Incremental Hemodialysis: What We Know so Far

Abstract

Traditionally, patients that develop progressive chronic kidney disease in need of kidney replacement therapy are prescribed thrice weekly in-center hemodialysis sessions at the beginning of therapy. This empiric prescription is based on historic trials that were comprised of mostly prevalent patients. Incremental hemodialysis is the process of performing <3 sessions of dialysis per week or limiting dialysis dose by duration at the initial onset of treatment to provide a more gradual transition, mimicking the progressive nature of kidney disease. Adding clearance contributions from residual kidney function is the standard of care with peritoneal dialysis but has not routinely been employed with hemodialysis. Accounting for residual kidney function accompanied by improvement in adjuvant pharmacotherapy, such as newer potassium binding agents and dietary modification, can augment dialytic clearances and allow for an incremental approach. Utilizing incremental dialysis has been associated with both preserving residual kidney function as well as improving patient quality of life. Barriers to this approach include concerns regarding patient acceptance of dialysis prescription changes, adherence to therapy, and provider factors that would require a restructuring of the current thrice weekly hemodialysis rubric. Candidacy for incremental therapy has shown the best outcomes when urea clearances exceed 3 mL/min and urine volumes are >500 mL/day, although these measures have been deemed conservative. A significant amount of retrospective and registry data has been supportive of initiating incremental hemodialysis and several pilot studies have shown the feasibility of implementing such an approach. Larger, randomized control trials are needed to fully evaluate safety and efficacy to allow for more widespread acceptance of this patient-centered approach to chronic kidney disease.

Challenges to Implementing Environmentally Sustainable Kidney Care in LMICs: An Opinion Piece

“… 43 - 45 Approaches to incremental dialysis can also help reduce waste generation. 46 , 47 Cultivating local expertise and generating guidelines to inform other HCPs can help champion ESKC.…”

Advances in Human-Centered Care to Address Contemporary Unmet Needs in Chronic Dialysis

“…There is renewed interest in incremental dialysis, which is defined as HD administered less than thrice weekly or limiting dialysis prescription by duration to allow for a more gradual transition. 91 This approach addresses patient concerns about the potential loss of independence and ability to work when adhering to a conventional haemodialysis regimen. A recent Australian study among individuals who were either presently undergoing HD or on the verge of starting demonstrated that all 26 participants preferred an incremental approach to HD.…”

Questioning one-size-fits-all dialysis prescription: balancing dialysis prescription and residual kidney function

“…En DP, il ne fait aucun doute que les régimes incrémentiels, en réduisant le nombre d'échanges de DPCA et en adaptant le volume intrapéritonéal en fonction de la surface corporelle et des besoins d'épuration, favorisent définitivement une meilleure perception de la qualité de vie par le patient, ce qui fait converger les gains cliniques et économiques. En revanche, en hémodialyse, il convient de se demander si la dialyse incrémentale est conçue pour réduire les coûts et la charge des séances ou pour adapter la prescription en fonction des besoins biologiques [47].…”

“…De plus, dans d'autres conditions cliniques, l'HD peu fréquente peut être inappropriée pour les patients présentant une prise de poids inter-dialytique élevée, même si la clearance résiduelle rénale de l'urée est en faveur d'une dialyse incrémentale [51]. Cet aspect est critique et pourrait bien expliquer le pic de mortalité et d'événements indésirables rapportés après le début de l'hémodialyse, en particulier chez les patients plus âgés, qui sont plus enclins aux atteintes cardiaques induites par l'hémodialyse [46,47]. Les taux d'ultrafiltration élevés, l'hypotension intra-dialytique et les lésions ischémiques associées sont une préoccupation chez les patients congestifs et chez ceux qui présentent une prise de poids inter-dialytique élevée [52,53].…”