Incremental haemodialysis

Abstract

Thrice-weekly haemodialysis schedules have become the standard default haemodialysis prescription worldwide. Whereas the measurement of residual renal function is accepted practice for peritoneal dialysis patients and the importance of residual renal function in determining technique success is well established, few centres routinely assess residual renal function in haemodialysis patients. Although intradialytic hypotension and episodes of acute kidney injury may predispose to an earlier loss of residual renal function, a significant proportion of haemodialysis patients maintain some residual function long after dialysis initiation. As such, an incremental approach to the initiation of dialysis with careful monitoring of residual renal function may potentially provide some haemodialysis patients with an improved quality of life and greater preservation of residual renal function whilst fewer dialysis sessions may reduce health care costs. Prospective trials are required to determine the optimum approach to the initiation of haemodialysis for the oliguric patient. Once residual renal function has been lost, then dialysis prescriptions should be re-examined to consider the use of longer or more frequent treatment sessions and switching from low-flux to high-flux dialysis or haemodiafiltration to offset retention of middle sized molecules and protein-bound azotaemic solutes.

Advances in Understanding and Management of Residual Renal Function in Patients with Chronic Kidney Disease

“…Most of the HD centers start patients on thriceweekly HD without consideration of RRF. Recently, emerging evidence has suggested that RRF may be better preserved by initiating less frequent and shorter dialysis sessions rather than standard HD [40] .…”

Plasma Beta-Trace Protein as a Marker of Residual Renal Function: The Effect of Different Hemodialysis Modalities and Intra-Individual Variability over Time

“…Given its clinical relevance, current guidelines recommend to routinely measure RRF and to adopt measures for preserving it [4, 5]. As such, RRF is an important part of the dialysis patient’s assessment and can be important in adjusting the dialysis regimen [6]. Unfortunately, accurate determination of RRF remains a diagnostic challenge.…”

Chapter 6 Adequacy of Haemodialysis in UK Adult Patients in 2016: National and Centre-specific Analyses

“…Our current analysis makes no adjustment for centre differences in terms of patient case-mix, patient non-adherence to dialysis session length or practice differences such as high flux dialysis or haemodiafiltration. Residual renal function is not accounted for in the URR calculation and centre practice differences around early versus delayed start dialysis as well as whether centres practice an incremental approach to initiating dialysis may account for some of the differences observed [27]. The effect of residual renal function most likely accounts for the increase in URR observed in the incident haemodialysis patients from the first quarter to the final quarter URR returns, as shown by one centre increasing from ,60% to .70%.…”