Journal of Nephrology

, Volume 30, Issue 4, pp 521–529 | Cite as

Is incremental hemodialysis ready to return on the scene? From empiricism to kinetic modelling

  • Carlo Basile
  • Francesco Gaetano Casino
  • Kamyar Kalantar-Zadeh


Most people who make the transition to maintenance dialysis therapy are treated with a fixed dose thrice-weekly hemodialysis regimen without considering their residual kidney function (RKF). The RKF provides effective and naturally continuous clearance of both small and middle molecules, plays a major role in metabolic homeostasis, nutritional status, and cardiovascular health, and aids in fluid management. The RKF is associated with better patient survival and greater health-related quality of life, although these effects may be confounded by patient comorbidities. Preservation of the RKF requires a careful approach, including regular monitoring, avoidance of nephrotoxins, gentle control of blood pressure to avoid intradialytic hypotension, and an individualized dialysis prescription including the consideration of incremental hemodialysis. There is currently no standardized method for applying incremental hemodialysis in practice. Infrequent (once- to twice-weekly) hemodialysis regimens are often used arbitrarily, without knowing which patients would benefit the most from them or how to escalate the dialysis dose as RKF declines over time. The recently heightened interest in incremental hemodialysis has been hindered by the current limitations of the urea kinetic models (UKM) which tend to overestimate the dialysis dose required in the presence of substantial RKF. This is due to an erroneous extrapolation of the equivalence between renal urea clearance (Kru) and dialyser urea clearance (Kd), correctly assumed by the UKM, to the clinical domain. In this context, each ml/min of Kd clears the urea from the blood just as 1 ml/min of Kru does. By no means should such kinetic equivalence imply that 1 ml/min of Kd is clinically equivalent to 1 ml/min of urea clearance provided by the native kidneys. A recent paper by Casino and Basile suggested a variable target model (VTM) as opposed to the fixed model, because the VTM gives more clinical weight to the RKF and allows less frequent hemodialysis treatments at lower RKF. The potentially important clinical and financial implications of incremental hemodialysis render it highly promising and warrant randomized controlled trials.


End-stage renal disease Incremental hemodialysis Initiation of dialysis Residual renal function Twice-weekly hemodialysis Urea kinetic modelling 


Compliance with ethical standards


No funding agency granted the present study.

Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

For this type of study formal consent is not required.

Research involving human participants and/or animals

This article does not contain any studies with human participants or animals performed by any of the authors.


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Copyright information

© Italian Society of Nephrology 2017

Authors and Affiliations

  1. 1.Clinical Research Branch, Division of NephrologyMiulli General HospitalAcquaviva delle FontiItaly
  2. 2.Dialysis Centre SM2PotenzaItaly
  3. 3.Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and HypertensionUniversity of California Irvine, School of MedicineOrangeUSA
  4. 4.Fielding School of Public Health at UCLALos AngelesUSA
  5. 5.Los Angeles Biomedical Research Institute at Harbor-UCLATorranceUSA

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