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19-1
Kimberly LaBrecque
NTR 404/504
Case Study No. 19
Case Questions for Medical Nutrition Therapy: A Case Study Approach 4th ed.
Title: Case 19 – Chronic Kidney Disease: Peritoneal Dialysis
Instructions: Answer the questions below. You may print your answers or e-mail them to your instructor.
Questions:
1.
Describe the major exocrine and endocrine functions of the kidney.
The kidney’s primary exocrine function is the elimination of nitrogenous wastes from the
body through the excretion of urine. The kidneys filter almost 1600 L of blood on a daily
basis to produce ultrafiltrate. Most of the ultrafiltrate is reabsorbed by the kidneys’ tubules,
which convert the remaining components to urine. Anywhere from 500 mL to 12 L of urine
is excreted daily. The main hormone that regulates this process is vasopressin (or
antidiuretic hormone). Inadequate amounts of water and increase in osmolality stimulates
the release of vasopressin by the posterior pituitary. Vasopressin causes the kidneys to retain
water (Mahan, Escott-Stump & Raymond, 2012, p. 800).
As for endocrine functions, the kidneys regulate blood volume and red blood cell production
through the renin angiotensin mechanism and synthesis of erythropoietin. When blood
volume declines, this stimulates the glomerulus to release the enzyme renin. Renin catalyzes
the formation and conversion of angiotensin I to angiotensin II. Angiotensin II stimulates the
adrenal glands to release the hormone aldosterone, which in turn encourages sodium and
water retention while constricting the vasculature to increase blood pressure. The function of
the hormone erythropoietin is to stimulate red blood cell production in the bone marrow. The
kidneys also play a role in calcium homeostasis by converting vitamin D into an active form,
D-1, 25-dihydroxycholecalciferol. 1, 25-dihydroxycholecalciferol inhibits the parathyroid
hormone from stimulating the osteoclasts to break down and resorb bone, and facilitates the
absorption of calcium in the intestines (Mahan et al., 2012, pp. 800-801).
2. What is glomerulonephritis and how can it lead to kidney failure?
Glomerulonephritis results in the inflammation and injury of the glomerulus. The
glomerulus synthesizes the ultrafiltrate and consists of a membrane-bound network of
capillaries within each nephron. Glomerulonephritis can be acute, or can lead to chronic
kidney disease as well as end stage renal disease, and symptoms include hypertension,
hematuria and decline in kidney filtration and function. Acute forms of glomerulonephritis
may result from a streptococcal infection (Mahan et al., 2012, p. 813).
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19-2
3. What laboratory values or other tests support Ms. C’s diagnosis of chronic kidney disease?
List all abnormal values and explain the likely cause for each abnormal value.
Lab Value
Ms. C
Normal Range
Etiology
Sodium
130 mEq/L
136 – 145 mEq/L
Increased fluid retention may have
resulted in mild hyponatremia.
Bicarbonate
16 mEq/L
21-32
According to KDOQI guidelines,
serum bicarbonate levels are
reduced in patients with a GFR
less than 60 mL/min/1.73 m2. The
low levels may indicate acidemia
and overall protein catabolic state.
Low serum bicarbonate is often
correlated with low albumin.
BUN
124 mg/dL
12-18 mg/dL
This value is high even for patients
on dialysis. It indicates that Ms.
C’s kidneys are not adequately
eliminating nitrogenous wastes.
Dialysis Patients: 50100 mg/dL
Creatinine
serum
6.8 mg/dL
GFR (nonAfrican
American)
6 mL/min/1.73 m2
61-589 mL/min/1.73
m2
GFR (AfricanAmerican
patients)
8 mL/min/1.73 m2
61-714 mL/min/1.73
m2
Phosphate
11.9 mg/dL
2.3-4.7 mg/dL
(inorganic)
0.6-1.2 mg/dL
Dialysis: <15 mg/dL
Dialysis: 3.0-5.5
mg/dL
Most patients with chronic kidney
disease have high creatinine levels.
This results from muscle and
protein catabolism. In addition,
daily or frequent dialysis can
lower creatinine levels.
The GFR measures the quantity of
filtrate produced by the nephrons
and is indicative of end stage renal
disease. Low GFR demonstrates
that the kidneys are not able to
filter and eliminate the waste
products of metabolism.
Phosphate levels increase as GFR
declines so more phosphate
remains in the bloodstream. A diet
high in protein as well as
processed foods will also be high
in phosphorus. Ms. C’s
consumption of an egg McMuffin,
cheeseburger, cola and roast beef
are contributing to higher
phosphate levels. However, she
does take Renvela, a phosphate
binder.
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19-3
Lab Value
Ms. C
Normal Range
Etiology
Calcium
8.3 mg/dL
9-11 mg/dL
The kidneys are unable to convert
to active Vitamin D, which aids in
calcium absorption. The patient’s
phosphate levels are high so
calcium needs increase. The
posterior pituitary continues to
release parathyroid hormone,
which stimulates the osteoclasts to
break down resorb bone. The
product of Ms. C’s phosphate and
calcium is about 98.7, which puts
her at risk for calciphylaxis.
Dialysis: 8.5-10.2
mg/dL
Anion Gap
22 mmol/L
10-20 mmol/L
The higher value is indicative of
metabolic acidosis caused by Ms.
C’s potential uremia. As
metabolic and nitrogenous wastes
accumulate, the kidneys are unable
to maintain an appropriate acidbase balance.
Protein, total
5.9 g/dL
6-8 g/dL
Although Ms. C’s protein lab
value is not much lower than
normal, it may indicate that she is
in a catabolic state and her body is
degrading protein faster than its
rate of synthesis.
Albumin
3.4 g/dL
3.0-5.5 g/dL
Although this value is normal for
patients without renal disease, Ms.
C is returning to dialysis. KDOQI
guidelines indicate that increased
mortality is associated with renal
patients who have albumin levels
under 4 g/dL. Because albumin
helps maintain osmotic pressure in
the plasma, lower levels result in
edema.
Dialysis: >3.5 g/dL
PT (sec)
12.4-14.4 (sec)
16.9 sec
This value indicates and increased
risk for blood clots.
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19-4
Lab Value
Ms. C
Normal Range
Etiology
RBC
2.33 x 106/mm3
4.2-5.4 x 106/mm3
Ms. C’s red blood cell count is low
due to reduced production of
erythropoietin, which stimulates
the bone marrow to synthesize red
blood cells. Ms. C’s uremia may
also cause destruction to existing
red blood cells so both of these
factors may be contributing to her
reduced red blood cell count.
Hemoglobin
6.6 g/dL
12-15 g/dL
Ms. C has a reduced number of red
blood cells as well as transferrin
and ferritin (indicating low hepatic
iron stores). Hemoglobin measures
the amount of iron in red blood
cells.
Hematocrit
19.0 %
37-47 %
Hematocrit reflects the overall
percentage of red blood cells in
Ms. C’s bloodstream. This is low
due to Ms. C’s reduced
erythropoietin and red blood cell
production.
Mean Cell
Volume
65.3 µm3
80-96 µm3
Ms. C’s red blood cells are
smaller than normal and may
reflect a lack of or diminished
amount of erythropoietin.
Mean Cell Hgb
21.5 pg
26-32 pg
Mean Cell Hgb
Content
19.5 g/dL
31.5-36 g/dL
These lower values may be caused
by the reduced synthesis and
number of red blood cells as well
as erythropoietin.
RBC
Distribution
16.8 %
11.6-16.5 %
Transferrin
219 mg/dL
250-380 mg/dL
Transferrin carries iron to the bone
marrow for hemoglobin synthesis.
This value may decrease with
inflammation and increase with
low iron stores.
Ferritin
5 mg/mL
20-120 mg/mL
Low ferritin levels indicate low
hepatic iron stores and reduced
absorption of iron. Declining
renal function leads to reduced
erythropoietin, which stimulates
red blood cell production. Since
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19-5
Ms. C’s red blood cell count and
hemoglobin values are low, she
may require an infusion of iron.
4. This patient has had two previous kidney transplants. What are the potential sources for a
donor kidney? How is rejection prevented after a kidney transplant? What does it mean when
the physician states she is experiencing acute rejection?
According to the National Kidney Foundation, kidneys are donated from either a deceased
donor on a state registry as well as a living donor through the patient’s transplant center at a
hospital. Family members, friends or strangers who are healthy and meet the established
criteria of the transplant center are eligible to become donors. Kidney recipients take
immunosuppressive medications to avoid rejecting the kidney (Mahan et al., 2012, p. 828).
Some of these immunosuppressive medications include sirolimus, calcineurin inhibitors,
corticosteroids, tacrolimus and azathioprine. Corticosteroids increase degradation of protein,
increase sodium and fluid retention as well as increase excretion of calcium and potassium.
This leads to an increased risk of developing osteoporosis with chronic corticosteroid use
(Mahan et al., 2012, p. 216).
Acute rejection occurs when the patient’s immune system treats the donated kidney as a
foreign substance and mounts an immune response to it. Ms. C’s laboratory values and GFR
indicate renal failure. In addition, she has dyspnea, nausea, and edema and appears to be
uremic by reporting altered food taste and decline in appetite.
5. Based on the admitting history and physical, what signs and symptoms does this patient
have that are consistent with acute rejection of the transplant?
Ms. C’s laboratory values and GFR indicate renal failure. Specifically, her GFR indicates
end stage renal disease since it is less than 15 mL/min/m2. In addition, the patient’s BUN is
124 mg/dL and creatinine is 6.8 mg/dL. Furthermore, Ms. C has dyspnea, edema and
appears to be uremic by reporting altered food taste, nausea and an overall decline in
appetite. Uremia occurs as nitrogenous wastes accumulate in the plasma and demonstrates
end stage renal disease in that the kidneys are not able to maintain an appropriate acid-base
balance and are unable to sufficiently excrete metabolic wastes. Additionally, Ms. C’s red
blood cell count, hemoglobin and hematocrit are very low indicating her kidneys are not able
to synthesize erythropoietin resulting in anemia related to chronic kidney disease. Acute
rejection also reduces urine output, although Ms. C’s net intake is greater than her net output,
which shows some decline in output although she is not oliguric (Mahan et al., 2012, p. 813).
6. Ms. C has requested that she restart peritoneal dialysis. Describe the basic concepts of
this medical treatment and how it differs from hemodialysis.
In peritoneal dialysis, a surgeon inserts a catheter into the patient’s peritoneum where a
dialysis solution is inserted into the peritoneum. The differences in concentration cause
wastes to diffuse out of the bloodstream and into the dialysate. The fluid is then removed
and replaced with new dialysate (usually a concentrated dextrose solution). One form of
peritoneal dialysis is CCPD, or continuous cycler assisted peritoneal dialysis, in which a
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19-6
machine performs the dialysis at night while the patient may keep a long dwell or “single
dialysate” during the day. Another form, CAPD, continuous ambulatory peritoneal dialysis,
occurs when the dialysate is placed in the peritoneum up to five times a day and filtered by
diffusion and gravity. Because peritoneal dialysis occurs more frequently, this provides more
stability to serum metabolite fluctuations. However, the dextrose solution can lead to weight
gain and the nature of the catheter insertion makes a patient more vulnerable to infections
such as peritonitis (Mahan et al., 2012, p. 815).
Peritoneal dialysis takes up to 40 minutes per exchange and is recommended up to four times
daily. The amount of time the dialysate remains in the peritoneum can be anywhere from
four to six hours. In CAPD, the patient is able to ambulate and continue with daily activities.
Unlike peritoneal dialysis, hemodialysis is usually performed at an outpatient clinic three
times a week. Each session lasts approximately three to five hours, or can occur for shorter
time periods more frequently during the week, or while the patient is sleeping at home. In
hemodialysis, a surgeon creates a fistula to join an artery and vein where the dialysis needle
will be inserted. Wastes are removed from the blood by diffusion through a filter or dialyzer
in a machine, and then the filtered blood is returned to the patient’s body (Mahan et al., 2012,
p. 815).
7. This patient was prescribed the following diet in the hospital: 1500 kcal, 75 g pro, 3000 mg
Na, 3500 mg K, 1000 mg P, 2000 cc fluid. Explain the rationale for each component of her
nutrition therapy Rx. How might this change once she has started peritoneal dialysis?
The prescribed energy needs reflect the decreased energy needs of a hospitalized patient with
impaired kidney function. According to KDOQI guidelines, Ms. C’s energy needs would fall
in the 35 kcal/kg range for patient’s under 60 (Mahan et al., 2012, p. 818). Ms. C’s ideal
body weight for height is approximately 52.3 kg and multiplied by 30, this would equate to
approximately 1569 kcal per day. KDOQI guidelines also indicate that protein needs for
patients six weeks following a transplant is approximately 1 g per kg of body weight, which
would range from 74 to 77.1 g of protein based on Ms. C’s usual and current body weights.
In addition, recommended sodium levels for those with impaired kidneys ranges from 2 to 3
grams daily to reduce edema. Her potassium intake is slightly higher than the 2 to 3 gram
recommended range for patients with impaired kidney function and but also reflects serum
potassium levels, which were within normal limits, about 3.8 mg/dL. However, Ms. C has
been taking a diuretic, Lasix, which promotes potassium excretion, and perhaps this amount
is higher to replete the potassium lost from diuretics. According to KDOQI guidelines,
patients who receive a transplant usually do not need to limit phosphorus as much as those
with impaired function, but since Ms. C has kidney failure and acute rejection, the
phosphorus levels reflect recommended amounts between 800 to 1000 mg per day. As for
fluid, the amount may be a little higher than what some patients may receive with chronic
kidney disease; however, Ms. C does not appear to be oliguric and she is not yet on dialysis
(Mahan et al., 2012, pp. 817-819).
Once Ms. C starts dialysis; however, her protein needs should increase to 1.2 to 1.3 g per kg
of body weight as peritoneal dialysis promotes protein loss of up to 1 g per hour (Mahan et
al., 2012, p. 822). In addition, per KDOQI guidelines, Ms. C’s energy needs should be
increased to 35 kcal/kg in order to provide adequate energy to avoid protein sparing that can
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19-7
occur in dialysis. Likewise, a proportion of calories will have to be deducted from the
overall energy needs to compensate the absorption of glucose from the dialysate.
8. Assess Ms. C’s height and weight. Calculate her BMI and her % usual body weight. How
would edema affect your interpretation of this information? Using the KDOQI guidelines,
what is Ms. C’s adjusted body weight?
Ms. C’s admission weight is 77.1 kg though her usual body weight is reported as about 74
kg. Using Ms. C’s current weight and height, her BMI is 31.1 [77.1kg/(1.574)2 ]. Ms. C’s
BMI using her usual body weight is 29.9 [74/(1.574)2], and she would be classified as
overweight.
Ms. C’s ideal body weight is 52.3 kg (115 lbs) based on her height using the Hamwi
equation. Her percent usual body weight would be approximately 104 percent (77.1kg /74 kg
x 100 %). It appears that Ms. C has gained approximately 3 kg in body fluid. According to
KDOQI guidelines, Ms. C’s adjusted body weight is 68.6 kg.
aBWef=BWef + [(SBW-BWef) x 0.25] = 74 kg + [(52.3 kg-74kg) x 0.25]= 68.6 kg
9. Determine Ms. C’s energy and protein requirements. Explain the rationale for the method
you used to calculate these requirements.
Ms. C’s energy needs before dialysis, using the Mifflin St. Jeor formula for normal or
overweight patients, are: 1453 kcal per day with a stress factor of 1.1
9.99 x 74 kg + 6.25 x 157.4 cm – 4.92 x 49-161= 1321 kcal x 1.1 stress factor = 1453 kcal
An appropriate range might be anywhere from 1500 to 1600 kcal per day, using either a
stress factor of either 1.1 or 1.2 since the patient is hospitalized and not ambulatory.
As for protein requirements, KDOQI guidelines generally recommend one gram of protein
per kilogram of body weight for post-transplant patients (beyond the initial six weeks of
surgery). However, Ms. C is experiencing acute kidney rejection and renal failure so her
protein needs, before dialysis, should be reduced in light of current labs and a GFR of 6
mL/min/m2. In addition, the patient’s protein requirements should be no more than 0.6
grams per kilogram of body weight. Given Ms. C’s fluid retention and weight gain, as well
as BMI of 29.9, it would be appropriate to use the patient’s adjusted body weight, or 68.6 kg.
Therefore, pre-dialysis, Ms. C’s protein needs would be about 41 grams per day.
Once Ms. C starts peritoneal dialysis, the recommended energy intake according to KDOQI
guidelines would be 35 kcal/kg of body weight for patients under 60. This would equate to
approximately 2400 kcal per day using Ms. C’s adjusted body weight. It is more appropriate
to use the patient’s adjusted body weight since she is retaining fluid and is overweight as
evidenced by a BMI of 29.9. This seems high for someone who may not be very active.
However, any form of dialysis requires adequate energy to avoid protein sparring since
protein depletion occurs with dialysis treatments. Therefore, it is necessary to ensure the
patient had adequate energy to avoid the muscle wasting that can occur with severe protein
depletion (Mahan et al., 2012, p. 822).
Likewise, Ms. C’s protein requirements on dialysis should increase to 1.2 to 1.3 g/kg of body
weight to replete the protein lost from dialysis. Using Ms. C’s adjusted body weight, her
protein needs would be anywhere from 82 to 89 grams per day.
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19-8
10. List all medications that Ms. C is receiving. Determine the action of each medication and
identify any drug–nutrient interactions that you should monitor for.
Medication
Function
Drug-Nutrient Interaction
Procardia
Calcium channel
blocker/antihypertensive
Patient should avoid consuming
grapefruit or related citrus fruits as
well as alcohol. Medication should
be taken on an empty stomach.
Carvedilol
Beta blocker/antihypertensive Patient should avoid any foods
(dilates blood vessels)
containing natural licorice
(glycyrrhiza glabra). Medication
Also used to treat heart
may interfere with calcium
failure in patients.
absorption. May also cause sodium
reabsorption as well as water
retention.
Catapres (clonidine)
Antihypertensive/Alphaadrenergic agonist
Patient should avoid any foods
containing natural licorice. Patients
should have adequate hydration and
avoid alcohol while taking
medication.
CellCept
Immunosuppressant (helps
prevent kidney transplant
rejection
Patients should take medication on
an empty stomach or two hours
after eating. A magnesium
supplement or antacid may be
recommended (assuming adequate
renal function).
Lasix
Loop diuretic
Medication may increase excretion
of potassium, magnesium, calcium
and sodium. If renal function is
adequate, then increased
consumption of foods containing
potassium, magnesium and calcium
may be recommended.
Prednisone
Corticosteroid, antiinflammatory,
immunosuppressant
Medication accelerates protein
degradation, and reduces calcium
absorption. It also promotes fluid
and sodium retention as well as
increases excretion of potassium,
calcium, zinc, vitamin C, and
reduced calcium absorption.
Supplementation of calcium and
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19-9
vitamin D is often required.
Medication should be taken with
food and patient should limit
caffeine to avoid GI disturbance as
well as avoid alcohol.
Gengraf
(cyclosporine)
Immunosuppressant
Prinivil
Antihypertensive, ACE
inhibitor
Medication may increase serum
potassium. Patients should avoid
natural licorice as well as salt
substitutes. Patients should insure
adequate hydration. This
medication may be contraindicated
in patients who require intravenous
iron fusions.
Sodium Bicarbonate
Antacid, alkalizing agent
Medication should be taken after
meals, with one cup of water.
Patient should use caution with
calcium supplementation or high
calcium intake. Decreasing sodium
may also be recommended. Any
iron supplements should be taken
two hours after or one hour before
taking medication.
Calcitriol
Calcium supplement used to
treat hypocalcemia as well as
secondary
hyperparathyroidism
Patient should avoid using vitamin
D or magnesium supplements while
taking this medication. For dialysis
patients on parenteral IV, avoid
high calcium and phosphorus diet.
Renal Caps
Supplement of B-complex
and C vitamins mainly used
for patients with chronic
kidney disease and dialysis.
No specific food or drug
interactions. The supplement
should be taken daily as prescribed
by the patient’s physician.
Renvela
Phosphate binder
Medication should be taken with
foods and at mealtime, swallowed
whole. Patients need to maintain a
low phosphate diet and frequent
monitoring of phosphate, calcium
and bicarbonate.
Medication is used to prevent
kidney transplant rejection.
Medication may increase sodium
and potassium absorption while
reducing magnesium levels. It may
also increase triglycerides so fat,
simple sugars and magnesium
intake should be monitored.
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19-10
Fish Oil
Anti-hyperlipidemic,
anticoagulant, antiinflammatory and antiarrhythmic, omega-3
supplement
Supplement should be taken with
food. Since the patient is allergic to
fish, it might be beneficial to
recommend a plant-based omega-3
supplement or encourage
consumption of foods high in
omega-3 fatty acids including flax
or chia seeds.
11. Ms. C’s laboratory values that you discussed previously in this case indicate she has anemia.
Why do renal patients suffer from anemia? How is this typically treated in dialysis patients?
Renal patients often suffer from anemia because their kidneys are unable to synthesize
enough of the hormone, erythropoietin. Erythropoietin (EPO) stimulates red blood cell
synthesis in the bone marrow. Declining EPO means fewer red blood cells are produced,
resulting in reduced hemoglobin. In addition to deficient EPO, dialysis and frequent blood
draws may deplete red blood cells. Finally, the accumulation of metabolic wastes in the
bloodstream from uremia can destroy existing red blood cells.
Most renal dialysis patients take a synthetic form of EPO that can induce red blood cell
production 2.5 times which leads to a rise in hematocrit. Often, the rise in red blood cell
concentration requires an infusion of iron to meet the increased demand by red blood cells
(Mahan et al., 2012, p.825).
12. What factors in Ms. C’s history may affect her ability to eat? What are the most likely causes
of these symptoms? Can you expect that they will change?
Ms. C has symptoms of uremia, which is typical of patients in end stage renal disease. As
Ms. C’s kidneys are unable to eliminate nitrogenous wastes, metabolic wastes, such as
ammonia and urea, accumulate in the bloodstream and can cause a patient to experience
nausea, vomiting, neurological impairment and a metallic taste in foods (Mahan et al., 2012,
p. 813). This may specifically result in food aversions, primarily to protein-containing foods.
Some patients are unable to tolerate meat. Other sources of high quality protein may need to
be provided such as eggs, tofu and poultry. Seasonings without salt and serving the protein
foods cold might alter the taste. The goal is to make food attractive and palatable to
encourage the patient to eat. However, once Ms. C begins peritoneal dialysis, her renal
function and GFR should improve enough to eliminate her symptoms of uremia, and she
should be able to tolerate foods better as her renal function improves (Mahan et al., 2012, p.
822).
13. Evaluate Ms. C’s diet history and 24-hour recall. Is her usual diet consistent with her
inpatient diet order?
According to Ms. C’s diet history, she consumes an excess of calories based on her energy
needs. Her breakfast and lunch consist of fast food items which tend to be high in fat,
sodium, energy and phosphate. Based on her diet and according to MyPlate’s SuperTracker,
Ms. C is consuming about 1885 kcal per day on current diet. It is not clear if this is reduced
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19-11
from what she normally eats, or if this was her typical diet before her symptoms of uremia
started. The following chart shows Ms. C’s diet based on her 24-hour recall compared with
what the physician’s admitting orders are:
Ms. C’s Diet
Protein Na
24-Hour
Recall
71 g
Admission 75 g
Orders
K
P
2491 mg 2737 mg 919 mg
Energy
Fluid
1885 kcal
34 fl oz (1005
mL)
3000 mg 3500 mg 1000 mg 1500 kcal
2000 cc fluid
(mL)
Although Ms. C’s energy is higher, most of her nutrient and fluid needs are less than what
was prescribed at admission. The nutrient, energy and fluid recommendations will change
once Ms. C begins peritoneal dialysis.
14. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses.
Based on her current laboratory values and history, Ms. C has the following nutrition-related
problems:

Altered nutrition-related laboratory values

Impaired nutrient utilization

Increased nutrient needs (protein, iron)

Excessive Energy Intake

Overweight/obesity
The primary problems that need to be addressed immediately are the altered nutrition-related
laboratory values and the impaired nutrient utilization. The other problems may be addressed
over time when Ms. C’s condition becomes stable.
15. Write a PES statement for each high-priority nutrition problem.
Altered nutrition-related laboratory values related to renal failure from glomerulonephritis
and acute kidney rejection as evidenced by GFR of 6 mL/min/1.73 m2, serum phosphate of
11.9 mg/dL and serum albumin of 3.4 g/dL.
Impaired nutrient utilization related to inability to metabolize urea, ammonia, nitrogen and
other metabolic wastes as evidenced by GFR of 6 mL/min/1.73 m2, BUN of 124 mg/dL and
serum creatinine of 6.8 mg/dL.
Altered nutrition-related laboratory values related to renal dysfunction and hypertension as
evidenced by GFR of 6 mL/min/1.73 m2 and blood pressure of 161/92.
Increased nutrient needs related to anemia of chronic kidney disease as evidenced by
hemoglobin of 6.6 g/dL, RBC of 2.33 x 106/mm3 and hematocrit of 19 percent.
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19-12
16. Ms. C was discharged from the hospital and was prescribed the following regimen of
peritoneal dialysis to begin at home: CCPD daily. Ca 2.50; Mg 0.5, Dextrose 2.5%. Total
fills (or exchanges) = 3 (3 fills/cycle @2500 mL). Total fill volume/24 hours: 10000 mL.
Determine the amount of energy that Ms. C’s PD prescription will provide each day. How
will this affect your nutrition recommendations?
If the total fill volume is 10000 mL per day, or 10 L, this would provide about 510 to 595
kcal per day.
10 L x 25 g/L = 250 g
250 g x 3.4 kcal/g = 850 kcal
850 kcal x 0.6 – 0.7 = 510 to 595 kcal
At energy requirements of 2400 kcal per day (35 kcal/68.6 kg), Ms. C’s energy needs would
be anywhere from 1800 to 1900 kcal per day subtracting 510 to 595 kcal from 2400.
17. Using the KDOQI adult guidelines for peritoneal dialysis patients, determine Ms. C’s
nutrition prescription for outpatient use. (Include energy, protein, phosphorus, calcium,
potassium, sodium, and fluid.)
According to KDOQI guidelines, Ms. C’s energy needs should be approximately 35 kcal/kg
of body weight. The guidelines recommend this energy intake for weight maintenance
because low body weight is associated with higher mortality in chronic dialysis patients and
protein energy malnutrition (KDOQI, p. 45-46). Since Ms. C is overweight (usual BMI of
29.9), it is appropriate to use her adjusted body weight of 68.6 kg. Her energy needs would
be approximately 2400 kcal per day before subtracting the amount of energy from dextrose
solution in peritoneal dialysate. Her energy needs would then be reduced to 1800 to 1900
kcal per day for weight maintenance. Moderate weight loss might be appropriate at a later
point when Ms. C’s condition becomes more stable.
As for protein, KDOQI guidelines recommend 1.2 to 1.3 g of protein per kg of body weight.
Therefore, using Ms. C’s adjusted body weight, her protein requirements would be anywhere
from 82 to 89 g of protein per day. The guidelines further stipulate that at least half the
protein intake should come from high quality protein sources (high biological value) such as
lean meat and eggs (animal sources).
According to KDOQI guidelines, Ms. C’s micronutrients and fluid needs should be as
follows:

Phosphorus: 800 to 1000 mg/day(0.8-1.0 g/day)

Sodium: 2000 mg/day (Ms. C has hypertension and should limit sodium as much as
possible)

Potassium: 2000-3000 mg/day (2 to 3 g/day)

Calcium: 1000 mg/day not to exceed 2500 mg/day (this includes phosphate binders as
well)
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
Fluid – Since Ms. C does not appear to be oliguric, then her fluid needs are at a
minimum of 2000 mL/day
18. Using the identified nutrition problems (and with the understanding that Ms. C has received a
significant amount of nutrition education in the past), what would you determine to be the
most important topics for nutrition education when she returns to the PD clinic?
Ms. C will have to readjust to a dialysis diet once again. There were fewer restrictions to her
diet with respect to phosphorus, potassium, and fluid after transplant. As well, Ms. C’s
protein needs will increase. Ms. C will have to readjust her diet to include high quality
protein from lean meats and eggs. She should reduce her phosphorus intake to 800 to 1000
mg a day by limiting consumption of fast foods and other processed foods which tend to be
high in phosphorus as well as sodium. The cola and coffee are also high in phosphorus and
Ms. C should consider replacing the cola with seltzer, water or even Sprite (if she does not
want to eliminate soda). Although she does not eat many fruits or vegetables, Ms. C will
have to avoid consuming more than six servings of fruits and vegetables day (including fruit
juice) (Mahan et al., 2012, p. 817-818).
19. List factors that you would monitor to assess Ms. C’s nutritional status when she returns to
the PD clinic.
A dietitian should plan to meet with Ms. C every month, and should monitor her weight,
BMI, blood pressure (due to her history of hypertension) and diet as well as energy and
protein intake through 24-hour recalls and/or food records. In addition, Ms. C’s laboratory
values should be monitored every month by the dietitian, specifically her albumin, GFR,
BUN, calcium, phosphate, potassium, sodium, creatinine, total protein, glucose, hemoglobin,
iron saturation, urea reduction rate, parathyroid hormone levels as well as current
medications and supplements. Coordination of care with Ms. C’s nephrologist, primary care
physician, family, and dialysis nurse is crucial (Mahan et al., 2012, pp. 817-818).
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References
Mahan, L. K., Escott-Stump, S. & Raymond, J. (2012). Krause’s Food & the Nutrition Care
Process (13th edition). St. Louis, MO: Elsevier Saunders.
National Kidney Foundation, KDOQI: http://www.kidney.org/index.cfm
http://www.kidney.org/professionals/kdoqi/guidelines_pedbone/guide7.htm
Pronsky, Z. (2010). Food and Medication Interactions. (17th edition). Birchrunville, PA: FoodMedication Interactions
© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.