Red Flags
- Symptomatic uraemia (encephalopathy, pericarditis, pleuritis, intractable nausea/vomiting), refractory hyperkalaemia, refractory acidosis, or refractory pulmonary oedema — emergency dialysis[1]
- Catheter-related bloodstream infection (fever + access tenderness/purulence) — blood cultures from catheter and peripheral, empirical anti-staphylococcal + Gram-negative cover; consider catheter removal[1]
- Peritonitis on PD (cloudy effluent + abdominal pain) — send PD effluent for cell count, Gram stain, culture; intra-peritoneal antibiotics within hours; ISPD protocol[1]
- Severe intradialytic hypotension or arrhythmia — stop UF, give saline bolus, troubleshoot dialysate temperature/sodium/calcium; ECG; cardiology if recurrent[1]
First-line treatment
Interventions
- Modality choice — shared decision making[1]Home therapies (PD, home HD) preferred where feasible; in-centre HD for those without home-care infrastructure or with PD contraindications. Transplant first when eligible — pre-emptive transplant best outcomes
- Haemodialysis prescription[1]≥4 hours thrice weekly using high-flux biocompatible dialyser; blood flow 300–400 mL/min; dialysate flow 500–800 mL/min; ultrapure dialysate; individualised ultrafiltration rate <13 mL/kg/h to limit intradialytic hypotension
- AV fistula as preferred vascular access[1]Plan AVF surgical creation when eGFR 15–20 or 6 months before anticipated dialysis; tunnelled CVC only as bridge; minimise CVC days; avoid PICC and proximal arm IVs in advanced CKD to preserve future fistula sites
- Peritoneal dialysis prescription[1]CAPD 4 exchanges/day or APD overnight cycler; biocompatible dialysate; preserve residual renal function with RAS inhibitor and avoiding nephrotoxins; ISPD-aligned exit-site care with topical antibiotic prophylaxis
- Anaemia management on dialysis[1]Hb target 100–115 g/L; iron repletion (ferritin >200 µg/L and TSAT >20%) before ESA; ESA dose adjusted to avoid Hb >120 g/L; HIF-PHI inhibitors emerging alternative
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Erythropoiesis-stimulating agent (epoetin alfa, darbepoetin)[1] | Recombinant erythropoietin / analogue | Epoetin alfa 50–100 U/kg SC thrice weekly or weekly; darbepoetin 0.45 µg/kg SC weekly or every 2 weeks | Epoetin alfa 50 U/kg SC thrice weekly start; titrate by Hb | Renal anaemia in dialysis CKD; titrate to Hb 100–115 g/L; monitor BP, K, ferritin, TSAT |
| Intravenous iron (ferric carboxymaltose, iron sucrose)[1] | Parenteral iron | Iron sucrose 100–200 mg IV per session × 5–10 doses then maintenance; ferric carboxymaltose 500–1000 mg IV every 1–4 weeks | Iron sucrose 1–2 mg/kg IV per session | Maintain ferritin 200–500 µg/L and TSAT 20–40% in dialysis patients; avoid in active sepsis |
| Cinacalcet or etelcalcetide[1] | Calcimimetic | Cinacalcet 30 mg PO daily titrated to PTH; etelcalcetide 5 mg IV thrice weekly post-HD | — | Secondary hyperparathyroidism in CKD G5D with PTH above target despite vitamin D analogue; hypocalcaemia limits dose |
| Heparin (anticoagulation for HD circuit)[1] | Unfractionated heparin | Bolus 25–50 U/kg at start of dialysis; infusion 500–1500 U/h targeting ACT 1.5–2× baseline | Bolus 50 U/kg then infusion per ACT | Standard circuit anticoagulation; alternatives (LMWH, regional citrate, no heparin) for bleeding risk; HIT screening if platelet drop |
Erythropoiesis-stimulating agent (epoetin alfa, darbepoetin)[1]
Recombinant erythropoietin / analogue
- Adult
- Epoetin alfa 50–100 U/kg SC thrice weekly or weekly; darbepoetin 0.45 µg/kg SC weekly or every 2 weeks
- Paediatric
- Epoetin alfa 50 U/kg SC thrice weekly start; titrate by Hb
Renal anaemia in dialysis CKD; titrate to Hb 100–115 g/L; monitor BP, K, ferritin, TSAT
Intravenous iron (ferric carboxymaltose, iron sucrose)[1]
Parenteral iron
- Adult
- Iron sucrose 100–200 mg IV per session × 5–10 doses then maintenance; ferric carboxymaltose 500–1000 mg IV every 1–4 weeks
- Paediatric
- Iron sucrose 1–2 mg/kg IV per session
Maintain ferritin 200–500 µg/L and TSAT 20–40% in dialysis patients; avoid in active sepsis
Cinacalcet or etelcalcetide[1]
Calcimimetic
- Adult
- Cinacalcet 30 mg PO daily titrated to PTH; etelcalcetide 5 mg IV thrice weekly post-HD
- Paediatric
- —
Secondary hyperparathyroidism in CKD G5D with PTH above target despite vitamin D analogue; hypocalcaemia limits dose
Heparin (anticoagulation for HD circuit)[1]
Unfractionated heparin
- Adult
- Bolus 25–50 U/kg at start of dialysis; infusion 500–1500 U/h targeting ACT 1.5–2× baseline
- Paediatric
- Bolus 50 U/kg then infusion per ACT
Standard circuit anticoagulation; alternatives (LMWH, regional citrate, no heparin) for bleeding risk; HIT screening if platelet drop
Safety-net
- Protect your fistula arm — no blood pressure cuffs, no IV lines, no constrictive jewellery; tell every healthcare worker[1]
- Cloudy PD bag, fever, or abdominal pain — go to your dialysis unit or emergency department same day; do not wait until next exchange[1]
- Excessive interdialytic weight gain raises blood pressure and pulmonary oedema risk — aim ≤2.5 kg between sessions; salt and fluid restriction is the lever[1]
Referral criteria
- Suspected access dysfunction (low flow, prolonged bleeding, thrombosis, aneurysm)Vascular access service same-day[1]
- Recurrent peritonitis on PD or refractory exit-site infectionPeritoneal dialysis specialist; consider transfer to HD if Tenckhoff replacement fails[1]
- Eligible for kidney transplantTransplant centre — pre-emptive listing where eGFR <20[1]
- Severe intradialytic hypotension, arrhythmia, or chest painCardiology and dialysis unit medical lead[1]
Clinical summary
Modality choice, vascular access, prescription, and complications management for adults with kidney failure on haemodialysis or peritoneal dialysis.