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# Residual kidney function: everyone values it, but few hemodialysis guidelines say how to measure it or use it
- URL: https://nephspace.com/residual-kidney-function-hemodialysis-guidelines/
- Published: 2026-10-26T09:57:00.000Z
- Updated: 2026-10-26T09:56:59.000Z
- Description: A global scoping review of 12 hemodialysis guideline documents found that only four gave guidance a clinician could act on, and only one, from 2007, covered measurement, dose and monitoring in full.
- Author: Dr Wael Hussein
- Tags: Dialysis, #story, #has-audio, #review, #full-story, #in-center-dialysis, Stories

**🎧 Listen:** [Weekly · Oct 26](https://nephspace.com/weekly-oct-26/), from 14:10.

### The question

Patients on hemodialysis who keep some kidney function do better, and residual kidney function is the basis for incremental hemodialysis, starting with less dialysis (for example twice a week) while the kidneys still contribute. Do the guidelines tell clinicians how to measure it and how to use it?

### What the review did

Dr. Sheikh Hiba, Dr. Mariana Murea (senior author) and colleagues at Wake Forest and other US centers reviewed 12 hemodialysis guideline documents from around the world.

### What they found

- Five gave no guidance on residual kidney function. Three acknowledged it, and incremental hemodialysis, without thresholds or a pathway. Four gave guidance a clinician could act on.
- Only one set out a complete framework: the European Best Practice Guidelines (ERA-EDTA, 2007), which define residual function as the mean of urea and creatinine clearance, call for measuring it twice a month or when a change is suspected, assume it is zero if unknown, set a minimum weekly dose, and allow twice-weekly treatment only with demonstrable residual function.
- In the US, the 2006 KDOQI guideline allowed a lower dose when residual urea clearance was at least 2 mL/min/1.73 m², and did not recommend twice-weekly dialysis below that. The 2015 update permits dose reduction with significant residual clearance measured "periodically," without a set threshold. KDIGO's 2019 controversies conference found the evidence insufficient for widespread adoption and set research priorities. The UK Kidney Association's 2019 guideline endorses incremental hemodialysis with measured residual function.
- In practice, clinicians rely on what patients say about their urine output; in a survey the authors cite, none reported measuring residual urea clearance.
- The usual adequacy targets (for example a single-pool Kt/V of 1.4 with thrice-weekly treatment) came from studies that excluded patients with residual function.

### Why it matters

The authors want future guidelines to say that patients with residual function should be evaluated for incremental hemodialysis, to specify how to measure it (residual urea clearance from a timed urine collection), and to set out when to increase the dose, for example with falling urine volume or rising interdialytic weight gain. Our take: don't just ask about urine. Collect it.

### Caveats

This is a review of guidelines, not a trial. It shows where the guidance is missing, not which approach to incremental dialysis is best.

Funding and ties: the authors declare no conflicts of interest.

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**The source:** Hiba SI, Woldemichael J, Awad AS, Abdel-Rahman E, Warfel OR, Gautam SC, Murea M. Clinical Practice Guidelines on the Integration of Residual Kidney Function in Hemodialysis Prescription: A Global Scoping Review. Hemodial Int. 2026\. doi:10.1111/hdi.70123 [Read the original](https://doi.org/10.1111/hdi.70123?ref=nephspace.com)

**🎧 Listen:** [Weekly · Oct 26](https://nephspace.com/weekly-oct-26/), from 14:10.

*Physician-led, AI-assisted. Dr. Wael Hussein chooses every item NephSpace covers and reviews and edits every story before it is published. The first draft was written in our own words with AI (Claude, by Anthropic) from the full text of the paper and checked against our reading notes; Dr. Hussein then reviewed and edited it. For education and information only, not medical advice. Please talk to your own physician or care team about your health. Clinicians: read the original before changing practice. See our* [*disclaimer*](https://nephspace.com/disclaimer/) *and* [*disclosures*](https://nephspace.com/disclosures/)*. Spotted an error?* [*Tell us*](mailto:hello@nephspace.com?subject=Correction)*.*