1. Part I: Assignment Instructions
FSHN 450
Hemodialysis Case Study and Renal Diet Calculation
Total 15 points (10 case and 5 diet calculation)
Due Date: November 7, 2014
Presentation: CN, a 41 year old female is a patient in the renal dialysis center.
Medical History: Stage 5 chronic kidney failure secondary to IgA nephropathy. Started on
hemodialysis 3x/week at an outpatient dialysis center.
Social History: Divorced, unemployed on medical disability. Lives alone, shops and cooks for
Goes to the health club 2- 3x per week for strength training and walks about 45 minutes most
days of the week.
Physical: Ht: 5'5” Current EDW = 60 Kg
Diet Hx: Patient has been receiving corticosteroids for IgA nephropathy but no special diet was
ever ordered. Corticosteroid treatment has been discontinued.
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)

2. 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
Medications: Lasix, Lisinopril, Metoprolol, Renvela, Zemplar, EPO, Ferrlecit
Laboratory:
Sodium 135 mEq/L
Potassium 4.4 mEq/L
Chloride 111 mEq/L
CO 2 15 mEq/L
Calcium 7.5 mg/dl
Phos 10.2 mg/dl
BUN 108 mg/dl
Creatinine 14.0 mg/dl
Albumin 2.8 g/dl
Hemoglobin 8.3 g/dl
Hct 24.3%
Transferrin Sat 18%
MCV 70 fl
WBC 8.7 109
/L

3. Urine protein 320 mg/24 hr
In table format, evaluate the patient’s laboratory data compared to goals for dialysis patients.
What is the purpose of each medication which has been prescribed for the patient? List
drug:nutrient (food:medication) interactions for each.
What is secondary hyperparathyroidism and why is this patients at risk? What are the
consequences and how is this managed medically? nutritionally?
Assess the patients Kcal, protein, Phos, K, Na and fluid intake recommendations.
Evaluate patient’s current dietary intake including the following points:
How does CN’s current intake compare these recommendations?
Calculate a dietary pattern which would meet recommendations for this patient and using
foods create a sample one day diet. Use table format and the handouts provided in
class. This part counts as your renal diet calculation in addition to your case study.
Write two PES statements – one in the clinical and one in the behavioral domain and provide an
intervention, monitoring and evaluation plan for each.

4. Part II: My Assignment Work
Molly Carroll
Renal Case Study
FSHN 450-001
11/7/14

5. Lab table:
Lab value Patient’s value Goal range for
dialysis patients
Reason for variance
Sodium 135 mEq/L 135-145 mEq/L WNL
Potassium 4.4 mEq/L 4.5-5.5 mEq/L Lasix drug causes
potassium depletion
Chloride 111 mEq/L 98-107 mEq/L Kidney failure
CO2 15 mEq/L 22-25 mEq/L Kidney failure
Calcium 7.5 mg/dL 8.4-9.5 mg/dL Elevated phosphorus
from kidney failure
Phosphorus 10.2 mg/dL 4.5-5.5 mg/dL Kidney failure
BUN 108 mg/dL 60-80 mg/dL Kidney failure, lasix,
lisinopril, renvela
drugs can cause
increased BUN
Creatinine 14.0 mg/dL 2-25 mg/dL WNL
Albumin 2.8 g/dL > 4.0 g/dL Kidney failure
Hemoglobin 8.3 g/dL 11-12 g/dL Reduced ability of
kidneys to make EPO
Hematocrit 24.3% 33-36% Reduced ability of
kidneys to make EPO
Transferrin sat 18% 20-50% Iron loss from blood
with dialysis or side
effect of EPO drug
MCV 70 fl 80-99 fl Iron deficiency
anemia from dialysis
iron loss
WBC 8.7 x 109
/L 6-17 x 109
/L WNL
Urine protein 320 mg/24 hrs <30 mg/24 hrs Kidney failure
Purpose of medications and drug:nutrient interactions:
 Lasix- diuretic and antihypertensive drug, promotes formation of urine and loss of water,
decreasing blood pressure. Increase potassium and magnesium in diet as this drug causes
potassium and magnesium depletion. Also causes decreased serum sodium, chloride,
calcium, and increased serum glucose, BUN, creatinine, cholesterol, LDL, VLDL,
triglycerides, and anemia. Monitor blood pressure and listed electrolytes with this drug.
May need to decrease Calories and sodium (although this drug can decrease serum
sodium, too much sodium in diet may block antihypertensive effect of drug). Avoid
natural licorice with this drug. (patient did consume a banana and an orange which are
high in potassium and can help prevent drug’s potassium depletion, and patient does not
appear to be eating high amounts of sodium or Calories, elevated BUN levels could be a
result of this drug)

6.  Lisinopril- antihypertensive, consume adequate fluids with this drug, may need to
decrease sodium and Calories with this drug, avoid salt substitutions with this drug,
caution with potassium supplements, caution with iron, avoid natural licorice with this
drug, drug can cause anorexia/weight loss. Drug can cause increased serum potassium,
decreased serum sodium, WBC, increased BUN, creatinine. Monitor blood pressure and
electrolytes with this drug. (patient is consuming adequate fluids for a dialysis patient,
does not appear to be consuming excess sodium or Calories, patient does not have high
serum potassium or decreased serum sodium or WBC, but does have a high BUN level,
which may be a result of this drug)
 Metoprolol- antihypertensive, may need decreased sodium and Calories with this drug,
avoid licorice with this drug, drug may rarely increase serum potassium and triglycerides.
Monitor blood pressure and heart rate with this drug. (as stated before, patient does not
appear to be consuming excessive sodium or Calories, but may be consuming too much
fat with cheese, ice cream, oreos)
 Renvela- phosphate binder to help bind increased serum phosphorus in kidney disease,
should be taken with low phosphorus diet. Drug causes decreased serum phosphorus,
LDL, cholesterol, parathyroid hormone, and increased serum calcium. Monitor serum
phosphorus, calcium, cholesterol, and bicarbonate with this drug. (the patient should
decrease her milk intake to help with a low phosphorus diet, as 1 cup of milk contains
235-273 mg of phosphorus, and she consumed 2 cups of this, patient may also want to
eliminate coke as it can be high in phosphorus, the patient does not have high serum
calcium, probably because her phosphorus levels are still high)
 Zemplar- to help with secondary hyperparathyroidism, analog form of vitamin D which
can function to decrease phosphorus levels and increase calcium absorption, should not
be taken with vitamin D or magnesium supplement, dialysis patients should consume
adequate but not excessive calcium with this drug and low phosphorus diet, drug
increases calcium absorption, can cause anorexia, decreased weight, and increased thirst.
Decreases serum parathyroid hormone, slightly increases calcium, phosphorus,
magnesium and can cause hypercalcemia, hyperphosphotemia, increased BUN, creatinine,
and cholesterol. Monitor serum calcium, phosphorus, magnesium, parathyroid hormone.
(patient’s diet appears to have high calcium, but serum levels are low probably due to
high serum phosphorus levels, patient’s diet appears to be high in phosphorus levels with
milk products and coke, patient’s increased BUN levels could be a result of this drug)
 EPO- helps with anemia resulting from kidney disease – when kidney is not able to
produce erythropoietin to stimulate development of red blood cells, anemia results –
synthetic EPO helps take over job of kidneys to stimulate RBC production. May need
iron, B12, or folate supplements with this drug and should be taken with a kidney disease
diet for those with kidney disease. Increases serum RBC, hemoglobin, hematocrit,
decreases serum iron, ferritin, transferrin saturation, bleeding time, rarely causes severe
anemia. Monitor hemoglobin, hematocrit, blood pressure, electrolytes, phosphorus, iron,

7. B12, folate. (patient still has low hemoglobin and hematocrit even with drug, decreased
transferrin saturation levels may be a result of this drug)
 Ferleccit- for iron deficiency, used with erythropoietin in renal dialysis. 200 mg vit C/30
mg iron in diet will increase absorption of drug, meat/fish/poultry will increase
absorption of drug, high vit A can decrease iron mobilization from stores, drug can
decrease zinc absorption. Drug increases serum hemoglobin, hematocrit,, ferritin, iron,
transferrin saturation, and can falsely decrease calcium. Monitor hemoglobin, hematocrit,
ferritin, iron, transferrin. (patient is consuming vitamin C with an orange and watermelon
which can increase the drug’s absorption, patient did not consume any meat/fish/poultry
which may help with the drug’s absorption, transferrin saturation levels of patient are still
low)
Secondary hyperparathyroidism:
What is secondary hyperparathyroidism and why is this patient at risk? What are the
consequences and how is this managed medically? Nutritionally?
Secondary hyperparathyroidism results from the inability of the kidney to convert the inactive
form of vitamin D to the active form – 1,25-[OH]2D3. Without the active form of vitamin D, the
gut cannot adequately absorb calcium or excrete phosphorus, initially leading to low levels of
calcium and high levels of phosphorus in the blood. Low levels of calcium then causes the
parathyroid gland to excrete parathyroid hormone, which increases resorption of calcium from
the bone. High phosphate levels in the blood will cause phosphorus to combine with calcium
released from the bones, and calcium phosphate crystals will form all over the body, decreasing
serum calcium levels once again and causing more parathyroid hormone to be released to resorb
more calcium from the bone. The cycle continues when this calcium combines with the excess
phosphorus in the blood and the resulting decreased calcium levels cause additional parathyroid
hormone to be released. This leads to a continuous excretion of parathyroid hormone and
hyperparathyroidism in the blood. This patient is at risk to develop secondary
hyperparathyroidism because she has kidney failure, which means her ability to convert vitamin
D to its active form is inadequate, leading to decreased calcium absorption and high phosphorus
levels, which will result in a continuous release of parathyroid hormone and cause
hyperparathyroidism. Consequences of hyperparathyroidism are the formation of calcium
phosphate crystals in the body, bone disease from demineralization of bones with calcium
resorption, and heart disease from calcium phosphate deposits in blood vessels/atherosclerosis of
these vessels. Medically, this can be managed with phosphate binders taken with meals to
decrease serum phosphorus, antihypertensive drugs which help decrease the risk of a
cardiovascular event, vitamin D analog drugs which help with calcium absorption and phosphate
excretion, and calcimimetics which help in preventing the release of parathyroid hormone.
Nutritionally, this is managed by limiting phosphorus in the diet to less than or equal to 12 mg
phosphorus/kg body weight and consuming adequate but not excessive calcium (exceeding 2
grams/day).

8. Patient’s intake recommendations:
60 kg patient:
30 kcal/kg= 30 x 60= 1,800 kcal
1.2 g protein/kg= 1.2 x 60= 72 g protein
2300 mg Na
2400 mg K
12 mg P/kg= 12 x 60= 720 mg P
1,000 mL fluid
Fat < 30%kcal= .30 x 1,800kcal= 540 kcal (9 kcal/gram fat)= 540/9= 60 g fat
The patient’s diet appears to contain adequate kcals and protein (from milk, cheese, and ice
cream). Her diet also appears to be within the limits of 2300 mg Na, as none of the foods she
consumed are typically high in sodium, and within the limits of 2400 mg K, as the only foods
high in potassium that she consumed were oranges and bananas. Her diet may be high in
phosphorus, as indicated by her high serum phosphorus levels, and her consumption of 2 full
cups of milk – which contain approximately 235-273 mg of phosphorus each – cheese, ice cream,
and coke, which are each foods high in phosphorus. The patient’s diet does not appear to contain
excess fluid, as she consumed 4 ½ cups of fluid during the day – 1 cup of coffe, 2 cups of milk,
and 1.5 cups of coke – although no more than 4 cups of fluid/1,000mL of fluid are technically
recommended. The patient may be consuming a little too much fat with ice cream, oreos, cheese,
and 2% milk.
CHO
grams
Protein
grams
Fat grams Na(mg) K(mg) P(mg)
½ cup
applesauce
15 - - 15 100 15
½ cup
cherries
15 - - 15 200 15
1 medium
orange
15 - - 15 350 15
1 cup
lettuce
5 2 - 15 100 20
½ cup
broccoli
5 2 - 15 200 20
½ cup
spinach
5 2 - 15 350 20
1/2 cup low
fat milk
6 4 - 60 190 115

9. Bread,
regular,
white (6
servings)
90 12 - 480 210 210
Meat,
medium fat
(7 servings)
- 49 (7g
protein per
serving)
35 (5 grams
fat per
serving)
175 (25 mg
Na per
serving)
525 (75 mg
K per
serving)
455 (65 mg
P per
serving)
Fat, regular
(4 servings)
- - 20 220 40 20
Totals 156 71 55 1,025 2,265 905
Goals =72 <60 <2,300 <2,400 <720
4kcals/g CHO, 4kcals/g protein, 9kcals/g fat
Kcals: (156 g CHO x 4) + (71g protein x 4) + (55 g fat x 9)= 1,403 kcals short of 1,800 kcal goal
1,800- 1,403= 397 remaining kcals fulfilled by sugars, 4 kcals/g sugar= 397/4= 99 g sugars
Fats: 55 g x 9= 495 kcals/1,800 kcals= 27.5% of kcals, meets goal of < 30%kcals
Assessment:
General: 41 year old female
Medical hx: stage 5 chronic kidney disease, started hemodialysis 3 times/week
Physical: height 5’5”, 60 kg
Diet: never given kidney disease diet plan, diet high in dairy, a little high in fat
PES statements:
Clinical- Impaired nutrient utilization (NC 2.1) related to chronic kidney failure as evidenced by
biochemical lab values.
Behavioral- Food and nutrition-related knowledge deficit (NB 1.1) related to inadequate kidney
disease diet education as evidenced by diet recall.
Intervention:
Clinical- Decrease high-phosphorus foods in the diet, limiting consumption of nuts, beans, dairy,
and meat/poultry/fish as much as possible; however, be sure to include adequate protein with
high biological value in the diet (meat, poultry, fish, eggs, milk), but any protein in excess to
estimated daily protein requirements should try to be avoided. Aim for a phosphorus
consumption that is less than or equal to 720 mg/day, but levels may need to be slightly higher if
protein levels are compromised. Use phosphate binders with a meal to help bind excess
phosphorus. Make sure dietary potassium is adequate but does not exceed 2,400 mg/day, and
have patient consume a fruit and vegetable with a low, medium, and high potassium value each
day to help receive adequate but not excessive potassium. Be sure that patient is consuming

10. adequate but not excessive calcium each day – no more than 2 grams/day – and no more than
1,000 mL of fluid per day.
Behavioral- Educate the patient on the function of the kidneys and what happens in the body
when the kidneys begin to fail – decreased ability to filter blood. Explain how kidney failure can
lead to decreased excretion of a mineral called phosphorus and decreased absorption of calcium
from the diet. Explain that high levels of phosphorus can cause it to precipitate with calcium in
the blood and lead to the formation of painful crystals throughout the body, bone loss as the body
tries to compensate for calcium loss in the blood, and an increased risk for developing heart
disease. Inform the patient about which types of foods are high in phosphorus – meats, poultry,
fish, milk, nuts, beans – and may need to be limited in the diet. Explain the importance of eating
adequate protein (7 servings of 7 grams) and consuming protein from sources that the body can
most efficiently use (sources of high biological value, meats, poultry, fish, eggs, milk). Explain
that any protein in addition to this requirement and any other foods high in phosphorus should be
limited as much as possible in the diet. Give patient educational materials that include a list of
foods high and low in phosphorus. Explain the importance of receiving adequate but not
excessive potassium in the diet, as kidney failure patients are at risk for having high potassium
levels in the blood. Explain that high potassium levels can cause an irregular heart rhythm and
increase the risk for a heart attack. Give patient fruit/vegetable potassium chart and tell patient
to choose one fruit and vegetable from low, medium, and high potassium category each day to
help manage potassium levels. Explain importance of limiting fluid intake to 1,000mL/4 cups of
fluid per day for easier dialysis – and explain to patient that dialysis mimics the filtration
function that the kidneys have lost.
Monitoring/evaluation:
Clinical- Have patient give diet recall on the third day of dialysis each week for 4 weeks. Be
sure that high phosphorus foods are not excessive, protein intake is adequate, high potassium
foods are not excessive, and that calcium intake is adequate but not excessive. Monitor serum
phosphorus, potassium, calcium, and BUN to ensure that phosphorus and potassium are not in
excess in the blood, calcium levels are not too low, and protein intake is adequate (BUN). After
4 weeks, check diet once every month or two, but continue monitoring serum levels weekly.
Behavioral- Discuss patient’s diet recalls weekly. Find out whether or not patient is consuming
adequate protein from high biological value sources, whether or not patient is minimizing high
phosphorus foods as much as possible, whether or not patient is choosing low, medium, and high
potassium-containing fruits and vegetables each day, and whether or not patient is limiting fluids
to 4 cups per day. If patient is not meeting these recommendations or is struggling to do so, ask
patient how they are struggling and provide methods to overcome these struggles.