Hemodialysis-Triggered Reno-Parenchymal Hypertension Complicated by Pres in Systemic Lupus Erythematosus

Objective: Intradialytic hypertension represents a paradoxical and often treatment-resistant phenomenon in patients with end-stage kidney disease undergoing maintenance hemodialysis, being associated with an increased risk of hypertensive emergencies. In patients with systemic lupus erythematosus (SLE), endothelial dysfunction, neurohormonal activation, and advanced renal involvement further predispose to severe blood pressure dysregulation and neurological complications, including posterior reversible encephalopathy syndrome (PRES).Design and method: We report the case of a 38 year old female with systemic lupus erythematosus and multiorgan involvement (cutaneous, articular, hematological, and renal), on chronic hemodialysis since 2020 for lupus nephritis (end-stage kidney disease, KDIGO stage G5d), who developed severe intradialytic hypertension with blood pressure values exceeding 200 mmHg, poorly responsive to standard antihypertensive therapy. Clinical manifestations included intense holocranial headache, nausea, vomiting, and visual disturbances. Laboratory evaluation revealed azotemia, mild normocytic normochromic anemia, mild thrombocytopenia, moderate elevation of liver enzymes, and markedly increased NT-proBNP levels. Cardiologic assessment showed left ventricular hypertrophy with preserved left ventricular ejection fraction. Based on the clinical presentation and imaging findings, a diagnosis of hypertensive emergency complicated by PRES was established. Prompt initiation of intravenous antihypertensive therapy requiring combination treatment and subsequent optimization of chronic antihypertensive medication led to gradual blood pressure control and complete resolution of neurological symptoms. Results: The development of posterior reversible encephalopathy syndrome (PRES) in the setting of a hypertensive crisis illustrates a rare and severe combination of acute complications superimposed on a chronic autoimmune disease. Serum NT-proBNP levels in patients at the initiation of hemodialysis represent a valuable and independent prognostic marker, being closely associated with an increased risk of short- and mid-term mortality. Serial monitoring of this biomarker enables early identification of patients at high cardiovascular risk, thereby facilitating individualized therapeutic management. Conclusions: This case highlights the refractory nature of intradialytic hypertension in hemodialysis patients with SLE and its role as a major trigger for PRES. Early recognition, strict blood pressure monitoring, and an individualized, multidisciplinary therapeutic approach are essential to prevent severe neurological complications and improve clinical outcomes.