Julia Wang

2021 Spring HNSC4240 Clinical Nutrition I

Case study 2 Chronic Kidney Disease
Due 04/28/2021

Instruction: Read the following case and complete the questions. Please type your
answers. The assignment must be turned in on time. One point will be deducted for
each day that the case study is late.

Please read the case below carefully then answer the questions.
Date of admission: 2/5/2021
Client Name: Amber King
DOB: 5/3
Age: 34
Sex: female
Education: High School
Occupation: Secretary
Household members: Married – lives with husband and daughter
Weight: 172 lbs
Weight history: 153 lb (6/5/2020); 153 lb (12/22/2020); 164 lb (2/1/2021)
Height: 5’3”
Ethnicity: African American

Patient history:
Mrs. King is a 34-year-old African American woman who was diagnosed with type 2 DM when
she was 12 years old and has been poorly compliant with prescribed treatment.
Onset of disease: Diagnosed with Stage 3 chronic kidney disease 2 years ago. Her acute symptoms
have developed over the last few months.
Medical History: Pt admits she recently stopped taking a prescribed hypoglycemic agent, and she
has never filled her prescription for anti-hypertensive medication. Progressive decompensation of
kidney function has been documented by declining GFR, increasing creatinine and urea
concentrations, elevated serum phosphate, and normochromic, normocytic anemia. She is being
admitted for preparation for kidney-replacement therapy.

Family History: What? T2DM. Who? Parents.

Tobacco use: No
Food Allergies: NKFA
Alcohol: Yes, 1-2 12-oz beers daily

Physical exam:
Vitals: Temp 98.4 F, BP 161/92 mmHg, HR 86 bpm, RR 25 bpm
Extremities: Muscle weakness; 3+ pitting edema to the knees
Abdomen: Bowel sounds positive, soft; generalized mild tenderness; no rebound
Skin: dry
Eyes: cloudy
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Laboratory values:

Normal Patient’s value Units

Blood work
Sodium 136-145 132 L mEq/L
Potassium 3.5-5 6.9 H mEq/L
Phosphorus 2.3-4.7 10 H mg/dL
Calcium 9-11 8.0 L mg/dL
Albumin 3.5-5 3.7 g/dL
GFR >90 11 L mL/min
Glucose 70-110 236 H mg/dL
Creatinine 0.6-1.2 12.0 H mg/dL
Fasting blood glucose 66-99 150 H mg/dL
HbA1C 4-6 9H %
Urinalysis
pH 5-7 7.9 H
Protein Neg 2+ H mg/dL
WBCs 0-5 20 H /HPF
Treatment plan:
Medications:
Lasix (furosemide) 40 mg twice daily
Erythropoietin 30 units/kg
Vitamin/mineral supplement daily
Renvela- three times daily with each meal
Glucophage 850 mg twice daily

Dietary recall:
Breakfast: whole milk 1 cup, 2 scrambled eggs with 1 tsp butter, 1 cup of scalloped potatoes, 4
slices bacon, 1 cup apple juice
Lunch: Pilly Cheesesteak sandwich (1 whole wheat roll, 2 tsp butter, 1/4 green bell pepper, 1/4
onion, 5 oz steak, 2 slices American cheese, 2 tsp worcestershire sauce), 1 mango, regular coke 1
cup
Dinner: Chicken salad (chicken breast 6 oz, 3 Tbsp honey mustard, 1 small onion, olive oil 1
Tbsp, 1 cup spinach, ½ cup red peppers, ½ cup tomato, ¼ avocado)
Snack: 4 chocolate chip cookies, cheddar cheese 2 oz, strawberry sorbet 1 cup

ANSWER THE FOLLOWING QUESTIONS

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1. What’s the correlation between diabetes and CKD? Discuss the mechanisms through
which they are interrelated.

Diabetes is a risk factor for renal failure and, along with hypertension, the cause of more than
half of ESRD cases in patients already with chronic kidney disease. It also causes oxidative stress
and decrease in filtration rate when condition is not being controlled. The accumulation of glucose
in blood causes glycation and oxidation of proteins and lipids, leading to rigidity and rupture of
thin vessels in high pressure. Kidney capillaries, in especial, are very susceptible to be damaged
by AGE’s due to their structure, causing failure in filtration. CKD can also affect diabetes by
increasing the need of insulin, through accumulation of uremic compounds and increased PTH
that causes insulin resistance. Elevated PTH, metabolic acidosis, decreased vitamin D and,
possibly, anemia due to impaired EPO production, all consequences of CRF, also cause reduction
of insulin secretion (Nasri and Rafieian-Kopaei, 2015), exacerbating the condition. Lastly, the
presence of protein in tubules due to impaired filtration triggers inflammation and injury, which
further worsens existent condition or leads to development of diabetes.

2. The patient was very upset that she needs to receive dialysis. She complained about not
being able to eat whatever she wanted. Please discuss her dietary intake goals (e.g.
potassium, sodium, fluid, phosphorus, calorie, protein, HBV proteins) (i) before she is
put on dialysis (ii) when she is on hemodialysis. Please include the steps of calculation.
Compare the differences and explain why the goals were modified based on her
situations.

The patient’s weight fluctuation in a short period of days indicates edema and her BMI shows
obesity status. Her daily calorie intake, calculated based on dry weight, should be 1282.5 kcal. The
appropriate diet for pre-dialysis would be protein-restricted, with total 30g protein, in which 15g
are from animal sources. There is no fluid nor calcium restriction at this stage, and patient should
be aware that she has high blood phosphorous and potassium, and should control her intake and
restrict to prevent worsening of clinical condition. Her sodium intake should be limited to no more
than 2.4g daily. Patient should also be aware that her blood glucose is elevated, and she should
avoid high sugary foods and consider consulting her physician to continue use of hypoglycemic
medication. When on hemodialysis, her protein intake should be increased to 47g, with 23.5g from
high biological value sources, to replenish amino acid loss with the dialysis membrane. In
addition, her daily micronutrients intake should be limited to 3g for sodium, 4g for potassium, 2g
for calcium and 1g for phosphorous. Her fluid is also restricted to no more than 1000ml, plus
additional ml to replenish urine output. These differences between pre and post dialysis diet goals
is due to less efficient electrolyte and water removal and to avoid overwork of impaired kidneys
when on hemodialysis.

Calculation
Height 5’ 3” = 63” = 1.60m
TBW 172 ÷ 2.2 = 78.2kg

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BMI 78.2 ÷ (1.60)2 = 30.5 (obese)

IBW 100 + (5x3) = 115lb = 52.3kg
ABW (172lb - 115lb) x 0.25x3 = 42.75kg
Calorie 42.75 x 30 = 1282.5 kcal
Protein Pre: 42.75 x 0.7 = 30g (HBV = 15g)
HD: 42.75 x 1.1 = 47g (HBV = 23.5g)

3. Analyze the patient’s dietary recall using the RENAL EXCHANGE TABLE and fill out the
table below. Point out which exchange group each food item belongs to, the nutrient content,
and the number of exchanges. Calculate the totals. Discuss the discrepancy between her
dietary recall and intake goals identified above, and what consequences may result from the
discrepancies (You may expand the table).

# of
Calories Protein Na
Food item Food group exchange K (mg) P (mg)
(kcal) (g) (mg)
s
Eggs High Protein 2 150 14 170 200 150
Steak High Protein 5 375 35 425 500 375
Chicken High Protein 6 450 42 510 600 450
Whole Milk High P Protein 1 75 8 85 100 200
Cheese High P Protein 4 300 32 340 400 800
Bacon High Na Protein 1 75 7 325 100 75
Potatoes High K Veg 2 110 4 50 800 80
Spinach High K Veg 2 110 4 50 800 80
Tomato High K Veg 1 55 2 25 400 40
Avocado High K Veg 0.5 27.5 1 12.5 200 20
Bell Pepper Medium K Veg 1.5 82.5 3 37.5 300 60
Onion Low K Veg 1.5 82.5 3 37.5 127.5 60
Mango Medium K Fruit 2 120 0 10 400 20
Apple Juice Low K Fruit 2 120 0 10 170 20
W. Wheat Roll Cereal & Grain 1 125 3 75 55 40
Cookie Cereal & Grain 1 125 3 75 55 40
Butter High Calorie 1 125 0 50 50 50
Olive Oil High Calorie 1 125 0 50 50 50
Sorbet High Calorie 2 250 0 100 100 100
Coke High Calorie 1 125 0 50 50 50
Sauce Flavoring 0.5 5 0 137.5 25 5
Mustard Flavoring 3 30 0 825 150 30
Total – – 3042.5 161 3450 5632.5 2795

Based on her dietary recall, the patient’s current diet is inadequate for her clinical conditions,
with excessive amounts of calories, total protein and all electrolytes. Because her kidneys are mal
functioning, indicated by her low efficient GFR and increased concentrations of nitrogenous
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waste, her ability to filtrate and excrete nutrients is impaired, as well as her ability of RBC
production and vitamin D activation, leading to the anemia, hypocalcemia and subsequently
hyperphosphatemia and hyperkalemia shown in lab tests. Her intake of phosphorous and
potassium, which should be restricted, is very high and may cause vascular calcification and
cardiac arrythmia if not a change in dietary choices is not adopted and intake is not decreased. Her
total protein is 5x higher than the limit in a pre-dialysis diet, and calorie intake is 2x her needs.
Continuous consumption of high protein intake will lead to further accumulation of creatinine and
urea and worsening of uremic syndrome. Excessive calorie intake will also worse her obesity
status and inflammation, and uncontrolled diabetes. Her sodium intake is also higher than the
2400mg limit, worsening her hypertension and increasing her risks of cardiovascular diseases and
further impact her kidney dysfunction. Thus, patient should consider a reduction of calories and
protein intake, and be aware of her mineral intake and food choices, which, although healthy in a
normal diet, may cause complications due to her clinical conditions.

4. Fill out exchange tables based on the dietary intake goals when she is on hemodialysis.
Modify from her 24-hr recall, design a one-day menu that contains breakfast, lunch, dinner
and 2 snacks that is compliant with the dietary prescription (use the tables below as a step-
by-step guide; you may expand the tables).

Calculate the exchanges

Exchange # of Calories Protein Sodium Potassium Phosphorus
group exchange (kcal) (g) (mg) (mg) (mg)
s
High protein 2.5 187.5 17.5 212.5 250 187.5
High P 0.5 37.5 4 42.5 100 100
protein
High sodium 0.5 37.5 3.5 162.5 50 37.5
protein
Low K 3.5 192.5 7 87.5 297.5 140
vegetables
Medium K 2 110 4 50 400 80
vegetables
High K 4 220 8 100 1600 160
vegetables
Low K fruits 3 180 0 15 255 30
Medium K 1 60 0 5 200 10
fruits
High K fruits 0 0 0 0 0 0
Bread/cereal 1 125 3 275 55 40
s
Calorie 0.5 62.5 0 25 25 25

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Flavoring 4 40 0 1100 200 40

Total – 1252.5 47 2075 3432.5 850
25g hbv

Hemodialysi – 1282.5 47 g 2000 – 2000 – 800 –

s kcal 23.5g hbv 3000 mg 4000 mg 1000 mg
Intake Goal

Please fill out the # of exchanges for each meal

Exchange group Total # of breakfast lunch dinner Snack 1 Snack 2
exchange
High protein 2.5 0 1 1.5 – –
High P protein 0.5 0.5 – – – –
High sodium protein 0.5 0.5 – – – –
Low K vegetables 3.5 1 1.5 1 – –
Medium K vegetables 2 – 1 1 – –
High K vegetables 4 1 2 1 – –
Low K fruits 3 – 1 1 1 –
Medium K fruits 1 – – – – 1
High K fruits – – – – – –
Bread/cereals 1 – – 1 – –
Calorie 0.5 – 0.5 – – –
Flavoring 4 – 2 2 – –

Plan the menu (you can expand the table)

Meal Food item Exchange group Number of exchanges
½ c Low Fat Milk High P Ptn. 0.5
Breakfast 2 slices Bacon High Na Ptn. 0.5
½ c Baked Sweet Potato w/ High K Veg. 1
½ c Baked Eggplant Low K Veg. 1
Lunch 1 oz Steak w/ High Protein 1
¼ c Shiitake Mushroom Low K Veg. 0.5
1 c Roasted Pumpkin w/ High K Veg. 2
½ tbsp Olive Oil High Calorie 0.5
½ c Kale Medium K Veg. 1
½ c Steamed Carrot Low K Veg. 1
2 tbsp Horseradish Flavoring 2
½ c Grapes Low K Fruit 1
Dinner 1.5 oz Chicken Breast High Protein 1.5
1 c Iceberg Lettuce Salad w/ Low K Veg. 1
½ c Steamed Broccoli Medium K Veg. 1
½ c Cherry Tomatoes High K Veg. 1
2 tbsp Honey Mustard Flavoring 2

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1 Whole Wheat Roll Bread/Cereal 1

½ c Strawberry Low K Fruit 1
Snack 1 1 Apple Low K Fruit 1
Snack 2 5 Prunes Medium K Fruit 1

5. The patient wants to get a kidney transplant. Based on the information you have,
evaluate whether she is a good candidate for transplant.

Unfortunately, the patient is not the best candidate to receive a kidney replacement due to
eligibility criteria. She is not committed to adopt lifestyle changes, shown in her actions of poor
management of diabetes and hypertension, and discontinued use of medications. This criterion is
very important because kidney transplants require lifetime commitment and untreated diabetes and
hypertension will impair the functioning of kidneys, predisposing again to the development of
renal dysfunction.

6. Pt’s husband heard from others that there are organic and inorganic phosphorus. He
is curious about what they are, which foods they are found in, and whether they have
different effect on his wife’s disease. Please look into peer-reviewed literature and answer his
questions above. Provide the patient with some recommendations about what she may do to
control her blood phosphorus level when she is on hemodialysis.

Phosphorous is a mineral that can be found in both organic and inorganic forms and is
naturally found in foods that are rich in protein. Organic phosphorous is mainly present in animal
and vegetarian protein sources, with absorption rate of 40 to 60% in animal products and less
bioavailability in plant products, due to plant phytates that bind to the mineral and inhibit its
absorption. The inorganic form of phosphorous is found mainly as a food preservative in
processed foods, such as processed cheese and cola beverages. They are not bound to protein but,
rather, found as salts, which increases its absorption to more than 90% (Kalantar-Zadeh et al.,
2010). Thus, the patient should be more aware of her intake of inorganic phosphorous and
processed foods. Studies suggest an association between increased mortality risks in hemodialysis
patients and a high ratio of dietary phosphorous to protein intake. His wife should control total
intake of phosphorous and choose the right food sources, avoiding the inorganic form from
processed foods and opting for the form of phosphorous found in plant-based proteins, and foods
with a dietary ratio of less than 10mg of phosphorous per 1 g of protein. Unprocessed eggs, for
example, with less than 2mg/g ratio, are an example of adequate food source of phosphorous when
in hemodialysis (Noori et al., 2010). Besides dietary restriction, control of phosphorous level can
also be achieved by use of phosphorous binders in advanced CKD stages (Adema et al., 2014),
increasing excretion of mineral through urine.

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References:

Adema, A. Y., de Borst, M. H., Ter Wee, P. M., Vervloet, M. G., & NIGRAM
Consortium (2014). Dietary and pharmacological modification of fibroblast growth
factor-23 in chronic kidney disease. Journal of renal nutrition : the official journal of
the Council on Renal Nutrition of the National Kidney Foundation, 24(3), 143–150.
https://doi.org/10.1053/j.jrn.2013.09.001

Kalantar-Zadeh, K., Gutekunst, L., Mehrotra, R., Kovesdy, C. P., Bross, R.,
Shinaberger, C. S., Noori, N., Hirschberg, R., Benner, D., Nissenson, A. R., &
Kopple, J. D. (2010). Understanding sources of dietary phosphorus in the treatment of
patients with chronic kidney disease. Clinical journal of the American Society of
Nephrology : CJASN, 5(3), 519–530. https://doi.org/10.2215/CJN.06080809

Nasri, H., & Rafieian-Kopaei, M. (2015). Diabetes mellitus and renal failure:
Prevention and management. Journal of research in medical sciences : the official
journal of Isfahan University of Medical Sciences, 20(11), 1112–1120.
https://doi.org/10.4103/1735-1995.172845

Noori, N., Sims, J. J., Kopple, J. D., Shah, A., Colman, S., Shinaberger, C. S., Bross,
R., Mehrotra, R., Kovesdy, C. P., & Kalantar-Zadeh, K. (2010). Organic and
inorganic dietary phosphorus and its management in chronic kidney disease. Iranian
journal of kidney diseases, 4(2), 89–100.