Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury: A Randomized Clinical Trial.

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.

Severe fluctuation in mean perfusion pressure is associated with increased risk of in-hospital mortality in critically ill patients with central venous pressure monitoring: A retrospective observational study.

BACKGROUND: The mean perfusion pressure (MPP) was recently proposed to personalize tissue perfusion pressure management in critically ill patients. Severe fluctuation in MPP may be associated with adverse outcomes. We sought to determine if higher MPP variability was correlated with increased mortality in critically ill patients with CVP monitoring. METHODS: We designed a retrospective observational study and analyzed data stored in the eICU Collaborative Research Database. Validation test was conducted in MIMIC-III database. The exposure was the coefficient of variation (CV) of MPP in the primary analyses, using the first 24 hours MPP data recorded within 72 hours in the first ICU stay. Primary endpoint was in-hospital mortality. RESULTS: A total of 6,111 patients were included. The in-hospital mortality of 17.6% and the median MPP-CV was 12.3%. Non-survivors had significantly higher MPP-CV than survivors (13.0% vs 12.2%, p<0.001). After accounting for confounders, the highest MPP-CV in decile (CV > 19.2%) were associated with increased risk of hospital mortality compared with those in the fifth and sixth decile (adjusted OR: 1.38, 95% Cl: 1.07-1.78). These relationships remained remarkable in the multiple sensitivity analyses. The validation test with 4,153 individuals also confirmed the results when MPP-CV > 21.3% (adjusted OR: 1.46, 95% Cl: 1.05-2.03). CONCLUSIONS: Severe fluctuation in MPP was associated with increased short-term mortality in critically ill patients with CVP monitoring.

Increased mean perfusion pressure variability is associated with subsequent deterioration of renal function in critically ill patients with central venous pressure monitoring: a retrospective observational study.

PURPOSE: The mean perfusion pressure (MPP) was recently proposed to personalized management tissue perfusion pressure in critically ill patients. Increased MPP variability (MPPV) may be associated with organ injuries. Our objective was to determine if increased MPPV was associated with subsequent deterioration of renal function in critically ill patients. METHODS: We analyzed data stored in the eICU-CRD and MIMIC-IV databases. The exposure was MPPV, measured as the coefficient of variation (CV) using the MPP data of the first 24 h after first ICU admission. The primary endpoint was deterioration of renal function, defined as new-onset or progress of acute kidney injury between 24 and 72 h after ICU admission. RESULTS: The study population consisted of 8,590 patients from eICU-CRD and 6,723 patients from MIMIC-IV database. A total of 28.4% and 30.2% of the study population experienced deteriorated renal function, respectively. Patients with deteriorated renal function had significantly higher median MPP-CV compared with those without (12.2% vs 11.5% and 12.8% vs 12.5%, p < .001). In fully adjusted multivariate logistic models, higher MPP-CV (adjusted OR per 1-SD, 1.08; 95% CI, 1.02-1.13 and adjusted OR per 1-SD, 1.06; 95% CI, 1.00-1.12, respectively) was significantly associated with greater risk of primary endpoint. The pooled analyses showed heterogeneity in patients with cardiac surgery, medical sepsis and others. CONCLUSION: Increased MPPV was associated with an increased risk of subsequent deterioration of renal function in critically ill patients with central venous pressure monitoring. Maintaining stable MPP may reduce the risk of renal function deterioration.

The Association of an Early Net Ultrafiltration Rate and 28-Day Mortality in Patients Receiving Continuous Kidney Replacement Therapy.

Background: An early net ultrafiltration (NUF) rate may be associated with prognosis in patients receiving continuous kidney replacement therapy (CKRT). In this study, we tested whether high or low early NUF rates in patients treated with CKRT were associated with increased mortality. Methods: We conducted a retrospective, observational study among all patients in the Medical Information Mart for Intensive Care IV database who received CKRT for more than 24 h within 14 days after intensive care unit admission. We defined the early (initial 48 h) NUF rate as the amount of fluid removal per hour adjusted by the patients' weight and took it as a classified variable (low rate: <1.6, moderate rate: 1.6-3.1 and high rate: > 3.1 ml/kg/h). The association between 28-day mortality and the NUF rate was analyzed by logistic regression and mediation analyses. Results: A total of 911 patients were included in our study. The median NUF rate was 2.71 (interquartile range 1.90-3.86) ml/kg/h and the 28-day mortality was 40.1%. Compared with the moderate NUF rate, the low NUF rate (adjusted odds ratio 1.56, 95% CI 1.04-2.35, p = 0.032) and high NUF rate (adjusted odds ratio 1.43, 95% CI 1.02-2.01, p = 0.040) were associated with higher 28-day mortality. The putative effect of high or low NUF rates on 28 day mortality was not direct [adjusted average direct effects (ADE) for a low NUF rate = 0.92, p = 0.064; adjusted ADE for a high NUF rate = 1.03, p = 0.096], but mediated by effects of the NUF rate on fluid balance during the same period [adjusted average causal mediation effects (ACME) 0.96, p = 0.010 for a low NUF rate; adjusted ACME 0.99, p = 0.042 for a high NUF rate]. Moreover, we found an increase trend in the NUF rate corresponding to the lowest mortality when fluid input increased. Conclusion: Compared with NUF rates between 1.6-3.1 ml/kg/h in the first 48 h of CKRT, NUF rates > 3.1 and <1.6 ml/kg/h were associated with higher mortality.

Body Composition Analysis as a Predictor of Prognosis for Patients With Acute Kidney Injury Requiring Kidney Replacement Therapy.

OBJECTIVES: The aim of this study is to investigate the association between body composition, measured by bioelectrical impedance analysis, and outcomes in patients with acute kidney injury (AKI) receiving kidney replacement therapy (KRT). METHODS: Patients with severe AKI treated with KRT in our hospital between September 2016 and August 2018 were enrolled. These patients were assessed by body composition analysis before KRT, and on the 3rd day and the 7th day after initiation of KRT. The predictors included lean tissue index (LTI), fat tissue index, and body cell mass index (BCMI). The association between all-cause mortality and predictors was analyzed using Cox regression. RESULTS: A total of 152 patients were included in this study, with a 28-day mortality of 46.7% and 1-year mortality of 60.5%. LTI (adjusted hazard ratio per standard deviation: 0.37; 95% confidence interval = 0.21-0.66, P < .001) and BCMI (adjusted hazard ratio per standard deviation: 0.37; 95% confidence interval = 0.21-0.67, P < .001) on day 7 after initiation of KRT, rather than before KRT, were associated with mortality during follow-up. LTI and BCMI before KRT were associated with 28-day mortality rather than 1-year mortality. CONCLUSIONS: LTI and BCMI before KRT were associated with short-term prognosis, and those on day 7 after KRT initiation were associated with intermediate mortality in patients with AKI requiring KRT.