Wang Han, Deng Lingling, Li Ting, Liu Kang, Mao Huijuan, Wu Buyun
Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.
Critical Care Center, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.
Crit Care. 2025 May 12;29(1):189. doi: 10.1186/s13054-025-05402-x.
Acute kidney injury (AKI) is a critical yet frequently under diagnosed condition in hospitalized patients, impacting morbidity and mortality. Electronic alerts for AKI aimed to assist physicians in early diagnosis and intervention, though evidence for their effectiveness is inconsistent.
A systematic search was conducted in PubMed, the Cochrane Central Register of Controlled Trials, Cochrane Library, and Web of Science from inception to November 2024. Eligible studies included randomized controlled trials (RCTs), before-and-after analyses, and stepped-wedge designs involving hospitalized patients. The primary outcomes were mortality and renal replacement therapy (RRT) rates, Secondary outcomes included hospital length of stay (LoS), AKI progression and recovery. Care-centered outcomes encompassed nephrologist consultation, nephrotoxic medication discontinuation and medication review. Subgroup analysis examined the impact of response intensity, hospital type and geographic region on these outcomes.
Twenty-two studies involving 170,696 participants were included: 8 RCTs (n = 21,710) and 14 non-RCTs or observational studies (n = 148,986). RCTs showed no effect on mortality (RR 1.02; 95% CI 0.97-1.07) or LoS (mean difference 0.04; 95% CI - 0.13 to 0.22) but a significant increase in RRT use (RR 1.13; 95% CI 1.02-1.26) with AKI alert systems. Non-RCTs, however, reported reduced mortality (RR 0.92; 95% CI 0.88-0.96), less AKI progression (RR 0.85; 95% CI 0.77-0.94), enhanced kidney recovery (RR 1.65; 95% CI 1.56-1.75), increased nephrotoxic drug discontinuation (RR 1.20; 95% CI 1.13-1.28), and higher drug review rates (RR 1.19; 95% CI 1.17-1.21), with no impact on RRT use (RR 1.08; 95% CI 0.87-1.36). Subgroup analysis revealed an increased in-hospital mortality in low response intensity (RR 1.15; 95% CI 1.00-1.32), reduced mortality in moderate response intensity (RR 0.93; 95% CI 0.89-0.97), and unclear effects in high response intensity (RR 0.88; 95% CI 0.70-1.09). AKI alert was also favored in teaching hospitals and in several regions (Europe, North America and South America).
The efficacy of AKI alerts remains inconclusive. Current evidence do not support or refute their effectiveness. Variability in response intensity, hospital type and geographic region may help explaining discrepancies, underscoring the need for further research to optimize AKI alert systems with more effective action in clinical practice.
急性肾损伤（AKI）是住院患者中一种严重但常被漏诊的疾病，影响发病率和死亡率。针对AKI的电子警报旨在帮助医生进行早期诊断和干预，但其有效性的证据并不一致。
从创刊至2024年11月，在PubMed、Cochrane对照试验中心注册库、Cochrane图书馆和科学网进行了系统检索。符合条件的研究包括随机对照试验（RCT）、前后分析以及涉及住院患者的阶梯楔形设计。主要结局为死亡率和肾脏替代治疗（RRT）率，次要结局包括住院时间（LoS）、AKI进展和恢复情况。以护理为中心的结局包括肾内科会诊、停用肾毒性药物和药物审查。亚组分析考察了反应强度、医院类型和地理区域对这些结局的影响。
纳入了22项涉及170,696名参与者的研究：8项RCT（n = 21,710）和14项非RCT或观察性研究（n = 148,986）。RCT显示对死亡率（RR 1.02；95% CI 0.97 - 1.07）或LoS（平均差0.04；95% CI - 0.13至0.22）无影响，但AKI警报系统使RRT使用显著增加（RR 1.13；95% CI 1.02 - 1.26）。然而，非RCT报告死亡率降低（RR 0.92；95% CI 0.88 - 0.96）、AKI进展减少（RR 0.85；95% CI 0.77 - 0.94）、肾脏恢复增强（RR 1.65；95% CI 1.56 - 1.75）、停用肾毒性药物增加（RR 1.20；95% CI 1.13 - 1.28）以及药物审查率提高（RR 1.19；95% CI 1.17 - 1.21），对RRT使用无影响（RR 1.08；95% CI 0.87 - 1.36）。亚组分析显示，低反应强度时院内死亡率增加（RR 1.15；95% CI 1.00 - 1.32），中等反应强度时死亡率降低（RR 0.93；95% CI 0.89 - 0.97），高反应强度时效果不明确（RR 0.88；95% CI 0.70 - 1.09）。AKI警报在教学医院和几个地区（欧洲、北美和南美）也更受青睐。
AKI警报的疗效仍不确定。目前的证据既不支持也不反驳其有效性。反应强度、医院类型和地理区域的差异可能有助于解释差异，强调需要进一步研究以优化AKI警报系统，使其在临床实践中采取更有效的行动。
