Section II — Renal Replacement
End Stage Renal Disease
Dialysis modality selection, vascular access planning, and chronic complication management. Focused on volume status, phosphate binders, and access vigilance.
Dialysis Modalities
Access: AV fistula (preferred), AV graft, tunneled catheter
Target spKt/V ≥ 1.2 per session
Dry weight assessed each session — fluid removal
Heparin or citrate anticoagulation during treatment
Vascular Access Hierarchy
preferred
AV Fistula
Matures 6–12 weeks
Lowest infection & thrombosis risk — gold standard
secondary
AV Graft
Usable 2–3 weeks
Synthetic bridge; higher thrombosis than fistula
temporary
Tunneled Catheter
Immediate
Highest infection risk; use as bridge only
AV Access Patency Assessment
Fistula & graft surveillance — exam, metrics, intervention
Look
- Skin integrity — erythema, breakdown, infection at needle sites
- Aneurysms, pseudoaneurysms, or scarring along the access
- Arm or facial swelling, distended collaterals (central stenosis)
Feel
- Thrill — continuous, soft palpable buzz over the access (normal)
- Bounding pulse without thrill suggests outflow obstruction
- Augmentation test — compress access, feel pulse loss proximally
Listen
- Bruit — low-pitched, continuous systolic-diastolic (normal)
- High-pitched or localized bruit → stenosis
- Absent bruit with pulsatile flow → venous outflow occlusion
Metric
AV Fistula
AV Graft
Note
Access flow (Qa)
< 600 mL/min → refer
< 600 mL/min → refer
> 25% decline trend also flags
Static venous pressure ratio
Variable
> 0.5 → stenosis
Ratio = access VP ÷ systemic MAP
Recirculation
> 10%
> 10%
Reversed flow or stenosis
Dynamic venous pressure
Rising trend
Rising trend
Trend across sessions, not single value
Dysfunction Red Flags
- Loss or change in thrill / bruit
- Difficulty cannulating or poor flow on the machine
- Prolonged bleeding after needle removal
- Arm swelling, high venous-pressure alarms
- Inadequate clearance — falling Kt/V or URR
- Unexplained drop in treated blood volume
Intervention Triggers
- 01Access flow < 600 mL/min or > 25% acute decline
- 02Static venous pressure ratio > 0.5 (graft)
- 03Recirculation > 10% on validated method
- 04Abnormal exam — absent thrill or altered bruit
- 05Escalate to fistulagram ± angioplasty / surgical revision
Chronic Complication Management
Anemia
Hb 10–11 g/dLDiagnostic Guidelines
- Check Hb every 3 months (monthly on ESA)
- Iron studies: TSAT < 20% or ferritin < 100 ng/mL → deficiency
- Exclude B12/folate deficiency, GI blood loss, hemolysis, malignancy
Medications
Epoetin alfa
50–100 U/kg · IV/SC 3×/week
Contraindication: Uncontrolled HTN; pure red cell aplasia; avoid Hb > 11.5
Darbepoetin alfa
0.45 mcg/kg · IV/SC weekly
Contraindication: Uncontrolled HTN; active malignancy
Iron sucrose
100 mg · IV weekly × 10
Contraindication: Hypersensitivity; ferritin > 800; active infection
Hyperphosphatemia
Phos 3.5–5.5 mg/dLDiagnostic Guidelines
- Check serum phosphorus monthly (q2 weeks if elevated)
- Dietary phosphate restriction 800–1000 mg/day
- Binders dosed with meals; monitor calcium to avoid hypercalcemia
Medications
Calcium acetate
667 mg · 1–2 tabs with each meal
Contraindication: Hypercalcemia (Ca > 10.2); high Ca-P product
Sevelamer
800 mg · 1–2 tabs with meals
Contraindication: Bowel obstruction; dysphagia; swallowing disorders
Lanthanum carbonate
500–1000 mg · chewable with meals
Contraindication: Bowel obstruction; severe hepatic impairment
Secondary Hyperparathyroidism
PTH 150–600 pg/mLDiagnostic Guidelines
- Check PTH, Ca, Phos every 3 months (monthly if abnormal)
- 25-OH vitamin D level annually
- Target PTH 2–9× upper limit of normal; avoid oversuppression (< 130)
Medications
Calcitriol
0.25–1 mcg · PO daily or IV with dialysis
Contraindication: Hypercalcemia; hyperphosphatemia
Cinacalcet
30 mg · PO daily, titrate (max 180 mg)
Contraindication: Hypocalcemia (Ca < 8.4); hypersensitivity
Etelcalcetide
5 mg · IV 3×/week at dialysis
Contraindication: Hypocalcemia; low PTH; GI bleeding risk
Volume Overload
Estimated dry weightDiagnostic Guidelines
- Assess dry weight each session; monitor BP and edema
- Interdialytic weight gain < 2.5 kg (< 4.5% body weight)
- Ultrafiltration rate < 10–13 mL/kg/hr to avoid hypotension
Medications
Furosemide
40–160 mg · PO BID (if residual function)
Contraindication: Anuria; severe hypokalemia; ototoxicity risk
Metolazone
2.5–5 mg · PO daily (added to loop)
Contraindication: Sulfa allergy; severe hypo-Na/K
Hypertension
Pre-HD < 140/90Diagnostic Guidelines
- Check BP pre-, intra-, and post-dialysis each session
- Home BP monitoring; 44-hr interdialytic ABPM if available
- Optimize dry weight first; then pharmacotherapy
Medications
Lisinopril (ACEi)
2.5–10 mg · PO daily
Contraindication: Pregnancy; hyperkalemia; bilateral RAS; angioedema
Losartan (ARB)
25–50 mg · PO daily
Contraindication: Pregnancy; hyperkalemia; bilateral RAS
Metoprolol succinate
25–50 mg · PO daily
Contraindication: Severe bradycardia; decompensated HF; asthma
Access Infection
Prompt recognitionDiagnostic Guidelines
- Inspect access each session for erythema, drainage, tenderness
- Blood cultures × 2 if febrile; exit-site swab if purulent
- Tunnel infection if erythema > 2 cm from exit site; remove catheter if persistent bacteremia
Medications
Vancomycin
15–20 mg/kg · IV post-dialysis, per trough
Contraindication: Hypersensitivity; Red Man Syndrome (slow infusion)
Cefepime
1–2 g · IV post-dialysis (gram-negative)
Contraindication: Cephalosporin allergy; seizure disorder
Ciprofloxacin
400 mg · IV post-dialysis
Contraindication: Tendon disorders; QT prolongation; pregnancy
Dialysis Initiation & Transplant Referral Triggers
01eGFR < 20 mL/min — initiate transplant evaluation
02eGFR < 15 (G5) — create dialysis access, modality education
03AV fistula creation ideally 6 months before anticipated start
04Uremic symptoms: anorexia, nausea, pruritus, fatigue
05Inability to manage fluid or metabolic complications medically
References & Further Reading
- 01KDOQI Clinical Practice Guideline for Hemodialysis Adequacy — National Kidney Foundation (2015)
- 02KDOQI Clinical Practice Guideline for Vascular Access — National Kidney Foundation (2019)
- 03KDIGO Dialysis Initiation and Modality Decision-Making — KDIGO Controversies Conference (2022)
- 04KDOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy — National Kidney Foundation (2006)
- 05USRDS Annual Data Report — End-Stage Renal Disease — United States Renal Data System (2023)