Dietary Management of Incremental Transition to Dialysis Therapy: Once-Weekly Hemodialysis Combined With Low-Protein Diet

Abstract

Initiation of thrice-weekly hemodialysis often results in a rapid loss of residual kidney function (RKF) including reduction in urine output. Preserving RKF longer is associated with better outcomes including greater survival in dialysis patients. An alternative approach aimed at preserving RKF is an incremental transition with less frequent hemodialysis sessions at the beginning with gradual increase in hemodialysis frequency over months. In addition to favorable clinical and economic implications, an incremental transition would also enhance a less stressful adaptation of the patient to dialysis therapy. The current guidelines provide only limited recommendations for incremental hemodialysis approach, whereas the potential role of nutritional management of newly transitioned hemodialysis patients is largely overlooked. We have reviewed previous reports and case studies of once-weekly hemodialysis treatment combined with low-protein, low-phosphorus, and normal-to-high-energy diet especially for nondialysis days, whereas on dialysis days, high protein can be provided. Such an adaptive dietary regimen may elicit more favorable outcomes including better preserved RKF, lower β2-microglobulin levels, improved phosphorus control, and lower doses of erythropoiesis-stimulating agents. Clinical and nutritional status and RKF should be closely monitored throughout the transition to once and then twice-weekly regimen and eventually thrice-weekly hemodialysis. Further studies are needed to verify the long-term safety and implications of this approach to dialysis transition.

Renal Replacement Therapy and Incremental Hemodialysis for Veterans with Advanced Chronic Kidney Disease

“…Notably, according to an Italian dialysis experience report, patients who started dialysis therapy on a once-weekly hemodialysis schedule continued a low protein diet on non-dialysis days, while on dialysis days a high protein diet was provided. 31 …”

Routine Is the Worst Enemy of the Dialysis Patient

“…This is the reason why the scientific nephrological community should strive to design and perform full-fledged RCTs testing incremental HD [10]. Such studies should be designed in order to include also the onceweekly HD treatment combined with lowprotein diet [11] and without low-protein diet [10] in the intervention arm of a potential RCT testing incremental HD. If the potential benefits of incremental HD will be confirmed, then starting dialysis at a full dose will be subjecting patients to unnecessarily long or more frequent treatments at higher cost.…”

Increasing Haemodialytic Clearances as Residual Renal Function Declines: An Incremental Approach

“…When patients have substantial RRF, then a less frequent, shorter session, smaller surface area dialyzer, slower blood or dialysate pump speeds and smaller needle size should be considered. On the other hand, when RRF has been lost, then introducing higher convective volume exchanges with online HDF, using a superflux dialyzer, or adding an adsorptive membrane or manipulating diet [39,41] is a potential option to increase solute clearances.…”