Dialysis Decisions: Are Hospitalized Patients Truly in Control?
"A pilot study reveals surprising insights into the perceptions of patients and their surrogates regarding dialysis initiation during critical illness."
When faced with acute kidney injury (AKI) and critical illness, the decision to start dialysis often happens quickly within a hospital setting. While dialysis is a life-saving treatment, how do patients (or their designated decision-makers) feel about this process when it occurs during a hospitalization? Understanding their perceptions is essential for improving the quality of care and ensuring patient-centered decisions.
A new study dives into this important question, exploring the experiences of hospitalized patients and their surrogate decision-makers (SDMs) concerning dialysis initiation. The research sheds light on decisional satisfaction, the extent of shared decision-making, and the level of patient involvement in this critical treatment choice.
This article breaks down the key findings of this pilot study, revealing potential gaps in communication and informed consent. Learn about the challenges of making dialysis decisions during acute illness and the importance of revisiting treatment options for those who continue to need dialysis long-term.
The Reality of Dialysis Decisions in the Hospital
The study, conducted at a large academic center, involved patients who started dialysis for AKI during a specific period. Researchers assessed decisional satisfaction and shared decision-making using validated scales and structured interviews. Here's what they found:
- Continuous Dialysis is Common: Continuous renal replacement therapy (CRRT) was used in 67% of cases, reflecting the critical care setting.
- High Mortality: The in-hospital mortality rate was 33%, highlighting the serious nature of the underlying conditions.
- Choice Perception: Despite the difficult circumstances, 90% of participants felt they had a choice in making the dialysis decision.
- Limited Awareness of Alternatives: However, a concerning 81% were unable to name any alternatives to dialysis initiation.
Research on Dialysis Strategy and Recovery
A 2025 review describes current evidence on postdischarge management of acute kidney injury requiring dialysis, including care after leaving the hospital. A separate randomized trial included 221 hemodynamically stable, nonintubated patients with acute kidney injury who had started dialysis. Another randomized clinical trial, involving 220 adults, examined a conservative strategy in which dialysis was given for specific metabolic or clinical indications to assess whether it could improve kidney-function recovery. Prediction models have also been identified as potentially useful for shared decisions about continued dialysis, conservative kidney management or withdrawal, and referral for permanent dialysis access.
Long-Term Risks and Evidence Gaps
A community-based cohort study examined whether hospitalized patients who survived acute kidney injury requiring temporary dialysis had poorer long-term all-cause survival than patients without acute kidney injury, including patients with and without chronic kidney disease. The study notes that earlier reports had largely focused on people with normal or near-normal kidney function or on all patients with chronic kidney disease. A 2022 report describes dialysis-treated acute kidney injury as increasingly common in intensive care units and associated with poor outcomes. It also identifies a gap in research on how illness severity and indications at dialysis initiation have changed over time and how they relate to patient outcomes.
Empowering Patients and Families in Critical Care
This study underscores the need to enhance communication and shared decision-making for hospitalized patients facing dialysis initiation. When patients lack the capacity to participate, it becomes even more crucial for healthcare providers to engage SDMs in thorough discussions about treatment options, potential outcomes, and the patient's values and preferences.
Recovery, Modality, and Long-Term Planning
A March 2026 article reports that more than 20% of patients receiving dialysis at in-center hemodialysis facilities began dialysis for acute kidney injury requiring dialysis (AKI-D), rather than end-stage kidney disease (ESKD). It argues that recognizing a transition from AKI-D to ESKD matters because care must shift from short-term monitoring for recovery toward long-term goals, including permanent dialysis planning. A 2024 article describes AKI, acute kidney disease, and chronic kidney disease as distinct defined categories that can form a continuum, with an initial injury potentially progressing to persistent damage, fibrosis, chronic kidney disease, and ESKD. The comparative effectiveness of peritoneal and extracorporeal dialysis for AKI-D remains controversial, according to a 2026 systematic review.
AKI Beyond the Kidney
A 2026 article describes acute kidney injury as a systemic syndrome whose consequences extend beyond structural and functional changes in the kidney. It reports that AKI affects approximately 15% of hospitalized people and nearly half of those admitted to intensive care units. The article highlights experimental research pointing to inflammation and the accumulation of metabolites as pivotal factors in AKI’s effects on other organs.
Evidence from Everyday Clinical Practice
A 2022 prospective study set out to describe a large cohort of patients with dialysis-requiring acute kidney injury treated in ordinary clinical practice in a large metropolitan area of an emerging country. Its authors note that information about AKI epidemiology in developing nations has mainly come from isolated centers, with few high-quality multicenter epidemiological studies. The study aimed to assess the impact of dialysis-requiring AKI in that real-world cohort.
For those who survive critical illness and remain dialysis-dependent, revisiting the initial decision is essential. This allows patients to better understand the rationale for dialysis, weigh the risks and benefits, and align their treatment plan with their long-term goals. It may also be helpful to explore alternative modalities such as conservative care.
By prioritizing patient-centered communication and shared decision-making, we can empower individuals and families to make informed choices that reflect their values, even in the face of critical illness. This ultimately leads to better care and improved quality of life.