Abstract Introduction 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, midodrine, and albumin support; however, refractory cases remain difficult to manage. Octreotide is primarily indicated for refractory orthostatic and postprandial hypotension, especially in patients with autonomic failure, due to its ability to reduce splanchnic blood pooling and increase blood pressure. We present a case of severe, recurrent IDH successfully managed with octreotide in a patient with multiorgan dysfunction. Case Description A 64-year-old female with ESRD on dialysis, type 2 diabetes, and HIV presented with weakness. During dialysis, her blood pressure dropped to 50/30 mmHg with 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 (0.1 µg/kg/min) and high-dose midodrine (20 mg TID-QID), she continued to experience significant intradialytic hypotension (BP 102/52 mmHg), limiting ultrafiltration. Imaging showed moderate pulmonary edema, and MRSA screening was positive.Octreotide 100 µg subcutaneously TID was initiated on hospital day 12 in addition to midodrine and norepinephrine. Following initiation, intradialytic hemodynamic stability improved, allowing gradual ultrafiltration of 1-1.4 L per session without hypotension. She was subsequently weaned off norepinephrine, tolerated intermittent dialysis with stable blood pressures (118/60 mmHg), maintained electrolyte and uremic control, and had gradual respiratory improvement. Discussion Octreotide reduces splanchnic blood pooling, redistributing blood flow centrally and improving vascular resistance. While its use is well established in orthostatic and postprandial hypotension, it is not routinely recommended or widely studied for IDH. In this case, octreotide resulted in marked hemodynamic improvement after failure of conventional measures, highlighting its potential as a safe and effective adjunctive therapy for refractory IDH, particularly in patients with sepsis or autonomic dysfunction.Although current evidence is limited to small studies and case reports, this case adds to the growing literature supporting octreotide in dialysis-related hemodynamic instability. Further prospective studies are warranted to determine optimal dosing, timing, and long-term outcomes. This abstract is funded by: none
Pack et al. (Fri,) studied this question.