Round and round we go! A case of access recirculation.

You see a 72 year Asian male with history of diabetes, hypertension, and ESRD on HD via a left radio-cephalic AVF while rounding in your dialysis unit. His dialysis Rx is a dialyzer D flux 250, Qb of 400ml/min, Qd- 600 ml/min for a duration of 4 hours. His Kt/V on three times a week hemodialysis has ranged between 1.6-1.8. Your dialysis unit nurse reports that most recently checked Kt/V has dropped down to 1.0 confirmed on 2 different checks. He has been compliant with his dialysis treatments and has completed the full 4 hours as prescribed. Patient feels fine. His physical exam is unremarkable with blood pressures ranging between 130-150 systolic and trace edema.