In a new study, Yale School of Medicine researchers set out to discover if personalized recommendations given by a kidney action team could improve the outcomes of hospitalized patients with acute kidney injury. Their findings could have significant implications for patient care, the researchers said.
The study was published in JAMA and selected by the American Society of Nephrology as a “high-impact clinical trial” at Kidney Week 2024.
Acute kidney injury is a common complication among hospitalized patients. “We see up to 20% of hospitalized patients develop acute kidney injury, and the number is even higher for patients who require intensive care,” said Abinet Aklilu, MD, MPH, instructor of medicine (nephrology) and first author of the study.
Acute kidney injury is associated with high mortality, prolonged hospitalization, and high care costs, Aklilu added. The condition can be caused by drug toxicity, obstruction to the flow of urine, prolonged dehydration, low blood pressure, or infection, among other factors, she said.
One goal of the study, a randomized clinical trial conducted at Yale New Haven Health System and the Johns Hopkins Health System, was to have personalized advice the moment a hospitalized patient develops acute kidney injury, said F. Perry Wilson, MD, MSCE, associate professor of medicine (nephrology) and public health (chronic disease epidemiology) and corresponding author of the study.
“Because acute kidney injury during hospitalization has many causes, and diagnosis is difficult, we hypothesized that part of the reason it is associated with poor outcomes is that providers don’t understand how to go about the diagnostic testing when it first starts, and potentially what treatment recommendations could be implemented early,” he said.
In the study, researchers created a kidney action team comprised of a clinician and pharmacist trained in acute kidney injury management. Of the 4,003 hospital patients enrolled in the clinical trial, those randomized to the intervention group received a note with personalized diagnostic and therapeutic recommendations from the team in their electronic health record. Patients randomized to the usual care group did not receive the team’s recommendations in their chart. The kidney action team did not know whether their recommendations would be delivered when they made them.
It’s time to take these clinical decision support interventions to the next level and prove that they actually improve patient outcomes, which has been hard to show.
F. Perry Wilson, MD, MSCE
Within 24 hours of randomization, the researchers checked to see if the recommendations were implemented by the primary care provider. After 14 days, they analyzed patients’ medical records for acute kidney injury worsening, dialysis occurrence, and mortality outcomes.
The researchers found that in the intervention group, approximately 34% of the recommendations given were followed by clinicians, compared to 24% in the usual care group. However, there was no difference in clinical patient outcomes between the two groups.
Despite improving provider adherence to these recommendations, the intervention did not improve patient outcomes, Aklilu said. “This might be telling us that we need to focus on a subgroup of patients with acute kidney injury, a specific phenotype of acute kidney injury, or perhaps patients admitted to certain units,” she said.
One takeaway from the study, Wilson said, is the feasibility of incorporating this type of intervention into hospital patient care.
“The kidney action team was remote; they weren’t running around to the bedside,” he said. “Sitting in their offices looking at the electronic health record, they were able to deliver recommendations to a patient’s chart within less than an hour of acute kidney injury developing, and they took about five to 10 minutes per patient to create their set of recommendations.”
Aklilu added that the feedback they collected from hospital teams showed that most clinicians viewed the recommendation note as favorable and did not find it disruptive to patient care.
Wilson noted that while these alert systems have been shown to help providers follow best practices, researchers need to dig deeper to determine if they help. “It’s time to take these clinical decision support interventions to the next level and prove that they actually improve patient outcomes, which has been hard to show,” he said.
Other YSM authors of the study include Dennis Moledina, Yu Yamamoto, Fan Li, Jeffrey Testani, Bashar Kadhim, Sophia Faulkner, Kyle O'Connor, Megan Baker, Jiawei Tan, Simon Correa Gaviria, Kyra Shelton, Melissa Martin, Claudia Coronel-Moreno, and Amrita Makhijani. Lead pharmacists from Yale New Haven Hospital include Kristina Shvets and Charles Jones.
Yale School of Medicine’s Department of Internal Medicine Section of Nephrology is committed to excellence in patient care, research, and education with the goal for both their faculty and trainees to be national and international leaders in the field of academic nephrology. To learn more, visit Nephrology.