Implementing a Protocol for Incremental Hemodialysis in Incident Patients With Kidney Failure: A Quality Improvement Initiative

Abstract

Background

Incremental hemodialysis (iHD), which adapts dialysis frequency to a patient’s residual kidney function, may ease the transition to dialysis, improve quality of life, and reduce costs.

Objectives

In our tertiary care center, we aimed to develop and implement an iHD protocol and to safely initiate 75% of eligible patients starting incident dialysis on iHD, defined as twice-weekly dialysis, over a two-year period. This project was a nephrology fellow–led quality improvement (QI) initiative conducted as part of the Canadian Society of Nephrology’s Quality Improvement and Implementation Science national curriculum.

Methods

We conducted a QI study from November 1, 2022, to December 31, 2024. An iHD protocol was developed with input from key stakeholders. It included a patient information sheet, routine 24-hour urine collections, a nursing safety checklist integrated into the electronic medical record, and an alert system to identify patients on iHD for physician review. Patients were eligible for iHD if medically stable without indications for thrice-weekly dialysis, and able to comply with physician recommendations and complete required 24-hour urine collections. The primary outcome measure was the proportion of incident patients initiated on iHD. Balancing measures included reasons for iHD discontinuation, hospitalization and mortality rates, and duration on iHD, while process measures included completion rates of nursing checklists and urine collections.

Results

Of 135 incident hemodialysis starts during the study period, 57 (42%) patients were deemed eligible for iHD, of which 44 (77%) were initiated on an incremental prescription (mean age 61 years). At the end of the study, 25% of patients remained on iHD, with a mean duration of 234 days on iHD. The most common reasons for transition to thrice-weekly hemodialysis were volume overload (54%) and inadequate clearance (33%). Five Plan–Do–Study–Act (PDSA) cycles led to refinements of the protocol, including increased frequency of nursing checklist, facilitated identification of patients on iHD, more frequent electrolyte monitoring, and multiple educational sessions with healthcare providers. Overall, the 24-hour urine collection completion rate by patients was 69%, while nursing checklist completion rates increased from 61% in the first 8 months to a 100% by study end. Mortality and dialysis-related hospitalization rates, excluding vascular access-related issues, were significantly lower in the incremental group than in the conventional group (mortality: 2.3% vs. 17.6%; hospitalization: 0.10 vs. 0.22 events per patient-year).

Conclusion

A structured iHD protocol, refined through iterative PDSA cycles, enabled safe initiation of iHD in 77% of eligible patients in our center. This study illustrates how a systematic, QI-driven approach can guide other centers in adopting incremental HD safely while promoting ongoing process improvement and patient-centred care.

Introduction

The transition from chronic kidney disease to dialysis is associated with substantial challenges for patients, including impaired physical and mental health, reduced functional capacity, limitations in daily activities, and decreased quality of life.^1-3

Conventional thrice-weekly in-center hemodialysis remains the predominant modality of kidney replacement therapy worldwide, regardless of individual patient characteristics. ⁴ Despite growing evidence from observational studies and pilot trials demonstrating non-inferior outcomes with initiation of incremental hemodialysis (iHD) in incident patients, there remains a substantial gap in knowledge and an absence of standardized protocols to support its implementation. ⁵ Addressing this gap is essential to promote more personalized, resource-efficient care and to ensure the safe and systemic adoption of iHD in clinical practice.

Patients starting in-center hemodialysis often have residual kidney function, which may permit a gradual approach to dialysis, starting with twice-weekly sessions. ⁶ This strategy may help preserve residual kidney function by reducing hemodialysis-induced stress on the kidneys, while offering a more patient-centred transition to life on dialysis.^7-10 In addition, it can improve quality of life, protect vascular access, lower healthcare costs, and optimize resource allocation.^11-16 As emphasized by the International Society of Nephrology in its call for planet-friendly renal care practices, iHD also represents an impactful approach to promoting environmental and economic sustainability, with measurable reductions in water and energy consumption — benefits that extend beyond the individual patient to the healthcare system as a whole.^17,18 However, these advantages must be weighed against potential risks, including uremic complications, electrolyte imbalances, and fluid overload. ¹⁹ For these reasons, iHD should be implemented with close monitoring, ideally guided by a structured protocol to ensure patient safety. ⁷

At our tertiary care center, which cares for over 300 prevalent patients receiving hemodialysis across three units, we aimed to increase the proportion of incident patients initiated on iHD, defined as twice-weekly dialysis, targeting 75% of eligible patients over a two-year period. To ensure safe implementation, we developed a structured protocol through stakeholder engagement and iterative Plan-Do-Study-Act (PDSA) cycles. Our ultimate goal was to provide a reproducible, quality improvement (QI)–driven model for other centers seeking to implement a safe and successful iHD program. This project was a nephrology fellow–led QI initiative conducted as part of the Canadian Society of Nephrology’s Quality Improvement and Implementation Science (CSN-QUIS) national curriculum. ²⁰

Methods

This single-center, mixed-methods QI project followed the principles described by Langley et al. ²¹ This included establishing a clear aim statement, evaluating outcomes, process and balancing measures, and performing iterative PDSA cycles to refine our intervention.

Study Period and Eligibility Criteria

This study was conducted between November 1, 2022, and December 31, 2024. Eligibility was defined as being a medically stable patient with kidney failure who had not yet started hemodialysis or had recently started (<2 weeks) with no acute medical issues, and no indication for more frequent dialysis (such as severe volume overload, severe hyperkalemia, calciphylaxis or uremia). Eligible patients were also expected, based on the treating team’s clinical assessment, to adhere to physician recommendations and complete regular 24-hour urine collections required for monitoring during iHD. Moreover, patients were excluded if they had (1) an acute coronary syndrome or congestive heart failure exacerbation within the preceding six months; (2) evidence of volume overload (defined as requiring >2L ultrafiltration per session), (3) inadequate clearance (defined as a urine volume < 600ml), or (4) severe uremia, calciphylaxis or other conditions requiring frequent dialysis. Patients who were not eligible or who met an exclusion criterion were initiated on thrice-weekly hemodialysis. Patient characteristics are listed in Table 1.

Table 1.

Patient Characteristics

Characteristic	Incremental patients	Non-incremental patients
Patients	N=44	N=91
Age, years, mean	61	73
Sex, n (%)
Male	20 (45)	56 (62)
Female	24 (55)	35 (38)
Total patients eligible for iHD, n (%)	44 (100)	13 (14)
Comorbidities, n (%)
Diabetes mellitus type 2	21 (48)	53 (58)
Hypertension	38 (86)	72 (79)
Coronary artery disease	9 (20)	18 (20)
Congestive heart failure	6 (14)	31 (34)
Cerebral vascular accident	4 (9)	4 (4)
Peripheral vascular disease	3 (7)	12 (13)
Cause of end-stage kidney disease, n (%)
Diabetic nephropathy	16 (36)	34 (37)
Hypertensive nephrosclerosis	8 (18)	5 (5)
Acute kidney injury	0 (0)	7 (8)
IgA nephropathy	1 (2)	4 (4)
Focal segmental glomerulosclerosis	1 (2)	2 (2)
Congenital kidney disease	2 (5)	7 (8)
Failed kidney transplant	2 (5)	1 (1)
Multiple myeloma	2 (5)	2 (2)
Obstructive pathology	3 (7)	2 (2)
Hepatorenal syndrome	0 (0)	2 (2)
Microscopic polyangiitis	1 (2)	1 (1)
Others (including unknown)	8 (18)	24 (26)
Type of vascular access, n (%)
Central venous catheter	37 (84)	81 (89)
Arteriovenous fistula	7 (16)	10 (11)

Measures

The primary outcome measure was the proportion of eligible incident patients initiated on iHD between November 1, 2022, and December 31, 2024.

Process measures included: (1) the mean number of completed nursing checklists and 24-hour urine collections per patient, (2) the overall completion rate of the iHD protocol, as well as completion rates during the periods of May–December 2023, January–September 2024, and October–December 2024, and (3) the overall completion rate of 24-hour urine collections.

Balancing measures included: (1) dialysis modality at study end (remained on iHD, transitioned to more frequent HD, modality switch, change to conservative management, recovered kidney function, transferred to another facility, or deceased), (2) mean annual hospitalization rates (all-cause, dialysis-related and vascular access-related) among iHD and non-iHD groups, (3) reasons for transitioning to thrice-weekly dialysis, (4) duration on iHD among patients who discontinued before study completion, and (5) mortality rates among patients on iHD versus conventional. Dialysis-related hospitalizations were defined as admissions for volume management issues, electrolyte abnormalities or uremic complications (including uremic symptoms, uremic pericardial disease, and related conditions). ²² We also evaluated vascular access-related hospitalizations (including infections, and access thrombosis/malfunction). Of note, outcomes for the iHD group were adjudicated only for the period during which patients remained on incremental dialysis.

Data Collection

Data were collected from manual chart review, the hospital database and the dialysis electronic medical record. Baseline characteristics, including age, sex, comorbidities, cause of kidney failure, and type of vascular access, were collected for all incident patients.

Development and Implementation of a Structured Protocol

A structured protocol was developed to ensure the safe implementation of iHD through input from stakeholders and was launched on November 1, 2022. The multidisciplinary team included nephrologists, nephrology trainees, dialysis nurses, nurse managers, nurse educators, dietitians and an information technology specialist. The initial protocol included a) a patient information sheet describing iHD (Figure S1), b) nursing and physician education sessions, c) a nurse-led protocol whereby every 6 weeks the patient was instructed to do a 24-hour urine collection to verify residual urine volume. Nurses also completed a safety checklist in the dialysis EMR, including a questionnaire screening for uremic symptoms (fatigue, itchiness or nausea), volume overload (shortness of breath, orthopnea, worsening edema, 1 episode of interdialytic gain greater than 2kg in the past week, extra dialysis session required), and hyperkalemia (K>5.5mmol/L) (Figure 1, and d) an alert system prompting physician review if any element in the checklist was positive. Importantly, while the checklist assessed specific signs and symptoms, the presence of a single criterion did not automatically prompt escalation to thrice-weekly HD. Rather, the checklist was intended as a screening tool based on patients’ symptoms and signs to alert physicians to reassess the patient’s overall status and determine whether escalation to conventional dialysis was warranted. The decision to transition patients remained at the discretion of the treating physician and was based on the overall clinical picture. No standardized diuretic protocol was implemented during the study to keep the protocol as practical as possible. Medication adjustments were made at the treating physician’s discretion. Multiple PDSA cycles were performed throughout the study to refine and optimize the protocol, with regular input from the multidisciplinary team. ²³

Figure 1.

Updated protocol embedded into the EMR (November 2024)

Ethical Considerations

An exemption from Research Ethics Board (REB) review was granted by the McGill University Health Centre’s Centre for Applied Ethics due to the study’s QI focus.

Results

Baseline Characteristics

Between November 1, 2022, and December 31, 2024, 135 patients started in-center hemodialysis. Among these patients, 57 (42%) were deemed eligible for iHD, of which n=44 (77%) began iHD. The remaining patients (n=13) were excluded due to physician preference, resulting in a total of 91 patients receiving thrice-weekly conventional HD.

As outlined in (Figure 2), 78 patients were deemed ineligible for iHD. The main reasons for ineligibility were: perceived need for higher solute clearance (n=48), including severe uremic symptoms, uremic pericardial disease, calciphylaxis, severe volume overload (n=22), concerns regarding adherence (n=6), hyperkalemia (n=1) and recent acute coronary syndrome (n=1). Baseline characteristics comparing the iHD and non-iHD groups are shown in (Table 1). The iHD cohort included fewer males (45% vs. 62%) and was younger (mean age 61 vs. 73 years) at dialysis initiation. Comorbidities and cause of kidney failure were similar between the two groups. In both cohorts, most patients received HD via a central venous catheter, 84% in the iHD cohort and 89% in the non-iHD cohort.

Figure 2.

Patient flow chart and patient trajectory after starting incremental hemodialysis (November 1,2022 to Dec 31, 2024)

Measures

Outcome Measure

We achieved our primary outcome measure by initiating iHD for 44 of the 57 eligible patients (77%).

Process Measures

On average, completion rates for the iHD protocol were 71% for the nursing checklist and 69% for the 24-hour urine collections. Checklist completion rates improved significantly over the study period following PDSA cycles, increasing from 61% during the first 8 months to a 100% at the end of the study (Table 2).

Table 2.

Process Measures

Protocol component, time point	Completion rate (%)
Nursing checklist, overall	71
Nursing checklist, at 8 months	61
Nursing checklist, at end of study	100
24-hour urine collection, overall	69

Balancing Measures

The median hemodialysis session length on iHD was 3.5 hours. At the end of the study period, 24 patients on iHD (55%) had transitioned to three times per week, while 11 (25%) remained on iHD. Two patients (5%) received a kidney transplant, 3 (7%) switched to home dialysis, 1 (2%) opted for conservative care, and 1 (2%) recovered kidney function. One patient (2%) was transferred to another facility, and there was one death, which was attributed to sudden cardiac death (2%) (Figure 2). Among the patients who transitioned to three times per week HD, the most common reason was volume overload (54%), followed by inadequate clearance parameters, including uremic symptoms (33%). One patient (4%) switched due to hyperkalemia, and two patients (8%) due to poorly controlled blood pressure. The mean duration on iHD was 234 days, ranging from 9 to 734 days (Table 3).

Table 3.

Reasons for Transition to Thrice-Weekly HD and Average Time on iHD

Reason for transition to three times a week HD, n (%)	N=24
Volume overload	13 (54)
Inadequate clearance	8 (33)
Poorly controlled blood pressure	2 (8)
Hyperkalemia	1 (4)
Average duration on iHD among patients who transitioned to thrice-weekly HD, days	234

All-cause hospitalization rates were lower among patients on iHD: 0.75 events per patient-year, compared with 0.86 among patients on regular HD. Dialysis-related hospitalization rates were also lower among patients on iHD: 0.10 events per patient-year, compared with 0.22. Vascular-related hospitalization rates were double in the incremental group: 0.13 events per patient-year, compared with 0.05 in the non-incremental group. Lastly, mortality was significantly lower in the iHD group compared to the non-iHD group (2.3% vs. 17.6%) (Table 4).

Table 4.

Mortality and Hospitalization Rates

Variable	iHD	Non-iHD
Mortality rates during the entire study period (%)	2.3	17.6
All-cause hospitalization rates (events per patient-year)	0.75	0.86
Dialysis-related hospitalization rates (events per patient-year)	0.10	0.22
Vascular-related hospitalization rates (event per patient- year)	0.13	0.05

The iHD protocol was launched on November 1, 2022 and updated following iterative PDSA cycles. It was integrated into our EMR (Renal Insight, Constellation Kidney Group) to enhance usability and facilitate patient monitoring (Figure 1). Key improvement strategies included: (1) repeated education sessions for nurses, trainees and physicians, (2) change of frequency of nursing checklist from every 6 weeks to a simplified weekly checklist, (3) adding an additional electrolyte measurement at the 3-week mark for safety, (4) alerts integrated into the EMR for nurses to remind the patients about urine collections, and (5) alerts integrated into the EMR to identify patients on iHD (Figure 3).

Figure 3.

PDSA cycles

Discussion

This QI study demonstrates the safe and feasible implementation of an iHD protocol for patients initiating dialysis at a tertiary care center, while also identifying opportunities for ongoing improvements. By integrating QI methodology, including iterative Plan-Do-Study-Act (PDSA) cycles, the protocol was iteratively adapted to optimize its use in real-world clinical settings.

Incremental HD was initiated in 77% of eligible patients, meeting our target of 75%, and indicating that our selection criteria were appropriate. Allowing patients to transition to iHD within two weeks of starting conventional hemodialysis provided flexibility in patient recruitment, especially for those who initially needed more frequent dialysis due to volume overload. Safety outcomes were favorable, with lower all-cause and dialysis-related hospitalizations and mortality rates observed among patients on iHD compared with conventional regimens. Many patients were deemed ineligible for iHD as the treating team, based on clinical judgment, determined they required a higher dialysis dose, often in the setting of severe uremic symptoms, volume overload, or other clinical concerns. Thus, the non-iHD cohort was overall more clinically fragile and had poorer residual kidney function at dialysis initiation. These baseline differences likely contributed to the higher rates of both all-cause and dialysis-related hospitalizations observed in the conventional hemodialysis group. While the younger age and lower comorbidity burden of the iHD cohort likely contributed to these outcomes, reflecting a degree of selection bias, the structured follow-up and close monitoring per protocol may have played an important role in preventing adverse outcomes.

Interestingly, vascular access-related hospitalizations were more frequent in the iHD cohort. This finding should be interpreted cautiously, given the small sample size and potential confounding factors, such as catheter exposure duration and follow-up intensity. The structured monitoring associated with the iHD protocol may have increased detection of access-related complications. Further studies are needed to determine whether this observation reflects true differences in vascular access outcomes.

It should be noted, however, that these outcomes were assessed only during the period patients remained on iHD; events occurring after transition to thrice-weekly hemodialysis, often prompted by clinical deterioration, were not included, introducing attrition bias. Nonetheless, the results suggest that incremental dialysis can be safely implemented in carefully selected patients.

An important proportion (55%) of our cohort increased HD frequency to three times per week during the study period. This rate was higher than that reported from a 2021 cohort study of 113 patients, with 45 patients undergoing iHD, in which 17% transitioned to thrice-weekly HD after 1 year and 32% after 2 years. ²⁴ A comparison is limited by the fact that they did not assess the underlying reasons leading to increased dialysis frequency. However, we hypothesize that we applied stricter criteria for maintaining patients on iHD. In our study, volume overload (>2kg interdialytic weight gain) was the most common reason for transitioning patients to more frequent HD. While we routinely assess volume status using interdialytic weight gain, monitor for symptoms of volume overload, and maximize diuretic doses in a standardized fashion, ²⁵ this suggests we may need to examine other contributory factors, such as dietitian review, adherence to medications, and interdialytic weight gain standardized to ideal body weight.

Iterative PDSA cycles were central to refining the protocol and supporting implementation. Ultimately, these changes improved recognition of patients needing alternate dialysis prescriptions and supported better clinical assessment. Moreover, a few educational PDSA cycles were completed among dialysis staff to ensure knowledge of protocol updates, address provider turnover, and maintain competency. Toward the end of the study, the frequency of the nurses’ checklist completion was increased to weekly to reduce the risk of errors. This change addressed nursing staff feedback about difficulty remembering when to administer the checklist and facilitated its integration into routine care. These PDSA cycles played a significant role in reinforcing adherence to the iHD protocol, as illustrated by the marked increase in checklist completion rates from 61% at the start of the study to 100% at the end. These findings highlight the importance of continuous QI processes in sustaining long-term adherence.

The iHD protocol remains in place beyond the study and continues to be implemented in our center. As with most QI initiatives, this project remains an evolving process aimed at long-term sustainability, and we continue to actively maintain and refine the protocol as part of our ongoing QI efforts. As illustrated, completion of urine collections remains suboptimal (69%). Future efforts will focus on increasing patient engagement with the protocol through educational materials and periodic reminders; to this end, patient information sheets and alert systems have been introduced to support adherence. The initial protocol did not include the evaluation of residual kidney function using the KRU calculation, ²⁶ as it was determined that assessing dialysis adequacy could be sufficiently achieved through monitoring urine volume, biochemistry parameters, and patient assessments. This approach reflects the study’s emphasis on patient-centred care and symptom-guided management rather than a sole focus on clearance metrics. However, following discussions with key stakeholders, the KRU calculation will be incorporated into subsequent PDSA cycles to enhance the evaluation of iHD adequacy. Additionally, to optimize volume management and hopefully reduce the transition rate to three times a week HD, standardized diuretic protocols will be implemented in future PDSA cycles.

This study has several strengths, including standardized patient monitoring through integration of an iHD protocol into our EMR system, a collaborative development process involving a multidisciplinary team, and iterative improvements guided by regular PDSA cycles. As mentioned earlier, iHD offers advantages in both economic and environmental sustainability. Although cost savings were not a prespecified outcome measure, the avoidance of 1 dialysis session per week in 44 patients indicates the potential for meaningful reductions in both resource use and healthcare costs. These advantages highlight an additional layer of value from implementing iHD, complementing its clinical safety and patient-centred benefits.

Nonetheless, certain limitations should be acknowledged. Firstly, our iHD protocol preferentially selects healthier patients on kidney replacement therapy, thus we are unable to draw definitive conclusions about the superiority of iHD over three times a week HD for all incident kidney failure patients. That being said, there does not seem to be a signal of excess risk with iHD in our experience. Secondly, an important limitation in comparing the two groups was the lack of available pre-dialysis data, including baseline clinical characteristics, residual kidney function measures, and nutritional and inflammatory markers. In particular, KRU was not systematically collected in this cohort. As mentioned previously, future cohorts will incorporate KRU measurements into the protocol to allow for a more comprehensive assessment of residual kidney function and dialysis adequacy. Thirdly, variability in healthcare providers’ education may have been present prior to enhanced training on the iHD protocol, which could have affected initial checklist completion rates. Additionally, this study was limited to a 2-year period, restricting assessment of long-term safety outcomes. Finally, the single-center design may limit the generalizability of our findings to other settings.

Conclusion

Overall, iHD is a safe, feasible, and patient-centred approach that supports efficient resource use and facilitates a gradual transition to hemodialysis. ²⁷ This study provides a model for other centers aiming to implement iHD safely and effectively. To further explore patient and provider perspectives on iHD, a qualitative follow-up study using semi-structured interviews was conducted at our center. ²⁸

ORCID iDs

Alba Sanchez-Allakhverdieva https://orcid.org/0009-0006-2849-6062

Noémie Laurier https://orcid.org/0009-0004-1895-5179

Daniel Blum https://orcid.org/0000-0001-5742-0848

Catherine Weber https://orcid.org/0000-0002-2558-6904

Emilie Trinh https://orcid.org/0000-0001-8479-6656