Download Case 2 - Vicky Pehling E-Folio

Your Name and/or Name of Partner (if working with one):
Vicky Pehling ___________________________
____________________________________________
University of Minnesota - Department of Food Science & Nutrition
FScN 4665 - Medical Nutrition Therapy II – Spring 2014
Case 2
100 Points
Adapted from Morrison, G., Stover, J. Case 1 Chronic Renal Failure: Advancing to Dialysis, in Integrative Systems and
Disease, Chapter 11, Part III. pp. 350-359.
Due Date: April 16, 2014
Please be sure to do the following:
 Show all calculations, and explain your rationale. Calculations do not have to be typed.
 Answer all questions directly on this form. Type all answers (except calculations). Submit in hard copy
in class on the due date. You will be deducted one point per day after the due date until the hard copy is
turned in.
 You may work ALONE or with ONE other person. Do not share your work with other individuals
beyond your group. If you work with a partner, you should hand in only ONE case with your name and
your partner’s name clearly listed at the top of the first page.
Some resources needed for solving the Case:
1. Krause’s Food and the Nutrition Care Process, 13th edition. Chapter 36: Medical Nutrition Therapy for
Renal Disorders.
2. Lecture notes and supplemental readings posted under the class topic “Renal Disorders” in the Moodle
site, particular the Chronic Kidney Disease notes and materials at the end of the note set.
3. I have created two Excel files that will help you calculate AB’s current intake, and your recommended
diet plan for AB. These are posted with the case on Moodle, and are labeled as follows:
a. “Case 2 Worksheet for Analysis of AB’s Current Intake” - contains formulas that will help you
evaluate AB’s current diet using National Renal Diet Food Lists
b. “Case 2 Worksheet for Renal Diet Calculations” – contains formulas that will help you devise
your renal diet plan for AB.
4. The following note sets are from MNT-1. These are posted in the Moodle under “Reference Materials
and Resources for Cases”  “Selected FSCN 4665 MNT I Course Materials for your Reference”:
a. Nutrition Assessment I-History and Physical Examination
b. Nutrition Assessment II- Anthropometry
c. Nutrition Assessment III-Biochemical/Laboratory
d. Module I: Nutrition Care Process, Nutrition Diagnosis and Medical Record Documentation
e. Module II: Energy, Protein, and Fluid Requirements in the Clinical Setting
5. Academy of Nutrition and Dietetics: Evidence Analysis Library Nutrition Guidelines on Chronic Kidney
Disease. Link to EAL website is posted in Moodle
6. White JV, Guenter P, Jensen GL, Malone A, Schofield M. Consensus Statement of the Academy of
Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics
Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). JPEN
2012;36(3):275-283.
7. KDOQI Guidelines: Nutrition in Chronic Renal Failure (PDF Download from National Kidney
Foundation site).
8. Brown, Compher, et al. ASPEN Clinical Guidelines: Nutrition Support in Adult Acute and Chronic
Renal Failure. JPEN July 2010; 34(4):366-377.
9. IDNT Manual
Part I.
AB, a 22-year-old Caucasian college student, presented to the emergency room with headaches and shortness of
breath (SOB). He was admitted to the hospital for evaluation when he was found to have a blood pressure of
200/120 mm Hg and mild congestive heart failure (CHF). AB reports that over the past year, his weight has
increased approximately 10 lb., although his diet has remained unchanged. He attributed this weight gain to
decreased exercise and a busy class schedule.
Past Medical History
AB has had no recent viral illness, sore throat, or upper respiratory infection. He has never had rheumatologic
symptoms and has no family history of renal disease. He had a history of multiple streptococcal infections of
the throat as a child, some of which were treated with antibiotics and some that went undiagnosed. He is
currently not taking any medications, vitamins, minerals, or herbal supplements, and has no known drug or food
allergies.
Social History
AB’s roommate at the dorms is a fellow student in good health. AB denies alcohol, tobacco, or oral drug use.
AB’s 24-Hour Diet History
Breakfast
Coffee, 8 oz, brewed strong
Whole milk,½ cup, heated, and mixed with coffee
Fried egg, 1
2 slices whole wheat toast with 2 Tbsp Butter
Orange juice, 8 oz
Lunch
Cheese burger (3 oz burger, white bun, 1 oz cheddar cheese)
Potato chips (2 oz)
1 medium banana
Coke, 12 oz
Snack
Pretzels, 1.5 oz
Coke, 12 oz Coke
Dinner
1 cup cream of mushroom soup made with milk
Baked potato,1 medium with 2 Tbsp Butter and 1/8 tsp season salt
Steamed broccoli, 1 cup
Small salad made with iceberg lettuce, 1 cup total with 2 Tbsp Wishbone Italian dressing
Snickers bar, 2 oz
Coke, 16 oz
Snack
Dry roasted salted peanuts, 1 oz
Coke, 12 oz
Review of Systems
General: Fatigue, weakness, SOB
GI: Anorexia
Physical Examination
Vital signs:
Temperature: 97° F
Heart rate:
96 beats per minute (BPM)
Respiration: 24 BPM
BP:
200/120 mm Hg
General:
well-developed man
Lungs:
decreased breath sounds with faint crackles at the right base
Cardiac:
regular rate and rhythm, systolic murmur at the apex, S3 gallop
Abdomen:
Soft, nontender, no hepatomegaly
Extremities: 3+ peripheral edema on both legs, ring tight on finger
Skin:
Warm to touch
Neurologic: Intact, mild asterixis
AB is 5'9" tall. His current weight is 77.3 kg.; Usual body weight (UBW): 70.5 kg. (6 mo. ago). Standard body
weight by NHANES tables: 78 kg
The following lab work was done:
Urinalysis: Protein 1+, 3+ heme
Lab Test
Result
Na+
135 mEq/L
136 – 145 mEq/L
Cl-
111 mEq/L
95 – 107 mEq/L
K+
5.8 mEq/L
3.5 – 5.0 mEq/L
BUN
108 mg/dL
8 - 25 mg/dL
Cr
14.0 mg/dL
0.8 - 1.2 mg/dL (men)
Phosphorus
10.2 mg/dL
2.6 - 4.5 mg/dL
Calcium
7.5 mg/dL
8.5 - 10.8 mg/dL
Albumin
3.2 g/dL
MCV
70 fL
Hct
24.3%
Hgb
8.3 g/dL
CO2
15 mEq/L
24-32 mEq/L
Transferrin saturation
18%
>20% (CRF)
Ferritin
142 ng/mL
WBC
8.7 x
Normal Range
3.5 - 5.0 g/dL
80-100 fL
109/L
42 - 52% (men)
14 - 18 g/dL (men)
>100 ng/mL (CRF)
4.5-11.0 x 109/L
Urinalysis
Urinalysis reveals blood and protein, indicating renal glomerular damage. RBC casts are highly suggestive of
glomerulonephritis, and broad waxy casts suggest dilated renal tubules associated with chronic
glomerulonephritis (CGN).
24-Hour Urine Collection
This procedure reveals the quantity of protein and creatinine excreted over 24 hours. If the amount of urinary
creatinine can be measured in a 24-hour urine specimen, a creatinine clearance can be calculated.
Protein Excretion
2.2 g per 24 hours, normal value <200 mg per 24 hours
Creatinine Clearance
Estimation of creatinine clearance can be calculated using the MDRD equation.
AB’s estimated creatinine clearance = 9.05 mL/min
Normal creatinine clearance for a male = 97–137 mL/min
Renal Ultrasound
Renal ultrasound revealed small kidneys bilaterally, which indicate irreversible renal disease (9 and 10 cm, right
and left, respectively). Only a renal biopsy could actually confirm the dx of CGN, but it is not performed once
small kidneys are identified since no treatment can reverse the kidney damage. AB’s significantly increased
serum phosphate and decreased serum calcium suggest that the GFR is less than 30 mL per minute, indicating
significant renal dysfunction. His estimated creatinine clearance in fact suggests that the GFR is below 10
ml/min.
Tests to eliminate other possible causes of CGN include the following.
Complement Levels
CH50, C3, C4 are all WNL (makes the dx of membranoproliferative disease, subacute bacterial endocarditis, an
acute poststreptococcal glomerulonephritis highly unlikely).
24-Hour Protein Collection
Eliminates the dx of nephrotic syndrome. AB’s hx and physical examination eliminate other causes of CGN,
such as Alport’s syndrome.
As a result of all the diagnostic tests, and in light of his physical examination, biochemical, and other
medical data, AB is diagnosed with chronic glomerulonephritis (CGN) and stage 5 CKD. 24-hour urine
collection revealed that AB’s urine output is approximately 750 ml/day. His nephrologists informs AB
that he needs to be treated with dialysis. He decides, with his physician, that he will go on CAPD when he
is discharged to home. The regimen will be: four 2-liter 1.5% PD exchanges daily.
UNDERSTANDING THE PATHOPHYSIOLOGY:
1. Based on AB’s history, explain the most likely cause of his CGN. (2 points)
Mostly likely explanation of AB’s CGN condition is his long history of strep infection. Strep antigens
provide an antibody immune response thus resulting in an antigen-antibody complex which ultimately
gets deposited in the glomeruli capillary walls, causing inflammation. His long history of strep
infections most likely provoked extended damage to the glomeruli and caused chronic kidney damage.
2. Explain the pathophysiology that is most likely driving AB’s hypertension and edema. (2 points)
Edema is driven by the retention of sodium due to inability of the kidneys to excrete as much sodium as
the amount of sodium intake. This leads to an increase in extracellular fluid retention and ultimately
edema.
Hypertension is also linked to sodium retention and volume overload. As sodium is a retained and
extracellular fluid increases, this subsequently causes an increase in pressure. Additionally, the
compromised kidneys have a difficult time inhibiting renin secretion which results in increase in fluid
volume and deficiency in vasodilation. Lastly, there is also dysfunction in the autonomic baroreceptors,
thus sensory information to the central nervous system regarding blood pressure is compromised.
NUTRITION ASSESSMENT
Anthropometric and PE Data
3. Which body weight will you use as the most “accurate” weight to reflect his “actual” or “dry” (i.e.
‘edema-free’) body weight for your assessment? EXPLAIN your thinking, using support from AB’s
physical examination data and any other relevant information from AB’s medical data and history. (2
points)
It is important to use edema-free body weight because it reflects the true weight under normal hydration
and no extraneous fluids. Since AB has malfunctioning kidneys, he is retaining extra fluid so his current
weight is not reflecting his true weight. We know AB has gained extra fluid because we see signs of
swelling from his physical examination, including 3+ peripheral edema on both legs and ring tight on
finger. Also, AB has reported gaining 10Ibs within the last year but hasn’t changed his diet.
Current weight= 77.3kg
Usual body weight =70.5kg
Percent UBW
77.3kg/70.5kg (100)= 110%
AB is currently 110% of his usual body weight. This reflects an increase in weight most likely due to
edema and fluid retention. Therefore it is more accurate to use his edema-free body weight
4. Evaluate the weight you chose in #3 by calculating AB’s BMI at that weight. Into which category does
AB fall, based upon the National Institutes of Health, National Heart, Lung, and Blood Institute’s
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults, which was provided in the “Nutrition Assessment II: Anthropometry” notes in FSCN 4665? (2
points)
UBW(70.5kg) BMI = 22.9 (normal class)
5. Evaluate AB’s edema-free body weight (identified in #3) in terms of % of the standard weight
determined by NHANES tables (this was provided in the case scenario). (2 points)
Usual body weight =70.5kg
Standard body weight= 78kg
Percent standard weight
70.5kg/78kg (100) = 90.4%
6. Do you intend to adjust his edema-free body weight, or use it as it is, for your assessment of nutrient
needs? Explain the rationale for your choice. If you do intend to adjust his weight, go ahead and
calculate it here. (2 points)
Adjusted edema-free body weight is necessary for individuals whose edema free body weight is less
than 95% or more than 115% of the median standard weight, in this case 78kg. Since AB’s weight is
less than 95% of the standard weight, an adjusted edema-free body weight is needed. It is important to
adjust because we don’t want to under calculate his nutrient needs
Adjusted BWef = BWef + [(SBW- BWef) x 0.25]
AB’s Adjusted BWef = 70.5+ [(78kg - 70.5kg) x 0.25] = 72.4kg
Biochemical Data
7. Explain what is happening to AB’s calcium-phosphorus balance. Explain the pathophysiology driving
any abnormalities that you observe in his serum concentrations of calcium and phosphorus. Discuss
what you know about the role of PTH and vitamin D. How might renal osteodystrophy result if these
abnormalities remain untreated? (6 points)
One of the major functions of the kidneys is to regulate calcium-phosphorus balance. For AB, he is
experiencing a high phosphorus concentration (10.2mg/dL) that is out of the normal range (2.64.5mg/dL). AB is also experiencing a low calcium concentration (7.5mg/dL) compared to the normal
range of 8.5-10.8mg/dL. The reason why AB has a higher than normal concentration of phosphorus is
because once the kidneys are damaged, phosphorus is retained and subsequently results in a high
concentration of phosphorus and low concentration of calcium. To regain phosphorus-calcium balance,
PTH is stimulated, which under normal conditions, responds to increase excretion of phosphorus and
decrease renal reabsorption to lower phosphorus concentrations and increase calcium concentration by
activating vitamin D (which increases GI calcium absorption), bone calcium resorption and kidney
calcium reabsorption. However, as the kidneys get more damaged, there is a greater imbalance between
high phosphorus concentration and low calcium concentration and hence more and more PTH is
released in an effort to correct but ultimately results in hyperparathyroidism. As it progresses untreated,
PTH continues to excessively release calcium from the bone and ultimately results in renal
osteodystrophy. Characterized by dull, aching bone pain, renal osteodystrophy is a result of calciumphosphorus abnormalities.
8. Discuss the interventions required to normalize serum calcium and phosphorus values in CKD patients.
Indicate the order in which the interventions should be initiated, and explain why. (4 points)
To normalize calcium-phosphorus balance, phosphorus must first be stabilized. This can be achieved by
first restricting dietary phosphorus to manage high blood phosphorus. Phosphorus binders may also be
taken with meals, to help prevent absorption and help serum phosphate to stay within the normal range.
They work by creating insoluble complexes with phosphate that are ultimately excreted. Only after
phosphorus levels are controlled, when the serum calcium x serum phosphorus <55, is the low calcium
concentrations stabilized by supplementing calcium in between meals. Calcium isn’t supplemented until
phosphorus levels are controlled because otherwise the supplementation will cause metastatic
calcification, in which calcium-phosphorus salts are deposited into soft tissue. This occurs when serum
calcium x serum phosphorus exceeds 70. Early phosphorus restriction and calcium supplementation may
prevent secondary hyperparathyroidism.
9. Indicate which lab values suggest that AB is anemic. What is the most likely reason for AB’s anemia?
(4 points)
AB’s lab values indicated that AB has a low hemoglobin status (8.3g/dL) and is out of the normal range
for men, which is 14-18g/dL. Additionally, AB has a low hematocrit status (24.3%) which is out of the
normal range for men, which is 42-52% and has a low ferritin status (142 ng/mL) which is less than 100200ng/dL normal range. The lower than normal status of hemoglobin, hematocrit and ferritin indicated
that AB is anemic. The most likely cause of AB’s anemia is due to the increased destruction of red blood
cells by uremic waste, impaired production of erythropoietin and poor iron absorption. Uremic waste
builds up in the blood because the kidneys are not able to remove uremic waste from the blood to be
excreted in the urine. Additionally, with impaired production of erythropoietin from the kidneys , the
hormone isn’t able to signal bone marrow to make more red blood cells and therefore contributes to
anemia.
Dietary Intake Data
10. Using AB’s dietary intake data:
Keeping in mind dietary recommendations for individuals who have CKD who will be on peritoneal
dialysis, evaluate AB’s diet PTA using the National Renal Diet Food Lists, where possible, in light of
the 1) phosphorus and 2) protein content. Use the “Case 2 Worksheet for Analysis of Abs Current
Intake” Excel file posted along with the case to calculate the values, being careful not to disturb any of
the cells containing equations or formulas! The first tab “Convert Diet into Food Groups” is where you
will find his dietary information entered and you will need to translate each food into servings from the
various food groups given to you at the end of the CKD notes (Table 34.2 “Average Calculation Figures
for Planning the Diet for ESRD”). The second tab “Nutrient Calculation Sheet” in the above named
Excel file will allow you to calculate the nutrients from the various food list categories you determined
from the worksheet at the first tab. You just have to enter in the number of servings of each of the food
groups and it will tally the phosphorus and protein (and you can also see the sodium, potassium, and
kcal content if you’re interested but you don’t have to do anything with that information for this
exercise). For cream soup, Snickers, and peanuts (which are not clearly found on the Food Lists), I have
entered in the phosphorus and protein values for you. The Excel file is set up to give you a grand total
of phosphorus and protein (including these three foods) highlighted in yellow. Report the value you
obtain for the grand total of protein and phosphorus in AB’s diet below. If you prefer not to use my
Excel worksheet, you can do your calculations by hand.
AB’s Estimated Current Phosphorus and Protein Intake: (4 points)
1) Phosphorus
1428
2) Protein
74.5
11. How many kcals will AB likely absorb per day from the CAPD dialysate solution? Show your
calculations. (3 points)
AB’s regimen will be: four 2-liter 1.5% PD exchanges daily.
1.5% solution: 15g dextrose/L
CAPD: absorption ~60%
.015 x 8000ml=120g dextrose x 3.4kcal/g= 408kcals
408kcals x 60% absorption = 244.8kcal absorbed
12. Once you have estimated AB’s current intake, you should compare it to the recommended dietary intake
strategies you would make for AB, now that he will be on peritoneal dialysis (CAPD).
A. First, specify the recommendations you would give to AB appropriate for PD with regard to
total daily intake of kcals, protein, phosphorus, supplemental calcium and vitamin D, sodium,
fluid, and potassium, showing all relevant calculations. Refer to your CKD class notes to
formulate your recommendations, and be specific in terms of total quantities. Be sure to think
carefully about which weight you will use for your assessment. (8 points)
1) Energy:
(and don’t forget to subtract out the kcals absorbed from the PD dialysate)
Adjusted edema-free wt = 72.4kg
35 kcal/kg edema-free body wt, (since AB is less than 60 years old)
2534 (total energy requrment) – 245(kcal absorbed from PD dialysate)
2289kcal/day
2) Protein:
Adjusted edema-free wt = 72.4kg
PD: ≥1.3g/kg edema-free body weight
72.4kg x 1.3g/kg = 94.12
≥94g protein/day
At least half of the protein should be of High Biological Value
3) Phosphorus:
Restrict to 800-1000mg/day or < 12mg/g protein
Can take phosphate binders to reduce serum phosphate
4) Supplemental calcium and vitamin D:
Calcium should be supplemented orally when calcium serum concentration x phosphate serum
concentration is < 55. After which, 1-1.5g/day of calcium may be supplemented or as needed.
Total oral intake of calcium, including binders, should be <2.0g/day.
Vitamin D supplementation is supplemented as warranted
5) Sodium:
Restrict to 1.5g Na/day
6) Potassium:
Since AB’s lab value shows that his potassium concentration was 5.8mEq/L, which above the
normal range (3.5-5.0 mEq/L), we are going to restrict potassium. If AB didn’t have
hyperkalemia, we would not need to restrict potassium.
72.4kg x 39mg/kg= 2823.6mg/d ay
Or <2.8g/day
7) Fluid:
Since AB is not anuric and his total 24hr urinary output is around 750ml fluid/day, AB is
therefore restricted to 2-3 L fluid/day
B. Now assess AB’s current dietary intake further, identifying ‘problem areas’, i.e. high sodium,
high potassium, and high phosphorus foods/beverages that AB is consuming. Then evaluate his
current dietary intake in specific terms for phosphorus and protein intake (from your calculations
in question # 10), by making a comparison to what AB should be consuming in order to be in
compliance with the recommendations for nutrition management with PD.
Current intake vs. recommended intake:
1) High-sodium foods/beverages that AB is currently consuming (2 points)
AB is currently consuming 1.9g Na+/day, which is over the recommendation of 1.5gNa+/day.
Some of the high sodium foods that AB is consuming include cheddar cheese, seasoning salt,
and potato chips
2) High-potassium foods/beverages that AB is currently consuming (2 points)
AB is currently consuming 3625mg/day of potassium, which is higher than the 2.8g of potassium
per day restriction. Some of the foods high in potassium is 1 cup of orange juice, the baked
potato, potato chips, the banana,
3) High-phosphorus foods/beverages that AB is currently consuming (2 points)
High phosphorus foods that AB is consuming is whole milk (110mg) and the (1 serving, 20.4
protein-phosphorus ratio) cheddar cheese. He is also consuming a lot of dark cola, equally to
about 220mg of phosphorous per day. Additionally, the cream soup made with milk adds about
275mg of phosphorus to his total phosphorus intake.
4) Current phosphorus intake compared to recommended intake (give specific numbers for
comparison, and evaluate if too high, too low or acceptable) (2 points)
AB is currently consuming 1428mg of phosphorus a day, which is higher than the restriction of
800-1000mg of phosphorus a day. This is too much phosphorus intake
5) Current protein intake compared to recommended intake (give specific numbers for
comparison, and evaluate if too high, too low or acceptable) (2 points)
AB current intake is 74.5g of protein a day, which is lower than the recommendation for a
peritoneal dialysis treatment. According to his adjusted body weight, AB requires at least 94g of
protein a day. AB needs to consume more protein, especially those with a low protein to
phosphorus ratio that are of high biologic value.
NUTRITION DIAGNOSIS
13. Refer to the Jensen article (Jensen GL, Hsiao PY, Wheeler D. Adult Nutrition Assessment Tutorial. J
Parenter Enteral Nutr 2012;36(3): 267-274.) and the ASPEN/Academy Consensus Statement (White
JV, Guenter P, Jensen GL, Malone A, Schofield M. Consensus Statement of the Academy of Nutrition
and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for
the Identification and Documentation of Adult Malnutrition (Undernutrition). J Parenter Enteral Nutr
2012;36(3):275-283.) to determine if AB meets the definition of a specific category of malnutrition.
Explain your rationale. (2 points)
History and clinical diagnosis: AB has chronic kidney disease and therefore is at greater risk to
become malnourished due to increase nutrition requirement and compromised dietary intake. AB
was admitted to the hospital from shortness of breath and headache. He had high blood pressure
and mild congestive heart failure, which are conditions associated with mild to moderate chronic
inflammatory response
Clinical signs and physical examination: No fever, hypothermia, or tachycardia. However with
the edema, the weight loss and reduction in body cell mass may not be apparent and mask true
weight.
Anthropometric Data: Self-reported weight gain. May be related to fluid retention and edema.
Laboratory indicators: AB has low serum albumin, 3.2g/dL compared to the normal range,
which is 3.5-5.0g/dL. Low serum albumin indicates systemic response to his kidney disease.
Despite these values, laboratory indicators cannot be reliably interpreted to support malnutrition
or inflammation. Normal white blood count
Dietary Assessment: Based upon AB’s diet, he was eating too much phosphorus, potassium and
sodium. AB’s been eating a compromised diet for weeks and prior to being admitted, was not
eating (anorexia).
Functional outcomes: AB is feeling weak and fatigued.
Based upon the above information, AB has clinical malnutrition syndrome characterized by
chronic disease associated malnutrition.
14. Based on what you discovered in earlier questions, identify TWO of AB’s most prominent nutritionrelated problems using the standard Nutrition Diagnostic Terminology and INCLUDE the CODE #
from the IDNT manual for each nutrition diagnosis you write.
A. Nutrition Diagnosis #1: (3 points)
Food and Nutrition knowledge deficit [NB-1.1]
B. Nutrition Diagnosis #2: (3 points)
Excessive phosphorus intake [NI 5.10.2 (6)]
15. For each nutrition diagnosis, write a complete nutrition diagnostic statement in PES format
(problem, etiology, signs and symptoms), labeling each section (P, E, and S) appropriately.
A. PES #1: (3 points)
(P)Food- and nutrition-related knowledge deficit related (E) related to new diagnosis of CKD (S)
as evidenced by 24hr hour recall consumption of foods high in phosphorus, potassium and
sodium.
B. PES #2: (3 points)
(P)Excessive mineral intake of phosphorus (E ) related to CKD and food- and nutrition- related
knowledge deficit (S) evidenced by 24 hour dietary intake consumption of foods high in
phosphorus including milk products, cheese, and excessive cola and high blood phosphorus lab
values (10.2mg/dL)
NUTRITION INTERVENTION
Prepare yourself for providing nutrition education and counseling to AB.
16. Thinking back to your evaluation of AB’s dietary intake data from question #12b, identify at least 5
foods/beverages in his current diet that he could change in order to better comply with the renal dietary
restrictions you have recommended. Be sure to explain why each particular food or beverage is a
problem. Suggest possible substitutions for each of these problem areas that AB could make in order to
accommodate the dietary restrictions he needs to follow. (5 points)
(1)Cream soup make with milk, (2) Cheddar Cheese, (3) Coke.
Cream soup made with milk, cheddar cheese and coke are foods that all contain high levels of
phosphorus and should be strictly limited. Phosphorus should be restricted because damaged
kidneys cannot remove phosphorus very well that can lead to hyperphosphatemia, Controlling
phosphate levels is important for bone health and preventing renal osteodystorphy and metastatic
calcification and from minimizing further damage to the kidneys. AB’s dietary recall indicated
that AB was consuming more phosphorus then the recommended intake of 800-100mg/day
(1428mg). AB ate 1 cup of cream soup made with milk, which contains 275mg, the cheddar
cheese slice contained 145mg and the 4 servings of 12oz Coke contained a total of 220mg of
phosphorus. These high phosphate containing foods contribute to AB’s uncontrolled high blood
phosphate concentrations. For better control of blood phosphorous, AB could make the cream
soup with water instead of the milk, which contains 90mg of phosphorus. AB could also
exchange eating cheddar cheese with cream cheese, which contains 30mg of phosphorus and
substitute the Coke with a non-cola soda such as a Ginger Ale or Sprite.
Additionally, the cheddar cheese is high in salt. See below for explanation for low salt
recommendation.
(4) Seasoning salt, (5) Pretzels
Eating too much food that is high in sodium will increase the amount of sodium in AB’s body.
Foods that are high salty foods from AB’s dietary intake data revealed he consumed seasoning
salt and pretzels. It’s best to limit dietary intake of salt because the extra salt will cause the body
to retain fluid/water and affect blood pressure and blood volume and can eventually lead to
greater heart and kidney damage. Instead of using seasoning salt, AB should try using different
herbs or lemon juice to add flavor to foods. AB could also replace the regular pretzels with a
low salt unsalted version.
17. Explain to AB (in easy-to-understand, lay language) why you want him to follow the recommendations
you made for protein, phosphorus, calcium, vitamin D, and sodium. (5 points)
1) Protein:
Your protein needs are higher because protein gets lost through your peritoneal dialysis
treatment. During dialysis, some protein escapes through the peritoneal membrane inside your
body and therefore to make up for this loss, you need to eat more protein then before. It’s best to
eat at least half of your protein as high biological value proteins. Proteins are a combination of
21 different amino acids; 9 of them being essential because we cannot make them by ourselves.
A high biologic value protein is one that provides the essential amino acids. Foods of high
biological value that are best suited for your renal condition are meat, fish, and eggs.
2) Phosphorus:
It’s important to limit phosphorus because your damaged kidneys have a hard time filtering and
excreting phosphorus. This leads to a build-up of phosphorus in your blood and causes an
imbalance of minerals, especially lowering calcium. Ultimately, this affects your bone health and
can lead to weaker bones and dangerous calcium deposits in blood vessels, lungs, eyes and heart.
3) Calcium
As mentioned before with phosphorus, the balance of minerals in the blood is a delicate balance.
Calcium consumption and calcium supplementations therefore must be carefully watched and
monitored. If don’t have enough calcium, then your body will pull off calcium from your bones,
which makes them weaker and more brittle. If you are consuming too much calcium before
phosphorus levels are controlled, then the balance is off and calcium is deposited in the blood
vessels, lungs, eyes and heart to cause hardening and damage. That’s why it is important to
supplement calcium only after we can get your phosphorus levels under control.
4) Vitamin D
Getting adequate Vitamin D is important because it helps maintain your mineral balance,
especially with calcium-phosphorus. Because of your kidney’s condition, you’re going to get
high levels of phosphorus and low levels of calcium. So to help, vitamin D works to reestablish
phosphorus-calcium balance in the blood. It does this by increasing absorption of calcium from
the foods you eat and by also decreasing the amount of phosphorus in your blood by helping
your body excrete it in your urine
5) Sodium:
Sodium, or salt, has many important roles in the body, especially its role in blood pressure and
blood volume control. Because of your CKD condition, your kidneys cannot excrete excess
sodium and fluid from your body. The result is sodium (salt) and fluid retention in your body
tissue and blood stream and therefore you see an increase in blood pressure and some swelling.
By restricting salt intake, we can help manage your high blood pressure and your extra fluid.
Plus, salt makes people thirsty and may make you drink more fluid than you should be.
Follow-Up
AB did fairly well on CAPD for 3 months until he began to have difficulty with the draining of PD fluid
through his dialysis catheter. He had repeated doses of a thrombolytic agent infused into the catheter in an
attempt to dissolve the proteinaceous material, with only minimal success. He eventually had a new catheter
inserted that only worked temporarily before the same problem developed. He was subsequently readmitted to
the hospital for an HD catheter and started regular outpatient hemodialysis treatments. At that time his urine
output had declined to less than 200 mL per 24 hours. AB has requested that you (the RD) now provide him
with a more detailed diet plan that he can follow.
18. Calculate a meal pattern for AB in compliance with the dietary recommendations for individuals on
hemodialysis. Start by calculating his nutrient needs for HD (including protein (total and HBV),
kcal, fluid, sodium, phosphorus, and potassium. NOTE that there may be important differences
between what you recommended previously for AB when he was on CAPD compared to what you
recommend for him now that he is on hemodialysis. Please show your work in the space below, and
write in your numbers on the following page. (6 points)
1) Protein (total and HBV)
Adjusted edema-free wt = 72.4kg
HD: ≥1.2g/kg edema-free body weight
72.4kg x 1.2g/kg = 86.88
>87g protein/day
87g x 50% =43.5g
>44g of the total protein recommendation should be High Biologic Value
2) Kcal
Adjusted edema-free wt = 72.4kg
35 kcal/kg edema-free body wt, (since AB is less than 60 years old)
72.4kg x 35kcal/g = 2534kcal/day
3) Fluid
Urinary Output + 500-1000mL
200+ 500-1000mL = 700+1200mL per day
4) Sodium
1.5g/day of sodium
5) Phosphorus
800-1000mg/day of phosphorus
6) Potassium
1 mEq Potassium = 39mg
39mg x 72.4kg =2823.6mg
2824mg/day of potassium
Diet Rx:
___87______ g protein, with at least__44____ g HBV protein
__2534______ kcal
__700-1200______ ml fluid
__1.5______ mg Na+
_800-1000___ mg phosphorus
__2824___ mg potassium
Average Calculation Figures for Planning ESRD Diet (REVISED)
Protein (g)
Na+ (mg)
K+ (mg)
Phos (mg)
Kcal
4.0
80
185
110
60**
Almond Milk (1/2 cup)
0.5
76
60
10
46
Soy Milk (½ cup)
3.5
45
165
60
40
Nondairy Milk Substitutes
0.5
40
80
30
140
Meats
7.0
25
100
65
65
*Tofu (½ cup)
10.0
10
150
120
95
*Legumes (½ cup)
8.0
-
340
130
110
*Peanut butter (2 Tbsp)
8.0
150
230
100
95
2.0
80
35
35
90
Low K+
1.0
15
70
20
25
Medium K+
1.0
15
150
20
25
High K+
1.0
15
270
20
25
Low K+
0.5
Trace
70
15
70
Medium K+
0.5
Trace
150
15
70
Food Choices
Milk and Dairy
Starches
Vegetables
Fruits
Protein (g)
Na+ (mg)
K+ (mg)
Phos (mg)
Kcal
0.5
Trace
270
15
70
Fats
Trace
55
10
5
45
High-Calorie Choices
Trace
15
20
5
100
Food Choices
High K
+
---250
---------Salt Choices
** NOTE: In your handout from the Manual of Clinical Dietetics, the average kcals listed for the milk and dairy group is 120
kcals for a ½ cup serving. This is an averagebased upon a wide range of products that fit in this group. If you simply plan for
the consumption of 2% milk, use 60 kcals. Refer to complete food lists in CKD notes packet for serving sizes of foods within
each group. *These are only a few choices for vegetarians. Refer to information in the CKD notes packet on planning
vegetarian renal diets.
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A. Baseline Calculations: Determine the number of servings in each food group based on the
diet prescription. Calculate the nutrient values and add to get the subtotals. NOTE: IT IS
ACCEPTABLE TO BE WITHIN ± 100 mg Phosphorus, ±100 mg Potassium, ±50 Kcal, ±1 g
Protein, and ± 500 mg Sodium of your goal targets in your calculated pattern. (6 points)
*Relevant for vegetarian meal plan or in specific circumstances based on diet recall only
# Servings
Protein (g)
Na+ (mg)
K+ (mg)
Phos (mg)
Kcal
1
.5
76
60
10
46
1
.5
40
80
30
140
9.5
66.5
237.5
617.5
617.5
1
8
150
230
100
95
4
8
320
140
140
360
3
3
45
210
60
75
Low K+
3
1.5
210
45
210
Medium K+
1
.5
150
15
70
Food Choices
Milk and Dairy
*Soy Milk
Almond Milk
Nondairy Milk
Substitutes
Meats
950
*Tofu
*Legumes
*Peanut Butter
*Other non-meat
________
Starches
Vegetables
Low K+
Medium K+
High K+
Fruits
High K+
88.5
868.5
2030
1017.5
SUBTOTALS
1613.5
B. Next, determine number of fat and high-calorie servings based on caloric needs and calculate
nutrient values. Keep in mind that you may not need to add any high-calorie choices. Total
values and adjust number of servings as needed to meet caloric needs and patient’s food
preferences. (2 points)
Food Choices
# Servings
Protein (g)
Na+ (mg)
K+ (mg)
Phos (mg)
Kcal
220
40
20
180
70
35
700
2140
1072.5
2493.5
SUBTOTALS
Fats
4
High-Calorie Choices
7
385
TOTALS
88.5
25
1473.5
C. Na+ allowed in diet prescription: ____1500______ mg
SUBTRACT Na+ calculated in pattern - ___1473.5_______mg = ____26.5________mg Na+ (1
point)
26
This is the remaining Na+ allowed to be distributed in the form of added salt or condiments (salt choices).
One salt choice contains ~250 mg sodium. Keep in mind that you may not deem it necessary to provide
any salt choices to Mr. D, depending upon your calculations in part b, and your assessment of Mr. D’s
need for a sodium restriction.
19. Help AB see how he might plan meals using the meal pattern you calculated. Plan out a
day’s meals with AB. (7 points)
ONE DAY MENU BASED ON CALCULATED DIET PATTERN
BREAKFAST
#Servings
Food Group
Menu Item
Milk
3
1
1
2
1
1
1
Soy Milk
Almond Milk
Nondairy Milk
Substitutes
Meats
3 eggs for Omelet
Tofu
Legumes
Peanut Butter Chunky peanut butter
Other non-meat:
Starches
Fruits – low K+
Fruits – med K+
Fruits – high K+
Vegetables – low K+
Vegetables – med K+
Vegetables – high K+
Fats
High-Cal Choices
1 slice of White toasted bread
Cranberry Juice, ½ cup, diced canned pears, 1/2c
Food Group
Menu Item
1/2c Cooked green pepper for Omelet
Cooking Oil, 1 tsp
2 tbsp of Honey
LUNCH
#Servings
Milk
3
Soy Milk
Almond Milk
Nondairy Milk
Substitutes
Meats
3oz piece of Roast Turkey
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Tofu
Legumes
Peanut Butter
Other non-meat:
1
2
2
3
Starches
Fruits – low K+
Fruits – med K+
Fruits – high K+
Vegetables – low K+
Vegetables – med K+
Vegetables – high K+
Fats
High-Cal Choices
1/2c of Egg Noodles
Food Group
Menu Item
Side Salad- 1c of lettuce, 1/2c sliced cucumbers
2 tsp of Italian dressing
1/2c cherry fruit ice, 1/4c Cranberry sauce dressing, 4 pieces of hardcandy
DINNER
#Servings
Milk
1
3.5
1
1
1
1
Soy Milk
Almond Milk 1/2c Almond milk
Nondairy Milk
1/2c nondairy vanilla frozen dessert
Substitutes
Meats
3.5 oz Grilled Salmon
Tofu
Legumes
Peanut Butter
Other non-meat:
Starches
Fruits – low K+
Fruits – med K+
Fruits – high K+
Vegetables – low K+
Vegetables – med K+
Vegetables – high K+
Fats
High-Cal Choices
½ c Cooked white rice
½ Lemon for Salmon
½ c Strawberries
1 tsp of Herbed Butter
SNACKS (SPREAD THROUGHOUT DAY AS NEEDED)
#Servings
Food Group
Menu Item
28
1
Milk
Soy Milk
Almond Milk
Nondairy Milk
Substitutes
Meats
Tofu
Legumes
Peanut Butter
Other non-meat:
1
3
Starches
Fruits – low K+
Fruits – med K+
Fruits – high K+
Vegetables – low K+
Vegetables – med K+
Vegetables – high K+
Fats
High-Cal Choices
1oz slice of Angel Food Cake
4 tbsp of strawberry jelly dressing, 1/2c Rainbow sherbet,
20. Now that AB is on hemodialysis, he needs to be much more careful with his fluid intake.
Describe 3 tips/strategies that you can you recommend to AB to help him stay within his
fluid restriction. (3 points)
Drink from small cups and glasses. For example, 1/2c of juice will look like more in a 6
ounce glass compared to a 12ounce glass
Stay cool. By keeping yourself cool, you can help you reduce fluid intake by reducing
your thirst. This is especially important in warmer weather
Sip your beverages. By sipping, you can savor the liquid longer and help reduce your
thirst
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