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Case Study #3

Objective: To provide evidence-based Medical Nutrition Therapy for a 62 y/o man initially
diagnosed with hypertension.
Primary Resources to be used: (you will need to use other resources from the Resource List
provided in Appendix B of the Course Syllabus.) Please list the resources that you used (using
abbreviations below) at the end of your answers to the questions that are shown in red.)
Academy of Nutrition and Dietetics Evidence Analysis Library (EAL) at
http://andevidencelibrary.com/default.cfm?auth=1
Academy of Nutrition and Dietetics Nutrition Care Manual (NCM) at
http://nutritioncaremanual.org/auth.cfm?p=%2Findex%2Ecfm%3F&err=NotLoggedIn
Cochrane Library of Systematic Reviews (CLSR)
http://www.thecochranelibrary.com/view/0/index.html#http://www.thecochranelibrary.com/view/0/browse.html

(Left sidebar Browse by Topic, click Expand, select Kidney Disease)


USE ONLY FOR HD SECTION: KDOQI Quidelines (KDOQI)
https://www.kidney.org/sites/default/files/docs/kdoqi2000nutritiongl.pdf
Kidney Disease: Improving Global Outcomes (KDIGO)
http://kdigo.org/home/guidelines/

Instructions: Answer the following case study questions and also complete the initial
assessment note and follow-up progress note.
Mr. Smith is a 62 y/o AA employed as a plant manager in the automobile industry in Cleveland,
OH. He enjoys his job, but it is highly stressful because of the pressure to produce as many cars
as possible in a short period of time. Mr. Smith is a worrier. He has been losing sleep over the
slow economy and the effect it may have on his job. He is married and has children, one in
college and two in high school. His wife works as a cashier in a food store and sometimes has to
work evenings. This has increased Mr. Smiths stress since he does not know how to cook and
the children always complain when he tries.
He has a history of HTN but has not been checking his BP as he should. He had a routine
physical recently and his BP was 175/100. This added to his concern because if it does not go
down, he fears the plant physician will force him to take sick leave.

His medications included:


- Captopril 50 mg BID
- Furosemide (Lasix) 30 mg qod or PRN for pedal edema
He has been on antihypertensive medication for five years but the strength of the medication has
been increasing for the last two years because of the gradual increase in his BP. Mr. Smith
frequently does not take his medication because he feels fine and believes he is too young to
have high BP, even though his father died from a stroke at 57. An uncle on his fathers side has
renal failure secondary to untreated HTN.
Mr. Smith is 510 (177.8 cm) and weighs 225 lbs (102.3 kg), has a medium frame, and is
moderately active. He has always been on the heavy side but his weight has increased by 20 lbs
(9.1 kg) in the past year. At his last physical, the MD found more pedal edema than usual. Mr.
Smith admitted to non-adherence in respect to his medication. The MD instructed him on the
importance of taking medication, talked to him about the effects of worrying, and told him to see
the plant dietitian. It was the RDs job to complete a nutritional assessment and determine his
energy and protein needs. She also has an order from the MD to instruct him on a 2 g Na diet
with appropriate kcals and protein based on her assessment.
1. Calculate Mr. Smiths BMI, UBW, and %UBW. (2 points)
BMI = kg/ m2
BMI = 102.3 kg / (1.782)
BMI = 32 (obese category)
UBW = 102.3 9.1 kg gained in past year
UBW = 93.2 kg
%UBW = 93.2 kg 102.3 kg/ 93.2 kg (100)
% UBW = 9.8%

2. Determine his protein needs. (2 points) (EAL, NCM)


With a blood pressure of 175/100, Mr. Smith has hypertension stage 2. For this medical
diagnosis, he should be following diet guidelines such as the DASH diet (dietary approaches
to stopping hypertension). The EAL states that, the effect of increased protein intake on
blood pressure is unclear, thus additional protein to a general healthy amount in the DASH
diet is not recommended. The NCM manual notes that this dietary protein should come from
other sources than just red meat. The DASH diet recommends that 18% of total calories
should come from protein daily.
Since Mr. Smith does not have an elevated need for protein in terms of an injury or wound
factor, the general healthful recommendation of 0.8g/kg/d can be used.
To calculate protein needs, first I am going to calculate Mr. Smiths desirable body weight
via the Hamwi formula.
Hamwi for men = 106lb for first 5 ft + 6 lb for each additional inch
2

DBW = 106# +10(6#) = 166# = 75.5 kg


ABW = (actual weight DBW).25 + DBW
ABW = (102.3kg 75.5kg).25 + 75.5kg = 82.2kg
Usual protein needs = 0.8g (82.2kg) = 65.76 ~ 66g pro/d
(66 g pro x 4kcal/g pro = 264 kcal) 264 kcal protein /2200 kcal/d this number is taken from
below = 12% protein
To reach closer to DASHs 18% protein, I am going to suggest a range of 70 80 g pro/d
(70 g pro x 4kcal/g pro = 280 kcal) per 2200 kcal/d = 13%
(80 g pro x 4kcal/g pro = 320 kcal) per 2200 kcal/d = 15%

3a. Calculate Mr. Smiths estimated energy needs. Indicate which equation you used to
estimate his needs and why. Show your work. (2 points) (EAL, NCM)
The EAL suggests using Mifflin St. Jeor estimated energy needs equation for overweight/obese
patients. For men, the Mifflin St. Jeor equation is:
10(kg) + 6.25(cm) 5(age) +5
10(102.3kg) + 6.25(177.8cm) 5(62) + 5 = 1829.25 ~ 1800 kcal/d
Because 1800 kcal/d is the pts RMR, an activity factor needs to be considered for total energy
requirement. I am choosing an activity factor of 1.6 because Mr. Smith is moderately active. An
injury factor does not need to be added at this time.
1800(1.6) = 2880 kcal/d ~2900 kcal/d
However, because Mr. Smith is obese, he should maintain a caloric deficit to lose weight. To
reach a caloric deficit, he should consume 70% of his energy needs in order to lose ~1#/week.
This equates to reducing energy intake by 500 kcal/week. To lose closer to 2#/week, Mr. Smith
would have to reduce kcal/d by 1000kcal. Losing 1-2#/week is considered a realistic, achievable,
and sustainable weight loss goal, according to Adult Weight Management Guidelines. Thus, Mr.
Smiths estimated energy needs are more around 1900 2400 kcal/d. Since this is a relatively
wide range, I would suggest starting at 2200-2400 kcal/d for a more realistic approach to weight
loss.
b. How many kcal/kg does this translate into? (2 points)
This translates into 22-23 kcal/kg.
2200 kcal/102.3 kg = 21.5
2400 kcal/102.3 kg = 23.4

4. What are the functions of Captopril and Lasix? (2 points) (National Library of Medicine)
Lasix, otherwise known as Furosemide, is classified as a loop diuretics. Lasix is prescribed to
patients to help treat edema. Lasix treats edema by stimulating the kidneys to produce more
urine. This drug can also be taken to treat hypertension. Captopril is another drug that treats
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hypertension. Captopril additionally treats heart failure, kidney problems caused by diabetes,
and is given to reduce the risk of death after a heart attack. Captopril is classified as an ACE
inhibitor. Its mechanism to treat hypertension blocks production of angiotensin II which
narrows blood vessels thus helping to keep blood vessels relaxed. This action lowers blood
pressure.

5. List any nutritional complications of Captopril and Lasix. (3 points) (National Library of
Medicine)
Lasix may cause hypokalemia and changes in blood sugar. It also may cause dry mouth,
increased thirst, nausea, vomiting, stomach pain, diarrhea, and loss of appetite. Captopril may
cause nausea, vomiting, loss of appetite, stomach pain, and sore throat. When beginning to
use either Lasix or Captropril, or if the pt is dehydrated, the medication may lower blood
pressure too much causing dizziness.

6. The physician ordered a 2 g sodium diet. What diet would you recommend? List the
principles of nutrition therapy for hypertension. (4 points) (EAL, NCM)
Because Mr. Smith has very high blood pressure at 175/100 (HTN stage 2), I would
recommend the DASH diet. 2 g Na diet may lower systolic blood pressure by approximately
2-8 mmHg but Mr. Smith needs to drastically lower his blood pressure by more than 2-8
mmHg. Therefore, I would recommend the DASH diet. The DASH diet also has guidelines
on more healthful eating overall in addition to a sodium restriction. For DASH, Mr. Smith
should not consume more than 1600 mg Na/d in order to lower his blood pressure. See the
table below for additional DASH diet recommendations
Foods
Grains
Fruits
Vegetables
Low-fat/
nonfat
dairy
Lean meat,
fish,
poultry
Nuts,
seeds,
legumes
Fats and
sweets

Servings or 2000 kcal diet


7-8 daily
4-5 daily
4-5 daily
2-3 daily

Servings for Mr. Smiths 2200-2400 kcal diet


8-9 daily
5-6 daily
5-6 daily
3-4 daily

2 or fewer daily

3 or fewer daily

4-5 weekly

5-6 weekly

Limited

Limited

This comes out to be about 27% of total kcal from total fat, 6% from saturated fat, 18% from
protein, 55% from carb, 150 mg cholesterol, 4700 mg potassium, 1250 mg calcium, 500 mg
magnesium, and 30 g fiber.

According to the NCM, the 7th Report of the Joint National Treatment of High Blood
Pressure also recommends certain lifestyle changes to manage hypertension such as
maintaining a normal BMI, engaging in aerobic physical activity ~30min/ most days of the
week, and limiting alcohol consumption to no more than two drinks per day (24 oz of beer,
10 oz of wine, or 3 oz of 80-proof whiskey).
To meet the DASH recommendations, Mr. Smith should not add salt to his foods. He should
also buy low sodium products, when available, such as low sodium soup broths, low sodium
cheese, low sodium canned beans, etc. He should be wary of anything boxed, bagged, or
cannedhe should try to avoid processed foods as much as possible. He should not purchase
or eat anything that has more than 300 mg Na per serving. He also should avoid high sodium
meats such as cured, smoked, and processed meats and lunch/deli meats. I would also tell
him not to rely on frozen or prepackaged dinners; pasta sauce; condiments such as BBQ
sauce, mustard, ketchup, and soy sauce; and, vegetables in brine such as pickles and
sauerkraut. If he does rely on many canned products such as beans and vegetables, I would
tell him to thoroughly rinse the content of the can in cold water before using in cooking. I
would also caution Mr. Smith on eating out, especially at fast food restaurants.

Date: 1/3/11
Mr. Smith had an initial appointment with the RD. She obtained a 24-hour recall as follows:
B:
AM Snack:
L:
PM Snack:
D:

HS Snack:

2 C coffee, 2 sausage biscuits


1 C Coffee
1 Sandwich (lunchmeat or bologna, cheese, mustard, mayo), 1 apple,
cookies, 1 piece of cake
1 soda
Some kind of meat (e.g meatloaf, chicken), French fries, vegetables
(mostly fried) with added seasoning, bread, occasional salad, pie or cake,
sweetened Kool-Aid
Potato chips, peanuts or cheese and crackers and a beer or two before bed

Mr. Smith states he does not care for fruit and that he is allergic to milk. When he drinks milk,
he gets a lot of cramps and gas. He does not eat yogurt, but likes cheese and it does not bother
him.

7.

What are the overall goals of nutritional therapy for Mr. Smith? (2 points) (EAL,
NCM)
According to the EAL, the main goal of nutrition therapy for hypertension (as in Mr. Smiths
case) is to reduce blood pressure to less than 140/90 mmHg. This value is associated with
preventing target organ damage and decreasing cardiovascular risk factors. The NCM wants
to achieve this goal by the pt achieving and maintain a healthy weight, reducing blood
pressure, and reducing the risk of DM, kidney disease, and CVD. The goals of MNT for
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hypertension include limiting alcohol intake; following the DASH diet; limiting consumption
of foods high in saturated fat, cholesterol, total fat, and sodium; increasing consumption of
vegetables, fruits, low-fat dairy foods, and whole grains; drinking more water; making wise
food choices when eating out; familiarizing oneself with the food label, especially with
sodium and fat content; substituting salt and high salt containing condiments with alternative
herbs and spices; achieving and maintain a healthy weight; and, beginning or continuing an
exercise program.
8. Estimate Mr. Smiths sodium intake. Indicate the specific resource you used to estimate his
sodium intake. Is his sodium intake high, low or appropriate? (2 points) (USDA)
To estimate sodium intake, I relied on the USDA nutrient list for sodium. Based on his 24
hour recall, he consumed over 6000 mg of Na in one day. This intake is extremely high.
Normal healthy Americans should consume 2-3 g of Na. However, because Mr. Smith has
hypertension, he should only be consuming around 1600 mg of Na.

9. Describe edema. Explain the relationship between BP and pedal edema. (2 points)
(American Family Physician)
Edema is fluid retention and swelling. Pedal edema is swelling of the feet and ankles. High
blood pressure may cause pedal edema by restricting adequate blood flow from the legs back
to the heart. Furthermore, kidneys regulate body fluid by adjusting sodium and water
excretion; changes in blood pressure affect the secretion of antidiuretic hormone, the primary
actor on adjusting body water, thus the kidneys are not able to properly regulate the fluid.
10. Should the RD be concerned about Mr. Smiths calcium intake? Explain. (2 points)
(EAL)
The DASH diet is high in calcium along with potassium, magnesium, and fiber. This is
proposed as a therapy to reduce blood pressure. However, according to the EAL, the effect
of calcium as a single nutrient on blood pressure in healthy or hypertensive adults is unclear.
While epidemiological studies have shown that diets containing calcium lower than the DRI
may be associated with elevated blood pressure, diets containing calcium above the DRI has
a minimal effect on blood pressure. The DRI for calcium for men between the ages of 51-70
is 1000mg/d. The UL for men in this age group is 2000 mg/d. Therefore, the DASH
recommendation listed above of 1250 mg Ca/d is a good recommended intake for Mr. Smith.
The RD should be concerned about Mr. Smiths calcium intake if he is not consuming more
than 1000 mg Ca/d, keeping the data from the epidemiologic studies in mind that the EAL
noted. Mr. Smith should also be consuming adequate amounts of potassium, fiber, and
magnesium, for the potential synergistic effects on blood pressure.
11. Considering Mr. Smiths medication (Captopril 50 mg BID, Lasix 30 mg PRN for pedal
edema), diets, and recall, outline the teaching program you would use for him. What
behavioral changes would you recommend? What foods would you recommend Mr.
Smith consume or avoid? Why would you make these recommendations? (4 points)
(NCM, EAL)

Behavioral change 1: First, for behavioral changes, I would urge Mr. Smith to think about a
way he can help himself reduce his stress level. Perhaps he can try meditation or make time
for a hobby.
Why: Not managing stress may lead to emotional eating, furthering increasing his blood
pressure. Reducing stress may also help him sleep better at night.
Behavioral change 2: I would encourage Mr. Smith to start exercising.
Why: Not only can exercise be an outlet for stress, but aerobic physical activity for at least 30
minutes/d on most days of the week can reduce systolic blood pressure by 4-9 mmHg,
according to EAL.
Behavioral Change 3: I would tell Mr. Smith that he needs to be proactive in reducing his
sodium intake. He must do this by reading food labels and avoiding salt when cooking and at
the table.
Why: In order to consume less than 2000 mg Na/d, Mr. Smith should not purchase or
consume any product with over 300 mg Na/ serving. When shopping, Mr. Smith needs to be
wary of all bagged, boxed, and canned items. If possible, he should buy only low-sodium
products. Overall, he should start buying less processed foods and snacks. As far as cooking
goes, he should rely on herbs and spices to season his meals and not salt.
Foods to avoid: Mr. Smith should avoid saturated and trans fats. These include fatty meats,
whole milk, butter, cream, products made with whole milk, tropical oils (palm, palm kernel,
and coconut), and hydrogenated fats. Mr. Smith should also avoid foods that are high in
sodium. These include canned vegetables, premade sauces and soups, processed cheese,
pickles, deli meat, and certain condiments (BBQ sauce, ketchup, mustard, soy sauce, etc.).
Additionally, he should only have up to 2 alcoholic drinks per day and avoid frying his food.
Why: High sodium diet will continue to worsen his blood pressure and HTN. He should
avoid saturated and trans fats to prevent hyperlipidemia which will further exacerbate his
cardiovascular problems.
Foods to consume: Mr. Smith should add more fruits and vegetables into his diet as well as
complex carbohydrates. If he doesnt like any fruit, then he should add more vegetables but I
would urge him to try different fruits and in different forms (in cereal, as a smoothie, etc.) to
see if there is something he can tolerate. Complex carbs include whole grain products such as
brown rice, and breads/pastas made from barley, whole wheat, and rye. If he relies on canned
vegetables/beans for convenience, he must wash the contents of the can in cold water before
cooking. He should also only consume low-sodium sauces and soups, low-sodium cheeses,
and low-sodium deli meat. As for healthy fats, he should include unsaturated fats and omega3 fatty acids into his diet. These include soybean, canola, olive, and sunflower oils, soft tub
margarines, and cold-water fish such as salmon and tuna. If he buys canned tuna, it should be
packaged in water. When preparing his meals, he or his wife who cooks should focus on
steaming/sauteeing/baking cooking techniques rather than frying. Since he exhibits stomach
cramps and gas when drinking milk, I would encourage him to try soy milk with add
calcium. He is also welcome to try soy products such as tofu for a source of lean protein.
Other sources of lean protein that he should choose include poultry without the skin, beans
and legumes, unsalted nuts and seeds, and lean beef/turkey/pork. As for fluids, Mr. Smith
should drink more by adding water into his diet. He should obtain a large re-usable water
bottle and have that with him throughout the day to promote water intake.
Why: Mr. Smith needs to limit his sodium intake to under 2000 mg/d. ideally, he should
consume no more than 1600 mg/d to lower his blood pressure and treat his hypertension. He
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also needs to lose weight so including fresh fruits and vegetables, whole grains, and lean
meat provides a healthful eating plan that is nutritionally dense.

At this point in the case study, complete an ADIME


Initial assessment note using your hospitals template.
(20 points)

______________________________________________________________________________

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After talking to the RD, Mr. Smith followed his meal plan for a few months, during which time
he lost approx. 18 lbs. He gradually felt better about himself, but as time passed, he went off his
meal plan. At first, he took his medications as ordered, but then he started to skip them on
occasion. He noticed that he had to go to the bathroom more frequently. He also noted that he
had been waking up during the night with leg cramps, something he had never experienced in the
past. He was not sure why this was happening, but it started after he began taking the new
medication. He believed the medication was causing the leg cramps, even though he did not
know what the relationship was. He observed that if he took Lasix every other day instead of
daily, he did not have as many leg cramps. Gradually, he started taking Lasix less and less
regularly. The pedal edema went away. He knew Lasix helped prevent edema, so he thought he
didnt need to take it any longer. His condition remained stable for several months. When
edema returned, he would take Lasix until it went away and then he would quit taking it. Every
time he had a doctors appointment he would take Lasix and his BP meds several days before the
appointment. He thought this would prevent obvious signs of edema and his BP checks would
be normal. It seemed to work. His BP was borderline or slightly elevated. After the doctors
visit, he would quit taking his meds because he thought he did not need it.
This continued for a couple of years. By the time he turned 66, Mr. Smith started to notice that
when the edema came back and he took Lasix, it would not go away. He did not go to the
bathroom as much. The pedal edema got worse. He was gaining weight, but he really did not
feel like he was eating any more than usual. He went off his meal plan by eating more fatty
foods but continued to watch his sodium intake for almost a year. By then he was completely
back to his old habits. One day he felt very fatigued and decided to go get his BP checked by the
plant nurse. It was 180/105. The nurse made an appointment for him to see his doctor. When
the doctor weighed him, he had gained all of his weight back and then some. He now weighed
235 lbs (106.8kg; 4.5 kg gain). The doctor made him an appointment to see a nephrologist.
The nephrologist examined him and had the following lab work done:
Date: 04/22/2015
WBC
Hgb
Hct
RBC
MCV
MCH
MCHC
Glu
BUN
Cr
Ca
Alb
Na
K
Cl

Result
5.2x103mm3
12.0 g/dl
37%
4.5x106/L
82 m3
26 pg/cell
32 g/dl
80 mg/dl
33 mg/dl
3.5 mg/dl
9.2 mg/dl
3.2 mg/dl
148 mEq/L
5.5 mEq/L
103 mEq/L

(H)
(H)
(L)
(H)
(H)

Reference Range
4.5-10.5x103mm3
12-16 mg/dl
36-48%
3.6-5.0x106/L
82-98 m3
26-34 pg/cell
32-36 g/dl
70-110 mg/dl
6-20 mg/dl
0.6-1.1 mg/dl
8.8-10.0 mg/dl
3.5-4.8 mg/dl
136-145 mEq/L
3.5-5.2 mEq/L
96-106 mEq/L
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P
Uric Acid

5.5 mEq/L
8.6 mg/dl

Urinalysis:
SG
Protein
Glucose
Ketones
pH

1.001
+2
Neg.
Neg.
8.1

(H)
(H)

2.7-4.5 mEq/L
3.4-7.0 mg/dl

1.002-1.030

(H)

4.6-8.0

12. Explain why Mr. Smith had leg cramps and explain what he could do to prevent them. (2
points)
Per his previous 24 hour recall and current lab values, Mr. Smiths leg cramps may be
attributed to dehydration. I am assuming his 24 hour recall reflects a typical day. In his recall
he did not state that he was drinking any water. Beer and caffeinated coffee may lead to
dehydration. The only other fluid he was consuming was kool-aidthis is not enough. Both
his BUN and Cr are high which may indicated dehydration. His Na level is also high. He also
has hyperkalemia which may be because of his limited fluid intake. Additionally, another
indicator that his cramps are caused by dehydration is the fact that he is taking Lasix. This
loop diuretic may lead to fluid and electrolyte imbalance. Thus, to prevent leg cramps, Mr.
Smith should be drinking adequate amounts of water.

13. Explain the pathology of renal disease and HTN. (4 points) (NCM, KDIGO)
According to the NCM, hypertension is a direct risk factor for renal disease. In fact, HTN is
one of the most common cause of renal disease in the United States second to diabetes. This
is because HTN can damage blood vessels in the kidneys. As damage continues to the
kidneys blood vessels, the kidneys will not be able to properly filter waste and fluids. At this
point, HTN may worsen. KDIGO states that, there is a strong association between CKD
and elevated BP whereby each can cause or aggravate the other. Controlling BP is pertinent
at all stages of CKD. HTN and CKD go hand-in-hand because the kidney maintains
extracellular fluid volume and plasma volume by regulating sodium and chloride. When the
kidney cannot function properly, Na retention can occur along with edema.

14. Which lab values and urinalysis results indicate that Mr. Smith has a renal problem?
(2 points)
Labs values and urinalysis results that indicate a renal problem include serum creatinine,
BUN, albumin, electrolytes, urine pH, and urine protein. Mr. Smith has high levels of BUN,
Cr, and urine protein. When the kidneys are not functioning properly, waste and fluid cannot
be excreted as normal. Thus, creatinine, a waste product from muscle activity, rises in the
blood. BUN is another waste product. Thus, it too will be elevated if the kidneys are not
functioning properly. Additionally, electrolytes such as Na and K will be elevated in relation
to a renal problem because of malfunction kidneys since there will be an imbalance of fluid
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and electrolytes. Presence of protein in the urine also indicates a renal problem. Protein
should not leak into the urine. A high urine pH also indicates a kidney issue. It is important to
note that albumin may also be referred to to identify a renal problem. Although albumin is
not a sensitive marker, it reflects nutrition and inflammatory status as kidney function
continues to decline. Albumin, GFR, and kidney function are directly related.

The nephrologist told Mr. Smith has Stage IV kidney disease and that he would have to go on a
very strict meal plan and medication schedule. The nephrologist orders Aldomet (methyldopa),
Hectorol (doxercalciferol), Lasix, and a fluid restriction.
15. Determine Mr. Smiths estimated calorie, protein and fluid requirements considering
his new diagnosis of kidney failure. (2 points) (NCM, EAL)
Current weight 106.8kg, (4.5 kg gain in 4 yr)
Current age 66 y/o
Current BP 180/105
Current BMI33.7 ~34
Stage IV CKD GFR: 15-29 mL/min/1.73m2
According to NCM, body weight may be evaluated using the opinion of the KDOQI
Nutrition Guideline recommendations. This opinion calls for the evaluation of standard body
weight (SBW).
SBW= from NHANES data
%SBW = (current weight/SBW) x 100
If %SBW is <95% or >115%, the NCM suggests calculating an adjusted edema-free body
weight (aBWef) for individuals with kidney disease. However, the KDOQI guidelines
suggest that aBWef should be used for maintenance of weight for patients receiving dialysis.
Since Mr. Smith is not yet receiving dialysis, I will keep aBWef in mind but will currently
not use this value to calculate nutrition needs. (aBWef = BWef + [(SBW BWef) x 0.25])
Instead, since Mr. Smith is obese and his current body weight is >125% of his usual body
weight, I am going to adjust it.
ABW = (actual weight DBW).25 + DBW
ABW = (106.8kg 75.5 kg).25 +75.5 kg
ABW = 83 kg
In a study noted by Steiber in JPENs Chronic Kidney Disease: Considerations for Nutrition
Interventions, it was found that patients with a BMI of 35 had the lowest risk of
cardiovascular mortality. Mr. Smiths BMI is currently 34. Thus, I plan to be extremely
prudent when using ABW to calculated energy needs. Since Mr. Smith has been diagnosed
with Stage IV CKD, he may need a transplant. However, if he is obese, he may not be
eligible for a transplant. Thus, he may need to carefully lose weight. Therefore, I am
suggesting energy needs based on his ABW. I am not going to add an activity factor into his
energy needs though. In another study noted by Steiber, patients with CKD were found to be
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more sedentary than patients without CKD. I am assuming at this point Mr. Smith is not as
active as he had been.
Energy needs
The NCM states that adults with CKD, not on dialysis, should consume 23-35 kcal/kg.
Because I am using his ABW, I am going to use 33-35kcal/kg to ensure prudent weight loss.
83 kg (33 kcal) = 2739 kcal
83 kg (35 kcal) = 2905 kcal
2700-2900 kcal/d
Protein needs
The NCM states that for patients with chronic kidney disease, protein needs can be calculated
using a range of 0.6-0.8 g protein/d/kg. In order to reduce proteinuria, I am going to use the
lower end of the range to calculate his protein needs.
83 kg (0.6 g) = 49.8 g
83 (0.8 g) = 66.4 g
50-60 g protein

Fluid needs
There is a need for a fluid restriction, as mentioned. According to the NCM, fluid restriction
is determined by BP control, edema, alterations in urine output, and medical status.
Currently, Mr. Smith is edematous, has low urine output, and a blood pressure of 180/105.
The Cleveland Clinic suggests that fluid needs should match urine output plus an additional
1-1.5 L/d to account for insensible losses. Therefore, I am going to restrict Mr. Smiths
fluid to 1.5-2 L/d

16. What are the functions of Aldomet (methyldopa) and Hectorol (Doxercalciferol)? Are there
nutritional considerations with either medication? If so, what are they? (3 points)
Aldomet may be taken in a tablet form to treat high blood pressure. This medicine may cause
dizziness, drowsiness, dark urine, pale stools, nausea, vomiting, decrease appetite, stomach
pain and bloating, diarrhea, or constipation.
Hectorol is a form of Vitamin D that lowers high levels of PTH. This usually is prescribed to
CKD patients as they receive dialysis. Calcium supplements or any other type of vitamin D
should not be used without first consulting MD. Antacids containing magnesium should also
not be used. Hectorol may cause metallic taste, dry mouth, loss of appetite and weight loss,
nausea, vomiting, constipation, fatigue, weight gain, and SOB.

The nephrologist had Mr. Smith see the outpatient renal RD before he went home. The RD
asked him who did the cooking. He told her his wife did all the cooking and grocery shopping.
The RD said that she wanted to talk to Mr. Smith and his wife together and made an appointment
for them. Mr. Smith came back with his wife and the RD instructed them on a meal plan and
cooking techniques.
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She also impressed upon them the importance of following a meal plan and medication orders.
Mr. Smith finally realized the importance of the meal plan and was frightened. He remembered
what happened to his uncle who had total kidney failure. He went home declaring that he would
follow his meal plan to the letter. The nephrologist told Mr. Smith that if he stayed on his meal
plan and took his medications, his renal disease may not get any worse and he may not need
dialysis, or he may be able to avoid it for years to come. The nephrologist also told him that if
he did not follow his meal plan and did not take his medications, he would very likely end up
with kidney failure.
______________________________________________________________________________
Mr. Smith followed his meal plan much more closely than he did last time and he also took all of
his medications. The increased dosage of Lasix caused him to go to the bathroom more and he
was losing weight. This went on for several months without a problem and then he noticed that
he was not going to the bathroom as much. The edema was coming back and so was the weight.
. Mr. Smith also noticed that he was feeling very tired and would get weak after doing easy
tasks. He began to experience anorexia, headaches, and nausea. Mr. Smith went back to his
nephrologist, who obtained another set of lab values. The lab values were as follows:
Date: 09/22/2015
WBC
Hgb
Hct
RBC
MCV
MCH
MCHC
Glu
BUN
Cr
Ca
Alb
Na
K
Cl
P
Uric Acid

Result
5.7x103mm3
11.0 g/dl
34%
4.5x106/L
77 m3
24 pg/cell
32 g/dl
85 mg/dl
49 mg/dl
2.5 mg/dl
9.3 mg/dl
3.2 mg/dl
149 mEq/L
5.8 mEq/L
103 mEq/L
6.2 mEq/L
9.2 mg/dl

Urinalysis:
SG
Protein
Glucose
Ketones
pH

1.001
+1
Neg.
Neg.
8.2

(L)
(L)
(L)
(L)

(H)
(H)
(L)
(H)
(H)
(H)
(H)

Reference Range
4.5-10.5x103mm3
12-16 mg/dl
36-48%
3.6-5.0x106/L
82-98 m3
26-34 pg/cell
32-36 g/dl
70-110 mg/dl
6-20 mg/dl
0.6-1.1 mg/dl
8.8-10.0 mg/dl
3.5-4.8 mg/dl
136-145 mEq/L
3.5-5.2 mEq/L
96-106 mEq/L
2.7-4.5 mEq/L
3.4-7.0 mg/dl

1.002-1.030

4.6-8.0

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17. Compare these labs to his labs during his visit five months ago. Describe any changes.
(2 points)
Abnormal
4/22/2015
9/22/2015
Reference range
labs/urinalysis
BUN
33 mg/dl
49 mg/dl
6-20 mg/dl
Cr
3.5 mg/dl
2.5 mg/dl
0.6-1.1 mg/dl
Alb
3.2 mg/dl
3.2 mg/dl
3.5-4.8 mg/dl
Na
148 mEq/L
149 mEq/L
136-145 mEq/L
K
5.5 mEq/L
5.8 mEq/L
3.5-5.2 mEq/L
P
5.5 mEq/L
6.2 mEq/L
2.7-4.5 mEq/L
Uric acid
8.6 mg/dl
9.2 mg/dl
3.4-7.0 mg/dl
Hct
37%
34%
36-48%
Hbg
12 mg/dl
11 mg/dl
12-16 mg/dl
3
3
MCV
82 m
77 m
82-98 m3
MCH
26 pg/cell
24 pg/cell
26-34 pg/cell
Protein in urine
+2
+1
0
Urine pH
8.1
8.2
4.6-8.0
Mr. Smiths BUN, Na, P, K, uric acid, and urine pH have continued to increase. His Cr, Hct,
Hgb, MCV, MCH, and protein in urine have decreased. His albumin level has stayed the same.
These results are consistent with worsening kidney function. The rest of his lab values and
urinalysis values not in the chart above are considered within normal limits thus not discussed.
18. Which lab values indicate that Mr. Smith is anemic? (2 points)
Lab values indicating anemia consist of Hct, Hgb, MCH, and MCV. He has low hemoglobin
and hematocrit as well as low mean corpuscular volume and mean corpuscular hemoglobin.
Therefore, Mr. Smith has a microcytic anemia.
19. Briefly define the following lab values: BUN, Cr, Alb, Na, K, P, uric acid. (2 points)
BUN: blood urea nitrogen (forms after protein breakdown)may indicate hydration status
and level of uremic toxins
Cr: serum creatinine (waste product from protein breakdown in muscles)may indicate
hydration status and level of uremic toxins
Alb: serum albumin (liver protein)may indicate nutritional status (**not a sensitive
marker), visceral protein related with metabolic stress and inflammation; affected by
hydration status
Na: serum sodiumindicates electrolyte balance
K: serum potassium- indicates electrolyte balance
P: serum phosphorusindicates risk of hyper-or hypoparathyroidism
Uric acid (forms after purine breakdown)indicator for hyperuricemia which may suggest
gout, acidosis, alcoholism, kidney disease, etc.
20. Considering Mr. Smiths condition, briefly explain why each value is high or low. (2 points)
Mr. Smith has Stage IV CKD (GFR = 15-29 mL/min/1.73m2)
uric acid, and urine pH , urine protein His albumin level low
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BUN and Cr are above normal. These two labs indicate that toxins are not able to be properly
filtered from the blood by the kidney.
Na and K, two electrolytes, are also above normal. This is due to electrolyte imbalance due to
the improper regulation of fluids and electrolytes since kidney function is declined.
CKD may cause also cause phosphorus imbalance which can lead to hypo-or
hyperparathyroidism. Too much phosphorus will lead to alterations in PTH gland sensitivity
to calcium. Because of this, the threshold of Ca needed to stimulated PTH production will
occurs. Kidney failure may result. Altered phosphorus metabolism as seen in CKD can result
in anemia. At this time, Mr. Smith is in fact anemic.
Higher than normal uric acid also indicates poor filtering of the blood. Uric acid is a waste
product of purine degradation. Thus toxins are not being properly disposed of due to
declining kidney function.
In CKD, proteins leak into the urine. Thus, presence of protein +1 indicates CKD.
Urine pH indicates changes in acid level in the body. A high pH suggests that the blood is
retaining H+ ions and lacking HCO3 because the kidney is not properly filtering the blood. A
high urine pH also suggests that the kidney is not properly filtering urine.
Low albumin can reflect protein-energy wasting as a chronic phase response protein. Altered
metabolism in CKD greatly increases the risk of protein-energy malnutrition.

The nephrologist told Mr. Smith that the results of his tests were not good. His kidneys were
going into renal failure and he would have to go on a hemodialysis (HD) machine for about 3 hrs
3x/wk. [Hi Mary Beth if you want to throw Mr. Smith into renal failure consider changing his
creatinine to 3 mg/dL or 3.5 mg/dL. A creatinine of 2.5 gives him an eGFR = 26 ml/min/1.73m
which puts him in the middle of Stage IV CKD.] He told Mr. Smith that he would require minor
surgery to have a primary AV fistula created in his arm to provide access to the dialysis machine.
He explained what an AV fistula was. Mr. Smiths weight was now 215 lbs (97.7 kg; 9.1 kg
weight loss; 8.5% weight loss). Mr. Smiths new orders for medications are as follows:
- Continue Hectorol
- Continue antihypertensive
- Start Epogen
- D/C Lasix

21. Describe HD and list the complications. (4 points) (NCM, KDOQI)


Hemodialysis is the most common form of renal replacement therapy, according to the NCM.
HD utilizes a semi-permeable membrane with a dialyzer (artificial kidney) to remove fluid,
reduce serum electrolytes, and reduce toxin concentrations via a filtering mechanism with a
varying degree of permeability. This is done for about 4 hours 3x week usually at a dialysis
center but it can also be performed at home with the proper equipment. A pt has access to
HD with a fistula, catheter, or graft. The amount of HD is based upon elimination or urea.
Both ultrafiltration and diffusion are performed in HD. The goal of hemodialysis is to
maintain optimal nutrition while limiting buildup of waste products. Possible complications
of HD include increased inflammation. This can occur when there is an impure dialysate, an
infection at the HD access site, thrombosed fistula/graft, volume overload, incompatible
membranes, and hemodiafiltration. Other possible complications of HD, according to
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KDOQI, include intradialytic arrhythmias and hypotension, low cardiac output, interdialytic
and post-dialytic symptoms of malaise, asthenia, general weakness/fatigue, skeletal muscle
cramps, decreased exercise capacity, or low peak oxygen consumption. Note; latter
complications may be treated with L-carnitine according to KDOQI.

22. Describe the AV fistula for HD. (2 points)


A surgically created AV fistula is a connection made between an artery and a vein. This
connection allows blood to flow directly from an artery into a vein, bypassing capillaries.
The tissues below the bypassed capillaries receive a lower amount of blood than normal. AV
fistulas may be placed anywhere.

23. List the dietary principles for a patient on HD. (4 points)


There are a number of dietary principles for a patient on HD. First, the pt must consume
adequate protein and energy to maintain protein balance and to reduce the risk of PEM.
Fluid, electrolytes, and water-soluble vitamins must also be addressed. First, in regards to
fluid intake, there must be a fluid restriction in order to avoid interdialytic weight gains,
HTN, edema, pleural effusion, and CHF. Fluid intake should match urine output plus an
additional 1000 cc. Sodium should also be restricted to less than 2400 mg/d for these same
reasons. The pt should similarly reduce intake of potassium and phosphorus to less than
2.4g/d and between 800-1000mg/d, respectively. Potassium should be reduced in addition to
maintaining optimal glucose control to prevent hyperkalemia. Phosphorus should be reduced
to avoid hyperphosphatemia and phosphate binders are usually required to decrease intestinal
absorption of phosphorus. To avoid hypercalcemia, which can cause calcification of blood
vessels, soft tissues, and organs, daily intake of calcium should be limited to no more than 2
g/d. Furthermore, some vitamins need to be individualized aside from the DRIs. For instance,
a pt on HD should consume 2 mg/d of vitamin B6, 60-100 mg/d of vitamin C, 1-5 mg/d of
folate, and 3 mcg/d of vitamin B12. The pt will also need to consume 15 mg/d of zinc and
may need an iron supplement if ferritin goes below 200 ng/ml.
24. Determine Mr. Smiths estimated calorie, protein and fluid requirements considering
his new order for hemodialysis. (2 points) (NCM, KDOQI)
215 lbs (97.7 kg; 9.1 kg weight loss; 8.5% weight loss
Since Mr. Smith is now on HD and his weight has dropped to 97.7kg, his nutritional needs
must be reassessed.
According to the NCM, most nutritional calculations for pt in the hospital are based on ABW
or actual body weight and not standard body weight from NHANES data. Thus, I am going
to used ABW since Mr. Smith is 125% of his DBW (75.5 kg).
ABW = (current weight DBW).25 + DBW
ABW = (97.7kg 75.5 kg).25 + 75.5
ABW = 81.05 ~81.1kg
Energy needs
NCM recommends using the range of kcal/kg = 30-35 for those greater than 60 years old
30 kcal (81.1kg) = 2433
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35 kcal (81.1kg) = 2838.5


2500-2800 kcal/d
Protein needs
NCM recommends using 1.2 g pro/kg
1.2 g (81.1 kg) = 97.32
97 g pro/d
Over 50% of the 97 g pro/d should be protein of high biological value (HBV). HBV indicates
that the protein source contains all the essential amino acids. Food sources of HBV include
animal proteins such as beef, pork, poultry, and dairy products.
Fluid needs
NCM recommends matching urine output plus 500-1000 mL/d. 1000 mL should be the
minimum a patient receives.
1500-2000 mL/d

25. What is a phosphate binder? What is its indicated use? Would you recommend a
phosphate binder for Mr. Smith? Which binder would you choose and why? (4 points)
(NCM, Cochrane, EAL)
A phosphate binder is prescribed to reduce the level of phosphorus intestinally absorbed from
dietary intake. High levels of phosphorus in the blood can affect bone health (development of
renal bone disease) and cause adverse alterations in metabolism and increase risk of CVD.
For instance, elevated phosphorus can cause a rise in PTH, secondary hyperparathyroidism,
decreased Ca, and vitamin D deficiency. Hyperphosphatemia can present as GFR declines to
<60ml/min.
Phosphate binders are commonly used in pt with CKD however, according to Cochrane, the
impact of phosphate binders on CKD remains controversial. There are multiple types of
phosphate binderssome contain aluminum, calcium, or magnesium. Others are calciumand aluminum-free. In a review comprised of 60 studies, investigators compared sevelamer
hydrochloride (binder without Ca or Al) to calcium-based phosphate agents. They found that
there was no significant reduction in all-cause mortality between the two different binders.
However, calcium-based binders did significantly reduced serum phosphorus and PTH but
also significantly increased the risk of hypercalcemia compared to Sevelamer hydrochloride.
According to the NCM, pt are instructed to limit total dietary intake of calcium when taking
calcium containing phosphate binders. Pt are told not to consume more than 2000 mg Ca/d to
avoid hypercalcemia. Furthermore, in the Cochrane review, it was outlined that there was a
significant increase in risk of adverse GI events with sevelamer hydrochloride compared to
the calcium agents. Lanthanum, another phosphate binder without calcium or aluminum, was
found to significantly reduce serum calcium but not serum phosphorus levels. The authors of
this review concluded that available phosphate-binding agents have been shown to reduce
phosphorus levels in comparison to placebo and that at this time, there is insufficient data to
establish the comparative superiority of novel non-calcium binding agents over calciumcontaining phosphate binders for all-cause mortality and CVD endpoints in pt with CKD.

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Because Mr. Smiths lab values have always indicated elevated serum phosphorus, I would
recommend a phosphate binder, especially since his GFR continues to decline. I would also
recommend a low-phosphorus diet of 800-1000 mg P/d or 10-12 mg P/ g pro (as specified by
the NCM). I would suggest a phosphate binder without calcium since Mr. Smith is still
taking Hectorol. When taking Hectorol, calcium supplements should be cautioned. Calciumcontaining phosphate binders also increase the risk of hypercalcemia which can cause
calcification of blood vessels and soft tissues. Although Mr. Smiths previous lab values
illustrated a Ca value (9.3) within normal limits, it was at the higher end of the healthy range
(10). The Cochrane review detailed that there is no significant difference in all-cause
mortality between calcium-based phosphate agents and phosphate agents without calcium. If
Hectorol is discontinued, I would suggest switching to a calcium-based phosphate agent
while also maintaining a diet with less than 2000 mg Ca/d. Ca-containing phosphate agents
may not have an elevated risk of adverse GI events compared to agents without calcium. Ca
agents also significantly reduce serum P and PTH compared to a non-Ca agent. However,
again, I would use my clinical judgement to prescribe a binder without calcium due to
Hectorol use.

Mr. Smith was admitted to the hospital to have a wrist (radial-cephalic) primary AV fistula
created in his left arm. While in the hospital, Mr. Smith received HD for the first time. His
weight upon admission to the hospital was 215 lbs. This was listed as his wet weight. After
dialysis, Mr. Smith was weighed again and weighed 210 lbs. This was listed as his dry weight.
The renal RD met with Mr. Smith and his wife again and explained changes in his new meal
plan. She emphasized the importance of increasing the protein and restricting sodium and fluid.
She also told Mr. Smith it was important for him to take in enough energy. To do this, it will
now be necessary for him to eat more sweets and fats. She suggested that whenever he eats
bread and toast, he should add margarine, and whenever he eats salad, he can add lots of lowsodium salad dressing. She also suggested that he eat more candy that did not have salted nuts in
it.

26. Explain the difference between wet/edematous weight and dry weight. (2 points)
Wet/edematous weight is body weight with excess fluid retention. Dry weight is measured after
dialysis and it is considered body weight free of excess fluid (more of a normal weight).
According to KDOQI and NCM, adjusted edema-free body weight (aBWef), essentially dry
weight, should be calculated and used when determining nutritional needs for individuals <95%
or > 115% of standard body weight. In an article by Agarwal R and Weir MR titled DryWeight: a concept revisited in an effort to avoid medication-directed approaches for blood
pressure control in hemodialysis patients, dry-weight is defined as the lowest tolerated
postdialysis weight achieved via gradual change in postdialysis weight at which there are
minimal signs or symptoms of hypovolemia or hypervolemia.
27. Mr. Smiths energy and protein requirements on HD are higher than his energy and protein
requirements without HD. Explain why. (2 points)
20

In a study done by Kamimura et al, HD was shown to elevate pts REE thus, nutrition needs
would be greater on HD. Also, according to KDOQI, malnutrition is a huge concern with
dialysis. To reduce the risk of PEM, a pt needs adequate dietary protein and energy intakes to
maintain protein balance and body composition. Therefore, energy and protein needs may be
increased. Malnutrition from dialysis is a major concern because HD can cause anorexia,
decreased intestinal absorption, alterations in metabolism, missed meals because of treatment
schedule, lack of energy to prepare meals, and many vitamin deficiencies.

28. The RD encouraged Mr. Smith to increase his caloric intake by eating more fat and sugar.
Comment on the advantages and disadvantages of doing this with a patient who has renal
disease. Briefly describe some of the recommendations you would make. (2 points)
Foods high in fat and sugar are more likely to be low in phosphorus, calcium, and potassium
which all must be restricted at this time. Sodium may be in some fatty and sweet foods so
still needs to be considered. Foods high in fat and sugar will also be calorically dense to
better help Mr. Smith meet his energy needs. However, more fat and sugar will not ensure
great nutritional value. Aside from simple sugars, Mr. Smith should also include some
starches (still watching for Ca, P, and K). As for fat, he should focus on plant oils rather than
animal fats. Such oils include canola oil, olive oil, soybean oil, sunflower oil, and soft tub
margarine. He may also want to use fish oil for adequate consumption of omega-3 fatty acids
which help with inflammation and reduce the risk of cardiovascular events.
I would recommend that Mr. Smith try to add extra sugar and fat to eat meal and snack
throughout the day. For example, for breakfast I would recommend juice as his fluid rather
than water for the extra sugar in juice. I would also tell him to add margarine and jam to his
toast. For lunch, I would recommend a sandwich on whole-wheat bread with additional
mayonnaise and a side salad with extra low-sodium dressing. Again for lunch I would
recommend juice/lemonade/sweetened iced tea over water to get in a few extra kcals. For
dinner I would recommend margarine with any dinner rolls, low-sodium dressing for side
salads, and a sweetened juice beverage. After dinner I would recommend eating a dessert
such as gelatin and cake.

At this point in the case study, complete an ADIME


follow-up assessment note using your hospitals template.
Adapted from: Billon W. Clinical Nutrition: Case Studies (4th Edition). Belmont, CA: Thomson Wadsworth, 2006.

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(10 point

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