI-5.2) related to altered nutrient needs due to prolonged catabolic illness and lack of food- and nutrition-related knowledge
- Protein Energy Wasting (PEW) as evidenced by BMI less than 18.5 and weight loss more than 10% over 6 months, underweight with muscle wasting, minimal body fat, and food and nutrition history report of prolonged insufficient intake of energy and protein and poor food intake
- Excess sodium intake, low intake of dietary fiber, and inadequate intake of carbohydrates, fats, and proteins as evidenced by lack of overall dietary intake.
Based on the nutritional assessment and diagnosis, nutrition intervention was planned for the patient. Before planning the nutrition intervention, a discussion was done with the Mrs. SD and her family members, to understand the food availability and their cooking practices. Moreover, diet prescription planned taking into consideration the following points. The points discussed were as follows. They were advised:
- To increase the kcal, proteins, and carbohydrate intake. It was explained to the relative that restricting diet and protein can sometimes also lead to malnutrition. Therefore, it is imperative that the diet of the patients suffering with CKD is planned carefully based on their weight
- To increase the dietary fiber intake
- To adhere to the daily water and sodium recommendation
- To increase the intake of the fruits and vegetables in the diet
- To limit the intake of the hot beverages such as tea
- They were also educated about the portion sizes. High Biological Value (HBV) proteins were suggested to improve the protein intake.
Nutrition monitoring and evaluation
To keep an eye on the compliance of the patient with the diet, a follow-up was scheduled after a week and 3 weeks thereafter. The 24-h diet recall was taken at every visit, and the diet improvised to increase the calorie and the protein intake to achieve the goal[Figure 2].
| Discussion|| |
NCP was applied the current case, and it helped coming to a proper nutrition diagnosis. A comparison between the pre- and post-nutrition intervention clearly showed an improvement in the biochemical parameters [Table 8]. A weight gain of 2 kg was also observed. Nutrition counseling with proper follow-ups also showed better patient compliance.
|Table 8: Comparison of the changes in the Biochemical Parameters of the Patient Post Dietary Intervention|
Click here to view
| Conclusion|| |
A triad approach of a well-planned diet regimen, patient and caretaker counseling, and support with behavioral modification helped achieve weight gain in the patient. A progressive improvement was noted in the patient's health as reflected from the biochemical investigations and increased appetite. Application of NCP also helped in documenting the patient history and come to a better nutrition diagnosis. Therefore, it can be concluded that application of NCP in a CRF Stage 5 patient aided in much better positive outcomes in a clinical setup.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lacey K, Pritchett E. Nutrition care process and model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc 2003;103:1061-72.
Sinelnikova EM, Dvoretskova TV, Kagan ZS. Intermediate plateaux in kinetics of the reaction catalyzed by biodegradative L-threonine dehydratase from Escherichia coli
. Biokhimiia 1975;40:645-51.
Chapter 1: Definition and classification of CKD. Kidney Int Suppl 2013;3:19-62.
K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis Off J Natl Kidney Found 2002;39 2 Suppl 1:S1-266.
Swan WI, Pertel DG, Hotson B, Lloyd L, Orrevall Y, Trostler N, et al
. Nutrition care process (NCP) update Part 2: Developing and using the NCP terminology to demonstrate efficacy of nutrition care and related outcomes. J Acad Nutr Diet 2019;119:840-55.
Pointner H, Flegel U. Treatment of exocrine pancreatic insufficiency with fungal lipase (author's transl). Arzneimittelforschung 1975;25:1833-5.
Camerotto C, Cupisti A, D'Alessandro C, Muzio F, Gallieni M. Dietary fiber and gut microbiota in renal diets. Nutrients 2019;11:2149.
Lim JU, Lee JH, Kim JS, Hwang YI, Kim TH, Lim SY, et al
. Comparison of World Health Organization and Asia-Pacific body mass index classifications in COPD patients. Int J Chron Obstruct Pulmon Dis 2017;12:2465-75.
Lopes AA. The malnutrition-inflammation score: A valid nutritional tool to assess mortality risk in kidney transplant patients. Am J Kidney Dis 2011;58:7-9.
Jagadeswaran D, Indhumathi E, Hemamalini AJ, Sivakumar V, Soundararajan P, Jayakumar M. Inflammation and nutritional status assessment by malnutrition inflammation score and its outcome in pre-dialysis chronic kidney disease patients. Clin Nutr 2019;38:341-7.
Wang W, Liang S, Zhu F, Liu J, Chen X, Cai G. Association of the malnutrition-inflammation score with anthropometry and body composition measurements in patients with chronic kidney disease. Annals of Palliative Medicine, North America 2019. Available from: http://apm.amegroups.com/article/view/31561
. [Last accessed on 2021 Jan 24].
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]