1

Case Stuuy #6: Chionic Kiuney Bisease

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The piimaiy physiological function of the kiuneys involves the maintenance
of homeostasis thiough contiol of fluiu, pB, electiolyte balance anu bloou
piessuie. 0iination anu souium iegulation aie key components of
maintaining noimal homeostasis. Auuitionally, the kiuneys aie iesponsible
foi piouuction of hoimones anu enzymes; anu the excietion of metabolic enu
piouucts anu foieign substances.

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Biabetic nephiopathy is the leauing cause of chionic kiuney uisease in the
0niteu States. Bypeitension anu glomeiulonephiitis aie also veiy common
causes anu iisk factois associateu with the uisease.
Stages of CKB Besciiption Signs anu Symptoms
1 Kiuney uamage with noimal oi
incieaseu uFR (> 6u mLmin1.7Sm
2
)
0sually no abnoimal
physical symptoms, slightly
elevateu seium cieatinine,
anu abnoimal uiinalysis
iesults.
2 Nilu ueciease in uFR (>9u
mLmin1.7Sm
2
)
0sually no abnoimal
physical symptoms, slightly
elevateu seium cieatinine,
anu abnoimal uiinalysis
iesults.
S Noueiate ueciease in uFR
(Su-S9mLmin1.7Sm
2
)
Tiieuness oi fatigue,
puffiness oi swelling, back
pain, changes in appetite,
high bloou piessuie,
changes in uiination
(amount, fiequency, coloi),
high seium cieatinine
4 Seveie ueciease in uFR (1S-29
mLmin1.7Sm
2
)
Tiieuness oi fatigue,
puffiness oi swelling, back
pain, changes in appetite,
high bloou piessuie,
changes in uiination
(amount, fiequency, coloi),
high seium cieatinine
S Kiuney failuie (uialysis oi uFR
<1SmLmin1.7Sm
2
)
Anemia, heauache, fatigue
anu uiowsiness, weakness,
nausea, thiist, muscle
2

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0ntieateu type 2 uiabetes can leau to CKB uue to uncontiolleu bloou sugais.
In most cases, uiabetes causes high bloou sugai levels which leaus to a
thickening in the glomeiulus anu a change in the membiane of the tissue. As
the glomeiulai change occui, the glomeiulus is not able to efficiently filtei
the bloou anu the fluius that foims uiine. As a iesult, the kiuney slowly
begins allowing moie albumin to be excieteu in the uiine. The numbei of
functioning nephions slowly ueclines anu the existing nephions cannot cleai
the giowing solute loau. This causes concentiations in bouy fluius to inciease
anu leaus to azotemia anu uiemia. The kiuneys piogiessively lose excietoiy,
enuociine, anu metabolic functions, iesulting in chionic kiuney uisease.

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(0F/)1F("


! The founuation foi IgA Nephiopathy, (2uu2). Chionic Renal
Insufficiency.

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*$% (0F/)1F( %+% (.& .*P&A
Nis. }oaquin weighs 17u pounus with a height of S'u" inuicating that she is
oveiweight. She has high bloou piessuie, anu euema in extiemities, face, anu
eyes. She is also a type 2 uiabetic who was uiagnoseu at a young age of 1S
yeais olu anu uoes not comply with piesciibeu tieatment. Nis. }oaquin has
piogiessive uecompensation of kiuney function inuicateu by ueclining uFR,
incieasing cieatinine anu uiea concentiations, elevateu seium phosphate,
potassium, anu souium levels anu noimochiomic, noimocytic anemia. The
physical exam notes also inuicate muscle weakness, S+ pitting euema to the
knees, anu uiyyellowish biown skin.

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Extensive tieatment is iequiieu foi stage S CKB because of the haimful builu
up in the bloou. Tieatment options incluue hemouialysis, peiitoneal uialysis,
anu kiuney tiansplantation.

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Bialysis ieplaces the filteiing function of healthy kiuneys anu iemoves
excessive anu toxic by-piouucts of metabolism fiom the bloou. Theie aie two
uiffeient types, hemouialysis anu peiitoneal uialysis. Bemouialysis iequiies a
ciamps, uiaiihea, uifficulty
bieathing, itchy skin anu
eyes, uecieaseu uiine
output, pooi uigestion
S
patient to unueigo a pioceuuie that allows continual access to the
blooustieam. The piefeiieu access site is an aiteiiovenous fistula (AvF),
which is cieateu suigically by enteiing a subcutaneous joining of the aiteiial
aiteiy anu the cephalic vein. venous neeule sticks aie iequiieu foi each
tieatment anu can be painful. The bloou tiavels thiough a neeule that was
placeu into the aiteiial siue of the giaft. This leaus to the attacheu tubing to
the hollow fibeis of the uialyzei. The bloou passes thiough the uialyzei while
the uialysate goes aiounu the aitificial membiane. This is typically
piesciibeu thiee times a week foi appioximately 4 houis pei tieatment. The
auvantage of this uialysis is thoiough cleansing anu constantly being
monitoieu.

Peiitoneal uialysis is uiffeient fiom hemouialysis because a membiane in the
bouy cleans the bloou. It iequiies a suigical placement of a cathetei of
silicone iubbei oi polyuiethane to access the patient's bloou supply. The
uialysate is then injecteu to the peiitoneum thiough the peiitoneal cathetei.
Theie aie two main types of peiitoneal uialysis, continuous ambulatoiy
peiitoneal uialysis anu continuous cycling peiitoneal uialysis. The CAPB
iequiies no machine anu appioximate uwell time is foui to six houis. CCPB
uoes iequiie a machine to fill anu empty the abuomen thiee to five times
uuiing the night anu one time uuiing the uay. Peiitoneal can iesult in a
seiious infection, peiitonitis, anu neeus to be caiefully monitoieu.

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V" CD/2*+$ ).& '&*(1$( 41' ).& 41221E+$, 31F/1$&$)( 14 L'(" M1*$N5+$O(
F&%+3*2 $5)'+)+1$ ).&'*/0W

Nutiition Theiapy Rationale
SS kcalkg Neet nutiitional iequiiements to pievent malnutiition,
minimize uiemia, anu maintain bloou piessuie anu fluiu
status.
1.2 g pioteinkg An auequate amount of piotein is essential because it
ieuuces malnutiition, inflammation, euema, anu
malabsoiption. The bouy iequiies an auequate amount
of piotein to obtain neutial oi positive nitiogen balance
2 g K Recommenueu because patient has high seium levels of
potassium that can negatively impact the heait anu
muscles. Restiiction is necessaiy to ieuuce the high
seium levels.
1 g phosphoius Patient has high levels of phosphoius as a iesult of
compiomiseu kiuney function. Bigh levels of phosphoius
in the bloou can cause loss of calcium fiom bones.
Consuming less phosphoius will lowei bloou
phosphoius levels.
4
2 g Na To pievent patient becoming oliguiic anu anuiic, which
commonly uevelops within the fiist 12 months of
hemouialysis. Also iegulates hyuiation status.
1,uuumL fluiu +uiine output Piopei intake of fluius that aie baseu on uiine output
will help maintain positive fluiu status. Essential foi
iegulating extiacellulai fluiu volume anu plasma
volume.

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Z" >*2352*)& *$% +$)&'/'&) L'(" M1*N5+$O( YL!" [1E %1&( &%&F* *44&3) 015'
+$)&'/'&)*)+1$A
Patient has a Bouy Nass Inuex of SS.27 kgm
2
. This measuiement classifieu
hei as obese. Euema may affect the weight status of patient, contiibuting to
an incieaseu weight. Watei ietention oi euema has been founu to cause an
inciease in bouy weight because of the excess fluiu in the tissues.

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3*2352*)& ).& &%&F*]4'&& *%^5()&% 91%0 E&+,.) =*Y;&4@W
>*2352*)& L'(" M1*N5+$O( &%&F*]4'&& E&+,.)" !( ).+( ).& (*F& *( %'0
E&+,.)A

aBWef = BWef + |(SBW-BWef) X u.2Sj 161 lbs+(6S-161) x .2S
aBWef= 16S+ |(6S-16S) xu.2Sj
aBWef= 14u lbs
The patient's euema-fiee weight is the same as hei uiy weight. Euema-fiee
weight is the appioximate weight of a patient without the excess fluiu
builuup. The weight of 14u pounus is the lowest weight that Nis. }oaquin can
ieach aftei uialysis to iemain healthy anu pievent losing too much fluiu anu
electiolytes.


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77" ;.*) *'& ).& &$&',0 '&N5+'&F&$)( 41' >?8A
Eneigy iequiiements foi both nonuialyzeu anu hemouialysis Chionic Kiuney
Bisease patients aie less than 6u yeais olu aie SS kilocaloiies pei kilogiam of
bouy weight. Foi those oluei than 6u yeais olu, Su-SS kilocaloiies pei
kilogiam of bouy weight aie iecommenueu. In oiuei to calculate eneigy anu
piotein neeus, it is iecommenueu to use the fiee aujusteu bouy weight.

7:" >*2352*)& E.*) L'(" M1*N5+$O( &$&',0 $&&%( E+22 9& 1$3& (.& 9&,+$(
.&F1%+*20(+("
Patient's eneigy neeus aie SS kilocaloiies pei kilogiam of bouy weight. Since
the patient's calculate euema-fiee bouy weight is 14u pounus, oi 6S.64 kg.
S
Baseu on this infoimation, Nis. }oaquin shoulu be consuming appioximately
:I::S 63*21'+&( /&' %*0.

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.&F1%+*20(+(A
Nis. }oaquin shoulu be consuming 1.2 giams of piotein pei kilogiam of bouy
weight. Bei piotein intake shoulu be SQ"BS, /&' %*0. At least Su% of the
piotein shoulu be of high biological value.

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/&'+)1$&*2 %+*20(+(A
The patient neeus to be obtaining an auequate amount of kilocaloiies to
pievent malnutiition anu ensuie piopei intake of the essential amino acius.
The eneigy iequiiements foi patients on peiitoneal uialysis aie the same.
The piotein iequiiement foi peiitoneal uialysis is slightly highei than foi
hemouialysis. Peiitoneal uialysis patients typically lose moie piotein anu
consequently iequiie 1.2-1.Sgkg pei uay.

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7J" X'& ).&'& *$0 /1)&$)+*2 9&$&4+)( 14 5(+$, %+44&'&$) )0/&( 14 /'1)&+$I (53.
*( /2*$) /'1)&+$ '*).&' ).*$ *$+F*2 /'1)&+$I +$ ).& %+&) 41' * /*)+&$)
E+). >?8A CD/2*+$"
Plant piotein can be beneficial foi CKB patients because most souices of
plant-baseu piotein contains ieuuceu amounts of satuiateu fat anu souium.
Nany plant-baseu pioteins aie a goou souice of lean piotein that can aiu in
ieuucing inflammation in the bouy. Intake of plant-baseu piotein shoulu be
limiteu because of high phosphoious content in beans anu nuts. A
combination of plant-baseu piotein anu animal piotein is essential foi CKB
patients because animal piotein contains all the essential amino acius anu is
easiei to uigest. Recommenuations incluue obtaining Su% of piotein fiom
high biological value souices such as animal meats.

7Q" L'(" M1*N5+$ .*( * `HG '&()'+3)+1$" ;.0A
Patient has a phosphoious iestiiction because hei compiomiseu kiuney
function is unable to iemove enough phosphoious fiom the bloou. Bigh
bloou phosphoious levels can cause a loss of calcium fiom the bones
iesulting in weak bones. Patient neeus to consume iestiicteu amounts of
phosphoious because she has high bloou phosphoious levels which is likely
contiibuting to hei muscle weakness.

7S" ;.*) 411%( .*P& ).& .+,.&() 2&P&2 14 /.1(/.1'5(A
Foous that have high amounts of phosphoious that shoulu be limiteu incluue:

! Beveiages: Ale, chocolate uiinks, uiinks maue with milk, canneu iceu
teas, beei, cocoa, uaik colas
6
! Baiiy piouucts: cheese, custaiu, milk, cieam soups, cottage cheese,
yoguit, puuuing, anu ice cieam
! Piotein: Caip, beef livei, fish ioe, oysteis, ciayfish, chicken livei, oigan
meats, anu saiuines
! vegetables: Biieu beans, bakeu beans, kiuney beans, chickpeas, lima
beans, soy beans, black beans, gaibanzo beans, lentils, noithein beans,
split peas
! 0theis: Bian ceieals, caiamels, seeus, whole-giain piouucts, Biewei's
yeast, nuts, anu wheat geim

7V" L'(" M1*N5+$ )&22( 015 ).*) 1$& 14 .&' 4'+&$%( 3*$ %'+$6 1$20 3&')*+$
*F15$)( 14 2+N5+% *$% E*$)( )1 6$1E +4 ).*) +( ).& 3*(& 41' .&'" ;.*)
411%( *'& 31$(+%&'&% )1 9& 425+%(A ;.*) '&31FF&$%*)+1$( 3*$ 015
F*6& 41' L'(" M1*N5+$A
It is impoitant foi patient to iemembei that fluius allowances aie highly
inuiviuualizeu anu aie baseu on iesiuual uiine output anu uialysis mouality.
The liquiu iestiictions of the patient's fiienu will vaiy fiom Nis. }oaquin
because of many inuiviuualizeu factois that aie taken into account. Foous
that aie consiueieu to be fluius incluue soups, popsicles, sheibet, ice cieam,
yoguit, custaiu, anu gelatin. Nis. }oaquin shoulu limit hei salt intake because
it will ieuuce thiist anu also be impoitant foi othei meuical complications
such as hei high bloou piessuie anu cholesteiol. Also, patient shoulu uiink
beveiages that aie less sweet anu shoulu ieuuce consumption of Coke anu
othei sugaiy beveiages.

7Z" !4 * /*)+&$) F5() 41221E * 425+% '&()'+3)+1$I E.*) 3*$ 9& %1$& )1 .&2/
'&%53& .+( 1' .&' ).+'()A
Theie aie many tips foi ieuucing thiist uuiing fluiu iestiiction. In auuition to
limiting high intake of salt anu high sugai beveiages that ieuuce thiist
quench, use soui canuy oi sugai-fiee gum to moisten mouth, auu lemon to
watei, swish mouth with colu watei oi suck on ice cubes when thiisty.

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*//'1/'+*)& %+*,$1()+3 )&'F"
! Inauequate oialfoou beveiage intake
! Nalnutiition
! Involuntaiy weight loss
! Foou anu nutiition-ielateu knowleuge ueficits
! Pooi nutiition quality of life
! 0nuesiiable foou choices

8" >2+$+3*2 81F*+$
:7" R&P&'*2 9+13.&F+3*2 +$%+3&( *'& 5(&% )1 %+*,$1(& 3.'1$+3 6+%$&0
%+(&*(&" H$& +( ,21F&'52*' 4+2)'*)+1$ '*)& =aK_@" ;.*) %1&( aK_
F&*(5'&A
7
uFR measuies the iate that substances aie cleaieu fiom the plasma by the
glomeiuli. The noimal uFR is 1SS-2uu liteis pei uay. This measuies kiuney
function by evaluating kiuney health, estimating the seveiity of uiagnoseu
uisease, anu monitoiing kiuney uisease piogiession.

::" ;.*) )&() +( 5(5*220 %1$& )1 &()+F*)& ,21F&'52*' 4+2)'*)+1$ '*)&A
Cleaiance tests (enuogenous cieatinine cleaiance tests) aie peifoimeu to
estimate uFR.

:B" L'(" M1*N5+$O( aK_ +( :V Fb<F+$" ;.*) %1&( ).+( )&22 015 *915) .&'
6+%$&0 45$3)+1$A
The patient's uFR of 28 mLmin inuicates that the patient is at stage 4 of
chionic kiuney uisease with a seveie ueciease in uFR. Recommenuation foi
patients in this auvanceu stage of CKB is to piepaie foi kiuney ieplacement
theiapy.

:G" CP*25*)& L'(" M1*N5+$O( 3.&F+()'0 '&/1')" ;.*) 2*9( (5//1') ).&
%+*,$1(+( 14 R)*,& G >?8A
! Bigh Souium
! Bigh Potassium
! Bigh Phosphoious
! Bigh Cieatinine
! Bigh Bloou 0iea Nitiogen
! Bigh Bemoglobin AIC

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L'(" M1*N5+$O( E&+,.) /1() %+*20(+(A ;.0 %+% +) 3.*$,&A
Patient's weight was 16S pounus post uialysis. Patient lost S pounus fiom the
uay befoie post uialysis because of piopei iemoval of excess waste anu fluiu.
This weight loss is a iesult of uialysis that impioveu ability to exciete fluius
anu metabolic piouucts of piotein.

:Q" ;.+3. 14 L'(" M1*N5+$O( 1).&' (0F/)1F( E152% 015 &D/&3) )1 9&,+$ )1
+F/'1P&A
0thei symptoms expecteu to impiove incluue inability to uiinate anu euema
in extiemities, face, anu eyes. Both of these symptoms aie causeu by
compiomiseu kiuney function anu builuup of fluiu in the bouy anu aie
expecteu to impiove with uialysis.

:S" CD/2*+$ E.0 ).& 41221E+$, F&%+3*)+1$( *'& /'&(3'+9&% 90 31F/2&)+$,
).& )*92&"

Neuication InuicationsNechanism Nutiitional Concein
vasotec 0seu to tieat high bloou
piessuie anu uiabetic
Behyuiation, electiolyte
uisoiueis, anu anoiexia
8
nephiopathy
Eiythiopoietin Stimulates ieu bloou cell
piouuction to tieat anemia
N&v anu uiaiihea. Also
may neeu vitamin B12
oi folate supplements.
vitaminmineial
supplement
Watei soluble vitamins (B's
anu C) pievent fluiu loss
uuiing uialysis
vaiying iecommenueu
uosage
Calcitiiol Foi hypocalcemia in uialysis Bo not take with a lot of
Ca oi low P
ulucophage Antihypeiglycemia agent,
incieases absoiption anu
uecieases hepatic glucose
piouuction
Anoiexia
Souium bicaibonate Antaciu Incieaseu thiist anu
fluiu weight
Phos Lo Phosphate binuei Anoiexia, N&v


:V" !%&$)+40 $5)'+)+1$ /'192&F( E+).+$ ).& 32+$+3*2 %1F*+$ 5(+$, ).&
*//'1/'+*)& %+*,$1()+3 )&'F"
! 0veiweightobesity (NC-S.S)
! Alteieu nutiition-ielateu lab values incluuing elevateu potassium,
phosphoious, anu cieatinine, anu uecieaseu uFR. (NC-2.2)

C" Y&.*P+1'*2]C$P+'1$F&$)*2 81F*+$
:Z" ;.*) .&*2). /'192&F( .*P& 9&&$ +%&$)+4+&% +$ ).& `+F* !$%+*$( ).'15,.
&/+%&F+121,+3*2 %*)*A
The Pima Inuians have a histoiy of high uiabetes anu obesity iates.
Appioximately Su% of theii auult population has uiabetes anu of those, 9S%
aie oveiweight. Stuuies have shown that oveiweight people have a slowei
metabolic iate compaieu to those of noimal weight.
! The Pima Inuians. (2uu2). The Pima Inuians: Pathfinueis foi Bealth.

B\" CD/2*+$ E.*) +( F&*$) 90 ).& c).'+4)0 ,&$&d ).&1'0"
The Pima Inuians ielieu on faiming, hunting, anu fishing foi thousanus of
yeais anu expeiienceu peiious of feast anu famine. Because populations such
as the Pima Inuians uiu not know when they woulu eat next, theii bouies
began to stoie fat uuiing times of plenty to ueciease staivation uuiing times
of famine. The cuiient westeinizeu lifestyle uoes not expeiience peiious of
famine anu theiefoie the thiifty gene that exists in Puma Inuians causes
iegulai excessive fat stoiage.
! Pima Inuians. 0besity Associateu with Bigh Rates of Biabetes
in the Pima Inuians.

B7" [1E %1&( $&/.'1/*).0 *44&3) `+F* !$%+*$(A
9
Biabetic nephiopathy is the leauing cause of enu-stage ienal uisease anu is
influenceu by genetic anu enviionmental factois. Reseaich concentiating on
the genome linkage analysis inuicates that Pima Inuians have susceptibility
loci foi uiabetic nephiopathy on specific chiomosomes (S, 7, anu 2u).
! Tanaka, N. and Babazono, T. (2005), Assessing genetic
susceptibility to diabetic nephropathy. Nephrology, 10: S17S21.

!e" T5)'+)+1$ 8+*,$1(+(

B:" >.11(& )E1 .+,.]/'+1'+)0 $5)'+)+1$ /'192&F( *$% 31F/2&)& * `CR
()*)&F&$) 41' &*3."
! 0niegulateu bloou sugai levels ielateu to limiteu auheience to
nutiition-ielateu iecommenuations, unuesiiable foou choices,
anu foou anu nutiition-ielateu knowleuge ueficit as eviuence
by high glucose levels, piogiessive type II uiabetes, anu
unfilleu piesciiptions.

! Inauequate fluiu intake ielateu to high souium consumption,
compiomiseu kiuney function anu fluiu ietention as eviuence
by low uFR lab values; lab uata of abnoimal souium, calcium,
phosphoious, anu potassium levels.

e" T5)'+)+1$ !$)&'P&$)+1$

BB" K1' &*3. `CR ()*)&F&$)I &()*92+(. *$ +%&*2 ,1*2 =9*(&% 1$ ).& (+,$(
*$% (0F/)1F(@ *$% *//'1/'+*)& +$)&'P&$)+1$ =9*(&% 1$ ).&
&)+121,0@"
1. The iueal goal is to iegulate bloou glucose levels by planning out
scheuuleu meals at the same time each uay to avoiu skipping meals.
Auuitionally, making piopei uietaiy choices by using caibohyuiate
counting at each meal.

2. The iueal goal is to contiol fluiu intake by consuming a low-souium
uiet. Fluiu intake is best contiolleu by limiting high-souium foous such
as piocesseu meats, piocesseu uaiiy, canneu, anu piepackageu foous.

BG" ;.&$ L'(" M1*N5+$ 9&,+$( %+*20(+(I &$&',0 *$% /'1)&+$
'&31FF&$%*)+1$( E+22 +$3'&*(&" CD/2*+$ E.0"
Eneigy anu piotein iecommenuations aie slightly incieaseu in
uialysis patients because it supplies the bouy with the piopei eneigy
anu nutiients neeueu foi the piocess. Stuuies show that patients aie
moie stable anu successful with uialysis when they have a goou
nutiitional status. Piotein iecommenuations inciease foi uialysis
patients because amino acius aie lost into uialysate anu ieuuceu
piotein synthesis occuis uuiing tieatment.
1u
! Nanagement of Piotein anu Eneigy Intake in Bialysis Patients.
(2uu8). !"#$%&' )*+' ,%+-.#'+-/, 2S, 29u2-291u.

BJ" ;.0 +( +) '&31FF&$%&% 41' /*)+&$)( )1 .*P& *) 2&*() J\f 14 ).&+'
/'1)&+$ 4'1F (15'3&( ).*) .*P& .+,. 9+121,+3*2 P*25&A
Patients aie iecommenueu to intake Su% of piotein neeus fiom high
biological value souices such as eggs, chicken, beef, anu most othei
animal piouucts. The othei Su% iecommenueu is plan-baseu pioteins
such as nuts anu legumes. The balance of the two is iecommenueu to
maintain a neutial oi positive nitiogen balance anu leau to a balanceu
uiet that helps maintain piopei souium anu phosphoious levels. Animal
piotein is also easiei foi the bouy to uigest anu the uigestion piocess of
"low quality" pioteins is longei.


BQ" U.& L8 1'%&'&% %*+20 5(& 14 * F52)+P+)*F+$<F+$&'*2 (5//2&F&$)
31$)*+$+$, Y]31F/2&DI 95) $1) 4*)](12592& P+)*F+$(" ;.0 *'& ).&(&
'&()'+3)+1$( (/&3+4+&%A
Boctois often iecommenu watei-soluble vitamins such as a B-
complex vitamin foi uialysis patients because they pioviue hyuiation
foi patients unueigoing uialysis anu fluiu loss. B-vitamins also aiu in
the eneigy ieleaseu fiom caibohyuiates, fats, anu pioteins. Fat-
soluble vitamins aie usually avoiueu because they builuup in the
bouy.

BS" ;.*) '&(15'3&( E152% 015 5(& )1 )&*3. L'(" M1*N5+$ *915) .&' %+&)A
In oiuei to teach Nis. }oaquin about hei uiet, I woulu use NyPlate to
infoim hei about an oveiall well-balanceu uiet. To specifically catei to
the hei uiet plan, I woulu then give Nis. }oaquin lists of foous that aie
high anu low in specific nutiients (similai to the tables in the
textbook) such as souium, phosphoious, anu fluius. I woulu also
pioviue Nis. }oaquin euucation on the National Renal Biet to give hei
an unueistanuing of foou options available to hei. Fiom the table I
woulu help Nis. }oaquin plan a few of hei basic meals anu use foou
mouels to ieview piopei seiving sizes.

BV" #(+$, L'(" M1*N5+$O( )0/+3*2 +$)*6& *$% ).& /'&(3'+9&% %+&)I E'+)& *
(*F/2& F&$5" L*6& (5'& 015 3*$ ^5()+40 015' 3.*$,&( *$% ).*) +) +(
31$(+()&$) E+). .&' $5)'+)+1$ /'&(3'+/)+1$"

Biet PTA Sample Nenu
Colu ceieal (S4 c unsweeteneu)
Bieau (2 slices) oi fiieu potato (1 meu)
1 fiieu egg
Bowl of coinflakes (low in K, P)
1 slice of bieau w maigaiine
Sciambleu eggbeateis 0$"'# %"123" 3$&'4
5 &6 7$&'" 8*'9 0:11"1 3+'&%*". ;2/ 7+-/
11
/& '*8*/ 1+*%< 3&-.28#/*&-4
Bologna sanuwich (2 slices white bieau,
2 slices bologna, mustaiu)
Potato chips (1 oz)
1 can Coke
Wiap on white toitilla with hummus,
choppeu peppeis, anu 2 oz. lean tuikey
w iice ciackeis anu ciystal light
0=2882. +11. #'+-/>;+."1 #%&/"*-?
"'*8*-+/" ;&'&@-+ ;A3 &B $*@$ .&1*28?
"'*8*-+/" 3&9" ;A3 &B $*@$ .2@+%? +-1 -&
#&/+/& 3$*#. ;"3+2." &B $*@$ .&1*28 +-1
#&/+..*284
Choppeu meat (S oz beef)
Fiieu potatoes (1.S meuium)
Ciackeis (6 saltines) anu peanut buttei
(2tbsp)
Lean chicken with couscous, lentils, anu
stiawbeiiies ('".. B+/? %"123" #&/+..*28
+-1 .&1*284


BZ" #(+$, ).& '&$*2 &D3.*$,& 2+()I /2*$ * 7]%*0 %+&) ).*) 31F/2+&( E+).
015' %+&) 1'%&'" `'1P+%& * $5)'+&$) *$*20(+( )1 *((5'& 31$(+()&$30
E+). *22 31F/1$&$)( 14 ).& /'&(3'+/)+1$"

Y'&*64*()W
Sciambleu egg
English Nuffin
Bluebeiiies
Soy Nilk

R$*36W
Almonus
Fiozen cantaloupe balls

b5$3.W
Couscous
Bakeu beans
uieen beans (low souium)

R$*36W
Rice puuuing
Slice of white bieau w maigaiine
8+$$&'W
Pasta with tomato sauce
Peas
Roasteu tuikey without skin
Binnei Roll w maigaiine
Ciystal Light
Wateimelon
12

R$*36W
Rice ciackeis
Peanut buttei

G\" ;'+)& *$ +$+)+*2 F&%+3*2 '&31'% $1)& 41' 015' 31$(52)*)+1$ E+). L'("
M1*N5+$"
Assessment:
Nis. }oaquin is a 24 yeai olu female of Native Ameiican uecent. She is
6u inches oi 1.S24 N anu weighs 17u pounus oi 77.27 kg. Bei
calculateu BNI at hei cuiient state is SS.27 kgm
2
. Patient's calculateu
euema-fiee bouy weight is 14u pounu. Patient was uiagnoseu with
type 2 uiabetes at the age of 1S yeais olu anu has monitoieu ienal
function foi the past 7 yeais. She has pooi kiuney function anu suffeis
with stage 4 chionic kiuney uisease. Patient was aumitteu to piepaie
foi kiuney ieplacement theiapy. Patient iecently complain of N&v, 4
kg weight loss in the past 2 weeks, euema in extiemities, face, anu
eyes, S0B, muscle ciamps, anu inability to uiinate.

8+*,$1(+(W
1. 0niegulateu bloou sugai levels ielateu to limiteu auheience to
nutiition-ielateu iecommenuations, unuesiiable foou choices, anu
foou anu nutiition-ielateu knowleuge ueficit as eviuence by high
glucose levels, piogiessive type II uiabetes, anu unfilleu piesciiptions.

2. Inauequate fluiu intake ielateu to high souium consumption,
compiomiseu kiuney function anu fluiu ietention as eviuence by low
uFR lab values; lab uata of abnoimal souium, calcium, phosphoious,
anu potassium levels.

!$)&'P&$)+1$W
The iueal goal is to iegulate bloou glucose levels by planning out
scheuuleu meals at the same time each uay to avoiu skipping meals.
Auuitionally, making piopei uietaiy choices by using caibohyuiate
counting at each meal. Patient shoulu begin tiacking uaily foou intake.
Nutiition euucation will be pioviueu weekly to the client.

The iueal goal is to contiol fluiu intake by consuming a low-souium
uiet. Fluiu intake is best contiolleu by limiting high-souium foous such
as piocesseu meats, piocesseu uaiiy, canneu, anu piepackageu foous.
Client will begin to tiack souium intake anu ieau foou labels foi
ieuuceu souium options.

L1$+)1' gCP*25*)+1$W
1S
Patient shoulu scheuule a follow-up appointment with uietitian within
one week to assess changes. Patient will be monitoieu baseu on
iecoiueu foou anu beveiage intake, mineial intake of souium anu
potassium, anu fluiu intake.