Transition from Convention al Hemodialysis to Incremental Hemodialysis in a Patient with Stage V Chronic Kidney Disease – A Case Report

Abstract

D.S., a a 77-year-old woman with end-stage diabetic nephropathy, initiated conventional hemodialysis (HD) on October 29, 2024, initially using a nontunneled central venous catheter (CVC) as vascular access for the first two months, followed by the use of a native arteriovenous fistula (AVF). She managed to preserve a significant residual urine volume (>0.3–0.5 L/day), which prompted consideration of transitioning to incremental hemodialysis. From November 2024 until April 10, 2025, she underwent conventional hemodialysis three times per week (weekly treatment time [WTT] ~660–720 minutes), achieving high dialysis adequacy (spKt/V 1.40–1.78, URR ~75–83% per session). Hemoglobin remained stable (~10.0–11.2 g/dL) with transferrin saturation (TSAT) levels of 24–26% and ferritin levels of 450–520 µg/L, using modest doses of Epoetin (~4500-6000 IU/week). Interdialytic weight gains were minimal (0.3-1.6% of dry weight), and mean arterial pressure (MAP) fluctuated around ~85–90 mmHg under antihypertensive therapy. Starting from April 10, 2025, the patient transitioned to incremental hemodialysis twice per week (total WTT ≈480 minuts) to take advantage of the persistence of residual renal function. After the change, dialysis parameters remained within target ranges: calculated spKt/V and URR values stayed above adequacy thresholds, volume status and blood pressure remained controlled, and hematological parameters for anemia evaluation remained stable without the need for further increases in erythropoietin (EPO) dosing. This clinical case illustrates that selected elderly patients with residual kidney function (RKF) can safely initiate dialysis using an incremental regimen without compromising adequacy or metabolic balance. In this case report, we discuss the rationale and safety of incremental hemodialysis in elderly diabetic patients, while also considering the latest protocols and studies supporting individualized and stepwise regimens to preserve residual function and quality of life (QOL).

Methods

This clinical case illustrates how the careful selection of elderly patients with significant residual renal function may benefit from a reduced HD frequency while preserving adequacy and clinical stability. We highlight four key domains: Dialysis Adequacy; Volume Control and Hemodynamics; Anemia management; Metabolic Balance. At 71 years old, our patient D.S. falls into the elderly dialysis population, where personalized goals may differ from younger cohorts. [5] Older adults typically have lower metabolic demands and often shorter life expectancy, shifting the risk-benefit balance. In the systematic review “Dialysis for Older Adults,” authors highlight that standard Kt/V target values may sometimes be too aggressive for elderly patients, and Number 1, Volume 1, 2025 incremental HD “should be considered the primary choice for most patients starting dialysis with residual kidney function.”

Results

When comparing literature, elderly patients on iHD often experience better outcomes when their RKF is utilized. According to Piccoli et al. 2022, among patients starting iHD, being diabetic and/or elderly did not predict differences in mortality. [8] Other authors have noted that frail elderly patients may benefit from fewer treatments – they experience less post-dialysis fatigue and maintain RKF longer. [5] Conversely, some studies emphasize that iHD can be risky if RKF is overestimated or lost quickly. Notably, Kalantar-Zadeh observed higher mortality in incremental regimens among patients with minimal baseline K/ru (≤3 mL/min). [6] This underscores the importance of regular RKF assessment. In D.S., we continue to measure her urinary volumes monthly; her clearance remains at ~3–4 mL/min. If/when her RKF is significantly reduced (e.g., <2 mL/min), returning to a conventional regimen will be indicated, following KDOQI protocols. [3] In summary, the patient’s post-transition data does not show loss of adequacy or safety: Kt/V remained above 1.2 and URR >65%, volume control and blood pressure remained stable, target anemia levels were achieved without additional therapy, and the patient reported a good sense of well-being. This real-life result aligns with the notion that incremental HD, when applied appropriately, can maintain clinical stability.

Conclusions

In this 71-year-old patient with diabetic nephropathy, incremental hemodialysis (reduction from three to two sessions per week) was successfully implemented without compromising adequacy or clinical stability. Residual kidney function allowed safe reduction in dialysis dose: adequacy targets were maintained, volume and blood pressure were controlled, and both anemia and metabolic parameters remained stable. Our patient’s case supports recent studies suggesting that some elderly patients with preserved urine output may be transitioned to less intensive dialysis regimens. [1][5] The decision for incremental dialysis – preserving residual renal function and patient quality of life – was successfully achieved in practice. Rigorous monitoring remains essential, and dialysis frequency must be escalated if residual function declines or lab parameters worsen. This case provides evidence that the traditional “one size fits all” approach of three sessions per week can be safely modified for elderly patients with some residual clearance, as long as protocols are followed and monitoring is continuous and rigorous.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

REFERENCES

1. Mathew AT, Obi Y, Rhee CM, Chou JA, Kalantar-Zadeh K. Incremental dialysis for preserving residual kidney function—Does one size fit all when initiating dialysis? Semin Dial. 2018;31(4):343–52.

2. Agar J. Incremental dialysis: Toward a nuanced approach. Home Dialysis Central [Internet]. 2019 May 9 [cited 2025 May 22]. Available from: https://homedialysis.org/news-andresearch/blog/308-incremental-dialysis-toward-anuanced-approach

3. Kidney Disease Outcomes Quality Initiative (KDOQI). Clinical Practice Guideline for Hemodialysis Adequacy: 2020 update. Am J Kidney Dis. 2020;76(3 Suppl 1):S1–S107.

4. Casino FG, Basile C. Incremental hemodialysis: A critical review on early start and transition strategies. Nephrol Dial Transplant. 2020;35(10):1803–18.

5. Khatri P, Davenport A. Dialysis for older adults: why should the targets be different? J Nephrol. 2024;37(4):841–50.

6. Obi Y, Streja E, Rhee CM, Ravel V, Amin AN, Cupisti A, et al. Incremental hemodialysis, residual kidney function, and mortality risk in incident dialysis patients: a cohort study. Am J Kidney Dis. 2016;68(2):256–65.

7. Berns JS. Interpretation of the Kidney Disease: Improving Global Outcomes guidelines for iron therapy: commentary and emerging evidence. Clin Kidney J. 2017;10(Suppl 1):i3–8.

8. Torreggiani M, Fois A, Chatrenet A, Nielsen L, Gendrot L, Longhitano E, et al. Incremental and personalized hemodialysis start: a new standard of care. Kidney Int Rep. 2022;7(5):1049–61.

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