The Advancing American Kidney Health Initiative has set a national priority of reducing end-stage renal disease (ESRD). To achieve this goal, it is crucial to focus on dialysis-requiring acute kidney injury (AKI-D), as it accounts for over 15% of patients starting dialysis at outpatient hemodialysis units. While the prevalence of AKI-D patients in these units is significant, the management of AKI-D differs from that of ESRD patients. However, there is uncertainty whether the actual management practices reflect these differences.
The existing research on AKI-D primarily revolves around when to initiate dialysis and determining the appropriate dosage. Studies indicate that approximately 30-40% of AKI-D patients who survive to hospital discharge regain enough kidney function to discontinue dialysis. However, little is known about how physicians monitor AKI-D patients for recovery and adjust dialysis prescriptions accordingly. Current literature on outpatient AKI-D management is limited to case series that focus on outcomes, rather than process measures.
One of the challenges in monitoring kidney function recovery in AKI-D patients is that dialysis treatments artificially clean the blood, making blood tests unreliable indicators of kidney function. Timed urine collections have been the most common method for estimating kidney function in dialysis-treated patients. However, according to a recent study, only a quarter of AKI-D patients completed a timed urine collection in the initial 30 days at the dialysis unit. Expert recommendations suggest weekly urine collections to facilitate the early detection of recovery, including subtle recovery that may go unnoticed otherwise.
There is a lack of clarity regarding the optimal approach to deprescribing dialysis as patients recover from AKI-D. Should dialysis be stopped directly, reduced in frequency, or progressively reduced in session duration? The aforementioned study found that most AKI-D patients were stopped directly from three times per week to zero times per week. However, there may be opportunities to wean dialysis more gradually (e.g., from thrice- to twice-weekly), resulting in potential cost savings and improvements in quality of life. This approach can be compared to the concept of “incremental dialysis” for patients with chronic kidney disease, where dialysis is initially started at a lower frequency.
While there are potential opportunities to deprescribe dialysis among AKI-D patients, there are significant systemic obstacles to recognizing recovery and reducing dialysis frequency. Deprescribing dialysis would result in cost savings for healthcare systems. However, dialysis providers may be disincentivized because they would receive less payment for fewer dialysis sessions and may have empty chairs during the week. Nephrologists also face challenges, as they lose the support of multidisciplinary clinical teams when patients recover and discontinue dialysis. Additionally, non-dialysis care is reimbursed at a lower rate compared to dialysis care, despite the complexities involved in managing patients with borderline kidney function.
While there are challenges in the management of AKI-D patients, efforts can be made to improve their care. Close monitoring for recovery using frequent timed urine collections can help identify early signs of kidney function improvement. Gradually reducing dialysis frequency can be explored in patients who have recovered to borderline levels of kidney function. Future research should focus on establishing evidence-based protocols for dialysis deprescribing and recovery monitoring, ensuring that patients are not left on dialysis longer than necessary.
The management of AKI-D patients requires a distinct approach from that of ESRD patients. However, the current practices in outpatient dialysis units do not always align with these differences. By closely monitoring kidney function recovery and exploring the gradual reduction of dialysis frequency, improvements can be made in the care of AKI-D patients. Additionally, addressing systemic barriers to deprescribing dialysis will aid in promoting optimal recovery and reducing the unnecessary burden of prolonged dialysis dependency.
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