Clinical Practice Guidelines on the Integration of Residual Kidney Function in Hemodialysis Prescription: A Global Scoping Review.

BACKGROUND

Residual kidney function (RKF) is strongly associated with improved outcomes in patients receiving hemodialysis, and incremental hemodialysis-where dialysis dose and frequency are tailored to RKF-has gained increasing attention. However, the extent to which hemodialysis clinical practice guidelines (CPGs) provide actionable guidance for RKF-based prescribing remains unclear.

METHODS

We conducted a scoping review using Joanna Briggs Institute methodology and PRISMA ScR reporting. National and international adult hemodialysis CPGs were identified through database and organizational website searches (inception-December 2025). Guidelines were classified by depth of RKF integration into three tiers: Tier 3 (no RKF guidance), Tier 2 (conceptual acknowledgment without operational protocols), and Tier 1 (explicit, operational RKF-based prescribing frameworks).

RESULTS

Twelve guideline documents were included. Five were classified as Tier 3, providing no RKF guidance for chronic hemodialysis prescribing. Three were Tier 2 guidelines which acknowledged RKF and provided the concept of incremental hemodialysis but did not have standardized thresholds or implementation pathways. Four guidelines met Tier 1 criteria; among these, one provided a fully specified, mathematically integrated framework linking RKF measurement to adequacy targets, monitoring frequency, and eligibility for reduced-frequency dialysis. Other Tier 1 guidelines endorsed incremental hemodialysis or RKF quantification but offered limited detail on measurement protocols, thresholds, or dose adjustment, resulting in substantial heterogeneity across approaches.

CONCLUSIONS

Despite growing interest in RKF-informed hemodialysis, most CPGs offer limited operational guidance. Fully actionable frameworks are rare, underscoring the need for future guidelines to standardize RKF measurement, integration into adequacy targets, and monitoring strategies to support consistent clinical implementation.