الفهرس 
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Abstract
The concept of incremental dialysis is inherent to the increasingly accepted idea of a new patient-centered prescription of dialysis (Mathew et al., 2018).
The majority of HD patients initiate dialysis with a relatively intense thrice weekly HD (3HD sessions /week) regimen of 3–4 h persession, with little individualization of prescription based on RKF or other patient factors (Mathew et al., 2016).
Although the regulatory agencies might consider this HD regimen as ‘standard of care’ and‘ adequate requirement’, it is by no means perfect. The 3HD/week regimen has been assumed, until recently, almost as a dogma in the dialysis community (Basile and Casino, 2019).
Our study aiming to Compare the intervention arm (incremental HD) with the control arm (standard3 HD/week).Incident patients will be randomized to one of the two treatment groups in equal proportion. Primary outcome is the preservation of RKF assessed as time to anuria (UO<100mL/day). Secondary outcomes are all-cause mortality and significant events, including vascular access failure and associated interventions, cardiovascular events and hospital admissions.
Criteria for candidates that may benefit from incremental hemodialysis (IHD);
• Good residual renal function with urine output > 0.5 L/d (or KRU>3 ml/min).
• Limited fluid retention between two conservative HD treatments with fluid gain < 2.5 kg (or < 5% of ideal dry weight) without HD for 3-4 days.
• Limited or readily manageable cardiovascular or pulmonary symptoms without clinically significant fluid overload.
• Suitable body size relative to renal residual kidney function.
• Hyperkalemia (K, >5.5 mEq/L) is infrequent or readily manageable.
• Hyperphosphatemia (P> 5.5 mEq/L) is infrequent or readily manageable.
• Good nutritional status without florid hypercatabolic state.
• Lack of profound anemia (Hb>8 g/dL) and appropriate responsiveness to anemia therapy.
• Infrequent hospitalizations and easily manageable comorbid conditions.
• Satisfactory health-related quality of life.
• Use of the criteria on 2x/week HD therapy patients should be re-evaluated once a month (Kalantar-Zadeh et al., 2014).
So, the optimal regimen for incident patients is not known. It is plausible that the routine practice of fixed-dose 3 HD/week in incident patients with substantial RKF may be harmful, contributing to accelerated loss of RKF. Despite increasing evidence derived from observational studies to support the use of incremental.
HD, RCTs are lacking and are urgently needed. If the potential benefits of incremental HD will be confirmed by RCTs, then starting dialysis at a full dose will be subjecting patients to unnecessarily long or more frequent treatments for an unnecessarily long time, and at higher cost.