Melissa Stucchio

HNSC 4240
Case Study 2-Chronic Kidney Disease
Please read the case below carefully then answer the questions.
Date of admission: 3/13/2015
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 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 ( 2/15/2015); 173 lb (12/10/2014); 172 lb (6/5/2014)
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
Blood work
Sodium
136-145
Potassium
3.5-5
Phosphorus
2.3-4.7
Calcium
9-11
Albumin
3.5-5
GFR
>90
Glucose
70-110
Creatinine
0.6-1.2
Fasting blood glucose
66-99
HbA1C
4-6
Urinalysis
pH
5-7
Protein
Neg
WBCs
0-5
Treatment plan:
Medications:
Lasix (furosemide) 40 mg twice daily
Erythropoietin 30 units/kg
Vitamin/mineral supplement daily

Patients value

Units

130 L
6.2 H
9.5 H
8.2 L
3.7
12 L
236 H
12.0 H
150 H
11 H

mEq/L
mEq/L
mg/dL
mg/dL
g/dL
mL/min
mg/dL
mg/dL
mg/dL
%

7.9 H
2+ H
20 H

mg/dL
/HPF

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: Cold cereal (cream of wheat) 1 cup, 2% milk 1/2 cup, whole wheat toast 2 slice, 1 sunny side
egg, butter 2 Tbsp
Lunch: Chicken sandwich (2 slices of whole wheat bread, 8 oz grilled chicken breast, 2 Tbsp mayonnaise),
cucumber salad 2 cups, 1 yogurt (2% fat, plain), 1 small apple, regular coke 1 cup
Dinner: Roasted beef 5 oz, steamed green beans 1 cup, steamed carrots 1 cup, mashed potatoes 1 cup,
olive oil 1 Tbsp
Snack: 2% milk 1 cup, orange juice 1 cup, crackers (6 saltines), peanut butter 2 Tbsp, lemon sorbet 1 cup
ANSWER THE FOLLOWING QUESTIONS
1. Discuss how well the patient manages her T1DM. Please explain what biomarkers you base your
conclusion on and how their values suggest good or poor management of T1DM.
The patient does not manage her T1DM well enough. Both her diet and lab results show that Ms.
Joaquin does not take care of her diabetes and health. From her diet, she is eating a lot of starches, fruits,
and dairy. She has had cold cereal, 2% milk, a couple of slices of bread, mashed potatoes, an apple, orange
juice, yogurt, and crackers. She also consumed a cup of Coke, which could explain her high levels of
glucose. Ms. Joaquin should be using the insulin-to-carb ratio to decide how many units of insulin should
be given to her, if she is going to manually do her own insulin. As for her lab values, her glucose, fasting
blood glucose, and hemoglobin A1C are extremely higher than they should be, which indicates that her
insulin injections are not working as properly as they should be in lowering her glucose levels or she is not
properly giving herself insulin. Since she is given regular insulin and her levels are still high, she should be
put on a continuous subcutaneous insulin infusion, which can pump rapid-acting insulin continuously into
her fat tissue to lower glucose levels between meals.

2. Whats the correlation between T1DM and CKD? Discuss the mechanisms through which they are
interrelated.
The correlation between T1DM and CKD is that advanced glycation end products (AGEs), oxidative
stress, and hypertension can all lead to renal disease. With the AGEs, accumulation of these substances can
lead to stiffening of major vascular dysfunctions, such as arteriole stiffening and renal glomerular
membrane thickening, which reduces the ability of nutrients to transport against. When this glomerular
filtration rate decreases as a result of the membrane thickening, the kidney begins to not filter the waste
from the blood as efficiently as it should be. As indicated in the patients lab values, her GFR was 12,
which is devastatingly lower than the normal of above 90. Because of this decrease in flow, less water and
electrolytes are reabsorbed back into the renal tubules and more creatinine is reabsorbed in the tubules,
also as indicated in the patients lab values, in which her blood creatinine was 12 instead of less than 1.2. A
high serum creatinine level indicates a low dysfunctional GFR. This also shows indication of slight
microalbuminuria in the patient due to the fact that her blood albumin level is on the lower end of the
normal range and her urine protein is positive, meaning that the albumin in the blood is beginning to leak
into her urine, as seen with the abnormal presence of urinary protein.
With hypertension, oxidative stress is placed on the kidneys due to the varying pressures exerted on it
during filtration of the kidneys. Any sodium that is left circulating through the blood stream could
potentially affect the fluid balance inside of the kidneys and can cause strain on the blood vessels leading
to the kidneys, creating a higher blood pressure and kidney failure. The damaged blood vessels can
decrease blood flow to organs, such as the kidneys. The nephrons inside the kidneys can also become
damaged as a result of hypertension, which can back-up waste product removal from the kidneys and can
increase the blood pressure even more. Since the patient has stage 2 hypertension, she is even more
susceptible to having severe kidney damage done to her.

3. The patient was very devastated by the fact that she lost her kidney transplant. She complained
about not being able to eat whatever she wanted. Please discuss her dietary intake goals (e.g.
potassium, sodium, fluid, phosphorus, calorie, protein, HBV proteins) when she had the transplant
2

and after she was put on hemodialysis again. Please include the steps of calculation. Compare the
differences and explain why the goals were modified based on her situations.
Calories- Her calories can remain the same both with the transplant and with the hemodialysis, with a
range from 25 kcal/kg to 35 kcal/kg. First, her BMI needs to be found out, to see if the adjusted body

662
134,273
weight equation needs to be used. Her BMI= 191 lbs x 703 =
= 30.8= Obese Class 1.
4,356

Since her BMI is over 25, she needs to use the adjusted body weight calculation to figure out her daily
caloric goals. Her AIBW= (191 lbs-130 lbs) x 0.25 + 130 lbs= 145.3 lbs/66 kg, which means her calories
can range from 25 x 66kg=1,650 kcal to 35 x 66kg=2,310 kcal.
Protein- Protein levels vary depending on the stage of CKD. Since the patient was given the kidney
transplant, her protein needs should have initially increased to 1.3g-1.5g/day and then should have been
maintained at normal levels from 0.8g- 1g/day, with at least half of the protein being consumed coming
from high biological value proteins, such as animal proteins. Like the initial stage of post-transplantation,
during hemodialysis, levels of protein also need to be increased to 1.1g-1.5g/day, with 50% coming from
the high biological proteins. Protein consumption needs to be increased during hemodialysis because of the
loss of protein happening in the blood. The lowest her protein should be is: 66kg x 1.1g=72.6g/d. From
high biological value, it should be: 60% x 72.6g= 43.6g. From low biological value, it should be: 72.6g
43.6= 29g.
Potassium- Potassium levels also vary depending on the stage of CKD. While the patient was recovering
from her kidney transplant, her potassium levels were unrestricted. However, when she was put back on
hemodialysis, her potassium levels should have been more restricted, with 2g-4g/day consumption. In
order to reduce the amount of potassium in foods, the patient could have leached her vegetables, so that the
potassium content would not have been so high. According to her lab values, her serum potassium levels
were high at 6.2 mEq/L during hemodialysis, which may mean that the potassium is not filtering out right
during hemodialysis.
Sodium- Sodium levels are based more individually and are based on urine output and dialysis modality.
After transplantation, her sodium levels should have been less than 2.4g/day. On hemodialysis, the level
ranges slightly higher, being 2.0g-3.0g/day.
Fluids- Fluid levels, like sodium levels, are also individualized and are based on urine output and dialysis
modality. After transplantation, fluid intake is not restricted in the patient. However, when put back on
hemodialysis, fluid intake must be great enough to produce 1000mg or higher of urine output. To manage
fluid restriction, the patient could have kept track of how many milliliters of fluids she was consuming a
day and by quenching her thirst by other means, besides fluid consumption.
Phosphorus- Phosphorus levels vary depending on the stage of CKD. After transplantation, the intake of
phosphorus is individualized. However, when put back on hemodialysis, her phosphorus levels should
have become more restricted, with 800mg-1000mg/day. Restriction of phosphorus could be achieved with
lower intake of high phosphorus foods, such as dairy, organ meats, beans, nuts, and whole grains. Also,
phosphate binders can be used to lower a phosphorus level, which explains why Ms. Joaquin is treated
with Phos Lo with each of her meals.

4. Analyze the patients dietary recall using the RENAL EXCHANGE TABLE and fill out the table
below. Point out which exchange group each food item belongs to, the nutrient content, and the
number of exchanges. Calculate the totals. Discuss the discrepancy between her dietary recall and
intake goals identified above, and what consequences may result from the discrepancies (You may
expand the table).
Food item

Food group

1 cup Cold cereal

Breads/Cereal
s

# of
exchange
s
1

Calorie
s (kcal)

Protein
(g)

Sodium
(mg)

Potassiu
m (mg)

Phosphorus
(mg)

125

75

55

40
3

 cup 2% milk
2 slices whole
wheat toast
1 sunny side egg
2 tbsp butter
2 slices whole
wheat bread
8 oz grilled
chicken breast
2 tbsp mayonnaise
2 cups cucumber
salad
1 yogurt (2%)
1 small apple
1 cup Coke
5 oz roasted beef
1 cup steamed
green beans
1 cup steamed
carrots
1 cup mashed
potatoes
1 tbsp olive oil
1 cup 2% milk
1 cup orange juice
6 saltines
2 tbsp peanut
butter
1 cup lemon
sorbet
Total

High-P protein
Breads/Cereal
s
High-Protein
Calorie
Breads/Cereal
s
High-Protein

37.5
250

4
6

42.5
150

100
110

100
80

1
2
2

75
150
250

7
0
6

85
100
150

100
100
110

75
100
80

600

56

680

800

600

Calorie
Low K veggie

2
4

150
220

0
8

100
100

100
340

100
160

High-P protein
Low K fruit
Calorie
High-Protein
Low K veggie

1
1
1
5
2

75
60
75
375
110

8
0
0
35
4

85
5
50
425
50

200
85
50
500
170

200
10
50
375
80

Low K veggie

110

50

170

80

High K veggie

110

50

800

80

Calorie
High-P protein
High K fruit
Bread/Cereals
High-P protein

1
1
2
1
1

75
75
120
187.5
75

0
8
0
4.5
8

50
85
10
112.5
85

50
200
800
82.5
200

50
200
20
60
200

Calorie

150

100

100

100

3455
kcal H

165.5g/kg
H

2640m
g

5222.5mg
H

2840mg H

According to her dietary recall and her intake goals, her calories, protein, potassium, and phosphorus
levels were all too high for her recommendations. Her calories consumed were at least 1000 more than
recommended, which can contribute to excess weight if not being properly expended. Since she is already
classified as obese, her calorie consumption should not exceed what is given to her. Her proteins
consumed were also higher than they should have been for her body weight. For her kilograms of body
weight, her protein should be around 86g of protein. From her dietary recall, however, she consumed
almost double the amount of protein and consumed 126g of high biological protein and 95g of low
biological protein, both of which are higher than her recommended values. If levels of protein are
exceeded, one possible consequence is that the protein can back-up in the blood, since the kidneys do not
filter the protein as well during CKD, which may lead to macroalbuminaria. Her potassium consumed was
also higher than it should have been. While on hemodialysis, her potassium levels should be between 2g
and 4g a day. Ms. Joaquin consumed about 1g more than that, at 5.2g. She should watch her potassium
levels especially since it is more restrictive during hemodialysis. Also, too high of a potassium level can
give her hyperkalemia, which can lead to a cardiac arrhythmia due to the stress placed on the kidneys to
try to filter out the excess potassium. Her phosphorus consumed was also higher than it should have been.
Phosphorus levels on hemodialysis should be between 800mg and 1000mg. Ms. Joaquin consumed almost
triple that level, at around 2800mg. A high phosphorus level can be dangerous because the kidneys are not
working properly in order to regulate phosphorus levels. Therefore, an influx of phosphorus can cause
hyperphosphatemia which can increase secretion of the pituitary hormone, which then can increase
phosphorus absorption in the small intestine and bone resorption. When bone resorption is increased, more
phosphorus and calcium are released into the blood and causes white spots on the skin, fatigue, and an
itchy feeling.
4

5. Fill out exchange tables based on the dietary intake goals when she is on hemodialysis. Plan a oneday menu that contains breakfast, lunch, dinner and 2 snacks that is compliant with the dietary
prescription (use the tables below as a step-by-step guide; you may expand the tables).
Calculate the exchanges Based on 25kcal = 1,650 kcal and 1.1g protein/kg = 72.6g protein
Exchange
# of
Calories Protein
Sodium
Potassium
Phosphorus
group
exchange (kcal)
(g)
(mg)
(mg)
(mg)
s
High protein 5
375
35
425
500
375
High P

37.5
4
42.5
100
100
protein
High sodium
protein
Low K
3
192.5
7
87.5
297.5
140
vegetables
Medium K
1
55
2
25
200
40
vegetables
High K

27.5
1
12.5
200
20
vegetables
Low K fruits 3
180
0
15
255
30
Medium K
1
60
0
5
200
10
fruits
High K fruits
Bread/cereal 4
500
12
300
220
160
s
Calorie
2
250
0
100
100
100
Flavoring
1
10
0
275
50
10
Total
1,687
61 g
1,287 mg 2,122.5 mg 985 mg
kcal
Please fill out the # of exchanges for each meal
Exchange
Total
breakfast lunch
group
Number
of
exchang
e
High protein 5
2
1
High P

protein
High sodium
protein
Low K
3

2
vegetables
Medium K
1

vegetables
High K

vegetables
Low K fruits 3
2
Medium K
1
fruits
High K fruits
Bread/cereal 4
2
1
s
Calorie
2
1
Flavoring
1

Plan the menu

dinner

Snack 1

Snack 2

1
1
1
1

Meal (breakfast,
lunch, dinner or
snack)
Breakfast
Breakfast
Breakfast
Breakfast
Breakfast
Lunch
Lunch
Lunch
Lunch
Lunch
Lunch
Lunch
Lunch
Snack 1
Snack 1
Dinner
Dinner
Dinner
Dinner
Dinner
Snack 2
Snack 2

Food item

Exchange group

Number of exchange

2 egg omelet
cup chopped
mushrooms in omelet
cup chopped
peppers in omelet
1 cup apple juice
1 English muffin
1 cup chopped lettuce
1 oz grilled shrimp in
salad
cup chopped carrots
in salad
cup chopped
cucumber in salad
cup avocado in
salad
1 tbsp. salad
dressing
tbsp. lemon juice
pita bread
cup yogurt
cup chopped fresh
strawberries
2 oz chopped grilled
chicken
cup penne pasta
cup cooked
chopped broccoli
1 tbsp. olive oil
1 clove chopped garlic
1 fresh pear
tbsp. lemon juice

High Protein
Low K Vegetables

Medium K Vegetables

Low K Fruits
Breads/Cereal
Low K Vegetables
High Protein

2
2
1
1

Low K Vegetables

Low K Vegetables

High K Vegetables

Calorie

Flavoring
Breads/Cereal
High P Protein
Low K Fruits

High Protein

Breads/Cereal
Medium K Vegetables

Calorie
Low K Vegetables
Medium K Fruits
Flavoring

6. The patient wants to get another kidney transplant. Based on the information you have, evaluate
whether she is a good candidate for transplant.
Based on the patients information, she is not a good candidate for another kidney transplant. The first
reasoning for this is that she did not comply to the rules when she received her first kidney transplant. As
evidenced in her dietary recall, her food choices are not favorable and their contents are not within the
appropriate ranges during the hemodialysis phase. Although some levels after transplantation are not
restricted, such as potassium consumption and fluid intake, the other dietary values must be within range
for the new kidney to function correctly. With her dietary recall, four out of five nutrients are in much
higher amounts than should be. If Ms. Joaquin cannot obtain her nutrient levels during hemodialysis, then
she would most likely also not obtain her nutrient levels after transplantation, which could possibly
increase the chance of the new kidney failing sooner than later.
The second reasoning for this is that her Type 1 diabetes is not controlled well enough for a new
kidney transplant. Since health status is a major consideration of transplantations, the fact that her levels of
HbA1C, fasting glucose, and plasma glucose were all high in her laboratory results may hinder her chance
of receiving a new kidney, since she cannot properly control one of her other diseases. The high levels
indicated on the laboratory report may be a result from a variety of factors, including proper insulin
injections and/or dietary consumption. If Ms. Joaquin would be considered for another kidney transplant,
she would have to control her diabetes first, to show that she is worthy of making changes in her life and
keeping those changes under control at all times.
The third and fourth reasoning for this is her age and her social support. Ms. Joaquin is now 60 years
6

old and a widow who lives alone. If she was given the kidney transplant, she would have to make sure that
she was able to do things by herself. Also, with no support at home, it may be more difficult to cope posttransplantation. Although 60 years old is not so old, her survival rate may be lower than someone who was
much younger, due to the fact that her first kidney transplant already failed once after 12 years. If she has
another transplant and it fails again, she will be around 70 years old, which can increase her chance of
mortality.
7. The patient said that she wanted to make changes to get better. However, as her memory got
worse, she often forgot to take her insulin and to check what she could eat. She asked if you could
design a handout for her to put on her refrigerator to remind her about those matters. Please help
your patient out (A4 paper, 1 page, any font size, graphics welcomed).