SEVERE MALNUTRITION .2.

W.R., a 46-year-old black male presented with malaise, dyspnea, and ankle swelling that developed over many months. He was found to be nephrotic and to have ESRD secondary to multiple myeloma. He was begun on chemotherapy and dialysis shortly after admission. Within the first three months of dialysis, he underwent four vascular access surgeries and received monthly oral chemotherapy. His nephrotic syndrome resolved over four months as urine output declined. He was admitted to the hospital three times in the first four months of dialysis for nausea and vomiting. He missed dialysis treatments twice a month because of scheduling conflicts and transportation problems. He lived alone and could not cook because of his frequent access surgeries and arm swelling. He responded poorly to erythropoietin. His urea reduction ratio was 70%, serum albumin 2.3 g/dl, and Hct 24% when oral nutritional supplements were first prescribed for a one-month trial. There was no improvement in nutritional status, however, and intradialytic parenteral nutrition was begun. Two months later, his serum albumin was 3.5 g/dl, and his appetite had returned. On a smaller dose of erythropoietin, his Hct was 29%. In addition, he now tolerated chemotherapy better.