Later HD, Less HD, No HD: A New Paradigm?
Recent studies have cast doubt on the universal superiority of the conventional approach to dialysis.
For more than half a century, we have regarded dialysis therapy as the life-saving intervention, assuming that without maintenance dialysis treatment survival would be impossible in patients with advanced kidney failure. To that end, more dialysis and earlier dialysis have been considered better patient care, whereas delayed initiation or less frequent hemodialysis (HD) treatment than at least thrice-weekly is unwanted.
Emerging studies in recent years, however, have cast doubt on the universal superiority of the conventional approach to the initiation to dialysis. A study in 2009 suggested that, among nursing home residents with advanced kidney insufficiency, initiation of dialysis was associated with a substantial and sustained decline in functional status. A provocative clinical trial from Australia and New Zealand in 2010 suggested that planned early initiation of dialysis in patients with stage 5 chronic kidney disease (CKD) was not associated with an improvement in survival or other clinical outcomes. These data have been supported by an increasing number of observational analyses in different dialysis populations.
Recently, there has been a resurgence of data about twice-weekly HD, a taboo subject in many nations where anything less than thrice-weekly HD is considered substandard and inferior. There are even data on once weekly on less frequent HD as a smoother transition to renal replacement therapy (RRT). Some experts have revisited the old school of the nutritional management of CKD and have advocated the use of low protein and low salt diets to slow progression of the kidney disease or to manage uremic symptoms conservatively and without dialysis initiation.
There have been more talks about the preservation of the native kidney function as long as possible even after the dialysis initiation. Are we on the verge of a major paradigm shift in RRT? I do not expect a revolution in the field, but we will likely experience important adjustments in the way dialysis treatment has been employed in this country and probably worldwide, as our ways are often followed by other nations. We will likely see an increased practice of twice-weekly HD in the first several months of dialysis initiation, along with more attention to the preservation of the residual kidney function, more frequent and longer use of conservative management of kidney disease, and maybe more use of hospice in lieu of transitioning to dialysis. There is a challenging but exciting future before us.
Kam Kalantar-Zadeh, MD, MPH, PhD, Chief, Division of Nephrology & Hypertension, Professor of Medicine, Pediatrics and Public Health, University of California Irvine School of Medicine
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