Twice-weekly and incremental hemodialysis treatment for initiation of kidney replacement therapy.
Mortality is highest in the first months of maintenance hemodialysis (HD) therapy. 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 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 article, 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/d), volume status, cardiovascular symptoms, body size, potassium and phosphorus levels, nutritional status, hemoglobin level, comorbid conditions, hospitalizations, and health-related quality of life. These 10 clinical criteria may identify which patients might benefit from beginning maintenance HD therapy 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 versus 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 during the first year of hemodialysis therapy. Such incremental and individualized HD therapy may prove to be the most appropriate approach for transitioning to dialytic therapy.
Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange; Veterans Affairs Long Beach Healthcare System, Long Beach, CA. Electronic address: kkz@uci.edu.
Kamyar
K
Kalantar-Zadeh
Division of Nephrology, University of New Mexico, Albuquerque, NM.
Mark
M
Unruh
Division of Nephrology, University of New Mexico, Albuquerque, NM.
Philip G
PG
Zager
University of Tennessee Health Science Center and Memphis VAMC, Memphis, TN.
Csaba P
CP
Kovesdy
University Health Network and the University of Toronto, Toronto, Canada.
Joanne M
JM
Bargman
Fudan University, Shanghai, China.
Jing
J
Chen
Nephrolife Dialysis, Bangalore, India.
Suresh
S
Sankarasubbaiyan
Veterans Affairs Long Beach Healthcare System, Long Beach, CA.
Gaurang
G
Shah
Vanderbilt University, Nashville, TN.
Thomas
T
Golper
Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ.
Richard A
RA
Sherman
New York Veterans Affairs Medical Center, New York, NY.
David S
DS
Goldfarb
D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy*; D006435:Renal Dialysis / Q000379:methods* / Q000401:mortality*; D017582:Renal Replacement Therapy / Q000379:methods* / Q000401:mortality*; D013997:Time Factors; D016896:Treatment Outcome
Transition of care; end-stage renal disease; incremental dialysis; incremental hemodialysis; kidney replacement therapy; renal replacement therapy; residual kidney function