Digital health and acute kidney injury: consensus report of the 27th Acute Disease Quality Initiative workgroup

Acute kidney injury (AKI), which is a common complication of acute illnesses, affects the health of individuals in community, acute care and post-acute care settings. Although the recognition, prevention and management of AKI has advanced over the past decades, its incidence and related morbidity, mortality and health care burden remain overwhelming. The rapid growth of digital technologies has provided a new platform to improve patient care, and reports show demonstrable benefits in care processes and, in some instances, in patient outcomes. However, despite great progress, the potential benefits of using digital technology to manage AKI has not yet been fully explored or implemented in clinical practice. Digital health studies in AKI have shown variable evidence of benefits, and the digital divide means that access to digital technologies is not equitable. Upstream research and development costs, limited stakeholder participation and acceptance, and poor scalability of digital health solutions have hindered their widespread implementation and use. Here, we provide recommendations from the Acute Disease Quality Initiative consensus meeting, which involved experts in adult and paediatric nephrology, critical care, pharmacy and data science, at which the use of digital health for risk prediction, prevention, identification and management of AKI and its consequences was discussed. In this Consensus Statement, the authors discuss a framework for the development, validation and implementation of digital health technologies across the acute kidney injury continuum — risk prediction, prevention, detection and management.


Current digital health landscape
Current DHAKI status DHAKI use in AKI management

Conclusion
A full list of affiliations appears at the end of the paper.e-mail: Kashani.Kianoush@mayo.edu;abihorac@ufl.edu;rmehta@health.ucsd.edu

Introduction
Acute kidney injury (AKI) is a common complication of acute illnesses and can occur in the community, and in acute or post-acute care settings.AKI is associated with considerable clinical outcomes and health care costs [1][2][3] .However, despite knowledge advances and technological innovations, improvements in the care and outcomes of patients with AKI worldwide have been limited.Digital innovation in medical technologies -digital health -is increasingly used in modern health care 4,5 .Digital health has been introduced and implemented in multiple domains and offers numerous opportunities to improve care throughout the AKI care continuum.This continuum comprises various interconnected states -AKI risk, kidney injury or dysfunction, and associated short-and long-term outcomes -and therefore encompasses AKI prevention, early recognition, management and recovery of patients, some of whom will be receiving dialysis 6,7 .Importantly, inequitable access to technology, also termed the 'digital divide', limits the potential benefits of digital health.The 27th Acute Disease Quality Initiative (ADQI) conference was convened to develop a framework for appropriate development, validation and implementation of digital health in AKI care (DHAKI).

Methods
The 27th ADQI Consensus Conference included a diverse panel of 30 participants who represented relevant disciplines, including paediatric and adult nephrology, critical care medicine, pharmacy, data science, ethics and digital law, from North America, South America and Europe.The consensus meeting followed the established ADQI process, using a modified Delphi method, as previously described 8 .The broad objective of ADQI is to assess current knowledge and provide expertise-based statements that can guide clinicians and investigators, and to identify clinical research priorities to address gaps in knowledge.The 27th ADQI consensus meeting focused on DHAKI and was held over 2.5 days in San Diego, California, USA, on 4-6 March 2022.
The activities at the consensus conference were divided into three parts.The pre-conference activities involved a comprehensive search of the literature for assessment of the current evidence related to the diagnostic and management strategies for the AKI continuum, including acute and post-acute care, as well as care in the community, using digital health solutions.Each workgroup was tasked with summarizing the scope, implementation and evaluation strategies currently used to develop, validate, and implement DHAKI-driven solutions.Using virtual meetings, each workgroup identified the current state of knowledge to enable the formulation of the main questions from which discussion and consensus would be developed before the panel meeting.The consensus meeting included several breakout sessions, during which each group created their consensus positions and recommendations, before sharing, debating and refining them in a plenary session, which involved the whole panel.This process (modified Delphi) was repeated three times during the conference before the final statements were formulated and shared with the entire group.After the meeting, the summary reports from each group were collated to generate a report and summary recommendations, followed by revision and approval by all ADQI participants.

Consensus statement
with greater health autonomy (through better patient engagement and shared decision-making) and empowerment for individuals to enable informed health decisions, and improved population-level interventions (that is, public health initiatives) 11,12 .Digital health could therefore improve clinical care and outcomes in several domains (Fig. 1).

Health information technology.
HIT involves the processing, storing and exchanging of health information in an electronic environment.EHRs are a vital part of HIT as they contain the medical and treatment histories of patients.These records can be integrated with clinical-decision support tools that health care professionals and patients can use to make health care decisions, and that enable automation and streamlining of health care professional workflows.
Artificial or augmented intelligence.Although health systems are increasingly turning to artificial intelligence (AI) to accelerate the informed decision process, we must emphasize that the judgment of health care professionals still has a crucial role in the decision-making process 13 .AI is an umbrella term that encompasses machine learning (ML) techniques, algorithms and software applications that mirror and support human decision-making by integrating, analysing and using health care data.Augmented intelligence uses AI to assist, facilitate, nudge and enhance human decision-making by leveraging computational methods such as machine or deep learning.
Telehealth and virtual care.Telehealth, also termed telemedicine, enables health care professionals to provide health care through electronic information and telecommunication technologies.Telehealth strategies came to the fore during the COVID-19 pandemic and have been used successfully to improve kidney care 14 .
Mobile health.mHealth is defined as medical and public health practice that is facilitated by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants and other wireless tools 15 .
Wearable sensors and devices.Innovations in wearables, hearables (that is, in-ear devices), and nearables (that is, neighbouring devices that interact with wearables) are transforming health care delivery, especially given the widespread availability of smartphones 16 .In addition, continuous progress in the miniaturization of integrated electronics has lowered the prices, size, weight and energy consumption of electronic sensors, while increasing their processing power, memory and wireless connectivity.Combined, these factors have boosted opportunities for wearable medical sensors to improve patient care across the care continuum.Notably, wearable biosensor technologies can be used to influence human behaviour, provide enhanced care at home, facilitate remote consults, patient education and connection with peer networks.
Digitally enabled therapeutics.DTx are evidence-based therapeutic interventions delivered to patients through software programs 17 .Although the role of DTx in AKI is not yet well-defined, several DTx tools have been successfully implemented in clinical care 18 .A relevant example of DTx includes fully automated and individualized insulin dosing using real-time glycaemic status data in patients with insulin-dependent diabetes mellitus 19 .

Current DHAKI status
What is the evidence that digital health influences patient outcomes in the AKI continuum?

Consensus statements
1. AKI alerts driven by concrete criteria improve early detection and prompt AKI management.2. Risk prediction models based on machine learning (ML) and/or AI might improve the identification of patients at a high risk of AKI who could benefit from tailored surveillance and primary prevention.3. The utility of ML-and/or AI-driven clinical decision support system (CDSS) tools to improve early recognition of AKI within the appropriate context, and to enable a multidisciplinary team to manage a patient through preventive and therapeutic interventions should be evaluated.
Most studies that evaluated electronic AKI alerts were retrospective and observational, although a few prospective observational

Consensus statement
quality improvement projects, quasi-experimental before-and-after studies and some randomized controlled trials (RCTs) have also been performed.These investigations were mostly directed at AKI recognition to facilitate timely patient management [20][21][22][23] .CDSS alert systems can recognize all stages of AKI.As most patients have stage 1 AKI at the time of detection, focusing on and implementing a directed intervention for patients with stage 1 AKI at a high risk of progression to stage 2 might be more useful than including all patients with stage 1 as most of these patients will only have transient kidney impairment.CDSS studies with patients at a high risk of AKI mainly include critically ill patients receiving nephrotoxins.The use of CDSS in these cases improved AKI documentation, recognition and response time 21,[24][25][26][27][28] , and reduced nephrotoxin administration 27,[29][30][31] .Of note, in most studies of such screening tools, the focus on achieving high alert sensitivity led to high numbers of false positives, which can cause alert fatigue and might dilute any improvements in relevant outcomes 32 .
Several kidney-related outcomes have also been evaluated, including AKI duration and progression, length of hospital stay, and the need for kidney replacement therapy (KRT) 28,30,31,[33][34][35] .Among patients who have already developed AKI, digital health might also be used to guide the personalized prescription of medication or KRT [36][37][38] , or to manage complications associated with AKI and dialysis (for example, intradialytic hypotension 39 ).However, findings on kidney-related outcomes have been inconsistent.Importantly, given that many of these CDSS alerts were designed for AKI recognition rather than as a clinical intervention, an effect on clinical and patient-centreed outcomes might have been unlikely 28,30,32,33,[40][41][42][43] .Of note, prospective RCTs and quality improvement studies that demonstrated improvements in kidney-related outcomes focused on risk and recognition, and typically involved a multidisciplinary team equipped with informatic resources 31,34,42 .Improved management of multidisciplinary teams is a proposed solution to improve processes of care and might therefore have contributed to the success of these CDSS-related trials 44 .Importantly, successful DHAKI adoption and implementation will require stakeholder engagement, which rarely occurs in prospective evaluations 45 .
As risk-based models for generating CDSS evolve, ML and the increasing digitalization of patient data yield opportunities for greater accuracy and timely prediction of AKI risk.In predominantly retrospective settings, researchers have demonstrated the ability of ML to predict AKI up to 48 h before onset [46][47][48][49][50][51][52][53][54] using routinely collected inpatient clinical data.Robust external validation 55 and evidence of transportability across sites 56 are promising, but the lack of prospective implementation and analysis of the clinical impact are significant gaps in the current literature.Any clinical benefits of digital health solutions will be more palpable as preventative or therapeutic strategies for AKI are developed and implemented.The potential successes of AKI prediction models in improving care processes or patient outcomes depend on the scale and scope of the datasets used to develop and validate these models.In addition, the explainability, adaptability and portability of these models affect their implementation and ability to guide feasible interventions that can affect relevant outcomes.However, nearly all current studies are limited by data inadequacy, whether in sample size or diversity, or by a lack of robust validation.Inadequate data transparency remains another substantial limitation.Furthermore, studies on the use of digital health solutions for the management of AKI are nearly impossible to replicate, as their findings are heavily dependent on the context of their development, applications and populations.Thus, drawing broad conclusions about these solutions is challenging without consensus standards for data management procedures, such as data harmonization and interoperability.

Consensus statements
1.The digital health influence on the AKI continuum at a population level is insufficiently addressed in the current literature.2. Health system-wide and/or nationwide population-based studies should be considered for DHAKI to assess its possible benefits, implementation barriers, costs, ease of use and portability, establish benchmarking for quality of care, and examine possible disadvantages in clinical practice.

Consensus statements
1.The evidence of digital health use for AKI recognition, risk classification, phenotyping and management in clinical settings has mainly originated from large academic tertiary care centres in resource-rich areas.2. DHAKI studies would benefit from differentiating AKI recognition and management in ambulatory compared with hospitalized settings, as well as in intensive care unit (ICU) compared with non-ICU settings across areas with different resource levels.3. The implementation of telehealth to support remote AKI and dialysis care in resource-limited areas will require additional investigation to assess adoption rates, utility and outcomes.
Current evidence on AKI alerts combined with ML and/or AI models used data from selected hospitalized patients in the ICU 54,[64][65][66] , in perioperative settings [67][68][69] or in the emergency department 70 .Of note, these have been primarily studies conducted in single health care settings in well-resourced areas.Data from community centres, particularly in resource-limited regions, are limited but the International Society of Nephrology's 0by25 initiative, which is an ongoing feasibility study focused on resource-limited areas, shows that a digital health strategy using telemedicine, coupled with an education programme and a point-of-care kidney function test for risk assessment, can identify AKI early, and guide treatment and patient education 71 .These findings support the feasibility of DHAKI implementation within integrated health systems in low-to-middle-income areas.
Successful teledialysis assessment for remote KRT management in rural acute care hospitals 72,73 suggests that this approach should be investigated further.Importantly, legal issues, costs and outcomes of AKI telemedicine remain unclear 74 .

Consensus statement
1.The utility of DHAKI in post-AKI management remains unclear, and substantial knowledge gaps must be addressed to determine the potential role of DHAKI in: Consensus statement • monitoring of kidney health in AKI survivors and patients at risk of CKD development or progression in ambulatory settings.• patient and clinician education through mobile applications.
• patient and caregiver empowerment through enhanced self-care.
Transitioning between the hospital and outpatient settings following AKI is challenging, and rehospitalizations are common 75,76 .DHAKI could empower patients to make informed decisions regarding their kidney health, especially during AKI recovery.However, although CDSS facilitates timely clinician recognition of AKI and subsequent intervention, these systems are not yet optimized to engage patients and caregivers.The role of digital mHealth applications and wearables has not been explored in AKI aftercare but, among patients with CKD or kidney transplant recipients, mHealth has had positive effects on medication adherence and safety [77][78][79] .Wearables were also beneficial in blood pressure monitoring, volume status assessment and oxygen saturation 80,81 .Future studies could focus on DHAKI-focused interventions that begin at or shortly after discharge 82 .

DHAKI use in AKI management
How should digital health be applied along the AKI care continuum?

Consensus statements
1. Patients and health care providers could use digital health to improve AKI risk stratification and recognition, personalize care, including the use of KRT, and optimize AKI recovery and follow-up.2. Digital health could guide resource allocation, surveillance and data integration at the health care system or population level.
Digital health could guide resource allocation by deploying and activating hospital and community nephrology rapid response teams (NRRTs) to identify patients at risk of AKI 83 .Population data from public health sources, integrated with social determinants of health, could be used to monitor trends in the incidence of community AKI and identify novel environmental risk factors.Numerous layers of digital patient health could be integrated through digital health technology, infrastructure and applications.Digital health could also influence patient care with prompts and appropriate alerts for AKI complications among patients at a high risk after hospital discharge.Digital health tools can also interface with pharmacists, nurses, primary care physicians and nephrologists to provide continuous updates on the kidney function of a patient and facilitate timely, guided and personalized treatment recommendations.For example, a digital health tool could guide avoidance of nephrotoxic medications in patients at a high risk, personalized resuscitation or de-resuscitation based on wearable technology, and AI-guided drug dose adjustment (Fig. 2).
In addition to the acute care setting, digital health tools such as point-of-care testing and wearable biosensors could be deployed in the community and in post-acute care to select patients at a high risk.For example, biosensor-enabled Bluetooth home toilet systems can provide biochemical urinalysis by integrating test strips 84 .Other applications of digital health solutions include monitoring kidney function in the community among patients who are at a high risk because they receive nephrotoxic medications, tracking the AKI-to-CKD transition by detecting the onset or progression of albuminuria early, or the development of cardiovascular diseases.Identifying such patients through these approaches could guide the implementation of evidence-based post-AKI long-term follow-up and prevention strategies.Approaches such as telemedicine-enabled virtual AKI clinics can prevent rehospitalization and reduce overburdening of patients or health care systems 73 .
Where in the AKI continuum could digital health be applied to improve care?

Consensus statements
1. Digital health could be applied in community (for example, at home or in pharmacies), acute (for example, emergency

Risk strati ication
Mobile health for prediction of drug-associated nephrotoxicity

Tailor response
Pre-procedure telehealth and virtual care consultation with providers

Virtual health coaching
Recognition Wearables for measurement of kidney function

Risk strati ication
AI-guided risk scores to predict recurrent hospitalization, CKD, cardiovascular events

Tailor response
• Wearables to tailor therapies for blood pressure, luid management • mHealth to optimize medication management and adherence

Guide AKI recovery
• Point of care testing to monitor recovery

Digital health pro ile
Patient data (wearables, mHealth) Health system data (HIT, telehealth) Population data (public health, social determinants) Fig. 2 | Areas with potential impact by digital health solutions across the AKI care continuum.Digital health solutions across the acute kidney injury (AKI) continuum could apply to the community, acute and post-acute care settings.The digital profile of individual patients, which is sourced from patient-related information, health care systems and population data, could be used to risk stratify patients for AKI, identify patients with AKI, tailor the clinical response to the risk or presence of AKI, and expedite AKI recovery in different settings.Adapted from the Acute Dialysis Quality Initiative 143 , CC BY 2.0 (https://creativecommons.org/licenses/by/2.0/).AI, artificial intelligence; CKD, chronic kidney disease; FAIR, findable, accessible, interoperable and reusable; HIT, health information technology; KRT, kidney replacement therapy; mHealth, mobile health.

Consensus statement
department, hospital ward or ICU), and post-acute (for example, in ambulatory care or skilled nursing facilities) care settings.Digital health solutions must be adapted to the available resources, data and technology to maintain continuity across settings.2. DHAKI stakeholders include patients, care partners, multidisciplinary clinicians, administrators, public health personnel, policymakers, payors, legal experts and industry.
Digital health solutions need to be validated in diverse cohorts across various AKI care continuums (Supplementary Table 2).These solutions must be acceptable and accessible to patients, providers and payors across different health care settings.Digital health could increase connectedness to transform AKI care, particularly if these solutions seamlessly cross the continuum of care to limit disruptions.For example, patients can receive virtual health coaching 85 before admission for a procedure associated with a high risk of AKI, followed by EHR-embedded risk prediction throughout the hospitalization period to deliver context-appropriate CDSS alerts or prompts to the care team 86 , followed by the use of wearables and remote monitoring to facilitate safe post-dismissal care and early detection of deterioration or complications 87 (Fig. 2).
Digital health applications must also be tailored to the available data, technology and resources.For example, using mobile phones and point-of-care tests in community and resource-limited settings could improve AKI detection and management 71 .In resource-intensive settings such as ICUs, digital health could be used to phenotype AKI and predict individual risks and responses to interventions 49 .(Supplementary Table 2).

Consensus statements
1. Digital health solutions for the AKI care continuum can improve access, timeliness, care coordination, self-management support, education, safety monitoring, quality, outcomes and the delivery of personalized care.2. Digital health could improve clinical decision-making and care quality through the development, standardization and monitoring of adherence to best practices, context-appropriate CDSS, resource allocation and suitability of care.
Digital systems have been used to improve the quality and safety of AKI care.EHRs have enabled the real-time or near real-time activation of NRRTs 86 .For example, the UK National Health Service (NHS) introduced a standardized electronic detection system for creatinine to decrease time-to-management 88 .For EHRs that support CDSS, computerized provider order entry and electronic prescribing, alerts related to rising creatinine can notify the clinical team or the patient via the EHR system or messaging, thereby providing real-time advice on the appropriate course of action and treatment choices 89 , sending an alert to a pharmacist or to an NRRT to prompt action 90,91 , and promote AKI prediction and earlier diagnosis 92 .The effects of employing similar systems to improve the quality of care throughout the AKI care continuum should be evaluated.

Consensus statements
1. Digital health supports discovery science and applied precision medicine by identifying causal pathways, social determinants and mechanisms of AKI, as well as enabling diagnostic and therapeutic discoveries, phenotyping and personalization.2. Digital health facilitates research across the AKI continuum through enhanced patient engagement, enrolment, intervention allocation in clinical trials, data collection, analysis and dissemination.3. Digital health interventions warrant independent evaluation for their use along the AKI continuum and within various cohorts (for example, paediatric and adult patients).
Potential applications of digital health technologies extend across the research spectrum from discovery to translational science.AI and/or ML now have an integral role in phenotyping, endotyping and genotyping kidney injury for individualized treatments, as well as in biomarker and drug discovery.Digital health solutions can target specific populations (for example, through enrichment of study populations according to risk profiles), to change the design, conduct and outcomes of AKI-related clinical trials.Other solutions, for example, virtual trial enrolment or the use of patient-collected data (obtained through wearables), can also facilitate patient participation in research and increase community engagement, thereby accelerating the collaborative development of patient-centred research.At a population level, digital health can improve the understanding of AKI by tracking disease epidemiology and augmenting the generation of real-world evidence.Importantly, digital health needs to be evaluated as an intervention itself.The effect of digital health applications on patient outcomes remains promising but is lacking thorough assessment (Supplementary Table 3).

Consensus statements
1. Implementation of digital health solutions should encompass four phases: exploration, deployment, implementation, and knowledge transfer or broad implementation.2. Exploration and preparation during the pre-implementation phase should focus on needs assessment, identifying the solution and engaging stakeholders.
Implementation science has delineated approaches and methods to measure the effectiveness of digital health solutions in clinical settings 93,94 (Fig. 3).Needs assessment 95 is a crucial component of implementation and comprises identifying important clinical problems within the AKI continuum, defining the target population and anticipated outcomes, value proposition, identifying and engaging relevant stakeholders, considering the availability of resources and expertise, assessing the local context and, finally, identifying the most appropriate digital health solution to address the defined needs 96 .Of note, technology readiness assessment is also important and involves engaging multiple disciplines with thorough knowledge of the available infrastructure, as well as personnel with the requisite expertise, to facilitate the uptake and validation of a digital health solution.Importantly, currently available tools for readiness assessment and implementation can facilitate behaviour change and technology acceptance 97 .

What are the key factors for a successful deployment and implementation of a DHAKI solution?
Consensus statements.Successful implementation of digital health tools requires strategic alignment with institutional priorities to

Consensus statement
enhance and sustain stakeholder engagement and secure adequate technological, personnel, educational, financial, and administrative resources for deployment, launch, quality assurance and performance improvement.
During the implementation phase, the digital health solution must be integrated within current workflows to support clinical needs, and ensure sustainability and applicability across various settings (Fig. 3).Given the heterogeneity in patients, processes of care and AKI settings, implementation techniques and methods might vary based on the DHAKI solution aims or users in an iterative process.Over time, the missteps and successes of the initial implementation should be leveraged to inform the sustainable and broader deployment of the tool, whether to other clinical service lines in the same location or other institutions.
RCTs can provide a high level of evidence regarding the efficacy and effectiveness of a digital health solution, but they also have some limitations, including the lack of external validity (that is, validation outside of the setting in which they were conducted), their high cost and complex logistics, the ethical challenges of exposing some patients to interventions of uncertain benefit or harm, potential cross-contamination between the intervention and control groups, (often) the inability to mitigate or resolve the constraints and barriers during or after completion of the trial, and the time required to perform the study.Therefore, other study designs, such as effectiveness-oriented research, might allow a better understanding of the optimal processes for successful implementation and dissemination of the intervention.In addition, these alternative study designs might prevent large-scale implementation delays and help care for all patients, including those traditionally at the highest risk of health care disparities.
The target population for DHAKI implementation should be based on comorbidity, health, digital literacy, social and cultural factors.The digital health solutions should be assessed for feasibility and efficacy in distinct clinical settings and patient populations, as well as its technical characteristics (such as maturity, performance, dependability, supply chain reliability, useability, acceptability and technical interdependency with upgrade capability), and human workflow integration abilities 98 .Interactions with pre-existing digital health solutions should be considered for synergies, contradictions and technical interdependencies.Last, institutional readiness, support and resources such as technical expertise also affect the ability to implement new tools successfully.
A nephrotoxic medication-associated AKI prevention programme that identified children at a higher risk of AKI based on available epidemiological data 99,100 transitioned from manual to automated processes 90,101 and evolved from a single-centre experience to successful multicentre dissemination and implementation, while imparting knowledge at each stage to accelerate wider dissemination 34 .The multicentre project secured a series of commitments from each centre before admission to the collaborative 34 (Supplementary Box 1).

Consensus statements
1. Sustaining an implemented digital health solution is a dynamic process to accommodate changes over time.2. Defining the scope of digital health solution dissemination is crucial as broader implementation could be achieved across service lines in a single hospital, health system, or a broader entity, including several health systems or countries.
To ensure that digital health solutions are sustainable, they should be systematically redirected to comply with changing policies and maintain stakeholder engagement at the community level 94 .Moreover, in most cases, DHAKI solutions such as AKI alerts have not been widely adopted [102][103][104][105] , despite their reported benefits 28,106,107 .The inability to successfully implement digital health solutions is primarily due to scarcity, conflict, or distrust in existing evidence.Digital health dissemination is challenging when standardization in EHRs, procedures, protocols and institutional culture and leadership is limited, because it increases the required effort, time, resources, and consensus across stakeholders.Digital health dissemination across health systems with different institutional and contextual structures requires a deep understanding of resources, institutional culture and the capabilities of stakeholders.

Challenges of DHAKI utilization in clinical practice
What are the barriers to implementing and sustaining DHAKI tools in routine clinical practice?

Consensus statements
1. Implementing digital health across the AKI continuum is complex and influenced by administrative issues, team capabilities, hardware and software limitations, and the cultural milieu.2. Following validation of DHAKI solutions in controlled research settings, translational studies are necessary to establish clinical benefits.
Several barriers and constraints can affect DHAKI implementation (Figs. 4 and 5).Varying access to health care and digital literacy is a fundamental problem 108,109 .Moreover, the datasets used to create AI and/or ML approaches to AKI risk management often lack diversity, which limits their generalizability 54 .Digital health resources and expertise in clinical environments can be very limited 110 .The heterogeneity in software and hardware environments across health care systems leads to competing devices with varying cost-effectiveness, which is a major barrier to digital health solution dissemination 111,112 .Equally important is the humantechnology interaction, which encompasses technology preparedness among health care providers, end-user acceptance 113,114

Consensus statement
to localize scientific units and language interfaces across the global market 115 .Digital health solution integration into clinical workflows is challenging.Changes in clinical workflows in tandem with the introduction of a new digital health solution are often necessary to maximize efficiency and effectiveness.Moreover, although AI advancements such as large language models, promise huge potential for applications such as medical documentation, decision support systems and patient education, they also raise many ethical and societal issues, especially regarding the misalignment of human-intended objectives and AI actions 116 .Digital health tools might meet the regulatory definition of a medical device and be subject to regulatory and approval processes, some of which might not be well adapted to specific aspects of digital health.Obtaining the necessary regulatory authorizations to introduce these tools into clinical use can therefore lead to delays and raise costs.Many digital health tools rely on shared data, which can raise complex ELSI concerns 117 .Therefore, improved transparency in the use of private health information might promote successful implementation of new digital health solutions 118 .
AKI-specific challenges include AKI heterogeneity, with differences across subpopulations 119,120 .The broad AKI spectrum in diverse practice settings mandates wide distribution [121][122][123] .Perceived therapeutic nihilism around current AKI management might also reduce end-user acceptance, particularly with competing priorities from other acute and chronic medical conditions such as heart or liver failure.Evaluation of predictive or diagnostic digital health solutions should also include reporting of sensitivity and specificity because too many false negatives (that is, missed cases) or false positives (that is, incorrect diagnoses) would likely reduce trust and acceptance.

What ethical, legal and social implications create DHAKI access and usage barriers?
Consensus statement.Existing inequities in communities, health care systems and data can potentially propagate biases during the development and implementation of digital health tools, leading to further discriminatory practices that disadvantage historically excluded groups.
ELSI concerns might arise from issues related to patient safety (owing to a lack of supportive evidence), equity (related, for example, to affordability, ease of use, health literacy or algorithm biases), lack of transparency, regulation (data protection, security, consent, conflicts of interest with industry), liability, accountability and unintentional impacts on the patient-clinician relationship [124][125][126] .Unequal access to care and technology, driven by historical biases and the digital divide, can compromise the ability of digital health solutions to serve a diverse, global population 127 .For example, the use of telemedicine increased rapidly during the COVID-19 pandemic.However, this increase also exposed the large divide between resource-rich and resource-constrained settings, where the lack of stable internet connectivity was a large barrier to access to care 128 .This multi-faceted problem should be tackled on different fronts, including through policies aimed at bringing equitable access to the internet, through novel technologies that can work in areas of poor connectivity or intermittent connections 129 , and by educating the end users in using the relevant technology.Hence, systems need to be carefully validated to ensure equitable performance across all affected population subgroups 130,131 .Patient-facing tools can also be inaccessible because of language barriers.Moreover, existing datasets and digital health design decisions might reflect the needs of a limited subset of patients with AKI, which could lead to biased predictions and recommendations 54 .For example, digital health solutions developed for resource-rich settings might not be relevant in resource-limited settings 132 , and the complexity of digital health solutions might negate the potential benefits to patients.Digital health tools using black-box AI and/or ML models (that is, models with undisclosed processes or features) might also introduce bias and, occasionally, be counterproductive when health care professionals, patients and the public misinterpret their reasoning 133 .

Consensus statement
Finally, transparency issues can lead to downstream safety and security issues in the case of complex models and tools.
We recognize that technology will not solve all existing ELSI issues.However, discourse around technology can start to provide solutions that address issues in justice, autonomy, privacy, security, trust, accountability and transparency 134 .Promoting responsive and sustainable solutions is also important, as emphasized by recent WHO guidelines on AI for health care 135 .For example, current data suggest that oxygen saturation and heart rate monitoring in wearable devices via photoplethysmography are affected by skin tone and are less accurate in individuals with darker skin tones 136 .This discrepancy might also apply to oxygen saturation monitoring using a pulse oximeter in inpatient settings 137 .Social determinants can also influence access to wearable technologies and the willingness to share health data 138 .Therefore, studies of wearables might fail to address the population needs appropriately, and perpetuate the under-representation of subsets of patients in collected datasets, and in the subsequent research and algorithm design.Additional ethical considerations are addressed in the US White House Blueprint for an AI Bill of Rights 139 , the US Department of Health and Human Services Office of the National Coordinator for Health Information Technology, the Coalition for Health AI, the Health AI Partnership, and the proposed Artificial Intelligence Act from the European Union 140 .In addition, playbooks and auditing tools are available to identify and reduce biases 141,142 .

Conclusion
Digital health tools offer a unique opportunity to enhance the care of patients with AKI worldwide by empowering both patients and providers to communicate effectively, bridging gaps in care delivery and reducing barriers of access to care.Given the rapid advancement and growth of digital health solutions, their use for AKI detection and management will continue to evolve.Importantly, implementation of DHAKI solutions will need to be monitored for unintended consequences, such as the introduction or exacerbation of inequities in care delivery.

Community setting Fig. 1 | Categories of digital health interventions and strategies for employing digital health across the care continuum. A
and the need The four phases of digital health solution implementation include exploring the need and resources, deploying the resources required for successful project conduct, implementing the digital health solution within the workflow, and finally, knowledge transfer and broader implementation of the digital health in acute kidney injury (DHAKI) solution across institutions, regions, countries and globally.Adapted from the Acute Dialysis Quality Initiative 143 , CC BY 2.0 (https://creativecommons.org/licenses/by/2.0/).

Interconnecting factors that restrict the choice of a DHAKI solution.
143ust 2023The development and implementation of digital health in acute kidney injury care (DHAKI) solutions must consider the needs that the solution must address, existing constraints, as well as the available technology choices and design approaches.A successful DHAKI solution implementation requires alignment among all of these major components.Adapted from the Acute Dialysis Quality Initiative143, CC BY 2.0 (https://creativecommons.org/licenses/by/2.0/).Cr, creatinine; DH, digital health; ELSI, ethical, legal and social implications; IT, information technology.