Long-Term Outcomes in Incident Patients on Incremental Hemodialysis vs. Standard Hemodialysis

Background: Incremental hemodialysis (< 3 sessions/week) has been offered in our center since 2013 to incident hemodialysis (HD) patients with adequate residual kidney function (RKF). We wanted to determine its impact on survival and the duration of incremental HD (IHD) until the transition to standard HD treatment (3x/week). Methods: IHD is implemented in incident HD patients who have a daily residual diuresis > 600 ml, a urea clearance > 2 ml/mn and an interdialytic weight gain < 2.5 kgs. Patients are clinically assessed every week and a 24 hr-urine sample is collected every other month in order to measure RKF. Results: From January 2013 to December 2023, 320 patients started maintenance HD in our center, of whom 125 started with IHD. These patients differed from those with a thrice-weekly incident HD regimen in terms of BMI (25+5 vs 23+9) and had less comorbidities (modified charlson score:7.4+3.1 vs 6.7+2.7). Residual diuresis, eGFR and urea clearance at IHD initiation were respectively 1798 + 712 ml/day, 6.7+ 2.7 ml/mn and 4.2 + 1.8 ml/mn. Diuresis and urea clearance declined after one year of IHD by 32 and 36% respectively. At the end of 2024, one third was either still on IHD or could stay on IHD until transplantation or death. Among the remaining 79 patients, mean duration of incremental HD until transition to a thrice-weekly HD regimen was 12 + 11 months (median, IQR: 10, 6-20). In multivariate analysis, long-term survival censored for transplantation was similar in patients starting with IHD than in patients with a thrice-weekly HD regimen (HR:0.71 (0.43-1.19); p=0.20). Conclusion: These results show that IHD can be safely implemented in incident HD patients as long as regular clinical and RKF assessments are found adequate. Results of randomised clinical trials assessing long-term survival and quality of life in IHD are awaited prior to its large-scale implementation.