Renal Assignment:

Case: Comment [JAK1]: Grade: 9.75/10

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/hroliguria. 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)

o Urine output decline to 15mL/hr: 15ml x 24 = 360 ml/day <500ml/ day

Oliguria as normal output is usually around 1.5 l/day Comment [JAK3]: You mean normal urine
o Elevated Serum Potassium level normal values should fall within 3.5 – 5.5 output

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.

3) Calculate Joyce’s energy needs (use quick method). (1.5/1.5 points)

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/day25x67=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 ml360 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%

% Protein = 80 g x 4 kcals/g = (320 kcals/1675)x100 = 19%

Moving to the remaining % for fat: 100 – (55 + 19) = 26%

SFA: 17 g x 9 kcals/g= (153 g/1675 kcals) x 100 = 9.13 % <10 % limit.
PUFA 10% limit  1675 kcals x 0.1 = 167.5 kcals/ 9 kcals/g= 18.61 g – 12 g = 6.61/5
g /exchange = 1.32 rounded to 1 exchange.
MUFA: 26 – (10 + 9.13) = 6.87 % x 1675 kcals =115 kcals/9 kcals/g= 12.78 g /5 Comment [JAK4]: Usually %MUFA should be
higher than %PUFA
g/exchange= 2.6 rounded to 3 MUFAs.

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

Snack 1 -2 starches = 1 English muffin

- 1 medium peach, sliced and cooked with
cinnamon spice-1 fruit Medium Potassium

Lunch -3 choice lean meat = 3 oz. cooked skinless

chicken breast
-3 choice of starch = 1.5 cup cooked rice Comment [JAK5]: 1 cup, 1 ex of rice is 1/3 cup
-1 PUFA= 1 tsp. vegetable oil (cooking)
-2 Medium K vegetable = 2 cups kale tossed in Comment [JAK6]: ½ cup kale is medium K so 2
exchanges are equivalent to 1 cup
lemon juice + 1 tsp olive oil
-1 MUFA = 1 Tsp olive oil for kale salad

Snack 2 -2 starches = 1 cup cocoa puffs- low salt, dry

cereal
Dinner -3 starches = 1.5 cup cooked pasta Comment [JAK7]: 1 cup same as rice
-2 lean meat-2 oz broiled fish
-2 MUFA-2 tsp canola oil for cooking
-1 cup low K Vegetable: 1 cup lettuce
-1 cup Low potassium Vegetable: 1 cup
cucumbers-tossed with lettuce in lemon
juice/balsamic vinegar no oil.
Food of Kcal Prot(g) CHO(g) Fat(g) Na(mg) K(mg) P(mg)
choice choices

Milk1/2c

Meat - 6 LM -270 -42 -12 g (SFA) 7 x 25 = 7 x 7 x 65

-5 g (SFA) 175 100= = 455
-1 MF -75 -7 700

Starch 12 960 24 180 12 g PUFA 12 x80= 12 x35= 12 x35

960 420 =420
Vegetable 4 100 8 20

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.