From the Guidelines
End-stage kidney disease management should prioritize a shared decision-making process among patients, their families, and physicians, considering options such as dialysis, kidney transplantation, and conservative management, with a focus on promoting quality of life and living, as emphasized in the 2015 update of the KDOQI clinical practice guideline for hemodialysis adequacy 1.
Management Options
The management of end-stage kidney disease (ESKD) involves several options, including:
- Dialysis, which comes in two main forms: hemodialysis and peritoneal dialysis
- Kidney transplantation, considered the optimal treatment for suitable candidates, offering better quality of life and survival compared to dialysis
- Conservative management, focusing on symptom control and quality of life without dialysis, appropriate for some elderly patients or those with multiple comorbidities
Comprehensive Care
All ESKD patients, regardless of treatment choice, require comprehensive care, including:
- Blood pressure control
- Anemia management with erythropoietin-stimulating agents
- Mineral-bone disorder treatment with phosphate binders and vitamin D analogs
- Regular monitoring of electrolytes and metabolic parameters
Treatment Selection
Treatment selection depends on patient factors, including age, comorbidities, functional status, and personal preferences, requiring thorough discussion of benefits and limitations of each option, as highlighted in the clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis 1.
Conservative Management
Conservative management, without dialysis or transplantation, is an appropriate option for some patients, focusing on maximizing quality of life and length of life through dietary and pharmacological therapy, including low-protein diets, keto-analogs of essential amino acids, loop diuretics, and sodium polystyrene sulfonate, as well as palliative care and hospice referral for patients with advanced kidney failure 1.
From the FDA Drug Label
Management of elevated serum phosphorus levels in patients with ESRD usually includes all of the following: reduction in dietary intake of phosphate, removal of phosphate by dialysis, and reduction of intestinal phosphate absorption with phosphate binders. The management options for end-stage kidney disease include:
- Reduction in dietary intake of phosphate
- Removal of phosphate by dialysis
- Reduction of intestinal phosphate absorption with phosphate binders 2
From the Research
Management Options for End-Stage Kidney Disease
- Renal transplantation is considered the preferred form of renal replacement therapy, but due to the limited supply of donor organs, dialytic therapies are also commonly used 3.
- Dialytic therapies include peritoneal dialysis and hemodialysis (HD), which can be used in a complementary manner to provide optimal outcomes while containing treatment costs 3.
- The decision to initiate dialysis should be made through shared decision-making, taking into account the patient's autonomy, medical and social factors, system-related issues, patient outcomes, and finances 4.
Medical Management of End-Stage Renal Disease
- Primary care clinicians should refer people at risk of end-stage renal disease (ESRD) to nephrology to optimize disease management 4.
- Vaccination against seasonal influenza, tetanus, hepatitis B, human papillomavirus, and Streptococcus pneumoniae is advised for patients with ESRD 4.
- Controlling blood pressure in patients receiving dialysis improves mortality, and volume control through adequate dialysis and sodium restriction can help optimize hypertension treatment 4.
- Insulin is the preferred treatment for patients with ESRD and diabetes mellitus requiring medication 4.
Phosphate Binders for Hyperphosphatemia
- Phosphate binders such as calcium acetate, calcium carbonate, sevelamer hydrochloride, and lanthanum carbonate can be used to treat hyperphosphatemia in patients with end-stage kidney disease undergoing hemodialysis 5, 6.
- These phosphate binders can help reduce serum phosphorus levels and prevent secondary hyperparathyroidism, vascular calcification, and renal osteodystrophy 6.
- Sevelamer hydrochloride may be superior to other phosphate binders in lowering the incidence of hypercalcemia 5.
Global Differences in End-Stage Kidney Disease Management
- There are disparities in access to renal replacement therapy and modality use worldwide, with some countries having better outcomes than others 7.
- Haemodialysis practices, such as the use of surgical vascular access and longer or more frequent dialysis sessions, can affect patient survival and quality of life 7.