What are the primary treatment options for a patient with End-Stage Renal Disease (ESRD), including management of comorbid conditions and medication therapy?

Primary Treatment Options for End-Stage Renal Disease (ESRD)

Kidney transplantation should be considered the preferred treatment option for eligible ESRD patients as it offers the best outcomes for mortality and quality of life compared to all other modalities. 1, 2

Renal Replacement Therapy Selection

Kidney Transplantation (First-Line)

• Transplantation yields the best patient outcomes and should be offered to all eligible candidates. 1, 2, 3
• Living donor preemptive renal transplantation should be considered when GFR is <20 ml/min/1.73 m² with evidence of progressive and irreversible CKD over 6-12 months. 1
• Patients should be referred for transplant evaluation early, even before dialysis initiation when appropriate. 4, 1
• For patients with sickle cell disease and ESRD, referral for renal transplant is specifically recommended despite potential complications. 4

Dialysis Modalities (When Transplant Not Immediately Available)

Dialysis initiation timing: Start dialysis when symptoms/signs attributable to kidney failure are present, inability to control volume status or blood pressure occurs, progressive deterioration in nutritional status develops, or cognitive impairment appears—typically when GFR is between 5-10 ml/min/1.73 m². 1

Hemodialysis Options:

• Arteriovenous fistulas (AVF) or arteriovenous grafts (AVG) are strongly preferred over tunneled central venous catheters (CVC) due to lower infection risk and better outcomes. 4, 1
• Primary AV fistula should be created when creatinine clearance is 25 mL/min, serum creatinine is 4 mg/dL, or within 1 year of anticipated dialysis need. 4
• AV fistulas require 1 month minimum maturation time, ideally 3-4 months before cannulation. 4
• AV grafts should be placed 3-6 weeks prior to anticipated hemodialysis need and not used until at least 14 days after placement. 4
• Avoid subclavian vein catheterization as it causes central venous stenosis that precludes future ipsilateral arm access. 4

Intensive hemodialysis considerations:

• In-center short frequent hemodialysis (5+ sessions per week, <3 hours per session) can be considered as an alternative to conventional thrice-weekly hemodialysis after discussing benefits and risks. 4, 1
• Home long hemodialysis (6-8 hours, 3-6 nights per week) may be appropriate for patients who prefer this for lifestyle considerations. 1
• Intensive hemodialysis improves quality of life, blood pressure control, reduces left ventricular hypertrophy, and allows discontinuation of fluid, sodium, and phosphate restrictions. 4

Peritoneal Dialysis:

• Both hemodialysis and peritoneal dialysis are equally effective long-term replacement therapies. 4
• Peritoneal dialysis allows greater flexibility and independence than in-center hemodialysis. 5
• Regular dialysis fluid exchanges are essential to maintain effective clearance of uremic toxins and prevent fluid overload. 6
• Patients can typically have four years of successful peritoneal dialysis before needing to switch to alternative RRT. 5

Conservative Management (Palliative Approach)

• Conservative management should be offered as a reasonable alternative to dialysis for patients with limited life expectancy, severe comorbid conditions, or who wish to avoid medical interventions. 1, 2
• This approach should be supported by comprehensive palliative care for symptom management. 1

Management of Comorbid Conditions

Cardiovascular Disease

• Blood pressure control through adequate dialysis and sodium restriction is critical as it improves mortality in dialysis patients. 2
• For patients with chronic stable angina, ranolazine may be beneficial, particularly in those with hemodynamic instability. 1
• ACE inhibitors or angiotensin receptor blockers are preferred for hypertensive patients with proteinuria. 7

Diabetes Management

• Insulin is the preferred treatment for patients with ESRD and diabetes mellitus requiring medication. 2
• Control of hyperglycemia is essential to reduce complications. 8
• Patients with diabetes and ESRD experience improved survival with enhanced Kt/V on dialysis or kidney transplantation. 8

Mineral and Bone Disorders

• Cinacalcet effectively reduces iPTH levels in ESRD patients on dialysis with secondary hyperparathyroidism. 9
• In clinical trials, 40% of patients on cinacalcet achieved iPTH ≤250 pg/mL compared to 5% on placebo (p<0.001). 9
• Cinacalcet also reduces calcium-phosphorus product, serum calcium, and phosphorus levels. 9
• For patients on long or long-frequent hemodialysis, maintain dialysate calcium at 1.50 mmol/L or higher to ensure neutral or positive calcium balance. 1
• If hypophosphatemia persists despite discontinuation of phosphate binders and diet liberalization, consider phosphate dialysate additives. 1

Nutritional Management

• Monitor patients for signs of protein-energy wasting and malnutrition, as poor nutritional status markedly increases mortality risk. 2, 8
• Treatment of malnutrition is a basic principle guiding therapy in ESRD patients with diabetes. 8

Anemia Management

• Recombinant human erythropoietin (rHuEPO) at 5,000 IU per day (30,000-40,000 IU per week) is the optimal dose for improving quality of life in ESRD patients. 4

Vaccination and Preventive Care

• Vaccinate against seasonal influenza, tetanus, hepatitis B, human papillomavirus (through age 26), and Streptococcus pneumoniae. 2
• Routine cancer screening for patients not receiving kidney transplantation is discouraged. 2

Critical Pitfalls to Avoid

• Never use subclavian vein catheters for temporary access as they cause irreversible central venous stenosis. 4
• Do not insert hemodialysis catheters until hemodialysis is actually needed to maximize their use-life. 4
• Avoid nephrotoxic drugs (non-steroidal anti-inflammatory agents, nephrotoxic antibiotics) and promptly treat infections, dehydration, hypercalcemia, and hyperuricemia. 4
• For intensive hemodialysis patients using AVF, use rope-ladder cannulation technique over buttonhole cannulation unless topical antimicrobial prophylaxis (mupirocin) is applied. 1

Individualized ESRD Life-Plan

• Develop an individualized ESRD Life-Plan for each patient considering medical situation, life goals, preferences, social support, and functional status. 1
• Review and update this plan regularly with annual comprehensive reviews and quarterly updates of vascular access functionality. 1
• The plan should be created by a coordinated team including nephrologist, surgeon, radiologist, nurse, and patient support persons. 1