- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT04040296
Personalized Recommendations for Acute Kidney Injury (AKI) Care
Personalized Recommendations for Acute Kidney Injury (AKI) Care Using a Kidney Action Team: A Randomized Trial
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Acute Kidney Injury (AKI), defined as an abrupt loss in kidney function, is common, occurring in 5-20% of hospitalized patients, and carries a significant and independent risk of inpatient mortality. International guidelines for the treatment of AKI focus on "best practices" that include appropriate management of drug dosing, the avoidance of kidney-toxic exposures, and careful assessment of fluid and electrolyte balance. Early nephrologist involvement may also improve outcomes in AKI. However, AKI, which is often asymptomatic, is frequently overlooked in a variety of hospital settings and many "best practices" occur infrequently and inconsistently.
The investigators previously conducted a randomized clinical trial testing the efficacy of electronic alerts for AKI, randomizing patients with AKI to usual care, or to an alert group in which a single alert was sent to the patient's primary provider. The study demonstrated clinical equipoise regarding the effectiveness of such alerting, as there was no improvement in the rates of AKI progression, dialysis or mortality among those in the alert group.
Rather than simply making providers aware of AKI, it may be beneficial to provide them with actionable items to increase recognition and rate of best practices. Further, because of the heterogeneous nature of AKI, personalized recommendations tailored to individual patients that are delivered directly to the patient care team may improve AKI outcomes. The aim of this study is to determine, through a single-blind, parallel group, randomized controlled multicenter clinical trial, if personalized recommendations, as delivered by a Kidney Action Team, for the work-up and treatment of AKI will improve patient outcomes. The Kidney Action team will serve as a centralized, remote monitoring service and will consist of a group of highly trained individuals, including an advanced practitioner, a pharmacist and a board-certified nephrologist, dedicated to reviewing enrolled patient's charts and providing recommendations for patient diagnosis and initial work up and care within 30 minutes of AKI onset. Recommendations will span five domains of care, including diagnostic workup, acid/base management, electrolyte management, hemodynamic management, and medication management.
Using the Kidney Disease: Improve Global Outcomes creatinine criteria, inpatients in sites of the Yale New Haven Health System and of the John Hopkins University Health System who develop AKI during the course of their hospitalization will be randomized to either receive usual care, or to an active intervention group in which the recommendations of the Kidney Action Team are delivered to the patient's primary care team in the form of a structured note in the electronic health record to be cosigned by the attending of record. The primary clinical outcome will be a composite of AKI progression, dialysis and death at 14 days post-randomization. The primary process outcome will be the percent of recommendations made that are enacted within 24 hours after randomization.
Study Type
Enrollment (Estimated)
Phase
- Not Applicable
Contacts and Locations
Study Contact
- Name: Francis P Wilson, MD MSCE
- Phone Number: 2037371704
- Email: francis.p.wilson@yale.edu
Study Locations
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Connecticut
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New Haven, Connecticut, United States, 06510
- Recruiting
- Yale New Haven Hospital
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Contact:
- Francis Wilson, MD
- Email: francis.p.wilson@yale.edu
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Adults ≥ 18 years admitted to a participating hospital (six hospitals in the Yale New Haven Health system and two hospitals of the John Hopkins University Health system)
Stage 1 Acute Kidney Injury as defined by KDIGO creatinine criteria:
- 0.3 mg/dl increase in inpatient serum creatine over 48 hours OR
- 50% relative increase in inpatient serum creatinine over 168 hours
Exclusion Criteria:
- Admission to hospice service or comfort measures only order
- Recipient of a solid organ transplant
Immediate dialytic indication determined by the following:
- serum K >/= 7
- arterial pH < 7.15
- BUN > 150 mg/dL
- acute ingestion of dialyzable toxins
- refractory volume overload
Patients who meet any of these critical values will not be enrolled in the trial and the Kidney Action Team will directly notify the treating team.
- Pre-existing CKD stage V or End Stage Kidney Disease
- Initial hospital creatinine > 4.0 mg/dl
- Patients who have been seen by nephrology or already have a nephrology consult
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Health Services Research
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Triple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
No Intervention: Usual Care
Kidney Action Team Recommendations will not be delivered to the primary care teams of randomized patients.
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Experimental: Kidney Action Team Recommendations
Recommendations made by the Kidney Action Team will be delivered to the patient's primary care team within 30 minutes of AKI development.
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Upon review of the patient's medical information, the Kidney Action Team will create personalized recommendations that will be delivered to the patient's primary care team via a specialized note in the electronic medical record system within 30 minutes of AKI development.
The attending of record will be identified as a cosigner to ensure that a member of the care team is made aware of the note's presence.
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Composite outcome showing the percentage of participants with any one of the following: progression of AKI, inpatient dialysis, or inpatient death
Time Frame: 14 days post randomization or at hospital discharge
|
Progression of AKI is defined by an increase in KDIGO creatinine stage from that present at the time of randomization. Dialysis is defined by the receipt of hemodialysis, continuous renal replacement therapy or peritoneal dialysis. Isolated ultrafiltration treatments (for the purpose of volume removal) will not be included. Mortality will be determined from hospital administrative records. The rates of the primary outcome will be compared between the study arms using the Cochrane-Mantel-Haenszel chi-square test, accounting for stratification by hospital. |
14 days post randomization or at hospital discharge
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Percentage of recommendations implemented by the primary care team
Time Frame: 24 hours after randomization
|
The AKI Response Team will make recommendations for all randomized patients in both the control group and the intervention group, however, recommendations will only be delivered to the primary care teams of patients in the intervention group.
In this way, we can compare the percentage of recommendations that were followed by primary care teams across both groups.
This outcome will be assessed by averaging the proportion of recommendations followed within 24 hours between the two study arms using the Van Elteren test to account for stratification by hospital.
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24 hours after randomization
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Percentage of patients with progression of Acute Kidney Injury
Time Frame: Assessed from time of randomization to time of AKI progression (within 14 days post randomization)
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Percentage of patients who progressed from stage 1 to stage 2 or 3 or from stage 2 to stage 3 (based on changes in creatinine) within 14 days of randomization
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Assessed from time of randomization to time of AKI progression (within 14 days post randomization)
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Percentage of patients who receive inpatient dialysis
Time Frame: Assessed from time of randomization to time of receipt of inpatient dialysis (within 14 days post randomization)
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Percentage of patients who receive hemodialysis, continuous renal replacement, or peritoneal dialysis during index hospitalization within 14 days of randomization
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Assessed from time of randomization to time of receipt of inpatient dialysis (within 14 days post randomization)
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Percentage of inpatient mortality
Time Frame: Assessed from time of randomization to date of death from any cause, within 14 days of randomization
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Proportion of patients who expire within 14 days of randomization
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Assessed from time of randomization to date of death from any cause, within 14 days of randomization
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Collaborators and Investigators
Sponsor
Collaborators
Investigators
- Principal Investigator: Francis P Wilson, Yale Univerisity
Publications and helpful links
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Estimated)
Study Completion (Estimated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Estimated)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- 2000026203
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
IPD Sharing Time Frame
IPD Sharing Supporting Information Type
- STUDY_PROTOCOL
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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