Managing acute kidney injury (AKI) can be challenging, in part because evidence about when to begin treatment — namely, dialysis and other forms of renal replacement therapy that artificially filter the blood — is quite limited and offers conflicting perspectives.
To help bring clarity to this common problem in ICUs – with serious consequences – Brigham and Women’s Hospital (BWH) researcher Mallika L. Mendu, MD, and her colleagues developed a decision-making algorithm to guide clinicians in deciding when to initiate renal replacement therapy (RRT). It captures and integrates current data around AKI, including randomized controlled trials, observational studies, and general clinical consensus. The algorithm (also called a Standardized Clinical Assessment and Management Plan or “SCAMP”) was tested in 176 patients managed by nine nephrologists in the Division of Renal Medicine at BWH. The prospective study was published in the Clinical Journal of the American Society of Nephrology in January 2017.
Recognizing the limits of existing evidence around AKI, Dr. Mendu and her colleagues also provided opportunities for clinicians to deviate from the algorithm and record those deviations. For example, for patients whose blood pH is severely low, the SCAMP recommends initiating RRT. Clinicians who deviate from this plan can indicate why they opted not to begin the therapy by choosing from a list of reasons or providing their own. This information was captured by the researchers for incorporation into subsequent studies.
Dr. Mendu and her colleagues found that physician adherence to the algorithm was associated with lower in-hospital patient mortality in less severe cases of AKI. No significant association was found for patients with severe disease.
“Algorithm-based care can help improve how we care for patients with complex diseases,” says Dr. Mendu, assistant medical director for Quality and Safety at BWH. “What’s exciting here is that we have some preliminary evidence of a real benefit for patients with acute kidney injury — a condition that is not only devastating for patients but also often challenging for physicians to manage.”
Based on these results, SCAMP is now being used in multiple ICUs at BWH, in alternating months to learn more about the algorithm’s impact. It is thought to be one of the only such tools in use in the United States. Dr. Mendu and colleagues also are working on a new phase of the study that expands the number and diversity of patients to include those in other intensive care settings. Partner sites have been identified in Brazil and at Baylor University.