2 Hemodialysis Case

National Kidney and Transplant Institute
Post Graduate Course on Renal Nutrition 2020
CASE STUDY PRESENTATION

January 24, 2020
OBJECTIVE
 Atthe end of the session, the participants
shall be able to integrate the principles of
renal nutrition therapy for CKD patients in
the clinical practice
CASES
CASE ON HEMODIALYSIS
CASE HEMODIALYSIS
 Patient NJ, a 25 year old female admitted due to uremia,
pallor
 Diagnosed with CKD 2o CGN
 s/p AVF creation
 For HD initiation of 2x a week

CASE DIALYSIS
 Clinical Assessment:
 (+) nausea, vomiting
 (-) constipation, diarrhea
 (-) difficulty in chewing & swallowing
 Physical Assessment:
 (-)edema
 (+) muscle wasting – clavicle & temporal area
 (+) pale
ANTHROPOMETRY:
 Height: 5’1”
 Actual Body Weight: 50 kg
 Post-HD Weight: 48.7 kg
Medications:
 Ferrous Sulfate
 Folic Acid
 Calcium Carbonate
 Febuxostat
CASE DIALYSIS
 Dietary Assessment:
 (-) Food Allergy
 (+) Good appetite – consumes 75% of served food
 (+) Consumes processed foods
 (-) Consultation to dietitian
LAB RESULTS DURING ADMISSION
Tests Results
Creatinine 15.3
0.6 – 1.1 mg/dl
eGFR 2.88
>90ml/min/1.73m2
Potassium 2.88
3.5 – 5.0 mEq/L
Hgb 8.1
12 – 16 g/dl
QUESTIONS:
 Assess the laboratory results
 Nutritional Assessment
 SGA
 IBW
 Actual Body Weight edema free
 % weight loss / % usual body weight
 Nutritional Diagnosis
 Nutritional Intervention
 Diet Rx
NUTRITION ASSESSMENT - SGA
Criteria Normal / Mild Moderate Severe
Weight loss None < 10% of usual weight > 10% of usual weight
Food Intake No change Suboptimal Starvation

(last 1 – 2 months)
Gastro Symptoms None Nausea / vomiting Anorexia, diarrhea
> 2 weeks
Functional capacity No change Dysfunction / suboptimal work Bedridden
< 3 weeks > 2 weeks
Bedridden < 2 weeks
Disease and relation to No or low stress Moderate stress Severe stress

nutritional requirements
Physical Examination 0 1 to 2 3
Subcutaneous fat Subcutaneous fat and/or muscle Subcutaneous fat and/or
and/or muscle loss loss muscle loss
Edema None None 1 or 2

BMI 18.5 to 25 25.1 to 30 < 18.5
Albumin > 3.4 2.5 to 3.4 < 2.5
Nutritional Status Normal Moderate Malnutrition Severe malnutrition
NUTRITION ASSESSMENT
 Height: 5’1” (154.94 cm)

 Actual Body Weight: 50 kg
 Post-HD Body Weight: 48.7 kg
 Ideal Body Weight: 49kg (NDAP Method)
 Ideal Body Weight: 49kg (Tannhauser Method)
 % SBW: = 48.7 kg / 49 kg x 100 = 99%
 aBWef: BWef + [(IBW – BWef) x 0.25 =
48.7 kg + (49 – 48.7 k) x 0.25 = 49 kg
 BMI: 20
NDAP Method: Female: 104 lbs (+ 4 lbs for every inch above 5 ft)
NUTRITION DIAGNOSIS
 Food, nutrition and nutrition-related knowledge deficit

related to no previous diet consultation as evidenced by
lack of computed diet (individualized meal plan) and
consumption of processed foods.
Nutrition Intervention
 Build basic / essential nutrition-knowledge by giving:
 Specific diet recommendation and individualized meal
plan on
 Low Sodium Low Purine Diet
 Give diet instruction with handouts on renal diet to patient

and relative / primary caregiver, including sample menu
and practical tips in food preparation
 An appropriate oral nutrition supplement may be

suggested to meet daily energy and nutrient requirements
NUTRITIONAL INTERVENTION
1. Compute Total ER
TER = 48.7 kg (IBW) x 35 kcal / kgBW
= 1704.5 calories ~ 1700 calories
2. Compute Total Protein Requirement Protein

TPR = 48.7 kg (IBW) x 1.2 g CHON / kgBW
= 58.4 grams ~ 60 grams
(~ 60 to 70% HBV)
3. Non-Protein Calories (NPC)

NPC = 60 grams x 4 kcal / gram = 240 calories
3. NPC
NPC = 60 grams x 4 kcal / gram = 240 calories
NPC = 1460 calories
4. Distribution
Carbohydrate: 70 % = 255.5 grams ~ 255 grams
Fat: 30 % = 48.6 grams ~ 50 grams
Food Dist. Amount
 Low Sodium Vegetables 2 cups
Low Purine
Fruit 3 exchanges
Milk 2 Tablespoons (powder)
 1700 calories
Rice
A (Rice & subs) 4 cups
 C 255 g
A (substitute) 1 serving (3 pieces crackers)
 P 60 g
Meat
 F 50 g A (Meat & Fish) 1 ½ matchboxsize (lean meat)
B (other Fish) 2 piece (low fat fish)
C (Egg) 1 piece chicken egg
Fat 7 teaspoons
SODIUM REQUIREMENT:
 Sodium Requirement per day: 2000

mg
 Inherent Sodium: 580 mg 2000 mg
 Added Sodium: 1420 mg - 580 mg
_____________
1420 mg
 ¼ teaspoon salt = 500 mg sodium
 Additional salt: ½ to ¾ teaspoon

Renal Exchange List:
Food No of CHO PRO FAT Na K Ca Ph Moist Cal
Item exchanges 255 g 60 g 50 g mg mg mg mg 1700
Vegs A– 2 6 1.2 - 4.0 120 30 30 60 32

A1 – 1 3 0.6 - 2.0 120 40 15 30 16
Fruit A - 2 (fresh) 20 0.8 - 6.0 240 20 20 64 80
B1-1 (canned) 10 0.2 2.0 60 5 5 42 40
Milk, ½ exchange 6 4 - 80 259 180 125 71 40
NF
Rice A– 8 184 16 - 16 480 120 280 600 800
B–1 23 4 - 115 60 20 35 10 100
Meat A (LF) – 1 ½ - 12 1.5 45 300 22.5 105 46.5 61.5

B1 (LF, Fish) - 2 - 16 2 120 400 70 180 70 82
C (MF) – 1 - 8 6 110 95 50 115 45 86
Fat 7 teaspoons - - 35 80 4 2 2 2 315
(3 teaspoons –
butter)
Sugar 3 teaspoons 15 - - - - - - 60
TOTAL 255 62.8 48 580 2138 559.5 912 1040.5 1712.5
Meal Distribution:
Food Household Breakfast Lunch Dinner AM PM Bed
Item meas. Snack Snack Time
Veg 2 cups 1 cup 1 cup
Fruit 3 pc/slice 1 pc/slice 1 pc/slice 1 pc/slice
Milk 2 Tbsp 2 Tbsp

Powdered Powdered
Rice/ 4 cups 1 cup 1 cup 1 cup ½ cup ½ cup

Bread
Meat 4 ½ mbs 2 1½ 1
Fat 7 tsp 2 tsp 2 tsp 1 tsp 1 tsp 1 tsp
Sugar 3 tsps 2 tsp 1 tsp

NUTRITIONAL MONITORING & EVALUATION
 Arrange follow-up with dietitian to check and monitor
patient’s compliance to diet recommendation
 1 to 2 weeks post discharge
 Adjust diet computation as necessary
 KDOQI: Quarterly visit to a dietitian
 A diet record / diary may be accomplished to monitor the

intake and evaluate its adequacy
 KDOQI: Biannually
 Monitor and evaluate nutritional status

 Weight changes (%SBW, % weight loss)
 Every 6 months (for patients who are at-risk of PEW)
SAMPLE MENU:
 Breakfast Sliced Papaya
Arroz Caldo with Hardboiled Egg
Non Fat Milk
 AM Snack Puto with Unsalted Butter
 Lunch Ampalaya con Carne

Rice
Apple
SAMPLE MENU:
 PM Snack Bihon Guisado
 Supper Fried Galunggong

Upo Guisado
Rice
Sliced Papaya

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National Kidney and Transplant Institute

Post Graduate Course on Renal Nutrition 2020

CASE STUDY PRESENTATION

 s/p AVF creation

 For HD initiation of 2x a week

Food Intake No change Suboptimal Starvation

Disease and relation to No or low stress Moderate stress Severe stress

Edema None None 1 or 2

 Height: 5’1” (154.94 cm)

 Food, nutrition and nutrition-related knowledge deficit

 Give diet instruction with handouts on renal diet to patient

 An appropriate oral nutrition supplement may be

2. Compute Total Protein Requirement Protein

3. Non-Protein Calories (NPC)

 Sodium Requirement per day: 2000

 ¼ teaspoon salt = 500 mg sodium

 Additional salt: ½ to ¾ teaspoon

Vegs A– 2 6 1.2 - 4.0 120 30 30 60 32

Meat A (LF) – 1 ½ - 12 1.5 45 300 22.5 105 46.5 61.5

Veg 2 cups 1 cup 1 cup

Fruit 3 pc/slice 1 pc/slice 1 pc/slice 1 pc/slice

Milk 2 Tbsp 2 Tbsp

Rice/ 4 cups 1 cup 1 cup 1 cup ½ cup ½ cup

Fat 7 tsp 2 tsp 2 tsp 1 tsp 1 tsp 1 tsp

Sugar 3 tsps 2 tsp 1 tsp

 A diet record / diary may be accomplished to monitor the

 Monitor and evaluate nutritional status

 AM Snack Puto with Unsalted Butter

 Lunch Ampalaya con Carne

 Supper Fried Galunggong

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