It’s not unusual for patients with declining kidney health to retain residual renal function, sometimes at substantial levels. Preserving that kidney function has many benefits for patients, including better survival and recognizing that the patient may not need a  full dose of dialysis. Use of incremental peritoneal dialysis by using a limited number of exchanges has been an accepted approach; what about incremental hemodialysis?

Guidelines for incremental HD (see sidebar) were published in 2014. A similar approach has been suggested by Kidney Disease Outcomes Quality Initiative guidelines  based on urea clearance >3 mL/min/1.73 m2).1

A major proponent of hemodialyzing patients twice a week is Kam Kalantar-Zadeh, MD, MPH, PhD, who serves as Chief of Nephrology at the University of California Irvine. He is the lead author on the above-mentioned 2014 international consensus paper and the lead author of several research papers in 2015 and 2016 on incremental hemodialysis in major nephrology journals. He authored a follow-up paper this past June in Panminerva Medica on use of incremental therapy as a conservative approach to treating kidney disease, and detailed his own University experience with colleagues in a paper published in the May 2017 issue of Seminars in Dialysis.

In an interview with NN&I, Kalantar-Zadeh detailed the best approach to identifying candidates for incremental HD  and how to transition into more frequent hemodialysis.

NN&I: Is there documented clinical success in using incremental dialysis to slow progression of kidney disease?

Kamyar Kalantar-Zadeh, MD, MPH: Yes. A major benefit of incremental HD (starting at 1-2 times a week HD and gradually increasing frequency according to periodic assessments and clinical criteria) is to preserve “residual kidney function” (RKF) longer.  Note that the keyword “RKF” is used the moment one transitions to dialysis, as opposed to eGFR.

There has been an exponential surge of publications in the last 2-3 years on longer preservation of RKF, including by incremental dialysis. Longer preserved RKF confers important clinical benefits, including greater patient longevity and better fluid and phosphorus management, among others.

NN&I: How do you determine who is a good candidate for incremental dialysis?

Kalantar-Zadeh: Ten criteria were presented in the AJKD international consensus paper, which included input from nephrologists Thomas Golper, Richard Sherman, JoAnne Bargeman, myself, and others. The guidelines have been refined and expanded to 11 criteria (to include KRU>3 ml/min) and are used widely around the world.

NN&I: How do you know when incremental dialysis is no longer effective and more is needed?

Kalantar-Zadeh: Anybody who makes more than 0.5 liters a day urine is likely good to start twice-weekly, as long as he/she also meets four of the other nine criteria. Then every 2-3 months he/she is evaluated to ascertain if 2x/week should be continued or if the patients should switch to 3x/week.

NN&I: How about the logistics in a clinic environment where scheduling three treatments a week is the norm?

Kalantar-Zadeh: Clinics wouldn’t likely be unhappy to have more twice-weekly patients. We and others have created innovative and pragmatic scheduling such as Mon-Thu, Tue-Fri, and Wed-Sat to start 3 twice-weekly patients in lieu of 2 thrice-weekly patients.

In Kalantar-Zadeh and colleague’s own experience at the University of Irvine, they compared outcomes of 13 ESRD patients enrolled in an incremental dialysis program from January 2015-August 2016, followed through December 2016. Five of the 13 patients received incremental dialysis over the near two-year program.

  • Ultimately, the results showed a need to define incremental dialysis more specifically, including:
  • What is the optimal prescription for using incremental dialysis?
  • Beyond assessing quarterly urea clearances, (per KDOQI guidelines), what other tools can be used to serially monitor patients’ RKF?
  • What other management strategies (medications, diet, physical activity) can be implemented with incremental dialysis to preserve RKF?
  • How can clinicians identify characteristics in patients with RKF that will allow them to remain on incremental hemodialysis vs. having to move to thrice-weekly HD?

Does incremental dialysis reduce costs in overall patient care vs. traditional thrice-weekly hemodialysis?

“Future studies are needed to refine the optimal approaches for implementation of the incremental twice-weekly hemodialysis regimen, as well as the ideal patient populations for this management strategy,” Kalantar-Zadeh and colleagues wrote.

Criteria for candidates that may benefit from incremental hemodialysis (IHD)

  • Good residual renal function with urine output > 0.5 L/d (or KRU>3 ml/min)
  • Limited fluid retention between two conservative HD treatments with fluid gain < 2.5 kg (or < 5% of ideal dry weight) without HD for 3-4 days
  • Limited or readily manageable cardiovascular or pulmonary symptoms without clinically significant fluid overload
  • Suitable body size relative to renal residual kidney function
  • Hyperphosphatemia (P> 5.5 mEq/L) is infrequent or readily manageable
  • Good nutrition status
  • Lack of profound anemia
  • Infrequent hospitalizations and easily manageable comorbid conditions
  • Satisfactory health-related quality of life
  • Use of the criteria on 2x/week HD therapy patients should be re-evaluated once a month.


Kalantar-Zadeh et al. Twice-weekly and incremental hemodialysis treatment for initiation of kidney replacement therapy, Am. Jrnl of Kid. Dis., 64 (2): 181-186, 2014.