Incremental Hemodialysis: The University of California Irvine Experience (original) (raw)
Related papers
Narrative Review of Incremental Hemodialysis
Kidney International Reports, 2020
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.
Incremental Hemodialysis: What We Know so Far
International Journal of Nephrology and Renovascular Disease
Traditionally, patients that develop progressive chronic kidney disease in need of kidney replacement therapy are prescribed thrice weekly in-center hemodialysis sessions at the beginning of therapy. This empiric prescription is based on historic trials that were comprised of mostly prevalent patients. Incremental hemodialysis is the process of performing <3 sessions of dialysis per week or limiting dialysis dose by duration at the initial onset of treatment to provide a more gradual transition, mimicking the progressive nature of kidney disease. Adding clearance contributions from residual kidney function is the standard of care with peritoneal dialysis but has not routinely been employed with hemodialysis. Accounting for residual kidney function accompanied by improvement in adjuvant pharmacotherapy, such as newer potassium binding agents and dietary modification, can augment dialytic clearances and allow for an incremental approach. Utilizing incremental dialysis has been associated with both preserving residual kidney function as well as improving patient quality of life. Barriers to this approach include concerns regarding patient acceptance of dialysis prescription changes, adherence to therapy, and provider factors that would require a restructuring of the current thrice weekly hemodialysis rubric. Candidacy for incremental therapy has shown the best outcomes when urea clearances exceed 3 mL/min and urine volumes are >500 mL/day, although these measures have been deemed conservative. A significant amount of retrospective and registry data has been supportive of initiating incremental hemodialysis and several pilot studies have shown the feasibility of implementing such an approach. Larger, randomized control trials are needed to fully evaluate safety and efficacy to allow for more widespread acceptance of this patient-centered approach to chronic kidney disease.
American Journal of Kidney Diseases, 2013
Intensive (longer and more frequent) hemodialysis has emerged as an alternative to conventional hemodialysis for the treatment of patients with end-stage renal disease. However, given the differences in dialysis delivery and models of care associated with intensive dialysis, alternative approaches to patient management may be required. The purpose of this work was to develop a clinical practice guideline for the Canadian Society of Nephrology. We applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for guideline development and performed targeted systematic reviews and metaanalysis (when appropriate) to address prioritized clinical management questions. We included studies addressing the treatment of patients with end-stage renal disease with short daily (Ն5 days per week, Ͻ3 hours per session), long (3-4 days per week, Ն5.5 hours per session), or long-frequent (Ն5 days per week, Ն5.5 hours per session) hemodialysis. We included clinical trials and observational studies with or without a control arm (1990 and later). Based on a prioritization exercise, 6 interventions of interest included optimal vascular access type, buttonhole cannulation, antimicrobial prophylaxis for buttonhole cannulation, closed connector devices, and dialysate calcium and dialysate phosphate additives for patients receiving intensive hemodialysis. We developed 6 recommendations addressing the interventions of interest. Overall quality of the evidence was very low and all recommendations were conditional. We provide detailed commentaries to guide in shared decision making. The main limitation was the very low overall quality of evidence that precluded strong recommendations. Most included studies were small single-arm observational studies. Three randomized controlled trials were applicable, but provided only indirect evidence. Published information for patient values and preference was lacking. In conclusion, we provide 6 recommendations for the practice of intensive hemodialysis. However, due to very low-quality evidence, all recommendations were conditional. We therefore also highlight priorities for future research.
Kidney International Reports, 2017
Introduction: We hypothesized that at least half of incident hemodialysis (HD) patients on 3-times weekly dialysis could safely start on an incremental, 2-times weekly HD schedule if residual kidney function (RKF) had been considered. Methods: RKF is assessed in all our HD patients. This single-center, retrospective cohort study of incident adult HD patients, who survived $6 months on a 3-times weekly HD regimen and had a timed urine collection within 3 months of starting HD, assessed each patient's theoretical ability to achieve adequate urea clearance, ultrafiltration rate, and hemodynamic stability if on 2-times weekly HD. Results: Of the 410 patients in the cohort, we found that 112 (27%) could have optimally and 107 (26%) could have been appropriately considered for 2-times weekly incremental HD. In general, diuretics were underutilized in >50% of subjects who had adequate RKF urea clearance. The optimal 2-times weekly patients had better potassium and phosphorus control. The correlation coefficient of calculated residual kidney urea clearance with 24-hour urine volume and with kinetic model residual kidney clearance was 0.68 and 0.99, respectively. Discussion: More than 50% of incident HD patients with RKF have adequate kidney urea clearance to be considered for 2-times weekly HD. When additionally ultrafiltration volume and blood pressure stability are taken into account, more than one-fourth of the total cohort could optimally start HD in an incremental fashion.
BMC Nephrology
Background: Most people who make the transition to renal replacement therapy (RRT) are treated with a fixed dose thrice-weekly hemodialysis réegimen, without considering their residual kidney function (RKF). Recent papers inform us that incremental hemodialysis is associated with preservation of RKF, whenever compared with conventional hemodialysis. The objective of the present controlled randomized trial (RCT) is to determine if start HD with one sessions per week (1-Wk/HD), it is associated with better patient survival and other safety parameters. Methods/design: IHDIP is a multicenter RCT experimental open trial. It is randomized in a 1:1 ratio and controlled through usual clinical practice, with a low intervention level and non-commercial. It includes 152 incident patients older than 18 years, with a RRF of ≥4 ml/min/1.73 m2, measured by renal clearance of urea (KrU). The intervention group includes 76 patients who will start with incremental HD (1-Wk/HD). The control group includes 76 patients who will start with thrice-weekly hemodialysis régimen. The primary outcome is assessing the survival rate, while the secondary outcomes are the morbidity rate, the clinical parameters, the quality of life and the efficiency. Discussion: This study will enable to know the number of sessions a patient should receive when starting HD, depending on his RRF. The potentially important clinical and financial implications of incremental hemodialysis warrant this RCT.
Al-Azhar International Medical Journal, 2021
Background: Incremental hemodialysis (HD) has several potential advantages for patients, physicians and health care systems. In incident HD patients, conservation of residual kidney function "RKF" is significant and is correlated with several advantages, including survival of patient, improved quality of life, improved overall nutritional status and less anemia. The aim of this work was to evaluate incremental hemodialysis (twice/week) compared with conventional dialysis (thrice/week) for the conservation of the residual kidneyfunction among patients initiating regular hemodialysis. Aim of work: The primary outcome of the study was an evaluation of incremental hemodialysis (twice/week) compared with conventional dialysis (thrice/week) for the conservation of the residual kidney function among patients initiating regular hemodialysis. Patient and Methods: We assigned 40 patients with chronic kidney disease stage V D who early started hemodialysis into 2 groups: Group 1: 20 patients underwent incremental hemodialysis (twice/week), and Group 2: 20 patients underwent conventional hemodialysis (thrice/week). All patients followed for laboratory findings of (complete blood picture, creatinine, urea, calcium, albumin, phosphorus, parathyroid hormone, alkaline phosphatase, glomerular filtration rate). Also, Kt/v at start and every month was done. Clinical outcome measures included; mortality, cardiovascular outcome, hospital admission and dialysis complications. Results: In the studied population, the mean age was (45.95 ± 2.97) years. Regarding sex 60% were males and 40% were females. Regarding outcome data, (20%) of patients had hypotension, (15%) had hospital admission, while nobody suffered mortality. Comparative study among the two groups showed a substantial decrease in the incidence of hypotension in the incremental group (40 %) relative to the conventional group (10%) (p = 0.03). Conclusion: To conclude, our research investigates the correlation among the frequency of HD treatment and survival of patient. In line with recent literature, our results show that some selected patients with acceptable RKF, sufficient control of interdialytic gaining weight, and low or moderate burden of comorbid disease (CCI < 5) in an incident HD population, an HD incremental approach may be deemed as an appropriate alternative to conventional thrice-weekly HD.
Advances in Nephrology, 2014
We present an observational study to evaluate a progressive schedule of dose of dialysis, starting with 2 HD/week, when the renal clearance of urea was equal to or greater than 2,5 mL/min/1,73 m2and the patient is in a stable clinical situation. From 2006 to 2011, 182 patients started hemodialysis in our center, of which 134 were included in the study. Residual renal function (RRF), Kt/V, eKru, nPCR, hemoglobin, weekly erythropoietin dose, and beta-2-microglobulin were determined at 6, 12, 18, 24, and 30 months after dialysis initiation. Seventy patients (52%) began with the progressive schedule of 2 HD/week and 64 (48%) patients began with the conventional thrice-weekly schedule (3 HD/week). The decline of RRF was lower in the group of 2 HD/week: 0,20 (0,02–0,53) versus 0,50 (0,14–1,08) mL/min/month (median and interquartile range,P=0,009). No relationship was found between the decline rate and the basal RRF. Survival analysis did not show differences between both groups. Our exper...
Giornale italiano di Nefrologia, 2022
Introduction: The term incremental haemodialysis (HD) means that both dialysis dose and frequency can be low at dialysis inception but should be progressively increased, to compensate for any subsequent reduction in residual kidney function. Policy of the Matera Dialysis Center is to attempt an incremental start of HD without a strict low-protein diet in all patients choosing HD and with urine output (UO) >500 ml/day. The present study aimed at analyzing the results of this policy over the last 20 years. Subjects and methods: The dataset of all patients starting HD between January 1 st , 2000 and December 31 st , 2019 was retrieved from the local electronic database. Exclusion criteria were: urine output <500 ml/day or follow-up <3 months after the start of the dialysis treatment. Results: A total of 266 patients were retrieved; 64 of them were excluded from the study. The remaining 202 patients were enrolled into the study and subdivided into 3 groups (G1, G2 and G3) according to the frequency of treatment at the start of dialysis: 117 patients (57.9%) started with once-a-week (1HD/wk) (G1); 46 (22.8%) with twice-a-week (2HD/wk) (G2); 39 (19.3%) with thrice-aweek (3HD/wk) dialysis regimen (G3). Patients of G1 remained on 1HD/wk for 11.9 ±14.8 months and then transferred to 2HD/wk for further 13.0 ±20.3 months. Patients of G2 remained on 2HD/wk for 16.7 ±23.2 months. Altogether, 25943 sessions were administered during the less frequent treatment periods instead of 47988, that would have been delivered if the patients had been on 3HD/wk, thus saving 22045 sessions (45.9%). Gross mortality of the entire group was 12.6%, comparable to the mean mortality of the Italian dialysis population (16.2%). Survival at 1 and 5 years was not significantly different among the 3 groups: 94% and 61% (G1); 83% and 39% (G2); 84% and 46% (G3). Conclusions: Our long-term observational study suggests that incremental HD is a valuable option for incident patients. For most of them (80.7%) it is viable for about 1-2 years, with obvious socioeconomic benefits and survival rates comparable to that of the Italian dialysis population. However, randomized controlled trials are lacking and therefore urgently needed. If they will confirm observational data, incremental HD will be a new standard of care.