Applied Nephrology Master Series

Chapter 17 Urgent-Start PD, Hospitalized Patients and Acute Clinical Scenarios

CHAPTER MISSION Build a bedside system for starting PD before the usual catheter-healing interval, preserving PD safely during hospitalization, and deciding when acute physiology requires temporary extracorporeal support. The goal is to match treatment speed, abdominal safety, access integrity, staff capability and the patient’s long-term modality plan—without reflexively converting every acute problem to hemodialysis.

Figure 17.1 — Acute-start PD is not one syndrome. Unplanned ESKD, hospitalization of an established PD patient and PD used for AKI require different goals, prescriptions and safety decisions.

MASTER PRINCIPLE First ask HOW FAST the physiology must be corrected and WHETHER the abdomen/access can safely deliver that correction. Then choose PD, adapt PD, or use temporary extracorporeal KRT as a bridge.

0. One-page chapter map

Table 17.1 — The eight decisions that govern urgent and inpatient PD.

Decision	Core question	Bedside output
1. Context	Unplanned ESKD, established PD in hospital, or AKI?	Correct clinical pathway
2. Urgency	How rapidly must K, acid-base status, uremia or congestion be corrected?	PD now vs bridge HD/CRRT
3. Abdomen	Is the peritoneal cavity safe and usable?	Feasibility / contraindication screen
4. Access	Existing functional catheter or new urgent access?	Access plan
5. Pressure	How do we protect a new catheter and wound?	Low-volume recumbent start
6. Prescription	Which cycle/dwell/osmotic lever addresses the acute problem?	Mechanism-based PD order
7. Hospital system	Can staff, supplies, procedures and infection prevention support PD?	Safe inpatient delivery
8. Transition	When can treatment de-escalate, resume home PD or change modality?	Planned handoff

Learning outcomes

Distinguish urgent-start maintenance PD from acute PD for AKI and from continuation of chronic PD during hospitalization.
Use the 2-week elective catheter break-in recommendation correctly without treating it as a ban on earlier PD.
Select low-volume recumbent urgent-start PD to reduce intraperitoneal pressure and leak risk.
Recognize when immediate physiologic instability favors temporary HD/CRRT before a later PD start.
Build an inpatient PD review that verifies the actual prescription, volume state, residual kidney function, access and medication/procedure plan.
Prepare PD patients safely for colonoscopy and invasive gynecologic procedures using current peritonitis-prevention principles.
Decide when surgery or critical illness requires PD modification, temporary interruption or extracorporeal KRT.
Use ISPD acute-PD guidance for AKI without importing chronic-PD targets into the ICU.
Plan discharge and modality transition before an acute hospital episode creates technique failure by default.

EVIDENCE POSTURE ISPD 2019 access guidance anchors catheter break-in and urgent-start technique. ISPD 2020/2021 acute-PD guidance anchors PD for AKI. ISPD 2022 peritonitis guidance and a 2023 PDI inpatient review anchor procedural/infection safety. Contemporary 2024–2025 meta-analyses support urgent-start feasibility but remain dominated by observational data and heterogeneous definitions. [1–11]

1. Core concept: “urgent” describes the clinical clock, not a single prescription

Urgent PD is often discussed as though it were a modality. It is better understood as a timing problem layered onto standard PD physiology. A patient may need maintenance dialysis before a newly placed catheter has fully healed; an established PD patient may be hospitalized with pneumonia or heart failure; or PD may be chosen as acute kidney replacement therapy for AKI. These situations share peritoneal transport, but differ in access maturity, physiologic urgency and treatment endpoint. [1–5]

Table 17.2 — Three acute-start contexts.

Context	Primary goal	What makes it different
Urgent-start maintenance PD	Start long-term PD without waiting the elective healing interval	New catheter + leak/mechanical risk
Hospitalized established PD	Preserve chronic modality while treating acute illness	Hospital system and prescription adaptation
Acute PD for AKI	Provide temporary kidney replacement therapy	Critical-illness physiology + renal-recovery endpoint

TERMINOLOGY RULE Do not use “urgent-start PD” and “acute PD for AKI” interchangeably. One is an accelerated start of maintenance dialysis; the other is temporary KRT for an acute kidney insult.

2. Definitions: use the break-in interval precisely

The ISPD 2019 access guideline defines the break-in period as the interval between catheter insertion and initiation of PD. It recommends at least 2 weeks before an elective start (1B). If PD must begin within 2 weeks, ISPD recommends a modified prescription using low-volume exchanges with the patient supine (1C). For leak prevention, the same guideline recommends a recumbent low-volume intermittent regimen with the peritoneal cavity dry during ambulatory periods. [1]

Table 17.3 — Timing language.

Term	Practical meaning	Evidence caveat
Elective / conventional start	PD after an adequate planned healing interval; ISPD recommends ≥2 weeks	Allows routine progression to full prescription
Urgent start	Commonly PD within <2 weeks after catheter insertion	Definitions vary across studies/programs
Immediate / very early start	PD begun within hours to a few days in some programs	Feasible in selected cohorts; protocols are not universal
Acute PD	PD prescribed for AKI/critical illness	Different dose and monitoring framework

DO NOT AUTOMATE “<14 days” identifies a study/program category; it does not dictate a fixed initial fill volume, number of exchanges or automatic hospital admission.

3. First decision: can PD correct the acute physiology fast enough?

Figure 17.2 — The first modality decision is driven by required speed of correction, clinical stability, abdominal suitability and access—not by allegiance to PD or HD.

Urgent-start PD is appropriate for many late-presenting patients with ESKD, but some patients present with immediately life-threatening metabolic or cardiopulmonary instability. Reviews of urgent-start programs emphasize that severe refractory hyperkalemia, severe acidosis, marked pulmonary edema, uremic pericarditis or critical hemodynamic/respiratory instability may justify initial urgent extracorporeal dialysis. Once stabilized, the patient should be reevaluated for PD rather than being locked into HD because a temporary catheter was used. [4,12,13]

Table 17.4 — Triage by physiologic need.

Finding	Clinical question	Direction
Hyperkalemia	Can medical therapy + PD correct K quickly enough?	If not, urgent extracorporeal KRT; reassess PD later
Severe metabolic acidosis	Is rapid buffering/solute removal required?	Choose modality by urgency and stability
Pulmonary edema / hypoxemia	Can PD generate adequate UF fast enough without delaying stabilization?	Bridge HD/CRRT if immediate removal is required
Uremic pericarditis / severe uremic syndrome	Is rapid reliable clearance required now?	Often extracorporeal bridge, then PD plan
Stable symptomatic uremia/volume overload	Can low-pressure PD meet need safely?	Urgent-start PD is reasonable when feasible

BRIDGE RULE A temporary HD/CRRT treatment can be the safest first step and still be part of a PD life plan. Acute stabilization and chronic modality choice are separate decisions.

4. Access: urgent-start PD succeeds or fails before the first exchange

For acute PD in adults, ISPD recommends flexible peritoneal catheters where resources and expertise exist and recommends that insertion technique be chosen according to patient factors and local skills. Appropriately trained nephrologists can insert PD catheters with functional results comparable to surgical placement in suitable patients. For urgent-start maintenance PD, rapid access to competent catheter placement is a program requirement, not an optional convenience. [1,2,4]

Table 17.5 — Urgent access questions.

Question	Why it matters	Action
Is the abdomen usable?	Acute bowel inflammation, compromised recent abdominal surgery or an uncorrected major abdominal-wall problem may make urgent PD unsafe	Alternate/bridge KRT and surgical review
Who can place the catheter safely now?	Delay converts a PD candidate into a CVC-dependent HD start	Use locally competent percutaneous, laparoscopic or surgical pathway
Is the exit site planned for long-term use?	Urgency should not create a poor chronic access	Apply Chapter 5 access principles
Is constipation/bladder distention addressed?	Early flow failure is often extrinsic	Bowel/bladder optimization before blaming catheter position

ACCESS RULE Urgent does not mean improvised chronic access. The catheter should still be planned as the patient’s long-term PD lifeline whenever that is the intended modality.

5. Protect the new catheter: pressure is the modifiable risk

Figure 17.3 — New-catheter urgent start is a pressure-management problem: low-volume recumbent exchanges, dry ambulatory periods and gradual escalation reduce stress on the healing tract.

The principal early trade-off is mechanical: dialysis must be delivered before the catheter tract and cuffs have fully healed. ISPD therefore recommends low-volume supine/recumbent exchanges when the break-in period is shorter than 2 weeks. Contemporary meta-analyses find broadly similar infectious outcomes to conventional start, but a higher rate of mechanical events—especially dialysate leak—in urgent-start cohorts. [1,6–9]

Table 17.6 — Pressure-protection bundle.

Lever	Mechanism	Bedside use
Low initial fill volume	Reduces intraperitoneal pressure	Start below routine full volume; individualize
Supine/recumbent exchanges	Reduces posture-related pressure	Especially important early after insertion
Dry abdomen while ambulatory	Avoids sustained upright pressure	ISPD leak-prevention strategy
Avoid constipation/straining	Reduces pressure spikes and catheter compression	Proactive bowel regimen
Gradual escalation	Lets wound tolerance declare itself	Increase only if no leak/pain/flow problem
Prompt leak response	Prevents enlarging tract defect	Reduce/hold PD and use Chapter 12 pathway

NUMERICAL HUMILITY ISPD gives the pressure principles but not one universal adult starting-volume ladder. Published programs use different volumes, insertion methods and escalation schedules. Use local urgent-start protocol, body habitus, wound integrity, respiratory tolerance and dialysis need.

6. Build the urgent-start prescription around the failing physiology

A safe low-pressure prescription still has to work. The clinician should name the dominant problem—uremia, hyperkalemia, acidosis, fluid overload or all four—and then use exchange frequency, dwell time, solution osmotic strength and total treatment time to meet that problem while preserving the new tract. There is no evidence-based reason to copy a fixed center-specific urgent-start schedule into every adult. [1,4,5]

Table 17.7 — Problem → prescription lever → reassessment.

Problem	Useful lever	Reassess
Predominant uremic symptoms	Increase effective exchange/dialysate exposure within pressure limits	Symptoms, urea trajectory, delivered treatment
Hyperkalemia	Shorter effective cycles can increase small-solute removal	Serum K and ECG/clinical urgency
Fluid overload	Increase osmotic gradient and/or treatment exposure as tolerated	Net balance, BP, oxygenation, leak risk
Acidosis	Increase effective solute clearance	Bicarbonate/pH trajectory
Pain/leak with acceptable labs	Reduce intraperitoneal pressure rather than chasing dose	Wound, symptoms, weight/labs
Inadequate correction despite safe maximal urgent PD	Do not persist with ineffective therapy	Temporary extracorporeal KRT

PRESCRIPTION RULE Urgent-start success is not “PD at any cost.” If the low-pressure prescription cannot safely correct the clinical problem, bridge therapy is appropriate.

7. Early mechanical complications: expect them, localize them, do not catastrophize

Urgent-start PD has a reproducible signal for more early mechanical complications than conventional start, particularly leaks. Most reported events are managed conservatively and do not automatically require catheter removal. Catheter migration, flow dysfunction and early pericatheter leakage belong to the Chapter 12 mechanical-complication framework. [1,6–9]

Table 17.8 — First-week urgent-start problems.

Problem	Common mechanism	Immediate response
Wet dressing / exit-site fluid	Pericatheter leak	Drain/reduce pressure; confirm source; peritoneal rest/bridge as needed
Genital/wall swelling	Boundary leak	Stop pressure escalation; Chapter 12 imaging pathway
Slow drain	Constipation, migration, kink, omentum	Bowel/bladder assessment → imaging if persistent
Inflow/drain pain	Tip irritation, suction, pressure, constipation	Modify mechanics; exclude peritonitis
Cloudy effluent	Peritonitis until excluded	Chapter 10 diagnostic pathway
New tunnel/exit-site purulence	Catheter-related infection	Chapter 11 pathway

8. Urgent-start is a program, not a prescription sheet

Successful urgent-start programs require rapid modality education, catheter access, trained nursing, a place to deliver early exchanges, home assessment, supply coordination and a defined transition to home training. A medically feasible patient can still fail urgent-start PD if the system cannot place the catheter or safely deliver early treatment. [4]

Table 17.9 — Program elements that prevent default CVC-HD.

Element	Operational question	Failure mode if absent
Same-day modality education	Can the patient receive unbiased choice despite late presentation?	Automatic HD default
Fast catheter pathway	Can access be placed promptly?	CVC placement while waiting
Early-exchange area	Can low-volume recumbent PD be supervised?	Unsafe improvised start
PD-trained staff	Can leaks, alarms and effluent abnormalities be recognized?	Unnecessary technique failure
Expedited home assessment	Is the home/support plan feasible?	Discharge delay or unsafe home start
Handoff to training	Who owns escalation after the first days?	Prescription drift and missed complications

SYSTEM PEARL Urgent-start PD is most reliable when the pathway is designed before the urgent patient arrives.

9. Hospitalized maintenance-PD patient: verify before changing

Figure 17.4 — Inpatient PD is a systems problem. The hospital must keep the prescription, volume plan, infection prevention, procedures and trained delivery aligned.

Hospitalization alone is not an indication to convert a maintenance-PD patient to HD. A 2023 PDI review highlights that unfamiliar staff, missing supplies and fragmented procedure planning can create unnecessary modality switches. The first inpatient order should therefore reconstruct what the patient actually does at home and why. [10,14]

Table 17.10 — Admission PD reconciliation.

Domain	Verify on admission	Why
Prescription	CAPD/APD, fill volumes, dwell pattern, solutions, last fill, icodextrin	Prevents under/overdialysis
Access	Function, exit site, tunnel symptoms	Detects access problem early
Volume	Weight trend, edema, BP, urine, net UF	Defines inpatient fluid strategy
RKF	Urine output and recent trajectory	Changes total dialysis need
Glycemia	Diabetes plan + glucose-solution exposure	Acute illness may destabilize glucose
Medications	Renally cleared drugs, antibiotics, diuretics, bowel regimen	Prevents avoidable toxicity/volume/constipation problems
Home capability	Who normally performs PD?	Determines staff vs patient/caregiver role in hospital

INPATIENT RULE Do not rewrite a stable home prescription from memory. Reconstruct it, identify what the acute illness changes, then alter only the necessary levers.

10. Inpatient prescription adaptation: acute illness changes goals

The maintenance prescription may need temporary adjustment for reduced oral intake, hyperglycemia, steroid therapy, loss of residual urine, intravenous fluids, sepsis, pulmonary congestion, immobilization or a procedure requiring an empty abdomen. The safest approach is daily clinical reassessment rather than a fixed “hospital PD” protocol. [10,15]

Table 17.11 — Common inpatient adaptations.

Hospital problem	PD consideration	Reassessment endpoint
NPO / reduced intake	Avoid unnecessary osmotic intensity; monitor glucose and volume	Weight/BP/labs/UF
IV fluids / transfusion	Account for non-oral volume input	Net fluid balance and oxygenation
Steroids / infection hyperglycemia	Dialysate glucose adds metabolic load	Bedside glucose strategy
Loss of residual urine	Total KRT requirement rises	Urine + symptoms + biochemistry
Immobility/constipation	Drainage can deteriorate	Bowel function + flow
Pulmonary edema	Increase UF only if PD can do so rapidly enough	Oxygenation/hemodynamics/net balance
Hypotension/sepsis	Excessive UF can worsen perfusion	BP/lactate/perfusion and volume phenotype

11. Procedures in hospital: empty abdomen + infection prevention

For colonoscopy and invasive gynecologic procedures, ISPD 2022 peritonitis guidance supports antibiotic prophylaxis. The inpatient review recommends carrying out these procedures without PD fluid in situ. Exact prophylactic antibiotic choice should follow the current ISPD/local protocol rather than be improvised from memory. [10,16]

Table 17.12 — Procedure preparation.

Procedure issue	PD action	Safety note
Colonoscopy	Drain abdomen; give guideline-consistent prophylaxis	Avoid phosphate-containing bowel preparations in advanced kidney failure
Invasive gynecologic procedure	Drain abdomen; guideline-consistent prophylaxis	Does not refer to routine Pap smear
Other endoscopy/procedure	Decide whether cavity should be empty and whether prophylaxis applies	Use local procedural + PD protocol
Any systemic antibiotic course	Co-prescribe antifungal prophylaxis per ISPD peritonitis guidance	Cross-reference Chapter 10
Post-procedure abdominal pain/cloudy bag	Do not dismiss as expected procedural pain	Urgent effluent assessment

PROCEDURE RULE The two errors to prevent are leaving an unnecessary dwell in place during a high-risk intra-abdominal procedure and forgetting peritonitis-prevention steps.

12. Contrast and imaging: do not dialyze the scan

Necessary iodinated contrast can be administered cautiously to PD patients; the inpatient review notes no evidence that the PD prescription should be intensified simply to remove contrast. The important modifiable issue is avoiding volume depletion and using current radiology/nephrology contrast-risk guidance. Likewise, there is no routine evidence-based reason to switch a PD patient to HD solely to “clear” modern gadolinium contrast; agent selection should follow current radiology guidance. [10]

Table 17.13 — Imaging questions.

Question	Reasoning	Direction
Does the study materially change care?	Residual kidney function still matters in PD	Use contrast when justified; minimize avoidable exposure
Is patient volume depleted?	Hypovolemia can threaten RKF and perfusion	Correct volume phenotype before elective contrast when appropriate
Should PD be intensified after iodinated contrast?	No evidence for extra dialysis solely for contrast clearance	Continue clinically indicated prescription
Should PD be converted to HD solely for gadolinium clearance?	Not routinely supported	Follow current agent-specific radiology guidance

13. Surgery: distinguish abdominal contamination from non-abdominal surgery

Perioperative PD should be individualized. Non-abdominal surgery, including cardiac surgery, does not automatically require conversion to HD. Contemporary observational cardiac-surgery data show no outcome advantage to routine conversion and support efforts to maintain PD when feasible. Abdominal surgery is different: peritoneal entry, bowel contamination, drains, wound integrity and risk of dialysate leak determine when and how PD can resume. [10,17–20]

Table 17.14 — Perioperative PD reasoning.

Situation	PD direction	Key condition
Non-abdominal surgery	Often continue/adapt PD	Hemodynamics and volume management permit
Cardiac surgery	Routine HD conversion is not evidence-based	Coordinate nephrology + cardiac surgery/ICU
Clean abdominal/laparoscopic surgery	PD may resume with low-pressure strategy in selected cases	Watertight closure; surgeon agreement; no contamination
Bowel perforation/peritonitis/major contamination	PD usually inappropriate during acute phase	Source control and temporary extracorporeal KRT
Hernia repair	Low-pressure postoperative PD can sometimes avoid interim HD	Use Chapter 12 pressure principles
Abdominal drain communicating with peritoneum	Leak/infection risk	Individual surgical-nephrology plan

SURGERY RULE The operative diagnosis—not the word “surgery”—determines whether the peritoneum is available for dialysis.

14. Critical illness and mechanical ventilation: PD can be continued selectively

Critical-care teams often convert maintenance-PD patients reflexively to extracorporeal therapy. Recent reviews argue for a more selective approach. PD can be continued in many critically ill patients, but respiratory mechanics, intra-abdominal pressure, required solute/UF intensity, proning, abdominal pathology and nursing expertise must be considered. Lower fill volumes can be used when abdominal pressure or ventilatory mechanics are a concern. [15,21]

Table 17.15 — ICU PD suitability.

Factor	Favors continuing PD	Favors extracorporeal KRT
Hemodynamics	Stable or benefits from gentle continuous removal	Need for precisely titratable rapid volume management
Ventilation	Acceptable respiratory mechanics with reduced fills	Severe pressure-related ventilatory compromise
Abdomen	Intact usable peritoneum	Recent major abdominal surgery, bowel ischemia/perforation, compartment syndrome
Metabolic demand	PD can meet clearance need	Severe hypercatabolism/rapid life-threatening correction needed
Access	Functional catheter	Unresolvable leak/flow failure/infection
Staff/system	PD-trained ICU team and supplies	No safe delivery capability

ICU RULE The correct question is not “Is the patient intubated?” It is “Can this PD prescription achieve the physiologic goal without worsening abdominal/respiratory mechanics?”

15. Acute PD for AKI: use the ISPD acute-KRT framework

ISPD 2020 acute-PD guidance states that PD should be considered a suitable modality for AKI in all settings (1B). Flexible catheters are preferred where resources and expertise exist. In the first 24–48 hours, short cycle times of about 1–2 hours may be required to correct uremia, hyperkalemia, fluid overload or metabolic acidosis; cycle times can often be extended to 4–6 hours once those problems are controlled. Dextrose concentration and cycle duration are adjusted to the fluid-removal need. [2]

Table 17.16 — Acute-PD anchors from ISPD 2020.

Parameter	Guideline direction	Clinical meaning
Modality	PD is a suitable AKI KRT modality (1B)	Do not reserve PD only for chronic dialysis
Access	Flexible catheter preferred when available (1B)	Durable, lower-complication access
Cycle time	Shorter early cycles for urgent metabolic/volume correction; longer once controlled	Match speed to physiology
Fluid overload	Increase osmotic strength and/or shorten cycles; neutral balance once euvolemic	Avoid permanent hypertonic escalation
Monitoring	Daily urea/creatinine/K/bicarbonate where resources permit; adequacy when clinically indicated	Acute prescription is dynamic
Stopping acute PD	Consider interruption when kidney recovery is evident clinically and biochemically	AKI endpoint is renal recovery, not chronic technique maintenance

ISPD also discusses delivered Kt/V targets for acute PD, but these are acute-KRT dose concepts derived from specific trials and should not be transplanted into chronic-PD adequacy or into every hospital order. Use them when managing acute PD as a formal AKI KRT program, not as a universal urgent-start-maintenance target. [2]

AKI DISTINCTION Urgent-start maintenance PD protects a healing catheter while beginning lifelong therapy. Acute PD for AKI may require far more intensive cycling because the endpoint is rapid correction and kidney recovery.

16. Acute clinical scenario matrix: decide by mechanism

Table 17.17 — Acute scenario → first PD question.

Scenario	First question	Direction
Late-presenting ESKD + stable uremia	Can low-pressure urgent-start PD meet need?	Urgent-start pathway
Refractory hyperkalemia + instability	Is PD fast enough right now?	Bridge HD/CRRT if not
Pulmonary edema	Can PD remove fluid quickly and safely enough?	Intensify PD only if timely; otherwise bridge
Sepsis + hypotension in established PD	Is congestion or depletion dominant?	Avoid reflex hypertonic PD; reassess hemodynamics
Pneumonia/intubation	Does fill volume worsen ventilation?	Lower-volume PD if otherwise feasible
Abdominal sepsis/perforation	Is the peritoneum safe to use?	Source control + extracorporeal KRT
Cloudy effluent in hospital	Peritonitis?	Chapter 10 immediate pathway
New poor drain after opioid use	Constipation/immobility?	Bowel + catheter troubleshooting before modality switch
Post-cardiac surgery	Can PD continue with coordinated ICU plan?	Do not automatically convert to HD

17. Discharge and transition: prevent the hospital from becoming technique failure

An acute admission can disrupt PD training, supplies, medications, home support and patient confidence. Discharge planning should therefore reconcile the current prescription against the preadmission prescription, document temporary changes, reset target weight/volume strategy, verify catheter and exit-site status, ensure antimicrobial/antifungal plans are complete, and define who will reassess the patient after discharge. Transitions to and from PD are common and should be anticipated as part of the dialysis life plan. [14,22]

Table 17.18 — Discharge checklist after urgent/inpatient PD.

Item	Question before discharge	Output
Prescription	Which temporary hospital changes remain necessary?	Written final PD order
Access	Any leak, flow problem, exit/tunnel issue?	Resolved pathway/follow-up
Volume	What is the new clinical target weight/diuretic plan?	Home monitoring plan
RKF	Did urine output change during illness?	Dose/volume reassessment trigger
Medications	Any new renally cleared drugs/antibiotics?	Dose + antifungal plan
Training	Did illness or hospitalization impair competency?	Retraining/assistance
Supplies/cycler	Are home materials and program settings ready?	No treatment gap
Backup modality	Was temporary HD used and is access still present?	Removal/transition plan when safe

18. Major clinical algorithms

Flowchart 17.1 — Unplanned ESKD urgent-start triage. Stabilize life-threatening physiology first; then preserve the patient’s long-term modality choice.

Flowchart 17.2 — First days after urgent catheter insertion. Low pressure is the default; prescription escalation is conditional on wound, flow and clinical response.

Flowchart 17.3 — Hospitalized maintenance-PD patient. Continue or adapt PD when adequate and safe; use problem-specific chapter pathways before switching modality.

Flowchart 17.4 — Acute PD for AKI. The prescription is driven by immediate metabolic and fluid goals, with daily reassessment for kidney recovery or need for extracorporeal KRT.

19. Retention tables: pattern recognition

Table 17.19 — If you see this, think this first.

Finding	First hypothesis	Immediate move
PD needed 3 days after catheter insertion	Urgent-start pressure problem	Low-volume recumbent PD; dry when ambulatory
Wet dressing after first exchanges	Early pericatheter leak	Drain/reduce pressure; Chapter 12 pathway
Stable hospital admission for pneumonia	PD can usually continue	Reconcile prescription and adapt only if needed
Cloudy effluent after colonoscopy	Peritonitis risk	Immediate Chapter 10 assessment
Severe pulmonary edema despite PD	Acute UF need may exceed current PD	Escalate/bridge rather than persist ineffectively
Intubation with rising airway pressures after fill	Intra-abdominal/respiratory interaction	Reduce fill/drain and reassess mechanics
Cardiac surgery planned	No automatic HD conversion	Coordinate perioperative PD plan
Iodinated contrast CT required	Do not “dialyze the contrast” reflexively	Use justified contrast + euvolemia; routine PD
AKI improving with urine recovery	Acute PD may no longer be needed	Trial interruption when clinically appropriate

Table 17.20 — What not to confuse.

Do not confuse	With	Correction
Urgent-start maintenance PD	Acute PD for AKI	Different endpoint and dose framework
Hospital admission	Indication for HD	Preserve PD if safe/adequate
New catheter	Need to wait 2 weeks at all costs	Urgent low-volume supine PD is guideline-supported
High leak risk	High infection risk	Urgent start primarily increases mechanical complications
Temporary HD bridge	Permanent PD failure	Reassess PD after stabilization
More dextrose	Better acute volume therapy automatically	Check hemodynamics, sodium, leak and speed needed
Abdominal surgery	Permanent PD contraindication	Depends on contamination and peritoneal integrity
Contrast exposure	Need for extra PD	No evidence for extra dialysis solely to clear contrast

20. Clinical pearls

1. Urgent-start PD is a timing strategy for maintenance dialysis; acute PD for AKI is a different therapeutic framework.

2. ISPD recommends at least 2 weeks before elective PD when possible—but explicitly supports earlier low-volume supine PD when needed.

3. The excess complication signal in urgent start is mechanical, especially leak, not a consistent increase in peritonitis.

4. A patient can receive one or more urgent HD treatments and still transition to PD as originally intended.

5. The safest early prescription minimizes pressure while still correcting the clinical problem.

6. There is no universal adult urgent-start fill-volume ladder supported across all programs.

7. Hospitalization is a reason to reconcile PD, not to erase it.

8. Constipation, immobility and opioids are common inpatient causes of poor drainage.

9. Colonoscopy and invasive gynecologic procedures require PD-specific peritonitis-prevention planning.

10. Antifungal prophylaxis should accompany antibiotic courses in PD patients according to ISPD peritonitis guidance.

11. Do not intensify PD merely to remove iodinated contrast.

12. Cardiac surgery does not automatically require conversion from PD to HD.

13. Mechanical ventilation is not itself a contraindication to PD; respiratory mechanics and intra-abdominal pressure matter.

14. For acute PD in AKI, cycle time is a clinical lever: short early when rapid correction is needed, longer once controlled.

15. Discharge after an acute admission is a modality-transition event and deserves a formal handoff.

21. Common pitfalls — and the correction

Table 17.21 — Pitfall → why it fails → correction.

Pitfall	Why it fails	Correction
“New catheter means no PD for 2 weeks”	Delays feasible urgent PD and often creates CVC-HD default	Use ISPD low-volume supine urgent-start strategy
Starting full routine fills immediately	Raises pressure before tract healing	Low-volume recumbent start + gradual escalation
Using one urgent-start protocol for everyone	Body habitus, wound, modality and urgency differ	Individualize within local protocol
Persisting with PD despite life-threatening inadequate correction	Delays definitive stabilization	Temporary extracorporeal KRT
Converting every hospitalized PD patient to HD	Creates unnecessary access/procedure risk	Continue/adapt PD when safe
Ignoring home prescription details	Causes under/overdialysis and medication mismatch	Formal inpatient reconciliation
Forgetting abdomen should be empty for selected procedures	Raises procedural/infection issues	Drain + guideline prophylaxis
Treating post-op abdominal pain as routine	Can miss leak/peritonitis/surgical abdomen	Mechanism-based assessment
Extra PD after contrast solely for clearance	No supporting evidence	Dialyze for clinical indication, not contrast removal
Assuming cardiac surgery requires HD	Not supported by observational outcomes	Plan perioperative PD with ICU/surgical team
Copying chronic Kt/V logic into acute AKI PD	Different trial framework and endpoint	Use acute-PD guideline dosing/monitoring
Discharging on an undocumented temporary prescription	Creates home treatment error	Explicit discharge PD order + follow-up

22. Mini-cases: decisions, not trivia

Case 1 — Late presenter, stable A 58-year-old with advanced CKD presents with nausea and edema. Dialysis is needed, but potassium and oxygenation are stable. He chooses PD and has no abdominal contraindication. DECISION: Urgent-start PD is reasonable. Arrange expedited catheter insertion, then a low-volume recumbent prescription rather than default CVC-HD.

Case 2 — Late presenter, unstable A patient wants PD but arrives with severe refractory hyperkalemia, marked pulmonary edema and escalating oxygen requirement. DECISION: Stabilize first with the fastest reliable KRT available—often urgent HD/CRRT—then return to the PD plan once stable.

Case 3 — Wet dressing on day 2 A new urgent-start patient develops clear fluid at the catheter incision after walking with dialysate in the abdomen. DECISION: Suspect an early leak. Drain, reduce pressure, keep dry ambulatory, and use the Chapter 12 leak pathway; do not simply increase dressing changes.

Case 4 — Pneumonia admission An established APD patient is admitted with pneumonia. The non-nephrology team proposes temporary HD “because she is in hospital.” DECISION: Hospitalization alone is not an indication. Reconcile home PD, volume, urine and acute changes; continue/adapt PD if adequate and safe.

Case 5 — Colonoscopy A PD patient is scheduled for inpatient colonoscopy after GI bleeding. DECISION: Coordinate PD-specific preparation: empty abdomen and current guideline-consistent prophylaxis; if pain/cloudy effluent follows, assess immediately for peritonitis.

Case 6 — Intubated patient A maintenance-PD patient is mechanically ventilated for severe pneumonia. Airway pressures rise when large fills are used. DECISION: Drain/reduce fill volume and reassess respiratory mechanics. Intubation itself does not mandate HD, but PD must not worsen ventilation or fail metabolic goals.

Case 7 — Cardiac surgery A stable PD patient is scheduled for CABG. The surgical team wants preemptive conversion to HD. DECISION: Routine conversion is not evidence-based. Build a coordinated perioperative PD plan; convert only for a specific clinical reason.

Case 8 — AKI in ICU A patient without prior CKD develops AKI with oliguria, acidosis and fluid overload in a unit experienced with acute PD. DECISION: This is acute PD for AKI, not urgent-start maintenance PD. Use the ISPD acute-PD cycle/monitoring framework and reassess daily for recovery.

23. Active recall

MUST MEMORIZE

Table 17.22 — Non-negotiable recall.

Question	Answer
ISPD elective break-in recommendation?	At least 2 weeks before elective PD start when possible.
Urgent start before 2 weeks?	Low-volume exchanges in the supine/recumbent position.
Ambulatory period early after urgent start?	Keep cavity dry when possible to reduce leak risk.
Main excess complication of urgent start?	Mechanical complications, particularly leaks.
Hospital admission means automatic HD?	No. Continue/adapt PD when safe and adequate.
Colonoscopy/invasive gynecologic procedure?	Empty abdomen + guideline-consistent antibiotic prophylaxis.
Systemic antibiotics in PD?	Use ISPD-recommended antifungal prophylaxis.
Extra PD after contrast solely for clearance?	No evidence-based indication.
PD in AKI?	ISPD considers PD a suitable KRT modality.
Acute PD cycle time early in severe metabolic/volume problems?	Short cycles may be needed; extend once controlled.

USE AS REFERENCE

Exact adult urgent-start starting fill volumes and escalation schedules: local protocol + patient factors.
Procedure-specific antimicrobial regimen: current ISPD/local antimicrobial guidance.
Post-abdominal-surgery PD restart timing: operation-specific surgical/nephrology plan.
Acute-PD Kt/V dose calculations: ISPD acute-AKI guideline and local ICU protocol.
Contrast/gadolinium agent selection: current radiology/nephrology guidance.
ICU proning, ventilation and intra-abdominal-pressure management: critical-care protocol and individual mechanics.

24. Flashcards: spaced repetition

Table 17.23 — Flashcards.

Front	Back
What is the break-in period?	Time from PD catheter insertion to initiation of PD.
What does ISPD recommend before elective PD?	At least a 2-week break-in when possible.
How should urgent PD start before 2 weeks?	Low-volume supine/recumbent intermittent exchanges, with dry ambulatory periods to reduce leak risk.
Why low volume?	To reduce intraperitoneal pressure on the healing tract.
Why does upright posture matter?	It increases intraperitoneal pressure and leak stress.
What is the main early urgent-start trade-off?	More mechanical complications, especially leaks.
Does urgent start clearly increase peritonitis?	Meta-analyses generally do not show a clear increase versus conventional start.
Can urgent HD be used before PD?	Yes—as stabilization/bridge therapy without abandoning the long-term PD plan.
What is the first inpatient PD task?	Reconcile the actual home prescription and access/volume/RKF status.
Does NPO status require stopping PD?	No; adapt prescription and glucose/volume plan as needed.
What often causes new inpatient drain failure?	Constipation, immobility, bladder distention or catheter mechanics.
What should be done before colonoscopy?	Drain the abdomen and use guideline-consistent prophylaxis.
What accompanies systemic antibiotic therapy in PD?	Antifungal prophylaxis per ISPD guidance.
Should PD be intensified just to clear iodinated contrast?	No.
Does cardiac surgery mandate HD?	No; perioperative PD can often be maintained.
Does intubation mandate HD?	No; assess respiratory mechanics and PD adequacy.
What is acute PD for AKI?	PD used as temporary kidney replacement therapy for an acute kidney insult.
How are acute-PD cycle times chosen?	By the urgency of uremia, K, acidosis and fluid overload.
When can acute PD cycles lengthen?	After the acute metabolic/volume problems are controlled.
What is the discharge risk after hospitalization?	Unreconciled prescription/support changes causing technique failure or treatment error.

25. Rapid differential / troubleshooting

Table 17.24 — Acute PD troubleshooting matrix.

Presentation	Think first	Do now	Escalation
Poor drainage after admission	Constipation/immobility/bladder/catheter	Bowel/bladder + position + Chapter 12 checks	Imaging/revision if persistent
New clear fluid at wound	Pericatheter leak	Drain/reduce pressure	Peritoneal rest/bridge if significant
Cloudy effluent	Peritonitis	Cell count/culture + Chapter 10 treatment	Source control if refractory
Dyspnea during fills	Overload vs pressure/pleural issue	Drain, examine volume, chest assessment	Bridge KRT if PD cannot meet need
Rising K despite PD	Insufficient small-solute clearance / catabolism	Check delivery; shorten cycles if appropriate	HD/CRRT if urgent/refractory
Hypotension with high-dextrose inpatient PD	Over-removal / sepsis / low effective volume	Reassess hemodynamics and UF intensity	Critical-care support
Post-op abdominal pain	Expected pain vs leak/peritonitis/surgical complication	Focused exam, effluent and surgical assessment	Hold PD/bridge when peritoneum unsafe
Unexpected hyperglycemia	Acute illness + dialysate glucose	Review solution + diabetes plan	Specialist diabetes input
Repeated alarms in unfamiliar ward	Setup/system/staff issue	PD-trained review and cycler check	Move to trained unit if unsafe

26. Final revision sheet

CORE CONCEPT Acute PD care is a matching problem: clinical clock + abdominal safety + access maturity + dialysis speed + hospital capability + long-term modality goal.

One-minute revision

Table 17.25 — One-minute chapter summary.

Domain	Memory anchor
Urgent start	<2-week start can be done; protect the healing tract
Elective start	≥2-week break-in recommended when possible
Pressure	Low volume + recumbent + dry ambulatory early
Triage	If PD is too slow for the immediate threat, bridge
Mechanical risk	Leak is the classic excess early complication
Hospitalization	Reconcile and preserve PD when safe
Procedures	Empty abdomen + correct prophylaxis for high-risk procedures
Antibiotics	Remember antifungal prophylaxis
Contrast	No extra PD solely to remove contrast
Surgery	Peritoneal integrity determines feasibility
ICU	Ventilation does not automatically preclude PD
AKI	PD is a valid acute KRT modality; cycle intensity follows physiology
Transition	Discharge/handoff is part of technique survival

TEN TAKE-HOME RULES 1) Separate urgent-start ESKD from acute-PD AKI. 2) Use the 2-week elective break-in recommendation correctly. 3) Low-volume recumbent PD is the early-start safety core. 4) Keep the abdomen dry when ambulatory early after insertion. 5) Expect leaks more than infections. 6) Use HD/CRRT as a bridge when immediate correction demands it. 7) Do not convert maintenance PD solely because of hospitalization. 8) Procedures and antibiotics require PD-specific infection prevention. 9) Surgery/ICU decisions are anatomy-and-physiology based. 10) Reconcile the final prescription before discharge.

Table 17.26 — One-minute bedside synthesis.

If you see…	Think…	Do now…
New catheter + dialysis needed now	Urgent-start pressure strategy	Low-volume recumbent PD
Severe unstable hyperK/edema	PD may be too slow now	Stabilize with fastest reliable KRT
Wet wound	Leak	Drain/reduce pressure
Hospital pneumonia	PD can often continue	Reconcile/adapt prescription
Colonoscopy	Peritonitis prevention	Drain + prophylaxis
Cardiac surgery	No automatic HD conversion	Coordinate perioperative PD
Intubation	Assess mechanics, not label	Reduce fills if needed; verify adequacy
AKI with PD program available	Acute PD is valid KRT	Short cycles early if needed + daily monitoring
Discharge after temporary HD	Transition hazard	Restore PD plan + remove unnecessary access when safe

FINAL MENTAL MODEL CONTEXT → URGENCY → ABDOMEN → ACCESS → PRESSURE → PRESCRIPTION → HOSPITAL SYSTEM → VERIFY → TRANSITION.

Rapid oral viva

Define the catheter break-in period and state the ISPD elective recommendation.
Explain why urgent-start PD uses low-volume recumbent exchanges.
Describe when temporary HD/CRRT is a bridge rather than a modality failure.
Build the admission reconciliation for an established PD patient.
Explain how you would prepare a PD patient for colonoscopy.
Describe why iodinated contrast does not require extra PD solely for clearance.
Explain whether PD must be stopped for cardiac surgery.
Describe how mechanical ventilation changes—but does not automatically prohibit—PD.
Distinguish urgent-start maintenance PD from acute PD for AKI.
Explain how acute-PD cycle time changes as hyperkalemia/acidosis/volume overload improve.

SAFETY BOUNDARY This chapter teaches decision architecture. Exact emergency-dialysis thresholds, urgent-start fill-volume ladders, catheter-insertion technique, procedure-specific antibiotic doses, antifungal regimens, acute-PD dosing calculations, vasopressor/ventilator targets, contrast-agent selection, post-surgical restart timing and temporary-HD access management require current local protocols and specialist judgment. Life-threatening hyperkalemia, acidosis, hypoxemic pulmonary edema, shock, abdominal catastrophe or other instability must not be delayed to preserve a preferred modality.

27. Selected authoritative references

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2. Cullis B, Al-Hwiesh A, Kilonzo K, et al. ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 update (adults). Perit Dial Int. 2021;41(1):15–31. https://doi.org/10.1177/0896860820970834. PMID: 33267747.

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8. He J, Wu B, Zhang Y, et al. Prognosis of urgent initiation of peritoneal dialysis: a systematic review and meta-analysis. Ren Fail. 2024;46(1):2312533. https://doi.org/10.1080/0886022X.2024.2312533. PMID: 38391179.

9. Duan P, Zhang H, Zhang Y. The effect of urgent-start peritoneal dialysis and urgent-start hemodialysis on clinical outcomes in patients with chronic kidney disease: an updated systematic review and meta-analysis. Int Urol Nephrol. 2024;56(7):2301–2312. https://doi.org/10.1007/s11255-024-03999-6. PMID: 38441869.

10. Albakr RB, Bargman JM. Care of the hospitalised patient receiving peritoneal dialysis: Your questions answered. Perit Dial Int. 2023;43(1):5–12. https://doi.org/10.1177/08968608221125714. PMID: 36113128.

11. Wu J, Cao Y, Wang T. A comparison of clinical outcomes in urgent-start hemodialysis versus urgent-start peritoneal dialysis in end-stage renal disease patients: a systematic review and meta-analysis. Blood Purif. 2025;54(9-10):565–575. https://doi.org/10.1159/000547049. PMID: 40555200.

12. See EJ, Johnson DW, Hawley CM, et al. Urgent-start peritoneal dialysis and patient outcomes: a systematic review and meta-analysis. Nephrology (Carlton). 2019. PMID: 30915761.

13. Blake PG, Jain AK. Urgent Start Peritoneal Dialysis: Defining What It Is and Why It Matters. Clin J Am Soc Nephrol. 2018;13(8):1278–1279. PMCID:PMC6086705.

14. Desbiens LC, Nadeau-Fredette AC. Transitions to and from peritoneal dialysis: your questions answered. Perit Dial Int. 2026;46(2):85–94. https://doi.org/10.1177/08968608251343768. PMID: 40455013.

15. Al Sahlawi M, Zhao J, McCullough K, et al. Peritoneal Dialysis in Critically Ill Patients: Time for a Critical Reevaluation? Clin J Am Soc Nephrol. 2023. PMID: 36754063.

16. Li PKT, Chow KM, Cho Y, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int. 2022;42(2):110–153. https://doi.org/10.1177/08968608221080586. PMID: 35264029.

17. Kumar VA, Ananthakrishnan S, Rasgon SA, Yan E, Burchette R, Dewar K. Comparing cardiac surgery in peritoneal dialysis and hemodialysis patients: perioperative outcomes and two-year survival. Perit Dial Int. 2012;32(2):137–141. PMID: 21965618.

18. Bassil E, et al. Cardiac Surgery Outcomes in Patients Receiving Hemodialysis Versus Peritoneal Dialysis. Kidney Med. 2024. PMID: 38435071.

19. Bargman JM. Reducing intra-abdominal pressure in peritoneal dialysis patients to avoid transient hemodialysis. Semin Dial. 2018;31(2):209–212. https://doi.org/10.1111/sdi.12676. PMID: 29383761.

20. Aziz F, Chaudhary K. Peritoneal Dialysis in Patients with Abdominal Surgeries and Abdominal Complications. Adv Perit Dial. 2017;33:40–46. PMID: 29668430.

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22. Brenner & Rector’s The Kidney. 12th ed. Elsevier; 2024. Chapters on peritoneal dialysis, interventional nephrology and acute kidney injury.

SOURCE NOTE ISPD guideline status and contemporary urgent-start/inpatient evidence were checked 3 September 2026. This chapter intentionally does not impose a universal adult urgent-start starting fill volume, escalation schedule, emergency-dialysis laboratory cutoff, post-surgical restart interval, ICU ventilator threshold or procedure-specific antibiotic dose. Those details vary by insertion technique, clinical urgency, body habitus, abdominal pathology, local antimicrobial policy, critical-care context and program capability. Current local protocols and specialist judgment take precedence.