Personalized Recommendations for Acute Kidney Injury (AKI) Care

Study Results

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Basic Information

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Recruitment Status

COMPLETED

Clinical Phase

NA

Total Enrollment

4003 participants

Study Classification

INTERVENTIONAL

Study Start Date

2021-10-29

Study Completion Date

2024-02-22

Brief Summary

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This is a randomized clinical trial of a "Kidney Action Team", which will provide timely, personalized recommendations for the diagnosis and initial treatment of hospitalized patients with Acute Kidney Injury (AKI).

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Detailed Description

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Acute Kidney Injury (AKI), defined as an abrupt loss in kidney function, is common, occurring in 5-20% of hospitalized patients, and carries a significant and independent risk of inpatient mortality. International guidelines for the treatment of AKI focus on "best practices" that include appropriate management of drug dosing, the avoidance of kidney-toxic exposures, and careful assessment of fluid and electrolyte balance. Early nephrologist involvement may also improve outcomes in AKI. However, AKI, which is often asymptomatic, is frequently overlooked in a variety of hospital settings and many "best practices" occur infrequently and inconsistently.

The investigators previously conducted a randomized clinical trial testing the efficacy of electronic alerts for AKI, randomizing patients with AKI to usual care, or to an alert group in which a single alert was sent to the patient's primary provider. The study demonstrated clinical equipoise regarding the effectiveness of such alerting, as there was no improvement in the rates of AKI progression, dialysis or mortality among those in the alert group.

Rather than simply making providers aware of AKI, it may be beneficial to provide them with actionable items to increase recognition and rate of best practices. Further, because of the heterogeneous nature of AKI, personalized recommendations tailored to individual patients that are delivered directly to the patient care team may improve AKI outcomes. The aim of this study is to determine, through a single-blind, parallel group, randomized controlled multicenter clinical trial, if personalized recommendations, as delivered by a Kidney Action Team, for the work-up and treatment of AKI will improve patient outcomes. The Kidney Action team will serve as a centralized, remote monitoring service and will consist of a group of highly trained individuals, including an advanced practitioner, a pharmacist and a board-certified nephrologist, dedicated to reviewing enrolled patient's charts and providing recommendations for patient diagnosis and initial work up and care within 60 minutes of AKI onset. Recommendations will span five domains of care, including diagnostic workup, acid/base management, electrolyte management, hemodynamic management, and medication management.

Using the Kidney Disease: Improve Global Outcomes creatinine criteria, inpatients in sites of the Yale New Haven Health System and of the John Hopkins University Health System who develop AKI during the course of their hospitalization will be randomized to either receive usual care, or to an active intervention group in which the recommendations of the Kidney Action Team are delivered to the patient's primary care team in the form of a structured note in the electronic health record to be cosigned by the attending of record. The primary clinical outcome will be a composite of AKI progression, dialysis and death at 14 days post-randomization. The primary process outcome will be the percent of recommendations made that are enacted within 24 hours after randomization.

Conditions

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Acute Kidney Injury

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

Primary Study Purpose

HEALTH_SERVICES_RESEARCH

Blinding Strategy

TRIPLE

Participants Investigators Outcome Assessors

Study Groups

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Usual Care

Kidney Action Team Recommendations will not be delivered to the primary care teams of randomized patients.

Group Type NO_INTERVENTION

No interventions assigned to this group

Kidney Action Team Recommendations

Recommendations made by the Kidney Action Team will be delivered to the patient's primary care team within 2 hours of AKI detection.

Group Type EXPERIMENTAL

Kidney Action Team Recommendations

Intervention Type OTHER

Upon review of the patient's medical information, the Kidney Action Team will create personalized recommendations that will be delivered to the patient's primary care team via a specialized note in the electronic medical record system within 2 hours of AKI detection. The attending of record will be identified as a cosigner to ensure that a member of the care team is made aware of the note's presence.

Interventions

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Kidney Action Team Recommendations

Upon review of the patient's medical information, the Kidney Action Team will create personalized recommendations that will be delivered to the patient's primary care team via a specialized note in the electronic medical record system within 2 hours of AKI detection. The attending of record will be identified as a cosigner to ensure that a member of the care team is made aware of the note's presence.

Intervention Type OTHER

Eligibility Criteria

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Inclusion Criteria

1. Adults ≥ 18 years admitted to a participating hospital (six hospitals in the Yale New Haven Health system and two hospitals of the John Hopkins University Health system)
2. Stage 1 Acute Kidney Injury as defined by KDIGO creatinine criteria:

* 0.3 mg/dl increase in inpatient serum creatine over 48 hours OR
* 50% relative increase in inpatient serum creatinine over 168 hours

Exclusion Criteria

1. Admission to hospice service or comfort measures only order
2. Recipient of a solid organ transplant
3. Immediate dialytic indication determined by the following:

* serum K \>/= 7
* arterial pH \< 7.15
* BUN \> 150 mg/dL
* acute ingestion of dialyzable toxins
* refractory volume overload

Patients who meet any of these critical values will not be enrolled in the trial and the Kidney Action Team will directly notify the treating team.
4. Pre-existing CKD stage V or End Stage Kidney Disease
5. Initial hospital creatinine \> 4.0 mg/dl
6. Patients who have been seen by nephrology or already have a nephrology consult
7. Status post-nephrectomy (partial or radical) during index admission

Minimum Eligible Age

18 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No