Successful Use of Droxidopa to Treat Intractable Hypotension Attributed to Vasodilatory Shock Due to Autonomic Failure in a Patient with ESKD Who Is Dependent on Continuous Kidney Replacement Therapy

Introduction: Droxidopa is a synthetic amino acid precursor, which acts as a prodrug to the neurotransmitter norepinephrine. It is used to treat neurogenic orthostatic hypotension caused by primary autonomic failure. The goal of our use of Droxidopa is to remove dependence on vasopressors in a patient who was receiving CRRT, as he was deemed unstable to transition to intermittent hemodialysis (iHD). Case Description: 61-year-old male patient, who has End Stage Kidney Disease, was admitted with hypotension(blood pressure 84/64 mmHg) and no cause of hypotension could be detected after extensive work-up. Primary autonomic failure (vasodilatory shock) was diagnosed based on exclusion of other causes of shock and therefore as receiving vasopressors and CRRT (continuous renal replacement therapy) as a renal replacement therapy. Many attempts and interventions (including midodrine 20 mg three times a day use) to wean off vasopressors and transition to intermittent hemodialysis were not successful over two months. We initiated Droxidopa at 100 mg three times a day in this patient and titrated the dose.We saw that once Droxidopa was initiated in our patient, vasopressors could be weaned off in 48 hours and we could transition to intermittent hemodialysis (as blood pressure improved to 109/75 mmHg)with no requirement of any vasopressors. During the period of initiation and use of Droxidopa no other interventions were made which led us to firmly believe that Droxidopa was the intervention that treated our patient. No adverse reactions were observed. Droxidopa use (vs. non-use) was associated with successful weaning of vasopressors and transition to Hemodialysis from CRRT. Discussion: In a patient with intractable hypotension who therefore required being in the ICU to receive CRRT for many months, initiation and titration of Droxidopa successfully made the transition from CRRT to iHD with no further dependence on vasopressors.Droxidopa can be used to treat severe vasoppressors requiring neurogenic orthostatic hypotension caused by primary autonomic failure in Dialysis patients.