What medications and lab monitoring are recommended for a patient with End-Stage Renal Disease (ESRD), diabetes, Hypertension (HTN), and dyslipidemia?

Medication Optimization in ESRD with Diabetes, Hypertension, and Dyslipidemia

Diabetes Management

In a dialysis patient, SGLT2 inhibitors should be continued until dialysis initiation or transplant, and metformin should be avoided given ESRD status. 1

• SGLT2 inhibitors remain first-line therapy and can be initiated if eGFR ≥20 ml/min/1.73m² and should be continued until dialysis or transplant 1, 2
• Metformin is contraindicated in ESRD (eGFR <30 ml/min/1.73m²) and must be discontinued 1
• GLP-1 receptor agonists can be added if needed to achieve glycemic targets, with dose adjustments based on specific agent 1
• Avoid sulfonylureas and insulin secretagogues when possible due to hypoglycemia risk in ESRD; if insulin is required, reduce doses by 25-50% due to decreased renal clearance 1

Glycemic Targets

• Target HbA1c of 7.0-8.0% is reasonable, recognizing that HbA1c accuracy declines significantly in dialysis patients 1
• Consider continuous glucose monitoring (CGM) or glucose management indicator (GMI) as HbA1c becomes unreliable in ESRD 1

Hypertension Management

ACE inhibitors or ARBs should generally be discontinued or significantly reduced in dialysis patients, with blood pressure primarily managed through ultrafiltration and volume control. 3

• Volume management is the cornerstone: Optimize dry weight through ultrafiltration and sodium restriction (<2.3 g/day) 1, 2, 3
• RAS inhibitors (ACEi/ARB) may be continued at reduced doses if tolerated, but many patients can discontinue them once on dialysis as volume control becomes primary strategy 1, 3
• Beta-blockers are reasonable first-line agents for dialysis patients, particularly those with heart failure or coronary disease 1, 3
• Calcium channel blockers (dihydropyridine) are effective and well-tolerated in ESRD 3
• Avoid medications removed by dialysis if patient has intradialytic hypotension; prefer nondialyzable agents 3

Blood Pressure Targets

• Target BP <130/80 mmHg in collaboration with nephrology, though this may need adjustment based on intradialytic tolerance 1, 2
• Home blood pressure monitoring is superior to dialysis unit measurements for guiding therapy 3

Lipid Management

All dialysis patients with diabetes should receive moderate-to-high intensity statin therapy regardless of LDL level, but do not initiate statins de novo in dialysis patients. 1, 4

• Continue statins if already prescribed prior to dialysis initiation for cardiovascular risk reduction 1, 2, 4
• Do not start new statin therapy in dialysis patients, as randomized trials (4D, AURORA, SHARP dialysis subgroup) showed no mortality benefit 5, 6
• Moderate-to-high intensity statin dosing: atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily 1, 4
• Ezetimibe can be added if LDL remains elevated and patient has high ASCVD risk 1
• PCSK9 inhibitors or icosapent ethyl may be considered based on ASCVD risk, though evidence in dialysis is limited 1

Lipid Targets

• No specific LDL target in dialysis patients; focus on statin continuation rather than treat-to-target approach 5, 6

Laboratory Monitoring Schedule

Monitor labs every 1-3 months (4 times per year minimum) given high-risk CKD stage. 1

Every 1-3 Months (Minimum 4 Times Yearly):

• HbA1c (or more frequent CGM/GMI if HbA1c unreliable) 1
• Serum potassium (critical with any RAS inhibitor use) 1
• Lipid panel (though less emphasis on targets in dialysis) 1
• Albumin and nutritional markers 1

Monthly (Standard Dialysis Monitoring):

• Serum creatinine (though less relevant on dialysis) 1
• Calcium, phosphorus, PTH for mineral bone disease 1
• Hemoglobin for anemia management 1

Within 2-4 Weeks After Any RAS Inhibitor Dose Change:

• Serum creatinine and potassium to assess for hyperkalemia or acute decline 1

Partnership with Nephrology on Blood Pressure Targets

Defer primary blood pressure management to nephrology team, focusing on volume status assessment rather than medication titration. 1, 3

Key Collaboration Points:

• Dry weight optimization is nephrology's primary tool; medication adjustments are secondary 3
• Intradialytic blood pressure patterns guide therapy more than pre-dialysis readings 3
• Home BP monitoring should be encouraged and shared with nephrology team 3
• Target <130/80 mmHg as general goal, but individualize based on intradialytic tolerance and cardiovascular comorbidities 1, 2
• Avoid aggressive BP lowering that causes intradialytic hypotension, as this increases mortality risk 3

Common Pitfalls:

• Do not aggressively add antihypertensives without first optimizing volume status through dialysis 3
• Recognize that "reverse epidemiology" exists in dialysis—lower BP may paradoxically associate with worse outcomes if due to cardiac dysfunction rather than good control 3, 7
• Pre-dialysis hypertension often improves with adequate ultrafiltration rather than requiring medication escalation 3

Multidisciplinary Care Approach

Regular reassessment every 3-6 months with integrated team including nephrology, endocrinology, and cardiology. 1, 2

• Lifestyle modifications: Sodium restriction, appropriate protein intake (1.0-1.2 g/kg for dialysis), smoking cessation, exercise as tolerated 1, 2
• Patient education on medication adherence, dietary restrictions, and self-monitoring 1
• Coordinate medication timing with dialysis schedule to optimize adherence and minimize intradialytic removal 3