What are the management strategies for a patient with End-Stage Renal Disease (ESRD), including medication adjustments and dietary restrictions?

Management Strategies for End-Stage Renal Disease (ESRD)

Patients with ESRD require comprehensive management focusing on renal replacement therapy options, symptom control, and nutritional support to improve mortality, morbidity, and quality of life.

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
• 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

Dialysis Initiation

• Dialysis should be initiated when one or more of the following are present: symptoms/signs attributable to kidney failure; 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
• Initiation of dialysis is recommended if there is evidence of deteriorating nutritional status despite vigorous attempts to optimize protein and energy intake 2

Hemodialysis Management

• Arteriovenous fistulas (AVF) or arteriovenous grafts (AVG) are preferred over tunneled central venous catheters (CVC) for vascular access 1, 3
• For patients using AVF with intensive hemodialysis, rope-ladder cannulation technique is recommended over buttonhole cannulation unless topical antimicrobial prophylaxis is used 3
• 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

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, 4
• Particularly appropriate for individuals with limited life expectancy, severe comorbid conditions, or who wish to avoid medical interventions 5

Nutritional Management

• Monitor for signs of protein-energy wasting and malnutrition, which are associated with increased mortality 5, 6
• Specific nutritional interventions should be implemented if any of these indicators show deterioration 2:
  1. More than 6% involuntary reduction in edema-free usual body weight or to less than 90% of standard body weight in less than 6 months 2
  2. Reduction in serum albumin by ≥0.3 g/dL to less than 4.0 g/dL 2
  3. Deterioration in Subjective Global Assessment by one category 2

Management of Complications

Cardiovascular Management

• Blood pressure control in patients receiving dialysis improves mortality 5
• Volume control through adequate dialysis and sodium restriction can help optimize hypertension treatment 5

Metabolic Management

• Insulin is the preferred treatment for patients with ESRD and diabetes mellitus requiring medication 5
• If hypophosphatemia persists despite discontinuation of phosphate binders and diet liberalization, consider phosphate dialysate additives 3

Medication Adjustments

• Many medications require dose adjustments or are contraindicated in ESRD
• Metformin is contraindicated in patients with eGFR less than 30 mL/min/1.73 m² 7
• For patients on metformin who require contrast studies, stop the medication at the time of the procedure if eGFR is between 30-60 mL/min/1.73 m² 7

Palliative Care Considerations

• Due to high physical symptom burden, palliative care is increasingly important in ESRD patients 2
• The palliative approach should focus on reducing symptom burden and suffering and improving quality of life 2
• Discontinuation of dialysis should be discussed for patients with severely limited life expectancy, low quality of life, refractory pain, or progressive deterioration due to an untreatable disease 2
• Common symptoms requiring management include fatigue, sleep disturbances, dyspnea, anxiety, pruritus, and xerostomia 2, 8

Preventive Care

• Vaccination against seasonal influenza, tetanus, hepatitis B, human papillomavirus (through 26 years of age), and Streptococcus pneumoniae is advised 5
• Routine cancer screening for patients not receiving kidney transplantation is generally discouraged 5

Individualized ESRD Life-Plan

• An individualized ESKD Life-Plan should be developed for each patient, considering their medical situation, life goals, preferences, social support, and functional status 1
• This plan should be regularly reviewed and updated, with annual comprehensive reviews 1
• Shared decision-making is essential when determining treatment approaches, particularly regarding initiation or discontinuation of dialysis 2