Liberation From Acute Dialysis

Not Applicable

Recruiting

Conditions: Acute Kidney Injury
Kidney; Disease, Acute
Dialysis Related Complication

Brief Summary: The goal of the LIBERATE-D clinical trial is to improve outcomes for patients recovering from dialysis-requiring acute kidney injury (AKI-D). The impact of a conservative dialysis strategy compared to standard clinical practice of thrice-weekly dialysis will be examined to help generate knowledge for how to guide delivery of dialysis to facilitate renal recovery.

Detailed Description: Dialysis-requiring acute kidney injury (AKI-D) is a devastating complication among hospitalized patients for which there are no treatments other than supportive care. Recovery of sufficient renal function to stop dialysis is an unequivocally important clinical and patient-oriented outcome. Shortening dialysis duration and increasing the number of AKI-D patients who recover would have a major clinical, public health and cost-saving impact. However, there is currently no evidence to guide the delivery of dialysis to facilitate recovery. The investigators hypothesize that in patients who have AKI-D and who are hemodynamically stable, a conservative dialysis strategy--in which hemodialysis is not continued unless specific metabolic or clinical indications for renal replacement therapy (RRT) are present--will improve the likelihood of renal recovery compared with the current standard clinical practice of thrice-weekly intermittent dialysis. The investigators have conducted a pilot clinical trial to demonstrate the feasibility of this approach. The investigators propose here a 2-center randomized controlled trial to test a conservative dialysis strategy in a larger AKI-D population (N = 220).

Recruitment & Eligibility

Inclusion Criteria

≥ 18 years of age
Inpatient with AKI-D (intermittent hemodialysis or continuous renal replacement therapy received on at least one calendar day) at least partially due t acute tubular necrosis per the clinical nephrology team
Hemodynamic stability: not requiring vasopressor support and with planned intermittent dialysis
Baseline estimated glomerular filtration rate (eGFR) ≥ 15 mL/min/1.73 m2

Exclusion Criteria

Nontraditional indication for dialysis (end-stage liver disease awaiting transplantation, fulminant hepatic failure, intoxication)
Complete nephrectomy as cause of AKI-D
Kidney transplant during index hospitalization
Dialysis > 3 months
Decompensated heart failure requiring left ventricular assist device or continuous inotropic support
Mechanical ventilation via endotracheal tube
Hypoxemia requiring significant oxygen support: >5 liters/min via nasal cannula or equivalent via face mask/tracheostomy mask to maintain oxygen saturation > 95%, or requiring fraction of inspired oxygen >50% in patients with tracheostomy requiring invasive or non-invasive ventilation
Unable to consent and no surrogate decisionmaker available
Pregnant
Prisoner
Clinical team declines to allow study participation
Anticipated discharge or transfer from study hospital within 48 hours

Arm && Interventions

Group	Intervention	Description
Conventional	Dialysis	Thrice-weekly intermittent dialysis until pre-specified criteria for recovery are met
Conservative	Dialysis	Conservative dialysis strategy--dialysis prescribed only when specific metabolic or clinical indications are met. These indications are: blood urea nitrogen \>112 mg/dL (40 mmol/L; blood potassium concentration \>6 mmol/L; blood potassium concentration \>5.5 mmol/L despite medical treatment; arterial blood gas pH \<7.15, or in the absence of an available blood gas, serum bicarbonate \<12 mmol/L, acute pulmonary edema due to fluid overload, responsible for hypoxemia requiring oxygen flow rate \>5 L/min or equivalent via face mask/tracheostomy mask to maintain SpO2 \>95% or requiring FiO2 \>50% in patients with tracheostomy already on invasive or non-invasive mechanical ventilation and despite diuretic therapy; clinician judgement

Primary Outcome Measures

Name	Time	Method
Proportion of patients with renal recovery at hospital discharge	Up to 14 days after hospital discharge (to allow for ascertainment of outcome at hospital discharge, which requires a period of sustained dialysis independence)	Alive and off dialysis at the time of discharge, with sustained independence from dialysis for 14 days. This outcome does not require that all 14 days of sustained independence occur in-hospital.

Secondary Outcome Measures

Name	Time	Method
Number of dialysis sessions/week	Up to 28 days	Number of dialysis sessions prescribed in each treatment arm, expressed per week.
Dialysis-free days to study day 28	Up to 28 days	The number of days that a patient did not need dialysis to study day 28. A patient can only accrue dialysis-free days after the final dialysis session that commences the monitoring period for renal recovery. Subjects who die before study day 28 will be considered to have zero dialysis-free days.

Locations (4): University of Califonia, San Francisco
🇺🇸
San Francisco, California, United States
Washington University in St Louis/Barnes-Jewish Hospital
🇺🇸
Saint Louis, Missouri, United States
Vanderbilt University Medical Center
🇺🇸
Nashville, Tennessee, United States
Intermountain Medical Center
🇺🇸
Murray, Utah, United States