What are the management strategies for common complaints in a patient with End-Stage Renal Disease (ESRD), including dietary adjustments, dialysis, and medications?

Management of ESRD Patients: Common Complaints, Diet, Dialysis, and Medications

Dialysis Prescription and Modality

For ESRD patients, conventional hemodialysis (3 times per week, 3-5 hours per session) remains the standard approach, though intensive hemodialysis regimens (more frequent and/or longer sessions) can be considered for selected patients with preserved urine output and dietary discipline. 1

Standard Hemodialysis Approach

• Conventional hemodialysis consists of 3 sessions per week, 3-5 hours per session 1
• Thrice-weekly hemodialysis is the most common modality, used in 67.7% of diabetic ESRD patients 2
• Peritoneal dialysis is an alternative home-based option with no difference in long-term mortality compared to hemodialysis 3

Intensive Hemodialysis Options

• Short daily hemodialysis: 5 or more sessions per week, fewer than 3 hours per session 1
• Long hemodialysis: ≥5.5 hours per session, 3-4 times per week 1
• Long-frequent hemodialysis: ≥5.5 hours per session, 5 or more sessions per week 1
• For selected patients with preserved urine output (GFR 5-10 mL/min/1.73m²) and dietary compliance, once-weekly hemodialysis combined with low-protein diet can preserve residual renal function and reduce hospitalization rates 4

Vascular Access Management

• Arteriovenous fistula is preferred and requires several months to mature before use 3
• Arteriovenous graft can be used in as few as 24 hours depending on graft material 3
• Central venous catheter is usable immediately but carries the highest infection risk 3
• For intensive hemodialysis, buttonhole cannulation techniques require specific antimicrobial prophylaxis considerations 1

Dietary Management

ESRD patients on maintenance hemodialysis require 1.2 g protein/kg body weight/day with at least 50% high biological value protein, and energy intake of 35 kcal/kg/day for patients <60 years or 30-35 kcal/kg/day for those ≥60 years. 5

Protein Requirements

• Maintenance hemodialysis: 1.2 g protein/kg/day, ≥50% high biological value 5
• Chronic peritoneal dialysis: 1.2-1.3 g protein/kg/day, ≥50% high biological value 5
• Protein-energy malnutrition is common and associated with increased mortality, particularly when present at dialysis initiation 5

Energy Requirements

• 35 kcal/kg/day for patients younger than 60 years 5
• 30-35 kcal/kg/day for patients 60 years or older 5

Phosphorus and Calcium Management

• For long or long-frequent hemodialysis, use dialysate calcium of 1.50 mmol/L or higher to maintain neutral or positive calcium balance while avoiding predialysis hypercalcemia and PTH oversuppression 1
• Avoid phosphate-containing medications given ESRD status 6
• Calcium-based phosphate binders may be discontinued in long-frequent hemodialysis, requiring dialysate calcium adjustment 1
• If hypophosphatemia persists after stopping phosphate binders and liberalizing diet in intensive hemodialysis, phosphate dialysate additives may be needed 5

Stepwise Nutritional Intervention

1. Regular nutritional monitoring every 1-3 months (more frequently if inadequate intake or malnutrition present) 5
2. Education and dietary counseling as first-line intervention, with creative menu planning considering patient preferences 5
3. High energy density foods, beverages, and nutritional supplements 5
4. If dietary counseling fails, consider nutritional support including food supplements, tube feeding, or intravenous nutrition 5
5. If protein-energy malnutrition develops or persists despite vigorous optimization attempts, consider initiating or intensifying dialysis or renal transplantation 5

Medication Management

Medication reconciliation must be performed at every care transition to prevent adverse drug events, as ESRD patients face altered pharmacokinetics requiring dose adjustments for most medications. 1

Critical Medication Safety Principles

• Medication reconciliation is the cornerstone of medication safety and must be prioritized at all care transitions 1
• ESRD patients are at heightened risk of adverse drug reactions due to polypharmacy, multiple comorbidities, and altered medication pharmacokinetics 1
• Acyclovir and gabapentin require significant dose reduction in dialysis patients to prevent toxicity 1

Specific Medication Considerations

Sedation and Analgesia:

• Avoid midazolam due to delayed metabolism and elimination in renal impairment 7
• Morphine and derivatives accumulate in renal failure; use shorter-acting opiates preferentially 7
• Oxycodone/acetaminophen requires careful dosing and monitoring 1

Anticoagulation:

• Use unfractionated heparin for therapeutic systemic anticoagulation as it is reversible and its metabolism is independent of renal function 7
• Avoid low molecular weight heparins due to renal-dependent clearance 7

Diuretics:

• Diuretic use is limited to patients with residual urine output 7
• Once-weekly dialysis combined with dietary restriction can preserve urine output in selected patients 4

Avoid Nephrotoxic Agents:

• Avoid nephrotoxic contrast when possible, but do not withhold necessary CT angiography when diagnostic benefit outweighs risk in life-threatening presentations 6
• Avoid phosphate-containing enemas and medications 1, 6

Management of Common Complications

Hyperkalemia

• Administer IV insulin and nebulized salbutamol to lower serum potassium until definitive treatment with RRT is instituted 7
• ESRD patients are at constant risk of hyperkalemia requiring vigilant monitoring 7

Hypocalcemia

• ESRD patients are prone to hypocalcemia, which requires IV replacement if associated with complications 7
• Monitor calcium balance considering dialysate calcium concentration, calcium-based phosphate binders, and ultrafiltration volumes 1

Anemia

• Patients on combined diet-dialysis programs (once-weekly HD with low-protein diet) demonstrate lower erythropoietin resistance index compared to thrice-weekly hemodialysis 4
• Erythropoietin therapy should be optimized with attention to iron status 2

Volume Overload and Hypertension

• Volume output and residual renal function are better maintained with once-weekly dialysis plus dietary restriction compared to thrice-weekly hemodialysis in selected patients 4
• Strict blood pressure control is essential, requiring medication adherence and dietary compliance 8
• Bioimpedance analysis can guide volume management 8

Metabolic Acidosis

• Bicarbonate supplementation should be adjusted when increasing dietary protein intake 5
• Regular monitoring of acid-base status is required 3

Mineral and Bone Disorders

• Increasing bone alkaline phosphatase and PTH suggest higher dialysate calcium may be required 1
• Cinacalcet requirements are lower in combined diet-dialysis programs compared to standard hemodialysis 4
• When increasing dietary protein, adjust phosphate binders accordingly 5

Sepsis Risk

• Risk of sepsis is higher among ESRD patients; empiric treatment should include both Gram-positive and Gram-negative coverage 7
• Add methicillin-resistant Staphylococcus aureus coverage if the patient has a dialysis catheter 7

Cardiovascular Disease

• Cardiovascular events account for the majority of deaths among ESRD patients 7
• Use troponin-I and CK-MB in combination as markers of acute myocardial damage; troponin-T and B-type natriuretic peptide values are less reliable in ESRD 7
• Control hypertension, hyperglycemia, and lipid abnormalities aggressively 2

Protein-Calorie Malnutrition

• Malnutrition at dialysis initiation predicts future mortality risk 5
• Nutritional decline becomes particularly notable when GFR falls below 25 mL/min 5
• Regular assessment of serum albumin, transferrin, and anthropometric measurements is essential 5

Special Considerations for Diabetic ESRD Patients

• Maximize renal replacement therapy by providing dialysis adequacy levels (Kt/V) higher than previously recommended or pursue transplantation 2
• Control hyperglycemia, hypertension, and lipid abnormalities aggressively 2
• Diabetic ESRD patients have the greatest number of comorbid conditions and highest physical dysfunction 2
• Mortality for diabetic ESRD patients has decreased from 46% in 1982 to 29% in 1993 with improved management 2

Multidisciplinary Team Approach

• A multidisciplinary team offering skilled dietary counseling, cardiac care, and regular bioimpedance analysis allows for better management and improved outcomes in ESRD patients 8
• Regular counseling for dietary compliance and drug adherence results in better blood pressure control and outcomes 8

Transplantation Consideration

• Transplantation is the treatment of choice for ESRD patients, and referral should be offered to all candidates 3
• Patients with diabetes experience improved survival after kidney transplant 2
• 19.1% of diabetic ESRD patients have functioning renal transplants 2

Palliative Care Option

• For patients who decide against RRT or choose to discontinue dialysis, palliative care and hospice referral are indicated 3
• Supportive care is a legitimate treatment option for selected ESRD patients 3