Mortality is highest in the first months of maintenance hemodialysis (HD). In many Western countries, patients who transition to kidney replacement therapy usually begin thrice-weekly HD regardless of their level of residual kidney function (RKF). RKF is a major predictor of survival. RKF may decline more rapidly with more thrice-weekly HD treatments, is associated with a reduced need for dialytic solute clearance, and is an important factor in the prescription of peritoneal dialysis. In this paper we review the concept of incremental HD, in which weekly dialysis dose, in particular HD treatment frequency, is based on a variety of clinical factors such as RKF (including urine output >0.5 L/day), volume status, cardiovascular symptoms, body size, potassium and phosphorus levels, nutritional status, hemoglobin, comorbid conditions, hospitalizations, and health related quality of life. These ten clinical criteria may identify which patients might benefit from beginning maintenance HD twice-weekly. Periodic monitoring of these criteria will determine the timing for increasing dialysis dose and frequency. We recognize that twice-weekly HD represents a major paradigm shift for many clinicians and jurisdictions. Therefore, we propose conducting randomized controlled trials of twice-weekly vs. thrice-weekly HD to assess the potential of twice-weekly HD to improve survival and health related quality of life while simultaneously reducing costs, protecting fragile vascular accesses, and optimizing resource use. Such incremental and individualized HD therapy may prove to be the most appropriate approach for transitioning to dialytic therapy.

In patients with ESRD, residual kidney function (RKF) contributes to achievement of adequate solute clearance. However, few studies have examined RKF in patients on hemodialysis. In a longitudinal cohort of 6538 patients who started maintenance hemodialysis over a 4-year period (January 2007 through December 2010) and had available renal urea clearance (CL) data at baseline and 1 year after hemodialysis initiation, we examined the association of annual change in renal CL rate with subsequent survival. The median (interquartile range) baseline value and mean±SD annual change of CL were 3.3 (1.9-5.0) and -1.1±2.8 ml/min per 1.73 m, respectively. Greater CL rate 1 year after hemodialysis initiation associated with better survival. Furthermore, we found a gradient association between loss of RKF and all-cause mortality: changes in CL rate of -6.0 and +3.0 ml/min per 1.73 m per year associated with case mix-adjusted hazard ratios (95% confidence intervals) of 2.00 (1.55 to 2.59) and 0. 61 (0.50 to 0.74), respectively (reference: -1.5 ml/min per 1.73 m per year). These associations remained robust against adjustment for laboratory variables and ultrafiltration rate and were consistent across strata of baseline CL, age, sex, race, diabetes status, presence of congestive heart failure, and hemoglobin, serum albumin, and serum phosphorus levels. Sensitivity analyses using urine volume as another index of RKF yielded consistent associations. In conclusion, RKF decline during the first year of dialysis has a graded association with all-cause mortality among incident hemodialysis patients. The clinical benefits of RKF preservation strategies on mortality should be determined.

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Although energy expenditure was lower than national recommendations, greater physical activity was associated with lower body mass. Public health strategies are needed to facilitate participation in physical activity, especially for women, elderly, and less educated individuals.