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Joyce, age 45, was admitted to the emergency room following a major automobile accident. She
had massive abdominal injuries and a fractured femur. She was taken immediately to surgery for
repair of a lacerated liver and perforated ileum. On the day after surgery, her urine output
declined to 15 ml/hroliguria. Increasing her body fluids with plasma expanders and blood did
not increase her urine output. Lab results indicated an elevated serum potassium levels, BUN 70
mg/dl, and serum creatinine 4 mg/dl. She was diagnosed as having acute renal injury but dialysis
was not initiated till now. Her usual weight is 67 kgs Dry body weight and her height is 160
cm.
1) What is acute renal injury (ARI)? What are the possible causes of ARI in Joyce’s
case? (1/1 point)
Acute Renal injury, also known as acute renal failure may be depicted as a sudden
reduction in glomerular filtration rate (GFR) which alters the ability of the kidney to
excrete the daily load of wastes (oliguria). Duration varies from a few days to several
weeks.
Possible causes for Joyce’s ARI:
Pre-renal as a result of circulatory collapse
Intrinsic: Acute tubular necrosis (as a result of trauma or surgery of her lacerated liver
and perforated ileum)
In this case, the main cause shall be attributed to a circulatory collapse as a result of
bleeding Massive abdominal injury and a broken femur reduced blood flow to
the kidney Pre-renal. Comment [JAK2]: Correct
2) What laboratory values indicate Acute Renal Failure in Joyce’s case? (Compare
with normal values.) (2/2 points)
mEq/L
o BUN 70 mg/dl compared to the normal value of 7-23 mg/dl
o Serum creatinine 4 mg/dl, the normal value is 0.6 – 1.5 mg/dl
All in all, Urine output < 400 ml/d coupled with Elevated BUN + Creatinine +
Serum potassium confirm Joyce’s diagnosis of Acute Renal Failure.
Prior to calculating Joyce’s energy needs, let us first compute her standard body
weight:
Standard body weight (female,45 years old, 160 cm in height and assumed as
medium size frame)62 kg
% SBW= (Dry Body weight/SBW) x 100= 67/62 x 100 = 108.06% within 95-115 Use
actual dry body weight in calculating her nutrient requirements:
BMI= Dry body weight (in kg)/ (height in m)2 = 67 kg/ (1.6 m)2 =26.17 kg/m2>25
kg/m2 falls within the “overweight” range.
Energy needs using the quick formula of 25-35 kcals/kg we shall start with 25
kcals/day25x67=1675kcals/day (as the patient falls within the overweight range).
4) How much protein, Na, K, Phosphorus and fluids should Joyce be approximately
consuming in the meantime? (1.5/1.5 points)
Sodium: 2-3 g/day
Potassium: 2-3 g/day (replace losses in diuretic phase)
Phosphorus : 8-15 mg/kg 536-1005 mg/Day
Fluid urine Output + 500 ml360 ml + 500= 860 ml/Day
Protein: 1.2 x 67 kg = 80.4 grams rounded to 80 g total 0.8-1.2 g/kg for Acute
kidney injury without dialysis
of which 50 – 60 % High Biological Value (dairy/milk/meat) 80 x 0.6 = 48 g/
7g/exchange= 6.86 rounded to 7 protein choices of HBV divided between 6 Lean
Meats and 1 Medium Fat.
The remaining protein shall consist of non-HBV (Non-starchy vegetables +
starches) 80 – 48 g = 32g divided into: 4 vegetables x 2 g protein/choice = 8g of non-
HBV protein
32 g- 8 g= 24 g/ 2 g protein/ starch exchange= 12 exchanges of starch x 15 g
CHO/exchange= 180 g CHO.
Fruit: 2 exchanges x 15 g CHO/exchange= 30 g
Moving on to computing the % of carbohydrate = 180 (starch) + 30 (fruit) + 20 (non-
starchy veg) = 230 g x 4 kcals/g= (920 kcal /1675kcal) x100 = 55%
5) Design a one-day dietary plan consistent with Joyce’s needs. (3.75/4 points)
Breakfast -2 starches = 2 slices of whole wheat bread
-1 lean meat=2 Tbsp Low fat labneh
-1 medium Fat= 1 hard-boiled egg
-½ cup blueberries- 1 low Potassium fruit
Milk1/2c
2 30 140 40
Low K
2 30 300 40
Medium
K
High K
2 140 30
Fruit
1 Trace 70 15
Low K
1 Trace 150 15
Medium
K
-
High K
Sub Total
Fat 4 x 55 4 4x5
15 g MUFA =220 x10=40 =20
MUFA 3 135
PUFA 1 45 5 g PUFA
Hi calorie
Beverage
1725 (a 81 g 230 g 49 g 1415 mg 1820 1005
little over Accep. Accept. Accep
Total EER due <2-3 g <2-3 g
to
estimation
error)
*Phosphorus within 536-1005 mg/day borderline
* As for beverages, ensure total intake of 860 ml/day may include unsweetened tea
depending on preference.