1. 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
Medications: Lasix, Lisinopril, Metoprolol, Renvela, Zemplar, EPO, Ferleset
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 3.2 g/dl
Hemoglobin 8.3 g/dl
Hct 24.3%
Transferrin Sat 18%
MCV 7 0 fl
WBC 8.7 109
/L
Urine protein 320 mg/24 hr
In table format, evaluate the patient’s laboratory data compared to goals for dialysis patients.

2. What is the purpose of each if the medications which have been prescribed for the patient? List
drug:nutrient (food:medication) interactions for each.
Assess the patients Kcal, protein needs and Phos, K and Na intake recommendations.
Evaluate patient’s current dietary intake including the following points:
How does SW’s current intake compare these recommendations?
AS demonstrated in lab on 10/29, calculate a dietary pattern which would meet recommendations
for this patient.
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.
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.
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.
CKD
Ashtin Spies
FSHN 450
“I have not given, received, or used any unauthorized material”

3. Patient Values Normal values Explanation
Sodium: 135 mEq/L 135-145 mEq/L N/A
Potassium: 4.4 mEq/L 4.5-5.5 mEq/L Hypokalemia/potassium
loss
Chloride: 111 mEq/L 96-109 mEq/L Hyperchloremia, kidney fxn
failure
CO2: 15 mEq/L No less than 18 mEq/L Acidic blood/protein
consumption
Calcium: 7.5 mg/dl 8.4-9.5 mg/dl Phosphorus interactions
Phosphorus: 10.2 mg/dl 4.5-5.5 mg/dl High phosphorus diet
BUN: 108 mg/dl 60-80 bg/dl Loss of kidney fxn/ high
blood pressure
Creatinine: 14.0 mg/dl 2-25 mg/dl N/A
Albumin: 3.2 g/dl 4 g/dl or < Chronic kidney failure
Hemoglobin: 8.3 g/dl 11-12 g/dl Low RBC/anemia
Hct: 24.3% 33-36% Decreased RBC/blood loss
Transferrin sat: 18% 20-50% Loss of iron
MCV 7: 0 fl 78-93 10 degree m/RBC Possible anemis
WBC: 8.7 10 degree/L 4-11 10 degree/L N/A
Urine Protein: 320 mg/24
hr
0-20 mg/24 hrs Kidney fxn failure
Lasix: Treats edema and high blood pressure- interact with potassium, patients will need to
consume potassium containing foods. Decreases in K and Mg. Supplement K, Mg, zinc, vit B
and C.
Lisinopril: ACE inhibitor treating high blood pressure and heart failure -may cause hyperkalemia
with high potassium intake, salt substitutes should be avoided
Metoprolol: Treats high blood pressure, angina, and heathy failure- beta blocker- Alcohol should
be avoided
Renvela: lowers amount of phosphorus in blood- binds with phosphate, keep levels healthy
Zemplar: Treats/prevents hyperparathyroidism interacts with Ca+, so antacids or Ca+
supplements should be avoided
EPO: stimulates RBC production. There are no serious interactions, but diet can aid in EPO
production.
Ferleset: Iron replacement- interacts with iron supplements, some vitamins, and herbal over the

4. counters
Kcals: 30 kcals/kg: 2,070 kcals/day
PRO: 1.2 g/kg/d: 82.8g/day
Phos: 10 mg/kg: 690mg/day
K: 2.4g/day
Na: 2.4g/day
1 banana: high potassium
1 c cornflakes: simple CHO
Grilled cheese sandwich (2 slices American cheese on
2 slices Wonder Bread grilled with butter): simple CHO high kcal
1 c coffee
2 slices watermelon (1" thick ): high glycemic index high potassium
1 cup 2% milk: high calcium/high fat
12 oz. Coke: high kcal/high sugars
1 cup 2% milk: high calcium/high fat
1 orange
6 Oreo cookies: high kcal/high sugars
1cup Ben & Jerry’s chocolate ice cream: high kcal high fat high sugars
SW is not eating properly in order to manage CKD. Potassium intakes are too high,
sodium intakes are too high, calcium intakes may be too high, phosphorus intake too high, and
overall calories are too high. SW is not maintaining a healthy diet for any individual, let alone a
diet healthy for CKD.
Exchange # serving c p f Na K P
Milk low fat .5 6 4 - 60 190 115
Fruit low K 1 15 - - 15 100 15
Fruit med K 1 15 - - 15 200 15
Fruit high K 1 15 - - 15 350 15
Veggies low K1 5 2 - 15 100 20
Veg med K 1 5 2 - 15 200 20
Veg high K 1 5 2 - 15 350 20
White bread 6 90 12 - 480 210 210
Med fat meat 6 - 42 30 150 450 390
Fat 4 - - 20 200 40 20
Totals 156 64 50 1000 2190 840
Kcals: 30 kcals/kg: 2,070 kcals/day
PRO: 1.2 g/kg/d: 82.8g/day
Phos: 10 mg/kg: 690mg/day
K: 2.4g/day
Na: 2.4g/day
Diet example:

5. Breakfast: 1 banana, 1 poached egg (500mg K, 100mg phos, 6g Pro, 182kcals)
Lunch: 1 med breaded catfish, ½ c Brussel sprouts, ½ c apple sauce, ½ c low-fat milk
(153mg K, 250mg Phos, apple sauce 150mg K)
Snack: 1 med peach (500mg K)
Dinner: Pork roast (224mg phos), ½ c split peas (97 mg phos), ½ c tomato juice (500mg
K), ½ c potatoes (500mg K)
K: 2,303mg Phos: 671mg PRO: 85.05g
Assessment:
Hypertension: cause of CKD
Shops/cooks for self: possible lack of knowledge
Divorced/unemployed: possible life stressors
Kcals: 30 kcals/kg: 2,070 kcals/day
PRO: 1.2 g/kg/d: 82.8g/day
Fluids: 1000 ml/day
Dietary recall:
Needs healthier dietary pattern. Overeating in areas. Needs to adhere to recommendations for
CKD
Diagnosis:
Intake: excessive phosphorus intake related to diagnosis of chronic kidney disease as
evidenced by dietary recall.
Clinical: Altered nutrition-related lab values- such as potassium related to CKD as
evidenced by high potassium food choices in dietary recall.
Behavioral: undesirable food choices related to diagnosis of chronic kidney disease as
evidenced by diet recall.
Intervention:
Intake: Assess knowledge of patient on proper intake goals.
Assess readiness to learn and implement learning tools for intake goals
Reduce phosphorus intake to 690mg/day
Clinical: Assess patients current knowledge of proper intake
Assess readiness to learn and implement learning tools for proper intake goals
Reduce potassium intake to 2.4 g/day
Behavioral: Assess patients current knowledge of proper diet for CKD
Assess readiness to learn and implement learning tools on diet change
Reduce potassium intake to 2.4 g/day
Reduce phosphorus intake to 690 mg/day
Replace at least 1 fortified food a day
Create healthy shopping list for each week
Monitor/Evaluate:
Intake: Keep dietary log

6. Suggest blood test for phosphorus
Clinical: Keep dietary log
Suggest blood test for potassium
Behavioral: Keep dietary log
Suggest blood test
Affirm adherence to healthy shopping list
Secondary hyperparathyroidism is an excess secretion of PTH due to hypocalcemia and
hyperplasia of the parathyroid gland. SW suffers from hypocalcemia. The patient may suffer
renal osteodystrophy, heart valve calcification, altered cardiovascular functions, immune
dysfunctions, and anemia. Medications such as sensipar can be prescribed. It is a phosphorus
binder. Vitamin D may also be administered during dialysis. The patient will want to limit
phosphorus consumption in their diet in combination with the medical treatments.
http://www.jabfm.org/content/22/5/574.full
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.

7. Suggest blood test for phosphorus
Clinical: Keep dietary log
Suggest blood test for potassium
Behavioral: Keep dietary log
Suggest blood test
Affirm adherence to healthy shopping list
Secondary hyperparathyroidism is an excess secretion of PTH due to hypocalcemia and
hyperplasia of the parathyroid gland. SW suffers from hypocalcemia. The patient may suffer
renal osteodystrophy, heart valve calcification, altered cardiovascular functions, immune
dysfunctions, and anemia. Medications such as sensipar can be prescribed. It is a phosphorus
binder. Vitamin D may also be administered during dialysis. The patient will want to limit
phosphorus consumption in their diet in combination with the medical treatments.
http://www.jabfm.org/content/22/5/574.full
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.