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Individuals afflicted with advanced kidney dysfunction who require dialysis for medical management exhibit different degrees of native kidney function, called residual kidney function (RKF), ranging from nil to appreciable levels. The primary focus of this manuscript is to delve into the concept of RKF, a pivotal yet under-represented topic in nephrology. To begin, we unpack the definition and intrinsic nature of RKF. We then juxtapose the efficiency of RKF against that of hemodialysis in preserving homeostatic equilibrium and facilitating physiological functions. Given the complex interplay of RKF and overall patient health, we shed light on the extent of its influence on patient outcomes, particularly in those living with advanced kidney dysfunction and on dialysis. This manuscript subsequently presents methodologies and measures to assess RKF, concluding with the potential benefits of targeted interventions aimed at preserving RKF.

Background Women treated with hemodialysis report lower health-related quality of life (HRQoL) compared with men. Whether this is related to sex-specific (biological) (e.g. under-dialysis due to body composition differences) or gender-specific (sociocultural) factors (e.g. greater domestic/caregiver responsibilities for women) is unknown. We examined the association between sex assigned at birth, gender score and HRQoL in individuals initiating conventional and incremental hemodialysis. Methods In this prospective multi-center cohort study, incident adult hemodialysis patients were recruited between 1 June 2020 and 30 April 2022 in Alberta, Canada. Sex assigned at birth and gender identity were self-reported. Gender-related characteristics were assessed by self-administered questionnaire to derive a composite measure of gender. The primary outcome was change in Kidney Disease Quality of Life 36 physical (PCS) and mental (MCS) component scores after 3 months of hemodialysis. Results Sixty participants were enrolled (conventional hemodialysis: 14 female, 19 male; incremental hemodialysis: 12 female, 15 male). PCS improved from baseline with conventional (P = .01) but not incremental (P = .52) hemodialysis in female participants. No difference in MCS was observed by hemodialysis type in female participants. Gender score was not associated with changes in PCS in female participants, irrespective of hemodialysis type. Higher gender score was associated with increased MCS with incremental (P = .04), but not conventional (P = .14), hemodialysis (P = .03 conventional vs incremental) in female participants. No change in PCS or MCS was seen in male participants, irrespective of hemodialysis type or gender score. Conclusion In this exploratory study, conventional hemodialysis was associated with improved PCS in female participants, while incremental hemodialysis was associated with improved MCS in female participants with more roles and responsibilities traditionally ascribed to women. Large prospective studies are required to further investigate these relationships. [ABSTRACT FROM AUTHOR]

Conventional hemodialysis (HD) (a 4 h session three times a week) is not appropriate for everyone and is excessive in the presence of substantial residual kidney function (RKF). However, it can be safely replaced by a softer incremental approach guided by the urea kinetic model (UKM), starting with one or two sessions a week. Observational data suggest that RKF may be lost less quickly if dialysis is initiated less frequently than 3 times a week. Incremental HD means that, in the presence of substantial RKF, kidney replacement therapy can begin with low doses and/or frequencies, which, however, must be adequately increased to compensate for any subsequent losses of RKF, keeping the total clearance level (kidney + dialysis) always above the minimum levels of adequacy. In HD, there are complexities in combining the dialysis dose with RKF, but tools have been developed to facilitate this issue. The literature findings lend support to the safety of incremental HD and highlight the potential for this method to be implemented as a new standard of care in dialysis patients with substantial RKF. Ongoing and future trials will likely generate further evidence of the clinical and healthcare benefits of incremental HD in routine practice.

Individuals afflicted with advanced kidney dysfunction who require dialysis for medical management exhibit different degrees of native kidney function, called residual kidney function (RKF), ranging from nil to appreciable levels. The primary focus of this manuscript is to delve into the concept of RKF, a pivotal yet under-represented topic in nephrology. To begin, we unpack the definition and intrinsic nature of RKF. We then juxtapose the efficiency of RKF against that of hemodialysis in preserving homeostatic equilibrium and facilitating physiological functions. Given the complex interplay of RKF and overall patient health, we shed light on the extent of its influence on patient outcomes, particularly in those living with advanced kidney dysfunction and on dialysis. This manuscript subsequently presents methodologies and measures to assess RKF, concluding with the potential benefits of targeted interventions aimed at preserving RKF.

SGLT-2i are the new standard of care for diabetic kidney disease (DKD), but previous studies have not included patients on kidney replacement therapy (KRT). Due to their high risk of cardiovascular, renal complications, and mortality, these patients would benefit the most from this therapy. Residual kidney function (RKF) conveys a survival benefit and cardiovascular health among hemodialysis (HD) patients, especially those on incremental hemodialysis (iHD). We retrospectively describe the safety and efficacy of SGLT2i regarding RKF preservation in seven diabetic patients with different clinical backgrounds who underwent iHD (one or two sessions per week) during a 12-month follow-up. All patients preserved RKF, measured as residual kidney urea clearance (KrU) in 24 h after the introduction of SGLT2i. KrU levels improved significantly from 4.91 ± 1.14 mL/min to 7.28 ± 1.68 mL/min at 12 months (p = 0.028). Pre-hemodialysis blood pressure improved 9.95% in mean systolic blood pressure (SBP) (p = 0.015) and 10.95% in mean diastolic blood pressure (DBP) (p = 0.041); as a result, antihypertensive medication was modified. Improvements in blood uric acid, hemoglobin A1c, urine albumin/creatinine ratio (UACR), and 24 h proteinuria were also significant. Regarding side effects, two patients developed uncomplicated urinary tract infections that were resolved. No other complications were reported. The use of SGLT2i in our sample of DKD patients starting iHD on a 1–2 weekly regimen appears to be safe and effective in preserving RKF. [ABSTRACT FROM AUTHOR]

The glucagon-like peptide-1 receptor agonists (GLP-1RA) are among the newest treatment options available for managing of type 2 diabetes mellitus and slowing the progression of diabetes kidney disease (DKD). Subcutaneous (SC) semaglutide (Ozempic®) is a GLP-1RA with an extended half-life of approximately 1 week. GLP-1RA are highly effective in improving glycemic control and also show other beneficial effects such as increased natriuresis; decreased blood pressure and albuminuria; reduction of oxidative stress and inflammation; delay of gastric emptying and suppress appetite; the latter may result in significant weight loss. GLP-1RA can be used in patients with advanced-stage CKD; the European Medicines Agency has approved the use of all commercially available human GLP-1 analogs up to a minimal eGFR of 15 mL/min/1.73 m2. However, studies of safety and use of these agents in renal replacement therapy are scarce. Therefore, herein we present 3 cases of patients with advanced DKD in maintenance incremental hemodialysis with 1 session per week to describe the efficacy and safety of the SC semaglutide treatment and the favorable effects on glycemic control, lowering HbA1c, albuminuria, weight, blood pressure control, and preservation of residual kidney function (RKF) during a 6-month follow-up in a hospital hemodialysis unit in Spain. These effects could produce an improvement in morbidity and mortality and could also prevent albuminuria and preserve the RKF. This may allow our patients to maintain a weekly hemodialysis session and could facilitate their inclusion in the kidney transplant waiting lists.

Hemodialysis therapy is the primary treatment for end-stage renal disease with the ultimate goal of improving quality of life and survival time. In the context of limited medical resources and the global prevalence of COVID-19, incremental hemodialysis, as a means of individualizing the dialysis regimen according to the patient's residual renal function, can not only better protect the residual renal function by individualizing the assessment of the patient's dialysis adequacy in multiple dimensions without affecting the hospitalization and survival rate, but also can reduce the medical burden and the risk of COVID-19 infection in hemodialysis patients. This review explains the concept, conditions of implementation, background, advantages and limitations of incremental hemodialysis, and aims to show that incremental hemodialysis will be an important strategy to achieve a balance among medical safety, survival, quality of life, and medical costs in the current medical and social environment in line with the requirements of precision medicine, and deserves further attention.

SGLT-2i are the new standard of care for diabetic kidney disease (DKD), but previous studies have not included patients on kidney replacement therapy (KRT). Due to their high risk of cardiovascular, renal complications, and mortality, these patients would benefit the most from this therapy. Residual kidney function (RKF) conveys a survival benefit and cardiovascular health among hemodialysis (HD) patients, especially those on incremental hemodialysis (iHD). We retrospectively describe the safety and efficacy of SGLT2i regarding RKF preservation in seven diabetic patients with different clinical backgrounds who underwent iHD (one or two sessions per week) during a 12-month follow-up. All patients preserved RKF, measured as residual kidney urea clearance (KrU) in 24 h after the introduction of SGLT2i. KrU levels improved significantly from 4.91 ± 1.14 mL/min to 7.28 ± 1.68 mL/min at 12 months (p = 0.028). Pre-hemodialysis blood pressure improved 9.95% in mean systolic blood pressure (SBP) (p = 0.015) and 10.95% in mean diastolic blood pressure (DBP) (p = 0.041); as a result, antihypertensive medication was modified. Improvements in blood uric acid, hemoglobin A1c, urine albumin/creatinine ratio (UACR), and 24 h proteinuria were also significant. Regarding side effects, two patients developed uncomplicated urinary tract infections that were resolved. No other complications were reported. The use of SGLT2i in our sample of DKD patients starting iHD on a 1–2 weekly regimen appears to be safe and effective in preserving RKF.

The glucagon-like peptide-1 receptor agonists (GLP-1RA) are among the newest treatment options available for managing of type 2 diabetes mellitus and slowing the progression of diabetes kidney disease (DKD). Subcutaneous (SC) semaglutide (Ozempic®) is a GLP-1RA with an extended half-life of approximately 1 week. GLP-1RA are highly effective in improving glycemic control and also show other beneficial effects such as increased natriuresis; decreased blood pressure and albuminuria; reduction of oxidative stress and inflammation; delay of gastric emptying and suppress appetite; the latter may result in significant weight loss. GLP-1RA can be used in patients with advanced-stage CKD; the European Medicines Agency has approved the use of all commercially available human GLP-1 analogs up to a minimal eGFR of 15 mL/min/1.73 m2. However, studies of safety and use of these agents in renal replacement therapy are scarce. Therefore, herein we present 3 cases of patients with advanced DKD in maintenance incremental hemodialysis with 1 session per week to describe the efficacy and safety of the SC semaglutide treatment and the favorable effects on glycemic control, lowering HbA1c, albuminuria, weight, blood pressure control, and preservation of residual kidney function (RKF) during a 6-month follow-up in a hospital hemodialysis unit in Spain. These effects could produce an improvement in morbidity and mortality and could also prevent albuminuria and preserve the RKF. This may allow our patients to maintain a weekly hemodialysis session and could facilitate their inclusion in the kidney transplant waiting lists. [ABSTRACT FROM AUTHOR]

Background: Incremental hemodialysis is based on the simple idea of adjusting its dose according to the metrics of residual kidney function. Indeed, most patients initiating dialysis have some degree of residual kidney function. Incremental dialysis may preserve residual renal function and improve survival in comparison with full-dose dialysis. Objective: To compare the intervention arm (incremental hemodialysis) with the control arm (standard 3 hemodialysis sessions/week). Patients and Methods: A prospective cohort study was conducted, recruiting 50 patients from multiple hemodialysis units, over six months. The prevalent patients were divided randomly into equal two treated groups. The outcomes compared adequacy of hemodialysis and detection of hazards as well as complications, including vascular access failure and associated interventions, cardiovascular events and hospital admissions, and mortality in both groups. Results: Regarding the occurrence of cardiovascular events, chest pain, there were no significant differences between both groups. Arrhythmia was not recorded in the incremental group, while in the conventional group it was recorded in 2 patients, and there was no significant difference between both groups. Regarding the need for hospital admission, there was no significant difference between both groups. As regards the occurrence of vascular access failure, it was recorded in 2 patients in the incremental group, compared to 4 patients in the conventional group, with no significant difference between both groups. Adequacy of hemodialysis (in the form of urea reduction ratio and KT/V) was better in the incremental group. Conclusion: Incremental hemodialysis was superior to the conventional one regarding the adequacy of dialysis, with monthly follow-up till 6 months. There were no significant differences between both groups regarding cardiovascular events, vascular access failure, and hospitalization. [ABSTRACT FROM AUTHOR]

Introduction: Incremental hemodialysis (iHD) may attenuate "dialysis shock" and reduce costs, preserving quality of life. It is considered difficult to reconcile with HD wards' routine; fear of underdialysis and increasing mortality are additional concerns. The aim of this study was to evaluate mortality, morbidity, and costs in a large HD ward where iHD is the standard of HD start., Methods: This observational study included all incident HD patients in 2017 to 2021, stratified according to HD start: iHD (1-2 sessions/wk), decremental HD (dHD, 3 sessions/wk at start, later reduced), or standard (3 sessions/wk). Results were compared with data recorded in the same unit before the incremental program (2015-2017) and with a propensity score-matched cohort from the French Renal Epidemiology and Information Network (REIN) registry., Results: A total of 158 patients started HD in 2017 to 2021, 57.6% on iHD, 8.9% dHD, and 33.5% standard HD schedule. Patients on the standard schedule had lower initial estimated glomerular filtration rate (eGFR) (5 vs. 7 ml/min per 1.72 m 2 , P  = 0.003). We found no survival differences according to period of start (same center) and propensity score matching (REIN). Patients intensively followed in the pre-HD period were more likely to start on iHD-dHD. Persistence on iHD-dHD was about 50% at 1 year and 35% at 2 years. Hospitalization rates and time to first hospitalization or death did not differ between the schedules. The iHD-dHD policy allowed a 16% cost saving, even accounting for supplemental biochemical tests., Conclusion: Our study reveals that iHD can be a new standard of care, as it is safe and feasible in up to two-thirds of patients on incident HD., (© 2022 International Society of Nephrology. Published by Elsevier Inc.)

Background: Incremental hemodialysis, a strategy to individualize dialysis prescription based on residual kidney function, may be associated with enhanced quality of life and decreased health care costs compared with conventional hemodialysis., Objective: We surveyed practicing Canadian nephrologists to assess knowledge, perceptions, and practice pattern on the use of incremental hemodialysis., Design/setting: We distributed a cross-sectional, web-based survey. We asked about incremental hemodialysis prescribing practices, including frequency of prescription, clinical factors used to determine suitability for treatment, and barriers to implementation. The survey was conducted from September 21 to October 30, 2020., Participants: We distributed the survey to practicing Canadian nephrologists identified from a private membership list of the Canadian Society of Nephrology (CSN), as well as to nephrologists named on a publicly available national list of practicing Canadian nephrologists created from provincial College of Physician registries. These were samples of convenience., Methods: We conducted descriptive analysis of categorical data including frequencies for nominal variables and measures of central tendency (mean) and dispersion (standard deviation) for ordinal variables. We used chi-square analysis to identify association between participant and practice characteristics and their opinions and attitudes toward incremental dialysis. We used simple thematic analysis on free-text responses on questions regarding the prescription of incremental hemodialysis, focusing on age and baseline management of cardiac and noncardiac comorbidities., Results: The response rate was 35% (243/691). Most (138/211, 65%) of the participants prescribed incremental hemodialysis using an individualized approach at the nephrologist's discretion. Most participants (200/203, 98%) did not report any policy for implementation. Residual urine output was identified as the most important factor for eligibility (112/172, 65%), followed by electrolyte stability (76/172, 44%) and patient goals of care (69/117, 40%). Most participants agreed that dialysis prescriptions should take residual kidney function into consideration; however, 74% of the participants disagreed with a statement that there was strong evidence supporting incremental hemodialysis. Barriers identified included patient safety, patient acceptance of dose escalation, and logistics of scheduling. Despite these barriers, 82% of participants felt that that incremental hemodialysis is feasible with their current resources and 78% agreed that with specific criteria, it is a safe option., Limitations: The generalizability of our study is limited by its response rate of 35%; however, this is comparable with typical response rates seen in electronic surveys. Most participants practice in an academic setting, which may have introduced bias to the results., Conclusions: Despite the perception of limited evidence and a lack of guidance on implementation, incremental hemodialysis is frequently practiced by Canadian nephrologists. Barriers to implementation were identified, highlighting the need for research to guide practice., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)