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Renal: Peritoneal Equilibration Test (PET) and 24 hour adequacy test Document No.
Guideline and
Procedure
Renal: Peritoneal Equilibration Test (PET) and 24hour Adequacy Test
Sites where Guideline and Procedure
applies
Target audience:
All sites where a Peritoneal Dialysis patient receives care.
Nephrology and Non nephrology clinical staff, who provide
care to Peritoneal Dialysis patients.
Description
This Guideline and Procedure applies to:
1. Adults
Yes
2. Children up to 16 years
No
3. Neonates – less than 29 days
No
Keywords
Replaces Existing Guideline and Procedure
Registration Number(s) and/or name and of
Superseded Documents
Related Legislation, Australian Standards, NSW Health Policy Directive, NSQHS Standard/EQuIP
Criterion and/or other, HNE Health Documents, Professional Guidelines, Codes of Practice or Ethics::



NSW Health Policy Directive 2007_079 Correct patient, Correct procedure, correct site
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf
NSW Health Policy PD 2005_406 Consent to Medical Treatment
http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf
NSW Health Policy Directive PD 2007_036 Infection Control Policy
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf
Registered Nurse or Endorsed Enrolled Nurse who has been
deemed
competent in the performance of peritoneal dialysis
Guideline and Procedure Note This Guideline and Procedure sets out the steps to be followed
when performing a peritoneal equilibration and 24hour Adequacy
test for a peritoneal dialysis patient. The procedural components of
the document such as, Preparation of patient, Preparation of
equipment, Technique, Cleaning up and Documentation are
considered mandatory.
Position responsible for the
HNELHD Renal Clinical Stream Leadership Group
Prerequisites (if required)
Guideline and Procedure and
authorised by
Contact Person
Contact Details
Date authorised
This Guideline and
Procedure contains advice
on therapeutics
Date of Issue
Review due date
TRIM Number
Version Number
Kelly Adams, Tina Straker, Renal Stream Coordinator, Nurse
Manager Community Dialysis
49 048800, 67769917
No
Month and Year
Renal: Peritoneal Equilibration Test (PET) and 24 hour adequacy test Document No.
Note: Over time links in this document may cease working. Where this occurs please source the document in
the PPG Directory at: http://ppg.hne.health.nsw.gov.au/
RISK CATEGORY: Clinical Care & Patient Safety;
OUTCOMES
1
The patient’s peritoneal membrane solute transport characteristics are determined and
classified according to Twardowski’s peritoneal membrane categories
2
The patients total (peritoneal plus residual renal) weekly Kt/V urea and Ccr (Adequacy)
measurement is performed.
3
The patient’s dialysis prescription is modified if required
ABBREVIATIONS & GLOSSARY
ANZDATA
APD
CARI
Ccr
CAPD
Kt/ V urea
Australian and New Zealand Dialysis & Transplant Registry
Automated Peritoneal Dialysis
Caring for Australians with Renal Impairment Guidelines
Creatinine clearance
Continuous Ambulatory Peritoneal Dialysis Effluent Drained peritoneal dialysis fluid
K = clearance, t = time, V = volume of body water in which urea is distributed.
Provides a patient specific index reflecting urea removal achieved over time.
GUIDELINE
This Guideline does not replace the need for the application of clinical judgment in respect to each
individual patient.
PREAMBLE
The PET was introduced by Twardowski in 1989 and is the standard method for evaluating
peritoneal transport characteristics in peritoneal dialysis (PD) patients. Based on the dialysate to
plasma creatinine ratio of creatinine, patients can be classified as high, high average, low average
or low transporters. The PET is very helpful for prescribing both APD and CAPD, since knowledge
of a patient's peritoneal permeability allows a better estimation of the dwell time that will achieve
the greatest efficiency in terms of ultrafiltration and small solute clearance.
 A PET should be performed approximately 4-6 weeks after initiating peritoneal dialysis, but
no earlier.
 PETs should be repeated at 2 years and then annually. PETs should be repeated earlier if
there is clinical evidence of fluid overload with a significant decrease in ultrafiltration,
hypertension or elevated serum urea levels, particularly in those patients who have had
episodes of peritonitis.
 Icodextrin should not be used in the preceding exchange before a PET as it increases the
dialysate: plasma (D/P) creatinine ratio.
The PET consists of dialysate samples taken at zero, two and four hour (hr.) dwell times. A blood
Sample is taken at the same time as the two hr. dwell dialysate sample. The combined 24hr
Adequacy test includes an “overnight” and 24hr dialysate sample plus 24hr urine collection. The
24hour Adequacy collection provides information on small solute clearance and is used as one of
The markers reflecting patient wellbeing.
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Renal: Peritoneal Equilibration Test (PET) and 24 hour adequacy test Document No.
Note: The PET and 24hr Adequacy test may be performed separately and repeated according to
CARI Guidelines and depending on the patients’ individual needs. The results from patient tests
are reported to ANZDATA and monitored against CARI Guidelines. The accuracy of these tests
can be effected by patient compliance, errors in sample collection, and errors in laboratory
handling and errors in data calculations and as such require great care by all service providers.
PROCEDURE
This procedure requires mandatory compliance.
PATIENT PREPARATION
ALERT: Patient preparation and 24hr collection procedure will vary slightly according to the
patients’ current therapy modality, individual prescription and use of specialized dialysis solutions
such as Icodextrin. The patient’s home training centre or renal outreach service should be
contacted for specific patient preparation and adequacy collection information.
Where possible, patients should use the same fill volume and Dialysate glucose concentration for
the dwell immediately preceding the PET. Icodextrin and 4.25% glucose solutions should be
avoided. The standardized procedure for the PET remains consistent.
General Patient Preparation – PET and 24hr collection, CAPD Patient.
1. Organise dates with patient and ensure patient has their instructions and equipment for
dialysate and urine collection
2. Instruct patient to keep drain out bags from previous day. I.e. Midday, afternoon and
evening effluent (if patient doing standard 4 exchanges per day otherwise instruct patient
to keep all drain bags except the first exchange of the morning) and bring bags with them
to the Unit.
3. Instruct patient to collect 24 hour urine sample if appropriate on day of bag collection.
4. Instruct patient to NOT DO FIRST EXCHANGE on the day of the PET (except under
specific individual circumstances)
5. Confirm with patient prior to procedure day that they understand the instructions and that
they will not exceed a 12hr overnight dwell by the time they arrive for their test. Patients
may need to adjust the time they attend their last exchange at night to prevent this.
General Patient Preparation – PET and 24hr collection, APD Patient.
1. Organise dates with patient and ensure patient has their instructions and equipment for
dialysate and urine collection.
2. Patient may need to adjust treatment time to ensure a minimum 4 hr dwell prior to PET, i.e.
from end of last fill. (Overnight sample)
3. Instruct patient to attach the appropriate APD effluent collection bag to the drain line after
the machine has completed “priming” the lines. Manual exchanges and “high dose”
exchange effluent also needs to be collected and taken to the Unit.
4. Instruct patient to collect 24 hour urine sample if appropriate on day of bag collection.
5. Confirm with patient prior to procedure day that they understand the instructions and how to
connect effluent collection bag.
NOTE: Specific individual instructions and preparations may be needed so ensure home training
centre or renal outreach service has been contracted prior to testing
Staff Preparation
It is mandatory for staff to follow relevant: “Five moments of hand hygiene”, infection control,
moving safely/safe manual handling, and documentation practices.
Ensure the patient’s home training centre or renal outreach service has been contacted for specific
Patient preparation and adequacy collection information and that the patient has their instructions
and correct appointment date. If, staff conducting the PET is not able to perform routine peripheral
venepuncture, Notify “blood collection” staff at pathology the day before the test that they will be
required.
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Equipment Requirements for PET

PD fluid 2000mls - 2.5% freeline solo / Staysafe 2.3% (heated)

Extra dialysis fluid will be required dependent upon extra exchanges needed.

1 x clotted tube

5 x UEC tubes (for UECS, Pet samples). If taking additional bloods you will also need to
collect these tubes

Minicap (betadine) one for each sample to be drawn, generally 3-8 are needed

2 x 30 ml syringes

5 x 10 ml syringes

6 x 19 or 21 gauge needles

Alcohol swabs

Tape (Micropore or other suitable)

Plastic specimen bag for pathology samples

2 x Medium plastic bags if 24 hr urine collection is being done at same time (need to double
bag urine specimens)

1 x Sterile/sanitised measuring jug

1 x Blue clamp

Scales

IV pole

Personal protective Equipment (protective eye wear, disposable gloves and plastic gown)

Alcohol Hand Gel
PAPERWORK
 Pathology request form signed by Nephrologist (Medicare form if needed) Note: patient must
sign Medicare form
 Patients Current PD prescription
 Patient Input form (PD Adequest)
 Patients’ own exchange record book
 Patients’ current medication list (some medications will impact on test results)
 Patient Medical Records to record testing
Procedure Steps 1: PET
1. Wash hands and then set-up as per exchange system procedure
2. DON personal protective equipment, scrub for 3 minutes
3. Connect and drain patient out, Note time drain is commenced, as this time is used to
calculate the “overnight dwell time”. The patient must be drained out completely.
4. Calculate the overnight dwell time and record on the input form.
5. Overnight dwell time is the time difference between the completion of fill phase from the
previous night and when the first drain phase of the PET is commenced. Verify times with
the patient and their record book.
6. Weight patient and overnight effluent and record this on the input form
a. If unable to weigh patient and drained effluent at this time, disconnect patient from current
exchange and connect to heated second bag as per exchange procedure.
b. Otherwise aseptically collect the overnight drain sample. If undertaking a 24 hours
adequacy test, also take 1% volume sample now (see following section).
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Renal: Peritoneal Equilibration Test (PET) and 24 hour adequacy test Document No.
7. Place the patient in the supine position. Place dialysate solution bag on IV pole and adjust
height so that the tubing is fully extended but does not place tension on the exit site and
allows the patient to roll from side to side. Note the time the infusion commenced and
completed. The actual “fill time” is to be recorded on the input form.
a. Whilst infusing, place a Minicap on the injection port of the dialysate bag and tape in position.
b. When infusion complete, note time. (Zero time on PET) Immediately place dialysate bag on
floor and drain-out approx. 200ml of fluid. Close line and bag clamps, gently shake bag to mix
fluid ensuring injection port has been squeezed
8. Use aseptic technique take sample from port on dialysate bag and place in UEC tube.
Hang bag back on pole and return drained fluid to patient. Label sample “PET 1”.
9. Dwell for 2 hours from Zero time (Pt. can stay connected, or if desired can disconnect from
system and ambulate freely).
10. At exactly 2 hrs. dwell time from the end of infusion (calculated from the zero dwell time)
place empty bag on the floor and drain 200ml of Dialysate. Take a sample of dialysate
(using the technique described in point 8). This is sample “PET 2” (Dialysate Sample #2 on
patient input form), label sample accordingly and place in specimen bag either in the fridge
or chilled environment.
11. Immediately return drained volume to patient. Patient is to be disconnected from exchange
set.
12. Ensure patient blood sample is collected and correctly labelled and sent to pathology
13. Leave dialysate fluid to dwell for a further two hours. Patient may ambulate. If patient is
leaving the unit during this time, ensure they are aware of the time they need to return
(allow 15 minutes before connection is due for the completion of the test).
14. Select appropriate dialysate fluid, based on patient prescription and connect patient 10
minutes prior to the 4 hours dwell being complete. At exactly 4 hr dwell time (calculated
from the end of initial infusion or zero dwell time) place fluid bag on the floor and drain
dialysate. This “drain” is timed. You will need to know the exact number of minutes the
drain took to complete. Thus frequently check for continuing effluent fluid flow.
15. When effluent drain out is completed, take a sample of dialysate (using the technique
described in point 8). This sample is “PET 3” (Dialysate Sample #3 on patient input form).
16. Record the patients actual drain time in the input form.
17. Complete new exchange – disconnect patient and complete patients’ dialysis records.
Weigh drain bag and record this volume. PET test is now complete.
Note : During the time between PET 1 sample collection and PET 2 sample collection, check
patient observations, including Blood glucose level if Diabetic, patient dialysis catheter exit site and
take a copy of current patient medications. Measure patient’s height.
Other Important Procedures
These must be completed prior to the patient departing the unit:
• Complete Patient Input form: Fill in all details including sex, height, weight, and age.
• Complete times of sample collections, dwell times and volumes on patient input form and the
24hour dialysis information.
SENDING SAMPLES TO PATHOLOGY
Pathology Request form details: Ensure contains the following as a minimum, nephrologists may
order other bloods to be added.
Blood; Urea, Creatinine, Albumin, Glucose
Pet 1, 2, 3; Urea and Creatinine
Overnight; Urea and Creatinine
24hr urine, Urea and Creatinine
24hr dialysate; urea and creatinine (always note total volume on form)
Note: please ensure all samples are collected properly (check date, time, correct tubes..etc),
otherwise, PET will not be performed.
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Renal: Peritoneal Equilibration Test (PET) and 24 hour adequacy test Document No.
Equipment Requirements for 24 hour Dialysis Adequacy
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Sterile jug
1 x 10ml syringes (4 for CAPD)
PPE including gloves, apron and protective eye wear
1 x alcohol wipes (4 for CAPD)
1x sharp 23g needles (4 for CAPD)
1 x plain (red top) blood tube
Pathology request form and specimen bag
Procedure Steps 2: 24 hour Dialysis Adequacy
1. Weigh Drainage bag (for CAPD Weigh and record each drain bag separately)
2. Mix solutes and drain 1% of effluent from drainage bag into a sterile jug
For CAPD- remove 1% of effluent from each bag and pool into a sterile jug
3. Use 10 ml syringe to drew 7 ml effluent from the sterile jug
4. Remove cap from plain tube Vacutainer blood tube and fill with fluid, replace cap
5. Label tube and request form appropriately including “Dialysate” as specimen type
6. Complete 24hr collection form (see appendix1)
7. Record pathology results and input into appropriate adequacy programme ie Adequest or
Patient On Line (POL)
Appendix
REFERENCES

Hand Hygiene Australia

Caring for Australians with Renal Impairment Guidelines (available via intranet)

Peritoneal transport and ultrafiltration (May2004), Monitoring patients on peritoneal dialysis
(July 2005).

Chung SH, Heimburger O, Stenvinkel P et al. Influence of peritoneal transport
rate,inflammation, and fluid removal on nutritional status and clinical outcome in prevalent
peritoneal dialysis patients. Perit Dial Int 2003; 23: 174–83.

Dauguirdas, J. T., Blake P. G., Ing T. S. (Eds). Handbook of Dialysis, Philadelphia: Lipincott
Williams & Wilkins, 2011.

Thomas, N. (Ed). Renal Nursing – 3rd edn, London: Baillere Tindal Elsevier, 2008

Twardowski ZJ. Clinical value of standardized equilibration tests in CAPD patients. Blood
Purif 1989; 7: 95–108.
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