Semestral Case Study

Mhea Sigourney O. Lofranco BSND-3 ND3201 April 28, 2021

General Information

Name of Patient: Duhilag Erlinda, Demecillo

Disease: End Stage Renal Disease
Age: 68 years old
Sex: Female
Nationality: Filipino
Religion: Born Again
Birthdate: Aug 7, 1952
Civil Status: Widow
Occupation: Housewife
Height: 5ft ; Weight: 53 kg UBW: 55 kg
Chief Complaint: High blood pressure, Edema, Diabetes, muscle weakness and fatigue.

Additional information:

The patient is well-nourished elderly female in a moderate distress. She is hypertensive

of 160/90 mm Hg and her glucose level ranges 500 mg/dL, 33 years ago and got
hospitalized. She was having insulin injections 3 times a week after she was diagnosed.
She has no physical activity because she is bed rest and can’t able to walk by herself
unless someone assisted her. She reported that she always eats salty foods like dried
fish before being diagnosed with kidney disease, also likes to eat vegetables, sugary
foods and beverages. Her father had Hypertension and Diabetes Mellitus. She already
had kidney disease for almost 2 years and now she undergoes Hemo-Dialysis started
January 2021 due to elevated Creatinine and Uremic symptoms (anemia, weakness &
fatigue). She maintains twice a week hemodialysis treatment started in January but now
it is already thrice a week and only her left kidney is working right now.

Medications:

Spironolactone 500 mg (1 tab 1x/day) Febuxostat 40 mg (1 tab daily)

Sangobion Capsule daily Entresto 200 mg (1 tab 2x/daily)
Atorvastatin 20 mg tablet daily Carvedilol 65 mg (1 tab daily)
Epoetin Alfa (Eposino) 4,000 iu every after HD Neurogen E tab daily
 1. Nutrition Assessment:
Anthropometrics (height, weight, IBW)
 Height: 152 cm (5 ft)
 Weight: 117 lbs (53 kg)
 IBW (Hamwi Method)
 Female
 5 ft------------100 lbs
45 kg
 Physical Activity : 35% (Light)

 TER/day = 1458 kcal

 BMR = 1 kcal x 45 kg x 24 hrs
= 1080 kcal
+PA= 378 (35% of 1080 kcal)
TER/day = 1458 kcal

 Method II (Krause Method):

CHON/day = 45 kg x 1.2 g/kg/day
CHON= 54 g
= 54 kg x 4 kcal = 216 kcal
= 1458 kcal - 216 kcal
NPC = 1242 kcal
CHO = 1242 kcal x .70 = 869 / 4 = 217 g
FAT = 1242 kcal x .30 = 373 / 9 = 41 g

 Diet Prescription TER/day: 1458 kcal

 CHO: 217 g; CHON: 54g; FAT: 41 g

 Biochemical
Lab Test Result Normal Values Rationale
RBC 2.76 4-6 x 10^12/L Low, indicate that there is
erythropoietin deficiency and
anemia due to nutritional
deficiency like iron, folate, B12
and B6 vitamins.
Hemoglobin 83.0 110-180 g/L Low, indicate that patient has
kidney failure and has nutritional
deficiencies including folate, iron
and vitamin b12.
Hematocrit 0.26 0.37 - 0.47 Low due to nutritional deficiency in
mmol/L vitamin B12, iron and folate and
indicate kidney failure.
Ionized Calcium 1.04 1.13-1.32 mmol/L Low, indicate that there is
malabsorption of calcium, kidney
failure and deficiency in vitamin D
Sodium 136.4 mEq/L 135-148 mEq/L Normal, due to persistent
 hemodialysis, which it removes
the excess sodium to a lesser
degree of diffusion.
Potassium 5.20 mEq/L 3.5-5.3 mEq/L Normal due to consistent
treatment of hemo-dialysis which
it remove the excess waste in the
blood as well as excess
potassium.
BUN 16.31 mmol/L 3.5-7.2 mmol/L Increased, indicate of kidney
Or disease or kidney failure, high
293. 6 mg/dL protein level and dehydration.
Creatinine 497.84 53-106 umol/L Increased, indicate kidney failure,
umol/L which kidneys does not working
or well.
8.0 mL/min It is due to high blood pressure,
diabetes and chronic kidney
failure.
Lymphocytes 0.39 0.25-0.35 Increased, indicate that patients
has infection.

 Clinical
 Has high blood pressure of 160/90 mm Hg and also had Diabetes Mellitus. She has
Edema in her left foot and right hand. She started Hemo-diaysis treatment since
January 2020 due to Creatinine and uremic symptoms (fatigue and muscle
weakness). She has Low (RBC, Hemoglobin, Hematocrit and Iodized Calcium), has
high in BUN and Creatinine.

 Dietary
Has a diet history of consumption of salty food items like dried fishes and eating sugary
food and beverages.

Dietary :
Meal Calories Potassium Phosphorus Sodium
Breakfast:
1 cup Utan Bisaya 61 kcal 211.5 mg 26 mg
1 cup Rice 200 kcal
AM Snacks:
Chicken Sopas 351 kcal 135 mg 104 mg
(lugaw)
Lunch:
1 pc Poached Tuna 185 kcal 130 mg 500 mg
Fish 200 kcal
1 Rice
PM Snacks:
Chicken Sopas 351 kcal 135 104 mg
(lugaw)
Dinner:
1 cup Utan Bisaya 61 kcal 211.5 mg 26 mg
1 cup Rice 200 kcal
Total 1609 kcal 423 mg 400 mg 760 mg

Relevant drug and nutrient interaction/food and drug interaction in table form,
example:
Name of the Drug Indication Possible Interaction
Spironolactone This medication help to Intake of other medication
treat high blood pressure. It like angiotensin-converting
also treat edema caused by enzyme together with this
kidney disease. drug can may raise the
- Potassium-sparing level of potassium in the
diuretics body to dangerous or
harmful levels.
If spironolactone drug taken
together with Nonsteroidal
anti-inflammatory drugs
(NSAIDs) like ibuprofen,
indomethacin and naproxen
It causes to have enlarged
breast.
Sangobion Capsule It treat patient having It cause the urine to turn
anemia or treat vitamin yellow.
deficiency due to certain
illness.
Atorvastatin It helps in lowering the If Atorvastatin is taken with
cholesterol level of the gemfibrozil drug, it might
patient. It functions by increase the risk of muscle
lowering the amount of damage, it can also cause
cholesterol produced by the muscle pain, weakness and
liver. dehydration.
Epoetin Alfa (Eposino) This treat patient having It may cause headache, low
anemia with long term fever and fatigue, muscle
kidney disease. pain and arthralgia at the
initial state of drug
administration.
Febuxostat It indicate as a lowering It may cause nausea and
drug for uric acid level. severe dizziness.
It is also reported that it can
increase in attacks of gout if
having this treatment at
early stages.
Entresto It helps or treat patients If Entresto is taken with
with long term heart failure. lithium drugs it can raise
the level of potassium in the
blood.
And if taken with NSAIDs
drugs it cause severity of
renal function.
Carvedilol This is used to treat high If Carvedilol is taken with
blood pressure and heart NSAIDs drugs like
failure to prevent from Ibuprofen it can raise the
stroke and kidney level of potassium in the
problems. blood and reduce the
effectivity of Carvedilol for
reducing the blood
pressure.
Neurogen E Treat or prevent vitamin It can cause severe allergic
deficiency due to poor diet, reaction, stomach upset
certain illnesses and severe dizziness.
It interfere also with some
drugs like cisplatin, certain
antibiotics, levodopa and
other nutritional
supplements.

Socio-economic data
 Lola Erlinda is a 68 year old that has an end stage renal disease
 She has Diabetes Mellitus type 2, Hypertension and has Edema on her foot and
right hand.
 She has no physical activity since she is a bed rest patient and can’t able to walk by
her own.
 Had a Family history Diabetes Mellitus and Hypertension.
 She is a loving mother to her sons and daughter
 Her religion is Born Again.
 Before she diagnosed in Renal Disease, she is always eating salty foods like dried
fish and sugary foods and beverages.
  Pathophysiology
-Diagnosed 33 yrs ago (1988) -160/90 mm Hg

- FBS (500 mg/dl) - due to age

- Genetics (father) - genetics (father)

- Consumption of sugary food items - Consumption of salty food items

1. Uncontrolled Diabetes 2. Hypertension

Mellitus Type 2
Biochemical Data

Increased BUN (16.31 mmol/L)

Chronic Kidney
Disease Increased Cr (497.84 umol/L)

Low (hct, hgb, rbc) lead to

anemia
CKD Medical Management
End Stage Renal CKD Nutrition Management
- Control BP (160/90 mmHg)
Disease - Sodium restriction
- Control FBS (500 mg/dl)
- CHON restriction
- Insulin injections (rapid acting-
insulin) - Phosphorus restriction
Signs and Symptoms - Potassium restriction
- Control anemia
- Edema (L foot & R - Fluid restriction
hand)

- Anemia (based on Lab

results)

- Muscle weakness

- Fatigue

ESRD Nutrition Management

ESRD Medical Management
- Prevent Nutritional deficiencies (low hct, hgb, rbc)
- Hemodialysis (3/week)
- Control Edema
Pathophysiology Rationale
Uncontrolled Diabetes High blood glucose leads to activation and production of
Mellitus unnecessary growth factors and oxidative stress that
will lead to chronic kidney failure.
Hypertentension It causes thickening of the blood vessel which leads
less blood flow to the kidneys to the nephrons, because
less blood is flowing to the kidneys it increase the heart
rate and further hypertension
Edema (L foot & R hand) It is due to the buildup of fluid in the tissues. It indicates
total body sodium overload. It is also because of kidney
disease which there is an extra fluid and sodium that
may cause edema.
Genetics It plays an important role on the association of an
increase risk of Kidney Failure because of hypertension
and diabetes Mellitus.

Age (68 y.o) As an individual increase in age, the prevalence of

Kidney disease also increase

Increased Cr Indicate of kidney disease or kidney failure, high protein

level and dehydration. It is increased because of
dehydration.
Increased BUN It is due to high blood pressure, diabetes and chronic
kidney failure. It is caused by low blood flow to the
kidneys due to dehydration and high blood pressure.
It is also caused by high protein in the diet.
Anemia It is caused by Low (hgb, hct and RBC) based on lab
result due to nutritional deficiencies in iron, folate, vit b6
and b12. It is caused by an inability of the kidney to
produce EPO, the hormone that stimulates the bone
marrow to produce red blood cells.
Medical Management
Insulin injections for uncontrolled DM
Hemodialysis
Spironolactone
Sangobion Capsule
Atorvastatin
Epoetin Alfa
Febuxostat
Entresto
Carvedilol
Nutrition Management
Low Sodium diet
Low Potassium
Low Purine diet
Low Oxalate diet
Low Phosphorus diet
Low Cholesterol diet
Limit fluid intake
Consumption of high in iron, vitamin b6 and b12, folate food sources to prevent
nutritional deficiencies based on the lab results (low hct, hgb & rbc)

2. Nutrition Diagnosis
 Altered Nutrition laboratory values (Cr, Bun) (NC-2.2) related to Kidney dysfunction
as evidenced by Biochemical data increased BUN (16.31 mmol/L), increased Cr
(497.84 umol/L).

 Food and Nutrition-related knowledge deficit (NB-1.1) related to lack of nutrition-

related education as evidenced by diet history which is consumption of high salt
food items like dried fish.

Identification of Nutrition and other related problems (For this table it’s a summary of the
assessment that has a direct impact on his/her nutrition status)
Example:
Parameters Nutrition Related Problems Other Related Problems
Anthropometry None None
Biochemical Increased BUN (16.31 mmol/L) None
Increased Cr (497.84 umol/L)
Low RBC (2.76 x 10^12/L)
Low Hgb (83.0 g/L)
Low Hct (0.26 mmol/L)
Low iCa (1.04 mmol/L)
Clinical Hypertension None
Diabetes Mellitus
Edema
Weakness and fatigue
Dietary No food allergy Fluid intake is 140 ml/day
Always eat dried fishes and
sugary food items.
Drug and Nutrient Febuxostat may cause nausea None
Interaction and severe dizziness
Others Has a family history of None
Hypertension and Diabetes
Mellitus on the father side.

Rationale: For my identified problem, I categorized it in the 5 parameters, for

biochemical, the patient has nutritional related problems which the BUN (16.31 mmol/L)
and Cr (497.84 umol/L) both are high and low in RBC (2.76 x 10^12/L), Hgb (83.0 g/L),
Hct (0.26 mmol/L), iCa (1.04 mmol/L). For the clinical, the patient has hypertension due
to age, diabetes mellitus and edema due to high consumption of salty foods. For the
dietary I identified a nutrition related problem which the patient is always consuming
salty foods like dried fishes based on her diet history. Hypertension and diabetes
mellitus is also genetics, on her father side. Also, for drug-nutrient interaction, the
problem is the adverse effects caused by Febuxostat which may cause nausea and
severe dizziness.

3. Nutrition Intervention
Rationale for Nutrition Intervention
Recommendation Amount Rationale
Low sodium 1-2 g/day To minimize fluid retention
and helps to control blood
pressure and lessen
sodium overload in the
body.

Low Phosphorous 0.8-1.2 g/day To change the progression

Low Potassium
Fluid restriction
of kidney disease in order
to prevent severe long
term damage. It should be
supplemented with Vit B6,
C, folate, B12, Vit D and
Vit. E because of
increased losses.
2-3 g/day or 40 mg/kg Potassium is restricted as
kidney is no longer able to
excrete all potassium
ingested.
750-1000 mL/day To control fluid retention.

Increased Iron Intake To make RBC and help

anemia.
Kcal 35 kcal/day Adequate energy intake is
necessary to spare protein
for tissue protein synthesis
and prevent protein to be
metabolized for energy.
Low Cholesterol <300 mg/day To control and prevent
Hyperlipidemia as well as
the HDL level or the bad
cholesterol.

Dietitian’s Nutrition Prescription:

Prescribe Diet: Full low protein diet, Low salt diet, Low Potassium, Low Phosphorous,
Low purine and Low cholesterol
Nutrient Amount % Distribution Remarks Rationale
CHO 174 g 70 % Complex To maintain IBW
Carbohydrates and To control blood
limit simple sugar level
 Carbohydrates
CHON 80 g 1.2 g/kg/day High Biological High Biological Value
Value Protein. Protein to meet
dietary needs and to
increase serum
albumin and prevent
protein malnutrition.
Adequate protein to
maintain muscle
mass and serum
protein level
FAT 52 g 30 % Fat less than 30%, To protect kidneys
saturated fat less and heart from bad
than 10% ; and cholesterol, since
cholesterol needs these fats can raise
less than 300 blood cholesterol
mg/day levels and clog blood
vessels.

Meal Management:
 Diet Prescription TER/day: 1458 kcal
 CHO: 217 g; CHON: 54g; FAT: 41 g

Macro-nutrient Distribution
List Food Group No. Of CHO CHON FAT KCAL
Ex
I Vegetables 1 3 1 - 16
II Fruit 1 10 - - 40
III Rice A-Low Protein 7 161 0 - 644
B- Medium Protein 2 46 4 - 200
IV Meat Low Fat 6 - 48 6 246
V Fat 7 - - 35 315
Total 220 g 53 g 41 g 1461 kcal

Distribution of Exchanges per Meal

Food Groups No. of Breakfast AM Lunch PM Dinner Bedtime
Exchange Snack Snack Snack
Vegetables 1 - - 1 - - -
Fruit 1 - 1 - - - -
Rice A-Low 5 2 2 - 2 1 -
chon
Rice B-Medium 2 - - 2 - - -
Protein
Meat (LF) 6 2 - 2 - 2 -
Fat 5 5 - 2 - - -
 One Days Sample Menu
Meal Food Group No. of Menu
Exchanges
Breakfast Rice A - LP 2 Boiled Rice
Meat (LF) 2 Fried fish (use herbs and spices instead
of salt)
Fat 5 Olive oil for frying
AM Snack Rice A - LP 2 Unsalted crackers
Fruit 1 Small Apple
Lunch Rice B - MP 2 Boiled Rice
Vegetables 1 Cucumber Salad with Vinaigrette
Meat (LF) 2 Baked Chicken Breast w/ olive(no added
Fat 2 salt)
PM Snack Rice A - LP 2 Unsalted pretzels
Dinner Rice A - LP 1 Boiled Rice
Meat (LF) 2 Grilled skinless chicken (breast)

Breakfast: Lunch: Dinner:

- 1 cup Boiled Rice
- 2 slices Fried Fish (use
herbs and spices instead of
salt)
- 1 cup Boiled Rice - 1 cup Boiled Rice
- 1/2 cup Cucumber Salad - 2 Mbs Grilled Skinless
with vinaigrette Chicken (breast)
- 2 Mbs Baked breast
chicken with olive(no added
salt)

AM Snacks: PM Snacks:
- 2 pcs Unsalted crackers - 2 pcs Unsalted pretzels
- 1 Small Apple

Nutritional Recommendations:

Management Short Term Rationale Long Term Rationale

Parameter Recommendation Recommendati
on
Dietary Low Phosphorus To prevent build up Low oxalate diet To improve kidney
Diet in blood because disease since it is low
kidneys does not in protein which cause
working well. kidney not to work so
hard and it will help
through reducing the
protein intake.

Reducing the amount

of oxalate required for
absorption in your GI
tract
Dietary Low Potassium To prevent build up Low salt diet To slow the
Diet in the blood that progression of renal
cause serious heart disease and to control
problems. blood pressure level.
Help reduce fluid
weight gains between
dialysis sessions since
salt increases thirst
and causes the body
to retain fluid.
Dietary Nutrition Education To prevent and Dietary advice To help patient with
manage CKD and the diets that must be
ESRD to improve applied through meal
patients’ knowledge planning to achieve
and understanding health goal of patient
of low protein and with ESRD .
low sodium diet.
Motivates patient to
reduce their protein
intake
Dietary Low fat diet To decrease the bad Low Purine Diet To decrease and help
cholesterol level. control the uric acid of
Consumption of high the patient.
in saturated fats and
trans fats should be
avoided because it
can increase the
cholesterol level as
well as the LDL
cholesterol.

4. Nutrition Monitoring and Evaluation

 Enable the patient to eat a palatable, attractive diet that fits her lifestyle as much as
possible.
 Regularly check blood sugar and blood pressure level.
 Provide initial nutrition education and long-term monitoring of patients.
 Check the lab result for Serum BUN and serum Cr levels
 Monitor the diet of the patient, specifically low potassium, low phosphorus, low
sodium, low fat, low oxalate and low purine diet.
 Monitor the amounts of fluid and certain nutrients (potassium, phosphorus, sodium)
that a patient takes in each day.
 5. Conclusion
The patient is having End stage renal disease because of having some underlying
diseases which is type 2 diabetes and hypertension as well as having edema (L foot
and R hand) due to sodium overload in the body. She started hemodialysis due to
elevated Creatinine and uremic symptoms. Her diet also one of the cause why she has
kidney disease because of consuming salty food items like dried fishes. It was found out
also that her BUN is increased which also indicates that she has kidney failure.

6. References
Stephens, C. (sept 29,2018). Blood urea nitrogen test. Retrieved from:
https://www.healthline.com/health/bun
Weatherspoon, D. (Nov. 2 2018). Red blood cell count. Retrieved from:
https://www.healthline.com/health/rbc-count
Weatherspoon, D. (Apr 23, 2020). High potassium. Retrieved from:
https://www.healthline.com/health/high-potassium-hyperkalemia
Murrell, D. (september 17, 2018). Isoniazid calcium test. Retrieved from:
https://www.healthline.com/health/calcium-ionized
https://medlineplus.gov/druginfo/meds/a682627.html
https://www.healthline.com/health/spironolactone-oral-tablet#interactions
https://www.webmd.com/drugs/2/drug-841/atorvastatin-oral/details
https://www.webmd.com/drugs/2/drug-1023/epoetin-alfa-injection/details
https://www.rxlist.com/entresto-drug.htm#warnings
https://www.webmd.com/interaction-checker/default.htm?result=5574-
carvedilol%20oral,5166-ibuprofen
Carter, A. (Feb 27, 2019). What to know about diuretics. Retrieved from:
https://www.healthline.com/health/diuretics#types
https://www.healthline.com/health/kidney-health/kidney-disease-and-potassium#other-
nutritional-needs
Heerspink H.L., Ritz E. Sodium chloride intake: Is lower always better? J. Am. Soc.
Nephrol. 2012;23:1136–1139. doi: 10.1681/ASN.2012010099.
Rodríguez-Iturbe B., Vaziri N.D., Herrera-Acosta J., Johnson R.J. Oxidative stress,
renal infiltration of immune cells, and salt-sensitive hypertension: All for one and one for
all. Am. J. Physiol. Ren. Physiol. 2004;286:F606–F616. doi:
10.1152/ajprenal.00269.2003.
Cianciaruso B., Bellizzi V., Minutolo R., Colucci G., Bisesti V., Russo D., Conte G., De
Nicola L. Renal adaptation to dietary sodium restriction in moderate renal failure
resulting from chronic glomerular disease. J. Am. Soc. Nephrol. 1996;7:306–313.
Cianciaruso B., Bellizzi V., Minutolo R., Tavera A., Capuano A., Conte G., De Nicola L.
Salt intake and renal outcome in patients with progressive renal disease. Miner.
Electrolyte Metab. 1998;24:296–301. doi: 10.1159/000057385.