title: Infrequent dialysis: a new paradigm for hemodialysis initiation.
abstract: Nearly a half-century ago, the thrice-weekly hemodialysis schedule was empirically established as a means to provide an adequate dialysis dose while also treating the greatest number of end-stage renal disease (ESRD) patients using limited resources. Landmark trials of hemodialysis adequacy have historically been anchored to thrice-weekly regimens, but a recent randomized controlled trial demonstrated that frequent hemodialysis (six times per week) confers cardiovascular and survival benefits. Based on these collective data and experience, clinical practice guidelines advise against a less than thrice-weekly treatment schedule in patients without residual renal function, yet provide limited guidance on the optimal treatment frequency when substantial native kidney function is present. Thus, during the transition from Stage 5 chronic kidney disease to ESRD, the current paradigm is to initiate hemodialysis on a "full-dose" thrice-weekly regimen even among patients with substantial residual renal function. However, emerging data suggest that frequent hemodialysis accelerates residual renal function decline, and infrequent regimens may provide better preservation of native kidney function. Given the high mortality rates during the first 6 months of hemodialysis and the survival benefits of preserved native kidney function, initiation with twice-weekly treatment schedules ("infrequent hemodialysis") with an incremental increase in frequency over time may provide an opportunity to optimize patient survival. This review outlines the clinical benefits of post-hemodialysis residual renal function, studies of twice-weekly treatment regimens, and the potential risks and benefits of infrequent hemodialysis.
authors.affiliation: Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California.
authors.forename: Connie M
authors.initials: CM
authors.lastname: Rhee
authors.forename: Mark
authors.initials: M
authors.lastname: Unruh
authors.forename: Jing
authors.initials: J
authors.lastname: Chen
authors.forename: Csaba P
authors.initials: CP
authors.lastname: Kovesdy
authors.forename: Phillip
authors.initials: P
authors.lastname: Zager
authors.forename: Kamyar
authors.initials: K
authors.lastname: Kalantar-Zadeh
mesh_terms: D005919:Glomerular Filtration Rate; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000401:mortality / Q000628:therapy*; D018579:Patient Selection; D010818:Practice Patterns, Physicians'; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods; D018570:Risk Assessment; D016896:Treatment Outcome
references.citation: Nephrol Dial Transplant. 2009 Aug;24(8):2502-10
references.pmid: 19240122
references.citation: Kidney Int. 2002 Aug;62(2):639-47
references.pmid: 12110029
references.citation: Nephrol Dial Transplant. 2002 Jan;17(1):28-32
references.pmid: 11773458
references.citation: Nephrol Dial Transplant. 2008 Jun;23(6):1801-5
references.pmid: 18344238
references.citation: Semin Dial. 2011 Sep-Oct;24(5):487-94
references.pmid: 21999737
references.citation: Am J Nephrol. 1999;19(6):625-33
references.pmid: 10592355
references.citation: Kidney Int. 2002 Sep;62(3):1046-53
references.pmid: 12164889
references.citation: N Engl J Med. 2011 Sep 22;365(12):1099-107
references.pmid: 21992122
references.citation: Clin J Am Soc Nephrol. 2013 Jan;8(1):116-25
references.pmid: 23085728
references.citation: N Engl J Med. 2002 Dec 19;347(25):2010-9
references.pmid: 12490682
references.citation: J Am Soc Nephrol. 2000 Mar;11(3):556-564
references.pmid: 10703680
references.citation: Clin J Am Soc Nephrol. 2009 May;4(5):914-20
references.pmid: 19357245
references.citation: Nephrol Dial Transplant. 2005 Apr;20(4):671-3
references.pmid: 15755759
references.citation: Nephrology (Carlton). 2009 Feb;14(1):59-64
references.pmid: 19019171
references.citation: Nephrol Dial Transplant. 2003 Nov;18(11):2332-8
references.pmid: 14551362
references.citation: Kidney Int Suppl. 1993 Feb;40:S106-10
references.pmid: 8445831
references.citation: Am J Kidney Dis. 1987 Sep;10(3):231-5
references.pmid: 3631070
references.citation: Nat Clin Pract Nephrol. 2009 Jan;5(1):34-44
references.pmid: 19030001
references.citation: Nephrol Dial Transplant. 1995 Dec;10(12):2274-80
references.pmid: 8808225
references.citation: Kidney Int. 1975 Feb;7(2):103-10
references.pmid: 1113451
references.citation: ASAIO J. 1995 Jul-Sep;41(3):M713-6
references.pmid: 8573899
references.citation: Nephrol Dial Transplant. 2000 Mar;15(3):396-401
references.pmid: 10692527
references.citation: Am J Kidney Dis. 1981 Jul;1(1):46-50
references.pmid: 6277187
references.citation: Semin Dial. 2004 May-Jun;17(3):196-201
references.pmid: 15144545
references.citation: Nephrol Dial Transplant. 2003 Apr;18(4):797-803
references.pmid: 12637651
references.citation: Perit Dial Int. 1997 Sep-Oct;17(5):426-30
references.pmid: 9358521
references.citation: J Am Soc Nephrol. 2004 Apr;15(4):1061-70
references.pmid: 15034110
references.citation: J Am Soc Nephrol. 1998 Dec;9(12 Suppl):S107-11
references.pmid: 11443756
references.citation: Am J Nephrol. 2012;35(6):548-58
references.pmid: 22677686
references.citation: Am J Kidney Dis. 2001 Jan;37(1 Suppl 2):S95-8
references.pmid: 11158870
references.citation: Am J Kidney Dis. 1999 Feb;33(2):344-8
references.pmid: 10023648
references.citation: J Am Soc Nephrol. 2002 May;13(5):1307-1320
references.pmid: 11961019
references.citation: Kidney Int. 2012 Jun;81(11):1108-15
references.pmid: 22297673
references.citation: N Engl J Med. 1977 Jan 6;296(1):14-9
references.pmid: 618364
references.citation: Kidney Int. 2013 May;83(5):949-58
references.pmid: 23344474
references.citation: Am J Kidney Dis. 2007 Mar;49(3):482-96
references.pmid: 17336711
references.citation: Hemodial Int. 2004 Apr 1;8(2):188-92
references.pmid: 19379416
references.citation: Am J Kidney Dis. 1999 Dec;34(6):1056-64
references.pmid: 10585315
references.citation: ASAIO Trans. 1991 Oct-Dec;37(4):598-604
references.pmid: 1768496
references.citation: Am J Kidney Dis. 2010 Aug;56(2):348-58
references.pmid: 20605303
references.citation: Kidney Int. 2002 Jan;61(1):256-65
references.pmid: 11786108
references.citation: Int Urol Nephrol. 1994;26(1):125-31
references.pmid: 8026917
references.citation: Am J Kidney Dis. 2004 Apr;43(4):712-20
references.pmid: 15042549
references.citation: Am J Kidney Dis. 1997 Sep;30(3 Suppl 2):S67-136
references.pmid: 9293258
references.citation: N Engl J Med. 1981 Nov 12;305(20):1176-81
references.pmid: 7027040
references.citation: Medicina (Kaunas). 2010;46(8):516-21
references.pmid: 20966627
references.citation: Nephrol Dial Transplant. 2009 Jan;24(1):217-24
references.pmid: 18678560
references.citation: N Engl J Med. 2010 Dec 9;363(24):2287-300
references.pmid: 21091062
references.citation: J Am Soc Nephrol. 2001 Oct;12(10):2158-2162
references.pmid: 11562415
references.citation: Blood Purif. 2012;33(1-3):66-72
references.pmid: 22212562
references.citation: J Med Assoc Thai. 2009 May;92(5):624-31
references.pmid: 19459522
references.citation: Nat Rev Nephrol. 2012 Feb 28;8(5):284-92
references.pmid: 22371250
references.citation: Am J Kidney Dis. 1994 Aug;24(2):192-204
references.pmid: 8048424
references.citation: Am J Kidney Dis. 2006 Jul;48 Suppl 1:S2-90
references.pmid: 16813990
references.citation: Perit Dial Int. 1999;19 Suppl 2:S276-80
references.pmid: 10406532
references.citation: J Am Soc Nephrol. 2001 Nov;12(11):2450-2457
references.pmid: 11675422
references.citation: Arab J Nephrol Transplant. 2012 May;5(2):81-6
references.pmid: 22612193