What are the guidelines for using steroids in patients undergoing dialysis?

Guidelines for Steroid Use in Dialysis Patients

Steroids should be used with caution in dialysis patients, with the lowest possible dose for the shortest duration necessary, and careful monitoring for adverse effects due to the increased risk of infection, cardiovascular complications, and metabolic disturbances in this population. 1, 2

General Principles for Steroid Use in Dialysis

• Steroids should be used at the lowest possible effective dose and for the shortest duration necessary to control the underlying condition 2
• A risk/benefit assessment must be made for each individual patient before initiating steroid therapy, considering the increased risks in dialysis patients 2, 3
• When reducing steroid dosage, tapering should be gradual to minimize the risk of adrenal insufficiency 2

Specific Considerations for Dialysis Patients

Cardiovascular and Fluid Balance

• Use steroids with caution in dialysis patients due to sodium retention and potassium loss, which can worsen hypertension and fluid management 2, 1
• Monitor for intradialytic hypotension, which can be exacerbated by steroids 1
• Avoid spironolactone or use with extreme caution in dialysis patients due to the risk of hyperkalemia 1

Infection Risk

• Dialysis patients already have an increased susceptibility to infections; steroids further increase this risk 3
• Peritoneal dialysis patients on high-dose or non-tapering steroid regimens have higher risks of peritonitis and exit site infections 4
• Consider prophylaxis against opportunistic infections when using higher doses of steroids (≥0.5 mg/kg/day) 1

Metabolic and Nutritional Effects

• Monitor nutritional status as steroid-treated dialysis patients may show less favorable nutritional conditions with lower serum albumin and body mass index 3
• Be aware that steroids can worsen glycemic control in diabetic dialysis patients, requiring adjustment of hypoglycemic agents 1
• Consider the impact on bone health, as steroids increase the risk of osteoporosis through decreased bone formation and increased bone resorption 2

Specific Clinical Scenarios

Failing Kidney Transplant

• For patients returning to dialysis after kidney transplant failure:
  • Consider gradual tapering of immunosuppression including steroids 1
  • For patients with residual graft function: maintain CNI ± low dose prednisone initially 1
  • For patients without residual graft function: taper more aggressively but monitor for graft intolerance syndrome 1

Glomerular Disease

• For IgA nephropathy patients on dialysis with high risk of progression:
  • A 6-month course of glucocorticoid therapy may be considered, but with extreme caution due to increased risk of adverse events 1
  • Treatment emergent toxicity must be thoroughly discussed, particularly in patients with eGFR <50 ml/min 1

Acute Interstitial Nephritis

• Early initiation of steroids is associated with better recovery of kidney function 5
• High-dose treatment for 3 weeks or prolonged treatment >8 weeks has not shown additional benefit 5

Monitoring and Adverse Effects

• Perform regular monitoring of:

  • Blood pressure and fluid status 1, 2
  • Electrolytes, particularly potassium and calcium 1
  • Blood glucose levels 1
  • Signs of infection 3, 4
  • Nutritional parameters 3

• Be vigilant for hypersensitivity reactions to steroids, which can occur rarely in dialysis patients 6

Common Pitfalls and Caveats

• Avoid using diuretics for blood pressure control in hemodialysis patients unless there is substantial residual kidney function 1
• Be aware that the pharmacokinetics of steroids may be altered in dialysis patients due to decreased clearance 2
• Consider that the risk of steroid-induced complications increases with higher doses and longer duration of treatment 2, 4
• Remember that steroids have been associated with a higher risk of scleroderma renal crisis; careful monitoring of blood pressure and renal function is essential 1

Alternative Approaches

• For malnourished CAPD patients, anabolic steroids (such as nandrolone decanoate) may be considered as an alternative to glucocorticoids for improving nutritional status 7
• For patients with congestive heart failure on dialysis, consider beta-blockers as first-line therapy and digitalis glycosides as third-line therapy rather than steroids 1