This document provides a case study on a 41-year-old male patient with chronic kidney disease who is undergoing hemodialysis 3 times per week. It includes his medical history, social history, physical assessment, laboratory results, current diet, medication regimen, and recommendations for improving his diet. A registered dietitian provides an analysis of his current intake compared to goals, recommends an appropriate dietary pattern to meet his needs, and includes an ADIME note with interventions and monitoring plans.

1. Marissa Uhlhorn
Chronic Kidney Disease Case Study
FSHN 450
Due Date: 11/13/15
I have not given or received any unauthorized assistance on this assignment
_________________________________________________

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
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

3. 1. In table format, evaluate the patient’s laboratory data compared to goals for dialysis
patients.
Lab Value Patient Value Normal Value 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
CO2 15 mEq/L 22-29 mmol/L Renal failure
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 No deviation
Albumin 3.2 g/dl 4.0 g/dl or greater 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 70 fl 78-93 micro
m^3/RBC
Possible anemia
WBC 8.7 x 10^7/L 3200-10600/ microL Tissue
injury/infection?
Urine Protein 320 mg/24 hr <144 mg/24 hr Kidney disease
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.
Lasix
Purpose: To treat edema associated with CHF, renal or hepatic disease
Nutrient interaction: increase K/Mg, decrease cal, decrease Na may be recommended. Avoid
natural licorice
Lisinopril
Purpose: CHF treatment, to treat left ventricular dysfunction/CHF post MI, acture MI adjunct, to
treat diabetic nephropathy
Nutrient interaction: insure adequate fluid intake/hydration. Decrease Na/cal may be
recommended, avoid salt subs. Caution K/Mg supplements
Renvela:
Purpose: Phosphate binder
Nutrient Interaction: Low phosphate diet
Zemplar:

4. Purpose: To treat Rickets or Osteomalacia-add Ca supplement
Nutrient Interaction: increase calcium absorption, anorexia, decrease wt, increase thirst.
EPO:
Purpose: Recombinant Human Erythropoietin, antianemic
Nutrient Interaction: May need Fe/Vit B12/or Fol supplement. ESRD-Diet compliance mandatory
3. Assess the patients Kcal, protein needs and Phos, K and Na intake recommendations.
Kcal Recommendations: (23-35kcal/kg/day)
28kcal * 69kg= 1,932kcal/kg/day
Protein Recommendations: (1.2g/kg/day)
1.2g * 69kg= 82.8g/kg/day
Phosphorous Recommendations: (12 mg P/kg/day)
12mg P * 69kg= 828mg P/kg/day
Potassium Recommendations: (2.4g/day)
Sodium Recommendations: (2.4 g/day)
4. Evaluate patient’s current dietary intake including the following points:
How does SW’s current intake compare these recommendations?
This patient's diet is very low in protein. He may be consuming a small amount of protein both in
his cheese and milk, but his intake is definitely not adequate, nor does it meet the requirements
calculated above.
Phosphorus estimations: Milk (~250mg*2= 500mg) +butter (3mg) + bread (27*2=54mg) +
cookies (~50mg) + ice cream (67 *2= 134mg) + banana (15mg) + orange (15mg) + watermelon
(15mg)+ corn flakes (50mg)
TOTAL: ~836mg
GOAL: 828 mg/day
His intake of phosphorus is almost exactly in line with his recommendations for daily intake.
Potassium estimations: banana (350 mg) + bread (70mg) + butter (10mg) + milk (760 mg) +
orange (350 mg) + watermelon (100mg)
TOTAL: ~1640 mg
GOAL: 2400 mg/day
His intake of potassium is slightly low
Sodium estimations: corn flakes (240mg) + milk (200 mg) + cheese (400 mg) + bread (360 mg) +
butter (3 mg) + oreos (280 mg) + ice cream (220 mg)
TOTAL: ~1703 mg

5. GOAL: 2400 mg/day
This total is okay- as he should not be consuming higher than 2400mg/day and presents with
hypertension. I would possibly even suggest lowering his intake to 1500 mg/day due to his
hypertension.
Kcal: I would estimate his kcal to be around ~2000kcal. This is close to his 1932 kcal goal.
Protein: I would estimate his protein intake to be around ~50g. This is about 38 grams off of
what he should be consuming.
I would suggest increasing his protein consumption, vegetables (which he does not have recorded
at all on this record), increase whole grains, and decrease processed/high fat foods.
5. AS demonstrated in lab on 10/29, calculate a dietary pattern, which would meet
recommendations for this patient.
Exchange Servin
g
CHO PRO FAT Na K P
Milk low fat 1 12 8 - 120 380 230
Fruit
Low K 2 30 - - 30 200 30
Med K 2 30 - - 30 400 30
High K 1 15 - - 15 350 15
Vegetable
Low K 2 10 4 - 30 200 40
Med K 2 10 4 - 30 400 40
Hi K 1 5 2 - 15 350 20
Bread 6 90 12 - 480 210 210
Meat (med
fat)
8 - 56 40 200 600 519
Fat (reg) 4 - - 20 220 40 20
Totals 202 86 60 2145 3120 1154
202*4= 808kcal CHO
86*4= 344kcal PRO
60*9=540kcal FAT
= 1692kcal
1932kcal-1692kcal=240kcal= 60g sugar
Meat and Milk= 64g/86g=74.4% (70-75%)
Fat 540kcal/1932kcal= 28% (30%)
6. Translate this pattern into a sample one-day diet (including specific foods). You may use

6. the tools for estimating potassium and phosphorous content, which are posted on Canvas.
Breakfast:
Milk low fat (1 serving)
½ c. applesauce
½ c. cantaloupe
2 slices of bread
2 Tbs butter
2 servings of meat
Lunch:
½ c. cucumbers
1 pepper
½ c. spinach
3 servings of meat
1 Tbs salad dressing (olive oil)
1 c. brown rice
1 orange
Snack:
2 plums
Dinner:
3 servings of meat
1 c. pasta
½ c. grapefruit
½ c. corn
½ c. broccoli
1 Tbs butter
7. 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:
Physical/Anthropometrics
• 41 y/o male
• 5'9”
• 69kg (BMI: 22.4- normal)
Medical
• Chronic Kidney Disease
• Hypertension

7. Social
• Divorced, lives alone
• Unemployed (due to medical issues- CKD)
• Shops and cooks for himself
• Works out 2-3x/week (strength and walking)
Diet
• Low protein consumption
• No record of vegetable intake
• High amount of sat fat/kcal from processed foods (cookies, cheese, white bread, ice
cream)
Diagnosis:
Intake- Imbalance of nutrients R/T diagnosis of Chronic Kidney Disease AEB low albumin levels,
high BUN and diet recall (low protein, low vegetable intake).
Intervention:
• Assess the patient's stage and readiness of change
• Educate patient about a balanced diet
• Have client come up with meals/snacks he enjoys (encourage a food journal/diet record)
• Educate patient of his protein needs and have him come up with ideas to incorporate more
in his day
• Educate patient of the importance of vegetables and have him come up with ideas to
incorporate in his day
Monitoring/Evaluation:
• Monitor patient's albumin, BUN, and urine protein levels
• Analyze patient's diet record
• Assess patient's protein intake and if he is incorporating this well
• Assess patient's vegetable intake and if he is incorporating a variety in his day
Clinical-Impaired nutrient utilization R/T altered lab values (Potassium, chloride, CO2,
phosphorous, BUN, and urine protein) AEB diagnosis of Chronic Kidney Disease and lab results
Intervention:
• Educate patient about the appropriate food choices for dialysis (esp. potassium, sodium,
and phosphorous)
• Have patient come up with (low, med, high) potassium containing fruits/veg he enjoys to
incorporate daily
• Identify with patient which foods he regularly consumes that contain phosphorus and how
to alter
• Encourage client to consume more whole foods and less processed (high sat fat) foods
Monitoring/Evaluation:

8. • Monitor and assess patient's lab values of concern (potassium, chloride, CO2, phosphorus,
BUN, urine protein)
• Assess how the patient is in compliance with choosing appropriate foods while on dialysis
• Assess patient's protein intake and if vegetables are also being incorporated daily
-Behavioral- Undesirable food choices R/T low consumption of protein, vegetables, and high fat
AEB diet recall and hypertension presentation
Intervention:
• Educate patient how to create a balanced meal (with all food groups)
• Have patient create a meal plan choosing appropriate, healthy foods
• Encourage client to keep a diet record for further analysis
• Educate patient of ways to decrease blood pressure (lower sodium intake, exercise, lower
fat...less processed foods)
Monitoring/Evaluation:
• Assess client's diet record for appropriate nutrient needs being met
• Monitor client's blood pressure
• Assess client's choices in meals and snacks (check to see a decrease in highly processed
foods)
• Make any necessary changes to current meal plans/specific nutrient recommendations
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.
Secondary hyperarathyroism results as an excessive secretion of the parathyroid is produced by
the parathyroid gland. This patient is at risk due to his diagnosis of chronic kidney disease. When
the kidney is unable to clean phosphorous from the blood and unable to make enough vitamin D,
phosphorous builds up and calcium levels are in turn very low. This stimulates the parathyroid
gland to secrete more parathyroid hormone. This condition could cause skeletal pain, fractures,
tendon ruptures, and other severe symptoms.
Treatment: Vitamin D analogues reduce PTH levels, phosphate binders reduce blood
phosphorous levels and calcimimetics increase the ability of cells to recognize high calcium levels
in the bloodstream so less PTH is produced.
Nutritionally: Dietary phosphate restriction, monitor levels of calcium, phosphorus, and vitamin
D, educate patient about the importance of taking phosphate binding agents. Possible protein
supplements (increase intake of protein), assistance in appropriate meal planing for patient if on
dialysis.
Citation:

9. Llach F, Yudd M. Current medical management of secondary hyperthyroidism. Am J Med Sci.
2000; 320(2):100-106. http://www.ncbi.nlm.nih.gov/pubmed/10981484
Note: Could not find the doi. So I used the url instead.
Am J Med Sci. 2000 Aug;320(2):100-6.
Current medical management of secondary hyperparathyroidism.
Yudd M1,Llach F.
Author information
Abstract
The treatment of secondary hyperparathyroidism (HPT) in patients with chronic renal disease has
improved markedly in recent years. The skeletal pain, disabling fractures, tendon ruptures, and
myriad other symptoms associated with HPT can now be avoided, and the quality of life of
patients with end-stage renal disease is improved. Control of hyperphosphatemia, maintenance of
normocalcemia, and appropriate dosing of vitamin D analogues can prevent HPT in many cases.
Palatable, nutritious diets should be followed; serum calcium, phosphorus, alkaline phosphatase,
and parathyroid hormone should be monitored; and treatment regimens should be adjusted
accordingly. If prevention fails, and even if severe HPT develops, many of these patients can still
be controlled medically with correction of hyperphosphatemia and high doses of intravenous
calcitriol. In our experience, only a few patients require surgical parathyroidectomy (usually
noncompliant patients or patients whose HPT has been poorly managed from early uremia). The
essence to medical management is to correct the two most important pathogenetic factors of
HPT, hyperphosphatemia, and calcitriol deficiency. We present the current approach to the
management of HPT, with highlights of recent advances.

10. Llach F, Yudd M. Current medical management of secondary hyperthyroidism. Am J Med Sci.
2000; 320(2):100-106. http://www.ncbi.nlm.nih.gov/pubmed/10981484
Note: Could not find the doi. So I used the url instead.
Am J Med Sci. 2000 Aug;320(2):100-6.
Current medical management of secondary hyperparathyroidism.
Yudd M1,Llach F.
Author information
Abstract
The treatment of secondary hyperparathyroidism (HPT) in patients with chronic renal disease has
improved markedly in recent years. The skeletal pain, disabling fractures, tendon ruptures, and
myriad other symptoms associated with HPT can now be avoided, and the quality of life of
patients with end-stage renal disease is improved. Control of hyperphosphatemia, maintenance of
normocalcemia, and appropriate dosing of vitamin D analogues can prevent HPT in many cases.
Palatable, nutritious diets should be followed; serum calcium, phosphorus, alkaline phosphatase,
and parathyroid hormone should be monitored; and treatment regimens should be adjusted
accordingly. If prevention fails, and even if severe HPT develops, many of these patients can still
be controlled medically with correction of hyperphosphatemia and high doses of intravenous
calcitriol. In our experience, only a few patients require surgical parathyroidectomy (usually
noncompliant patients or patients whose HPT has been poorly managed from early uremia). The
essence to medical management is to correct the two most important pathogenetic factors of
HPT, hyperphosphatemia, and calcitriol deficiency. We present the current approach to the
management of HPT, with highlights of recent advances.