Incremental dialysis in ESRD: systematic review and meta-analysis



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.

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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.

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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.

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Correspondence to Carlo Garofalo.

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Garofalo, C., Borrelli, S., De Stefano, T. et al. Incremental dialysis in ESRD: systematic review and meta-analysis. J Nephrol 32, 823–836 (2019).

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  • Incremental hemodialysis
  • Incremental peritoneal dialysis
  • Meta-analysis
  • Systematic review
  • ESRD