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Nephrogenic Ascites Dialysis High Protein SAAG — ESENeph MCQ

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HardHaemodialysisNephrogenic Ascites Dialysis High Protein SAAGESENeph

A 65-year-old man with CKD G5D on haemodialysis has a well-functioning AV fistula but develops refractory ascites. He has no liver disease — the ascites is attributed to 'nephrogenic ascites.' Diagnostic paracentesis shows a SAAG <11 g/L and high protein content. What is the underlying mechanism?

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Correct answer: E — Peritoneal fluid overload from inadequate ultrafiltration during dialysis

Nephrogenic (uraemic) ascites is a poorly understood condition occurring in long-term dialysis patients (typically >2 years on HD). The ascites fluid characteristically has high protein (>25 g/L) and low SAAG (<11 g/L), distinguishing it from portal hypertension-related ascites. The mechanism involves chronic volume overload with peritoneal ultrafiltration failure, altered peritoneal membrane permeability, and possibly impaired lymphatic drainage in the uraemic milieu. Management involves aggressive fluid removal (intensified dialysis, strict fluid restriction, therapeutic paracentesis), and consideration of PD (which can paradoxically help by enhancing peritoneal drainage). Renal transplantation is the most effective treatment.

Reference: Cintin et al 2002 – Nephrogenic Ascites; UKKA 2019 – HD Complications