Protein : CD’s current meal plan, before any treatment intervention, contained 1122 calories and 68g of protein. To maintain a protein requirement of approximately 65g/day while observing fluid and electrolyte restrictions, the following modifications are recommended:

• Limit milk in coffee to 1 to 2 ounces (30 to 60 mL) per cup.

• Substitute a plain hamburger on a bun, or an equivalent, such as 3 ounces of fresh roast beef, turkey, chicken, or rinsed water-packed tuna on two slices bread for a cheeseburger at lunchtime Encourage the amount of chicken at dinner to be 4 ounces (a large-sized chicken breast).

• Omit all cheese and nuts because they are generally high in phosphorus and/or potassium and sodium, and substitute unsalted pretzels with one tablespoon of regular mustard as a night snack.

Electrolytes : CD’s total body water and sodium are elevated, as evidenced by 3+ peripheral edema and mild CHF on her chest X-ray. Therefore, a low-sodium diet (2.5g/day) is indicated at this time. CD’s potassium level is within the normal range; thus, no potassium restriction is needed at this time.

Her initial serum calcium and phosphorus levels of 7.5 and 10.2 mg/dL, respectively, are a result of decreased GI calcium absorption and increased phosphate retention. Lowering serum phospho- rus levels by dietary restriction and phosphate-binding medication will improve serum calcium initially without calcium supplementation between meals.

Restricting the daily allowance of dietary phosphorus to approximately 1000mg is indicated. A phosphate-binding polymer was added in small doses in combination with calcium acetate to CD’s medication regimen. The goal was to reduce serum phosphorus levels to less than or equal to 5.5 mg/dL and to normalize serum calcium levels.

Fluid Given that CD’s 24-hour urine output was 700mL in the hospital, a total fluid intake of 1200mL/day or 40 ounces (700mL plus 500mL for insensible fluid losses) should be recom- mended. To stay within the fluid restriction of 1200mL/day, limit morning coffee to 8 ounces (240mL), the lunch beverage to 12 ounces (360mL), the dinner beverage to 8 ounces (240mL), and the snack beverage to 8 ounces (240mL). Allowing for an additional 4 ounces (120mL) of juice or water with medications is acceptable.

Using CD’s lab values to estimate renal function and her vital signs and chest X-ray results to determine her hemodynamic status, what are the immediate and long-term treatment modalities you would recommend?

From these data, CD has a creatinine of 8.0mg/dL, blood pressure of 200/120mm Hg, and CHF. Therefore, CD underwent two acute hemodialysis treatments, which effectively removed sodium and water as well as the buildup of uremic products secondary to CGN. She chose PD instead of hemodialysis for her long-term treatment. PD will allow her to perform dialysis exchanges herself in her apartment and have more freedom so she can work during the day. A catheter (used to instill PD solution into the peritoneal cavity) was scheduled to be placed after she was discharged from the hospital. PD is usually started 2 weeks after a PD catheter is inserted to allow for adequate wound healing. She will initially do continuous ambulatory peritoneal dialysis (CAPD) training, as this modality requires less training time than PD done overnight by the automated cycler machine. This way she can get back to her job sooner, but will have to do at least one exchange at work. She will then plan to train for continuous cycling peritoneal dialysis (CCPD) when she can take a vacation.