1/10 Last #NephJC we discussed dialysis frequency in AKI-D #TenPostNephJC We sought to answer an age-old question: Is less is really more? Or less is just simply what it is….less? pubmed.ncbi.nlm.nih.gov/41201895/

A new #NephJC short by @hswapnil.medsky.social Read all about 📰BigPAK. Can a biomarker-guided preventive care strategy reduce moderate or severe AKI after major surgery? This one might raise a few eyebrows 🤨 #NephSky #MedSky www.nephjc.com/news/2025/12/16/bigpak

Thank you all for joining! I’m @notjustdialysis.bsky.social (Sridatta) signing off. See you next year #NephJC. 🛌💙🩺

We,thank our mentors @brianrifkin.bsky.social @hswapnil.medsky.social @nephroseeker.medsky.social

Thank my team @msocomd.bsky.social @sejalplakhani.bsky.social & @dramiliflores.bsky.social

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We are then going back to our regularly scheduled programming 1/13/26 at 9pm EST VALIANT: Trial of Pegcetacoplan in C3 Glomerulopathy and Immune-Complex MPGN. #NephJC www.nejm.org/doi/ful...#NephJC

Next up: 1/6/26, 9pm EST #NephJC TOP TEN NEPHROLOGY STORIES OF 2025! You voted, we tallied. Let’s discuss! We’re going back to Twitter (yes, it is still called Twitter for those who really care), so pack your bags and join us on the “other place” as we count ‘em down.

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What surprised you about this study? Does LIBERATE-D reinforce what you already do? Did this study make you rethink dialysis frequency? Are there other routine dialysis orders that we should reconsider in AKI-D patients vs ESKD patients? #NephJC

T3p LIBERATE-D is good, but not definitive. Crossovers, pragmatic design, and modest sample size mean further studies may refine necessary RRT thresholds. However the direction is clearer→ more dialysis doesn’t mean better outcomes. #NephJC

T3o Should we routinely hold HD in stable patients unless a compelling indication appears? Should our morning rounds begin with “Does this patient need HD?” instead of “Is today a dialysis day?” Time for a self-audit. #NephJC

T3n Were we asking the wrong questions? For years we asked: “When should we dialyze?” LIBERATE-D asks: “When should we not dialyze?” That reframing is powerful. Will you change your practice based upon this study? #NephJC

T3m Even after recovery, AKI-D survivors are at ⬆️risk for CKD. Hypothesis: Less dialysis-induced ischemia → better long-term slope? The study wasn’t powered for this, but it is plausible. Would this data further compel you to follow the Conservative strategy? #NephJC

T3l LIBERATE-D suggests a hybrid decision model: 🧪Use simple biochemical and physiologic triggers 🤔Layer clinician assessment on top But will this create chaos during care hand-offs between nephrology partners? Perhaps it is at least a reminder to try to dialyze less? #NephJC

T3k Questions to be answered❓ #NephJC Should all dialysis programs adopt the same RRT thresholds? Should nephrologists retain full freedom to use judgment? (AI has entered the chat 🤖) Can Conservative strategies be used on outpatients? (non-daily assessments)

T3j Weaknesses 🔀Crossovers 🔫Trigger thresholds partly arbitrary 🗓️No long-term follow-up 🤔Clinician-judgment variability Not powered to determine mortality or long-term CKD risk #NephJC

T3i Strengths Large-scale, randomized evidence that a selective, criteria-driven decision tool can decrease dialysis exposure & improve outcomes. Clear separation in RRT frequency,missing data, recovery rates in the Conventional group that matched power calculations. #NephJC

T3h 3x weekly RRT for AKI-D may soon join the #TWDFNR list. It was built on the basis of ESKD adequacy, not physiology/renal recovery. And now we have an RCT showing: 👎Worse recovery 👎More treatments 👎More hypotension 👎No safety advantage The dogma is crumbling. #NephJC

T3g Earlier AKI trials consistently showed: ⭐Early dialysis does NOT improve mortality ⭐Conservative strategies are safe ⭐Many patients can avoid dialysis entirely LIBERATE-D takes the next logical step: Once you start dialysis, continue only when necessary. #NephJC

T3f Despite how central kidney recovery is to AKI-D outcomes, very few RCTs have meaningfully studied how to optimize recovery. LIBERATE-D forces us to confront the possibility that we’ve been researching the wrong questions for decades. #NephJC

T3e Clinician judgment was the most common trigger for dialysis in the Conservative arm. Not labs, thresholds, or formulas. It shows we CAN pick up subtle uremia: worsening fatigue, ⬇️alertness, respiratory changes, worsening edema- if we are attentive. #NephJC

T3d LIBERATE-D quietly challenges us: Is BUN > 112 mg/dL a meaningful threshold for toxicity, or just a traditional num? BUN alone has limited predictive power for symptoms or outcomes. Yet it’s one of the most commonly used reasons for “dialyzing just to be safe.” What’s your threshold? #NephJC

T3c This study raises an uncomfortable but necessary question: Have we, as nephrologists, become so accustomed to reflexively continuing dialysis schedules that we’ve forgotten to assess when patients are actually capable of recovery? #NephJC

T3b This suggests that our long-standing dialysis reflex, inherited from ESRD practices, may inadvertently delay renal recovery in AKI-D. LIBERATE-D does not just challenge the routine it provides a pragmatic, safe, possibly more physiologic alternative. #NephJC

T3a The results establish a strong pattern, Conservative treatment had: 👍Better kidney recovery 👍More dialysis-free days 👍Fewer dialysis sessions 👍Fewer hypotensive events 👍No increase in mortality or harm #NephJC

The discussion is next #NephJC

T2i Does reducing RRT frequency put pts at ⬆️ risk of harm? Mortality & SAE were similar in both groups. There was ⬆️emergent RRT need in the Conservative group (9 vs 4) The Conservative strategy was non-inferior for safety & superior for recovery- the best possible combination. #NephJC

T2h Intradialytic hypotension can delay tubular recovery. IDH- Conservative: 69 events Conventional: 97 events The Conservative arm had half the number of HDs, yet they had fewer total hypotensive episodes. Are you surprised ⬇️treatments didn’t equate to more aggressive UF/⬇️BP? #NephJC

T2g Dialysis-Free Days by Day 28: Conservative: 21 days Conventional: 5 days 🌟Most pronounced divergence within the first 10-12 days In the Conservative arm, the most common trigger for dialysis was clinician judgment related to volume overload or uremia concerns. #NephJC

T2f Dialysis-Free Days by Day 28: Conservative: 21 days Conventional: 5 days Most pronounced divergence within the first 10-12 days Clinically, this means these patients spent most of their hospital course not needing dialysis, something no earlier AKI-D trial has demonstrated so clearly. #NephJC

T2e Crossovers were permitted & expected. If a pts needed RRT outside protocol rules, clinical judgement prevailed. Importantly, even with crossovers diluting differences, the conservative arm showed more rapid renal recovery. This suggests the true physiologic benefit may be even larger.#NephJC

T2d Although QOL was not specifically addressed… dialysis-free time is not just a number, it represents: 🪡Fewer needles 😴Fewer episodes of post-dialysis fatigue 📉Fewer hypotensive crashes ⌚Fewer hours tied to a machine #NephJC

T2c 14 dialysis-free days before D/C: Conservative 64% vs Conventional 50% After adjusting for age, sex, race, ethnicity & baseline eGFR, the difference WAS NOT statistically significant (aOR, 1.56; 95% CI, 0.86–2.84, p = 0.15). Do you think this result is clinically meaningful? #NephJC

T2b Most cases of AKI-D were from ischemia, nephrotoxin exposure, sepsis, or postoperative complications. 80% were randomized prior to ICU admission. One-third of participants had diabetes, and 15% remained on vasopressors 2 days after randomization. #NephJC

T2a 909 patients were assessed and 221 randomized. Of note nearly 400 patients were excluded due to the “clinical team declining participation”. Do you think the Conservative strategy criteria were viewed as too risky? #NephJC

Did fewer dialysis sessions harm patients? Did patients recover faster when spared hemodynamic stress? Did we trade safety for recovery, or did we gain both? THE RESULTS move this from theoretical debate to actionable practice. #NephJC

T1i The pragmatic design mirrored real practice. Clinicians made decisions & the protocol allowed for differences in style & workflow. Does this give LIBERATE-D greater clinical validity as an AKI-D trial? Would you have changed the design? #NephJC

T1h The study used intention-to-treat as the primary analytic method. Per-protocol and exploratory analyses reinforced the findings. This framework balanced real-world crossover complexity with rigorous statistical methodology. #NephJC

T1g 2° Outcomes: #NephJC 🙌Dialysis-free days by day 28 🧮Total number of dialysis sessions 📉Intradialytic hypotensive (IDH) events 🏥Hospital length of stay ☠️Mortality Anything else you’d quantify?

T1f In both groups, final treatment decisions, including escalation to continuous hemodialysis were made by the clinical team, and interventions ended at hospital discharge. F/U continued to day 90. The active study intervention ended at hospital discharge. #NephJC

T1e 1° Outcome #NephJC 🚫14 consecutive dialysis-free days prior to discharge A 14-day window ensured renal recovery was stable & not transient. It also allowed detection of “false recoveries” (relapse). Pts that recovered from AKI but did not survive the hospitalization were not counted.

T1d #NephJC All pts were liberated from RRT if: 1️⃣Urine output >1 L/day without diuretics or >2 L/day with diuretics 2️⃣CrCl >20 ml/min 3️⃣Spontaneous ⬇️serum creatinine ♻️During RRT withdrawal trials, dialysis was restarted if conservative criteria were met again after HD was withheld

T1c #NephJC 1️⃣Conservative RRT group RRT was done only if one of the following occurred: ✅BUN >112 mg/dL ✅Potassium >6.0 mmol/L, >5.5 after meds ✅pH <7.15 or HCO3 < 12 meq/L ✅Hypoxemia or pulmonary edema ✅Symptomatic overload ✅Clinician judgment 2️⃣ Conventional RRT was 3x/wk

T1b Conducted across 4 major US academic centers. Oversight included a three-member independent data and safety monitoring board with a prespecified interim review after enrollment of 110 participants and authority to recommend stopping for safety, efficacy, or futility. #NephJC

T1a Population: stable AKI-D patients with realistic renal recovery potential Exactly the “gray zone” group we debate daily whether dialysis continuation is necessary. 👀Check out the inclusion/exclusion criteria #NephJC

Let’s review some methods #NephJC

T0g The hypothesis: RRT only when needed → ⬆️ recovery, ⬇️treatments & complications This represents a shift from “normalizing labs” to “treating patients”. The trial tests if intentionally withholding RRT in stable, recovering patients accelerates their return to renal autonomy. #NephJC

T0f Similarly, early outpatient initiation of dialysis in CKD 5 is not associated with an improvement in survival or clinical outcomes. So, should we aim for late starts but early finish in AKI-D? LIBERATE-D attempts to answer how to limit RRT exposure once it has been initiated. #NephJC