Chronic Kidney Disease/Hemodialysis Case Study
CAROLINA CHAVES
“I HAVE NOT GIVEN, RECEIVED OR USED ANY UNAUTHORIZED ASSISTANCE ON
THIS ASSIGNMENT”
Carolina Chaves
NOV-13-2015

Chronic Kidney Disease/Hemodialysis Case Study
FN 520
Fall 2015
Due Date 11/14/15
Presentation: SW, a 41 year old male is a patient in the renal dialysis center.
Medical History: Chronic Kidney Disease secondary to severe hypertension. Started on
hemodialysis 3x/week at an outpatient dialysis center.
Social History: Divorced, unemployed on medical disability. Lives alone, shops and cooks for
himself. Goes to the health club 2- 3x per week for strength training and walks about 45 minutes
most days of the week.
Physical: Ht: 5'9” Current EDW = 69 Kg
24 Hour Dietary Intake:
Breakfast: 1 banana Lunch: Grilled cheese sandwich (2 slices American cheese on
1 c cornflakes 2 slices Wonder Bread grilled with butter)
1 c coffee 2 slices watermelon (1" thick)
1 cup 2% milk 12 oz. Coke
Dinner: 1 cup 2% milk
1 orange
6 Oreo cookies
1cup Ben & Jerry’s chocolate ice cream

In table format, evaluate the patient’s laboratory data compared to goals for dialysis patients.
Lab data Patient value Normal range
for dialysis
Reason for variance
Sodium 135 mEq/L 135-145 mEq/L Normal
Potassium 4.4 mEq/L 4.5-5.5 mEq/L ↓ Due to Renal disease.
Chloride 111 mEq/L 98-107 mEq/L Normal
CO 2 15 mEq/L 22-29 mEq/L ↓ renal failure
Calcium 7.5 mg/dl 8.4-9.5 mg/dl ↓ elevated phosphorus and hypoalbuminemia
Phos 10.2 mg/dl 4.5-5.5 mg/dl ↑ ESRD and severe nephritis, hypocalcemia.
BUN 108 mg/dl 60-80mg/dl ↑ Due to renal failure.
Creatinine 14.0 mg/dl 2-25 mg/dl Normal
Albumin 3.2 g/dl 4.0 g/dL or > ↓ESRD, low protein intake.
Hemoglobin 8.3 g/dl 11-12 g/dL ↓ Anemia.
Hct 24.3% 33-36% ↓ Anemia.
MCV 7 70 fl 78-93 fl ↓ Iron de. Anemia.
Transferrin
Sat
18% 20-50% ↓ Iron deficiency.
WBC 8.7 109
/L 3,200-10,600
109
/L
Normal
Urine protein 320 mg/24 hr 0 mg/24 hr ↑ CKD and glomerulonephritis.
What is the purpose of each if the medications which have been prescribed for the patient?
List drug: nutrient (food: medication) interactions for each.
Medications: purpose Drug: nutrient interaction.
Lasix Diuretic,
antihypertensive
 Increase K, Mg intake
 Decrease Na and calcium
 Increase thirst
Lisinopril Antihypertensive  Avoid salt substitutes.
 Caution with K and Mg supplements.
 Limit alcohol.
 Decreased Na and calcium may be
recommended.
Metoprolol Antihypertensive
Antiangina
CHF treatment
Cardioselective beta
blocker.
 Take with food to increase bioavailability
 Decrease Na and Ca
 Avoid natural licorice.
Renvela Phosphate binder  Low phosphate diet
 Monitor P, Ca, Cl and bicarbonate.
Zemplar Treatment of  Don’t take with Mg or vit. D supplement

Secondary
hyperparathyroidism
in ESRD
Ca regulator
Treat hypocalcemia
 Adequate Ca, low P diet.
 Drug increase calcium absorption.
EPO Stimulates red blood
cell production
Antianemic drug
 May need Fe, vit B12 or folate supplement.
Ferleset Antianemic
Stimulates RBC
production.
 False decrease calcium
 Unreliable iron and ferritin
Assess the patients Kcal, protein needs and Phos, K and Na intake recommendations.
Evaluate patient’s current dietary intake including the following points:
How does SW’s current intake compare these recommendations?
GFR = 175 * (14.00 mg/dl^ (-1.154)) *(41 ^ (-0.203))
= 4 ml/min/1.73m^ (2)
Stage of CKD: 5 (kidney failure)
Nutrient: Patient
recommendation
Patient current dietary intake and evaluation:
Kcal 23-35 kcal/kg
2415 kcal/kg/day
Patient intake: 2010 kcal/ day.
Patient calorie intake is lower than recommended. He needs to
increase his daily intake to spare protein for tissue repair and
maintenance. Furthermore, high energy is recommended as
patient is currently using hemodialysis therapy.
Protein 1.2 g/kg/d with
60% HBV
82.8 g/day
Patient intake: 46.4 g/day
Patient protein intake is lower than recommended. His diet as
evidence by the 24 hour recall is low in protein and don’t meet
the recommendation. Furthermore, patient is not consuming
HBV proteins which are critical for stage 5 kidney failure as
they produce fewer nitrogenous waste products.
Phos 10-12mg/kg
690 mg/ day
Patient intake: 825 mg/ day
Patient current dietaryintake is higher than recommended. This
is evidence in his blood lab results. The 24 hour diet recall
shows that patient consume high phosphorus foods like: cheese,
milk, Oreos. Cornflakes are a hidden source of phosphorus;
patient should choose a breakfast option lower in phosphorus
per serving.
Na < 2.4 g/day Patient intake: 1.88g/day
Patient sodium intake level is normal as evidence by his blood
lab values. Although he is selecting high Na foods such as
Oreos. Patient should avoid soda as is high in Na.

K 2.4 g/day Patient intake: 1.92g/day
Patient potassium intake meets the recommendation.
Although patient lab values indicate low K levels due to
medication, patient is consuming High-K foods such as bananas
and oranges. Watermelon is an excellent option as is low in
potassium.
AS demonstrated in lab on 10/29, calculate a dietary pattern which would meet
recommendations for this patient.
Exchange # of
servings
CHO
(g)
Protein
(g)
Fat (g) Na
(mg)
K (mg) P (mg)
Milk low fat 0.5 c 6 4 0 60 190 115
Fruit:
Low K 1 15 0 0 15 100 15
Medium K 1 15 0 0 15 200 15
High K 1 15 0 0 15 350 15
Vegetables:
Low K 1 5 2 0 15 100 20
Medium K 1 5 2 0 15 200 20
High K 1 5 2 0 15 350 20
Bread
(regular-white)
7 105 14 0 560 245 245
Meat (med –
fat)
7 0 49 35 175 525 455
Fat (regular) 4 0 0 20 220 40 20
Total 171 73 55 1105 2300 940
Recommended 82.8g 2400 2400 690
Kcal 684 292 495
Total kcal: 1471
Recommended kcal: 2415 kcal/kg/day
Recommended grams of sugar: 2415 – 1471= 944 kcal/ 4 kcal/ g = 236 g
% HBV: (53g/73 g)*100= 72%
Fat: (494/2415 kcal)* 100 = 20.5%
Translate this pattern into a sample one day diet (including specific foods). You may use the
tools for estimating potassium and phosphorous content which are posted on Canvas.
Meal menu Servings:
Breakfast 1 egg
2 slices toast with 1 teaspoons jelly
0.5 cup low fat milk
1 serving protein
2 servings CHO + 2 servings fat
0.5 servings low fat milk
Lunch Turkey sandwich: 2 slices bread, 3 2 servings CHO + 3 servings

ounces sliced turkey, 1 cup leaf lettuce, 1
teaspoons mayonnaise.
½ cup carrots
1 medium apple
1 cup cranberry juice
protein + 1 serving low K
vegetable + 2 servings fat.
1 serving medium K vegetable
1 serving medium K fruit
1 serving low K fruit.
Dinner 3 serving broiled fish
½ cup spinach
2 dinner roll
1 cup ice tea
3 servings protein
1 serving high K vegetable
2 servings CHO
Fluid
Snack 1 slice pound cake
1 medium orange
1 serving CHO
1 serving high K fruit.
Complete and ADIME note including three PES statements – one in each of the intake, clinical
and behavioral domains and provide an intervention, monitoring and evaluation plan for each.
1. Nutrition assessment:
Client history:
- 41 year old male patient in the renal dialysis center.
- Medical history: Chronic Kidney Disease secondary to severe hypertension
- Treatments: hemodialysis 3x/week at an outpatient dialysis center.
- Social history: Divorced, unemployed on medical disability. Lives alone, shops and cooks
for himself. Goes to the health club 2- 3x per week for strength training and walks about 45
minutes most days of the week.
- Medications: Lasix, Lisinopril, Metoprolol, Renvela, Zemplar, EPO, Ferleset
Anthropometric
measurements
Biochemical data, medical
test and procedures
Food/nutrition related food.
Height: 1.75 m
Current EDW:69 kg
BMI: 22.5
Lab data:
Low lab values:
K, CO2, Ca, albumin,
hemoglobin, Hct, MCV
7, transferrin sat.
High lab values:
Phos, BUN, urine
protein.
24 hour dietary intake analysis:
-no vegetable consumption.
-good quantity of fruit but patient is
choosing high potassium fruits:
bananas and orange.
-high phosphorus dairy and other
choices: milk, cheese, cookies and ice
cream.
-high sodium and phosphorus cereal
choice.
- Imbalance diet as there is not much
protein and greens.
- Adequate Fluid intake but no
adequate sources: coke, ice cream,
coffee, milk.
-no nutritious meal high sugary and fat
diet.

2. Nutrition diagnosis:
Intake Clinical Behavioral-environmental
Increased nutrient needs
(protein) related to
hemodialysis as evidence by
low albumin blood levels and
low protein intake in 24 hour
dietary intake. ( NI-5.1)
Altered nutrition-related
laboratory values (potassium,
calcium) related to stage 5 CKF
as evidence by abnormal
electrolyte levels in lab results.
(NC-2.2)
Food- and nutrition- related
knowledge deficit related to
high phosphorus food choices
as evidence by high phosphorus
blood levels and 24 hour dietary
intake. (NB-1.1)
Nutrition intervention:
Goal: patient will increase his
protein intake by 2x more what
he is currently consuming to
meet recommended levels.
Patient would assist to a
nutrition care center which will
control his hypertension as he
will increase his protein intake.
Patient will assist to nutrition
education intervention where he
will learn about HBV proteins.
He will be asked to write a 24
hour dietary intake.
Nutrition intervention:
Patient will assist to nutrition
counseling where he and his
counselor will establish food,
nutrition and physical activity
priorities.
Patient will limit fluid to 1000
ml/day to regulate electrolytes.
Patient will increase his
physical activity.
Na and K intake will be control
closely as patient have high
blood pressure and his dietary
food choices are high potassium
foods.
Patient will assist to nutrition
education program where he
will learn about electrolytes
balance and interaction with
protein/ other electrolytes.
Nutrition intervention:
Goal: patient would be able to
differentiate low-moderate from
high phosphorus foods after 2
nutrition education
intervention.
Patient would assist a nutrition
education programs that would
increase his knowledge about
high and low phosphorus food
choices. He will learn to select
low phosphorus, sodium and
potassium foods.
Nutrition monitoring and
evaluation:
Patient will be monitor weekly
in the nutrition care center for
any changes in his BP as he will
be increasing his protein intake.
Counselor will evaluate 24 hour
dietary intake of the patient to
determine if patient is
consuming the recommended
amount of protein as well as he
will look for HBV proteins,
patient have to consume around
30 g/day more of protein as he
is currently consuming.
Nutrition monitoring and
evaluation:
Counselor will monitor patient
lab values to see any
improvements in electrolytes
and to compare electrolytes and
macronutrients.
Counselor will monitor patient
blood pressure and physical
activity as well as fluid intake
which should be limit to no
more than 1000ml per day.
Nutrition monitoring and
evaluation:
Patient will be monitor weekly
by a counselor regarding his
knowledge about low
phosphorus foods. Determine if
his goal has been meet by ask
him to develop low phosphorus
and sodium recipes.

What is secondary hyperparathyroidism and why is this patient at risk? What are the
consequences and how is this managed medically? Nutritionally? Find one recent reference
from the literature which deals with the risk of secondary hyperparathyroidism or treatment
of hyperparathyroidism in CKD patients.
Secondary hyperparathyroidism describes an alteration in bone and mineral metabolism that occurs
as a result of CKD.
As the kidney is unable to produce enough vitamin D and clean the blood phosphorus it leads to a
decrease in serum calcium. Low levels of calcium stimulate the parathyroid glands to increase PTH
production. As CKD progresses parathyroid glands over secrete PTH. Over secretion of PTH causes
bone mineralization to increase calcium levels and if calcium levels don’t increase and PTH remain
high it leads to secondary hyperparathyroidism. (Francisco).
The patient is at risk because he has decreased serum calcium levels as evidence by his lab results.
The consequences are severe vascular and heart valve calcification and non-cardiac vascular
calcification; alterations in cardiovascular structure and function; immune dysfunction. This is
mange by restricting phosphate in patient diet, use oral phosphate binders with meals, vitamin D and
its analogues, and, in severe cases, parathyroidectomy. Treatments also include calcimimetic therapy
and allosteric regulator of the parathyroid calcium receptor. (Francisco)
Abstract:
Conventional therapies for treating SHPT are limited and include calcium-based and calcium-free
phosphate binders for reducing serum phosphorus and vitamin D or its analogues for simultaneous
stimulation of calcium absorption and suppression of parathyroid hormone (PTH) gene expression.
Control of SHPT using these therapies has typically been poor. Recent studies have demonstrated
that use of calcimimetics that reduce PTH secretion by increasing the sensitivity of the parathyroid
gland calcium-sensing receptor to circulating calcium allow improved control of serum PTH,
calcium, phosphorus and calcium–phosphorus product. This review describes experimental data and
the clinical rationale supporting novel strategies for the integration of calcimimetics with
conventional therapies to improve control of SHPT.
References:
Francisco A, Carrera F. A New Paradigm for the Treatment of Secondary Hyperparathyroidism.
Oxford journals. January 7 2011; doi: 10.1093/ndtplus/sfm041.