Management of End-Stage Renal Disease (ESRD) with Anuria
For patients with ESRD and anuria, renal replacement therapy (RRT) via hemodialysis, peritoneal dialysis, or kidney transplantation is the cornerstone of management, with transplantation offering the best outcomes for suitable candidates.
Renal Replacement Therapy Options
- Hemodialysis (HD) and Peritoneal Dialysis (PD) are the primary dialysis modalities for ESRD patients with anuria, with no significant differences in long-term mortality rates between them 1
- Kidney transplantation is the preferred treatment option for ESRD patients who are suitable candidates, offering better long-term outcomes 2
- For patients receiving hemodialysis, arteriovenous access (AVF or AVG) is recommended over tunneled central venous catheters (CVC) 3
- For patients using CVC for hemodialysis access, "closed connector" devices are suggested to reduce infection risk 3
Intensive Hemodialysis Considerations
- Intensive hemodialysis regimens (more frequent and/or longer sessions) may improve quality of life, blood pressure control, and reduce left ventricular hypertrophy 3
- For patients on intensive hemodialysis, a dialysate calcium of 1.50 mmol/L or higher is recommended to maintain neutral or positive calcium balance 3
- If hypophosphatemia develops during intensive hemodialysis, phosphate dialysate additives should be considered after stopping phosphate binders and liberalizing diet 3
Management of Electrolyte Abnormalities
Hyperkalemia is a common complication in anuric ESRD patients requiring prompt treatment:
Mineral and bone disorders require careful management:
Indications for Urgent Dialysis
- Persistent hyperkalemia unresponsive to medical therapy 3
- Severe metabolic acidosis 3
- Volume overload unresponsive to diuretic therapy (in patients with residual function) 3
- Overt uremic symptoms including pericarditis and severe encephalopathy 3
- Severe progressive hyperphosphatemia (>6 mg/dL) or symptomatic hypocalcemia 3
Vascular Access Considerations
- Early referral for arteriovenous fistula (AVF) creation is essential as it requires several months to mature 1
- Arteriovenous grafts (AVG) can be used sooner (within 24 hours depending on material) but have higher complication rates than AVF 1
- Central venous catheters provide immediate access but carry the highest infection risk 1
- For patients using buttonhole cannulation technique with AVF, mupirocin antibacterial cream is recommended to reduce infection risk 3
Supportive Care Considerations
- A palliative approach is a reasonable alternative to dialysis for patients with limited life expectancy, severe comorbidities, or those wishing to avoid medical interventions 2
- Patients choosing conservative management should be referred for palliative care and hospice services 1
- Protein-energy wasting and malnutrition are common complications requiring nutritional monitoring and intervention 2
Blood Pressure Management
- Blood pressure control improves mortality in dialysis patients 2
- Volume control through adequate dialysis and sodium restriction helps optimize hypertension treatment 2
- ACE inhibitors or angiotensin receptor blockers are preferred for hypertensive patients with proteinuria 3
- Calcium channel blockers should be avoided in patients receiving protease inhibitors due to potential interactions 3
Preventive Care
- Vaccination against seasonal influenza, tetanus, hepatitis B, human papillomavirus (through age 26), and Streptococcus pneumoniae is recommended 2
- Routine cancer screening for patients not receiving kidney transplantation is generally discouraged 2
Complications and Monitoring
- ESRD patients have higher risk of sepsis compared to those with normal renal function 5
- Cardiovascular events account for the majority of deaths among ESRD patients 5
- Drug dosing requires careful adjustment due to altered pharmacokinetics in ESRD 5
- Frequent dialysis sessions may be required to adequately control uremic symptoms and fluid status 3