Incremental dialysis in ESRD: systematic review and meta-analysis

  • Carlo GarofaloEmail author
  • Silvio Borrelli
  • Toni De Stefano
  • Michele Provenzano
  • Michele Andreucci
  • Gianfranca Cabiddu
  • Vincenzo La Milia
  • Valerio Vizzardi
  • Massimo Sandrini
  • Giovanni Cancarini
  • Adamasco Cupisti
  • Vincenzo Bellizzi
  • Roberto Russo
  • Paolo Chiodini
  • Roberto Minutolo
  • Giuseppe Conte
  • Luca De Nicola
Original Article



Incremental dialysis may preserve residual renal function and improve survival in comparison with full-dose dialysis; however, available evidence is limited. We therefore compared all-cause mortality and residual kidney function (RKF) loss in incremental and full-dose dialysis and time to full-dose dialysis in incremental hemodialysis (IHD) and incremental peritoneal dialysis (IPD).


We performed a systematic review and meta-analysis of cohort studies of adults with ESRD starting IHD and IPD. We identified in PubMed and Web of Science database all cohort studies evaluating incremental dialysis evaluating three outcomes: all-cause mortality, RKF loss, time to full dialysis. IPD was defined as < 3 daily dwells in Continuous Ambulatory Peritoneal Dialysis and < 5 sessions per week in Automated Peritoneal Dialysis, while IHD was defined as < 3 HD sessions per week.


22 studies (75,292 participants), 15 in HD and 7 in PD, were analyzed. Mean age at dialysis start was 62 and 57 years in IHD and IPD subjects, respectively. When compared to full dose, incremental dialysis (IHD or IPD) had an overall mortality risk of 1.14 [95% CI 0.85–1.52] with high heterogeneity among studies (I2 86%, P < 0.001), and lower mean RKF loss (− 0.58 ml/min/months, 95% CI 0.16–1.01, P = 0.007). Overall, time to full-dose dialysis was 12.1 months (95% CI 9.8–14.3) with no difference between IHD and IPD (P = 0.217).


Incremental dialysis allows longer preservation of RKF thus deferring full-dose dialysis, by about 1 year in HD and PD, with no increase in mortality risk. Large and adequate studies are needed to confirm these findings.


Incremental hemodialysis Incremental peritoneal dialysis Meta-analysis Systematic review ESRD 


Author Contributions

Research idea and study design: CG, RM, LDN, GC, TDS, MP, SB, MA, GC, VLM, VV, MS, GC, VB, RR, AC. Data acquisition: CG, SB, AC, MS, TDS. Data analysis/interpretation: CG, RM, LDN, GC, MP, SB, MA, GC, VLM, VV, MS, GC, VB, RR, AC. Statistical analysis: CG, PC, SB, MP, TDS. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. CG takes responsibility that this study has been reported honestly, accurately, and transparently; that no important aspects of the study have been omitted and that any discrepancies from the study as planned have been explained.


This work was endorsed by the Italian Society of Nephrology (Gruppi di Progetto sul “Trattamento Conservativo della Insufficienza Renale Cronica” e “Dialisi Peritoneale”) without any financial support.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Supplementary material

40620_2018_577_MOESM1_ESM.docx (39 kb)
Supplementary material 1 (DOCX 38 KB)


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Copyright information

© Italian Society of Nephrology 2019

Authors and Affiliations

  • Carlo Garofalo
    • 1
    Email author
  • Silvio Borrelli
    • 1
  • Toni De Stefano
    • 1
  • Michele Provenzano
    • 2
  • Michele Andreucci
    • 2
  • Gianfranca Cabiddu
    • 3
  • Vincenzo La Milia
    • 4
  • Valerio Vizzardi
    • 5
  • Massimo Sandrini
    • 5
  • Giovanni Cancarini
    • 5
  • Adamasco Cupisti
    • 6
  • Vincenzo Bellizzi
    • 7
  • Roberto Russo
    • 8
  • Paolo Chiodini
    • 9
  • Roberto Minutolo
    • 1
  • Giuseppe Conte
    • 1
  • Luca De Nicola
    • 1
  1. 1.Division of Nephrology, Department of Scienze Mediche e Chirurgiche AvanzateUniversity of Campania “Luigi Vanvitelli”NaplesItaly
  2. 2.Nephrology and Dialysis DivisionUniversity Magna Graecia in CatanzaroCatanzaroItaly
  3. 3.Nephrology and Dialysis DivisionG. Brotzu HospitalCagliariItaly
  4. 4.Nephrology and Dialysis DivisionE. Bassini HospitalMilanItaly
  5. 5.Nephrology and Dialysis DivisionASST Spedali Civili and University of BresciaBresciaItaly
  6. 6.Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
  7. 7.Ruggi d’Aragona Hospital in SalernoBariItaly
  8. 8.Azienda Ospedaliera Universitaria PoliclinicoBariItaly
  9. 9.Statistic and Epidemiologic DivisionUniversity L. Vanvitelli in NaplesNaplesItaly

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