What guideline-directed medical therapy (GDMT) is acceptable for patients with End-Stage Renal Disease (ESRD) on Hemodialysis (HD)?

Guideline-Directed Medical Therapy for ESRD Patients on Hemodialysis

For patients with ESRD on hemodialysis, arteriovenous access (AVF or AVG) is recommended over tunneled central venous catheters for vascular access, with appropriate management of dialysate calcium and phosphate to optimize 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 hemodialysis 1
• For patients using AVF with intensive hemodialysis, rope-ladder cannulation technique is recommended over buttonhole cannulation unless topical antimicrobial prophylaxis is used 1
• If buttonhole cannulation technique is used, mupirocin antibacterial cream should be applied to reduce infection risk 1
• For patients requiring CVC access, "closed connector" devices should be used over standard care to reduce complications 1

Dialysate Composition Management

• For patients on long or long-frequent hemodialysis, dialysate calcium should be maintained at 1.50 mmol/L or higher to ensure neutral or positive calcium balance 1
• This approach helps avoid predialysis hypercalcemia and prevents oversuppression of parathyroid hormone (PTH) 1
• If hypophosphatemia persists despite discontinuation of phosphate binders and diet liberalization, phosphate dialysate additives should be used to maintain predialysis phosphate in the normal range 1

Cardiovascular Management

• Blood pressure control through adequate dialysis and sodium restriction is essential for optimizing outcomes in ESRD patients 2
• For patients with heart failure and ESRD, guideline-directed medical therapy should still be implemented, as it shows efficacy in reducing adverse cardiovascular events similar to non-CKD patients 3
• ACE inhibitors, ARBs, and beta-blockers are reasonable first-line agents for most ESRD patients requiring antihypertensive therapy 4
• Medications that are removed with dialysis may be preferred in patients prone to intradialytic hypotension 4

Medication Considerations

• When selecting antihypertensive medications, consider dialyzability characteristics - some medications within the same class may have significant variability in removal during dialysis 4
• For nonadherent patients, thrice-weekly dosing of medications after dialysis can provide effective blood pressure control 4
• Insulin remains the preferred treatment for ESRD patients with diabetes mellitus requiring medication 2

Monitoring and Complications

• Regular monitoring for protein-energy wasting and malnutrition is essential in ESRD patients 2
• Vaccination against seasonal influenza, tetanus, hepatitis B, HPV (through age 26), and Streptococcus pneumoniae is recommended 2
• Routine cancer screening for patients not receiving kidney transplantation is generally discouraged 2

Common Pitfalls and Caveats

• The evidence supporting GDMT in ESRD is generally of very low quality, with most recommendations being conditional rather than strong 1
• Intradialytic hypertension should be managed by reassessing the patient's dry weight and using non-dialyzable medications 4
• While kidney transplantation typically yields the best patient outcomes, most ESRD patients are treated with dialysis 2
• Preservation of peripheral veins is crucial for patients with stage III to V chronic kidney disease who may eventually need hemodialysis 2