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Abstract: SA-PO368

Rescue Therapy for an Old Challenging Problem: Droxidopa in the Management of Intradialytic Hypotension

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis


  • Sankar, Lakshna, Geisinger Health, Danville, Pennsylvania, United States
  • Kalra, Kartik, Geisinger Health, Danville, Pennsylvania, United States

Intradialytic hypotension (IDH) is a common complication affecting 20-30% of hemodialysis (HD) sessions resulting in adverse outcomes. Here we describe the effect of droxidopa in our patient with resistant IDH.

Case Description

72-year-old year old woman with past medical history of end stage kidney disease on HD since 2003, previous failed 2 kidney transplants, failed peritoneal dialysis, aortic and mitral valve replacement, atrial fibrillation on chronic anticoagulation. Her HD sessions were complicated by episodes of symptomatic hypotension for the last 1 - 2 years. Systolic blood pressure (SBP) ranging in between 60 - 70 mm Hg pre -dialysis. As a result, her HD sessions were cut short, and she was often symptomatic with altered mental status requiring multiple hospitalizations. Her symptoms during inter dialytic period were fatigue and exhaustion despite pharmacological measures such as midodrine 15 mg TID and fludrocortisone 0.2 mg on HD. To counter this, her intradialytic temperature was adjusted (cool dialysate), ultrafiltration (UF) goal was limited (different UF profiles were attempted), counseling on interdialytic weight gain and dietary sodium intake, blood flow and dialysate flow were reduced, dry weight was continuously reassessed, time on HD was increased. Despite above measures, she developed symptoms of volume overload as her HD sessions were continuously interrupted by IDH requiring multiple fluid boluses. Her cardiology and neurology evaluation were unremarkable. No evidence of adrenal insufficiency noted. Eventually she was prescribed droxidopa 100 mg TID and gradually escalated to 300 mg TID. Patient overall felt better (SBP improved to 110-120s mm Hg) and is currently tolerating UF removal without further interruptions in HD sessions and no further hospitalizations in the last 6 months.


Management strategies for treatment and prevention of IDH is challenging. Droxidopa, a synthetic amino acid analogue metabolized to norepinephrine by dopa-decarboxylase increases blood pressure through peripheral arterial and venous vasoconstriction. It is currently approved for neurogenic orthostatic hypotension. We propose that Droxidopa can be considered for off label use for symptomatic IDH after work up for other etiologies of hypotension is ruled out, potentially as a rescue therapy failing other pharmacological and conservative measures.