key: cord-0783201-7x2w4df2 authors: Siga, Esteban; Cusumano, Carlos; Garcia, Mariano; Cusumano, Ana title: Twice-weekly hemodialysis in times of COVID-19: A multicenter study in prevalent patients date: 2021-07-06 journal: Clin Kidney J DOI: 10.1093/ckj/sfab115 sha: eb6b12df2070f2b7e5cb489eb120f805bac26a35 doc_id: 783201 cord_uid: 7x2w4df2 nan Patients undergoing long-term in-center hemodialysis (HD) are particularly vulnerable to COVID-19. One option to reduce the exposure of these vulnerable patients is to lower the dialysis frequency from three to two sessions a week 1 . Recently, in a small unicenter study 2 , 16 out of 48 patients (33%) were switched from three to two sessions a week. During this 6-month study, none of the twice-weekly patients presented COVID-19 disease nor required hospitalization or emergency dialysis. However, the only parameter applied for selection was a required ultrafiltration rate (UFR) of less than 8.5 ml/Kg/h. Hyperkalemia and poor nutritional status, two well-known factors that increase mortality 3 , were not taken into account. Our aim in the present multicenter study was to elaborate a practical approach to safely transfer hemodialysis patients to a short-term twice-weekly schedule. We designed a cross-sectional, multicenter study. It was performed in accordance with the Declaration of Helsinki. Demographic and laboratory data were extracted from 178 deidentified patients older than 18 years old, undergoing a thrice-weekly session schedule. Predialysis blood samples of the second weekly session were processed in local laboratories. Laboratory determinations were performed using automated and standardized methods. Funding was provided by each dialysis unit. Data (available on request) are reported as mean (95% CI) or median (interquartile range, IQR) as appropriate. Table 1 shows the main demographic characteristics and laboratory data of the whole sample. The prevalence of diabetes was lower than the national prevalence (19 % vs. 28%) 5 , but the other parameters did not differ from the average HD patient. Our stepwise approach to estimate the feasibility of twice-weekly HD is comprised of three successive steps. First, we aimed to establish a hypothetical cut-off UFR that would exclude most patients in danger of volume overload. Of the four different criteria used to estimate it (see Figure 1 ), a UFR of < 8.5 ml/kg/h was the most selective. This criterion (fulfilled by 60% of the sample) was step 1. Potassium < 5.5 mEq/l was step 2 and nutritional state (GNRI > 96) was step 3. Figure 1 shows that neither step 2 nor step 3 significantly decreased the number of patients suitable for twice-weekly hemodialysis sessions. Forty-two out of the 89 patients selected for twice-weekly hemodialysis reported a residual diuresis of at least 200 ml/day. The current sustained health crisis is prompting us to consider different options for the care of our HD patients, while ensuring the safety of both patients and health care workers . The option of reducing for a short period of time the usual thrice-weekly schedule to a twice-weekly one has been advocated by some authors 1,2 but rejected by others 9,10 . Our results suggest that as many as 50% of patients could be safely transferred to a twice-weekly schedule for a short period. Therefore, we considered that this approach could be implemented at least in COVID-19 positive patients during their isolation period. It is important to emphasize that we propose implementing a twice-weekly schedule for just a short time. For this reason, we did not include dialysis adequacy parameters or residual kidney function in the stepwise approach. It could be argued that if anemia and hyperphosphatemia were included 8 , the number of patients suitable for twice-weekly HD would be significantly lower. However, an increase in the EPO dose and an intensive low-phosphorus diet combined with binders could deal with both conditions during the twice-weekly period. In conclusion, we suggest that during the COVID-19 pandemic the focus should be on reducing the exposure to the virus of in-center HD patients. This can be achieved by reducing the thrice-weekly session schedule to a twice-weekly one, provided suitable patients are carefully selected, and as long as volume overload and hyperkalemia are avoided. The associated increased professional workload must be recognized and reimbursed accordingly. ES designed the study and drafted the manuscript. ES, CC, MG and AC collected and analyzed the data. All authors revised the final manuscript. None of the authors had any financial or personal relations with people or organizations that could have inappropriately influenced their work. The corresponding author states that he had full access to all the data in the study and had final responsibility for the decision to submit for publication 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Legend to Figure 1 : Stepwise approach to evaluate prevalent trice-wekly hemodialysis patients (pts) for short-term twice-weekly hemodialysis. For elegibility, patients must fulfill all Steps. Step 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Legend to Figure 1 . Stepwise approach to evaluate prevalent trice-wekly hemodialysis patients (pts) for short-term twiceweekly hemodialysis. For elegibility, patients must fulfill all Steps. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Twice-Weekly Hemodialysis Is an Option for Many Patients in Times of Dialysis Unit Stress Reduced frequency hemodialysis in times of COVID-19: A prospective study in prevalent patients Metabolic complications in chronic kidney disease: hyperphosphatemia, hyperkalemia and anemia Geriatric Nutritional Risk Index: a new index for evaluating at-risk elderly medical patients Kt/V (and specially its modifications) remain a useful measure of hemodialysis dose Kirmizis D et al on behalf of the EUDIAL Working Group of ERA-EDTA (2020) The reasons for a clinical trial Twice-weekly and incremental hemodialysis treatment for initiation of kidney replacement therapy