When Can a New Peritoneal Dialysis Catheter Be Used?
For elective starts, wait 14 days (2 weeks) after catheter placement before initiating full-volume peritoneal dialysis exchanges to minimize mechanical complications, particularly dialysate leaks. 1, 2
Optimal Timing for Elective Initiation
- The 14-day waiting period reduces dialysate leak rates to approximately 9%, compared to a three-fold increase in leaks when starting at 7 days. 1
- Do not extend the waiting period beyond 2 weeks, especially in diabetic patients, as waiting 4 weeks increases technique failure rates from 7% to 29% in this population without further reducing leak risk. 1
- All dialysate leaks in pediatric patients occurred when the break-in period was less than 14 days, strongly supporting the 2-week recommendation across age groups. 3
- Early catheter use (≤5 days post-insertion) is an independent risk factor for complications, including malposition, omental entrapment, and dialysate leakage. 4
Urgent-Start Protocol (When Dialysis Cannot Wait 14 Days)
If dialysis is urgently needed within 10 days of catheter placement, initiate low-volume supine exchanges immediately using the following protocol: 2, 1, 5
Initial Exchange Parameters
- Start with 500-1000 mL per exchange (approximately 10-15 mL/kg) to minimize intra-abdominal pressure and leak risk. 1, 5
- Keep the patient strictly supine for all exchanges during the first week to reduce pressure gradients that cause catheter tract leaks. 1, 5
- Use short dwell times of 60-120 minutes with exchanges every 1-2 hours to provide adequate solute clearance while limiting fluid accumulation. 1, 5
Volume Escalation Strategy
- Increase fill volume by 200 mL every 1-2 days, targeting 1300-2000 mL by days 7-10. 1
- Do not allow upright positioning until the patient tolerates at least 1.5 L volumes for 48 hours. 5
- Peritoneal leaks occur in approximately 28% of urgent-start cases but typically resolve with conservative management alone (temporary cessation, reduced volumes). 1
Target Full-Volume Prescription (After Break-In Period)
Once the appropriate waiting period has elapsed, initiate full-volume exchanges based on body surface area (BSA): 2, 5
- BSA <1.7 m²: 2.0 L per exchange 5
- BSA 1.7-2.0 m²: 2.5 L per exchange 5
- BSA >2.0 m²: 3.0 L per exchange 2, 5
For CAPD, prescribe four exchanges daily; for APD, approximately 85% of patients require daytime dwells in addition to nighttime cycling to achieve adequacy targets. 2, 5
Critical Monitoring After Initiation
- Measure delivered Kt/V and creatinine clearance at 2-4 weeks after starting maintenance volumes to verify adequacy. 1, 2
- Patients without residual renal function require earlier dose measurement at 2 weeks to ensure adequate clearance from the outset. 1
- Perform a Peritoneal Equilibration Test (PET) approximately 1 month after start to characterize transport characteristics and optimize the prescription. 1, 2
Common Pitfalls to Avoid
- Do not use full 2-3 L volumes immediately when starting <10 days post-catheter placement—this dramatically increases leak and dysfunction risk. 1, 5
- Do not assume nighttime-only APD will suffice in anuric patients—they almost always need daytime dwells to reach Kt/V targets of 2.0. 5
- Do not delay increasing the prescription if Kt/V <2.0—mortality and malnutrition risk increase substantially below this threshold. 5, 2
- In pediatric patients with low body weight, single-cuffed catheters, or neonates, be especially vigilant as these factors significantly increase leak risk even with appropriate break-in periods. 3