Comparison of characteristics of centers practicing incremental vs. conventional approaches to hemodialysis delivery – postdialysis recovery time and patient survival

Abstract

Introduction: Conventional haemodialysis (HD) involves treatment times of around 4 hours thrice weekly, taking no account of residual kidney function (RKF). In incremental HD the frequency and duration of dialysis sessions are individualized according to RKF. There are no studies comparing these approaches. We utilized data from a recent multicenter study to compare patient characteristics and outcomes between a center practicing incremental HD and others using a conventional approach. Methods: Seven hundred and nine patients attending for routine outpatient HD in five UK centers were studied. One center practiced incremental dialysis (n = 254) and four conventional HD (n = 455). Data collected included demographics, comorbidity, dialysis parameters, routine biochemistry and hematology, recovery time postdialysis, and Beck Depression Inventory‐II score (BDI‐II). Patients were followed for a minimum of 12 months. Findings: Pre‐ and postdialysis BP, serum calcium and phosphate were higher in the incremental center, whilst sessional Kt/Vurea was lower (all P < 0.001), as was the proportion of patients with a mean postdialysis BP <100 mmHg (P = 0.011). Patients recovered from their HD session more quickly in the incremental center, with significantly more patients reporting recovery within 1 and 4 hours Short‐term survival was significantly better in the incremental center both unadjusted and adjusted for age, gender, ethnicity, dialysis vintage, anuria, history of cancer, heart disease, diabetes mellitus, body mass index, serum albumin, BDI‐II score, and sessional Kt/V. Discussion: The association between incremental dialysis, shorter postdialysis recovery times and improved short‐term survival may be related to reduced haemodynamic stress as a consequence of less intensive ultrafiltration and reduced length of dialysis sessions. Prospective studies are required to test this hypothesis.

Reducing the risk of intradialytic hypotension by altering the composition of the dialysate

“…Both symptomatic and asymptomatic IDH is associated with significant dialysis patient morbidity both in the short and long term, 55,56 and increased risk of mortality 4 . In the short term, choosing a dialysate with a higher sodium, magnesium, and calcium concentration and lower temperature reduces the risk of IDH.…”

Changes in extracellular water with hemodialysis and fall in systolic blood pressure

“…In keeping with other reports patients with residual renal function prescribed diuretics had smaller changes in ECW, 23 and supporting the contention that one of the benefits of maintaining residual renal function is to prevent volume overload. 24 Several different interventions or combinations have been introduced to reduce the risk of IDH, ranging from cooling the dialysate, ultrafiltration profiling, increased dialysate sodium concentrations, administration of alphaadrenergic agonists, or more frequent and longer hemodialysis sessions. 18 Selecting a higher dialysate sodium concentration compared to plasma sodium has been reported to improve hemodynamic stability and prevent intradialytic symptoms.…”

Evaluation of Residual Kidney Function during Once-Weekly Incremental Hemodialysis

“…The work carried out here may serve as a pilot study for the evaluation of RKF during a 1WHD IH program and potentially provide a means of avoiding lengthy and inaccurate urine collections. Recent findings reported in the literature promote the use of IH strategies in patients with an RKF of eGFR > 3 mL/min/1.73 m 2 [1][2][3][4][5]25]. Moreover, in 1WHD IH patients, the carrying out of scrupulous periodic monitoring is mandatory; reliable, validated formulas such as urea nitrogen appearance [41] may also be applied to establish protein intake in patients on 1WHD.…”

“…In the context of IH, Kr should be tailored according to dosage, frequency of dialysis and protein intake in patients undergoing once-weekly hemodialysis (1WHD) [4]. Parameters to be considered include BUN or, preferably, serum urea nitrogen (SUN), serum Cr (sCr), or rather, time average concentration (TAC) of the latter, namely, urine urea and creatininuria, all of which are characterized by increasing values in IH patients during IDI, compared to values obtained in more stable patients with advanced CKD undergoing conservative treatment (CKD5) [3]. The above considerations, all widely discussed by Obi [13], indicate the need for a computerized assessment program.…”

“…Recent literature reports have shown a growing interest in incremental hemodialysis (IH) (protocols [1][2][3][4][5]. Encouraged by the positive effects observed in slowingdown loss of residual kidney function (RKF) [6][7][8], these Blood Purif 2021;50:246-253 DOI: 10.1159/000509790 new strategic trends have led to the implementation of research programs aimed at identifying the most appropriate methods for use in optimizing evaluation of RKF based on residual renal clearance (Kr) and in monitoring patients receiving IH.…”