Incremental (Twice-Weekly) Hemodialysis Treatment Criteria* Adequate residual kidney function with a urine output >600 ml/day (transition to thrice-weekly if urine output drops to <500 ml/day) ‡ Limited fluid retention between two consecutive HD treatments with a fluid gain <2.5 kg (or less than 5% of the ideal dry weight) without HD for three to four days Limited or readily manageable cardiovascular or pulmonary symptoms without clinically significant fluid overload† Suitable body size relative to residual renal function; patients with larger body size may be suitable for twice-weekly hemodialysis if not hypercatabolic Hyperkalemia (K >5.5 mEq/L) infrequent or readily manageable Hyperphosphatemia (P >5.5 mg/dL) infrequent or readily manageable Good nutritional status without florid hypercatabolic state Lack of profound anemia (hemoglobin>8 g/dL) and appropriate responsiveness to anemia therapy Infrequent hospitalization and easily manageable comorbid conditions Satisfactory health-related quality of life and functional status Residual urea clearance (KRU) >3 ml/min/1.73m2 (transition to thrice-weekly if KRU <2 ml/min/1.73m2)¶

Implementation Strategies In order to initiate twice-weekly hemodialysis, the patient should meet the first (urine output >600 ml/day) and the last criteria (KRU> 3 ml/min/1.73m2)¶, plus most (five out of nine) other criteria. Examine these criteria every one to three months in all twice-weekly hemodialysis patients and compare outcome measures between twice-weekly and thrice-weekly hemodialysis patients to assure outcome non-inferiority for continuation of twice-weekly hemodialysis. Consider transition from a twice-weekly to thrice-weekly hemodialysis regimen if patient’s urine output drops <500ml/day, if KRU declines < 2 ml/min/1.73m2, or if patient’s nutritional status or general health condition shows a deteriorating trend over time.

^*The proposed criteria may be refined for use in clinical trials and clinical decision making.

^‡The minimum required urine output to initiate twice-weekly has been changed to 600 ml/day in this adaptation, while >500 ml/day is needed to maintain twice-weekly regimen.

^†Lack of systolic dysfunction (EF>40%) and no major coronary intervention over the past three months.

^¶Criterion #11 in this adaptation.