. 2019 Dec 6;5(2):135–148. doi: 10.1016/j.ekir.2019.11.014

Table 1.

Perceived barriers to incremental hemodialysis

Obstacle	Reason	Potential solution
Concern for inadequate clearance of uremic solutes (including solutes other than urea) due to insidious and unpredictable loss of RKF	No study done to determine the required minimum amount of solute clearance in patients with incident ESKD, with or without appreciable RKF, starting HD. At risk for untimely transition from less frequent to conventional thrice-weekly HD treatments	Time-delineated incremental HD
Concern for insidious onset of volume overload and adverse clinical outcomes	In patients on conventional thrice-weekly HD, patient mortality is higher after the longer interdialytic interval.	Aggressive combined diuretic therapy Timely adjustment in target weight and dialysis duration/frequency
Undefined effects on patient survival and other important clinical outcomes (e.g., changes in RKF, rate of cardiovascular events, hospitalization, nutrition, vascular access complications, quality of life, control of uremic symptoms)	Retrospective, observational data on incremental HD produced heterogeneous results.	Clinical trials powered to determine the effects of different schedules of incremental HD on patient survival
Uncertain patient adherence to serial urine collections	Reliance on potentially inaccurate urine collections. Retrospective studies showed that RKF assessment is not routinely done, even at dialysis units with structural organization for incremental HD.	An incentive for patients to collect urine is incremental dialysis (less frequent and/or shorter HD sessions)
Uncertain patient adherence to recommended changes in HD treatment frequency or length	Many nephrologists experience patient refusal when increasing the dialysis frequency/time; this risk has not been systematically quantified.	Set expectations from the outset: when the time comes to increase HD dose, the discussion is about how to do it, not whether it will be done. Leadership and firmness must accompany the empathy for the added dialysis burden.⁹⁸
Faulty identification of patients who can undergo incremental HD	Assessment of RKF may be inaccurate. Confusion among nephrologists about the suitable tests to assess RKF A large panel of criteria to identify patients suitable for incremental HD perceived as not pragmatic	Apply incremental HD to cases of certain suitability Simplify suitability criteria to consist mainly of urine output volume and patient volume status
Added workload for the dialysis staff and nephrologist	Requirement of additional medical team members to monitor serial assessment of RKF and to implement changes in HD prescription in a timely manner	Operationalize the process of serial urine collections Develop an automatic electronic system to calculate RKF, Kru (based on interdialytic urine collection), and the required dialysis spKt/V_urea (based on HD prescription) to achieve desired stdKt/V_urea
Shortfall in financial reimbursement for all dialysis stakeholders	Per current reimbursement model, payment is based on the number of dialysis sessions delivered per patient.	Use shorter, thrice-weekly HD as the form of incremental HD; this approach bears no financial shortfalls, unless spKt/V_urea reports <1.2.

ESKD, end-stage kidney disease; HD, hemodialysis; RKF, residual kidney function.