News: AI-triggered nephrology consult fails to prevent acute kidney injury in trial

Early nephrology consultations triggered by real-time machine-learning risk scores failed to prevent increases in peak serum creatinine among hospitalized patients at risk for severe acute kidney injury (AKI), a randomized trial published in JAMA Network Open showed.

The single-center trial ran at the University of Chicago from March 2019 to August 2024, randomizing 180 hospitalized patients without baseline AKI who triggered an Electronic Signal to Prevent AKI (ESTOP-AKI) score greater than 0.01. Triggered by ESTOP-AKI score, the automated nephrology consultation included an in-person assessment covering volume status, kidney perfusion, drug dosing, electrolytes, nutrition, and diagnostic testing.

Because these findings were framed as traditional, non-mandatory consultation notes rather than direct orders, primary teams were not obligated to follow them. The usual care group only received nephrology consultations upon a direct, manual request from the primary team.

Among 180 patients, the adjusted mean difference in seven-day serum creatinine was comparable between those who had an early nephrology consultation and those who received usual care (0.04 mg/dL versus -0.03 mg/dL, P=0.30), according o the researchers.

Additionally, there was no significant difference between the two arms in the development of Kidney Disease: Improving Global Outcomes (KDIGO) stage 1 or higher AKI (42% versus 36%, P=0.47) or stage 2 or higher AKI (19% versus 13%, P=0.28).

The intervention also did not show a significant effect on secondary endpoints such as AKI severity, hospital length of stay, inpatient mortality, or 90-day outcomes.

While the intervention group received substantially more recommendations versus the usual care group, clinician adherence to these recommendations was low. "It is possible that this low uptake of early consultative recommendations contributed to the trial outcome," researchers pointed out.

During the study period, there were 121 early nephrology consultations containing 270 recommendations compared with 19 usual care consultations and 36 recommendations. The most common recommendations in the intervention and usual care groups included:

• Changing patients' diet: 28.9% versus 13.9%
• Stopping medications: 20.7% versus 16.7%
• Changing medication doses: 11.9% versus 11.1%

Recommendations for medication dosage and discontinuation, diuretics or fluids, and vasopressors were more likely to be completely followed in the usual care arm (68%) compared with the intervention arm (41%). Evidence-based recommendations may simply be ineffective before KDIGO-defined AKI fully manifests, researchers suggested. "It is not clear if stopping exposure to a nephrotoxin or dose reducing a medication before there is evidence of [serum creatinine]-based AKI improves outcomes," they wrote.

Because so many hospitalized patients have general AKI risks, primary teams may struggle to distinguish critical recommendations from minor ones, the report said.

Editor’s note: To read the full study, click here. To read the accompanying commentary, click here. To read additional coverage from MedPage Today, click here.