Initiating Peritoneal Dialysis in Post-CABG Patients

Immediate Initiation Protocol

The American Journal of Kidney Diseases recommends initiating peritoneal dialysis immediately with low-volume supine dialysis using 500-1000 mL exchanges (approximately 10-15 mL/kg) performed hourly or every 2 hours in the supine position, then gradually increasing to full-volume exchanges (2.0-3.0 L based on BSA) over 7-10 days as tolerated in post-CABG patients with low cardiac output syndrome and anuria 1, 2
Begin with reduced fill volumes of 500-1000 mL to minimize risk of dialysate leak, catheter dysfunction, and hemodynamic compromise in this critically ill cardiac patient 1, 2, 3
Keep patient strictly supine during exchanges to reduce intra-abdominal pressure and leak risk 1, 2, 4
Use short dwell times (1-2 hours initially) with frequent exchanges to maximize solute clearance in this anuric patient 1, 2

Increase fill volume by 200-500 mL every 1-2 days as tolerated, targeting final volumes based on BSA 1, 2, 5
Target fill volumes are:

The American Journal of Kidney Diseases recommends achieving the entire weekly Kt/V of 2.0 from peritoneal clearance alone in anuric patients 1, 6, 5
Four 2.0-3.0 L exchanges daily for CAPD, or automated PD with 9-10 hours nightly PLUS mandatory daytime dwells (approximately 85% of anuric patients require daytime exchanges to reach targets) 1, 5

Measure delivered Kt/V and creatinine clearance at 2-4 weeks using 24-hour dialysate collections 1, 7, 5
Assess volume status and ultrafiltration adequacy daily initially, then weekly 1, 5
Perform peritoneal equilibration test (PET) at 4 weeks to characterize transport status and optimize prescription 7, 8

Do not use full 2-3 L volumes immediately—this dramatically increases leak and dysfunction risk when starting <10 days post-catheter placement 1, 2, 3
Do not allow patient upright positioning until tolerating at least 1.5 L volumes for 48 hours 1, 2
Do not assume nighttime-only automated PD will suffice—anuric patients almost always need daytime dwells to reach Kt/V targets 1, 5
Do not delay increasing prescription if Kt/V <2.0—mortality and malnutrition risk increase substantially below this threshold 1, 6, 5
Do not confuse poor drainage from catheter malposition with low transporter status—verify catheter function before adjusting prescription 7
Do not overlook residual kidney function assessment—though your patient is currently anuric, even minimal recovery (>100 mL/day urine) significantly impacts prescription needs 1, 6, 5