How should refractory volume overload be managed in an end‑stage renal disease patient who refuses hemodialysis?

Managing Refractory Volume Overload in ESRD Patients Who Refuse Hemodialysis

For patients with end-stage renal disease who refuse hemodialysis, you should pursue aggressive medical management with combination diuretics (metolazone 2.5-10mg daily plus high-dose loop diuretics), sodium restriction to 2g daily, and fluid restriction to 2L daily, while simultaneously initiating integrated palliative care to address symptoms and quality of life. 1, 2, 3

Immediate Pharmacologic Management

First-Line: Sequential Nephron Blockade

• Start metolazone 2.5-10mg once daily in addition to maximizing loop diuretic dosing (e.g., torsemide up to 200mg daily or furosemide up to 600mg daily), as this combination works synergistically even at GFR <30 mL/min. 2
• Alternative thiazide options include hydrochlorothiazide 25-100mg once or twice daily, or IV chlorothiazide 500-1000mg if oral absorption is compromised. 2
• Check electrolytes (potassium, sodium, magnesium), renal function, and blood pressure daily during active diuresis due to high risk of electrolyte depletion. 2

If Oral Combination Therapy Fails

• Consider hospitalization for IV loop diuretics at 2-2.5 times the home oral dose, administered as continuous infusion or frequent boluses. 2
• Low-dose dopamine infusion (2-5 mcg/kg/min) may be added to loop diuretics to improve diuresis and potentially preserve remaining renal function. 2
• Target weight loss of 0.5-1.0 kg daily during active diuresis, monitoring for signs of excessive volume depletion (hypotension, worsening azotemia beyond baseline). 2

Critical Pitfall to Avoid

• Do not reduce diuretics due to mild-to-moderate increases in creatinine or BUN if the patient remains volume overloaded and asymptomatic, as small elevations should not lead to minimizing therapy intensity. 2

Essential Non-Pharmacologic Interventions

Dietary Modifications

• Restrict dietary sodium to ≤2g daily to reduce fluid retention and support diuretic efficacy. 2, 3
• Implement fluid restriction to 2L daily to minimize volume accumulation between treatment interventions. 2

Preserving Residual Kidney Function

• Aggressively preserve any remaining kidney function by avoiding nephrotoxins (NSAIDs, aminoglycosides, contrast agents), maintaining adequate perfusion, and preventing hypotension. 1
• Residual kidney function provides continuous solute clearance and allows more liberal fluid intake, significantly improving volume management and survival. 1

Palliative Care Integration (Mandatory Component)

When to Initiate Palliative Care

• All patients with ESRD who refuse or discontinue dialysis should receive integrated palliative care immediately, not as an afterthought. 1
• This approach is patient- and family-centered, focusing on reducing symptom burden and improving quality of life rather than disease-modifying interventions. 1

Symptom Management Priorities

• Address dyspnea (from volume overload and uremia) with opioids (fentanyl or methadone preferred in ESRD), supplemental oxygen, and positioning. 1, 4
• Manage fatigue through treatment of anemia (if appropriate given goals of care), optimization of nutrition, and screening for depression. 4
• Control pruritus with phosphate binders, ondansetron, or naltrexone. 4
• Treat nausea with ondansetron, metoclopramide, or haloperidol. 4
• Address pain with fentanyl or methadone (safest opioids in ESRD), avoiding morphine and codeine due to toxic metabolite accumulation. 4

Advance Care Planning

• Ensure advance directives are documented, including specific situations where the patient would want or refuse interventions (hospitalization, ICU care, mechanical ventilation). 1, 4
• Engage in shared decision-making through open and empathetic discussions about prognosis, expected symptom trajectory, and goals of care. 1

Alternative Renal Replacement Consideration: Peritoneal Dialysis

Why Consider PD in Dialysis-Refusing Patients

If the patient's refusal is specifically about hemodialysis (not all dialysis), peritoneal dialysis may be acceptable as it:

• Can be performed at home without vascular access 5
• Provides continuous, gentle fluid removal 5
• May be better tolerated than intermittent hemodialysis 5

PD Prescription for Volume Overload

If PD is acceptable to the patient:

• Use manual CAPD with 4-5 short exchanges daily rather than APD with long dwells, as long dwells (>8 hours) cause net fluid reabsorption that worsens volume overload. 6
• Use icodextrin solution for any necessary long dwells to maintain ultrafiltration throughout extended dwell times. 6
• Never allow negative ultrafiltration (fluid absorption) in any exchange when managing volume overload. 6
• Monitor drain volumes closely and adjust dwell times/glucose concentrations to optimize fluid removal. 1, 6

When Medical Management Fails

Ultrafiltration

• Isolated ultrafiltration may be considered as a last resort for refractory congestion unresponsive to all diuretic strategies, though this requires the patient to accept a dialysis-like procedure. 2

Prognosis and Expectations

• Conservative management (maximal medical therapy without dialysis) is a recognized alternative for ESRD patients with severely limited life expectancy, low quality of life, or progressive deterioration from untreatable disease. 1
• Without dialysis, life expectancy depends on residual kidney function, comorbidities, and degree of uremia, typically ranging from weeks to months. 1, 3
• Nondialytic management may not significantly decrease life expectancy in older patients with multiple comorbidities compared to dialysis initiation. 4

Monitoring Strategy

• Assess volume status, symptoms, and functional status weekly during active management. 2
• Re-evaluate goals of care regularly as the clinical situation evolves, ensuring alignment between interventions and patient wishes. 1
• Involve palliative care and hospice services early rather than waiting until the terminal phase. 1, 4