From niche to norm: a multiaction plan to close gaps and mainstream incremental hemodialysis

Attention is increasingly turning toward the individualization of hemodialysis prescriptions through an incremental start. This approach prioritizes the patient's clinical needs over rigid metrics like dialysis urea depuration, begins with fewer sessions (1 or 2 per week), and gradually increases in frequency and/or duration based on the patient's evolving clinical condition. Clinical manifestations related to uremia are managed through a combination of residual kidney function, dialysis, dietary modification, and medications. Treatment adequacy is evaluated using clinical assessment, blood tests, and measurement of residual kidney function. Many observational studies and a number of pilot trials have shown that clinical outcomes with incremental-start hemodialysis are not inferior to the standard approach of hemodialysis initiation with 3 sessions per week. Consequently, some centers have adopted incremental-start hemodialysis as routine care. However, most centers apply the standardized practice of thrice-weekly hemodialysis as soon as dialysis is introduced in patient care and afterward, regardless of the patient's individual characteristics. This article does not prescribe a specific approach but rather describes the current practice of incremental-start hemodialysis. We seek to advance the practice of incremental-start hemodialysis by addressing critical gaps in knowledge, practice models, and supportive infrastructure with a view to more widespread implementation. Drawing on the Consolidated Framework for Implementation Research, we identify foundational factors at individual, organizational, and systemic levels that need development to facilitate broader adoption. Finally, we propose actionable items to ensure that incremental-start hemodialysis becomes a viable, patient-centered option accessible to all who might benefit.