Kidney Transplantation as Curative Therapy for Refractory Dialysis-induced Hypotension: A Case Report and Literature...

Persistent chronic hypotension (PCH) is a debilitating condition in patients undergoing long-term hemodialysis that is often deemed a relative contraindication to kidney transplantation. We present a high-risk case demonstrating the feasibility and curative potential of transplantation under a stringent, multidisciplinary protocol.

A 26-year-old woman with end-stage renal disease after 16 years of hemodialysis presented with severe, refractory PCH (70/50 mm Hg at rest, dropping to 50/30 mm Hg during dialysis), superior vena cava obstruction, anuria, and a microscopic bladder capacity of 15 cc. Following multidisciplinary evaluation and preoperative bladder training, the patient underwent living-related kidney transplantation. A dual renal artery graft, necessitating back-table side-to-side reconstruction, complicated the procedure. Intraoperative management included invasive hemodynamic monitoring, transesophageal echocardiography (TEE), and preemptive norepinephrine infusion.

The allograft achieved immediate function upon reperfusion. Vasopressor support was weaned and discontinued early postoperatively, with concurrent cessation of all pretransplant antihypotensive medications. The patient's blood pressure rapidly normalized to the reference ranges without pharmacological support. The patient was discharged on postoperative day 7 with excellent and sustained graft function.

Kidney transplantation is the only curative treatment for refractory dialysis-induced hypotension. The successful outcome, even in the presence of major comorbidities, was contingent on a proactive, protocol-driven, and multidisciplinary perioperative strategy. Consequently, PCH should not be a barrier to transplantation but rather an indication for referral to a specialized center capable of providing this level of care.