Early, Individualized Recommendations for Hospitalized Patients With Acute Kidney Injury: A Randomized Clinical Trial

Abstract

Importance: Acute kidney injury (AKI) is a common complication during hospitalization and is associated with adverse outcomes.

Objective: To evaluate whether diagnostic and therapeutic recommendations sent by a kidney action team through the electronic health record improve outcomes among patients hospitalized with AKI compared with usual care.

Design, setting, and participants: Randomized clinical trial conducted at 7 hospitals in 2 health systems: in New Haven, Bridgeport, New London, and Waterbury, Connecticut, and Westerly, Rhode Island; and in Baltimore, Maryland. Hospitalized patients with AKI were randomized between October 29, 2021, and February 8, 2024. Final follow-up occurred February 22, 2024.

Intervention: An alert about AKI was sent to the kidney action team, consisting of a study physician and study pharmacist, which sent personalized recommendations through the electronic health record in 5 major categories (diagnostic testing, volume, potassium, acid base, and medications) within 1 hour of AKI detection. The note was immediately visible to anyone with access to the electronic health record. Randomization to the intervention or usual care occurred after the recommendations were generated, but the note was only delivered to clinicians of patients randomized to the intervention group.

Main outcomes and measures: The primary outcome was a composite outcome consisting of AKI progression to a higher stage of AKI, dialysis, or mortality occurring while the patient remained hospitalized and within 14 days from randomization.

Results: Of the 4003 patients randomized (median age, 72 years [IQR, 61-81 years), 1874 (47%) were female and 931 (23%) were Black patients. The kidney action team made 14 539 recommendations, with a median of 3 (IQR, 2-5) per patient. The primary outcome occurred in 19.8% of the intervention group and in 18.4% in the usual care group (difference, 1.4%, 95% CI, -1.1% to 3.8,% P = .28). Of 6 secondary outcomes, only 1 secondary outcome, rates of recommendation implementation, significantly differed between the 2 groups: 2459 of 7270 recommendations (33.8%) were implemented in the intervention group and 1766 of 7269 undelivered recommendations (24.3%) were implemented in the usual care group within 24 hours (difference, 9.5%; 95% CI, 8.1% to 11.0%).

Conclusions and relevance: Among patients hospitalized with AKI, recommendations from a kidney action team did not significantly reduce the composite outcome of worsening AKI stage, dialysis, or mortality, despite a higher rate of recommendation implementation in the intervention group than in the usual care group.

Trial registration: ClinicalTrials.gov Identifier: NCT04040296.

Figure.. Study Flow of Patients in the KAT-AKI Study

^aEligibility was based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria, age older than 18 years, no known end-stage kidney disease, and no hospice flag. A physician and a pharmacist, members of the kidney action team (KAT), received an electronic acute kidney injury (AKI) alert as soon as a patient met KDIGO-creatinine AKI criteria. The KAT members screened the patient’s chart further for eligibility criteria, provided recommendations in 5 major areas of evaluation and management, and the KAT randomized the patients to either the intervention group or the usual care group. Recommendations were only entered into the electronic health record of patients randomized to the intervention group. ^bA patient could meet multiple exclusion criteria.