Michelle Srour

2016 Spring HNSC4240 Medical Nutrition Therapy

Case study 2 Chronic Kidney Disease

Date of admission: 3/24/2016

Client Name: Amber Joaquin
DOB: 5/3
Age: 60
Sex: female
Education: High School
Occupation: Retired food service
Household members: Widowed; lived by self
Weight: 191 lb
Height: 56
Ethnicity: African American

Patient history:
Patient was diagnosed with type 1 diabetes when she was 9 years old resulting in end-stage renal disease
15 years ago. Initiated hemodialysis at that time and received transplant from her sister 1 year later.
Transplant failed after 12 years resulted in re-initiation of hemodialysis two years ago. She is being
admitted to the ER due to DKA, blood glucose stabilized after IV fluids and insulin injection.
Medical history: Allograft transplant x1; hypertension; type 1 diabetes; dyslipidemia; anemia of chronic
kidney disease
Family History: Father- T1DM, lung cancer; Mother- Breast cancer
Tobacco use: No
Food Allergies: NKFA
Weight history: 175 lb ( 2/15/2016); 173 lb (12/10/2015); 172 lb (6/5/2015)

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

Laboratory values:
 Normal Patients value Units
Blood work
Sodium 136-145 130 L mEq/L
Potassium 3.5-5 6.2 H mEq/L
Phosphorus 2.3-4.7 9.5 H mg/dL
Calcium 9-11 8.2 L mg/dL
Albumin 3.5-5 3.7 g/dL
GFR >90 12 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 11 H %
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
Phos Lo (calcium bicarbonate) three times daily with each meal
Lipitor 20 mg daily
Regular insulin 1 unit/mL NS 40 mEq KCl/liter @ 300 mL/hr. Begin infusion at 0.1 unit/kg/hr =3.7
units/hr and increase to 5 units/hr. Flush new IV tubing 50 mL of insulin drip solution prior to connecting
to patient and starting insulin infusion.

Dietary recall:
Breakfast: 2% milk 1 cup, 2 small donuts, 1 sunny side egg
Lunch: Fried bologna sandwich (1 tbsp oil, 2 slices of whole wheat bread, 6 oz bologna, 2 slices
American cheese, 1 Tbsp mustard), 1 yogurt (2% fat), 1 small orange, regular coke 1 cup
Dinner: steak salad (pan-fried steak 6 oz, 2 Tbsp mayonnaise, 2 Tbsp sour cream, 1 tsp vinegar, 1 tsp salt,
tsp black pepper, 1 small onion, olive oil 1 Tbsp, 1 cup spinach, cup red peppers)
Snack: 2% milk 1 cup, orange juice 1 cup, 4 sugar cookies, peanut butter 2 Tbsp, lemon sorbet 1 cup

1. Based on her lab values, Mrs. Amber Joaquin does not manage her T1DM well. Ambers general

blood glucose is at 236 mg/dL and her fasting blood glucose is 150 mg/dL. This alone does not

determine Mrs. Joaquins T1DM, because it is possible that Amber may have forgotten her insulin this

morning or the night before. The patients HbA1C provides a more accurate marker of Ambers blood

glucose control, giving us an average over a 3 month period of Mrs. Joaquins blood glucose. Given
 that the HbA1c value is at 11%, along with a fasting blood glucose of 150 mg/dL and glucose of 200

mg/dL, way over the recommended level, the patient is not managing her T1DM well.

2. CKD is a syndrome of progressive and irreversible loss of the functions of kidney secondary to kidney

damage. More than 35% of people aged 20 years or older with diabetes have CKD. High glucose in

the blood causes the kidneys to overwork by filtering out excess glucose. In addition, AGES are

produced in diabetes. This can lead to leaky vessels and hardening of the renal tubules, which makes

the renal more vulnerable to rupture. This can increase oxidative stress and inflammation that can

damage the structure of the renal tubule and eventually lead to kidney disease.

3. Ambers dietary intake goals are very different having a kidney transplant from having a failed kidney

undergoing hemodialysis. After completing Ambers BMI, I recognized that she was obese with a

BMI of 30.8. I composed her IBW (100 + 5 * 6= 130lbs) which came out to 130 lbs. Her ABW (191-

130 * .25 + 130) then came out to n145 lbs. Ambers caloric intake must be between 1647 calories and

2307 calories both with a kidney transplant and with a failed kidney undergoing hemodialysis.

However, since Mrs. Joaquin is overweight, she may want to keep her caloric goals between 1647 and

1977 kcal a day to promote weight loss.

Post-kidney transplant, the patients protein intake must be at least 53g of protein and 26g being HBV

protein. Sodium should be equal to or less than 2400 mg, potassium and fluid are not restricted while

phosphorous is correlated to lab values. Given that Ambers phosphorus is incredibly high; her

phosphorus may be restricted or she may be required to take medication such as, phosphate binders.

When Mrs. Joaquin is undergoing hemodialysis her protein intake should be between 73 and 99g of

protein a day and about 50-60% of her protein should come from HBV protein. Sodium intake should

be between 2,000 and 3,000 mg a day, her potassium intake should be between 2,000 and 3,000 mg,

her phosphorous should be between 800 and 1000 mg, while fluid should be 1000 + urine output

however, it is highly individualized based on urine output.

4.

Food item Food group # of Calories Protein (g) Sodium Potassium (mg) Phosphorus (mg)

exchanges (kcal) (mg)

1 cup 2% Milk High-P Protein 1 75 8 85 200 80
2 small Donuts Breads and Rolls 2 250 6 150 110 80

1 egg High-Protein Foods 1 75 7 85 100 75

1 Tbs oil High Cal 1 125 0 50 50 50

2 slices whole wheat bread Breads/ Cereal 2 250 6 150 110 80

/Grains
6 oz bologna fried High-Na Protein 3 225 21 975 300 225
2 slices American cheese High-P Protein 2 150 16 170 400 400

1 Tbs mustard Flavorings 1 10 0 275 50 10

1 yogurt 2% High-P Protein 1 75 8 85 200 200
1 small orange High-K Fruit 1 60 0 5 400 10

1 cup regular coke High Cal 1 125 0 50 50 50

6oz Pan-fried steak High Protein 6 450 42 510 600 450
2 Tbs mayo High Cal 2 250 0 100 110 80
2 Tbs sour cream High Cal 2 250 0 100 100 100
1 tsp vinegar Flavorings 1 10 0 275 50 10
1 small onion Low-K Vegetable 1 55 2 25 85 40

1 tbs olive oil High Cal 1 125 0 50 50 50

1 cup spinach High-K Vegetable 2 110 4 50 800 80
cup red peppers Medium-K 1 55 2 25 200 40

Vegetable
1 cup 2% milk High-P Protein 1 75 8 85 200 200
1 cup orange juice High K Fruit 2 120 0 10 800 20
4 sugar cookies Bread/ Cereal/ 1 125 3 75 55 40

Grains
2 Tbs peanut butter High-P Protein 1 200 8 85 200 200
1 cup lemon sorbet High Cal 2 250 0 100 100 100

Total 3,495 142 3570 5120 2670

Firstly, Amber is eating a tremendous amount of calories which will most definitely lead to weight gain. In

addition her protein intake is high. Moreover, her sodium potassium and phosphorus is extremely high which is

correlated with her blood work. If Ambers diet continues this way she may experience may worsen her

hypertension, kidney and make her hemodialysis more difficult. It may lead to a failed fistula and severe

kidney damage. She may experience many other metabolic complications that may result in atherosclerosis or

even death.

5.

Exchange group # of Calories Protein (g) Sodium (mg) Potassium (mg) Phosphorus (mg)

exchanges (kcal)
High protein 4 300 28 340 400 300
High P protein 38 4 43 100 100
High sodium protein 3 225 21 975 300 225
Low K vegetables 2 110 4 25 170 80
Medium K vegetables 1 55 2 25 200 40
High K vegetables 1 55 2 25 400 40
Low K fruits 1 60 0 5 85 10
Medium K fruits 1 60 0 5 200 10
High K fruits
Bread/cereals 5 625 15 375 275 200
Calorie 1 125 0 50 50 50
Flavoring
Total 1653 76 1868 2180 1055

Exchange group Total breakfast lunch dinner Snack 1 Snack 2 Snack 3

Number of

exchange
High protein 4 1 3
High P protein 1/2 1
High sodium 3 2 1

protein
Low K vegetables 2 1 1
Medium K 1 1

vegetables
High K vegetables 1 1
Low K fruits 1 1
Medium K fruits 1 1
High K fruits
Bread/cereals 5 2 2 1
Calorie 1 1
Flavoring
Meal (breakfast, lunch, dinner or Food item Exchange group Number of exchange

snack)
Breakfast 1 egg High Protein 1
cup of milk High-P Protein
2 slices whole wheat toast Bread/Cereal/Grains 2
cup of tomatoes High K Veggie 1
Snack 1 1 apple Low- K Fruit 1
Lunch 4 oz Turkey Bologna High- Na Protein 2
2 slices of whole wheat bread Bread/Cereal/ Grain 2
1 cup of lettuce Low-K Veggie 1
Snack 2 cup of cottage cheese High Na Protein 1
1 Pear Medium-K fruit 1
Dinner 3oz Steak High Protein 3
cup of brown rice Bread/Cereal/Grains 1
1 small onion Low-K Veggie 1
cup of red peppers Medium-K Veggie 1
Snack 3 cup lemon sorbet High Cal 1

6. Based on the patients medical history, physical exam and laboratory values, Mrs. Joaquin is not a

good candidate for a kidney transplant. Given that Mrs. Joaquin was admitted to the ER due to DKA,

it is clear that Amber is not taking control of her T1D. Her lab values indicate extremly high blood

glucose, fasting blood glucose and HbA1C while her physical exam indicates cloudy eyes, all signs of

uncontrolled diabetes. In addition, the patient is experiencing muscle weakness and edema. A kidney

transplant is a highly invasive surgery; given that Mrs. Joaquin does not seem healthy she should not

be a candidate. Moreover, Mrs. Joaquins lab values indicate high K, high P, high protein high pH and

high WBCs. Amber is not following a healthy diet or a hemodialysis specific diet. She is not eating

correctly for someone with CKD thus may not eat healthy or follow a diet with the transplant as well.

Furthermore, Mrs. Joaquin has high blood pressure. Although a kidney transplant would be ideal for

Mrs. Amber Joaquins health, she is not a fit candidate. She is not healthy, nor is she fit to adhere to a

lifestyle modification (she is clearly incapable of doing so now). Mrs. Joaquin must first take care of

insulin injection for her T1D along with other modifications to take control of health.