What is the comprehensive management approach for a patient on maintenance hemodialysis?

Comprehensive Management of Maintenance Hemodialysis Patients

Patients on maintenance hemodialysis require a structured approach encompassing dialysis prescription optimization, vascular access management, volume control, symptom management, and preservation of residual kidney function to maximize survival and quality of life. 1

Dialysis Prescription and Adequacy

Standard hemodialysis consists of 3 sessions per week, 3-5 hours per session, with a target single pool Kt/V of 1.4 and minimum delivered spKt/V of 1.2. 1 Treatment time should be at least 3 hours per session for patients with residual kidney function <2 mL/min. 1

• Measure delivered dialysis dose monthly using properly collected pre- and post-dialysis BUN samples to calculate Kt/V or URR, ensuring adequacy targets are consistently met. 2
• For patients with large interdialytic weight gains and high ultrafiltration requirements, consider additional sessions or longer treatment times to prevent intradialytic hypotension. 1
• Intensive hemodialysis options include short daily hemodialysis (≥5 sessions/week, <3 hours each) or long hemodialysis (≥5.5 hours/session, 3-4 times weekly), which improve quality of life, reduce left ventricular hypertrophy, and provide better blood pressure control. 1

Vascular Access Management

Arteriovenous fistula (AVF) is strongly preferred over arteriovenous graft (AVG) or central venous catheter due to lower infection risk and superior outcomes. 1 AVF has the lowest infection and thrombosis rates, longest patency, and best morbidity and mortality outcomes of any access modality. 3

• Inspect vascular access site at every session for patency, signs of infection, and complications. 2
• Assess fistula integrity using hydraulic compression test to detect potential recirculation. 2
• For intensive home hemodialysis with AVF, use rope-ladder cannulation over buttonhole technique unless topical antimicrobial prophylaxis is employed. 2
• If central venous catheter is necessary, use "closed connector" devices to reduce infection risk. 2

Volume and Blood Pressure Control

Achieve true dry weight through appropriate ultrafiltration at every session, dietary sodium restriction to <2 grams daily, and lower dialysate sodium concentrations (135-140 mmol/L rather than 145-155 mmol/L). 4 High dialysate sodium and sodium profiling should be discouraged as they aggravate thirst, fluid gain, and hypertension. 4

• Monitor blood pressure throughout each session to detect intradialytic hypotension, particularly in patients with low residual kidney function. 2
• Document pre- and post-dialysis weight, comparing to target dry weight at every session. 2
• Recognize the lag phenomenon: persistent hypertension during volume control should not be construed as treatment failure, as blood pressure normalization may take weeks to months after achieving dry weight. 4
• Loop diuretics (furosemide, bumetanide, torsemide) can promote sodium and water loss in patients with residual urine output, reducing ultrafiltration requirements during dialysis, but use with caution. 4

Preservation of Residual Kidney Function

Residual kidney function is one of the most important predictors of patient survival and must be actively preserved. 4 RKF provides continuous clearance of small and large solutes, permits more fluid and potassium intake, and reduces fluctuations in body fluid volumes. 4

• Measure 24-hour urine collection for urea clearance (Kr) at least every 4 months or when decreased RKF is suspected. 4
• Avoid nephrotoxic insults: NSAIDs, aminoglycosides, radiocontrast agents, and episodes of intravascular volume depletion during hemodialysis. 4
• Maintain hemodynamic stability during dialysis by avoiding excessive ultrafiltration, maintaining target hematocrit, reducing dialysate temperature, and considering midodrine administration pre-dialysis. 4
• ACE inhibitors and ARBs are generally renoprotective despite causing reversible decreases in GFR, though caution is warranted in ischemic renal disease. 4
• Use of biocompatible membranes, high-flux dialysis, bicarbonate buffers, and ultrapure water may contribute to more prolonged preservation of RKF. 4

Dialysate Composition

Use dialysate calcium ≥1.50 mmol/L to maintain neutral or positive calcium balance while avoiding predialysis hypercalcemia and oversuppression of PTH. 1, 2

• Adjust dialysate potassium based on individual patient needs to prevent excessive removal or inadequate clearance. 5
• If hypophosphatemia persists after stopping phosphate binders and liberalizing diet in intensive hemodialysis patients, add phosphate to dialysate to maintain predialysis phosphate in normal range. 2

Symptom Management

Prioritize nonpharmacologic interventions first, including cognitive behavioral therapy, exercise, mindfulness, and social support, as these lack adverse effects and medication interactions. 4

Nonpharmacologic Approaches:

• Aerobic exercise reduces depressive symptom burden and may improve anxiety symptoms in hemodialysis patients, with moderate-quality evidence from meta-analyses. 4
• Physical activity reduces fatigue in chronic kidney disease patients based on small clinical trials. 4
• Cognitive behavioral therapy has demonstrated efficacy in reducing depression. 4
• Manual acupressure provides short-term benefits for fatigue and depression as an adjuvant intervention. 4
• Music reduces pain perception during arteriovenous fistula cannulation. 4

Pharmacologic Approaches:

• Exercise caution with SSRIs: small randomized placebo-controlled trials in hemodialysis patients have not shown consistent benefit over placebo and documented increased gastrointestinal adverse effects. 4
• When prescribing psychotropic medications, uptitrate from subtherapeutic doses carefully, prioritizing efficacy and safety, and consider adverse effects like QT prolongation and altered pharmacokinetics in kidney failure. 4
• Difelikefalin (highly selective kappa opioid receptor agonist) is now approved in the US and Europe for pruritus in hemodialysis patients. 4

Intradialytic Monitoring

Monitor blood pressure, extracorporeal pressures, blood flow rate (Qb), dialysate flow rate (Qd), and effective treatment time (Td) throughout each session, comparing to prescribed parameters. 2

• Review hemodialysis log to ensure prescribed versus actual parameters match. 2
• Assess patients post-dialysis for symptoms of dialysis disequilibrium syndrome and signs of excessive ultrafiltration. 2
• Obtain post-dialysis BUN sample using slow flow/stop pump technique to prevent sample dilution with recirculated blood. 2

Urgent Dialysis Indications

Immediate hemodialysis is required for: 1

• Persistent hyperkalemia unresponsive to medical therapy
• Severe metabolic acidosis
• Volume overload unresponsive to diuretics
• Overt uremic symptoms (pericarditis, encephalopathy, bleeding diathesis)
• Severe progressive hyperphosphatemia or symptomatic hypocalcemia

Common Pitfalls to Avoid

• Do not assume achieving Kt/V targets means comprehensive patient care is complete—adequacy is only one component of management. 1
• Do not rely solely on pre-dialysis blood pressure readings—they are imprecise estimates of interdialytic blood pressure and should not be used exclusively for hypertension management. 2
• Do not delay investigation when Kt/V or URR falls below target—systematically evaluate clearance (K) issues, treatment time (Td) issues, and sampling/processing errors. 2
• Do not use high dialysate sodium concentrations or sodium profiling routinely—these aggravate thirst, fluid gain, and hypertension despite reducing intradialytic symptoms. 4

Special Populations

Pregnant women with ESRD should receive long frequent hemodialysis either in-center or at home. 1 This intensive approach improves maternal and fetal outcomes compared to standard thrice-weekly dialysis.