When is it safe to start peritoneal dialysis after catheter placement, and what urgent‑start protocol can be used if dialysis is needed sooner?

When to Start Peritoneal Dialysis After Catheter Placement

Start peritoneal dialysis 14 days (2 weeks) after catheter placement to minimize mechanical complications, particularly dialysate leaks. 1

Standard Timing for Elective Start

• Wait 10–14 days after catheter insertion before initiating full-volume peritoneal dialysis exchanges whenever clinically feasible. 1, 2

• Starting at 7 days increases leak risk three-fold (28% leak rate) compared to waiting 2 weeks (9% leak rate), based on randomized controlled trial data. 1, 3

• Do not wait 4 weeks in diabetic patients—this extended delay is associated with significantly higher technique failure rates (29% vs 7% at 2 weeks) without further reducing leak complications. 1, 3

• The 2-week interval allows the catheter tract to heal adequately while avoiding unnecessary delays that increase morbidity from prolonged hemodialysis dependence. 1

Urgent-Start Protocol (When Dialysis Cannot Wait 14 Days)

When immediate dialysis is required, use a low-volume supine protocol rather than delaying treatment: 1, 4, 2

Initial Phase (Days 1–3)

• Fill volume: 500–1,000 mL per exchange (approximately 10–15 mL/kg body weight). 1, 4, 5
• Patient position: Strictly supine for all exchanges to minimize intra-abdominal pressure and leak risk. 1, 4, 5
• Dwell time: 60–120 minutes per exchange. 1, 5
• Exchange frequency: Every 1–2 hours to maintain adequate solute clearance despite low volumes. 1, 4

Volume Escalation (Days 4–10)

• Increase fill volume by 200 mL every 1–2 days as tolerated, targeting 1,300–2,000 mL by day 7–10. 1, 5
• Gradually extend dwell times by 30 minutes every 2 days, reaching 180 minutes by day 7. 5
• Allow upright positioning only after the patient tolerates at least 1,500 mL volumes for 48 hours without complications. 4

Expected Outcomes

• Peritoneal leaks occur in approximately 28% of urgent-start cases but typically resolve with conservative management (volume reduction and supine positioning) without requiring catheter removal or hemodialysis transfer. 1, 5

Full-Volume Prescription After Break-In Period

Once the break-in period is complete (2 weeks elective or 7–10 days urgent-start), prescribe based on body surface area (BSA): 1, 2

For Continuous Ambulatory Peritoneal Dialysis (CAPD)

• BSA < 1.7 m²: Four 2.0 L exchanges daily 1, 2
• BSA 1.7–2.0 m²: Four 2.5 L exchanges daily 1, 2
• BSA > 2.0 m²: Four 3.0 L exchanges daily 1, 2

For Automated Peritoneal Dialysis (APD/CCPD)

• BSA < 1.7 m²: 2.0 L exchanges for 9 hours nightly plus 2.0 L daytime dwell 2
• BSA 1.7–2.0 m²: 2.5 L exchanges for 9 hours nightly plus 2.0 L daytime dwell 2
• BSA > 2.0 m²: 3.0 L exchanges for 9 hours nightly plus 3.0 L daytime dwell 2

Note: Approximately 85% of patients on automated PD require additional daytime dwells to achieve adequacy targets, particularly those with minimal residual kidney function. 1, 2

Early Monitoring and Adequacy Assessment

Week 2–4 After Starting Maintenance Volumes

• Measure delivered Kt/V and creatinine clearance using 24-hour dialysate and urine collections. 6, 1
• Perform this assessment at 2 weeks for anuric patients (no residual kidney function) to confirm adequacy immediately. 1, 4
• For patients with residual function, measurement at 2–4 weeks is acceptable. 6, 1

Week 4 After Initiation

• Perform Peritoneal Equilibration Test (PET) approximately 1 month after starting dialysis to characterize membrane transport characteristics (low, low-average, high-average, or high transporter). 6, 1, 2
• Do not perform PET during the first 4 weeks—initial dialysate instillation causes transient changes in peritoneal vascularity and cytokine production that affect transport measurements. 2

Critical Pitfalls to Avoid

• Never use full 2–3 L volumes immediately when starting before 10 days post-insertion—this dramatically increases leak and catheter dysfunction risk. 1, 4

• Do not allow upright positioning during urgent-start protocols until the patient tolerates adequate volumes supine for at least 48 hours. 4

• Do not delay prescription escalation if Kt/V is below 2.0—inadequate dialysis dose is associated with increased mortality and malnutrition risk. 1, 4

• Do not assume nighttime-only automated PD will suffice for anuric patients—nearly all require daytime exchanges to reach target clearances. 1, 4

• Do not confuse poor drainage from catheter malposition with low membrane transporter status—verify mechanical catheter function before adjusting the prescription based on transport characteristics. 4