A large randomized clinical trial found that personalized recommendations from a kidney action team, triggered by real-time acute kidney injury alerts through the electronic health record, did not significantly reduce the composite outcome of worsening kidney injury, dialysis, or mortality—despite achieving higher rates of recommendation implementation compared with usual care.
In the study, published in JAMA, researchers recruited 4,003 patients across seven hospitals in Connecticut, Rhode Island, and Maryland between October 2021 and February 2024.
The patients were hospitalized with acute kidney injury (AKI) based on KDIGO criteria. The study population had a median age of 72 years (interquartile range [IQR] = 61–81), with 47% female and 23% Black participants. Comorbidities included hypertension (81.1%), diabetes (47.1%), heart failure (44.6%), chronic kidney disease (41.6%), atrial fibrillation (31.7%), chronic obstructive pulmonary disease (30.2%), cirrhosis (6.7%), and malignancy (5.8%).
At enrollment, the patients had a median baseline creatinine level of 1.18 mg/dL (IQR = 0.90–1.57) and a median baseline estimated glomerular filtration rate (eGFR) of 57.9 mL/min (IQR = 40.3–83.8). The modified SOFA score median was 2.0 (IQR = 1.0–3.0).
Initial AKI staging showed:
- Stage I: 91.2% of patients
- Stage II: 6.8% of patients
- Stage III: 1.1% of patients
- Normal: 1.0% of patients.
Patients were distributed across hospital services:
- General medical floor: 50%
- Hospitalist service: 36%
- Teaching medicine team: 14%
- ICU/SDU: 20%
- Surgical floor: 17%
- Specialist medical floor: 14%.
Among the patients in the intervention group, 19.8% experienced the primary composite outcome compared with 18.4% of those in the usual care group (difference = 1.4%, 95% confidence interval [CI] = –1.1% to 3.8%, P = .28).
The kidney action team (KAT), consisting of 20 physicians and 12 pharmacists, made 14,539 recommendations across five major categories: diagnostic testing, volume management, potassium management, acid-base management, and medications. The median was three recommendations per patient (IQR = 2–5). The recommendations were implemented at significantly higher rates within 24 hours in the intervention group (33.8%) compared with the usual care group (24.3%; difference = 9.5%, 95% CI = 8.1%–11.0%).
The median time from AKI detection to randomization was 56.3 minutes (IQR = 33.5–83.2). Among the KAT notes requiring cosignature, 75% of them (n = 382/509) were cosigned within 24 hours. At the time of AKI detection, 27.2% of the patients were receiving antibiotics, 21.2% had contrast exposure, 9.3% were receiving non-steroidal anti-inflammatory drugs (NSAIDs), 9.3% had sustained hypotension, and 0.7% were receiving vasopressors.
No statistically significant differences were found between the intervention and usual care groups for:
- AKI progression (13.5% vs 13.0%, difference = 0.5%, 95% CI = –1.6% to 2.6%)
- Mortality (9.6% vs 9.2%, difference = 0.4%, 95% CI = –1.5% to 2.1%)
- Dialysis initiation (1.6% vs 1.5%, difference = 0.1%, 95% CI = –0.7% to 0.8%)
- Discharge to hospice (4.4% vs 5.3%, difference = –0.9%, 95% CI = –2.3% to 0.4%)
- Nephrology consultations (16.1% vs 14.2%, difference = 1.9%, 95% CI = –0.3% to 4.1%).
The researchers found that 16.1% of the patients received recommendations for medication discontinuation or substitution, 26.5% received dose adjustment or monitoring recommendations, and 12.0% received both types of recommendations.
The length of stay showed no statistically significant difference between the groups (intervention: median = 5.1 days, IQR = 2.1–10.0 vs control: median = 5.2 days, IQR = 2.2–9.5, P = .78).
Peak AKI stage distribution during the study showed that 73% of the patients reached stage I, 11.8% reached stage II, and 5.1% reached stage III, with no statistically significant differences between the groups.
Conflict of interest disclosures can be found in the study.
