Patient, Nurse, and Physician Perspectives on Personalized, Incremental Hemodialysis
Authors: Glenda V. Roberts, Nichole M. Jefferson, Rossella Picillo, Massimo Torreggiani, Giorgina B. Piccoli, David A. Jaques, Vandana D. Niyyar, Janice Lea, Maud Hercé, Isabelle Heude, Julie Rouleau, Aurélie Livet, Fabienne Ribot, Célia Pernet, Paul T. Conway, Mariana Murea
Journal: Journal of the American Society of Nephrology (2024)

Routine, thrice-weekly full-dose hemodialysis with disregard of residual kidney function has been prioritized to patients who choose hemodialysis,1 unlike the approach for patients who choose peritoneal dialysis.2 In-center, incremental hemodialysis involves once- or twice-weekly dialysis sessions, usually lasting 3–4 hours, for patients with residual kidney function at initiation, with subsequent individualized adjustments on the basis of changes in residual kidney function or clinical manifestations.3,4 Notwithstanding growing data affirming the safety of incremental hemodialysis for patients with residual kidney function,5 it remains underutilized.6 We present patient and physician perspectives on incremental hemodialysis, aiming to expand treatment options. Why We Should Be Offered Incremental Hemodialysis: Patient Perspectives Dialysis affects employment and livelihoods, often leading to job loss and dependency. The demanding full-dialysis schedule of 3–4 hours, three times per week, contributes to this steep disability, with each hemodialysis session amounting up to 8–9 hours when factoring in travel and post-treatment recovery. Residual kidney function, individual needs and wishes, and respect of patients' time outside dialysis treatment are often overlooked. Gradually starting hemodialysis, when feasible, helps patients adjust to a new lifestyle. It may allow for a better development of the dialysis vascular access, reducing, in the French experience, hospitalization for vascular access problems.7 "I am a manager; I understand numbers and growing needs. Incremental hemodialysis is the only logic[al] way to deal with its start. I never adapted, but at least it made dialysis transition bearable and understandable," a patient with 20-year hemodialysis history and two kidney transplants said. How to Prepare Patients for Incremental Hemodialysis: Physician Perspectives A supportive patient–physician relationship, initiated whenever possible during the predialysis phase and maintained by nurses and physicians at dialysis centers, is noteworthy. According to the French experience, patients followed with intensive predialysis care were ten times more likely to initiate incremental hemodialysis compared with those without such an exposure.7 Certain behaviors could optimize incremental hemodialysis adoption (Figure 1). 1. Prepare patients for incremental hemodialysis when medically appropriate. Figure 1: Patient–medical team collaboration throughout the cycle of dialysis and personalized care.Thoroughly explain the option of incremental hemodialysis and the rationale behind adjusting dialysis intensity according to biological needs, including the use of timed urine collection for monitoring residual kidney function when necessary. 2. Build trust in the patient–physician relationship. Incremental hemodialysis is more than a treatment schedule; it is a personalized journey requiring regular clinical and psychological discussions. Regularly reassessing the hemodialysis dose and modality reassures patients and strengthens the patient–physician bond. 3. Educate patients about expectations and self-responsibility. Incremental hemodialysis requires patients to understand and discuss their symptoms with their physicians without fear of dialysis intensification. Treatment success depends on patients' willingness to adjust dialysis intensity when medically recommended. 4. Understand what matters and consider variability in individual preferences. Recognize that patients' readiness for change varies, evolving uniquely for each individual. This attitude departs from the usual hemodialysis care, which focuses more on numbers than on the patient's overall well-being. How We Should Be Coached at Transition from Less to More Dialysis: Patient Perspectives Patients should have a say in gauging the benefits of more hemodialysis in the context of their needs as persons. If higher hemodialysis intensity improves their sense of well-being, adherence is more likely. If patients initially resist additional dialysis, physicians should respect this view as much as possible without risks. Often, we need time to understand the risks and the need for changes and to coordinate with family and work. Empathetic patient–physician dialogues facilitate transparency, promote positive relationships, and demonstrate physicians' knowledge of patients' needs outside merely a medical prescription. Why Incremental Hemodialysis Works: Nurse Perspectives on Overcoming Skepticism and Recognizing Benefits As dialysis nurses with over a decade of experience, our initial reaction to incremental hemodialysis was skepticism because of the traditional standards and concerns about underdialysis. We also questioned patients' ability to understand the new process. Despite these initial reservations, we came to recognize the logic behind incremental hemodialysis and have grown comfortable with its monitoring requirements. We observed that it offers several advantages: greater patient comfort, time for adaptation and learning, enhanced quality of life, and better work–life integration for younger patients. We would never get back to the previous routine. Nonetheless, it requires more logistical planning, and there may be competition with peritoneal dialysis because some patients may prefer the lower frequency of hemodialysis sessions. Why Incremental Hemodialysis Has Not Been Widely Adopted: Physician Perspective Nephrologists may hesitate to offer incremental hemodialysis because of prejudgments that patients resist prescription changes and/or do not periodically submit timed urine collection, concerns about rapid decline in residual kidney function after hemodialysis initiation, belief that more hemodialysis equates to better outcomes even for patients with residual kidney function, and financial disincentives linked to per-hemodialysis payment. These biases inhibit innovation in dialysis practices. Experiences from France7 and Switzerland,8 where incremental hemodialysis is commonly practiced and advocated as means "to gain time, adapt to treatment and, if possible, get a kidney transplant," show that resistance to prescription changes is rare when patients are educated and involved in decision making. Speculations around patients not submitting urine collections and experiencing underdialysis lack supporting evidence. Clinical and biochemical data can often guide prescription adjustments without timed urine collections. Studies have shown that the decline in residual kidney function is similar between patients treated with hemodialysis and peritoneal dialysis.8 Why We Should Spare Disparaging Labels: Shared Perspectives Demeaning terms such as "end-stage" or "failure" can be replaced with "kidney dysfunction requiring dialysis."9 Meaningful discussions between the medical workforce—physicians, advanced practice providers, nurses, dietitians, and social workers—and patients should foster mutual respect within a nonpunitive mindset.10 Terms like "noncompliance" or "nonadherence" ought to be avoided (Figure 1). First, these terms create (or exacerbate) adversarial or subservient relationships between physicians and patients. The objective should be to understand why patients may be hesitant to increase the dialysis dose, especially if they feel well on their current regimen. Second, "noncompliance" or "nonadherence" stigmatizes patients. Such language can influence the attitudes of other clinicians, putting the patients at risk of compromised care. Third, terms such as "no show," "noncompliance," or "nonadherence" miss chances to enhance patient-centered care. Instead, these instances should be seen as sentinel events warranting more attention to logistic problems (e.g., transportation) or miscommunication. What Opportunities and Challenges Exist in Personalized, Incremental Hemodialysis: Patient Perspectives Dialysis care historically prioritized workforce convenience, assuming a passive patient role. Growing patient advocacy has shifted the focus to patient-centered care, exemplified by incremental hemodialysis. This personalized approach can improve access to dialysis in low- to medium-income countries and reduce the economic and ecological effect in high-income countries. Furthermore, an incremental approach to home hemodialysis is feasible and could encourage greater adoption and long-term sustainability of home dialysis. How to Fulfill the Potential of Incremental Hemodialysis: Physician Perspectives Science and policy reforms are paramount. Ongoing clinical trials in Europe, Australia, Canada, and United States could strengthen the scientific foundation and compel adoption of incremental hemodialysis by all physicians, important for streamlining transitions amidst physician changes from pre- to postdialysis care.11 Incentivizing individualized care and incorporating patient accountability through refined policies are, nevertheless, requisites. Closing Incremental hemodialysis embodies team collaboration and compassion. To enhance patient engagement, physicians should adopt nonpunitive approaches, giving patients freedom of choice and informed decision. Progress necessitates policy makers to mend quantity-driven reimbursement systems and introduce shared responsibility between patients and physicians for treatment outcomes.