This case study describes 86-year-old John Doe who has several medical conditions including hypertension, COPD, CKD stage 3, and dementia. A nutrition assessment found he has a BMI of 22.7 kg/m2 and has lost 3 pounds recently. Lab results show low albumin and protein levels indicative of inadequate protein and calorie intake related to his diseases. The nutrition diagnosis identifies this inadequate intake and altered lab values related to his CKD. The nutrition intervention increases his calorie and protein goals and recommends a renal diet with supplements. Monitoring will evaluate his compliance through repeated labs and food journals over time.

1. CASE STUDY 3
Lindsay Johnson
Michelle Ten
Tara Sarvghad Tousi
Athena Bechere
Kirandeep Samra

2. Photo: Google Drive
Meet John Doe, 86 y/o Male
Dx: HTN, COPD, unspecified psychosis, CKD Stage 3, Dementia
Photo Google drive, 6-3-2016

3. HTN Pathophysiology, Etiology1
74 million Americans have HTN and 26 million CKD
Two main causes HTN & CKD in U.S. are:
● Primary HTN (unknown cause); Diabetes
● Secondary HTN (underlying disease); High blood pressure
● Age, ethnicity, gene expression (both diseases)
Kidneys control BP:
● Renin
● Activates RAS
Labs indicative HTN organ disease:
● Cr >1.5 mg/dL (2.1 mg/dL)
● Proteinuria 1+ (urine albumin)
● Albumin <3.5 g/dL (3.3 g/dL)
Photo kidneysmart.org, 6-3-2016

4. CKD Stage 3 Pathophysiology & Comorbidity2,3
● Decreased GFR = excretion waste products, fluid & electrolyte balance,
synth. hormones (macrocytic anemia)
● Symptoms = malaise, weakness, N/V, muscle cramps/itching, metallic taste,
neurologic impairment (psychosis)
http://www.thevisualmd.com/center/?idg=8313&t=9314
Photo Kidneysmart.org, 6-3-
2016

5. COPD Pathophysiology,
Comorbidity4,3
Systemic inflammation r/t CVD, CKD?
● Prevalence COPD was related to kidney function
● COPD was present in 47% patients eGFR <60
● Strongest in Pts with moderate CKD
● long-term mortality in patients with CKD
http://www.thevisualmd.com/read_videoguide/?idu=1083618873&q=COPD%20video
Photo Encyclopedia Rocks, 6-3-2016

6. Nutrition Assessment
➔ Age - 86 years old
➔ Sex - Male
➔ Height - 67” (5’7”/170cm/1m70cm)
➔ Weight - 145# (65.9kg) → [There is a weight loss from 148.8# to 145#]
➔ IBW - 148#
➔ %IBW - 98%
➔ BMI - 22.7kg/m2 (within normal levels)
➔ Medical Hx: Dementia, unsp Psychosis, HTN, COPD, CKD stage 3
➔ Usual intake: feeds himself and appetite is good, consumes 100% of his breakfast,
100% of his lunch, and 75% of his dinner.
➔ Diet order: Renal, recommended Suplena TID (8 oz, 3x/day)
Photo Specialneeds, 6-30-2016

7. Nutrition Assessment
→ EER + 125% = 4440 - 5180 kcals/day
→ Est Pro needs (0.8 - 1.2 g/CBW) = 53-79 g/kg
→ Est Fluid needs = 1648 cc/day (25 mL/day)
(Six 8 oz. c H20/day, unless urine output normal, customized by Pt reported urine vol.,
handout given “How to Limit Fluid Intake”)
→ Laboratory Values: FPG: 78 mg/dL (N), creatinine: 2.1 mg/dL (H), albumin: 3.3
g/dL (L), BUN: 42 mg/dL (H), total PRO: 5.3 g/dL (L) RBC: 4.32 uL (L), MCV: 97.7
fL (H) eGFR: 30 mL/min
Photo Medifitbiologicals, 6-3-2016

8. Nutrition Diagnosis5
1. Inadequate protein-energy intake related to current disease state, as
evidence by wt loss from 148.8# in April to current wt of 145#, pt is 98%
IBW, low serum albumin 3.3 g/dL, and low total protein 5.3 g/dL.
2. Altered nutrition-related laboratory values related to CKD stage 3 as
evidenced by ↑MCV, ↓RBC, and ↓eGFR.
Photo Bradleydibble, 6-20-2016

9. Nutrition Intervention6
Nutrition Prescription:
● ↑ 1977- 2307 kcal/day
● ↑ PRO 1.2 g/kg (HBV)
● ↑ Folate, B12 (Suplena 8oz TID)
● Rx Renal MV, folate and B12, 25(OH)D, EPO (Macrocytic Anemia)
Photo NKDEP, 7-1-2016

10. Nutrition Intervention6
Nutrition Education (Content):
Nutrition relationship to disease:
● Educate Pt importance ↑ protein and total energy in diet (CKD/COPD)
● Teach Pt 50% HBV protein
● Utilize Health Belief Model prevent ↓eGFR, Pt lifestyle/diet changes
● Educate Pt on potential food-drug interaction through handout
Recommend modifications:
● Customize meal plan using exchanges, portion sizes to meet kcal and PRO goals
● Sodium and fluid intake customized according to Pt urine output, symptoms, lab values
● 3 day food journals
Photo NKDEP, 7-1-2016

11. Nutrition Education Handout 7

12. Nutrition Intervention6
Nutrition Education (Application):
Short term goals:
● For 2 weeks, Pt ↑ protein sources low in P (beans, fish and poultry).
● Pt eliminates salt when cooking (~2g Na/day goal)
● Pt drinks six 8oz c water/day
● ↑ folate and B12 by ingesting Suplena 8oz TID
Long term goals:
● Pt will demonstrate understanding of portion sizes, HBV PRO, ↑B12/folate through supp, ↓
sodium/fluid.
● Pt will be referred to exercise physiologist/Senior classes preserve LBM.
Photo NKDEP,7-1-2016

13. Monitoring & Evaluation
Monitor lab values to
determine if Pt complies
with nutrition Rx 1 week
prior to appointment
➔ Albumin
➔ BUN
➔ Creatinine with eGFR
➔ Chloride
➔ MCV
➔ Potassium
➔ RBC
➔ PRO, total
➔ Sodium
Photo MNT 2Yourhealth, 6-30-201616

14. Monitoring & Evaluation
➔ Follow up with RD within 2 weeks
➔ Monitor weight, LBM, BMI
➔ Evaluate fluid status
◆ Pt urine output
◆ Presence of edema
Photo Healthylifestyleart, 6-30-2016
Photo Wardoundstuff, 6-3-2016
Photo Loveyourkidneys, 6-3-2016

15. Monitoring & Evaluation
➔ Evaluate Pt food intake, 3-day food journals
◆ Monitor Pt appetite, modify diet as needed
➔ Assess Pt functional status via anthropometric
measurements bi-weekly
◆ Follow-up on recommended exercise
● 30 min/day, 5 x/week
➔ Refer followup mental status examination
Photo ddce.utexas.edu,, 6-30-2016
Photo Freshfoodperspectives, 6-30-2016
Photo Entwellbeing.au., 6-30-2016

16. References
1. Escott-Stump, Sylvia, and Janice L. Raymond. "Medical Nutrition Therapy for CVD." Krause's Food and the Nutrition Care Process. By
Kathleen L. Mahan. 13th ed. Saint Louis: Elsevier Sanders, 2012. 758-61. Print.
2. Escott-Stump, Sylvia, and Janice L. Raymond. "Medical Nutrition Therapy for Renal Disorders." Krause's Food and the Nutrition Care
Process. By Kathleen L. Mahan. 13th ed. Saint Louis: Elsevier Sanders, 2012. 814. Print.
3. "Chronic Kidney Disease Health Center." Chronic Kidney Disease Health Center. Ed. The Anatomical Travelogue LLC. The Visual MD,
2014. Web. 01 July 2016.
4. Y. R. B. M. Van Gestel, M. Chonchol, S. E. Hoeks, G. M. J. M. Welten, H. Stam, F. W. Mertens, R. T. Van Domburg, and D. Poldermans.
"Association between Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease in Vascular Surgery Patients." Nephrology
Dialysis Transplantation 24.9 (2009): 2763-767. Web. 30 June 2016.
5. Association, American Dietetic. "Reference Manual." International Dietetics & Nutritional Terminology. American Dietetic Association,
2011. Web. 2 July 2016. <http:///www.nutritioncaremanual.org>.
6. National Kidney Disease Education Program (NKDEP, Nkdep. "CKD and Diet | Assessment, Management, and Treatment." CKD and
Diet: Assessment Management and Treatment (n.d.): n. pag. National Kidney Disease Education Program (NKDEP. NIH, Apr. 2015.
Web.
7. "Drug Interactions Checker Drugs, Food & Alcohol." Drugs.com. Ed. Micromedex® Kluwer™. Cerner Multum™, 30 May 2016. Web. 01
July 2016.

17. Q&A?
Thank You!