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Renal Diet Case Study Analysis
- 1. Anya Guy FSHN 450 Hemodialysis Case Study and Renal Diet Calculation November 7, 2014 “I have not given, received, or used any unauthorized assistance.”
- 2. In table format, evaluate the patient’s laboratory data compared to goals for dialysis patients. Patient’s value Normal value Reason Sodium 135 mEqL 136-‐144 mEq/L Renal insufficiency Potassium 4.4 mEq/L 4.5-‐5.5 mEq/L Renal insufficiency Chloride 111 mEq/L 98-‐107 mEq/L Renal insufficiency CO2 15 mEq/L 22-‐29 mEq/L Renal failure Calcium 7.5 mg/dl 8.4-‐9.5 mg/dl Elevated phosphate Phosphate 10.2 mg/dl 4.5-‐5.5 mg/dl Renal insufficiency BUN 108 mg/dl 60-‐80 mg/dl Renal failure Creatinine 14.0 mg/dl 2-‐25 mg/dl Normal Albumin 2.8 g/dl 4.0 g/dl or higher Nephrotic syndrome Hemoglobin 8.3 g/dl 11-‐12 g/dl Chronic kidney failure Hematocrit 24.3 % 33-‐36 % Blood loss/anemia Transferrin saturation 18% 20%-‐50% Renal failure MCV 70 fl 78-‐93 fl Anemia WBC 8.7 10^9/L 3,200-‐10,600/L Kidney failure Urine protein 320 mg/24 hours <30 mg/24 hr. Chronic kidney failure What is the purpose of each medication which has been prescribed for the patient? List drug:nutrient (food:medication) interactions for each. Lasix • Diuretic, antihypertensive drug • Food decreases bioavailability • Increase K, Mg supplements • Decrease calories • Decrease Na • Increase thirst • Decrease renal function Lisinopril • Antihypertensive drug • Take without regard to food • Adequate fluid intake • Avoid salt substitutes
- 3. • Decrease Na, decrease calories • Caution with K and Mg supplements Metoprolol • Antihypertensive drug, antiangina drug, CHF treatment, cardioselective beta blocker • Take with food to increase bioavailability • Decrease Na, decrease calories may be recommended • Avoid natural licorice Renvela • Phosphate binder • Take with each meal • Take 1 hr. after or 3 hr. before meal • Swallow whole (do not crush, chew, or divide) • Low phosphate diet • Monitor P, Ca, Cl, bicarbonate Zemplar • Secondary hyperparathyroidism drug, Ca regulator, treat hypocalcemia • May mix solution with food or juice • Take with regard to food • Not with Vit. D or Mg supplement • Adequate but not excessive Ca, low P diet • Drug increases calcium absorption EPO • Recombinant human erythropoietin, antianemic drug • Stimulates RBC production • May need Fe, Vit. B12, or Folate supplement • Monitor Hb/HCT, BP, and renal function Ferrlesit • Antiamemic drug, mineral supplement for Fe • Single dose vial = 5 mL = 62.5 mg Fe • 20% sucrose, benzyl alcohol 45 mg • Watch RDA (18 mg/day) and UL (45 mg/day) for iron • False decrease calcium • Unreliable iron and ferritin • Parenteral Fe decrease absorption of concomitant oral Fe What is secondary hyperparathyroidism and why is this patients at risk? What are the consequences and how is this managed medically? Nutritionally?
- 4. Since the kidney activates Vitamin D and is not working properly, there is a decrease in serum calcium and therefore an increase in serum phosphate. This increases parathyroid hormone secretion to increase serum calcium levels. This patient is at risk because they have decreased serum calcium levels as evidenced by their lab values. She is also at a higher risk because she is female. The consequences are non-atherosclerotic coronary artery calcification, aortic calcification, cardiac valve calcification, and non-cardiac vascular calcification. This is managed by regulating electrolyte intake and serum levels through dialysis. Treatments also include calcimimetic therapy and allosteric regulator of the parathyroid calcium receptor. A primary dietary strategy is to reduce phosphorous intake and use phosphate binders with meals. Assess the patients Kcal, protein, Phos, K, Na and fluid intake recommendations. • Kcal o 28 kcal/kg = 1,680 kcal • Protein o 1.2 g Pro/kg BW/day = 72 g Protein o 72 g x 4 = 288 kcal o 288kcal/1680 kcal = 17% kcal o 70-75 % HBV = 50-54 g HBV • Fat o 30% kcal = 504 kcal o 504 kcal/9 = 56 g • Sodium o 2300 mg Na • Potassium o 2400 mg K o 60 mEq/day • Phosphorus o 12 mg P/kg = 720 mg/day • Fluid o 1000 ml/day Evaluate patient’s current dietary intake including the following points: How does CN’s current intake compare these recommendations? Breakfast: Her choice of a banana is poor because it is a high potassium option. She should opt for a low or medium potassium option like grapes or an apple. Corn flakes are a hidden source of phosphorus; since she needs to watch her phosphorus levels, she should choose a breakfast option lower in phosphorus per serving. For milk, she should choose low fat milk to keep her electrolyte levels balanced. Lunch: The milk option should be low fat. The orange is a high potassium option; she should choose a medium or low potassium option instead. The Oreos are not a good option because they are very high in sodium. Chocolate ice cream is not a good option either because it is high in sugar and saturated fat.
- 5. Dinner: Watermelon is a good option that is low in potassium. The bread option is good, but the cheese should be low fat. She should avoid soda because it is high in sodium and sugar. Calculate a dietary pattern that 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. Na (mg) K (mg) P (mg) 1 c milk 120 380 230 Fruit: Grapes (1/2 c) 15 100 (5-150) 15 Apple (1) 15 200 (150-250) 15 Banana (1) 15 350 (250-500) 15 Vegetable: Lettuce (1 c) 15 100 (5-150) 20 Broccoli (1/2 c) 15 200 (150-250) 20 Tomato (1) 15 350 (250-500) 20 Bread 80 35 35 SF meat 25 75 65 Reg Fat 55 10 5 Serving Carb. Pro Fat Na (mg) K (mg) P (mg) Low fat milk 0.5 c 6 4 - 60 190 115 Fruit: Grapes 1 15 - - 15 100 15 Apple 1 15 - - 15 200 15 Banana 1 15 - - 15 350 15 Veg: Lettuce 1 5 2 - 15 100 20 Broccoli 1 5 2 - 15 200 20 Tomato 1 5 2 - 15 350 20 Bread (reg- white) 7 105 14 - 560 245 245 Meat (med. Fat) 7 - 49 35 175 525 455 Fat (reg) 4 - - 20 220 40 20 Total: 171 73 55 1105 (2300) 2300 (2400) 940 (720) Kcal: X4 684 X4 292 X9 495
- 6. Kcal = 1,471 1,680 – 1,471 = 209 kcal = 52 g. sugar Percent HBV 49 + 4 = 53 g (meat and milk)/73(total) = 72% (70-75%) Fat: 495/1,680 = 29% (30%) Write two PES statements – one in the clinical and one in the behavioral domain and provide an intervention, monitoring and evaluation plan for each. Clinical: • Altered nutrition-related laboratory values (NC-2.2) related to chronic kidney failure as evidenced by abnormal electrolyte levels in lab results. • Intervention o Control blood pressure by reducing sodium intake. § Monitor blood pressure in outpatient clinic. § Evaluate serum sodium levels. o Recommend taking medicines the way the provider says to do § Ask patient to keep log of when they take medicine with regard to food. o Advise becoming more active. § Monitor activity log and evaluate dry weight. o Limit fluid to 1,000 ml/day to regulate electrolytes. § Recommend keeping log of what fluid is used for the 1,000 ml limit. o Provide education on electrolyte balance and interactions with protein/other electrolytes. § Monitor lab values to see comparison of electrolytes and macronutrients. Behavioral: • Undesirable food choices (NB-1.7) related to chronic kidney failure diet recommendations as evidenced by 24-hour dietary intake recall. • Intervention o Recommend choosing and preparing foods with less sodium. § Monitor diet recall and evaluate sodium intake in each meal. § Compare sodium intake to recommended amount. o Advise eating the right amount of the right type of protein. § Evaluate protein intake from diet recall in comparison to recommendation. o Choose heart healthy foods such as lean meat, fish, vegetables, fruits, and low fat milk. § Evaluate how this diet change can alter electrolyte lab values.
- 7. o Choose low phosphorus foods such as fresh fruits and vegetables, breads and corn/rice cereals. § Monitor lab values and make sure that the patient is using the phosphorus finder guide. o Choose foods that have the right amount of potassium. § Evaluate potassium in the dietary recall and assure the patient is using the potassium finder guide to make healthful decisions on potassium sources.