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

Authors

Abinet M. Aklilu, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.Follow
Steven Menez, Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
Megan L. Baker, Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
Dannielle Brown, Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland.
Katie K. Dircksen, Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland.
Kisha A. Dunkley, Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland.
Simon Correa Gaviria, Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
Salia Farrokh, Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland.
Sophia C. Faulkner, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.
Charles Jones, Department of Pharmacy, Yale New Haven Hospital, New Haven, Connecticut.
Bashar A. Kadhim, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.
Dustin Le, Division of Nephrology, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania.
Fan Li, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.
Amrita Makhijani, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.
Melissa Martin, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.
Dennis G. Moledina, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.
Claudia Coronel-Moreno, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.Follow
Kyle D. O'Connor, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.
Kyra Shelton, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.
Kristina Shvets, Department of Pharmacy, Yale New Haven Hospital, New Haven, Connecticut.
Nityasree Srialluri, Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
Jia Wei Tan, Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
Jeffrey M. Testani, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.
Celia P. Corona-Villalobos, Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.Follow
Yu Yamamoto, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.
Chirag R. Parikh, Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
F Perry Wilson, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut.

Document Type

Article

Publication Title

JAMA

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.

DOI

10.1001/jama.2024.22718

Publication Date

10-25-2024

Identifier

39454050 (pubmed); 10.1001/jama.2024.22718 (doi); 2825492 (pii)

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