Renal Replacement Therapy and Incremental Hemodialysis for Veterans with Advanced Chronic Kidney Disease

Abstract

Each year approximately 13,000 Veterans transition to maintenance dialysis, mostly in the traditional form of thrice-weekly hemodialysis from the start. Among >6,000 dialysis units nationwide, there are currently approximately 70 Veterans Affairs (VA) dialysis centers. Given this number of VA dialysis centers and their limited capacity, only 10% of all incident dialysis Veterans initiate treatment in a VA center. Evidence suggests that, among Veterans, receipt of care within the VA system is associated with favorable outcomes, potentially due to enhanced access to healthcare resources. Data from the United States Renal Data System Special Study Center “Transition-of-Care-in-CKD” suggest that Veterans who receive dialysis in a VA unit exhibit greater survival compared to non-VA centers. Substantial financial expenditures arise from the high volume of outsourced care and higher dialysis reimbursement paid by the VA than by Medicare to outsourced providers. Given the exceedingly high mortality and abrupt decline in residual kidney function (RKF) in the first dialysis year, it is possible that incremental transition to dialysis through an initial twice-weekly hemodialysis regimen preserves RKF, prolongs vascular access longevity, improves patients’ quality of life, and is a more patient-centered approach and consistent with “personalized” dialysis. Broad implementation of incremental dialysis may also result in more Veterans receiving care within a VA dialysis unit. Controlled trials are urgently needed to examine safety and efficacy of incremental hemodialysis in Veterans and other populations, and the administrative and health care as well as provider structure within the VA system would facilitate the performance of such trials.

Prevalence of Chronic Kidney Disease, Thrombotic Cardiovascular Events, and Use of Oral P2Y₁₂ Inhibitors among Veterans

“…On the other hand, we found the period prevalence of dialysis-dependent CKD to be much higher than the general population (2.4 vs. <1%). Our findings are similar to recent studies that reported higher incidence of dialysis-dependent CKD among Veterans compared to the non-Veteran population [10,11]. A majority of the Veteran population that develops dialysis-dependent CKD chooses VA as the primary payer over Medicare, given the large differences in out-of-pocket medication co-payments or reimbursements, which is much less in the VA.…”

End-Stage Kidney Patients Require Hemodialysis Therapy Full Start

“…Because the short daily Frequent Hemodialysis Network trial has reported a 78% increase of vascular access interventions with 6-weekly short HD sessions compared to standard HD [52], several papers point out a presumed advantage of better or potentially better vascular access longevity with incremental HD, compared to standard HD [9,16,32,53]. Presently there is no evidence that twice-or thrice-weekly needle insertions make a difference in the vascular access longevity.…”

“…The latest literature about incremental dialysis uses urea clearance and UO. According to recent proposals, RRF/UO should be assessed every 1-3 months to ensure that twice-weekly HD prescription does not pose a risk to patients, with thresholds of 3 mL/min/1.73m 2 for urea clearance and 600 mL/ day for UO [14,32]. On a large scale, it remains a significant burden for all the stakeholders in the dialysis unit.…”

Routine Is the Worst Enemy of the Dialysis Patients: Reply to Drs Basile and Casino

“…And it is during the first months of HD that RKF is at its maximum even in thrice-weekly programs. Last but not least, because of warnings [2], the leading team pushing for incremental dialysis recommends a large panel of criteria to qualify for twice-weekly dialysis and to limit the risk of "underdialysis" [3]. This makes the incremental program not suitable for a significant number of patients.…”