A Conservative Dialysis Strategy and Kidney Function Recovery in Dialysis-Requiring Acute Kidney Injury
LIBERATE-D trial design and results
Design
Multicentre, unblinded, randomised superiority trial at 4 US sites
Treatment
Conservative dialysis strategy, dialysing less frequently
Control
Usual dialysis strategy
Population
220 participants with dialysis-requiring acute kidney injury, mean age 56, 67% male, mean baseline eGFR 64.8 mL/min/1.73 m2
Follow-up
To hospital discharge, with dialysis-free days counted to day 28
Primary endpoint
Unadjusted kidney function recovery at hospital discharge — alive, off dialysis, with at least 14 consecutive dialysis-free days
Result
Kidney function recovery at discharge occurred in 70 of 111 (64%) with the conservative strategy versus 55 of 109 (50%) with conventional dialysis — difference 13.8 percentage points (95% CI 0.8 to 26.8, p=0.04); unadjusted odds ratio 1.76 (1.02 to 3.03, p=0.04), falling to 1.56 (0.86 to 2.84, p=0.15) after prespecified adjustment. The conservative group received fewer dialysis sessions per week (median 1.8 versus 3.1) and had 16 more consecutive dialysis-free days to day 28 (21 versus 5, 95% CI 5 to 27). Dialysis-associated hypotension occurred 69 versus 97 times.
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.
The trial authors, in the published abstract
How it has aged
Extends the question beyond when to start (STARRT-AKI, AKIKI 2) to how much dialysis to give once started, using kidney recovery rather than mortality — the outcome that determines whether a patient leaves hospital dialysis-dependent. The prespecified primary analysis was unadjusted and positive; adjustment removes significance, and the authors are explicit that the effect size is uncertain and needs a larger trial.
Publications
A Conservative Dialysis Strategy and Kidney Function Recovery in Dialysis-Requiring Acute Kidney Injury: The Liberation From Acute Dialysis (LIBERATE-D) Randomized Clinical Trial
Liu KD, Siew ED, Tuot DS, et al. A Conservative Dialysis Strategy and Kidney Function Recovery in Dialysis-Requiring Acute Kidney Injury: The Liberation From Acute Dialysis (LIBERATE-D) Randomized Clinical Trial. JAMA 2026 Jan 27;335(4):326-335.
16 more consecutive dialysis-free days to day 28 with the conservative strategy
Fewer episodes of dialysis-associated hypotension
Primary endpoint positive unadjusted (64% vs 50%, p=0.04); adjusted odds ratio 1.56 not significant