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cardio.acute-hf.end-stage-renal-disease.v1PRODUCTION
cardio.acute-hf.end-stage-renal-disease.v1

Acute HF — HD-dependent ESRD

cardiologyacuteadult
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Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

ADHF in HD-dependent ESRD — IV loop diuretic USELESS if anuric → ULTRAFILTRATION primary; IDH dominant complication; SGLT2i avoid if eGFR <20; access protection mandatory

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Advance rule
Set
Advance when

ESRD-HD framing + anuria status confirmed

Patient inputs (11)

Age affects ICD/CRT decision in dialysis (less benefit per DanISH-CKD); transplant candidacy

In-center HD vs home HD vs PD; thrice-weekly schedule; documented dry weight + access type/site essential for fluid management

Anuric (UOP <100 mL/day) → IV loop USELESS; oliguric (UOP 100-500) → IV loop may have residual benefit; preserves residual renal function → less aggressive UF needed

AVF/AVG arm: NO BP cuff, NO IV access, NO blood draws — protect access; TDC site informs antibiotic stewardship + bacteremia screen

Pre-HD SBP guides UF tolerability; post-HD SBP <90 = IDH; trend across sessions informs dry weight + UF rate adjustment

HD patients often hyperK pre-HD (4.5-6.5 typical) — alters ARNI/ACEi/MRA decisions and emergency K management

Hyperphosphatemia + secondary hyperPTH drive vascular calcification + LV remodeling; CKD-MBD bundle

Chronic troponin elevation common in HD; trend (delta) more useful than absolute for ACS rule-in

NT-proBNP ALWAYS elevated in HD baseline (renal cleared); trend + dry-weight comparison rather than absolute

HFrEF vs HFpEF in dialysis; calcific valve + uremic cardiomyopathy assessment; AVF flow effect on cardiac output

AVF/AVG flow measurement when high-output HF suspected (flow >2 L/min); supports banding/ligation discussion

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (4)

4 need judgement
  • informationallife_threateningesrd_with_severe_hyperkalemia_from_gdmt_combination
    K >6.0 pre-HD or with EKG changes in patient on ARNI/ACEi + MRA + insufficient binder
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningesrd_with_missed_dialysis_triggers_volume_overload
    ≥1 missed HD session + acute pulmonary edema OR severe hyperK OR uremic encephalopathy/pericarditis
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereesrd_with_intradialytic_hypotension_severe
    SBP <80 with symptoms during HD UF, OR recurrent post-HD dizziness/syncope, OR HD session terminated early × 2 in week
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereesrd_with_avf_flow_above_2lpm_worsening_hf
    AVF flow >2 L/min on access US AND high-output HF features (CI >4, NYHA worsening, distal limb ischemia from steal)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

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Recommended regimen

ESRD-HD ADHF — UF primary, RAAS-K-aware, BB metoprolol succinate preferred, SGLT2i avoid, MRA debated (KDIGO 2024; ACC/AHA 2022; DOHAS PMID 24722440)
axis: esrd_hd_adhf_phenotype
Selected axis "ESRD-HD ADHF — UF primary, RAAS-K-aware, BB metoprolol succinate preferred, SGLT2i avoid, MRA debated (KDIGO 2024; ACC/AHA 2022; DOHAS PMID 24722440)" by default fallback (first axis)
  • furosemide
    first line
    loop_diuretic
    IV 160-320 mg ONLY if residual UOP >100 mL/day; expect minimal-to-no effect if anuric • IV • q12h trial
    triggers: esrd_with_residual_urine_output_above_100ml_day
    High-dose IV loop trial only if residual renal function; if anuric, drug is useless and adds K-wasting risk; pivot to UF
    rxcui 4603
  • metoprolol succinate
    first line
    beta_blocker_extended_release
    25 mg PO daily; titrate q2 weeks; max 200 mg daily • PO • daily
    triggers: hfref_in_hd_patient
    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
    rxcui 6918
  • carvedilol
    second line
    beta_blocker
    3.125 mg PO BID; titrate q2 weeks; max 25 mg BID • PO • BID
    triggers: hfref_in_hd_metoprolol_intolerant
    Variable HD removal but acceptable alternative; alpha-blockade may help with HTN; B-CONVINCED — do not stop chronic BB during ADHF
    rxcui 20352
  • sacubitril-valsartan
    first line
    arni
    Start 24/26 mg BID with K binder co-prescribed; titrate q4 weeks if K <5.5 + SBP ≥110 • PO • BID
    triggers: hfref_in_hd_with_k_below_5.5_and_binder_available
    PIONEER-HF + PARADIGM-HF — small ESRD subgroup data; benefit preserved if K controlled with binder; HOLD if K >5.5
    rxcui 1656328
  • enalapril
    second line
    acei
    2.5 mg PO BID; titrate cautiously; max 10 mg BID in HD • PO • BID
    triggers: arni_unavailable_in_hd_patient
    CONSENSUS + SOLVD — generally acceptable in HD; lower dose ceiling to mitigate K + symptomatic hypotension
    rxcui 203123
  • spironolactone
    add on
    mra
    12.5 mg PO post-HD only (3×/week); reassess K weekly × 4 then monthly • PO • 3×/week post-HD
    triggers: hfref_in_hd_with_k_reliably_below_5.0
    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
    rxcui 9997
  • empagliflozin
    contraindication substitute
    SGLT2_inhibitor
    AVOID in eGFR <20 / on HD (most common scenario) • PO • avoid
    triggers: esrd_on_hd_eGFR_below_20
    EMPULSE/EMPEROR/DAPA-HF — efficacy/safety unestablished in eGFR <20 / dialysis; do NOT initiate; if patient transitioning into HD, taper off
    rxcui 1545653
  • midodrine
    comorbidity specific
    alpha1_agonist
    5-10 mg PO 30 min pre-HD • PO • pre-HD on each session
    triggers: recurrent_intradialytic_hypotension
    KDIGO 2024 — adjunct to reduce IDH; vasoconstrictor stabilizes BP during UF; do NOT use chronic supine HTN
    rxcui 6963
  • patiromer
    comorbidity specific
    k_binder
    8.4 g PO daily; titrate to 25.2 g daily; separate from other meds by 3h • PO • daily
    triggers: hyperkalemia_limiting_arni_acei_mra_in_hd
    OPAL-HK PMID 25415803 — enables RAAS continuation in CKD/HD; off-label in HD but commonly used; alternative SZC
    rxcui 1716203
  • apixaban
    comorbidity specific
    doac_factor_xa_direct
    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
    triggers: af_with_cha2ds2_above_2_in_hd
    ARISTOTLE — apixaban acceptable in HD per FDA label since 2014; safer than rivaroxaban/dabigatran in HD; warfarin alternative if cost or apixaban contraindicated
    rxcui 1364430
  • ultrafiltration via HD or SCUF
    first line
    extracorporeal_volume_removal
    UF rate ≤10 mL/kg/h to limit IDH; SCUF if hemodynamically unstable • extracorporeal • per HD schedule or continuous SCUF
    triggers: esrd_with_volume_overload_anuric
    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
    rxcui 11149

outpatient playbook — drug actions (3)

  1. 1. maintain K-aware GDMT + binder bundle
    rxcui 1656328
    ARNI + metoprolol succinate + selective MRA + patiromer • PO • as scheduled
    trigger: HFrEF in HD
    ACC/AHA 2022 + KDIGO 2024
  2. 2. statin secondary prevention only
    rxcui 83367
    atorvastatin 40 mg daily ONLY if prior ASCVD • PO • daily
    trigger: secondary ASCVD
    4D PMID 16034009 + AURORA — no primary prevention benefit in HD; continue secondary only
  3. 3. apixaban for AF
    rxcui 1364430
    5 mg PO BID (or 2.5 BID if dose-reduction criteria) • PO • BID
    trigger: AF + CHA2DS2-VASc ≥2
    ARISTOTLE; FDA HD label since 2014

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ESRD on chronic HD + acute volume overload (inter-dialytic weight gain >5% dry weight + dyspnea/orthopnea) → ADHF in dialysis-dependent patient; 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute HF — HD-dependent ESRD** (cardio.acute-hf.end-stage-renal-disease.v1).
Scope: ADHF in HD-dependent ESRD — IV loop diuretic USELESS if anuric → ULTRAFILTRATION primary; IDH dominant complication; SGLT2i avoid if eGFR <20; access protection mandatory

No severity triggers fired against current inputs.

Plan

Regimen axis: **ESRD-HD ADHF — UF primary, RAAS-K-aware, BB metoprolol succinate preferred, SGLT2i avoid, MRA debated (KDIGO 2024; ACC/AHA 2022; DOHAS PMID 24722440)**.
1. furosemide IV 160-320 mg ONLY if residual UOP >100 mL/day; expect minimal-to-no effect if anuric IV q12h trial (loop_diuretic, first line) — High-dose IV loop trial only if residual renal function; if anuric, drug is useless and adds K-wasting risk; pivot to UF
2. metoprolol succinate 25 mg PO daily; titrate q2 weeks; max 200 mg daily PO daily (beta_blocker_extended_release, first line) — 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
3. carvedilol 3.125 mg PO BID; titrate q2 weeks; max 25 mg BID PO BID (beta_blocker, second line) — Variable HD removal but acceptable alternative; alpha-blockade may help with HTN; B-CONVINCED — do not stop chronic BB during ADHF
4. sacubitril-valsartan Start 24/26 mg BID with K binder co-prescribed; titrate q4 weeks if K <5.5 + SBP ≥110 PO BID (arni, first line) — PIONEER-HF + PARADIGM-HF — small ESRD subgroup data; benefit preserved if K controlled with binder; HOLD if K >5.5
5. enalapril 2.5 mg PO BID; titrate cautiously; max 10 mg BID in HD PO BID (acei, second line) — CONSENSUS + SOLVD — generally acceptable in HD; lower dose ceiling to mitigate K + symptomatic hypotension
6. spironolactone 12.5 mg PO post-HD only (3×/week); reassess K weekly × 4 then monthly PO 3×/week post-HD (mra, add on) — 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
7. empagliflozin AVOID in eGFR <20 / on HD (most common scenario) PO avoid (SGLT2_inhibitor, contraindication substitute) — EMPULSE/EMPEROR/DAPA-HF — efficacy/safety unestablished in eGFR <20 / dialysis; do NOT initiate; if patient transitioning into HD, taper off
8. midodrine 5-10 mg PO 30 min pre-HD PO pre-HD on each session (alpha1_agonist, comorbidity specific) — KDIGO 2024 — adjunct to reduce IDH; vasoconstrictor stabilizes BP during UF; do NOT use chronic supine HTN
9. patiromer 8.4 g PO daily; titrate to 25.2 g daily; separate from other meds by 3h PO daily (k_binder, comorbidity specific) — OPAL-HK PMID 25415803 — enables RAAS continuation in CKD/HD; off-label in HD but commonly used; alternative SZC
10. 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 (doac_factor_xa_direct, comorbidity specific) — ARISTOTLE — apixaban acceptable in HD per FDA label since 2014; safer than rivaroxaban/dabigatran in HD; warfarin alternative if cost or apixaban contraindicated
11. 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 (extracorporeal_volume_removal, first line) — 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

Setting playbook (outpatient) — Long-term ESRD-HF surveillance via shared HF-nephrology clinic; transplant + LVAD eligibility ongoing eval; access surveillance; ICD/CRT case-by-case shared decision per DanISH-CKD/MADIT-II subgroups
12. maintain K-aware GDMT + binder bundle ARNI + metoprolol succinate + selective MRA + patiromer PO as scheduled — HFrEF in HD (ACC/AHA 2022 + KDIGO 2024)
13. statin secondary prevention only atorvastatin 40 mg daily ONLY if prior ASCVD PO daily — secondary ASCVD (4D PMID 16034009 + AURORA — no primary prevention benefit in HD; continue secondary only)
14. apixaban for AF 5 mg PO BID (or 2.5 BID if dose-reduction criteria) PO BID — AF + CHA2DS2-VASc ≥2 (ARISTOTLE; FDA HD label since 2014)

Non-pharmacologic actions:
- Annual access US for stenosis + flow >2 L/min screen
- Transplant list maintenance
- LVAD eval at experienced center if NYHA IIIb-IV despite max therapy
- POLST/MOLST in place
- Hospice referral if frequent admissions + GoC alignment

AVOID / contraindication checks:
- Do_not_use_loop_diuretic_alone_in_anuric_esrd (useless; pivot to UF)
- Avoid_sglt2i_in_egfr_below_20_or_dialysis (unestablished in dialysis)
- Hold_arni_acei_arb_if_pre_hd_K_above_5.5 (hyperK risk; restart with K binder)
- Mra_only_if_K_reliably_below_5.0_and_post_hd_dosing_schedule (DOHAS context; RALES excluded HD; risk real)
- Metoprolol_succinate_preferred_BB_in_hd_over_atenolol (atenolol heavily HD removed → unstable serum levels)
- No_bp_cuff_or_iv_in_avf_avg_arm (access protection; permanent damage if violated)
- Tdc_associated_bacteremia_screen_with_fever_in_hd (high mortality if missed)
- Avoid_aggressive_uf_above_10_ml_kg_h (intradialytic hypotension precipitant)
- Statin_no_primary_prevention_benefit_in_hd_per_4d_aurora (continue for secondary ASCVD only)
- Dabigatran_rivaroxaban_avoid_in_hd_prefer_apixaban_or_warfarin (label + outcomes data)

Monitoring

Regimen monitoring:
- pre and post hd weight and bp (UF tolerability + dry-weight refinement)
- pre hd K phos HCO3 at each session (drives HD prescription K bath + binder dose)
- troponin trend for acs rule in (chronic elevation baseline; delta matters)
- NT proBNP trend not absolute (always elevated in HD baseline)
- access exam q shift thrill bruit bleeding (preserve access)
- telemetry during and after hd (electrolyte shifts → arrhythmia risk)
- access us annually for flow and stenosis (high-output HF screen at flow >2 L/min)
- monthly K after mra initiation x 3 then q3mo (DOHAS-style protocol)

Setting (outpatient) monitoring:
- Quarterly K + phos + Hb + clinic visit
- Annual echo + access US

Follow-up plan: 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
- Close-out criterion: shared dialysis-HF clinic + transplant eval booked

Monitoring phase: Pre/post-HD weight + BP, daily K + phos + HCO3 + Cr, daily access exam (thrill + bruit), telemetry for arrhythmia (especially during/after HD), daily echo if shock, NT-proBNP trend (use change not absolute)

Disposition

Current setting: outpatient — Long-term ESRD-HF surveillance via shared HF-nephrology clinic; transplant + LVAD eligibility ongoing eval; access surveillance; ICD/CRT case-by-case shared decision per DanISH-CKD/MADIT-II subgroups

Disposition criteria:
- Long-term continuation; cross-link to neph.ckd.core.v1 + cardio.hfref.core.v1; transition to hospice if functional decline + frequent admissions + GoC alignment

Escalation triggers (move to higher acuity):
- Recurrent ADHF → extra HD/extend UF + reassess dry weight
- Persistent hyperK → up-titrate binder + reduce/hold RAAS-MRA
- Progressive HF despite max therapy → transplant/LVAD reconsideration
- High-output HF (AVF flow >2 L/min + CI >4) → vascular surgery banding/ligation eval

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] K >6.0 pre-HD or with EKG changes in patient on ARNI/ACEi + MRA + insufficient binder
- [LIFE_THREATENING] ≥1 missed HD session + acute pulmonary edema OR severe hyperK OR uremic encephalopathy/pericarditis
- [SEVERE] SBP <80 with symptoms during HD UF, OR recurrent post-HD dizziness/syncope, OR HD session terminated early × 2 in week

Citations

- KDIGO 2024 CKD/HD + 2022 ACC/AHA HF + DOHAS (Matsumoto JASN 2014) + 4D/AURORA [PMID:35363499](https://pubmed.ncbi.nlm.nih.gov/35363499/)
- Cited evidence (PMID 38264914) [PMID:38264914](https://pubmed.ncbi.nlm.nih.gov/38264914/)
- Cited evidence (PMID 24722440) [PMID:24722440](https://pubmed.ncbi.nlm.nih.gov/24722440/)
- Cited evidence (PMID 16034009) [PMID:16034009](https://pubmed.ncbi.nlm.nih.gov/16034009/)
- Cited evidence (PMID 28154077) [PMID:28154077](https://pubmed.ncbi.nlm.nih.gov/28154077/)

Last reconciled with current guidelines: 2026-05-15.
References