last authored: Oct 2014, Becca Green-LaPierre
Mary is a 44 year old woman who has chronic kidney disease, diagnosed 3 years ago. The cause is unclear and you do not have recent bloodwork available. She takes Ramipril (ACE inhibitor) 10mg when she can afford it.
She asks you how her diet could help improve her health.
What nutrients are relevant in CKD?
There are a number of nutrients of importance to discuss with Mary, including:
You are also concerned about the adequacy of her overall caloric and nutrient intake.
What questions could you ask Mary conduct a diet history?
There are a variety of helpful questions to assess the usual energy and nutrient intake of Mary, including:
What socioeconomic questions would you ask?
Questions to help understand her situation better could include:
What elements of the physical exam do you perform?
Collect a weight and ask about recent weight loss (if she does not have access to a scale ask if her clothes fit differently)
Assess for loss of muscle mass.
Assess for edema.
Assess her blood pressure.
From your nutritional assessment you learn…
Mary weighs 101 pounds and has noted her clothes seem to be getting bigger and bigger over the past few months. She reports her strength is failing, she can no longer lift up her youngest grandchild anymore and hasn’t been able to lift the soup pot for months.
Mary does not seem to consume adequate calories or dietary fat and protein.
Her usual breakfast is sweet tea and a banana. Midday she has a small bowl of Aseda (millet porridge) and boiled water to drink.
Common evening meals are vegetable stews with kisera (flatbread). Typically she and her daughter make a large pot of vegetable stew (e.g. eggplants, sweet potato and peanut butter in a tomato broth) and that feeds the family (3 adults and 4 children) for a couple days. Mary will eat a bowl of stew and one piece of homemade whole wheat flat bread each evening and boiled water to drink. Before bed each night she eats another piece of fruit, typically a banana or mango.
They have a vegetable garden and raise chickens for eggs and meat.
What recommendations do you make to Mary?
You do not think Mary is consuming enough calories each day and in particular believe there is a lack of dietary protein to meet her essential amino acid needs. You are also concerned about the amount of fluids she’s consuming. You recommend:
Fluids: Monitor frequency and colour of urine – Mary may need to increase her fluid intake if she is not producing pale urine throughout the day.
Sodium: Encourage Mary to flavour stews with herbs and spices to limit salt intake as much as possible.
Potassium: if urine output declines, Mary will need to watch her potassium intake. Bananas, mangos, sweet potatoes, tomatoes are all rich in potassium - choose only one fruit rich in potassium each day (but maintain the stew).
Protein: Add one chicken egg for breakfast, and ensure one serving of high quality protein each day at the supper meal (~3oz of fish or meat - a portion about the size of the palm of her hand).
Calories: increase daily calorie intake by adding sesame seeds, peanuts and dried fruit to porridge.
Calcium: if available, supplement with calcium carbonate 500mg bid, along with Vitamin D3.