Direct outpatient initiation of once- or twice-weekly incremental hemodialysis: a ten-year single-center descriptive cohort of treatment pathways and a dialysis-delivery fee scenario

Incremental hemodialysis (IHD) aligns treatment frequency with residual kidney function (RKF); however, direct outpatient programs and their operating rules are rarely described. We report a 10-year single-center program in Japan. We retrospectively studied 61 consecutive adults who initiated maintenance hemodialysis directly as outpatients on once- or twice-weekly schedules from July 2013 to July 2023; nine patients who initiated conventional thrice-weekly hemodialysis were described separately. The starting frequency was selected through individualized written shared decision-making that considered creatinine clearance (Ccr), urine volume, nutrition, comorbidity, clinical judgment, adherence, activities of daily living, and patient preference without a numeric allocation threshold. Conservative kidney management without dialysis was presented to every patient as an alternative, and none chose it. Five prespecified criteria prompted a recommendation to increase the frequency. Survival time began at the first outpatient IHD session; death was the event, escalation did not censor follow-up, and transplantation was censored on the transplantation date. Ccr and urine volume were analyzed on an available-case basis. Of 70 adults, 61 (87.1%) started outpatient IHD (40 once weekly; 21 twice weekly). The median age was 63 years (IQR 49–72), the Charlson comorbidity index was 5 (4–7), and Ccr was 4.32 mL/min (3.26–6.71; n = 58). Over 2642 patient-months (median follow-up 39.1 months), nine patients died, six underwent transplantation by study end, and three were lost to follow-up. No death occurred within 90 days. Survival was 98.2% (95% CI 88.0–99.7) at 1 year and 87.3% (71.2–94.7) at 5 years. Thirty once-weekly initiators transitioned to twice-weekly treatment after a median of 6.1 months, and six transitioned directly to thrice-weekly treatment. Over 1709 reconstructed incremental patient-months, the dialysis-delivery fee scenario was 41.6% lower than the same exposure when valued at the thrice-weekly rate. Direct outpatient once- or twice-weekly IHD was operationally sustained for a decade. Selection based on RKF, clinical stability, and patient preference, together with the absence of a concurrent comparator, limits interpretation of these findings to feasibility and treatment pathways; they do not establish comparative effectiveness, safety, RKF preservation, or lower total costs. Not applicable.