A 56‐year‐old white male had longstanding insulin‐requiring diabetes mellitus and diffuse vascular disease. At age 50, he underwent coronary artery bypass grafting and placement of a permanent cardiac pacemaker. Four years later, he required bilateral above‐knee amputations for severe peripheral arterial disease. Over the next two years, he was hospitalized fifteen times for angina pectoris and congestive heart failure (CHF).In September 1990, six years following his cardiac surgery, Swan‐Ganz catheter data confirmed low cardiac performance. He required dopamine, dobutamine, angiotensin‐converting enzyme inhibitors, and high dose parenteral diuretics. Blood urea nitrogen (BUN) was 30 mg/dl, serum creatinine was 1.8 mg/dl, serum albumin was 3.9 g/dl and total serum protein was 7.1 g/dl. Fractional urinary sodium excretion was 0.36. Endogenous creatinine clearance was 20 ml/min. Urine protein excretion was 640 mg/day. Anasarca was attributed to CHF, and renal insufficiency was felt to be due to a combination of nephrosclerosis and low renal perfusion. Conservative management proved futile with development of worsening edema, progressive azotemia, and hyponatremia. At the time of nephrologic consultation, BUN was 159 mg/dl, serum creatinine was 4.5 mg/dl and serum sodium was 114 mEq/l. Pulmonary capillary wedge pressure was 22 mmHg and chest X ray confirmed the presence of large bilateral pleural effusions. Blood pressure had remained surprisingly normal at 126/70 mmHg.A Tenckhoff peritoneal dialysis catheter was placed and peritoneal dialysis begun using 1 l volume exchanges. Over the next several days, dialysis fluid volume was increased to 2 l, with dwell time and dextrose concentration being adjusted to allow for gradual fluid loss. Dialysis was continued on a daily basis for two weeks with a 40 pound weight loss and total resolution of CHF. He was discharged home, but required intermittent peritoneal dialysis over the next six weeks.He was trained to perform peritoneal dialysis using the technique of continuous ambulatory peritoneal dialysis (CAPD). His regimen consisted of 4 two‐liter exchanges daily with variable use of 1.5% and 4.25% dextrose‐containing solutions and intraperitoneal insulin. Over the ensuing months he required only 24 days of hospitalization. He regained use of his lower extremity prostheses and was able to drive his truck. He had no episodes of peritonitis, but required short‐term oral antibiotics for peritoneal catheter exit‐site infection. He expired of acute myocardial infarction afte