This handout is for acute hf — hd-dependent esrd. Your care team identified this based on: esrd on chronic hd + acute volume overload (inter-dialytic weight gain >5% dry weight + dyspnea/orthopnea) → adhf in dialysis-dependent patient.
Other reasons your team may use this plan: missed ≥1 hd session + pulmonary edema (most common adhf trigger in hd; mortality risk especially after long inter-dialytic interval); intradialytic hypotension (idh) episodes + worsening nyha → flag for hf-dialysis prescription review; avf/avg flow >2 l/min on access us + features of high-output hf (cardiac index >4) → consider access banding/ligation eval.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| furosemide | IV 160-320 mg ONLY if residual UOP >100 mL/day; expect minimal-to-no effect if anuric | IV | q12h trial | High-dose IV loop trial only if residual renal function; if anuric, drug is useless and adds K-wasting risk; pivot to UF |
| metoprolol succinate | 25 mg PO daily; titrate q2 weeks; max 200 mg daily | PO | daily | Minimally removed by HD (vs carvedilol variable HD removal, atenolol heavily removed) → consistent serum levels across HD vs non-HD days; preferred BB in HD per KDIGO 2024 + ACC/AHA 2022 |
| carvedilol | 3.125 mg PO BID; titrate q2 weeks; max 25 mg BID | PO | BID | Variable HD removal but acceptable alternative; alpha-blockade may help with HTN; B-CONVINCED — do not stop chronic BB during ADHF |
| sacubitril-valsartan | Start 24/26 mg BID with K binder co-prescribed; titrate q4 weeks if K <5.5 + SBP ≥110 | PO | BID | PIONEER-HF + PARADIGM-HF — small ESRD subgroup data; benefit preserved if K controlled with binder; HOLD if K >5.5 |
| enalapril | 2.5 mg PO BID; titrate cautiously; max 10 mg BID in HD | PO | BID | CONSENSUS + SOLVD — generally acceptable in HD; lower dose ceiling to mitigate K + symptomatic hypotension |
| spironolactone | 12.5 mg PO post-HD only (3×/week); reassess K weekly × 4 then monthly | PO | 3×/week post-HD | DOHAS PMID 24722440 + RALES-HD substudies — mortality benefit signal in HD but RALES excluded HD; K risk REAL → strict K monitoring + post-HD-only dosing schedule + immediate hold if K >5.5 |
| empagliflozin | AVOID in eGFR <20 / on HD (most common scenario) | PO | avoid | EMPULSE/EMPEROR/DAPA-HF — efficacy/safety unestablished in eGFR <20 / dialysis; do NOT initiate; if patient transitioning into HD, taper off |
| midodrine | 5-10 mg PO 30 min pre-HD | PO | pre-HD on each session | KDIGO 2024 — adjunct to reduce IDH; vasoconstrictor stabilizes BP during UF; do NOT use chronic supine HTN |
| patiromer | 8.4 g PO daily; titrate to 25.2 g daily; separate from other meds by 3h | PO | daily | OPAL-HK PMID 25415803 — enables RAAS continuation in CKD/HD; off-label in HD but commonly used; alternative SZC |
| apixaban | 5 mg PO BID (or 2.5 BID per dose-reduction criteria — age ≥80, Cr ≥1.5, weight ≤60, but Cr criteria irrelevant in HD anuric — use age + weight) | PO | BID | ARISTOTLE — apixaban acceptable in HD per FDA label since 2014; safer than rivaroxaban/dabigatran in HD; warfarin alternative if cost or apixaban contraindicated |
| ultrafiltration via HD or SCUF | UF rate ≤10 mL/kg/h to limit IDH; SCUF if hemodynamically unstable | extracorporeal | per HD schedule or continuous SCUF | KDIGO 2024 — primary volume removal in anuric ESRD; CARRESS-HF context (UF NOT first-line in non-ESRD ADHF) does NOT apply to HD-dependent patients; SCUF preferred over conventional HD if shock |
Plan: ESRD-HD ADHF — UF primary, RAAS-K-aware, BB metoprolol succinate preferred, SGLT2i avoid, MRA debated (KDIGO 2024; ACC/AHA 2022; DOHAS PMID 24722440)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Coordinate with home dialysis center (in-center 3×/wk vs home), nephrology + HF clinic shared visits, dry-weight reassessment q3 mo, AVF surveillance US annually, transplant evaluation if not done, statin secondary prevention only, ICD/CRT case-by-case + shared decision per DanISH-CKD/MADIT-II
Guideline: KDIGO 2024 CKD/HD + 2022 ACC/AHA HF + DOHAS (Matsumoto JASN 2014) + 4D/AURORA