---
title: "When to stop KRT in critically ill children: evidence and practical pediatric nephrology guidance"
id: "pubmed-42909501"
canonical_url: "https://medichelpline.com/clinical-feed/pubmed-42909501"
content_type: "clinical_feed_article"
specialty: "Nephrology"
source_name: "PubMed / NCBI"
source_url: "https://pubmed.ncbi.nlm.nih.gov/42909501/"
doi: "10.1007/s00467-026-07588-w"
published_at: "2026-10-23T00:00:00.000Z"
evidence_level: "Journal Article"
license: "CC-BY-NC-4.0 / Informational Use"
---
# When to stop KRT in critically ill children: evidence and practical pediatric nephrology guidance
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/pubmed-42909501
- **Specialty:** [Nephrology](https://medichelpline.com/clinical-feed/nephrology.md)
- **Primary Source:** PubMed / NCBI
- **Source URL:** [Original Journal Publication](https://pubmed.ncbi.nlm.nih.gov/42909501/)
- **DOI:** [10.1007/s00467-026-07588-w](https://doi.org/10.1007%2Fs00467-026-07588-w)
- **Published At:** 2026-10-23T00:00:00.000Z
- **Evidence Rating:** Journal Article
## Executive GIST (TL;DR)
- Kidney replacement therapy (**KRT**) saves lives in children with severe **acute kidney injury (AKI)** but the optimal timing for stopping extracorporeal support remains unclear and poorly standardized. - The literature emphasizes a trade-off: stopping too early risks recurrent or worsening kidney injury, while prolonged **KRT** exposes children to unnecessary extracorporeal support and associated burdens. - Investigators reported that successful liberation from **KRT** requires both clinical readiness and measurable renal recovery; the process should be staged rather than binary. - Data indicate that **urine output** is the clinical variable most consistently associated with successful discontinuation across pediatric studies; this signal outperforms many other routinely measured parameters. - Study authors noted that structural kidney biomarkers show promise for predicting recovery, but pediatric validation is still lacking and the source did not report validated pediatric biomarker thresholds for liberation decisions. - Adult trial results inform physiological and conceptual frameworks, yet adult data cannot be directly applied to children because of developmental and disease-specific differences; the source explicitly states extrapolation is limited. - The review team advocated a structured approach using predefined renal recovery criteria interpreted within each patient's clinical context to improve consistency in liberation decisions while awaiting prospective pediatric trials. - The abstract did not report specific numeric thresholds, protocolized stopping rules, dosing details, or prospective pediatric trial results defining evidence-based liberation strategies; these remain gaps for future research.
## Clinical Analysis & Structured Key Points
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Online ahead of print. # When to stop kidney replacement therapy in critically ill children: current evidence and practical considerations from a pediatric critical care nephrology perspective [Giovanni Ceschia](https://pubmed.ncbi.nlm.nih.gov/?term=Ceschia+G&cauthor_id=42909501)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42909501/#full-view-affiliation-1 "University of Padova, Padova, Italy. gio.ceschia@gmail.com.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42909501/#full-view-affiliation-2 "Pediatric Nephrology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy. gio.ceschia@gmail.com.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42909501/#full-view-affiliation-3 "Institute of Pediatric Research "Città della Speranza", Padova, Italy. gio.ceschia@gmail.com."), [Enrico Vidal](https://pubmed.ncbi.nlm.nih.gov/?term=Vidal+E&cauthor_id=42909501)[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42909501/#full-view-affiliation-4 "Pediatric Nephrology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy.")[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42909501/#full-view-affiliation-5 "Institute of Pediatric Research "Città della Speranza", Padova, Italy.")[ 6 ](https://pubmed.ncbi.nlm.nih.gov/42909501/#full-view-affiliation-6 "Department of Medicine \(DMED\), University of Udine, Udine, Italy.") Affiliations Expand ### Affiliations * 1 University of Padova, Padova, Italy. gio.ceschia@gmail.com. * 2 Pediatric Nephrology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy. gio.ceschia@gmail.com. * 3 Institute of Pediatric Research "Città della Speranza", Padova, Italy. gio.ceschia@gmail.com. * 4 Pediatric Nephrology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy. * 5 Institute of Pediatric Research "Città della Speranza", Padova, Italy. * 6 Department of Medicine (DMED), University of Udine, Udine, Italy. * PMID: **42909501** * DOI: [ 10.1007/s00467-026-07588-w ](https://doi.org/10.1007/s00467-026-07588-w) Item in Clipboard # When to stop kidney replacement therapy in critically ill children: current evidence and practical considerations from a pediatric critical care nephrology perspective Giovanni Ceschia et al. Pediatr Nephrol. 2026. Show details Display options Display options Format Abstract PubMed PMID Pediatr Nephrol Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Pediatr+Nephrol%22%5Bjour%5D&sort=date&sort_order=desc) * [ Search in NLM Catalog ](https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Pediatr+Nephrol%22%5BTitle+Abbreviation%5D) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42909501/) . 2026 Oct 23. doi: 10.1007/s00467-026-07588-w. Online ahead of print. ### Authors [Giovanni Ceschia](https://pubmed.ncbi.nlm.nih.gov/?term=Ceschia+G&cauthor_id=42909501)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42909501/#short-view-affiliation-1 "University of Padova, Padova, Italy. gio.ceschia@gmail.com.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42909501/#short-view-affiliation-2 "Pediatric Nephrology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy. gio.ceschia@gmail.com.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42909501/#short-view-affiliation-3 "Institute of Pediatric Research "Città della Speranza", Padova, Italy. gio.ceschia@gmail.com."), [Enrico Vidal](https://pubmed.ncbi.nlm.nih.gov/?term=Vidal+E&cauthor_id=42909501)[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42909501/#short-view-affiliation-4 "Pediatric Nephrology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy.")[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42909501/#short-view-affiliation-5 "Institute of Pediatric Research "Città della Speranza", Padova, Italy.")[ 6 ](https://pubmed.ncbi.nlm.nih.gov/42909501/#short-view-affiliation-6 "Department of Medicine \(DMED\), University of Udine, Udine, Italy.") ### Affiliations * 1 University of Padova, Padova, Italy. gio.ceschia@gmail.com. * 2 Pediatric Nephrology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy. gio.ceschia@gmail.com. * 3 Institute of Pediatric Research "Città della Speranza", Padova, Italy. gio.ceschia@gmail.com. * 4 Pediatric Nephrology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy. * 5 Institute of Pediatric Research "Città della Speranza", Padova, Italy. * 6 Department of Medicine (DMED), University of Udine, Udine, Italy. * PMID: **42909501** * DOI: [ 10.1007/s00467-026-07588-w ](https://doi.org/10.1007/s00467-026-07588-w) Item in Clipboard Cite Display options Display options Format Abstract PubMed PMID Linked Discoveries ## Abstract Kidney replacement therapy (KRT) is a life-saving intervention for critically ill children with severe acute kidney injury (AKI). However, the optimal timing of KRT liberation remains uncertain, and decisions regarding treatment discontinuation are among the least standardized aspects of AKI management. Whereas the timing of KRT initiation has been extensively investigated, evidence guiding KRT liberation in children remains scarce. Successful liberation requires balancing the risks of premature discontinuation against those of unnecessarily prolonged extracorporeal support. KRT liberation is best conceptualized as a process requiring both clinical readiness and sufficient renal recovery. Current pediatric evidence indicates that urine output is the clinical variable most consistently associated with successful liberation, whereas other factors, such as structural kidney biomarkers, are promising but have yet to be validated. Adult studies provide valuable physiological and conceptual insights but cannot be directly extrapolated to children because of important developmental and disease-specific differences. A structured approach based on predefined renal recovery criteria, interpreted within the individual patient's clinical context, may improve the consistency of liberation decisions while awaiting prospective pediatric studies capable of defining evidence-based liberation strategies. **Keywords:** AKI; CKRT; Children; KRT Liberation; Renal replacement therapy. © 2026. The Author(s). [PubMed Disclaimer](https://pubmed.ncbi.nlm.nih.gov/disclaimer/) ## Conflict of interest statement Declarations. Conflict of interest: The authors declare no competing interests. ## References 1. 1. Gist KM, Menon S, Anton-Martin P, Bigelow AM, Cortina G, Deep A, De la Mata-Navazo S, Gelbart B, Gorga S, Guzzo I, Mah KE, Ollberding NJ, Shin HS, Thadani S, Uber A, Zang H, Zappitelli M, Selewski DT, WE-ROCK Investigators (2024) Time to continuous renal replacement therapy initiation and 90-day major adverse kidney events in children and young adults. JAMA Netw Open 7:e2349871 2. 1. Goldstein SL, Krallman KA, Roy JP, Collins M, Chima RS, Basu RK, Chawla L, Fei L (2023) Real-time acute kidney injury risk stratification-biomarker directed fluid management improves outcomes in critically Ill children and young adults. Kidney Int Rep 8:2690–2700 - [DOI](https://doi.org/10.1016/j.ekir.2023.09.019) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/38106571/) - [PMC](https://pmc.ncbi.nlm.nih.gov/articles/10719644/) 3. 1. Clover-Brown I, Ceschia G, Gist KM, Hasson DC, Krallman KA, Standage SW, Goldstein SL, Stanski NL (2025) Furosemide stress test use in children at risk for acute kidney injury. Kidney Int Rep 10:4241–4251 - [DOI](https://doi.org/10.1016/j.ekir.2025.09.029) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/41426025/) - [PMC](https://pmc.ncbi.nlm.nih.gov/articles/12712464/) 4. 1. Goldstein SL, Akcan-Arikan A, Alobaidi R, Askenazi DJ, Bagshaw SM, Barhight M, Barreto E, Bayrakci B, Bignall ONR, Bjornstad E, Brophy PD, Chanchlani R, Charlton JR, Conroy AL, Deep A, Devarajan P, Dolan K, Fuhrman DY, Gist KM, Gorga SM, Pediatric ADQI Collaborative (2022) Consensus-based recommendations on priority activities to address acute kidney injury in children: A modified delphi consensus statement. JAMA Netw Open 5:e2229442 5. 1. Fuhrman DY, Gist KM, Arikan AA, Bagshaw SM, Shaw AD, Legrand M, Duquette D, Menon S, Ollberding NJ, Sarkar I, Ricci Z, Alobaidi R, See E, Soranno DE, Selewski DT, Kakajiwala A, Goldstein SL, WE-ROCK Investigators (2026) A Hierarchical Endpoint Analysis of the Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) Cohort. Clin J Am Soc Nephrol. 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