Incremental start and modulation of hemodialysis frequency may be based on clinical assessment and biochemical data without need for 24 hour urine collection. A pilot experience.

Incremental start and modulation of hemodialysis frequency may be based on clinical assessment and biochemical data without need for 24 hour urine collection. A pilot experience.

A gradual, incremental dialysis start is presently considered the standard of care in peritoneal dialysis and is increasingly spreading on hemodialysis (HD). The best way to monitor and modulate dialysis frequency is not established. Assessment of urea clearance on 24 hour urine collection is increasingly advocated but may be unpractical and not devoid of errors, in particular in elderly patients. The aim of this study was to analyse the decisional pathway leading to the start of incremental (iHD) or standard (sHD) hemodialysis and its modulation according to patient’s clinical features, in a setting in which about two-thirds of patients start with an incremental schedule.

We conducted an observational study including all patients starting chronic hemodialysis at the Centre Hospitalier Le Mans (CHM) between January 2021 and August 2023, followed-up for at least one month, until September 2023. A simple questionnaire on the reasons for starting and modulating HD was built through a brainstorming session and was completed by the caregiver nephrologist, indicating the reasons for starting and changing HD frequency (5 clinical items, scored from 0 to 100). Biochemical data were also gathered. Patient survival and persistence on iHD were analysed by Kaplan-Maier curves.

Of the 136 patients (median age 66.5 years, 30.9% female, 71.9% with a Subjective Global Assessment score of A, a median Malnutrition Inflammation Score of 5 and a median Charlson Comorbidity Index score of 7) who started chronic HD at the CHM in the period of study, 68.38% started with a iHD schedule (45.58% with 1 session/week and 22.8% with 2 sessions/week) while 31.62% patients started sHD. The reasons for choosing to start HD were the same for the two schedules: fluid overload, severe hypertension and malaise/anorexia captured over 95% of the cases; no difference was observed in terms of age. The reasons for increasing the frequency of HD were similar to those for starting HD. The main biochemical differences at the start of iHD or sHD were observed for hemoglobin and estimated Glomerular Filtration Rate level (lower in patients starting on sHD) and for C-reactive protein and phosphorus levels (higher on sHD). The persistence on iHD was 57% at one year. iHD start was associated with a higher short-term survival (Figure 1).

Our study supports a comprehensive clinical evaluation as a guide to start dialysis with incremental schedules and to modulate it, regardless of age and comorbidity, allowing to personalize the treatment for a mostly elderly population.