Imagine that you are a nutrition education assistant who is working at the county health department’s nutrition outreach program. You have received a patient referral from the local dialysis center. While all dialysis centers have nutrition professionals and nutrition education is reimbursed through insurance, Medicare, or Medicaid, this is a serious case of non-compliance and the dialysis center is trying to gather more support sources for the patient. The supervising nutrition director has assigned you to review the referral information to help prepare an appropriate intervention.

Referral Information: Mr. D is a 48 year old Caucasian male with poorly managed type 2 diabetes for over 15 years and has been on dialysis three times a week for 1 year. Medical records reveal that his diabetes was most likely obesity related and was never well controlled. Mr. D required insulin shots soon after his initial diagnosis. 1 year ago his friend found him unconscious in his apartment and took him to the hospital. Upon admission, his blood sugar was over 700 mg/dl. He was already in the pre-dialysis stages of kidney disease prior to this hospital stay. His friend reported that he rarely saw Mr. D check his blood sugar or administer insulin shots. His friend also informed the hospital’s nurse that Mr. D once told him that he could lose weight fast by letting his blood sugars get really high and skipping insulin doses.

From Chart-Patient Summary:
Mr. D was 33 years old when he was first diagnosed with Type 2 Diabetes. Weight: 270 pounds (15 yrs ago)
Height: 5’10”
Diet order: 1800 calorie diabetic diet
Clinical Progression of disease: Pancreatic function declined and insulin resistance increased due to Mr. D’s dietary and medical non-compliance.

Medical Intervention: Short and long acting insulin shots were added to his therapy about 10 years ago.
Hospital and Physician visits: Multiple recorded diabetic ketoacidosis (DKA) episodes are documented, including the DKA episode that ultimately caused his kidneys to fully fail when his friend found Mr. D unconscious in his apartment.

Hemodialysis Center reports:
12 months of hemodialysis on Mondays, Wednesdays & Fridays.
Weight one year ago (age 47): 185 pounds (dry weight measured after dialysis session)
Current age: 48
Current weight: 158 pounds
Height: 5’10. The patient has lost 15% of his “dry weight” (commonly used with dialysis patients to obtain a more accurate weight due to fluid fluctuations).
Labs: His sodium, potassium, BUN, Cr, glucose are all out of range and very inconsistent (sometimes very high and sometimes very low, but rarely normal).
Urine output: Negligible
Dialysis Compliance: Only attends dialysis sessions about 75% of the time.
Dietary Information: Increased Calorie Renal diet, carbohydrate restrictions, high protein and a 1250 ml fluid restriction.
Dialysis nursing notes: Heavy alcohol (ETOH) consumption, often complains of (c/o) nausea/vomiting (N/V) after dialysis, and he usually appears very somber.

Address the following questions in a paragraph-type format:
1. Why did Mr. D’s kidneys fail (requiring dialysis)? Why was Mr. D’s risk for developing End Stage Renal Disease (ESRD) higher compared to other type 2 diabetic patients?
2. What caused Mr. D’s excessive weight loss from age 33 to 47? (Diabetes diagnosis to the start of dialysis?) What contributed to the 15% weight loss in since he started dialysis? (one year ago)
Choose several applicable nutritional diagnoses phrases/ nutrition problems from the Nutrition diagnosis list in chapter 11 (Box 11-1). Which one do you think is the most important and why?
4. Why do dialysis patients require so much protein? What are Mr. D’s current estimated calorie and protein needs?
5. Are there any referrals to community programs that may help Mr. D? What can be done to increase his compliance with the dietary and medical therapies?
6. How can Mr. D’s compliance be assessed? Which assessment methods and tools should be utilized? (Weight monitoring, clinical/social referrals/background info, labs, etc.)

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Diabetes and ESRD

Diabetes can predispose an individual to kidney failure. This is because diabetes as condition destroys the blood filtering blood vessels in the kidney leading to its malfunction (Mehrotra et al., 2011). Over time, continued impairment of the kidney leads to a build up toxic substances that eventually lead to End Stage Renal Disease (ESRD). Mr. D, unlike other diabetic patients, is at higher risk of developing ESRD because his condition is poorly managed. As narrated in the nurse’s notes, Mr. D does not seem to care much about his medical nutrition therapy. To start with, his compliance to dialysis treatment is 75%; this is below the threshold. He skips his insulin shots on purpose with the notion that a spike in the blood sugars will help him cut weight. He does present any reasonable argument for the non-compliance. The dialysis nursing notes also indicate that Mr. D consumes a lot alcohol, which is contraindicated in diabetes and ESRD. In the dietary front, Mr. D...

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