Updates in Hospital Medicine: Nephrology

On-Demand" Dialysis Appears Safe and Possibly Beneficial to Dialysis-Requiring AKIHospitalists frequently manage patients with dialysis-requiring acute kidney injury (AKI-D).Standard practice typically defaults to scheduled thrice-weekly hemodialysis until recovery is present. 1,2However, frequent dialysis may inadvertently prolong renal injury through subclinical intradialytic hypotension and repetitive ischemic insults and/or inflammation. 3The recent LIBERATE-D trial investigated whether a conservative, indication-driven ("on-demand") dialysis strategy improves kidney recovery compared to the conventional scheduled approach. 4his multicenter, unblinded randomized clinical trial enrolled 220 hemodynamically stable adults with AKI-D who had already initiated renal replacement therapy at four U.S. academic centers. 4Patients requiring vasopressors or with severe baseline chronic kidney disease (eGFR <15 mL/min/1.73m) were excluded.Using 1:1 randomization stratified by site and baseline eGFR, participants were assigned to a "on-demand" strategy, where dialysis occurred only for specific metabolic triggers (serum urea nitrogen >112 mg/dL, potassium >6 mmol/L, pH <7.15, refractory volume overload) or clinician judgment, versus a conventional strategy of scheduled thriceweekly dialysis until recovery markers were met.The primary outcome was kidney function recovery at hospital discharge, defined as survival and dialysis independence for at least 14 consecutive days. 4