CASE STUDY #2

PERITONEAL DIALYSIS
INTRODUCTION
This study examines the nutritional treatment of a patient with end stage renal disease who is
receiving peritoneal dialysis. The student should review the medical nutrition therapy for the
various types of dialysis treatments prior to studying the case.
****************************************************************************************

TO PREPARE:
IN THIS SECTION, YOU SHOULD RESEARCH AND DEFINE SEVERAL TERMS.
FOR THE ITEMS BELOW, PLEASE BE SURE THAT YOU UNDERSTAND THE
FOLLOWING ABBREVIATIONS, LAB VALUES, MEDICATIONS, AND MEDICAL
TERMS. YOU DO NOT NEED TO TURN IN THIS TO PREPARE SECTION, BUT
YOU SHOULD TAKE THE TIME TO UNDERSTAND THIS INFORMATION.
Abbreviations
Knowledge of the following abbreviations is required in order to understand this case. You
should learn these abbreviations before you begin to read the study.
Please be able to define the following abbreviations: CAPD, ESRD, HD, AND PD.
Laboratory Values
You will need to be able to interpret the nutritional significance of the following laboratory
values for this case study.
Please be able to define the following and briefly discuss their interpretation:
BUN, Ca, Cl, Cr, glucose, K, Mg, Na, Phos and ser alb.
Formulas
The formulas used in this case study include metric conversions, ideal body weight, and energy
expenditure for renal patients.
Medications
Become familiar with the following medications before reading the case study. Note the dietdrug interactions. dosages, and methods of administration, gastrointestinal tract reactions, etc.
Please be able to briefly describe the following medications and list the
condition(s) that they are indicated for: 1. Fosrenal (lanthanum carbonate);
2. Aranesp (darbepoetin alfa); 3. Hectorol (doxercalciferol); 4. ACE inhibitor
1

CS#2 - PERITONEAL DIALYSIS

You can use your own resources to research these medications or the websites provided
Blackboard/your syllabus.
****************************************************************************************

BT is a 45 YOWM who is a successful executive and has a history of malignant hypertension.

Because of his lifestyle, it was not convenient for him to comply with his diet and medication
regimens. As a result, BT was diagnosed with ESRD and required dialysis. Hemodialysis was not
an option for him because it required that he sit still for at least three hours three times a week.
Hes a very busy man and did not have time for hemodialysis. When continuous ambulatory
peritoneal dialysis (CAPD) was described to him, it seemed like his best option. A catheter was
surgically placed into his peritoneal cavity and he was instructed on how to complete the
procedure of CAPD. BT has been on CAPD for three years. At least monthly, BT meets with the
dietitian for an evaluation. In his last evaluation the following information was obtained from his
medical record:
BTs ht is 177.8 cm, and he weighs 85kg. His usual body weight prior to renal failure was 75kg.
His daily dialysis prescription is as follows: 4 exchanges of 2.5% dextrose, each exchange to
dwell in his peritoneum for 4 hrs during waking hours; 1 exchange of 2.5% dextrose to dwell in
his peritoneum for 6 hrs during sleeping hours. An exchange consists of 2 L.
His nutritional prescription included the following: 35 kcals/kg of IBW, 1.2 g of protein per kg
of IBW, 2g of Na, K unrestricted, 2000ml of fluid + urinary output, and 10-12 mg of Phos per kg
of IBW. The dietitian discussed BTs diet with him and obtained a 24-hour recall. She was
convinced that BT was complying with his diet and medication plans reasonably well. Upon her
evaluation, she recommended reducing his kcals to 25/kg of IBW, increasing his protein to
1.4g/kg of IBW, and letting Na and fluid remain the same and decreasing his K and phos.
His lab values were as follows:

BASIC METABOLIC PACKAGE

REFERENCE UNITS
TEST

RESULT

REFERENCE UNITS
TEST

Conventio
nal

SI

RESULT
Convention
al

SI

Glu

105
mg/dl

70-110
mg/dl

3.8-6.1
mmol/L

Na

133
mEq/L

136-145
mEq/L

136-145
mmol/L

BUN

60 mg/dl

6-20
mg/dl

2.1-7.1
mmol/L

6.0
mEq/L

3.5-5.2
mEq/L

3.5-5.2
mmol/L

[2]

CS#2 - PERITONEAL DIALYSIS

Cr

7.0
mg/dl

0.9-1.3
mg/dl

80-115
mol/dl

Cl

100mEq/
L

96-106
mEq/L

96-106
mmol/L

Ca

8.8
mg/dl

8.8-10.0
mg/dl

2.202.60
mmol/L

Mg

2.0
mEq/L

1.8-2.6
mEq/L

136-145
mmol/L

Ser
alb

3.7 g/dl

3.5-4.8
g/dl

39-50
g/dl

Phos

6.2 mg/dl

2.7-4.5
mg/dl

4.7-6.0
kPa

1. Determine BTs IBW and BMI. Calculate the kcals, grams of protein and mg Phos BT should be
consuming in the original diet plan and the new plan recommended by the dietitian. Please show your
work. Why did the RD suggest these changes? What level of K restriction do you think is appropriate?
BMI: (187lbs/(70*70)) * 703= 27 BMI Overweight
IBW: (106#+(6# * 10))= 166 # IBW
% IBW= (187/166)*100= 113 % IBW overweight
MSJ: (9.99* 85) +( 6.25 * 177.8)- (4.92 * 45) + 5
849.15 + 1111.25 221.4 + 5
= 1734 kcals
Activity Factor: sedentary 1.2
1734 *1.2= 2080 Kcals
Protein: Renal-HD 1.2- 1.3 g/kg
85* 1.2=102 g Protein
85 *1.3=110.5 g Protein
Original Diet Plan: 35 kcals/kg of IBW, 1.2 g of protein per kg of IBW, 2g of Na, K unrestricted, 2000ml
of fluid + urinary output, and 10-12 mg of Phos per kg of IBW
Kcals :
35kcals * 75 kg= 2,625 kcals of IBW
Protein:
75kg * 1.2g= 90g Protein
potassium :
unrestricted
Phos: 10- 12mg
75kg * 10mg= 750 mg
75kg * 12 mg= 900 mg

CS#2 - PERITONEAL DIALYSIS

New Diet: 25/kg of IBW, increasing his protein to 1.4g/kg of IBW, and letting Na and fluid remain the same and
decreasing his K and phos.
Kcals:
25k * 75 kg= 1875 kcals
Protein:
75kg * 1.4g= 105g of Protein
K: 3-4 g/day
Phos: : .8-1.2g / day
The dietitian suggested a decrease of potassium and phosphorus because lab values were high.
A high level of potassium is fatal and may cause hyperkalemia-induced arrhythmia. I believe 34g per day is appropriate because an unrestricted amount may cause abnormal heart rhythms that
can lead to death. The phosphorus was lowered as well because there was an increase of protein.
We want to limit the phosphorus intake because a high concentration in the blood will increase
the mortality risk with patients with ESRD. A high level of phosphorus will also cause
hyperparathyroidism. It is important that BT takes Foresnol as well as adhering to a low
phosphorus diet.

*************************************************************************************
***
BTs medications included:
Fosrenol (lanthanum carbonate)
This is a phosphate binder that is used at end stage of renal disease.
BT will have to have a low phosphate diet because a high phosphate diet can make it hard
for the body to absorb calcium.
Must take this medication with or immediately after meals to help with absorption
Aranesp (darbepoetin alfa)
Treats anemia in patients with chronic kidney failure
This stimulates bone marrow to produce more red blood cells to help reduce symptoms of
anemia.
We will need to increase Fe, Vitamin B12 or foliate supplement.
Hectorol (doxercalciferol)
This drug lowers the elevated parathyroid hormone levels.
It is a synthetic form of vitamin D, which is important for the absorption of calcium and
phosphate by the body, as well as normal bone development maintenance.

[4]

CS#2 - PERITONEAL DIALYSIS

Aldomet (Hydrochloride)
This drug is use to treat hypertension
We will need to monitor iron intake because it may interfere with the absorption and
reduce its effectiveness.
2. Compare the differences between hemodialysis, peritoneal dialysis, and continuous ambulatory
peritoneal dialysis as related to kcals, protein, Na, K, Phos, and fluid intake. Explain why the kcal
allotment for CAPD is lower than HD. Explain why protein, Na, K and fluids are usually higher
in CAPD than HD.
kcals
protein
Na
K
Phos

HD
35 g/kg
1.2 g/kg
2-3g/day
40mg/kg IBW
.08-1.2g/day or <17 mg/kg
IBW

PD
30-35g/kg
1.2-1.5 g/kg
2.-4g
3-4g
10-12 mg/g

CAPD
25-35kcal/kg
1.2-1.5 g/kg
2-4 g
3-4g
< 17 mg/kg

Fluid
750-100ml/day +urine output 2000ml + UO
2000 ml +urine output
A patient being treated with HD requires more calories because the treatment creates a open wound
that needs healing while the CAPD does no create a wound because there is a catheter surgically
placed into the peritoneal cavity.
There is a higher amount of NA, K , Phos and fluid intake with CAPD because they receive treatment
more frequently and the increase amount is to help maintain a balance.
3. List the advantages/disadvantages of hemodialysis, continuous cyclical peritoneal dialysis, and
continuous ambulatory peritoneal dialysis.
Advantages
HD

Have lower mortality rates

Waste products are removed by diffusion
You have four dialysis free days
No equipment/supplies kept at home

CCPD

CAPD

A flexible lifestyle and independence

Doesn't use needles
Provides continuous therapy, which is more like your natural kidneys
Don't have to travel to dialysis unit for treatment
Easy to do your therapy while you travel
You can do it alone.
You can do it at times you choose as long as you perform the required number of exchanges each
day.
You dont need a machine.
You wont have the ups and downs that many patients on hemodialysis feel.
You dont need to travel to a center three times a week.
Disadvantages

CS#2 - PERITONEAL DIALYSIS

HD

Confined to one place and diet restrictive

It increases your risk of bloodstream infections.

Travel to center three times a week on a fixed schedule
Restricted diet/limited fluid intake

CCPD

You need a machine.

Your movement at night is limited by your connection to the cycler.

CAPD

It is a continuous treatment, and all exchanges must be performed 7 days a week.

Weight gain and glucose control is poor

4. It is recommended that at least 50% of the protein fed to PD patients be of HBV. What does that
mean and why is it important?
Yes, at least 50% of protein must be high biological value, which mean it must be an animal protein,
which contains all the essential amino acids. This is important because BT is on a restricted protein
and calorie intake, he must stay with in his restriction. We want to prevent protein energy wasting
because most patients loss their appetite. It is important to provide a high protein value in a small
portion. This will help conserve body protein.
5. Today some are using a new glucose polymer, icodextrin, in peritoneal dialysis in place of glucose.
Research icodextrin and describe the results reported thus far for this new polymer. In which
patients might this be especially useful?
Icodextrin also known as Extraneal, it is a long chain, non-absorbed sugar. It is used as a dialysis solution
that draws fluid and wastes from your bloodstream into your peritoneal cavity by ultrafiltration without
the excessive dextrose absorption. This can benefit patients with diabetes mellitus.
6. Describe the relationships of Fosrenol, Aranesp, and Hectorol to ESRD.
Fosrenol:

It is a phosphate binder.

Fosrenol is used for reducing phosphate levels in patients with ESRD

Aranesp:
Stimulates the production of red blood cells; erythropoiesis.
Aranesp is often used to treat anemia.
Anemia is commonly associated with ESRD.
Hectorol:

A synthetic form of vitamin D.

[6]

CS#2 - PERITONEAL DIALYSIS

It is used to reduce elevated parathyroid hormone in the treatment of patients undergoing chronic
renal dialysis
It helps lower raises calcium levels

7. Another medical problem that patients with ESRD have to contend with is renal osteodystrophy.
Briefly describe this and please relate why this is a concern.
Renal osteodystrophy is a metabolic bone disease that occurs when your kidneys fail to maintain proper
levels of calcium and phosphorus in the blood. This is due to the decrease levels of calcium in the body.
The kidneys cannot convert inactive vitamin D to its active form, causing a decrease in absorption of
calcium in the GI. The increase need of both calcium and phosphate triggers the release of parathyroid
hormone. Which causes the bones to release calcium by stimulating osteoclast activity. If this continues
for a period of time it will lead to sever bone demineralization.
8. Write a PES statement for BT.
Excessive mineral intake of Phosphorus R/T overconsumption of high Phosphorus foods and not taking
Phosphate Binders AEB hypophosphatemia.
9. Complete the MSU Assessment Form.