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Hillary
Lawson
 


NUT
116BL


F
12
– 
1PM 


February
27,
2013


Case
Study
#3
Renal 


1.
 


Lab
 


Value 


Normal
Range 


Interpretation
 


Case
Based
Interpretation


Reference


with
CKD
ranges
(NTP
p.
532‐

533)


GFR


15
mL/min


Greater
than
90


Extremely
Low 


15‐ 
29
mL/min



Pocket


mL/min


Kidney
damage:
severe
 reduction
of
GFR
 (recommendation
for
kidney
 replacement
dialysis)


Reference


pg.109


BUN


90mg/dL


10‐ 20
mg/dL


Greater
than
normal


60‐ 80mg/dL
Hypercatabolism
 or
excessive
protein
intake,
 inadequate
dialysi s
(p.111)


Pocket


and
exceeding
CKD


Reference


range


pg.71


Waste
product
that
comes
 from
the
protein
we
consume.
 Normally
removed
by
the
 kidneys,
a
high
BUN
shows
 altered
kidney
function.
 


Serum


14mg/dL


.5
– 
1.1
mg/dL


Too
High,
but
with
 CKD
Range
 


2‐ 15mg/dL
 Close
to
high
end
=
excess


Pocket


Creatinine


Reference
p.


 

protein,
inadequate
dialysis,
 muscle
damage)
p.112 


74


Creatinine


17.0mL/min


88‐ 188ml/min


Extremely
Low 


Creatinine
is
a
waste
product
 in
the
blood
from
muscles,
it
is
 normally
removed
by
the
 kidneys.
When
kidney
 function
is
slow
the
clearance
 is
low.
 


 

Clearance


for
women


Serum


142mEq/L


136
– 
146


WNL


 

Pocket


Sodium



mEq/L


Reference


p.80


Serum


5.7mEq/L


3.5‐ 5.0mEq/L


Excessive
K
in
the


3.5‐ 6.0mEq/L
CKD,
 inadequate
dialysis,
excessive
 oral
intake
(high
or
low
levels
 can
weaken
muscles
and
 change
your
heartbeat) 


Pocket


Potassium


diet,
renal
failure,


Reference


renal
HTN


p.79,113


Serum


2.8g/dL


 

Too
Low
 *maybe
be
due
to
 dilution 


*ideal
is
greater
than

4.0
g/dL


Pocket


Albumin 


3.5‐ 5.0
g/dL


(p.
111)


Reference


*Fluid
overload
(nephritic


pg.71


 

syndrome)


Hgb/Hct 


11.5g/dL
/


12‐ 
16
g/dl 


Both
are
too
low
and
 indicate
anemia 


10‐ 12g/dL/33‐ 36%
 Renal
failure/
renal
artery
 stenosis,
uremia.


Pocket


28%


and


Reference
p.


37
– 
47%


 

77,
112


(anemia
or
inadequate
ESA)
 


Serum


155mg/dL


250‐ 380mg/L


Low


Low
iron
stores
linked
to
 anemia.
 


Pocket


Transferrin


Anemia,
nephrosis


Reference



 

p.81

 


BP 


160/100


Lower
than


High
 HTN
is
greater
than


Indicates
arterial
narrowing
 or
plaque
build ‐ up,
high
 volume
fluid 


NTP
p.289


standing,
right


120/80mmHg



arm


140/90mmHg



Urine
pH


7.31


4.6
to
8
 


WNL


A
pH
below
4.5
would
be
very


 

acidic
and
cause
renal
 damage.
 


Serum


5.0mg/dL


3.0‐ 4.5mg/dL


Too
high



3.5‐ 5.5mg/dL
(within
range) 
 CKD,
inadequate
P
binder
 (High
levels
can
lead
to
weak
 bones
and
calcifications
in
the
 blood
when
bound
to
serum
 calcium) 


NTP
532‐

Phosphorus


533


PTH


100pg/mL


 

Too
High


indicates
a
poor
balance
of


Pocket


10‐ 65
pg/mL


calcium
and
phosphorous
in


Reference
p.


Renal
hypercalcemia 


the
body
and
could
cause


79


bone
disease.



Urine
Volume


450‐ mL/24hr


800‐

Low
urine
output


Indicates
poor
kidney
function


NTP


2000ml/24hr


(18.75ml/hr)


and
CKD


(based
on
2L


normal
intake) 


References:

http://www.kidney.org/kidneydisease/understandinglabvalues.cfm 
 
























 http://lifeoptions.org/kidneyinfo/labvalues.php 
 http://www.nlm.nih.gov/medlineplus/ency/article/003425.htm 


2.
 Type
II
Diabetes
Mellitus
is
one
of
the
most
common
causes
of
chronic
kidney
disease
 due
to
 its
affect
on
the
glomerulus
and
renal
solute
load.
It
typically
becomes
a
risk
with


increasingly
uncontrolled
glucose
levels.
A
patient
with
type
II
DM
has
a
thickening
of
the
 glomerulus
of
the
kidney,
which
is
responsible
for
filtering
the
blood
and
consolidating
the
 waste
products
into
urine
to
be
excreted
from
the
body.
As
the
thickening
of
the
 glomerulus
worsens,
more
protein
than
normal
is
lost
through
urine.
After
an
increasing
 number
of
glomeruli
are
destroyed,
the
amount
of
albumin
excreted
in
the
 urine
increases,
 which
decreases
the
serum
concentration
of
albumin.
The
amount
of
nephrons
declines
 and
a
diminished
number
of
nephrons
are
left
to
handle
the
same
solute
load,
which
causes
 a
limit
on
how
much
solute
is
filtered
at
a
time.
As
a
result,
th e
body
fluid
concentration
 increases
and
leaves
the
patient
susceptible
to
azotemia
and
uremia,
as
well
as
an
obvious


decrease
in
GFR,
which
is
a
hallmark
of
CKD
(NTP.
527).


3.
 Although
BK
complains
of
anorexia
and
weight
loss,
she
has
gained
weight
due
t o
her
 high
fluid
consumption
and
inability
to
filter
and
urinate
out
the
additional
fluid.
Patients
 with
chronic
kidney
disease
have
reduced
or
complete
loss
of
kidney
function
and
have
an
 inability
to
filter
their
blood.
This
inability
causes
a
back
up
of 
fluid
in
the
system
and
a
 higher
volume
of
fluid
retained
in
the
body.
Patients
with
CKD
have
two
weights.
Their
 “wet
weight”
is
the
weight
in
which
they
are
carrying
additional
fluid
that
is
not
urinated
 out
or
filtered
through
dialysis;
the
“dry
weight”
is
the
weight
in
which
the
patient
has
no
 excess
fluid
in
their
system
or
just
after
dialysis.
Excessive
fluid
in
a
patient
can
cause
 abnormal
lab
values,
edema,
hypertension,
and
cardiac
stress.
 


4.

Which
foods
in
her
usual
diet
are
contributing
most
t o: 
 a)
Phosphorous
levels:
 Eggs, Corn
Tortillas,
Ice
Cream,
Whole
Milk,
Cheese
 (Quesadillas) 
 b)
Potassium
levels:
 Tampico
(citrus
juice),
Orange
Juice,
Banana,
Whole
Milk,
Ice
 Cream
 Sources:
 


 

‐ http://www.davita.com/kidney ‐ basi cs/phosphorus‐ and ‐ chronic‐

disease/diet‐ and ‐ nutrition/diet ‐ kidney‐ disease/e/5306


‐ http://www.davita.com/kidney ‐ disease/diet‐ and ‐ nutrition/diet%20basics/potassium‐ and ‐ chronic‐ kidney‐ disease/e/5308

5.

Explain
the
rationale
for
the
following
interventions: 


a) Phosphate
Binder
:
A
phosphate
bind er
is
used
to
prevent
the
gastrointestinal
 absorption
of
phosphorous
by
acting
like
a
sponge
and
binding
up
the
available
 phosphorous
in
the
stomach.
Unbound
serum
phosphorous
can
calcify
with
Calcium.
 Typically,
high
Calcium
foods
are
high
in
phosphorous
as
well;
when
these
foods
are


consumed,
the
excess
phosphorous
must
be
controlled
somehow.



b)
 Calcium
Supplement: 
A
Calcium
supplement
is
typically
given
to
a
CKD
patient
because
 there
is
a
deficiency
in
the
active
form
of
vitamin
D
due
to
parathyroid
hormone(PTH)
loop
 inhibition.
PTH
is
involved
with
the
regulation
of
calcium
in
the
body
by
stimulating
 calcium
reabsorption,
phosphorous
excretion,
and
the
activation
of Vitamin
D,
which
then
 stimulates
the
absorption
of
intestinal
Calcium.
When
damaged
kid neys
are
unable
to
 convert
Vitamin
D
to
the
active
form,
the
PTH
loop
is
disabled,
and
bone/mineral
disorders
 can
ensue.

High
calcium
foods
are
typically
high
in
phosphorous
as
well,
which
can
result
 in
calcifications
in
serum.
Thus,
Calcium
supplements
i n
conjunction
with
calcium
in
the


diet
are
used
to
meet
requirements
of
CKD
patients.
Calcium‐ based
phosphate
binders
are
 sometimes
used
to
increase
calcium
levels
in
patients
while
lowering
phosphate
to


maintain
bone/mineral
density
(NTP
524,541).


c)
 Iron
and
EPO:
 
Iron
deficiency
is
common
among
CKD
patients
because
the
kidneys
are
 unable
to
make
adequate
erythropoietin
(during
dialysis)
for
RBC
production.
 Erythropoietin
is
made
by
the
renal
tubular
cells;
in
compromised
kidneys,
the
RBC
 production
declines
in
the
bone
marrow
and
results
in
low
hemoglobin.
Recombinant
 Human
Erythropoietin
is
used
to
supplement
CKD
patients
and
increase
RBC
production.
 Typically,
the
effectiveness
of
erythropoietin
depends
on
iron
status
because
RBC
 production
requires
a
great
deal
of
iron,
which
is
why
CKD
patients
are
often
given
 supplements.

Untreated
anemia
can
result
in
cardiac
or
ventricular
hypertrophy,
angina,
 CHF,
malnutrition
or
impaired
immunological
responses
(NTP544‐ 545).



d)
 Vitamin
Supplement
containing
on ly
WSV: 
Due
to
increased
losses
of
water
soluble
 vitamins
during
dialysis,
anorexia,
or
poor
dietary
intake,
WSV
supplements
are
necessary.
 The
renal
diet
is
also
very
low
in
fresh
fruits
and
vegetables,
whole
grains,
and
dairy;
these
 groups
of
food
that
are
high
in
water‐ soluble
vitamins.
Renal
WSV
supplements
typically
 contain
B
vitamins,
folic
acid,
and
Vitamin
C;
fat ‐ soluble
vitamins
and
minerals
need
not
be


included
in
these
supplements
(NTP
549).



6.
Explain
the
purpose
of
each
of
the
following
inter ventions
and
li st
the
data
 indicating
the
need
for
treatment: 
(NTP
p.532 ­33) 


a) Protein
Restriction:
A
low
protein
diet
is
recommended
for
those
in
the
early
stages
of


CKD,
and
a
high
protein
diet
is
recommended
for
those
on
dialysis.
CKD
patients
on
a
 protein
restriction
should
limit
their
protein
intake
because
their
kidneys
are
unable
to
 filter
the
waste
products
of
protein
metabolism.
By
reducing
protein
intake,
it
reduces
the
 workload
of
the
kidneys
as
well
as
the
risk
of
azotemia
and
uremia,
and
may
st ifle
the
 progression
of
the
disease.
However,
it
is
important
that
the
patients
on
limited
protein
 consume
at
least
50%
high
bioavailable
protein
for
protein
sparing.
 Low
albumin
(below


3.5
mg/dL)
and
high
protein
waste
values
(Creatinine,
CC,
BUN)
indicate
kidney
issues,
as


well
as
a
decreasing
GFR
rate
showing
a
decreasing
ability
to
filter.
 


b)
 Phosphorous
Restriction:
Phosphorous
in
the
body
is
used
for
maintaining
and
building
 strong
bones
and
teeth,
or
aiding
in
the
conversion
of
food
to
energy.
Kidney
disease
can
 prevent
the
body
from
excreting
phosphorous,
causing
secondary
issues
affecting
the
 bones
and
the
heart
binding
with
calcium
in
the
serum,
which
causes
calcifications
in
the
 blood
and
possible
osteoporosis.
Phosphorous
restriction
is
used
to
control
the
amount
of
 serum
phosphorous.
It
is
also
important
when
on
hemodialysis
to
limit
phosphorous,
 because
when
there
is
excess
phosphorus
in
the
blood,
patients
have
complained
of
itching.



A
phosphorous
level
greater
than
4.5mg/dL
indicates
a
high
serum
level
and
inability
to


clear,
a
high
PTH
level
can
also
be
associated
with
high
phosphorous
and
Calcium
9greater


than
65pg/mL). 


c)
Potassium
Restriction:
The
kidneys
are
responsible
for
potassium
regulation.
In
the
case


of
chronic
kidney
disease,
potassium
levels
cannot
be
controlled,
and
the
buildup
of


potassium
can
result
in
hyperkalemia
and
undesirable
cardiac
events.
Potassium


restriction
is
important
to
maintain
electrolyte
balances
and
prevent
cardiac
events.
 
A
 potassium
level
greater
than
5. 0
mEq/L
can
indicate
a
need
for
treatment.
 


d)
Fluid
and/or
Sodium
Restriction:
Fluid
and
sodium
restrictions
are
used
to
control
blood
 pressure
and
maintain
fluid
electrolyte
balances.
The
kidneys
are
responsible
for
filtering
 toxins
from
the
blood
and
d ue
to
reduced
kidney
function
the
urine
output
is
decreased.
A
 lower
urine
output
means
a
higher
fluid
load
on
the
vasculature
of
the
body
and
the
heart
 to
pump.
In
order
to
reduce
the
workload
on
the
body
and
reduce
fluid
retention,
fluid
and
 sodium
restrictions
are
important;
they
can
reduce
the
risk
of
edema,
hypertension
(a
 common
cause
of
CKD),
shortness
of
breath,
cardiac
stress,
and
fatigue.

A
sodium
level


greater
than
146
mEq/L
with
edema
indicates
a
need
for
treatment.
Also,
a
low
urinary


output
o f
less
than
500
mL
per
24
hours
indicates
a
need
for
treatment.



7.
Assessment:


Subjective:
 Patient
is
42
yo
female
with
type
2
DM,
HTN,
hyperlipidemia,
and
CKD
that
has
 progressed
from
stage
3
two
years
ago
to
now
where
the
patient
c/o
of
an
inability
to 


urinate,
itching
(pruritus),
and
a
weight
gain
of
5kg
in
10
days.
The
patient
c/o
N/V,


secondary
anorexia,
edema,
and
worsened
SOB.
Patient
has
2
children
both
macrosomic
at


birth
and
finds
it
hard
to
adhere
to
DM
or
CKD
management
due
to
her
busy
lifestyle.
 


Objective:

Anthropometrics: 
 Edema‐ Free
W:
71.81kg

 SW
(Med)
=
61kg 
 Adj.BW
=
EFW
+
(SW ‐ EFWx0.25)


Work:
65.36
kg=66.8
+((61 ‐ 66.8)
x0.25) 


IBW:
50
kg 


Ht:
1.575m


%IBW:130.72%
(ABW)


BM I
(AdjBW):
26.5
(overweight)
 Recommended
weight
for
HD
patients:


(PR
pg.
110)


A
BMI
of
23.6
for
women
for
increased


survival
rate 


58.54kg
or
~
129lbs


Diet
History: 


‐ 
Sub
3500
kcal 


34%
Total
Fat
 


15%
Sat
Fat
(11%Mono


5%Poly)


18%
Protein



Ca:
2082mg



K:
4431mg
 



Phos:
2802mg
Na:
6450mg


Lab
Values: 


GFR:
15
ml/min
(indicating
near


ESRD)
 


BUN:
90
mg/dL
=
High



Serum
Creatinine:
14mg/dL
=
high


CC:
17.0mL/min
=
low


Albumin
=
2.8
g/dL
=
Low 


Hgb/Hct
=
indicate
anemia
@
11.5


g/dL
and
28%


Transferrin:
155
mg/dL
=
Low


BP:
160/100
indicates
Stage
II
HTN


Phos:
5.0
mg/dL
=
High


PTH
100pg/mL
=
High


Urine
output:
450
mL/24hr
=
low


Na:
WNL


K:
5.7
mEq/L
=
High

Calculations: 
 Recommended
Kcals
for
 Weight
maintenance:


35kcals/kgBW/d
per
CKD


patients
<
65
yo 


‐ 
2287.6
or
~2300kcal


Protein:
 Recommended
≥
1.2
g/kgBW 


65.36
x
1.2
=
78.43
(~80g)
PRO


Fluid:
Gains
between
HD:
 3.3
kg
WG
brown
HD
appt. 
 Tx
Fluid
Plan: 


1.5L
restriction


Recommendations
for
Diet :
 Sub
2300kcal
 


CHO:
sub
56%
(~322g)


PRO:
79g
(~80g)
or
greater
than
13.9%


Greater
than
50%
HBV


Fat:
less
than
30%
total
fat 


Less
than
77g


Less
than
10%
Sat
Fat
(or
26g)


2gm
Na.



2gm
K.


1gm
Ph
 


Drugs:


Purpose:


Nutrient
Interactions:


Side
Effects:


Metformin


Oral
hypoglycemic 


Avoid
Alcohol


Lactic
Acidosis,
GI
 distress,
chest
pain,
loss


of
appetite
(PR
p160)


Lasix


Treatment
for
edema,


Avoid
alcohol,
 barbituates ,
and
 narcotics


Jaundice,
anorexia,
 paresthesias,
diarrhea,
 N/V,
dizziness,
rash,


urticaria
etc.
9pdr.net)


loop
diuretic


Vasotec


ACE
inhibitor
used
to


Use
caution
with
K+
 containing
salt
 substitutes
or
 supplements 


Fatigue,
Headache,


decrease
BP
and


Dizziness
(pdr.net)


decrease
HTN


Diagnosis: 
 PES:
 Unintended
weight
gain
(NC‐ 3.4)
R/T
progression
of
chronic
kidney
disease
AEB
5kg


weight
gain
in
10
days
counter
indicated
by
secondary
anorexia,
inability
to
urinate
(GFR


15mL/min,
Urine
Volume
450mL/24hr),
altered
lab
values
(Albumin
2.8g/dL,
CC
17.0


mL/min,
Creatinine
14
mg/dL,
PTH
100ph/mL),
pitting
edema
3+
with
BP
160/100,


worsened
SOB,
N/V
(Phosphorous
5.0mg/dL
[barely
normal],
 5.7
mEq/L),
ronchi
with
 rales,
and
fatigue.
 


*
I
chose
unintended
weight
gain
as
the
main
p roblem
due
to
the
fact
that
the
5kg
 weight
is
possibly
due
to
BK’s
inability
to
adhere
to
recommendations
concerning


her
current
condition.
She
has
been
a
CKD
patient
for
2
years
and
a
T2DM
for
most
of


her
life.
The
added
weight
gain
more
than
likely
is
ca using
the
exacerbated
 symptoms
of
edema,
HTN,
dilution,
SOB,
fatigue,
etc.
 


State
of
 Δ:
BK
is
in
the
 contemplation
 stage
of
the
transtheoretical
model
of
behavior


change.
BK
was
diagnosed
with
type
II
DM
at
the
age
of
12
with
a
FMH
of
the
disease
and


was
diagnosed
with
CKD
stage
3
two
years
ago,
yet
she
has
not
made
the
recommended


changes
to
her
diet
or
lifestyle
and
is
not
adherent
to
her
medication
regiment.
The
patient


is
aware
of
her
medical
conditions
but
neglects
to
follow
a
treatment
plan
or
make
small


changes.



Intervention:


‐ 
Meet
with
the
patient
3
times
a
week
before
HD
appoint ments
and
slow
the
imminent


progression
of
the
ESRD
to
mortality.

‐ 
Reeducate
the
patient
on
DM
and
CKD
as
it
relates
to
the
progression
of
BK's
CKD
stage
3


to
end
stage.
 


‐ 
Reintroduce
the
patient
to
the
Renal
diet
and
restrictions
on
sodium,
potassium,


p hosphorous,
and
fluid.



‐ 
Recommend
the
patient
for
Hemodialysis
(3xwk,
4hrs)
and
educate
the
patient
on
the


nutrition
variations
specific
to
Hemodialysis;
specifically
fluid
restriction,
dry
versus
wet
 weight,
electrolyte
restrictions
(K,
Na,
P),
and
high 
protein
intake.
 


‐ 
Introduce
the
patient
to
phosphate
binders
and
stress
the
importance
of
maintaining
her


medications
regimen;
making
the
patient
aware
of
her
iron‐ deficiency
anemia,
CKD
stage
5
 and
electrolyte
importance,
and
mortality.
 Goals:

1)
Recommend
the
patient
keep
a
food/fluid/weight
journal
while
adhering
to
the
Renal


diet
(as
long
as
the
patient
is
on
dialysis)
until
the
patient
is
able
to
unconditionally
follow
 the
diet
and
maintain
electrolyte/weight/protein
related
markers
within
normal
CK D
 ranges.



2)
Maintain
a
high
protein
diet
of
at
least
80
grams
of
protein
a
day
while
decreasing


weight
until
a
BMI
of
sub
24
is
reached
to
improve
QOL
and
effectiveness
of
HD.



3)
Decrease
fluid
intake
to
1.5
L
per
day
to
improve
efficiency
of
HD
and
control
weight


gain
between
treatments,
while
decreasing
soda
(Tampico)
and
other
electrolyte ‐ rich
 fluids
(whole
milk
and
orange
juice). 


Monitor/Evaluate: 


‐ 
Meet
with
the
patient
3
times
a
week
before
HD
appointments
and
monitor
the
patient’s


adherence
to
the
Renal
diet
by
the
food/fluid/weight
journal
the
patient
will
keep. 


‐ 
Monitor
electrolyte
levels
while
patient
is
on
Renal
diet
and
over
the
course
of
HD


treatments
pertaining
to
the
kidneys
(K,
P,
Na,
and
Ca),
protein/protein
waste
markers
 (Albumin,
BUN, 
Creatinine),
and
weight
before
and
after
HD
treatments.


‐ 
Evaluate
Patient’s
adherence
to
the
high
protein
diet
through
journal
and
the
use
of
UUN
 in
the
nitrogen
balance
equation. 


‐ 
Monitor
and
evaluate
the
patient’s
anemic
status
over
the
course
of
trea tment
 (Diet/HD/EPO/Iron)
for
improvement
(Hgb/Hct).



 
 
 
 
 
 Printed
Name:
 
 
 
 
 
 Signature: 
 

Printed
Name:

Signature: 

Date/Time:


Renal
Diet
Pattern:


2gm
Sodium,
2gm
Potassium,
1gm
Phosphorous,
and
1.5
L
Fluid


Food # of Choices

Kcal

Pro (g)

Na (mg)

K (mg)

Phos (mg)

Meat (total of 8)

         

-

Animal Protein HBV

400

(80)

35

(7)

375

(75)

250

(50)

250

(50)

(5)

       

-

Vegetarian Protein (3)

300

(100)

18

(6)

150

(50)

300

(100)

240

(40)

Milk (1)

100

4.0

80

185

110

Bread/starch (8)

800

(100)

16

(2)

640

(80)

360

(40)

240

(30)

Vegetable

         

- Low (1)

50

2

45

75

50

- Medium (1)

50

2

45

150

50

- High (0)

0

Fruit

         

- Low (2)

150

(75)

2 (1)

50

(25)

100

(50)

50

- Medium (1)

75

1

25

160

50

- High (0)

Fat (5)

225

(45)

trace

275(55)

50

(10)

25

(5)

Extra (2)

120

(60)

trace

30

(15)

40

(20)

10

(5)

Fluids (1.5L) Choices:

         

-

use the milk option

Total

2270

80

1715

1670

1075

Sources: NTP p. 537 (NRD Nutrition Composition of Foods for People on Dialysis) https://smartsite.ucdavis.edu/access/content/group/bc09b3ba ‐ c660‐ 4648‐ bcf5‐

e8ac1577a1f7/week%206/HandoutRenalDietExchanges.pdf


Food
Options:

8.
 
Weight
fluctuations
between
hemodialysis
sessions
is
normal.
Hemodialysis
is
the
 process
of
removing
fluid
and
waste
from
the
blood
as
it
is
filtered
through
an
artificial
 kidney.
The
artificial
kidney
removes
waste
products
and
excess
fluid
via
diffusion,
 ultrafiltration,
and
osmosis.
The
artificial
kidney
does
the
job
of
the
human
kidney,
but
only
 during
sessions
at
a
limited
rate.
Typically,
a
patient
does
three
sessions
a
week 
that
each
 last
about
four
hours,
whereas
a
normal
kidney
is
working
24/7
filtering
the
blood.
In ‐ between
sessions,
the
kidney
is
not
able
to
filter
the
blood
as
efficiently
or
at
all,
and
all
of
 the
excess
fluid
consumed
and
waste
products
of
the
body
remain,
resulting
in
added
 weight.
Because
the
body
retains
any
excess
fluid
between
HD
sessions,
fluid
and
sodium
 restrictions
are
important
to
reduce
HTN,
edema,
cardiac
stress,
SOB,
etc.
 (http://www.davita.com/kidney ‐ disease/diet‐ and ‐ nutrition/diet ‐ basics/fluid‐ control‐ for‐ kidney‐ disease‐ patients ‐ on‐ dialysis/e/5321)




 9.
 
BK’s
protein
consumption
on
February
25 th
9.
 
BK’s
protein
consumption
on
February
25 th 
reflected
69.375
grams
of
protein
ingested

and
 71.25
grams
on
her
subsequent
visit
February
27.
BK
is
shy
of
consuming
the
amount

of
protein
I
recommended
for
her.
As
an
end
stage
renal
disease
patient
on
hemodialysis,

BK
requires
a
higher
protein
intake
in
order
to
replace
the
protein
that
is
lost
through

dialysis.
It
is
no
longer
recommended
that
BK
eat
low
protein
because
the
protein
waste
is

being
removed
via
dialysis
and
protein
is
important
in
order
for
BK
not
to
lose
muscle
mass

and
maintain
her
ability
to
fight
infection.
I
had
recommended
that
BK
consume
80
grams

of
protein
or
more
a
day,
roughly
1.2g/kg
BW/d.
The
patient
is
just
under
my

recommendation,
and
in
reality
I
would
like
her
to
be
consuming
80
 or
more. 

10
.
Sodium
in
the
diet
is
important,
it
is
a
way
to
regulate
blood
pressure
and
volume,


transmit
impulse,
and
regulate
the
body’s
acid ‐ base
balance.
However,
in
a
patient
with 
 CKD,
consuming
too
much
causes
water
retention
with
such
complications
as
swelling,
 cardiac
issues,
and
SOB
due
to
the
kidney’s
inability
to
excrete
the
excess
sodium.
With
a
 patient
like
BK,
on
hemodialysis,
a
low
sodium
diet
is
recommended.
The
use
of
salt
 substitutes
to
maintain
a
low
sodium
intake
 would
not
be
recommended
because
some
salt
 substitutes
contain
potassium,
which
also
needs
to
be
regulated
with
CKD
patients.
The
 best
thing
for
BK
to
do
would
be
to
find
ways
to
remove
sodium
from
her
diet
a s
opposed
 to
using
salt
substitutes,
such
as
using
spices
to
boost
the
flavor
of
foods
or
reading
food
 labels.
 
 (http://www.davita.com/kidney ‐ disease/diet‐ and ‐ nutrition/diet ‐ basics/sodium‐ and ‐ chronic‐ kidney‐ disease/e/5310)