December 2005: (I)423– 426
Nutrition Grand Rounds
Eating Disorder in a Hemodialysis Patient: Case Report
Anne-Marie Desai, RD, Ronald Perrone, MD, and Johanna Dwyer, DSc, RD
Renal replacement therapy may encourage eating dis-
orders in some patients. Hemodialysis requires pa-
tients to attend dialysis sessions three times per week,
during which time they are weighed pre- and post-
treatment, so the importance of limiting “fluid
weight” gains to prevent fluid overload and elevated
blood pressure are constantly reinforced by the dial-
ysis team. Patients must also follow rigorous thera-
peutic dietary modifications to prevent the buildup of
urea and harmful waste products between treatments.
This is a case report of a 30-year-old man receiving
renal replacement therapy who had anorexia nervosa
of the bulimic subtype.
Key words: end stage renal disease, hemodialysis,
anorexia nervosa, bulimia nervosa
© 2005 International Life Sciences Institute
doi: 10.1301/nr.2005.dec.423– 426
INTRODUCTION
Eating disorders have not been widely reported
among patients with end-stage renal disease (ESRD), but
they may be more common than has previously been
suspected.1,2 According to the Diagnostic and Statistical
Manual of Mental Disorders,3 anorexia nervosa of the
bulimic subtype is defined as:
Ms. Desai is with the Dialysis Clinic and Frances
Stern Nutrition Center, Tufts-New England Medical
Center, Boston, Massachusetts, USA; Dr. Perrone is
Associate Chief, Division of Nephrology and Medical
Director of the Kidney Transplantation Program, Tufts-
New England Medical Center, Boston; Dr. Dwyer is
Professor of Medicine and Community Health, Fried-
man School of Nutrition Science and Policy and
School of Medicine, Tufts University and Director,
Frances Stern Nutrition Center, Tufts-New England
Medical Center, Boston.
Please address all correspondence to: Anne-
Marie Desai, Dialysis Clinic and Frances Stern Nu-
trition Center, Tufts-New England Medical Center,
750 Washington St., Box 783, Boston, MA 02111;
Phone: 617-636-9941; Fax: 617-636-8325; E-mail:
amew@yahoo.com.
Nutrition Reviews姞, Vol. 63, No. 12
. . . refusal to maintain weight within a normal
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range for height and age (more than 15 percent
below ideal body weight). There is a fear of weight
gain and severe body image disturbance in which
body image is the predominant measure of self-
worth and a denial of the seriousness of the illness.
During episodes of anorexia nervosa of the binge-
purge type, individuals regularly binge on food and
purge using techniques such as: self-induced vom-
iting or the misuse of laxatives or diuretics.3
Dieting to lose weight or for other purposes is
sometimes associated with the development of eating
disorders.4-7 Some dieters strive for perfection and are
unable to stop, becoming entrenched in a pattern of
constant restriction. However, eating disorders also oc-
cur in chronic illnesses, such as among teenage girls with
type 1 diabetes.8-10 Teenage boys with diabetes are also
at increased future risk for eating disorders.11 The trig-
gers for the development of eating disorders among
diabetics include dietary restraint and a focus on weight.
Particularly susceptible patients may also include those
struggling with a sense of loss of personal control and an
external locus of control, who believe that the diabetes is
controlling their lives.11,12 The dietary constraints im-
posed on renal patients may potentially trigger eating
disorders in such susceptible individuals.2
CASE STUDY
The patient was a 30-year-old male with ESRD
secondary to reflux nephropathy, who was transferred to
the dialysis unit at Tufts-New England Medical Center
from an overseas institution. He had been receiving renal
replacement therapy for 10 years, and was transferred
with the intention of receiving kidney transplantation.
The patient did not speak English and interpreters were
used throughout his medical treatment.
Upon the patient’s arrival in the dialysis unit, vari-
ous members of the dialysis staff expressed concern
regarding his dietary habits and cachectic appearance.
His estimated dry weight was 43 kg and his body mass
index (BMI) was 14.8, while the normal range for his
height was 18.5 to 25. His ideal body weight was
estimated at 58 kg (based on a BMI of 20), and therefore
423
he presented at 74% of ideal body weight. Further
investigation revealed that the patient had de-mineralized
maxillary dentition on three or four upper teeth on the
lingual side and calluses on his knuckles, signs consistent
with frequent self-induced vomiting. The patient said
that he had vomited involuntarily after meals since he
had begun dialysis treatment a decade ago. The patient
attributed vomiting to the inability of his body to digest
all the food he consumed. He said that “eating large
meals makes me feel heavy and after I vomit I feel free.”
The patient denied the presence of an eating disorder
despite repeated questioning.
time, dietary intervention by the renal dietitian was
limited until the question of whether the patient had an
eating disorder or a serious underlying medical problem
was resolved. A double-contrast upper gastrointestinal
radiographic study showed normal stomach distensibility
and normal esophageal function. An abdominal CT scan
showed no evidence of intestinal obstruction, abnormal
masses, or other pathology.
Initial nutritional intervention involved a recommen-
dation that the patient attempt to follow a meal plan of
three small meals and three small snacks timed evenly
throughout the day. One of the snacks was to be a

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Dietary recall showed his estimated calorie and
protein intake to be below the National Kidney Founda-
tion’s recommended estimated caloric requirement of
2030 kcal (35 ⫻ kilograms ideal body weight) and 70 g
protein (1.2 ⫻ kilograms ideal body weight).13 The
patient’s caloric intake was 650 kcal (32% of estimated
requirement) and his protein intake was 25 g (36% of
estimated requirement).
Estimated intake of electrolytes showed potassium
intake to be 500 mg (20% of estimated requirement) and
sodium intake to be 680 mg (34% of estimated require-
ment). Intake of calcium and phosphorus were 1730 mg
(115% of estimated requirement) and 400 mg (50% of
estimated requirement), respectively.
Initial laboratory values taken at admission to the
outpatient dialysis unit were unremarkable, with the
exception of carbon dioxide, which was found to be
elevated (37 mEq/L compared with the normal range of
20 –30 mEq/L), as would be expected in a patient who
was chronically vomiting (Table 1). The usual sign of
low serum potassium attributed to vomiting was not
apparent due to the lack of functioning kidneys (Table 1).
Numerous medical investigations were performed to
rule out an organic cause of the vomiting. During this
high-calorie/high-protein supplement. The meal plan was
devised based on the patient’s dietary recall, and would
provide approximately 1500 kcal and 70 g protein if
completely consumed. The secondary aim of the dietary
therapy was to increase calories once the patient was
established on this new eating pattern.
Neither at the time of initial consultation nor at
follow-up did the patient exhibit a commitment to weight
gain. Subsequent consultations showed little change in
the patient’s dietary habits, and no weight was gained
during the 3 months that he received dialysis in the unit.
Other causes of malnutrition such as diabetes, thy-
roid deficiency, parasitic infection, systemic lupus ery-
thematosus, and celiac disease were also ruled out. Al-
though clearly anorectic and cachectic, the patient’s
vitamin and mineral status was variable due to the
presence of renal vitamins; vitamin B1 was found to be
normal at 13.8 ␮g/L (normal range 4 –20 ␮g/L) and
vitamin B12 was slightly elevated at 1387 pg/mL (normal
range 230 –1220 pg/mL).
A crisis was reached when the patient experienced
an episode of presyncope at the dialysis unit and was
admitted to the emergency department. Further investi-
gation, including an echocardiogram, revealed mitral

Table 1. Initial Routine Pre-Dialysis Laboratory Values Taken at Admission to the Outpatient Dialysis Unit
for Case Study Patient
Substance Measurement Normal Range
Sodium 144 mmol/L 135–145 mmol/L
Potassium 3.7 mmol/L 3.6–5.1 mmol/L
Creatinine 0.81 mmol/L 0.03–0.11 mmol/L
Blood urea nitrogen 14.6 mmol/L 2.1–8.5 mmol/L
Chloride 91 mmol/L 98–110 mmol/L
Carbon dioxide 37 mmol/L 20–30 mmol/L
Random blood glucose 7.8 mmol/L (140 mg/dL) 3.3–8.35 mg/dL
Calcium 2.4 mmol/L (9.3 mg/dL) 2.1–2.65 mg/dL
Phosphorus 2.06 mmol/L (6.4 mg/dL) 0.87–1.45 mg/dL
Ferritin 0.66 mmol/L 0.05–0.622 mmol/L
Albumin 34 g/L (3.4 g/dL) 34–48 g/L
Total protein 63 g/L (6.3 g/dL) 60–80 g/L
Hemoglobin 124 g/L (12.4 g/dL) 135–160 g/L
Hematocrit 0.387 (38.7%) 0.37–0.47

424 Nutrition Reviews姞, Vol. 63, No. 12

valve insufficiency and dilated cardiomyopathy with an
ejection fraction of 15%. To evaluate these severe med-
ical problems, further intensive questioning was initi-
ated. After extensive discussion, the patient finally ad-
mitted to a 5-year history of self-induced vomiting and
expressed a marked fear of weight gain. The patient
described a pattern of daily vomiting, sometimes several
times per day. He had never sought treatment for this
vomiting and had concealed it from his health care
providers.
In light of these findings, it was determined that the
patient would be best served by returning to his home
country for further psychiatric and medical management
prior to transplantation. The patient was informed that
recovery from his eating disorder and improved cardiac
function would then enable him to receive transplanta-
tion in the future.
DISCUSSION
Malnutrition is widespread in dialysis patients, with
as many as half of the patients suffering from protein and
energy malnutrition. Its causes are multifactorial and
include medical, social, and psychological factors, but it
is seldom attributed to eating disorders.14-17 This case
highlights the difficulty of diagnosing anorexia and bu-
limia when a patient has an underlying serious medical
problem.
Physicians who care for patients who present with
low body weight and vomiting in the setting of renal
failure must thoroughly examine every complaint to rule
out organic and potentially life-threatening causes of
cachexia and vomiting. Anorexia nervosa is often not
considered in the differential diagnosis of malnourished
male patients. Typically, male anorectic patients present-
ing to acute care settings undergo extensive medical tests
to determine the cause of weight loss and do not readily
disclose their eating behavior.18,19 Anorexia nervosa is
still perceived by many to be a female disease, despite
the fact that 10% of all patients are male.20 Anderson and
Holman21 found that males went on diets for different
reasons than females. Males were more likely to diet to
achieve a particular goal, for example “to improve sports
performance,” or “to avoid weight-related medical con-
ditions that their fathers had.” In contrast, for females the
goal of dieting was weight loss. This distinction may also
hold true for male ESRD patients, who may be at higher
risk for anorexia or bulimia nervosa because of their
attempts to achieve desired nutritional parameters, in-
cluding controlling fluid gains. Depression in ESRD
patients can also lead to poor food intake, although it
presents very differently from eating disorders.
The dietary management of type 1 diabetics and
patients with ESRD are similar in that they include
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rigorous dietary instructions and an emphasis on weight.
In many respects, ESRD patients may be at greater risk
of developing disordered eating because, along with
dietary restraint, they must “weigh in” at least three times
per week at each dialysis session. A patient’s sense of
personal control may also play a role. ESRD patients
who exhibited an internal locus of control were less
depressed and exhibited better adaptation and psycho-
logical adjustment to their life on dialysis than those with
an external locus of control.22-24
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Improving Diagnosis of Eating Disorders in
Chronic Disease
Malnourished patients should be assessed for disor-
dered eating patterns by the health care team—preferably
the dietitian, who is likely to have the most information
on food intake. Physicians need to be alert for the
presence of eating disorders, which may occur more
commonly than is reported in the literature. A screening
tool such as the “SCOFF” questions (Table 2)25 can be
used to assess patients who have no organic cause for
failure to thrive. Although this is not a replacement for a
more thorough assessment, these tools may be useful in
the non-psychiatric setting.
Treatment of Eating Disorders
Successful treatment of eating disorders first re-
quires that the individual recognize that he/she has a
problem. Many individuals with purging and restricting
behavior are ashamed and will attempt to hide and deny
the problem despite strong physical evidence of self-
induced vomiting.26,27 In the case presented here, the
patient showed classical signs of self-induced vomiting,
although he denied that he had a problem until faced with
a catastrophic diagnosis. Patients suspected of having
disordered eating behavior or who have a confirmed
eating disorder should be referred to a specialist for
psychiatric assessment and management.
Table 2. SCOFF Questions25*
Do you make yourself Sick because you feel
uncomfortably full?
Do you worry you have lost Control over how much
you eat?
Have you recently lost more than One stone (14
pounds) in a three-month period?
Do you believe yourself to be Fat when others say you
are too thin?
Would you say that Food dominates your life?
*One point is given for every “yes” answer; a score of two or
more is a likely indication of anorexia nervosa or bulimia.
425
 Given the many life stresses created by renal disease
and the many dietary restraints placed on these patients,
it is highly likely that there are many hemodialysis
patients with eating disorders that have not yet been
identified. Physicians, renal dietitians, and nurses should
be aware of the need to monitor these patients for signs
of eating disorders.
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