In an article recently published in AJKD, Kalantar-Zadeh and colleagues present a unique perspective on initiating hemodialysis by questioning the dogma of thrice-weekly treatments. The authors provide the history behind thrice-weekly dialysis treatments, and discuss some of the potential adverse effects of dialysis stemming from the loss of residual kidney function (RKF).
Their primary argument for testing the feasibility, safety, and efficacy of incremental dosing for dialysis rests on the importance of RKF, and is based on the assumption that twice-weekly treatments may reduce the rate of RKF decline. Indeed, twice-weekly dialysis is quite common in Asia and other developing countries, and some evidence does suggest better retention of RKF with less dialysis treatment. There is also little doubt that RKF is an independent predictor of all-cause mortality in patients on dialysis, and it may also have positive effects on hospitalizations and health-related quality of life. Furthermore, the inconvenience of traveling to a dialysis facility thrice weekly may also be reduced for some patients with twice-weekly treatments.
The authors also propose a cautious set of treatment guidelines/suggestions for the kind of patients who may be candidates for twice-weekly dialysis. Most of the criteria appear reasonable, and focus around a residual urine output of at least 0.5 liters daily. It would be important to know what proportion of current dialysis patients from the USRDS or DOPPS would truly meet five of the nine criteria suggested by the authors. In addition, a survey of community nephrologists to assess the feasibility of delivering twice weekly dialysis, as well their views on clinical equipoise to test the hypothesis, would be critical in furthering this proposal. Nonetheless, the authors of this perspective should be congratulated on putting forward an intriguing yet controversial hypothesis, and challenging the non-evidence based dogma of thrice-weekly in center dialysis treatments.
Navdeep Tangri, MD, PhD, FRCPC