The role of once-weekly online hemodiafiltration with low protein diet for initiation of renal replacement therapy: A case series

Incremental hemodialysis (HD) has become an exciting approach according to the recognition of the importance of preserving residual kidney function (RKF). However, not all incident HD patients are suitable for this approach, particularly once-weekly HD. This is the first study which reported the effectiveness of once-weekly online-hemodiafiltration (OL-HDF) plus low protein diet (LPD) in incident HD patients. All stage 5 CKD patients who had chosen HD as their treatment modality at the HD center of King Chulalongkorn Memorial Hospital, Bangkok, Thailand, with RKF ⩾ 3 mL/min calculated by renal clearance of urea and urine output ⩾ 800 mL/day, started the treatment with once-weekly OL-HDF. Dietitians advised patients to consume LPD (0.6–0.8 g/kg/day) on non-dialysis days and a regular protein diet on the dialysis day (1.2 g/kg/day). Eleven incident HD patients were enrolled in the study. The mean RKF and urine volume at baseline were 4.56 ± 2.21 mL/min and 2,019.54 ± 743.73 mL/day, respectively. After 6 and 12 months of follow-up, the mean RKF of the patients who remained in the once-weekly OL-HDF protocol were 3.82 ± 1.68 mL/min and 3.28 ± 0.95 mL/min, respectively. The median duration of once-weekly OL-HDF before transitioning to twice- or thrice-weekly OL-HDF was 7 months (3–24 months). The most common indication for stepping prescription was too low RKF. We reported that dialysis initiation in the university-based center with once-weekly OL-HDF in carefully selected incident HD patients combined with LPD under serial monitoring is practical. Further studies on the clinical benefits of once-weekly OL-HDF are still required.

Patiromer in a Patient with Severe Hyperkalemia on Incremental Hemodialysis with 1 Session per Week: A Case Report and Literature Review

Hyperkalemia is common in patients with ESRD, undergoing hemodialysis (HD), and is associated with an increase in hospitalization and mortality. Residual kidney function in long-term dialysis patients is associated with lower morbidity and mortality in HD patients. Although the 2015 National Kidney Foundation-Kidney Disease Outcomes Quality Initiate (NKD-KDOQI) guidelines allow the reduction in the weekly HD dose for patients with a residual kidney urea clearance (Kur) >3 mL/min/1.73 m², very few centers adjust the dialysis dose based on these criteria. In our center, the pattern of incremental hemodialysis (iHD) with once-a-week schedule (1 HD/W) has been an option for a group of patients showing very good results. This pattern is maintained as long as residual diuresis is >1,000 mL/24 h, Kur is >4 mL/min, and there is no presence of edema or volume overload, as well as no analytical parameters persistently outside the advisable range (serum phosphorus >6 mg/dL or potassium [K⁺] >6.5 mmol/L). Management of hyperkalemia in HD patients includes reduction of dietary intake, dosing of medications that contribute to hyperkalemia, and use of cation-exchange resins such as calcium or sodium polystyrene sulfonate. Two newer potassium binders, patiromer sorbitex calcium and sodium zirconium cyclosilicate, have been safely used for potassium imbalance treatment in patients with ESRD in HD with a conventional regimen of thrice weekly, but has not yet been studied in 1 HD/W schedules. We present the case of a 76-year-old woman in iHD (1 HD/W) treated with patiromer for severe HK and describe her clinical characteristics and outcomes. In addition, we review the corresponding literature. Based on these data, it can be anticipated that the use of patiromer may overcome the risk of hyperkalemia in patients with incident ESRD treated with less-frequent HD regimens.

Online hemofiltration in incremental dialysis prescription

Incremental dialysis is increasingly recognized as a safe and beneficial method of initiating dialysis. Different centers use distinct prescription methods. We discuss the advantages of incremental hemodialysis and the potential benefit of preserving residual renal function as we present our experience. We reviewed the data from 20 incident patients, with a mean follow‑up of 9.5 months, who started dialysis with our prescription method, using hemofiltration as the preferred depurative technique. All patients tolerated treatment well; no major complications were reported. Dialysis adequacy targets were achieved. While data are clearly limited, we raise the hypothesis that convective techniques could bring additional benefit in preserving residual renal function in incident patients, and that this strategy should be studied and compared with others.

Knowledge and Practice of Incremental Hemodialysis: A Survey of Canadian Nephrologists

Background: Incremental hemodialysis, a strategy to individualize dialysis prescription based on residual kidney function, may be associated with enhanced quality of life and decreased health care costs compared with conventional hemodialysis. Objective: We surveyed practicing Canadian nephrologists to assess knowledge, perceptions, and practice pattern on the use of incremental hemodialysis. Design/Setting: We distributed a cross-sectional, web-based survey. We asked about incremental hemodialysis prescribing practices, including frequency of prescription, clinical factors used to determine suitability for treatment, and barriers to implementation. The survey was conducted from September 21 to October 30, 2020. Participants: We distributed the survey to practicing Canadian nephrologists identified from a private membership list of the Canadian Society of Nephrology (CSN), as well as to nephrologists named on a publicly available national list of practicing Canadian nephrologists created from provincial College of Physician registries. These were samples of convenience. Methods: We conducted descriptive analysis of categorical data including frequencies for nominal variables and measures of central tendency (mean) and dispersion (standard deviation) for ordinal variables. We used chi-square analysis to identify association between participant and practice characteristics and their opinions and attitudes toward incremental dialysis. We used simple thematic analysis on free-text responses on questions regarding the prescription of incremental hemodialysis, focusing on age and baseline management of cardiac and noncardiac comorbidities. Results: The response rate was 35% (243/691). Most (138/211, 65%) of the participants prescribed incremental hemodialysis using an individualized approach at the nephrologist’s discretion. Most participants (200/203, 98%) did not report any policy for implementation. Residual urine output was identified as the most important factor for eligibility (112/172, 65%), followed by electrolyte stability (76/172, 44%) and patient goals of care (69/117, 40%). Most participants agreed that dialysis prescriptions should take residual kidney function into consideration; however, 74% of the participants disagreed with a statement that there was strong evidence supporting incremental hemodialysis. Barriers identified included patient safety, patient acceptance of dose escalation, and logistics of scheduling. Despite these barriers, 82% of participants felt that that incremental hemodialysis is feasible with their current resources and 78% agreed that with specific criteria, it is a safe option. Limitations: The generalizability of our study is limited by its response rate of 35%; however, this is comparable with typical response rates seen in electronic surveys. Most participants practice in an academic setting, which may have introduced bias to the results. Conclusions: Despite the perception of limited evidence and a lack of guidance on implementation, incremental hemodialysis is frequently practiced by Canadian nephrologists. Barriers to implementation were identified, highlighting the need for research to guide practice.

Evaluation of Residual Kidney Function during Once-Weekly Incremental Hemodialysis

<b><i>Background:</i></b> The initial once-weekly administration of incremental hemodialysis to patients with residual kidney function (RKF) has recently attracted considerable interest. <b><i>Methods:</i></b> The aim of our study was to assess the performance of a series of different methods in measuring serum urea nitrogen and serum Cr (sCr) RKF in patients on once-weekly hemodialysis (1WHD). Evaluations were carried out by means of 24-h predialysis urine collection (Kr-24H) or 6-day inter-dialysis collection (Kr-IDI) and estimation of glomerular filtration rate based on (KrSUN + KrsCr)/2 for the purpose of identifying a simple reference calculation to be used in assessing RKF in patients on 1WHD dialysis. Ninety-five urine samples were collected from 12 1WHD patients. A solute solver urea and Cr kinetic modeling program was used to calculate residual urea and Cr clearances. Mann-Whitney U test, Pearson’s correlation coefficient (<i>R</i>), and linear determination coefficient (<i>R</i>²) were used for statistical analysis. <b><i>Results:</i></b> 1WHD patients displayed a mean KrSUN-IDI of 4.5 ± 1.2 mL/min, while KrSUN-24H corresponded to 4.1 ± 0.9 mL/min, mean KrsCr-IDI to 9.1 ± 4.0 mL/min, and KrsCr 24H to 8.9 ± 4.2 mL/min, with a high regression between IDI and 24-h clearances (for IDI had <i>R</i>² = 0.9149 and for 24H had <i>R</i>² = 0.9595). A good correlation was also observed between KrSUN-24H and (KrSUN + KrsCR/2) (<i>R</i>² = 0.7466, <i>p</i> &#x3c; 0.01. <b><i>Discussion:</i></b> Urine collection over a 24-h predialysis period yielded similar results for both KrSUN and KrsCr compared to collection over a longer interdialytic interval (KrSUN + KrsCr)/2 could be applied to reliably assess RKF in patients on 1WHD. <b><i>Conclusion:</i></b> The parameters evaluated are suitable for use as a routine daily method indicating the commencement and continued use of the 1WHD Incremental Program.

P1086REVERSE INCREMENTAL HEMODIALYSIS IS A GOOD METHOD FOR SETTING DIALYSIS DOSE CONSIDERING THE INDIVIDUAL RESIDUAL RENAL FUNCTION

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&lt;100mg/dL, serum creatinine&lt;20.0 mg/dL, K&lt;5.5mEq/L, HCO3-&gt;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.