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Abstract. Rationale:. Severe heart failure in chronic hemodialysis (HD) patients is a great treatment challenge. Here we reported a chronic HD patient with the lowest ejection fraction reported so far and hypotension who well tolerated and benefited from angiotensin-receptor neprilysin inhibitor (ARNI) treatment. Patient concerns:. This case was a 67 year old lady with decompensated heart failure and hypotension who was on regular HD. Intensified hemofiltration failed to improve her heart failure symptoms and was also retarded by hypotension. Diagnosis:. Chronic HD with decompensated heart failure. Interventions:. In addition to regular HD, low does sacubitril/valsartan was initiated and titrated from 12/13 mg to 24/26 mg twice daily. Outcomes:. Sacubitril/valsartan treatment was well tolerated and did not affect ultrafiltration during HD treatment. Transthoracic echocardiology at 3 months after initiation of ARNI treatment indicated significant improvement of both systolic and diastolic cardiac function. The patient has improved from New York Heart Association class 4 to class 2. Lessons:. Low does ARNI treatment could effectively improve cardiac function in HD patients with heart failure and hypotension. It was also safe and well tolerated.