Plan of Care for ESRD Patients on Hemodialysis
For patients with ESRD on hemodialysis, establish arteriovenous fistula or graft as the primary vascular access, optimize dialysis adequacy through individualized prescription (considering incremental approaches for those with residual kidney function), manage complications including anemia and mineral-bone disorders, and maintain strict medication reconciliation at every encounter to avoid nephrotoxic agents and prescribing cascades. 1, 2, 3, 4
Vascular Access Management
Prioritize arteriovenous fistula (AVF) or arteriovenous graft (AVG) over tunneled central venous catheter for all patients receiving hemodialysis. 5
- AVF requires several months to mature before use but provides the best long-term outcomes 3
- AVG can be used in as few as 24 hours depending on graft material 3
- Central venous catheters are usable immediately but carry the highest infection risk and should only be used when AVF/AVG is not feasible 3
- Protect the vascular access limb at all costs—avoid blood pressure measurements, venipuncture, and IV placement in the access arm 1
- Preserve peripheral veins in patients with stage III-V CKD who may eventually need hemodialysis 4
For Intensive Hemodialysis Patients:
- Use rope-ladder cannulation over buttonhole technique for AVF access unless topical antimicrobial prophylaxis is employed 5
- If buttonhole cannulation is used, apply mupirocin antibacterial cream to reduce infection risk 5
- For patients requiring CVC access, use "closed connector" devices over standard care 5
Dialysis Prescription and Adequacy
Tailor the dialysis prescription to the individual patient's residual kidney function, volume status, and clinical stability rather than defaulting to standard thrice-weekly sessions. 6, 7
Incremental Hemodialysis Approach:
Consider twice-weekly hemodialysis for patients with: 6
- Substantial residual kidney function (RKF >3-5 mL/min)
- Adequate volume control and preserved urine output
- Absence of significant anemia or electrolyte imbalances
- Low comorbidity burden and good nutritional status
- Satisfactory quality of life
Benefits of incremental approach include preservation of residual kidney function and extended arteriovenous access lifespan, but requires regular RKF monitoring (at least every 1-3 months) to increase frequency as kidney function declines. 6, 7
Critical caveat: Twice-weekly dialysis carries risks of increased hospitalization and mortality from fluid/electrolyte shifts after long interdialytic intervals—only appropriate for carefully selected patients. 6
For Long or Long-Frequent Hemodialysis:
- Use dialysate calcium ≥1.50 mmol/L to maintain neutral or positive calcium balance while avoiding predialysis hypercalcemia and PTH oversuppression 5
- Add phosphate to dialysate if hypophosphatemia persists despite stopping phosphate binders and liberalizing diet 5
Medication Management
Perform comprehensive medication reconciliation at every clinical encounter to identify all medications, prevent adverse drug interactions, and avoid prescribing cascades. 1, 2
Medication Selection Principles:
- Select antibiotics and other medications that avoid nephrotoxic agents and require no renal dose adjustment, prioritizing hepatically-metabolized options 1
- Avoid nephrotoxic agents even in dialysis-dependent patients, as preserving residual kidney function remains critically important 1, 8
- Avoid all phosphate-containing products including certain topical preparations and enemas 1, 8
- For diabetes management, insulin is the preferred treatment for patients requiring medication 4
Diagnostic Imaging Considerations:
Do not withhold necessary CT with contrast if deep infection or life-threatening condition is suspected—the diagnostic benefit outweighs nephrotoxic risk in critical presentations. 1, 8
Management of Complications
Anemia Management:
- Iron supplementation is nearly universal in hemodialysis patients receiving erythropoiesis-stimulating agents 2
- Monitor for iron overload from excessive IV iron administration 2
- Erythropoietin resistance index should be tracked regularly 7
Mineral and Bone Disorders:
- Monitor and treat hyperphosphatemia, hypocalcemia, and secondary hyperparathyroidism 3, 4
- Adjust phosphate binders and vitamin D analogs based on laboratory values 7
- Consider cinacalcet for refractory hyperparathyroidism 7
Volume and Blood Pressure Control:
- Control blood pressure through adequate dialysis and sodium restriction to improve mortality 4
- Volume control is achieved through adequate dialysis ultrafiltration and dietary sodium restriction 4
- Maintain preserved urine output when possible, as this aids volume management 7
Electrolyte Management:
- Monitor for hyperkalemia and treat with dietary restriction, potassium binders, and adequate dialysis 3
- Address metabolic acidosis through dialysate bicarbonate adjustment 3
- Monitor electrolytes after any intervention to prevent disturbances 2
Nutritional Status:
- Monitor for protein-energy wasting and malnutrition at every visit 3, 4
- For patients on incremental dialysis with preserved RKF, standard low-protein diet (0.6-0.8 g/kg/day) may be beneficial 7
- Ensure adequate caloric intake to prevent hypercatabolism 6
Preventive Care and Vaccinations
Administer vaccinations for seasonal influenza, tetanus, hepatitis B, human papillomavirus (through age 26), and Streptococcus pneumoniae. 4
- Routine cancer screening is discouraged for patients not receiving kidney transplantation 4
Kidney Transplantation Evaluation
Refer all appropriate candidates for kidney transplantation evaluation, as transplantation yields the best patient outcomes compared to dialysis. 3, 4
- Transplantation is the treatment of choice for eligible ESRD patients 3
- Referral should be offered early in the disease course 4
Alternative Care Pathways
Palliative and Supportive Care:
For patients with severely limited life expectancy, severe comorbid conditions, or those who wish to avoid medical interventions, a palliative approach to ESRD is a reasonable alternative to dialysis. 2, 3, 4
- Palliative care and hospice referral are indicated for patients who decline renal replacement therapy or choose to discontinue dialysis 3
- Focus on symptom management rather than definitive interventions for patients with poor quality of life 2
- Assess symptom burden regularly, as ESRD patients have high physical symptom burden requiring ongoing palliative approaches 2
Home Dialysis Considerations
Present home dialysis (peritoneal dialysis or home hemodialysis) as a first-line option, as it offers high quality treatment, greater patient independence, and is financially attractive. 9