Renal Replacement Therapy and Incremental Hemodialysis for Veterans with Advanced Chronic Kidney Disease


Each year approximately 13,000 USA veterans develop end stage kidney failure and require dialysis. There are only 70 Veterans Affairs (VA) run dialysis unit which can accommodate only 10% of the veterans requiring dialysis. Evidence suggests that those veterans in the VA centres have a more favourable outcome. This is despite the substantial costs arising from outsourced care. By slowly and incrementally providing dialysis to veterans in the VA system more veterans can be given care within VA dialysis units.


Each year approximately 13,000 Veterans transition to maintenance dialysis, mostly in the traditional form of thrice-weekly hemodialysis from the start. Among >6,000 dialysis units nationwide, there are currently approximately 70 Veterans Affairs (VA) dialysis centers. Given this number of VA dialysis centers and their limited capacity, only 10% of all incident dialysis Veterans initiate treatment in a VA center. Evidence suggests that, among Veterans, receipt of care within the VA system is associated with favorable outcomes, potentially due to enhanced access to healthcare resources. Data from the United States Renal Data System Special Study Center “Transition-of-Care-in-CKD” suggest that Veterans who receive dialysis in a VA unit exhibit greater survival compared to non-VA centers. Substantial financial expenditures arise from the high volume of outsourced care and higher dialysis reimbursement paid by the VA than by Medicare to outsourced providers. Given the exceedingly high mortality and abrupt decline in residual kidney function (RKF) in the first dialysis year, it is possible that incremental transition to dialysis through an initial twice-weekly hemodialysis regimen preserves RKF, prolongs vascular access longevity, improves patients’ quality of life, and is a more patient-centered approach and consistent with “personalized” dialysis. Broad implementation of incremental dialysis may also result in more Veterans receiving care within a VA dialysis unit. Controlled trials are urgently needed to examine safety and efficacy of incremental hemodialysis in Veterans and other populations, and the administrative and health care as well as provider structure within the VA system would facilitate the performance of such trials.

Full Reference

Renal Replacement Therapy and Incremental Hemodialysis for Veterans with Advanced Chronic Kidney Disease Kamyar Kalantar-Zadeh, Susan T. Crowley, Srinivasan Beddhu, Joline LT Chen, John T Daugirdas, David S. Goldfarb, Anna Jin, Csaba P. Kovesdy, David J. Leehey, Hamid Moradi, Sankar D Navaneethan, Keith C Norris, Yoshitsugu Obi, Ann O’Hare, Tariq Shafi, Elani Streja, Mark L. Unruh, Tushar Vachharajani, Steven Weisbord, Connie M. Rhee Semin Dial. Author manuscript; available in PMC 2018 May 1. Published in final edited form as: Semin Dial. 2017 May; 30(3): 251–261. Published online 2017 Apr 18. doi: 10.1111/sdi.12601 PMCID: PMC5418081