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Wang X, Bian Z, Zhu R, Chen S. A Review of Electronic Early Warning Systems for Acute Kidney Injury. Adv Urol 2024; 2024:6456411. [PMID: 39381592 PMCID: PMC11461063 DOI: 10.1155/2024/6456411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 07/08/2024] [Accepted: 08/29/2024] [Indexed: 10/10/2024] Open
Abstract
Acute kidney injury (AKI) is characterized by impaired renal function that can result in irreversible severe renal impairment or lifelong dependence on renal replacement therapy in some cases. Early intervention can significantly slow down the progression of AKI and reduce mortality. In recent years, electronic early warning systems for patients with AKI have been gaining attention as a potential clinical decision-support option. This paper presents a review of the application of electronic early warning systems for AKI from four aspects: development process, types of output, influencing factors, and system evaluation.
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Affiliation(s)
- Xiangxiang Wang
- Department of NephrologyShanghai Fourth People's HospitalSchool of MedicineTongji University, Shanghai 200434, China
| | - Zhixiang Bian
- Department of NephrologyShanghai Fourth People's HospitalSchool of MedicineTongji University, Shanghai 200434, China
| | - Rui Zhu
- Department of NephrologyShanghai Fourth People's HospitalSchool of MedicineTongji University, Shanghai 200434, China
| | - Shunjie Chen
- Department of NephrologyShanghai Fourth People's HospitalSchool of MedicineTongji University, Shanghai 200434, China
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Chen JJ, Lee TH, Chan MJ, Tsai TY, Fan PC, Lee CC, Wu VC, Tu YK, Chang CH. Electronic Alert Systems for Patients With Acute Kidney Injury: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2430401. [PMID: 39190304 PMCID: PMC11350470 DOI: 10.1001/jamanetworkopen.2024.30401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 07/02/2024] [Indexed: 08/28/2024] Open
Abstract
Importance The acute kidney injury (AKI) electronic alert (e-alert) system was hypothesized to improve the outcomes of AKI. However, its association with different patient outcomes and clinical practice patterns remains systematically unexplored. Objective To assess the association of AKI e-alerts with patient outcomes (mortality, AKI progression, dialysis, and kidney recovery) and clinical practice patterns. Data Sources A search of Embase and PubMed on March 18, 2024, and a search of the Cochrane Library on March 20, 2024, to identify all relevant studies. There were no limitations on language or article types. Study Selection Studies evaluating the specified outcomes in adult patients with AKI comparing AKI e-alerts with standard care or no e-alerts were included. Studies were excluded if they were duplicate cohorts, had insufficient outcome data, or had no control group. Data Extraction and Synthesis Two investigators independently extracted data and assessed bias. The systematic review and meta-analysis followed the PRISMA guidelines. Random-effects model meta-analysis, with predefined subgroup analysis and trial sequential analyses, were conducted. Main Outcomes and Measures Primary outcomes included mortality, AKI progression, dialysis, and kidney recovery. Secondary outcomes were nephrologist consultations, post-AKI exposure to nonsteroidal anti-inflammatory drugs (NSAID), post-AKI angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker (ACEI/ARB) prescription, hospital length of stay, costs, and AKI documentation. Results Thirteen unique studies with 41 837 unique patients were included (mean age range, 60.5-79.0 years]; 29.3%-48.5% female). The risk ratios (RRs) for the AKI e-alerts group compared with standard care were 0.96 for mortality (95% CI, 0.89-1.03), 0.91 for AKI stage progression (95% CI, 0.84-0.99), 1.16 for dialysis (95% CI, 1.05-1.28), and 1.13 for kidney recovery (95% CI, 0.86-1.49). The AKI e-alerts group had RRs of 1.45 (95% CI, 1.04-2.02) for nephrologist consultation, 0.75 (95% CI, 0.59-0.95) for post-AKI NSAID exposure. The pooled RR for post-AKI ACEI/ARB exposure in the AKI e-alerts group compared with the control group was 0.91 (95% CI, 0.78-1.06) and 1.28 (95% CI, 1.04-1.58) for AKI documentation. Use of AKI e-alerts was not associated with lower hospital length of stay (mean difference, -0.09 [95% CI, -0.47 to 0.30] days) or lower cost (mean difference, US $655.26 [95% CI, -$656.98 to $1967.5]) but was associated with greater AKI documentation (RR, 1.28 [95% CI, 1.04-1.58]). Trial sequential analysis confirmed true-positive results of AKI e-alerts on increased nephrologist consultations and reduced post-AKI NSAID exposure and its lack of association with mortality. Conclusions and Relevance In this systematic review and meta-analysis, AKI e-alerts were not associated with a lower risk for mortality but were associated with changes in clinical practices. They were associated with lower risk for AKI progression. Further research is needed to confirm these results and integrate early AKI markers or prediction models to improve outcomes.
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Affiliation(s)
- Jia-Jin Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tao-Han Lee
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Nephrology, Chansn Hospital, Taoyuan City, Taiwan
| | - Ming-Jen Chan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Tsung-Yu Tsai
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Chun Fan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- National Taiwan University Study Group on Acute Renal Failure, Taipei, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Li T, Wu B, Li L, Bian A, Ni J, Liu K, Qin Z, Peng Y, Shen Y, Lv M, Lu X, Xing C, Mao H. Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2351710. [PMID: 38241047 PMCID: PMC10799260 DOI: 10.1001/jamanetworkopen.2023.51710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 11/03/2023] [Indexed: 01/22/2024] Open
Abstract
Importance Despite the expansion of published electronic alerts for acute kidney injury (AKI), there are still concerns regarding their effect on the clinical outcomes of patients. Objective To evaluate the effect of the AKI alert combined with a care bundle on the care and clinical outcomes of patients with hospital-acquired AKI. Design, Setting, and Participants This single-center, double-blind, parallel-group randomized clinical trial was conducted in a tertiary teaching hospital in Nanjing, China, from August 1, 2019, to December 31, 2021. The inclusion criteria were inpatient adults aged 18 years or older with AKI, which was defined using the Kidney Disease: Improving Global Outcomes creatinine criteria. Participants were randomized 1:1 to either the alert group or the usual care group, which were stratified by medical vs surgical ward and by intensive care unit (ICU) vs non-ICU setting. Analyses were conducted on the modified intention-to-treat population. Interventions A programmatic AKI alert system generated randomization automatically and sent messages to the mobile telephones of clinicians (alert group) or did not send messages (usual care group). A care bundle accompanied the AKI alert and consisted of general, nonindividualized, and nonmandatory AKI management measures. Main Outcomes and Measures The primary outcome was maximum change in estimated glomerular filtration rate (eGFR) within 7 days after randomization. Secondary patient-centered outcomes included death, dialysis, AKI progression, and AKI recovery. Care-centered outcomes included diagnostic and therapeutic interventions for AKI. Results A total of 2208 patients (median [IQR] age, 65 [54-72] years; 1560 males [70.7%]) were randomized to the alert group (n = 1123) or the usual care group (n = 1085) and analyzed. Within 7 days of randomization, median (IQR) maximum absolute changes in eGFR were 3.7 (-6.4 to 19.3) mL/min/1.73 m2 in the alert group and 2.9 (-9.2 to 16.9) mL/min/1.73 m2 in the usual care group (P = .24). This result was robust in all subgroups in an exploratory analysis. For care-centered outcomes, patients in the alert group had more intravenous fluids (927 [82.6%] vs 670 [61.8%]; P < .001), less exposure to nonsteroidal anti-inflammatory drugs (56 [5.0%] vs 119 [11.0%]; P < .001), and more AKI documentation at discharge (560 [49.9%] vs 296 [27.3%]; P < .001) than patients in the usual care group. No differences were observed in patient-centered secondary outcomes between the 2 groups. Conclusions and Relevance Results of this randomized clinical trial showed that the electronic AKI alert did not improve kidney function or other patient-centered outcomes but changed patient care behaviors. The findings warrant the use of a combination of high-quality interventions and AKI alert in future clinical practice. Trial Registration ClinicalTrials.gov Identifier: NCT03736304.
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Affiliation(s)
- Ting Li
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Buyun Wu
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Li Li
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ao Bian
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Juan Ni
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kang Liu
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhongke Qin
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yudie Peng
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yining Shen
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mengru Lv
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xinyi Lu
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Changying Xing
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huijuan Mao
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Kashani KB, Awdishu L, Bagshaw SM, Barreto EF, Claure-Del Granado R, Evans BJ, Forni LG, Ghosh E, Goldstein SL, Kane-Gill SL, Koola J, Koyner JL, Liu M, Murugan R, Nadkarni GN, Neyra JA, Ninan J, Ostermann M, Pannu N, Rashidi P, Ronco C, Rosner MH, Selby NM, Shickel B, Singh K, Soranno DE, Sutherland SM, Bihorac A, Mehta RL. Digital health and acute kidney injury: consensus report of the 27th Acute Disease Quality Initiative workgroup. Nat Rev Nephrol 2023; 19:807-818. [PMID: 37580570 PMCID: PMC11285755 DOI: 10.1038/s41581-023-00744-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/16/2023]
Abstract
Acute kidney injury (AKI), which is a common complication of acute illnesses, affects the health of individuals in community, acute care and post-acute care settings. Although the recognition, prevention and management of AKI has advanced over the past decades, its incidence and related morbidity, mortality and health care burden remain overwhelming. The rapid growth of digital technologies has provided a new platform to improve patient care, and reports show demonstrable benefits in care processes and, in some instances, in patient outcomes. However, despite great progress, the potential benefits of using digital technology to manage AKI has not yet been fully explored or implemented in clinical practice. Digital health studies in AKI have shown variable evidence of benefits, and the digital divide means that access to digital technologies is not equitable. Upstream research and development costs, limited stakeholder participation and acceptance, and poor scalability of digital health solutions have hindered their widespread implementation and use. Here, we provide recommendations from the Acute Disease Quality Initiative consensus meeting, which involved experts in adult and paediatric nephrology, critical care, pharmacy and data science, at which the use of digital health for risk prediction, prevention, identification and management of AKI and its consequences was discussed.
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Affiliation(s)
- Kianoush B Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Linda Awdishu
- Clinical Pharmacy, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | | | - Rolando Claure-Del Granado
- Division of Nephrology, Hospital Obrero No 2 - CNS, Cochabamba, Bolivia
- Universidad Mayor de San Simon, School of Medicine, Cochabamba, Bolivia
| | - Barbara J Evans
- Intelligent Critical Care Center, University of Florida, Gainesville, FL, USA
| | - Lui G Forni
- Department of Critical Care, Royal Surrey Hospital NHS Foundation Trust & Department of Clinical & Experimental Medicine, University of Surrey, Guildford, UK
| | - Erina Ghosh
- Philips Research North America, Cambridge, MA, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sandra L Kane-Gill
- Biomedical Informatics and Clinical Translational Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jejo Koola
- UC San Diego Health Department of Biomedical Informatics, Department of Medicine, La Jolla, CA, USA
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mei Liu
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, USA
| | - Raghavan Murugan
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- The Clinical Research, Investigation, and Systems Modelling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Girish N Nadkarni
- Division of Data-Driven and Digital Medicine (D3M), Department of Medicine, Icahn School of Medicine at Mount Sinai; Mount Sinai Clinical Intelligence Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jacob Ninan
- Division of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Neesh Pannu
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Parisa Rashidi
- Intelligent Critical Care Center, University of Florida, Gainesville, FL, USA
| | - Claudio Ronco
- Università di Padova; Scientific Director Foundation IRRIV; International Renal Research Institute; San Bortolo Hospital, Vicenza, Italy
| | - Mitchell H Rosner
- Department of Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Academic Unit of Translational Medical Sciences, University of Nottingham, Nottingham, UK
- Department of Renal Medicine, Royal Derby Hospital, Derby, UK
| | - Benjamin Shickel
- Intelligent Critical Care Center, University of Florida, Gainesville, FL, USA
| | - Karandeep Singh
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Danielle E Soranno
- Section of Nephrology, Department of Pediatrics, Indiana University, Riley Hospital for Children, Indianapolis, IN, USA
| | - Scott M Sutherland
- Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Azra Bihorac
- Intelligent Critical Care Center, University of Florida, Gainesville, FL, USA.
| | - Ravindra L Mehta
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA, USA.
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See CY, Pan HC, Chen JY, Wu CY, Liao HW, Huang YT, Liu JH, Wu VC, Ostermann M. Improvement of composite kidney outcomes by AKI care bundles: a systematic review and meta-analysis. Crit Care 2023; 27:390. [PMID: 37814334 PMCID: PMC10563300 DOI: 10.1186/s13054-023-04641-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/06/2023] [Indexed: 10/11/2023] Open
Abstract
INTRODUCTION Various approaches have been suggested to identify acute kidney injury (AKI) early and to initiate kidney-protective measures in patients at risk or with AKI. The objective of this study was to evaluate whether care bundles improve kidney outcomes in these patients. METHODS We conducted a systematic review of the literature to evaluate the clinical effectiveness of AKI care bundles with or without urinary biomarkers in the recognition and management of AKI. The main outcomes were major adverse kidney events (MAKEs) consisting of moderate-severe AKI, receipt of renal replacement therapy (RRT), and mortality. RESULTS Out of 7434 abstracts screened, 946 published studies were identified. Thirteen studies [five randomized controlled trials (RCTs) and eight non-RCTs] including 16,540 patients were eligible for inclusion in the meta-analysis. Meta-analysis showed a lower incidence of MAKE in the AKI care bundle group [odds ratio (OR) 0.73, 95% confidence interval (CI) 0.66-0.81] with differences in all 3 individual outcomes [moderate-severe AKI (OR 0.65, 95% CI 0.51-0.82), RRT (OR 0.63, 95% CI = 0.46-0.88) and mortality]. Subgroup analysis of the RCTs, all adopted biomarker-based approach, decreased the risk of MAKE (OR 0.55, 95% CI 0.41-0.74). Network meta-analysis could reveal that the incorporation of biomarkers in care bundles carried a significantly lower risk of MAKE when compared to care bundles without biomarkers (OR = 0.693, 95% CI = 0.50-0.96), while the usual care subgroup had a significantly higher risk (OR = 1.29, 95% CI = 1.09-1.52). CONCLUSION Our meta-analysis demonstrated that care bundles decreased the risk of MAKE, moderate-severe AKI and need for RRT in AKI patients. Moreover, the inclusion of biomarkers in care bundles had a greater impact than care bundles without biomarkers.
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Affiliation(s)
- Chun Yin See
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, 100, Taiwan
| | - Heng-Chih Pan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, 100, Taiwan
- Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, 204, Taiwan
- College of Medicine, Chang Gung University, Taoyüan, 333, Taiwan
- Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, 204, Taiwan
| | - Jui-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Chun-Yi Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Nursing, Asia University, Taichung, Taiwan
| | - Hung-Wei Liao
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, 11696, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 11031, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Jung-Hua Liu
- Department of Communication, National Chung Cheng University, Chiayi, Taiwan
| | - Vin-Cent Wu
- Department of Internal Medicine, Clinical Research Building, National Taiwan University Hospital, 7 Chung-Shan South Road, Room 1555, Taipei, Taiwan.
- NSARF (National Taiwan University Hospital Study Group on Acute Renal Failure), Taipei, Taiwan.
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St. Thomas' Foundation Trust, Westminster Bridge, London, SE1 7EH, UK.
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Iwers R, Sliziuk V, Haase M, Barabasch S, Zänker M, Butter C, Haase-Fielitz A. Care Bundle for Acute Kidney Injury in Cardiac Patients: A Cluster-Randomized Trial. J Clin Med 2023; 12:6391. [PMID: 37835034 PMCID: PMC10573102 DOI: 10.3390/jcm12196391] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/02/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023] Open
Abstract
Detection and timely intervention of acute kidney injury (AKI) is a major challenge worldwide. Electronic alerts for AKI may improve process- and patient-related endpoints. The present study evaluated the efficacy of an AKI electronic alert system and care bundle. This is a two-arm, prospective, cluster-randomized, controlled trial enrolling patients with AKI (KDIGO criteria) and cardiac diseases. Patients were randomly assigned to a routine care group or intervention group (DRKS-IDDRKS00017751). Two hundred patients (age 79 years, 46% female) were enrolled, with 100 patients in each group. The primary endpoint did not differ between patients in the routine care group 0.5 (-7.6-10.8) mL/min/1.73 m2 versus patients in the intervention group 1.0 (-13.5-15.1) mL/min/1.73 m2, p = 0.527. Proportions of patients in both study groups with hyperkalemia, pulmonary edema, and renal acidosis were comparable. The stop of antihypertensive medication during hypotensive periods was more frequent in patients in the intervention group compared to patients in the control group, p = 0.029. The AKI diagnosis and text module for AKI in the discharge letter were more frequently documented in patients in the intervention group (40%/48% vs. 25%/34%, p = 0.034; p = 0.044, respectively). Continued intake of RAAS inhibitors and the presence of a cardiac device were independently associated with a less pronounced decrease in eGFR from admission to the lowest value. In this RCT, electronic alerts for AKI and a care bundle improved process- but not patient-related endpoints.
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Affiliation(s)
- Ragna Iwers
- Department of Cardiology, Heart Center Brandenburg Bernau & Faculty of Health Sciences (FGW) Brandenburg, Brandenburg Medical School (MHB) Theodor Fontane, Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany; (R.I.); (C.B.)
- Institute of Social Medicine and Health System Research, Otto von Guericke University Magdeburg, 39120 Magdeburg, Germany
| | - Veronika Sliziuk
- Department of Cardiovascular Surgery, Heart Center Brandenburg Bernau & Faculty of Health Sciences (FGW) Brandenburg, Brandenburg Medical School (MHB) Theodor Fontane, 16321 Bernau bei Berlin, Germany
| | - Michael Haase
- Medical Faculty, Otto-von-Guericke University Magdeburg, 39106 Magdeburg, Germany;
- Diamedikum MVZ, 14473 Potsdam, Germany
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
| | - Sophie Barabasch
- Department of Anesthesia and Intensive Care, Unfallkrankenhaus Berlin, 12683 Berlin, Germany
| | - Michael Zänker
- Department of Gastroenterology & Internal Medicine, Heart Center Brandenburg Bernau & Faculty of Health Sciences (FGW) Brandenburg, Brandenburg Medical School (MHB) Theodor Fontane, 16321 Bernau bei Berlin, Germany
| | - Christian Butter
- Department of Cardiology, Heart Center Brandenburg Bernau & Faculty of Health Sciences (FGW) Brandenburg, Brandenburg Medical School (MHB) Theodor Fontane, Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany; (R.I.); (C.B.)
| | - Anja Haase-Fielitz
- Department of Cardiology, Heart Center Brandenburg Bernau & Faculty of Health Sciences (FGW) Brandenburg, Brandenburg Medical School (MHB) Theodor Fontane, Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany; (R.I.); (C.B.)
- Institute of Social Medicine and Health System Research, Otto von Guericke University Magdeburg, 39120 Magdeburg, Germany
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Bhatraju PK, Prince DK, Mansour S, Ikizler TA, Siew ED, Chinchilli VM, Garg AX, Go AS, Kaufman JS, Kimmel PL, Coca SG, Parikh CR, Wurfel MM, Himmelfarb J. Integrated Analysis of Blood and Urine Biomarkers to Identify Acute Kidney Injury Subphenotypes and Associations With Long-term Outcomes. Am J Kidney Dis 2023; 82:311-321.e1. [PMID: 37178093 PMCID: PMC10523857 DOI: 10.1053/j.ajkd.2023.01.449] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/15/2023] [Indexed: 05/15/2023]
Abstract
RATIONALE & OBJECTIVE Acute kidney injury (AKI) is a heterogeneous clinical syndrome with varying causes, pathophysiology, and outcomes. We incorporated plasma and urine biomarker measurements to identify AKI subgroups (subphenotypes) more tightly linked to underlying pathophysiology and long-term clinical outcomes. STUDY DESIGN Multicenter cohort study. SETTING & PARTICIPANTS 769 hospitalized adults with AKI matched with 769 without AKI, enrolled from December 2009 to February 2015 in the ASSESS-AKI Study. PREDICTORS 29 clinical, plasma, and urinary biomarker parameters used to identify AKI subphenotypes. OUTCOME Composite of major adverse kidney events (MAKE) with a median follow-up period of 4.7 years. ANALYTICAL APPROACH Latent class analysis (LCA) and k-means clustering were applied to 29 clinical, plasma, and urinary biomarker parameters. Associations between AKI subphenotypes and MAKE were analyzed using Kaplan-Meier curves and Cox proportional hazard models. RESULTS Among 769 AKI patients both LCA and k-means identified 2 distinct AKI subphenotypes (classes 1 and 2). The long-term risk for MAKE was higher with class 2 (adjusted HR, 1.41 [95% CI, 1.08-1.84]; P=0.01) compared with class 1, adjusting for demographics, hospital level factors, and KDIGO stage of AKI. The higher risk of MAKE among class 2 was explained by a higher risk of long-term chronic kidney disease progression and dialysis. The top variables that were different between classes 1 and 2 included plasma and urinary biomarkers of inflammation and epithelial cell injury; serum creatinine ranked 20th out of the 29 variables for differentiating classes. LIMITATIONS A replication cohort with simultaneously collected blood and urine sampling in hospitalized adults with AKI and long-term outcomes was unavailable. CONCLUSIONS We identify 2 molecularly distinct AKI subphenotypes with differing risk of long-term outcomes, independent of the current criteria to risk stratify AKI. Future identification of AKI subphenotypes may facilitate linking therapies to underlying pathophysiology to prevent long-term sequalae after AKI. PLAIN-LANGUAGE SUMMARY Acute kidney injury (AKI) occurs commonly in hospitalized patients and is associated with high morbidity and mortality. The AKI definition lumps many different types of AKI together, but subgroups of AKI may be more tightly linked to the underlying biology and clinical outcomes. We used 29 different clinical, blood, and urinary biomarkers and applied 2 different statistical algorithms to identify AKI subtypes and their association with long-term outcomes. Both clustering algorithms identified 2 AKI subtypes with different risk of chronic kidney disease, independent of the serum creatinine concentrations (the current gold standard to determine severity of AKI). Identification of AKI subtypes may facilitate linking therapies to underlying biology to prevent long-term consequences after AKI.
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Affiliation(s)
- Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington; Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington.
| | - David K Prince
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Sherry Mansour
- Division of Nephrology, Yale University, New Haven, Connecticut
| | - T Alp Ikizler
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vernon M Chinchilli
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Alan S Go
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - James S Kaufman
- Division of Nephrology, School of Medicine, New York University, New York, New York; Division of Nephrology, VA New York Harbor Healthcare System, New York, New York
| | - Paul L Kimmel
- National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Steve G Coca
- Section of Nephrology, Department of Internal Medicine, Mount Sinai School of Medicine, New York, New York
| | - Chirag R Parikh
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington; Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
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8
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Li L, Baker J, Rathnayake K, Kotwal S, Westbrook JI, Day R, Endre Z. Medication use and hospital-acquired acute kidney injury: an electronic health record-based study. Intern Med J 2023; 53:1625-1633. [PMID: 36264150 DOI: 10.1111/imj.15938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/21/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Medications remain an important contributor to the development of acute kidney injury (AKI). This study aimed to examine associations between (i) administration of medications known to reduce glomerular filtration rate (GFR), that is, GFR modifiers and subsequent hospital-acquired AKI; and (ii) potentially medication-related AKI and patient adverse outcomes. METHODS A retrospective cohort study utilising electronic health record data of patients admitted to a tertiary hospital in Australia in 2015. Timing of medication administration was compared with timing of AKI development. AKI cases were identified using an algorithm based on serum creatinine level changes. Multilevel regression models were applied with adjustment for relevant demographic and clinical factors. RESULTS Among 11 503 admissions, AKI was identified in 955 patients (8.3%) and 637 (66.7% of 955) were preceded by administration of a GFR modifier. Patients without prior AKI were 17% more likely to develop AKI after administration of these medications (adjusted odds ratio 1.17, 95% confidence interval (CI) 1.003-1.37). Older age and comorbidity with diabetes, acute myocardial infarction, peripheral vascular disease, liver cirrhosis and multiple myeloma were also significant predictors. Patients with potentially medication-related AKI were 11.69 times more likely to die in hospital (95% CI 7.84-17.43) and stayed 3.49 times longer in hospital (95% CI 3.26-3.73), compared with those without AKI. CONCLUSIONS Administration of medications contributing to the reduction of GFR is associated with an increased risk of hospital-acquired AKI and worse patient outcomes. Caution is required when prescribing these medications to patients at risk of developing AKI, and monitoring patients for deterioration is needed if administered.
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Affiliation(s)
- Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Jannah Baker
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Kasun Rathnayake
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Sradha Kotwal
- Department of Nephrology, Prince of Wales Hospital and Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Richard Day
- Department of Clinical, Pharmacology & Toxicology, Therapeutics Centre, St Vincent's Hospital Sydney, St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Zoltan Endre
- Department of Nephrology, Prince of Wales Hospital and Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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9
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Krishnasamy S, Sinha A, Bagga A. Management of Acute Kidney Injury in Critically Ill Children. Indian J Pediatr 2023; 90:481-491. [PMID: 36859513 PMCID: PMC9977639 DOI: 10.1007/s12098-023-04483-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 01/09/2023] [Indexed: 03/03/2023]
Abstract
Acute kidney injury (AKI) is common in critically ill patients, affecting almost one in four critically ill children and one in three neonates. Higher stages of AKI portend worse outcomes. Identifying AKI timely and instituting appropriate measures to prevent and manage severe AKI is important, since it is independently associated with mortality. Methods to predict severe AKI should be applied to all critically ill patients. Assessment of volume status to prevent the development of fluid overload is useful to prevent adverse outcomes. Patients with metabolic or clinical complications of AKI need prompt kidney replacement therapy (KRT). Various modes of KRT are available, and the choice of modality depends most on the technical competence of the center, patient size, and hemodynamic stability. Given the significant risk of chronic kidney disease, patients with AKI require long-term follow-up. It is important to focus on improving awareness about AKI, incorporate AKI prevention as a quality initiative, and improve detection, prevention, and management of AKI with the aim of reducing acute and long-term morbidity and mortality.
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Affiliation(s)
- Sudarsan Krishnasamy
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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10
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Rodrigues CE, Endre ZH. Definitions, phenotypes, and subphenotypes in acute kidney injury-Moving towards precision medicine. Nephrology (Carlton) 2023; 28:83-96. [PMID: 36370326 PMCID: PMC10100386 DOI: 10.1111/nep.14132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/23/2022] [Accepted: 10/31/2022] [Indexed: 11/13/2022]
Abstract
The current definition of acute kidney injury (AKI) is generic and, based only on markers of function, is unsuitable for guiding individualized treatment. AKI is a complex syndrome with multiple presentations and causes. Targeted AKI management will only be possible if different phenotypes and subphenotypes of AKI are recognised, based on causation and related pathophysiology. Molecular signatures to identify subphenotypes are being recognised, as specific biomarkers reveal activated pathways. Assessment of individual clinical risk needs wider dissemination to allow identification of patients at high risk of AKI. New and more timely markers for glomerular filtration rate (GFR) are available. However, AKI diagnosis and classification should not be limited to GFR, but include tubular function and damage. Combining damage and stress biomarkers with functional markers enhances risk prediction, and identifies a population enriched for clinical trials targeting AKI. We review novel developments and aim to encourage implementation of these new techniques into clinical practice as a strategy for individualizing AKI treatment akin to a precision medicine-based approach.
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Affiliation(s)
- Camila Eleuterio Rodrigues
- Nephrology DepartmentPrince of Wales Clinical School – UNSW MedicineSydneyNew South WalesAustralia
- Nephrology DepartmentHospital das Clínicas – University of São Paulo School of MedicineSão PauloBrazil
| | - Zoltán H. Endre
- Nephrology DepartmentPrince of Wales Clinical School – UNSW MedicineSydneyNew South WalesAustralia
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de Morais DG, Sanches TRC, Santinho MAR, Yada EY, Segura GC, Lowe D, Navarro G, Seabra VF, Taniguchi LU, Malbouisson LMS, de André CDS, Andrade L, Rodrigues CE. Urinary sodium excretion is low prior to acute kidney injury in patients in the intensive care unit. FRONTIERS IN NEPHROLOGY 2022; 2:929743. [PMID: 37675036 PMCID: PMC10479577 DOI: 10.3389/fneph.2022.929743] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/31/2022] [Indexed: 09/08/2023]
Abstract
Background The incidence of acute kidney injury (AKI) is high in intensive care units (ICUs), and a better understanding of AKI is needed. Early chronic kidney disease is associated with urinary concentration inability and AKI recovery with increased urinary solutes in humans. Whether the inability of the kidneys to concentrate urine and excrete solutes at appropriate levels could occur prior to the diagnosis of AKI is still uncertain, and the associated mechanisms have not been studied. Methods In this single-center prospective observational study, high AKI risk in ICU patients was followed up for 7 days or until ICU discharge. They were grouped as "AKI" or "No AKI" according to their AKI status throughout admission. We collected daily urine samples to measure solute concentrations and osmolality. Data were analyzed 1 day before AKI, or from the first to the fifth day of admission in the "No AKI" group. We used logistic regression models to evaluate the influence of the variables on future AKI diagnosis. The expression of kidney transporters in urine was evaluated by Western blotting. Results We identified 29 patients as "No AKI" and 23 patients as "AKI," the latter being mostly low severity AKI. Urinary sodium excretion was lower in "AKI" patients prior to AKI diagnosis, particularly in septic patients. The expression of Na+/H+ exchanger (NHE3), a urinary sodium transporter, was higher in "AKI" patients. Conclusions Urinary sodium excretion is low before an AKI episode in ICU patients, and high expressions of proximal tubule sodium transporters might contribute to this.
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Affiliation(s)
- David Gomes de Morais
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Talita Rojas Cunha Sanches
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Mirela Aparecida Rodrigues Santinho
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Yuki Yada
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Gabriela Cardoso Segura
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Diogo Lowe
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Guilherme Navarro
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Victor Faria Seabra
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Leandro Utino Taniguchi
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carmen Diva Saldiva de André
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Lúcia Andrade
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Camila Eleuterio Rodrigues
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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