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EMiNEM Case #4: Answers and Discussion

EMiNEM Case #4: Answers and Discussion

Answer is 1:

  1. Milk consumption is excessive and is providing 2000mg of phosphorus per day. The phosphorus in milk is well absorbed and has a high phosphorus to protein ratio of 29mg/g pro. With this high ratio of phosphorus to protein the milk can be limited without compromising protein nutritionSee Appendix 3 of (http://www.kidney.org/professionals/kdoqi/guidelines_updates/pdf/CPGPedNutr2008.pdf) for a good summary of phosphorus/protein ratios.
  2. The patient consumes almost no processed or convenience foods; the sole source of added phosphate comes from baking powder which the family was counselled to limit
  3. Eggs are a significant source of well-absorbed phosphorus and have a phosphorus to protein ratio of 14mg/g protein – less than half that of milk. 
  4. Meats provide over 50% of the dietary phosphorus of most dialysis patients but they also constitute the most important source of protein for the patients. In general the phosphorus to protein ratio for unprocessed meat products is less than 10mg/g protein. Limiting meat and poultry in a dialysis patient can negatively affect nutritional status and phosphate control should not be attempted at the expense of adequate protein.

Answer 2:

  1. This is possible since dietary protein carries a significant phosphate load, however the patient had not really changed his dietary protein intake from foods. An increase in milk intake would have explained the jump in both potassium and phosphorus however the patient denied increasing his dairy.
  2. Mr. A was on a relatively low dose of calcium containing phosphate binders and it would be reasonable to question if a higher dose was needed.  Sevelamer and Lanthanum are not options for the patient due to their high cost.
  3. The correct answer turned out to be #3.  The herbal supplements were examined and shown to contain a number of phosphate containing additives as well as potassium additives. The phosphate additives were used to add nutrition in the form of calcium phosphate and in many of the powdered products, as anticaking agents. Unfortunately the phosphate and calcium content of the products could not be determined. However phosphorus from additives has been shown to be extremely well absorbed in the gut.