Mesenteric ischemia in patients with end-stage renal disease can have an unusual clinical presentation. Despite the absence of severe occlusive disease of the mesenteric circulation, hypotension related to dialysis occasionally results in mesenteric ischemia, bowel resection, and ultimately death. We present a case series of hemodialysis patients presenting with mesenteric ischemia in the setting of chronic asymptomatic mesenteric disease and report their outcomes. This is a single-institution retrospective review of hemodialysis patients who presented with abdominal pain and were found to have ischemic changes on computed tomography (CT) from January 2010 to December 2018. The comorbidities, clinical presentation, operative management, CT imaging, hemodynamics during dialysis, and outcomes were captured. Variables were analyzed using descriptive statistics. Twenty-one hemodialysis patients presented with nonocclusive mesenteric ischemia (Table). Demographics for the population are 9 female, 12 male, age 67.05 (standard deviation [SD], 12.06) years, 95.24% white, and body mass index of 29.7 kg/m2 (SD, 10.93 kg/m2). Presentation of acute abdominal pain was seen in all patients, with one patient presenting with acute-on-chronic abdominal pain. Only four patients had prior postprandial pain or weight loss; 84% of patients requiring bowel resections were septic at presentation, with 77% presenting with peritonitis. Fourteen patients were dialyzed within 24 hours of presentation. Hypotension during dialysis occurred in 11 patients (64.71%), with an average of 1350 mL (SD, 1216.55 mL) removed. Thirteen underwent bowel resection, four were managed supportively, and four had endovascular stenting (three superior mesenteric artery [SMA] and one celiac). One patient had a bowel resection before urgent SMA stenting. CT demonstrated celiac and SMA stenosis in 70% of the patients in the nonstented group. SMA was >50% stenotic in 66.7% of all patients. Postoperative complications for the nonstented group included bleeding (11.76%), sepsis (88.24%), cardiac events (two myocardial infarction, three congestive heart failure), and death (11 [64.71%]). All patients in the stented group survived. At follow-up for the nonstented group, for all-cause mortality, there were no survivors at 2 years. Mesenteric ischemia represents a significant source of morbidity and mortality for the end-stage renal disease patient on dialysis even without complete occlusive disease. Most of these patients have a combination of celiac and SMA disease that leads to acute ischemia after volume depletion and hypotension during dialysis. To our knowledge, this is the first review to examine this presentation in the dialysis patient. Acute abdominal pain after hemodialysis should be managed expeditiously as it may be a life-threatening condition.TableHemodialysis patients presenting with nonocclusive mesenteric ischemiaVariablesHemodialysis patients, 21 patients total, No. (%)Demographics Female sex9 (42.86) Age, years (SD)67.05 (12.06) Previous bowel resection4 (19.05)Indication for dialysis ESRD requiring iHD20 (95.24) AKI requiring iHD1 (4.76)Not stented, 17 patients total, No. (%)Stented, 4 patients total, No. (%)Presentation Septic11 (64.71)0 (0.00) Peritonitis10 (58.82)0 (0.00)CT findings Pneumatosis15 (88.24)0 (0.00) Location of stenosisCeliac2 (11.76)0 (0.00)SMA0 (0.00)2 (50.00)Celiac + SMA12 (70.59)2 (50.00) Celiac stenosisNone2 (11.76)0 (0.00)Mild (1%-49%)6 (35.29)1 (25.00)Moderate (50%-74%)2 (11.76)0 (0.00)Severe (75%-99%)2 (11.76)1 (25.00)Occluded (100%)4 (23.53)0 (0.00) SMA stenosisNone4 (23.53)0 (0.00)Mild (1%-49%)2 (11.76)0 (0.00)Moderate (50%-74%)7 (41.18)2 (50.00)Severe (75%-99%)3 (17.65)2 (50.00) Plaque compositionNone2 (11.76)0 (0.00)Calcified6 (35.29)3 (75.00)Thrombus1 (5.88)0 (0.00)Both8 (47.06)1 (25.00)Operative data Observation, no OR3 (17.65)– Bowel resection13 (76.47)1 (25.00) Negative exploratory laparotomy1 (5.88)0 (0.00) Second look11 (64.71)0 (0.00)Postoperative complications Sepsis15 (88.24)0 (0.00) RTOR9 (52.94)0 (0.00) ICU17 (100.00)1 (25.00) LOS, days21.24 (22.56)4.75 (5.12) 30-Day death8 (47.06)0 (0.00)Dialysis-related variables Preoperative hypotension11 (64.71)1 (25.00) Postoperative hypotension5 (29.41)1 (25.00) Lowest systolic BP91 (15.90)104.50 (23.33) Lowest diastolic BP50.5 (11.71)71.50 (16.26) Dialysis within 48 hours12 (70.59)4 (100.00) Volume iHD off (SD)1350 (1216.55)1150 (212.13)AKI, Acute kidney injury; BP, blood pressure; CT, computed tomography; ESRD, end-stage renal disease; ICU, intensive care unit; iHD, intermittent hemodialysis; LOS, length of stay; OR, operating room; RTOR, return to operating room; SD, standard deviation; SMA, superior mesenteric artery. Open table in a new tab