Individualized Incremental Hemodialysis Study
Individualized Incremental Hemodialysis Study
Thrice weekly hemodialysis has been the standard of care all-over the world for end-stage
 renal disease (ESRD) requiring renal replacement therapy (RRT). Despite being in the era of
 precision medicine and individualized healthcare, this program doesn't take into account
 patients with residual kidney function (RKF) who don't require a thrice weekly hemodialysis
 frequency. Incremental hemodialysis (defined as twice weekly hemodialysis initiation in
 incident hemodialysis patients with residual kidney function) has been raised as an
 alternative to the conventional thrice weekly dialysis. Retrospective trials has proved
 safety of a twice weekly initiation with comparative efficacy to the thrice weekly program.
 Despite that, there is paucity of prospective observational and rarity of randomized
 controlled trials comparing both regimens. In this study, the investigators tend to provide a
 more individualized incremental hemodialysis approach to incident hemodialysis patients with
 residual urine volume and RKF. The investigators will compare the results to ESRD patients
 initiating a thrice weekly hemodialysis program.
This project aims to study the feasibility, safety and efficacy of individualized incremental
 (twice weekly, once weekly, once/10days or less frequent) hemodialysis (IIHD) initiation
 versus conventional thrice weekly HD for incident end stage renal disease (ESRD) patients
 with residual urine volume (RUV > 0.5 L/day, as a reference to residual kidney functions) who
 chose hemodialysis as their method of renal replacement therapy (RRT).

 Incremental HD has been an area of research interest in the past few years with many
 publications discussing its feasibility and safety for incident HD patients. Smooth
 transition to dialysis in incident ESRD patients through incremental twice (or even once)
 weekly dialysis initiation has shown benefits in preservation of residual kidney functions
 (RKF) in comparison to thrice weekly HD. It has also been proposed as a method of reducing
 healthcare cost while providing quality healthcare to the patients(1). However, most
 available data are retrospective analysis, few data are present to compare the results to
 thrice weekly HD in a randomized controlled or even in a prospective manner. Incremental HD
 has been also practiced in some parts of Egypt in the last 2-3 years. The investigators will
 compare outcomes of participants starting a less frequent dialysis program to conventional
 thrice weekly HD in a multi-center study.
Inclusion Criteria:

 1. Patients with stage 5 chronic kidney disease (CKD) with estimated glomerular
 filtration rate of less than 10 ml/min/1.73m2 (using CKD-EPI equation for eGFR).

 2. Residual urine volume at least 0.5 L/day or more.

 Exclusion Criteria:

 1. Children < 18 years of age.

 2. Patients who were previously on other types of RRT, either on peritoneal dialysis, or
 on kidney transplant.

 3. Recent (within 3 months) acute kidney injury (AKI).

 4. Urine output less than 0.5 L/day.

 5. Active malignancy at time of inclusion.

 6. Active inflammatory disease with immunosuppressive treatment.

 7. Decompensated Liver disease, Hepatorenal syndrome.

 8. Cardiovascular disease defined as: heart failure type IV of the New York Heart
 Association (NYHA) or Cardiorenal syndrome.