What are the treatment options for a patient with end-stage renal disease (ESRD)?

Treatment for End-Stage Renal Disease

For patients with ESRD, kidney transplantation is the treatment of choice and should be offered to all suitable candidates, as it provides superior survival and quality of life compared to dialysis. 1, 2

Primary Treatment Modalities

Kidney Transplantation (First-Line Treatment)

Transplantation should be pursued pre-emptively before dialysis initiation whenever possible. 3

• Live donor transplantation achieves 90% ten-year survival, compared to 74% with deceased donor organs. 3
• Transplantation replicates normal renal physiology far more closely than any dialysis modality 3
• Referral for transplant evaluation should occur when patients reach advanced CKD (stages 4-5) 1

Transplant candidacy requirements: 3

• Adequate cardiovascular status to tolerate general anesthesia and surgery
• Sufficient vascular supply and urinary drainage capacity
• Anatomic space for kidney placement
• Ability to tolerate long-term immunosuppression

Special considerations for sickle cell disease patients: 1

• Referral for renal transplant is recommended despite very low certainty evidence
• Adhere closely to perioperative transfusion requirements
• Use corticosteroids judiciously in immunosuppression regimens due to vaso-occlusive pain risk
• One-year survival post-transplant is 88% (95% CI: 80.1-95.5%) 1

Dialysis Modalities

When transplantation is not immediately available or contraindicated, dialysis becomes necessary, with no conclusive evidence favoring either modality for long-term mortality. 3, 2

Hemodialysis

• Most commonly used modality, typically performed at dialysis centers three times weekly 2, 4
• Annual mortality ranges from 17-20% in the United States 5
• Three-year and five-year survival rates are only 55% and 40% respectively 5
• Requires vascular access via: 2
  • Arteriovenous fistula (preferred): Provides superior one-year survival (84%) but requires several months to mature 5, 2
  • Arteriovenous graft: Can be used in 24 hours depending on material; one-year survival 78.2% 5, 2
  • Central venous catheter: Usable immediately but highest infection risk; one-year survival only 69.6% 5, 2

Critical management parameters for hemodialysis: 5

• Maintain minimum single-pool Kt/V of 1.2 for thrice-weekly dialysis
• Target URR ≥65%
• Monitor interdialytic home blood pressure (not pre/post-dialysis readings, which correlate poorly with mortality) 5
• Achieve dry weight through progressive ultrafiltration

Peritoneal Dialysis

• Performed at home, offering greater flexibility 3, 2
• Does not provide the same level of fluid and toxin removal as hemodialysis 3
• Many patients require transfer to hemodialysis within 2-3 years as PD gradually loses effectiveness 3
• Age is not a contraindication; can be used safely in older patients 6
• Assisted peritoneal dialysis is effective for patients with functional limitations 6

Conservative Management (Non-Dialytic Approach)

For patients with severely limited life expectancy, severe comorbidities, or who wish to avoid medical interventions, conservative management with integrated palliative care is a reasonable alternative to dialysis. 7, 8

When to Consider Conservative Management: 8

• Severely limited life expectancy
• Low quality of life
• Refractory pain
• Progressive deterioration from untreatable disease

Essential Components: 7, 8

• Integrated palliative care focusing on symptom burden reduction and quality of life improvement 7, 8
• Multidisciplinary team approach involving nephrology, primary care, community nurses, and palliative care specialists 7, 8
• Regular symptom screening using validated tools (ESAS-r:R or Dialysis Symptom Index) 7
• Management of common symptoms: fatigue, sleep disturbances, dyspnea, anxiety, pruritus, xerostomia 7, 8
• Bereavement support for families after patient death 7

Survival comparison: Conservative management has been shown to offer comparable survival rates and hospital-free days to RRT in selected older patients 6

Medical Management of ESRD Complications

Anemia Management

Do NOT target hemoglobin levels greater than 11 g/dL with erythropoiesis-stimulating agents (ESAs), as this increases mortality, cardiovascular events, and stroke risk. 9

ESA dosing principles: 9

• Initiate treatment only when hemoglobin is less than 10 g/dL
• Use the lowest dose sufficient to reduce RBC transfusion need
• For adult CKD patients on dialysis: start 50-100 Units/kg three times weekly
• If hemoglobin approaches or exceeds 11 g/dL, reduce or interrupt ESA dose
• Monitor hemoglobin weekly until stable, then monthly
• Evaluate and supplement iron when ferritin <100 mcg/L or transferrin saturation <20% 9

Critical safety data: 9

• NHS trial: Higher mortality (35% vs 29%) with hemoglobin target of 14 g/dL vs 10 g/dL
• CHOIR trial: 18% major cardiovascular events with hemoglobin 13.5 g/dL vs 14% with 11.3 g/dL
• TREAT trial: Stroke risk nearly doubled (HR 1.92) with higher hemoglobin targets

Metabolic Complications

Metabolic acidosis: 1

• Monitor serum bicarbonate at least every 3 months when GFR ≤30 mL/min/1.73 m²
• Correct chronic metabolic acidosis to serum bicarbonate ≥22 mmol/L

Mineral and bone disorders: 1

• Measure serum calcium and phosphorus at least every 3 months when GFR ≤30 mL/min/1.73 m²
• Measure intact PTH at least once initially
• If calcium/phosphorus abnormal, monitor iPTH at least every 3 months

Blood pressure control: 1

• Optimize blood pressure to reduce nephropathy progression
• Use ACE inhibitors or ARBs as first-line agents 1, 5

Cardiovascular Disease Management

Cardiovascular disease is the leading cause of death in ESRD patients. 5

Post-myocardial infarction management: 5

• Treat identically to non-dialysis population
• Use percutaneous coronary intervention, CABG, antiplatelet agents, beta-blockers, and lipid-lowering agents
• For ST-elevation MI, prefer emergent PCI over thrombolytic therapy (increased hemorrhagic risk)
• Implement prophylactic care including aspirin, beta-blockers, and ACE inhibitors
• Without treatment, post-MI dialysis patients face approximately 75% mortality within 2 years 5

Diabetes Management

Insulin is the preferred treatment for ESRD patients with diabetes requiring medication. 4

Vaccination Requirements

For all ESRD patients, vaccinate against: 4

• Seasonal influenza
• Tetanus
• Hepatitis B
• Human papillomavirus (through age 26)
• Streptococcus pneumoniae

Common Pitfalls

• Preserving peripheral veins is critical for patients with stage III-V CKD who may require hemodialysis 4
• Avoid relying on pre-dialysis or post-dialysis blood pressure measurements; use interdialytic home readings instead 5
• Do not withhold standard post-MI therapies due to dialysis status 5
• Recognize that low blood pressure in dialysis patients may paradoxically indicate higher mortality risk from underlying cardiac dysfunction 5
• Routine cancer screening for patients not receiving kidney transplantation is discouraged 4
• Monitor for protein-energy wasting and malnutrition 4