More Americans are on dialysis. Could more safely wean off it?
University of California - San Francisco
Weaning patients with acute kidney injury (AKI) from dialysis while they are still hospitalized may save them from remaining on the treatment for the rest of their lives, according to a new study led by UC San Francisco.
Instead, some patients who may have the potential to recover kidney function while hospitalized are transferred to outpatient centers with fewer specialty doctors and less intensive monitoring, where subtle signs of recovery may be overlooked.
Although dialysis is needed to support patients with low kidney function, paradoxically it can delay or even prevent the kidneys’ natural ability to recover from AKI. Dialysis slows kidney recovery by dropping blood pressure and reducing blood and oxygen flow, causing additional damage that may lead to irreversible kidney failure.
“Patients with AKI go from seeing a nephrologist every day or every other day while they are hospitalized, to once a week, or as infrequently as once a month after they transfer to outpatient dialysis centers,” said senior author Chi-yuan Hsu, MD.
“Stopping dialysis can be risky, so it’s natural for nephrologists to be conservative and continue with regularly scheduled dialysis unless recovery is very obvious.”
The number of people on dialysis continues to swell, due to chronic conditions like diabetes, that can cause irreversible end-stage kidney disease. These patients require lifelong dialysis unless they receive a donated kidney. But up to 1 in 4 new referrals at dialysis centers have AKI, triggered by conditions like sepsis, heart failure, trauma to the kidneys, or serious surgical complications. An estimated 50% of patients with AKI die in the hospital. Of those who survive, temporary dialysis is the goal.
In the study, 220 hospitalized patients, whose average age was 56, were randomly divided into two groups. One group received dialysis three times a week until there were clear indications that their kidney function had improved. The second group only received dialysis when they absolutely needed it.
At discharge, 50% of those on conventional dialysis recovered kidney function and no longer required dialysis. But 64% of those who received minimal dialysis reached this milestone. The researchers saw no differences in adverse outcomes between the two groups.
“Generally, dialysis centers do not have the infrastructure to support our weaning intervention. This would include daily assessments of patients’ labs and vital signs,” said Kathleen Liu, MD, PhD, first author of the paper. “Larger studies are needed to confirm our findings, and additional studies would be needed to determine how weaning can be adapted for patients with AKI at outpatient dialysis centers.”
Journal: JAMA: The Journal of the American Medical Association
Other authors and disclosures: Please see the paper
Funding: National Institutes of Health (R01DK122797, K23DK128605, K23DK139456).
About UCSF: The University of California, San Francisco (UCSF) is exclusively focused on the health sciences and is dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. UCSF Health, which serves as UCSF's primary academic medical center, includes top-ranked specialty hospitals and other clinical programs, and has affiliations throughout the Bay Area. UCSF School of Medicine also has a regional campus in Fresno. Learn more at ucsf.edu, or see our Fact Sheet.
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Journal
JAMA
Article Publication Date
7-Nov-2025
High-impact clinical trials generate promising results for improving kidney health - part 2
American Society of Nephrology
- Individuals who require long-term hemodialysis therapy have a high risk of cardiovascular (CV) events and related death, with CV risk factors that are similar to the general population (traditional risk factors) as well as others related to having kidney disease or being on dialysis (non-traditional risk factors). In the PISCES multicenter randomized trial, investigators evaluated the effect of taking omega-3 polyunsaturated fatty acid (fish oil) capsules versus placebo capsules every day on serious CV events such as fatal and non-fatal heart attacks and strokes, peripheral vascular disease needing a limb amputation, and CV-related death. The trial, which included 26 dialysis units in Canada and Australia that recruited 1,228 patients on hemodialysis, found that the rate of serious CV outcomes was reduced by approximately half in patients who took fish oil capsules compared with placebo capsules, with reductions in CV death, heart attacks, stroke and peripheral vascular disease needing an amputation. “Additional studies are ongoing to better understand the mechanisms underlying these benefits,” said corresponding author Charmaine Lok, MD, of the University Health Network and the University of Toronto.
Protection Against Incidences of Serious Cardiovascular Events Study with Daily Fish Oil Supplementation in Patients on Dialysis (PISCES)
- Patients with severe acute kidney injury (AKI) in the hospital often need to start dialysis. The LIBERation from AcuTE Dialysis (LIBERATE-D) trial randomized hospitalized patients with AKI to receive hemodialysis only when specific clinical and metabolic indications were met (conservative dialysis strategy) versus thrice weekly hemodialysis (conventional arm with dialysis cessation based on urine output or creatinine clearance). In the conservative dialysis (intervention) arm, 70 of 109 (64%) participants recovered their kidney function at hospital discharge versus 55 of 109 (50%) participants in the conventional (control) arm. Those in the conservative dialysis arm received fewer dialysis sessions per week and recovered earlier. “Unlike patients with kidney failure, there is the potential for some hospitalized patients with acute kidney injury to recover enough kidney function to come off dialysis, which is a very important clinical and patient-centered outcome. In this clinical trial, we tested an approach to managing dialysis that increased the likelihood of these patients coming off dialysis—the first intervention ever demonstrated to have such a beneficial effect,” said senior author Chi-yuan Hsu, MD, MS, of the University of California San Francisco. “Our next steps will be to continue to test and refine this intervention in more patients and additional settings,” added first author, Kathleen Liu, MD, PhD, MAS
LIBERation from AcuTE Dialysis (LIBERATE-D)
- In a randomized clinical trial involving 2,046 hospitalized patients, investigators utilized an AI-based model that is often used in marketing to predict which patients would benefit from clinician-directed electronic alerts for acute kidney injury. Although targeted alerts did not significantly improve the risk of progression of kidney injury, needing dialysis, or mortality among patients, they led to less nephrology consults and lower risk of hospital readmission. “Targeting alerts based on predicted benefit might improve patient outcomes while reducing alert fatigue,” said corresponding author Laura Aponte Becerra, MD, of Yale University.
Individual Treatment Effect Modeling for AKI Alerts: A Randomized Trial
- Older kidney transplant patients are less likely to reject their new organ but are more vulnerable to medication side effects. The OPTIMIZE study tested whether less intense immuno-suppression could improve their outcomes. The 379-participant trial compared everolimus and reduced-dose tacrolimus versus mycophenolate mofetil and tacrolimus immunosuppression. The lighter treatment regimen was safe but did not lead to better survival or kidney function at 2 years after transplantation. “More research is needed to find the best balance for older transplant recipients,” said corresponding author Stefan Berger, MD, PhD, of the University Medical Center Groningen, in the Netherlands.
Randomized Clinical Trial in Older Adult Kidney Transplant Recipients Comparing Everolimus and Reduced-Dose Tacrolimus with Mycophenolate and Tacrolimus Immunosuppression: The OPTIMIZE Study
- In the SURPASS-CVOT trial, people with type 2 diabetes and cardiovascular disease were given either tirzepatide (which activates receptors for both glucose-dependent insulinotropic polypeptideand glucagon-like peptide-1) or dulaglutide (which activates only the glucagon-like peptide-1 receptor). The study showed that treatment with tirzepatide compared with dulaglutide slowed kidney function decline and reduced the risk of serious kidney events among those at high risk or very high risk of chronic kidney disease. “These findings demonstrate the potential for benefits of tirzepatide when treating high-risk patients,” said corresponding author Sophia Zoungas, PhD, of Monash University, in Australia.
Tirzepatide vs. Dulaglutide Is Associated with Reduced Major Kidney Events in Patients with Type 2 Diabetes, CVD, and Very High-Risk Kidney Diseases
- Guidelines have different levels of recommendation for use of sodium-glucose co-transporter 2 (SGLT2) inhibitors depending on diabetes status and urine albumin:creatinine ratio (uACR). In a meta-analysis of 8 large placebo-control trials including 58,816 participants, investigators found that SGLT2 inhbitors helped protect the kidneys, reduce deaths, and lower hospitalizations in people with chronic kidney disease (CKD), regardless of whether they had diabetes or their level of albuminuria. In people with more protein in their urine, more cases of kidney disease progression were prevented, while in those with lower levels, the numbers of hospitalizations and deaths avoided were similar in people with and without diabetes. Overall, the benefits far outweighed the risks, supporting the broad use of these drugs in people with CKD. “These data encourage removal of stratification by level of albuminuria from guideline recommendations for use of SGLT2 inhibitors in chronic kidney disease, and consequently help maximize widespread utilization,” said lead author Natalie Staplin, PhD, of the University of Oxford.
Net Effects of SGLT2 Inhibitors by Diabetes Status and Albuminuria
Join ASN and approximately 12,000 other kidney professionals from across the globe at Kidney Week 2025 in Houston, TX. The world's premier nephrology meeting, Kidney Week, provides participants with exciting and challenging opportunities to exchange knowledge, learn the latest scientific and medical advances, and listen to engaging and provocative discussions with leading experts in the field. Early programs begin on November 5, followed by the Annual Meeting from November 6-9. Follow the conversation at #KidneyWk.
About the American Society of Nephrology (ASN)
Since 1966, ASN has been leading the fight to prevent, treat, and cure kidney diseases throughout the world by educating health professionals and scientists, advancing research and innovation, communicating new knowledge and advocating for the highest quality care for patients. ASN has nearly 22,000 members representing 141 countries. For more information, visit www.asn-online.org and follow us on Facebook, X, LinkedIn, and Instagram.
