What medications should be held or adjusted for a patient with Chronic Kidney Disease (CKD) starting dialysis for the first time?

Pre-Dialysis Orders for CKD Patients Starting Hemodialysis

For a patient with CKD initiating dialysis for the first time, immediately hold or adjust all renally-excreted and nephrotoxic medications, particularly RAAS blockers, diuretics, NSAIDs, metformin, lithium, and digoxin, while initiating phosphate binders and ensuring appropriate dosing of all continuing medications based on dialyzability and residual renal function. 1

Medications to HOLD or DISCONTINUE

Immediately Hold Before First Dialysis Session

• RAAS blockers (ACE inhibitors, ARBs, aldosterone antagonists, direct renin inhibitors) - these increase hyperkalemia risk and are nephrotoxic in acute settings 1
• Diuretics - no longer effective with GFR <10-15 mL/min and increase risk of hypotension during dialysis 1, 2
• NSAIDs - nephrotoxic and increase bleeding risk 1
• Metformin - must be discontinued with GFR <30 mL/min due to lactic acidosis risk 1
• Lithium - requires close monitoring and dose adjustment; consider holding until stable on dialysis 1
• Digoxin - narrow therapeutic window, renally excreted, requires dose adjustment 1

Adjust or Review

• Aldosterone antagonists - routine use not recommended in advanced CKD due to severe hyperkalemia risk 2
• Potassium-sparing medications - including trimethoprim, calcineurin inhibitors, nonselective beta-blockers, heparin 2

Medications to START

Phosphate Binders (Essential)

• Sevelamer hydrochloride is indicated for phosphorus control in dialysis patients 3
• Starting dose based on serum phosphorus: 3
  • Phosphorus >5.5 and <7.5 mg/dL: 800 mg three times daily with meals
  • Phosphorus ≥7.5 and <9 mg/dL: 1600 mg three times daily with meals
  • Phosphorus ≥9 mg/dL: 2400 mg three times daily with meals
• Goal: Lower serum phosphorus to ≤5.5 mg/dL 3
• Monitoring: Titrate by one tablet per meal at 2-week intervals based on phosphorus levels 3

Metabolic Acidosis Management

• Sodium bicarbonate 0.5-1 mEq/kg/day orally if serum bicarbonate <22 mmol/L 2
• Goal: Achieve bicarbonate 22-24 mmol/L 2
• Important: Correct hypocalcemia BEFORE treating acidosis 2
• Note: Sevelamer can worsen acidosis, requiring closer monitoring 2

Diabetes Medications Requiring Adjustment

Adjust Based on eGFR 1

• Metformin: Contraindicated at GFR <30 mL/min; discontinue 1
• SGLT2 inhibitors:
  • Canagliflozin: Maximum 100 mg daily; may continue until dialysis initiation 1
  • Dapagliflozin: May continue if tolerated until dialysis (not for glycemic control) 1
  • Empagliflozin/Ertugliflozin: Not recommended <45 mL/min 1
• Insulin: Initiate and titrate conservatively to avoid hypoglycemia 1
• DPP-4 inhibitors: Require dose reduction (e.g., sitagliptin to 25 mg daily) 1
• Sulfonylureas: Initiate conservatively; avoid glyburide entirely 1

Cardiovascular Medications

Continue with Monitoring

• Statins: Continue for cardiovascular protection; no dose adjustment typically needed 1
• Aspirin: Continue for secondary prevention if indicated 1
• Beta-blockers: Continue but monitor for hypotension during dialysis 1

Anticoagulation Considerations

• Avoid low molecular weight heparin - altered clearance in kidney failure 1
• Bivalirudin preferred for procedures requiring anticoagulation with dialysis-specific dosing 1

Critical Monitoring Parameters

Before First Dialysis Session

• Serum potassium - treat if >5.5 mEq/L or if ECG changes present 2
• Serum phosphorus - initiate binders as above 3
• Serum bicarbonate - supplement if <22 mmol/L 2
• Volume status - assess for fluid overload 2
• Medication reconciliation - review ALL medications for renal dosing 1, 4

Hyperkalemia Management (if K+ >5.5 mEq/L)

• Without ECG changes: 2
  • Dietary potassium restriction
  • Oral ion exchange resins
  • Review and hold potassium-raising medications
• With ECG changes or symptoms: 2
  • 10% calcium gluconate IV
  • Insulin and glucose IV
  • Salbutamol
  • Consider urgent dialysis if GFR <10 mL/min

Timing Considerations for First Dialysis

Dialysis Scheduling

• Avoid dialysis within 48 hours of acute coronary syndrome if possible, balancing volume status and electrolyte disturbances 1
• Use gentle dialysis prescription initially to minimize hypotension risk 1
• Collaborate with nephrology regarding timing if patient has acute illness 1

Common Pitfalls to Avoid

• Do NOT continue metformin - absolute contraindication at dialysis initiation 1
• Do NOT use gadolinium contrast if GFR <15 mL/min unless no alternative exists 1
• Do NOT forget to start phosphate binders - hyperphosphatemia is immediate concern 3
• Do NOT assume standard drug dosing - most medications require adjustment 5, 4
• Do NOT use herbal remedies - contraindicated in CKD 1
• Do NOT combine multiple nephrotoxic agents even at dialysis initiation 1

Additional Considerations

Vitamin Supplementation

• Monitor fat-soluble vitamins (D, E, K) and folic acid - sevelamer can reduce levels 3
• Most dialysis patients receive vitamin supplements - this is standard practice 3

Patient Education

• Advise seeking medical/pharmacist advice before using over-the-counter medicines or protein supplements 1
• Fluid intake: Recommend 1.5-2 liters daily unless edematous 2
• Dietary protein: Limit to <1 g/kg/day to reduce acid production 2
• Low-potassium diet essential with GFR <20 mL/min 2