Conservative Dialysis Strategy Linked to Kidney Recovery in AKI

Key Takeaways

• Kidney recovery at discharge was more frequent with the conservative strategy, although the prespecified adjusted analysis was not statistically significant.
• The conservative strategy was associated with fewer dialysis sessions per week and more dialysis-free days through day 28.
• Dialysis-associated hypotension was reported less often with the conservative strategy, with uncertainty around the effect size.

Recovery occurred in 64% of the conservative group and 50% of the conventional group. The comparison was between dialysis given only for specific metabolic or clinical indications and dialysis scheduled three times weekly.

This multicenter randomized superiority trial was unblinded and enrolled adults at four U.S. sites from January 23, 2020, to March 10, 2025. Overall, 221 participants were randomized and 220 received the allocated intervention. Eligibility required dialysis-requiring acute kidney injury, prior kidney replacement therapy initiation, baseline eGFR above 15 mL/min/1.73 m2, hemodynamic stability, and planned intermittent hemodialysis. Mean age was 56 years, 67% were male, 13% were Black, 60% were White, mean baseline eGFR was 64.8 mL/min/1.73 m2, and randomization occurred a median of 9 days after kidney replacement therapy started.

The conservative group received dialysis only when specific metabolic or clinical indications were met. The conventional group received dialysis three times per week until urine output or creatinine clearance criteria were met. The primary end point was kidney function recovery at hospital discharge, defined as being alive, off dialysis, and having at least 14 consecutive days without dialysis, including after discharge.

Kidney recovery at discharge occurred in 70 of 109 participants, or 64%, in the conservative group and 55 of 109, or 50%, in the conventional group. The absolute difference was 13.8% with a 95% CI of 0.8% to 26.8%, and P=.04. The unadjusted odds ratio was 1.76 with a 95% CI of 1.02 to 3.03 and P=.04. In the prespecified adjusted analysis, the odds ratio was 1.56 with a 95% CI of 0.86 to 2.84 and P=.15 and was not statistically significant.

For the prespecified key secondary end points, the conservative strategy was associated with fewer dialysis sessions per week and more dialysis-free days to day 28. Median dialysis sessions per week were 1.8 versus 3.1, a difference of -1.4 with a 95% CI of -1.8 to -1.0. Median consecutive dialysis-free days to day 28 were 21 versus 5, a difference of 16 days with a 95% CI of 5 to 27. Dialysis-associated hypotension occurred less often in the conservative group, with 69 versus 97 events.

Investigators concluded that the conservative strategy was associated with shorter time to recovery and higher recovery rates in the unadjusted analysis. Last follow-up was June 10, 2025, and the trial was registered at ClinicalTrials.gov as NCT04218370. They also noted uncertainty around the estimated effect size and stated that larger-population testing is warranted.