A major U.S. clinical trial has found that a conservative, indication-based approach to dialysis can significantly improve kidney recovery in patients with dialysis-requiring acute kidney injury (AKI). The findings challenge long-standing dialysis routines and could shift clinical practice toward more personalised, physiology-guided care.
Conservative Dialysis Leads to Higher Recovery Rates
The LIBERATE-D randomized trial included 220 adults with AKI who had already started dialysis but remained hemodynamically stable. Instead of dialysing three times per week, the conventional approach, the conservative strategy delivered dialysis only when specific metabolic or clinical triggers were present, such as rising potassium or fluid overload.
By hospital discharge, 64% of patients in the conservative group had recovered kidney function compared with 50% receiving standard dialysis. Recovery was defined as being alive, off dialysis, and remaining dialysis-free for at least 14 days.
Fewer Dialysis Sessions and Improved Safety Profile
Patients receiving conservative care underwent significantly fewer dialysis sessions, 1.8 vs 3.1 sessions per week, and accumulated more dialysis-free days in the first month (median 21 vs 5 days). Dialysis-associated hypotension occurred less often in the conservative group (69 vs 97 events), suggesting an added safety advantage.
Although adjusted analyses showed some uncertainty in the effect size, the trend consistently favored the conservative strategy.
Implications for Future AKI Management
AKI requiring dialysis is associated with high mortality, prolonged recovery, and long-term dialysis dependence. Even incremental improvements in renal recovery could translate to major benefits for patients’ long-term health, quality of life, and healthcare utilisation.
The researchers note that larger, confirmatory studies are needed to determine the broader applicability of this approach and to identify which patient groups may benefit most. Still, the LIBERATE-D findings offer promising early evidence that a “less is more” strategy may give the kidneys the time they need to heal.
Reference
Liu KD 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. 7, 2025;DOI: :10.1001/jama.2025.21530.
