Abstract
Background and Aims: We previously reported on Planned Incremental Hemodialysis (PIHD) for patients with good adherence to a prescribed diet and consideration of residual renal function (RRF), and some reports have been suggested that IHD in ESRD patients may have a positive effect on survival rates and RRF. On the other hand, the ESRD patients are commonly started on thrice-weekly HD at hospitals in Japan. However, and interestingly, careful observation of our ESRD patients whose CKD was gradually increased, and in some cases, we detected some recovery of their RRF. If there is RRF, IHD can be performed and potentially reduce dialysis frequency. We named this method “Reverse Incremental Hemodialysis (RIHD).” Method: One hundred thirteen patients who were started on thrice-weekly HD in other hospitals and who had been referred to our clinic since 2013, we selected 11 patients (9 males and two females) on the basis of their laboratory data and careful physical examination. The number of patients by the causes of their ESRD is as follows: 3 patients with Chronic glomerulonephritis, two patients with Nephrosclerosis, one patient with Diabetic kidney disease, one patient with Polycystic kidney disease, one patient with Chronic interstitial nephritis, one patient with Interstitial nephritis, one patient with Nephrotic syndrome, and one patient with Fabry disease. In order to reduce the number of dialysis sessions for patients, we considered the following laboratory data were required to be within the control standards before dialysis at the maximum dialysis interval, as follows: BUN<100mg/dL, serum creatinine<20.0 mg/dL, K<5.5mEq/L, HCO3->20.0mmol/L, respectively. To avoid over-volume, we also restricted the patient‘s weight gain as the Once-weekly HD patient is within 3.0 kg/week, and Twice-weekly HD patient is within 6.0 kg/week. We also checked physical examination and X-rays, if necessary, we sometimes checked the patient’s hANP. We also considered the dialysis volume evaluated like Peritoneal Dialysis (PD) such as weekly Kt/V urea above 1.7 together with RRF as an appropriate dialysis volume. Results: The average dialysis duration of 11 patients was 35.2 months (M) as 5-97M. Eight patients were able to reduce their HD from thrice-weekly to twice-weekly HD, and the average dialysis duration was 9.9M (1-32M). Three patients gradually reduced from thrice-weekly to once-weekly HD, and their average dialysis duration was 26.3M (10-37M). Eight patients who reduced their number of HD to twice-weekly HD, the average RRF weekly Kt/V urea was 0.10, actual HD weekly standardized (std) Kt/V urea was 1.37 and total weekly Kt/V urea was 1.47. Three patients who decreased their number of HD to once-weekly HD, the average RRF weekly Kt/V urea was 0.83, actual HD weekly std Kt/V urea was 0.56, and total weekly Kt/V urea was 1.39. Two patients (18.2%) had exceeded their weekly weight restriction, but no one had clinical symptoms of over-volume such as hypoxia, pulmonary edema, and pleural effusion. The laboratory data that we considered to be within the control standards before dialysis at the maximum dialysis interval was respected as 97.8% (11patients‘ BUN, s-Cr, K, and HCO3- laboratory datas:43 out of total 44 points) were observed. Their total weekly Kt/V urea data were lower than that of the weekly Kt/V urea recommended for PD patients, but our patient’s clinical status was within a controllable range. Conclusion: Some patients can gradually reduce the number of dialysis sessions with careful follow-up with considered their RRF and total weekly Kt/V urea, and setting weight gain limits individually. We still need to consider adjusting the treatment of total weekly Kt/V urea, as indicated by PD treatment recommendation for their prognosis. However, RIHD is a flexibly responds to insufficient renal function for RRT individually and might be suitable for QOL and cost-effective treatment for some ESRD patients.
Benefits of Incremental Hemodialysis Seen in a Historical Cohort Study
