CSR Case Analysis & Practical Application 3 — Questions and Answers
Question 1: A transplant recipient 6 months post-transplant on tacrolimus and prednisone develops new-onset hyperglycemia and a 15 lb weight gain. Which nutrition counseling priority is MOST appropriate?
- Increase carbohydrate intake to improve glycemic control
- Provide a calorie-controlled, low glycemic index diet and monitor for post-transplant diabetes (Correct answer)
- Recommend a very high protein diet to counteract muscle wasting from steroids
- Restrict all fruits and vegetables to control blood glucose
Correct answer: Provide a calorie-controlled, low glycemic index diet and monitor for post-transplant diabetes
Calorie-controlled, low glycemic index eating patterns help manage post-transplant diabetes mellitus (PTDM), a common complication of immunosuppressive therapy.
Question 2: A 70-year-old male CKD Stage 5 patient not on dialysis (conservative management) has a serum albumin of 2.8 g/dL. His family requests aggressive nutritional support. What should the dietitian consider FIRST?
- Start IDPN immediately to reverse hypoalbuminemia
- Assess whether the low albumin reflects inflammation/illness rather than dietary deficiency alone (Correct answer)
- Prescribe 2.0 g/kg protein to rapidly rebuild serum albumin levels
- Initiate PD immediately to improve nutritional status
Correct answer: Assess whether the low albumin reflects inflammation/illness rather than dietary deficiency alone
Hypoalbuminemia in CKD is often an acute-phase reactant response to inflammation rather than pure protein malnutrition, and aggressive protein loading may not correct it.
Question 3: A hemodialysis patient presents with bone pain, elevated alkaline phosphatase, and a calcium-phosphorus product of 72 mg²/dL². His PTH is 850 pg/mL. Which dietary intervention is MOST critical?
- Increase calcium supplement dosage to suppress PTH
- Aggressively restrict dietary phosphorus and review phosphate binder adherence (Correct answer)
- Increase vitamin D-rich foods to manage secondary hyperparathyroidism
- Increase protein intake to support bone matrix formation
Correct answer: Aggressively restrict dietary phosphorus and review phosphate binder adherence
Persistent hyperphosphatemia drives secondary hyperparathyroidism; dietary phosphorus restriction and binder optimization are first-line nutritional interventions.
Question 4: A PD patient reports frequent episodes of exit site infections and peritonitis. Her serum prealbumin is 14 mg/dL. How does nutritional status relate to her infection risk?
- Poor nutritional status has no impact on infection risk in PD patients
- Malnutrition impairs immune function, increasing susceptibility to peritonitis and exit site infections (Correct answer)
- High protein intake directly causes peritonitis in PD patients
- Vitamin D supplementation is the only nutritional factor that affects infection risk
Correct answer: Malnutrition impairs immune function, increasing susceptibility to peritonitis and exit site infections
Protein-energy malnutrition impairs immune function in PD patients, increasing vulnerability to infection, and improving nutritional status is an important adjunct to infection prevention.
Question 5: A renal dietitian reviews labs for a hemodialysis patient whose Kt/V is 1.1 (target ≥1.2) and nPCR is 0.7 g/kg/day. What does this combination most likely suggest?
- Adequate dialysis with poor dietary compliance
- Possible underdialysis contributing to anorexia and reduced dietary protein intake (Correct answer)
- Excessive protein intake overwhelming dialysis clearance capacity
- High fluid intake diluting the Kt/V measurement
Correct answer: Possible underdialysis contributing to anorexia and reduced dietary protein intake
A low Kt/V combined with low nPCR suggests inadequate dialysis dose may be suppressing appetite and contributing to poor protein intake.
Question 6: A CKD patient asks about using herbal supplements for kidney support, specifically astragalus and dandelion root. What is the renal dietitian's BEST response?
- Both supplements are safe and beneficial for CKD patients
- These supplements lack evidence for benefit in CKD and may pose risks including herb-drug interactions and potassium loading (Correct answer)
- Only dandelion root should be avoided; astragalus is safe for CKD
- Recommend both supplements along with standard dietary modifications
Correct answer: These supplements lack evidence for benefit in CKD and may pose risks including herb-drug interactions and potassium loading
Most herbal supplements are not proven safe or effective in CKD and carry risks of nephrotoxicity, herb-drug interactions, and electrolyte imbalances.
Question 7: A 52-year-old woman on hemodialysis is a strict vegan. Her labs show low serum B12 and her nPCR is 0.9 g/kg/day. What is the PRIMARY nutritional concern and recommendation?
- Switch her to a meat-based diet to ensure adequate protein and B12
- Assess total protein quality and quantity, recommend plant-based complementary proteins and B12 supplementation (Correct answer)
- Restrict all plant proteins as they are inferior to animal proteins for dialysis patients
- Her vegan diet is contraindicated in dialysis; recommend stopping it
Correct answer: Assess total protein quality and quantity, recommend plant-based complementary proteins and B12 supplementation
Vegan diets can meet protein needs in HD patients with careful planning using complementary plant proteins; B12 supplementation is essential as it is absent from plant foods.
CSR Case Analysis & Practical Application 3
A transplant recipient 6 months post-transplant on tacrolimus and prednisone develops new-onset hyperglycemia and a 15 lb weight gain.
Which nutrition counseling priority is MOST appropriate?