Max Schroder

Thao Tran
3/12/18

Case Study #2: Case 19 (CKD Treated with Dialysis)

Answer the following questions:

Nutrition Assessment:
1. Ms. Joaquin’s labs were checked on admission before she started on hemodialysis. Provide a
rationale for the following abnormal labs (7 points):

Ref. Range 3/5 0700 Rationale

Sodium 136 - 145 130! Hyponatremia: Kidneys not able to regulate Na+ properly,
and cannot rid of excess water in the body. Fluid overload
correlated to low GFR rate (Zhang, 2017)

Potassium 3.5 - 5.1 5.8! Hyperkalemia: with renal failure, the kidneys cannot rid of
excess K+. In addition, pts taking ACE inhibitors can
exacerbate the problem (National Kidney Foundation,
2014)

BUN 6 - 20 69! Build-up of urea nitrogen due to damaged kidneys not

being able to clear kidneys (Nelms, 2016)

Creatinine 0.6 -1.1 F 12.0! Elevated levels of creatinine can indicate impaired renal
function, muscle damage, CKD, among others (Nelms,
2016)

BUN/Creatinine 10.0-20.0 5.75! High blood urea nitrogen can indicate dehydration,
ratio hypercatabolism, along with insufficient filtration in the
kidneys (Nelms, 2016)

Estimated GFR > 60 4! Low clearance rate due to minimally functioning kidney. A
GFR < 15 indicates dialysis or kidney transplant must be
pursued ASAP (National Kidney Foundation, 2017)

Glucose 70 - 99 282! High glucose can indicate uncontrolled DM, which can
lead to diabetic nephropathy if unchecked (Nelms, 2016)

Phosphate 2.2 - 4.6 6.4! High levels can lead to CKD, vitamin D intoxication, and
diurnal rhythm (Nelms, 2016)

Calcium 8.6 -10.2 8.2! Inadequate vitamin D can prevent calcium reabsorption in
the intestines (Nelms, 2016)

Albumin 3.5 - 5.5 3.3! Low levels of albumin can contribute to fluid overload,
chronic liver disease, along with protein loss in the urine
due to protein-energy malnutrition (Nelms, 2016).

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RBC 4.2 - 5.4 F 3.1! Low RBC count can be caused by anemia, bone marrow
failure, hemorrhage, iron deficiency, which which can lead
to chronic kidney disease (Nelms, 2016).

Hemoglobin 12 - 16 F 10.5! Low levels of hemoglobin can be caused by anemia, blood

loss, and CKD (Nelms, 2016)

Hematocrit 37 - 47 F 33! Anemia, blood loss, and CKD can be contributing to low
levels of hematocrit (Nelms, 2016)

2. What is Mrs. Joaquin’s estimated dry weight? (Hint: Current weight – weight gained in the
past 2 weeks = dry weight). (2 points)

170 lbs - 8.8 lbs = 161.2 lbs

3. Assume that Mrs. Joaquin has started hemodialysis. Calculate her calorie and protein needs
and provide recommendations for her daily sodium, potassium, phosphorus, and fluid
restrictions. Use Mrs. Joaquin’s adjusted body weight to calculate her energy and protein needs.
(5 points)

a) Adjusted wt: (Dry weight – ideal body weight) x 0.25 + ideal body weight
IBW: 100 lbs. + 5(0) = 100lbs
Adjusted weight: (161.2 - 100) x .25 + 100 = 115.3

b) Kcal: 1192 kcal (23 kcal/kg/day)

REE: 10W + 6.25H - 5A -161
REE: 10(52) + 6.25(152.4) - 5(24) -161
REE: 520 + 952.5 - 120 -161 = 1192 kcals

c) Protein: 42g (1.2-1.3g/kg/day) The higher amount of protein reflects the losses which will
happen with hemodialysis, as well as preventing protein energy wasting (PEW)(Nelms, 2016).
Mrs. J’s albumin lab showed a result of 3.3g/dL, which can mean inflammation or malnutrition
(American Association for Clinical Chemistry, 2018), hence the increased order of daily protein.
The doctor has recommended 1.2g protein, but it should be closely monitored to make sure Mrs.
J maintains a positive balance (Nelms, 2016).

d) Potassium: 2000 mg/day. Mrs. J’s lab of 5.8mEq/L is indicative of hyperkalemia, which can
cause heart arrhythmias, or cardiac arrest if left untreated (Nelms, 2016). We will therefore
restrict her K+ intake to 2g per the doctor’s orders.

e) Phosphorus: 1000 mg/day (Nelms, 2016) Mrs. J’s lab of 6.4mg/dL is indicative of
hyperphosphatemia, which impairs the activation of Vit. D (calcitriol). High P also results in

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decreased Ca2+ absorption in the intestines and an overall Ca2+/P imbalance. (Nelms, 2016).
We will therefore restrict P per doctor’s orders.

f) Fluids: 1 L/day (Nelms, 2016) The kidney’s role is to balance fluids, and if they are not
working properly, they won’t be able to get rid of waste, which makes the body retain fluids.
Mrs. J must follow this fluid restriction in order not to retain fluids, which would raise her blood
pressure., Fluid can also build up in the lungs, making it difficult to breathe (Davita, 2018), as
evidenced by Mrs. J’s shortness of breath. Alternatively, when Mrs. J undergoes hemodialysis,
she can experience hypotension due to a sudden drop in fluids (Nelms, 2016), so care must be
taken to make sure they she is hydrated properly.

4. Mrs. Joaquin would like to know if she has to follow the diet you recommended after she gets
discharged from the hospital. Explain to Mrs. Joaquin the consequences inadequate protein
intake and excessive sodium, fluid, potassium, and phosphorus intake. (5 points)

a) Inadequate protein intake: High biological value protein (lean meats, fish) is important
because of losses (10-12g/protein day, and 5-15g albumin/day) from hemodialysis
(Nelms, 2016). Proteins such as peanut butter, nuts, seeds, dried beans and lentils not
recommended due to high potassium and phosphorus content (National Kidney
Foundation, 2017a). Inadequate protein results in fatigue, greater risk of infections, and
weight loss (National Kidney Foundation, 2016). We would also recommend education
for Mrs. J in order for her to gain knowledge on HBV protein choices.

b) Excessive sodium intake: Although Mrs. J does not exhibit high sodium labs, she does
have comorbidities of high blood pressure Stage 3, (220/80) and a Hemoglobin A1c
value of 9.2%

c) Excessive fluid intake: The kidney’s role is to balance fluids, and if they are not working
properly, they won’t be able to get rid of waste, which makes the body retain fluids. Mrs. J must
follow this fluid restriction in order not to retain fluids, which would raise her blood pressure,
and fluid is building up in the lungs, making it difficult to breathe (Davita, 2018), as evidenced
by Mrs. J’s shortness of breath. Alternatively, when Mrs. J undergoes hemodialysis, she can
experience hypotension due to a sudden drop in fluids (Nelms, 2015).

d) Excessive potassium intake: Mrs. J’s lab of 5.8mEq/L is indicative of hyperkalemia, which
can cause heart arrhythmias, or cardiac arrest if left untreated (Nelms, 2015). To avoid severe
hyperkalemia, limiting high-potassium foods such as chocolate, avocado, banana, milk, and
refried beans is highly recommended (Nelms, 2016)

e) Excessive phosphorus intake: Mrs. J’s lab of 6.4mg/dL is indicative of hyperphosphatemia,

which impairs the activation of Vit. D (calcitriol). High P also results in decreased Ca2+
absorption in the intestines and an overall Ca2+/P imbalance. (Nelms, 2015)

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Billing and Coding:
5. Medicare pays for some MNT services provided by RDs. Answer the following questions:
a. Which MNT services are covered under Medicare?
Medicare Part B covers MNT for patients with kidney disease to meet with a Registered
Dietitian if a doctor refers them. Services would include:
● An initial nutrition and lifestyle assessment
● Individual and/or group nutrition therapy services
● Follow-up visits to check progress in managing diet (U.S. Centers for Medicare and
Medicaid Services, n.d.)

b. If Mrs. Joaquin were referred by her physician to an RD in an outpatient clinic, would the RD
be able to bill Medicare for any MNT services? (3 points)
Yes, these services are covered by Medicare Part B and the RD must accept these assignments.
As well, if the patient lives far from services, MNT is now covered through telehealth.

6. As part of your nutrition assessment, you assess the patient for malnutrition using the
A.S.P.E.N./Academy malnutrition framework. Answer the following questions: (4 points)?

a. Which information would you collect from the patient in order to conduct this assessment?
● Formal nutrition assessment, which includes Nutrition Focused Physical Exam, and
looking at labs to assess inflammation
i. Albumin lab <3.8g.dL (White, et al., 2012)
● Is there weight loss in the patient? If so, use the A.S.P.E.N. guide regarding interpretation
of weight loss as seen as a percentage over a period of time (White, et al., 2012)
● Is there insufficient energy intake?
● Is there fluid accumulation? (White, et al., 2012)
● Is there diminished functional status, such as diminished hand-grip strength? (Brown,
2010).

b. Does the patient meet any criteria for malnutrition based on the information provided in the
case study?
Mrs. J meets the following criteria:
- Inflammation assessment: Albumin lab value of 3.3g/dL
- Insufficient energy intake
- Unintended weight loss as evidenced by anorexia, N/V
- Edema (Probable)
- Diminished functional status: lethargic, muscle weakness. If she were permitted to
take a grip-strength test, it would probably indicate diminished function

c. If the patient met criteria for malnutrition, how would you ensure that the diagnosis is
appropriately documented in her medical record and the patient gets “coded” for malnutrition?
If patients meet criteria for malnutrition, the health care provider must use the

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 International Classification of Diseases (ICD-9) codes, prior to implementing
interventions (Malone and Hamilton, 2013)
● 260 - Kwashiorkor
● 261 - Marasmus
● 262 - Other, severe protein- calorie malnutrition
● 263 - Other and unspecified protein-calorie malnutrition
● 263.0 - Moderate malnutrition
● 263.1 - Mild malnutrition

Nutrition Diagnosis
7. Choose two high-priority nutrition problems and complete a PES statement for each. Please
use appropriate nutrition diagnostic terminology from Appendix C2 in your textbook. (3 points)

a. Limited adherence to nutrition-related recommendations (NB-1.6) related to the patient

not complying to dietary guidance as evidenced by poor food choices consisting of sugar
sweetened beverages, processed foods, foods high in carbs, and an overall lack of fruits
and vegetables.

b. Excessive carbohydrate intake (NI-5.8.2) related to her daily dietary choices as evidenced
food recall and increased glucose levels.

Nutrition Intervention
8. For each PES statement, establish an ideal goal (based on the signs and symptoms) and a list
of specific interventions and recommendations (based on the etiology). (6 points)

a. Mrs. J has not followed dietary advice since she was diagnosed with T2DM at the age of
13. It is possible that the dietitian didn’t meet Mrs. J at a point where Mrs. J felt
comfortable making changes. It is also possible that the dietitian directed Mrs. J to eat in
a manner that was too challenging for her. It is important that the patient feel empowered
to make changes that come from within them. It sounds like Mrs. J felt overwhelmed
with this new diet and gave up completely. We are going to work with Mrs. J to make
small changes over time, because we know what will happen if she feels overwhelmed.
We would specifically work with her to:
i. Find which quality proteins are accessible to her
ii. Find out which fruits and vegetables are available to her and which ones she
would eat (and feed her family)
iii. Ask her if she would be willing to substitute sugar sweetened beverages with diet
alternatives, or increase water intake (many times water is more expensive than
sodas in these areas)
iv. Educate her on the importance of maintaining a healthy diet to aid with her
treatment and CKD.

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 Ideal Goal: Have Mrs. J look at her dietary recall list alongside the National Kidney
Foundation’s Dietary Guidelines (National Kidney Foundation, 2017a) and have her list
1-2 small changes she can make and live with. Having the changes come from her will
give her a sense of empowerment for change. It could also open up the conversation
about whether she has access or the money to buy alternative sources of food. For
example, perhaps fish (not frozen breaded/prefried) is not an option in her local grocery
store.

b. Ideal Goal: Reduce daily CHO content. Again, in the Pima tribe in particular, over
40% of the women have Type 2 Diabetes, food insecurity is high and nutrition
interventions are not specific to the Pima Indians (Booth, 2017). From the literature, it
seems that doing nutritional interventions would be received better if done in a
community setting, incorporate community input, and have researched options for
“healthy nutritional and cultural foods” rather than one-on-one counseling (Satterfield,
2016). As evidenced below, Mrs. J is eating in excess of 325g of CHO each day, so there
is lots of room for improvement at every meal. Mrs. J should consider seeing a Dietitian
for further education to establish a diet plan in order to maintain her health.

Mrs. J estimated caloric needs are 1192 kcals.

45% (representing CHO) = 536.4kcals/4 kcals = 134g/day/ 3 meals = ~45g/meal

Usual dietary intake Food choices CHO content

Breakfast Cold cereal 15g

(assuming milk w/ cereal) 12g

Bread or fried potatoes ~30g

Fried egg 0

coffee 0

Lunch Bologna sandwich 30g

Potato chips 15g

Coke 40g

Dinner Chili con carne 30g

Indian Fry Bread (USDA, n.d.) 73g

Iced Tea (assuming sugar sweetened) ~30g

Crackers and Peanut butter 30g

Other Beer (1-2 daily) 14 - 28g

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 Total Carbs ~325g/day

9. Assume that Mrs. Joaquin is on hemodialysis. Using Mrs. Joaquin’s typical intake and the
prescribed diet (question 3), write a sample menu and explain the rationale for each change. Use
the Diabetic Exchange Lists in Appendix K1 to estimate the carbohydrate, protein, and calorie
content of your sample menu (15 points).

- Carbohydrates: Please provide a consistent amount of carbohydrates throughout the day.

- Protein: The diet recommended should provide adequate protein to meet the estimated protein
needs.
- Calories: Provide enough calories to meet her estimated needs.
- Electrolytes: You do not have to add up sodium, potassium, or phosphorus, but you should
recommend foods that are appropriate for patients on a renal diet. Try to add foods that are low
in sodium and potassium and limit high phosphorus foods.
- Fluids: When adding fluids, do not exceed Mrs. Joaquin’s fluid restriction

The sample menu listed below is a “best-case scenario” in which Mrs. J has made small changes
over time and has come to a point where she is open to making greater changes in her diet.
Usual Dietary Serving Type Calories Carbs Protein Rationale (Why are you
Intake Size of food (kcal) (grams) (grams) making the change?)

Example: 1 small 1 small Apple 60 15 0 Apple contains less

orange (4 oz) potassium than orange

Breakfast:Cold ¾c Cream of wheat 103kcals 20.5g 3g Cereals like cream of wheat,

cereal (¾ c corn flakes, rice cereal are
unsweetened) low in added sugar, K, and
P ( Kidney Diet Tips, 2018)

Bread (2 slices) or ½c Homemade 80 kcal 10g 2g Replaced the fried potatoes

fried potatoes (1 hash browns with soaked hashbrowns,
med potato) cooked with ¼ soaking first to get rid of
c onions and potassium, and adding in
peppers low P vegetables for
vitamins

1 fried egg 2 eggs Scrambled egg 156 ~0 12g Low in P, K, and cholesterol
(occasionally) whites kcals

Lunch:Bologna 1 sw ¼ c Tuna salad Bread: Bread: Bread: 12 grain bread has a lower
sandwich on 12 142 25.74g, 5g, glycemic index compared to

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 sandwich (2 grain bread kcals, Tuna: Tuna: white bread (Mofidi, 2012),
slices white with mayo, Tuna: 4.82g 8g tuna is an excellent source
bread, 2 slices lettuce (Spoek, 95.75 Total: Total: of protein
2018) kcals 30.56g 13g
bologna, Total:
mustard) 238kcals

Potato chips (1 oz) 2 cups Stove-cooked 62 kcals 12g 1g Avoid processed foods.
Popcorn with Popcorn is a healthy option
pinch of salt due to its low sodium
content

1 can Coke 8 oz Diet Ginger ale ~0g 0g ~0g Clear diet sodas, ginger ale
are low in P)
(National Kidney
Foundation,2017)

Dinner:Chopped 3.5oz Grilled chicken Chicken: Chicken Chicke Choose low in saturated fat
meat (3 oz beef) (per Green beans 296 : 0g, n: 13g, meats (chicken, fish, or lean
USDA kcals green green meat). Use herbs instead to
:1 Green beans: beans: salt
piece) beans: 4.56g 1g Add vegetables for a well-
½C 24 kcals balanced diet

Fried potatoes (1 ½ ½C Mashed 121 kcal 15g 1.5g soak and boil potato to
medium) potatoes (pinch reduce potassium, add herbs
salt) with Mrs. for seasoning
Dash seasoning

HS Snack:Crackers 1C fruit (grapes, 114 kcal 27.8g 1g Incorporate fruits into diet
(6 saltines) and total apple, to avoid high blood sugar
peanut butter (2 fruit blueberries, or levels; berries, pineapple,
pineapple) apple, and grapes are low in
tbsp) P
(Nelms, 2016)

Totals 1,193 151 g 47.5 g

kcals CHO PRO

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https://labtestsonline.org/tests/albumin

American Heart Association. (2017). How High Blood Pressure Can Lead to Kidney
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