CSR Case Analysis & Practical Application 2 — Questions and Answers
Question 1: A 58-year-old male on hemodialysis presents with serum potassium of 6.8 mEq/L after reporting he consumed a large amount of tomato sauce with pasta. Which dietary modification is the MOST urgent recommendation?
- Eliminate all fruits from the diet
- Limit tomato-based products and other high-potassium foods to reduce intake (Correct answer)
- Increase fluid restriction to dilute potassium levels
- Add a sodium bicarbonate supplement to shift potassium intracellularly
Correct answer: Limit tomato-based products and other high-potassium foods to reduce intake
Limiting high-potassium foods like tomato products is the primary dietary intervention for hyperkalemia management in dialysis patients.
Question 2: A peritoneal dialysis patient with residual kidney function has a GFR of 8 mL/min. How should protein recommendations differ from a standard HD patient with no residual function?
- Protein should be restricted to 0.6 g/kg/day to protect residual function
- Protein needs may be slightly lower since residual function provides additional clearance (Correct answer)
- Protein needs are identical regardless of residual kidney function
- Protein should be increased to 1.8 g/kg/day due to PD losses
Correct answer: Protein needs may be slightly lower since residual function provides additional clearance
Residual kidney function in PD patients contributes to overall solute clearance, which can modestly reduce the protein prescription compared to anuric PD patients.
Question 3: A CKD Stage 4 patient (GFR 22 mL/min) has a serum bicarbonate of 18 mEq/L. Which dietary strategy can help address this metabolic acidosis?
- Increase dietary protein intake to provide anabolic support
- Encourage consumption of fruits and vegetables to provide an alkaline ash load (Correct answer)
- Restrict all fruits and vegetables to control potassium
- Increase phosphorus intake to buffer the acidosis
Correct answer: Encourage consumption of fruits and vegetables to provide an alkaline ash load
Fruits and vegetables provide an alkaline dietary load that can help correct metabolic acidosis in CKD patients with adequate urine output.
Question 4: During a nutrition assessment, a hemodialysis patient reports eating a protein supplement between sessions. Her nPCR is 1.4 g/kg/day but she has persistent hyperphosphatemia. What is the MOST likely issue?
- She is not eating enough protein to meet her needs
- Her high protein intake from supplements may be contributing to phosphorus load (Correct answer)
- Her dialysis dose is inadequate and needs prescription adjustment
- She should switch to a lower calorie diet to reduce overall intake
Correct answer: Her high protein intake from supplements may be contributing to phosphorus load
High protein intakes, especially from supplements containing phosphorus additives, can worsen hyperphosphatemia even when phosphate binders are prescribed.
Question 5: A renal dietitian evaluates a patient newly started on hemodialysis who was previously following a very low protein diet (0.6 g/kg) for CKD. What change in protein recommendation is warranted?
- Maintain the 0.6 g/kg restriction since dialysis does not change protein needs
- Increase protein to at least 1.2 g/kg/day to account for dialytic losses (Correct answer)
- Decrease protein further to 0.4 g/kg/day due to reduced kidney clearance
- Protein is not a priority; focus solely on potassium and phosphorus
Correct answer: Increase protein to at least 1.2 g/kg/day to account for dialytic losses
Once hemodialysis begins, protein requirements increase to 1.2 g/kg/day or more to compensate for amino acid losses during dialysis sessions.
Question 6: A 45-year-old female HD patient with diabetes reports a calorie intake of only 1,100 kcal/day and has lost 5 lbs over 2 months. Her SGA score indicates moderate malnutrition. What is the FIRST step in her nutrition intervention?
- Immediately initiate intradialytic parenteral nutrition (IDPN)
- Conduct a thorough food history to identify barriers to adequate intake (Correct answer)
- Prescribe an oral nutritional supplement without further assessment
- Refer her for PEG tube placement for enteral nutrition
Correct answer: Conduct a thorough food history to identify barriers to adequate intake
A comprehensive food history is essential before selecting an intervention to identify the underlying cause of poor intake and tailor appropriate support.
Question 7: A patient on hemodialysis presents with intradialytic hypotension during sessions and has been told to increase salt and fluid intake between treatments. How should the renal dietitian respond to this advice?
- Agree and encourage liberal sodium and fluid intake to prevent hypotension
- Evaluate the recommendation critically, as excess sodium/fluid can worsen interdialytic weight gain and hypertension (Correct answer)
- Increase dietary phosphorus to support blood pressure regulation
- Restrict protein intake to reduce the dialysis ultrafiltration requirement
Correct answer: Evaluate the recommendation critically, as excess sodium/fluid can worsen interdialytic weight gain and hypertension
While some sodium may help maintain blood pressure, excess sodium drives thirst and fluid accumulation, increasing interdialytic weight gain and cardiovascular risk.
CSR Case Analysis & Practical Application 2
A 58-year-old male on hemodialysis presents with serum potassium of 6.8 mEq/L after reporting he consumed a large amount of tomato sauce with pasta.
Which dietary modification is the MOST urgent recommendation?