ASN Releases Guidance on Outpatient Management of Dialysis-Requiring AKI

Kathleen Liu, MD, PhD

Credit: UCSF Health

The American Society of Nephrology (ASN) has released its Kidney Health Guidance on the outpatient management of patients with dialysis-requiring acute kidney injury (AKI-D) to address the unique, individualized care needs of these patients.¹

“For people with AKI-D, one of the most important outcomes is to recover adequate kidney function to be liberated from dialysis,” Kathleen Liu, MD, PhD, a professor of medicine and anesthesia in the divisions of nephrology and critical care medicine at the University of California San Francisco and chair of the Kidney Health Guidance Oversight Committee, stated in a press release.² “While outpatient facilities provide excellent long-term dialysis care, we must help ensure that every patient receives the optimal care for their individual circumstances. This new guidance will help facilitate the transition from the hospital setting to outpatient care for people with AKI-D and help care teams identify the early signs of possible recovery in order to promote a life free of kidney disease and its consequences.”

Members of the multidisciplinary expert workgroup specialized in adult and pediatric nephrology; social work; pharmacy; and advanced practice nursing, all with direct experience caring for patients with AKI-D in the outpatient setting. The workgroup followed an iterative, modified Delphi process to achieve consensus on clinical guidance practice points after initial meetings focused on generating key clinical questions and a review of relevant studies.¹

The guidance emphasizes the importance of recovering adequate kidney function to achieve liberation from dialysis, which requires the early identification of improvements in kidney function and the delivery of care that optimizes chances of recovery. Authors note dialysis prescription should follow a "first do no (kidney) harm" approach to avoid dialytrauma, which may decrease the chances of recovery.¹

They also highlight the need for individualized management due to the heterogeneity of AKI-D. Accordingly, the guidance varies depending on patients’ clinical characteristics.¹

According to the guidance, hospital discharge planning should include a “warm handoff” to the outpatient nephrology and dialysis care team to ensure continuity of care and to set appropriate expectations based on the kidney recovery phenotype. Additionally, authors call attention to the importance of differentiating AKI-D from end-stage kidney disease (ESKD), highlighting notable differences in care needed for each patient population.¹

Specifically, they note patients with AKI-D should be classified as “unstable” under Medicare’s Conditions for Coverage standards for dialysis facilities and undergo monthly Comprehensive Interdisciplinary Patient Assessments.¹

Due to the poor quality of life experienced by many patients with AKI-D, authors highlight the need for intensive psychosocial support from social workers, nurses, and dietitians. Because AKI-D-specific care is often ill-defined, patients sometimes receive protocolized care intended for ESKD patients.¹

However, the guidance notes those with AKI-D require more frequent monitoring with weekly assessment of endogenous kidney function and 12- or 24-hour urine collection before hemodialysis, but also warns that serum creatinine trends should be interpreted with caution in these patients.¹

Authors note there is not enough experience or data to inform certain aspects of care, including the optimal modality of outpatient dialysis for individuals with AKI; the optimal dose of dialysis for a patient receiving outpatient dialysis for AKI; the optimal BP target in AKI-D; and the measurement and management of bone and mineral disease in patients with AKI-D.¹

For hemodialysis vascular access, the guidance says a tunneled dialysis catheter in the internal jugular vein is optimal. While the optimal BP target is not certain, volume management is usually targeted at maximizing fluid removal but can lead to an increased risk of dialytrauma and intradialytic hypotension.¹

Recognizing that anemia is a common complication in AKI-D and the lack of definitive evidence that IV iron impairs recovery of kidney function in these patients, the guidance recommends IV iron be administered to correct iron deficiency when present.¹

Authors also emphasize the importance of medication review and management at every transition of care due to the potential for medication-related complications. In patients with moderate-to-high likelihood of recovery of kidney function, alternative medications are recommended when clinically feasible.¹

In the absence of uniform criteria for dialysis discontinuation when recovery from AKI-D is suspected, dialysis discontinuation requires a joint decision-making model between the nephrologist and the patient. Additionally, there is no single strategy for de-escalating or discontinuing dialysis in recovering kidney function.¹

Authors also highlight the limited data available on recovery of kidney function and outpatient follow-up of children with AKI-D, although they note many studies in pediatric populations mirror findings in adult patients.¹

“The clinical practice points presented are based on available but limited evidence and consensus-based expert opinion and intended to promote knowledge in caring for this vulnerable population,” investigators concluded.¹

REFERENCES

1. Vijayan A, Heung M, Awdishu L, et al. ASN Kidney Health Guidance on the Outpatient Management of Patients with Dialysis-Requiring Acute Kidney Injury. Journal of the American Society of Nephrology. doi:10.1681/ASN.0000000646

2. American Society of Nephrology. American Society of Nephrology Releases Kidney Health Guidance on the Outpatient Management of Patients with Dialysis-Requiring Acute Kidney Injury. Newswise. February 27, 2025. Accessed February 28, 2025. https://www.newswise.com/articles/view/824419/