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Case Study: Renal Disease

PART I: Medical Management of Renal Insufficiency

Mrs. L. is a 66 yo retired elementary school teacher in a rural community. She is active in outdoor
gardening and social clubs, but has been feeling like her health has begun to limit her lifestyle. She
has a previous history of renal insufficiency. She was recently seen by her personal physician who
has referred her to the renal clinic. You are the RDN at the outpatient renal clinic and have been
consulted for a nutrition referral and patient counseling.

Present Illness: She c/o increasing frequency of headaches, nausea and vomiting, severe itching, an
unpleasant taste in her mouth, muscle cramps and twitching, weight loss, weakness, and drowsiness
with difficulty concentrating.

Past Medical History: Streptococcal infection of throat at age 11, followed by glomerulonephritis;
nephrotic syndrome and renal insufficiency Dx at age 50y; progressive CKD over past 15 y

Social History: Married, Retired 2nd grade teacher, 2 adult children, 3 grandchildren

Physical Examination:
General appearance: white female who appears her age; lethargic, thin
Vitals: 57 56.6 kg (UBW 61 kg) 2 yrs ago; medium frame (has lost the weight over past 6
months). BP 155/98, right arm, sitting. HR 76 bpm, regular. RR 17 bpm. T 99.0F.
Heart: S4, S1 and S2 regular rate and rhythm: heart without murmur or gallop.
HEENT: non contributory
Neurologic: oriented to person, place and time
Extremities: muscle weakness, 3+ pedal edema.
Skin: dry, warm, irritated and red in areas
Chest/Lungs: generalized rhonchi with rales that are mild at bases
Peripheral vascular: normal pulse (3+) bilaterally
Abdomen: bowel sounds positive, soft; generalized mild tenderness; no rebound
Urinary: Urine volume =500 mL/24 h; proteinuria negative

Nutrition History:
General: Intake has been poor due to anorexia. Patient states that she tried to follow the diet that
she was taught a few years back. It went pretty well for a while but it was hard to keep up.
Diet Recall (doesnt finish it all)
Breakfast: 1 c oatmeal, c milk, banana
Lunch: chicken noodle soup, coke
Dinner: meat, potato and green beans
Snacks: yogurt
Food allergies/intolerances/aversions: none
Previous MNT: 2-3 gm sodium diet 6 years ago
Food purchase/preparation: mostly husband
Vitamin and mineral intake: One-a-Day
1. Interpret the following laboratory values, using the indices for CKD in the PG. (8 points)
Laboratory Results
Lab Parameter Patient Interpretation (, or wnl)
Value
GFR 20 ml/min low (severe)
BUN 90 mg/dl high
Serum Creatinine 4.35 mg/dl wnl for CKD but high for healthy reference range
Creatinine Clearance 17 ml/min Low
Serum Sodium 150 mEq/L High
Serum Potassium 5.7 mEq/L wnl for CKD but high for healthy reference range
Serum Albumin 2.8 g/dl Low
Hgb 11.5 g/dl wnl for CKD but low for healthy reference range
Hct 28% wnl for CKD but low for healthy reference range
Serum Transferrin 155 mg/dl Low
Serum Phosphorus 5.2 mg/dl wnl for CKD but high for healthy reference range
PTH 100 pg/ml wnl for CKD but high for healthy reference range
Serum Alkaline Phosphatase 180 units/L high
Blood Co2 14.8 mEq/L low
Your assessment of CKD Stage stage 4

Physicians Dx and Orders:

Impression: Chronic renal failure in a 66 yo underweight female with history of renal insufficiency
and nephrotic syndrome. EDW = 52 kg

Plan: Nutrition referral for diet counseling: protein restriction; Na 1.5 g; K 2.5 g; Phos 1 g; fluids
output + 500 mL

Rx: Furosemide (Lasix) 60 mg TID; Losartan (Cozaar) 50 mg BID; sodium bicarbonate 1 g TID
RTC in 2 weeks with completed lab tests

2. Explain the purpose of each of the following interventions, and list the data (laboratory
parameters, symptoms, etc.) indicating the need for treatment. (10 pts)

a. Losartan

Purpose: This is an antihypertensive drug. High blood pressure is damaging to the


kidneys. This drug helps keep her blood pressure within a healthy range.

Data: BP 155/98, headaches


b. Protein restriction

Purpose: Reducing the amount of protein that the glomeruli have to filter helps to
retard the progression of CKD. This prevents/corrects uremia and decreases the rate
of GFR decline.
Data: 20 ml/min GFR, BUN 90 mg/dl, Serum Creatinine 4.35 mg/dl, Creatinine
Clearance 17 ml/min, anorexia, nausea and vomiting, severe itching, an unpleasant
taste in her mouth, muscle cramps and twitching, weight loss, weakness, and
drowsiness with difficulty concentrating

c. Phosphorus restriction

Purpose: Excess phosphorus in the blood stimulates release of excess parathyroid


hormone. Normally, that would result in excretion of the excess phosphorus.
Impaired kidneys have less capacity to excrete phosphorus, so in CKD, the PTH
levels keep rising. This can cause the following sequence: parathyroid hyperplasia,
secondary hyperparathyroidism, renal osteodystrophy. Bones are weakened as the
calcium is pulled out of them. Restricting dietary phosphorus slows this process.

Data: Serum Phosphorus 5.2 mg/dl, PTH 100 pg/ml, Serum Alkaline Phosphatase
180 units/L, severe itching, muscle cramps and twitching, irritated and red skin

d. Potassium restriction

Purpose: This is to prevent excess potassium in the blood. If too high, this can cause
a heart attack.

Data: Serum potassium 5.7 mEq/L, nausea, muscle weakness

e. Fluid restriction

Purpose: Reducing the amount of fluids her kidneys have to filter will put less stress
on her kidneys, heart, lungs, etc. It will help reduce her blood pressure.

Data: 3+ pedal edema, BP 155/98, rhonchi and rales, Urine volume =500 mL/24 h

3. The patient asks about using a salt substitute. Is this appropriate, and explain why or why not? (2
pts)

No. Salt substitutes contain potassium chloride. She needs to restrict potassium as well as sodium.
Also, there is a caution against using salt substitutes when taking Losartan.

4. Evaluate the patients diet recall for appropriateness in light of the new diet order. Assume that
this is a typical food pattern with usual type of food choices. Complete the information below and
indicate whether each food item is OK, or list a suggested substitute to help the patient meet the diet
guidelines. (9 points)
OK Suggested Substitute___________________

Breakfast: 1 c oatmeal cream of wheat, corn meal, cream of rice, grits

c milk cashew, rice, or almond milk

banana fresh ( cup unless otherwise stated):


blueberries, cherries, grapes, 1 apricot,
boysenberries, raspberries, pineapple, 1 plum
blackberries, 1 tangerine, strawberries, 1
clementine, or 1 small apple. Also: applesauce
or 1/3 cup dried cranberries

Lunch: chicken noodle soup sandwich or salad (such as egg, tuna, chicken,
turkey,* with vegetables) or low-sodium and
low-potassium homemade soup or casserole

Coke water, juices/nectars of pear, cranberry, grape,


apricot, apple, pineapple, lemon- or lime-aid,
ginger ale, lemon-lime, grape, or cream soda,
or root beer

Dinner: meat OK*

potato cauliflower, yellow, scallop or spaghetti


squash, turnips, cooked carrots, canned beets,
lettuce, bell peppers, celery, cucumber, pasta,
rice, polenta, or bread

green beans OK
1
Snacks: yogurt /8 1/4 cup hummus with raw vegetables such
as bell peppers, celery, cucumber

*Alternate types of protein, within the amount allowed. Select eggs, fish, poultry or lamb more
often than beef. Tofu, shrimp, and pork should be avoided. Omit high salt meats such as sausage,
corned beef, bacon, etc.

5. Based on all of the pertinent information above, write your nutrition assessment ADIME note
including PES statement. (16 points)

(ADIME starts on page 7)

PART II: Dialysis

Mrs. L. has returned to clinic for a 6 month follow up appointment. She is no longer able to keep
up her ADL and has had continued poor intake. Her GFR is now 16 mL/min. Her Nephrologist
recommends a transplant, but a kidney is not immediately available. As a consequence, RRT is
recommended. Patient and medical team decide on PD.
A peritoneal catheter is surgically inserted. Two months later, her serum potassium level has risen
further and BUN is 110 mg/dL. Her BP has also risen. Her pre-CAPD weight is 56 kg at this time,
and her EDW is considered to be 50 kg. She is started on CAPD 7 days a week.
Her diet prescription now reads: Na 2.5 g; K 3.5 g; phosphorus 1.2 g. She is given prescriptions for
a phosphate binder, and a vitamin supplement that does not contain vitamin A. She will receive
EPO and Fe.

6. How much protein and calories per day would you recommend for Mrs. L. and why? (refer to
lecture) (4 pts)

Protein: 65 70 g/day

Kcals: 1050 1300 kcal/day (dietary)

Reason: Dialysis removes some protein, so protein needs increase. Patients absorb calories
from the dialysate solution, so dietary calories have to be adjusted to account for that. Also,
now that she is on dialysis, her needs have been calculated based on her current adjusted
edema-free weight (protein) and/or her EDW (kcal based on range using both), rather than
her CBW. Adjusted edema-free weight was used rather than or in addition to EDW, because
she has lost so much weight.

7. The CAPD prescription is Three 2 L exchanges of 2.5% dextrose each day. Calculate what this
will contribute to her caloric intake. (2 pts)

How many grams of dextrose does this supply? 150 g

What does this provide as absorbed calories? 306 357 kcal/day

8. Explain the rationale for the following interventions: (3 pts)

a) Phosphate binder

Dietary phosphorus restriction isnt enough once a patient begins dialysis. Dialysis
removes some protein, so protein needs increase. Protein foods are high in phosphorus.
Dialysis also removes phosphorus, but not as much as healthy kidneys would. So, a
phosphate binder is used to allow enough protein in the diet without having excess
phosphorus. This is necessary to prevent consequences of hyperphosphatemia such as
secondary hyperparathyroidism, left ventricular hypertrophy, and calcium phosphate
deposits in various organs.

b) Iron and EPO

She was anemic 6 months ago because her kidneys are not producing adequate EPO and
therefore her bone marrow is not producing enough red blood cells. She also had low
iron at that time. The EPO is to replace that not provided by her body. The iron is
because she had low iron status to begin with and now she is on EPO. Her body will
need more iron to make new RBCs. It will respond better to the EPO if she has adequate
iron stores.
c) Vitamin supplement containing only water soluble vitamins

She has higher needs for water soluble vitamins because she is malnourished and will
also lose vitamins in the dialysate. Her intake and absorption will continue to be low
because renal diets restrict sources of some micronutrients (F&V, dairy, whole grains),
her metabolism is altered, and her intestinal absorption ability is decreased.

Fat soluble vitamins arent included in renal vitamin supplements because they have to
be individualized, if needed. Impaired kidneys cant catabolize vitamin A as much, and
it is not removed in dialysis, so levels are usually high in PD patients. A vitamin A
supplement would only be needed if she was deficient. I would expect her to need
supplemental vitamin D at some point because impaired kidneys cant activate vitamin
D, but that would depend on her levels of vitamin D, calcium, phosphorus, and PTH.
Effects of vitamin E supplementation in dialysis patients over the long term have not yet
been thoroughly investigated, so that would only be recommended if she was deficient.
Vitamin K supplementation is not needed because she is not on antibiotics.

9. If Jenny were to choose Hemodialysis, instead of PD, how would your nutrition
recommendations change? List 3 nutrition items, state how your recommendations would
change and provide the rationale for each. (6 pts)

Protein: The recommendation would be slightly lower, because needs for patients on HD are
lower. Maybe 60-63 g/day.

Carbohydrates (and dietary kcal): On PD, there would be a recommendation to restrict simple
carbohydrates, to allow for the dextrose in the dialysate and to allow for higher protein intake
within a smaller dietary calorie range. PD would provide 306 357 kcal of dextrose per day, or
the equivalent of about 77-90 grams of carbohydrate. On HD, the osmotic agent is sodium, so
all kcal would come from the diet. Therefore, kcal recommendation would now be the same as
total kcal needs (1400-1600), and carbohydrate would not be restricted.

Potassium: The recommended limit of K would be lower on HD. It would be about 2.5g.
ADIME

3/15/17 10 am

Assessment

Patient History:
66 yo female with stage 4 CKD referred for nutrition consult and pt counseling. Past Hx of
glomerulonephritis and nephrotic syndrome. Renal insufficiency Dx age 50.

MD Diet Order/Rx:
Protein restriction; Na 1.5 g; K 2.5 g; Phos 1 g; fluids output + 500 mL

Anthropometrics:
Ht: 170 cm UBW: 61 kg IBW: 61 kg CBW: 56.6 kg EDW: 52 kg
Based on actual weight: BMI: 19.5 (low normal) % change BW: -7.2% % IBW: 92.8%
Based on EDW: BMI: 18 (low normal) % change BW: -14.8% (severe) % IBW: 85.2%

Weight Hx:
UBW: 61 kg CBW: 56.6 kg EDW: 52 kg Pt has lost weight over the past 6 months.
Based on actual weight: % change BW: -7.2%
Based on EDW: BMI: 18 (low normal) % change BW: -14.8% (severe weight loss)
Due to edema and other data indicating water retention, severity of weight loss is estimated to be
near the % change based on EDW, not CBW. Patient is at risk for PEM.

Nutrition focused physical finding:


Overall appearance: thin, uncomfortable, tired young senior female
GI: N&V, anorexia, dysguesia
Cognition: alert and oriented X 3; pt reports difficulty concentrating.
Skin: dry, warm, irritated and red in areas; pt reports severe itching
Lungs: crackles
Extremities: swollen feet and ankles; 3+ pitting edema
BP: 155/98 per RN

Biomedical data/labs:
Lab Parameter Patient Interpretation (, or wnl)
Value
GFR 20 ml/min low (severe)
BUN 90 mg/dl high
Serum Creatinine 4.35 mg/dl wnl for CKD but high for healthy reference range
Creatinine Clearance 17 ml/min Low
Serum Sodium 150 mEq/L High
Serum Potassium 5.7 mEq/L wnl for CKD but high for healthy reference range
Serum Albumin 2.8 g/dl Low
Hgb 11.5 g/dl wnl for CKD but low for healthy reference range
Hct 28% wnl for CKD but low for healthy reference range
Serum Transferrin 155 mg/dl Low
Serum Phosphorus 5.2 mg/dl wnl for CKD but high for healthy reference range
PTH 100 pg/ml wnl for CKD but high for healthy reference range
Serum Alkaline Phosphatase 180 units/L high
Blood Co2 14.8 mEq/L low
Your assessment of CKD Stage stage 4
Urine volume = 500 mL/24 h; proteinuria negative

Medications:
Furosemide (Lasix) 60 mg TID; Losartan (Cozaar) 50 mg BID; sodium bicarbonate 1 g TID

Estimated Nutrient Needs (based on 56.6 kg wt):


Energy: BEE x AF/IF (as necessary)
MSJ: 1480 1708 kcal (based on AF 1.3 1.5) Shortcut (based on EDW): 1300-1820 kcal
Range: 1480 1780 kcal/day

Protein: 34 43 g PRO per day (based on 0.6 0.75 g per kg CBW/day)

Fluid: 1000 ml per day (per MD order urine output + 500mL, w/urine output of 500mL)

Food and Nutrition Hx:


Patient reports anorexia, poor intake, and dysguesia. Patient indicates that she had trouble staying
on the previous recommended diet.
Diet Recall (doesnt finish it all):
Breakfast: 1 c oatmeal, c milk, banana
Lunch: chicken noodle soup, coke
Dinner: meat, potato and green beans
Snacks: yogurt
Food allergies/intolerances/aversions: none
Previous MNT: 2-3 gm sodium diet 6 years ago
Food purchase/preparation: mostly husband
Vitamin and mineral intake: One-a-Day

Diagnosis:

Unintended weight loss NC-3.2 related to CKD and poor intake as evidenced by loss of 4.4 kg in
past 6 months (-7.2% change in BW), and estimated -14.8% change in BW based on EDW (severe
weight loss).

Excessive mineral intake of phosphorus, potassium, and sodium NI-5.10.2 related to food- and
nutrition-related knowledge deficit as evidenced by diet recall with multiple foods high in
phosphorus, potassium, and sodium, and the following lab values: serum phosphorus 5.2 mg/dl,
serum potassium 5.7 mEq/L, and serum sodium 150 mEq/L.

Intervention:

Goal is to prevent additional weight loss and maintain/achieve serum values of phosphorus,
potassium and sodium within CKD range.
Diet Rx:
Renal diet.
1480 1780 kcal/day
34 43 g pro per day (50% or more HBV protein)
1000 mL fluids
Na 1.5 g, K 2.5 g, Phos 1 g

- Explained diet guidelines, discussed appropriate alternative foods.


- Provided pt with handouts: Nutrition & Chronic Kidney Disease, Potassium, Phosphorus, and
How to Reduce Dietary Sodium.
- Recd pt put handouts up where they will be easy to see when planning grocery lists and meals.
- Recd SFM and selection of nutrient dense foods from appropriate lists to increase intake.

Stressed importance of following diet recommendations. Patient indicated that she will:
Go over the diet guidelines and handouts with husband over the next few days,
Help him plan a shopping list and meals that she can and wants to eat (since he does much
of the shopping and cooking), and
Log her foods for 2 or 3 days before our next appointment.

Patient appeared overwhelmed, but indicated motivation to try to follow the diet so that she
would feel better and get some energy back. Patient didnt understand all the restrictions yet, but
should after reading the handouts. Compliance with diet will probably not be complete.

Monitoring/Evaluation:

Monitor patient weight. Look for EDW to stabilize.


Monitor lab values of serum phosphorus, potassium and sodium. Look for phosphorus and
potassium to remain within CKD range, and for sodium level to reduce to within CKD range.
Assess patient knowledge and compliance by asking about the behavior goals, evaluating food
log and asking patient to teach back key information.
Meet with patient and her husband Feb. 22 to go over diet again and answer questions. Assess
food log and patient understanding at this visit.
Reassess patient in 1 month. Assess weight and lab values at this visit.

(signature) 3/15/2017
Calculations for Final Case Study
Anthropometrics:
2.54cm
Ht: 67in = 170.18 cm UBW: 61 kg IBW: 61 kg CBW: 56.6 kg EDW: 52 kg
in
kg
IBW: 100 + 5 7 = 135 lbs; 135 lbs 2.2 lbs = 61 kg
56.6 56.6
Based on actual BW: % IBW: 100% = 92.8% BMI: 1.70182 = 19.5
61
56.6
% change BW: 100 100% = 7.2%
61
52 52
Based on EDW: % IBW: 61 100% = 85.2% BMI: 1.70182 = 18
52
% change BW: 100 61 100% = 14.8%

Estimated Nutrient Needs (based on 56.6 kg wt):


Energy: BEE x AF/IF (as necessary)
MSJ: (10 56.6 kg) + (6.25 170.18 cm) (5 66) 161 = 1138.625 kcal
1138.625 1.3 (ambulatory ) 1.5 (less than avg. activity) = 1480 1708 kcal
kcal
25 35 52 kg = 1300 1820 kcal
kg
Estimated energy needs: 1480 1780 kcal/day
Protein:
0.6 0.75 g PRO per day
56.6 kg = 34 42.5 g PRO per day
kg
Fluid:
urine output 500mL + 500 mL = 1000 ml per day

Estimated needs on PD:


IBW: 61 kg CBW: 56 EDW: 50 (use ABWef and round values up, due to severe wt loss)
Adjusted edema free body weight: 50 + [(61 50) 0.25] = 52.75 kg
g PRO
Protein: 52.75 kg 1.2 1.3 = 63.3 68.6 kg
kg

Kcals:
MSJ: (10 50 kg) + (6.25 170.18 cm) (5 66) 161 = 1072.625 kcal
1075.625 1.2 (ambulatory) 1.3 (low activity) = 1287 1394 kcal
NKF K/DOQI Recommendations:
kcal
30 35 52.75 kg = 1582.5 1846 kcal
kg
Range: 1400 1600 kcal total, then subtract 306 357 for kcal absorbed from dialysate:
1400 357 = 1043; 1600 306 = 1294 So, range for dietary kcal: 1050 1300

Three 2 L exchanges of 2.5% dextrose/day provides:


Grams of dextrose: 3 50g = 150 g

kcal kcal
Absorbed kcal: 3.4 150g 0.6 0.7 (60 70% absorption) = 306 357 day
g

Needs on HD:
g PRO g PRO
Protein: 50 kg 1.2 = 60; 52.75 kg 1.2 = 63.3 kg
kg kg

mg
Potassium: 61kg 40 kg = 2440 mg