Twice-Weekly and Incremental Hemodialysis Treatment for Initiation of Kidney Replacement Therapy

Abstract

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.

Transition of care from pre-dialysis prelude to renal replacement therapy: the blueprints of emerging research in advanced chronic kidney disease

“…once to twice-weekly hemodialysis) [24], conventional (thriceweekly hemodialysis) and frequent (four or more times per week hemodialysis)] [25]; (2) transition from non-dialysisdependent CKD to pre-emptive transplantation; (3) transition among or across dialysis modalities, formats and frequency (hemodialysis to peritoneal dialysis or vice versa, in-center to home, and less to more frequent, also known as incremental or progressive dialysis therapy [26]); (4) transition from dialysis therapy to kidney transplantation; (5) transition from a gradually failing kidney transplantation back to dialysis therapy; and (6) transition from any of the above stages to partial or full…”

Clinical, patient-related, and economic outcomes of home-based high-dose hemodialysis versus conventional in-center hemodialysis

“…95 The potential drawbacks of twice-weekly regimen can be significant due to further prolongation of interdialytic intervals, which has been strongly associated with cardiovascular morbidity and mortality. 15,96 Furthermore, addressing transition from twice-to thrice-weekly regimens as proposed 93,94 can be difficult from a patient perspective, potentially leading to suboptimal outcomes. 96,97 The recommendation of a minimum of thrice-weekly dialysis was recently supported by Hakim and Saha 98 in their review of the effects of dialysis frequency versus dialysis time.…”

Timing of Initiation of RRT and Modality Selection

“…This is the concept of incremental dialysis and eases the patient onto the therapy (29). In center-based therapy, incremental hemodialysis could comprise fewer hours per session, fewer sessions per week, or both.…”