Successful Use of Octreotide in Refractory Intradialytic Hypotension: A Case Report

Intradialytic hypotension (IDH) is a frequent and challenging complication of hemodialysis, particularly in critically ill patients with end-stage renal disease (ESRD). Persistent IDH can limit ultrafiltration, compromise solute clearance, and contribute to multi-organ dysfunction. Standard management includes adjusting ultrafiltration rates, midodrine, cool dialysate, and albumin support; however, refractory cases remain difficult to manage. Octreotide, a somatostatin analog, reduces splanchnic blood pooling and increases systemic vascular resistance and is primarily indicated for refractory orthostatic and postprandial hypotension in patients with autonomic failure. We present the case of severe, recurrent IDH successfully managed with octreotide in a critically ill patient with multiorgan dysfunction. A 64-year-old female with ESRD on hemodialysis, type 2 diabetes mellitus, and HIV presented with generalized weakness. During hemodialysis, her blood pressure dropped to 50/30 mmHg with an oxygen saturation of 70%, partially improving after an 800 mL fluid bolus. She was managed for sepsis with empiric antibiotics and supportive care. Despite norepinephrine infusion (0.1 µg/kg/min) and high-dose midodrine (20 mg TID-QID), she continued to experience significant IDH with blood pressures as low as 102/52 mmHg, limiting ultrafiltration. Imaging revealed moderate pulmonary edema, and methicillin-resistant Staphylococcus aureus (MRSA) screening was positive. Octreotide 100 µg subcutaneously three times daily was initiated on hospital day 12 in addition to midodrine and norepinephrine. Following initiation, intradialytic hemodynamic stability improved markedly, allowing gradual ultrafiltration of 1-1.4 L per session without hypotension. She was subsequently weaned off norepinephrine, tolerated intermittent hemodialysis with stable blood pressures (118/60 mmHg), maintained electrolyte and uremic control, and demonstrated gradual respiratory improvement. This case highlights octreotide as a potential safe and effective adjunctive therapy for refractory IDH, particularly in patients with concurrent sepsis and autonomic dysfunction. Further prospective studies are warranted to determine optimal dosing, timing, and long-term outcomes.