Incremental Hemodialysis: What We Know so Far

Figures & data

Figure 1 Prescribed dialysis sessions per week in the United States from 1st quarter 2012–2nd quarter 2019 by incidence and prevalence shows that the overwhelming majority of patients initiate hemodialysis on a thrice weekly schedule. (<90d)/prevalent (90 +d). Adapted from DOPPS practice monitor – hemodialysis; 2021. Available from: https://www.dopps.org/DPM-HD/DPMSlideBrowser.aspx?type=ComGrp&id=18. Accessed October 11, 2021. Modifying DOPPS Practice Monitor data, tables, or graphics in any form is not permitted without prior approval from the DOPPS coordinating center staff at Arbor Research. You may contact us at  [email protected].¹⁰

Abbreviation: d, days.

Figure 2 Proposed twice weekly vs traditional thrice weekly schedules for a single dialysis chair over 1 week. With incremental dialysis, there is potential for one station to be used by 3 patients instead of the 2 that would be able to be managed in the traditional schedule. Note that once weekly dialysis (not pictured) has also been proposed as an option in incremental initiation. Adapted from Kalantar-Zadeh K, Crowley ST, Beddhu S, et al. Renal Replacement Therapy and Incremental Hemodialysis for Veterans with Advanced Chronic Kidney Disease. Semin Dial. 2017;30(3): 251-261. © 2017 Wiley Periodicals, Inc.⁵³

Table 1 Values for Modeling Included 6–8 L Ultrafiltration per Week and Watson TBW 42.9 L

Frequency (Treatments per Week)	Kt/V Target per Treatment	Kt/V Target per Week
2	2	4
3	1.2	3.6
4	0.7	2.8
5	0.56	2.8
6	0.43	2.6
7	0.36	2.5

Legend: Approximate per treatment Kt/V corresponding to standard Kt/V of 2.1/week. Values are calculated with frequent hemodialysis network ultrafiltration-corrected standard Kt/V calculator as posted on www.hdcn.com.

Table 2 List of Studies Comparing Incremental Dialysis Regimens with Traditional Thrice Weekly Dialysis Regimens

Year (Dur)	Author/Country	No. of Incident Patients with RKF if Measured		Baseline GFR (mL/min)	Study Design
		< 3x-HD	3x-HD
1999 (3)	Hanson/USA^Citation36	570	14,497	NA	RC	Mortality similar when adjusted for eGFR at time of dialysis initiation.
2009 (8)	Lin/Taiwan^Citation37	23	51	3.4±1.4	PC	2x-HD group had a slower decline of RKF
2010 (8)	Stankuviene/ Lithuania^Citation38	1007 2x-HD 879 1x-HD	1425	NA	RC	Dialysis limited by availability: 2x-HD had shorter survival
2012 (5)	Fernandez/Spain^Citation39	41	54	6±2	PC	2x-HD group had greater survival (log-rank: 3.964; P=0.04). Loss in RKF and 24-hour diuresis was lower in 2x-HD.
2012 (2)	Elamin/Sudan^Citation40	756	255	NA	PC	1-year survival in 2x-HD was 85% compared to 89% for SD (P=0.06)
2012 (2)	Lin/China^Citation41	532	756	NA	PC	2x-HD had similar survival of SD
2014 (1)	Panaput/Thailand^Citation42	61	169	4.4±2.3	PC	1 year survival rate was similar in 2x-HD and SD
2014 (2)	Caria/Italy^Citation2	38	30	7.8±1.9	PC	Volume output and RKF were maintained in the 1x-HD + low protein diet group; at 24 months survival rates were 94.7% vs 86.8% for 1x-HD vs SD
2014 (1)	Zhang /China^Citation43	30	55	1.82±1.97	PC	2x-HD during the first year of dialysis therapy appears to be associated with better RKF preservation (10 vs 40%, p = 0.03).
2016 (3)	Hwang/Korea^Citation44	113	137	61.0±14.2	PC	Greater risk of mortality in 2x-HD compared with SD (in presence of RKF)
2016 (4)	Obi/USA^Citation45	351	8068	4.8	RC	2x-HD associated with greater preservation of RKF while higher mortality observed after 1 year in those with lowest RKF
2016 (5)	Mathew/USA^Citation46	434	50,162	5.4	RC	No difference in mortality in 2x-HD compared to 3x-HD
2017 (6)	Park/Korea^Citation34	105	207	7.5 ±3.4	PC	No differences in survival and daily urine volume
2017 (1.5)	Mukherjee/India^Citation47	35	82	NA	RC	Greater risk of mortality with 2x-HD compared with 3x-HD; 3x-HD associated with increased levels of insurance coverage and affordability
2018 (2.5)	Yan/China^Citation5	123	290	NA	RC	No difference in survival or hospitalization noted in 2x-HD vs 3x-HD regardless of RKF.
2020 (6)	Dai/China^Citation48	12	2	>1–3	MCT RCT	Comparable inflammatory and nutritional clinical outcomes and adverse events. Quality of life was better for 2x-HD.
2021 (1)	Vilar/United Kingdom^Citation49	29	26	6.44/6.98	MCT RCT	2x-HD safe and associated with fewer adverse events and hospitalizations and lower cost. No discernable impact on rate of loss of RKF and quality of life.
2021 (2)	Fang/China^Citation28	54/44	90/89	Oliguric/anuric	PC	2x-HD had worse volume status compared to 3x-HD especially for long-term dialysis vintage. B-type natriuretic peptide was predictor of mortality in HD patients.
2021 (0.75)	Murea/USA^Citation50	23	25	Clearance > 2 mL/min	MCT RCT	Preliminary results show 2x-HD confers better preservation of residual kidney function. All patients were switched to 3x-HD at week 7.

Abbreviations: 1x-HD, once weekly dialysis; 2x-HD, twice weekly dialysis; 3x-HD, standard thrice weekly dialysis; Dur, duration in years; eGFR, estimated glomerular filtration rate; GFR, glomerular filtration rate; HD, hemodialysis; MCT RCT, multicenter randomized controlled trial; NA, not available; RC, retrospective cohort; RKF, residual kidney function; PC, prospective cohort; SD, standard dialysis ; USA, United States of America.

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