Knowledge and Practice of Incremental Hemodialysis: A Survey of Canadian Nephrologists

Abstract

Background: Incremental hemodialysis, a strategy to individualize dialysis prescription based on residual kidney function, may be associated with enhanced quality of life and decreased health care costs compared with conventional hemodialysis. Objective: We surveyed practicing Canadian nephrologists to assess knowledge, perceptions, and practice pattern on the use of incremental hemodialysis. Design/Setting: We distributed a cross-sectional, web-based survey. We asked about incremental hemodialysis prescribing practices, including frequency of prescription, clinical factors used to determine suitability for treatment, and barriers to implementation. The survey was conducted from September 21 to October 30, 2020. Participants: We distributed the survey to practicing Canadian nephrologists identified from a private membership list of the Canadian Society of Nephrology (CSN), as well as to nephrologists named on a publicly available national list of practicing Canadian nephrologists created from provincial College of Physician registries. These were samples of convenience. Methods: We conducted descriptive analysis of categorical data including frequencies for nominal variables and measures of central tendency (mean) and dispersion (standard deviation) for ordinal variables. We used chi-square analysis to identify association between participant and practice characteristics and their opinions and attitudes toward incremental dialysis. We used simple thematic analysis on free-text responses on questions regarding the prescription of incremental hemodialysis, focusing on age and baseline management of cardiac and noncardiac comorbidities. Results: The response rate was 35% (243/691). Most (138/211, 65%) of the participants prescribed incremental hemodialysis using an individualized approach at the nephrologist’s discretion. Most participants (200/203, 98%) did not report any policy for implementation. Residual urine output was identified as the most important factor for eligibility (112/172, 65%), followed by electrolyte stability (76/172, 44%) and patient goals of care (69/117, 40%). Most participants agreed that dialysis prescriptions should take residual kidney function into consideration; however, 74% of the participants disagreed with a statement that there was strong evidence supporting incremental hemodialysis. Barriers identified included patient safety, patient acceptance of dose escalation, and logistics of scheduling. Despite these barriers, 82% of participants felt that that incremental hemodialysis is feasible with their current resources and 78% agreed that with specific criteria, it is a safe option. Limitations: The generalizability of our study is limited by its response rate of 35%; however, this is comparable with typical response rates seen in electronic surveys. Most participants practice in an academic setting, which may have introduced bias to the results. Conclusions: Despite the perception of limited evidence and a lack of guidance on implementation, incremental hemodialysis is frequently practiced by Canadian nephrologists. Barriers to implementation were identified, highlighting the need for research to guide practice.

Personalising haemodialysis treatment with incremental dialysis for incident patients with end-stage kidney disease: an implementation study protocol

“…To be successful in implementing the incremental dialysis project, we have formally consulted with patients currently receiving dialysis, nephrologists (nationally and locally), operational leadership (ie, Alberta Kidney Care), unit management, nursing staff and other allied health professionals within the planning stages. A national survey 14 was disseminated to Canadian nephrologists indicating the practice of incremental dialysis is widespread, but discretionary, with no systematic approach to assessment and monitoring. Despite these barriers, 82% of nephrologists felt that incremental dialysis is feasible with their current resources and 78% agreed that with specific criteria, it is a safe option.…”

“…Implementation of an incremental dialysis approach has the potential to reduce burden on patients in terms of time and out-of-pocket costs associated with dialysis (eg, travel, parking) as well as reduce the per-patient cost of care delivery and increase treatment capacity in an overburdened healthcare system. In a survey of Canadian nephrologists, 14 65% of physicians reported prescribing incremental dialysis; however, 98% reported there was no local policy or systematic programme of assessment or care for patients receiving this treatment.…”