Medication-targeted alerts for the risk of AKI

Automated alerts for acute kidney injury (AKI) in hospitalised patients who are about to receive either non-steroidal anti-inflammatory drugs (NSAIDs), renin–angiotensin–aldosterone system inhibitors (RAASi), or proton pump inhibitors (PPIs) can increase the rate of cessation of these potentially nephrotoxic medications. Patients who were exposed to PPIs experienced significantly improved outcomes [1].

“AKI in the hospital often goes undetected,” said Dr F. Perry Wilson (Yale School of Medicine, CT, USA). “It is particularly common in individuals who are exposed to certain medications. What is more concerning though is a high rate of continuation of medications amongst these patients, which may influence kidney function.” This relates especially to NSAIDs and RAAS which decrease kidney perfusion, as well as PPIs, which may contribute significantly to interstitial inflammation. NSAIDs are often discontinued in AKI patients, NSAIDS are debated, and PPIs are generally not stopped in patients with AKI.

A pragmatic, open-label, parallel-group, randomised controlled trial conducted from August 2020 to November 2021 at 4 US hospitals, assessed the effect of an automated, electronic ‘pop-up’ alert during medication order entry, which flagged the above-mentioned drugs for potential discontinuation, versus usual care. The primary outcome was a composite of progression of AKI, dialysis, or death within 14 days or hospital discharge, whichever occurred first. Eligible patients were hospitalised adults with Kidney Disease Improving Global Outcomes (KDIGO) stage 1 AKI and an active order for either NSAIDs, RAASi, or PPIs. In total, 5,060 patients were included over 15 months; median age was 70 years, 48% were female, and 19% were Black. Most patients were receiving a PPI (65% each in the alert and usual care group), followed by an RAASi (53% in each group), and an NSAID (30% and 32%, respectively). “Overall, a statistically significant increase in the rate of drug cessation of any or at least 1 of the 3 drug classes within 24 hours after the alert occurred in 61.1% of patients in the alert group versus 55.9% of patients in the usual care group (P=0.0003). The most significant increase in discontinuation occurred in those patients taking PPIs,” Dr Wilson explained. The composite outcome occurred in 23.1% of patients in the alert group and 25.3% of patients in the usual care group (RR 0.92; 95% CI 0.83–1.01; P=0.09). The results were consistent across several pre-specified subgroups based on parameters such as age, sex, and race. However, Dr Wilson highlighted that the alerts were most helpful in patients with low baseline serum creatinine levels at admission. According to Dr Wilson, a potential explanation for the improved outcomes in patients on PPIs at the time of admission could be that PPIs are underappreciated as a contributor to AKI and that treatment with a PPI may be a marker of ‘sicker’ patients who may have more to gain from quicker identification of their AKI. “The next step is to assess adding more refinement to the alert process,” Dr Wilson concluded [1].

1. Wilson FP, et al. Automated, Medication-Targeted Alerts on AKI Outcomes: A Multi-Center Randomized, Controlled Trial. FR-OR63, ASN Kidney Week 2022, 3–6 Nov.

 

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Posted on 8 December 2022