Preparing for Renal Replacement Therapy

General Advice

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 too much information too early – this will vary patient to patient.

  • Advise patients (and appropriate others e.g., spouse) regarding the potential need for RRT
  • Introduce concepts of both haemo- and peritoneal dialysis early in conversation
  • Emphasise the importance of patients’ preference in the decision making
  • Discuss transplantation where appropriate (including pre-emptive transplantation)
  • Remember that no RRT is an appropriate option for some patients
Referrals

About 6-12 months before the patient is expected to reach end-stage, refer to:

  • Social Work Department: Download a proforma and send with copy of clinic letter (in Edinburgh)
  • Community Dialysis Team (CDT): Download proforma and send with 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 patients who may be considering PD and HD (repeat visits, if necessary), and will arrange invitation to a Patients’ Information Evening.  They will see potential PD and home HD patients within their own home; those who are likely to do hospital HD can be seen at clinic visits. It is important to ensure that you get feedback from each of the above referrals and discuss this with the patient to ensure their understanding of the information shared with them.

 

New Start Dialysis “SHAVE” Checklist

Click here for a checklist which may help when starting patients on dialysis. Consider also using the checklist whenever a tunneled dialysis catheter (“permcath”) is inserted, either into new patients or existing dialysis patients who require alternative vascular access.

 

Hepatitis B immunization

This should be carried out by request to patient’s GP (link to protocol).

 

MRSA Screening & Eradication

MRSA Screening and Eradication (link to protocol)

 

Vascular Access

Aterio-venous fistulas should be created at least 6 months before starting haemodialysis to ensure that it is successful and mature prior to cannulation. Some patients may require multiple operations for fistula formation and so referral should be made well in advance where possible.

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

 

PD catheter insertion

Catheters for peritoneal dialysis should be inserted at least 2 weeks before starting PD. Operation dates are arranged through the transplant surgeons.

 

Pre-Dialysis and Pre-Transplant Investigations

You can download this proforma as a PDF file suitable for printing out and inserting into patient notes. The information should also be kept up to date on Vital Data. If you are uncertain where to record particular information, please seek advice from senior medical staff.

 

Test Dialysis Tansplant 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. It was updated by Ashley Simpson in 2019. The last modified date is shown in the footer.