Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Correspondence
  • Published:

Gradual initiation of dialysis as a means to reduce cost while providing quality health care

Nature Reviews Nephrology volume 13, page 720 (2017)Cite this article

Subjects

Access through your institution
Buy or subscribe

We read with interest the comprehensive Review by R. Vanholder et al. (Reducing the costs of chronic kidney disease while delivering quality health care: a call to action. Nat. Rev. Nephrol. 13, 393–409; 2017)1. In their Review, the authors provide an excellent discussion of the cost of care for patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) as well as approaches to decrease these costs without affecting the quality of care. We would, however, like to add to the list of proposed approaches to decrease the costs associated with renal replacement therapy, the concept of incremental haemodialysis, whereby patients undergo a gradual transformation from conservative CKD care to dialysis. Although thrice weekly haemodialysis is the standard of care in most parts of the world, patients with ESRD continue to experience low health-related quality of life2, accelerated loss of residual kidney function (RKF)3 and high mortality rates, especially in the first year of dialysis initiation4,5. Moreover, dialysis places a huge financial burden on health-care systems.

Gradual initiation of haemodialysis could provide a more individualized approach for patients with incident ESRD, with the frequency of dialysis determined by various criteria, including residual urine volume (RUV), RKF, cardiovascular status (that is, the presence or absence of heart failure), the presence of comorbidities, findings from pre-dialysis laboratory investigations (for example, acidosis and levels of potassium, phosphorus, haemoglobin, and albumin), nutritional status and self-motivation. For example, once weekly dialysis sessions could facilitate the smooth initiation of dialysis for certain individuals without negatively affecting their social activities, working hours and, theoretically through preservation of RKF6 and cardiovascular condition (reported to be the main cause of mortality in the first year of dialysis initiation5,7,8). Such an incremental approach to dialysis initiation also allows additional time to plan for fistula creation and maturation, preserves RKF and decreases health-care costs9. Cost reductions would not only result from the reduced number of haemodialysis sessions, but would also ensue due to vascular access preservation owing to the lower frequencies of punctures, reduced hospitalization from myocardial ischaemic events (as preserved RKF6 and RUV enables a lower ultrafiltration rate, which is associated with a low risk of myocardial stunning)9 and reduced absence from work.

This is a preview of subscription content, access via your institution

Access options

Access through your institution

Buy this article

  • Purchase on SpringerLink
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

References

  1. Vanholder, R. et al. Reducing the costs of chronic kidney disease while delivering quality health care: a call to action. Nat. Rev. Nephrol. 13, 393–409 (2017).

    Article  Google Scholar 

  2. Kalantar-Zadeh, K. et al. Twice-weekly and incremental hemodialysis treatment for initiation of kidney replacement therapy. Am. J. Kidney Dis. 64, 181–186 (2014).

    Article  Google Scholar 

  3. Diao, Z. et al. Preservation of residual renal function with limited water removal in hemodialysis patients. Ren. Fail. 33, 875–877 (2011).

    Article  CAS  Google Scholar 

  4. Zhang, H. et al. Dialysis outcomes and analysis of practice patterns suggests the dialysis schedule affects day-of-week mortality. Kidney Int. 81, 1108–1115 (2012).

    Article  Google Scholar 

  5. Bradbury, B. D. et al. Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Clin. J. Am. Soc. Nephrol. 2, 89–99 (2007).

    Article  Google Scholar 

  6. Lin, Y.-F. et al. Comparison of residual renal function in patients undergoing twice-weekly versus three-times-weekly haemodialysis. Nephrology (Carlton) 14, 59–64 (2009).

    Article  CAS  Google Scholar 

  7. Eckardt, K.-U. et al. High cardiovascular event rates occur within the first weeks of starting hemodialysis. Kidney Int. 88, 1117–1125 (2015).

    Article  Google Scholar 

  8. Steenkamp, R., Rao, A. & Fraser, S. UK Renal Registry 18 th annual report (December 2015) chapter 5: survival and causes of death in UK adult patients on renal replacement therapy in 2014: national and centre-specific analyses. Nephron 132 (Suppl. 1), 111–144 (2016).

    Article  Google Scholar 

  9. 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. 15, 172 (2014).

    Article  Google Scholar 

  10. Lee, M. J. et al. Prognostic value of residual urine volume, GFR by 24-hour urine collection, and eGFR in patients receiving dialysis. Clin. J. Am. Soc. Nephrol. 12, 426–434 (2017).

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Nephrology Department, Kidney and Urology Center, 236 Porsaid Street, Cleopatra, Alexandria, Egypt

    Mohamed E. Elrggal & Rowan Zyada

Authors
  1. Mohamed E. Elrggal
    View author publications

    Search author on:PubMed Google Scholar

  2. Rowan Zyada
    View author publications

    Search author on:PubMed Google Scholar

Corresponding authors

Correspondence to Mohamed E. Elrggal or Rowan Zyada.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Elrggal, M., Zyada, R. Gradual initiation of dialysis as a means to reduce cost while providing quality health care. Nat Rev Nephrol 13, 720 (2017). https://doi.org/10.1038/nrneph.2017.135

Download citation

  • Published:

  • Issue date:

  • DOI: https://doi.org/10.1038/nrneph.2017.135

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing