Conservative Dialysis Strategy Linked to More Kidney Recovery in AKI-D

Key Takeaways

• Kidney recovery at discharge was observed more often with the conservative strategy than with thrice-weekly hemodialysis.
• The conservative approach was associated with lower dialysis exposure and more dialysis-free time during early follow-up.
• Serious adverse events were uncommon, dialysis-associated hypotension was reported less often with the conservative strategy, and mortality differences were not statistically significant.

In the LIBERATE-D randomized trial, hemodynamically stable hospitalized adults with dialysis-requiring acute kidney injury recovered kidney function at discharge more often with a conservative strategy than with thrice-weekly hemodialysis. The primary endpoint rates were 64.2% and 50.5%, a 13.8 percentage-point difference between groups at hospital discharge. A prespecified adjusted analysis reduced the estimate and did not meet conventional statistical significance thresholds. Overall, the unadjusted analysis favored the less intensive dialysis approach for recovery at discharge.

This multicenter, unblinded, randomized superiority trial was conducted at 4 US sites. Investigators enrolled hospitalized adults with dialysis-requiring AKI who were hemodynamically stable, had baseline eGFR at least 15 mL/min/1.73 m2, and had a mean baseline eGFR of 64.8 mL/min/1.73 m2. Of 909 patients assessed, 221 were randomized and 220 received assigned treatment after a median of 9 days of kidney replacement therapy. The conservative strategy used dialysis only when prespecified metabolic or clinical indications were met, whereas the conventional group received thrice-weekly hemodialysis until urine output or creatinine clearance supported cessation. The primary endpoint was being alive and off dialysis for at least 14 consecutive days at hospital discharge, including after discharge.

Kidney function recovery at discharge occurred in 70 of 109 patients (64.2%) with conservative dialysis and 55 of 109 (50.5%) with conventional treatment. That translated to a 13.8 percentage-point difference, with a 95% CI of 0.8 to 26.8 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. Median dialysis sessions per week were 1.8 with the conservative strategy and 3.1 with conventional treatment. Dialysis-free days to day 28 were 21 and 5, and time to kidney recovery by day 90 was 2 and 8.5 days, favoring lower dialysis exposure.

Serious adverse events excluding death were uncommon, affecting 11 conservative-group patients and 13 conventional-group patients. Dialysis-associated hypotension occurred in 69 versus 97 events, although the proportion with at least one event was similar at 32% and 36%. In-hospital death occurred in 10 of 110 patients and 7 of 109, while death by day 90 occurred in 16 of 109 and 20 of 108. There were no statistically significant differences in mortality outcomes or length of hospital stay during follow-up. Interpretation was limited by the open-label design, frequent clinician judgment triggers in the conservative arm, the short intervention period, and the authors' call for testing in a larger population.