When to stop kidney replacement therapy in critically ill children: current evidence and practical considerations from a pediatric critical care nephrology perspective

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.