What are the indications for continuing or intensifying maintenance hemodialysis in a chronic kidney disease patient already on maintenance hemodialysis?

Indications for Continuing Maintenance Hemodialysis in CKD Patients Already on Dialysis

Patients already established on maintenance hemodialysis should continue therapy based on persistent uremic symptoms, inability to maintain metabolic homeostasis, volume control requirements, nutritional status, and alignment with patient goals of care rather than any specific laboratory threshold. 1

Core Clinical Indications for Ongoing Hemodialysis

Uremic Symptom Control

• Continue hemodialysis when uremic symptoms persist or recur, including nausea, fatigue, altered mental status, pericarditis, encephalopathy, or bleeding diathesis 1
• Patients experiencing these symptoms despite dialysis may require intensification of the dialysis prescription rather than discontinuation 2

Metabolic Management

• Maintain dialysis for refractory hyperkalemia (typically >6.5-7.0 mEq/L) unresponsive to dietary restriction and medical management 1
• Continue therapy for severe metabolic acidosis that cannot be controlled with oral bicarbonate supplementation (serum bicarbonate <22 mmol/L) 1, 3
• Electrolyte and acid-base disturbances requiring ongoing dialytic correction constitute absolute indications for continuation 1

Volume Status

• Persistent volume overload with refractory peripheral edema, dyspnea, or pulmonary congestion despite diuretic therapy mandates continued hemodialysis 1, 4
• Adequate ultrafiltration to maintain normal extracellular volume is an essential component of dialytic treatment 5

Nutritional Considerations

• Protein-energy malnutrition that persists despite vigorous nutritional optimization is an indication to continue and potentially optimize dialysis adequacy 2, 1
• The development or persistence of malnutrition with no apparent cause other than inadequate dialysis clearance requires continuation of therapy 2

Dialysis Adequacy Monitoring

Small-Solute Clearance Targets

• Delivered spKt/V should be at least 1.2 per treatment when dialyzing 3 times weekly to optimize clinical outcomes 2
• Patients not meeting this target may experience the "residual syndrome" with persistent symptoms requiring prescription adjustment rather than discontinuation 2

Residual Kidney Function Integration

• Monitor residual kidney function (Kru) monthly in patients with significant urine output, as abrupt loss of residual function necessitates immediate prescription adjustment to avoid inadequate dialysis 2
• When Kru changes abruptly (indicated by urine volume changes or during hospitalization), perform unscheduled adequacy measurements 2

Intensification Considerations

When to Increase Dialysis Intensity

• Consider longer or more frequent sessions when patients exhibit persistent uremic symptoms, inadequate volume control, or refractory metabolic abnormalities despite standard 3-times-weekly regimens 2, 6
• Younger patients, those with fatigue, previous vascular access complications, absence of heart failure, and shorter travel times show greater acceptance of intensified regimens 6

Treatment Frequency Options

• Standard regimen: 3 sessions per week, 4 hours per session 6
• Longer regimen: 3 sessions per week, 4.5 hours per session 6
• More frequent regimen: 4 sessions per week, 4 hours per session 6

Critical Pitfalls to Avoid

Common Management Errors

• Do not rely solely on laboratory values (such as eGFR or BUN) to determine continuation; clinical symptoms and quality of life must guide decisions 2, 4
• Avoid delaying prescription adjustments when adequacy measurements fall below target, as prolonged insufficient dialysis worsens outcomes 2
• Do not overlook cardiovascular complications, which represent the most common cause of mortality in dialysis patients and may require treatment optimization 7, 5

Access-Related Considerations

• Catheter-related bloodstream infections occur at 1.1-5.5 episodes per 1000 catheter-days, affecting approximately 50% of patients within 6 months 4
• Malfunction of dialysis access can interfere with adequate dialysis delivery and requires prompt intervention 4

Discontinuation Considerations

When Dialysis May Be Withdrawn

• Dialysis can be ethically discontinued when a patient with decision-making capacity requests withdrawal, has irreversible profound neurologic impairment, or has terminal illness from non-renal causes 8
• Patients who are dialysis-dependent without extrarenal disease manifestations may not require maintenance immunosuppressive therapy (in the context of vasculitis), but this does not indicate dialysis discontinuation 2
• All patients who forego dialysis must receive comprehensive palliative care with hospice involvement 8

Shared Decision-Making Framework

• Patients with decision-making capacity have the absolute right to refuse or withdraw dialysis, and this decision must be respected by the renal care team 8
• Time-limited trials with predetermined reassessment endpoints should be offered when prognosis is uncertain 8

Monitoring Parameters for Ongoing Therapy

Regular Assessment Schedule

• Monitor delivered Kt/V monthly to ensure adequacy targets are consistently met 2
• Assess nutritional status regularly using serum albumin, normalized protein nitrogen appearance (nPNA), and anthropometric measurements 2
• Evaluate cardiovascular status continuously, as hypertension and cardiac disease require aggressive management in dialysis patients 5

Laboratory Surveillance

• Track predialysis and postdialysis BUN ratios to calculate spKt/V 2
• Monitor serum bicarbonate, potassium, calcium, phosphorus, and parathyroid hormone levels 3, 5
• Assess hemoglobin and consider transfusion support in patients with marginal cardiovascular function 5