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The global burden of kidney disease is increasing, paralleled by a rising number of natural and man-made crises. During these tumultuous times, accessing vital health care resources becomes challenging, posing significant risks to individuals, particularly those with kidney disease. This review delves into the impact of crises on kidney disease, with a particular focus on acute kidney injury (AKI), kidney failure, and kidney transplant. Patients experiencing crush injuries leading to AKI may encounter delayed diagnosis due to the chaotic nature of disasters and limited availability of resources. In chronic crises such as conflicts, patients with kidney failure are particularly affected, and deviations from dialysis standards are unfortunately common, impacting morbidity and mortality rates. Additionally, crises also disrupt access to kidney transplants, potentially compromising transplant outcomes. This review underscores the critical importance of preparedness measures and proactive management for kidney disease in crisis settings. Collaborative efforts among government bodies, rescue teams, health care providers, humanitarian agencies, and nongovernmental organizations are imperative to ensure equitable and reasonable care for kidney disease patients during times of crises, with the aim of saving lives and improving outcomes., (Copyright © 2024 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients., Methods: An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m 2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients' all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients)., Discussion: Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers., Trial Registration: Clinicaltrials.gov NCT05828823. Registered on 25 April 2023., (© 2024. The Author(s).)