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Incorporating residual kidney function into the dosing of intermittent hemodialysis

Anthony Bleyer, MD, MS
Thomas A Golper, MD
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD


Most incident end-stage renal disease (ESRD) patients have some level of native renal function remaining when they initiate hemodialysis. For selected patients who have significant residual kidney function, some expert clinicians advocate that, under certain circumstances, the hemodialysis dose can be adjusted for the clearance provided by native kidney function. In such patients, the target clearance (ie, Kt/V) is the sum of clearances provided by hemodialysis and native kidney function [1-3]. As a result, the hemodialysis dose is lower than that which is typically prescribed. This method of prescribing a lower hemodialysis dose depending on the clearance provided by residual kidney function is called incremental hemodialysis [4].

The amount of prescribed hemodialysis can be decreased by reducing the dialysis time (for example, by time per session or by number of sessions) or by altering operating conditions such as dialyzer size and type, dialysate flow rate, or blood flow rate. The dose of dialysis must then be increased over time as residual kidney function declines in order to avoid uremia.

This topic review provides methods of providing incremental hemodialysis, including methods of estimating the dialysis dose based upon residual kidney function clearance.

Calculation of the standard dialysis dose is discussed elsewhere. (See "Prescribing and assessing adequate hemodialysis".)

Incremental peritoneal dialysis is discussed elsewhere. (See "Prescribing and assessing adequate peritoneal dialysis", section on 'Solute clearance'.)


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Literature review current through: Sep 2016. | This topic last updated: Jan 6, 2016.
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  1. Kalantar-Zadeh K, Unruh M, Zager PG, et al. Twice-weekly and incremental hemodialysis treatment for initiation of kidney replacement therapy. Am J Kidney Dis 2014; 64:181.
  2. Caria S, Cupisti A, Sau G, Bolasco P. The incremental treatment of ESRD: a low-protein diet combined with weekly hemodialysis may be beneficial for selected patients. BMC Nephrol 2014; 15:172.
  3. Davenport A. Will incremental hemodialysis preserve residual function and improve patient survival? Semin Dial 2015; 28:16.
  4. Wong J, Vilar E, Davenport A, Farrington K. Incremental haemodialysis. Nephrol Dial Transplant 2015; 30:1639.
  5. Daugirdas JT, Depner TA, Greene T, et al. Standard Kt/Vurea: a method of calculation that includes effects of fluid removal and residual kidney clearance. Kidney Int 2010; 77:637.
  6. Teruel-Briones JL, Fernández-Lucas M, Rivera-Gorrin M, et al. Progression of residual renal function with an increase in dialysis: haemodialysis versus peritoneal dialysis. Nefrologia 2013; 33:640.
  7. Bargman JM, Thorpe KE, Churchill DN, CANUSA Peritoneal Dialysis Study Group. Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study. J Am Soc Nephrol 2001; 12:2158.
  8. Paniagua R, Amato D, Vonesh E, et al. Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized, controlled trial. J Am Soc Nephrol 2002; 13:1307.
  9. Eknoyan G, Beck GJ, Cheung AK, et al. Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med 2002; 347:2010.
  10. Vilar E, Wellsted D, Chandna SM, et al. Residual renal function improves outcome in incremental haemodialysis despite reduced dialysis dose. Nephrol Dial Transplant 2009; 24:2502.
  11. Zhang M, Wang M, Li H, et al. Association of initial twice-weekly hemodialysis treatment with preservation of residual kidney function in ESRD patients. Am J Nephrol 2014; 40:140.
  12. Hanson JA, Hulbert-Shearon TE, Ojo AO, et al. Prescription of twice-weekly hemodialysis in the USA. Am J Nephrol 1999; 19:625.
  13. Lin X, Yan Y, Ni Z, et al. Clinical outcome of twice-weekly hemodialysis patients in shanghai. Blood Purif 2012; 33:66.
  14. Elamin S, Abu-Aisha H. Reaching target hemoglobin level and having a functioning arteriovenous fistula significantly improve one year survival in twice weekly hemodialysis. Arab J Nephrol Transplant 2012; 5:81.
  15. Stankuvienė A, Ziginskienė E, Kuzminskis V, Bumblytė IA. Impact of hemodialysis dose and frequency on survival of patients on chronic hemodialysis in Lithuania during 1998-2005. Medicina (Kaunas) 2010; 46:516.
  16. National Kidney Foundation. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 update. Am J Kidney Dis 2015; 66:884.
  17. Gotch FA. The current place of urea kinetic modelling with respect to different dialysis modalities. Nephrol Dial Transplant 1998; 13 Suppl 6:10.
  18. Watson PE, Watson ID, Batt RD. Total body water volumes for adult males and females estimated from simple anthropometric measurements. Am J Clin Nutr 1980; 33:27.