Life threatening nutritional deficiencies in a dialysis patient

Nutritional deficiencies are very common among the patient on chronic hemodialysis. But they can be easily overlooked or misdiagnosed. Deficiencies of trace elements and phosphorous is rare among this patient population but if neglected can lead to catastrophic effects. We describe a case report of a patient with ESRD recently started on outpatient maintenance hemodialysis, who presented with life threatening muscular weakness with respiratory failure requiring prolonged mechanical ventilation. On initial workup, it was unclear what the cause of her weakness was, however, further investigations showed undetectable phosphorous levels as well as very low levels of trace elements. Replacement of these compounds to normal levels led to marked improvement in the clinical picture. On further evaluation, the patient was also found to be profoundly depressed with poor appetite even prior to initiation of hemodialysis. This case report highlights the importance of early diagnosis of depression and malnutrition in patients on chronic hemodialysis, as severe depression can contribute to malnutrition and life threatening deficiencies of organic as well as inorganic compounds, which may cause life threatening complications as evidenced in this patient.