1. Megan Blackburn
FSHN 450: CKD Case Study
CSU ID: 830130344
I have not given or received any unauthorized assistance on this
assignment:
___________________________________________

2. In table format, evaluate the patient’s laboratory data compared to goals for dialysis
patients.
Laboratory: Patient’s value: Normal Range: Reason for deviation:
Sodium 135 mEq/L 136-144 mEq/L Edema
Potassium 4.4 mEq/L 4.5-5.5 mEq/L Renal Disease
Chloride 111 mEq/L 98-107 mEq/L Renal insufficiency
CO 2 15 mEq/L 22-29 mmol/L Renal Failure
Calcium 7.5 mg/dl 8.4-10.2 High Phosphorus
Phos 10.2 mg/dl 4.5-5.5 mg/dl Severe nephritis
BUN 108 mg/dl 60-80 mg/dl Renal failure
Creatinine 14.0 mg/dl 2-25 mg/dl N/A
Albumin 3.2 g/dl 4.0 g/dl Edema
Hemoglobin 8.3 g/dl 11-12 g/dl Possible anemia
Hct 24.3% 33-36% Possible anemia
Transferrin Sat 18% 20-50% Possible anemia
MCV 7 70 fl 78-93 fl Possible anemia
WBC 8.7 109/L 3200-
10600/microL
N/A
Urine protein 320 mg/24 hr <144 mg/24 hr Kidney disease
What is the purpose of each if the medications, which have been prescribed for the
patient? List drug:nutrient (food:medication) interactions for each.
 Lasix: to treat edema associated with CHF, renal or hepatic disease
o Nutrient interaction: increase K/Mg, decrease cal, decrease Na may be
recommended. Avoid natural licorice
 Lisinopril: CHF treatment, to treat left ventricular dysfunction/CHF post MI,
acture MI adjunct, to treat diabetic nephropathy
o Nutrient interaction: insure adequate fluid intake/hydration.
Decrease Na/cal may be recommended, avoid salt subs. Caution K/Mg
supplements
 Metroprolol: Anti-hypertensive, anti-angina, CHF treatment.
o Nutrient Interaction: Decrease sodium and calories, avoid natural
licorice
 Renvela: Phosphate binder
o Nutrient Interaction: Low phosphate diet
 Zemplar: To treat Rickets or Osteomalacia-add Ca supplement
o Nutrient Interaction: increase calcium absorption, anorexia, decrease
wt, increase thirst.
 EPO: Recombinant Human Erythropoietin, antianemic
o Nutrient Interaction: May need Fe/Vit B12/or Fol supplement. ESRD-
Diet compliance mandatory
 Ferrlecit: hematinic, anti-anemic, 200 mg of vitamin C and 30 mg of iron will
increase iron absorption.
o Nutrient Interaction: Meat, fish, and poultry will increase iron

3. absorption. Take carbonate antacids. Ca, P, Zn, or Cu supplements
need to be taken separately by 2 hours.
Assess the patients Kcal, protein needs and Phos, K and Na intake recommendations.
 Kcal: 23-35 kcal/kg =
o 23-25 * 69kg = 1,587-1,725 Kg
 Protein: 1.2 g/kg/day=
o 1.2 g * 69 = 82.8 g
 Phosphorous: 8-12 mg/Kg
o 8-12 mg * 69 Kg = 552-828 mg
 Potassium: 2.4 g/day
 Sodium: 2.4 g/day
Evaluate patient’s current dietary intake including the following points:
 Breakfast:
o 1 banana: 105 kcal, 1mg sodium, 1g protein, 422 mg potassium, 26 mg
phosphorus
o 1 c cornflakes: 101 kcal, 266 mg sodium, 1.88g protein, 22 mg
potassium,
o 1 c coffee: 2 kcal, 116 mg potassium
o 1 cup 2% milk: 122 kcal, 100 mg sodium, 266 mg potassium, 8.1 g
protein
 Lunch:
o Grilled cheese sandwich:
 Cheese: 191 kcal, 735 mg sodium, 155 mg potassium, 10.75 g
protein
 Bread: 158 kcal, 318 mg sodium, 4 g protein
o 2 slices watermelon: 171 kcal, 6 mg sodium, 638 mg potassium, 3.48 g
protein
o 12 oz coke: 143 kcal, 49 mg sodium
 Dinner:
o 1 cup 2 % milk: 122 kcal, 100 mg sodium, 266 mg potassium, 8.1 g
protein
o 1 orange: 62 kcal, 237.11 mg potassium, 1.2 g protein
o 6 oreo cookies: 270 kcal, 220 mg, 95 mg, 2 g protein
o 1 c ben & jerry’s chocolate ice cream: 500 kcal, 4 g protein
How does SW’s current intake compare these recommendations?
 Totals from Dietary intake:
o Kcal: 1,947  slightly high but barely
o Protein: 44g  very low! Only about half of his recommended needs
o Phosphorus: well over daily recommended amount of phosphorus

4. o Potassium: 2.23 g  low
o Sodium: 1.6 g  low
AS demonstrated in lab on 10/29, calculate a dietary pattern which would meet
recommendations for this patient.
Food: Exchange
# serving
CHO Protein Fat Na (mg) K (mg) P (mg)
Milk-
low fat
1.5 18 12 -- 180 570 345
Fruit:
Low K
2 30 -- -- 30 200 30
Med K 2 30 -- -- 30 400 30
High K 1 15 -- -- 15 350 15
Veg:
Low K
3 15 6 -- 45 300 60
Med K 2 10 4 -- 30 400 40
High K 1 5 2 -- 15 350 20
Bread
(reg-
white)
6 90 12 -- 480 210 210
Meat
(med
fat)
6 -- 42 30 150 450 390
Fat
(reg)
4 -- -- 20 220 40 20
Total: 213 78 50 1195 3270 1160
 Kcal: (213*4)+(78*4)+(78*9)=1,614 Kcal total
 28 kcal * 69 kg = 1,932
o 1,932-1,614=318 Kcal = 79.5 gm sugars
 Percent HBV: 54 g (meat/milk) / 78 = 69% (70-75%)
 Fat 450/1,932=23% (20%)
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.

5.  Breakfast:
o 1 cup low fat milk
o ½ c grapes
o ½ cup cherries
o 2 English muffins
o 1 tbsp butter
o 1 medium egg white
o 2 servings meat
o ½ c greens
o 1 banana
 Lunch:
o 2 slices whole wheat bread
o 2 servings meat
o ½ c applesauce
o ½ cup canned peaches
o ½ c cucumber
o ½ cup nonfat cottage cheese
o ½ c carrots
 Dinner:
o 2 slices whole wheat bread
o 2 servings meat
o ½ cup corn
o ½ c broccoli
o ½ c lentils
o ½ cup sherbet
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.
 Assessment:
o 41 y/o male
o Medical Hx: Chronic kidney disease, secondary to severe
hypertension. Started hemodialysis 3x/week at an outpatient dialysis
center.
o Social Hx: 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.
o Physical: Ht: 5’9’’. Current EDW= 69 Kg.
o Medications: Lasix, lisinopril, metoprolol, renvela, zemplar, EPO,
ferrlecit
o Labs:
 Low: sodium, potassium, CO2, albumin, hemoglobin, Hct,
transferrin, MCV 7,
 High: Chloride, Phos, BUN, Urine protein
 Diagnosis:

6. o Intake: inadequate protein intake r/t consumption of half of
recommended intake AEB 24 hour dietary recall
o Clinical: Altered GI function r/t altered lab values due to kidney
disease AEB low potassium, high BUN, high urine protein levels.
o Behavioral: Food and nutrition-related knowledge deficit r/t
excessive intake of non nutritious foods (little/no consumption of
fruits and vegetables and high consumption of sugary/high fat foods)
AEB 24 hour dietary recall
 Intervention:
1. Encourage more protein intake (at least 82 g/day), supply SW with
proper handouts that list foods high in protein.
2. Educate patient about proper food choice while on dialysis. Watch
sodium, potassium, phosphorus, and protein levels.
3. Encourage healthy eating: nutrient dense foods (4-5 servings of fruits
and vegetables each day, complex carbohydrates, and 1.2 g
protein/day). Supply SW with proper handouts and “my plate” model
 Monitoring/Evaluation:
o Have SW keep a food diary. Check food diary for increased protein
intake.
o During check-up (3-4 weeks later) monitor labs, possibly order new
lab check.
o Have SW keep a food diary, see if nutritious food has increased/take a
24 hour diet recall at check-up.
What is secondary hyperparathyroidism and why is this patients 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.
http://www.jabfm.org/content/22/5/574.full
Abstract: Secondary hyperparathyroidism is a frequently encountered problem in
the management of patients with chronic kidney disease (CKD). Its pathophysiology
is mainly due to hyperphosphatemia and vitamin D deficiency and resistance. This
condition has a high impact on the mortality and morbidity of dialysis patients.
Early diagnosis of secondary hyperparathyroidism is crucial in the management of
patients with CKD. The treatment remains a challenge for patients and their
clinicians. It should include a combination of dietary phosphorus restriction,
phosphate binders, vitamin D analogues, and calcimimetics.
 Secondary Hyperparathyroidism: excessive secretion of parathyroid
hormone by the parathyroid glands in response to hypocalcemia.
 This patient is at risk because this disorder is especially seen in patients with
chronic kidney failure. About 50% of patients develop hyperparathyroidism.
 Consequences of SHPT are vascular/valvular calcification, alterations in

7. cardiovascular structure and function, immune dysfunction, and renal
anaemia.
 SHPT is managed medically by measures to control phosphorus retention,
maintain serum calcium concentrations within normal range, and prevent
excess parathyroaid hormone secretion.
 Dietary restriction of phosphorus, supplements with an active form of
Vitamin D such as calcitriol, doxercalciferol, paricalcitol, and phosphate
binders.
 Nutritionally: low-protein diets may help prevent SHPT, suggest considering
vitamin D supplementation