This document presents a case study of a 41-year-old male patient (SW) with chronic kidney disease who is undergoing hemodialysis 3 times per week. It provides details on his medical history, social history, physical exam findings, laboratory values, current diet, and medication regimen. It finds that his current diet is low in calories and protein and high in phosphorus and potassium. It develops an intervention plan focused on increasing calorie intake, reducing phosphorus intake, and educating on limiting high potassium and phosphorus foods given his chronic kidney disease and medications. It discusses how the patient is at risk for secondary hyperparathyroidism due to low calcium levels and provides a recent literature reference on managing this condition in

1. CKD Case Study
EMILY RODERICK
FSHN 450 MNT
NOVEMBER 13, 2015
I have not given, received or used and unauthorized
assistance
__________Emily Roderick____________________

2. 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
Lab Value Goal for Dialysis Patient Value Reason
Sodium 136-144 mEq/L 135 mEq/L Dialysis
Potassium 4.5-5.5 mEq/L 4.4 mEq/L N/A
Chloride N/A. Normal values:
98-107 mEq/L
111 mEq/L High- renal
insufficiency,
dehydration
CO2 N/A. Normal values:
22-29 mmol/L
15 mEq/L Low-renal failure
Calcium 8.4-9.5 mg/dl 7.5 mg/dl Low-elevated P,
hypoparathyroidism
Phosphorus 3.5-5.5 mg/dL 10.2 mg/dl Very high- Zemplar
interaction, high P
intake in diet
BUN 60-80 mg/dl 108 mg/dl High-renal failure
Creatinine 2-25 mg/dl 14.0 mg/dl N/A
Albumin 4.0 g/dl or greater 3.2 g/dl Low-low protein intake
Hemoglobin 11-12 g/dl 8.3 g/dl Low
Hct 33-36% 24.3% Low

3. Transferrin Saturation 20-50% 18%
MCV N/A. Normal values: 7 (70?) fl Low
WBC N/A. Normal values: 8.7 109
/L
Urine Protein N/A. Normal values: 320 mg/24 hr
Drug Reason for Taking Drug: nutrient Interactions
Lasix Diuretic. Edema associated
with renal disease
K depleting, Mg depleting,
avoid licorice
Lisinopril Antihypertensive May dehydrate
Metoprolol Antihypertensive Lower intake of Na and Ca
recommended. Avoid licorice
Renvela Phosphate binder, used for
chronic kidney disease
Need to have low Phosphorus
diet.
Zemplar -Used for treatment of
secondary hyperparathyroidism
for chronic kidney disease.
-Synthetic Vitamin D, helps
treat hypocalcemia
-Do not take with Vit D or Mg
supplement
-Adequate Ca, low P diet with
dialysis
EPO Stimulates RBC production for
patients with chronic kidney
disease, prevents anemia
Must adhere to chronic kidney
disease diet.
Ferleset Iron- prevents anemia N/A
Kcal, protein needs and Phos, K and Na intake recommendations.
Protein: 1.2gx69kg= 82.8 g Pro/kg/day= 331 kcal=19% of Kcal
-75% HBV=.75x331=248/4kcal=62 g HBV Pro
Kcal: 25kcalx69kg=1725kcal/day
Phos: 10 mgx69kg= 690mg/day
K: 2 g/day=2000 mg/39= 51mEq
Sodium: 2400 mg/day
1000 ml fluid
Fat: 518 kcal=58 g
How does SW’s current intake compare these recommendations?
Kcal: The patient’s overall energy intake is low.
Pro: intake is low as well, and most sources are from animal products. Should be consuming
more vegetable/meat sources of protein (high biological value)
-K/P: The client is currently consuming a lot of dairy products (milk, ice cream, cheese) and is
drinking coca cola. All of these foods are high in both phosphorus and potassium which should
both be limited while a patient is on dialysis.
-Sodium: within recommended range
-Fluid: fluid intakes are slightly high, but not significantly.

4. -Fat: fat intake is higher than assessed recommendations for dialysis patients.
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.
Food Item Srv.
Size
C P F Na (mg) K (mg) P (mg)
Breakfast
Blueberry 1 c 21 g 1 g .5 g 15 100 15
Corn flakes ¾ c 18 g 1 g 153 mg 150 65
2% milk ½ c 6 g 4 g 2.5 g 50 mg 190 115
Lunch
Tortilla 1 ea. 20 g 3 g 3.5 g 310 mg 100 65
Hummus 1/3 c 12 g 6 g 7 g 310 mg 200 125
Cucumber ½ c 2 g 15 100 20
Avocado ¼ c 3 g 1 g 5 g 15 150 20
Alfalfa sprt ½ c 15 100 20
Dinner
Brown Rice ½ c 22 g 2.5 g 1 g 100 100
Snow peas ¼ c 1 g .5 g 15 100 20
Peppers ½ c 3 g .5 g 15 200 20
Chicken 3 oz 19 g 10 g 50 mg 200 165
Low sod.
Teriyaki
sauce
2 Tbsp 6 g 2 g 690 mg 80 50
TOTAL 114 g 40.5 29.5 1653 mg 1770 mg 800 mg
Total
kcal
low-
would
need
210.5 g
sugar to
ensure
adequate
kcal
intake
(seems
like a
ton)
456 kcal 162 kcal
18% kcal
265.5 kcal
30% kcal
Under
2400
Under
2000 mg
Slightly
high
Fluid 1000 ml
Complete an 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

5. 41 y/o male presents with chronic kidney disease and severe hypertension. Currently on
hemodialysis 3 times a week at an outpatient dialysis center. Patient reports walking 45 minutes
most days of the week and strength trains 2-3 times per week. Lives alone, purchases and
prepares meals for himself.
Anthopometrics: Measured Ht 5’ 9” (cm), EDW 69 kg
Lab Values: Significant for low serum calcium, albumin, hemoglobin, hematocrit and transferrin
saturation. Significant for high BUN.
Energy Needs:
Kcal: 25kcalx69kg=1725kcal/day.
Protein: 1.2gx69kg= 82.8 g Pro/kg/day= 331 kcal=19% of Kcal
-75% HBV=.75x331=248/4kcal=62 g HBV Pro
Dietary Intake: Significant for low energy intake, low protein intake. Very high intake of animal
products such as cheese and milk. High intake of potassium and phosphorus.
Diagnosis
1. Inadequate energy intake (NI-1.4) r/t low overall calories consumed by patient AEB 24 hour
dietary intake.
2. Predicted food-medication interaction (NC-2.4) r/t need for low phosphorus diet while taking
phosphate-binding drug Zemplar AEB reported 24 hour dietary intake high in phosphorus.
3. Undesirable food choices (NB-1.7) r/t chronic kidney disease AEB reported 24 hour dietary
intake high in potassium and phosphorus.
Intervention
1. Inform patient about current kcal intake compared to assessed kcal needs and provide a list of
foods that are calorie dense and easy to prepare for them to include in their diet.
2. Educate client about drug-nutrient interaction of Zemplar and phosphorus and encourage to
reduce phosphorus intake to ensure that the patient is maintaining phosphorus levels.
3. Educate patient about dangers of high potassium and phosphorus diets with CKD and provide
lists of foods that are low, moderate or high sources of each that they can use when planning
what to eat.
Monitoring and Evaluation
1. Have patient keep food diary and monitor weight. Evaluate diary at each appointment to
monitor for changes in kcal intake.
2. Monitor diet for phosphorus intake.
3. Have patient keep food diary of potassium and phosphorus sources in diet. Evaluate at each
appointment and offer ideas for improvement.
What is secondary hyperparathyroidism and why is this patients at risk? What are the consequences
and how is this managed medically? Nutritionally?
Hyperparathyroidism is when the parathyroid secretes excessing parathyroid hormone (PTH) in
response to low serum calcium, because the body wants to increase serum calcium. This patient is at
risk because their serum calcium levels are low. Medically, patients are often given a vitamin D
analogue to encourage calcium to stay within the bone. Nutritionally, foods high in vitamin D and
calcium are encouraged (while still staying within the range for phosphorus and potassium needed

6. for dialysis)
Find one recent reference from the literature which deals with the risk of secondary
hyperparathyroidism or treatment of hyperparathyroidism in CKD patients.
Abstract
It is uncertain whether increasing 25-hydroxyvitamin D (25-D) levels in chronic kidney disease
(CKD) patients above those recommended bycurrent guidelines result in progressive amelioration of
secondary hyperparathyroidism. Our objective was to identify a potential therapeutic 25-D target
which optimally lowers plasma parathyroid hormone (PTH) without producing excessive
hypercalcemia or hyperphosphatemia in CKD.
Ennis J, Worcester E, Coe F, Sprague S. Current recommended 25-hydroxyvitamin D targets for
chronic kidney disease management maybe too low. Journal of Nephrology. 2015:1-8. doi: 10.1007/
s40620-015-0186-0