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Alternative Renal Disease SIM Case Study

Alternative E-Reserves Renal Disease SIM Case Study

Clarissa Sumanting

Professor Baird

December 17, 2020

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Alternative Renal Disease SIM Case Study

1. What other assessments do you suggest and why? Present your results in the

ABCDE format.

Other assessments that one could suggest are the following:

Anthropometrics – N/A

Biochemical – Recommend phosphorus labs and lipid panel. If the patient’s phosphorus

lab is high, he may need education on foods that are high in phosphorus and the

purpose for limiting this mineral. A lipid panel would be helpful to evaluate if the

diagnosis of hypercholesterolemia is still accurate and if the patient needs education.

Clinical – Perform a nutrition-focused physical exam to assess if the patient has any

muscle wasting or subcutaneous fat loss.

Diet – Recommend the patient keeping a food log/food journal to assess his

understanding of the renal diet and to also use it as a tool to incorporate additional

snacks to meet his caloric needs.

Environmental/Behavioral/Social – N/A

2. What is the nutrition and dietetic diagnosis? Write this as a PASS statement.

The diagnosis is: Inadequate oral intake (NI-2.1). The PES statement is: Inadequate oral

intake (NI-2.1) related to decreased appetite as evidenced by patient report of reduced

appetite beginning 6 weeks ago and a severe weight loss of 8% in 3 months.

3. What is the aim of your dietetic intervention plan? Include SMART goal(s) and

outcome measures.
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Alternative Renal Disease SIM Case Study

The aim of the dietetic intervention plan is to assist Martin in increasing his intake to

meet his estimated nutrition needs. This may include smaller, frequent meals and/or

oral supplementation that is lower in protein. Additionally, education of a renal diet or

refresher on the renal diet may be needed.

An example of a SMART goal is the following:

Martin will begin a food journal starting Monday for the next two weeks before his

follow-up appointment.

Outcome measures could include looking at Martin’s food log to assess how many

calories and protein he had consumed during the two weeks and his weight.

4. How would you involve Martin in his dietetic goal setting?

After reviewing over his nutrition needs and the basics of a renal diet, Martin can be

involved in his dietetic goal setting by reviewing over the foods he likes to eat and

incorporating this into his meals or making substitutions for food items he may need to

limit. Additionally, as his wife seems to be involved, we can review over recipes that are

kidney friendly that may be found on websites such as Fresenius Kidney Care.

5. How would you evaluate Martin’s progress? Justify your choice of outcome

measures.

Martin’s progress could be evaluated by reviewing over his food log to ensure he is

consuming enough calories to prevent weight loss/maintain his weight and to also

ensure he is consuming an adequate amount of protein. His food log may also be used
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to measure his understanding of a renal diet, specifically what foods are protein, which

foods contain phosphorus and which foods are high in potassium that he needs to

currently avoid due to his high potassium labs.

6. How would you obtain feedback from Martin on your service?

I could obtain feedback from Martin on his service during his next follow-up visit by

inquiring how his eating patterns have been, if the kidney-friendly recipes were helpful

and/or if there has been an improvement in his appetite.

7. What are the important biochemical results and how did you distinguish them from

the other results provided?

In regards to assessing kidney function, the important biochemical results are the

following: phosphorus, potassium, sodium, eGFR, urea, creatinine and albumin.

The eGFR evaluates at which stage of chronic kidney disease the patient is due to how

well the kidney is filtering. Urea, creatinine and albumin are evaluated because it relates

to how well the kidney is filtering these waste products and protein from the blood. If

their lab results are high, the kidney function is declining. From a dietitian’s point of

view, phosphorus, potassium and sodium are significant. High levels of phosphorus can

pull calcium out of the patient’s bone resulting in brittle bones. High levels of potassium

affect the heart and can result in irregular heartbeat or a heart attack. A high

consumption of salt can increase one’s blood pressure and ultimately put more strain on

the kidney. According to the patient’s results, the labs that are abnormal are urea (H),
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Alternative Renal Disease SIM Case Study

creatinine (H), potassium (H), sodium (slightly elevated), and eGFR (L).

8. What are the possible barriers to change?

The possible barriers to change may include difficulty meeting his estimated nutrition

needs due to his lack of appetite. Martin may find it difficult trying to eat more foods

with the restrictions of a renal diet.

9. Explain how you would implement the dietetic intervention.

The dietetic intervention could be implemented by reviewing over the patient’s 24-hour

diet recall and, using the MyPlate as a visual guide, adding additional items that he is

missing from his diet, such as fruits and vegetables, that he finds appetizing.

Additionally, kidney recipes may be reviewed over with the patient and his wife and

printed out for them to try at home. Providing a list of fruits and vegetables that are low

in potassium may also be helpful when they go grocery shopping.

10. What information would you need to collect to monitor and review Martin?

The information that I would need to collect to monitor and review Martin are his food

journal, weight measurements, fluid intake, and his pertinent labs such as potassium,

phosphorus, and sodium.

11. What would your answer be if Martin asked what should he eat in order to help his

kidney function once his appetite improves?

I would review the importance of limiting his protein and sodium intake and following a
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meal pattern that involves fresh produce, limiting his intake of vitamin K-rich vegetables

if his labs are still elevated.

12. How else would you monitor nutritional status if Martin had oedema and his weight

change was unreliable?

If the patient has edema and his weight change was unreliable, evaluating his most

recent sodium labs may be indicative as to whether he is consuming a diet high in

sodium which contributing to the extra fluid. Reviewing over the importance of adhering

to a diet low in sodium may be needed.

13. Should Martin have his nutritional status monitored regularly?

Yes, I believe Martin should have his nutritional status monitored regularly to ensure he

is adhering to a kidney-friendly diet to while meeting his estimated caloric and protein

needs.

14. When should you refer on to specialist renal team?

A referral to a specialist renal team should be placed when there is a significant decline

in the patient’s kidney function, reflected in his eGFR labs, which may indicate the need

for dialysis once the patient reaches stage 5 CKD.

1. Patient Data M.X. / 67 y.o. / M

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 Patient Profile: 67-year-old male admitted due to hyperkalemia, recent weight

loss and diagnoses of hematuria, proteinuria, UTI and lethargy from visiting his
GP a week ago.
 Past Medical History / Past surgical history: HTN, hypercholesterolemia
 Patient Current Diagnosis: CKD stage 3, hematuria, proteinuria, UTI
 Socio-economic status – Patient is retired and married.
2. Nutritional Assessment
Anthropometric, Diet history, medical history, social history, intake, weight history – weight loss or gain,
NFPE, other disciplines physical findings, documentation
 Anthropometrics
o Wt. 69 kg / 151.8 lb
o Ht. 1.75 m / 69 in
o BMI 22.5 kg/m2
o IBW 160 lb / 72.7 kg
o % IBW 95%
o Adj wt – N/A
o UBW – N/A
o Weight history – Patient weighed 75 kg (165 lb) three months ago,
indicating a severe weight loss of 8%.
 Labs:
o Urea 21 mmol/L
o Cr 205 umol/L
o K 6.0 mmol/L
o Bicarbonate 20 mmol/L
o Albumin 34 g/L
o eGFR 30 mL/min
 Medications
o Amlodipine 10 mg od
o Ramipril 5 mg od
o Simvastatin 20 mg od
 Diet / Allergies
o NKA
 Nutritional Status / Estimated Nutritional Needs (kcal, protein, fluids)
o Based upon 30-35 kcal/kg of current body wt 69 kg
 2070 – 2415 kcal/day
o Based upon 0.6-0.8 g/kg of current bod wt 69 kg
o 41 – 55 g/day of protein
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Alternative Renal Disease SIM Case Study

o Based upon 1mL/kcal

 2070 – 2415 mL/day
3. Nutrition Focus Physical Exam – N/A
4. Full assessment / Assessment Summary
 67-year-old male admitted due to hyperkalemia recent weight loss and
diagnoses of hematuria, proteinuria, UTI and lethargy from visiting his GP a week
ago. BMI of 22.5 kg/m2 indicates he is of normal weight but he recently
experienced a severe weight loss of 8% in 3 months. Patient states his appetite
has been poor for the past 6 weeks. Based upon his 24-hour diet recall, he is not
meeting his estimated nutrition needs. He reports drinking 2 mugs of an oral
supplement (Complan) yesterday due to his decreased appetite.
5. Nutrition Care Process: Implementation of MNT - Medical Nutrition Therapy
 Nutrition Diagnosis
o Inadequate oral intake (NI-2.1)
 PES
o Inadequate oral intake (NI-2.1) related to decreased appetite as
evidenced by patient report of reduced appetite beginning 6 weeks ago
and a severe weight loss of 8% in 3 months.
 Nutritional Interventions
o Diet – Continue following a renal diet.
o Commercial beverages – Continue consumption of 2 mugs of Complan
per day if appetite continues to be poor.
 Recommendations
o Recommend consuming small, frequent meals to increase caloric intake.
o Recommend patient to start a food log/food journal.
o Recommend visiting websites such as Fresenius Kidney Care for kidney-
friendly recipes.
 Goals / Plan
o Patient to meet >75% of his estimated nutrition needs in 3-5 business
days.
 Education (if provided)
o Reviewed over the renal diet and the importance of following a meal
pattern low in protein, phosphorus, potassium, and sodium.
6. Federal Regulations / Billing and coding for MNT
 MNT units 15 units for initial assessment. N18.30 Chronic kidney disease,
stage 3 unspecified
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Alternative Renal Disease SIM Case Study

Summary of the Disease

Chronic kidney disease is defined as the irreversible loss of the kidney’s functions for

more than three months.1 This disease is progressive and affects the metabolic, endocrine and

excretory functions of the kidney.2 There are five stages of chronic kidney disease (CKD), each

categorized according to the glomerular filtration rate (GFR). CKD is defined as a GFR of less

than or equal to 60 mL/min/1.73m2 for three months or longer.2 Individuals may remain in the

beginning stages of CKD for years until progressing to stage 5 or end-stage renal disease (ESRD)

in which the individual will need dialysis, either hemodialysis (HD) or peritoneal dialysis (PD), or

kidney transplantation.2 The National Kidney Foundation Kidney Disease Outcomes Quality

Initiative (NKF KDOQI) established the evidence-based clinical practice guidelines for each stage

of CKD in 1997.2

In regards to counseling an individual diagnosed with stages 1-4 of CKD, a Registered

Dietitian (RDN) must complete a full nutrition assessment of the patient to evaluate for any

comorbidities, issues with nutrient digestion or absorption, review of one’s intake and/or

changes in intake, physical assessment and social barriers that may affect intake. 2 Nutrition

intervention focuses on maintaining or improving the patient’s nutritional status throughout

this chronic disease.2 Specifically, the purpose of medical nutrition therapy (MNT) is to prevent

malnutrition by providing adequate calories, normalize blood lipids and treat vitamin and

mineral abnormalities present in CKD.2 Nutrition therapy for pre-dialysis CKD emphasizes a

protein intake that is in moderation, 0.6-0.75 g/kg/d, and limited sodium intake. 2 Other nutrient
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restrictions that varies on the stage of CKD, type of dialysis, age and recent weight gain or loss

are one’s potassium, phosphorous, calcium and fluid intake. 2 As CKD progresses, the kidney

function declines and therefore cannot excrete waste products effectively.

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Alternative Renal Disease SIM Case Study

References:

1. Academy of Nutrition and Dietetics. Nutrition Care Manual. Chronic Kidney Disease:
Overview. [Link]
ncm_category_id=1&lv1=5537&lv2=274796&lv3=274797&ncm_tooc_id=274797&ncm_
heading=Nutrition%20Care Accessed December 16, 2020.

2. Nelms M, Sucher KP, Lacey K. Nutrition Therapy and Pathophysiology. Boston, MA:
Cengage Learning; 2016.