KAT-AKI: Tailored EHR Alerts Fail to Improve AKI Management in Hospitalized Patients

F. Perry Wilson, MD
Credit: Yale Medicine

A randomized trial conducted by investigators from the Yale University School of Medicine suggests personalized recommendations for management of acute kidney injury (AKI) delivered through electronic health records failed to improve kidney outcomes among hospitalized patients.

Presented at the American Society of Nephrology’s Kidney Week 2024, the KAT-AKI trial 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.¹

“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,” said principal investigator F. Perry Wilson, MD, associate professor of medicine (nephrology) in the Yale Department of Internal Medicine.²

With previous research evidencing the prevalence of AKI and its association with adverse outcomes in hospitalized patient, Wilson and a team of colleagues sought to evaluate whether a specially designed support tool for clinical decision might improve interventions and outcomes for this patient population in a randomized, parallel-group, investigator-blinded clinical trial.¹

Per trial design, the support tool sent an alert about AKI to the kidney action team, which consisted of a study physician and a study pharmacist. These alerts contained personalized recommendations within 1 hour of AKI detection pertaining to 5 major categories: diagnostic testing, volume, potassium, acid base, and medications. Investigators pointed out the alerts were immediately visible to anyone with access to the electronic health record.¹

The primary outcome of interest for the study was a composite outcome defined as progression to a higher stage of AKI, dialysis, or mortality occurring while the patient remained hospitalized and within 14 days from randomization. A key secondary outcome of interest for the study was the proportion of recommendations completed within 24 hours of randomization.¹

Inn total, 4003 patients underwent randomization. This cohort had a median age of 72 (IQR, 61 to 81) years, 47% were female, and 23% were Black. Of the 4003 included, 1999 patients were randomized to the intervention arm and 2004 were randomized to the usual care group.¹

A total of 14,539 recommendations were made, with a median of 3 (IQR, 2 to 5) per patient. Investigators pointed out at least 1 recommendation was made for 96.2% of patients in the general diagnostics and monitoring category, 79.8% in the volume category, 15.5% in the potassium category, 10.3% in the acidosis evaluation and management category, and 54.7% in the medication category.¹

Results of the primary outcome analysis revealed an event of interest occurred among 19.1% of the overall cohort, with no significant difference in events observed for the intervention (19.8%) and the usual care (18.4%) groups (Relative Risk [RR], 1.07; 95% CI, 0.94 to 1.22; P = .28). Similarly, there were no significant differences between the groups for the proportion of patients with AKI progression, (13.5% vs 13.0%; mean difference, 0.5%; 95% CI, −1.6% to 2.6%), dialysis receipt, (1.6% vs 1.5%; mean difference, 0.1%; 95% CI, −0.7% to 0.8%), or mortality incidence (9.6% vs 9.2%; mean difference, 0.4%; 95% CI, −1.5% to 2.1%).¹

Further analysis suggested 33.8% of recommendations were implemented among the intervention group compared to 24.3% in the usual care group despite not having been communicated (mean difference, 9.5%; 95% CI, 8.1% to 11.0%).¹

“We found that the intervention significantly improved several clinician behaviors regarding the management of AKI but did not reduce the primary outcome of developing worsening kidney injury, needing dialysis, or death,” said lead investigator Abinet M. Aklilu, MD, MPH, of Yale University School of Medicine.³ “In future studies, we plan to assess if recommendations targeting individuals at high risk for severe kidney injury and specific phenotypes of kidney injury lead to improved outcomes.”

References:

1. Aklilu AM, Menez S, Baker ML, et al. Early, Individualized Recommendations for Hospitalized Patients With Acute Kidney Injury: A Randomized Clinical Trial. JAMA. Published online October 25, 2024. doi:10.1001/jama.2024.22718
2. Crawford S. Can a “kidney action team” improve patient outcomes? Yale School of Medicine. October 25, 2024. Accessed October 25, 2024. https://medicine.yale.edu/internal-medicine/nephrol/news-article/can-a-kidney-action-team-improve-patient-outcomes/.
3. American Society of Nephrology. High-Impact Clinical Trials Generate Promising Results for Improving Kidney Health: Part 1. Newswise. October 25, 2024. Accessed October 25, 2024. https://www.newswise.com/articles/high-impact-clinical-trials-generate-promising-results-for-improving-kidney-health-part-1.