Would you consider not returning the blood from the dialysis circuit as a strategy for managing polycythemia in a patient with ESKD on hemodialysis who has a hemoglobin level greater than 16 g/dL?

It has been a while since I had a patient on hemodialysis with polycythemia, but I have “wasted” the blood circuit so the patient wouldn’t have to go for phlebotomy on a non-dialysis day. I believe that we didn’t return the blood once a week until his hematocrit was at goal, and then as needed thereafter. I believe that a typical phlebotomy is 450 mL to 500 mL, and the typical combined circuit plus dialyzer is approximately 230 mL to 260 mL, depending on the tubing and dialyzer. For an “average” patient therapeutic phlebotomy lowers the hemoglobin by about 1 g so we would expect an approximate 0.5 g decrease in Hb following wasting the circuit. I would be interested in others' experience.

I have not done that for polycythemia. I am not sure if I have even encountered that situation. Definitely, I have done that for patients with very high ferritin levels and those with iron overload.

I have not actually done this, but it makes perfect rationale sense.