Renal
(Mod 2)
(Mod 2)
Which assessment tool is used to assess risk for malnutrition and protein-energy wasting (PEW) in dialysis patients?
1. MUST
2. SGA
3. MNA
SGA
Which foods are high in copper and should be avoided in Wilson's disease?
Beef and oranges
Liver and shellfish
Wheat bread and wheat pasta
White milk and cheese
2. Liver and Shellfish
Jamison is a 14 YO male with cystic fibrosis. His BMI-for-age according to CDC growth chats has plotted along the 35th% for the past 2 years. His FEV1% shows moderate pulmonary function impairment. What recommendations should the RDN make regarding Jamison’s growth and weight to support improvement in pulmonary function?
The RDN should recommend that Jamison lose weight to be <25th% BMI-for-age
The RDN should recommend that Jamison maintain weight to remain 35th% BMI-for-age
The RDN should recommend that Jamison gain weight to be 50th% BMI-for-age
The RDN should recommend that Jamison gain weight to be 75th% BMI-for-age
3. The RDN should recommend that Jamison gain weight to be 50th% BMI-for-age
Positive relationship between BMI & FEV1%
Age 0 to 2 YO: weight for length ≥50thpercentile Age 2 to 20 YO: BMI for age ≥50thpercentile
Adult Males: 23 kg/m2
Adult Females: 22 kg/m2
Darnice is a post-operative patient in the surgical ICU. She has a preoperative BMI of 23.4kg/m2. Indirect calorimetry is not available. According to ASPEN guidelines, the RDN should estimate her energy and protein needs using:
25 – 30kcal/kg actual body weight, 1.2 – 1.5g/kg ideal body weight
25 – 30kcal/kg ideal body weight, 1.2 – 1.5g/kg actual body weight
25 – 30kcal/kg ideal body weight, 1.2 – 1.5g/kg ideal body weight
25 – 30kcal/kg actual body weight, 1.2 – 1.5g/kg actual body weight
4. 25 – 30kcal/kg actual body weight, 1.2 – 1.5g/kg actual body weight
Module 8
Which nutrients should be supplemented with long-term use of corticosteroids?
Calcium and vitamin D
Long-term use negatively affects bone mineralization and increases risk of osteoporosis
Which dietary pattern was brought into the 2020 KDOQI Guidelines as it shows evidence of benefit for pre-dialysis CKD patients?
1. DASH Diet
2. Mediterranean Diet
3. Ketogenic Diet
2. Mediterranean Diet
Ms. Susan is a 72 YO female diagnosed with cirrhosis of the liver. She has severe abdominal ascites and edema in her lower extremities. Her current body weight is 70kg. Her usual (dry) body weight is 67kg. Which anthropometric value should the RDN use when assessing Ms. Susan’s nutrition status and calculated her estimated nutrient requirements?
Adjusted body weight
Current body weight
Usual body weight
Ideal body weight
Usual body weight
Current body weight should not be used since it includes additional fluid weight from ascites and edema and will result in overestimation. Nutrient needs estimated using current weight will not reflect her true nutrient needs. Likewise adjusted body weight and ideal body weight will not accurately reflect her true nutrient needs as they lead to underestimation.
Shirley is a 35 YO female patient with asthma. She is tall, weighs 170lb, and has a waist circumference of 38inches. She reports following a plant-based diet. She is taking 2,000 IU Vitamin D supplement per day. She is not taking any other supplements. Which evidence-based nutrition intervention should the RDN recommend to Shirley for controlling and improving her asthma symptoms?
Add omega 3 fatty acids rich fish oil supplement of 1g/daily
Decrease daily calorie intake and increase physical activity to lose weight
Increase vitamin D supplementation to 5,000 IU daily
Switch from a plant-based diet to an animal-based diet
2. Decrease daily calorie intake and increase physical activity to lose weight
Danny experienced severe trauma when he fell off a ladder while roofing a house. His body temperature is 100.2˚F, mean arterial pressure 45 with high dose pressor agents being administered, blood pressure 80/65 mmHg.
A) Is the patient in the ebb phase or flow phase?
B) When should nutrition support be started?
A) Ebb, B) Nutrition support should be withheld until the patient’s condition is stabilized
Ebb (24-48 hrs): LOW cardiac output, O2, body temp, BP, metabolic rate, insulin
Flow: (7-14 days): HIGH cardiac output, O2, body temp, energy expenditure, protein catabolism, glucose production, fatty acid release, catecholamine
Module 5 - Neoplastic Disease
Mr. Darcy is a 55YO male with colon cancer receiving radiation and chemotherapy. He is 68 inches tall. His body weight at diagnosis 1 month ago was 210lb. His current weight is 198lb. His albumin is 2.8 g/dL, and CRP is 5mg/L. He is consuming 75% of his meals. His nutrition-focused physical exam demonstrates mild atrophy orbital fat, central adiposity, abdominal pain, decreased appetite, diarrhea, nausea, no edema, dry mucous membranes of the mouth, no muscle atrophy, presence of muscle weakness, dry skin, poor skin turgor. Which nutrition diagnosis would be most appropriate for this patient?
Inadequate oral intake
Moderate chronic disease-related malnutrition
Unintended weight loss
Moderate starvation-related malnutrition
2. Moderate chronic disease-related malnutrition
The patient has cancer, a chronic disease. The patient demonstrates multiple nutrition risk factors (see s/s). He also displays mild-moderate inflammation based on decreased albumin and increased CRP. He demonstrates 2 confirmed signs of malnutrition – 5.7% significant weight loss x 1 month and mild atrophy orbital fat, which align with non-severe (moderate) chronic disease-related malnutrition.
Inadequate oral intake is not correct; not enough data provided to confirm s/s of inadequate intake; we know he is consuming 75% of meals, but we do not know how his current nutrient intake compares with his estimated needs. Moderate starvation-related malnutrition is not correct – the cause of his malnutrition is his chronic illness of cancer. Unintended weight loss is not correct; while the patient has significant weight loss, his weight loss is a sign of a more substantial nutrition problem – malnutrition – caused by cancer
What pharmacotherapy considerations should the RDN be aware of when working with CKD patients?
1. Phosphate binders, calcium, iron, fish oil
2. Phosphate binders, vitamin D, iron
3. Vitamin D, calcium, iron, fish oil
2. Phosphate binders, vitamin D, iron, multivitamin
Phosphate binders must be taken with all meals and snacks; impaired kidneys cannot excrete excess phos
Vitamin D: Kidneys usually convert vit D to its active form; also can help correct proteinuria
Iron: Anemia may result from lack of EPO & increased destruction of RBC d/t uremic waste products
Mr. Shane is an 22YO male status post-cholecystectomy (gallbladder removal) due to gallstones. Which intervention should the RDN recommend?
No fat diet (<10g total fat)
Moderate fat diet (20-35% kcal from fat)
Very low-fat diet (<10% kcal from fat)
Low fat diet (<20% kcal from fat)
Moderate fat diet (20-35% kcals from fat).
Following cholecystectomy patients may return to moderate fat diet following AMDR and heart healthy guidelines. Prior to surgery patients should follow a low-fat diet, defined as < 30% kcal fat, to reduce contractions of the gallbladder.
Evan RDN is conducting a nutrition-focused physical exam on a patient with COPD. Which findings would be consistent with a patient who presents chronic bronchitis?
Wheezing lung sounds, thin physique, severe muscle and fat loss, barrel chest
Wheezing lung sounds, overweight physique, mild muscle and fat loss, normal chest
Productive cough, rhonchi lung sounds, overweight physique, mild muscle and fat loss, normal chest
Rhonchi lung sounds, thin physique, severe muscle and fat loss, barrel chest
3. Productive cough, rhonchi lung sounds, overweight physique, mild muscle and fat loss, normal chest
chronic bronchitis - overweight, normal chest, productive cough
emphysema - thin and cachexic, barrel chest, crackles and wheezing
Disco Ball is admitted to the surgical intensive care unit (SICU) with severe abdominal trauma. He is comatose and unable to provide a nutrition history. He has been NPO for 18hrs since admission. Disco’s wife reports that he has been healthy up to this point, prior to admission was eating a balanced diet – 3 meals and 2 snacks a day, 5’10” tall, usual body weight 180lb. His wife is not aware of any changes in his weight over the past year. A nutrition-focused physical exam shows no atrophy of fat or muscle. His laboratory profile is as follows: Albumin 2.5 g/dL, prealbumin 8 mg/dL, C-reactive protein 15 mg/L. Which of the following is the correct interpretation of this information?
He presents with moderate acute disease related to malnutrition
He presents with moderate protein energy malnutrition
He presents with stress-related inflammation secondary to trauma
He presents systemic inflammatory response syndrome secondary to trauma
He presents with stress-related inflammation secondary to trauma
Because of the trauma, his body is undergoing an inflammatory response. Albumin and prealbumin are negative acute phase proteins which decrease during inflammation regardless of concentration prior to trauma and resultant inflammation. Darryl’s lab values indicate inflammation with elevated CRP in combination with decreased albumin and prealbumin.
Module 1
Ms. Patsy is a 60 YO female whose nutrition assessment indicates inadequate calcium and vitamin D intake. Ms. Patsy works with the RDN to increase her calcium and vitamin D intake. Which biochemical marker should the RDN monitor and evaluate as a clinical indicator of Ms. Patsy’s calcium homeostasis and bone metabolism?
Parathyroid hormone (PTH)
Serum calcium
Serum 25(OH)D
Serum 1,25(OH2)D3
1. Parathyroid hormone (PTH)
PTH should be monitored in patients at-risk for osteoporosis, including those with inadequate calcium and vitamin D intake. PTH maintains calcium homeostasis in the presence of low serum calcium by increasing resorption of calcium and reducing calcium excretion via the kidneys, increasing synthesis of calcitriol via the kidneys to increase dietary calcium absorption through the small intestines, and increasing osteoclast activity to break down and release calcium from bone. Elevated PTH could be a sign of abnormally elevated osteoclast activity to maintain serum calcium homeostasis.
Mr. Smith has chronic calcium oxalate nephrolithiasis (kidney stones). What MNT should the RDN recommend?
Decrease fluid intake to 1.5L per day, decrease calcium intake to <500mg per day, decrease oxalate to <200mg per day
Decrease fluid intake to 1.5L per day, achieve calcium intake to 800 to 1,200mg per day, decrease oxalate to <200mg per day
Increase fluid intake to 3L per day, decrease calcium intake to <500mg per day, decrease oxalate to <200mg per day
Increase fluid intake to 3L per day, achieve calcium intake to 800 to 1,200mg per day, decrease oxalate to <200mg per day
4. Increase fluid intake to 3 L per day, achieve calcium intake 800-1200 mg/day, decrease oxalate to <200 mg per day
Kidney stones form in a supersaturated solution when hydration status is low and mineral content is high. To prevent kidney stone formation fluid intake should increase to 3 L per day. For calcium oxalate kidney stones calcium intake in the diet should achieve DRIs to bind oxalate in the intestine to reduce oxalate absorption and thereby excretion via kidneys.
Mr. James is a 45 YO male diagnosed with obesity (BMI >40kg/m2) and non-alcoholic steatohepatitis (NASH). He does not have DM or hypertriglyceridemia. His estimated energy needs are 2,500kcal/day. Which nutrition prescription can help minimize or reduce progression of NASH?
3% to 5% weight loss via 1,500 to 2,00kcal diet, 1g fish oil per day, 300min moderate intensity physical activity/week
7% to 10% weight loss via 1,500 to 2,00kcal diet, 1g fish oil per day, 300min moderate intensity physical activity/week
7% to 10% weight loss via 1,500 to 2,00kcal diet, 800 IU Vitamin E per day, 150min moderate intensity physical activity/week
3% to 5% weight loss via 1,500 to 2,00kcal diet, 800 IU Vitamin E per day, 150min moderate intensity physical activity/week
3. 7% to 10% weight loss via 1,500 to 2,00kcal diet, 800 IU Vitamin E per day, 150min moderate intensity physical activity/week
According to current evidence, 7-10% weight loss both improves steatosis and reduces inflammation in patients with NASH. Weight loss should be achieved through a hypocaloric diet providing 500-1000 fewer calories per day in comparison to energy needs. Vitamin E supplementation of 800 IU/day in patients without diabetes who have NASH is recommended to improve steatosis and inflammation. Physical activity of 150 mins of moderate intensity activity per week is also recommended.
Karly is an 8 YO female with cystic fibrosis. Her physical activity level is classified as active. Her estimated energy requirement (EER) per the Dietary Reference Intake (DRIs) is 1,800kcal per day. Her estimated protein needs per the RDA for an 8 YO female is 19g. Her BMI-for-age according to CDC growth charts plots along the 55th%. Which nutrition intervention should the RDN prescribe?
1,800kcal low fat diet (25-30% kcal fat) and minimum 19g protein
1,800kcal high fat diet (35-40% kcal fat) and minimum 19g protein
2,350kcal low fat diet (25-30% kcal fat) and minimum 29g protein
2,350kcal high fat diet (35-40% kcal fat) and minimum 29g protein
4. 2,350kcal high fat diet (35-40% kcal fat) and minimum 29g protein
Comparative Standards - Energy: 130% –150% EER (DRI) for ageFat: 35% to 40% kcalProtein: 15% to 20% kcal (or 1.5 –2.0 x RDA for age)CHO: 45% to 60% kcal (glycemic control)
Interventions - High kcal, high fat diet, ONS or EN Support, PERT, Lactose free diet, Fat soluble vitamin supplementation, Salt supplementation +1/8 to 1/4 tsp daily
Mrs. S was admitted to the ICU and requires EN support. Her estimated needs are 1850-2150 kcals, 90-110 g protein, and 1850-2150 ml fluid. Use the standard formular Jevity 1.2 to determine an appropriate rate.
(Jevity 1.2 provides 1.2 kcals/ml, 55.5 g protein/L, 807 ml water/L)
1850 kcals/1.2 kcals per ml /24 hrs = 64.2 ml/hr
2150 kcals/1.2 kcals per ml /24 hrs = 74.6 ml/hr
65 ml/hr would provide 1872 kcals, 87 g protein, 1259 ml fluid -> can add protein modular
70 ml/hr would provide 2016 kcals, 93 g protein, 1355 ml fluid
*add water flushes
Module 5 - Neoplastic Disease
Mr. Walters has stage 3 lung cancer. He demonstrated significant loss of weight and lean body mass (LBM) over the past year. The RDN has already prescribed a liberalized high calorie, high protein, regular diet with oral nutrition supplement (ONS) 3x/day. Mr. Walter consumes approximated 75% of his estimated needs through his regular meals and meets his additional needs by drinking 2 of the 3 ONS daily; however, he continues to lose weight and LBM. If no contraindications are present, which evidence-based nutrition intervention should the RDN consider next to support weight stabilization and prevention of LBM in Mr. Walters?
Fish oil supplement providing 1g EPA daily
Megace providing 400 to 800mg daily
Phenergan providing 25mg every 4-6hrs PRN
Vitamin D3 supplement providing 5,000 IU daily
Fish oil supplement providing 1g EPA daily
Per the AND EAL Oncology Project, “if suboptimal symptom control or inadequate dietary intake has been addressed and the adult oncology patient is still experiencing loss weight and LBM, the RDN may consider use of dietary supplements containing EPA as a component of nutrition intervention. Research indicates that dietary supplements containing fish oil (actual consumption 0.77 - 6 g of EPA/day), resulted in weight stabilization and improvement or preservation of LBM in adult oncology patients with weight loss.
Megace is a prescribed appetite stimulant to stimulate appetite and oral intake in the presence of anorexia; Mr. Walters is eating 75% of estimated needs via oral diet plus consuming 2 ONS daily
Phenergan is an anti-emetic agent to prevent and control n/v.
Mr. Jones is a 55YO Caucasian male who develops acute kidney injury (AKI) secondary to a myocardial infarction (pre-renal cause of AKI). He is stable condition receiving treatment in the cardiac step-down unit and does not require any form of renal replacement therapy (RRT). What are the goals of medical nutrition therapy (MNT) for this patient?
Achieve nutrition adequacy via protein at 0.8 – 1.0g/kg and energy 30kcal/kg
Achieve nutrition anabolism via protein at 1.5 – 2.0g/kg and energy 35kcal/kg
Prevent nutrition catabolism via protein at 1.2 – 1.5g/kg and energy 35kcal/kg
Prevent uremia and azotemia via protein at 0.6 – 0.8g/kg and energy 25kcal/kg
1. Achieve nutrition adequacy via protein at 0.8-1.0 g/kg and energy 30 kcal/kg. Guidelines recommend that patients who are not catabolic, non-dialyzed receive 0.8-1.0 g/kg and energy 30-35 kcal/kg.
"Achieve nutrition anabolism via protein 1.5-2 g/kg and energy 35 kcal/kg" aligns with recommendations for patients who are hypercatabolic and/or receiving continuous renal replacement therapy.
"Prevent nutrition catabolism via protein 1.2-1.5 g/kg and energy 35 kcal/kg" - for patients receiving RRT.
"Prevent uremia and azotemia" is for pre-dialysis CKD patients
Which supplements have shown evidence for benefit in patients with NAFLD (non-alcoholic fatty liver disease)
1. vitamin E and iron
2. MCT oil and iron
3. omega-3 FA and vitamin E
3. omega-3 FA and vitamin E
Vitamin E: Vitamin E 800 IU/day improves liver histology in nondiabetic adults with liver biopsy proven NASH; not recommended to treat NASH in diabetic patients, NAFLD without liver biopsy, NASH cirrhosis or cryptogenic cirrhosis. (AASLD 2017)
OMEGA 3 fatty acids: 1.0 to 2.7 grams/day for 6-12 months may improve hepatic steatosis, inflammation, and fibrosis. Further research is needed before this approach is used as a mainstream treatment for NAFLD. May be used to treat hypertriglyceridemia in patients with NAFLD.
Janelle is a 42 YO female hospitalized for exacerbation of asthma. Her arterial blood gases (ABGs) include pH 7.31, PaCO2 55 mmHg (normal: 35 to 45 mmHg), HCO3 24 mEq/L (normal: 22 to 26 mEq/L). The patient presents with which condition?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
3. Respiratory acidosis - pH low, paCO2 high, HCO3 normal
pH & PaCO2 are inversely related. – If correlation is correct, imbalance is probably primarily RESPIRATORY related.
pH & HCO3 are directly related. – If the correlation is correct, imbalance is probably primarily METABOLIC related.
*what pneumonic device can help us remember this?
Roy is admitted to the ICU with traumatic brain injury (TBI) and is medically sedated using propofol at 6ml/hr continuous infusion round-the-clock. He is also receiving lactated ringers at 50ml/hr and D5W at 20ml/hr, both continuous infusion round-the-clock. What is her non-nutritional calorie provision in a 24hr period?
6ml/hr propofol x 24 hrs = 144 ml; 144 ml x 1.1 kcal/ml = 158.4 kcal from propofol
20ml/hr D5W x 24 hrs = 480 ml x 5% = 24 grams dextrose; 24 g x 3.4 kcal/g = 81.6 kcals
158.4 + 81.6 = 240 non-nutritional kcals
Jerry is a 32 YO male who experiences a spinal cord injury during a motor vehicle accident that leaves him paralyzed from the waist down (paraplegia). He is otherwise healthy with a BMI classified as normal. He is currently completing a rehabilitation program. What comparative standards should the RDN use to estimate his energy and proteins needs?
30kcal/kg, protein 0.8 – 1.0g/kg, fluids 1ml/kcal
Mifflin-St Jeor x 1.2 IF x 1.1 AF, protein 2.0g/kg, fluid 40ml/kg + 500ml
28kcal/kg, protein 0.8g – 1.0g/kg, fluid 1ml/kcal + 500ml
Mifflin-St Jeor + 500kcal/day, protein 1.2g – 1.5g/kg, fluid 1ml/kcal
3. 28kcal/kg, protein 0.8g – 1.0g/kg, fluid 1ml/kcal + 500ml
In the absence of pressure injury, patients require slightly less kcals due to decreased metabolic activity in denervated muscle, normal protein needs, and slightly increased fluid needs due to neurogenic bowel.