Phase 1 · Pre-HD Readiness

Pre-Dialysis Initiation Checklist

Complete before the first hemodialysis session. Click each item to mark it done. Flagged items generate alerts in the summary bar.

⚠️ Clinical reference only. MRSA screening and TB testing are governed by local institutional policy — check items marked LOCAL POLICY against your unit's protocol. Not affiliated with any guideline body. Developed by Dr. Abbas Deeb.

READY

Complete checklist items to see status flags

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Serology & Virology

Infection control placement and machine assignment depend on HBsAg status

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Infection control note: Dedicated machine and isolated room/bay are required for HBsAg-positive patients only. For HCV-RNA positive patients, standard universal precautions are generally sufficient and isolation is not routinely required — though some countries/units still apply machine or area separation as local policy. Anti-HBs and anti-HBc inform immunity/vaccination status, not isolation decisions.

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HBsAg

Hepatitis B surface antigen. If positive: dedicated machine + isolated bay mandatory. Do not use machine shared with HBsAg-negative patients.

⚠ HBsAg POSITIVE — Dedicated machine + isolated room required. Review vaccination status of close contacts.

PENDING

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Anti-HBs (quantitative)

Determines vaccine-induced immunity. Target ≥10 IU/L = immune. If <10 IU/L and HBsAg negative → vaccinate (see vaccination domain).

⚠ Anti-HBs <10 IU/L — Patient is non-immune. High-dose HBV vaccination required before or at HD initiation.

PENDING

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Anti-HBc (total)

Past HBV exposure marker. If anti-HBc positive + HBsAg negative + anti-HBs negative: consider resolved infection or occult HBV. HBV DNA to exclude occult if immunosuppression planned.

PENDING

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Anti-HCV + HCV RNA (if Ab positive)

Anti-HCV screening first. If reactive → confirm with HCV RNA (NAT). RNA-positive patients are infectious but managed with standard universal precautions — isolation not routinely required by most guidelines. Refer to hepatology for DAA therapy.

ℹ HCV Ab reactive — Confirm with HCV RNA. Universal precautions apply. Hepatology referral for direct-acting antiviral (DAA) therapy.

PENDING

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HIV (4th generation Ag/Ab)

Baseline screening. Universal precautions apply regardless. If positive: confirm with HIV RNA; ensure ART optimisation; infectious disease co-management. No dedicated machine required.

PENDING

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MRSA Screen (nasal ± groin swab) LOCAL POLICY

Not a universal standard across all HD programs. Perform per local infection control policy — particularly relevant for CVC-dependent patients, recent hospital admission, or high-prevalence unit. If positive: mupirocin nasal ointment 3× daily ×5 days; chlorhexidine wash.

⚠ MRSA POSITIVE — Decolonisation protocol: mupirocin nasal ointment 3×/day ×5 days + chlorhexidine body wash. Alert infection control.

LOCAL POLICY

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TB (IGRA or TST) RISK-BASED

Not routine for all HD starts. Indicated if: planned immunosuppression (transplant workup, vasculitis treatment), endemic area, known exposure history, or clinical suspicion. IGRA preferred in BCG-vaccinated patients.

RISK-BASED

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Vaccination

Prioritise before dialysis initiation — immune response is better pre-ESRD

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⚠️ Timing principle: Live vaccines (varicella, MMR) must be given before dialysis initiation and before any immunosuppression. HBV vaccine response is significantly better when given pre-ESRD (eGFR 15–29) — vaccinate early if not already done.

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Hepatitis B Vaccine (high-dose)

Give only if anti-HBs <10 IU/L and HBsAg negative. High-dose schedule in ESRD: Engerix-B 40 mcg IM at 0, 1, 2, 6 months (4-dose) OR Heplisav-B 0.5 mL at 0 and 1 month (2-dose, preferred if available). Check anti-HBs titre 4–8 weeks after series — repeat if non-responder.

ℹ HBV vaccination incomplete or anti-HBs <10 IU/L — Schedule high-dose series. Document schedule and titre follow-up.

PENDING

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Influenza (annual)

Inactivated influenza vaccine. Give annually. High-dose formulation (Fluzone HD) preferred in adults ≥65 years and immunocompromised patients where available.

PENDING

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Pneumococcal

PCV20 (single dose, preferred if available) OR PCV15 followed by PPSV23 at ≥8 weeks. Patients previously vaccinated with PPSV23: give PCV15/20 ≥1 year later. ESRD is a high-risk indication regardless of age.

PENDING

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Varicella / MMR (if non-immune) LIVE VACCINE

Give only before dialysis initiation and before any immunosuppression. Check VZV IgG and MMR immunity if history uncertain. Live vaccines are generally contraindicated once significant immunosuppression begins. Allow 4 weeks before immunosuppression.

⚠ LIVE VACCINE — Must be administered before immunosuppression. Confirm immunosuppression timeline before scheduling.

PENDING

❤️

Cardiac Assessment

Baseline cardiac function guides UFR tolerance and HD intensity

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12-lead ECG (baseline)

Essential baseline reference for future intradialytic events (arrhythmia, chest pain). Documents QTc interval (important for QT-prolonging medications common in ESRD), LVH pattern, and conduction abnormalities.

PENDING

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Echocardiography WHEN CLINICALLY INDICATED

Particularly valuable in: known cardiac disease, symptoms of heart failure, LVH on ECG, pre-transplant workup, or unexplained dyspnoea. Identifies: EF (guides UF tolerance and IDH risk), pericardial effusion (uremic pericarditis), significant valvular disease. Not mandatory for every HD start in a cardiology-reviewed patient with known normal function.

ℹ Echo result pending or EF reduced — Inform first-session prescription: limit UFR, cool dialysate, conservative UF targets.

PENDING

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Cardiology referral (if EF <35% or significant valvular disease)

Optimise cardiac function before initiation where possible. Shared decision-making re: HD vs peritoneal dialysis in severe cardiomyopathy. Coordinate pacemaker/ICD checks if relevant.

PENDING

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Baseline Laboratory Panel

Reference values for adequacy monitoring and complication tracking

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CBC + Reticulocyte count

Anemia baseline. Reticulocyte count to determine if erythropoietic response is adequate or if ESA/iron therapy needed.

PENDING

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Iron studies (Ferritin, TSAT, serum iron)

Ferritin and TSAT are required to define iron deficiency before starting ESA. Target: Ferritin 200–500 ng/mL, TSAT ≥20% in HD patients on maintenance therapy.

PENDING

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Electrolytes, BUN, Creatinine, BMP

Baseline BUN and creatinine for Kt/V reference. Pre-HD K⁺ critical for anticoagulation and arrhythmia risk stratification in session 1. Bicarbonate to guide dialysate HCO₃⁻ prescription.

PENDING

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CKD-MBD panel (PTH, Ca, Phosphate, ALP, Vit D)

Establishes CKD-mineral bone disease baseline. Guides dialysate Ca²⁺ prescription (2.5 mEq/L standard). Severe hyperphosphatemia may influence initial dialysate selection and binder prescribing.

PENDING

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Albumin, LFTs, Blood group & screen

Albumin: nutritional and inflammatory marker. LFTs: baseline liver function, especially relevant if HBV/HCV positive. Blood group + antibody screen: essential pre-requisite for any potential transfusion or transplant pathway. Note: Prealbumin is not routinely recommended at HD initiation — it is strongly influenced by acute inflammation and illness, limiting its interpretability in this setting.

PENDING

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Vascular Access

Access type directly determines first-session BFR ceiling

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Access type confirmed and documented

AVF: confirm maturation criteria met (diameter ≥6 mm, depth ≤6 mm, flow ≥500 mL/min, compressible, pulsatile). AVG: confirm graft palpable, no haematoma, post-operative oedema resolved. CVC: confirm position on CXR (tip at SVC-RA junction), good blood flow >300 mL/min from each lumen.

PENDING

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CXR (if CVC placed)

Mandatory after new CVC insertion: confirm tip position, exclude pneumothorax and haemothorax. Document CXR result in notes before first session use.

PENDING

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Dry weight estimated

Clinical assessment (JVP, lung auscultation, ankle oedema, BP). Bioimpedance analysis (BIA) if available adds objectivity. Document baseline weight. For session 1: target conservative UF — correct symptomatic fluid overload only. Avoid aggressive UF on day 1.

PENDING

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Clinical & Administrative

Consent, medication reconciliation, and multidisciplinary coordination

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Medication reconciliation

Stop nephrotoxins (NSAIDs, aminoglycosides, IV contrast agents — plan future imaging accordingly). Adjust doses of renally cleared drugs. Antihypertensives: hold on HD days (AM dose) if IDH-prone, or timing adjustment. Review potassium-sparing agents, phosphate binders, ESA, iron, vitamin D analogues.

PENDING

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Dietitian referral

HD dietary requirements differ from CKD conservative management. Counsel on K⁺ and phosphate dietary restriction, fluid allowance (500 mL + residual urine output), adequate protein intake (1.0–1.2 g/kg/day in HD).

PENDING

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Cognitive / baseline neurological assessment

Useful baseline for monitoring disequilibrium syndrome (particularly in first sessions with high BUN). Brief cognitive screen (e.g. MMSE or MoCA) — helps detect subtle changes post-session. Ophthalmology referral if diabetic nephropathy.

PENDING

Dialysis Pro · HD Initiation v1.0 · Developed by Dr. Abbas Deeb · Not affiliated with KDOQI or KDIGO

Phase 2 · First Sessions Protocol

Initiating Hemodialysis

A graduated approach to first HD sessions. Numbers below are reasonable starting points for most patients — individualise based on clinical status, BUN level, access type, and haemodynamic stability.

⚠️ Individualisation is essential. No fixed Kt/V target is required on Day 1 — the goal is safe initiation and disequilibrium prevention, not achieving full adequacy. The session ramp below should be adapted to each patient's clinical response.

Session Ramp Overview

Gradual escalation over first 3 sessions — typical thrice-weekly initiation

SESSION 1

Cautious Start

BFR150–200 mL/min

DFR300–500 mL/min

Duration≤ 2 hours

UFMinimal / symptomatic only

URR target~30–40% (limit)

Dialysate Na⁺138–140 mEq/L

Dialysate K⁺Guided by pre-HD K⁺

SESSION 2 (Day 3)

Gradual Escalation

BFR200–250 mL/min

DFR400–500 mL/min

Duration2.5–3 hours

UFConservative — reassess fluid status

Tolerance checkReview Session 1 symptoms

AnticoagulationAdjust based on Session 1

SESSION 3+ (Day 5+)

Approaching Target

BFR250–300 mL/min

DFR500 mL/min

Duration3–3.5 hours

UFTarget dry weight (UFR ≤13 mL/kg/h)

AdequacyFirst formal Kt/V at 1 month

MembraneEscalate to high-flux if indicated

ℹ URR vs Kt/V in Session 1: A full Kt/V is not meaningful or required on Day 1. The aim is to limit urea reduction to approximately 30–40% (URR) in the first session to reduce the osmotic gradient driving cerebral oedema. No fixed numeric Kt/V target — prioritise symptom monitoring over adequacy metrics in the first week.

Session-by-Session Prescribing

Key decisions for each early session

Before Session 1 — set the intensity ceiling

Determine disequilibrium risk. Higher risk = lower BFR and shorter duration:

Risk Factor	Implication for Session 1
BUN >100 mg/dL (urea >36 mmol/L)	Keep BFR 150–180 mL/min; limit to 90–120 min
BUN >150 mg/dL (urea >54 mmol/L)	BFR 150 mL/min max; 60–90 min; consider mannitol*
Neurological symptoms (confusion, asterixis)	Slowest initiation; close neuro monitoring throughout
Haemodynamically fragile / low EF	Cool dialysate (35–36°C); minimal UF; IDH protocol ready
Paediatric / low body weight	Scale BFR to body weight; specialist paediatric protocol

✱ Mannitol note: Prophylactic mannitol 20% 100 mL IV at session start may be considered in selected very high-risk patients (BUN >150 mg/dL + neurological symptoms or frailty). This is not a routine standard for all high-BUN starts — reserve for highest-risk cases.

Dialysate composition — Session 1 defaults

Parameter	Recommended Range	Rationale
Sodium (Na⁺)	138–140 mEq/L	Avoids hypo-osmolality; do not use low-Na dialysate on first session
Potassium (K⁺)	Per pre-HD serum K⁺	If K⁺ >6.5 → use K⁺ 2 mEq/L; if K⁺ 4–6 → use K⁺ 2–3 mEq/L; avoid K⁺ <2 unless critical hyperkalaemia
Calcium (Ca²⁺)	2.5 mEq/L (standard)	Adjust to serum Ca and PTH; use 2.5 for most initiation patients
Bicarbonate (HCO₃⁻)	35–38 mEq/L	Correct metabolic acidosis; avoid overcorrection (rapid pH rise can trigger arrhythmia)
Temperature	36.5°C (standard) or 35–36°C if IDH-prone	Cool dialysate preserves vascular tone

Membrane — no restriction by type for initiation

Clearance intensity in Session 1 is controlled by BFR and duration, not membrane type. A synthetic biocompatible membrane (polysulfone, polyamide, polyethersulfone) is the standard choice. High-flux or low-flux distinction is less important than limiting session intensity. Avoid AN69 membrane if patient is on an ACE inhibitor (bradykinin reaction risk).

After each of the first 3 sessions — review

Before escalating to the next session intensity, confirm:

No headache or confusion during/after session
BP stable (no significant IDH episodes)
No chest pain or significant arrhythmia
Access functioning adequately at target BFR
Document any complications for next session adjustment

First formal adequacy assessment

Perform first Kt/V measurement at 1 month (approximately 12 sessions in), once the prescription has been titrated to maintenance targets. Standard adequacy benchmarks (spKt/V ≥1.4 per session, 3×/week) apply from this point. Adequacy assessment in the first week is not clinically meaningful and should not be used to drive prescription changes.

Anticoagulation for First Sessions

Individualise based on bleeding risk and access type — no universal dose

Scenario	Anticoagulation approach
Standard patient, CVC or AVF, no bleeding risk	UFH 500–1,000 U IV bolus pre-session; 500 U/h infusion; stop 30–60 min before end. Adjust based on circuit clotting or bleeding signs.
Recent surgery (<48–72h), active bleeding, thrombocytopenia	Heparin-free HD: NS flushes 100–200 mL q20–30 min; reduce session time; high DFR to keep circuit flowing.
Known HIT or HIT-risk	Zero heparin. Argatroban 0.1 mg/kg/h IV; or citrate anticoagulation (machine-specific protocol). Haematology input.
High thrombosis risk (hypercoagulable, AVF/AVG, prior clotting)	UFH full anticoagulation target ACT 200–250s. Consider LMWH (tinzaparin, enoxaparin — dialysis-appropriate doses) where available.
CVC-only access, stable patient	UFH 500–1,000 U bolus; adjust to clotting risk. Ensure catheter lock at end of session (see Catheter Dysfunction protocol).

UFH — Standard initiation dosing Bolus: 500–1,000 U IV pre-session (lower end for bleeding risk)
Infusion: 500–1,000 U/h during session
Stop infusion: 30–60 min before end of session
Target ACT: 200–250s (if monitoring available)

Heparin-free HD NS flush 100–200 mL q20–30 min through arterial limb
Increase BFR to maximum tolerated (reduces stasis)
Higher DFR (500 mL/min) to maintain flow gradient
Limit session duration — circuit clotting risk increases beyond 3h heparin-free

Monitoring During First Sessions

Frequency is higher in first sessions — reduce as tolerance established

Parameter	Frequency — Sessions 1–3	What to look for
Blood pressure	Every 15–30 min	SBP drop ≥20 mmHg or <90 mmHg → IDH protocol
Heart rate	Every 30 min	Tachycardia (fluid loss, pain) or arrhythmia
O₂ saturation	Start + every 30 min	Desaturation → air embolism, haemolysis, cardiac event
Symptoms	Active enquiry every 30 min	Headache, nausea, confusion → DDS risk; reduce intensity
Circuit pressures	Continuous machine monitoring	Rising venous or falling arterial → access or clotting issue
Blood line inspection	Visually every 30 min	Dark blood → clotting; cherry-red → haemolysis
Post-session weight	Every session	Compare to pre-session for UF accuracy and dry weight titration

Special Initiation Scenarios

Reserve modified approaches for selected patients

⚠ Very High BUN (>150 mg/dL)

BFR 150 mL/min maximum. Duration 60–90 min for Session 1. Neurological observation every 15 min.

Consider SLED (sustained low-efficiency dialysis) as an alternative to conventional HD initiation — slower solute clearance, better haemodynamic tolerance. Mannitol prophylaxis in selected highest-risk patients only (neurological symptoms, frailty).

🫀 Haemodynamically Fragile / Low EF

Dialysate temperature 35–36°C from Session 1. Na⁺ modelling (if machine available). Minimal UF — correct symptomatic overload only. BFR at lower end of range (150 mL/min).

Consider peritoneal dialysis referral in severe cardiomyopathy (EF <20%) — better haemodynamic tolerance.

✓ Planned Transplant Pathway

Complete vaccination catch-up urgently (especially HBV). Finalize crossmatch and HLA typing. CVC avoidance preferred (AVF) to preserve central veins for future access. Document baseline Kt/V and labs for transplant centre.

⏱ Urgent Start / Unplanned Initiation

Pre-HD checklist condensed — at minimum: serology, ECG, access CXR, baseline electrolytes, consent. Remainder of checklist completed within first 2–4 weeks.

Document urgency indication. Prioritise patient safety over completeness of workup.

Incremental HD

2×/week initiation if significant residual kidney function (RKF)

✓ Incremental HD (starting with twice-weekly sessions) is appropriate when significant RKF remains — typically urine output >500 mL/day or residual Kt/V ≥1.0/week. Preserves RKF longer, reduces cardiovascular burden, and improves quality of life in the transition period.

Criterion	Guidance
Urine output	>500 mL/day — consider twice-weekly initiation
Residual GFR	>3–5 mL/min/1.73m² — may support twice-weekly schedule
Combined Kt/V target	Total (HD + residual) standard-equivalent Kt/V ≥2.0/week for twice-weekly schedule — calculate residual urea clearance (Kr) every 1–3 months
Escalation trigger	Urine output <200 mL/day or clinical symptoms not controlled on 2×/week → transition to 3×/week
Monitoring	24h urine collection for Kr every 1–3 months; reassess schedule accordingly

⚠️ Incremental HD requires reliable measurement of residual kidney function and close monitoring. Not appropriate if: hyperkalaemia not controlled between sessions, fluid overload on 2×/week, or patient non-compliance with dietary/fluid restriction.

Dialysis Pro · HD Initiation v1.0 · Developed by Dr. Abbas Deeb · Not affiliated with KDOQI or KDIGO