Preparing patients for RRT

The appropriate time to prepare someone for dialysis can be difficult to judge. It is essential that preparation should not be left until too late; it may, however, be inappropriate to burden people with this information too early.

  • advise patients (and others e.g., spouse, as appropriate) re need for RRT
  • introduce concepts of PD and HD early
  • emphasise the importance of patients’ preference
  • discuss transplantation (including pre-emptive transplantation)
  • remember that no RRT is one option for management

About 6-12 months before expected ESRF, refer to:

  • Social worker – download a proforma and copy of clinic letter (in Edinburgh)
  • Community Dialysis Team: a written referral (In Edinburgh) (use downloadable proforma and copy
  • clinic letter, including:
  • Relevant PMH
  • Any medical contraindications to PD/HD
  • Very brief social history
  • Urgency of referral
  • Transplant team (unless clearly contraindicated) – see below for additional investigations required.

The CDT will arrange visits to see PD and HD (repeat if necessary), and will arrange invitation to a Patients’ Evening.  They will see potential PD patients at home; those who are likely to do HD can be seen at clinic visits.

Get feedback from above visits/referrals, and at monthly Pre Dialysis MDT meeting check understanding.

Hepatitis B immunization should be carried out by request to patient’s GP (see antimicrobial policy).

AV access (fistula) should be created at least 6 months before starting HD to ensure that it is successful and mature. Some may require multiple operations.

  • Refer to Vascular Access Coordinator (Ext 21199) and use specific referral performa.

CAPD catheter should be inserted at least 2 weeks before starting PD

  • Operation dates are arranged through either the transplant or vascular surgical team. There is a coordinator for vascular access.

See below for blood tests required : Cytotoxic antibodies should be checked each OP visit for patients on the transplant list, or monthly.

Data Accuracy
Keep computer screens updated with dialysis/transplant decisions made, and other information requested. Liaise with consultants or computing staff if unclear how to do this.

New start on dialysis checklist
Click here for a checklist which may help when starting patients on dialysis. Consider using the checklist whenever a Permcath is inserted (either into new patients or existing dialysis patients).

Pre-dialysis and pre-transplant investigations
Proforma suitable for inserting into front of notes.

You can also download this proforma as a pdf file suitable for printing out and inserting into front of notes: click to download it now

Mandatory pre-
Test dialysis transplant Date Comment
VIROLOGY EBV is not routinely tested for but can be investigated on saved samples.
Hep B, C
3
3
HIV
3
3
CMV
3
VZV, EBV
3
IMMUNOLOGY Measure CABs at each visit in patients on the transplant list (monthly for HD patients)
Tissue typing
3
Cytotoxic antibodies
3
Blood group
3
RADIOLOGY No routine imaging of bones required pre-transplant, but PTH should have been measured. Surgical team may request pelvic XR in some.
CXR
3
3
Renal imaging
3
3
Other
UROLOGY Pre-transplant, consider further investigation if history of recurrent infection, obstruction, or bladder dysfunction
CARDIOLOGY Pre-transplant, echo mandatory if any history of cardiac disease, and refer if symptomatic or high risk
ECG
3
3
Echo
 3?
Other (eg ETT) ETT mandatory if for SKP transplant
GASTRIC If any symptoms or previous history to suggest increased risk of ulceration
Endoscopy
REFERRALS
Community dialysis team
3
Social assessment
3
Vasc. access/ PD cath
3
Transplant team
3

 

Acknowledgements:   Neil Turner was the main author for this page. The last modified date is shown in the footer.

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