Optimizing Electronic Alerts for Acute Kidney Injury

Acute kidney injury (AKI) carries a significant, independent risk of mortality among
hospitalized patients. Recent studies have demonstrated increased mortality among patients
with even small increases in serum creatinine concentration. International guidelines for the
treatment of AKI focus on appropriate management of drug dosing, avoiding nephrotoxic
exposures, and careful attention to fluid and electrolyte balance. Early nephrologist
involvement may also improve outcomes in AKI. Without appropriate provider recognition of
AKI, however, none of these measures can be taken, and patient outcomes may suffer. AKI is
frequently overlooked by clinicians, but carries a substantial cost, morbidity and mortality
burden.

The investigators conducted a pilot, randomized trial of electronic alerts for acute kidney
injury in 2014. The trial, which randomized 2400 patients with AKI as defined by an increase
in creatinine of 0.3mg/dl over 48 hours or 50% over 7 days, found that alerting physicians to
the presence of AKI did not improve the course of acute kidney injury, reduce dialysis or
death rates. However this study was conducted in a single hospital, and the alert itself did
not describe specific actions that a provider could take. In the present proposal, the
investigators seek to expand upon their prior study to determine both the modes of alerting
that would be most effective and to determine if targeting alerts (such as to patients on
medications that may worsen acute kidney injury) will improve effectiveness.

This study will be a randomized, controlled trial of an electronic AKI alert system. Using
the Kidney Disease: Improve Global Outcomes creatinine criteria, inpatients at several
hospitals will be randomized to usual care versus electronic alerting. The primary outcome
will be a composite of progression of acute kidney injury, dialysis and death.

Inclusion Criteria:

- Adult ≥ 18 years admitted to a participating study hospital

- Acute Kidney Injury as defined by KDIGO consensus creatinine criteria (0.3mg/dl
increase in serum creatinine over 48 hours or 50% relative increase over 7 days).

Exclusion Criteria:

- ESKD diagnosis code

- Dialysis order prior to AKI onset

- Initial creatinine >=4.0mg/dl

- Prior admission in which patient was randomized.

- Admission to hospice service or comfort measures only order

- Kidney transplant within 6 months