title: Rapid resolution of severe sustained low blood pressure in haemodialysis patients after successful renal transplantation.
abstract: BACKGROUND
  Low blood pressure occurring in the absence of volume depletion, anti-hypertensive medication, heart failure or cortisol deficiency occurs in ~5-10% of haemodialysis patients, and can result in serious complications. The pathophysiology of this syndrome is poorly understood.
  
  
  METHODS
  We describe eight cases with dialysis-associated hypotension who underwent renal transplantation. Four patients were severely hypotensive with a systolic blood pressure (SBP) <100 mmHg before and during dialysis, and four had a SBP usually <100 mmHg during dialysis, but usually >100 mmHg between sessions. All had donor-specific human leukocyte antigen antibodies. Six patients underwent pre-transplant plasmapheresis, which was curtailed in two because of further falls in blood pressure. Two patients experienced clotting of their arteriovenous fistula. In one patient cryofiltration was used, which was tolerated without severe falls in the BP. The remaining patient, who had hypotension-associated retinal vein thrombosis before transplant, was supported with an epinephrine infusion and did not receive plasmapheresis.
  
  
  RESULTS
  Post-transplant, the first patient did not receive pressor therapy and died from bowel ischaemia. The other seven patients were supported with inotropes on critical care. The administration of steroids did not reverse hypotension. The mean pre-treatment SBP was 96 mmHg (range 71-110, SEM 5.0). After inotropes were withdrawn and graft function was established, the mean SBP was 127 mmHg (range 113-149, SEM 4.9) (P < 0.01).
  
  
  CONCLUSIONS
  Renal transplantation was performed successfully and safely in patients when pressor therapy was used to treat severe dialysis-associated hypotension and, moreover, the blood pressure normalized rapidly after graft function was established.
authors.affiliation: Warwick Medical School, University of Warwick, Coventry, UK. lindsaymuscroft@gmail.com
authors.forename: Lindsay
authors.initials: L
authors.lastname: Muscroft
authors.forename: Daniel
authors.initials: D
authors.lastname: Zehnder
authors.forename: Simon
authors.initials: S
authors.lastname: Fletcher
authors.forename: Nithya
authors.initials: N
authors.lastname: Krishnan
authors.forename: Duncan
authors.initials: D
authors.lastname: Watson
authors.forename: Buddhaavarapu
authors.initials: B
authors.lastname: Murthy
authors.forename: Rob
authors.initials: R
authors.lastname: Higgins
mesh_terms: D000328:Adult; D000368:Aged; D001794:Blood Pressure / Q000187:drug effects*; D005260:Female; D006801:Humans; D007022:Hypotension / Q000188:drug therapy* / Q000503:physiopathology / Q000601:surgery; D007676:Kidney Failure, Chronic / Q000150:complications / Q000601:surgery / Q000628:therapy*; D016030:Kidney Transplantation / Q000009:adverse effects / Q000379:methods*; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology*; D006435:Renal Dialysis / Q000009:adverse effects*; D016896:Treatment Outcome