Investigation and treatment
Complete blood count (CBC), HGB ranges from 8.4g/dl to 10g/dl with MCV of 82 + 5 but normal white blood cell and platelet count. Her liver function test (LFT), serum sodium, potassium, chlorine, ionized calcium, and phosphorus are normal. Her stable creatinine is about 4.5mg/dl – 5.5mg/dl with eGFR < 10ml/min/1.73m2.  Ferritin is 466ng/dl. Echocardiography shows mild concentric left ventricular hypertrophy (LVH) with preserved biventricular systolic function. Duplex arterial study of lower extremity report shows right middle superficial femoral artery (SFA) and superficial femoral vein (SFV) fistula with aneurysmal dilation and partial peripherally located thrombus. Computed tomography angiography (CTA) shows right SFA and SFV fistula with mild aneurismal dilatation at the AVF site (Figure 1).
After a diagnosis of spontaneous AVF was made, she was admitted to the vascular surgery ward while hemodialysis continued where the open surgical repair was done, the above medications continued (prednisolone was changed to hydrocortisone for 3 days).