Evaluating a Team-Based Kidney Care Program After Hospital Discharge for Adults with Moderate to Severe Acute Kidney Injury

What this Trial Is About

This research investigates the impact of a team-based kidney care program on adults who have survived moderate to severe acute kidney injury AKI after a hospital stay. The study aims to evaluate how this multidisciplinary approach affects patient-centered outcomes compared to usual care. The goal is to improve recovery and prevent complications after hospital discharge by providing tailored support based on individual risk. Participants are assigned to one of two groups. The intervention group receives risk-based kidney care before leaving the hospital, which may include education, referrals to primary care with medication reviews, or nephrologist-led care combined with remote monitoring for up to 90 days post-discharge. The usual care group receives standard education, laboratory tests, and clinical follow-up after discharge. This pragmatic trial compares these approaches to assess their effects on health outcomes. During the study, participants are monitored for hospital-free days over 90 days, 180 days, and one year. Researchers also track hospital readmissions, death, kidney function changes, recurrence of AKI, chronic kidney disease progression, and cardiovascular events. Follow-up evaluations include laboratory tests, medication reviews, and specialist consultations. The research spans up to one year to assess the long-term effects of the kidney care program on patient health and recovery.

Acute Kidney Injury In Care Transitions (ACT): Pragmatic Clinical Trial