Will you implement the conservative dialysis strategy from the LIBERATE-D trial for patients with dialysis-requiring acute kidney injury, or will you continue dialysis on a schedule until recovery based on creatinine and urine output?

I think I have always dialyzed patients with AKI on an as-needed basis. The question is whether to follow the parameters set by the LIBERATE-D study (bun >112, etc.). I am not yet sure what my practice will look like in the future as far as the parameters. It is likely the case, though, that I would be less willing to do dialysis on an AKI patient with borderline uremic findings.

The real problem is fluid. Patients with ATN are often oliguric, and we all know that ICU patients are almost always fluid overloaded. Even with 3 days per week dialysis, it is hard to keep fluid balance even in an ICU patient who may still be hypotensive. In the LIBERATE-D trial, the intervention arm had more ultrafiltration sessions; however, this was not enough to compensate for the lower number of dialysis treatments. Future trials should consider not only renal function but also overall mortality, cardiovascular, and pulmonary events. Another question is whether we should do more ultrafiltration treatments versus hemodialysis treatments.