DIFFICULT MANAGEMENT PROBLEMS IN DIALYSIS .2. ACCESS RECIRCULATION

A 72-year-old white female with end-stage renal disease (ESRD) seconda ry to chronic glomerulonephritis has been on chronic hemodialysis for the past one and a half years. She has a history of congestive heart f ailure which has not been symptomatic since she began dialysis. She we ighs 47 kg (103.4 lbs) and receives 3 hr of ''conventional'' hemodialy sis with a blood flow rate of 350 ml/min which is well tolerated. Trea tments are provided using a left upper arm polytetraflourethylene (PTF E) graft. Monthly percentage reduction in urea (PRU) values have been approximately 65%. However, her most recent PRU was 57% (predialysis b lood urea nitrogen (BUN) 82 mg/dl, postdialysis BUN 35 mg/dl). Since h er treatment parameters had not been changed, recirculation studies we re obtained. The BUN values were: peripheral vein (P)-58 mg/dl, arteri al line (A)-48 mg/dl, venous line (V)-23 mg/dl. Calculated recirculati on was 29% ([P - A]/[P - V], [58 - 48]/[58 - 23]). The high level of r ecirculation prompted radiologic evaluation of the access. A fistulogr am, including views of arterial inflow and central veins, showed no st enotic lesions. Needle placement was reviewed and found to be satisfac tory. Repeat recirculation studies yielded similar results.