Conservative strategy speeds recovery in patients with acute kidney injury requiring dialysis, study shows
Presenter: Chi-yuan Hsu, MD, University of California San Francisco
Liberation from Acute Dialysis (LIBERATE-D). Abstract FR-OR083. Presented November 7, 2025.
In patients with acute kidney injury requiring dialysis, a conservative approach to dialysis was safe and supported earlier recovery of kidney function, according to results of a randomized trial presented at American Society of Nephrology Kidney Week 2025.
Compared with the conventional approach of dialysis three times a week, the conservative strategy promoted higher rates of recovery in a shorter time, according to results of the study, published simultaneously in JAMA.
In the conservative dialysis group, participants received dialysis only when specific metabolic or clinical thresholds were met, such as elevated urea levels, high potassium, metabolic acidosis, or fluid overload leading to hypoxemia.
“The conventional approach is to continue dialysis until patients recover, and then stop, but we essentially stopped earlier to foster recovery,” said investigator Chi-yuan Hsu, MD, of the University of California San Francisco, who presented results of the LIBERATE-D study in an oral abstract session featuring high-impact clinical trials.
These findings could be practice-changing for patients with dialysis-requiring acute kidney injury, which is linked to increased morbidity and mortality, poor quality of life, and increased use of healthcare resources.
The study, Liberation from Acute Dialysis (LIBERATE-D), is built on the hypothesis that hemodialysis itself causes additional ischemic injury. As such, less intensive dialysis could increase the speed of renal recovery while improving the rate of renal recovery overall.
To date, however, no clinical trials have directly addressed this question.
"There have been clinical trials in dialysis, particularly looking at when to start, how much dialysis to give, and what type of dialysis, whether continuous or intermittent. But there haven't been any trials focused on when to stop,” Dr. Hsu said. “That's a big gap in knowledge."
"Second, there have been hints of data suggesting that dialysis itself can lower blood pressure, and that when the blood contacts the dialysis membrane, it can trigger inflammation, which could further damage the kidneys,” he added, “so dialysis may actually beget more dialysis."
To test the effect of a conservative dialysis strategy on kidney function, the LIBERATE-D study enrolled 220 hemodynamically stable participants with dialysis-requiring acute kidney injury at four US clinical sites. The mean age of participants was 56 years, 33% were female, and the mean estimated glomerular filtration rate at baseline was 65 mL/min/1.73 m2.
Participants were randomized to either conventional, three-times-weekly dialysis, or the conservative strategy of hemodialysis only when specific clinical and metabolic indications were met. The primary endpoint was renal recovery at hospital discharge.
Significantly more participants in the conservative dialysis group achieved this endpoint than in the standard dialysis group, Dr. Hsu and co-investigators reported.
A total of 64% of the participants in the conservative-treatment group achieved renal recovery at hospital discharge, meaning they were alive and off dialysis for 14 days. Only 50% of participants in the conventional dialysis group met that endpoint, for an absolute difference of 13.8% (95% confidence interval 0.8%–26.8%, P = .04).
Participants in the conservative dialysis group also received fewer dialysis sessions per week, a median of 1.7 sessions versus 3.1 sessions in the conventional dialysis group. They also recovered earlier, with 21 dialysis-free days to day 28, versus just 5 such days in the conventional group.
No differences emerged in adverse events including hyperkalemia and hypoxemia, the investigators reported. However, conservative dialysis was associated with fewer dialysis-associated hypotension events as compared to standard dialysis.
Based on these findings, more clinicians should be considering a conservative approach, according to LIBERATE-D investigator Kathleen D. Liu, MD, PhD, of the University of California San Francisco.
“Many programs have traditionally dialyzed patients three times a week until it's very obvious they have recovered, but some people have already leaned to the other side, which is toward doing less dialysis,” Dr. Liu said. “There's really a range of practice out there, and we hope our findings will push people toward the more conservative end of that spectrum.”
Disclosures
Chi-yuan Hsu, MD, and co-authors reported funding support from the National Institute of Diabetes and Digestive and Kidney Diseases.
References
Hsu CY, Siew ED, Tuot DS, et al. Liberation from Acute Dialysis (LIBERATE-D) [abstract]. Presented at: American Society of Nephrology Kidney Week 2025; November 6–9, 2025; Houston, TX. doi:10.1681/ASN.2025s5zzdf8h
Liu KD, Siew ED, Tuot DS, et al. A conservative dialysis strategy and kidney function recovery in dialysis-requiring acute kidney injury: the Liberation From Acute Dialysis (LIBERATE-D) randomized clinical trial. JAMA. Published online November 7, 2025. doi:10.1001/jama.2025.21530