title: Can twice weekly hemodialysis expand patient access under resource constraints?
abstract: The convention of prescribing hemodialysis on a thrice weekly schedule began empirically when it seemed that this frequency was convenient and likely to treat symptoms for a majority of patients. Later, when urea was identified as the main target and marker of clearance, studies supported the prevailing notion that thrice weekly dialysis provided appropriate clearance of urea. Today, national guidelines on hemodialysis from most countries recommend patients receive at least thrice weekly therapy. However, resource constraints in low- and middle-income countries (LMIC) have resulted in a substantial proportion of patients using less frequent hemodialysis in these settings. Observational studies of patients on twice weekly dialysis show that twice weekly therapy has noninferior survival rates compared with thrice weekly therapy. In fact, models of urea clearance also show that twice weekly therapy can meet urea clearance "targets" if patients have significant residual function or if they follow a protein-restricted diet, as may be common in LMIC. Greater reliance on twice weekly therapy, at least at the start of hemodialysis, therefore has potential to reduce health care costs and increase access to renal replacement therapy in low-resource settings; however, randomized control trials are needed to better understand long-term outcomes of twice versus thrice weekly therapy.
authors.affiliation: Student Affairs, Icahn School of Medicine at Mt. Sinai, New York, New York, USA.
authors.forename: Dipal
authors.initials: D
authors.lastname: Savla
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Glenn M
authors.initials: GM
authors.lastname: Chertow
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Stanford, California, USA.|Division of Nephrology, Palo Alto Veterans Affairs Health Care System, Palo Alto, California, USA.
authors.forename: Timothy
authors.initials: T
authors.lastname: Meyer
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Shuchi
authors.initials: S
authors.lastname: Anand
mesh_terms: D005260:Female; D017048:Health Care Costs; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000628:therapy*; D008297:Male; D006435:Renal Dialysis / Q000191:economics* / Q000379:methods; D016019:Survival Analysis
keywords: Renal replacement therapy; frequency of hemodialysis; health care costs; low- and middle-income countries