1. Kody Springsteen
Chronic Kidney Disease/Hemodialysis Case Study
November 13, 2015
“I have not given, received, or used any unauthorized assistance on this assignment”
_________________________________________ _____________

2. Value Patient’s Value Goals for Dialysis
Patients
Reason
Sodium 135 mEq/L 136-144 mEq/L Low due to water
intoxication due
to fluid retention
drugs
Potassium 4.4 mEq/L 4.5-5.5 mEq/L Low due to renal
disease
Chloride 111 mEq/L 98-107 mEq/L High due to
anemia or renal
insufficiency
CO2 15 mEq/L 22-29 mEq/L Low due to renal
failure
Calcium 7.5 mg/dl 8.4-9.5 mg/dl Low due to
elevated
phosphorous
Phosphorous 10.2 mg/dl 4.5-5.5 mg/dl High due to
ESRD
BUN 108 mg/dl 60-80 mg/dl High due to renal
failure
Creatinine 14.0 mg/dl 2-25 mg/dl Normal
Albumin 3.2 g/dl 4.0 g/dl or greater Low due to
edema, renal
failure
Hemoglobin 8.3 g/dl 11-12 g/dl Low due to
anemia
Hct 24.3% 33-36% Low due to
anemia
Transferrin sat 18% 20-50% Low due to
anemia
MCV 70 fl. 78-93 u3
/RBC High due to
anemia
WBC 8.7 109
/L 3200-10,600/uL High due to
trauma or tissue
injury
Urine protein 320 mg/24 hours <30 mg/24 hours High due to
hypertension
Medications:
The purpose of Lasix is to treat fluid retention in in people with a kidney disorder.
• Drug: nutrient reactions: May need to increase K and Mg. May need to decrease
calorie and sodium intake.
The purpose of Lisinopril is to treat high blood pressure because it is an ACE inhibitor,
which helps lower the intra-glomerular pressure and reduce proteinuria.

3. • Drug: nutrient reactions: Need to have adequate fluid intake. May need to
decrease sodium and calorie intake. Lisinopril has high MG content, may need to
increase K intake.
The purpose of Metroprolol is to treat hypertension as a beta-blocker.
• Drug: nutrient reactions: May need to decrease calorie and sodium intake.
The purpose of Renvela is to serve as a phosphate binder for use in ESRD.
• Drug: nutrient reactions: Decrease phosphorous in diet.
The purpose of Zemplar is to treat secondary hyperparathyroidism.
• Drug: nutrient reactions: Should get adequate Ca (not excessive) and have a low
phosphorous diet.
EPO serves as an antianemic.
• Drug: nutrient reactions: May need Fe, Vit B12, or Folate supplement. ESRD diet
compliance mandatory.
The purpose of Ferrlecit is to serve as an antianemic during dialysis.
• Drug: nutrient reactions: Need 200 mg of Vit C, 30 mg of Fe, take carbonate
antacids, Ca, P, Zn, or Cu supplements separately by 2 hours. Increase Vit A
intake to decrease Fe mobilization from stores.
Assessment:
Kcal: 25 kcal/kg x 69 kg = 1725 kcal
Protein: 1.2 g pro/kg x 69 kg = 83 g pro
Pro: 83 g = 332 kcal = 19% of Kcal
Phosphorous: 12 mg PO4 x 69 kg = 828 mg PO4
K: 2400 mg/39 = 60 mEq
Na: 2300 mg
Fluid: 1000 ml/day
Fat: > 30 en% = 518 Kcal/9 = 58 g
SW’s current intake is not meeting the recommendations. He seems to have a diet high in
diary products, which is good for protein, but high in phosphorous. He also eats high
potassium fruits, which should be limited since he has CKD and is in dialysis. He also
has some nutrient: drug interactions with his current intake and the medications he is on.

4. Exchange #
Servings
C P F Na
(mg)
K
(mg)
P
(mg)
Milk Low Fat .5 6 4 - 60 190 115
Fruit
Low K (Watermelon ½ cup)
Med K (1 Apple)
High K (1 banana)
1
1
1
15
15
15
-
-
-
-
-
-
15
15
15
100
200
350
15
15
15
Vegetable
Low K (4 spears asparagus)
Med K (Carrots ½ cup)
High K (1/2 cup spinach)
1
1
1
5
5
5
2
2
2
-
-
-
15
15
15
100
200
350
20
20
20
Bread (reg-white) 7 97 19 - 560 245 245
Meat (med fat) 8 - 56 40 200 600 520
Fat (reg) 8 - - 40 440 80 40
Totals 163 81 80 1290
(2300)
2225
(2400)
910
(828)
Kcal: C: 163 x 4 = 652
P: 81 x 4 = 324
F: 80 x 9 = 720
= 652 + 324 + 720 = 1,696
1725-1696 = 29 Kcal/3.8 = 8 g sugar
Percent HBV 60 g (meat and milk)/ 81 g total = 74.1% (70-75%)
Fat 720/1725 = 41.7% (30%)
PES Statements:
Impaired nutrient utilization (NC-2.1) R/T CKD and dialysis AEB hyperparathyroidism
and elevated phosphorous levels.
Intervention:
1. Eat adequate amount of calories with a reduction in foods that contain
phosphorous and potassium.
2. Limit fluid to about 4 cups a day (1000 ml).
3. Incorporate phosphate binders into meal and snack times.
4. Educate patient on what kind of diet they should be eating (low phosphorous, low
potassium, high protein, high calcium).
5. Educate patient about role of kidney in the body.
Monitoring/Evaluation:
Monitor lab values to make sure they are meeting the goals for patients on dialysis. Take
blood every month. Follow up visit one-month post-operation. Monitor fluid a few times
a week. Monitor medication intake. Monitor physical signs of edema.

5. Food and nutrition-related knowledge deficit (NB-1.1) R/T high phosphorous diet AEB
24 hour recall (dairy products) and elevated phosphorous lab values.
Intervention:
1. Avoid foods containing phosphorous and potassium.
2. Try to eat more protein and calcium.
3. Educate on type of foods to eat (low phosphorous meats and grains and know how
much potassium is in the fruits and veggies).
4. Increase physical activity levels post-operation.
Monitoring/Evaluation:
Monitor food intake using diet recalls. Monitor labs and GFR to make sure SW is making
appropriate changes to diet and lifestyle. Monitor fluid intake a few times a week.
Follow-up visit to answer any questions about renal diet.
Excessive phosphorous intake (NI-5.10.26) R/T high phosphorous diet AEB 24 hour
recall (dairy products) and elevated phosphorous lab values.
Intervention:
1. Avoid foods containing phosphorous.
2. Educate on foods that contain high and low amounts of phosphorous.
3. Educate patient about role of kidney in the body.
4. Educate patient on function of phosphorous in the body.
Monitoring/Evaluation:
Monitor food intake using diet recalls. Monitor lab values to make sure SW is making
appropriate changes to his diet. Follow-up visit to answer any questions about
phosphorous, the renal diet, or the kidneys.
Secondary hyperparathyroidism is the excessive secretion of parathyroid hormone in
response to low blood calcium levels. This patient is at risk because he had CKD and is
on dialysis. Most dialysis patients exhibit secondary hyperparathyroidism. The
consequences are vascular and valvular calcification, such as non-atherosclerotic
coronary artery calcification, aortic calcification, cardiac valve calcification, and non-
cardiac vascular calcification. Prescription drugs, dialysis, a kidney transplant, or surgery
manages it medically. It is managed nutritionally by increasing vitamin D and calcium
intake, as well as avoiding phosphate in the diet.
Wu Q, Lai XL, Zhu ZY, et al. Evidence for Chronic Kidney Disease-Mineral and Bone
Disorder Associated With Metabolic Pathway Changes. J Med. 2015; 94(32):e1273. doi:
10.1097/MD.0000000000001273