Can incremental haemodialysis reduce early mortality rates in patients starting maintenance haemodialysis?

Hazara, Adil M.; Bhandari, Sunil

doi:10.1097/mnh.0000000000000537

Cited by 12 publications

(9 citation statements)

References 53 publications

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“…Our version of incremental HD is novel as we apply twice-weekly HD in a time-limited manner (i.e., the first 15 weeks of dialysis), which does not require time urine collections. In our regime, the key aim is to focus on reducing the risk of decompensation in the early days of dialysis, while patients are still adapting (and hence aiming to reduce the high rates of early mortality) which we hypothesise is related to intensity of dialysis [ 51 ]—our approach is in contrast to other therapy regimens [ 19 , 46 , 52 ] where the primary aim of treatment is to preserve RRF and hence influencing medium/long-term outcomes. Our regime is of a relatively short duration as we expect RRF to decline significantly [ 53 , 54 ] in first few months of dialysis making twice-weekly HD unsustainable.…”

Section: Discussionmentioning

confidence: 99%

A mixed-method feasibility study of a novel transitional regime of incremental haemodialysis: study design and protocol

et al. 2021

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Background Incremental haemodialysis/haemodiafiltration (HD) may help reduce early mortality rates in patients starting HD. This mixed-method feasibility study aims to test the acceptability, tolerance and safety of a novel incremental HD regime, and to study its impact on parameters of patient wellbeing. Method We aim to enrol 20 patients who will commence HD twice-weekly with progressive increases in duration and frequency, achieving conventional treatment times over 15 weeks (incremental group). Participants will be followed-up for 6 months and will undergo regular tests including urine collections, bio-impedance analyses and quality-of-life questionnaires. Semi-structured interviews will be conducted to explore patients’ prior expectations from HD, their motivations for participation and experiences of receiving incremental HD. For comparison of safety and indicators of dialysis adequacy, a cohort of 40 matched patients who previously received conventional HD will be constructed from local dialysis records (historical controls). Results Data will be recorded on the numbers screened and proportions consented and completing the study (primary outcome). Incremental and conventional groups will be compared in terms of differences in blood pressure control, interdialytic weight changes, indicators of dialysis adequacy and differences in adverse and serious adverse events. In analyses restricted to incremental group, measurements of RRF, fluid load and quality-of-life during follow-up will be compared with baseline values. From patient interviews, a narrative description of key themes along with anonymised quotes will be presented. Conclusion Results from this study will address a significant knowledge gap in the prescription HD therapy and inform the development novel future therapy regimens.

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Section: Discussionmentioning

confidence: 99%

A mixed-method feasibility study of a novel transitional regime of incremental haemodialysis: study design and protocol

et al. 2021

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“…The idea that, in dialysis, "more is better" is not true for fragile patients. The failure of early dialysis start, which was previously considered synonymous with "healthy" dialysis start, to improve patients' prognoses, the recognition of the importance of residual kidney function in determining survival, and the association of the latter with better nutritional status are all elements in favor of a progressive, incremental dialysis start aimed at reducing dialysis-related morbidity and mitigating "dialysis shock" [21][22][23][94][95][96][97][98][99].…”

Section: Concept and Context: A Special Case Incremental Hemodialysismentioning

confidence: 99%

“…There is disagreement about the definition of incremental dialysis regarding the number of sessions there should be per week and what their scheduling and sequence should be (starting with shorter sessions, increasing frequency first and duration later or starting with fewer sessions of longer duration). Consequently, nutritional indications must once more be contextualized and adapted [21][22][23][99][100][101][102].…”

Section: Concept and Context: A Special Case Incremental Hemodialysismentioning

confidence: 99%

Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach

et al. 2020

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Dialysis and nutrition are two sides of the same coin—dialysis depurates metabolic waste that is typically produced by food intake. Hence, dietetic restrictions are commonly imposed in order to limit potassium and phosphate and avoid fluid overload. Conversely, malnutrition is a major challenge and, albeit to differing degrees, all nutritional markers are associated with survival. Dialysis-related malnutrition has a multifactorial origin related to uremic syndrome and comorbidities but also to dialysis treatment. Both an insufficient dialysis dose and excessive removal are contributing factors. It is thus not surprising that dialysis alone, without proper nutritional management, often fails to be effective in combatting malnutrition. While composite indexes can be used to identify patients with poor prognosis, none is fully satisfactory, and the definitions of malnutrition and protein energy wasting are still controversial. Furthermore, most nutritional markers and interventions were assessed in hemodialysis patients, while hemodiafiltration and peritoneal dialysis have been less extensively studied. The significant loss of albumin in these two dialysis modalities makes it extremely difficult to interpret common markers and scores. Despite these problems, hemodialysis sessions represent a valuable opportunity to monitor nutritional status and prescribe nutritional interventions, and several approaches have been tried. In this concept paper, we review the current evidence on intradialytic nutrition and propose an algorithm for adapting nutritional interventions to individual patients.

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“…Consequently, it has been hypothesized that personalized HD therapy consisting of less frequent HD treatments at dialysis initiation in those who have suitable levels of residual kidney function, with subsequent adaptations in dialysis frequency to thrice-weekly or more often HD as residual kidney function declines—i.e., incremental HD—could be conducive to better adjustment to life style changes and better health-related quality of life. In spite of the alluring attributes of incremental HD rendered by other potential benefits such as better or non-inferior patient survival for significant economic savings, high-quality research focused on clinical outcomes and patient-reported outcomes with incremental HD is scarce [ 13 , 14 ]. Registry-based studies showed that about 30% of patients with incident KDRD could be treated with an initial schedule of less frequent HD based on their residual kidney function and morbidity profile [ 15 ], yet incremental HD remains grossly underused in the United States [ 16 ], possibly due to lack of clinical trials to validate the safety of this treatment approach as well as other potential barriers reviewed in former publications [ 17 ].…”

Section: Introductionmentioning

confidence: 99%

Patient-reported outcomes in a pilot clinical trial of twice-weekly hemodialysis start with adjuvant pharmacotherapy and transition to thrice-weekly hemodialysis vs conventional hemodialysis

et al. 2022

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Background Physical and emotional symptoms are prevalent in patients with kidney-dysfunction requiring dialysis (KDRD) and the rigors of thrice-weekly hemodialysis (HD) may contribute to deteriorated health-related quality of life. Less intensive HD schedules might be associated with lower symptom and/or emotional burden. Methods The TWOPLUS Pilot study was an individually-randomized trial conducted at 14 dialysis units, with the primary goal to assess feasibility and safety. Patients with incident KDRD and residual kidney function were assigned to incremental HD start (twice-weekly HD for 6 weeks followed by thrice-weekly HD) vs conventional HD (thrice-weekly HD). In exploratory analyses, we compared the two treatment groups with respect to three patient-reported outcomes measures. We analyzed the change from baseline in the score on Dialysis Symptom Index (DSI, range 0–150), Generalized Anxiety Disorder-7 (GAD-7, range 0–21), and Patient Health Questionnaire-9 (PHQ-9, range 0–27) at 6 (n = 20 in each treatment group) and 12 weeks (n = 21); with lower scores denoting lower symptom burden. Analyses were adjusted for age, race, gender, baseline urine volume, diabetes mellitus, and malignancy. Participants’ views on the intervention were sought using a Patient Feedback Questionnaire (n = 14 in incremental and n = 15 in conventional group). Results The change from baseline to week 6 in estimated mean score (standard error; P value) in the incremental and conventional group was − 9.7 (4.8; P = 0.05) and − 13.8 (5.0; P = 0.009) for DSI; − 1.9 (1.0; P = 0.07) and − 1.5 (1.4; P = 0.31) for GAD-7; and − 2.5 (1.1; P = 0.03) and − 3.5 (1.5; P = 0.02) for PHQ-9, respectively. Corresponding changes from week 6 to week 12 were − 3.1 (3.2; P = 0.34) and − 2.4 (5.5; P = 0.67) in DSI score; 0.5 (0.6; P = 0.46) and 0.1 (0.6; P = 0.87) in GAD-7 score; and − 0.3 (0.6; P = 0.70) and − 0.5 (0.6; P = 0.47) in PHQ-9 score, respectively. Majority of respondents felt their healthcare was not jeopardized and expressed their motivation for study participation was to help advance the care of patients with KDRD. Conclusions This study suggests a possible mitigating effect of twice-weekly HD start on symptoms of anxiety and depression at transition from pre-dialysis to KDRD. Larger clinical trials are required to rigorously test clinically-matched incrementally-prescribed HD across diverse organizations and patient populations. Trial registration Registered at ClinicalTrials.gov with study identifier NCT03740048, registration date 14/11/2018.

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Can incremental haemodialysis reduce early mortality rates in patients starting maintenance haemodialysis?

Cited by 12 publications

References 53 publications

A mixed-method feasibility study of a novel transitional regime of incremental haemodialysis: study design and protocol

A mixed-method feasibility study of a novel transitional regime of incremental haemodialysis: study design and protocol

Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach

Patient-reported outcomes in a pilot clinical trial of twice-weekly hemodialysis start with adjuvant pharmacotherapy and transition to thrice-weekly hemodialysis vs conventional hemodialysis

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