This protocol is available as a printable PDF
Definition and Considerations
Acute, or urgent, start PD refers to using PD to manage end stage kidney disease within 2 weeks of inserting a PD catheter. This means that the PD catheter will not have fully healed, and the risk of a fluid leak through the tunnel and exit site is high. This would then require catheter resting and could be complicated by infection, fluid retention and potential need for catheter removal. The acute start PD prescription is therefore tailored to reduce this risk by minimising the volume of each dwell and administering the treatment supine if possible using automated PD (APD).
Who Can have Acute Start PD?
In theory, any patient who is otherwise suitable for PD and is currently fit for a PD catheter insertion under general anaesthetic or local anaesthetic could have acute start PD. This will be at the discretion of the community dialysis team (CDT) and surgeon who would insert the catheter. There are no absolute contraindications in this context, although the presence of a gastrointestinal stoma would generally preclude PD.
Referral for Acute PD
Any patient who needs renal replacement therapy (RRT) should be referred to the community dialysis team who will then review the patient and liase with the surgical team and PD Consultants to determine suitability for Acute PD. There may not always be surgical availability for PD catheter insertion but this is the subject of ongoing audit and should not prevent patients being referred.
Logistics of Where Treatment is Administered
Patients who are inpatients can have acute PD administered in ward 206 or 215. The CDT nurses will set up the machine with the appropriate program.
If patients are otherwise fit for discharge, there is an option for them to attend CDT to have treatment during the hours of 8-6pm utilising one of the treatment rooms. These decisions will be made by CDT staff with the support of PD Consultants.
Acute PD is to allow patients to start treatment immediately, with the support of CDT to administer the treatment. The expectation is that the patients will be trained to perform the treatment themselves once they are well enough, but assisted APD is an option for those unable to manage independently.
Acute Start PD Prescription
The initial prescription will depend upon the clinical presentation of the patient and whether the priority is solute (including potassium) clearance and or fluid overload.
General principles:
- Aim to keep patient lying flat/semi- recumbent while they have fluid in their abdomen/while attached to the APD machine.
- APD is the preferred option to provide greater solute clearance but CAPD using consecutive low volume extraneal dwells may be an option if fluid overload is the dominant issue.
- No last fill on APD ie patient has dry abdomen at the end of the APD programme.
- If there is a fluid leak, treatment needs to stop, PD fluid drained and relative risks:benefits re-evaluated depending upon the clinical scenario.
Suggested APD Prescription
Type of Dialysate
- Use hypertonic (green) dialysate if fluid overloaded
- Use isotonic (yellow) dialysate if euvolaemic.
| Day 1-2 | Therapy: APD Tidal (75%)
Total volume: 10000 Time: 12hrs Fill volume: 1200 |
No ambulant day fill
Dwell time: 60 minutes Cycles: 10 Tidal volume 900 Total Vol 9300mls |
| Day 3-4 | Therapy: APD Tidal (80%)
Total volume: 10000 Time: 12hours Fill volume: 1500 |
No ambulant day fill
Dwell time: 60 minutes Cycles: 9 Tidal volume 1200 |
| Day 5-7 | Therapy: APD CCPD/IPD
Total volume: 10000 Time: 12hours Fill volume: 1500 |
No ambulant day fill
Dwell time: 60 minutes Cycles: 6 Tidal volume 1275 |
Thereafter the prescription should be reviewed alongside the patient’s serum biochemistry results, their fluid balance and symptoms.
By 2 weeks most PD catheters will be healed but the preference would be to avoid a last fill so that the patient’s abdomen is dry when they are upright and ambulant.
Timing of formal training will be decided by CDT staff.