Impact of real-time electronic alerting of acute kidney injury on therapeutic intervention and progression of RIFLE class*

Colpaert, Kirsten; Hoste, Eric; Steurbaut, Kristof; Benoît, Dominique; Hoecke, Sofie Van; Turck, Filip De; Decruyenaere, Johan

doi:10.1097/ccm.0b013e3182387a6b

Cited by 205 publications

(172 citation statements)

References 19 publications

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“…Opportunities for improvement in patient care exist with identification and management of low-and high-risk AKI patients. Automated clinical surveillance systems are effective for a variety of clinical conditions including the identification of sepsis (19), adverse drug reactions (20,21), and more recently, AKI (22,23). These surveillance systems have assisted with faster identification of events compared with usual care that has been shown to improve shortterm progression of AKI severity (22,24,25).…”

Section: Discussionmentioning

confidence: 99%

“…Automated clinical surveillance systems are effective for a variety of clinical conditions including the identification of sepsis (19), adverse drug reactions (20,21), and more recently, AKI (22,23). These surveillance systems have assisted with faster identification of events compared with usual care that has been shown to improve shortterm progression of AKI severity (22,24,25). Future studies are needed to determine the effect of clinical surveillance systems used to detect AKI on long-term recovery of renal function, as well as how these systems can be further refined to enhance the detection and management of AKI.…”

Section: Discussionmentioning

confidence: 99%

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AKI in Low-Risk versus High-Risk Patients in Intensive Care

Sileanu

Murugan

Lucko

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives AKI in critically ill patients is usually part of multiorgan failure. However, nonrenal organ failure may not always precede AKI and patients without evidence of these organ failures may not be at low risk for AKI. This study examined the risk and outcomes associated with AKI in critically ill patients with and without cardiovascular or respiratory organ failures at presentation to the intensive care unit (ICU).Design, setting, participants, & measurements A large, academic medical center database, with records from July 2000 through October 2008, was used and the authors identified a low-risk cohort as patients without cardiovascular and respiratory organ failures defined as not receiving vasopressor support or mechanical ventilation within the first 24 hours of ICU admission. AKI was defined using Kidney Disease Improving Global Outcomes criteria. The primary end points were moderate to severe AKI (stages 2-3) and risk-adjusted hospital mortality.Results Of 40,152 critically ill patients, 44.9% received neither vasopressors nor mechanical ventilation on ICU day 1. Stages 2-3 AKI occurred less frequently in the low-risk patients versus high-risk patients within 24 hours (14.3% versus 29.1%) and within 1 week (25.7% versus 51.7%) of ICU admission. Patients developing AKI in both risk groups had higher risk of death before hospital discharge. However, the adjusted odds of hospital mortality were greater (odds ratio, 2.99; 95% confidence interval, 2.62 to 3.41) when AKI occurred in low-risk patients compared with those with respiratory or cardiovascular failures (odds ratio, 1.19; 95% confidence interval, 1.09 to 1.3); interaction P,0.001.Conclusions Patients admitted to ICU without respiratory or cardiovascular failure have a substantial likelihood of developing AKI. Although survival for low-risk patients is better than for high-risk patients, the relative increase in mortality associated with AKI is actually greater for low-risk patients. Strategies aimed at preventing AKI should not exclude ICU patients without cardiovascular or respiratory organ failures.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

AKI in Low-Risk versus High-Risk Patients in Intensive Care

Sileanu

Murugan

Lucko

et al. 2015

Clinical Journal of the American Society of Nephrology

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“…Prior studies have shown that the incidence of AKI can be reduced by measures, including isotonic intravenous fluid infusion before iodinated contrast administration, 28 off-versus on-pump coronary artery bypass surgery, 29 and potentially, real-time detection of incipient acute worsening of renal function 30 as well as early inpatient nephrology consultation. 31 If the AKI-BP elevation association is causal, then reducing the risk of AKI may not only reduce mortality and morbidity in the short term but also, confer large long-term public health benefits.…”

Section: Discussionmentioning

confidence: 99%

Elevated BP after AKI

Hsu

Hsu²,

Yang

et al. 2016

Journal of the American Society of Nephrology

146

111

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The connection between AKI and BP elevation is unclear. We conducted a retrospective cohort study to evaluate whether AKI in the hospital is independently associated with BP elevation during the first 2 years after discharge among previously normotensive adults. We studied adult members of Kaiser Permanente Northern California, a large integrated health care delivery system, who were hospitalized between 2008 and 2011, had available preadmission serum creatinine and BP measures, and were not known to be hypertensive or have BP.140/90 mmHg. Among 43,611 eligible patients, 2451 experienced AKI defined using observed changes in serum creatinine concentration measured during hospitalization. Survivors of AKI were more likely than those without AKI to have elevated BP-defined as documented BP.140/90 mmHg measured during an ambulatory, nonemergency department visit-during follow-up (46.1% versus 41.2% at 730 days; P,0.001). This difference was evident within the first 180 days (30.6% versus 23.1%; P,0.001). In multivariable models, AKI was independently associated with a 22% (95% confidence interval, 12% to 33%) increase in the odds of developing elevated BP during follow-up, with higher adjusted odds with more severe AKI. Results were similar in sensitivity analyses when elevated BP was defined as having at least two BP readings of .140/90 mmHg or those with evidence of CKD were excluded. We conclude that AKI is an independent risk factor for subsequent development of elevated BP. Preventing AKI during a hospitalization may have clinical and public health benefits beyond the immediate hospitalization.

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“…Our study used MAKE30, a patient-centered outcome recommended for phase III trials by the National Institute of Diabetes and Digestive and Kidney Diseases workgroup on Clinical Trials in AKI (18,20,34). Finally, although previous studies have examined informatics-based interventions (35)(36)(37) or leveraged the EHR to facilitate aspects of trial conduct (37)(38)(39), to our knowledge, this is the first large, critical care clinical trial to be conducted entirely within the EHR. By successfully enrolling nearly 1,000 critically ill adults, accurately delivering the assigned intervention in a time-sensitive manner, and collecting detailed data on patient characteristics, fluid receipt, laboratory values, and clinical outcomes, SALT demonstrated that the EHR-embedded clinical trial (13,14,40) is a powerful new tool for generating evidence to guide clinical practice in critical care.…”

Section: Original Articlementioning

confidence: 99%

Balanced Crystalloids versus Saline in the Intensive Care Unit. The SALT Randomized Trial

Semler

Wang

Byrne

et al. 2017

Am J Respir Crit Care Med

215

205

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Rationale: Saline is the intravenous fluid most commonly administered to critically ill adults, but it may be associated with acute kidney injury and death. Whether use of balanced crystalloids rather than saline affects patient outcomes remains unknown.Objectives: To pilot a cluster-randomized, multiple-crossover trial using software tools within the electronic health record to compare saline to balanced crystalloids.Methods: This was a cluster-randomized, multiple-crossover trial among 974 adults admitted to a tertiary medical intensive care unit from February 3, 2015 to May 31, 2015. The intravenous crystalloid used in the unit alternated monthly between saline (0.9% sodium chloride) and balanced crystalloids (lactated Ringer's solution or PlasmaLyte A). Enrollment, fluid delivery, and data collection were performed using software tools within the electronic health record. The primary outcome was the difference between study groups in the proportion of isotonic crystalloid administered that was saline. The secondary outcome was major adverse kidney events within 30 days (MAKE30), a composite of death, dialysis, or persistent renal dysfunction.Measurements and Main Results: Patients assigned to saline (n = 454) and balanced crystalloids (n = 520) were similar at baseline and received similar volumes of crystalloid by 30 days (median [interquartile range]: 1,424 ml [500-3,377] vs. 1,617 ml [500-3,628]; P = 0.40). Saline made up a larger proportion of the isotonic crystalloid given in the saline group than in the balanced crystalloid group (91% vs. 21%; P , 0.001). MAKE30 did not differ between groups (24.7% vs. 24.6%; P = 0.98).Conclusions: An electronic health record-embedded, clusterrandomized, multiple-crossover trial comparing saline with balanced crystalloids can produce well-balanced study groups and separation in crystalloid receipt.Clinical trial registered with www.clinicaltrials.gov (NCT 02345486).

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Impact of real-time electronic alerting of acute kidney injury on therapeutic intervention and progression of RIFLE class*

Cited by 205 publications

References 19 publications

AKI in Low-Risk versus High-Risk Patients in Intensive Care

AKI in Low-Risk versus High-Risk Patients in Intensive Care

Elevated BP after AKI

Balanced Crystalloids versus Saline in the Intensive Care Unit. The SALT Randomized Trial

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