What is the most appropriate adjustment to a patient's medication regimen when initiating hemodialysis for end-stage kidney disease?

Medication Management for a Patient Initiating Hemodialysis

For a patient with end-stage kidney disease initiating hemodialysis, the most appropriate next step is to discontinue lanthanum. 1

Rationale for Discontinuing Lanthanum

Lanthanum carbonate is a phosphate binder commonly used to treat hyperphosphatemia in patients with chronic kidney disease. However, once hemodialysis is initiated, several considerations support discontinuing this medication:

1. Dialysis removes phosphate directly - Hemodialysis effectively removes phosphate from the blood, potentially reducing the need for phosphate binders 2

2. Potential for adverse effects - Lanthanum can accumulate and deposit in gastric mucosa of dialysis patients, as evidenced by case reports showing whitish spots in the stomach of patients on long-term lanthanum therapy 3

3. Medication burden - Patients on dialysis typically have high pill burdens, and removing unnecessary medications improves adherence to essential therapies

Medication Management During Transition to Hemodialysis

When initiating hemodialysis, medication regimens require careful adjustment:

Medications to Continue

• Antihypertensives (amlodipine, metoprolol) - Continue but monitor blood pressure closely as hemodialysis may affect volume status 4
• Aspirin - Continue for secondary prevention of cardiovascular events given the patient's history of myocardial infarction
• Atorvastatin - Continue as per KDOQI guidelines which recommend maintaining statin therapy in patients already receiving it at the time of dialysis initiation 1
• Levothyroxine - Continue with regular thyroid function monitoring
• Insulin - Continue as it remains the preferred treatment for diabetes in ESRD 4
• Epoetin alfa - Continue for anemia management, typically administered after dialysis sessions 1

Medications to Adjust

• Lisinopril - Consider dose reduction or potential discontinuation based on blood pressure control and residual kidney function
• Furosemide - May need dose adjustment as effectiveness decreases with declining kidney function 1

Medications to Consider for IV Administration

• Iron supplementation - Change oral ferrous sulfate to IV iron (such as sodium ferric gluconate) for better absorption and effectiveness in hemodialysis patients 1

Monitoring Recommendations

1. Phosphate levels - Monitor regularly to determine if phosphate binders need to be reintroduced
2. Hemoglobin - Monitor response to epoetin alfa therapy
3. Blood pressure - Assess before, during, and after dialysis sessions
4. Electrolytes - Particularly potassium and calcium levels
5. Dry weight - Establish target and adjust medications accordingly

Special Considerations

• Timing of medication administration - Most medications should be given after hemodialysis to avoid premature removal 1
• Diabetes management - Insulin requirements may change with initiation of dialysis 4
• Cardiovascular risk - This patient has multiple risk factors requiring continued attention to secondary prevention

Potential Pitfalls

• Overmedication - Continuing medications that are no longer necessary increases pill burden and risk of adverse effects
• Undertreatment - Inadequate phosphate control if lanthanum is discontinued without appropriate monitoring
• Medication timing - Administering medications before dialysis may lead to their removal during the procedure

By discontinuing lanthanum while maintaining appropriate monitoring of phosphate levels, the patient's medication regimen can be optimized for the transition to hemodialysis therapy.