In recent trips to India, China, Brazil, and other countries, I was intrigued by large numbers of patients with end-stage renal disease who underwent hemodialysis (HD) less frequently than three times a week. Indeed, I encountered sporadic patients who received HD as infrequently as only once to twice a month!

Dialysis treatment time could be as short as two to three hours per session. I was told that these patients would usually do well, especially because most of them have decent residual renal function with good urine output. Some Chinese nephrologists are even proud that by offering infrequent and short HD treatments, they preserve patients’ residual renal function for a longer time, similar to what we consider a main advantage of peritoneal dialysis. 

In the United States, we feel that patients deserve an “adequate” dialysis treatment dose, at least three times a week, with each session lasting three to four hours. Western European countries and Japan usually follow our lead.

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Some French nephrology centers offer five to eight hours of HD three times a week. Although some opinion leaders suggest even higher dialysis doses such as daily or long nocturnal HD, convincing data to show whether short and infrequent dialysis is significantly inferior are lacking. While I do not dispute the potential role of finances and resource constraints in making infrequent dialysis so prevalent in some countries, this practice may offer unique opportunities to learn.

Many Indian and Chinese nephrologists are more aggressive than their American counterparts with regard to strategies to preserve residual renal function with low- to very low-protein diets combined with essential amino acids or their keto-analogues.

Given the heightened discussion of early versus late dialysis initiation and recent data questioning the wisdom of early dialysis start, it is time to explore alternatives.

In my opinion, it never makes sense that patients with chronic kidney disease suddenly need to start full-blown dialysis treatment. In the same way that worsening kidney function happens gradually, perhaps offering dialysis treatment should also be gradual, starting from one HD treatment a week, or as necessary.

We keep a freshly transplanted patient “on the wet side” to keep the new kidney well perfused, so maybe we should be more conservative with the native kidneys and avoid excessive diuresis or frequent HD and its associated circulatory compromise during the first few months of therapy.

Though these fundamental questions have not been raised before, I would say it is never too late to start.