FScN 4665 - Medical Nutrition Therapy II – Spring 2014
Your Name and/or Name of Partner (if working with one):Courtney Leinen____________________________________________Andrew Eelkema____________________________________________University of Minnesota - Department of Food Science & NutritionFScN 4665 - Medical Nutrition Therapy II – Spring 2014Case 2100 PointsAdapted from Morrison, G., Stover, J. Case 1 Chronic Renal Failure: Advancing to Dialysis, in Integrative Systems and Disease, Chapter 11, Part III. pp. 350-359. Due Date: April 16, 2014Please be sure to do the following:Show all calculations, and explain your rationale. Calculations do not have to be typed.Answer all questions directly on this form. Type all answers (except calculations). Submit in hard copy in class on the due date. You will be deducted one point per day after the due date until the hard copy is turned in.You may work ALONE or with ONE other person. Do not share your work with other individuals beyond your group. If you work with a partner, you should hand in only ONE case with your name and your partner’s name clearly listed at the top of the first page. Some resources needed for solving the Case:Krause’s Food and the Nutrition Care Process, 13th edition. Chapter 36: Medical Nutrition Therapy for Renal Disorders.Lecture notes and supplemental readings posted under the class topic “Renal Disorders” in the Moodle site, particular the Chronic Kidney Disease notes and materials at the end of the note set.I have created two Excel files that will help you calculate AB’s current intake, and your recommended diet plan for AB. These are posted with the case on Moodle, and are labeled as follows:“Case 2 Worksheet for Analysis of AB’s Current Intake” - contains formulas that will help you evaluate AB’s current diet using National Renal Diet Food Lists“Case 2 Worksheet for Renal Diet Calculations” – contains formulas that will help you devise your renal diet plan for AB. The following note sets are from MNT-1. These are posted in the Moodle under “Reference Materials and Resources for Cases” “Selected FSCN 4665 MNT I Course Materials for your Reference”:Nutrition Assessment I-History and Physical ExaminationNutrition Assessment II- AnthropometryNutrition Assessment III-Biochemical/LaboratoryModule I: Nutrition Care Process, Nutrition Diagnosis and Medical Record DocumentationModule II: Energy, Protein, and Fluid Requirements in the Clinical SettingAcademy of Nutrition and Dietetics: Evidence Analysis Library Nutrition Guidelines on Chronic Kidney Disease. Link to EAL website is posted in MoodleWhite JV, Guenter P, Jensen GL, Malone A, Schofield M. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). JPEN 2012;36(3):275-283.KDOQI Guidelines: Nutrition in Chronic Renal Failure (PDF Download from National Kidney Foundation site).Brown, Compher, et al. ASPEN Clinical Guidelines: Nutrition Support in Adult Acute and Chronic Renal Failure. JPEN July 2010; 34(4):366-377. IDNT ManualPart I.AB, a 22-year-old Caucasian college student, presented to the emergency room with headaches and shortness of breath (SOB). He was admitted to the hospital for evaluation when he was found to have a blood pressure of 200/120 mm Hg and mild congestive heart failure (CHF). AB reports that over the past year, his weight has increased approximately 10 lb., although his diet has remained unchanged. He attributed this weight gain to decreased exercise and a busy class schedule.Past Medical HistoryAB has had no recent viral illness, sore throat, or upper respiratory infection. He has never had rheumatologic symptoms and has no family history of renal disease. He had a history of multiple streptococcal infections of the throat as a child, some of which were treated with antibiotics and some that went undiagnosed. He is currently not taking any medications, vitamins, minerals, or herbal supplements, and has no known drug or food allergies.Social HistoryAB’s roommate at the dorms is a fellow student in good health. AB denies alcohol, tobacco, or oral drug use. AB’s 24-Hour Diet HistoryBreakfastCoffee, 8 oz, brewed strongWhole milk,? cup, heated, and mixed with coffeeFried egg, 12 slices whole wheat toast with 2 Tbsp ButterOrange juice, 8 ozLunchCheese burger (3 oz burger, white bun, 1 oz cheddar cheese)Potato chips (2 oz)1 medium bananaCoke, 12 ozSnackPretzels, 1.5 ozCoke, 12 oz CokeDinner1 cup cream of mushroom soup made with milkBaked potato,1 medium with 2 Tbsp Butter and 1/8 tsp season saltSteamed broccoli, 1 cupSmall salad made with iceberg lettuce, 1 cup total with 2 Tbsp Wishbone Italian dressingSnickers bar, 2 ozCoke, 16 ozSnackDry roasted salted peanuts, 1 ozCoke, 12 ozReview of SystemsGeneral: Fatigue, weakness, SOBGI: AnorexiaPhysical ExaminationVital signs:Temperature: 97° FHeart rate:96 beats per minute (BPM)Respiration: 24 BPMBP: 200/120 mm HgGeneral: well-developed manLungs: decreased breath sounds with faint crackles at the right baseCardiac:regular rate and rhythm, systolic murmur at the apex, S3 gallopAbdomen:Soft, nontender, no hepatomegalyExtremities: 3+ peripheral edema on both legs, ring tight on fingerSkin:Warm to touchNeurologic:Intact, mild asterixisAB is 5'9" tall. His current weight is 77.3 kg.; Usual body weight (UBW): 70.5 kg. (6 mo. ago). Standard body weight by NHANES tables: 78 kg The following lab work was done:Urinalysis: Protein 1+, 3+ hemeLab TestResultNormal RangeNa+135 mEq/L136 – 145 mEq/LCl-111 mEq/L95 – 107 mEq/LK+5.8 mEq/L3.5 – 5.0 mEq/LBUN108 mg/dL8 - 25 mg/dLCr14.0 mg/dL0.8 - 1.2 mg/dL (men)Phosphorus10.2 mg/dL2.6 - 4.5 mg/dLCalcium7.5 mg/dL8.5 - 10.8 mg/dLAlbumin3.2 g/dL3.5 - 5.0 g/dLMCV70 fL80-100 fLHct24.3%42 - 52% (men)Hgb8.3 g/dL14 - 18 g/dL (men)CO215 mEq/L24-32 mEq/LTransferrin saturation18%>20% (CRF)Ferritin142 ng/mL>100 ng/mL (CRF)WBC8.7 x 109/L4.5-11.0 x 109/LUrinalysisUrinalysis reveals blood and protein, indicating renal glomerular damage. RBC casts are highly suggestive of glomerulonephritis, and broad waxy casts suggest dilated renal tubules associated with chronic glomerulonephritis (CGN).24-Hour Urine CollectionThis procedure reveals the quantity of protein and creatinine excreted over 24 hours. If the amount of urinary creatinine can be measured in a 24-hour urine specimen, a creatinine clearance can be calculated.Protein Excretion2.2 g per 24 hours, normal value <200 mg per 24 hours Creatinine ClearanceEstimation of creatinine clearance can be calculated using the MDRD equation. AB’s estimated creatinine clearance = 9.05 mL/minNormal creatinine clearance for a male = 97–137 mL/minRenal UltrasoundRenal ultrasound revealed small kidneys bilaterally, which indicate irreversible renal disease (9 and 10 cm, right and left, respectively). Only a renal biopsy could actually confirm the dx of CGN, but it is not performed once small kidneys are identified since no treatment can reverse the kidney damage. AB’s significantly increased serum phosphate and decreased serum calcium suggest that the GFR is less than 30 mL per minute, indicating significant renal dysfunction. His estimated creatinine clearance in fact suggests that the GFR is below 10 ml/min.Tests to eliminate other possible causes of CGN include the following. Complement LevelsCH50, C3, C4 are all WNL (makes the dx of membranoproliferative disease, subacute bacterial endocarditis, an acute poststreptococcal glomerulonephritis highly unlikely). 24-Hour Protein CollectionEliminates the dx of nephrotic syndrome. AB’s hx and physical examination eliminate other causes of CGN, such as Alport’s syndrome. As a result of all the diagnostic tests, and in light of his physical examination, biochemical, and other medical data, AB is diagnosed with chronic glomerulonephritis (CGN) and stage 5 CKD. 24-hour urine collection revealed that AB’s urine output is approximately 750 ml/day. His nephrologists informs AB that he needs to be treated with dialysis. He decides, with his physician, that he will go on CAPD when he is discharged to home. The regimen will be: four 2-liter 1.5% PD exchanges daily. UNDERSTANDING THE PATHOPHYSIOLOGY:Based on AB’s history, explain the most likely cause of his CGN. (2 points)Many of the common causes have been ruled out; the exact cause cannot be determined with any certainty from the remaining possibilities, given that the diagnostic science is still under development. However, given AB’s history of untreated strep infections as a child, the most likely possibility is some form of IgA nephropathy: current research suggests that a past episode of acute glomerulophritis may resolve without further symptoms only to recur years later as chronic glomerulonephritis; given AB’s history of untreated strep infections as a child, this is a real possibility here. Glomerular damage results from IgA settling in the kidneys; the first sign is usually blood in the urine, which AB exhibits considerable amounts of. IgA nephropathy is one of the most common causes of CKD not caused by complications from diabetes or hypertension. 25% of adults living with IgA nephropathy develop ESRD.11. the pathophysiology that is most likely driving AB’s hypertension and edema. (2 points)Two separate pathways likely drive AB’s edema, both related to his impaired kidney function. First, his decreased glomerular filtration rate (GFR) will impair his ability to excrete sodium and water; as he takes in more water than he can excrete (his urine output is only 750 ml/day), it will buildup in circulation, and the extra hydrostatic pressure will drive it out of circulation into the interstitial spaces, resulting in edema. Second, his damaged nephrons have created excess glomerular permeability, which is driving his proteinuria. Although his slight hypoalbuminemia may be explainable by dilution of serum, it is likely that he is experiencing albuminuria as well. This is indirectly driving edema by decreasing plasma volume (as fewer suspended proteins retain less fluid in circulation), which causes release of anti-diuretic hormone (ADH), which will in turn cause further retention of water and sodium, eventually actuating edema in the same way as decreased GNUTRITION ASSESSMENTAnthropometric and PE DataWhich body weight will you use as the most “accurate” weight to reflect his “actual” or “dry” (i.e. ‘edema-free’) body weight for your assessment? EXPLAIN your thinking, using support from AB’s physical examination data and any other relevant information from AB’s medical data and history. (2 points)AB’s UBW is 70.5 kg, and the standard weight for his height by NHANES data is 78 kg. Thus, his UBW is (70.5/78)x100 = 90.3% of standard body weight. According to the KDOQI guidelines, we should therefore adjust his edema free body weight for determining nutritional needs.Adjusted Bwef = 70.5 kg + [(78 – 70.5) x 0.25] = 72.4 kg72.4 kg is the weight we will use for determining AB’s nutritional needs.It should be noted that AB’s reported weight gain of 10 pounds in one year is ostensibly explicable as a normal consequence of college living and a changing metabolism. However, given his very high blood pressure, notable edema, and reports of a consistent diet, it is reasonable to assume that the majority of this 10 pound gain is attributable to retained fluid.Evaluate the weight you chose in #3 by calculating AB’s BMI at that weight. Into which category does AB fall, based upon the National Institutes of Health, National Heart, Lung, and Blood Institute’s Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, which was provided in the “Nutrition Assessment II: Anthropometry” notes in FSCN 4665? (2 points)72.4 kg / (1.75 m)2 = 23.6A BMI of 23.6 places AB in the “normal” range of 18.5 – 25.0Evaluate AB’s edema-free body weight (identified in #3) in terms of % of the standard weight determined by NHANES tables (this was provided in the case scenario). (2 points)(72.4 / 78) x 100 = 92.8%AB’s adjusted edema free body weight is 92.8% of standard weight for his height according to NHANES data.Do you intend to adjust his edema-free body weight, or use it as it is, for your assessment of nutrient needs? Explain the rationale for your choice. If you do intend to adjust his weight, go ahead and calculate it here. (2 points)As calculated in question 3: because AB’s UBW, or normal edema-free BW, is <95% of standard weight for his height according to NHANES data, the KDOQI guidelines indicate that we should adjust his edema free body weight. As before:Adjusted Bwef = 70.5 kg + [(78 – 70.5) x 0.25] = 72.4 kgThis adjusted edema free BW of 72.4 kg is the weight that will be used to calculate his nutrient needs.Biochemical DataExplain what is happening to AB’s calcium-phosphorus balance. Explain the pathophysiology driving any abnormalities that you observe in his serum concentrations of calcium and phosphorus. Discuss what you know about the role of PTH and vitamin D. How might renal osteodystrophy result if these abnormalities remain untreated? (6 points)PTH is usually released in response to low serum calcium and high serum phosphorous. This stimulates bone resorption of calcium, along with increased reabsorption in the kidneys. Further, PTH stimulates the production of the active form of Vitamin D in the kidneys, which will also increase serum calcium levels by increasing gastrointestinal absorption of dietary calcium. PTH also stimulates renal excretion of phosphates. The net result under normal conditions is the normalization of serum calcium and phosphorous balance.Under CKD conditions, such as AB is experiencing, the kidney is unable to excrete phosphorous properly, and PTH is released to counteract this. In early CKD, serum phosphorous levels are maintained, but at the cost of chronic hyperparathyroidism. PTH action is further altered by the fact that kidney insufficiency results in a deficiency of active vitamin D, which limits GI capacity to absorb dietary calcium. Calcium levels are maintained by increased renal reabsorption and resorption from bone.As the kidneys fail and serum P rises, calcium-phosphorous precipitates will form, removing calcium from circulation, resulting in metastatic calcification of joints and soft tissues and further PTH release. This chronic PTH release can result in osteodystrophy; precipitates form in soft tissue, and bones are demineralized by excessive osteoclast activity and become fibrous and brittle.Discuss the interventions required to normalize serum calcium and phosphorus values in CKD patients. Indicate the order in which the interventions should be initiated, and explain why. (4 points)- First, dietary phosphorous intake must be restricted to retard progression of renal failure; limiting dietary P to 12mg/g protein, or 800-1,000 mg/day, as soon as elevated serum phosphorous levels are observed, may retard progression of CKD.- Successfully restricting dietary phosphorous should reduce serum levels of phosphorous; supplemental calcium should ben given once the Ca-P product < 55.- Phosphorous binders may be taken with meals to help maintain serum P within a normal range; usually these binders are calcium based. This will form precipitates that will not be absorbed, and thus calcium taken as a phosphorous binder will not contribute to dietary intake.- Supplemental calcium to raise serum levels into target range should therefore be taken separate from meals. No more than 1,000-1,500 mg/day should be taken, and supplementation should not be initiated until serum P levels are < 6-7 mg/dl, to prevent metastatic calcification by calcium-phosphate precipitates.- Early restriction of P and supplementation of calcium may prevent secondary hyperparathyroidism.Indicate which lab values suggest that AB is anemic. What is the most likely reason for AB’s anemia? (4 points)AB’s hemoglobin levels suggest that he is anemic: his serum levels are 8.3 g/dl, whereas a normal range is 14-18 g/dl. His anemia is most likely caused by his renal dysfunction: as a clinical manifestation of uremia, uremic waste built up in the bloodstream will increase destruction of red blood cells (RBC); impaired kidney function will also reduce production of erythropoietin, which will limit physiological capacity to replace RBC.Dietary Intake DataUsing AB’s dietary intake data:Keeping in mind dietary recommendations for individuals who have CKD who will be on peritoneal dialysis, evaluate AB’s diet PTA using the National Renal Diet Food Lists, where possible, in light of the 1) phosphorus and 2) protein content. Use the “Case 2 Worksheet for Analysis of Abs Current Intake” Excel file posted along with the case to calculate the values, being careful not to disturb any of the cells containing equations or formulas! The first tab “Convert Diet into Food Groups” is where you will find his dietary information entered and you will need to translate each food into servings from the various food groups given to you at the end of the CKD notes (Table 34.2 “Average Calculation Figures for Planning the Diet for ESRD”). The second tab “Nutrient Calculation Sheet” in the above named Excel file will allow you to calculate the nutrients from the various food list categories you determined from the worksheet at the first tab. You just have to enter in the number of servings of each of the food groups and it will tally the phosphorus and protein (and you can also see the sodium, potassium, and kcal content if you’re interested but you don’t have to do anything with that information for this exercise). For cream soup, Snickers, and peanuts (which are not clearly found on the Food Lists), I have entered in the phosphorus and protein values for you. The Excel file is set up to give you a grand total of phosphorus and protein (including these three foods) highlighted in yellow. Report the value you obtain for the grand total of protein and phosphorus in AB’s diet below. If you prefer not to use my Excel worksheet, you can do your calculations by hand. AB’s Estimated Current Phosphorus and Protein Intake: (4 points)Phosphorus1318 mgProtein71 gHow many kcals will AB likely absorb per day from the CAPD dialysate solution? Show your calculations. (3 points)Under AB’s CAPD regimen, he will receive a 2L exchange of 1.5% dextrose dialysate, four times/day. Typical absorption of dextrose calories for dialysate during CAPD is 60%. Therefore:(4 exchanges)(2000 ml)(1.5% dextrose)= 0.15 x 8000 ml = 120 g dextrose;(120 g dextrose)(3.4 kcals/g) = 408 kcals(408 kcals)(0.6) = 245 kcals absorbed from CAPD regimenOnce you have estimated AB’s current intake, you should compare it to the recommended dietary intake strategies you would make for AB, now that he will be on peritoneal dialysis (CAPD).First, specify the recommendations you would give to AB appropriate for PD with regard to total daily intake of kcals, protein, phosphorus, supplemental calcium and vitamin D, sodium, fluid, and potassium, showing all relevant calculations. Refer to your CKD class notes to formulate your recommendations, and be specific in terms of total quantities. Be sure to think carefully about which weight you will use for your assessment. (8 points)Energy:(35 kcals/kg) x (72.4 kg adjusted Bwef) – 245 from CAPD = 2290 kcals/dayProtein:Protein needs are >1.3 g pro/kg of Bwef72.4 kg x 1.3 = 94 g protein/dayPhosphorus:< 12 mg/g pro, or 800-1,000 mg/day12mg x 94 g pro = 1,128. This is in excess of the more conservative KDOQI recommendation. So, phosphorous will be restricted to > 1000 mg/daySupplemental calcium and vitamin D:Once Ca-P product is < 55, supplement with 1 – 1.5 g calcium a day as needed. Total daily intake must be < 2 g. Treatment goal isto maintain serum calcium concentrations within normal range: currently, AB’s serum calcium is7.5 mg/dl compared to a normal range of 8.5 – 10.8 mg/dl.Vitamin D supplementation provided as calcitriol if warranted.Sodium: Sodium will be restricted to < 1,500 mg/dayPotassium:Guidelines indicate 39 mg/kg Bw, or 2-3 g /day.(39mg/kg) x (72.4 kg) = 2,823 mg.Potassium will b restricted to < 2,825 mg/dayFluid:Fluid intake should be between 2-3 L/day based on AB’s CAPD regimenNow assess AB’s current dietary intake further, identifying ‘problem areas’, i.e. high sodium, high potassium, and high phosphorus foods/beverages that AB is consuming. Then evaluate his current dietary intake in specific terms for phosphorus and protein intake (from your calculations in question # 10), by making a comparison to what AB should be consuming in order to be in compliance with the recommendations for nutrition management with PD. Current intake vs. recommended intake: High-sodium foods/beverages that AB is currently consuming (2 points)Dry roasted, salted peanuts contain roughly 230 mg sodium /ounce; this could be reduced by substituting unsalted peanuts, which contain only 5 mg/ounce.Similarly, although the type of butter AB uses is not specified, salted butter contains 82 mg sodium/tbsp., while unsalted butter contains only 2 mg sodium/tbsp.Finally, AB could reduce excess sodium by omitting the 1/8 tsp. of season salt, which contributes 250 mg sodium.Beverages are not contributing substantially to AB’s sodium intakeHigh-potassium foods/beverages that AB is currently consuming (2 points)High potassium foods Ab is currently consuming are: baked potato, orange juice, and banana, averaging 270 mg K each for 1,080 mg K for just these four items. He does not need to restrict potassium while on CAPD though.High-phosphorus foods/beverages that AB is currently consuming (2 points)The simplified exchange counting method indicates that AB is within guidelines for P intake. However, when the true amount of P in cola is used (55 mg/12 oz), AB is in excess of recommendations.Reduction or total omission of soda consumption is therefore a priority target for reducing phosphorous intake; AB’s 52 ounces of daily intake are contributing about 240 mg P!If further restriction proves necessary, the high phosphorous foods in AB’s diet are the fried egg, the cheese, and the milk in the coffee. Substituting creamer for whole milk could save over 80 mg P, though at the cost of some protein.Current phosphorus intake compared to recommended intake (give specific numbers for comparison, and evaluate if too high, too low or acceptable) (2 points)AB’s current phosphorous intake is estimated at 1318.mg day, which is in excess of the dietary management recommendations of < 1,000 mg/day. This is contributing to his observed elevated serum phosphorous levels, which must be reduced. He must reduce his intake below 1,000 mg day, and possibly further, in order to normalize serum P levels.Current protein intake compared to recommended intake (give specific numbers for comparison, and evaluate if too high, too low or acceptable) (2 points)Current intake is only 56.5 g pro/day, compared to a recommendation of 94 g /day, or only 60% of recommendations. This is too low, and should be increased to prevent protein malnutrition complications during CAPD. NUTRITION DIAGNOSISRefer to the Jensen article (Jensen GL, Hsiao PY, Wheeler D. Adult Nutrition Assessment Tutorial. J Parenter Enteral Nutr 2012;36(3): 267-274.) and the ASPEN/Academy Consensus Statement (White JV, Guenter P, Jensen GL, Malone A, Schofield M. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). J Parenter Enteral Nutr 2012;36(3):275-283.) to determine if AB meets the definition of a specific category of malnutrition. Explain your rationale. (2 points)AB does not meet the criteria for a diagnosis of malnutrition. His BMI is within normal ranges, his intake is consistent and well above 70% of recommendations, and physical assessment reveals no signs of muscle wasting or unexpected weight loss.Based on what you discovered in earlier questions, identify TWO of AB’s most prominent nutrition-related problems using the standard Nutrition Diagnostic Terminology and INCLUDE the CODE # from the IDNT manual for each nutrition diagnosis you write. Nutrition Diagnosis #1: (3 points)NB-1.1: Food and nutrition related knowledge deficitNutrition Diagnosis #2: (3 points)NC-2.2: 10760: Altered nutrition-related laboratory values: altered serum Ca and P values, with a dangerous Ca-P product of 76.5For each nutrition diagnosis, write a complete nutrition diagnostic statement in PES format (problem, etiology, signs and symptoms), labeling each section (P, E, and S) appropriately. PES #1: (3 points)Patient has a food and nutrition related knowledge deficit, related to his previous unawareness of his chronic glomuerulonephritis, as evidenced by his new diagnosis of stage 5 CKD, and his typical diet being poorly matched to management of CKD, with excess P, K and Na consumption.PES #2: (3 points)Patient has altered nutrition related lab values, related to his impaired kidney function due to CGN and end stage CKD, as evidenced by depressed serum calcium levels (7.5 mg/dl versus a normal range of 8.5-10.8 mg/dl) and elevated serum phosphorus levels (10.2 mg/dl versus a normal range of 2.6-4.5 mg/dl)NUTRITION INTERVENTIONPrepare yourself for providing nutrition education and counseling to AB. Thinking back to your evaluation of AB’s dietary intake data from question #12b, identify at least 5 foods/beverages in his current diet that he could change in order to better comply with the renal dietary restrictions you have recommended. Be sure to explain why each particular food or beverage is a problem. Suggest possible substitutions for each of these problem areas that AB could make in order to accommodate the dietary restrictions he needs to follow. (5 points)The first food we would recommend changing in AB’s diet is the orange juice. The orange juice is high in potassium and can be substituted with a lower potassium juice like cranberry or grape. Another high potassium food that can be substituted is the banana. A lower potassium option is blueberries. Making both of these changes will help AB lower their potassium by about 400 mg. The baked potato that AB ate is also high in potassium and can be substituted with summer squash, which saves 120 mg. Keeping a low potassium level for patients is most important if the patient is on hemodialysis or hyperkalemic, however keeping a low potassium level will help the patient by decreasing the risk of constipation while restricting other dietary needs.The dry roasted, salted peanuts are high in sodium and if substituted for unsalted peanuts will reduce the daily sodium intake by 225 mg. Keeping sodium levels low is important because restricting sodium can decrease fluid retention and hypertension, as well as prevent excessive thirst while restricting fluids.The Coca Cola that AB drinks should be replaced with water, as it is high in phosphorus. This substitution reduces the phosphorus intake by 240 mg. Keeping phosphorus low for this patient is important to retard progression of renal failure and CKD.Explain to AB (in easy-to-understand, lay language) why you want him to follow the recommendations you made for protein, phosphorus, calcium, vitamin D, and sodium. (5 points)Protein: You have to be getting enough protein because your body needs it to fight infections and heal wounds. It’s especially important to get extra protein when your on dialysis, for a few reasons: your body is already deficient in some proteins because you’ve been losing them in the urine; getting more will help restore what you’ve lost. Also, you lose some protein every time you have a dialysis flush, so you have to be getting extra to make up for that extra loss.Phosphorus: Too much phosphorous in your diet leads to too much in the blood, and that’s dangerous: it leads to soft, brittle bones and will make your kidneys deteriorate faster. We need to limit it in your diet in order to prevent high levels in the blood. This will help preserve what kidney function you still have for as long as possibleCalcium: Too little calcium in the blood will cause your bones to give up their calcium to make up the difference. Over time, this can lead to soft, brittle bones that break easily. The other reason we take calcium is to prevent some phosphorous absorption; calcium you take with meals will bind to the phosphorous in that meal, preventing you from absorbing both of them. That’s why you also take calcium separate from meals, so that dose can actually be absorbed.Vitamin D: One of the kidney’s jobs is to make the active form of vitamin D. Because your kidneys are damaged, they can’t make enough. This is why you need to get supplemental vitamin D in the diet. Too little vitamin D can make it hard to absorb other important nutrients like calcium, cause general aches and pains, and exacerbate your high blood pressure.Sodium: Because of your kidney disease, you’ve developed dangerously high blood pressure. Sodium acts to increase blood pressure by making you retain water, so there’s more fluid in your circulation, causing more pressure. This pressure can be dangerous, leading to heart attack or stroke. Limiting sodium in the diet will help to bring your blood pressure back down to a normal, healthy level.Follow-UpAB did fairly well on CAPD for 3 months until he began to have difficulty with the draining of PD fluid through his dialysis catheter. He had repeated doses of a thrombolytic agent infused into the catheter in an attempt to dissolve the proteinaceous material, with only minimal success. He eventually had a new catheter inserted that only worked temporarily before the same problem developed. He was subsequently readmitted to the hospital for an HD catheter and started regular outpatient hemodialysis treatments. At that time his urine output had declined to less than 200 mL per 24 hours. AB has requested that you (the RD) now provide him with a more detailed diet plan that he can follow.Calculate a meal pattern for AB in compliance with the dietary recommendations for individuals on hemodialysis. Start by calculating his nutrient needs for HD (including protein (total and HBV), kcal, fluid, sodium, phosphorus, and potassium. NOTE that there may be important differences between what you recommended previously for AB when he was on CAPD compared to what you recommend for him now that he is on hemodialysis. Please show your work in the space below, and write in your numbers on the following page. (6 points)Protein (total and HBV)HD requires 1.2+g/pro/kg BWef /day: (72.4 kg) x 1.2 g pro/kg BWef = 87 g pro/dayat least 50% of this, or 43.5 g, should be High Biologic Value (HBV) proteinKcal30-35 kcals/kg BWef /day,or:(72.4 kg)(30 kcals/kg) = 2172(72.4 kg)(35 kcals/kg) = 25342172 – 2534 is an acceptable range according to the KDOQI guidelinesassuming his weight was stable under the CAPD regimen of 2353 kcals/day, and because AB is on the low end of the normal weight range, it is reasonable to formulate a diet based on the high end of this range, or 2535 kcals/dayFluidHD will require greater fluid restriction than CADP; guidelines state that urine output + 500-1,000 ml/day is appropriate. So,200ml + 500-1,000 ml = 700–1,200 ml/daySodiumSodium is to be restricted to the same level as under CAPD: 1,500 mg/dayPhosphorusPhosphorous is to be restricted to the same level as under CAPD: 800-1,000 mg/dayPotassiumUnder hemodialysis, the proper guideline is 2-3 g potassium/day. By the molar equivalent for protein, AB should take in: (39 mg/g pro)x(87 g pro) = 3,454 mg K/day. This in excess of the guidelines, so K is restricted to 3,000 mg/day Diet Rx:____87__ g protein, with at least__44__ g HBV protein__2535__ kcal700-1,200 ml fluid_1,500__ mg Na+_1,000__ mg phosphorus__3,000__ mg potassiumAverage Calculation Figures for Planning ESRD Diet (REVISED)Food ChoicesProtein (g)Na+ (mg)K+ (mg)Phos (mg)KcalMilk and Dairy4.08018511060**Almond Milk (1/2 cup)0.576601046 Soy Milk (? cup)3.5451656040Nondairy Milk Substitutes0.5408030140Meats7.0251006565*Tofu (? cup)10.01015012095 *Legumes (? cup)8.0-340130110*Peanut butter (2 Tbsp)8.015023010095Starches2.080353590Vegetables Low K+ 1.015702025 Medium K+ 1.0151502025 High K+ 1.0152702025Fruits Low K+ 0.5Trace701570 Medium K+ 0.5Trace1501570 High K+ 0.5Trace2701570FatsTrace5510545High-Calorie ChoicesTrace15205100Salt Choices----250------------** NOTE: In your handout from the Manual of Clinical Dietetics, the average kcals listed for the milk and dairy group is 120 kcals for a ? cup serving. This is an averagebased upon a wide range of products that fit in this group. If you simply plan for the consumption of 2% milk, use 60 kcals. Refer to complete food lists in CKD notes packet for serving sizes of foods withineach group. *These are only a few choices for vegetarians. Refer to information in the CKD notes packet on planning vegetarian renal diets.A. Baseline Calculations: Determine the number of servings in each food group based on the diet prescription. Calculate the nutrient values and add to get the subtotals. NOTE: IT IS ACCEPTABLE TO BE WITHIN ± 100 mg Phosphorus, ±100 mg Potassium, ±50 Kcal, ±1 g Protein, and ± 500 mg Sodium of your goal targets in your calculated pattern. (6 points)*Relevant for vegetarian meal plan or in specific circumstances based on diet recall onlyFood Choices# ServingsProtein (g)Na+ (mg)K+ (mg)Phos (mg)KcalMilk and Dairy*Soy MilkAlmond Milk211521202092Nondairy Milk SubstitutesMeats963225900585585*Tofu *Legumes*Peanut Butter*Other non-meat ________Starches1020800350350900Vegetables Low K+ 22301404050 Medium K+ 11151502050 High K+ Fruits Low K+ 10.5Trace701570 Medium K+ 10.5Trace1501570 High K+ SUBTOTALS881,2221,8801,0451,807Next, determine number of fat and high-calorie servings based on caloric needs and calculate nutrient values. Keep in mind that you may not need to add any high-calorie choices. Total values and adjust number of servings as needed to meet caloric needs and patient’s food preferences. (2 points)Food Choices# ServingsProtein (g)Na+ (mg)K+ (mg)Phos (mg)KcalSUBTOTALS881,2221,8801,0451,807Fats7Trace3857035315High-Calorie Choices4Trace608020400TOTALS881,6672,0301,1002,522Na+ allowed in diet prescription: ___1,500_____ mg SUBTRACT Na+ calculated in pattern - __1,667_______mg = _____0_______mg Na+ (1 point)This is the remaining Na+ allowed to be distributed in the form of added salt or condiments (salt choices). One salt choice contains ~250 mg sodium. Keep in mind that you may not deem it necessary to provide any salt choices to Mr. D, depending upon your calculations in part b, and your assessment of Mr. D’s need for a sodium restriction. Help AB see how he might plan meals using the meal pattern you calculated. Plan out a day’s meals with AB. (7 points) ONE DAY MENU BASED ON CALCULATED DIET PATTERNBREAKFAST#ServingsFood GroupMenu ItemMilkSoy Milk2Almond MilkMilk for on cereal, or to make oatmeal withNondairy Milk Substitutes2Meats2 hardboiled eggsTofuLegumesPeanut ButterOther non-meat:2StarchesDry cereal or oatmeal1Fruits – low K+Blueberries for cereal/oatmealFruits – med K+Fruits – high K+Vegetables – low K+Vegetables – med K+Vegetables – high K+1FatsNon-dairy creamer in coffeeHigh-Cal ChoicesLUNCH#ServingsFood GroupMenu ItemMilkSoy MilkAlmond MilkNondairy Milk Substitutes3MeatsTurkey burgerTofuLegumesPeanut ButterOther non-meat:3StarchesBun for turkey burger (large bun)Fruits – low K+1Fruits – med K+AppleFruits – high K+1Vegetables – low K+Lettuce/onions on burgerVegetables – med K+Vegetables – high K+2FatsCreamy condiment like mayo for burgerHigh-Cal ChoicesDINNER#ServingsFood GroupMenu ItemMilkSoy MilkAlmond MilkNondairy Milk Substitutes3MeatsBaked chicken, seasoned without saltTofuLegumesPeanut ButterOther non-meat:3StarchesSide of rice/other grainFruits – low K+Fruits – med K+Fruits – high K+Vegetables – low K+1Vegetables – med K+Broccoli or brussel sproutsVegetables – high K+2FatsButter for rice2High-Cal ChoicesSweet dessertSNACKS (SPREAD THROUGHOUT DAY AS NEEDED)#ServingsFood GroupMenu ItemMilkSoy MilkAlmond MilkNondairy Milk Substitutes1MeatsHardboiled eggTofuLegumesPeanut ButterOther non-meat:2StarchesDry cerealFruits – low K+Fruits – med K+Fruits – high K+1Vegetables – low K+Celery or bell peppersVegetables – med K+Vegetables – high K+2FatsDressing for cut raw vegetables2High-Cal ChoicesDiscretionary high calorie snack choicesNow that AB is on hemodialysis, he needs to be much more careful with his fluid intake. Describe 3 tips/strategies that you can you recommend to AB to help him stay within his fluid restriction. (3 points)Restricting fluid can be difficult, so to ease his potential thirst AB can suck on ice chip to alleviate any dryness in his mouth. Eating cold, sliced fruit or sour candy can also help with the struggle of fluid restriction, as they can instigate a salivary reaction and help lessen any dry mouth. In the case that neither of these methods works, AB can try using spray mouthwash to relieve his thirst. ................
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