Back in August 2012, I wrote a provocative editorial in this space titled, “How About Twice-Weekly Hemodialysis?” This was the first time the topic of dialysis provided less frequently than 3 times a week was brought up in the 21st century. I argued that because kidney function worsens gradually, dialysis treatment should be gradual and incremental, starting with 1 to 2 hemodialysis (HD) treatments a week.

The 2012 editorial encountered some mixed reactions, including from colleagues who were interested to know more about twice-weekly dialysis, but also from colleagues who found the idea unacceptable and even repulsive. I explained back then that during my trips to Mexico, India, China, and other Latin American and Asian countries, I was intrigued by the large numbers of patients with end-stage renal disease who underwent HD less frequently, usually twice a week. In 2014, several colleagues and I published the first consensus paper on twice-weekly and incremental HD in the American Journal of Kidney Disease. The paper included 10 eligibility criteria for transition to a twice-weekly regimen. At the same time, my team at the University of California Irvine (UCI) started the first incremental dialysis transition program in the United States using these criteria. Today, at any given time, up to a third of all dialysis patients treated at UCI have been on a twice-weekly schedule. Meanwhile, a large number of landmark studies have been published suggesting favorable outcomes associated with incremental dialysis, including longer preservation of residual kidney function and greater quality of life and patient centeredness. Interestingly, in our UCI program, all patients have survived the twice-weekly dialysis regimen, and most have successfully transitioned to thrice-weekly or more frequent regimens from 3 months to 3 years after initiation of incremental dialysis.

In July 2019, President Donald Trump signed an Executive Order launching the “Advancing American Kidney Health Initiative,” which is expected to support incremental dialysis because it is patient-centered and offers financial advantages. Today, the incremental dialysis model we introduced at UCI is being used in many of the 7000 dialysis units across the nation. Even dialysis facilities in Western Europe—where twice-weekly HD met with harsh criticism and resistance—have incorporated this approach. Still, incremental dialysis is in its infancy, and additional studies including controlled trials with home dialysis are needed. Meanwhile, we should be committed to offering patients the dialysis regimen they prefer.