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Randomized Controlled Trial
. 2025 May 20;14(10):e038920.
doi: 10.1161/JAHA.124.038920. Epub 2025 May 15.

Sustained Improvements After Intervention to Prevent Contrast-Associated Acute Kidney Injury: A Randomized Controlled Trial

Michael E Matheny  1   2 , Elizabeth Carpenter-Song  3 , Iben M Ricket  4   5 , Richard J Solomon  6 , Meagan E Stabler  7 , Sharon E Davis  1 , Lisa Zubkoff  8 , Dax M Westerman  1 , Chad Dorn  1 , Kevin C Cox  3 , Freneka F Minter  1 , Hani Jneid  9 , Jesse W Currier  10   11 , S Ahmed Athar  12   13 , Saket Girotra  14 , Calvin Leung  15 , Thomas J Helton  16 , Ajay Agarwal  17 , Mladen I Vidovich  18 , Mary E Plomondon  19 , Stephen W Waldo  19   20   21 , Kelly A Aschbrenner  3 , Virginia McKay  22 , A James O'Malley  5 , Jeremiah R Brown  4   5   23
Affiliations
Randomized Controlled Trial

Sustained Improvements After Intervention to Prevent Contrast-Associated Acute Kidney Injury: A Randomized Controlled Trial

Michael E Matheny et al. J Am Heart Assoc. .

Abstract

Background: In the IMPROVE AKI (A Cluster-Randomized Trial of Team-Based Coaching Interventions to Improve Acute Kidney Injury) trial, a combination of team-based coaching and data-driven surveillance dashboards reduced the odds of AKI following cardiac catheterization by 46%. The objective of this study was to determine if improvements in AKI outcomes would be sustained after completion of the active intervention.

Methods and results: A 2×2 factorial cluster-randomized trial with an 18-month active intervention phase (October 2019-March 2021) and an 18-month sustainability phase (April 2021-September 2022) conducted among cardiac catheterization laboratories in 20 Veterans Affairs sites. Interventions included team-based coaching in a virtual learning collaborative or technical assistance, with and without access to an automated surveillance reporting dashboard. Data were collected on procedures involving adult patients undergoing diagnostic coronary angiography or percutaneous coronary interventions and not receiving chronic dialysis. The main outcome was AKI within 7 days of cardiac catheterization among all participants and those with preexisting chronic kidney disease. In addition, survey and focused interview data were collected to understand barriers and facilitators to sustaining AKI improvements. In this phase, 440 of 4160 patients experienced AKI, including 216 of 1260 patients with chronic kidney disease. Compared with technical assistance alone, we observed a reduction in AKI among virtual learning collaborative + automated surveillance reporting sites (adjusted odds ratio, 0.60 [95% CI, 0.42-0.86]). Sites had implemented standardized orders (11), oral and intravenous hydration standing orders (13), and contrast limiting protocols (10).

Conclusions: Team-based coaching coupled with data-driven surveillance dashboards reduced AKI by 40% during the 18 months after active participation in the trial. Process improvement education, care process standardization, and automated outcome feedback may be effective and durable methods for reducing AKI.

Registration: URL: https://clinicaltrials.gov/; Unique Identifier: NCT03556293.

Keywords: acute kidney injury; chronic kidney disease; contrast nephropathy; prevention.

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Conflict of interest statement

Agarwal reports employment with VA Medical Center, Wright State University, and an advisory or leadership role for the American College of Cardiology Board of Trustees—Ohio Chapter (an unpaid position). S.A. Athar reports employment with Loma Linda VA Medical Center. E. Carpenter‐Song served as a consultant for Westat during 2022 to support the use of qualitative methods in 2 studies: (1) a study examining an employment program for veterans transitioning to civilian life and (2) a study examining evidence‐based supported employment for young adults with serious mental illnesses. E. Carpenter‐Song was part of a research team that received funding in 2020 from the Bristol Meyers Squibb Foundation to conduct research examining the impact of COVID‐19 on rural health systems and communities. S. Girotra reports research funding from National Heart, Lung, and Blood Institute (R01HL160734, R56HL158803, and R01HL166305). T.J. Helton reports employment with James H. Quillen VA Medical Center and ownership interest in Apple, AirBNB, ASML holding, Confluent, Crowdstrike, Microsoft, Shopify, and Upstart. C. Leung reports employment with Orlando Veterans Affairs Medical Center. M.E. Matheny reports employment with Department of Veterans Affairs and consultancy agreements with NIH‐VA‐DoD Pain Management Grant Consortium (PMC3), and membership in Informatics & Methods Section, SMRB Study Section, VA HSR&D; Steering Committee—Indianapolis VA HSR&D COIN Center; and Steering Committee—VA HSR&D VIREC. A.J. O'Malley reports consultancy agreements with JB Associates and an advisory or leadership role for Statistics in Medicine and Observational Studies. M.E. Plomondon reports employment with Veterans Health Administration, Washington, DC. R. Solomon reports consultancy agreements with MediBeacon, Inc., PLC Inc., and Sonogenix, Inc.; research funding from REATA and Vera Pharmaceuticals; and advisory or leadership roles for MediBeacon, PLC Med, Inc., and Sonogenix. M.I. Vidovich reports consultancy agreements with Boston Scientific, research funding from Boston Scientific, patents or royalties from Merit Medical, and an advisory or leadership role for Intersocietal Accreditation Commission. S.W. Waldo reports employment with Rocky Mountain Regional VA Medical Center and research funding from Cardiovascular Systems Incorporated and Janssen Pharmaceuticals. L. Zubkoff reports employment with Birmingham VA Healthcare System. All remaining authors have nothing to disclose.

Figures

Figure 1
Figure 1. Hierarchically risk‐adjusted odds ratios for 7‐day AKI comparing interventions to technical assistance in active intervention phase, sustainability phase, and both phases combined for all patients (A) and only among patients with CKD (B).
Patient characteristics were included in adjustment, such as age, race, tobacco use, anemia, heart failure, CKD, diabetes, hypertension, prior percutaneous coronary intervention, prior coronary artery bypass surgery, prior myocardial infarction, peripheral vascular disease, left ventricle ejection fraction, shock status, laboratory‐based creatinine assessment, procedural urgency, and site baseline‐level performance. AKI indicates acute kidney injury; and CKD, chronic kidney disease.
See this image and copyright information in PMC

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