UNIVERSITY OF KWAZULU-NATAL DIETETICS & HUMAN NUTRITION EXAMINATION: NOVEMBER/DECEMBER...
Transcript of UNIVERSITY OF KWAZULU-NATAL DIETETICS & HUMAN NUTRITION EXAMINATION: NOVEMBER/DECEMBER...
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UNIVERSITY OF KWAZULU-NATAL
SCHOOL OF AGRICULTURAL, EARTH & ENVIRONMENTAL SCIENCES
DIETETICS & HUMAN NUTRITION
EXAMINATION: NOVEMBER/DECEMBER 2013
SUBJECT, COURSE & CODE: DIET THERAPY – SURGICAL DIET360 - P2
DURATION : 3 HOURS TOTAL MARKS : 100
External Examiner : Mrs C MacDougall
Internal Examiner : Ms C Biggs
NOTE: THIS PAPER CONSISTS OF 26 PAGES AND A 26 PAGE FORMULA
HANDOUT. PLEASE CHECK THAT YOU HAVE ALL OF THEM.
ANSWER TWO (2) OUT OF THREE (3) QUESTIONS
QUESTION 1
1. Mr Knockdown, a 30 year old black African male, has been transferred to your surgical ICU
suffering from multiple trauma after being run over by a truck. He was resuscitated
efficiently and did not experience circulatory shock or reperfusion injury and is currently
being ventilated with high concentrations of oxygen. The air conditioners in the ICU have
not been functioning properly and with the very hot weather he has been sweating
excessively. As there was no enteral access the referring hospital initiated CPN with feed
ITN 8801A.
Additional information at the time of transfer is tabulated below.
Body weight (kg) 52 Urea (mmol/l) 15
Height (m) 1.74 Creatinine (mmol/l) 100
TST (mm) 10 Sodium (mmol/l) 124
MUAC (cm) 23.0 Potassium (mmol/l) 4.5
MAMC (cm) 19.8 Chloride (mmol/l) 99
Heart rate (beats per minute) 100 Bicarbonate (mmol/l) 23
Temperature (⁰C) 39 Blood glucose (mmol/l) 15
Respiratory rate (breaths/min) 25 Albumin (g/dl) 18
White blood cell count (mm3) 13 000 (high)
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DIETETICS & HUMAN NUTRITION
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DIET 360 P2
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DIET 360 P2
1.1.1 Using anthropometry and relevant biochemistry assess his nutritional status. (8)
Calculation/reading Interpretation
BMI
(kg/m2)
IBW (kg)
TST (mm)
MUAC
(cm)
MAMC
(cm)
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DIET 360 P2
Biochemistry
1.1.2 It was mentioned on the ward round that he has SIRS. From what you know about
this patient is there evidence of this? Elaborate and include a definition of SIRS.
(9)
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EXAMINATION: NOVEMBER/DECEMBER 2013
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1.1.3 Calculate his energy and macronutrient requirements – use 1.5 g protein per kg ABW.
(7)
BMR
Stress factor
Activity factor
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EXAMINATION: NOVEMBER/DECEMBER 2013
DIET 360 P2
Total energy
Total protein (g)
Protein % of
Total energy
Total nitrogen (g)
NPE (kJ)
NPE to N ratio
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Total CHO (g)
Mg/kg/min
Total fat
Reasoning if necessary:
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1.1.4 Interpret his abnormal (out of range) biochemical laboratory results and explain the
possible causes of each derangement. (8)
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EXAMINATION: NOVEMBER/DECEMBER 2013
DIET 360 P2
1.1.6 There is now some limited enteral access – the team has asked you whether giving one
litre of Intestamine enterally in addition to the CPN would benefit this patient as they feel
that he is at an increased risk of oxidative damage from ROS production. The team is
concerned about giving him too much calcium.
1.1.6.1 Discuss the possible reasons for this patient being at an increased risk for oxidative
damage. (4)
1.1.6.2 What is your opinion regarding their recommendation of Intestamine? Discuss and
include a description of the product. (4)
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DIETETICS & HUMAN NUTRITION
EXAMINATION: NOVEMBER/DECEMBER 2013
DIET 360 P2
1.2 Liverish (7 year old white male) has been referred to you for the dietary treatment of fatty
liver disease. There is a family history of diabetes and hypertension. His current
biochemical results are found in the table below.
Blood glucose (mmol/l) 4.5
Albumin (g/l) 42
Triglycerides (mmol/l) 3
AST (u/l) 80
ALT (u/l) 100
Weight (kg) 35
Height (m) 1.15
Discuss the dietary approach that you would use. (6)
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DIET 360 P2
QUESTION 2
2.1 Mrs Reenil is a 46 year old female (black African) who has been admitted into hospital
with end stage renal failure. A clinical examination on admission reveals that her nails
are very pale and she scratches her skin constantly. There is no noticeable oedema. At
present she is nauseas but not vomiting. She does not smoke or drink as she had a stroke
15 years previously. There is a family history of hypertension.
Currently she is receiving haemodialysis 3 times per week. Her current medications
include Calcitriol (vitamin D3), Pregamal (iron and folic acid supplement),
Erythropoietin and Titralac.
On admission:
GFR (ml/min) 2
Albumin (g/l) 20
Hb (g/dl) 8.9
Iron (umol/l) 6.9
Urea (mmol/l) 20.0
Creatinine (mmol/) 1487
Sodium (mmol/l) 140
Potassium (mmol/l) 4.3
Chloride (mmol/l) 100
Bicarbonate (mmol/l) 26
Calcium (mmol/l) 1.5
Phosphate (mmol/l) 3.22
PTH High
2.2.1 Interpret her abnormal (out of range) biochemical laboratory results. Discuss in detail the
causes and where possible link them to her physical symptoms. (15)
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EXAMINATION: NOVEMBER/DECEMBER 2013
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2.1.2 Are the medications that her doctor prescribed appropriate? Elaborate in detail. (8)
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2.1.3 You calculated her renal prescription as follows: protein 67g, energy 8400kJ,
carbohydrate 277g and the remainder as fat with the usual ranges for Na, K and
phosphate. Her current food intake is summarized in the exchanges which follow. Do
you need to adjust her intake/exchanges or can she continue on her current intake? If you
feel you can improve her intake then support this with minor changes to the exchanges
please. (2)
Group
Number
of
exchanges
Energy
(kJ)
Protein
(g)
Fat
(g)
CHO
(g)
PO4
(mg)
Na
(mg)
K
(mg)
Meat & meat substitutes
Meat - high P, low Na 2 700 14 10 0 240 110 180
Meat - high P, high Na 2 700 14 10 0 240 860 180
Meat - low P, low Na 0 0 0 0 0 0 0 0
Meat - low P, high Na 0 0 0 0 0 0 0 0
Legumes low Na 1 350 7 5 15 120 55 245
Legumes high Na 0 0 0 0 0 0 0
Milk 0 0 0 0 0 0 0
low kJ, fat, CHO 1 325 4 5 10 110 65 185
high kJ, fat, CHO 1 835 4 10 20 110 65 185
Starch 0 0 0 0 0 0 0
Starch low K, low kJ, low fat 7 2450 14 0 140 280 490 350
Starch low K, high kJ, high fat 1 835 2 10 20 40 70 50
Starch high K, low kJ, low fat 1 350 2 0 20 40 70 245
Starch high K, high kJ, high fat 1 835 2 10 20 40 70 245
Vegetables 0 0 0 0 0 0 0
Vegetables low K 1 90 1 0 2 20 20 75
Vegetables moderate K 1 90 1 0 2 20 20 150
Vegetables high K 0 0 0 0 0 0 0
Fruit 0 0 0 0 0 0 0
Fruit low K 0 0 0 0 0 0 0 0
Fruit moderate K 1 250 0.5 0 10 15 5 170
Fruit high K 1 250 0.5 0 10 15 5 240
Beverages 0 0 0 0 0 0 0
Beverages low kJ 0 0 0 0 0 0 0 0
Beverages high kJ 0 0 0 0 0 0 0 0
Sugar 1 155 0 0 10 0 0 10
Fat 1 160 0 5 0 0 45 0
Totals 0 8375 66 65 279 1290 1950 2510
Percent of total 14% 30% 56%
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DIETETICS & HUMAN NUTRITION
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DIET 360 P2
2.2 Bill Wrath underwent a gastrectomy (Bilroth 2) to surgically remove a very large gastric
ulcer. Post surgery, he was initially fed a semi elemental feed via a jejunostomy tube.
Subsequently he has successfully tolerated ice, water, clear and full fluids such as milk. It
is day 5 post surgery and he is ready to begin eating solid food – he does not need a puree
diet. Using the exchanges that follow please plan an appropriate diet remembering that he
loves pizza (thin base), tuna, haddock, beef stew with lots of vegetables, eggs, custard
(UltraMel or made from custard powder), chocolate, plain butter milk cake and pineapples.
You may use your renal exchanges to do this. MEAL PLANS CAN BE FILLED IN
USING PENCIL.
Food Exchange
Meat/legumes 10
Milk 2
Starch 10
Vegetables 2
Fruit 3
Fat 6
Sugar 0
Beverages As many as you decide
Briefly write down the type of diet that you are about to plan.
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Exchange Code Number Meal plan
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Exchange Code Number Meal plan
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DIET 360 P2
QUESTION 3
3.1 KC is a 10 year old black African male who is suffering from end stage chronic liver
cirrhosis with cholestasis (no jaundice) as a consequence of eating lots of mouldy
peanuts.
On assessment you discover that he has moderate ascites. He suffers from muscle
cramps (which annoy him immensely) and falls over things at night as he does not see
them in his way. His food tastes funny and he gets full very quickly. Over the next 6
months he is being worked up for a liver transplant using the kasei procedure.
Current medication includes lactulose, cholestyramine, an aminoglycoside diuretic and
pancreatic enzymes.
Additional information:
Weight (kg) 30.0
Height (m) 1.25
MUAC (cm) 12.5
TST (mm) 6
Blood glucose (mmol/l) 2.1 to 2.9
Sodium (mmol/l) 142
Potassium (mmol/l) 2.5
Chloride (mmol/l) 103
Bicarbonate (mmol/l) 25
Ammonia Not raised
3.1.1 Nutritionally assess KC using anthropometry only. (11)
Reading eg Z score etc Interpretation
Calculate estimated
weight
Estimated weight for
age
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DIET 360 P2
% expected weight for
age
Estimated weight age
Height for age 1.25 m
% Expected height for
age
Height age
TST 6 mm
MAC 12.5 cm
MAMC
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DIET 360 P2
3.1.2 Interpret his abnormal (out of range) biochemical laboratory results and explain the
possible causes of each derangement in detail. (5)
3.1.3 Based on the little that you know about his symptoms do you think that he might benefit
from supplementation with specific vitamins and minerals? Discuss in detail how any
possible deficiencies that you have identified could be related to the liver cirrhosis. (9)
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3.1.4 Discuss whether each medication is appropriate for KC and include the reason for its use.
(5)
3.1.5 His mother is very puzzled as you have prescribed corn flour as part of his treatment.
She wants to know if she can give him stew and use the corn flour as a thickener when
cooking his meals. Discuss with her why you feel it is necessary as well as when and
how it should be given. (4)
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3.1.6 A new BCAA supplement is available on the local market. Discuss briefly whether
BCAA may be of benefit in the treatment of liver disease in general and then whether you
think KC in particular would benefit. (6)
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4.1 The hypermetabolic response in both trauma and burns is very important in the early
stages of the injury. Fill in the summary diagram below to demonstrate the
hypermetabolic response in burns. (10)
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UNIVERSITY OF KWAZULU-NATAL
SCHOOL OF AGRICULTURAL, EARTH & ENVIRONMENTAL SCIENCES
DIETETICS & HUMAN NUTRITION
EXAMINATION: NOVEMBER/DECEMBER 2013
SUBJECT, COURSE & CODE: DIET THERAPY – SURGICAL DIET360 - P2
DURATION : 3 HOURS TOTAL MARKS : 100
External Examiner : Mrs. C MacDougall
Internal Examiner : Ms C Biggs
NOTE: THIS PAPER CONSISTS OF 39 PAGES AND A 27 PAGE FORMULA
HANDOUT PLEASE CHECK THAT YOU HAVE ALL OF THEM
DO TWO (2) OUT OF THREE (3) QUESTIONS
STUDENT NUMBER:___________________________________________________________
QUESTION 1
Mr Knockdown, a 30 year old black African male, has been transferred to your surgical ICU
suffering from multiple trauma after being run over by a truck. He was resuscitated efficiently
and did not experience circulatory shock or reperfusion injury and is currently being ventilated
with high concentrations of oxygen. The air conditioners in the ICU have not been functioning
properly and with the very hot weather he has been sweating excessively. As there was no
enteral access the referring hospital initiated CPN with feed ITN 8801A.
Additional information at the time of transfer is tabulated below.
Body weight (kg) 52 Urea (mmol/l) 15
Height (m) 1.74 Creatinine (mmol/l) 100
TST (mm) 10 Sodium (mmol/l) 124
MUAC (cm) 23.0 Potassium (mmol/l) 4.5
MAMC (cm) 19.8 Chloride (mmol/l) 99
Heart rate (beats per minute) 100 Bicarbonate (mmol/l) 23
Temperature (⁰C) 39 Blood glucose (mmol/l) 15
Respiratory rate (breaths/min) 25 Albumin (g/dl) 18
White blood cell count (mm3) 13 000 (high)
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Body weight (kg) 52
Height (m) 1.74
TST (mm) 10
MUAC (cm) 23.0
MAMC (cm) 19.8
Heart rate (beats per minute) 100 High
Temperature (⁰C) 39 High
Respiratory rate (breaths/min) 25 High
White blood cell count (mm3) 13 000 (high) High
Urea (mmol/l) 15 High
Creatinine (mmol/l) 100 Normal
Sodium (mmol/l) 124 Low
Potassium (mmol/l) 4.5 Normal
Chloride (mmol/l) 99 Normal
Bicarbonate (mmol/l) 23 Normal
Blood glucose (mmol/l) 15 High
Albumin (g/dl) 18 Severely depleted
1.1.2 Using anthropometry and relevant biochemistry assess his nutritional status. (8)
Biochemistry
BMI (kgm2) 17.2 Mild malnutrition (golden and golden)
Ideal body
weight
56.0 ie 18.5 lower end of BMI
TST On 50th
normal fat stores
MUAC Below the 5th Just above 22 cm – below would be
mildly malnourished so thin arms
MAMC 19.8 Below the 5th low muscle stores
Albumin is severely depleted – could
reflect nutritional status as mildly
malnourished but more likely a result of
trauma and the acute phase response
So mild malnutrition as low BMI with
low muscle mass but normal fat stores
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1.1.2 It was mentioned on the ward round that he has SIRS. From what you know about
this patient is there evidence of this? Elaborate including a definition of SIRS. (9)
The most common points left out here was the fact that he was a high risk as he had experienced
multiple trauma and was in the surgical ICU
Definition
Systemic Inflammatory Response Syndrome - This is an excessive inflammation from the
activation of the innate immune system and the proinflammatory cascade (Clifford 2004)
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with the increased formation of humoral mediators (catecholamines, glucocorticoids),
proinflammatory cytokines (TNF, IL-1, IL-6) and chemokines (C5a, LTB4, PAF) which shifts
the T-helper cells to the Th1-type
Diagnosis/symptoms of SIRS is 2 or more of the following
Temperature >38⁰C or <36⁰C his temp is 39⁰C
Heart rate of >90 beats per minute – his heart rate is 100
Respiratory rate of >20 breathes per minute his is 25
White blood cell count >12 000/mm3 – his is 13 000
High risk is surgical ICU and multiple trauma
So yes he has SIRS
1.1.3 Calculate his energy and macronutrient requirements – use 1.5 g protein per kg ABW.
This was poorly done as most used the stress factor for multiple trauma and not the SIRS – I was
surprised because I did go over this in class and in a practical session plus a similar question was
in their last practical on schofield calculations – fat and CHO will vary according to each
students preference. There should have been 8 marks allocated not 7. Full marks given for NPE
and max ox rate only if the result was explained ie above the recc NPE of 420 therefore
sufficient NPE supplied to protect protein.
(7)
Answer
Ventilated so an activity factor of -15%
SIRS as opposed to multiple trauma therefore 50% stress factor not 40%
Basal Metabolic Rate: 6158 kJ
Metabolic rate adjustment 50 % 3079 kJ
Activity factor -15 % -924 kJ
Total Energy 8313 kJ
Protein g/kg BW Protein
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(g)
1.5 78
% TE NPE:gN
16 560
CHO
% of Tot E Total CHO (g)
54 264
mg/kg/min
3.5
Fat
% of Tot E Total Fat (g)
30 66
1.1.4 Interpret his abnormal (out of range) biochemical laboratory results explaining the possible
causes of each derangements. (8)
Most did not look at the CPN regimes he was on to determine if he was being overfed.
White blood cell count (mm3) 13 000
Urea (mmol/l) 15
Creatinine (mmol/l) 100
Blood glucose (mmol/l) 15
Sodium (mmol/l) 124
High WBC indicates infection
High urea but normal creatinine so not acute kidney injury likely to be from overfeeding
protein as the feed they are on gives 22.4 g N instead of 12.5 g nitrogen – also massive
breakdown from the skeletal muscle and release of protein – release of catabolic hormones -
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High blood sugar levels – can be from overfeeding cho but the amount being given does not
exceed the maximal oxidative rate – usually insulin resistance from release of catabolic
hormones Accelerated (increased glucagon levels) Results in hyperglycaemia to maintain a
supply of glucose during hypotension and poor organ perfusion (GIT is also an organ)
Low sodium possibly from dehydration as has been excessive sweating
1.1.5 There is now limited enteral access – the team has asked you whether giving one litre
of Intestamine enterally in addition to the CPN would benefit this patient as they feel
that he at an increased risk of oxidative damage from ROS production. The team is
concerned about giving him too much calcium.
I am surprised as to how badly this question was answered. They had 2 practical sessions on
feeds including Intestamine and it was gone over in a practical and in class.
1.1.6.1 Do you think that he is at an increased risk for oxidative damage? Discuss.
(4)
Yes as there is increased ROS production from:
Tissue damage and inflammation (trauma , ischemia, infection)
Increase in BMR
Catecholamines released during trauma and critical illness
Being ventilated with high concentrations of oxygen to obtain sufficient arterial oxygenation
1.1.7.1 Would you agree with their recommendation of Intestamine?
Discuss including a description of the product. (4)
The amount is incorrect ie not to give more than 500 ml
Would agree with the principle though as it contains a mix of glutamine, selenium, zinc,
betacarotene, vitamin C and E and antioxidant cocktails have been shown to reduce mortality
and days on the ventilator, less infections. but there is no calcium in intestamine so that is not
a problem
1.2 Liverish (7 year old white male) has been referred to you for the dietary treatment of fatty
liver disease. There is a family history of diabetes and hypertension.
Blood glucose (mmol/l) 4.5
Albumin (g/l) 42
Triglycerides (mmol/l) 3
AST (U/l) 80
ALT (u/l) 100
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Weight (kg) 35
Height (m) 1.15
Blood glucose (mmol/l) 4.5 Normal
Albumin (g/l) 42 Normal
Triglycerides (mmol/l) 3 High
AST (U/l) 80 High
ALT (u/l) 100 High
Weight (kg) 35
Height (m) 1.15
Discuss the dietary approach you would take. (6)
First need to establish that the child is very overweight for actual height as BMI is
35/1.32 = 26.5 which is way above the plus 3 z score ie weighs too much for his height
so this needs to be treated so need a controlled weight loss as to rapid a weight loss will
exacerbate this problem by releasing lots of fat – Rapid weight loss might enhance the
disease progression (Angulo 2002 citing Franzese et al 1997) by leading to portal
inflammation and fibrosis (Angulo & Lindor 2001). A loss of ½ kg per week in
children (Angulo 2002 citing Franzese et al 1997) Weight loss needs to be maintained.
As the TG levels are high these need to be decreased by reducing the use of refined CHO
decreasing SUFA and cholesterol and increase PUFA and fibre and antioxidants.
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QUESTION 2
Mrs Reenil is a 46 year old female (black African) who has been admitted into hospital with end
stage renal failure. A clinical examination on admission reveals that her nails are very pale and
she scratches her skin constantly. There is no noticeable oedema. At present she is nauseas but
not vomiting. She does not smoke or drink as she had a stroke 15 years previously. There is a
family history of hypertension.
Currently she is receiving haemodialysis 3 times per week. Her current medications include
vitamin D3 (Calcitriol), Pregamal (iron and folic acid supplement), Erythropoietin and Titralac.
On admission:
GFR (ml/min) 2
Albumin (g/l) 20
Hb (g/dl) 8.9
Iron (umol/l) 6.9
Urea (mmol/l) 20.0
Creatinine (mmol/) 1487
Sodium (mmol/l) 140
Potassium (mmol/l) 4.3
Chloride (mmol/l) 100
Bicarbonate (mmol/l) 26
Calcium (mmol/l) 1.5
Phosphate (mmol/l) 3.22
PTH High
2.2.1 Interpret her abnormal (out of range) biochemical laboratory results. Discuss in detail the
causes and where possible link them to her physical symptoms. (15)
GFR (ml/min) 2
Albumin (g/l) 22 moderately depleted
Hb (g/dl) 8.9 Low
Iron (umol/l) 6.9 Low
Urea (mmol/l) 20.0 High
Creatinine (mmol/) 1487 High
Calcium (mmol/l) 1.5 Low
Phosphate (mmol/l) 3.22 High
PTH high High
Albumin is moderately depleted as a result of stress ie the kidney is involved with the
manufacture of albumin so this is not an appropriate nutritional indicator as in this case
it probably reflects stress rather than chronic malnutrition
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Urea is very high and this in combination with a high creatinine confirms the diagnosis of
renal failure.The kidney is unable to clear the urea and creatinine which are the
breakdown products of protein. This contributes to the nausea.
The calcium levels are low which can be expected in decompensated end stage renal
disease as the rise in phosphate levels bind with calcium causing the calcium levels to
drop however the albumin levels are also low and calcium binds to albumin so as this is
not a corrected calcium the levels may not actually be low so interpret with caution.
Phosphate levels are very high – expected in renal disease as the kidney can no longer
excrete phosphate – this causes calcium and phosphate to bind which in turn lowers
calcium levels which stimulates the release of PTH which explains the raised levels of
PTH. The raised levels of phosphate also are the cause of the itchy skin.
Her haemoglobin and serum iron levels are low ie she is anaemic – this correlates to the
pale nails – expect this in renal failure as there is a def of EPO which manufactures rbc
which in turn carries iron. There is also a low protein diet ½ , blood loss from
haemodialysis, ½GI bleeding, ½ frequent blood sampling, ½her high levels of
uremia destroy red blood cells, ½ she is nauseas so eating less ½ and decreased iron
absorption ½ – she is not on salicylates so no mark for this.
2.2.2 Are the medications that her doctor prescribed appropriate? Elaborate in detail. (8)
Vitamin D3 (Calcitriol)
Vitamin D3 is appropriate as Vitamin D is inactivated by high levels of urea which
reduce the biologic action of calcitriol and phosphate (reduce renal enzyme (1- -
hydoxylase) which converts vitamin D to its active form and the kidney stimulates the
conversion of vitamin D to its active form.
Pregamal
Pregamal as an iron supplement is appropriate because she has been started on EPO and
the additional iron is needed to manufacture the newly created red blood cells.
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Folic acid is appropriate as renal patients are often deficient in folate and folic acid is
essential in the formation of red blood cells so appropriate with the EPO.
Erythropoietin
EPO – is appropriate as in end stage renal failure the kidney can no longer manufacture
this and this results in the anemia which needs correcting
Titralac
Titralac is both a calcium supplement and a phosphate binder – necessary as it is taken
with meals and snacks – the calcium binds with the phosphate in the GIT and reduces the
absorption of phosphate – very necessary in this case because of the high phosphate
levels however usually the levels of phosphate are lowered first before a phosphate
binder is used.
2.1.3 You calculated her renal prescription as follows: protein 67g, energy 8400kJ,
carbohydrate 277g and the remainder as fat with the usual ranges for Na, K and phosphate. Her
current food intake is summarized in the exchanges which follow. Do you need to adjust her
intake/exchanges or can she continue on her current intake? If you feel you can improve her
intake then support this with minor changes to the exchanges please. (2)
Group
Number
of
exchanges
Energy
(kJ)
Protein
(g)
Fat
(g)
CHO
(g)
PO4
(mg)
Na
(mg)
K
(mg)
Meat & meat substitutes
Meat - high P, low Na 2 700 14 10 0 240 110 180
Meat - high P, high Na 2 700 14 10 0 240 860 180
Meat - low P, low Na 0 0 0 0 0 0 0 0
Meat - low P, high Na 0 0 0 0 0 0 0 0
Legumes low Na 1 350 7 5 15 120 55 245
Legumes high Na 0 0 0 0 0 0 0
0 0 0 0 0 0 0
Milk 0 0 0 0 0 0 0
low kJ, fat, CHO 1 325 4 5 10 110 65 185
high kJ, fat, CHO 1 835 4 10 20 110 65 185
0 0 0 0 0 0 0
Starch 0 0 0 0 0 0 0
Starch low K, low kJ, low
fat 7 2450 14 0 140 280 490 350
Starch low K, high kJ, high
fat 1 835 2 10 20 40 70 50
Starch high K, low kJ, low
fat 1 350 2 0 20 40 70 245
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Starch high K, high kJ, high
fat 1 835 2 10 20 40 70 245
0 0 0 0 0 0 0
Vegetables 0 0 0 0 0 0 0
Vegetables low K 1 90 1 0 2 20 20 75
Vegetables moderate K 1 90 1 0 2 20 20 150
Vegetables high K 0 0 0 0 0 0 0
0 0 0 0 0 0 0
Fruit 0 0 0 0 0 0 0
Fruit low K 0 0 0 0 0 0 0 0
Fruit moderate K 1 250 0.5 0 10 15 5 170
Fruit high K 1 250 0.5 0 10 15 5 240
0 0 0 0 0 0 0
Beverages 0 0 0 0 0 0 0
Beverages low kJ 0 0 0 0 0 0 0 0
Beverages high kJ 0 0 0 0 0 0 0 0
Sugar 1 155 0 0 10 0 0 10
Fat 1 160 0 5 0 0 45 0
Totals 0 8375 66 65 279 1290 1950 2510
Percent of total 14% 30% 56%
Group
Number
of
exchanges
Energy
(kJ)
Protein
(g)
Fat
(g)
CHO
(g)
PO4
(mg)
Na
(mg)
K
(mg)
Meat & meat substitutes
Meat - high P, low Na 0 0 0 0 0 0 0 0
Meat - high P, high Na 0 0 0 0 0 0 0 0
Meat - low P, low Na 2 700 14 10 0 130 110 180
Meat - low P, high Na 2 700 14 10 0 130 860 180
Legumes low Na 1 350 7 5 15 120 55 245
Legumes high Na 0 0 0 0 0 0 0
0 0 0 0 0 0 0
Milk 0 0 0 0 0 0 0
low kJ, fat, CHO 1 325 4 5 10 110 65 185
high kJ, fat, CHO 1 835 4 10 20 110 65 185
0 0 0 0 0 0 0
Starch 0 0 0 0 0 0 0
Starch low K, low kJ, low
fat 7 2450 14 0 140 280 490 350
Starch low K, high kJ, high
fat 1 835 2 10 20 40 70 50
42
Starch high K, low kJ, low
fat 1 350 2 0 20 40 70 245
Starch high K, high kJ, high
fat 1 835 2 10 20 40 70 245
0 0 0 0 0 0 0
Vegetables 0 0 0 0 0 0 0
Vegetables low K 1 90 1 0 2 20 20 75
Vegetables moderate K 1 90 1 0 2 20 20 150
Vegetables high K 0 0 0 0 0 0 0
0 0 0 0 0 0 0
Fruit 0 0 0 0 0 0 0
Fruit low K 0 0 0 0 0 0 0 0
Fruit moderate K 1 250 0.5 0 10 15 5 170
Fruit high K 1 250 0.5 0 10 15 5 240
0 0 0 0 0 0 0
Beverages 0 0 0 0 0 0 0
Beverages low Kj 0 0 0 0 0 0 0 0
Beverages high Kj 0 0 0 0 0 0 0 0
Sugar 1 155 0 0 10 0 0 10
Fat 1 160 0 5 0 0 45 0
Totals 0 8375 66 65 279 1070 1950 2510
So prescription great except for phosphate being too high so need to simply change the 4 high
phosphate meats to 4 low phosphate meats.
2.3 Bill Wrath underwent a gastrectomy (Bilroth 2) to surgically remove a very large gastric
ulcer. Post surgery, he was initially fed a semi elemental feed via a jejunostomy tube.
Subsequently he has successfully tolerated ice, water, both clear and full fluids such as
milk. It is day 5 post surgery and he is ready to begin eating solid food – he does not need a
puree diet. Using the exchanges that follow please plan an appropriate diet remembering
that he loves pizza (thin base), tuna, haddock, beef stew with lots of vegetables, eggs,
custard (UltraMel or made from custard powder), chocolate, plain butter milk cake and
pineapples. You may use your renal exchanges to do this.
Food Exchange
Meat/legumes 10
Milk 2
Starch 10
Vegetables 2
Fruit 3
Fat 6
Sugar 0
Beverages As many as you decide
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First briefly summarize the diet you are going to plan.
Mark sheet
Need to plan a light moderate fat no refined cho diet (no sugar, sweets, sugar containing cold
drinks or carbonated beverages) with small frequent feeds and separating liquids from solids.
Food Exchange Planned
Meat/legumes 10
Milk 2
Starch 10
Vegetables 2
Fruit 3
Fat 6
Sugar 0
Beverages As many as you decide
Based on above table has the student planned the correct number of exchanges? Yes/No
Are the correct amounts and foods allocated to each exchange? Eg is 1 starch = 1 slice of bread
etc Yes/No
If no then write incorrect foods/amounts below.
Did they separate liquids from solids? Yes/No
Did they avoid sugar, refined carbohydrates and other sweet things?
Did they include foods not allowed on the light diet? Yes/No
Did they give small, frequent meals Yes/No
Did they include as many favorite foods as possible?
Pizza Not allowed on light diet
Tuna Tinned in water should have been included
Haddock Not allowed on light diet as smoked fish
Beef stew Allowed but needed to stipulate the vegetables for light
diet
Eggs Allowed but not fried
Custard Only allowed if sugar not used
Chocolate Not allowed on light diet
Plain butter milk cake Not allowed as a refined carbohydrate
Pineapples Not allowed on light diet
Breakfast
Snack
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Lunch
Snack
Supper
Final comment:
QUESTION 3
3.1 KC is a 10 year old black African male who is suffering from end stage chronic liver
cirrhosis with cholestasis (no jaundice) as a consequence of eating lots of mouldy peanuts.
On assessment you discover that he is moderately ascetic. He suffers from muscle cramps
(which annoy him immensely) and falls over things at night as he does not see them in his way.
His food tastes funny and he gets full very quickly. Over the next 6 months he is being worked
up for a liver transplant using the kasei procedure.
Current medication includes lactulose, cholestyramine, an aminoglycoside diuretic and
pancreatic enzymes.
Additional information:
Weight (kg) 30.0
Height (m) 1.25
MUAC (cm) 12.5
TST (mm) 6
Blood glucose (mmol/l) 2.1 to 2.9
Sodium (mmol/l) 142
Potassium (mmol/l) 2.5
Chloride (mmol/l) 103
Bicarbonate (mmol/l) 25
Ammonia Not raised
3.1.7 Nutritionally assess KC using anthropometry only. (11)
How to calculate the weight of a child with ascites was done in a test in class and gone
over in class therefore this should have been done properly
45
Reading eg Z score etc Interpretation
Calculate estimated
weight
Need to use BMI for age ie on the 0 Z score is 16.5 therefore 16.5 X
1.56 = 25.8 kg.
Estimated weight for
age
Below the 10th percentile
Underweight/very underweight ie
no WHO terminology as a
percentile not a z score
% expected weight for
age
25.8/32*100= 80.6 %
Normal nutrition according to the
welcome ie not below 80%
Estimated weight age 8 years
Height for age 1.25 m On minus 2 Z score
Stunted
% Expected height for
age
1.25/1.38*100= 90.6%
Mild malnutrition
Height age 7 years 6 months
TST 6 mm Below 5th
So low fat stores
MAC 12.5 cm Below 5th
So thin arms
MAMC About 10.5 Below 5th
So low muscle stores
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He is suffering from mild chronic malnutrition (stunted) with low fat and muscle stores.
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3.1.8 Interpret his abnormal (out of range) biochemical laboratory results explaining the
possible causes of each derangement in detail. (5)
Blood glucose (mmol/l) 2.1 to 2.9 Low
Sodium (mmol/l) 142 Normal
Potassium (mmol/l) 2.5 Low
Chloride (mmol/l) 103 Normal
Bicarbonate (mmol/l) 25 Normal
Ammonia Not raised normal
He is hypoglycaemic – would expect this in liver failure esp in children – often insufficient
storage of CHO because of because of spatial limitations (no space) and liver cell damage
This can eventually result in hypoglycaemia (also made worse by the decreasing capacity for
gluconeogenesis)
He is hypokalemic - probably from the aminoglycoside diuretic
3.1.9 Based on the little that you know about his symptoms do you think that he might benefit
from supplementation with specific vitamins and minerals? Discuss in detail how any
possible deficiencies that you identify can be related to the liver cirrhosis. (9)
49
There are taste changes, muscle cramps and night blindness so……..
Deficiency most likely in chronic alcoholic liver disease and longstanding cholestasis. Might be
night blindness. therefore needs vitamin A supplementation Circulating concentrations of
retinol and carotenoids are decreased . Decreased hepatic synthesis and release of RBP ie
decreased release from hepatic stores. Decreased hepatic vitamin A and carotenoid stores,
increased urinary loss of RBP. Been implicated in abnormal taste perception but
controversial (Garrow, James and Ralph, 2000 pg 579)
Cholestryamine impairs absorption of fat soluble vitamins
Food tastes funny and muscle cramps so would supplement with mg and zinc supplementation
especially as zinc and vit A def often exist together
3.1.10 Discuss whether each medication is appropriate for KC and include the reason for its use.
(5)
Cholestyramine may be prescribed to promote gall bladder contractions and he has
cholestasis
Pancreatic enzyme supplementation - has cholestasis and as bile salts are necessary to
activate pancreatic lipase, pancreatic enzyme supplementation may be necessary in
cholestasis.
Lactulose - is a nonabsorbable disaccharide ie oligosaccharide which increases the
production of SCFA in the colon thus lowering colonic pH which in turn decreases the
number of ammonia producing bacteria and decreases the absorption of ammonia from
the GIT
aminoglycoside Diuretics – need to use this as persistent ascites ie in combo with a salt
restriction and perhaps a fluid restriction.
3.1.11 His mother is very puzzled as you have prescribed cornflour as part of his treatment. She
wants to know if she can give him stew and use the cornflour as a thickener when
cooking his meals. Discuss with her why you feel it is necessary as well as when and
how it should be given. (4)
Why necessary - Uncooked corn starch (raw cornflour) releases glucose slowly and results in a
smoother blood sugar curve when compared to glucose polymers which will help prevent low
blood sugar levels.
When it should be given - This effect may last approximately 4 to 9 hours if the cornflour is
given every 4 to 6 hours
How it should be given - can mix with drinks (fruit juice, milk etc) or cold foods.
50
The cornstarch has to be raw so cooking it as a stew thickener will defeat the purpose
3.1.12 A new BCAA supplement is available on the local market. Discuss briefly whether
BCAA may be of benefit in the treatment of liver disease in general and then whether you
think KC in particular would benefit. (6)
Most AA from both endogenous and exogenous protein are metabolised by the liver.
BCAA are the exception in that they are mainly broken down by skeletal muscle, heart and
kidney and are both an nb source of E to the muscle as well as being precursors of other
AA’s. So supplementation with BCAA might help prevent the protein energy
malnutrition by being able to give more protein without placing additional stress on the
liver
May be a role for BCAA in severe encephalopathy which this child is not in as the
ammonia levels are not raised
There was a large lack of compliance and high drop out rate due to the unacceptable taste
of the solution and this child has no appetite already ie food tastes funny and gets full
quickly
No RCT with BCAA in children in liver failure so don’t actually know
4.1 The hypermetabolic response in both trauma and burns is very important in the early
stages of the injury. Fill in the summary diagram below to demonstrate the hypermetabolic
response in burns. (10)
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