What are the common management strategies for patients undergoing Hemodialysis (HD)?

Essential Management Strategies for Common Cases During Hemodialysis

The management of patients undergoing hemodialysis should focus on optimizing volume status, blood pressure control, and dialysis adequacy, with a target single pool Kt/V of 1.4 per session for thrice-weekly treatments to minimize morbidity and mortality. 1

Blood Pressure Management

Assessment and Targets

• Pre- and post-dialysis BP measurements alone are imprecise and should not be used as the sole basis for diagnosing and managing hypertension, though they remain important for assessing hemodynamic stability during HD sessions 1
• A reasonable goal for predialysis blood pressure is 140/90 mmHg (measured in sitting position) provided there is no substantial orthostatic hypotension or symptomatic intradialytic hypotension 1
• Ambulatory BP monitoring is the gold standard for BP evaluation, with home BP monitoring as a practical alternative when ambulatory monitoring is unavailable 1

Hypertension Management

• Address volume overload first through adjusting the dialysis prescription, as volume is the most significant contributor to hypertension in dialysis patients 2
• Use an algorithmic approach starting with lifestyle modifications, particularly salt restriction and achieving dry weight 1
• If pharmacological treatment is needed, ACE inhibitors or ARBs should be first-line agents as they reduce left ventricular hypertrophy and may be associated with decreased mortality 1, 2
• Beta-blockers are preferred in patients with previous myocardial infarction or established coronary artery disease 1
• Calcium channel antagonists and anti-alpha-adrenergic drugs should be added if necessary to achieve control 1
• Consider administering antihypertensive drugs at night to reduce nocturnal BP surge and minimize intradialytic hypotension 2

Intradialytic Hypotension Management

• Immediately reduce or temporarily stop ultrafiltration when hypotension occurs 3
• Administer intravenous normal saline bolus to rapidly expand plasma volume 3
• Place patient in Trendelenburg position to improve venous return 3
• Consider preventive strategies:
  • Administer midodrine 30 minutes before dialysis initiation 3
  • Increase dialysate sodium concentration to 148 mEq/L or use sodium profiling 3
  • Reduce dialysate temperature from 37°C to 34-35°C to increase peripheral vasoconstriction 3
  • Avoid food intake immediately before or during hemodialysis 3

Volume Management

Assessment and Targets

• Prescribe an ultrafiltration rate that balances achieving euvolemia, adequate BP control, and solute clearance while minimizing hemodynamic instability 1
• Consider additional HD sessions or longer treatment times for patients with large weight gains, high ultrafiltration rates, poorly controlled BP, or difficulty achieving dry weight 1
• Recommend both reducing dietary sodium intake and adequate sodium/water removal with HD to manage hypertension, hypervolemia, and left ventricular hypertrophy 1

Strategies for Optimizing Volume Control

• For patients with low residual kidney function (<2 mL/min) on thrice-weekly HD, prescribe a minimum of 3 hours per session 1
• Limit fluid intake between dialysis sessions to reduce interdialytic weight gain 3
• Monitor blood volume changes during ultrafiltration to prevent excessive volume depletion 4
• Consider the slope of blood volume reduction in the first 30 minutes of HD as a parameter to identify overhydrated patients 4

Dialysis Adequacy

Targets and Measurement

• Target single pool Kt/V (spKt/V) of 1.4 per HD session for patients treated thrice weekly, with a minimum delivered spKt/V of 1.2 1
• For HD schedules other than thrice weekly, target standard Kt/V of 2.3 volumes per week with a minimum delivered dose of 2.1 1
• In patients with significant residual kidney function, the dose of HD may be reduced provided residual function is measured periodically 1

Membrane Selection

• Use biocompatible, either high or low flux HD membranes for intermittent HD 1

Special Considerations

Residual Kidney Function

• Preserve residual kidney function through:
  • Avoiding nephrotoxins 1
  • Avoiding intradialytic hypotension 1
  • Using RAS blockers when appropriate 1
  • Using high-flux membranes 1

Peritoneal Dialysis Specific Management

• Maximize peritoneal ultrafiltration by optimizing the PD prescription to achieve euvolemia 5
• Use icodextrin solution for long dwells to increase ultrafiltration and decrease extracellular fluid volume 5
• Consider shortening dwell times with glucose-based solutions, especially for high transporters, to prevent fluid reabsorption 5
• Restrict dietary sodium intake if persistent hypertension and fluid overload are present 5

Emergency Management

• Develop protocols for managing life-threatening complications such as arrhythmia, acute coronary syndrome, stroke, epilepsy, trauma, sepsis, allergic reactions, or bleeding 6
• Ensure dialysis staff are trained in recognizing and managing medical emergencies that may occur during HD sessions 6
• Monitor for rare but serious complications such as hemolysis, air embolism, dialyzer reactions, and dialysis disequilibrium syndrome 6

By implementing these management strategies, healthcare providers can optimize outcomes for patients undergoing hemodialysis, minimizing complications and improving quality of life.