What is the recommended treatment and management plan for patients with end-stage renal disease (ESRD) requiring dialysis?

From the Guidelines

The recommended treatment for patients with end-stage renal disease (ESRD) requiring dialysis is intensive hemodialysis, which includes short daily, long, or long-frequent hemodialysis, as it has been shown to improve quality of life and patient survival 1. The management plan for these patients should include the use of arteriovenous access (AVF or AVG) over tunneled CVC for vascular access, as suggested by the Canadian Society of Nephrology guidelines 1.

• Key aspects of the management plan include:
  • The use of rope-ladder cannulation over buttonhole cannulation unless topical antimicrobial prophylaxis is used 1
  • The use of mupirocin antibacterial cream to reduce the risk of infection in patients using buttonhole cannulation for intensive home hemodialysis 1
  • The use of a dialysate calcium of 1.50 mmol/L or higher to maintain a neutral or positive calcium balance, while avoiding predialysis hypercalcemia and oversuppression of PTH 1
  • The use of a phosphate dialysate additive to maintain the predialysis phosphate in the normal range if hypophosphatemia persists after stopping phosphate binders and liberalizing the diet 1
  • Regular monitoring of dialysis adequacy through Kt/V measurements, along with routine laboratory assessments of electrolytes, hemoglobin, and bone mineral markers 1
  • Dietary restrictions, including limiting daily intake of potassium, phosphorus, sodium, and fluid, are also crucial in the management of patients with ESRD requiring dialysis 1
  • Medication adjustments, including renal dosing for drugs cleared by the kidneys, and specific medications to address complications such as anemia, hyperphosphatemia, and secondary hyperparathyroidism, are also essential in the management of these patients 1

From the FDA Drug Label

For adult patients with CKD on dialysis: Initiate Aranesp treatment when the hemoglobin level is less than 10 g/dL. If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of Aranesp. The recommended starting dose is 0.45 mcg/kg intravenously or subcutaneously as a weekly injection or 0.75 mcg/kg once every 2 weeks as appropriate. The intravenous route is recommended for patients on hemodialysis

The recommended treatment and management plan for patients with end-stage renal disease (ESRD) requiring dialysis includes:

• Initiating Aranesp treatment when the hemoglobin level is less than 10 g/dL
• Reducing or interrupting the dose of Aranesp if the hemoglobin level approaches or exceeds 11 g/dL
• Using the lowest dose of Aranesp sufficient to reduce the need for RBC transfusions
• Monitoring hemoglobin levels at least weekly until stable, then at least monthly
• Adjusting the dose based on hemoglobin rate of rise, rate of decline, ESA responsiveness, and hemoglobin variability 2 Key considerations:
• Evaluate iron stores and nutritional factors before and during treatment
• Administer supplemental iron therapy when necessary
• Monitor response to therapy and adjust the dose as needed
• Avoid frequent dose adjustments and use the lowest effective dose to minimize risks 2

From the Research

Treatment and Management Plan for ESRD Patients Requiring Dialysis

The recommended treatment and management plan for patients with end-stage renal disease (ESRD) requiring dialysis involves several key considerations, including:

• Referral to nephrology to optimize disease management 3
• Shared decision-making to initiate dialysis 3
• Preservation of peripheral veins for patients with stage III to V chronic kidney disease 3
• Vaccination against seasonal influenza, tetanus, hepatitis B, human papillomavirus, and Streptococcus pneumoniae 3
• Controlling blood pressure through adequate dialysis and sodium restriction 3
• Insulin as the preferred treatment for patients with ESRD and diabetes mellitus requiring medication 3
• Monitoring for signs of protein-energy wasting and malnutrition 3

Dialysis Options

Patients with ESRD have two primary dialysis options: peritoneal dialysis (PD) and hemodialysis (HD) 4. The selection of PD or HD is typically based on patient motivation, desire, geographic distance from an HD unit, physician and/or nurse bias, and patient education. PD may offer a survival advantage, especially in the first 3 months of dialysis, and patient satisfaction may be higher with PD 4.

Timing of Dialysis Initiation

The timing of renal replacement therapy for patients with ESRD has been subject to considerable variation 5. While early initiation of dialysis was once believed to improve patient survival, several observational studies and one randomized controlled trial have found no beneficial effect and even an increase in mortality associated with early dialysis initiation 5. The decision to start dialysis should be based on careful clinical evaluation, rather than a predefined estimated glomerular filtration rate (eGFR) value 5.

Use of Erythropoietin

Erythropoietin (EPO) is recommended in individuals progressing toward ESRD to correct anemia and its complications 6. The use of EPO before dialysis has been shown to confer a survival benefit to ESRD patients, especially in patients with an adequate hematocrit response before initiation of dialysis 6.

Guidelines and Recommendations

Recent guidelines from the US National Kidney Foundation Dialysis Outcomes Quality Initiative recommend an earlier start of dialysis treatment than has been common practice 7. However, the implementation of these guidelines would have a substantial effect on patients' daily lives and increase costs, and the evidence is still largely opinion-based 7.