Impact of incremental initiation of haemodialysis on mortality: a systematic review and meta-analysis

Abstract

Background Incremental haemodialysis initiation entails lower sessional duration and/or frequency than the standard four hours thrice-weekly approach. Dialysis dose is increased as residual kidney function (RKF) declines. This systematic review evaluates its safety, efficacy and cost-effectiveness. Methods We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library databases from inception to 27th February 2022. Eligible studies compared incremental haemodialysis (sessions either < 3 times weekly or of duration < 3.5 hours) with standard treatment. The primary outcome was mortality. Secondary outcomes included treatment-emergent adverse events, loss of RKF, quality of life and cost effectiveness. The study protocol was prospectively registered. Risk of bias assessment used the Newcastle-Ottawa Scale and the revised Cochrane risk of bias tool, as appropriate. Meta-analyses were undertaken in Review Manager, Version 5.4. Results 644 records were identified. 26 met the inclusion criteria—including 22 cohort studies and two randomised controlled trials (RCTs). Sample size ranged from 48 to 50 596 participants (total 101 476). We found no mortality differences (HR = 0.99; 95% CI: 0.80–1.24). Cohort studies suggested similar hospitalisation rates though the two small RCTs suggested less hospitalisation after incremental initiation (RR = 0.31; 95% CI: 0.18- 0.54). Data on other treatment emergent adverse events and quality of life was limited. Observational studies suggested reduced loss of RKF in incremental haemodialysis. This was not supported by RCT data. Four studies reported reduced costs of incremental treatments. Conclusions Incremental initiation of haemodialysis does not confer greater risk of mortality compared to standard treatment. Hospitalisation may be reduced and costs are less.

Extracorporeal Techniques in Kidney Failure

“…Frequency is dependent on the individual metabolic needs and amount of dialysis per treatment session. On one end of the spectrum, incremental dialysis is a regimen aimed at delivering a low (i.e., once or twice per week) treatment frequency to those patients having sufficient residual kidney function [13,14]. The duration and/or frequency of dialysis is adjusted incrementally to reflect the loss of residual kidney function, vintage on dialysis, and/or advancing uremic solute burden.…”

Shared decision making in elderly patients with kidney failure

“…A meta-analysis of 22 observational studies reported that incremental dialysis resulted in a lower mean loss of residual kidney function (–0.58 mL/min/month, P = .007) than a full-dose start [ 59 ]. Additionally, another meta-analysis showed no significant difference in mortality between the incremental and conventional HD groups (HR 0.99; I 2 = 82%) [ 60 ]. Recently, an RCT, albeit with limited sample size, also found that incremental dialysis was associated with a 69% lower risk of hospitalization compared with full-dose dialysis [ 61 ].…”

The Hemodialysis Prescription: Past, Present, and Future

“…Indeed, in some countries, incremental HD programs are already integrated as a new standard of care; their experiences will enhance the findings from ongoing clinical trials. 7,9 Hesitance to abandon entrenched practices and lack of studies to objectively compare different streams of HD care are some of the factors that contribute to the slow progress toward individualized HD. Ongoing and planned clinical trials that compare outcomes between RKF-coupled versus RKF-uncoupled HD prescription will hopefully boost adoption of individualized treatment (NCT05465044 and NCT05828823).…”

“… 6 Many studies have shown that maintaining full-dose, HD-based urea clearance at thrice-weekly treatments provided no benefit in patients with appreciable volume and solute removal afforded by RKF. 7 However, RKF is neither measured nor incorporated routinely in the HD prescription.…”