Is it time to reconsider how we initiate maintenance dialysi
Indications for the initiation of kidney replacement therapy (KRT) are heterogenous and has evolved over the years since dialysis was provided as a maintenance therapy more than 50 years ago. The earlier indications such as significant fluid overload, and substantially altered biochemical measures of critical hyperkalemia or metabolic acidosis are now replaced by more subjective criteria or simply an estimated glomerular filtration rate (eGFR) less than a specific threshold, usually 10 ml/min/1.73 m2 or less. Despite the evolving criteria for the decision to start maintenance dialysis, the dialysis prescription at the time of initiation has been very concrete and unchanged, at least for the last several decades. For example, most maintenance hemodialysis (MHD) patients will initiate RRT with a thrice-weekly hemodialysis regimen aimed at minimal single-pool Kt/V of 1.2.

While incremental peritoneal dialysis has been described since the early 90s, its implementation has been sporadic. There are now multiple reports indicating the importance and preference of a more patient friendly and gradual initiation of maintenance dialysis in patients with advanced kidney disease. In addition, in countries where there are significant number of patients with financial constraints, initiation of MHD with two session per week schedule is common although this approach heavily relies on physician decision more than having an established approach. Incremental hemodialysis where the approach was standardized to provide sufficient dialytic clearance of uremic solutes and appropriate volume control coupled with escalation of dose frequency as needed determined by clinical assessment.