Management of Diabetes, Hypertension, and Dyslipidemia in ESRD

Diabetes Management

The American Diabetes Association and the National Kidney Foundation recommend that SGLT2 inhibitors should be continued until dialysis initiation or transplant, and metformin should be avoided given ESRD status, as metformin is contraindicated in ESRD (eGFR <30 ml/min/1.73m²) 1
The Kidney International journal suggests that GLP-1 receptor agonists can be added if needed to achieve glycemic targets, with dose adjustments based on specific agent 1
The Kidney International journal recommends avoiding sulfonylureas and insulin secretagogues when possible due to hypoglycemia risk in ESRD; if insulin is required, reduce doses by 25-50% due to decreased renal clearance 3, 4
The American College of Endocrinology recommends a target HbA1c of 7.0-8.0% is reasonable, recognizing that HbA1c accuracy declines significantly in dialysis patients 3, 4

The American Heart Association recommends that volume management is the cornerstone: Optimize dry weight through ultrafiltration and sodium restriction (<2.3 g/day) 1, 2
The National Kidney Foundation suggests that RAS inhibitors (ACEi/ARB) may be continued at reduced doses if tolerated, but many patients can discontinue them once on dialysis as volume control becomes primary strategy 3, 4
The American College of Cardiology recommends that beta-blockers are reasonable first-line agents for dialysis patients, particularly those with heart failure or coronary disease 5
The American Heart Association recommends a target BP <130/80 mmHg in collaboration with nephrology, though this may need adjustment based on intradialytic tolerance 1, 2

The American College of Cardiology recommends that all dialysis patients with diabetes should receive moderate-to-high intensity statin therapy regardless of LDL level, but do not initiate statins de novo in dialysis patients 1
The National Lipid Association suggests that moderate-to-high intensity statin dosing: atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily 1
The American Heart Association recommends that ezetimibe can be added if LDL remains elevated and patient has high ASCVD risk 1

The National Kidney Foundation recommends monitoring labs every 1-3 months (4 times per year minimum) given high-risk CKD stage 1
The American College of Endocrinology suggests monitoring HbA1c (or more frequent CGM/GMI if HbA1c unreliable) every 1-3 months 3, 4
The National Kidney Foundation recommends monitoring serum potassium (critical with any RAS inhibitor use) every 1-3 months 3, 4
The American College of Cardiology suggests monitoring lipid panel (though less emphasis on targets in dialysis) every 1-3 months 1

The American College of Physicians recommends regular reassessment every 3-6 months with integrated team including nephrology, endocrinology, and cardiology 1, 2
The National Kidney Foundation suggests lifestyle modifications: Sodium restriction, appropriate protein intake (1.0-1.2 g/kg for dialysis), smoking cessation, exercise as tolerated 1, 4, 2