Management of Break in Peritoneal Dialysis Orders
For patients requiring urgent peritoneal dialysis, avoid starting dialysis within 48 hours of catheter insertion to minimize early technical complications, but if urgent dialysis is needed within 2-13 days, this remains safe and does not compromise long-term outcomes. 1
Optimal Break-In Period
The standard recommendation is a 2-week break-in period before initiating peritoneal dialysis to allow for proper catheter healing and reduce mechanical complications 2
Starting PD within 2-13 days (but avoiding the first 48 hours) is an acceptable alternative when urgent dialysis is needed, with significantly lower early technical complications (10.3%) compared to starting within 48 hours (28.2%) 1
If dialysis must start within 48 hours, expect higher rates of catheter malposition requiring repositioning procedures (14.6% vs 3.4% when waiting 2-13 days) 1
Clinical Decision Algorithm
When Urgent Dialysis is Required:
If hemodynamically stable and can wait 2-13 days:
- Proceed with PD after this break-in period for optimal outcomes 1
- This approach minimizes catheter dysfunction and repositioning needs 1
If critically unstable requiring immediate dialysis (<48 hours):
- PD remains feasible but anticipate higher mechanical complication rates 1
- For hemodynamically unstable patients, prolonged modalities of renal replacement therapy including continuous PD are preferred 3
- Consider using tidal automated PD with frequent short cycles (1-2 hours) to rapidly correct uremia, hyperkalemia, and fluid overload 2
Prescription During Break-In Period
Initial prescription targets:
- Target weekly Kt/V of 2.2 for most AKI patients (equivalent outcomes to higher doses) 2
- For critically ill patients, weekly Kt/V of 3.5 provides outcomes comparable to daily hemodialysis 2
- Use short cycle times (1-2 hours) initially to rapidly correct metabolic derangements, then increase to 4-6 hours once controlled 2
Solution selection:
- Use bicarbonate-containing solutions in critically ill patients, especially those with liver dysfunction and elevated lactate 2
- Add potassium to dialysate once serum levels fall below 4 mmol/L to prevent hypokalemia 2
Monitoring During Break-In
Essential monitoring parameters:
- Daily measurement of creatinine, urea, potassium, and bicarbonate levels when resources permit 2
- Assess for early mechanical complications including leaks, catheter malposition, and dialysate flow problems 4
- Monitor for peritonitis and exit-site infections, though these rates are not significantly different regardless of break-in period 1
Long-Term Outcomes
Reassuring data on break-in timing:
- Long-term PD maintenance and patient survival are independent of whether dialysis starts within 48 hours or 2-13 days 1
- No significant difference in catheter dysfunction requiring conversion to hemodialysis within 6 months 1
- Peritonitis and exit-site infection rates are comparable regardless of break-in period 1
Common Pitfalls to Avoid
Critical errors in early PD management:
- Starting dialysis immediately after catheter insertion (<48 hours) when not absolutely necessary increases repositioning procedures by 4-fold 1
- Most mechanical complications occur early due to catheter insertion or increased intra-abdominal pressure from dialysate 4
- Failure to use prophylactic antibiotics prior to catheter implantation increases infection risk 2
- Using non-tunneled catheters increases peritonitis and peri-catheter leak rates 2
Preserving Residual Renal Function
Critical considerations during dialysis interruption:
- Avoid nephrotoxic agents including NSAIDs and COX-2 inhibitors, which are particularly harmful with preexisting renal insufficiency 5
- Prevent volume depletion episodes, which decrease urine volume and residual function 5
- Avoid hypercalcemia from aggressive calcium or calcitriol therapy, as this can be nephrotoxic 5
- If contrast studies are necessary, ensure adequate hydration and use minimal dye volume; consider N-acetylcysteine pretreatment 5