The Role of Duloxetine for Management of Persistent Hypotension in ESKD
- Hemodialysis: Case Reports, Series, QI Projects
November 04, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
- 801 Dialysis: Hemodialysis and Frequent Dialysis
- Mohamed Abdul Rahman, Rasha, Hamad Medical Corporation, Doha, Ad Dawhah, Qatar
- Al Jerdi, Salman, Weill Cornell Medicine - Qatar, Doha, Qatar
- Nauman, Awais, Hamad Medical Corporation, Doha, Ad Dawhah, Qatar
- Abuhelaiqa, Essa, Hamad Medical Corporation, Doha, Ad Dawhah, Qatar
Uremic neuropathy is a known complication of end stage kidney disease (ESKD) that has significant morbidity and mortality. It can present as distal sensory, motor neuropathy, or autonomic dysfunction that worsen over several months. ESKD patients can develop intra-dialytic hypotension or persistent hypotension due to sympathetic and parasympathetic dysregulation characterized by preserved cardiac index, absence of reflex tachycardia, anhidrosis and reduction is systemic vascular resistance.
Here, we evaluate the use of duloxetine, a serotonin–norepinephrine reuptake inhibitor, for management of persistent hypotension in ESKD on hemodialysis.
33-year-old lady history of ESKD started on hemodialysis for 19 years that over the past 5 years patient has been experiencing progressive and persistent hypotension. 5 years ago, her blood pressure was 90/50mmHg and now it is constantly 40/20 mmHg. Underwent cardiac, and endocrine investigation of hypotension with no specific cause. Therefore, thought to be associated with uremic neuropathy causing autonomic dysfunction. Despite intensifying hemodialysis, use of midodrine, hydrocortisone, and fludrocortisone, patient had no improvement in hypotension. Due to the severe hypotension the patient developed bilateral ischemic retinopathy and vision loss, multiple small bowel ulceration, and peripheral neuropathy. Patient was started on duloxetine 40mg daily trial for peripheral neuropathy. Within one week of therapy, patient noted improvement in neuropathic pain and in addition, blood pressure increase to 50/26. With Blood pressure improvement, patient developed diffuse and constant pulsing headaches required oral analgesic. Upon discontinuing duloxetine, headaches resolved and blood pressure returned to her baseline (41/19).
Duloxetine has been commonly used for treatment of depression and anxiety in addition to peripheral neuropathy. One of the known side effects of duloxetine is hypertension, which is thought to be due to increase in norepinephrine levels, therefore, agonizing alpha-receptor, arterial vasoconstriction and increase systemic vascular resistance. Hence, duloxetine has a potential role in management of uremic neuropathy and an alternative treatment of persistent hypotension in ESKD.