Prioritize recovery: American Society of Nephrology releases AKI clinical guidance
Key takeaways:
- Health care professionals should monitor closely for patient recovery, adjusting dialysis dose and frequency as appropriate.
- Care teams should also offer prognosis discussions to inform and educate patients and families.
The American Society of Nephrology released new clinical guidance in the Journal of the American Society of Nephrology on the outpatient management of AKI requiring dialysis.
“Patients with dialysis-requiring AKI consistently report that being able to stop dialysis is one of the most important patient-centered outcomes to them. There is compelling data that even some individuals with stage 4 chronic kidney disease may experience enough renal recovery to allow them to come off dialysis,” Kathleen Liu, MD, PhD, MAS, professor of medicine and anesthesia at the University of California, San Francisco, and chair of the ASN Kidney Health Guidance Oversight Committee, told Healio. “However, there are a lack of best practices and guidance for nephrologists about how to optimize care for these patients to maximize the likelihood that they will come off dialysis.”
To that end, recommendations were developed by a team of kidney professionals for patients with AKI requiring dialysis (AKI-D) at risk for dialysis dependence, cardiovascular complications, rehospitalization and death. The group included adult and pediatric nephrologists, social workers, pharmacists and advanced practice nurses — all familiar with AKI-D-specific considerations based on current evidence. To enhance outcomes, the panel formulated key clinical questions, conducted a structured evidence review and reached a consensus using a modified Delphi process. Researchers also accounted for patient input.
Overall, the guidance serves as a resource for an interdisciplinary approach to dialysis care, providing recommendations without replacing clinical judgment, according to the authors.
“A key aspect of AKI-D care is the potential for multiple transitions of care and handoffs between care settings, and the nephrology community should work toward improving communication at these critical junctures through more standardized means,” according to the authors.
Individual care remains key, according to the guidance, and treatment decisions should be tailored to patient preferences, comorbidities and other relevant factors. Specifically, the guidance outlines several practice points for providers:
Dialysis and kidney recovery
- Tailor dialysis and ultrafiltration to minimize trauma and hypotension.
- Adjust dialysis dose and frequency to encourage recovery.
- Use a tunneled internal jugular catheter before outpatient transition.
Patient education and transition of care
- Prioritize prognosis discussions and goals of care; plan early for end-stage kidney disease transition.
- Ensure smooth inpatient-to-outpatient transition including AKI-D-specific orders.
- Offer ESKD-specific support like vascular access planning and transplant evaluation.
Monitoring and weaning
- Track recovery through nondialysis dependent-CKD serum creatinine and timed urine collections.
- Gradually taper dialysis based on urine output to avoid unnecessary treatment.
- Trial dialysis cessation based on creatinine clearance and hyperkalemia volume.
Blood pressure and volume management
- Prevent intradialytic hypotension and tolerate higher systolic BP.
- In pediatrics, use online hematocrit monitoring for volume and adjust BP targets.
Anemia and mineral bone disease management
- Use IV iron for deficiency but avoid routine maintenance.
- Limit phosphate binders unless serum phosphate is higher than 8 mg/dL.
- Monitor secondary hyperparathyroidism; treat if dialysis-dependent over 30 days.
Medication management
- Adjust kidney-cleared drugs based on dialysis tapering.
- Regularly reconcile medications at care transitions to prevent errors.
- Evaluate nephrotoxic medications and weigh benefits vs. risks.
One of the key challenges to care is “oftentimes, patients transition from dialysis in-hospital to the outpatient setting and have an entirely new set of providers unfamiliar with their prior course,” Liu said. The guidance pinpoints “what information should be handed off to the outpatient care team. It also addresses management issues related to dialysis that the outpatient care team may need to customize or modify for the AKI-D patient.”
In addition to clinical practice recommendations, the guidance identifies key areas for future research and policy initiatives to enhance the management of AKI-D. The authors listed a number of priorities, including preventing dialysis-related hypotension; strategizing methods to wean patients off dialysis during recovery; and improving interoperability between hospital and outpatient electronic health records. The researchers emphasized the need for further studies, legislation and improved communication between care settings.
By addressing best practices, research gaps and policy needs, the guidance lays the foundation for more effective, patient-centered care, according to Liu.
“For patients with AKI-D, optimizing care to promote renal recovery should be the top priority of the nephrology care team because renal recovery is likely for many patients, and patients consistently report that coming off dialysis is a top priority,” she said. “Perhaps most importantly, patients and their multidisciplinary team should include nephrologists, pharmacists, social workers, nutritionists and nurses — all working together.”
Reference:
American Society of Nephrology releases kidney health guidance on the outpatient management of patients with dialysis-requiring acute kidney injury. https://www.asn-online.org/about/press/releases/ASN_PR_20250227_finalakiguidance2.2.pdf. Published Feb. 27, 2025. Accessed March 20, 2025.
For more information:
Kathleen Liu, MD, PhD, MAS, can be reached at kathleen.liu@ucsf.edu.
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