Acute Kidney Injury (AKI), defined as an abrupt loss in kidney function, is common,
occurring in 5-20% of hospitalized patients, and carries a significant and independent
risk of inpatient mortality. International guidelines for the treatment of AKI focus on
"best practices" that include appropriate management of drug dosing, the avoidance of
kidney-toxic exposures, and careful assessment of fluid and electrolyte balance. Early
nephrologist involvement may also improve outcomes in AKI. However, AKI, which is often
asymptomatic, is frequently overlooked in a variety of hospital settings and many "best
practices" occur infrequently and inconsistently.
The investigators previously conducted a randomized clinical trial testing the efficacy
of electronic alerts for AKI, randomizing patients with AKI to usual care, or to an alert
group in which a single alert was sent to the patient's primary provider. The study
demonstrated clinical equipoise regarding the effectiveness of such alerting, as there
was no improvement in the rates of AKI progression, dialysis or mortality among those in
the alert group.
Rather than simply making providers aware of AKI, it may be beneficial to provide them
with actionable items to increase recognition and rate of best practices. Further,
because of the heterogeneous nature of AKI, personalized recommendations tailored to
individual patients that are delivered directly to the patient care team may improve AKI
outcomes. The aim of this study is to determine, through a single-blind, parallel group,
randomized controlled multicenter clinical trial, if personalized recommendations, as
delivered by a Kidney Action Team, for the work-up and treatment of AKI will improve
patient outcomes. The Kidney Action team will serve as a centralized, remote monitoring
service and will consist of a group of highly trained individuals, including an advanced
practitioner, a pharmacist and a board-certified nephrologist, dedicated to reviewing
enrolled patient's charts and providing recommendations for patient diagnosis and initial
work up and care within 30 minutes of AKI onset. Recommendations will span five domains
of care, including diagnostic workup, acid/base management, electrolyte management,
hemodynamic management, and medication management.
Using the Kidney Disease: Improve Global Outcomes creatinine criteria, inpatients in
sites of the Yale New Haven Health System and of the John Hopkins University Health
System who develop AKI during the course of their hospitalization will be randomized to
either receive usual care, or to an active intervention group in which the
recommendations of the Kidney Action Team are delivered to the patient's primary care
team in the form of a structured note in the electronic health record to be cosigned by
the attending of record. The primary clinical outcome will be a composite of AKI
progression, dialysis and death at 14 days post-randomization. The primary process
outcome will be the percent of recommendations made that are enacted within 24 hours
after randomization.