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      Twice-weekly and incremental hemodialysis treatment for initiation of kidney replacement therapy.

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          Mortality is highest in the first months of maintenance hemodialysis (HD) therapy. In many Western countries, patients who transition to kidney replacement therapy usually begin thrice-weekly HD regardless of their level of residual kidney function (RKF). RKF is a major predictor of survival. RKF may decline more rapidly with thrice-weekly HD treatments, is associated with a reduced need for dialytic solute clearance, and is an important factor in the prescription of peritoneal dialysis. In this article, we review the concept of incremental HD, in which weekly dialysis dose, in particular HD treatment frequency, is based on a variety of clinical factors, such as RKF (including urine output > 0.5 L/d), volume status, cardiovascular symptoms, body size, potassium and phosphorus levels, nutritional status, hemoglobin level, comorbid conditions, hospitalizations, and health-related quality of life. These 10 clinical criteria may identify which patients might benefit from beginning maintenance HD therapy twice weekly. Periodic monitoring of these criteria will determine the timing for increasing dialysis dose and frequency. We recognize that twice-weekly HD represents a major paradigm shift for many clinicians and jurisdictions. Therefore, we propose conducting randomized controlled trials of twice-weekly versus thrice-weekly HD to assess the potential of twice-weekly HD to improve survival and health-related quality of life while simultaneously reducing costs, protecting fragile vascular accesses, and optimizing resource use during the first year of hemodialysis therapy. Such incremental and individualized HD therapy may prove to be the most appropriate approach for transitioning to dialytic therapy.

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          Author and article information

          Am. J. Kidney Dis.
          American journal of kidney diseases : the official journal of the National Kidney Foundation
          Aug 2014
          : 64
          : 2
          [1 ] Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange; Veterans Affairs Long Beach Healthcare System, Long Beach, CA. Electronic address: kkz@uci.edu.
          [2 ] Division of Nephrology, University of New Mexico, Albuquerque, NM.
          [3 ] University of Tennessee Health Science Center and Memphis VAMC, Memphis, TN.
          [4 ] University Health Network and the University of Toronto, Toronto, Canada.
          [5 ] Fudan University, Shanghai, China.
          [6 ] Nephrolife Dialysis, Bangalore, India.
          [7 ] Veterans Affairs Long Beach Healthcare System, Long Beach, CA.
          [8 ] Vanderbilt University, Nashville, TN.
          [9 ] Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ.
          [10 ] New York Veterans Affairs Medical Center, New York, NY.
          S0272-6386(14)00803-8 NIHMS590144
          Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.


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