ABSTRACT: BACKGROUND: There is little published guideline or evidence on treating bipolar affective disorder in patients with renal failure having haemodialysis. CASE: We present two patients with bipolar affective disorder with renal failure having haemodialysis. We used lorazepam in one patient to manage the immediate risk of non-engagement with dialysis. Risperidone was added in the second patient for managing psychotic symptoms. Valproate was started as a mood stabiliser and titrated upwards for long-term management of the illness. CONCLUSION: We discuss the similarities in the two cases and the care plan we used to manage them.