Incremental Dialysis: Toward a Nuanced Approach

This blog post was made by Dr. John Agar on May 9th, 2019.
Incremental Dialysis: Toward a Nuanced Approach

Much has been written, though agreement remains elusive, about when to start dialysis ( 1, 2 ). The Ideal Trial from ANZ—now a decade old—has provided the most certain of all uncertain guides 3, but no trials have been done to guide the most vexing question of all: once dialysis is deemed necessary, how should it then start?

Recently, the concept of incremental dialysis has become quite a hot topic, ( 4, 5, 6 ) despite that there are, as yet, no large trial data to prove or disprove its value. And, if a dialysis start is to be incremental, what does “incremental” mean, and what should be the increment(s)?

Incremental dialysis is built around the premise that a step-wise introduction of dialysis may help preserve residual renal function. In turn, preservation of residual renal function in haemodialysis patients is likely to be highly beneficial—at is has been proven to be in peritoneal dialysis patients—with even low levels of native renal function benefitting the removal of some of the more complex toxins: p-cresol, middle molecules, the indoles and guanadines, etc.

But back to the question “what should the increment be?This author has long espoused time (t) and frequency (f) as the two most powerful levers in the dialysis prescription. But, the natural nemesis of t and f has always been the powerful resistive psychology of chair time…especially in centre-based dialysis programs where the patient catch-cry—“I don’t want to spend a minute longer on that machine”—is commonly encountered.

Incremental dialysis, as it has currently been used in the literature, is a composite of a mean lower f (1-2 sessions/week), a shorter ‘t’ (reduced hours/session), or some combination of the two ( 4, 5 ).

I fully agree that it clearly makes no sense at all to enforce immediate “full dialysis”—whatever that means—right from the get go. It makes far more sense to blend dialysis in gently, as residual renal function dwindles through the slowly progressive latter phases of CKD5. But, at what point along the CKD5 path should this ‘blend’ begin, and what factors should create this seamless blend?

While dialysis t and f indisputedly exert the most powerful influence on the efficiency of dialysis, the psychology of chair time is profound.

With human nature as it is, once starting with a low f and/or a short t any subsequent attempt to incrementally increase hours/session and/or sessional frequency will be inevitably met by all but the most malleable and dialysis-savvy patients with dispute, argument, angst, and a flat “no.” Reasoned explanation is unlikely to win the day. Patients will claim to be—or be—passably well. After all, they are likely to still have some residual native renal function—and refuse or resist any up-ramping of their schedule.

Suggested regimens for incremental programs in the literature have centered around 1-2 dialysis sessions weekly, those sessions also being shorter, perhaps 1.5 – 2.5 hours duration, until a further decline in urine output and excretory function forces an upscaling of frequency or time (or both), towards an ultimate “full” maintenance dialysis regime—whatever that means.

So, what science might the professional use to underpin the reason for serial t and/or f upgrades? Unfortunately, this is very boggy ground indeed, for our capacity to measure low-level residual function is neither simple, nor precise.

Timed blood and urine samples are the current best option, but should this be for:

  • Urea clearance

  • Creatinine clearance

  • A mathematically-averaged mean of both urea and creatinine clearance

  • Cystatin C excretion

Any, or all? And, what of the role of urine output—large, small or none at all—in the all-important aspect of volume management?

The literature still fails to agree on the best measure of RRF itself, let alone the ideal time interval between RRF testing:

  • Once a month

  • Once each 3 months

  • Each 6 months?

The lack of data in this space would make it very difficult to justify to reluctant patients why an expansion of chair time or treatment frequency was necessary at this specific point in time. Based, they might ask, on exactly what black and white science and proof?

There is a clearly commonsense argument for a rolling dialysis schedule; i.e., dialysis done every second day without an artificial “weekend” long break). But, the 3 sessions/week concept has long been firmly embedded in dialysis lore. People approaching dialysis through the final phases of CKD “know” this to be so, and funding bodies are not likely to embrace an extra treatment for all, every 2 weeks, with gratitude. So, for this blog, and for now, I shall (reluctantly) leave alternate day treatments to one side.

Similarly, expected chair time clearly differs across jurisdictions [US expectations are for 3.0-4.0 hours/session while the Australian and New Zealand expectation is for 4.5-5 hours/session]. Thus, chair time is a jurisdictional “expectation.” For all the arguments supporting longer dialysis treatments, US agencies seem unlikely to dramatically up-regulate sessional duration any time soon, despite Mel Hodges admirable idea to pay by the hour of dialysis, not by the session 7. But, for now, I will leave this to one side, too.

I am aware that my comments in this blog apply as much, or perhaps more so, to the majority who access centre-based care rather than to the luckier few who use home dialysis, although residual renal function is crucial to both. But, for now, I will simply consider dialysis as it is, and not as it should be!

That said, and depending on the jurisdiction, it is a current fact that most centre-based patients will ultimately end up receiving 3 sessions per week, with the hours per session dictated by local practice (between 2.5 and 5.0 hours). Let’s accept and not argue this further, for now.

Let us return to the question of how best to blend dialysis in slowly with conservative care as CKD5 progresses, much as a chef does not pour all the milk into a flour mixture at the start lest the blend fails to smoothly integrate, and goes lumpy. Indeed, there are several other ways to blend.

While incremental dialysis—I personally prefer the term “accretive” dialysis—can clearly be achieved by slowly increasing ‘t’ and/or ‘f’, as I have pointed out, patient resistance and argument against increasing sessional frequency and chair time is likely to be loud and strident. In addition, the complexities that may be encountered by dialysis services in the scheduling of multi-frequency and duration treatments are also significant. But, luckily, many roads lead to Rome.

Dialysis efficiency/efficacy is also influenced by:

  • The blood flow rate (Qb),

  • The dialysate flow rate (Qd)

  • The trans-membrane pressure gradient (TMP)

  • The ultrafiltration rate (UFR), and by

  • Dialyser membrane surface area (SA)

It should be possible to effect accretive (incremental) dialysis as residual renal function wanes by an imperceptive background increase in some (or all) of these factors, while delivering – from the start – the jurisdictional long-term intended t (whether it be 2.5 or 5 hours/session) and f (3 weekly sessions), unaltered.

Again, while I fully accept and support the notion of incremental or accretive treatment as native residual function wanes, the psychology of potential patient resistance is likely to be strong. Matched against a low scientific measure for RRF and thus a concrete argument for longer or more frequent sessions, the dialysis unit floor would become a blood-bath of argument.

Staff: “We need to increase your treatments from two to three per week”

Patient: “Why? I feel just fine, and my life has now been adjusted around two sessions”

Staff: “Let’s not start an argument about this—you have to.”

Patient: “No! I don’t feel any different…”

Staff: “We need to increase your hours from 2 to 3 per session as your RRF is dropping and increasing your UFR is unsafe.”

Patient: “I am NOT going to spend one more minute in that chair. Just try and make me!”

There are always alternative paths to winning a war! If dialysis is introduced when and how it is currently jurisdictionally practiced, with t and f prescribed at their long-term goal from the get-go, it is still possible to be smartly “incremental,” but in subtler, less confronting ways.

It should be simple to use the softer background levers of Qb, Qd, TMP, UFR, and SA to achieve the same blend-in result. This approach may, in the end, prove less problematic. If the early dialysis week/months start with:

  • A Qb of (say) 200-220

  • A Qd of 500

  • Iso-volemic or “mini”-volemic dialysis to ensure a subliminal UFR

  • Dialing a gentler TMP

  • Attaching a smaller surface area membrane

All of this can be up-adjusted as and when needed—but done so in the background, this approach would ensure incrementality—with its purported benefits—yet without disputation:

  • The Qb can be slowly increased from 200—>250—>300—>325 mL/min.

  • The UF rate can be increased as or if the inter-dialytic urine volume (formally measured each 2-3 months) were to fall away.

  • A larger surface area and/or higher flux dialyser could be introduced.

  • The platform could be switched seamlessly in the background from haemodialysis to haemodiafiltration.

All this can be done within the standard practice of t and f, and without turning the dialysis floor into a battleground of argument over t and f schedules.

To my mind, this is a discussion that cries out to be had, and an area ripe for a series of well-designed trials by up-and-coming smart nephrologists. In-program nuanced or smart dialysis might be an alternative approach to research in the future.

Meanwhile, the equally crucial issues of (1) Adoption of a rolling schedule (i.e., abolition of the long break), and (2) Introduction of chair time as a Key Performance Indicator (KPI) to permit a gentler, slower UFR 8, are both left for another day.

References

  1. 1. Chen T, Lee VWS, Harris DC. When to initiate dialysis for end-stage kidney disease: evidence and challenges. Med J Aust 2018; 209 (6). doi: 10.5694/mja18.00297

  2. 2. Tattersall J et al [on behalf of the European Renal Best Practice Advisory Board]. When to start dialysis: updated guidance following publication of the Initiating Dialysis Early and Late (IDEAL) study. Nephrol Dial Transplant. 2011 (26(7) 2018-2016.

  3. 3. Cooper BA et al. [on behalf of the IDEAL Trial Study Group]. A Randomized, Controlled Trial of Early versus Late Initiation of Dialysis. N Engl J Med 2010; 363:609-619

  4. 4. Obi Y, Kalantar-Zadeh K. Incremental and Once- to Twice-Weekly Hemodialysis: From Experience to Evidence. KI Reports. 2017. 2(5): 781–784.

  5. 5. Kalantar-Zadeh K et al. Twice-Weekly and Incremental Hemodialysis Treatment for Initiation of Kidney Replacement Therapy. Am J Kidney Dis. 2014. 64(2): 181–186

  6. 6. Wong J, Vilar E, Davenport A, Farrington K. Incremental haemodialysis. Nephrol Dial Transplant. 2015. 30(10): 1639–1648

  7. 7. Hodge M. Letter to Congressman Jim McDermott (Kidney Caucus Co-Chairman), US Congress, Washington DC.

    [A KidneyViews blog post]. To be found at: https://homedialysis.org/news-and-research/blog/153-kidney-caucus-letter-repayment-basis

  8. 8. Agar JWM. From Blog to Dialysis Chair: Implementing Volume 101.

    [A KidneyViews blog post]. To be found at: https://www.homedialysis.org/news-and-research/blog/119-from-blog-to-dialysis-chair-implementing-volume-101

Comments

  • Jerry Smith

    May 16, 2019 7:47 AM

    One of your blog comments seemed to go unnoticed, that is "preservation of residual renal function in haemodialysis patients is likely to be highly beneficial—at is has been proven to be in peritoneal dialysis patients—with even low levels of native renal function benefitting the removal of some of...."

    While I suspect most of those who replied are on hemo and certainly your comments seem to relate 100% to hemo, you may have not given PD the benefits it may deserve as it relates to RRF. The other issue (and somewhat related) is that all of our diseases are not the same. That is, some of us still have our native kidneys and even a relatively high RRF. In my own case, it took a large dose of cajoling with my neph doctor, who I highly respect, to allow me to begin to reduce my PD treatment. It seems there is some merit in letting those of us who have a decent RRF be sure our kidneys are not blunted and also allowed to continue to their natural job to avoid more loss due to inactivity (atrophy). In any event, that was my theory and I was able to convience my doctor to slowly reduce my treatment along with many other major lifestyle changes to improve my kidney problems with the hope of coming off of dialysis entirely (after three years). It worked. I've been off for almost two years now (GFR=18 today). I certainly continue with the lifestyle changes I began and give those changes a good bit of credit for my success. Again, each of us as patients is unique and we do not all fit in the same box. Thanks.

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  • Nieltje Gedney

    May 15, 2019 7:06 AM

    I truly appreciate your tackling the controversial subject of “incremental dialysis”. As you know, I am passionate on this subject. But more than just being about incremental, I am about incorporating that protocol, and other prescription variations, into a “no one size fits all” dialysis program. Like you, I will leave aside the need for ongoing studies to fine tune this treatment regime, because we all agree on that. But like Debra, incorporating the patient perspective into the dialysis treatment requires a much needed paradigm shift in clinical thinking and practice. (BTW, for us without science brains, can you clarify the technical aspect of your post, i.e. Qb, Qd, TMP, UFR, and SA.)

    I agree with Debra Null, and disagree with your stated concern that patients will not accept more dialysis when and if it is needed. I firmly believe that, instead of just plopping patients in the chair, and dictating a treatment to them, if you engage and educate them from the beginning on their care, that (unless they have a subconscious death wish) they will do what makes them feel good. We see it every day on our FB groups – patients are doing 4-6 tx a week of 3-8 hours. Why? Because they feel better! Taking a page from Dori’s book – they have learned not just what matters, but what matters to them!! So if 5 treatments a week of 2.5 hours let’s one patient go from death’s door to singing in his band, then he’s doing it. But if those same 5 treatments cause another patient to feel washed out, tired, and unable to face the day, then looking at incrementally less dialysis, initially, (along with the treatment parameters of labs, blood flow, ufr, and dialysate and comorbids) is a good place to start.

    One way to look at it is to compare dialysis treatment to that of a diabetic. Would you hand a diabetic 3 insulin shots of 100 units and tell him to deal with it? Of course not, the result would most likely be death, and yet that is exactly what we do to dialyzors. Or imagine a patient being told “we don’t care about your residual, because we know you are going to lose it anyway”. That patient has just been deprived of any hope of achieving an acceptable quality of life and will now just succumb to the chair. As Henning so eloquently blogged here, a while back, you have just committed that patient to a life of learned helplessness. No wonder the in center rate of death, especially in the first 90 days to one year is so high. As Debra stated, education of both the patient and the staff in managing the dialysis prescription to achieve their individual desired quality of life, and not just focusing on extending length of life (at any cost), will result in a collaborative treatment program, where the patient is participating in the treatment decision-making. I am 67 years old, and I admit that I still bristle when someone “tells” me what I have to do. But let’s sit down, discuss my options, what the expected outcomes might be, and the reasons behind the recommendations, and I am probably going to give it a try. Even better, when my input, feedback and concerns are addressed as well, then I feel valued, and am even more likely to make changes. Nobody likes change, but more often than not, change can be a good thing! It’s just how we get there that makes the difference.

    You also described how it is customary to start PD incrementally to allow the body time to adjust to filling the peritoneum, so why would not (in most cases) the same apply for hemodialysis. Doesn’t having the blood removed from the body, cleansed, and returned require some fine tuning to get it to where that patient can dialyze comfortably? I firmly believe, and the majority of home patients will anecdotally substantiate, that if you educate your patient in what matters to them, they will collaborate with you on their tx to achieve their best quality of life by doing the treatment that gets them there.

    When I started dialysis in center, waiting to get trained for home, the pain on treatment in hour 4 was excruciating. Enough that I considered stopping dialysis. I described it to the clinicians, and was told a resounding “deal with it” or did I want a Percocet (NO!). If I had not signed off at 3 hours, when the pain started, I might not be here today. After a month, my labs actually improved, and the neph was so pleased he lowered my time to 2:45. Later, I started home training, and time and days increased, and again, I was close to quitting, from feeling so drained. We cut back the schedule, and I felt an immediate improvement. Soon I began to correlate this to my residual function – too much dialysis, too little pee. It is a balancing act, and I am meticulous about checking ALL labs, and even have requested and required additional ones to make sure I am adequately dialyzed. Which means anything from 2-4 times per week 2.5-3.5 hours, changing from treatment to treatment. Ideally, I wish there were a test for dialyzors, just like diabetics check their sugar, that could guide them in setting their tx parameters for each and every treatment, based on what their body actually needed at that moment in time, instead of what is arbitrarily prescribed. But that, I know, is not realistic, especially in the dialysis culture in the US today.

    I know we are all in agreement that more dialysis is better. But just as you pointed out, at what point along the CKD and ESRD path should this ‘blend’ begin, and what factors should create this seamless blend? Herein lies the problem, because that blend will be unique for every dialyzor. I believe that the dialysis prescription MUST be titrated to each individual’s needs, at that moment in time. To do this will require, as I stated initially, a paradigm shift in dialysis prescription management from one size fits all to one of patient/clinician coordination and cooperation, based on acceptable biomarkers, labs, and patient reported outcomes. I can dream….can’t I?

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    • Peter Laird

      May 15, 2019 4:10 PM

      Nieltje, diabetes care is very analogous to dialysis care in several elements.

      The (Diabetes Control and Complications Trial )DCCT in the early 1990's showed significant reduced complications from "tight" control of blood sugars as measured by the HbA1C.

      What is missing in the incremental literature is a prospective study showing specific implementation of RRF preservation. All studies to date are retrospective and observational. Further, many have looked at in-center data of extra dialysis sessions without controlling for the very high incidence of CHF in those with 4+ sessions a week as a rescue strategy for the sickest patients. Thus, comparing incremental strategies of less than thrice weekly is looking at apples and oranges. They are not a comparable group.

      The idea of intensive diabetes management led to higher incidences of hypoglycemia which has significant longterm complications. Preventing hypoglycemia with intensive control led directly to insulin pumps and now many have continuous glucose monitoring for up to the minute control.

      The results are staggering as far as improved survival.

      The issue of preservation of RRF has several factors of which excessive UF appears to be one of the major components of loss of RRF. Just as with diabetes, more TIME and frequency is a time tested and observational study documented strategy with some RCT confirmation at least in the FHN short dialysis trial of 6 days a week as well as an interesting RCT by Culleton in 2007.

      https://jamanetwork.com/journals/jama/fullarticle/208864

      I have yet to see any specific trial controlling UF rates as the study parameter to see it's contribution to RRF. Scribner's Hemodialysis product predicts improved outcomes with increased frequency and TIME on dialysis. If this was combined with controlling UF rates we would likely approach the same effects gained with tight diabetes control with insulin pumps.

      Intensive diabetes interventions work. Scribner and Oreopoulos would contend that the Hemodialysis product is the best survival strategy for longterm survival on dialysis.

      Incremental dialysis has a place in initiation of dialysis but I do not see incremental dialysis as a longterm survival strategy. I am deeply concerned that some researchers promote incremental dialysis even for patients with a GFR of 3 ml/min which is essentially near complete cessation of residual renal function.

      This implies it could be construed as an effective strategy for nearly all dialysis patients. However, we do have substantial observational studies from the 1960's and 1970's showing twice weekly dialysis ineffective. I believe in many ways, incremental dialysis as promoted by many is a major step backwards and a great benefit to CMS for cost reduction at the price of increased morbidity and mortality in the long run.

      Intensive dialysis as intensive diabetes care on the other hand is a proven strategy if complications are limited in both.

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      • John Agar

        May 15, 2019 6:59 PM

        The best thing to emerge from this blog is the discussion it has prompted from wise and erudite patients .. those with a lived experience of dialysis. While all comments - from Nieltje, Debra and Peter - make interesting reading, I fancy Debra and Nieltje are conflating incremental starts with a longer-term and established regimen, and this was not my intent, nor what I understand the proponents if incremental starts intend. As such, I tend to side with Peter’s interpretation.

        Incremental starts as a means of prolonging RRF do make sense, provided that up-regulation of the dialysis ‘dose’ matches and parallels the decline in RRF. My blog intended to address the best way to structure this up-regulation ... i.e. the up-regulation of dose using the levers of time ‘t’ and frequency ‘f’ (a strategy that I fear - if attempted with many less savvy patients - may prove fraught) vs. the up-regulation of Qb (blood flow - read pump speed), Qd (dialysate flow rate), TMP (transmembrane pressure), UFR (the ultrafiltration rate), or SA (membrane surface area - read dialyser ‘size’) within the framework of the ultimately intended and long-term ‘t’ and ‘f’ regimen. That, of course, still allows the argument about what the ultimate ‘t’ and ‘f’ strategy should be ... and I think we all agree that both should be more than most programs offer ... but the tag ‘incremental’ as I have used it does not apply to the long term maintenance dialysis strategy, but to the initiation phase of dialysis alone.

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        • Peter Laird

          May 15, 2019 8:50 PM

          John, the thrice weekly schedule is slow death spiral. I have aged greatly in the last year. When I do get a full 5 hours, my face shows less puffiness even though fluids are not at all an issue for me. I can see the benefit in a more healthy appearing countenance as opposed to a sickly countenance.

          I eagerly await returning to my home program but Fresenius is still being completely intransigent at their highest levels. We are facing great opportunity in the US with the recent goals set by the current administration to get over 20% of the USRDS population home. But we are facing an industry with little regard for their patients well being, only their bottom line profit margins.

          There is no comparison to 20+ hours a week of dialysis as far as feeling well and remaining productive. It is time that common sense finally prevails if it only will.

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  • Debra Null

    May 14, 2019 9:10 AM

    Fully recognizing the complexity of a dialysis prescription vs. any other type of medication or treatment prescription, I'd just like to make a couple of layman comparisons.

    First, regarding reluctance to increase "chair time," I understand and agree it is a difficult concept if you cannot show a patient in terms they understand that their disease is progressing and will continue to progress without additional treatment. If a cancer patient is shown scans that clearly prove a cancer is spreading, then they can understand and accept more treatment or make a decision that they are finished and enter a palliative or hospice phase of treatment. It's difficult to provide that kind of proof to a kidney patient. A great deal of re-education would be needed. Not only patient re-education, but also physician and other professional staff re-education. Personally, I think it would be worth the effort, but will require years and more scientific research and results, etc.

    The other thing that always goes through my mind is how dialysis culture (at least here in the US that I have been exposed to) is a take it or leave it production. If my doctor has prescribed x mg of a particular medication for me, but I am experiencing horrible side effects to where my quality of life is substantially altered, he may adjust my dose to a point where a satisfactory compromise can be made between controlling my condition and allowing some quality of life to be restored. That often does not seem to be the case with dialysis. It seems, from a patient's perspective, to be "you are required to receive x treatment because it is medically necessary and we don't care about your wishes or your quality of life." I believe when a patient has mental capacity and is presented with the pros and cons of increasing treatment it is definitely their right to choose less treatment even if it means a shorter life. To me, quality of life trumps length of life every time. I would much rather live 5 good years than 15 miserable years and I feel I should have the right to choose as long as I retain mental capacity to make my own informed choices as an adult. So, yes, with incremental treatment, there would be a battle, but is it not our battle to control, our life to live? I realize doctors must, in good faith, assure an appropriate treatment. But if this is documented and "signed off" by a patient refusing to increase treatment so the doctor, clinic, LDO, and any other professionals cannot be held liable for negligence, then I feel it should be the patient's option to choose what they want to do with the life they have remaining.

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    • Peter Laird

      May 15, 2019 5:36 PM

      Debra,

      I am not sure that research and further studies is what is needed. Remember, the longest living patients in the world came from Dr. Scribner's Seattle program. Dr. Robin Eady and now Nancy Spaeth. Dr. Eady began dialysis in 1962 and lived until 2017 at the age of 76.

      Nancy is still active professionally and as an advocate and she started dialysis in 1966.

      We already know how to do dialysis well. It is not a lack of knowledge, but the problem of a lack of adherence to providing the best treatments to the most. Instead, the standard treatment in-center leads to the highest morbidity and mortality of any population in the developed world.

      It is greed and money first over physiologic dialysis strategies. We knew much as early as the first patient who lived for over 10 years.

      Further research is not what is needed. Simply apply the principles Scribner established and we will reverse the years of despair and suffering our for profit system has generated.

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    • John Agar

      May 14, 2019 7:24 PM

      Thanks, Debra, for your thoughtful comments.

      And, yes, I agree, that the educational commitment - for both patients and professionals - would be long and complex. The depth and breadth of the re-education task would, as you point out, take years.

      As for the second part of your response, I think the concept of 'incremental dialysis' as it currently is (1) intended and (2) is applied is to dialysis starts ... that early period where efforts to preserve residual renal function should be taken - where, at present and broadly, they are not. Your comment, however, seems to extend beyond the initiation phase (where incrementality, as we currently think of it, applies) into the later and ongoing dialysis journey where the longer aspirations of each individual patient should be considered within an individualised, personalised dialysis prescription.

      I remember publishing on this issue some 15 years ago ... Agar JWM et al. ‘Flexible’ or ‘lifestyle’ dialysis: Is this the way forward? Nephrology (Carlton) 10(5): 525 -529, October 2005 ... a paper in the peak Asia/Pacific nephrology journal 'Nephrology' ... where I first proposed this approach.

      The approach to dialysis over the long-haul of a patients' journey through dialysis seems to me to be a different issue - at least under the current definition of 'incremental' dialysis. Incrementality - as it is currently used - applies more specifically to the introduction of dialysis, seeking to lessen the impact of dialysis on residual renal function, prolonging (preserving) it for as long as possible.

      To me, the prescription over the longer haul is a separate - though strikingly crucial - matter. Hence my now 15 year old plea to adopt a more flexible approach and to individualise patient programs.

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  • Eric Weinhandl

    May 13, 2019 11:54 AM

    John,

    This blog entry is actually one of the best that I can remember among your entries. Your approach is very thoughtful.

    In truth, a good part of my skepticism about incremental hemodialysis is not about the clinical effects of such a regimen - although I harbor some skepticism in that domain - but about the health care delivery system's diligence in measuring RRF (in all of its important facets). How often do you measure RRF?

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    • John Agar

      May 13, 2019 5:58 PM

      Thanks, Eric.

      The measurement of residual renal function (RRF) is a really difficult problem. Nothing within the measurement concept is either agreed, or accurate. The accuracy of the component measures at the lower limits of GFR ‘fuzz’ out and become increasingly unreliable, the measurement parameters (what should be used and in what combination), at what frequency should it be measured, and - for each measure - over what time period should the collection run ... all of these and more are ‘best guess’ at best.

      As I think I may have said before, the mean of urea clearance (= under-estimates true GFR at low levels of renal function) and creatinine clearance (= over-estimates true GFR at low levels of renal function) is likely the best current measure we have and in my view, till better is proven, remains the best way to determine GFR at levels likely below an eGFR of +/- 15 (i.e. in CKD5). eGFR using creatinine alone is fraught ... yet it IS what we all still do!

      More problematic still is the issue of time (t): both the ‘t’ to use for the collection of urine (should it be over 24 hrs, 48 hrs, the long break, the short break) and the ‘t’ of collection frequency (i.e. ?? every how many ‘x’ months).

      Finally, there is the most vexed issue of all ... would all services adhere to a collection and standardisation regime? ... and being as we are, my suspicion is a big fat NO!

      If I were writing the protocol for current regular RRF assessments in HD patients (dialysing at any site - home or centre), I would be suggesting:

      1. Three collections a year (4th monthly);
      2. A mean (averaged) calculation of creatinine and urea clearance (to attempt to minimise the respective and inherent over- and under-estimations of the two solutes);
      3. Collections done over 48 hours MINUS the dialysis time in the first short break of the week ... i.e. Monday post-dialysis to Wednesday pre-dialysis, or Tuesday post-dialysis to Thursday pre-dialysis - depending on the schedule ... with the duration of the next dialysis subtracted from the 48 hr analysis (i.e. a 5 hour regime would mean a 43 hour collection, a 4 hour regime would = a 44 hour collection and a 3 hour regime would = a 45 hour collection).

      But, there is ABSOLUTELY nothing to substantiate any of that musing ... and it is, I must say, regretful that after some 60-70 years of maintenance dialysis, no standardised way of measuring RRF has yet been agreed - or even diligently researched.

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  • Peter Laird

    May 10, 2019 5:51 PM

    Great blog as always John.

    I like your term “accretive dialysis.” Adding more Frequency and TIME is an effective strategy I have used in my treatment plans. Doing dialysis at home mainly on the evenings or night dissipates that angst of chair time with tge sdded factor of just being home.

    After a year of in-center care, just getting ready to go to the center is difficult and relentless. I have missed out on much this last year due to their inflexible schedule.

    It is really a form of incarceration thrice weekly that is draining to the spirit.

    The use of long, slow and gentle every other day dialysis is a great compromise between time costs, freedom and feeling well physiologically.

    The surrogate markers of well being are just that, surrogate markers where the most fundamental measure, “how do you feel!” Is conveniently ignored.

    This is the great failing that is missing especially in American nephrology. The standard treatment protocols are absurdly terrible. It is essentially impossible to feel well on a thrice weekly schedule even though your labs are great.

    “Yes doctor, the operation is a success but the patient died.” How ironic that American nephrology is not moved by the unacceptable morbidity and mortality of standard care.

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  • John Agar

    May 9, 2019 7:30 PM

    Dear Gail

    Thanks for your response. I suspect you are confirming - at least that is my interpretation - my point re the problematic psychology’ of lower frequency starts. Ratcheting up frequency from 1 or 2 treatments per week to any number more will likely prove difficult for many patients.

    While clearly everything in my blog post related to patients starting on haemodialysis, you raise the interesting parallel of incremental starts in peritoneal dialysis. But we do this already, don’t we. Most of us already routinely introduce PD using low volume exchanges .. 1 litre gradually in increasing to 1.5 litres, then 2 litres etc .. to allow for the slow and comfortable adjustment of the peritoneum to the presence of added intra-abdominal fluid. We already commonly initially use a low osmolar (low glucose) dialysis fluid .. unless there is a clinical imperative to more rapidly reduce the intra- and extra-vascular volume .. and commonly start with a lower number of exchanges, too.

    Thinking about this takes me back to my training days before Harry Tenckhoff introduced his flexible, implantable silastic catheter and Moncrief and Popovich devised the delivery system that became known as continuos ambulatory PD (CAPD) .. for before that, PD was intermittent - usually two treatments on centre-based treatment each week - delivered by short term, rigid, ‘stick’ catheters .. catheters that, as a trainee registrar, I would have to insert and remove each treatment. In those days, the intermittent nature of the treatment, I recall, led (among many other problems and complications) to fluid accumulation and unstable rising/falling blood pressures, much like we still routinely see in centre-based HD these days.

    One of the chief ‘beauties’ of PD - if any of it can be called beautiful - is its’ background constancy. Thus, regressing to any form of intermittent ‘on/off’ program, to my simple mind, would be exactly that .. a regression.

    So, no .. I do not think intermittent or low frequency therapy a good option. Again, I would rather go the low volume, low tonicity route.

    Here, where CAPD has been almost fully replaced by overnight cycler automated PD (APD), the cycle volume and cycle frequency through the night can easily be programmed to accomodate up-regulation, as can the daily dwell volume of icodextrin. But, I would not encourage dry periods .. eg: PD on Monday, Wednesday and Friday, but not on T/T/S/S .. as I think that would throw up the same set of problems I described for HD.

    That was a long answer to say that I think adjusting the ‘levers’ within the treatment process makes more sense than reverting to intermittency, then trying to increase over time to a more continuous brand of therapy.

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  • Gale Schulke

    May 9, 2019 3:07 PM

    We have several patients on "Incremental" dialysis. We are already running into issues when the pt clearly needs to add a cycle. For PD, which do you advocate: fewer cycles, vs fewer days? We have both.

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