Acute Kidney Injury in Care Transitions: The ACT Pragmatic Trial
openNIDDK - National Institute of Diabetes and Digestive and Kidney Diseases
PROJECT SUMMARY/ABSTRACT
Acute kidney injury (AKI) is an abrupt loss of kidney function that affects 1 in 5 hospitalized patients. AKI
survivors experience a 1.5-2.5-fold higher risk of chronic kidney disease (CKD), a 1.4-fold higher risk of
cardiovascular disease, and 50% of affected individuals are readmitted within 1 year. Despite these grave
sequelae, the care of non-dialysis-dependent AKI survivors is inadequate. One-third of patients fail to receive
basic kidney health follow-up (i.e., laboratory assessment of kidney function and a visit with a clinician). 87% of
AKI survivors use nephrotoxic medications in the 3 years after discharge, which independently increases the
risk for CKD. These gaps are especially prominent in the 20% of AKI survivors from rural settings who
experience health disparities including transportation barriers, a higher comorbidity burden, decreased health
literacy, and reduced access to nephrology specialist care. Addressing these gaps in care facilitates
prognostication, decision making, medication reconciliation and supportive care which can limit AKI
complications. We therefore developed the AKI in Care Transitions (ACT) program, a multidisciplinary bundled
care delivery model tailored to individual prognosis. AKI survivors are risk-stratified according to post-discharge
prognosis. Those at the lowest risk are provided access to informational resources about AKI. Patients at
moderate risk receive kidney health education before discharge from nurses and coordinated follow-up in
primary care with a provider and a pharmacist in the 7-14 days after discharge. The highest-risk patients are
provided with home monitoring technology (e.g., blood pressure cuff, tablet for symptom assessments) and
followed remotely by nephrology specialists for up to 90 days. Pilot testing in an academic medical center
demonstrated feasibility, a significant increase in timely and complete follow-up, improved medication
reconciliation, and a decreased incidence of kidney disease progression. This proposal extends ACT to rural
settings to address the overall goal of creating effective, patient-centered, scalable care delivery models that
improve health outcomes for all AKI survivors. We will test the impact of ACT on health outcomes and
processes of care (e.g., kidney disease progression, excess days in acute care, adverse drug events,
guideline-concordant care) in rural patients using a pragmatic cluster randomized trial conducted in the Mayo
Clinic Health System (MCHS; Aim 1). We will then richly characterize the rural AKI survivor experience
including illness burden, treatment burden, and patient capacity (Aim 2a) and assess the impact of ACT (Aim
2b) using qualitative data gathered from rural patients at MCHS and the University of Maryland Medical
System. This innovative proposal leverages digital health and the multidisciplinary team to improve outcomes
and reduce health disparities for AKI survivors in rural settings.
Up to $796K
health research