How would you manage an ESKD patient who complains of severe fatigue after hemodialysis, but does not experience intradialytic or post-dialysis hypotension and has not responded to dry weight adjustments?

Difficult but unfortunately not uncommon situation. My theory is that more frequent dialysis would be beneficial to avoid dramatic electrolyte and fluid shifts that occur with intermittent hemodialysis. Would see if peritoneal dialysis or home hemodialysis would be an option. If not, maybe 4 days per week, but most often, patients would be very resistant to that. Of course, optimizing hemoglobin and urea shifts would also be indicated but unlikely to be too beneficial.

I would love to see if HDF would resolve the fatigue…

Second and third options are still hemodialysis and if fatigue is due to “rapid “solute removal and electrolytes shift, it may not work but change of modality is also a big move.