inpatient / Nephrology

End-Stage Renal Disease (ESRD) and Missed Dialysis

Last Updated: 1/6/23


-- History: *** dialysis type (iHD, peritoneal), access (line, AV graft, AV fistula), schedule, last dialysis date, urine output, listed for transplant, protected limbs
-- Clinical/Exam: *** AMS, volume (JVP, crackles, ascites, edema, POCUS)
-- Data: *** VBG (pH), BMP (potassium, BUN), NT-proBNP
-- Etiology: diabetes, HTN, primary renal dx

-- Emergent indications for dialysis (acidosis pH 7.2 refractory to bicarb, hyperK >6 refractory to other methods, ingestion, overload refractory to diuretics, uremia leading to encephalopathy or pericarditis)
-- Continue inpatient dialysis on *** schedule
-- Volume/Pressure: *** pulling, midodrine support
-- Continue home *** phos binders (sevelamer, calcium acetate or carbonate), nephrocaps, calcium, vitamin D, bicarb
-- Avoid blood draws on ***
-- Renal Diet - 2g sodium, 1.5-3g potassium, low phos, 1L fluid restriction

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If You Remember Nothing Else

When patients present with ESRD or missed dialysis, you need to address acidosis, hyperkalemia and overload. Common home meds you should consider continuing include phosphate binders, nephrocaps, calcium, vitamin D, and bicarbonate. Be mindful of the timing and dosing of other medications, and coordinate with pharmacy. Avoid morphine, baclofen, gabapentin, fleets enemas, lovenox, and potassium repletion.

Clinical Pearls

  • The average life expectancy for patients on dialysis is 5-10 years; many can do much better, especially if younger and the cause of ESRD is primary renal dx vs T2DM or HTN; the biggest cause of death in ESRD patients is cardiovascular events
  • New HD starts in those with ESRD not based on specific GFR cutoff, but rather when symptoms start - poor PO intake and appetite, weight loss, nausea, lyte abnormalities, hypertension, overload
  • Fistula > graft - foreign material can lead to infections and clotting; however 60% of fistulas will not mature and not be able to be used; fistula can be used in 2-3 months, graft can be used in 2-3 weeks, TDC can be used immediately if in the right position
  • When you start hemodialysis, patients usually lose their RRF within a few months which itself makes going off dialysis essentially impossible and is associated with worse outcomes - RRF better with peritoneal dialysis in the short term
  • The general goal is to keep Hgb between 10-11 with EPO injections; lack of natural EPO 2/2 reduced functional renal mass
  • Avoid BP measurements and drawing labs on protected limbs (usually the non-dominant arm, especially antecubital fossa) and do not place PICCs in those patients
  • ACEi are proven to be most effective at preserving residual renal function (RRF)
  • Patients with ESRD have an increased risk of hypoglycemia, as insulin is not cleared as well
  • Should use unfractionated heparin for DVT ppx
  • Opioids like morphine and codeine should be avoided as they can build up rapidly and cause toxicity - choose hydromorphone and fentanyl
  • Should dose antibiotics after dialysis - coordinate with pharmacy
  • Dialyzable toxins include lithium, aspirin, methanol, ethylene glycol, metformin
  • Dialysis does not do a good job of getting rid of phosphorus, high levels can lead to more PTH which leads to resorption and bone disease - goal is to take in less phosphorus and binders (TUMS, sevelamer) can help with that - in general not great data to guide what to do here and what the evidence of tightly controlling this level is; just whatever works to keep phos levels in range
  • Conservative care is a perfectly reasonable option for patients with ESRD, and they often do better than you’d expect without dialysis
  • Transplant leads to best length of life and quality of life among the options; The rough age cutoff for transplant is ~70 years old
  • Cinacalcet is a calcimimetic that can also help keep PTH down
  • ESRD patients do not make vitamin D - need to supplement to help keep PTH down - usually given IV at dialysis
  • Patients on midodrine do poorly - likely not due to the medicine, but rather that those who need the BP support for whatever reason are sicker and more likely to have poor outcomes
  • Hypertension in ESRD patients is almost always driven by volume - best addressed by adjusting to their dry weight in the dialysis unit
  • Loop diuretics are okay to use if there is RRF, but may not work very well with low GFR
  • There are trials investigating whether ACEi should be stopped in CKD4+, but are totally fine to resume when the patient is on dialysis
  • As renal function worsens, hepcidin increases and thus oral absorption of iron goes down - very common to have IDA and need to supplement via IV; IDA made worse by blood loss associated with dialysis - usually addressed by the dialysis unit
  • You should stop all cancer screening for patients on dialysis unless they are very young and have much longer life expectancy
  • If you are not on a statin when you start dialysis, you do not have to start one, but you should continue if you are - odd guideline recommendation, but the no survival benefit probably due to it being too late to make a meaningful difference since life expectancy is already low
  • Do not use fleet’s enema in ESRD patients - tons of phosphate, leads to hypocalcium, can kill these patients
  • Gabapentin should not be given more than 300mg per day - very commonly accumulates and leads to AMS in ESRD; also avoid baclofen
  • ESRD patients are usually excluded from AC trials for AFib - usually okay for apixaban 2.5-5mg BID - but there are no trials
  • Don’t replete potassium after dialysis (or really at all on ESRD patients unless you have  a really good reason)
  • Dropping PTH does not lead to less fractures, less cardiovascular events - poor data

Trials and Literature

  • IDEAL Trial - when to start dialysis - start at GFR 12 vs 7 (essentially symptoms-based - poor PO intake and appetite, weight loss, nausea, lyte abnormalities, hypertension, overload) showed no difference in outcomes, so okay to wait (NEJM, 2010)
  • Survival Estimates for patients on dialysis by age and etiology - PDF

Other Resources