A conservative dialysis strategy, delivered only when specific metabolic or clinical conditions are met, versus conventional dialysis of three times per week, appears to improve recovery in patients with dialysis-dependent AKI.
A US study, published in JAMA [link here] and presented at ASN Kidney Week by Professor Chi-yuan Hsu from the University of California San Francisco, found more patients managed with the conservative dialysis strategy achieved kidney function recovery at hospital discharge and recovered earlier.
They also had fewer dialysis sessions per week and more dialysis-free days.
“This trial showed that for patients with AKI-D who are haemodynamically stable, a conservative dialysis strategy – performing dialysis only when specific metabolic or clinical indications are met – resulted in less health care resource use and better clinical outcomes, including sooner and more frequent liberation from dialysis,” the study concluded.
The LIBERATE-D trial randomised 221 adult patients, with AKI severe enough to warrant at least one dialysis session, to either conservative or conventional dialysis between January 2020 and March 2025.
Participants were mostly male (67%), white (60%), with a mean age of 56 years, and had started kidney replacement therapy a median of 9 days before randomisation. Causes of AKI included ischaemia, nephrotoxin, sepsis and postoperative.
In the conservative dialysis group, participants received a haemodialysis treatment only when meeting a specific indication such as serum urea nitrogen level >112 mg/dL, hyperkalemia >6 mmol/L (or >5.5 mmol/L despite medical treatment), or arterial blood gas pH <7.15 from pure metabolic acidosis (or bicarbonate level <12 mEq/L in the absence of an available blood gas level).
The primary end point of kidney function recovery at hospital discharge was achieved in 64% of those on conservative dialysis compared to 50% of those on conventional dialysis (P = 0.04; aOR 1.56).
In key and other secondary end points:
- There were fewer dialysis sessions per week after randomisation in the conservative dialysis group (1.8 v 3.1; p <0.001)
- More dialysis free days in the conservative dialysis group (21 v 5; p <0.001)
- Faster time to kidney function recovery in the conservative dialysis group (2 v 8.5 days; p <0.001)
Other measures such as length of hospital stay, in-hospital deaths, kidney function recovery at days 28 and 90, and deaths by days 28 or 90 were similar in both treatment groups.
“The results suggest the amount of dialysis targeted for delivery to patients with AKI-D should be more nuanced than indicated by current guidelines,” the study said.
#KidneyWk AKI-D positive trial! Dr. Hsu reporting our LIBERATE-D trial at the late breaking clinical trials session, with simultaneous publication in JAMA: https://t.co/QZBir2RNqK pic.twitter.com/l4fliZZedz
— Ian McCoy, MD, MS (@NephroNinja) November 7, 2025
Biological mechanisms by which dialysis may delay or prevent recovery include transient hypoperfusion of the kidneys resulting in repetitive ischaemic insults or immune activation and inflammation instigated by blood contact with the extracorporeal circuit.
The study found no indication that conservative dialysis was a safety risk. Only one of the 24 serious adverse events reported was deemed probably related to the study, and occurred in a patient in the conservative dialysis group.
The predefined adverse event of ≥1 dialysis-associated hypotension events was slightly more common in the conventional dialysis group (32% v 36%).
Nondialysis adverse events on or after study randomisation including cardiopulmonary arrest or new arrhythmia, need for urgent KRT, or the development of severe hypoxemia, hyperkalemia, metabolic acidosis, hyperphosphatemia, or hyponatremia were uncommon and similar in frequency in both groups.
An accompanying editorial in the journal [link here] said the trial results should change clinical practice by emphasising that KRT with haemodialysis, although life-saving, was nephrotoxic.
“Each dialysis session exposes litres upon litres of blood to plastic tubing, an artificial membrane, and rapid solute/volume fluxes that do not resemble anything in normal human physiology,” the author said.
“Investigators are now revisiting the concept of minimising haemodialysis in the long-term setting for new patients with residual kidney function: rather than automatically assigning a thrice-weekly prescription to new patients, incremental dialysis starts with 1 or 2 weekly sessions as a method to gradually introduce patients to treatment while sustaining residual kidney function.”
He said both incremental dialysis initiation and LIBERATE-D rest on the same recognition that residual kidney function was superior to anything we can currently replace with machines.
🧵 JAMA, @JAMAInternalMed, and @JAMANetworkOpen conclude #KidneyWk with impactful findings:
In stable AKI patients, indication-based dialysis enabled faster liberation from dialysis and reduced health care resource use compared to conventional thrice-weekly treatment.… pic.twitter.com/ul3LRBWBRO
— JAMA (@JAMA_current) November 8, 2025