Medical Nutrition Therapy for Chronic Kidney Disease in Pregnancy: A Case Report

In the United States, the prevalence of chronic kidney disease (CKD) in pregnant women has been reported to be 0.03% to 0.12%.1, 2 In Mexico, in a third-level specialty hospital, the prevalence was 0.33%.3 Chronic kidney disease during pregnancy has been associated with higher risk of gestational hypertension, preeclampsia, polyhydramnios, intrauterine growth restriction, preterm birth, and low birth weight.3, 4, 5

Pregnancy involves many metabolic, physiologic, and hemodynamic adaptations that are necessary for adequate fetal development and growth. Women with CKD have lower capacity to adapt to these changes.6Dialysis treatment and its intensity during pregnancy have been shown to decrease the clinical adverse outcomes and improve nutritional status.7

Medical nutrition therapy (MNT) in CKD during pregnancy is essential, but nutrient recommendations are very general, and evidence is scarce.5, 8, 9 Although some guidelines exist, most recommendations have been extrapolated from CKD nutrition treatment (without pregnancy) and from pregnancy nutrition recommendations.9, 10

We present a case study from a pregnant young woman with CKD (stage V), receiving hemodialysis (HD).

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Case Study

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Nutrition Assessment (First Visit—14.3 Weeks of Gestation)

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Client History

A 22-year-old woman had a CKD diagnosis (stage V— Kidney Disease Outcomes Quality Initiative)11 (7 months ago) from an unknown cause. She was from a rural area, close to Mexico City, where she was diagnosed and referred to a third-level hospital in Mexico City. Hemodialysis was started (10.5 h/wk). At 13.5 weeks of gestation, she was referred to another specialty hospital for follow-up of her gestation. The departments of Nephrology, Gynecology, Fetal-Maternal Medicine, and Nutrition were involved in her treatment. Hemodialysis was continued during pregnancy and was increased to 14 h/wk.

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Food/Nutrition-Related History

Before pregnancy, the patient never received any nutritional guidance. Usual dietary intake was recorded: Energy intake was adequate (112%); protein intake was excessive (1.9 g/kg pregestational ideal body weight [IBW]); sodium (Na) intake appeared to be excessive, given that Na intake from foods represented 100% of needs, without considering table salt; and iron (Fe) intake (dietary and supplemented) was adequate (92% of recommended) (Table 1).

Table 1Energy, macronutrient, vitamin, and mineral intake throughout pregnancy for a woman with chronic kidney disease receiving medical nutrition therapya
First trimesterb Second trimesterc Third trimesterd Reference intake10, 18
Gestational age (wk) 13.3 24.2 30.5
Energy (kcal/d) 2,869 2,281 1,873 Individualized
Protein (g/d) 122.5 83.9 91.1 75.3-94.2 (1st trimester)

85.3-104.2 (2nd and 3rd trimesters)e

Carbohydrates (g/d) 376.9 288.8 247.5 175 g
Carbohydrates (%) 50.0 49.7 52.4 45-65
Fiber (g/d) 34.0 23.8 19.9 28
Fat (g/d) 113.0 92.7 59.2
Fat (%) 33.7 35.9 28.3 20-35
SFAf (g/d) 26.8 26.1 18.2
SFA (%) 8.0 10.1 8.7
MUFAg (g/d) 34.5 29.7 18.0
MUFA (%) 10.3 11.5 9.0
Vitamin C (mg/d) 61.2 117.7 41.7 ≥170
Vitamin A (μg/d) 327.4 177.2 659.9 800
Vitamin A supplementation (μg) 450 450
Folate (dietary folate equivalents) (μg/d) 532.9 200.3 153.5 1,800
Folic acid supplementation (mg) 5,000 6,000 6,000
Iron (mg/d) 25.5 10.2 14.7 200
Iron supplementation (mg/d) 160 160 460
Calcium (mg/d) 1,437.1 1,002.2 806.7 1,000-1,200
Calcium

supplementation (mg/d)

300 550 550
Potassium (mg/d) 2,656.8 1,690.5 2,525.1 2,512h or Individualized
Sodium (mg/d) 2,503.3 1,484.7 958.7 2,000-3,000
Phosphorus (mg/d) 1,570.4 1,392.6 1,493.5 1,200 or individualized (labs)
Magnesium (mg/d) 295.2 302.4 271.4 200-300
aNutrient analysis was obtained with Food Processor SQL software (version 10.4, 2008, ESHA Research).
bUsual intake with detailed quantities and ingredients.
c2-d food record.
dTwo multiple-pass 24-h recalls.
e1.2-1.5 g/kg pregestational ideal body weight (IBW); + 0 g/d (1st trimester) or + 10 g/d (2nd and 3rd trimesters).
fSFA=saturated fatty acids.
gMUFA=monounsaturated fatty acids.
h40 mg/kg pregestational IBW.

Since becoming pregnant, she reported starting some positive lifestyle changes (decreased sweetened carbonated beverage intake, minimum salt use, and eating more meals at home); nevertheless, high-energy-density foods were frequently consumed (eg, pastries, Mexican fried foods). She ate three meals/day (only one at home), and her mother prepared her food.

Daily fluid intake included natural water (500 mL/day), 100% fruit juice (250 to 300 mL/day), and lemon tea (480 mL/day). She reported drinking sweetened carbonated beverages (250 to 500 mL/day), 4 times/wk.

She was taking several nutrition supplements: folic acid (5 mg/day), calcium (Ca; 300 mg/day), and vitamin D3 (200 IU/day).

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Anthropometric Measurements

The patient was overweight when she became pregnant (pregestational body mass index, 27.08), and during the first visit she had an adequate weight gain for gestational age (1.2 kg).12

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Biochemical Data, Medical Tests, and Procedures

Electrolyte and mineral status were within normal ranges at week 10.5. Biochemical data are described in Table 2.

Table 2Biochemical data about renal function, electrolyte and mineral status, anemia, and hepatic function throughout pregnancy for a woman with chronic kidney disease receiving medical nutrition therapy
Biochemical marker First trimester Second trimester Third trimester
Gestational age (wk) 10.5 16.5 23.3 27.2 31.3 32.5 34.2
Glucose (mg/dL)a 81 105 73 78 73 137
Oral glucose tolerance test: 0 min/60 min/120 min (mg/dL) 103/91/105 72/67/95
Blood urea nitrogen (BUN; mg/dL)b 29 36 28 32 37 42 38
Creatinine (mg/dL)c 5.2 4.3 3.7 4.2 4.4 5.6 5.1
Uric acid (mg/dL)d 4.1 4.7 2.9 4.1 3.8 5.4 5.3
Creatinine clearance (mL/min) 6.04 4.5 6.3 6.9 3.5
Sodium (mEq/L)e 135.0 134.8 139.0 134.0 134.0 137.0 135.0
Potassium (mEq/L)e 4.5 5.1 4.6 5.4 4.5 4.9 5.1
Chloride (mEq/L)e 98 101 103 97.5 98.1 100 98.9
Magnesium (mg/dL)f 2.2 2.2 2.1 2.2 2.0 2.2 1.7
Calcium (mg/dL)g 8.9 9.5 9.1 9.8 8.9 8.8 8.0
Hemoglobin (g/dL) 6.1 9.3 9.1 9.4 8.1 7.3 7.6
Hematocrit (%) 19.7 28.5 28.2 28.1 24.1 21.7 23.1
Proteinuria (mg/24 h) 1,036 976 640
Aspartate aminotransferase (IU/L) 7 7 7 9 10 15 12
Alanine aminotransferase (IU/L) 5 7 9 9 8 13 8
Total bilirubin (mg/dL) 0.2 0.2 0.2 0.3 0.3 0.3 0.8
Direct bilirubin (mg/dL) 0.1 0.1 0.1 0.1 0.1 0.2
Indirect bilirubin (mg/dL) 0.1 0.1 0.2 0.2 0.2 0.5
aTo convert mg/dL glucose to mmol/L, multiply mg/dL by 0.0555. To convert mmol/L glucose to mg/dL multiply by 18. Glucose of 108 mg/dL=6 mmol/L.
bTo convert mg/dL BUN to mmol/L, multiply mg/dL by 0.357. To convert mmol/L BUN to mg/dL, mg/dL, multiply mmol/L by 2.8. BUN of 11.2 mg/dL=4 mmol/L.
cTo convert mg/dL creatinine to μmol/L, multiply mg/dL by 88.4. To convert μmol/L creatinine to mg/dL, multiply μmol/L by 0.0113. Creatinine of 0.9 mg/dL=80 μmol/L.
dTo convert mg/dL uric acid to μmol/L, multiply mg/dL by 59.5. To convert μmol/L uric acid to mg/dL, multiply μmol/L by 0.017. Uric acid of 5 mg/dL=297.5 μmol/L.
eSodium mEq/L=mmol/L, potassium mEq/L=mmol/L, chloride mEq/L=mmol/L.
fTo convert mg/dL magnesium to mmol/L, multiply mg/dL by 0.4114. To convert mmol/L magnesium to mg/dL, multiply mmol/L by 2.431. Magnesium of 2.43 mg/dL=1 mmol/L.
gTo convert mg/dL calcium to mmol/L, multiply mg/dL by 0.25. To convert mmol/L calcium to mg/dL, multiply mmol/L by 4.01. Calcium of 10 mg/dL=2.5 mmol/L.

She had a diuresis of 1.8 L. She was receiving 4,000 IU/HD session of erythropoietin, and 100 mg/HD session of elemental Fe.

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Estimated Requirements

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    Client History
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    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Energy

30-35 kcal/d×pregestational IBW=30-35 kcal×62.8 kg13=1,884-2,198 kcal/d+352 kcal/d (2nd trimester)=2,236 to 2,550 kcal/d.

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Protein

1.2-1.5 g/d*pregestational IBW=1.2-1.5×62.8 kg13=75.3-94.2 g/d+10 g/d=85.3-104.2 g/d.9, 10

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Nutrition Diagnosis

Excessive protein intake (NI, 5.7.2 [Nutrient Intake category from the Academy of Nutrition and Dietetics’ Nutrition Care Process terminology]) (1.9 g/kg pregestational IBW) related to lack of knowledge regarding nutrition and CKD and undesirable food choices, as evidenced by proteinuria (1,036 mg/24-h urine).

Undesirable food choices (NB, 1.7 [Behavioral category from the Academy of Nutrition and Dietetics’ Nutrition Care Process terminology]) related to eating away from home and a complicated schedule because of HD sessions were evidenced by high intake of high-energy-density and high-Na foods.

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Nutrition Intervention

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  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
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    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

MNT Objectives:

  • 1.

    Promote adequate intake of energy, protein, and other nutrients to promote optimal fetal growth and to meet nutrient needs according to CKD and hemodialysis treatment.

  • 2.

    Increase awareness about the importance of improvement of food choices for perinatal health and maintaining adequate electrolyte and mineral status.

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Nutrition Prescription

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Nutrition Plan

Energy: 2,000 kcal/d (considering fewer HD sessions than indicated for pregnancy and being overweight), and 99 g/d protein (1.4 g/kg pregestational IBW+10 g/d) were recommended.

Macronutrients. Fifty-five percent carbohydrates, 19% protein, and 26% lipids were recommended.

Fluid. No restriction of fluids was instituted.

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Food and/or Nutrient Delivery

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  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
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  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Decreased Protein Intake

The patient was asked to eliminate high-phosphorus foods, except for dairy products that were recommended. Moderate Na intake (2,000 g/d) and potassium (K) restriction (foods providing >250 mg/serving size) were recommended, as well as eating five meals/day. The patient was told to continue with nutrient supplements (Fe, folic acid, Ca, vitamin D3).

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Nutrition Education

The importance of MNT for her condition was explained, as well as risks and complications associated with her disease. Food sources with high Na, K, and phosphorus content were discussed. We also explained the nutrition plan with the different choices from each food group. An example of a 1-day menu with the recommended food groups and serving sizes was provided to the patient.

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Nutrition Monitoring

Nutrition monitoring ensued every 2 to 4 weeks.

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Follow-up

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Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Nutrition Assessment and Monitoring

The patient moved to Mexico City from Tuesday to Friday with her mother. Mother still cooks for her during breakfast and dinner; lunch was prepared by the housekeeper. The patient’s food intake schedule varies according to activities, especially during HD days.

Primary positive nutrition changes during pregnancy included decreased intake of sweetened carbonated beverages and fried or high-fat Mexican food, select low-fat cooking methods, increased vegetable intake, and decreased intake of high-Na, high-phosphorus, and other high-fat foods. At the end of pregnancy, she reported good adherence to the nutrition plan. The patient was successful in increasing the number of meals (4-5 meals/day). Fluid intake was maintained at 1,000 to 1,100 mL/day.

In general, her energy intake tended to decrease. Total protein, carbohydrate, and fat intake were significantly reduced during pregnancy. Her estimated Na intake from food sources decreased from 2,500 mg/d to 958 mg/d. Potassium was maintained within the recommended intake. Phosphorus intake was decreased from the first trimester to the second trimester, but it appeared to be on the upper limit. Iron intake (dietary and supplement) was low during the second trimester, achieving adequate intake until the third trimester, because of an increase in Fe dose to 400 mg/HD session (Table 1).

Folic acid, vitamin D3, and erythropoietin supplementation was maintained throughout pregnancy. A multivitamin was added at 22.2 weeks of gestation that provided 1,500 IU vitamin A, 200 mg vitamin C, 250 IU vitamin D3, 1 mg folic acid, 250 mg Ca, and 60 mg Fe. Physical activity was increased; mainly, the patient used the stationary bike during her HD sessions (4 days/wk).

From 22 weeks of gestation, the patient’s weight gain per week of gestation was accelerated (Table 3 andFigure 1). The interdialytic weight gain range was between 2.2 and 2.5 kg, which is higher than recommended.

Table 3Weight gain during pregnancy and classification according to the Institute of Medicine guidelines12
Gestational week Weight gain (kg) Weekly weight gaina Interpretation
14.3 1.2
18.3 0 0 kg Insufficient
22.2 1.8 0.46 kg Excessive
24.5 1.3 0.56 kg Excessive
27.5 3.2 1.06 kg Excessive
29.5 1.4 0.7 kg Excessive
31.5 0.5 0.25 kg Adequate
aRecommended weekly weight gain in overweight women: 0.23-0.33 kg.12 Pregestational weight=79 kg.

Thumbnail image of Figure 1. Opens large image

Figure 1

Weight gain during pregnancy, according to Institute of Medicine guidelines.

Fetal growth was reported to be adequate, except at week 30.2, when the fetus was classified as large for gestational age (LGA; estimated fetal weight percentile, 81), and polyhydramnios was diagnosed.

Blood urea nitrogen (BUN), uric acid, and creatinine were within goals throughout pregnancy; BUN was always maintained at less than 50 mg/dL. Sodium, K, chloride, magnesium, and Ca were within normal range during pregnancy; phosphorus was not measured. Proteinuria was decreased from 1,036 mg/day to 640 mg/day (Table 2). Residual renal function was maintained (range, 800 to 1,850 mL/24-h urine output). No physical evidence of overhydration was observed.

Impaired glucose tolerance was diagnosed with a 75-g oral glucose tolerance test (OGTT) performed at 16.5 weeks of gestation.14 A second OGTT was performed at 31.3 weeks, with a normal result. Blood pressure was maintained within normal ranges.

Anemia was present during the pregnancy, with Hb values less than 10 mg/dL (100 g/L; range, 6.1 to 9.4 mg/dL [61 to 94 g/L]), and hematocrit between 19.7% and 28.5%, respectively.

Jump to Section
Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Primary Nutrition Diagnosis during Follow-up

Excessive carbohydrate intake (NI, 5.8.2) related to impaired glucose tolerance, as evidenced by altered fasting glucose (103 mg/dL).

Imbalance of fluids (NI, 5.5) probably was related to insufficient HD therapy (14 h/wk) and irregular urine output as evidenced by excessive interdialytic weight gain and adequate fetal growth.

Inadequate Fe intake (NI, 5.10.1) (85% of recommendation) (from diet and supplementation) during the second trimester was related to higher requirements attributable to HD sessions, erythropoietin use, and pregnancy, as evidenced by low hemoglobin and hematocrit values (9.1 to 9.4 g/dL [91 to 94 g/L], and 28.1% to 28.5%, respectively).

Jump to Section
Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Nutrition Intervention

Energy and protein intake recommendations were maintained throughout pregnancy (2,050 kcal/d and 99 g/d, respectively). High-quality protein was emphasized. At 22.2 weeks’ gestation, a carbohydrate-controlled nutrition plan was recommended (45% carbohydrates, 230 g/d), with 35% of lipids, because of the diagnosis of impaired glucose tolerance.

Basic carbohydrate counting was taught. Food sources of carbohydrates, serving sizes, the even distribution of carbohydrates throughout the day, as well as the importance of consistency of carbohydrate eating between days was discussed.

Healthy food selection was always a primary nutrition education subject. Moderate restriction of K was continued throughout the pregnancy, as well as a decrease in high-sugar, high-fat food sources. Individual goals were to decrease juices, pastries, and chips. Phosphorus intake was controlled. The importance of eating high-Fe food sources also was emphasized.

Jump to Section
Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Clinical Outcomes

Pregnancy was interrupted because of premature rupture of membranes at 34.2 weeks’ gestation. A male newborn was born, with a weight of 1,995 g (z-score −0.8), length of 44 cm (z-score −0.4), and head circumference 32 cm (z-score 0.4).15 His Apgar score was 4/9. He was hospitalized with respiratory distress syndrome, multi-etiology hyperbilirubinemia, patent ductus arteriosus, late sepsis, neuroinfection, and severe pulmonary bronchodysplasia. Growth rate during hospitalization (43 d) was subadequate (Figure 2).

Figure 2Perinatal outcomes: Optimal and adverse.
Maternal and fetal Perinatal outcome Newborn
Optimal outcomes Blood urea nitrogen, potassium, and sodium serum levels maintained Alive newborn Normal anthropometric indices at birth (10th-90th percentile)
Blood pressure within normal ranges throughout pregnancy Newborn classified as adequate for gestational age
Proteinuria was reduced (1,036-640 mg/24 h urine) No intrauterine growth restriction
No preeclampsia
Normal fetal growth during 1st and 2nd trimesters
Adverse outcomes Impaired glucose tolerance at 2nd trimester Preterm birth (gestational age: 34.2 wk) Clinical diagnoses: respiratory distress syndrome, hyperbilirrubinemia, patent ductus arteriosus, sepsis, neuroinfection, and severe pulmonary bronchodysplasia
Anemia Apgar 4/9 Suboptimal growth rate during hospitalization
Polyhydramnios Low birth weight (1,900 g) 43 d in neonatal intermediate/intensive care
Large for gestational age fetus at 30.2 wk Borderline low thorax circumference (29 cm)
Jump to Section
Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Discussion

MNT for CKD during pregnancy is essential but remains a challenge. This case demonstrates that a multidisciplinary treatment may help attenuate the high-risk profile of CKD during pregnancy.

Our patient did not develop hypertensive disorders in pregnancy. Even though impaired glucose tolerance was observed during the second trimester, low glucose values were observed on a third trimester OGTT. A preterm birth of 34.2 weeks was a positive outcome, considering the reported mean of 32 weeks of gestation in this population.5 Although the newborn was classified as low birth weight (<2,500 g), anthropometric indices at birth were all adequate (10th to 90th percentiles).15

Nutrition intervention was successful in reducing the patient’s intake of high-energy foods, sweetened carbonated beverages, juices, and in controlling Na, K, and phosphorus intake. The patient was able to increase her vegetable intake. The intervention appeared to have a positive effect on electrolyte and mineral status. Considering past reports, HD for these patients should be given for a total of 20 h/wk,16, 17 although this patient received HD for 14 h/wk, and BUN was maintained at less than 50 mg/dL.8 Residual renal function was stable, and anuria was avoided.

One of the main challenges of MNT was the recommendation of energy intake. For CKD in pregnancy receiving HD treatment, energy intake may be estimated as 30 to 35 kcal/kg.5, 8, 10 Most reports did not specify whether this should be calculated using current dry body weight, pregestational IBW, or other; some suggest adding the energy cost of pregnancy. In this case, fetal surveillance was the primary outcome to modify energy or protein recommendations. Higher Fe supplementation doses should have been given during pregnancy to maintain Hb values at greater than 10 g/dL, as well as erythropoietin treatment.9 Fetal growth was adequate throughout pregnancy, except for an upper limit estimated fetal weight at 30.2 weeks. In pregnant women with CKD receiving HD, weight gain is difficult to interpret. This patient had excessive weight gain from 22.5 to 29.5 weeks of gestation.12 Possibly the HD was insufficient. Thus, considering fetal growth and the patient’s weight gain, the energy intake recommendation was estimated and maintained at 30 kcal/kg pregestational IBW.

Adverse perinatal outcomes for this patient included polyhydramnios, anemia, and premature rupture of membranes, and the clinical evolution of the newborn was not optimal (Figure 2).

Jump to Section
Case Study
  Nutrition Assessment (First Visit—14.3 Weeks of Gestation)
    Client History
    Food/Nutrition-Related History
    Anthropometric Measurements
    Biochemical Data, Medical Tests, and Procedures
  Estimated Requirements
    Energy
    Protein
  Nutrition Diagnosis
  Nutrition Intervention
    MNT Objectives:
  Nutrition Prescription
    Nutrition Plan
  Food and/or Nutrient Delivery
    Decreased Protein Intake
  Nutrition Education
  Nutrition Monitoring
  Follow-up
    Nutrition Assessment and Monitoring
  Primary Nutrition Diagnosis during Follow-up
  Nutrition Intervention
  Clinical Outcomes
Discussion
Conclusions
References

Conclusions

This is one of the few cases that reports the challenge of applying the nutrition care process for CKD during pregnancy. As expected, some positive and some adverse clinical outcomes were observed. The renal RDN has a unique role within the health care team responsible for treating CKD in pregnancy. RDNs must provide specific renal nutrition therapy interventions and nutrition education and counseling. Studies describing nutritional and clinical status throughout pregnancy in women with CKD are urgent, as is the evaluation of MNT with specific nutrition strategies.

Published by: davidgerting

I'm 32, I live in Westminster Md. For the longest time I struggle to figure out what I want to do for a living. Until I realize for the last 4 or so years, everything I love doing was about health and fitness so about 2 years ago. I decided to go to school for exercise science I got my A.A degree then I processed to study for the National Academy sports medicine (NASM) exam after I pass I started my journey to try different workouts and different meal plans I even start my education trying to became a dietitian hopefully I'll be a RD in the next 2 years through out the day I strive to learn as much as I can. Now I can honestly say, I can help anyone the wants to lose weight gain muscle or just over all want to be more healthier.

Categories Chronic Health conditions and physical or Functional Limitations Tips and Facts, Nutrition tips & FactsLeave a comment

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