eTable 1b. Functionality and effects of the reported AKI alerting systems.
| Author |
Early warning system: fully or semiautomated *1/ recipient |
Algorithm triggering the alert (AKI definition) |
Relay of information on AKI (disruptive/ non-disruptive) |
Concrete treatment recommendations |
Nephrology consultant support |
Recovery of renal function |
Progress parameter | In-hospital mortality |
| Rind et al. (18) |
Fully automated Treating hospital physicians |
≥ 44 μmol/L creatinine increase + administration of nephrotoxic/ renally eliminated medication ≥ 50% creatinine increase to >177 μmol/L |
Non-disruptive (by email with response/reply options) |
Yes (indication that AKI developed while nephrotoxic substance was given) | – | – | Stopping nephrotoxic medication: 21 h earlier than in control group Creatinine increase in patients on nephrotoxic drugs: 26 µmol/L lower than in control group |
|
| McCoy et al. (19) |
Semiautomated Treating hospital physicians |
≥ 0.5 mg/dL creatinine increase/decrease within 48 h after admission + administration of nephrotoxic/renally eliminated medication | Combination of non-disruptive and disruptive (dose adjustment according to renal function) elements | Yes (medication check) | – | – | Medication intervention (dose adjustment/ stopping medication) within 24 h after AKI: increase from 35% to 53% | – |
| Thomas et al. (20) |
Fully automated Treating hospital physicians |
≥ 75% creatinine increase from previous level |
Non-disruptive (text alert in laboratory program) | No | – | 83% (without deterioration of renal function according to CKD stage) |
Acute kidney replacement therapy: 2.8% | AKI stage 1–3: 36% AKI stage 1: 29% AKI stage 2: 38% AKI stage 3: 42% |
| Selby et al. (13, 21) |
Semiautomated Treating hospital physicians |
>50% creatinine increase from previous level |
Non-disruptive (text alert in laboratory program) | Yes (link to bundled treatment recommendations) |
7.5% | AKI total: 73% AKI stage 1: 80.0% AKI stage 2: 69.9% AKI stage 3: 58.8% |
Duration: AKI stage 1: 8 days AKI stage 2: 9 days AKI stage 3: 11 days Acute kidney replacement therapy: 3.4% |
AKI stage 1–3: 23.8% AKI stage 1: 16.1% AKI stage 2: 33% AKI stage 3: 36.1% 30 day mortality: 23.7% (before AKI alert) vs 19.5% (after introduction of AKI alert + bundle of measures), RR: 1.22 (95%-CI unquantifiable) |
| McCoy et al. (22) |
Semiautomated Treating hospital physicians, hospital pharmacists |
≥ 0.5 mg/dL creatinine increase/decrease within 48 h after admission + administration of nephrotoxic/renally eliminated medication | Non-disruptive (pharmacy with real-time display of medications in patients with creatinine increase) | Yes (medication check) | – | – | Adverse drug effects: control group 8.0% vs intervention group 7.1% | – |
| Ahmed et al. (24) |
– Treating hospital physicians |
>50% creatinine increase from earlier level within 7 days (max) or >26 µmol/L increase from previous level in 2 days (max) | – | – | – | – | – | – |
| Flynn, Dawney (26) |
Fully automated Treating hospital physicians |
>50% creatinine increase from earlier level within 7 days (max) and creatinine increase >50 µmol/L Creatinine increase to >300 µmol/L | Non-disruptive (text alert in laboratory program, if higher creatinine level >50 µmol/L), disruptive (laboratory informed ward physician if creatinine level >100 µmol/L) | Yes (link to bundled treatment recommendations) | – | 80% (up to 120 days after AKI episode: subsequent creatinine level no higher than 20% of original level) | – | AKI stage 1–3: 23.9% AKI stage 1: 11% AKI stage 2: 27% AKI stage 3: 50% |
| Colpaert et al. (23) |
Fully automated Treating ITU physicians |
>50% creatinine increase from earlier level within 7 days (max) or reduction of diuresis <0.5 ml/kg/h over a minimum of 6 h | Disruptive (alert via DECT telephone call) | Yes (clinical re-evaluation, re-evaluation of findings) | – | AKI alert group vs AKI non-alert group: 66% vs 62% |
|
|
| Prendecki et al. (12) |
Fully automated Treating hospital physicians |
>150% creatinine increase from earlier level | Non-disruptive (text alert in laboratory program) | Yes (if medical emergency team was requested to attend simultaneously with AKI) | – | – | 9.7% readmission to hospital with AKI
|
24.9%, of which: 47.5% vs 19.4%: >24 h vs <24 h after aki alert seen by critical care and outreach team
|
| Thomas et al. (25) |
Fully automated “Before“ phase: Treating hospital physicians “After“ phase: Treating hospital physicians + nephrologist |
≥ 75% creatinine increase from earlier level | Non-disruptive (text alert in laboratory program) | Yes (nephrology consultant support in “after“ phase: fluids, medication, diagnosis, monitoring, nutrition/diet) |
|
– |
|
After 3 years:
|
| Porter et al. (27) |
Fully automated Treating hospital physicians |
>50% creatinine increase from previous level within 7 days (max) or >26 µmol/L increase from previous level within 2 days (max) | Non-disruptive (text alert in laboratory program) | Yes (link to bundled treatment recommendations) | – | – | Length of hospital stay: AKI: median 9 days AKI stage 1: 9 days AKI stage 2: 9 days AK stage 3: 10 days AKI progression: 24.8% AKI stage 1 to 2: 8.2% AKI stage 1 to 3: 2.6% AKI stage 2 to 3: 14% |
AKI stage 1–3: 18.5% AKI stage 1: 12.5% AKI stage 2: 28.4% AKI stage 3: 35.7% |
| Wallace et al. (28) |
Semiautomated Treating hospital physicians |
>26 µmol/L or >50% creatinine increase from previous level; creatinine increase to >300 µmol/L in non-dialysis patients |
Non-disruptive in AKI stage 1 (text alert); disruptive in AKI stage 2 with information to ward physician; AKI stage 3 with information to ward physician and nephrologist | Yes (link to bundled treatment recommendations) | – | – | Acute kidney replacement therapy: 4% Length of inpatient stay: without AKI: 2 days with AKI: 8 days (stage 1: 8 days, stage 2: 9 days, stage 3: 9 days) AKI progression: 9.9% AKI stage 1 to 2: 50% AKI stage 1 to 3 or 2 to 3: 50% |
Without AKI: 2.3% With AKI: 21.4% AKI stage 1: 18% AKI stage 2: 22% AKI stage 3: 32% |
| Gulliford, Sloan (29) |
Fully automated Doctor trained for AKI treatment, with information to treating hospital physicians |
>200% creatinine increase from previous level within 7 days (max) or acute dialysis | Non-disruptive | Yes (consultant support by acute medical specialists trained in AKI) | – | – | Higher rate of renal ultrasonography, specialist treatment than in the international comparison (Medcalf J. NHS Kidney Care 2012) | After 3 months:
|
| Wilson et al. (14) |
Fully automated Medical ward staff (intern, resident, nurse practitioner) and ward pharmacist |
>50% creatinine increase from previous level within 7 days (max) or >26 µmol/L increase from previous level within 2 days (max) | Non-disruptive (text page/letter/fax) | No (link to AKI-KDIGO guidelines, 273 pages) | Group with alert: 10% Group without alert: 9% |
– | Creatinine increase, length of inpatient stay (9.7 days), dialysis rate (8.7%) non-significant;no difference between groups in AKI treatment (fluids, aminoglycosides and NSAIDs, urinanalysis, ultrasonography) and AKI documentation | Group with alert: 9.8% Group without alert: 9.4%
|
| Kolhe et al. (11, 30) |
In both studies: fully automated Treating hospital physicians |
In both studies: >50% creatinine increase from previous level within 7 days (max) or >26 µmol/L increase from previous level within 2 days (max) | In both studies: disruptive (regarding relaying the treatment recommendation: disruptive in one study period versus non-disruptive in the next study period) |
In both studies: yes (standardized bundle of measures, further education/training in AKI for all specialty disciplines) | 15.7% and 14.5% |
– and – |
AKI program: 6.3/7.4%,of which: group with implemented treatment recommendations in <24 h (3.9/6.0%) vs >24 h (8.1/8.0%), p = 0.01/ 0.042; Length of inpatient stay <24 h (11/10.9 days) vs >24 h (13/ 11.5 days) acute dialysis: –/2.1% non-significant |
18/20.4% (early treatment group) vs 23.1%/24.4%, (late treatment group) p = 0.046/0.017
|
*1 Fully automated: algorithm identifies defined creatinine increase and automatically triggers alarm signal to recipient; semiautomated: algorithm identifies defined creatinine increase, which is verified by a doctor—in most cases a laboratory physician—before the doctor triggers the alarm signal.
*2 RR, relative risk of dying for patients in the control group, compared with patients in the alert group. AKI, acute kidney injury; CKD stage, chronic kidney disease stage; ITU, intensive care unit; 95% CI, 95% confidence interval