key: cord-0766764-n6lgheka
authors: Clark, David A.; West, Kenneth A.; Tennankore, Karthik K.
title: Feasibility of Twice Weekly Hemodialysis: Contingency Planning for COVID-19
date: 2021-02-05
journal: Kidney Med
DOI: 10.1016/j.xkme.2020.12.005
sha: 599ba877b2a1fc83d14ccbde32d930fa79412d88
doc_id: 766764
cord_uid: n6lgheka

nan

To the Editor:

Patients receiving facility-based hemodialysis represent a unique and vulnerable population during the COVID-19 pandemic. These individuals require life sustaining treatment on average three times weekly at a dialysis center and cannot remain isolated at home. For each treatment, patients regularly interact with transportation workers, other dialysis patients, and members of the health care team. This places them at heightened risk of acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Furthermore, potential shortages of hemodialysis staffing and/or supplies (i.e. from illness, quarantine, and markedly increased numbers of patients requiring acute dialysis for acute kidney injury) has been acknowledged as a significant risk to continued adequate delivery of facilitybased hemodialysis care during the pandemic. 1, 2

As part of contingency planning for lowering coronavirus transmission and/or the potential scenario of fixed/reduced resources during the COVID-19 pandemic, the strategy of reducing hemodialysis treatments from three times weekly to twice-weekly has received international attention. 1-3 A twice-weekly hemodialysis strategy extrapolates from research efforts evaluating incremental hemodialysis, including prior observational studies from the United States and China. [4] [5] [6] [7] These studies concluded a twice-weekly hemodialysis prescription as non-inferior to thrice-weekly treatment in select patients with preserved residual kidney function, minimal interdialytic weight gain, and without hyperkalemia or marked comorbidity. Authority Renal Program provides kidney replacement therapy to individuals from a catchment area of >750,000 individuals. In April 2020 a rapid systematic review of all prevalent patients receiving at least thrice-weekly hemodialysis was performed, utilizing a stepwise approach to apply key selection criteria (adapted from previously studied criteria 5-7 ) for twice-weekly hemodialysis eligibility (Fig 1; Further details of the stepwise approach are available in Item S1).Characteristics of patients who fulfilled twice-weekly criteria were reported using univariable statistics.

Of 473 patients assessed in a three-week period, only 18 (4%) fulfilled criteria for twice-weekly hemodialysis (Fig 1. ) Of these patients, average age was 63 ± 12 (SD) years, average BMI was 29 ± 5 Kg/m 2 , 61% had diabetes, 95% white; and at least 67% receiving dialysis for 6+ months prior to assessment (Table 1) . Fifteen (83%) of eligible patients missed 0 treatments in the preceding month, and none missed >1 treatment.

Average for serum albumin was 36 ± 4 g/L, Urea reduction ratio, 72.7, and residual urea clearance, 5.7 ± 2.7 mL/min/1.73m2 (no patient's pre-dialysis serum urea values demonstrated >10% variability in the preceding 3 months).

Our stepwise approach for the assessment of twice-weekly hemodialysis eligibility permitted a rapid, evidence-based assessment for contingency planning purposes. Although feasible, a twice-weekly hemodialysis strategy could only be applied J o u r n a l P r e -p r o o f to a small proportion of our patient population, a finding which coincides with similarly low reported rates of twice-weekly hemodialysis patients in the United States. 8 This common pattern reinforces the notion that a higher percentage of North Americans may be precluded from twice-weekly eligibility due to a concurrent higher burden of comorbid diseases as compared to patients from other countries (i.e. China) where twiceweekly hemodialysis is more common. 9 Furthermore, the 'intention to defer' strategy for initiating patients on dialysis in Canada 10 may also partly explain the lower rate of eligibility observed at our center, assuming fewer hemodialysis patients with sufficient residual kidney function to qualify.

While we recognize the utility of twice-weekly hemodialysis in lowering coronavirus transmission and/or mitigating challenges caused by the potential scenario of fixed/reduced resources 2 , our findings suggest alternative contingency strategies need be explored; a conclusion which extends to other Canadian centers if results to our strategy are generalized nationally. Recognizing that the inclusion criteria for twice-weekly hemodialysis eligibility were adapted into our stepwise approach and re-purposed for contingency planning, if criteria for residual kidney function were relaxed, eligibility for twice-weekly hemodialysis would be higher, approximating 40% of patients. Of note, these patients still met inclusion criteria addressing hypervolemia, hyperkalemia, and multimorbidity, all major issues of concern for patients reducing from thrice to twiceweekly hemodialysis in a recently published counterpoint paper arguing against the use of twice-weekly hemodialysis in times of dialysis unit stress. 9 However it is important to acknowledge the limited number of studies and available data to date evaluating outcomes of twice-weekly versus thrice-weekly hemodialysis. 9 Therefore, we concur that J o u r n a l P r e -p r o o f a twice-weekly strategy only be implemented as an option of last resort. 1,9 As future adversity resulting in dialysis unit stress is inevitable (i.e. natural disasters) we suggest that our rapid assessment approach be validated across other centers to inform the applicability of this contingency option.

David A Clark, MD 1,2 ; Kenneth A West, MD 1 ; Karthik K Tennankore, MD MSc 1

Item S1. Detailed methods

Supplementary File (PDF) Item S1

Article Information Table 1 . Characteristics of patients who meet criteria for twice-weekly hemodialysis.

N=18 Age (mean years ± SD) 

Step 1

Step 2

Step 3

No

Management of Outpatient Hemodialysis During the COVID-19 Pandemic: Recommendations from the Canadian Society of Nephrology COVID-19 Rapid Response Team

Twice-Weekly Hemodialysis Is an Option for Many Patients in Times of Dialysis Unit Stress

National Institute for Health and Care Excellence. COVID-19 rapid guideline: dialysis service delivery

Two-times weekly hemodialysis in China: frequency, associated patient and treatment characteristics and Quality of Life in the China Dialysis Outcomes and Practice Patterns study. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association -European Renal Association

Twice-weekly and incremental hemodialysis treatment for initiation of kidney replacement therapy. American journal of kidney diseases : the official journal of the National Kidney Foundation

Incremental Hemodialysis, Residual Kidney Function, and Mortality Risk in Incident Dialysis Patients: A Cohort Study

Incremental and infrequent hemodialysis: a new paradigm for both dialysis initiation and conservative management

Predictors of treatment with dialysis modalities in observational studies for comparative effectiveness research

Counterpoint: Twice-Weekly Hemodialysis Should Be an Approach of Last Resort Even in Times of Dialysis Unit Stress

Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis

4.6 ± 0.4 Serum Hemoglobin (mean g/L ± SD) 109 ± 13 URR (mean % ± SD) 72 ± 7 Pre HD sBp/dBp 3 (mean mmHg ± SD) 152 ± 16 / 70 ± 9 Post HD sBp/dBp 3 (mean mmHg ± SD) 142 ± 20 / 66 ± 17 Kru (mean mL/min/1.73m 2 ± SD) 5.7 ± 2.7 1 Considered all sessions from four weeks preceding twice-weekly assessment 2 Values from routine testing within 6-week period prior to twice-weekly assessment 3 Average of values from three preceding sessions prior to twice-weekly assessment BMI, Body mass index; CVC, Central venous catheter; AVF, Arterio-venous fistula; URR, Urea reduction ratio; HD, Hemodialysis; sBp, Systolic blood pressure; dBp, Diastolic blood pressure; Kru, Residual urea clearance