Management of End-Stage Renal Disease (ESRD) on Dialysis
For patients with End-Stage Renal Disease (ESRD), the management plan should prioritize arteriovenous access (AVF or AVG) over tunneled central venous catheters for vascular access to reduce infection risk and improve outcomes. 1
Vascular Access Management
- Arteriovenous fistulas (AVF) or arteriovenous grafts (AVG) are preferred over tunneled central venous catheters (CVC) for vascular access in ESRD patients on intensive hemodialysis 1
- For patients using AVF with intensive home hemodialysis, rope-ladder cannulation is recommended over buttonhole cannulation unless antimicrobial prophylaxis is used 1
- If buttonhole cannulation technique is employed, mupirocin antibacterial cream should be applied to reduce infection risk 1
- For patients requiring CVC access, "closed connector" devices should be used over standard connectors to minimize infection risk 1
Dialysis Prescription and Modality
- Intensive hemodialysis options include:
- Short daily hemodialysis (<3 hours, 5-7 days/week)
- Long hemodialysis (≥5.5 hours, 3-4 sessions/week)
- Long-frequent hemodialysis (≥5.5 hours, 5-7 sessions/week) 1
- No significant difference in long-term mortality has been demonstrated between peritoneal dialysis and hemodialysis modalities 2
- Peritoneal dialysis offers the advantage of home-based treatment 2
- Regular measurement of dialysis efficacy is essential to achieve target clearances 3
Mineral and Bone Metabolism Management
- For patients on long or long-frequent hemodialysis, use dialysate calcium of 1.50 mmol/L or higher to maintain neutral or positive calcium balance while avoiding predialysis hypercalcemia and PTH oversuppression 1
- If hypophosphatemia persists despite stopping phosphate binders and liberalizing diet, consider using phosphate dialysate additives to maintain predialysis phosphate in normal range 1
- Calcium acetate is indicated to reduce serum phosphorus in ESRD patients, with initial dosing of 2 capsules with each meal, gradually increasing to 3-4 capsules per meal as needed 4
- Monitor for hypercalcemia (reported in 16% of patients), especially during dosage adjustment periods 4
- Maintain serum calcium-phosphorus (Ca × P) product below 55 mg²/dL² 4
Cardiovascular Risk Management
- Blood pressure control improves mortality in dialysis patients 5
- Volume control through adequate dialysis and sodium restriction helps optimize hypertension treatment 5, 6
- Traditional cardiovascular risk factors (hypertension, diabetes, dyslipidemia) are highly prevalent in ESRD patients and require aggressive management 7
- Non-traditional risk factors to address include systemic inflammation, disordered mineral metabolism, and infectious complications 7
Nutritional Management
- Regular monitoring for protein-energy wasting and malnutrition is essential 5
- Patients on intensive hemodialysis may be able to liberalize dietary restrictions for fluid, sodium, and phosphate 1
- Nutritional support should be provided as needed to maintain adequate protein and calorie intake 3
Medication Management
- Insulin is the preferred treatment for ESRD patients with diabetes requiring medication 5
- Medication dosages often require adjustment due to altered pharmacokinetics in ESRD 6
- Avoid medications that may worsen hypercalcemia when patients are on calcium-based phosphate binders 4
- Be aware that hypercalcemia may aggravate digitalis toxicity 4
Preventive Care
- Recommended vaccinations include:
- Seasonal influenza
- Tetanus
- Hepatitis B
- Human papillomavirus (through age 26)
- Streptococcus pneumoniae 5
- Routine cancer screening for patients not receiving kidney transplantation is generally discouraged 5
Palliative Approach
- Consider palliative care for patients who opt against renal replacement therapy or choose to discontinue dialysis 2, 5
- A palliative approach may be particularly appropriate for individuals with limited life expectancy or severe comorbid conditions 5