Implementing a Protocol for Incremental Hemodialysis in Incident Patients With Kidney Failure: A Quality Improvement Initiative.

Background: Incremental hemodialysis (iHD), which adapts dialysis frequency to a patient's residual kidney function, may ease the transition to dialysis, improve quality of life, and reduce costs. Objectives: In our tertiary care center, we aimed to develop and implement an iHD protocol and to safely initiate 75% of eligible patients starting incident dialysis on iHD, defined as twice-weekly dialysis, over a two-year period. This project was a nephrology fellow-led quality improvement (QI) initiative conducted as part of the Canadian Society of Nephrology's Quality Improvement and Implementation Science national curriculum. Methods: We conducted a QI study from November 1, 2022, to December 31, 2024. An iHD protocol was developed with input from key stakeholders. It included a patient information sheet, routine 24-hour urine collections, a nursing safety checklist integrated into the electronic medical record, and an alert system to identify patients on iHD for physician review. Patients were eligible for iHD if medically stable without indications for thrice-weekly dialysis, and able to comply with physician recommendations and complete required 24-hour urine collections. The primary outcome measure was the proportion of incident patients initiated on iHD. Balancing measures included reasons for iHD discontinuation, hospitalization and mortality rates, and duration on iHD, while process measures included completion rates of nursing checklists and urine collections. Results: Of 135 incident hemodialysis starts during the study period, 57 (42%) patients were deemed eligible for iHD, of which 44 (77%) were initiated on an incremental prescription (mean age 61 years). At the end of the study, 25% of patients remained on iHD, with a mean duration of 234 days on iHD. The most common reasons for transition to thrice-weekly hemodialysis were volume overload (54%) and inadequate clearance (33%). Five Plan-Do-Study-Act (PDSA) cycles led to refinements of the protocol, including increased frequency of nursing checklist, facilitated identification of patients on iHD, more frequent electrolyte monitoring, and multiple educational sessions with healthcare providers. Overall, the 24-hour urine collection completion rate by patients was 69%, while nursing checklist completion rates increased from 61% in the first 8 months to a 100% by study end. Mortality and dialysis-related hospitalization rates, excluding vascular access-related issues, were significantly lower in the incremental group than in the conventional group (mortality: 2.3% vs. 17.6%; hospitalization: 0.10 vs. 0.22 events per patient-year). Conclusion: A structured iHD protocol, refined through iterative PDSA cycles, enabled safe initiation of iHD in 77% of eligible patients in our center. This study illustrates how a systematic, QI-driven approach can guide other centers in adopting incremental HD safely while promoting ongoing process improvement and patient-centred care.