A multicenter feasibility randomized controlled trial to assess the impact of incremental versus conventional initiation of hemodialysis on residual kidney function

Real experience of young and middle-aged hemodialysis patients: a qualitative meta-synthesis

Background

About 89% of global End-stage renal disease (ESRD) patients receive hemodialysis. Data show that about 40% ~ 60% of dialysis patients are young and middle-aged. Hemodialysis significantly impacts the daily life and rehabilitation of patients, underscoring the urgency of understanding their experiences and needs. However, findings from previous individual qualitative studies may lack representativeness.

Aims

This study used Meta-synthesis to offer a thorough understanding of the lived experiences, psychological states, and needs of young and middle-aged hemodialysis patients.

Design

Systematic review and meta-synthesis.

Methods

A systematic search was conducted in PubMed, Embase, The Cochrane Library, Web of Science, CINAHL, CBM, CNKI, WanFang, and VIP databases from the establishment of each database to November 4, 2024, targeting qualitative studies on the experiences of young and middle-aged hemodialysis patients (aged 18-65 years old). Quality assessment used the Joanna Briggs Institute's 2016 Checklist for Qualitative Research, followed by meta-synthesis. The study's reporting was informed by the principles of the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) framework. The thematic analysis approach was employed to synthesize the findings.

Results

Twenty-two studies were included, covering 14 countries. The inclusion of 22 studies yielded 83 findings, categorized into nine subthemes and condensed into four overarching themes: negative emotional experiences toward illness and hemodialysis, experience of financial problems due to long-term hemodialysis treatment, disruptions to normal life, and seeking multiple forms of support among hemodialysis patients.

Conclusion

Healthcare providers should attach importance to this group, to meet their specific needs, and support their active recovery. The goal is to help them relieve negative emotions, reduce financial burden, return to normal life and meet multiple forms of support.

Twice against thrice-weekly hemodialysis (TATH): a multicenter nonrandomized trial

BACKGROUND

The optimal frequency of maintenance hemodialysis remains a subject of debate. In many countries, twice-weekly hemodialysis is still commonly practiced. This trial aimed to compare the outcomes of patients undergoing twice-weekly versus thrice-weekly hemodialysis.

METHODS

This prospective, multicenter, nonrandomized trial included incident adult patients, with chronic kidney disease stage 5, initiating hemodialysis between January 2018 and August 2021. Patients were allocated to either a twice-weekly or thrice-weekly regimen, and monitored at 1, 3, 6, 12 and 24 months. This trial was terminated before reaching the required sample size due to the COVID-19 pandemic and economic factors. Recruitment achieved 25% of the projected number. Missing baseline factors were imputed using multiple imputation algorithms, then entered in a logistic regression model to estimate propensity scores. The primary outcome was two-year survival analyzed using a Cox regression survival model adjusted for propensity scores and baseline residual urine output. Secondary outcomes included hospitalization rates, uncontrolled hypertension and cumulative erythropoietin dose at two years, analyzed using regression models adjusted for propensity scores and baseline residual urine output. All analyses were conducted on an intention-to-treat basis.

RESULTS

A total of 132 patients on thrice-weekly hemodialysis and 71 on twice-weekly hemodialysis were included. The mean age was 67 ± 15 years and the median eGFR at dialysis initiation was 6 (4,8) mL/min/1.73 m2. At one year, patients in the twice-weekly group had greater residual urine output. At two years, there was no significant difference in survival (HR = 0.84; 95% CI: 0.37, 1.90), hospitalization rates (P = 0.515) or uncontrolled hypertension (P = 0.442). The twice-weekly group showed a trend toward higher erythropoietin requirements (P = 0.08). Serum potassium levels and the number of antihypertensive medications were greater in the twice-weekly group.

CONCLUSIONS

Patients on twice-weekly hemodialysis showed comparable overall survival at two years to those on thrice-weekly hemodialysis. While a twice-weekly regimen may be a viable option during the first year of dialysis, especially in low-resource settings, it carries potential risks that necessitate careful monitoring after the first year.

TRIAL REGISTRATION

The trial was registered on ClinicalTrials.gov on January 16, 2018 (Identifier NCT03415776).

Home dialysis: there's no place like home

PURPOSE OF REVIEW

The rapid rise in incidence and prevalence of end-stage kidney disease (ESKD) over the past 50 years was matched by a drop-off in use of home dialysis and a proliferation of in-center hemodialysis across the United States. There is renewed interest in improving access to home dialysis modalities for patients with ESKD. The aim of this review is to update kidney care providers with clinical outcome data and new guidelines that promote patient-centered choices, and to address barriers to home dialysis uptake and continued use.

RECENT FINDINGS

Recent literature, including changing practice guidelines for prescribing home dialysis and examining the goals of treatment from the patient and caregiver perspectives will be reviewed. We will examine the impact of newer care models to promote home dialysis for incident ESKD patients. Assisted home dialysis, home dialysis in a nursing home and the impact of new payment models rewarding home dialysis providers will be examined.

SUMMARY

This concise review of recent pertinent literature should give the dialysis provider confidence in advising their patients on the benefits of home dialysis, a glimpse into the future landscape for home dialysis, and hopefully transform kidney care providers into unbiased patient advocates.

Chronic kidney disease

Chronic kidney disease (CKD) is defined by persistent abnormalities of kidney function or structure that have consequences for the health. A progressive decline of excretory kidney function has effects on body homeostasis. CKD is tightly associated with accelerated cardiovascular disease and severe infections, and with premature death. Kidney failure without access to kidney replacement therapy is fatal - a reality in many regions of the world. CKD can be the consequence of a single cause, but CKD in adults frequently relates rather to sequential injuries accumulating over the life course or to the presence of concomitant risk factors. The shared pathomechanism of CKD progression is the irreversible loss of kidney cells or nephrons together with haemodynamic and metabolic overload of the remaining nephrons, leading to further loss of kidney cells or nephrons. The management of patients with CKD focuses on early detection and on controlling all modifiable risk factors. This approach includes reducing the overload of the remaining nephrons with inhibitors of the renin-angiotensin system and the sodium-glucose transporter 2, as well as disease-specific drug interventions, if available. Hypertension, anaemia, metabolic acidosis and secondary hyperparathyroidism contribute to cardiovascular morbidity and reduced quality of life, and require diagnosis and treatment.

Incremental hemodialysis transition in veterans and nonveterans with kidney failure

PURPOSE OF REVIEW

Initiation of hemodialysis treatment with a thrice-weekly prescription is currently the standard of care irrespective of patients' residual kidney function (RKF), comorbidities, and preferences.

RECENT FINDINGS

Each year ∼12 000 Veterans with advanced kidney disease progress to end-stage kidney disease (ESKD) requiring dialysis and comprise greater than 10% of the US incident ESKD population. Dialysis is costly and is associated with impaired health-related quality of life (HRQOL) and high mortality risk, especially in the first year of treatment. Evidence suggests an incremental dialysis transition using twice-weekly hemodialysis provides various benefits, including more dialysis-free time, longer RKF preservation, less vascular access damage, and lower patient burden. Pragmatic studies are needed to inform the efficacy and safety of incremental hemodialysis as a personalized dialysis regimen, and could inform its consideration as a conservation strategy during times of supply shortages. Broadly implementing twice-weekly hemodialysis could also potentially allow more Veterans to receive care within VA-based dialysis units. The VA IncHVets Trial is a pragmatic, multicenter, randomized controlled trial comparing the efficacy and safety of twice-weekly incremental vs. thrice-weekly hemodialysis among Veterans transitioning to ESKD.

SUMMARY

Further research is needed to determine whether incremental hemodialysis is well tolerated, effective, and facilitates a more favorable transition to dialysis.

Chronic Dialysis Therapies

While both in-center and home dialysis modalities have improved life expectancy for people with end-stage kidney disease and have served as a bridge to eventual kidney transplantation, kidney health care providers must be keenly aware of the potential complications associated with these therapies. The following questions aim to shed light on some of the more important potential physiological consequences and medical dilemmas associated with the three primary dialysis modalities including in-center hemodialysis, home hemodialysis, and peritoneal dialysis. Moreover, we hope to highlight that caring for those requiring dialytic therapy necessitates a significant breadth of understanding in other core internal medicine disciplines beyond nephrology itself, including cardiovascular, infectious, and musculoskeletal disease entities.

Redefining the concept of residual renal function with kidney sodium MRI: a pilot study

BACKGROUND

The concept of residual kidney function (RKF) is exclusively based upon urine volume and small solute clearance, making RKF challenging to assess in clinical practice. The aim of this study was to test the technical feasibility of obtaining usable sodium magnetic resonance imaging (23Na-MRI) kidney images in hemodialysis (HD) participants.

METHODS

We conducted an exploratory prospective study to quantify the cortico-medullary sodium gradient in 17 healthy volunteers and 21 HD participants. Participants fasted for 8 h prior to their study visit. Urine samples were collected to measure urinary osmolarity, before MRI. Proton and sodium pictures were merged; regions of interest were delineated for the medulla and cortex when feasible. In cases where cortex could not be identified, we considered the corticomedullary gradient (CMG) to be no longer present, resulting in a medulla-to-cortex ratio of 1.

RESULTS

Median (interquartile range) fasting medulla-to-cortex ratio was significantly higher 1.56 (1.5-1.61) in healthy volunteers compared with HD patients 1.22 (1.13-1.3), P < .0001. Medulla to cortex ratio and median urinary osmolarity were correlated (r = 0.87, P < .0001) in the whole population. We found a significant association between HD vintage and medulla-to-cortex ratio, whereas we did not find any association with urine volume. Sodium signal intensity distribution within healthy kidney describes two different peaks relating to well defined cortex and medulla, whereas HD participants displays only a single peak indicative of the markedly lower sodium concentration.

LIMITATIONS

This study is only exploratory, with a modest number of patients.

CONCLUSIONS

The application of kidney 23Na-MRI to the study of RKF in patients receiving maintenance HD is practical and provides a previously unavailable ability to interrogate the function of remnant tubular function.Clinical Trial Registration: NCT05014178.

A practical approach to implementing incremental haemodialysis

The majority of end-stage kidney disease patients are treated with haemodialysis (HD). Starting HD can pose physical, social, and psychological challenges to patients, and mortality rates within the first 6 months are disproportionately high, with intensive HD regimens implicated as a potential factor. Starting HD with an incremental approach, taking residual kidney function (RKF) into account, potentially allows for a gentle start with reduced dialysis intensity. Dialysis intensity (session time or frequency) can then be proportionally increased as RKF reduces. This approach to starting HD has been reported in observational studies to result in better patient self-reported health quality of life and reduced costs, and now several definitive randomised controlled trials are underway comparing an incremental approach to the conventional thrice weekly paradigm. Physician concerns over the risk of inadequate dialysis, with consequent increased emergency admissions, and practical challenges of how to estimate RKF and implement incremental dialysis have impeded widespread adoption. Addressing these challenges is paramount to increasing the uptake of incremental HD. Careful patient selection lies at the heart of a successful incremental HD programme. Generally, patients with a residual urea clearance of > 3 ml/min/1.73 m2 can be considered suitable for starting with incremental HD provided they comply with fluid intake, salt and other dietary recommendations. Calculating RKF from regular interdialytic urine collections and appropriately adjusting sessional HD clearance targets are practical and conceptual challenges. In this report we aim to disentangle these complexities and provide a step-by-step guide for patient selection and adjusting dialysis sessional targets.

Incremental hemodialysis and vascular access complications: a 12-year experience in a hospital hemodialysis unit

BACKGROUND

Incremental hemodialysis (HD) is considered a valid alternative for patients with residual kidney function. Evidence concerning its effect on vascular access is scarce. We present our 12-year experience of an incremental hemodialysis program with the aim of evaluating survival and complications of arteriovenous fistula in these patients compared to the thrice-weekly scheme.

METHODS

From January 1st, 2006 to December 31st, 2017, 220 incident patients started hemodialysis, 132 (60%) of whom began hemodialysis with two sessions per week and 88 (40%) with three sessions per week. Demographic and clinical variables were assessed at the start of treatment. Data regarding arteriovenous fistula survival and complications were collected.

RESULTS

Both groups had similar baseline sociodemographic and clinical characteristics. A total of 188 (85%) patients were dialyzed with an arteriovenous fistula during follow-up. Eighty-three patients had one or more fistula complications, with no differences between incremental and conventional groups (p = 0.55). Fistula survival rates showed no significant difference between the two groups, whether analyzed from the date of fistula creation (Log Rank p = 0.810) or from the date of initial fistula cannulation (Log Rank p = 0.695).

CONCLUSIONS

We found no differences in arteriovenous fistula survival or complication rate between patients who started HD with an incremental versus a conventional treatment scheme. Randomized controlled clinical trials may be warranted to achieve a higher degree of evidence.

Twice Weekly versus Thrice Weekly Hemodialysis-A Pilot Cross-Over Equivalence Trial

Key Points

The 2015 Kidney Disease Outcomes Quality Initiative Guideline Update increased the contribution of residual kidney function, shortening the time required for twice weekly hemodialysis. No study had yet assessed the feasibility of prescribing twice weekly hemodialysis according to the updated guideline. Twice weekly hemodialysis prescribed using the updated guideline maintained quality of life and controlled fluid gain, potassium, and uremic solutes.

Background

The 2015 Update of the Kidney Disease Outcomes Quality Initiative (KDOQI) Guideline for Hemodialysis Adequacy increased the contribution of residual kidney function in calculating standard Kt/Vurea (stdKt/Vurea). However, no study has assessed the effect of prescribing twice weekly hemodialysis according to this guideline on patients' quality of life or uremic solute levels.

Methods

Twenty six hemodialysis patients with average residual urea clearance (Kru) 4.7±1.8 ml/min and hemodialysis vintage of 12±15 months (range 2 months to 4.9 years) underwent a cross-over trial comparing four weeks of twice weekly hemodialysis and four weeks of thrice weekly hemodialysis. Twice weekly hemodialysis was prescribed to achieve stdKt/Vurea 2.2 incorporating Kru using the 2015 KDOQI Guideline. Thrice weekly hemodialysis was prescribed to achieve spKt/Vurea 1.3 regardless of Kru. Quality of life and plasma levels of secreted uremic solutes and β 2 microglobulin were assessed at the end of each period.

Results

Equivalence testing between twice and thrice weekly hemodialysis based on the Kidney Disease Quality of Life instrument (primary analysis) was inconclusive. Symptoms as assessed by the secondary outcomes Dialysis Symptom Index and Post-Dialysis Recovery Time were not worse with twice weekly hemodialysis. StdKt/Vurea was adequate during twice weekly hemodialysis (2.7±0.5), and ultrafiltration rate and plasma potassium were controlled with minimally longer treatment times (twice weekly: 195±20 versus thrice weekly: 191±17 minutes). Plasma levels of the secreted solutes and β 2 microglobulin were not higher with twice weekly than thrice weekly hemodialysis.

Conclusions

Twice weekly hemodialysis can be prescribed using the higher contribution assigned to Kru by the 2015 KDOQI Guideline. With twice weekly hemodialysis, quality of life was unchanged, and the continuous function of the residual kidneys controlled fluid gain and plasma levels of potassium and uremic solutes without substantially longer treatment times.

Clinical Trial registration number:

NCT03874117 .

Comparative effectiveness of an individualized model of hemodialysis vs conventional hemodialysis: a study protocol for a multicenter randomized controlled trial (the TwoPlus trial)

BACKGROUND

Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients.

METHODS

An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients' all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients).

DISCUSSION

Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05828823. Registered on 25 April 2023.

Dialysis for older adults: why should the targets be different?

The number of patients aged > 75-years treated by dialysis continues to increase, particularly in developed countries. Haemodialysis is a well-established treatment with national and international clinical guidelines designed to provide patients with optimal treatment. However, these were developed when the dialysis population was younger, and less co-morbid. This change in patient demographics questions whether these guideline targets still apply to older patients. More patients now start dialysis with residual kidney function and could benefit from a less frequent dialysis schedule. Older patients have a lower thirst drive, so lower interdialytic gains, reduced appetite, muscle mass and physical activity would potentially allow starting dialysis with less frequent sessions a practical option. Similarly, patients with residual kidney function and lower metabolic activity may not need to meet current dialyser Kt/Vurea clearance targets to remain healthy. Instead, some elderly patients may be at risk of malnutrition and might need liberalisation of the low salt, potassium and phosphate dietary restrictions, or even additional supplements to ensure adequate protein intake. Although a fistula is the preferred vascular access, a forearm fistula may not be an option due to vascular disease, while a brachial fistula can potentially compromise cardiovascular reserve, so a dialysis catheter becomes the de facto access, especially in patients with limited life expectancy. Thus, clinical guideline targets designed for a younger less co-morbid dialysis population may not be equally applicable to the older patient initiating dialysis, and so a more individualised approach to dialysis prescription and vascular access is required.

Shared decision making in elderly patients with kidney failure

'Elderly' is most commonly defined as an individual aged 65 years or older. However, this definition fails to account for the differences in genetics, lifestyle and overall health that contribute to significant heterogeneity among the elderly beyond chronological age. As the world population continues to age, the prevalence of chronic diseases, including chronic kidney disease (CKD), is increasing and CKD frequently progresses to kidney failure. Moreover, frailty represents a multidimensional clinical entity highly prevalent in this population, which needs to be adequately assessed to inform and support medical decisions. Selecting the optimal treatment pathway for the elderly and frail kidney failure population, be it haemodialysis, peritoneal dialysis or conservative kidney management, is complex because of the presence of comorbidities associated with low survival rates and impaired quality of life. Management of these patients should involve a multidisciplinary approach including doctors from various specialties, nurses, psychologists, dieticians and physiotherapists. Studies are mostly retrospective and observational, lacking adjustment for confounders or addressing selection and indication biases, making it difficult to use these data to guide treatment decisions. Throughout this review we discuss the difficulty of making a one-size-fits-all recommendation for the clinical needs of older patients with kidney failure. We advocate that a research agenda for optimization of the critical issues we present in this review be implemented. We recommend prospective studies that address these issues, and systematic reviews incorporating the complementary evidence of both observational and interventional studies. Furthermore, we strongly support a shared decision-making process matching evidence with patient preferences to ensure that individualized choices are made regarding dialysis vs conservative kidney management, dialysis modality and optimal vascular access.

Incremental dialysis: two complementary views

Franco Casino and Mariana Murea discuss today's knowledge about the 'incremental dialysis' concept. Franco Casino frames the problem by saying that, in the presence of substantial residual kidney function, kidney replacement therapy can begin with low doses and/or frequencies, to be gradually increased to compensate for any subsequent losses of residual kidney function, keeping the total clearance above the minimum levels of adequacy. He remarks that studies so far have documented that this approach is safe. He recognizes that adequate randomized controlled trials (RCTs) are necessary to confirm the safety and simplify and standardize the practical aspects of this approach. Mariana Murea objects that most of the evidence gathered so far primarily derives from retrospective and observational studies, which can be influenced by socioeconomic constraints. She argues for the need for RCTs to provide compelling empirical evidence on the efficacy of incremental dialysis. Nephrologists are still reluctant to adopt this approach for various reasons, including unfamiliarity with the method, lack of practical guidance and financial disincentives. Several countries have ongoing or planned RCTs comparing incremental dialysis with conventional dialysis. These trials can shift the haemodialysis paradigm if they validate the safety and effectiveness of this approach. The moderators believe that the results of ongoing trials must be carefully interpreted, and further validation may be needed across different patient populations or healthcare settings. The ultimate goal is to gather robust evidence that could lead to widespread adoption of incremental haemodialysis, optimizing treatment, reducing overtreatment, preserving resources and improving patients' quality of life.

Incremental dialysis: review of the literature with pediatric perspective

Drivers towards initiation of kidney replacement therapy in advanced chronic kidney disease include metabolic and fluid derangements, growth, and nutritional status with focus on health optimization. Once initiated, prescription of dialysis is often uniform despite variability in patient characteristics and etiology of kidney failure. Preservation of residual kidney function has been associated with improved outcomes in patients with advanced chronic kidney disease on dialysis. Incremental dialysis is the approach of reducing the dialysis dose by reduction in treatment time, days, or efficiency of clearance. Incremental dialysis has been described in adults at initiation of kidney replacement therapy, to better preserve residual kidney function and meet the individual needs of the patient. Consideration of incremental dialysis in pediatrics may be reasonable in a subset of children with continued emphasis on promotion of growth and development.

Incremental versus conventional haemodialysis in end-stage kidney disease: a systematic review and meta-analysis

Background

Appropriate dialysis prescription in the transitional setting from chronic kidney disease to end-stage kidney disease is still challenging. Conventional thrice-weekly haemodialysis (HD) might be associated with rapid loss of residual kidney function (RKF) and high mortality. The benefits and risks of incremental HD compared with conventional HD were explored in this systematic review and meta-analysis.

Methods

We searched MEDLINE, Scopus and Cochrane Central Register of Controlled Trials up to April 2023 for studies that compared the impacts of incremental (once- or twice-weekly HD) and conventional thrice-weekly HD on cardiovascular events, RKF, vascular access complications, quality of life, hospitalization and mortality.

Results

A total of 36 articles (138 939 participants) were included in this meta-analysis. The mortality rate and cardiovascular events were similar between incremental and conventional HD {odds ratio [OR] 0.87 [95% confidence interval (CI)] 0.72-1.04 and OR 0.67 [95% CI 0.43-1.05], respectively}. However, hospitalization and loss of RKF were significantly lower in patients treated with incremental HD [OR 0.44 (95% CI 0.27-0.72) and OR 0.31 (95% CI 0.25-0.39), respectively]. In a sensitivity analysis that included studies restricted to those with RKF or urine output criteria, incremental HD had significantly lower cardiovascular events [OR 0.22 (95% CI 0.08-0.63)] and mortality [OR 0.54 (95% CI 0.37-0.79)]. Vascular access complications, hyperkalaemia and volume overload were not statistically different between groups.

Conclusions

Incremental HD has been shown to be safe and may provide superior benefits in clinical outcomes, particularly in appropriately selected patients. Large-scale randomized controlled trials are required to confirm these potential advantages.

Incremental hemodialysis in pediatric patients

BACKGROUND

Incremental hemodialysis follows the concept of adjusting dialysis dose according to residual kidney function. Data on incremental hemodialysis in pediatric patients is lacking.

METHODS

We conducted a retrospective analysis of children initiating hemodialysis between January 2015 and July 2020 in a single tertiary center, comparing the characteristics and outcomes of those who commenced with incremental hemodialysis vs with conventional thrice-weekly regimen.

RESULTS

Data on forty patients, 15 (37.5%) on incremental hemodialysis and 25 (63%) on thrice-weekly hemodialysis were analyzed. No differences in age, estimated glomerular filtration rate and metabolic parameters were noted between groups at baseline, but there were more males (73 vs 40%, p = 0.04), more patients with congenital anomalies of kidney and urinary tract (60 vs 20%, p = 0.01), higher urine output (2.5 ± 1 vs 1 ± 0.8 ml/kg/h, p < 0.001), lower use of antihypertensive medications (20 vs 72%, p = 0.002) and lower prevalence of left ventricular hypertrophy (6.7 vs 32%, p = 0.003) in the incremental hemodialysis group vs thrice-weekly hemodialysis. During follow up, 5 (33%) incremental hemodialysis patients were transplanted, 1 (7%) remained on incremental hemodialysis at 24 months, and 9 (60%) transitioned to thrice-weekly hemodialysis at a median (IQR) time of 8.7 (4.2, 11.8) months. At last follow up, fewer patients who initiated incremental hemodialysis had left ventricular hypertrophy (0 vs 32%, p = 0.016) and urine output < 100 ml/24 h (20 vs 60%, p = 0.02) compared to thrice-weekly hemodialysis, with no significant differences in metabolic or growth parameters.

CONCLUSION

Incremental hemodialysis is a viable option for initiating dialysis in selected pediatric patients, that may help improve patients' quality of life and reduce dialysis burden without compromising clinical outcome.

Australian Workshops on Patients' Perspectives on Hemodialysis and Incremental Start

Introduction

Most patients with kidney failure commence and continue hemodialysis (HD) thrice weekly. Incremental initiation (defined as HD less than thrice weekly) is increasingly considered to be safe and less burdensome, but little is known about patients' perspectives. We aimed to describe patients' priorities and concerns regarding incremental HD.

Methods

Patients currently, previously, or soon to be receiving HD in Australia participated in two 90-minute online workshops to discuss views about HD focusing on incremental start and priorities for trial outcomes. Transcripts were analyzed using thematic analysis. Outcomes were ranked on the basis of the sum of participants' priority scores (i.e., single allocation of 3 points for most important, 2 for second, and 1 for third most important outcome).

Results

All 26 participants (1 caregiver and 25 patients) preferred an incremental HD approach. The top prioritized outcomes were quality of life (QOL) (56 points), residual kidney function (RKF) (27 points), and mortality (16 points). The following 4 themes underpinning outcome priorities, experience, and safety concerns were identified: (i) unpreparedness and pressure to adapt, (ii) disruption to daily living, (iii) threats to safety, and (iv) hope and future planning.

Conclusion

Patients with kidney failure preferred an incremental start to HD to minimize disruption to daily living and reduce the negative impacts on their education, ability to work, and family life. QOL was the most critically important outcome, followed by RKF and survival.

On the importance of the interplay of residual renal function with clinical outcomes in end-stage kidney disease

Chronic kidney disease (CKD) is one of the most important public health concerns of the century, and is associated with high rates of morbidity, mortality and social costs. CKD evolving towards end-stage kidney disease (ESKD) is on the rise resulting in a greater number of patients requiring peritoneal dialysis (PD) and hemodialysis (HD). The aim of this manuscript is to review the current literature on the interplay of residual renal function (RRF) with clinical outcomes in ESKD. The persistence of RRF is one of the most important predictors of decreased morbidity, mortality, and better quality of life in both PD and HD patients. RRF contributes to the well-being of ESKD patients through various mechanisms including higher clearance of solutes, maintenance of fluid balance, removal of uremic toxins and control of electrolytes. Furthermore, RRF has beneficial effects on inflammation, anemia, malnutrition, diabetes mellitus, obesity, changes in the microbiota, and cardiac diseases. Several strategies have been proposed to preserve RRF, such as blockade of the renin-angiotensin-aldosterone system, better blood pressure control, incremental PD and HD. Several clinical trials investigating the issue of preservation of RRF are ongoing. They are needed to broaden our understanding of the interplay of RRF with clinical outcomes in ESKD.

Impact of incremental initiation of haemodialysis on mortality: a systematic review and meta-analysis

BACKGROUND

Incremental haemodialysis initiation entails lower sessional duration and/or frequency than the standard 4 h thrice-weekly approach. Dialysis dose is increased as residual kidney function (RKF) declines. This systematic review evaluates its safety, efficacy and cost-effectiveness.

METHODS

We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library databases from inception to 27 February 2022. Eligible studies compared incremental haemodialysis (sessions either fewer than three times weekly or of duration <3.5 h) with standard treatment. The primary outcome was mortality. Secondary outcomes included treatment-emergent adverse events, loss of RKF, quality of life and cost effectiveness. The study protocol was prospectively registered. Risk of bias assessment used the Newcastle-Ottawa Scale and the revised Cochrane risk of bias tool, as appropriate. Meta-analyses were undertaken in Review Manager, Version 5.4.

RESULTS

A total of 644 records were identified. Twenty-six met the inclusion criteria, including 22 cohort studies and two randomized controlled trials (RCTs). Sample size ranged from 48 to 50 596 participants (total 101 476). We found no mortality differences (hazard ratio = 0.99; 95% CI 0.80-1.24). Cohort studies suggested similar hospitalization rates though the two small RCTs suggested less hospitalization after incremental initiation (relative risk = 0.31; 95% CI 0.18-0.54). Data on other treatment-emergent adverse events and quality of life was limited. Observational studies suggested reduced loss of RKF in incremental haemodialysis. This was not supported by RCT data. Four studies reported reduced costs of incremental treatments.

CONCLUSIONS

Incremental initiation of haemodialysis does not confer greater risk of mortality compared with standard treatment. Hospitalization may be reduced and costs are lower.

Twice versus thrice weekly hemodialysis: A systematic review

INTRODUCTION

Thrice weekly hemodialysis (HD) is currently the norm in high income countries but there is mounting interest in twice weekly HD in certain settings. We performed this systematic review to summarize the available evidence comparing twice to thrice weekly HD.

METHODS

A systematic literature search was performed in Ovid MEDLINE, Ovid Embase, and the Cochrane Central Register of Controlled Trials to identify cohort and randomized controlled trials evaluating outcomes of twice versus thrice weekly HD. The bibliographies of identified studies were hand searched to find any additional studies. Risk of bias was assessed using the Newcastle-Ottawa scale for observational studies.

FINDINGS

No randomized controlled trials and 21 cohort studies were identified. Overall study quality was modest with high risk of selection bias and inadequate controlling for confounders. The most commonly evaluated outcome measures were survival and residual kidney function. No studies assessed quality of life. Study results were variable and there was no clear signal for overwhelming risk or benefit of twice versus thrice weekly HD with the exception of residual kidney function which consistently showed slower decline in the twice weekly group.

DISCUSSION

There is a paucity of high quality data comparing the risks and benefits of twice vs thrice weekly HD. Randomized controlled trial evidence is required to inform clinicians and HD prescription guidelines.

Twice-Weekly Hemodialysis With Adjuvant Pharmacotherapy and Transition to Thrice-Weekly Hemodialysis: A Pilot Study

RATIONALE & OBJECTIVE

Thrice-weekly hemodialysis (HD) is the most common treatment modality for kidney failure in the United States. We conducted a pilot study to assess the feasibility and safety of incremental-start HD in patients beginning maintenance HD.

STUDY DESIGN

Pilot study.

SETTING & PARTICIPANTS

Adults with estimated glomerular filtration rate (eGFR) ≥5 mL/min/1.73 m² and urine volume ≥500 mL/d beginning maintenance HD at 14 outpatient dialysis units.

EXPOSURE

Randomized allocation (1:1 ratio) to twice-weekly HD and adjuvant pharmacologic therapy for 6 weeks followed by thrice-weekly HD (incremental HD group) or thrice-weekly HD (conventional HD group).

OUTCOME

The primary outcome was feasibility. Secondary outcomes included changes in urine volume and solute clearance.

RESULTS

Of 77 patients invited to participate, 51 consented to do so, representing 66% of eligible patients. We randomized 23 patients to the incremental HD group and 25 patients to the conventional HD group. Protocol-based loop diuretics, sodium bicarbonate, and patiromer were prescribed to 100%, 39%, and 17% of patients on twice-weekly HD, respectively. At a mean follow-up of 281.9 days, participant adherence was 96% to the HD schedule (22 of 23 and 24 of 25 in the incremental and conventional groups, respectively) and 100% in both groups to serial timed urine collection. The incidence rate ratio for all-cause hospitalization was 0.31 (95% CI, 0.08-1.17); and 7 deaths were recorded (1 in the incremental and 6 in the conventional group). At week 24, the incremental HD group had lower declines in urine volume (a difference of 51.0 [95% CI, -0.7 to 102.8] percentage points) and in the averaged urea and creatinine clearances (a difference of 57.9 [95% CI, -22.6 to 138.4] percentage points).

LIMITATIONS

Small sample size, time-limited twice-weekly HD.

CONCLUSIONS

It is feasible to enroll patients beginning maintenance HD into a randomized study of incremental-start HD with adjuvant pharmacotherapy who adhere to the study protocol during follow-up. Larger multicenter clinical trials are indicated to determine the efficacy and safety of incremental HD with longer twice-weekly HD periods.

FUNDING

Funding was provided by Vifor Inc.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov, identifier NCT03740048.

Outcomes of incident patients treated with incremental haemodialysis as compared with standard haemodialysis and peritoneal dialysis

BACKGROUND

Residual kidney function is considered better preserved with incremental haemodialysis (I-HD) or peritoneal dialysis (PD) as compared with conventional thrice-weekly HD (TW-HD) and is associated with improved survival. We aimed to describe outcomes of patients initiating dialysis with I-HD, TW-HD or PD.

METHODS

We conducted a retrospective analysis of a prospectively assembled cohort in a single university centre including all adults initiating dialysis from January 2013 to December 2020. Primary and secondary endpoints were overall survival and hospitalization days at 1 year, respectively.

RESULTS

We included 313 patients with 234 starting on HD (166 TW-HD and 68 I-HD) and 79 on PD. At the end of the study, 10 were still on I-HD while 45 transitioned to TW-HD after a mean duration of 9.8 ± 9.1 months. Patients who stayed on I-HD were less frequently diabetics (P = .007). Mean follow-up was 33.1 ± 30.8 months during which 124 (39.6%) patients died. Compared with patients on TW-HD, those on I-HD had improved survival (hazard ratio 0.49, 95% confidence interval 0.26-0.93, P = .029), while those on PD had similar survival. Initial kidney replacement therapy modality was not significantly associated with hospitalization days at 1 year.

CONCLUSIONS

I-HD is suitable for selected patients starting dialysis and can be maintained for a significant amount of time before transition to TW-HD, with diabetes being a risk factor. Although hospitalization days at 1 year are similar, initiation with I-HD is associated with improved survival as compared with TW-HD or PD. Results of randomized controlled trials are awaited prior to large-scale implementation of I-HD programmes.

Incremental Hemodialysis: What We Know so Far

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.

Incremental and Personalized Hemodialysis Start: A New Standard of Care

Introduction

Incremental hemodialysis (iHD) may attenuate “dialysis shock” and reduce costs, preserving quality of life. It is considered difficult to reconcile with HD wards’ routine; fear of underdialysis and increasing mortality are additional concerns. The aim of this study was to evaluate mortality, morbidity, and costs in a large HD ward where iHD is the standard of HD start.

Methods

This observational study included all incident HD patients in 2017 to 2021, stratified according to HD start: iHD (1–2 sessions/wk), decremental HD (dHD, 3 sessions/wk at start, later reduced), or standard (3 sessions/wk). Results were compared with data recorded in the same unit before the incremental program (2015–2017) and with a propensity score-matched cohort from the French Renal Epidemiology and Information Network (REIN) registry.

Results

A total of 158 patients started HD in 2017 to 2021, 57.6% on iHD, 8.9% dHD, and 33.5% standard HD schedule. Patients on the standard schedule had lower initial estimated glomerular filtration rate (eGFR) (5 vs. 7 ml/min per 1.72 m², P = 0.003). We found no survival differences according to period of start (same center) and propensity score matching (REIN). Patients intensively followed in the pre-HD period were more likely to start on iHD-dHD. Persistence on iHD-dHD was about 50% at 1 year and 35% at 2 years. Hospitalization rates and time to first hospitalization or death did not differ between the schedules. The iHD-dHD policy allowed a 16% cost saving, even accounting for supplemental biochemical tests.

Conclusion

Our study reveals that iHD can be a new standard of care, as it is safe and feasible in up to two-thirds of patients on incident HD.

Does delivering more dialysis improve clinical outcomes? What randomized controlled trials have shown

Some randomized controlled trials (RCTs) have sought to determine whether different dialysis techniques, dialysis doses and frequencies of treatment are able to improve clinical outcomes in end-stage kidney disease (ESKD). Virtually all of these RCTs were enacted on the premise that 'more' haemodialysis might improve clinical outcomes compared to 'conventional' haemodialysis. Aim of the present narrative review was to analyse these landmark RCTs by posing the following question: were their intervention strategies (i.e., earlier dialysis start, higher haemodialysis dose, intensive haemodialysis, increase in convective transport, starting haemodialysis with three sessions per week) able to improve clinical outcomes? The answer is no. There are at least two main reasons why many RCTs have failed to demonstrate the expected benefits thus far: (1) in general, RCTs included relatively small cohorts and short follow-ups, thus producing low event rates and limited statistical power; (2) the designs of these studies did not take into account that ESKD does not result from a single disease entity: it is a collection of different diseases and subtypes of kidney dysfunction. Patients with advanced kidney failure requiring dialysis treatment differ on a multitude of levels including residual kidney function, biochemical parameters (e.g., acid base balance, serum electrolytes, mineral and bone disorder), and volume overload. In conclusion, the different intervention strategies of the RCTs herein reviewed were not able to improve clinical outcomes of ESKD patients. Higher quality studies are needed to guide patients and clinicians in the decision-making process. Future RCTs should account for the heterogeneity of patients when considering inclusion/exclusion criteria and study design, and should a priori consider subgroup analyses to highlight specific subgroups that can benefit most from a particular intervention.

Patient-centred approaches for the management of unpleasant symptoms in kidney disease

Patients with chronic kidney disease (CKD) frequently experience unpleasant symptoms. These can be gastrointestinal (constipation, nausea, vomiting and diarrhoea), psychological (anxiety and sadness), neurological (lightheadedness, headache and numbness), cardiopulmonary (shortness of breath and oedema), dermatological (pruritus and dry skin), painful (muscle cramps, chest pain and abdominal pain) or involve sexual dysfunction, sleep disorders and fatigue. These symptoms often occur in clusters, with one of them as the lead symptom and others as secondary symptoms. Uraemic toxins (also called uremic toxins) are often considered to be the main cause of CKD-associated symptom burden, but treatment of uraemia by dialysis often fails to resolve them and can engender additional symptoms. Indeed, symptoms can be exacerbated by comorbid conditions, pharmacotherapies, lifestyle and dietary regimens, kidney replacement therapy and ageing. Patients with kidney disease, including those who depend on dialysis or transplantation, should feel actively supported in their symptom management through the identification and targeting of unpleasant symptoms via a tailored palliative care approach. Such an approach may help minimize the burden and consequences of kidney disease, and lead to improved patient outcomes including health-related quality of life and better life participation.