A malnourished haemodialysis patient—a diagnostic surprise

(Section Editor: K. Kühn) Malnutrition is prevalent among patients receiving chronic haemodialysis (HD). The mechanism of malnutrition has not been fully understood, but several factors could be involved [1]. We present an interesting case with an important but easily overlooked cause of malnutrition. A 63-year-old Chinese woman presented in 1995 with end-stage renal failure as a consequence of diabetic nephropathy. She started on regular HD thrice a week at an outpatient HD facility. Multi-infarct dementia developed in the recent years and prevented her from self-care. In April 1996, poor appetite and general malaise were initially noted. Predialysis laboratory investigations showed total protein of 6.1 g/dl, albumin 3.1 g/dl, transferrin 183 mg/dl, blood urea nitrogen 32 mg/dl, creatinine 3.9 mg/dl, white cell count 10700/mm3 with neutrophil 80.5% and lymphocyte 9.0% and a haemoglobin of 9.6 g/dl despite recombinant erythropoietin at a maintenence dose of 100 I.U./kg/week. The mean value of Kt/Vurea [2] was 0.85 due to a decrease in the flow of arteriovenous fistula (AVF) upon HD sessions. Initially, inadequate dialysis leading to malnutrition was considered. She underwent a fistulography, which revealed incomplete occlusion at the venous anastomosis of AVF. After percutaneous transluminal angioplasty for stenotic AVF lesion and intensified HD, however, the patient still did not feel well. She was referred to our institution in June 1996.