What are the evidence‑based guidelines for the comprehensive care of chronic dialysis patients, including vascular access, dialysis adequacy, fluid and electrolyte management, anemia, bone‑mineral disease, nutrition, cardiovascular risk, infection prevention, medication dosing, and routine monitoring?

Comprehensive Guidelines for Dialysis Patient Care

Dialysis patient care should follow the KDOQI evidence-based framework that addresses vascular access optimization, dialysis adequacy monitoring, metabolic complications, cardiovascular risk reduction, and individualized treatment planning through a patient-centered "Life-Plan" approach. 1, 2

1. Timing of Dialysis Initiation

Initiate dialysis based on clinical symptoms and complications, not GFR alone. 1, 2, 3

• Start dialysis when GFR falls below 10 mL/min/1.73 m² and uremic symptoms are present (nausea, vomiting, encephalopathy, serositis, pruritus). 2, 3
• Absolute indications include: life-threatening hyperkalemia, severe metabolic acidosis unresponsive to medical therapy, refractory volume overload/pulmonary edema, uremic pericarditis, and protein-energy wasting (>6% weight loss in <6 months or albumin drop ≥0.3 g/dL to <4.0 g/dL). 2, 3
• Do not initiate dialysis early based solely on GFR thresholds - the 2015 KDOQI guidelines explicitly state there is no survival advantage to early initiation, and observational studies show hazard ratios of 1.14-2.44 for death with higher GFR initiation. 1, 3
• Begin patient education and access planning at CKD stage 4 (GFR <30 mL/min/1.73 m²), covering all options: in-center HD, home HD, peritoneal dialysis, transplantation, and conservative management. 1, 2

2. Vascular Access Management

Arteriovenous fistula (AVF) is the preferred permanent access and should be created during CKD stage 4 to allow adequate maturation. 1, 2

• AVF carries the lowest infection risk and should be the first choice when suitable vessels are available, requiring 1-3 months for maturation. 2, 4
• Arteriovenous graft (AVG) is second-line when AVF creation is not feasible, usable 2-4 weeks after placement. 4
• Tunneled cuffed catheters should be temporary - place in internal jugular vein (first choice), then external jugular, femoral, subclavian, and lumbar veins in order of preference. 4
• Right-sided catheter placement is preferred over left due to more direct venous anatomy. 4
• Avoid subclavian vein catheterization as it causes central venous stenosis, limiting future access options. 4
• Long-term catheters are only appropriate for patients with limited life expectancy, multiple failed AV accesses with no options, or informed patient preference after discussing risks. 4
• Perform quarterly reviews of vascular access functionality, complication risks, and future access options. 4
• De-emphasize routine AV access surveillance but increase emphasis on improved monitoring training and application. 1

3. Dialysis Adequacy Targets

For thrice-weekly hemodialysis, achieve minimum urea reduction ratio (URR) ≥65% or single-pool Kt/V ≥1.2. 1, 2

• Measure dialysis dose regularly to ensure adequate small-solute removal. 1
• Increasing dose beyond Kt/V >1.2 or using high-flux membranes does not confer additional mortality benefit - the HEMO Study definitively showed no advantage. 1, 2
• Weekly residual renal Kt/Vurea <2.0 (approximately 7 mL/min urea clearance) signals the need to start dialysis. 2
• Standard prescription: 3-4 hours per session, three times per week, adjusted based on residual kidney function, patient size, and volume status. 2

4. Alternative Dialysis Modalities

Consider frequent or extended hemodialysis for select patients after discussing quality of life benefits and risks. 1

• In-center short frequent hemodialysis (>3 times/week) may improve volume control and blood pressure but increases risk of vascular access procedures and intradialytic hypotension. 1
• Home long hemodialysis (6-8 hours, 3-6 nights/week) can be considered for appropriate candidates. 1
• Peritoneal dialysis may better preserve residual kidney function and provides gentler, continuous solute removal. 2
• PD adequacy targets are adjusted according to residual kidney function; CAPD involves 4-5 manual exchanges daily, APD uses overnight cycler. 2

5. Fluid and Blood Pressure Management

Manage volume status through ultrafiltration rate control and dry weight assessment to prevent intradialytic hypotension. 1, 2

• Intradialytic hypotension results from rapid ultrafiltration and loss of residual kidney function, and repeated episodes accelerate residual function decline. 2
• Management strategies: lower ultrafiltration rate, reassess dry weight, use cooled dialysate, add midodrine for refractory cases. 2
• Inability to control volume status or blood pressure despite diuretic therapy is an indication for dialysis initiation. 3
• Emphasize close collaboration with patients over fluid removal targets. 5

6. Anemia Management

Monitor hemoglobin and iron parameters regularly; catheter patients require higher EPO doses than those with AV access. 6, 7

• Incident dialysis patients have lower hemoglobin (9.9 vs 11.0 g/dL) and transferrin saturation (26 vs 31%) compared to prevalent patients. 6
• Patients dialyzed via central venous catheters require higher recombinant EPO doses (U/kg/week) to achieve similar hemoglobin levels compared to AVF/AVG patients. 7
• Treatment time and transferrin saturation are major factors influencing attainment of anemia treatment targets. 6
• Significant improvements in hemoglobin and TSAT occur within the first 6 months of hemodialysis when protocols are followed. 6

7. Nutrition Management

Monitor protein-energy wasting aggressively and provide adequate protein and caloric intake. 1, 2

• Hemodialysis patients require ≥1.2 g protein/kg/day (≥50% high-biological-value) and energy 35 kcal/kg/day (<60 years) or 30-35 kcal/kg/day (≥60 years). 2
• Peritoneal dialysis patients require 1.2-1.3 g protein/kg/day with same energy targets. 2
• Monitor with serum albumin, pre-albumin, transferrin, Subjective Global Assessment, anthropometry, and dietary intake. 2
• Low serum albumin at dialysis initiation independently predicts higher mortality. 2
• Incident patients have lower albumin (37 vs 40 g/L) compared to prevalent patients, with significant improvement over first 6 months. 6
• Progressive malnutrition refractory to dietary intervention is an absolute indication for dialysis initiation. 3

8. Mineral-Bone Disorder Management

Monitor parathyroid hormone, calcium, and phosphorus regularly; treat hyperkalemia with dietary restriction and adequate dialysis. 2, 6

• Incident patients have lower iPTH (372 vs 496 pg/ml) compared to prevalent patients, with significant improvement over 6 months. 6
• Hyperkalemia is treated with dietary potassium restriction, adequate dialysis, and sodium polystyrene sulfonate when needed. 2
• Persistent hyperkalemia unresponsive to medical management is an absolute indication for dialysis initiation. 3
• Dialysate potassium levels must be individualized to prevent excessive removal or inadequate clearance. 5

9. Cardiovascular Risk Management

Address cardiovascular disease early, as complications begin years before dialysis initiation. 1, 8

• Nearly one-third of patients with mild CKD (creatinine clearance 50-75 mL/min) already show left ventricular hypertrophy, increasing to 75% by dialysis start. 1
• Cardiovascular disease is the leading cause of death in dialysis patients, with first-year mortality exceeding 20%. 1, 8
• Traditional risk factors (smoking, dyslipidemia, blood pressure, glycemic control) and non-traditional factors (anemia, vitamin D/hyperparathyroidism, calcium/phosphorus metabolism, magnesium) require attention. 8
• Current evidence does not support routine statin use or antiplatelet medication in dialysis patients. 8

10. Infection Prevention

Minimize catheter use and duration to reduce infection risk, which is highest with central venous catheters. 1, 4, 7

• Prolonged catheter dependence increases mortality and severe infection risk. 4
• Target infection rate reduction for central venous catheters as a primary performance measure. 1
• AVF has the lowest infection risk among all access types. 2

11. Pre-Dialysis Preparation (CKD Stage 4)

Implement comprehensive preparation when GFR 15-29 mL/min/1.73 m² including education, access planning, and nutritional counseling. 2, 3

• Provide intensive dietary counseling every 1-2 months, targeting protein 0.6-0.75 g/kg/day and energy 35 kcal/kg/day (<60 years) or 30-35 kcal/kg/day (≥60 years). 2
• Consider keto-analog supplementation when restricting protein intake. 2
• Monitor nutritional markers, inflammatory markers (CRP), and estimate GFR using validated equations or measured clearances - not serum creatinine alone. 2
• Education must cover all kidney replacement options and involve family members and caregivers. 1, 2
• Create vascular access when eGFR falls to 15-20 mL/min/1.73 m². 3

12. Routine Monitoring and Quality Targets

Establish three primary performance targets: individualized Life-Plan updates, dialysis adequacy achievement, and access-specific complication reduction. 1

• Each patient requires a regularly updated Life-Plan designed with their goals to achieve the most suitable dialysis access type. 1
• Track URR/Kt/V achievement rates as adequacy targets. 1, 6
• Monitor access-specific complications (infection rates for catheters, thrombosis rates for AV access). 1
• Significant improvements in adequacy (Kt/V), albumin, hemoglobin, TSAT, and iPTH occur within first 6 months when protocols are followed. 6

13. Special Populations

Diabetic patients may require earlier dialysis initiation and closer nutritional monitoring. 2

• Nutritional deterioration becomes apparent when GFR falls below 50 mL/min and creatinine clearance drops below 25 mL/min in diabetics. 2
• Elderly and frail patients may not benefit from dialysis; conservative management without dialysis is legitimate. 3
• Patients with multiple comorbidities tend to start dialysis at higher GFR due to earlier symptom development. 3

14. Conservative (Non-Dialytic) Management

Conservative management is appropriate until GFR declines below 15 mL/min/1.73 m² unless specific complications develop. 2

• Low-protein diet 0.6-0.75 g/kg/day with keto-analog supplementation. 2
• Loop diuretics for volume control and sodium polystyrene sulfonate for hyperkalemia. 2
• Emphasize palliative care and hospice referral for patients who decline dialysis. 2

15. Critical Pitfalls to Avoid

• Never start dialysis based solely on GFR threshold without assessing symptoms or complications - early initiation provides no survival benefit and increases complication exposure. 1, 2, 3
• Never postpone nephrology referral - refer patients at CKD stage 4 to allow adequate preparation. 2
• Never overlook malnutrition as it is linked to increased mortality at dialysis initiation. 2
• Never use prolonged catheter dependence when AV access is feasible - catheter patients have poorer adequacy, lower albumin, and require higher EPO doses despite similar hemoglobin levels. 4, 7
• Never assume all patients benefit equally - despite practice guidelines, patients dialyzed via catheters have persistently poorer outcome measures requiring appropriate adjustments. 7