PREPARING PATIENTS FOR RENAL REPLACEMENT THERAPY

The appropriate time to prepare someone for dialysis can be difficult to judge. It is essential that preparation should not be left until too late; it may, however, be inappropriate to burden people with this information too early.

	advise patients (and others e.g., spouse, as appropriate) re need for RRT
	introduce concepts of PD and HD early
	emphasise the importance of patients' preference
	discuss transplantation (including pre-emptive transplantation)
	remember that no RRT is one option for management

About 6-12 months before expected ESRF, refer to

• Social worker - download a proforma and copy of clinic letter (in Edinburgh)
• Community Dialysis Team: a written referral (In Edinburgh) (use downloadable proforma and copy clinic letter, including:
• Relevant PMH
• Any medical contraindications to PD/HD
• Very brief social history
• Urgency of referral
• Transplant team (unless clearly contraindicated) - see below for additional investigations required.

The CDT will arrange visits to see PD and HD (repeat if necessary), and will arrange invitation to a Patients’ Evening.  They will see potential PD patients at home; those who are likely to do HD can be seen at clinic visits. 

Get feedback from above visits/referrals, and at monthly Pre Dialysis MDT meeting check understanding.

Hepatitis B immunization should be carried out by request to patient's GP (see antimicrobial policy).

AV access (fistula) should be created at least 6 months before starting HD to ensure that it is successful and mature. Some may require multiple operations.

• Refer to Vascular Access Coordinator (Ext 21199) and use specific referral performa.

CAPD catheter should be inserted at least 2 weeks before starting PD

• Operation dates are arranged through either the transplant or vascular surgical team. There is a coordinator for vascular access.

See below for blood tests required Cytotoxic antibodies should be checked each OP visit for patients on the transplant list, or monthly.

Data Accuracy

Keep computer screens updated with dialysis/translplant decisions made, and other information requested. Liaise with consultants or computing staff if unclear how to do this.

Pre-dialysis and pre-transplant investigations

Proforma suitable for inserting into front of notes

You can also download this proforma as a pdf file suitable for printing out and inserting into front of notes: click to download it now

Test	Mandatory pre-		Date	Comment
	dialysis	transplant
VIROLOGY	EBV is not routinely tested for but can be investigated on saved samples.
Hep B, C	3	3
HIV	3	3
CMV		3
VZV, EBV		3
IMMUNOLOGY	Measure CABs at each visit in patients on the transplant list (monthly for HD patients)
Tissue typing		3
Cytotoxic antibodies		3
Blood group		3
RADIOLOGY	No routine imaging of bones required pre-transplant, but PTH should have been measured. Surgical team may request pelvic XR in some.
CXR	3	3
Renal imaging	3	3
Other
UROLOGY	Pre-transplant, consider further investigation if history of recurrent infection, obstruction, or bladder dysfunction
CARDIOLOGY	Pre-transplant, echo mandatory if any history of cardiac disease, and refer if symptomatic or high risk
ECG	3	3
Echo	3?
Other (eg ETT)				ETT mandatory if for SKP transplant
GASTRIC	If any symptoms or previous history to suggest increased risk of ulceration
Endoscopy
REFERRALS
Community dialysis team	3
Social assessment	3
Vasc. access/ PD cath	3
Transplant team		3

Neil Turner was the main author for this page, last amended Thursday, November 30, 2006.

NOTE that the accuracy of any statements in this information CANNOT be guaranteed. It is published in the belief that it is correct, and we endeavour to keep it so - but we do make mistakes. Furthermore, over some subjects there are differing opinions, or differing degrees of certainty. We have usually not attempted to discuss these here because the aim has been to provide an immediate and brief guide. In all areas, prior medical knowledge is assumed. The EdRenHANDBOOK is not suitable for use by those without such a background. Contact us by email or at the address given at the foot of the contents page with any comments or corrections.