
Incremental Hemodialysis: What We Know so Far
Author(s) -
Vivek Soi,
Mark D. Faber,
Ritika Paul
Publication year - 2022
Publication title -
international journal of nephrology and renovascular disease
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.846
H-Index - 27
ISSN - 1178-7058
DOI - 10.2147/ijnrd.s286947
Subject(s) - medicine , hemodialysis , dialysis , peritoneal dialysis , intensive care medicine , kidney disease , medical prescription , renal replacement therapy , randomized controlled trial , home hemodialysis , nephrology , urology , pharmacology
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.