RATIONALE & OBJECTIVE:There is a lack of consensus on the key elements needed to foster clear and effective clinical communication after an episode of inpatient acute kidney injury (AKI). This study sought to achieve consensus on key elements of AKI communication between inpatient and outpatient healthcare professionals. STUDY DESIGN:Three sequential rounds of a modified Delphi process to develop, refine, and achieve consensus on items for inclusion in standardized post-AKI clinical communications. Each round included a survey followed by a virtual discussion. SETTINGS & PARTICIPANTS:Forty-seven participants from 12 countries were recruited through purposive and snowball sampling, including 33 physicians (27 nephrologists), 10 allied health practitioners, and 4 patients and/or caregivers. ANALYTIC APPROACH:Quantitative data were summarized using counts and percentages. Qualitative content analysis was performed to capture additional themes. Consensus recommendations (≥80% agreement) and qualitative findings were iteratively integrated into a draft guide. RESULTS:Participants strongly agreed that post-AKI communication between health care teams should focus on medication changes and describe the trends in serum creatinine. For patients requiring dialysis at discharge, the dates dialysis began and was last administered should be reported. Topics of post-AKI communication by clinicians to patients should focus on medication changes as well as follow-up testing and clinical monitoring. Qualitative evaluation highlighted that the effectiveness of a post-AKI clinical communication guide is dependent on the systematic reporting of clinical information, the provision of actionable guidance for health care professionals and patients, and the monitoring for kidney recovery. LIMITATIONS:Potentially limited generalizability because participants were mostly health care practitioners from high resource healthcare settings. CONCLUSIONS:A multidisciplinary panel of stakeholders reached consensus on key elements of post-AKI clinical communication. The recommendations may valuably inform post-AKI care.

OBJECTIVE:While infection is a leading cause of mortality among patients on hemodialysis, there are limited data on patients' infection prevention knowledge and attitudes. We aimed to assess hemodialysis patients' knowledge of their elevated infection risk, their willingness to actively prevent infections, and the acceptability of a long-term intranasal decolonization intervention. DESIGN:We surveyed patients as part of a stepped wedge cluster randomized trial evaluating intranasal povidone-iodine (PVI) decolonization. SETTING:Sixteen outpatient hemodialysis centers affiliated with 5 academic medical centers. PARTICIPANTS:Patients undergoing outpatient hemodialysis. METHODS:Patients were asked to complete a pre-intervention survey (9 questions) and two intervention surveys (13 questions; only patients interested in PVI) at 1 month and 6 months after starting PVI. We used the chi-squared test to compare responses over time. RESULTS:469 (∼25%) participants completed at least one survey. Most (55%) participants underestimated their infection risk compared with an average person in the United States. The percentage of participants willing to expend "a lot of effort" to prevent an infection decreased from 79% (pre-intervention) to 63% (final survey) (p < 0.01). Among the 102 participants using PVI at 6 months, 87% said PVI felt neutral or pleasant and 75% used PVI for the past 3 dialysis sessions. Only 9.4% reported side effects. CONCLUSIONS:Patients on hemodialysis underestimate their infection risk. Most patients found intranasal PVI to be acceptable. Future research should aim to improve patient education on their infection risk and remove barriers to adherence with infection prevention interventions.Clinical trial information: NCT04210505, https://clinicaltrials.gov/.

Importance:For patients with dialysis-requiring acute kidney injury, persistent need for dialysis is associated with increased morbidity and mortality, high health care use, and poor quality of life. Objective:To test the effect of a conservative dialysis strategy on recovery of kidney function. Design, Setting, and Participants:This multicenter, unblinded, randomized superiority trial enrolled participants with dialysis-requiring acute kidney injury who had a baseline estimated glomerular filtration rate greater than 15 mL/min/1.73 m2, had already initiated kidney replacement therapy, and were hemodynamically stable, with planned intermittent hemodialysis between January 23, 2020, and March 10, 2025, at 4 clinical sites in the United States. Of 909 patients assessed for eligibility, 221 were randomized and 220 received the allocated intervention. The date of last follow-up was June 10, 2025. Intervention:With the conservative dialysis strategy, participants received dialysis only when specific metabolic or clinical indications were met. Participants in the conventional dialysis group received dialysis 3 times per week until urine output or creatinine clearance criteria were met. Main Outcomes and Measures:The primary study end point was unadjusted kidney function recovery at hospital discharge, defined as being alive and not receiving dialysis, with at least 14 consecutive days without dialysis (including after discharge). Two prespecified key secondary end points were the number of dialysis sessions per week and the number of dialysis-free days to day 28. Results:The mean age of participants was 56 years (SD, 16 years). A total of 148 of 220 participants (67%) were male, 28 (13%) were Black, and 133 (60%) were White. Mean baseline estimated glomerular filtration rate was 64.8 mL/min/1.73 m2 (SD, 30.9 mL/min/1.73 m2). Participants had started kidney replacement therapy a median of 9 days (IQR, 5-18.5 days) before randomization. In the conservative dialysis intervention group, 70 of 109 participants (64%) achieved kidney function recovery at hospital discharge vs 55 of 109 participants (50%) in the conventional dialysis control group (difference, 13.8% [95% CI, 0.8%-26.8%; P = .04]; unadjusted odds ratio, 1.76 [95% CI, 1.02-3.03; P = .04]; after prespecified adjustment: odds ratio, 1.56 [95% CI, 0.86-2.84; P = .15]). Participants in the conservative dialysis group received fewer dialysis sessions per week (median, 1.8 [IQR, 0-2.6] vs 3.1 [IQR, 2.6-3.5]; difference, -1.4 [95% CI, -1.8 to -1.0]) and recovered earlier (21 [IQR, 0-28] vs 5 [IQR, 0-21] consecutive dialysis-free days to day 28; difference, 16 days [95% CI, 5-27]). Dialysis-associated hypotension occurred less frequently in the conservative dialysis group (69 vs 97 events). Conclusions and Relevance:A conservative dialysis strategy in dialysis-requiring acute kidney injury resulted in a shorter time to and higher rates of recovery of kidney function in the unadjusted analysis. Given uncertainty regarding the estimated effect size, this approach should be tested in a larger study population. Trial Registration:ClinicalTrials.gov Identifier: NCT04218370.

BACKGROUND:Anticipating when dialysis can be discontinued for patients with acute kidney injury requiring dialysis (AKI-D) is a common, but challenging, clinical problem. While timed urine collection metrics like creatinine clearance and urine output are often proposed to inform the decision, few studies have rigorously quantified the need for ongoing dialysis by level of creatinine clearance, particularly in the period after critical illness has resolved when competing risk of death drops and liberation from dialysis becomes a relatively higher clinical priority. We hypothesized that many patients would not require dialysis even at relatively low levels of residual kidney function (e.g., creatinine clearance below 10 mL/min). METHODS:In this ancillary study of the LIBERATE-D trial intervention arm, timed urine collections blinded to clinicians were performed per protocol, and dialysis was performed for prespecified indications. Logistic regressions computed predicted probabilities of requiring dialysis in the subsequent seven days by level of measured creatinine clearance, urea clearance, the average of creatinine and urea clearances, urine output, and eGFR calculated from the serum creatinine. The fraction of patients requiring dialysis in the subsequent week at various thresholds of creatinine clearance and urine output were also reported. RESULTS:Among 147 timed urine collections from 85 patients with AKI-D, median [IQR] creatinine clearance was 7.1 [3.1-15.9] mL/min and median urine output was 930 [471-1786] mL/day. Creatinine clearance demonstrated significantly higher discrimination (AUC 0.84) than urine output (AUC 0.78). Dialysis was not required in the subsequent week for 81% (22 out of 27) of urine collections with creatinine clearance 10-20 mL/min and 44% (19 out of 43) with creatinine clearance 5-<10 mL/min. CONCLUSIONS:In a clinical trial with protocolized dialysis indications for hemodynamically stable patients with AKI-D, patients with lower levels of kidney function such as creatinine clearance of 5-10 mL/min were often able to discontinue dialysis.

Background Hospitalized patients with cirrhosis are at high risk for kidney failure and subsequent in-hospital mortality, but predictors of in-hospital mortality for patients that require acute renal replacement therapy (RRT) remains underexplored. Methods Retrospective, observational cohort study including patients ≥18 years of age with cirrhosis from any cause who were admitted to the ICU between March 2013 and May 2018 and started on RRT. The primary outcome was in-hospital mortality. Logistic regression was used to identify factors associated with poor outcomes and a decision tree analysis was performed to visualize characteristics associated in-hospital mortality. Results A total of 138 patients were included and 103 (75%) died in the hospital. Factors associated with in-hospital mortality were lower temperature (odds ratio [OR] 0.349, 95% Confidence Interval [CI] 0.131 to 0.928), increased heart rate (OR 1.094, 95% CI 1.040 to 1.150), increased BUN-to-creatinine ratio (OR 1.206, 95% CI 1.072 to 1.357), increased hemoglobin (OR 1.085, 95% CI 1.030 to 1.144), decreased platelets (OR 0.988, 95% CI 0.978 to 0.998), and increased total bilirubin (OR 1.006, 95% CI 1.000 to 1.012). Decision tree analysis found that temperature, heart rate, MELD-Na, and platelet count were associated worse outcomes. Conclusions Decreased temperature, increased heart rate, and decreased serum platelets were repeatedly associated with in-hospital mortality in patients with cirrhosis on acute RRT.

Abstract Background The SHEA/IDSA/APIC Strategies to Prevent MRSA Transmission and Infection Practice Recommendations advised that facilities consider decolonizing patients on hemodialysis. We implemented a nasal decolonization intervention in which patients self-administered povidone-iodine (PVI) at each dialysis session. We aimed to assess intervention safety and effectiveness. Methods We performed a stepped wedge cluster randomized trial at 16 outpatient hemodialysis units affiliated with 5 academic medical centers between 2020-2023. Adverse events were self-reported at 1 and 6 months. While the analysis was at the hemodialysis unit level, patients were required to give verbal informed consent for PVI use. Outcomes included National Healthcare Safety Network reportable dialysis events aggregated at hemodialysis unit level, including bloodstream infections (BSI), access-related BSI, and central venous catheter (CVC) BSI for all pathogens and for Staphylococcus aureus (SA). The primary outcome was SA BSI. A generalized linear mixed model with a negative binomial distribution, log link function, and an offset for person-months with a random intercept for each hemodialysis unit was performed. Results Overall, 1,351 patients received hemodialysis at these centers each month. Of those, 362 patients verbally consented to use PVI. Among these, 3.9% reported side effects: nasal drip, congestion or burning/stinging, unpleasant smell, headache, or minor nose bleed. A reported side effect ‘yellow tears’ was assessed via chart review and resolved by discontinuing PVI. There were no statistically significant associations between unit level randomization to the PVI intervention and infections. However, there was a non-statistically significant trend toward a protective association between unit-level randomization to PVI and SA infections, particularly SA CVC BSI.(Table) Conclusion Long-term nasal decolonization with PVI was safe with few adverse events. Unit level randomization to the PVI intervention did not significantly decrease unit-level infections. Given low patient enrollment and added infection prevention interventions due to COVID-19, the study could not determine if PVI decolonization could decrease BSI rates in the hemodialysis setting. Disclosures Marin Schweizer, PhD, 3M: Grant/Research Support Anitha Vijayan, MD, Baxter: Honoraria|NxStage: Advisor/Consultant|Qanta: Honoraria David A. Pegues, MD, DaVita/Total Renal Care: Advisor/Consultant Daniel Diekema, MD, Affinity Biosensors: Grant/Research Support|bioMerieux, Inc: Grant/Research Support Loreen Herwaldt, MD, 3M: Grant/Research Support|PDI: Grant/Research Support

Parvathareddy, Vishnupriyadevi; Vijayan, Anitha; Penrod, Ashley; Lam, Gon; Wong, Leslie P. Author Information

Introduction AKI is a common and serious complication among hospitalized adult and pediatric patients,1 with severe cases requiring KRT. Although recent studies have shown improving hospital mortality rates for patients with dialysis-requiring AKI (AKI-D),2 up to 30% of AKI-D survivors will require dialysis beyond discharge.3 Data from the United States Renal Data System (USRDS) demonstrate a marked increase in patients with AKI receiving outpatient hemodialysis in ESKD facilities, from 6400 individuals in 2017 to a peak of 11,964 in 2020.4 After hospitalization, patients with AKI-D who are dialysis dependent at discharge remain at significantly increased risk of adverse outcomes, including CKD, permanent dialysis dependence, cardiovascular disease, rehospitalization, and death.5 In the United States, despite numerous regulatory and policy initiatives aimed at facilitating outpatient care of patients with AKI-D, there remain significant gaps in care.6 A paucity of high-level evidence to guide management has resulted in wide variability in clinical practices. AKI survivors report inconsistent care in outpatient dialysis facilities, and despite significant pathophysiological differences, their care often mirrors that of the patient with ESKD.7,8 Recognizing the significant vulnerability of this population, the American Society of Nephrology (ASN) Kidney Health Guidance (KHG) oversight committee convened a multidisciplinary expert workgroup to address the need for clinical guidance in the care of patients with AKI-D who continue to require dialysis after hospital discharge. This guidance does not address the management of patients with AKI-D who achieve dialysis independence before discharge from the hospital. In addition, while the clinical guidance in this document may be applicable globally, some of the regulatory challenges and suggestions are primarily meant for patients dialyzing in outpatient facilities in the United States. Methodology Workgroup member expertise included adult and pediatric nephrology, social work, pharmacy, and advanced practice nursing, all with direct experience caring for patients with AKI-D in the outpatient setting. Initial workgroup meetings focused on formulation of key clinical questions to guide a structured evidence review. An external expert conducted the literature review, and relevant studies were reviewed by the workgroup. The workgroup followed an iterative, modified Delphi process to achieve consensus on clinical guidance practice points. This guidance reflects the current evidence and key opinions from this expert workgroup plus input from patients who have experienced outpatient AKI-D care and is intended for all members of the interdisciplinary dialysis care team. The guidance should not preclude clinical judgment and must be applied individually accounting for patient preferences, comorbidities, and other factors. Determining Prognosis for Posthospitalization Recovery of Kidney Function One of the most important outcomes for patients with AKI-D is recovering adequate kidney function to achieve liberation from dialysis. Nephrologists have an important responsibility to identify improvements in kidney function as early as possible and to deliver care that optimizes chances of recovery (Figure 1: Outpatient Management of AKI-D). The term dialytrauma was introduced initially in the critical care literature to describe complications—including hypotension and distant organ injury—associated with hemodialysis or continuous KRT.9,10 We believe this term remains highly relevant for patients with AKI-D because dialytrauma caused by ongoing dialysis may decrease the chances of achieving recovery. As such, a first do no (kidney) harm approach is critical when it comes to dialysis prescription for AKI-D and serves as a guiding principle for this document.Figure 1: Clinical care pathway for the outpatient management of patients with AKI-D. *Evidence of recovery includes increasing UOP, increasing measured CrCl, decreasing IDWG, declining trend in prehemodialysis Cr. **Continuing monitoring should include ongoing patient education, resetting expectations and GOC discussions. Table 2 (recovery phenotypes), Table 3 (warm handoffs), and Table 4 (key practice points) should be referenced for detailed guidance. AKI-D, dialysis-requiring AKI; GOC, goals of care; HD, hemodialysis; IDWG, interdialytic weight gain; UOP, urine output.AKI-D is a heterogeneous syndrome and requires significant individualization of management in the outpatient dialysis setting. We present guidance that varies depending on a patient's clinical characteristics (i.e., phenotype), with the most important phenotypic distinction being the likelihood of kidney function recovery. Previous data suggest that outpatient recovery of kidney function ranges from 20% to 60% of patients.3 Recent USRDS data found that at 6 months after discharge, 31% of patients with AKI-D achieved dialysis independence.4 Unfortunately, predicting which patients will recover remains challenging. Studies have developed predictive models for AKI-D recovery in the outpatient setting,11–13 but these tools are hampered by modest discrimination and limited external validation. Nonetheless, certain risk factors can help inform clinical prognostication and management (Table 1).14 Table 1 - Patient characteristics associated with kidney function recovery from dialysis-requiring AKI Patient Characteristic Effect on Likelihood of Recovery Baseline kidney function11,12,15–17 eGFR Increases with higher baseline eGFR Albuminuria Decreases with greater albuminuria Age12,13,16 Decreases with older age Comorbidities Diabetes mellitus12 Decreases with increasing comorbidity burden and presence of specific comorbidities Chronic liver disease12 Heart failure13,16,17 Comorbidity index11,15 Severity of AKI Duration of dialysis before discharge11 Decreases as duration of dialysis increases The strongest predictive factor for AKI recovery is baseline kidney function. Most patients with normal (eGFR >60 ml/min per 1.73 m2) prehospitalization kidney function will eventually recover to dialysis independence. However, even among patients with stage 4 CKD, up to 20%–30% of patients will experience recovery.12,18,19 Thus, any single factor is inadequate in assessing the likelihood of recovery with certainty. Because of poor predictive accuracy, it is appropriate to err on the side of assuming that most patients will recover, and therefore, all patients should initially receive AKI-D–specific individualized care (versus protocolized care typical for patients on long-term maintenance dialysis). For patients with a high likelihood of recovery of kidney function, it is appropriate to maintain this approach for at least 90 days after discharge. Conversely, for patients with low likelihood for recovery, earlier designation of ESKD diagnosis may be appropriate so as not to delay care (e.g., vascular access placement or transplant evaluation). In addition, for patients with AKI-D and significant comorbidities (such as severe frailty, advanced heart failure, and advanced malignancy), nephrologists should facilitate shared goals-of-care discussions, including advanced care planning and palliative care options.20Table 2 presents a framework for applying the practice points presented in this document, on the basis of recovery phenotype. Table 2 - Framework for approach to management of patients with dialysis-requiring AKI in the outpatient setting on the basis of likelihood of renal recovery Estimated Likelihood for Recovery of Kidney Function Example Scenarios—At Point of Discharge or Outpatient Dialysis Intake Approach High (>30%) recovery phenotype • All patients with baseline eGFR >60• Younger patients (<55 yr) with baseline CKD but minimal comorbidity burden (e.g., no liver or heart failure)• Patients with short duration of dialysis dependence <30 d • Care focused on promoting kidney function recovery• Close monitoring for recovery for at least 90 d after discharge Moderate (10%–30%) recovery phenotype • Patients with baseline CKD and limited comorbidity burden• Patients with baseline CKD and intermediate duration of dialysis dependence (30–90 d) • Care focused on promoting kidney function recovery• Close monitoring for recovery for at least 30–60 d after discharge Low (<10%) recovery phenotype • Patients with 3 or more of the following ○ Advanced baseline CKD (eGFR <15 or eGFR <30 with A3 albuminuria) ○ Older age (>75 yr) ○ Significant comorbidities (decompensated liver or heart failure) ○ Prolonged duration of dialysis dependence (>90 d) • Initial care focused on promoting kidney function recovery• Consideration for early (<30 d) transition to ESKD diagnosis with appropriate shift in management Transition of Care from Hospital to Outpatient Facility As a result of changes in Centers for Medicare & Medicaid Services policy, beginning in January 2017, dialysis care for US outpatients with AKI-D largely shifted from the inpatient setting and hospital-based dialysis centers to free-standing ESKD-certified facilities.6 Although this resulted in some benefits (e.g., reduced patient travel, reduced inpatient length of stay, and decreased pressure for early ESKD certification), concerns arose for unintended detrimental consequences potentially leading to lower likelihood of kidney recovery.21 As a starting point, we strongly suggest that hospital discharge planning include a warm handoff (i.e., direct, live communication between clinicians) to the outpatient nephrology and dialysis care team to ensure continuity of care and to set appropriate expectations on the basis of the kidney recovery phenotype. The accepting nephrologist should place AKI-D–specific orders, as dialysis prescription, laboratory studies, and nursing assessments should differ from standard ESKD protocols. Table 3 summarizes key elements for handoff from hospitalization to outpatient dialysis. Table 3 - Key elements for handoff from hospitalization to outpatient dialysis facility in patients with dialysis-requiring AKI Category Data Elements Hospitalization diagnoses • Date of hospital admission• Primary reason for hospitalization• Key secondary diagnoses• Inpatient procedures ○ Surgery ○ Angiography• Hospital course/complications ○ ICU stay ○ Acquired infections Baseline kidney status • Prehospitalization kidney function ○ Serum creatinine and eGFR (date) ○ Urine albumin-to-creatinine ratio (date)• Kidney disease history (if applicable) ○ Diagnosis ○ Duration ○ Prior treatment ○ Name of prehospitalization nephrologist Course of AKI • Etiology of AKI• Pre-KRT course• Hospital KRT management ○ Date of initial KRT ○ Initial KRT modality ○ Changes in KRT modality Comorbidities • Diabetes mellitus?• Heart failure?• Liver cirrhosis?• Active malignancy?• Hypertension?• Other? Discharge data • Daily UOP at time of discharge• Most recent chemistry panel (date and results)• Most recent prehemodialysis serum creatinine and BUN (date and results)• Most recent hemoglobin (date and results)• Most recent iron panel and ferritin (date and results)• Hepatitis B surface antigen/antibody, core antibody, and hepatitis C antibody (date and results)• Dialysis-related medications ○ Any IV iron or ESA use? ○ Any phosphate binders? Dialysis management at discharge • Current dialysis prescription• Most recent treatment flow sheets (up to three)• Access for dialysis• Dialysis tolerance (e.g., intradialytic hypotension)• Estimated volume status ○ Target end-dialysis weight ○ Most recent achieved end-dialysis weight• Recommendations for monitoring recovery of kidney function Prognosis/quality of life • Functional status• Discharge disposition ○ Home ○ Inpatient rehabilitation/skilled nursing facility• Nonrenal prognosis• Prognosis for recovery of kidney function• Any palliative or GOC discussion? ESA, erythropoiesis-stimulating agent; GOC, goals of care; ICU, intensive care unit; IV, intravenous; UOP, urine output. Accepting dialysis facilities must clearly distinguish patients with AKI-D from those with ESKD. Staff should receive education about differences in care for patients with AKI-D. As an example, some centers have developed specialized AKI-D care units (embedded in the traditional ESKD dialysis facility) focusing on individualized care.15,17 Unfortunately, despite higher complexity and monitoring needs in AKI-D, there are no changes in mandated staffing ratios for this population. Patients with AKI-D should be classified as unstable under Medicare's Conditions for Coverage standards for dialysis facilities 22 and thus undergo monthly Comprehensive Interdisciplinary Patient Assessments. We suggest adopting an AKI-D–specific care plan for these patients with additional focus from the interdisciplinary team (IDT) on clinical assessment, BP management, volume status, and weekly laboratory tests (see Supplement 1). Communication expectations between the nephrologist and other members of the IDT should be established upon admission, including frequency of meetings and AKI care plan–specific charting. The dietitian should clearly delineate AKI-specific dietary recommendations to account for posthospitalization nutritional deficits and changing requirements with recovery. Patient education on kidney function, potential complications of AKI, and CKD management is another critical aspect of comprehensive care. Direct communication with patients and their families must be prioritized to set expectations around potential signs and symptoms of recovery. Psychosocial Factors Patients with AKI-D often have poor health-related quality of life and need intensive psychosocial support.23 Psychosocial concerns are likely even greater with preexisting health disparities, such as lower health literacy or socioeconomic status. Financial stress may arise from patients becoming unemployed or underemployed during hospitalization, along with accrual of out-of-pocket health care expenses. Complicating this are varying rules of eligibility for benefit programs (e.g., short-term disability, Family Medical Leave Act, and health insurance coverage) that can be challenging to navigate. Unlike ESKD, a diagnosis of AKI-D does not qualify patients for Medicare coverage. Patients and their caregivers must be active participants in monitoring for kidney function recovery, dietary changes, and medication monitoring. Yet the cognitive load of incorporating these aspects of care can be overwhelming, especially during the vulnerable transition period to outpatient dialysis. Social workers, nurses, and dietitians are all instrumental in providing psychosocial support and identifying and connecting patients and families with appropriate financial, nutritional, and behavioral health resources and education. Care in the Outpatient Dialysis Facility The care in the outpatient dialysis unit is typically geared toward a patient with ESKD. AKI-D–specific care is ill defined, and in most centers, patients with AKI-D may receive protocolized care that is typically provided for patients on long-term maintenance dialysis (Figure 2). The following sections describe the key components of care in the outpatient dialysis facility that should be individualized for patients with AKI-D, as compared with the therapeutic plans and algorithms applied for patients with ESKD.Figure 2: Current care model for patients with AKI-D in the outpatient dialysis facility. Patients with AKI requiring dialysis often experience fragmented care without clear clinical guidance.Monitoring of Kidney Function Patients with AKI-D may have rapidly changing native kidney function as their AKI resolves or worsens. Therefore, patients with AKI-D require more frequent monitoring than the typical monthly laboratory tests.24 At minimum, weekly assessment of endogenous kidney function should be performed, particularly in patients with a moderate-to-high recovery phenotype and/or increasing urine output (UOP). These assessments should include measurement of predialysis serum creatinine, timed urine collection, and evaluation of BP, and volume status (Supplement 2 offers a nursing checklist to assist the staff in assessments of patients with AKI-D). Serum creatinine is affected by dialysis, muscle mass, and nutritional status, and therefore, eGFR equations should not be used to estimate residual kidney function.25 However, predialysis serum creatinine remains a useful and easily obtainable metric, and downward trends can be an indicator of recovering kidney function in nonoliguric patients; in the absence of increasing UOP, serum creatinine trends should be interpreted with caution because they may also result from illness-associated reduction in creatinine production or be masked by increased creatinine production during convalescence. Timed urine collections for urea and creatinine clearance in patients undergoing hemodialysis have historically been performed over a 44-hour period (i.e., interval between treatments) for logistical simplicity. However, this may underestimate kidney function because both urinary volume and solute clearance decrease sharply at the end of hemodialysis treatment and slowly recover during the interdialytic interval, presumably because of decreased renal perfusion during dialysis.26 Therefore, the optimal method may be a 12- or 24-hour urine collection immediately preceding a hemodialysis session with a prehemodialysis blood draw to calculate urea and creatinine clearance. The average of urinary urea and creatinine clearances provides the best estimate of residual kidney function.26 Modality of Dialysis The optimal modality of outpatient dialysis for individuals with AKI is uncertain. Until recently, the only outpatient option in the United States was in-center hemodialysis. However, the Centers for Medicare & Medicaid Services ESKD Prospective Payment System final rule for 2025 included a provision to extend coverage for Medicare patients with AKI to include home dialysis beginning January 2025.27 In the hospital setting, acute peritoneal dialysis (PD) has been associated with similar clinical outcomes when compared with hemodialysis.28–30 Experience from the coronavirus disease 2019 pandemic further provides optimism as to feasibility of PD as an outpatient option for AKI.31 PD may be associated with less intradialytic hypotension and therefore better recovery, although this has not been evaluated in clinical trials. However, home dialysis may be associated with increased patient and caregiver stress at an already challenging time. Importantly, the new rule also extends dialysis coverage to skilled nursing facilities, and assisted PD in this setting may offer a middle ground to overcome some barriers. At present, there is not enough experience to provide clinical practice points for PD in AKI-D, and our remaining guidance will focus on hemodialysis. Vascular Access The optimal hemodialysis vascular access for patients with AKI-D is usually a tunneled dialysis catheter in the internal jugular vein. If patients with underlying advanced CKD already have an existing arteriovenous fistula or graft, then that vascular access should be used instead. Placement of an arteriovenous access should be deferred until there is reasonable certainty that kidney function is unlikely to recover after adequate patient counseling. Timing of vascular access can be informed by estimating the recovery phenotype as presented earlier. Dose and Adequacy of Dialysis There are no rigorous data regarding the optimal dose of dialysis for a patient receiving outpatient dialysis for AKI. On the basis of the ATN study, in anuric patients, thrice-weekly hemodialysis with a single pool Kt/Vurea of 1.2–1.4 per treatment32 is the recommended dose of hemodialysis in AKI. More intensive dialysis has been associated with a reduced likelihood of kidney function recovery.33,34 Underdosing may risk hyperkalemia and metabolic acidosis, and less frequent dialysis and ultrafiltration may lead to volume overload. BP Management The optimal BP target in AKI-D is unknown. Observational studies in patients on long-term maintenance dialysis show a U-shaped relationship between predialysis systolic BP and mortality, with the lowest risk of systolic BPs of 140–179 mm Hg.35,36 Most AKI-D experts advocate for strategies to avoid hemodynamic instability because hypotension can negatively affect kidney recovery.37,38 As such, we suggest a more permissive approach to BP control to maintain predialysis systolic BP <180 mm Hg, although the optimal target is unknown and should be individualized to the patient. Volume Management In patients on maintenance dialysis, volume management is usually targeted at maximizing fluid removal to improve BP control and minimize symptoms of volume overload. This approach is, however, associated with increased risk of dialytrauma and intradialytic hypotension.19,39,40 Optimal volume management in patients with AKI-D may therefore require a degree of permissive hypervolemia to minimize the risk of hypovolemia-induced hypotension during dialysis.38 This approach must be balanced against avoiding volume overload severe enough to produce symptoms or precipitate hospitalization. Target weight and ultrafiltration goals in AKI-D are dynamic targets because patients may gain back weight lost during acute illness or potentially lose weight because of ongoing illness. Volume and BP assessments thus need to be conducted at every hemodialysis treatment and used to set fluid removal goals. In addition to a physical examination, patients should be asked about changes in urine production; caloric intake; sodium and fluid intake; physical conditioning; and any posthemodialysis symptoms, such as cramping, nausea, or vomiting. Nurses and other members of the IDT should be trained to participate in this monitoring and report important clinical changes (Supplement 2). In the ESKD population, higher ultrafiltration rates are associated with adverse outcomes, including hypotension, lower survival, and faster decline in residual kidney function.41 In patients with AKI-D, a more conservative approach to ultrafiltration has been associated with decreased risk of intradialytic hypotension,42 and we suggest that prescribed ultrafiltration should be <10 ml/kg per hour. In nonoliguric patients, loop diuretics can help control fluid accumulation and reduce ultrafiltration needs. High-dose loop diuretics are associated with less risk of intradialytic hypotension, presumably by increasing UOP and thereby decreasing the ultrafiltration goals per dialysis session.43 Loop diuretics are also associated with decreased risk of hospitalization in patients with incident ESKD.44 Extrapolating this information to AKI-D, we suggest a trial of furosemide 160 mg twice a day (or equivalent dose of torsemide or bumetanide) in all patients with AKI, except in those with already significant UOP and minimal interdialytic weight gain (<1 kg).45 In patients who remain oligoanuric, diuretics can be held until there is a reported or documented increase in UOP. Beyond reducing ultrafiltration rates, data are limited to guide best practices in reducing intradialytic hypotension. One of the most studied interventions in the ESKD population is cool dialysate, which reduces intradialytic hypotension46 and organ damage related to dialytrauma.47,48 Cool dialysate has also been found beneficial in the AKI-D setting43 and is therefore a reasonable tool for patients at increased risk of intradialytic hemodynamic instability (Supplement 3 reviews measures to prevent intradialytic hypotension and their benefits and potential pitfalls). Anemia Anemia is a common complication among patients with AKI-D, and nephrologists should address reversible causes of anemia, including iron deficiency. Although intravenous (IV) iron is associated with direct kidney injury and endothelial cell dysfunction in human and animal models,49 there is no definitive evidence that IV iron impairs recovery of kidney function in patients with AKI-D. Therefore, IV iron should be administered to correct iron deficiency when present, but caution should be taken to avoid IV iron protocols targeting supratherapeutic iron stores that are prevalent in the maintenance dialysis population.50 Relatedly, erythropoietin production is decreased during AKI and may lag behind recovery of kidney function.51 Erythropoiesis-stimulating agent (ESA) treatment is currently widely used in the AKI setting.52,53 ESAs are assumed to have similar benefit and risk profile in patients with AKI-D as in those with ESKD, but there are no high-quality data assessing their safety or efficacy in this population, nor are there studies to establish optimal hemoglobin targets. It is reasonable to use ESAs in patients with AKI-D with severe anemia, particularly those with >30 days of dialysis dependence and/or with low recovery phenotype and no contraindications to ESA use. We suggest not targeting a hemoglobin >11 g/dl on the basis of data from the ESKD literature. The primary goal of ESA titration should be prevention of transfusion because allosensitization from blood transfusions may hinder patients' candidacy for kidney transplantation. Bone and Mineral Disease Hyperphosphatemia, hypocalcemia, vitamin D deficiency, and elevated parathyroid hormone are commonly observed in patients with AKI.54,55 The short- and long-term effects of dysregulated mineral metabolism in AKI-D on clinically relevant outcomes, such as kidney function recovery, cardiovascular events, and mortality, are unknown. In this context, no data exist to guide the measurement and management of bone and mineral disease in patients with AKI-D. Patients recovering from critical illness often have vitamin D deficiency, and this should be assessed and treated if present.56 Presumably, patients with low likelihood of kidney function recovery are most susceptible to long-term complications of dysregulated mineral metabolism. Therefore, it is reasonable to apply ESKD bone disease protocols to patients with AKI-D with a low recovery phenotype. In patients with moderate-to-high likelihood of kidney function recovery, we suggest that phosphate binders should be reserved for severe and persistent hyperphosphatemia (>8 mg/dl). The risks from mild–moderate hyperphosphatemia (5–8 mg/dl) are primarily related to long-term exposure beyond the typical observation period for AKI-D recovery. Conversely, hypophosphatemia can have adverse effects, such as muscle weakness, which is more likely to occur in patients with AKI-D. Medication Management Patients with AKI-D typically have a significant medication burden, including many potentially new medications from hospitalization, and are at risk of medication-related complications. In the care of patients with AKI, pharmacist-assisted medication management improves patient knowledge, reduces the risk of nephrotoxin exposure, and lowers rehospitalization rates.57,58 Medication review and management (beyond simple medication reconciliation) at every transition of care is critical to avoid medication-related errors (omissions, duplications, dosing errors, and drug interactions) and to identify nephrotoxins. Nephrotoxins should be avoided whenever possible in the maintenance and recovery phases of AKI. Potential nephrotoxins include NSAIDs, certain antimicrobial agents, proton pump inhibitors, iodinated contrast, and herbal supplements. In patients with moderate-to-high likelihood of recovery of kidney function, alternative medications should be used when clinically feasible. In patients with AKI-D, timed urine collections for creatinine and urea clearances can inform drug dosing.37,59 In anuric patients, an eGFR <10 ml/min should be generally used for drug dosing, but for medications cleared by dialysis, supplemental dosing may be required after dialysis. One should also be aware of cardio and renal protective medications and restart or initiate them in a timely manner as AKI survivors are at high risk of adverse cardiovascular events.60 In large observational studies, use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers is associated with lower post-AKI mortality, although these studies included few patients with AKI-D. Clinicians should consider initiation or restarting of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers early (within 3 months after AKI), with careful monitoring for recurrent AKI and/or hyperkalemia. Similarly, reinitiating or starting sodium glucose cotransporter 2 inhibitors after non–AKI-D is associated with reduced risk of death, progression to kidney disease, and recurrent AKI.64,65 However, no data exist regarding use of sodium glucose cotransporter 2 inhibitors in AKI-D. With regard to statins, these agents should be considered for patients with AKI-D (if no contraindications) because large observational studies have shown that statins are associated with reduced mortality after AKI.66–68 Dialysis Discontinuation There are no uniform criteria for dialysis discontinuation when recovery from AKI-D is suspected. Randomized clinical trials of AKI-D management in the hospital setting have used varying definitions of recovery, requiring UOP of >0.4–0.5/L per day69–71 or creatinine clearance of ≥12 ml/min from a timed urine collection.32 Literature from the ESKD population on incremental dialysis (starting hemodialysis at a frequency of 2×/wk rather than 3×/wk) suggests that hemodialysis frequency of 2×/wk is likely safe in patients with residual urea clearance of >2.0 ml/min.72,73 By analogy, many patients with CKD stage 5 with residual eGFR 5–10 ml/min per 1.73 m2 can be safely maintained off dialysis, albeit with close follow-up. Ultimat

Acute kidney injury is a common diagnosis in hospitalized patients and can range in severity from a minor, reversible rise in creatinine to a more severe kidney injury with resultant complications. In a small but significant percentage of patients with acute kidney injury, renal replacement therapy is required for supportive care. Patients who require renal replacement therapy and survive to hospital discharge face major challenges in recovering from acute illness while adapting to an outpatient dialysis system that was not designed for patients with acute kidney injury. In addition, treating clinicians must navigate complex transitions of care and remain cognizant of signs of renal recovery. This review describes the current evidence in postdischarge acute kidney injury requiring dialysis management. We discuss risk factors for dialysis dependency, markers of kidney recovery, transitions of care, dialysis customization, and quality of life.

In this second installment of the proceedings of the University of Alabama at Birmingham Continuous Renal Replacement Therapy (CRRT) Academy, we focus on the topic of transitions of care in acute renal replacement therapy (RRT). Although we have accumulated data from thousands of critically ill patients with AKI randomized to different strategies for RRT initiation, no trial data exist to guide de-escalation of RRT in the intensive care unit. However, for survivors of severe AKI whose kidney function does not recovery rapidly enough to allow for liberation directly from CRRT, successful de-escalation of care requires the transition from CRRT to intermittent RRT modalities. These transition periods must be carefully navigated since they can be a source of complications, such as failure to transition or intradialytic hypotension, which are in turn associated with an increased risk of mortality and reduced odds of kidney recovery. In this review, we focus on the critical factors to consider during de-escalation of RRT care, with a focus on modality transition, the role of volume status in guiding the approach to de-escalation of RRT, and the vital importance of careful dosing of drugs, especially antimicrobial agents, during this transitional period.

ABSTRACT:High-dose methotrexate (MTX) results in high rates of acute kidney injury (AKI), neutropenia, and hepatotoxicity. Glucarpidase is a recombinant enzyme that cleaves MTX, but clinical data supporting its use are scarce. We examined the association between glucarpidase administration and outcomes in adults with MTX-AKI from 28 cancer centers across the United States using a sequential target trial emulation framework. The primary end point was kidney recovery at hospital discharge, defined as survival to discharge with serum creatinine <1.5-fold baseline and without dialysis dependence. Key secondary end points were time to kidney recovery, neutropenia, and transaminitis on day 7, and time to death. Using multivariable logistic and Cox regression models, we compared outcomes in patients who received glucarpidase within 4 days following MTX initiation with those in patients who did not. Among 708 patients with MTX-AKI, 209 (29.5%) received glucarpidase. Overall, 183 (25.8%) had a primary end point event. Glucarpidase receipt was associated with a 2.70-fold higher adjusted odds of kidney recovery (95% confidence interval [CI], 1.69-4.31) compared with no glucarpidase receipt. Patients treated with glucarpidase also had faster time to kidney recovery (adjusted hazard ratio [aHR], 1.88; 95% CI, 1.18-3.33) and lower risks of grade ≥2 neutropenia (adjusted odds ratio [aOR], 0.50; 95% CI, 0.28-0.91) and grade ≥2 transaminitis (aOR, 0.50; 95% CI, 0.28-0.91) on day 7. There was no difference in time to death (aHR, 0.76; 95% CI, 0.49-1.18). These data suggest glucarpidase may improve both renal and extrarenal outcomes in patients with MTX-AKI.

QuestionCan a conservative dialysis strategy improve recovery of kidney function for patients with acute kidney injury who require dialysis?FindingsIn this randomized clinical trial with 220 adults, dialyzing based on specific metabolic or clinical indications increased the likelihood of achieving recovery of kidney function at hospital discharge (64%) compared with the conventional treatment of 3 times per week (50%).MeaningA conservative dialysis strategy promoted recovery from dialysis-requiring acute kidney injury. ImportanceFor patients with dialysis-requiring acute kidney injury, persistent need for dialysis is associated with increased morbidity and mortality, high health care use, and poor quality of life.ObjectiveTo test the effect of a conservative dialysis strategy on recovery of kidney function.Design, Setting, and ParticipantsThis multicenter, unblinded, randomized superiority trial enrolled participants with dialysis-requiring acute kidney injury who had a baseline estimated glomerular filtration rate greater than 15 mL/min/1.73 m2, had already initiated kidney replacement therapy, and were hemodynamically stable, with planned intermittent hemodialysis between January 23, 2020, and March 10, 2025, at 4 clinical sites in the United States. Of 909 patients assessed for eligibility, 221 were randomized and 220 received the allocated intervention. The date of last follow-up was June 10, 2025.InterventionWith the conservative dialysis strategy, participants received dialysis only when specific metabolic or clinical indications were met. Participants in the conventional dialysis group received dialysis 3 times per week until urine output or creatinine clearance criteria were met.Main Outcomes and MeasuresThe primary study end point was unadjusted kidney function recovery at hospital discharge, defined as being alive and not receiving dialysis, with at least 14 consecutive days without dialysis (including after discharge). Two prespecified key secondary end points were the number of dialysis sessions per week and the number of dialysis-free days to day 28.ResultsThe mean age of participants was 56 years (SD, 16 years). A total of 148 of 220 participants (67%) were male, 28 (13%) were Black, and 133 (60%) were White. Mean baseline estimated glomerular filtration rate was 64.8 mL/min/1.73 m2 (SD, 30.9 mL/min/1.73 m2). Participants had started kidney replacement therapy a median of 9 days (IQR, 5-18.5 days) before randomization. In the conservative dialysis intervention group, 70 of 109 participants (64%) achieved kidney function recovery at hospital discharge vs 55 of 109 participants (50%) in the conventional dialysis control group (difference, 13.8% [95% CI, 0.8%-26.8%; P = .04]; unadjusted odds ratio, 1.76 [95% CI, 1.02-3.03; P = .04]; after prespecified adjustment: odds ratio, 1.56 [95% CI, 0.86-2.84; P = .15]). Participants in the conservative dialysis group received fewer dialysis sessions per week (median, 1.8 [IQR, 0-2.6] vs 3.1 [IQR, 2.6-3.5]; difference, -1.4 [95% CI, -1.8 to -1.0]) and recovered earlier (21 [IQR, 0-28] vs 5 [IQR, 0-21] consecutive dialysis-free days to day 28; difference, 16 days [95% CI, 5-27]). Dialysis-associated hypotension occurred less frequently in the conservative dialysis group (69 vs 97 events).Conclusions and RelevanceA conservative dialysis strategy in dialysis-requiring acute kidney injury resulted in a shorter time to and higher rates of recovery of kidney function in the unadjusted analysis. Given uncertainty regarding the estimated effect size, this approach should be tested in a larger study population.Trial RegistrationClinicalTrials.gov Identifier: NCT04218370 This trial examines whether a conservative dialysis strategy can improve recovery of kidney function for patients with acute kidney injury who require dialysis.

Background: Patients undergoing hemodialysis are at high risk for healthcare-associated infections; they are at 100 times the risk of Staphylococcus aureus bloodstream infections (BSI) compared with U.S. adults not on hemodialysis. Prior studies found that nasal decolonization with mupirocin prevented S. aureus BSI among hemodialysis patients. We implemented a nasal decolonization intervention in which patients self-administered povidone-iodine (PVI) at each dialysis session. We aimed to assess: 1) hemodialysis patients’ knowledge of their infection risk and their willingness to take an active role in infection prevention; 2) the acceptability of the PVI nasal decolonization intervention. Methods: We performed a stepped wedge cluster randomized trial at 16 outpatient hemodialysis centers. Patients were surveyed: before starting PVI, 1 month after their center started using PVI, and ~6 months after starting PVI. We used a chi-square test to compare results. Results: 469 patients completed at least 1 survey: 400 pre-intervention, 237 at 1 month and 201 at 6 months. Overall, 56% of patients thought that their risk of infection was average or below average compared with an average person in the U.S. (Figure). Over 98% agreed with the statement “One of the most important things I can do for my health is to take an active role in my health care." In the pre-intervention survey, 73% were willing to do “a lot of effort” to prevent an infection. This proportion was similar (73%) in the 2nd survey, but decreased to 63% in the final survey (p < 0 .01). Among 106 patients who reported starting PVI, 85% reported that PVI felt neutral or pleasant, 9.4% reported a side effect, and 79% reported using it during the past 3 dialysis sessions. Among 102 patients who reported using PVI at 6 months, 87% said it felt neutral/pleasant, 3.9% reported a side effect and 75% reported using it during the past 3 dialysis sessions. Side effects included nasal dripping, congestion or burning/stinging, unpleasant smell, headache, yellow tears, and minor nose bleeding. Conclusions: Hemodialysis patients are not aware of their high risk of infection. Although many were willing to expend a lot of effort to prevent an infection, this willingness decreased during an infection prevention intervention. There were few PVI side effects and most patients stated that PVI felt neutral/pleasant, yet many patients chose to not use PVI. Future research should aim to improve patient education on their risk of infection and assess barriers to adherence with infection prevention interventions.

Peptide receptor radionuclide therapy (PRRT) can be a very useful treatment for patients with neuroendocrine neoplasms and metastatic castration-resistant prostate cancer but it is routinely avoided in those with advanced kidney disease because it can adversely affect the renal function. Accordingly, no clear guidelines exist on the use of PRRT for patients on hemodialysis (HD). We performed a literature review to identify publications on HD patients who received PRRT with Lutetium-177 (Lu-177) Dotatate and Y-90 and obtained information on Lu-177 pharmacokinetics and early testing data from the manufacturer. We also perused the most recent North American Neuroendocrine Tumor Society (NANETS)/European Neuroendocrine Tumor Society (ENETS) recommendations. Seven relevant publications with a total of 15 patients were included. Patients received dose-adjusted fractions of PRRT with HD occurring usually within 24 h. There were no immediate or long-term serious adverse events attributed to the radioligand, although data was limited. Using available evidence and input from a multidisciplinary group, we have created an institutional workflow. Dose-adjusted PRRT can be offered to patients undergoing HD under careful, multidisciplinary supervision.

Acute kidney injury (AKI) is common among patients undergoing cardiopulmonary bypass (CPB) surgery. AKI diagnosis relies on serum creatinine and urine output which show poor sensitivity and specificity. New AKI biomarkers have not been widely adopted into clinical care due to limitations. A shortcoming of existing AKI biomarkers is lack of kidney tissue specificity. We previously described the kidney specific enzyme, myo-inositol oxygenase (MIOX), as a potential plasma AKI biomarker. In this study, we evaluated urine MIOX as an AKI biomarker in patients undergoing CPB surgery and compare MIOX with kidney injury molecule-1 (KIM-1) and neutrophil gelatinase associated lipocalin (NGAL).

Key Points AKI survivors experience gaps in care that contribute to worse outcomes, experience, and cost. Challenges to optimal care include issues with information transfer, education, collaborative care, and use of digital health tools. Research is needed to study these challenges and inform optimal use of diagnostic and therapeutic interventions to promote recovery AKI affects one in five hospitalized patients and is associated with poor short-term and long-term clinical and patient-centered outcomes. Among those who survive to discharge, significant gaps in documentation, education, communication, and follow-up have been observed. The American Society of Nephrology established the AKINow taskforce to address these gaps and improve AKI care. The AKINow Recovery workgroup convened two focus groups, one each focused on dialysis-independent and dialysis-requiring AKI, to summarize the key considerations, challenges, and opportunities in the care of AKI survivors. This article highlights the discussion surrounding care of AKI survivors discharged without the need for dialysis. On May 3, 2022, 48 patients and multidisciplinary clinicians from diverse settings were gathered virtually. The agenda included a patient testimonial, plenary sessions, facilitated small group discussions, and debriefing. Core challenges and opportunities for AKI care identified were in the domains of transitions of care, education, collaborative care delivery, diagnostic and therapeutic interventions, and digital health applications. Integrated multispecialty care delivery was identified as one of the greatest challenges to AKI survivor care. Adequate templates for communication and documentation; education of patients, care partners, and clinicians about AKI; and a well-coordinated multidisciplinary posthospital follow-up plan form the basis for a successful care transition at hospital discharge. The AKINow Recovery workgroup concluded that advancements in evidence-based, patient-centered care of AKI survivors are needed to improve health outcomes, care quality, and patient and provider experience. Tools are being developed by the AKINow Recovery workgroup for use at the hospital discharge to facilitate care continuity.