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Abstract

French

Background:

In 2022, we implemented an incremental hemodialysis (iHD) protocol to initiate twice-weekly treatment for eligible patients. This patient-centered approach aims to ease the transition to dialysis and enhance quality of life. However, limited data exists on how iHD is experienced by patients and health care providers (HCPs).

Objective:

The aim of the study was to explore the benefits and challenges of iHD from patients’ and HCPs’ perspectives, and to generate practical considerations for its implementation.

Study Design:

We conducted an exploratory descriptive qualitative study, guided by an interpretivist-constructivist paradigm, using semi-structured interviews (March-May 2024).

Setting:

The study was conducted in a tertiary care center.

Participants:

Participants included patients who were actively or had previously received iHD and HCPs caring for iHD patients.

Methods:

Interview data was analyzed thematically using inductive thematic analysis.

Results:

Ten patients and five HCPs were interviewed. Six major themes were identified: (1) better quality of life than conventional hemodialysis, (2) travel and financial benefits, (3) psychosocial and emotional impact similar to conventional hemodialysis, (4) coordination of care and logistics, (5) knowledge and training challenges, and (6) challenges when switching modality. Patients preferred iHD because it afforded them more time for participation in daily life activities. However, the start of a dialysis treatment remained “traumatic” for some patients. While HCPs recognized the greater quality of life for iHD patients, HCPs expressed a need for increased monitoring to ensure adequate care. Patients noticed an inconsistency in care coordination and reduced opportunities to see nephrologists. Some HCPs reported a lack of guidance on iHD. Finally, HCPs observed patients negotiating to stay on iHD even when it became unsafe.

Limitations:

The small sample size and single-center setting may limit the findings’ transferability.

Conclusions:

IHD was shown to offer quality of life advantages. However, the transition to iHD remained emotionally challenging for patients. Patients often exhibited resistance when moving from twice-weekly to a thrice-weekly schedule. Logistical issues for HCPs and educational barriers must be addressed to optimize delivery of iHD.

Keywords

incremental dialysis hemodialysis quality of life perspective

Introduction

Conventional thrice-weekly hemodialysis remains the most widely utilized modality of kidney replacement therapy globally. However, this treatment is frequently associated with important patient challenges, including impaired physical and mental health, reduced functional capacity, limited participation in daily activities, and diminished quality of life.^1,2 Recent guidelines from Kidney Disease Improving Global Outcomes emphasize a comprehensive approach to the management of kidney failure, placing a priority on patient goals and experience.³

Incremental hemodialysis (iHD) is an alternative approach to conventional hemodialysis in which patients with end-stage kidney disease who have sufficient residual kidney function are prescribed an individualized dialysis regimen <3 times per week that is adjusted based on their needs.² IHD aims to deliver adequate clearance and volume control while potentially facilitating the transition to dialysis, reducing patient and caregiver burden and improving quality of life.^4-6 Studies have also suggested benefits with regard to clinical outcomes such as preservation of residual kidney function, as well as health care cost benefits.^7-10 However, there are risks and complications to iHD, including insufficient clearance and fluid overload.¹¹

In November 2022, we implemented a protocol for iHD at a single university health center, consisting of 3 affiliated sites, as part of a nephrology fellow-led quality improvement initiative. We aimed to initiate 75% of eligible incident patients on an incremental regimen. The protocol incorporated a weekly nursing checklist within the electronic medical record, more frequent laboratory monitoring, and a 24-hour urine collection every 6 weeks for patients receiving iHD. Over a 2-year period, 40 of 122 incident patients were started on an iHD prescription.

Prior literature has highlighted the benefits of iHD on health-related quality of life and symptom management using structured questionnaires,² however, an explorative study of patients’ and health care providers (HCPs)’ perspectives is lacking. The need for a standardized approach to delivering iHD has been highlighted, but precise recommendations are also lacking.^12-14 We aimed to explore the perspectives of patients and HCPs on iHD to better understand the perceived benefits and challenges with this approach in clinical practice with the goal of providing practical considerations for its implementation. Specifically, our research questions included (1) how do patients and HCPs view and understand iHD and (2) what are the challenges in implementing iHD?

Methods

We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline and checklist to ensure the rigor in the reporting of our study. This study was approved by the research ethics board of the McGill University Health Centre (Montreal, Quebec, Canada)—study identifier 2024-9790.

Study Design

Drawing on an interpretivist-constructivist approach, we adopted a descriptive qualitative exploratory study design,^15-17 which involves studying a phenomenon through the ways in which individuals understand and construct meaning from it. This study design was best suited for gaining deeper insight into the meaning, perspectives, benefits, and challenges of patients and HCPs on iHD beyond mere description. We used semi-structured interviews and interpretivist inductive thematic analysis to unpack how patients and HCPs make meaning of iHD and its impacts.¹⁵ The interview guides were developed based on Kallio et al’s¹⁸ Five Phases framework, published in 2016. The interview guides were thematically designed to explore patients’ and HCPs’ experiences, perceptions, and recommendations regarding iHD. The primary areas of questioning for patients focused on how they learned about iHD, their reasons for choosing this modality, their perceptions of its impact on their lives, and their views regarding the potential need to increase dialysis frequency in the future. For HCPs, the interviews explored their knowledge about iHD, the challenges and benefits they encountered in clinical practice, and the feedback they received from patients. Interview guides are attached as Supplementary Item 1. Signed informed consent was obtained from all participants.

Definitions

We defined iHD as a hemodialysis prescription of 2 sessions per week, prescribed by a HCP based on the patient’s urine output and clinical status.¹⁹

Inclusion and Exclusion Criteria

Patient participants were eligible if they were adults (≥18 years of age) who were treated with an iHD prescription or who had been previously prescribed iHD at one of our 3 affiliated sites, from November 1, 2022, to March 1, 2024. Patient participants were excluded if they were being treated for unstable medical conditions, including acute coronary syndrome or congestive heart failure exacerbation within the last 6 months and if they were not able to provide informed consent for the interview. Patients who were unable to communicate in English or French were also excluded. Eligible HCPs were physicians and nurses involved in the care of patients on iHD at our tertiary care center.

Sample and Recruitment Approach

We used a convenience sampling approach, approaching all eligible patients and HCPs during the study period and including those who agreed to participate.²⁰ In this context, we did not establish an a priori sample size given a limited participant pool, and recruitment was done through direct contact by a research assistant (C.W.-M.) who had no pre-existing relationship with participants to explain the study objectives and protocol. All patients and HCPs participants were compensated with $40 in appreciation of their time and contribution.

Data Collection

A trained qualitative female student researcher with 4 years of experience in conducting qualitative studies (C.W.-M.) conducted semi-structured in-person interviews with patients within affiliated dialysis centers. Interviews lasted 30 to 60 minutes. A male postgraduate nephrology resident (A.M.) and female research assistant (J.R.) conducted 30 to 60 minutes semi-structured interviews with eligible HCPs in-person within affiliated dialysis centers (n = 2) or virtually via Zoom (n = 3). All participants were interviewed between March and May 2024 and interviews were audio recorded and transcribed with participant consent. Data was collected using audio recording at home and in the clinic. Identifiers were removed from transcriptions and recordings were deleted after transcription. No repeat interviews were conducted.

Data Analysis

Interview transcripts were analyzed using interpretivist-constructivist thematic analysis and an iterative inductive approach to examine emergent themes.²¹ The inductive thematic analysis began with a preliminary reading of the transcripts to identify and develop a codebook from the data, followed by line-by-line coding of the dataset, iterative refinement and reorganization of codes to reflect the meaning patients and HCPs construct based on their experiences with iHD. Themes were continuously reflexively reviewed to allow for patterns to progressively evolve throughout the analysis. The qualitative researcher C.W.-M., along with a second coder (A.P.-B., male >5 years of experience in qualitative research), analyzed the interview data using the qualitative analysis software NVivo (version 14) to consolidate the themes by revising and regrouping codes. Analysis, interpretation, and summary of data were conducted by N.L. and the rest of the team members. Due to the small iHD population and sample size, achieving thematic saturation, that is the development of theoretical themes, was not exhaustive in that individuals from diverse demographics may have contributed to the development on new themes. However, we achieved data saturation among our small patient sample after the eighth interview, in that the data collected repeated findings previously collected and no new data emerged.²²

Results

Study Population

Fifteen (15) iHD patients were identified as eligible for the study. Eleven (11) patients consented to participate in the study, but 2 patients were withdrawn from the study because of a lack of response. A total of 10 iHD patients were included, of which 3 patients remained on iHD at time of interview, 6 patients had transitioned from iHD to 3 times a week dialysis and 1 patient had transitioned from 3 times a week to iHD (Table 1). Fifteen HCPs were identified as eligible for the study, but only five agreed to participate in the study. This consisted of 3 physicians and 2 nurses (Table 1). Six major themes were identified in both patient and HCPs perspectives of iHD: (1) better quality of life than conventional hemodialysis; (2) travel and financial benefits; (3) psychosocial and emotional impact similar to conventional hemodialysis; (4) coordination of care and logistics; (5) knowledge and training challenges; and (6) challenges when switching modality (Figure 1). Illustrative quotes are presented in Table 2.

Table 1.

Patients and Health Care Providers Demographics.

Characteristics
Patients	N = 10
Age, years, mean	61
Sex, n (%)
Male	4 (40)
Female	6 (60)
Dialysis modality, n (%)
Incremental	4 (40)
Incremental to conventional	6 (60)
Ethnicity, n (%)
White	8 (80)
Black	1 (10)
Indigenous	1 (10)
Education level, n (%)
Elementary school	1 (10)
High school	3 (30)
College/technical school	5 (50)
University	1 (10)
Employment status, n (%)
Retired	5 (50)
Unemployed	3 (30)
Employed full-time	2 (20)
Marital status, n (%)
Married/civil union	4 (40)
Divorced	2 (20)
Widowed	2 (20)
Single	2 (20)
Annual income ($), n (%)
<30 000	5 (50)
30 000-99 999	4 (40)
>100 000	1 (10)
Health care providers	N = 5
Sex, n (%)
Male	1 (20)
Female	4 (80)
Role, n (%)
Physician	3 (60)
Head nurse	2 (40)
Length of practice, years, n (%)
<5	2 (40)
5-10	2 (40)
15-20	1 (20)

Figure 1.

Main themes and practical considerations when implementing incremental hemodialysis.

Table 2.

Illustrative Quotes That Highlight the Themes Identified.

Patients	Health care providers
Perceived benefits of iHD (themes 1 and 2)
Theme 1: Better quality of life than conventional hemodialysis
“That really affects your day-to-day life. It affects. You don’t think it is. But when everything gets laid out on a platter, now you’ve got all these other things which are scheduled into your life, week, style, lifestyle, and then now you have to make those changes.” (Patient 1) “Well, like I said, I have my daughter, so in choosing the twice a week when [the doctor] told me, this is what’s going to happen, and then she talked about the days that I can do it. I choose the days because I wanted to be able to, um, have weekends with family and do things like that if that was possible.” (Patient 4) “I feel like it’s hindered me from doing things that I planned on doing. You know, my life is on pause at the moment I went to school, in the moment I finished school, I started dialysis, so I couldn’t go work.” (Patient 8)	“They’re super happy. They don’t have to be here three times a week, more than I think that’s sort of the biggest thing. They just don’t have to be here.” (HCP 1) “I think it’s a positive impact for them. Because I mean, to be honest to cut especially for in center dialysis coming in three times a week, it’s not just the four hours are on dialysis, it’s the hour transport before and after, it’s the 15 minutes waiting in the (room) (. . .) So that’s a seven-hour thing. That’s like almost a full day. So if you wanted to do that twice a week, then three times a week, I think that’s a huge impact on quality of life for patients.” (HCP 1) “They love it, they love—yes, that’s the end of it. Except some patients really cannot handle the fluid. So when they reduce dialysis, they can’t cope with a fluid accumulation. So those patients actually very quickly go back to three times a week. But those who can manage the fluid, they tend to ignore, like a bad numbers and phosphate and everything. (. . .) I’ve seen many patients who can’t cope with fluid. So a patient comes in short of breath. And when we try to move, move forward, they crash blood pressure they can pass out. And if they have to repeat that every single dialysis, so they quickly give up to three times a week, what quality of life, I think, in the middle of the winter, instead of coming three times coming twice a week. Yeah, everybody loves that.” (HCP 2) “If we look into the preservation of your kidney function for your patients, I believe it will really help. And we tried to preserve their kidney function. Plus, we have to encourage it to those patients who qualify for it so that they, again will be having a better quality of life.” (HCP 4)
Theme 2: Travel and financial benefits
“Well, the fact that it gave me a more flexible schedule and that I only need to get somebody to bring me here twice a week and just gave me more time at home.” (Patient 7) “I asked the doctor at one point if I could do twice a week because I was having trouble getting transportation to come here, and it was becoming costly, it’s hard coming here.” (Patient 7) “It was more money” (Patient 8)	N/A
Challenges in implementing iHD (themes 3-6)
Theme 3: Psychosocial and emotional impact similar to conventional hemodialysis
“A lot of people, they’re traumatized when they get here [dialysis center] for sure. Yeah, I wasn’t traumatized. I was just like, I’m gonna do this and I have to do it, you know, so I wasn’t really traumatized.” (Patient 3) “With dialysis, my biggest problem was anxiety. Yeah, like, I was anxious a lot. I didn’t know what to expect. I think my world was crumbling down. I had so much looking forward to. And I think with that, I was. I would no longer be able to achieve what I . . . So that was. That was my biggest thing. I still think about it. I still fear. I know a lot has changed because of that. I would have to do things differently. I would have to make a lot of more planning, you know?” (Patient 4) “I kind of was like mad, but I wasn’t doing too good on two times a week because, like, nothing was balancing out. But with three times a week, the vacation and stuff, it helps. It really does. And I really appreciate it. You know, at least I don’t feel sick. You know, twice a week was working, but it wasn’t working quite well. And they were like, well, three times a week. But I was kind of mad.” (Patient 3)	“We’ve had several people who, I think even before that was protocolized, went from three times to twice a week, and they were just much happier.” (HCP 1) Subtheme: difficulty transitioning to three times a week “Somebody’s disappointed because now they have to do three times per week but on the other side, what I’m telling them is okay, yes, now it’s like that. Nobody is happy with this, but you now need more but on the other side, for all this time, you profited from twice weekly. So, you had the opportunity to have less dialysis, it was a good thing, but now unfortunately, you need more so it’s the disease process that is like that. I tried to give a positive message, saying that if they are candidates, let’s hope that they will get a transplant soon now.” (HCP 3) It’s hard because he started twice a week and then increased to three times a week. And then sometimes he had to come four times to five times. So, he was kind of discouraged. But now it’s okay, it’s under control. He comes regularly three times. But it was hard when he changed though.” (HCP 5)
Theme 4: Coordination of care and logistics
“I wasn’t scheduled for any days when the doctors were coming.” (Patient 1) “There’s seven days in a week. Right. You knock out two versus three is a big difference. And you get three days. Then you get three days when you don’t have to come. It was strictly for that reason only.” (Patient 1) “So, it was good. You get used to it. You know, you sort of build the routines. You get used to it and you work around it. Now I’m back to three. I am finding it a little difficult to adjust. As I said, you know, one day in between sessions, the only time I have a little bit of respite is the two days between, Saturday and Tuesday.” (Patient 9)	“I think what would facilitate it is if a lot of these things were sort of done with, maybe like a checklist that the nurse could do at the beginning, like, you know, just assessing if every patient did a urine collection. Then I think that would make things a little easier.” (HCP 1) Subtheme: challenges to coordinating care “Challenge, it’s the need for closer monitoring. (. . .) And we have to always monitor that the timing to switch to conventional three times a week. Rather than if you have patients already on the conventional treatment, then we don’t have to worry about these things. But constantly we have to check and make sure that the patients are well” (HCP 2) “You know, if you see that you don’t provide adequate dialysis, you need to be vigilant. It’s not that you forget after shooting the patient but I think it’s monitoring them closely . . . I think that should be part of our job, in my opinion, you know, it’s if somebody medically who can be treated with twice weekly, I think it’s malpractice if we say, that’s too much for our workload.” (HCP 3) “I mean, not really doing the bedside care most of the time. So my challenge for me as a as a practice nurse, my position is that monitoring patients who need to be monitored, I mean, the incremental patients, if their blood tests are not being done on time, if their urine collection is not being done, I find that it’s difficult for me to trace more of how they’re progressing, or how they’re performing with incremental dialysis.” (HCP 4) “So just a closer monitoring, you have to monitor a bit closer. That’s it. I will still keep reminding the nurses because we rotate, . . . every nurse needs to take care of all the patients. So, they’re not always aware that a patient is incremental. Especially for those part timers, they don’t do work that much. Sometimes the kidney nurse did need more of those reminders.” (HCP 5)
Theme 5: Knowledge and training challenges
“I would say they [the HCPs] played a pretty big role in it. They gave me all the information that I needed and they presented me with options, and then they said certain options wouldn’t be possible for me and stuff like that. So it’s like they pretty much helped me quite a bit in deciding.” (Patient 5) “I was told about the different types of dialysis, but I wasn’t told about the two days.” (Patient-4) “At that time, they gave me this big book called living with kidney disease, which covered all. Everything to do with living with kidney disease. Like, you know, this thing, business here, or you can have the different. types of dialysis, or you can do it at home and this book explained all of that.” (Patient 1)	Subtheme: HCP perception of iHD “I think more education and updating in terms of the changes with the protocol would help because sometimes we read changes that were made that were not disseminated properly. So, there were confusions among the staff, and expectations by the doctors. So, I think education should be done. And if an info sheet will be available, not just for the patient, but also for the professionals, I think it will also help, especially if there’s any changes, because then we can track the versions of other incremental data.” (HCP 4) Subtheme: iHD training “If I rank it from zero to 10; 10-being well informed, I’m more of a six or seven. When I basically did the presentation, it was there. But there were some doubts that I encountered as I go along with it. So that made me around six or seven. But now after the clarification that I did, I’m more of a 9-10.” (HCP 4)
Theme 6: Challenges when switching modality
“I will save the nurse time, I will save the hospital time too, because they need a nurse to assist me for three and a half hours.” (Patient 2) “When she originally told me, I’m gonna die, she said, it’s three times a week. So I said to her, look, I don’t like that three times a week business, you know, and at that time, I was still working at the funeral home.” (Patient 1) “Like, I was not like an emergency. That’s what I got from her. So, I mean, I still needed a dialysis, but it would work for me twice . . . This is where we’re gonna start, you know, and if we need more and more, then I would, because as of now, I still use the washroom quite often.” (Patient 4)	“Challenge number two is resistance, have the patience to go back to conventional dialysis. Nobody wants three times a week, as compared to twice a week.” (HCP 2)

Note. HCP = health care provider; iHD = incremental hemodialysis; N/A = not applicable.

Perceived Benefits of iHD

Theme 1: Better quality of life than conventional hemodialysis

A predominant theme emerging from both patient and provider interviews was an improved quality of life among patients on iHD, primarily by allowing greater participation in daily activities. Being on dialysis in the hospital center multiple times a week is difficult, as one patient described “What I don’t like about it is it’s really long and boring time. Sit around and wait for the machine to wash your blood, you know, it’s like I could be outside doing something else” (Patient 3). With fewer dialysis sessions, patients could maintain personal commitments such as work and family time, as one patient shared: “I have my daughter, so in choosing the twice a week . . . I have weekends with family” (Patient 4).

HCPs also observed life participation benefits with iHD. One HCP specifically reported finding a direct association between quality of life and the number of hemodialysis sessions per week: “So if you see patients who are incremental assets, I think they’re more active, they’re more positive with life because they can live four hours more than the others” (HCP 4). The same HCP ended their quote by saying that it “makes a big difference for them at least” (HCP 4). HCPs also noticed that iHD patients were able to go to school and plan their activities better because of the time gained back from being in the dialysis unit. One HCP highlighted this when speaking about an iHD patient: “He’s going to school, and with incremental dialysis protocol . . . he has more time studying and doing more things” (HCP 4).

Theme 2: Travel and financial benefits

Patients found iHD improved the transportation logistics due to “the fact that it gave me more flexibility schedule and that I only need to get somebody to bring me here twice a week, and it just gave me more time at home” (Patient 7). Decreased traveling frequency to the hospital was also found to reduce patients’ financial burden associated with transportation in comparison with conventional HD, which “was more money” (Patient 8).

Challenges in Implementing iHD

Theme 3: Psychosocial and emotional impact similar to conventional hemodialysis

The main psychosocial and emotional impact of iHD was linked to the challenges of the dialysis experience in general. Patients described the overall experience of dialysis as being “traumatic” and “terrifying,” as explained by one patient: “It’s very traumatic to know you have to be hooked up to a machine for the rest of your life” (Patient 1). Other patients explained feeling anxious due to the uncertainty and lack of preparedness for dialysis, and perceived iHD as a barrier to achieve their life goals: “my biggest problem was anxiety . . . I was anxious a lot. Didn’t know what to expect. I think my world was crumbling down” (Patient 4). The lifestyle changes and lifelong commitment to dialysis in combination with the uncertainty of the future can have a serious psychosocial and emotional impact on patients. Several patients described feeling depressed and isolated on dialysis despite the benefits of iHD: “that’s no life for me (. . .) I feel like a prisoner” (Patient 6). Nonetheless, patients with a close relationship with their HCPs expressed trust to help make the best decisions for their dialysis treatment. One patient on dialysis explained, “because I trust them enough, . . . and they always tell me, my doctor, that we’re gonna do what’s best” (Patient 4).

On the other hand, HCPs found that patients who switched from conventional hemodialysis to iHD “were just much happier” (HCP 1). The dialysis environment can make patients “more cognizant of how unwell they are” and so coming in less often “was just better for their sense of well-being” (HCP 1). Other HCPs described the difficult readjustment from twice a week dialysis to 3 times a week dialysis, and that their role was to manage patients’ disappointment. Some explained approaching this situation by explaining to their patients that iHD has given them the opportunity to decrease their number of dialysis sessions for some time, but that they now need more sessions to maintain overall health. One stated “I try to give a positive message, saying if they are candidates, that let’s hope that you will get a transplant soon” (HCP 3). Overall, HCPs saw their role in psychosocial concerns as managing expectations and overall adjustment to the dialysis treatment.

Theme 4: Coordination of care and logistics

Different logistical challenges were perceived by patients and providers. Patients recognized that one of the main logistical challenges with iHD was their reduced chance of seeing a nephrologist when going to dialysis, as one patient stated: “I wasn’t scheduled for any days when the doctors were coming” (Patient 1). This problem in coordination of care was also noticed by HCPs.

All HCPs interviewed identified the need for increased monitoring of patients on iHD when compared to patients on conventional hemodialysis. The following quote highlights this logistical challenge: “We have to always monitor the timing to switch to conventional three times a week. So, I think rather than if you have patients already on the conventional treatment, then we don’t have to worry about these things. But constantly we have to check and make sure that the patients are well” (HCP 2). A need for monitoring of compliance was also identified by one HCP because “skipping one session a week, when they come three times a week versus skipping one session when they only come twice a week has, you know, a bigger impact” (HCP 1). Moreover, it was challenging for HCPs to understand whose responsibility it was to closely monitor patients on iHD. Some felt they had to take on responsibilities for which they were not comfortable in, as described by the following HCP: “So my challenge for me as a practice nurse, is monitoring incremental patients, . . ., I find that it’s difficult for me to trace more of how they’re progressing, or how they’re performing with incremental dialysis” (HCP 4).

Theme 5: Knowledge and training challenges

Appropriate HCPs training plays an important role in the successful implementation of new clinical protocols. Some HCPs identified insufficient training of iHD at the time of protocol implementation. One HCP proposed the use of learning material as a solution for teaching appropriate protocols, stating that “an info sheet should be available, not just for the patient, but also for the professionals, I think it will also help, especially if there are any changes” (HCP 4).

In contrast, most patients did not perceive a lack of knowledge from their HCPs during the presentation and explanation of treatment modalities. As one participant noted: “I would say they [the HCPs] played a pretty big role in it. They gave me all the information that I needed, and they presented me with options, and then they said certain options wouldn’t be possible for me” (Patient 5). The same patient concluded by stating that the shared information on iHD greatly helped them in choosing their dialysis modality. However, others highlighted the need for more detailed explanations when introduced to iHD, or never being told about twice a week dialysis stating: “if it’s explained to you more, in more detail at the beginning, what you’re going to have to deal with, then it’s easier for you to relate that to your family members and your friends” (Patient 1). Interestingly, some patients expressed a preference for receiving minimal information when discussing dialysis options, as exemplified by one participant who remarked, “Sometimes I don’t want to see anything related to kidneys” (Patient 10).

Theme 6: Challenges when switching modality

Many HCPs identified challenges in transitioning iHD patients to conventional hemodialysis when they no longer met the eligibility criteria for iHD. These criteria include the development of uremic symptoms, abnormal biochemical parameters, persistent fluid overload, or a decline in residual kidney function. This negotiation often involved addressing patients’ resistance toward more dialysis, as illustrated by one HCP: “challenge number two is resistance, have the patience to go back to conventional dialysis. Nobody wants three times a week, as compared to twice a week” (HCP 2). The patients’ resistance to change was believed to stem from patients’ expectations about their treatment schedules. One HCP explained: “Some patients take it for granted, that will be twice per week forever, I tell them, well, we may change it to three times per week later, and you might need more dialysis” (HCP 3). HCPs felt like they had to help manage patient expectations with iHD in the event that they needed more dialysis.

Patients similarly described a reluctance to transition from 2 to 3 times per week schedule. One patient attributed the reluctance to the fact iHD afforded an increased independence and convenience while also “saving hospital resources” (Patient 2).

Discussion

Overall, iHD offers notable benefits to patients and health care systems, including greater patient engagement in daily activities and improved quality of life. However, our study also highlights the challenges of implementing iHD in clinical practice. Namely, (1) transition to iHD remains emotionally challenging for patients and their families; (2) coordinating care between HCPs and ensuring iHD patients are monitored closely; and (3) managing patient expectations, psychosocial concerns and/or emotions when increasing dialysis to a conventional 3 times per week schedule. We provide 4 practical considerations when implementing iHD that are discussed below and presented in Figure 1.

First, iHD permitted patients to increase their participation in daily activities, including work, school, family, and other community roles. Some patients perceived that increased participation in daily life activities improved their quality of life. However, most of the patients on iHD in our study still described psychosocial concerns, which were related to the overall experience of being on dialysis and the significant time spent in dialysis centers and were thus not specific to iHD. For this reason, it is important to note that iHD is not a replacement for kidney transplantation in eligible patients. While iHD can serve as a bridge therapy to ease the transition to dialysis, it is equally important to discuss all available kidney replacement options, particularly for patients who are ineligible for or choose not to pursue transplantation. This discussion should include home hemodialysis, peritoneal dialysis, and conservative/non-dialysis care, allowing patients to make individualized, informed choices that align with their preferences, quality of life, and overall goals of care.

Second, this study identified a common concern among HCPs regarding the need for increased monitoring of iHD patients when compared to patients on thrice weekly dialysis. There was considerable ambiguity among HCPs regarding the delineation of tasks for iHD eligibility monitoring. In fact, they found it unclear who was in charge of regularly monitoring important metrics such as volume status, residual kidney function and uremic symptoms.^13,14 Our findings were consistent with a survey of Canadian nephrologists published in 2021, which indicated that nephrologists across the country found there was no existing systematic approach to the monitoring of patients on iHD.¹² A study published by Wanner et al in 2022 also found monitoring of iHD patients to be complex and not standardized across centers.²³ To successfully implement new clinical protocols, it is critical to clearly define roles and responsibilities, encourage active communication between team members, and organize frequent multidisciplinary meetings to evaluate and address the protocol’s needs for modifications.²⁴ Based on the findings of this study, we implemented a protocol to facilitate these challenges, which is presented in Figure 2. Briefly, this protocol was developed as part of a trainee-led quality improvement initiative as part of the Canadian Society of Nephrology Quality Improvement and Implementation Science (CSN-QUIS) program from November 2022 to December 2024. Key components of the protocol included patient education materials, structured nursing training, a nursing-led safety weekly checklist, and automated alerts for treatment escalation when indicated.

Figure 2.

Incremental hemodialysis patients’ monitoring protocol.

Finally, the transition from iHD to conventional hemodialysis was perceived as significant challenge given patient reluctance. Health care providers highlighted the need to manage patient expectations with iHD as a secondary effect of switching dialysis schedules. Patients tended to negotiate with their HCPs in the hopes of staying on iHD despite the need for more dialysis sessions. The greater life participation and improved quality of life afforded to patients by an iHD regimen made it difficult for some patients to readjust to thrice-weekly schedule when needed. However, when asked if they would choose iHD if they could restart the dialysis journey all over again, all patients responded they would still have started with iHD and gradually increased to conventional hemodialysis. To address the difficult transition from iHD to conventional hemodialysis as well as the dialysis experience in general, we emphasize the importance of available psychosocial support within dialysis programs. This support should include access to peer support groups and mental health resources. We also recommend routine screening for depression, anxiety, and other psychosocial concerns. Of note, a 2020 systematic review suggested using the Beck Depression—Inventory Fast Screen as screening tool for depression in patients treated with dialysis.²⁵ Clear comprehensive patient educational resources is also essential to explain the benefits, limitations and expected course with iHD. It is also important to recognize that some patients may choose to continue iHD even if they no longer meet the formal criteria. Therefore, decisions regarding transitioning to more frequent dialysis should follow a shared decision-making approach that considers patients’ reasons for reluctance, quality of life, psychosocial factors, and overall goals of care, in addition to medical considerations.

Limitations of this study should be noted. First, the small sample sizes of both patients and HCPs may limit the transferability of the findings to a broader population. The use of convenience sampling, necessitated by the small sample size, may also limit the transferability of the results. Additionally, the study was conducted at a single tertiary care center comprising 3 affiliated sites, and the identified challenges may not be universally applicable to other health care settings. Moreover, as a qualitative study, the results were based on subjective data gathered from a limited group of participants and may not fully represent the perspectives of other patients or HCPs who were not interviewed. We also did not use validated quality of life scores to obtain data on this outcome due to the interpretivist study design.

Nonetheless, our data is relevant to the kidney community. We conducted an in-depth exploration of patients and HCPs perspectives on iHD, highlighted key challenges, and reported practical considerations to improve delivery of iHD. Our findings have important implications given the rising burden of kidney disease and the demand for cost-effective approaches to deliver kidney replacement therapies.²⁶

Conclusions

Incremental hemodialysis offers notable benefits, including greater patient engagement in daily activities and improved quality of life. However, the transition to iHD remains emotionally challenging for patients and their families. This study highlighted patients’ reluctance to move from incremental to thrice-weekly hemodialysis and underscored the critical role of trust in the patient-provider relationship during this transition. Health care providers also faced difficulties in guiding patients toward more frequent dialysis when they no longer met the criteria for iHD. We have provided practical considerations to improve safety and success of iHD implementation across health care centers.

Supplemental Material

sj-docx-1-cjk-10.1177_20543581251399138 – Supplemental material for Benefits and Challenges When Implementing Incremental Hemodialysis: A Qualitative Study of Patients and Providers

Supplemental material, sj-docx-1-cjk-10.1177_20543581251399138 for Benefits and Challenges When Implementing Incremental Hemodialysis: A Qualitative Study of Patients and Providers by Noémie Laurier, Chloe Wong-Mersereau, Shaifali Sandal, Antoine Przybylak-Brouillard, Ali Taha, Alexander Messina, Daniel Blum, Catherine Weber and Emilie Trinh in Canadian Journal of Kidney Health and Disease

Footnotes

Acknowledgements

The results of the study were presented as a poster at the 2025 Canadian Society of Nephrology Annual General meeting.

ORCID iDs

Noémie Laurier

Shaifali Sandal

Daniel Blum

Catherine Weber

Emilie Trinh

Ethical Considerations

This study was approved by the research ethics board of McGill University Health Centre in Montreal, Canada.

Author Contributions

Research idea and conception: E.T., A.P.-B., C.W.-M.; study design: E.T., A.P.-B., C.W.-M.; participant recruitment and identification: A.M., A.T., C.W.-M.; data acquisition: C.W.-M., A.M.; Data analysis and interpretation: C.W.-M., A.P.-B., N.L., E.T., S.S.; supervision or mentorship: E.T., S.S.; created the first draft of the manuscript: N.L., C.W.-M., E.T.; reviewed and revised the manuscript critically for important intellectual content: N.L., C.W.-M., S.S., A.P.-B., A.T., A.M., D.B., C.W., E.T. All authors approve the final the version to be published and agree to be accountable for all aspects of the work.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by an investigator-initiated grant from Otsuka Canada.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: E.T. has received investigator-initiated research funds from GSK Inc, outside of the submitted work. The other authors have no relevant disclosures to declare.

Data Availability Statement

The data supporting the results of this study will be made available on reasonable request to the corresponding author and following ethics approval and a contract agreement between institutions.

Supplemental Material

Supplemental material for this article is available online.

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