Dialysis — initiation and maintenance

Red Flags

Symptomatic uraemia (encephalopathy, pericarditis, pleuritis, intractable nausea/vomiting), refractory hyperkalaemia, refractory acidosis, or refractory pulmonary oedema — emergency dialysis^[1]
Catheter-related bloodstream infection (fever + access tenderness/purulence) — blood cultures from catheter and peripheral, empirical anti-staphylococcal + Gram-negative cover; consider catheter removal^[1]
Peritonitis on PD (cloudy effluent + abdominal pain) — send PD effluent for cell count, Gram stain, culture; intra-peritoneal antibiotics within hours; ISPD protocol^[1]
Severe intradialytic hypotension or arrhythmia — stop UF, give saline bolus, troubleshoot dialysate temperature/sodium/calcium; ECG; cardiology if recurrent^[1]

Modality choice — shared decision making^[1]
Home therapies (PD, home HD) preferred where feasible; in-centre HD for those without home-care infrastructure or with PD contraindications. Transplant first when eligible — pre-emptive transplant best outcomes
Haemodialysis prescription^[1]
≥4 hours thrice weekly using high-flux biocompatible dialyser; blood flow 300–400 mL/min; dialysate flow 500–800 mL/min; ultrapure dialysate; individualised ultrafiltration rate <13 mL/kg/h to limit intradialytic hypotension
AV fistula as preferred vascular access^[1]
Plan AVF surgical creation when eGFR 15–20 or 6 months before anticipated dialysis; tunnelled CVC only as bridge; minimise CVC days; avoid PICC and proximal arm IVs in advanced CKD to preserve future fistula sites
Peritoneal dialysis prescription^[1]
CAPD 4 exchanges/day or APD overnight cycler; biocompatible dialysate; preserve residual renal function with RAS inhibitor and avoiding nephrotoxins; ISPD-aligned exit-site care with topical antibiotic prophylaxis
Anaemia management on dialysis^[1]
Hb target 100–115 g/L; iron repletion (ferritin >200 µg/L and TSAT >20%) before ESA; ESA dose adjusted to avoid Hb >120 g/L; HIF-PHI inhibitors emerging alternative

Drug	Class	Adult	Paediatric	Notes
Erythropoiesis-stimulating agent (epoetin alfa, darbepoetin)^[1]	Recombinant erythropoietin / analogue	Epoetin alfa 50–100 U/kg SC thrice weekly or weekly; darbepoetin 0.45 µg/kg SC weekly or every 2 weeks	Epoetin alfa 50 U/kg SC thrice weekly start; titrate by Hb	Renal anaemia in dialysis CKD; titrate to Hb 100–115 g/L; monitor BP, K, ferritin, TSAT
Intravenous iron (ferric carboxymaltose, iron sucrose)^[1]	Parenteral iron	Iron sucrose 100–200 mg IV per session × 5–10 doses then maintenance; ferric carboxymaltose 500–1000 mg IV every 1–4 weeks	Iron sucrose 1–2 mg/kg IV per session	Maintain ferritin 200–500 µg/L and TSAT 20–40% in dialysis patients; avoid in active sepsis
Cinacalcet or etelcalcetide^[1]	Calcimimetic	Cinacalcet 30 mg PO daily titrated to PTH; etelcalcetide 5 mg IV thrice weekly post-HD	—	Secondary hyperparathyroidism in CKD G5D with PTH above target despite vitamin D analogue; hypocalcaemia limits dose
Heparin (anticoagulation for HD circuit)^[1]	Unfractionated heparin	Bolus 25–50 U/kg at start of dialysis; infusion 500–1500 U/h targeting ACT 1.5–2× baseline	Bolus 50 U/kg then infusion per ACT	Standard circuit anticoagulation; alternatives (LMWH, regional citrate, no heparin) for bleeding risk; HIT screening if platelet drop

Erythropoiesis-stimulating agent (epoetin alfa, darbepoetin)^[1]

Recombinant erythropoietin / analogue

Adult: Epoetin alfa 50–100 U/kg SC thrice weekly or weekly; darbepoetin 0.45 µg/kg SC weekly or every 2 weeks
Paediatric: Epoetin alfa 50 U/kg SC thrice weekly start; titrate by Hb

Renal anaemia in dialysis CKD; titrate to Hb 100–115 g/L; monitor BP, K, ferritin, TSAT

Intravenous iron (ferric carboxymaltose, iron sucrose)^[1]

Parenteral iron

Adult: Iron sucrose 100–200 mg IV per session × 5–10 doses then maintenance; ferric carboxymaltose 500–1000 mg IV every 1–4 weeks
Paediatric: Iron sucrose 1–2 mg/kg IV per session

Maintain ferritin 200–500 µg/L and TSAT 20–40% in dialysis patients; avoid in active sepsis

Cinacalcet or etelcalcetide^[1]

Calcimimetic

Adult: Cinacalcet 30 mg PO daily titrated to PTH; etelcalcetide 5 mg IV thrice weekly post-HD
Paediatric: —

Secondary hyperparathyroidism in CKD G5D with PTH above target despite vitamin D analogue; hypocalcaemia limits dose

Heparin (anticoagulation for HD circuit)^[1]

Unfractionated heparin

Adult: Bolus 25–50 U/kg at start of dialysis; infusion 500–1500 U/h targeting ACT 1.5–2× baseline
Paediatric: Bolus 50 U/kg then infusion per ACT

Standard circuit anticoagulation; alternatives (LMWH, regional citrate, no heparin) for bleeding risk; HIT screening if platelet drop

Protect your fistula arm — no blood pressure cuffs, no IV lines, no constrictive jewellery; tell every healthcare worker^[1]
Cloudy PD bag, fever, or abdominal pain — go to your dialysis unit or emergency department same day; do not wait until next exchange^[1]
Excessive interdialytic weight gain raises blood pressure and pulmonary oedema risk — aim ≤2.5 kg between sessions; salt and fluid restriction is the lever^[1]

Suspected access dysfunction (low flow, prolonged bleeding, thrombosis, aneurysm)Vascular access service same-day^[1]
Recurrent peritonitis on PD or refractory exit-site infectionPeritoneal dialysis specialist; consider transfer to HD if Tenckhoff replacement fails^[1]
Eligible for kidney transplantTransplant centre — pre-emptive listing where eGFR <20^[1]
Severe intradialytic hypotension, arrhythmia, or chest painCardiology and dialysis unit medical lead^[1]

Modality choice, vascular access, prescription, and complications management for adults with kidney failure on haemodialysis or peritoneal dialysis.

1.Indian Society of Nephrology Guidelines for Dialysis (2023); KDOQI Clinical Practice Guideline for Hemodialysis Adequacy (2015 update); ISPD Peritoneal Dialysis Guidelines (2023)