The benefit of a specific intervention for hospitalised patients with AKI

Among patients with Acute Kidney Injury, recommendations did not significantly reduce the composite outcome of worsening AKI stage, dialysis or mortality.

Early, individualized recommendations for hospitalized patients with AKI

A randomized trial conducted by investigators from the Yale University School of Medicine found use of a tailored support tool was not associated with a difference in a composite outcome consisting of AKI progression to a higher stage of AKI, dialysis, or mortality during hospitalization.

Acute kidney injury (AKI) affects approximately 20% of hospitalized patients and is associated with increased morbidity, mortality, and progression to chronic kidney disease. The KAT-AKI clinical trial sought to determine whether early, individualized recommendations delivered via electronic health records (EHR) could improve AKI outcomes.

The study involved 4003 patients who met the KDIGO criteria for AKI. Patients were randomized to receive either usual care or structured recommendations from a kidney action team (KAT), consisting of a physician and a pharmacist, within one hour of AKI detection. The recommendations covered five major areas: diagnostic testing, fluid management, potassium balance, acid-base disturbances, and medication adjustments. Despite a significantly higher rate of recommendation implementation in the intervention group (33.8% vs. 24.3% in usual care), the study found no reduction in AKI progression, dialysis requirement, or mortality.

Impact on clinical practice

The primary outcome, defined as a composite of AKI progression, dialysis, or in-hospital mortality within 14 days, occurred in 19.8% of the intervention group compared to 18.4% in the usual care group (P = 0.28). Secondary outcomes also showed no significant differences in dialysis rates (1.6% vs. 1.5%), mortality (9.6% vs. 9.2%), or AKI progression (13.5% vs. 13.0%). While diagnostic and medication-related recommendations were more frequently implemented, therapeutic interventions such as fluid resuscitation or electrolyte management did not show substantial uptake. Notably, nephrology consultation rates within 14 days were similar between groups (16.1% vs. 14.2%).

One of the key insights from the trial is the discrepancy between adherence to recommendations and patient outcomes. This suggests that while compliance with evidence-based strategies is essential, it is not always sufficient to alter the trajectory of AKI. The variability in clinician adoption of recommendations, possibly due to competing clinical priorities or skepticism regarding guideline efficacy, remains a significant barrier to improving outcomes. Furthermore, the lack of significant differences in AKI progression rates indicates that other unmeasured factors, such as hemodynamic instability, ongoing nephrotoxic exposure, and underlying comorbidities, may play a larger role in determining patient prognosis than early recommendation implementation alone.

Key considerations for clinicians

  1. Early detection alone is insufficient - The use of EHR alerts has facilitated the rapid identification of AKI, but improved recognition has not translated into better patient outcomes. Future interventions should focus on integrating clinical decision support with direct clinical involvement.
  2. Adherence to best practices remains a challenge - While general diagnostic and medication-related recommendations were well received, actionable therapeutic changes were less frequently implemented, suggesting the need for better integration into routine workflows.
  3. Personalized interventions may be more effective - The results suggest that a one-size-fits-all approach to AKI management may not be optimal. Future studies should explore targeted strategies based on patient-specific risk factors and AKI phenotypes.
  4. Nephrology consultation timing matters - Given the lack of impact on AKI progression, early involvement of nephrologists in high-risk cases may be beneficial.
  5. Limitations of current decision support tools - Although digital alerts increased compliance with best practices, the lack of impact on clinical outcomes highlights the necessity for enhanced decision support tools that integrate real-time patient physiology, trends in laboratory data, and individual risk stratification models.
  6. Role of fluid management in AKI - The study results suggest that the role of fluid resuscitation remains controversial. While some patients may benefit from aggressive volume expansion, others with underlying cardiac or hepatic dysfunction may be at higher risk of volume overload, leading to adverse effects. Future research should aim to refine fluid administration strategies tailored to individual hemodynamic profiles.

Improved clinical compliance but no outcome benefit

Physicians who participated in the study changed their behaviour in response to the personalised recommendations, particularly with regard to diagnostic and therapeutic orders. The recommendations increased the analysis of electrolytes in urine and the appropriate dosage of medication. Furthermore, the clinical experts complied with the diagnostic recommendations and documented the information on AKI better than in previous studies. Despite these positive results, the personalized recommendations did not have a significant impact on patients' clinical outcomes.

In conclusion, this study raises doubts as to whether early diagnostic testing can improve the outcomes of patients with AKI. Although personalized recommendations had an impact on clinical practice, they had no significant effect on patient outcomes. Further research is needed to better understand how to improve the management and outcomes of AKI in hospitalised patients.

Source:
  1. Aklilu AM, Menez S, Baker ML, Brown D, Dircksen KK, Dunkley KA, Gaviria SC, Farrokh S, Faulkner SC, Jones C, Kadhim BA, Le D, Li F, Makhijani A, Martin M, Moledina DG, Coronel-Moreno C, O'Connor KD, Shelton K, Shvets K, Srialluri N, Tan JW, Testani JM, Corona-Villalobos CP, Yamamoto Y, Parikh CR, Wilson FP; KAT-AKI Team. Early, Individualized Recommendations for Hospitalized Patients With Acute Kidney Injury: A Randomized Clinical Trial. JAMA. 2024 Dec 24;332(24):2081-2090. doi: 10.1001/jama.2024.22718. PMID: 39454050; PMCID: PMC11669049.