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通讯作者:

王俭勤(1964-),男,甘肃平凉人,博士生导师,主要从事肾脏疾病相关研究。E-mail:wangjianqin@medmail.com.cn

中图分类号:R459.5

文献标识码:A

文章编号:2096-8965(2021)04-0080-05

DOI:10.12287/j.issn.2096-8965.20210411

参考文献 1
GBD Chronic Kidney Disease Collaboration.Global,regional,and national burden of chronic kidney disease,1990-2017:a systematic analysis for the Global Burden of Disease Study 2017[J].Lancet,2020,395(10225):709-733.
参考文献 2
CHIN A I,APPASAMY S,CAREY R J,et al.Feasibility of incremental 2-times weekly hemodialysis in incident patients with residual kidney function[J].Kidney Int Rep,2017,2(5):933-942.
参考文献 3
中国围透析期慢性肾脏病管理规范专家组.中国围透析期慢性肾脏病管理规范[J].中华肾脏病杂志,2021,37(8):690-704.
参考文献 4
CLARK D A,WEST K A,TENNANKORE K K.Feasibility of twice-weekly hemodialysis:contingency planning for COVID-19[J].Kidney Med,2021,3(2):314-316.
参考文献 5
SURI R S,ANTOSEN J E,BANKS C A,et al.Management of outpatient hemodialysis during theCOVID19 pandemic:recommendations from the Canadian society of nephrology COVID-19 rapid response team[J].Can J Kidney Health Dis,2020,11:1-15.
参考文献 6
MUREA M,MOOSSAVI S,GARNEATA L,et al.Narrative review of incremental hemodialysis[J].Kidney Int Rep,2019,5(2):135-148.
参考文献 7
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参考文献 8
KALANTAR K,CROWLEY S T,BEDDHU S,et al.Renal replacement therapy and incremental hemodialysis for veterans with advanced chronic kidney disease[J].Semin Dial,2017,30(3):251-261.
参考文献 9
LI T,WILCOX C S,LIPKOWITZ M S,et al.Rationale and strategies for preserving residual kidney function in dialysis patients[J].Am J Nephrol,2019,50(6):411-421.
参考文献 10
BESSELING P J,PIETERS T T,NGUYEN I T N,et al.A plasma creatinine-and urea-based equation to estimate glomerular filtration rate in rats[J].Am J Physiol Renal Physiol,2021,320(3):F518-F524.
参考文献 11
LEE Y J,OKUDA Y,SY J,et al.Ultrafiltration rate,residual kidney function,and survival among patients treated with reduced-frequency hemodialysis[J].Am J Kidney Dis,2020,75(3):342-350.
参考文献 12
CHIN A I,APPASAMY S,CAREY R J,et al.Feasibility of incremental 2-times weekly hemodialysis in incident patients with residual kidney function[J].Kidney Int,2017,2(5):933-942.
参考文献 13
FERNANDEZ M,RUIZ G,MERINO J L,et al.Initiating renal replacement therapy through incremental haemodialysis:protocol for a randomized multicentre clinical trial[J].Trials,2020,21(1):206.
参考文献 14
OBI Y,KALANTAR-ZADEH K.Incremental and onceto twice-weekly hemodialysis:from experience to evidence[J].Kidney Int Rep,2017,2(5):781-784.
参考文献 15
VIJAYAN A,DELOS SANTOS R B,LI T T,et al.Effect of frequent dialysis on renal recovery:results from the acute renal failure trial network study[J].Kidney Int Rep,2018,3(2):456-463.
参考文献 16
ZHANG M M,WANG M J,LI H M,et al.Association of initial twice-weekly hemodialysis treatment with preservation of residual kidney function in ESRD patients [J].Am J Nephrol,2014,40(2):140-150.
参考文献 17
LEE Y,OKUDA Y,SY J,et al.Ultrafiltration rate effects declines in residual kidney function in hemodialysis patients[J].Am J Nephrol,2019,50(6):481-488.
参考文献 18
HUR I,LEE Y K,KALANTAR-ZADEH K,et al.Individualized hemodialysis treatment:a perspective on residual kidney function and precision medicine in nephrology[J].Cardiorenal Med,2019,9(2):69-82.
参考文献 19
LEE Y J,RHEE C M,KALANTAR-ZADEH K,et al.Residual kidney function in twice-weekly hemodialysis:irreplaceable contribution to dialysis adequacy[J].Ann Transl Med,2018,6(16):317.
参考文献 20
SKEAT L,MASTERSON R,TJIPTO A C,et al.Residual kidney function in nocturnal vs conventional haemodialysis patients:a prospective observational study[J].Int Urol Nephrol,2020,52(4):757-764.
参考文献 21
KUO G,LEE T H,CHEN J J,et al.The dialysis facility levels and sizes are associated with outcomes of incident hemodialysis patients[J].Sci Rep,2021,11(1):20560.
参考文献 22
TORIGOE K,MUTA K,TSUJI K,et al.Association of urinary dickkopf-3 with residual renal function decline in patients undergoing peritoneal dialysis[J].Medicina(Kaunas),2021,57(6):631.
参考文献 23
DING L,JOHNSTON J,PINSK M N.Monitoring dialysis adequacy:history and current practice[J].Pediatr Nephrol,2021,36(8):2265-2277.
参考文献 24
HANSSON J H,FINKELSTEIN F O.Peritoneal dialysis in the United States:lessons for the future[J].Kidney Med,2020,2(5):529-531.
参考文献 25
CHEN W S,WANG M J,ZHANG M M,et al.Benefits of incremental hemodialysis seen in a historical cohort study[J].Ther Clin Risk Manag,2021,17:1177-1186.
参考文献 26
LEONG S C,SAO J N,TAUSSIG A,et al.Residual function effectively controls plasma concentrations of secreted solutes in patients on twice weekly hemodialysis [J].J Am Soc Nephrol,2018,29(7):1992-1999.
参考文献 27
WANG K,KESTENBAUM B.Proximal tubular secretory clearance:a neglected partner of kidney function[J].Clin J Am Soc Nephrol,2018,13(18):1291-1296.
参考文献 28
TORREGGIANI M,FOIS A,NJANDJO L,et al.Toward an individualized determination of dialysis adequacy:a narrative review with special emphasis on incremental hemodialysis[J].Expert Rev Mol Diagn,2021,21(11):1119-1137.
参考文献 29
DAI L,LU C,LIU J,et al.Impact of twice-or three-times-weekly maintenance hemodialysis on patient outcomes:a multicenter randomized trial[J].Medicine(Baltimore),2020,99(20):e20202.
参考文献 30
VILAR E,KAJA KAMAZ R M,FOTHERINGHAM J,et al.A multicenter feasibility randomized controlled trial to assess the impact of incremental versus conventional initiation of hemodialysis on residual kidney function[J].Kidney Int,2021(21):S0085.
参考文献 31
NAKAO T,KANAZAWA Y,TAKAHASHI T,et al.Once-weekly hemodialysis combined with low-protein and low-salt dietary treatment as a favorable therapeutic modality for selected patients with end-stage renal failure:a prospective observational study in Japanese patients[J].BMC Nephrol,2018,19(1):151.
参考文献 32
YOU A S,KALANTAR-ZADEH K,OBI Y,et al.Residual urine output and mortality in a prospective hemodialysis cohort[J].Kidney Int Rep,2020,5(5):643-653.
参考文献 33
MUREA M,KALANTAR-ZADEH K.Incremental and twice-weekly hemodialysis program in practice[J].Clin J Am Soc Nephrol,2020,16(1):147-149.
参考文献 34
KIM T W,CHANG T I,KIM T H,et al.Association of ultrafifiltration rate with mortality in incident hemodialysis patients[J].Nephron,2018,139(1):13-22.
参考文献 35
YAN Y,WANG M,ZEE J,et al.Twice-weekly hemodialysis and clinical outcomes in the China dialysis outcomes and practice patterns study[J].Kidney Int Rep,2018,3(4):889-896.
目录contents

    摘要

    血液透析治疗是终末期肾脏病的主要治疗手段,其最终目标是改善患者生活质量和生存时间。在医疗资源有限和新型冠状病毒肺炎 (Corona Virus Disease 2019,COVID-19) 疫情下,递增式血液透析作为一种根据患者残余肾功能情况个体化调整透析方案的手段,通过多维度个体化评估患者透析充分性。在不影响住院率和生存率的情况下,递增式血液透析不仅可以更好地保护残余肾功能,还可在一定程度上减轻医疗负担,降低血液透析患者感染新型冠状病毒肺炎的风险。 本文就递增式血液透析的概念、施行条件、提出背景、优势及局限性等方面进行综述,旨在说明递增式血液透析将会是目前医疗及社会环境下符合精准医学要求,并实现医疗安全、生存率、生活质量、医疗费用之间平衡的重要策略,值得进一步关注。

    Abstract

    Hemodialysis therapy is the primary treatment for end-stage renal disease with the ultimate goal of improving quality of life and survival time. In the context of limited medical resources and the global prevalence of COVID-19, incremental hemodialysis, as a means of individualizing the dialysis regimen according to the patient's residual renal function, can not only better protect the residual renal function by individualizing the assessment of the patient's dialysis adequacy in multiple dimensions without affecting the hospitalization and survival rate, but also can reduce the medical burden and the risk of COVID-19 infection in hemodialysis patients. This review explains the concept, conditions of implementation, background, advantages and limitations of incremental hemodialysis, and aims to show that incremental hemodialysis will be an important strategy to achieve a balance among medical safety, survival, quality of life, and medical costs in the current medical and social environment in line with the requirements of precision medicine, and deserves further attention.

  • 前言

  • 世界范围内约10%的人患有慢性肾脏病 (Chronic Kidney Disease,CKD),其中有200万患者需行透析治疗[1]。CKD具有“高患病率、高致残率、低知晓率”三大特点[2],当CKD患者一旦进入终末期肾病 (End Stage Renal Disease,ESRD),就需行昂贵的肾脏替代治疗来维持生命,血液透析 (Hemodialysis, HD) 是其主要治疗手段之一。 2015年的 《中国肾脏疾病科学报告》 指出,CKD住院患者人数占当年住院患者总人数的4.8%,我国CKD患者的住院中位医疗费用为14 965元,其医疗花费占到整体医疗支出的6.34%,ESRD已经给我国医疗卫生体系带来沉重的经济负担[3]。3次/周的透析是目前全球公认的标准透析处方[1],在医疗资源有限和COVID-19疫情下,递增式血液透析不仅可以更好地保护患者的残余肾功能 (Regres⁃ sion of Residual Kidney Function,RKF),还可在一定程度上减轻医疗费用负担,将有限的透析资源用于更多患者,亦能为降低透析患者感染COVID-19的风险提供一种思路[4, 5]

  • 1 递增式血液透析的概念

  • 递增式HD是根据RKF来个性化调整透析处方 (包括透析频率、时间、血流量等) 的一种透析方式,可分为3种:(1) 起始时2次/周HD并随RKF下降调整为3次/周HD;(2) 1次/周HD辅以低蛋白饮食并随后调整为更高频率的HD[6];(3) 3次/周HD并缩短透析疗程 (每个疗程<4h),随RKF下降逐渐增加透析时长 (每个疗程<4h)。

  • 2 递增式血液透析的条件

  • 2014年Kalantar-Zadeh等[7] 提出了可考虑进行递增式透析的十一条标准。每日尿量>600mL和残肾尿素清除率≥3mL/min是必须具备的两个条件,此外,如果患者符合以下五个或者九个其它标准,例如:(1) 透析间期体重增长小于2.5kg;(2) 心血管症状较轻或易于管理;(3) 较少住院;(4) 症状及健康相关生活质量满意;(5) 合适的体型; (6) 良好的营养状态,无高代谢状态;(7) 没有高钾血症;(8) 没有高磷血症;(9) 没有严重贫血[6],可考虑进行2次/周的递增式血液透析。进行递增式透析的每位患者应定期监测RKF (每月或每季度评估一次),当尿量降低至0.5L/d或残肾尿素清除率 ≤2mL/min时,患者的血液透析处方应从2次/周调整为3次/周,以更好补充RKF的下降[8]

  • 3 递增式血液透析的提出

  • 血液透析作为ESRD的主要治疗方法,从构建到引进已有半个多世纪,但HD治疗的最佳处方 (即频率、持续时间和剂量) 仍未确定。无论患者开始透析时间的长短,无论有无残余肾功能,目前绝大多数接受血液透析的ESRD患者均采用“一刀切式”的标准方案,即3次/周[9],Besseling等[10] 的研究指出,对ESRD患者而言,从透析前到开始透析的几个月,3次/周的标准化血液透析既不利于RKF的保护,还可能使患者的死亡风险增高。Li等[9, 10] 的文章中提到20世纪70年代初,Babb和Mi⁃ lutinovic等人就呼吁关注RKF,他们主张为患者开具透析处方时应充分考虑RKF的影响,然而当时其观点并未得到足够重视。2015年美国肾脏数据系统 (the United States Renal Data System,USRDS) 的数据指出,开始透析时ESRD患者的平均肾小球滤过率 (estimated Glomerular Filtration Rate,eGFR) 为9.8mL/(min·1.73m2),其中39%的患者eGFR ≥10mL/(min·1.73m2[11, 12]。由此可知,很大比例的ESRD患者早期都有一定的RKF,而RKF保持时间越长患者寿命越长,因此,对于早期有足够RKF的患者来说递增式透析较标准透析而言是更好的选择[13]

  • 4 递增式血液透析的优势

  • 4.1 保护残余肾功能

  • Obi等[11, 14] 的研究表明递增式血液透析能更好地保护患者的RKF,因为透析本身会使RKF受到一定程度的破坏。Vijayan等[15] 关于透析相关急性肾损伤的研究指出低频次透析对固有肾功能有潜在有益影响,该研究亦表明接受3次/周血液透析治疗的患者在第28天的肾功能恢复率 (肌酐清除率>20mL/min) 更低。Zhang等[16] 的回顾性研究指出在开始透析时,2次/周可能比3次/周的透析治疗更有利于保护患者的RKF。Lee等[17] 的研究验证了此观点,同时还表明3次/周的标准化血液透析不仅不利于RKF的保护,同时还可能使患者的死亡风险增高。腹膜透析比血液透析患者丧失RKF的风险低65%,这归因于更稳定的血流动力学。血液透析患者的RKF最常用尿素清除率的平均值进行估计[18]。目前认为,与RKF下降较快相关的因素是女性、非白人种族、糖尿病、充血性心力衰竭、未控制的高血压、蛋白尿、生物相容膜、低血压[13]。RKF的作用机制至今尚不明确,Lee等[11] 认为与改善液体容量、清除体内蛋白结合毒素和中分子物质、减少炎症反应、保留红细胞生成素和维生素D的产生有关。有临床研究报道使用肾素-血管紧张素-醛固酮系统抑制剂、递增式透析、生物相容性较好的透析膜对保护RKF有益处[19]。RKF与透析年限呈反比关系[20],与生存率呈正相关关系[18]。总之,已有许多临床实验证明RKF是透析患者重要且有利的预后指标,足够的RKF可降低死亡率,提高患者生活质量[18, 19],因此,尽可能保护血透患者的RKF是我们亟需重视的问题。

  • 4.2 提高患者生存率

  • 开始进行肾脏替代治疗预示着高比率的不良事件发生,维持性HD的死亡率在治疗的前6个月最高[21]。Torigoe等[22] 关于ESRD的临床研究认为,患者生存率的提高归因于肾脏的清除率而非透析的清除率情况,肾肌酐清除率每增加5L·w-1 ·1.73m-2 死亡率就会下降10%[6],而递增式透析可帮助ESRD患者“平稳过渡”到透析阶段[23]。Hansson等[9, 24] 认为从非透析依赖的ESRD突然过渡到3次/周的HD治疗可能导致高死亡率,HD治疗开始后RKF的丧失可能是导致高死亡率的一个因素,因为HD可导致肾脏的短暂性缺血损伤进而导致重复性的缺血事件,这可能会加速RKF的下降。目前国内外均有研究指出,对有足够RKF患者而言,2次/周比3次/周HD患者的生存率更高[21, 25]

  • 4.3 联合药物辅助治疗,提高透析安全性

  • 递增式血液透析适合有一定RKF的患者,该疗法选择患者的核心标准是RKF水平是否达标,当患者每日尿量<600mL或残肾尿素清除率<2mL/min时需重新评估患者RKF。Leong等[26] 指出RKF可参与液体、蛋白结合溶质及毒素的清除,磷、钾等物质的排泄、内源性维生素D和促红细胞生成素的产生,这是HD所不能提供的[27]。基于此Torreggiani等[28] 提出等效连续清除率 (Equivalent Continuous Clearance,ECC)这一概念,随着RKF的减少,透析清除率应加以补偿,而使用利尿剂、降钾药物、碳酸氢钠可起到补充减少RKF的作用。Obi等[14] 的研究验证了对2次/周的HD患者使用呋塞米可以较好改善患者透析间期的体重增加,从而降低患者超滤率,增加透析的安全性。

  • 4.4 进行个体化充分性评估

  • 递增式血液透析是对有足够RKF的患者制定的个体化透析方案,因此对透析充分性的评估也应是个性化的,而保证透析充分性可提高患者的生存率[27]。没有任何一种分子或数学公式可以单独评估透析充分性。根据Torreggiani等[28] 的建议,我们可以使用临床症状和生物标志物相结合的方法,综合并发症、患者预期寿命、营养状况、残余肾功能、中分子 (β2-微球蛋白)、小分子 (尿素和Kt/V) 毒素的清除情况评估透析充分性,从而为每位患者制定最佳透析处方。

  • 4.5 在COVID-19疫情下的应用优势

  • 众所周知,血液透析患者因免疫力低下极易感染各类疾病,而3次/周的HD使得患者频繁往返于医院,从而增加了暴露风险,此外,透析室封闭的环境及聚集的人群亦是增加暴露风险的重要因素,在COVID-19疫情下,我们应做好疫情常态化准备,此时个体化透析方案有着重要意义。递增式透析与3次/周的标准透析相比,住院率与患者的生存率并无明显差异[9]。Dai等[29] 的研究表明,2次/周与3次/周的HD患者治疗前后两组间的血红蛋白 (Hb)、超敏C-反应蛋白 (hsCRP)、血清白蛋白 (ALB)、胆固醇 (CHO)、甘油三酯 (TG)、钙 (Ca)、磷酸盐、甲状旁腺激素 (PTH) 和射血分数 (Ejection Fraction,EF) 均无差异,与此同时短期 (1年) 内2次/周的HD并没有导致心血管疾病率增加,但这可能还需要进一步研究得以验证。Vilar等[30] 的研究显示与标准透析组相比,递增式透析组发生严重不良事件甚至更少。递增式透析患者的生活质量评定量表 (Quality of Life,QOL) 分数更高[31]。此外递增式透析还有可能延长血管通路的寿命[14]。与此同时,递增式透析组费用的中位数明显降低[25]。综上所述,递增式血液透析对有足够RKF的患者是安全的。对初始透析患者来讲,可根据患者RKF情况选择施行递增式血液透析,这不仅符合精准医学的要求,还可减轻国家的财政负担[9, 30],同时还可降低透析患者感染COVID-19的风险。

  • 5 递增式透析的局限性

  • 第一,目前国内外还没有关于递增式透析的前瞻性大型临床数据报告[32],用以说明递增式透析对于中分子及大分子毒素的清除情况,还需要更多的实验数据来验证。第二,尽管有部分实验已说明2次/周的递增式HD与3次/周的传统HD相比,更有利于RKF的保留[33],但这些结论还需要更完善、全面、长期的研究来证实。第三,递增式HD是否能降低初始透析患者第一年的死亡率也有待证实[34]。减少透析次数意味着会增加相应的超滤率 (Ultra⁃ filtration Rate,UFR),超滤率是一个综合指标,包括透析间期体重增加 (Interdialytic Weight Gain, IDWG)、治疗时间和透析后体重,递增式透析意味着需要更多依靠RKF及严格限制液体入量同时配合辅助用药。在施行递增式透析治疗时,高IDWG或缩短治疗时间可能需要更高的UFR[11],而更高的UFR可能会增加透析中低血压的发生,同期一些观察性实验已说明,高UFR会增加透析患者的全因死亡率和心血管死亡事件的发生[35]。UFR是由透析前体重、干重 (透析后的理想体重) 和治疗时间共同决定的,未来还需要相关研究来证实在接受递增式透析的患者中,高UFR和病人的预后之间是否存在因果关系[11]。此外,目前还未明确的是,血液透析患者的其他干预措施能否与递增式透析产生协同作用,比如调节血管紧张素信号通路、大剂量使用袢利尿剂、避免静脉注射造影剂等[6, 35]

  • 6 小结及展望

  • HD为终末期肾脏病的主要治疗手段,其最终目标是改善患者生活质量和生存时间。递增式血液透析在COVID-19疫情的影响下,可根据患者残余肾功能对透析方案进行个体化调整,通过多维度评估患者透析充分性,透析间期体重增加 (IDWG)、干体重、营养等在内的生化指标或生理参数,在不影响患者住院率和生存率的情况下,不仅可以更好的保护患者的RKF,还可在一定程度上减轻医疗负担,降低血液透析患者感染COVID-19的风险,值得进一步研究和推广使用。

  • 参考文献

    • [1] GBD Chronic Kidney Disease Collaboration.Global,regional,and national burden of chronic kidney disease,1990-2017:a systematic analysis for the Global Burden of Disease Study 2017[J].Lancet,2020,395(10225):709-733.

    • [2] CHIN A I,APPASAMY S,CAREY R J,et al.Feasibility of incremental 2-times weekly hemodialysis in incident patients with residual kidney function[J].Kidney Int Rep,2017,2(5):933-942.

    • [3] 中国围透析期慢性肾脏病管理规范专家组.中国围透析期慢性肾脏病管理规范[J].中华肾脏病杂志,2021,37(8):690-704.

    • [4] CLARK D A,WEST K A,TENNANKORE K K.Feasibility of twice-weekly hemodialysis:contingency planning for COVID-19[J].Kidney Med,2021,3(2):314-316.

    • [5] SURI R S,ANTOSEN J E,BANKS C A,et al.Management of outpatient hemodialysis during theCOVID19 pandemic:recommendations from the Canadian society of nephrology COVID-19 rapid response team[J].Can J Kidney Health Dis,2020,11:1-15.

    • [6] MUREA M,MOOSSAVI S,GARNEATA L,et al.Narrative review of incremental hemodialysis[J].Kidney Int Rep,2019,5(2):135-148.

    • [7] KALANTAR-ZADEH K,UNRUH M,ZAGER P G,et al.Twice-weekly and incremental hemodialysis treatment for initiation of kidney replacement therapy[J].Am J Kidney Dis,2014,64(2):181-186.

    • [8] KALANTAR K,CROWLEY S T,BEDDHU S,et al.Renal replacement therapy and incremental hemodialysis for veterans with advanced chronic kidney disease[J].Semin Dial,2017,30(3):251-261.

    • [9] LI T,WILCOX C S,LIPKOWITZ M S,et al.Rationale and strategies for preserving residual kidney function in dialysis patients[J].Am J Nephrol,2019,50(6):411-421.

    • [10] BESSELING P J,PIETERS T T,NGUYEN I T N,et al.A plasma creatinine-and urea-based equation to estimate glomerular filtration rate in rats[J].Am J Physiol Renal Physiol,2021,320(3):F518-F524.

    • [11] LEE Y J,OKUDA Y,SY J,et al.Ultrafiltration rate,residual kidney function,and survival among patients treated with reduced-frequency hemodialysis[J].Am J Kidney Dis,2020,75(3):342-350.

    • [12] CHIN A I,APPASAMY S,CAREY R J,et al.Feasibility of incremental 2-times weekly hemodialysis in incident patients with residual kidney function[J].Kidney Int,2017,2(5):933-942.

    • [13] FERNANDEZ M,RUIZ G,MERINO J L,et al.Initiating renal replacement therapy through incremental haemodialysis:protocol for a randomized multicentre clinical trial[J].Trials,2020,21(1):206.

    • [14] OBI Y,KALANTAR-ZADEH K.Incremental and onceto twice-weekly hemodialysis:from experience to evidence[J].Kidney Int Rep,2017,2(5):781-784.

    • [15] VIJAYAN A,DELOS SANTOS R B,LI T T,et al.Effect of frequent dialysis on renal recovery:results from the acute renal failure trial network study[J].Kidney Int Rep,2018,3(2):456-463.

    • [16] ZHANG M M,WANG M J,LI H M,et al.Association of initial twice-weekly hemodialysis treatment with preservation of residual kidney function in ESRD patients [J].Am J Nephrol,2014,40(2):140-150.

    • [17] LEE Y,OKUDA Y,SY J,et al.Ultrafiltration rate effects declines in residual kidney function in hemodialysis patients[J].Am J Nephrol,2019,50(6):481-488.

    • [18] HUR I,LEE Y K,KALANTAR-ZADEH K,et al.Individualized hemodialysis treatment:a perspective on residual kidney function and precision medicine in nephrology[J].Cardiorenal Med,2019,9(2):69-82.

    • [19] LEE Y J,RHEE C M,KALANTAR-ZADEH K,et al.Residual kidney function in twice-weekly hemodialysis:irreplaceable contribution to dialysis adequacy[J].Ann Transl Med,2018,6(16):317.

    • [20] SKEAT L,MASTERSON R,TJIPTO A C,et al.Residual kidney function in nocturnal vs conventional haemodialysis patients:a prospective observational study[J].Int Urol Nephrol,2020,52(4):757-764.

    • [21] KUO G,LEE T H,CHEN J J,et al.The dialysis facility levels and sizes are associated with outcomes of incident hemodialysis patients[J].Sci Rep,2021,11(1):20560.

    • [22] TORIGOE K,MUTA K,TSUJI K,et al.Association of urinary dickkopf-3 with residual renal function decline in patients undergoing peritoneal dialysis[J].Medicina(Kaunas),2021,57(6):631.

    • [23] DING L,JOHNSTON J,PINSK M N.Monitoring dialysis adequacy:history and current practice[J].Pediatr Nephrol,2021,36(8):2265-2277.

    • [24] HANSSON J H,FINKELSTEIN F O.Peritoneal dialysis in the United States:lessons for the future[J].Kidney Med,2020,2(5):529-531.

    • [25] CHEN W S,WANG M J,ZHANG M M,et al.Benefits of incremental hemodialysis seen in a historical cohort study[J].Ther Clin Risk Manag,2021,17:1177-1186.

    • [26] LEONG S C,SAO J N,TAUSSIG A,et al.Residual function effectively controls plasma concentrations of secreted solutes in patients on twice weekly hemodialysis [J].J Am Soc Nephrol,2018,29(7):1992-1999.

    • [27] WANG K,KESTENBAUM B.Proximal tubular secretory clearance:a neglected partner of kidney function[J].Clin J Am Soc Nephrol,2018,13(18):1291-1296.

    • [28] TORREGGIANI M,FOIS A,NJANDJO L,et al.Toward an individualized determination of dialysis adequacy:a narrative review with special emphasis on incremental hemodialysis[J].Expert Rev Mol Diagn,2021,21(11):1119-1137.

    • [29] DAI L,LU C,LIU J,et al.Impact of twice-or three-times-weekly maintenance hemodialysis on patient outcomes:a multicenter randomized trial[J].Medicine(Baltimore),2020,99(20):e20202.

    • [30] VILAR E,KAJA KAMAZ R M,FOTHERINGHAM J,et al.A multicenter feasibility randomized controlled trial to assess the impact of incremental versus conventional initiation of hemodialysis on residual kidney function[J].Kidney Int,2021(21):S0085.

    • [31] NAKAO T,KANAZAWA Y,TAKAHASHI T,et al.Once-weekly hemodialysis combined with low-protein and low-salt dietary treatment as a favorable therapeutic modality for selected patients with end-stage renal failure:a prospective observational study in Japanese patients[J].BMC Nephrol,2018,19(1):151.

    • [32] YOU A S,KALANTAR-ZADEH K,OBI Y,et al.Residual urine output and mortality in a prospective hemodialysis cohort[J].Kidney Int Rep,2020,5(5):643-653.

    • [33] MUREA M,KALANTAR-ZADEH K.Incremental and twice-weekly hemodialysis program in practice[J].Clin J Am Soc Nephrol,2020,16(1):147-149.

    • [34] KIM T W,CHANG T I,KIM T H,et al.Association of ultrafifiltration rate with mortality in incident hemodialysis patients[J].Nephron,2018,139(1):13-22.

    • [35] YAN Y,WANG M,ZEE J,et al.Twice-weekly hemodialysis and clinical outcomes in the China dialysis outcomes and practice patterns study[J].Kidney Int Rep,2018,3(4):889-896.

  • 参考文献

    • [1] GBD Chronic Kidney Disease Collaboration.Global,regional,and national burden of chronic kidney disease,1990-2017:a systematic analysis for the Global Burden of Disease Study 2017[J].Lancet,2020,395(10225):709-733.

    • [2] CHIN A I,APPASAMY S,CAREY R J,et al.Feasibility of incremental 2-times weekly hemodialysis in incident patients with residual kidney function[J].Kidney Int Rep,2017,2(5):933-942.

    • [3] 中国围透析期慢性肾脏病管理规范专家组.中国围透析期慢性肾脏病管理规范[J].中华肾脏病杂志,2021,37(8):690-704.

    • [4] CLARK D A,WEST K A,TENNANKORE K K.Feasibility of twice-weekly hemodialysis:contingency planning for COVID-19[J].Kidney Med,2021,3(2):314-316.

    • [5] SURI R S,ANTOSEN J E,BANKS C A,et al.Management of outpatient hemodialysis during theCOVID19 pandemic:recommendations from the Canadian society of nephrology COVID-19 rapid response team[J].Can J Kidney Health Dis,2020,11:1-15.

    • [6] MUREA M,MOOSSAVI S,GARNEATA L,et al.Narrative review of incremental hemodialysis[J].Kidney Int Rep,2019,5(2):135-148.

    • [7] KALANTAR-ZADEH K,UNRUH M,ZAGER P G,et al.Twice-weekly and incremental hemodialysis treatment for initiation of kidney replacement therapy[J].Am J Kidney Dis,2014,64(2):181-186.

    • [8] KALANTAR K,CROWLEY S T,BEDDHU S,et al.Renal replacement therapy and incremental hemodialysis for veterans with advanced chronic kidney disease[J].Semin Dial,2017,30(3):251-261.

    • [9] LI T,WILCOX C S,LIPKOWITZ M S,et al.Rationale and strategies for preserving residual kidney function in dialysis patients[J].Am J Nephrol,2019,50(6):411-421.

    • [10] BESSELING P J,PIETERS T T,NGUYEN I T N,et al.A plasma creatinine-and urea-based equation to estimate glomerular filtration rate in rats[J].Am J Physiol Renal Physiol,2021,320(3):F518-F524.

    • [11] LEE Y J,OKUDA Y,SY J,et al.Ultrafiltration rate,residual kidney function,and survival among patients treated with reduced-frequency hemodialysis[J].Am J Kidney Dis,2020,75(3):342-350.

    • [12] CHIN A I,APPASAMY S,CAREY R J,et al.Feasibility of incremental 2-times weekly hemodialysis in incident patients with residual kidney function[J].Kidney Int,2017,2(5):933-942.

    • [13] FERNANDEZ M,RUIZ G,MERINO J L,et al.Initiating renal replacement therapy through incremental haemodialysis:protocol for a randomized multicentre clinical trial[J].Trials,2020,21(1):206.

    • [14] OBI Y,KALANTAR-ZADEH K.Incremental and onceto twice-weekly hemodialysis:from experience to evidence[J].Kidney Int Rep,2017,2(5):781-784.

    • [15] VIJAYAN A,DELOS SANTOS R B,LI T T,et al.Effect of frequent dialysis on renal recovery:results from the acute renal failure trial network study[J].Kidney Int Rep,2018,3(2):456-463.

    • [16] ZHANG M M,WANG M J,LI H M,et al.Association of initial twice-weekly hemodialysis treatment with preservation of residual kidney function in ESRD patients [J].Am J Nephrol,2014,40(2):140-150.

    • [17] LEE Y,OKUDA Y,SY J,et al.Ultrafiltration rate effects declines in residual kidney function in hemodialysis patients[J].Am J Nephrol,2019,50(6):481-488.

    • [18] HUR I,LEE Y K,KALANTAR-ZADEH K,et al.Individualized hemodialysis treatment:a perspective on residual kidney function and precision medicine in nephrology[J].Cardiorenal Med,2019,9(2):69-82.

    • [19] LEE Y J,RHEE C M,KALANTAR-ZADEH K,et al.Residual kidney function in twice-weekly hemodialysis:irreplaceable contribution to dialysis adequacy[J].Ann Transl Med,2018,6(16):317.

    • [20] SKEAT L,MASTERSON R,TJIPTO A C,et al.Residual kidney function in nocturnal vs conventional haemodialysis patients:a prospective observational study[J].Int Urol Nephrol,2020,52(4):757-764.

    • [21] KUO G,LEE T H,CHEN J J,et al.The dialysis facility levels and sizes are associated with outcomes of incident hemodialysis patients[J].Sci Rep,2021,11(1):20560.

    • [22] TORIGOE K,MUTA K,TSUJI K,et al.Association of urinary dickkopf-3 with residual renal function decline in patients undergoing peritoneal dialysis[J].Medicina(Kaunas),2021,57(6):631.

    • [23] DING L,JOHNSTON J,PINSK M N.Monitoring dialysis adequacy:history and current practice[J].Pediatr Nephrol,2021,36(8):2265-2277.

    • [24] HANSSON J H,FINKELSTEIN F O.Peritoneal dialysis in the United States:lessons for the future[J].Kidney Med,2020,2(5):529-531.

    • [25] CHEN W S,WANG M J,ZHANG M M,et al.Benefits of incremental hemodialysis seen in a historical cohort study[J].Ther Clin Risk Manag,2021,17:1177-1186.

    • [26] LEONG S C,SAO J N,TAUSSIG A,et al.Residual function effectively controls plasma concentrations of secreted solutes in patients on twice weekly hemodialysis [J].J Am Soc Nephrol,2018,29(7):1992-1999.

    • [27] WANG K,KESTENBAUM B.Proximal tubular secretory clearance:a neglected partner of kidney function[J].Clin J Am Soc Nephrol,2018,13(18):1291-1296.

    • [28] TORREGGIANI M,FOIS A,NJANDJO L,et al.Toward an individualized determination of dialysis adequacy:a narrative review with special emphasis on incremental hemodialysis[J].Expert Rev Mol Diagn,2021,21(11):1119-1137.

    • [29] DAI L,LU C,LIU J,et al.Impact of twice-or three-times-weekly maintenance hemodialysis on patient outcomes:a multicenter randomized trial[J].Medicine(Baltimore),2020,99(20):e20202.

    • [30] VILAR E,KAJA KAMAZ R M,FOTHERINGHAM J,et al.A multicenter feasibility randomized controlled trial to assess the impact of incremental versus conventional initiation of hemodialysis on residual kidney function[J].Kidney Int,2021(21):S0085.

    • [31] NAKAO T,KANAZAWA Y,TAKAHASHI T,et al.Once-weekly hemodialysis combined with low-protein and low-salt dietary treatment as a favorable therapeutic modality for selected patients with end-stage renal failure:a prospective observational study in Japanese patients[J].BMC Nephrol,2018,19(1):151.

    • [32] YOU A S,KALANTAR-ZADEH K,OBI Y,et al.Residual urine output and mortality in a prospective hemodialysis cohort[J].Kidney Int Rep,2020,5(5):643-653.

    • [33] MUREA M,KALANTAR-ZADEH K.Incremental and twice-weekly hemodialysis program in practice[J].Clin J Am Soc Nephrol,2020,16(1):147-149.

    • [34] KIM T W,CHANG T I,KIM T H,et al.Association of ultrafifiltration rate with mortality in incident hemodialysis patients[J].Nephron,2018,139(1):13-22.

    • [35] YAN Y,WANG M,ZEE J,et al.Twice-weekly hemodialysis and clinical outcomes in the China dialysis outcomes and practice patterns study[J].Kidney Int Rep,2018,3(4):889-896.

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