Nutritional Requirements of a Patient with Diabetes Receiving Dialysis
Obesity is a primary risk factor for End Stage Renal Disease (ESRD) along with hypertension. Mr. D’s kidneys failed due to glomerulopathy. The factors associated with obesity-associated glomerulopathy are glomerular hyperfiltration, which results from increased glomerular capillary pressure and therefore enhances capillary wall stress (Andreoli, Ritz & Rosivall, 2006). The transmission of pressure from the aorta to the glomeruli is conducive to the development of glomerulosclerosis and proteinuria. In addition, the renin-angiotensin-aldosterone system (RAAS) and the adrenergic system are activated in obesity. These have pro-fibrotic and pro-inflammatory effects (Andreoli et al. 2006). Moreover, sodium retention can be induced by hyperinsulinemia, as well as glomerular hypertrophy, and both are due to the indirect and direct cell effects through IGF-1 receptors (Henrich, 2012). Aside from these, insulin resistance, increased leptin, infrarenal lipid deposition, and tissue pressure lipotoxicity are also contributory factors in ESRD due to glomerulopathy (Henrich, 2012).
Mr. D’s unexplained weight loss from his diagnosis to present can be explained by the magnitude of his insulin resistance. According to Eakin et al. (2014), patients who are insulin resistant are unable to get glucose into the body’s cells. Therefore, the body utilizes muscle and fat as sources of energy. Aside from this, diabetic ketoacidosis (DKA) is a condition wherein high levels of ketones are produced in the body as a response to the lack of insulin. DKA causes diabetic patients to use their stored fat for energy instead of carbohydrates (Eakin et al. 2014). The metabolism of fatty acids produces ketones, which leads to DKA. The lack of insulin causes a rise in the levels of glucagon, which in turn leads to the increased release of glucose by the liver. High glucose content spills over into the urine during osmotic diuresis. Lipolysis then releases fatty acids and these are converted into ketone bodies through beta oxidation. Ketone bodies have a low pKa and are therefore acidic. To compensate for this, Kussmaul respiration may occur in order to lower the carbon dioxide levels in the blood (Eakin et al. 2014). Since he started dialysis, his weight loss can be attributed to the loss of fluids that dialysis causes. Therefore, Mr. D’s 15% weight loss is fluid loss.
Protein energy wasting (PEW) is a term that was coined by the International Society of Renal Nutrition and Metabolism (van Diepen et al. 2014). PEW is a state of energy and protein wasting during which the reserves of the body gradually decline. During dialysis, the detrimental combination of decreased intake and the increased need for nutritional components contributes to PEW. The increased need for nutrition is caused by chronic kidney disease (CKD). Dialysis treatment itself is a catabolic process and the pro-inflammatory state during dialysis increases the need for nutrition (van Diepen et al. 2014). In addition to these, Mr. D’s protein requirements are higher because he has a chronic illness which necessitates the need for more phosphorous in the diet due to the consumption of phosphorous by …
