Dialysis Patient-Centeredness and Precision Medicine: Focus on Incremental Home Hemodialysis and Preserving Residual Kidney Function

Summary: An exponential interest in incremental transition to dialysis recently has emerged in lieu of outright three times/wk hemodialysis initiation as the standard of care. Incremental dialysis is consistent with precision medicine, given individualized dialysis dose adjustment based on patient's dynamic needs, leading to reduced patient suffering from longer or more frequent dialysis treatments and improved health-related quality of life. It includes twice-weekly or less frequent hemodialysis treatments with or without a low-protein diet on nondialysis days, or a shorter (<3 h) hemodialysis treatment three times per week or more frequent treatments, a useful approach for home hemodialysis initiation. Peritoneal dialysis also can be initiated incrementally with a shorter dwell time, less daily solution volume, or therapy for fewer than 7days per week. Subsequent transition to more frequent or more intense dialysis therapy within several months or longer will counter worsening fluid retention and uremia, for example, whenever residual urea clearance decreases to less than 2mL/min or if urine volume reaches less than 500mL/d, especially if loss of nocturia ensues. There are many advantages to using precision medicine tools to institute incremental dialysis protocols including preservation of residual kidney function, adhering to patient preference, and allowing for a greater patient-centeredness. Incremental dialysis may become the treatment of choice in End-stage renal disease Seamless Care Organizations (ESCO). This article also features a home hemodialysis patient's experience as a real-world scenario of how individualization of dialysis therapy based on unique patient characteristics and adjustment and shortening of hemodialysis treatment time and frequency led to improved patient experience, compliance with treatment regimen, and increased urine output, and the role of future ESCOs.