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CAPD as Treatment of Chronic Debilitating Hemodialysis Hypotension

Editor: Dialysis-related hypotension remains a common problem despite improvements in hemodialysis (HD) technique. Chronic hypovolemia, antihypertensive treatment, heart failure, adrenal insufficiency, autonomic neuropathy, and vasoactive substances are the leading causes of HD hypotension (1–3). Intraand interdialytic hypotensive episodes cause deterioration in patients’ well-being, delaying their rehabilitation and increasing their morbidity and mortality (1,4,5). We present 2 patients with sustained and severe hypotension on HD that totally recovered with continuous ambulatory peritoneal dialysis (CAPD). The first patient was a 56-year-old woman with chronic renal failure due to systemic amyloidosis secondary to rheumatoid arthritis, who had been on HD for 9 months. From the beginning, she presented daily, severe, sustained hypotension (systolic blood pressure < 90 mmHg) that worsened during HD sessions. Intradialytic hypotension caused several vascular access thromboses and made HD sessions intolerable. The patient was totally handicapped, even for routine daily activities. Autonomic neuropathy and adrenal insufficiency were excluded and echocardiogram did not indicate myocardial amyloidosis. Conventional maneuvers directed toward avoidance of intradialytic hypotensive episodes were ineffective. In 1999, she was transferred to CAPD. Since then, her blood pressure has normalized and now, 2 years later, she is selfsufficient. The second patient was a 62-year-old female with chronic renal failure secondary to focal glomerular sclerosis, who was started on HD in 1987. From the beginning of her HD, she suffered from severe interand intradialytic hypotension. She needed familial help for nearly everything (getting dressed and eating, for example). She was investigated for autonomic dysfunction, adrenal insufficiency, and myocardial failure. Studies were normal. As with the patient described above, conventional maneuvers to prevent intradialytic hypotension were ineffective. In 1997, she was transferred to CAPD and experienced total normalization of blood pressure. Clinical outcome was excellent. We have presented two typical cases of debilitating chronic hypotension related to HD, with total recovery after their transfer to CAPD. In our cases, hypotension on HD was due probably to poor cardiovascular response to quick changes in blood volume (1–3). CAPD is a continuous dialytic technique that allows high volume extraction (1 – 3 L/day) without hemodynamic instability. Therefore, we think that patients with debilitating hypotension on HD must be transferred to CAPD to improve their clinical situation and quality of life.