Incremental introduction of haemodialysis can benefit ESKD patients, study finds

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Haemodialysis (HD) is traditionally implemented in four-hour sessions, three times a week. The efficiency of this approach has been questioned, however, by the authors of a new study published in Nephrology Dialysis Transplantation. Led by Emma Caton (School of Life and Medical Sciences, Hatfield, UK), it looked at whether it benefitted end-stage kidney disease (ESKD) patients to have their dialysis sessions gradually increased in line with the progression of their condition.

HD patients often show disproportionately high rates of mortality in the first few months of treatment, said the study authors. The prevailing style of HD implementation poses difficulty in adjusting to the treatment for patients, who “may benefit from a gentler start to dialysis.”

Incremental HD starts patients on lower doses tailored to the specific stage of their illness, measured in residual kidney function (RKF).  This normally entails an initial reduction in sessional frequency from thrice to twice weekly. Not only does this offer “cost benefits for the healthcare service,” the study suggested, but it also “is likely to appeal to the HD population,” who often prioritise “dialysis-free time” according to the Standardised Outcomes in Nephrology-Haemodialysis (SONG-HD) initiative.

The study was a retrospective meta-analysis of studies, drawing on existing research comparing incremental with traditional implementation, and looking at some 644 records. Its primary endpoint was mortality, while secondary endpoints included “treatment-emergent adverse events, loss of RKF, quality of life and cost effectiveness.”

There was no significant difference in mortality between the groups who experienced traditional or gradual HD implementation. Most studies examined suggested incremental implementation did not change the risk of patient hospitalisation, while two randomised controlled trials suggested it decreased it, and one study suggested it increased it.

No significant differences in quality of life emerged. The authors were keen to note that the 44% reduction in individual dialysis sessions required by participating hospitals compared with traditional implementation resulted in significant cost reduction. They pointed to a study by Vilar et al that indicated incremental HD could cause a more than 20% reduction in costs per patient per year.

There remain questions about incremental HD, the authors stated. The studies they reviewed included “patients [who] did not have fair or equal access to dialysis treatment and were initiated on less frequent HD as a result of financial pressures or a lack of adequate healthcare services.” This may have affected the findings, while further limitations included the researchers’ exclusion of studies who did not report on mortality at all, instead only including data points on secondary endpoints. Nevertheless, the authors concluded, the review “lend[s] support to the safety of incremental HD as a treatment for ESKD.”

 

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