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Marshall Wynngarden, a 34-year-old physician, came to Johns Hopkins in 1986, with a history of insulin-dependent diabetes since age 9 and renal failure since 1983. He was complaining of fatigue, arthritic pains, sexual dysfunction, and muscle cramps. Despite an ACE inhibitor and moderate protein restriction, his kidney function declined. In 1988 he was started on a very-low-protein diet, supplemented by amino acids alternating with ketoacids. Symptoms improved, but he continued to have difficulty with control of his diabetes. Kidney function continued to decline slowly, and he finally decided to start dialysis in 1992, after four years.

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