Incremental versus conventional hemodialysis in end-stage kidney disease: a systematic review and meta-analysis

Abstract Introduction Appropriate dialysis prescription in the transitional setting from chronic kidney disease to end-stage kidney disease is still challenging. Conventional thrice weekly hemodialysis (HD) might be associated with rapid loss of residual kidney function (RKF) and high mortality. The benefits and risks of incremental HD, compared with conventional HD were explored in this systematic review and meta-analysis. Methods We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials up to April 2023 for studies that compared the impacts of incremental (once- or twice-weekly HD) and conventional thrice-weekly HD on cardiovascular events, RKF, vascular access complications, quality of life, hospitalization, and mortality. Results A total of 36 articles (138,939 participants) were included in this meta-analysis. The mortality rate and cardiovascular events were similar between incremental and conventional HD (OR 0.87; 95% CI 0.72-1.04 and OR 0.67; 95% CI 0.43-1.05, respectively). However, hospitalization and loss of RKF were significantly lower in patients treated with incremental HD (OR 0.54; 95% CI 0.32-0.89 and OR 0.31; 95% CI 0.25-0.39, respectively). In a sensitivity analysis that included studies restricted to those with RKF or urine output criteria, incremental HD had significantly lower cardiovascular events (OR 0.22; 95% CI 0.08-0.63) and mortality (OR 0.54; 95% CI 0.37-0.79). Vascular access complications, hyperkalemia, and volume overload were not statistically different between groups. Conclusions Incremental HD has been shown to be safe and may provide superior benefits in clinical outcomes, particularly in appropriately selected patients. Large-scale randomized controlled trials are required to confirm these potential advantages.