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Incremental Hemodialysis Provides Better Savings, Same Outcomes as Standard Hemodialysis


Researchers found that implementing an incremental schedule for hemodialysis in patients with residual kidney disease produced similar clinical outcomes and significant savings for health systems compared with hemodialysis administered on a more traditional schedule.

Incremental hemodialysis may be a safe and effective method for patients with residual kidney function (RKF) and could lead to significant cost-savings for clinics, according to a recent study published in Kidney International.

The randomized controlled feasibility trial assessed the potential impact of incremental hemodialysis therapy on clinical outcomes, quality of life, and cost-savings compared with hemodialysis on a standard schedule. It is the first prospective randomized trial to compare the 2 hemodialysis schedules.

“[Our results] may reassure clinicians fearful of underdialysis and its consequences,” the investigators suggested.

Hemodialysis on an incremental schedule typically involves patients receiving therapy twice per week instead of the standard thrice weekly regimen. Each session lasts for about 3.5 to 4.0 hours. The amount of dialysis delivered to patients undergoing incremental hemodialysis increases progressively. For this to be done safely, frequent measurement of RKF and prescription adjustments for dialysis are often needed.

If done accordingly, incremental hemodialysis could lead to reduced vascular access problems, catheter-related infections, and ultrafiltration-induced myocardial ischemia as well as improved quality of life for patients by lowering incidence of depression and treatment burden. Dialysis centers could also have more space freed up for other patients, allowing for centers to better accommodate any additional patients or enhanced sessional frequency. However, clinicians may be hesitant to prescribe incremental scheduling because of concerns about underdialysis and more research is needed on the clinical benefits.

Overall, 55 patients aged 18 years or older receiving hemodialysis therapy for 3 months or less were recruited from 4 dialysis center in the United Kingdom between December 28, 2018 and April 3, 2019 for the study. The patients were randomized to follow an incremental schedule (n = 29) or a standard schedule (n = 26) for 12 months.

The mean (SD) age was 63.1 (12.3) years in the standard group and 61.4 (15.2) years in the incremental group. Over 75% of the patients in both groups were white. Nearly 70% of the incremental group and 73.1% of the standard group were men.

After 6 months, 17 patients in the standard arm and 25 in the incremental arm remained in the study. At the 1-year mark, 12 patients from the standard group and 21 from the incremental group remained. There were 3 deaths in each arm.

Hospitalization rates were higher in the standard arm (P < .001). Vascular access event rate and hyperkalemia event rate were also higher in this group, but it was not statistically significant.

Serious adverse events potentially related to hemodialysis were less frequent in the incremental arm but there was no difference between the groups regarding experiencing 1 or more serious adverse event. Serious adverse events that were not linked to hemodialysis were also less frequent in the incremental group.

There were no group differences in urea clearance slope. Serum bicarbonate was significantly lower in the patients within the incremental group, suggesting that supplementation should be considered for patients on a twice-weekly regimen. Outcomes such as blood pressure, extracellular fluid, and patient-reported outcomes were similar between the groups.

There were no significant benefits with incremental hemodialysis regarding protection of RKF or quality of life compared with standard hemodialysis.

The median health care provider costs were higher in the standard arm compared to the incremental arm, amounting to £26,125 (95% CI, £23,025 to £29,224) vs £19,875 (95% CI, £17,941 to £21,810), respectively.

“Future trials should also assess the health economics benefits of lower intensity dialysis regimes. It is noteworthy that the costs recorded in this study were somewhat lower than those reported elsewhere, which may reflect the selective nature of our trial cohort,” the investigators wrote.


Vilar E, Kamal RMK, Fotheringham J, et al. A multicenter feasibility randomized controlled trial to assess the impact of incremental versus conventional initiation of hemodialysis on residual kidney function. Kidney Int. 2022; 101:615-625. doi:10.1016/ j.kint.2021.07.025

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