What is the care plan for a patient with End-Stage Renal Disease (ESRD)?

Care Plan for End-Stage Renal Disease (ESRD)

The optimal care plan for ESRD patients should include a multidisciplinary approach with individualized ESKD Life-Plan, appropriate renal replacement therapy (dialysis or transplantation), and comprehensive management of complications to improve morbidity, mortality, and quality of life. 1

ESKD Life-Plan Development

• An individualized ESKD Life-Plan should be developed for each patient with ESRD, considering their medical situation, life goals, preferences, social support, and functional status 1
• This plan should be regularly reviewed, updated, and documented in the medical record, with annual comprehensive reviews and quarterly updates of vascular access functionality 1
• The ESKD Life-Plan should be created by a coordinated team including nephrologist, surgeon, radiologist, nurse, and patient support persons 1

Renal Replacement Therapy Options

Kidney Transplantation

• Kidney transplantation should be considered the preferred treatment option for eligible ESRD patients as it offers the best outcomes for mortality and quality of life 1, 2
• Living donor preemptive renal transplantation should be considered when GFR is <20 ml/min/1.73 m² with evidence of progressive and irreversible CKD over 6-12 months 1
• Patients with SCD and ESRD should be referred for renal transplant evaluation 1

Dialysis Initiation

• Dialysis should be initiated when one or more of the following are present: symptoms/signs attributable to kidney failure (serositis, acid-base or electrolyte abnormalities, pruritus); inability to control volume status or blood pressure; progressive deterioration in nutritional status; or cognitive impairment 1
• This typically occurs when GFR is between 5-10 ml/min/1.73 m², but should not be based solely on kidney function estimates 1

Hemodialysis Options

• Consider in-center short frequent hemodialysis as an alternative to conventional thrice-weekly hemodialysis after discussing potential benefits and risks 1
• Home long hemodialysis (6-8 hours, 3-6 nights per week) may be appropriate for patients who prefer this therapy for lifestyle considerations 1
• During pregnancy, women with ESRD should receive long frequent hemodialysis either in-center or at home 1

Vascular Access for Hemodialysis

• Arteriovenous fistulas (AVF) or arteriovenous grafts (AVG) are preferred over tunneled central venous catheters (CVC) 3
• For patients using AVF with intensive hemodialysis, rope-ladder cannulation technique is recommended over buttonhole cannulation unless topical antimicrobial prophylaxis is used 3
• If buttonhole cannulation is necessary, apply mupirocin antibacterial cream to reduce infection risk 3
• For patients requiring CVC access, use "closed connector" devices over standard care to reduce complications 3

Peritoneal Dialysis

• Peritoneal dialysis is a home-based alternative with no difference in long-term mortality compared to hemodialysis 4
• This option may be preferable for patients who desire more independence and home-based care 2, 4

Conservative Management

• Conservative management should be offered as an option for patients who choose not to pursue renal replacement therapy 1
• This should be supported by a comprehensive management program including palliative care for symptom management 1, 2

Management of ESRD Complications

Cardiovascular Management

• Blood pressure control improves mortality in dialysis patients, with volume control through adequate dialysis and sodium restriction 2
• Consider renin-angiotensin system blockers (telmisartan, candesartan) and beta-blockers (carvedilol) as they have demonstrated survival benefits in ESRD patients 5
• For patients with chronic stable angina, ranolazine may be beneficial, particularly in those with hemodynamic instability, as its antianginal effect does not depend on changes in heart rate or blood pressure 6

Dialysate Composition Management

• Maintain dialysate calcium at 1.50 mmol/L or higher for patients on long or long-frequent hemodialysis to ensure neutral or positive calcium balance 3
• If hypophosphatemia persists despite discontinuation of phosphate binders and diet liberalization, consider phosphate dialysate additives 3

Other Medical Management

• Provide appropriate vaccinations including seasonal influenza, tetanus, hepatitis B, HPV (through age 26), and pneumococcal vaccines 2
• Insulin is the preferred treatment for ESRD patients with diabetes mellitus requiring medication 2
• Monitor for and manage common complications including hyperkalemia, hypervolemia, metabolic acidosis, anemia, mineral and bone disorders, and protein-calorie malnutrition 4
• Routine cancer screening for patients not receiving kidney transplantation is generally discouraged 2

Referral Considerations

• Refer patients to nephrology services early to optimize disease management and avoid late referral (defined as less than 1 year before start of renal replacement therapy) 1
• Consider referral to palliative care services for patients choosing conservative management or discontinuing dialysis 4