The variable target model: A paradigm shift in the incremental haemodialysis prescription

Abstract

Background. The recent interest in incremental haemodialysis (HD) is hindered by the current prescription based on a fixed target model (FTM) for the total (dialytic + renal) equivalent continuous clearance (ECC). The latter is expressed either as standard Kt/V (stdKt/V), i.e. the pre-dialysis averaged concentration of urea-based ECC, or EKRc, i.e. the time averaged concentration-based ECC, corrected for volume (V) = 40 L. Accordingly, there are two different targets: stdKt/V = 2.3 volumes per week (v/wk) and EKRc = 13 mL/min/40 L. However, fixing the total ECC necessarily implies perfect equivalence of its components-the residual renal urea clearance (Kru) and dialysis clearance (Kd). This assumption is wrong because Kru has much greater clinical weight than Kd. Here we propose that the ECC target varies as an inverse function of Kru, from a maximum value in anuria to a minimum value at Kru levels not yet requiring dialysis. The aim of the present study was to compare the current FTM with the proposed variable target model (VTM). Methods. The double pool urea kinetic model was used to model dialysis sessions for 360 virtual patients and establish equations predicting the ECC as a function of Kd, Kru and the number of sessions per week. An end-dialysis urea distribution V of 35 L (corresponding to a body surface area of 1.73 m2) was used, so that the current EKRc target of 13 mL/min/40 L could be recalculated at an EKRc35 value of 12 mL/min/35 L equal to 12 mL/min/1.73 m2. The latter also coincides with the maximum value of the EKRc35 variable target in anuria. The minimum target value of EKRc35 was assumed to coincide with Kru corrected for V = 35 L (i.e. Krc35 = 6 mL/min/1.73 m2). The corresponding target for stdKt/V was assumed to vary from 2.3 v/wk at Krc35 = 0 to 1.7 v/wk at Krc35 = 6 mL/min/1.73 m2. On this basis, the variable target values can be obtained from the following linear equations: target EKRc35= 12 Krc35; target stdKt/V = 2.3 0.1 Krc35. Two versions of stdKt/V were considered: the classic version (stdKt/VGotch) with Kru at 70%, and the current version (stdKt/VDaug) with Kru at 100%. Results. The VTMwith stdKt/VGotch produces results very close to those using the FTM with stdKt/VDaug. Once-weekly HD is virtually not allowed by the FTM. In contrast, the VTM allows dialysis to start at Krc35 5 mL/min/1.73 m2 on a once-weekly HD schedule, at least in relatively healthy patients; this schedule can be maintained until Krc35 falls below 4 mL/min/1.73 m2, at which point the schedule should be changed to a twice-weekly HD schedule, that, in turn, could be maintained until Krc35 falls below 2 mL/min/1.73 m2. Conclusions. A paradigm shift from the FTM to the VTM in the prescription of incremental HD is proposed, whereby the VTM would allow less frequent treatments at lower Kru, with important clinical and economic implications. This approach is likely to be safe but needs to be confirmed by randomized controlled trials.