Perspectives on Quality of Life, Vascular Access, and Fluid Balance in Incremental Hemodialysis

Abstract

Hemodialysis is an intensive treatment with a substantial time burden for patients. Generally, a standard hemodialysis schedule consists of three treatments per week, each lasting 4 hours. However, it can be debated whether this schedule is appropriate for all patients. Incremental hemodialysis refers to a treatment approach where hemodialysis is initiated with a less intensive schedule (i.e., fewer sessions per week) and gradually increased as residual kidney function declines. The effects of incremental hemodialysis on key outcomes—health-related quality of life, vascular access-related complications, and fluid overload—were discussed in this review. Although incremental hemodialysis is hypothesized to improve health-related quality of life, most studies found no significant difference. Similarly, most studies did not report significant differences in vascular access-related complications. Concerns have been raised regarding fluid overload due to extended intervals between sessions and underdialysis, especially when the transition to a thrice-weekly schedule is delayed. However, most studies found no difference in fluid overload related outcomes. Incremental hemodialysis is a promising, personalized treatment that could reduce the socioeconomic burden of dialysis. Given the methodologic limitations of available studies, ongoing trials will contribute to a clearer understanding of the role of incremental hemodialysis with varying residual kidney function at initiation.

Introduction

Hemodialysis is a time-intensive treatment for kidney failure, typically requiring three sessions per week, each lasting about 4 hours.¹ Despite improvements in care, hemodialysis continues to impose a significant disease burden, including high cardiovascular mortality rates, frequent hospitalizations, and an impaired health-related quality of life (HRQoL).^2–4 These persistent challenges underscore the need for standardized research outcomes meaningful to all stakeholders, especially patients. In response, the Standardized Outcomes in Nephrology initiative was established.⁵ As part of this initiative, a Delphi study identified dialysis-free time, HRQoL, the reduction of vascular access-related complications, and cardiovascular disease as among the most important research outcomes. In light of these outcomes, incremental hemodialysis, where patients with sufficient residual kidney function (RKF) begin hemodialysis at a lower frequency, transitioning to more frequent sessions as RKF declines, is an interesting treatment option.⁶ This typically involves a twice-weekly schedule although practical implementation varies.

In Figure 1, several potential benefits and concerns of incremental hemodialysis are summarized. It is hypothesized that incremental hemodialysis could improve HRQoL, reduce vascular access-related complications, and prolong preservation of RKF. Dialysis facilities can reduce costs by lowering the use of resources such as dialysate, dialyzers, saline, bloodlines, bicarbonate cartridges, and needles as well as by reducing staff workload.⁷ Several high-quality cohort studies have shown that incremental hemodialysis does not pose a higher mortality risk compared with standard treatment.⁸ However, if deteriorating RKF is recognized too late, incremental hemodialysis may lead to complications. Incremental hemodialysis in patients with residual urea clearance ≤3.0 ml/min per 1.73 m² was associated with higher mortality in one study, potentially due to fluid overload.⁹ However, it is important to recognize that, beyond RKF, factors such as comorbid conditions, dietary and fluid intake, and medication adherence also significantly influence outcomes in incremental hemodialysis.¹⁰ Fluid overload could lead to an increased pill burden or hospitalizations.¹¹ In addition, since RKF helps maintain plasma urea levels in twice-weekly hemodialysis patients, delayed detection of its decline may lead to reduced clearance of uremic solutes.¹² Incremental hemodialysis is mentioned in several guidelines, but the implementation is not yet standardized.^1,13,14 The 2019 British guideline mentions that an incremental schedule may be optimal in patients with significant RKF.¹⁴ However, as with the decision to initiate conventional dialysis, the choice to start incremental hemodialysis is not based solely on RKF. There is no international consensus on the other specific eligibility criteria, but Kalantar-Zadeh et al. proposed eight criteria based on expert opinion.¹⁵ Key eligibility criteria among these, in addition to residual diuresis >500 ml/24 hours, include minimal fluid retention between sessions, manageable comorbidities, and controllable electrolyte imbalances, particularly potassium and phosphate levels. Although most literature regarding incremental hemodialysis is observational, several studies suggest a beneficial association between incremental hemodialysis and the preservation of RKF and no increased mortality risk.^8,16,17 Several studies have shown that RKF preservation may contribute to improved fluid homeostasis and HRQoL.^18,19 However, less is known about the effect of incremental hemodialysis on HRQoL, vascular access-related complications, or fluid overload.

Figure 1.

Potential benefits and concerns of incremental hemodialysis. This figure was created in BioRender (Roos S, 2025, https://BioRender.com/j97b522). HRQoL, health-related quality of life; RKF, residual kidney function.

This narrative review will explore the key aspects of incremental hemodialysis aligned with the Standardized Outcomes in Nephrology initiative, focusing on potential benefits on HRQoL and vascular access-related complications, as well as addressing concerns related to fluid overload. An overview of the discussed studies including their specific definitions of incremental hemodialysis is presented in Supplemental Table 1.^11,20–30

History of Hemodialysis Schedules

The Social Security Amendments in 1972 marked hemodialysis as a lifesaving treatment, resulting in financial reimbursement and widespread adoption in the United States.^31–33 Since that time, the frequency, duration, and dose of hemodialysis sessions have varied significantly.³³ Initially, sessions often exceeded 6 hours due to technical limitations such as inefficient small dialyzer surfaces. Inconvenient locations and manual setup added to the time burden, creating a demand for shorter schedules. As the dialyzer became more efficient, treatment times could be substantially reduced.^34,35 Observational studies showed that thrice-weekly was superior compared with twice-weekly, especially for cognitive function.^36,37 Following the National Cooperative Dialysis Study in 1981, thrice-weekly schedules with shorter durations became the standard.³⁸ This trial demonstrated that low BUN concentration, rather than session duration, was crucial for preventing death or medical illness, shifting the focus to urea clearance and the Kt/V metric. However, in 2002, the Hemodialysis (HEMO) study demonstrated no significant differences in mortality or hospitalization between high and conventional urea clearance in thrice-weekly hemodialysis patients, although the difference in weekly standard Kt/V between intensive and standard regimens was marginal (3.60±0.57 versus 2.57±0.26, respectively).^39,40 Of course, this finding was done against a background of enhanced efficiency over the previous decades. Several studies have shown beneficial effects of hemodialysis schedules with longer durations. Although based only on the observational studies, longer hemodialysis sessions lasting over 4 hours may decrease mortality.^41,42 The effect of more than thrice-weekly hemodialysis on overall mortality is still uncertain, but the Frequent Dialysis Network trial demonstrated that six weekly hemodialysis sessions reduced mortality and improved hypertension control and cardiac function by reducing left ventricular mass compared with thrice-weekly hemodialysis.^40,43,44 On the other hand, the nocturnal Frequent Dialysis Network trial showed that more frequent dialysis sessions can lead to an accelerated loss of RKF.⁴⁵ A key limitation of many of these studies is the exclusion of patients with substantial RKF or the lack of adjustment for it.^38,39,41 As a result, it remains unclear whether these findings are applicable to incident hemodialysis patients with substantial RKF, for whom incremental hemodialysis may be considered.

HRQoL

Incremental hemodialysis has been linked to both improved and decreased HRQoL. It has been suggested that HRQoL may be enhanced due to the reduced time burden resulting from fewer sessions.¹⁴ In addition, incremental hemodialysis most likely preserves RKF, which is associated with an improved HRQoL.^17,19 On the other hand, it is conceivable that increased fluid overload, potentially associated with incremental hemodialysis, could exacerbate symptoms such as dyspnea and edema, thereby decreasing HRQoL.

Studies on HRQoL in incremental hemodialysis are scarce. A systematic review in 2022 yielded no studies reporting on HRQoL.⁴⁶ However, there is one randomized controlled trial (RCT) and one observational study that reported on this outcome (Table 1). Vilar et al. demonstrated no significant difference in the Europe Quality of Life 5-Dimension 5-Level index value after 6 and 12 months in a small feasibility RCT, but the number of participants was very limited.¹¹ Park et al. found no difference in the physical component score or mental component score of the Kidney Disease Quality of Life-Short-Form 12 between the incremental group, including once-weekly schedules, and the conventional group, measured at 3 and 12 months, but only 27% of patients completed the 12-month questionnaire.²⁸

Table 1.

Comparison of incremental and conventional hemodialysis schedules on health-related quality of life–related outcomes

Author (Year)	Study Design	Outcome	Results			P Value
			Score	Incremental	Conventional
Vilar et al. (2022)11	RCT	EQ-5D-5L index valuea	Total score at 6 mo	0.83 (IQR, 0.70–0.91)	0.74 (IQR, 0.61–0.93)	P = 0.81b
			Total score at 12 mo	0.81 (IQR, 0.69–0.93)	0.81 (IQR, 0.70–0.92)
Park et al. (2016)28	Observational	KDQOL-SF12	PCS at 3 mo	41.6±8.4	39.8±9.8	P = 0.27
			PCS at 12 mo	43.4±10.2	41.9±9.4	P = 0.48
			MCS at 3 mo	40.8±8.5	39.9±10.0	P = 0.61
			MCS at 12 mo	42.5±9.9	40.6±8.6	P = 0.36

EQ-5D-5L, Europe Quality of Life-5-Dimension5-Level; IQR, interquartile range; KDQOL, Kidney Disease Quality of Life; MCS, mental component score; PCS, physical component score; RCT, randomized controlled trial; SF12, Short-Form 12.

^aRanges from 1.0 (best possible score) to 0.0 (worst possible score).

^bStatistical significance of the difference in scores between the schedules from baseline to the last available score in the study.

Two Chinese studies compared the effect of maintenance twice-weekly hemodialysis on HRQoL. One RCT reported a higher total score of the Kidney Disease Quality of Life Short Form-36 in the twice-weekly group after 1 year.⁴⁷ Another cross-sectional study found no significant differences in the Kidney Disease Quality of Life-Short-Form 12.⁴⁸ However, these studies do not examine incremental hemodialysis, and patients on maintenance twice-weekly hemodialysis in China had a lower socioeconomic status, less health insurance, and the age in general was about 15 years lower than Western populations.^11,28,47,48

Despite the fact that data on HRQoL are limited, some studies have examined outcomes which could affect HRQoL. In the TwoPlus Pilot RCT, conventional hemodialysis was compared with a schedule of twice-weekly hemodialysis during 6 weeks, followed by a transition to thrice-weekly hemodialysis.⁴⁹ The dialysis symptom index (DSI), the generalized anxiety (Generalized Anxiety Disorder 7-Item [GAD-7]), and depression scores (Patient Health Questionnaire-9 [PHQ-9]) were examined after 6 and 12 weeks. The DSI scores regarding physical symptoms were slightly, but not significantly, better in the conventional group. On the other hand, the GAD-7 and PHQ-9 scores were better in the incremental group. Although psychologic symptoms were better in the incremental group, an increased number of physical symptoms could negatively affect HRQoL. Furthermore, assessments in this study stopped after 12 weeks, thus possibly missing long-term negative effects on HRQoL. Theoretically, psychologic symptoms could worsen as RKF declines and transitioning to thrice-weekly sessions becomes necessary, as this transition may be more difficult than starting with thrice-weekly sessions from the start. In a different observational study, Davenport et al. found no difference in the Beck Depression scale among prevalent hemodialysis patients on an incremental schedule and those on a conventional schedule but performed no follow-up of this questionnaire.²⁴

In conclusion, evidence on HRQoL difference between incremental and conventional hemodialysis is limited with only two studies, both with small sample sizes and short follow-up periods. Future larger randomized trials or observational studies with extended follow-up are needed. Furthermore, qualitative studies could explore how patients experience specific aspects of HRQoL with incremental versus conventional hemodialysis.

Vascular Access-Related Complications

It is hypothesized that twice-weekly hemodialysis could reduce vascular access-related complications compared to thrice-weekly hemodialysis, particularly in patients with an arteriovenous fistula (AVF) or arteriovenous graft (AVG). Vascular access-related complications are a significant cause of hospitalization for patients on hemodialysis.^50,51 Supposed mechanisms of the relationship between incremental hemodialysis and vascular access-related complications are summarized in Figure 2. First, fewer punctures can reduce local inflammation, cytokine release, and intimal proliferation, all of which may contribute to stenosis.⁵² Fewer punctures may also lower the risk of infection, but studies comparing six-weekly hemodialysis to thrice-weekly hemodialysis found no relation between dialysis frequency and infection risk.⁵³ The risk of hematoma formation, which can progress to pseudo-aneurysms, may also be lowered.⁵⁴ Second, reduced shear forces during blood return may lower the risk of intimal proliferation and therefore of stenosis of the AVF or AVG.⁵⁵ Finally, the HEMO study found an association between intradialytic hypotension and an increased risk of fistula thrombosis.⁵⁶ Since RKF is a key eligibility criterion for starting with incremental hemodialysis, these patients more often have RKF, require less ultrafiltration, and therefore experience intradialytic hypotension less frequently, which may help reduce fistula thrombosis.^15,17

Figure 2.

Supposed mechanisms of the relationship between incremental hemodialysis and the possible reduction of vascular access-related complications. Incremental hemodialysis is associated with less intradialytic hypotension, which is associated with fistula thrombosis, and it decreases the number of punctures, possibly reducing stenosis, (pseudo)aneurysms, and infections.^52–54,56 Reduced shear forces may decrease the risk of stenosis.⁵⁵ This figure was created in BioRender (Roos S, 2025, https://BioRender.com/i12e044).

It is important to note that the hypothesis of a relationship between hemodialysis frequency and the risk of vascular access-related complications originates from studies comparing six-weekly dialysis with thrice-weekly dialysis, which observed a higher incidence of vascular access-related complications in the frequent dialysis schedule.⁵³ Notably, the difference in puncture frequency is more pronounced in these comparisons: 12 punctures versus six for double-needle cannulations. It remains unclear whether these results extend to the comparison between thrice-weekly and twice-weekly schedules, where the difference is smaller. In Figure 3, two RCTs and seven observational studies comparing incremental and conventional schedules on vascular access-related events are summarized. Details of these results are presented in Supplemental Table 2. In a RCT by Vilar et al., the conventional group demonstrated nonsignificantly higher vascular access-related complication rates compared with the incremental group.¹¹ In a pilot trial by Murea et al., which reported on the causes of hospitalization over a mean follow-up of 9 months, the low number of events in both groups made it difficult to draw any meaningful conclusions.²⁰ In the most recent study of Lucas et al., the complication rates of AVFs in 112 patients on an incremental schedule were compared with those in 76 patients on a conventional schedule, all from a single dialysis unit.²⁶ After a mean follow-up of 2 years, no difference was found and AVG or catheter complications were not reported. Chen et al. was the only study to report a significant reduction in vascular access-related complications in the incremental group.²³ However, this study included once-weekly schedules in the incremental group, with fewer punctures, potentially contributing to a greater difference. Caria et al. compared a schedule of once-weekly hemodialysis, combined with a low-protein diet, with conventional thrice-weekly hemodialysis and found no significant difference in vascular access-related hospitalizations.²¹ Two studies did not focus on incremental hemodialysis but compared long-term hemodialysis patients that maintained on twice-weekly versus thrice-weekly schedules and they found no difference in dysfunction of the AVF or vascular access-related hospitalizations.^57,58

Figure 3.

Comparison of incremental and conventional hemodialysis schedules on vascular access-related complications. ^aNo incidence rate ratio could be calculated because zero events occurred in the incremental group. ^bHR reported. Murea et al.²⁰ and Vilar et al.¹¹ were the only RCTs reporting this outcome. Both the study of Lin et al.⁵⁷ and Panaput et al.⁵⁸ compared maintenance twice-versus thrice weekly hemodialysis instead of incremental hemodialysis. HR, hazard ratio; RCT, randomized controlled trial.

Several methodologic limitations of the abovementioned studies must be taken into account. Most studies were observational, and prospective studies were small with <100 inclusions per the treatment group. Many studies only examined complications of AVF or grouped all types of vascular access-related complications together, including catheter-related complications, without distinguishing the results by access type. The relatively small sample sizes of many of the studies limit their ability to detect any significant differences in vascular access-related complications. Furthermore, the inclusion of once-weekly schedules into two studies complicates comparisons between the studies.^21,23

Fluid Overload

Several studies have reported an increased risk of cardiovascular events on Mondays or on the day after a 2-day interdialytic interval for patients on hemodialysis.^59–61 This may be explained by electrolyte imbalances as well as by fluid accumulation after the dialysis break. However, RKF (daily urine output or average creatinine-urea clearance) was not accurately reported in some of these studies, and no increased risk was found in the subgroup of patients with <12 months of dialysis treatment history, where the proportion of RKF is likely higher.⁶⁰ Therefore, it remains unclear whether the longer dialysis-free interval in incremental hemodialysis poses a risk for fluid overload. Mathew et al. reported that in facilities practicing incremental hemodialysis, about 56% (interquartile range, 37%–64%) of patients had urine collection within the first 91 days of dialysis.⁶² Lack of serial assessment of RKF could lead to late recognition of deteriorating RKF in patients on incremental hemodialysis and, consequently, a delay in schedule intensification. In addition, although no study has yet investigated this, patients may find it psychologically challenging to increase hemodialysis frequency as soon as this becomes necessary, which can contribute to a delay. A delay in schedule intensification could lead to an inadequate dialysis efficiency which could lead to fluid overload. The results of some small descriptive studies suggest that interdialytic weight gain was increased at the moment before transitioning from twice-weekly to thrice-weekly hemodialysis, providing some indication that delayed transitioning could be a potential concern in incremental hemodialysis.^62,63 Furthermore, some studies of patients on maintenance twice-weekly hemodialysis reported an increased risk of volume overload.^64,65

As no standard measurement method exists for the evaluation of fluid overload, we discussed studies that reported on outcomes related to fluid overload such as fluid overload related hospitalizations or events, ultrafiltration, BP (N-terminal pro [NT-pro]), brain natriuretic peptide (BNP), bioimpedance measurements, interdialytic weight gain, number of antihypertensive drugs, or fluid overload-related symptoms. The results of one RCT and five observational studies that evaluated any of these outcomes are presented in Table 2. The study of Vilar et al. was the only RCT that examined outcomes related to fluid overload.¹¹ Although, after 12 months, the incremental group had 1 L more extracellular water on bioimpedance and both the number of antihypertensive drugs used and the number of fluid overload-related events were higher in the incremental group, none of these differences were statistically significant.

Table 2.

Comparison of incremental and conventional hemodialysis schedules on outcomes related to fluid overload

Author (Year)	Study Design	Outcome	Results		P Value	Conclusion
			Incremental	Conventional
Vilar et al. (2022)11	RCT	Amount of antihypertensives at 12 mo	3.1 pills (95% CI, 2.5 to 3.8)	2.1 pills (95% CI, 0.9 to 3.2)	NSa	No difference
		Fluid overload related events	Three per person-year	Two per person-year	P = 0.49	No difference
		Pre-dialysis systolic BP at 12 mo	158 mm Hg (95% CI, 146 to 170)	160 mm Hg (95% CI, 143 to 176	NSa	No difference
		Extracellular water on bioimpedance measurement	20.8 L (95% CI, 19 to 23)	19.9 L (95% CI, 18 to 22)	NSa	No difference
Caria et al. (2014)21	Observational	Fluid overload related events	0	Two (acute pulmonary edema and congestive heart failure)	NR	N/A
Casino et al. (2022)22	Observational	Ultrafiltration at 3 mo	1×/wk: 1.95±1.06 L/session	2.2±0.84 L/session	P = 0.04b	N/A
			2×/wk: 2.3±1.07 L/session
Davenport et al. (2019)24	Observational	Pre-dialysis systolic BP	149±25 mm Hg	139±24 mm Hg	P < 0.001	Increased risk incremental group
		Pre-dialysis diastolic BP	77±16 mm Hg	71±16 mm Hg	P < 0.001
Kaja Kamal et al. (2017)25	Observational	Ultrafiltration		568 ml more compared to incremental group	P < 0.001	Increased risk conventional group
Torreggiani et al. (2022)30	Observational	Median NT-pro-BNP	1×/wk: 1970 ng/L (IQR, 1471–8018)	3×/wk: 4122 ng/L (IQR, 2103–9180)	P = 0.59a	N/A
			2×/wk: 3734 ng/L (IQR, 1590–10028)

Reported outcomes related to fluid overload: fluid overload related events/hospitalizations (n); ultrafiltration (ml or l or kg/session); systolic BP (mm Hg); N-terminal pro-brain natriuretic peptide (ng/ml); amount of antihypertensives (N); extracellular water (L). CI, confidence interval; IQR, interquartile range; N/A, not applicable; NR, not reported; NT-pro-BNP, N-terminal pro-brain natriuretic peptide; RCT, randomized controlled trial.

^aBased on 95% confidence intervals instead of P value.

^bStatistical significance between three groups is reported, no pairwise comparisons were performed.

Caria et al. reported no fluid overload-related events in 38 patients from the incremental group with a follow-up of 2 years.²¹ Davenport et al. was the only study that reported results that may indicate an increased risk of fluid overload in the incremental group.²⁴ In this observational study, a higher predialysis systolic and diastolic BP was reported in the incremental group. However, neither baseline BP nor RKF was reported.

Two studies reported results that may indicate a higher risk of fluid overload in the conventional group. First, Kaja Kamal et al. reported higher ultrafiltration in the conventional group.²⁵ This may partly be explained by selection bias, as patients in the conventional group were significantly older and had more diabetes and peripheral vascular disease compared with the incremental group. Second, Casino et al. conducted a one-way ANOVA to compare the ultrafiltration among patients with diuresis above 500 ml, divided into three groups: once-weekly, twice-weekly, and thrice-weekly dialysis schedules.²² The analysis revealed a significant difference between the groups, with lower ultrafiltration in the once-weekly group. However, pairwise comparisons between the twice-weekly and thrice-weekly groups were not specifically tested, and the difference between these two groups was minimal (0.1 L).

Effects of hemodialysis frequency on (NT-pro) BNP have been reported in one study, which found no difference between the two schedules.³⁰ However, both NT-pro BNP and BNP are partially cleared by the kidneys, meaning their levels are influenced by kidney function, and no definitive optimal cutoff for these biomarkers has been established.^66,67 Both biomarkers are partially cleared by dialysis, which further complicates their interpretation. The dry-weight reduction In hypertensive hemodialysis patients trial demonstrated that in hypertensive hemodialysis patients, BNP levels are primarily influenced by baseline BNP concentrations, and a decline in BNP levels did not predict reduction in dry weight.⁶⁸

To the best of our knowledge, there are no studies that report on symptoms related to fluid overload, such as dyspnea, coughing, or edema. Although these symptoms rely on subjective reporting, they are clinically relevant and the use of the DSI could provide more objective measurements. Furthermore, the clinically relevant effect of incremental hemodialysis on long-term fluid overload and more severe hypertension has not been evaluated but may contribute to the high prevalence of diastolic dysfunction in dialysis patients.⁶⁹

Conclusion

Since the initiation of chronic hemodialysis in 1960, several developments have led to the adoption of a standard thrice-weekly schedule. This schedule is now being reevaluated with the concept of incremental hemodialysis. Multiple studies have demonstrated the safety of incremental hemodialysis regarding mortality and the positive effect on RKF. Some guidelines also mention the option of incremental hemodialysis for patients with RKF, but its implementation is not yet standardized. Evidence regarding its effect on HRQoL remains limited. This is largely due to the small number of studies, limited sample sizes, and short follow-up periods. Furthermore, most studies regarding vascular access-related complications showed no difference between the conventional and the incremental group. Finally, the heterogeneity in reported outcomes is high, but most studies did not show an increased risk of fluid overload with the incremental schedule. Regular serial urine collections remain crucial for detecting declining RKF in a timely manner and enabling appropriate intensification of the dialysis schedule.

It is important to recognize that the absence of standardized protocols for implementing incremental hemodialysis leads to variability in outcomes across studies. Therefore, ongoing trials will contribute to a clearer understanding of the role of incremental hemodialysis. We identified 11 ongoing RCTs, of which ten will report on quality of life,^70–79 four on vascular access-related complications,^73,75,76,79 and seven on outcomes related to fluid overload.^{73–77,79,80} Since RCTs often face challenges such as limited sample sizes or short follow-up periods, large observational cohort studies with extended follow-up can offer additional valuable insights. As long as patients are counseled that schedules generally need to be intensified over time and that twice-weekly dialysis will not be permanent, this treatment approach undoubtedly has a place in the current era of personalized medicine.

Supplementary Material

kidney360-7-435-s001.pdf ^{(1.4MB, pdf)}

Disclosures

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/KN9/B314.

Author Contributions

Conceptualization: Erik L. Penne, Sanne Roos, Thomas S. van Lieshout.

Supervision: Erik L. Penne.

Visualization: Sanne Roos, Thomas S. van Lieshout.

Writing – original draft: Sanne Roos, Thomas S. van Lieshout.

Writing – review & editing: Alferso C. Abrahams, Erik L. Penne, Sanne Roos, Frans J. van Ittersum, Brigit C. van Jaarsveld, Thomas S. van Lieshout.

Funding

None.

Supplemental Material

This article contains the following supplemental material online at http://links.lww.com/KN9/B315.

Supplemental Table 1. Discussed observational and randomized studies comparing incremental with conventional hemodialysis schedules.

Supplemental Table 2. Comparison of incremental and conventional hemodialysis schedules on vascular access-related events.