Narrative Review of Incremental Hemodialysis

Abstract

The prescription of hemodialysis (HD) in patients with incident end-stage kidney disease (ESKD) is fundamentally empirical. The abrupt transition from nondialysis chronic kidney disease (CKD) to thriceweekly in-center HD of much the same dialysis intensity as in those with prevalent ESKD underappreciates the progressive nature of kidney disease whereby the decline in renal function has been gradual and ongoing-including at the time of HD initiation. Adjuvant pharmacologic treatment (i.e., diuretics, acid buffers, potassium binders), coupled with residual kidney function (RKF), can complement an initial HD regimen of lower intensity. Barriers to less intensive HD in incident ESKD include risk of inadequate clearance of uremic toxins due to variable and unexpected loss of RKF, lack of patient adherence to assessments of RKF or adjustment of HD intensity, increased burden for all stakeholders in the dialysis units, and negative financial repercussions. A stepped dialysis regimen with scheduled transition from time-delineated twice-weekly HD to thrice-weekly HD could represent an effective and safe strategy to standardize incremental HD in patients with CKD transitioning to early-stage ESKD. Patients' adherence and survival as well as other clinical outcomes should be rigorously evaluated in clinical trials before largescale implementation of different incremental schedules of HD. This review discusses potential benefits of and barriers to alternative dialysis regimens in patients with incident ESKD, with emphasis on twiceweekly HD with pharmacologic therapy, and summarizes in-progress clinical trials of incremental HD schedules.

Hemodialysis—Nutritional Flaws in Diagnosis and Prescriptions. Could Amino Acid Losses Be the Sharpest “Sword of Damocles”?

“…The correct intake of phosphate and potassium is difficult to establish as this is affected by dialysis adequacy, the quantity of phosphate and potassium binding and state of the uremic microbiota. The use of lanthanum carbonate as a phosphate binder leads to a decreasing microbial diversity and lower network complexity [ 79 , 80 ]. In an incremental/infrequent HD strategy [ 81 ], whilst the exact protein intake in a twice weekly hemodialysis has not yet been established, there is agreement that protein intake should be 0.6 g/kg/day (50% animal proteins) [ 82 , 83 ].…”

Renal replacement treatment initiation with twice-weekly versus thrice-weekly haemodialysis in patients with incident dialysis-dependent kidney disease: rationale and design of the TWOPLUS pilot clinical trial

“…11 12 This gradual intensification of HD prescription including HD frequency, termed incremental HD, can be realised by changing either the HD frequency or the HD duration per session. [12][13][14][15][16] Retrospective and observational data suggested that, compared with standard thrice-weekly HD, no worse and possibly better outcomes of RKF preservation, 17 18 patientreported quality of life 17 19 and possibly patient survival especially in the first months after dialysis transition 20 can be attained with less frequent schedules of HD in patients with incident DDKD and considerable RKF. Confounding these results is selection bias and lack of description of longitudinal changes in RKF with incremental schedules of HD relative to standard HD schedules.…”

“… 11 12 This gradual intensification of HD prescription including HD frequency, termed incremental HD, can be realised by changing either the HD frequency or the HD duration per session. 12–16 …”

Incremental and Twice-Weekly Hemodialysis Program in Practice

“…While anecdotal data on incremental hemodialysis showed that most patients complied with the prescribed incremental hemodialysis schedule and that very few experienced an end-of-life event before transitioning from twice-weekly to thrice-weekly hemodialysis, there are currently no outcome reports from prospectively collected large clinical data on incremental hemodialysis, and recently started clinical trials have yet to be completed (8), as also suggested by the 2015 KDOQI Guidelines (9). Middle and large molecule clearance with less-frequent hemodialysis requires more studies, as underway by other investigators at VA Palo Alto, California (10).…”