AKI Intervention Falls Short of Improving Patient Outcomes

SAN DIEGO — A strategy to improve the management of hospitalized patients with acute kidney injury (AKI) through rapid personalized recommendations made by a dedicated kidney action team facilitates testing and other measures, but ultimately falls short in improving clinical outcomes, a randomized, multicenter study shows.

Although recommendations from a dedicated physician and pharmacist team improved the rate of a best-practice implementation within 24 hours, the intervention did not lead to improved patient outcomes, said lead author Abinet M. Aklilu, MD, MPH, of Yale University School of Medicine, New Haven, Connecticut.

The study was presented at Kidney Week 2024, organized by the American Society of Nephrology, and simultaneously published in the Journal of the American Medical Association.

While AKI affects as many as 20% of hospitalized patients, the condition often goes undiagnosed, potentially resulting in disease progression and mortality. 

Previous efforts to improve AKI outcomes with clinical decision support tools, including an intervention from the team at Yale using electronic alerts for AKI, have had mixed results, with various factors, including the issue of “alert fatigue,” speculated to have hindered the ultimate goal of improving in patient outcomes. 

“These studies were probably limited by unintended harm from alerts and limited experience and confidence in managing the diverse [nature] of AKI, where a one-size-fits-all approach will not work,” Aklilu explained.

To address some of those issues, a new intervention was developed to add real-time rapid recommendations from a dedicated kidney action team consisting of a physician and pharmacist directly to a patient’s electronic health record.

The intervention was evaluated in a randomized, investigator-blinded trial in the Yale and Johns Hopkins hospital systems between October 2021 and February 2024. 

Personalized Recommendations and Process Outcome

Upon receiving an alert of a patient having AKI, the physician and pharmacist kidney action team remotely reviewed the patient’s individual charts and provided personalized recommendations in the major categories of general diagnostics, volume, potassium, acidosis, and medications.

The patients were then randomized 1:1 to either have the kidney action team’s recommendations appear in their charts or not. The median time from the automated AKI diagnosis to randomization was 56 minutes.

Overall, 4003 patients were included, with 786 (20%) in the ICU. Patients with end-stage kidney disease or stage 5 chronic kidney disease (CKD), solid organ transplant, or meeting urgent renal consult criteria were excluded.

The patients had a median age of 72 years, 47% were female, 23% were Black, and 41% had CKD. 

The median number of recommendations made for patients was three, and most patients had at least one recommendation. The kidney action team made a total of 14,539 recommendations.

In terms of the study’s process outcome — defined as the proportion of recommendations completed within 24 hours of randomization — the proportion in the kidney action team intervention arm (n = 1,999) was significantly higher at 34% vs 24% in the usual care arm (n = 2004; P<.001 wp_automatic_readability="127.63696525644">

Specific guideline interventions that were more commonly completed within 24 hours in the kidney action team group included renal ultrasounds (P creatinine kinase (P = .002), bladder scan (P P

Other areas of diagnostic and therapeutic improvement included orthostatic vitals, obstruction evaluation, AKI documentation, and medication changes.

However, no differences were observed between those who did and did not receive the kidney action team notes in terms of the primary clinical outcome, a composite of AKI progression, dialysis, or mortality within 14 days (P = .28).

Likewise, no significant differences were observed in specific secondary outcomes, including AKI progression (13.5% with the intervention vs 13% usual care; P = .65), mortality, (9.6% vs 9.2%, respectively; P = .72); dialysis (1.6% vs 1.5%; P = .89) and nephrology consult (16.1% vs 14.2%; P = .09).

Key Hurdles: Differing Causes of AKI; Need for Better Treatments

With the lack of change in clinical outcomes, ” this study raises questions about whether early diagnostic testing using tests commonly available in the hospital can improve outcomes in hospitalized patients with AKI,” the authors write in the study.

Importantly, “although diagnostic recommendations (such as urine analysis) were implemented more frequently in the intervention group, testing alone cannot improve outcomes,” they added. 

“Follow-up, interpretation, and management must follow diagnostic testing. These activities were outside the scope of the KAT study.”

Senior author F. Perry Wilson, MD, also of Yale University School of Medicine, further speculated that key reasons could explain why clinical outcomes don’t appear to be changing despite “moving the needle on the process of detecting, diagnosing, and intervening on AKI.”

Among them is the “horse is out the barn” hypothesis: ” It may be that by the time AKI is detected (via creatinine increase), it is simply too late to do anything,” Wilson told Medscape Medical News.

“Another possibility is that we just don’t have good treatments yet,” Wilson added. “If we had a drug that worked, we could apply it, but we don’t have a [universal] drug for AKI.

“Lastly, and interestingly to me, we found that early on in AKI, it is still very hard to know why the patient developed AKI,” Wilson explained. “There are protean causes, and so without knowing the cause, it can be hard even for experts to start clinicians down the right treatment path.

“In the future, we are very interested in measuring biomarkers in real-time at the moment of AKI detection to aid with this issue,” he said.

The team also plans to “assess if recommendations targeting individuals at high risk for severe kidney injury and specific phenotypes of kidney injury lead to improved outcomes.” Aklilu noted in a press statement.

Of note, despite the mixed clinical outcomes, AKI alert systems have gained use around the world over the past decade, and are indeed required by the National Health Service in England, the authors wrote. 

Further commenting on the study, Emily Chang, MD, associate professor of medicine with the Division of Nephrology and Hypertension at the University of North Carolina, Chapel Hill, agreed that, despite the failure to meet the primary outcomes, the benefits that were observed are notable and potentially important.

“There are a lot of things nephrologists deal with, and if our time could be spared for things like the highly specialized tasks and some of these lower-level issues could be otherwise addressed, that would reduce the burden and burnout on us,” she told Medscape Medical News.

That being said, Chang added the caveat that the study excluded some patients with more severe illness. “I was a little surprised [by the lack of difference in the primary clinical outcomes], but I think [it’s important that] these were less severe, milder cases, while the more severe ones would be going to a nephrologist, and you probably need a large number to see more of an effect.”

Wilson reports receiving research funding from Amgen, AstraZeneca, Whoop, and Vifor Pharma, and consulting fees from Aura Care and Hekaheart LLC. He is a regular columnist for Medscape. Chang and Aklilu reported no relevant financial relationships.