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healthy son decided to donate a to the mechanism. In conclusion, renal OBSERVATIONS her. Thus, she was placed on immuno- transplantation might be the final solu- suppressive therapy with tacrolimus, my- tion for dialysis patients with chronic cophenolate mofetil, and steroids. Low hypotension. Renal doses of dopamine were infused for 5 Transplantation days after surgery. Her blood pressure CHIAO-YIN SUN, MD normalized (120–140/60–80 mmHg) on MAI-SZU WU, MD Reversed Intractable the first day after the transplantation. For From the Division of , School of Medi- Hypotension in a posttransplant , the cine, Chang Gung University, Chang Gung Memo- Diabetic Patient patient was supported by hemodialysis rial Hospital, Keelung, Taiwan. for 3 weeks. Address correspondence to Mai-Szu Wu, MD, Two months later, her creatinine level Division of Nephrology, Chang Gung Memorial Hospital 222, Mai-Chin Road, Keelung, Taiwan. small fraction of hemodialysis pa- dropped to 1.0 mg/dl, her daily urinary E-mail: [email protected]. tients have chronic hypotension volume rose to 2,000 ml, and her blood DOI: 10.2337/dc07-0074 A (1). Autonomic dysfunction, a pressure remained normotensive. Aldo- © 2007 by the American Diabetes Association. product of diabetes and , may be sterone (588 pg/ml) and renin (44.2 pg/ml) ●●●●●●●●●●●●●●●●●●●●●●● the most important cause that contributes prominently fell from the pretransplant to hypotension in dialysis patients (1). levels. References Unfortunately, there is no specific or ef- Studies of heart rate variability reveal 1. Cases A, Coll E: Chronic hypotension in fective therapy for them. that renal transplantation improves ure- the dialysis patient. J Nephrol 15:331– 335, 2002 A 59-year-old female with hyperten- mic autonomic dysfunction (2), and rare Ͼ 2. Yildiz A, Sever MS, Demirel S, Akkaya V, sion and type 2 diabetes for 16 years reports describe changes of blood pres- Turk S, Turkmen A, Ecder T, Ark E: Im- received hemodialysis treatment 6 years sure after renal transplantation in dialysis provement of uremic autonomic dysfunc- ago, due to diabetic nephropathy. Chronic patients with chronic hypotension. Renal tion after renal transplantation: a heart hypotension (80–100/50–60 mmHg) transplantation failed to normalize the rate variability study. 80:57–60, developed, which resulted in limited daily blood pressure of patients with Bartter’s 1998 activity and inadequate dialysis for the past syndrome and Gitelman’s syndrome (3). 3. Calo LA, Marchini F, Davis PA, Rigotti P, 2 years. Her cardiac performance and nutri- Blunted pressor responses and increased Pagnin E, Semplicini A: Kidney transplant tion status were fair. and renin production of vasodilator agents were re- in Gitelman’s syndrome: report of the first levels were high (1,307 and 67.5 pg/ml, ported to be involved in the pathophysi- case. J Nephrol 16:144–147, 2003 4. Cases A, Esforzado N, Lario S, Vera M, respectively), and adjusting dialysis pre- ology of chronic hypotension in dialysis Lopez-Pedret J, Rivera-Fillat F, Jimenez scriptions and medical therapy with a spe- patients (1,4), and we speculated that the W: Increased plasma adrenomedullin lev- cific ␣-agonist and mineralocorticoid grafted kidney might modulate the pres- els in hemodialysis patients with sus- analog did not ameliorate the dilemma. sor response or the vasodilator produc- tained hypotension. Kidney Int 57:664– To aid the situation, her 27-year-old tion. More studies are needed to clarify 670, 2000

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