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Lim AKH, Kerr PG. The impact of obesity on body surface area adjusted estimated glomerular filtration rate in patients with chronic kidney disease. Intern Med J 2024. [PMID: 39011848 DOI: 10.1111/imj.16477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 06/23/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Assessment of kidney function is necessary for prescribing renally excreted drugs. The estimated glomerular filtration rate (eGFR) routinely reported by laboratories is indexed to a body surface area (BSA) of 1.73 m2. In obese patients, the indexed eGFR may underestimate directly measured GFR. AIMS To determine the prevalence of obesity in patients with chronic kidney disease (CKD) and examine the effect of adjusting the indexed eGFR for patient BSA (deindexing) across CKD Stages 2-5. METHODS We conducted a cross-sectional study of 575 adults with stable CKD from two general nephrology clinics over 6 months. Dialysis and kidney transplant patients were excluded. We used four equations (Mosteller, Dubois, Haycock and Schlich) to determine BSA based on actual body weight and applied Bland-Altman plots and piecewise linear regression to examine the relationship between deindexed and indexed eGFR. RESULTS The median age was 68 years (58% male). The prevalence of overweight and obesity was 31% and 47% respectively. Mean body mass index was 29.7 kg/m2. The Schlich equation for BSA produced the smallest adjustment in eGFR, while the Haycock equation produced the largest adjustment. Males experienced the largest change in eGFR from deindexing because of larger BSAs. Although bias became increasingly positive with higher eGFR, the linear regression stratified by CKD stage indicated that deindexing had little impact with eGFR <45 mL/min/1.73 m2. CONCLUSIONS In CKD, deindexing the Chronic Kidney Disease Epidemiology Collaboration eGFR may not be necessary when the eGFR is <45 mL/min/1.73 m2, particularly if the patient is female.
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Affiliation(s)
- Andy K H Lim
- Department of General Medicine, Monash Health, Melbourne, Victoria, Australia
- Department of Nephrology, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, Monash University School of Clinical Sciences, Melbourne, Victoria, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, Monash University School of Clinical Sciences, Melbourne, Victoria, Australia
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2
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Očovská Z, Procházková J, Maříková M, Vlček J. Renal drug dosage adjustments and adverse drug events in patients with chronic kidney disease admitted to the hospital: a cross-sectional study. Expert Opin Drug Saf 2024; 23:457-467. [PMID: 38332533 DOI: 10.1080/14740338.2023.2295980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/28/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND The study aimed to evaluate the agreement of prescribed drug dosages with renal dosing recommendations and describe adverse drug events (ADEs) contributing to hospital admissions of patients with chronic kidney disease (CKD). METHODS This cross-sectional study focused on CKD patients admitted to University Hospital Hradec Králové, with an estimated glomerular filtration rate below 60 ml/min. The necessity for renal dosage adjustments was determined using the Summary of Product Characteristics (SmPC). For medications requiring renal dosage adjustment according to SmPC, agreement between the prescribed and recommended renal dosage was assessed. ADEs were adjudicated using the OPERAM drug-related hospital admissions adjudication guide. RESULTS Of 375 CKD patients, 112 (30%, 95% CI 25-34) were prescribed drug dosages in disagreement with SmPC renal dosage recommendations. Perindopril, metformin, and ramipril were most frequently dosed in disagreement with SmPC. ADE-related hospital admissions occurred in 20% (95% CI 16-24) of CKD patients. CONCLUSION CKD patients are often prescribed medication dosages in disagreement with SmPC renal dosing recommendations. Besides explicit factors, treatment goals, feasibility of monitoring and alternative treatment must be weighed when assessing drug and dosage appropriateness. Gastrointestinal bleeding was the most frequent ADE that contributed to hospital admissions of CKD patients.
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Affiliation(s)
- Zuzana Očovská
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Jana Procházková
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Martina Maříková
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
- Department of Clinical Pharmacy, Hospital Pharmacy, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jiří Vlček
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
- Department of Clinical Pharmacy, Hospital Pharmacy, University Hospital Hradec Králové, Hradec Králové, Czech Republic
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Kaas-Hansen BS, Leal Rodríguez C, Placido D, Thorsen-Meyer HC, Nielsen AP, Dérian N, Brunak S, Andersen SE. Using Machine Learning to Identify Patients at High Risk of Inappropriate Drug Dosing in Periods with Renal Dysfunction. Clin Epidemiol 2022; 14:213-223. [PMID: 35228820 PMCID: PMC8881932 DOI: 10.2147/clep.s344435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/24/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose Dosing of renally cleared drugs in patients with kidney failure often deviates from clinical guidelines, so we sought to elicit predictors of receiving inappropriate doses of renal risk drugs. Patients and methods We combined data from the Danish National Patient Register and in-hospital data on drug administrations and estimated glomerular filtration rates for admissions between 1 October 2009 and 1 June 2016, from a pool of about 2.6 million persons. We trained artificial neural network and linear logistic ridge regression models to predict the risk of five outcomes (>0, ≥1, ≥2, ≥3 and ≥5 inappropriate doses daily) with index set 24 hours after admission. We used time-series validation for evaluating discrimination, calibration, clinical utility and explanations. Results Of 52,451 admissions included, 42,250 (81%) were used for model development. The median age was 77 years; 50% of admissions were of women. ≥5 drugs were used between admission start and index in 23,124 admissions (44%); the most common drug classes were analgesics, systemic antibacterials, diuretics, antithrombotics, and antacids. The neural network models had better discriminative power (all AUROCs between 0.77 and 0.81) and were better calibrated than their linear counterparts. The main prediction drivers were use of anti-inflammatory, antidiabetic and anti-Parkinson's drugs as well as having a diagnosis of chronic kidney failure. Sex and age affected predictions but slightly. Conclusion Our models can flag patients at high risk of receiving at least one inappropriate dose daily in a controlled in-silico setting. A prospective clinical study may confirm that this holds in real-life settings and translates into benefits in hard endpoints.
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Affiliation(s)
- Benjamin Skov Kaas-Hansen
- Clinical Pharmacology Unit, Zealand University Hospital, Roskilde, Denmark
- NNF Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
- Section for Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Correspondence: Benjamin Skov Kaas-Hansen, Clinical Pharmacology Unit, Zealand University Hospital, Munkesoevej 18, Roskilde, 4000, Denmark, Tel +45 60 19 68 02, Email
| | | | - Davide Placido
- NNF Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
| | - Hans-Christian Thorsen-Meyer
- NNF Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
- Department of Intensive Care Medicine, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Anna Pors Nielsen
- NNF Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
| | - Nicolas Dérian
- Data and Development Support, Region Zealand, Sorø, Denmark
| | - Søren Brunak
- NNF Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
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4
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Golla K, Mannell H, Benesic A, Dreischulte T, Grill E, Strobach D. Feasibility of the MELD score as a screening tool for pharmacists to identify patients with impaired hepatic function at hospital admission. J Clin Pharm Ther 2022; 47:676-684. [PMID: 35014073 DOI: 10.1111/jcpt.13597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/23/2021] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Hepatic impairment (HI) is a known risk factor for drug safety. The MELD score (Model-for-endstage-liver-disease), calculated from serum creatinine, bilirubin and International Normalized Ratio (INR), is a promising screening tool corresponding to Child-Pugh Score (CPS) for drug adjustment. We tested the feasibility of MELD as an automatic screening tool accounting for correct calculation, interfering factors (IF) and detection of patients corresponding to CPS-B/C potentially requiring drug adjustment. METHODS We retrospectively calculated MELD for a 3-month cohort of surgical patients and assessed need for adjustment of MELD parameters to standard values. IF for INR (oral anticoagulants) and serum creatinine (renal insufficiency (RI; eGFR<60 ml/min/1.73m²); as well as drugs elevating creatinine levels (DECL)) and the number of patients with MELD scores corresponding to CPS-B/C were analysed. For MELD ≥7.5, liver and bile diagnoses were recorded. RESULTS AND DISCUSSION Of 1183 patients, MELD was calculable for 761 (64%; median 7.5, range 6.4-36.8). Parameters had to be adjusted for 690 (91%) patients. IF of parameters were RI in 172 (23%), INR-elevating drugs in 105 (14%) and DECL in 33 (4%) patients. Of 335 (44%) patients with MELD ≥7.5, 122 (36%) had documented liver or bile diagnoses. MELD 10-<15 (corresponding to CPS-B) was found for 105 (14%), MELD ≥15 (corresponding to CPS-C) for 66 (9%) of the 761 patients with a calculated MELD. Referred to all patients, drug adjustments due to possible HI were recommendable for 14% of patients with suspected CPS-B/C. WHAT IS NEW AND CONCLUSION MELD is a feasible screening tool for HI as a risk factor for drug safety at hospital admission when appropriately considering correct parameter adjustment and RI and INR-elevating drugs as IF. Further evaluation of sensitivity and specificity is needed.
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Affiliation(s)
- Kathrin Golla
- Hospital Pharmacy, University Hospital, LMU Munich, Munich, Germany.,Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - Hanna Mannell
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - Andreas Benesic
- Department of Internal Medicine - Gastroenterology, Krankenhaus GmbH Weilheim-Schongau, Schongau, Germany
| | - Tobias Dreischulte
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Eva Grill
- Institute for Medical Information Processing, Biometrics and Epidemiology, LMU Munich, Munich, Germany
| | - Dorothea Strobach
- Hospital Pharmacy, University Hospital, LMU Munich, Munich, Germany.,Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
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Sukeishi A, Itohara K, Yonezawa A, Sato Y, Matsumura K, Katada Y, Nakagawa T, Hamada S, Tanabe N, Imoto E, Kai S, Hirai T, Yanagita M, Ohtsuru S, Terada T, Ito I. Population pharmacokinetic modeling of GS-441524, the active metabolite of remdesivir, in Japanese COVID-19 patients with renal dysfunction. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 11:94-103. [PMID: 34793625 PMCID: PMC8646568 DOI: 10.1002/psp4.12736] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/28/2021] [Accepted: 10/12/2021] [Indexed: 12/21/2022]
Abstract
Remdesivir, a prodrug of the nucleoside analog GS‐441524, plays a key role in the treatment of coronavirus disease 2019 (COVID‐19). However, owing to limited information on clinical trials and inexperienced clinical use, there is a lack of pharmacokinetic (PK) data in patients with COVID‐19 with special characteristics. In this study, we aimed to measure serum GS‐441524 concentrations and develop a population PK (PopPK) model. Remdesivir was administered at a 200 mg loading dose on the first day followed by 100 mg from day 2, based on the package insert, in patients with an estimated glomerular filtration rate (eGFR) greater than or equal to 30 ml/min. In total, 190 concentrations from 37 Japanese patients were used in the analysis. The GS‐441524 trough concentrations were significantly higher in the eGFR less than 60 ml/min group than in the eGFR greater than or equal to 60 ml/min group. Extracorporeal membrane oxygenation in four patients hardly affected the total body clearance (CL) and volume of distribution (Vd) of GS‐441524. A one‐compartment model described serum GS‐441524 concentration data. The CL and Vd of GS‐441524 were significantly affected by eGFR readjusted by individual body surface area and age, respectively. Simulations proposed a dose regimen of 200 mg on day 1 followed by 100 mg once every 2 days from day 2 in patients with an eGFR of 30 ml/min or less. In conclusion, we successfully established a PopPK model of GS‐441524 using retrospectively obtained serum GS‐441524 concentrations in Japanese patients with COVID‐19, which would be helpful for optimal individualized therapy of remdesivir.
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Affiliation(s)
- Asami Sukeishi
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan.,Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, Japan
| | - Yuki Sato
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Katsuyuki Matsumura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Yoshiki Katada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Takayuki Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Satoshi Hamada
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Naoya Tanabe
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Shinichi Kai
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Toyohiro Hirai
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Institute for the Advanced Study of Human Biology (WPI-ASHBi), Kyoto University, Kyoto, Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Isao Ito
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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6
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Seiberth S, Bauer D, Schönermarck U, Mannell H, Stief C, Hasford J, Strobach D. Implementation of a renal pharmacist consultant service - Information sharing in paper versus digital form. J Clin Pharm Ther 2021; 46:838-845. [PMID: 33609054 DOI: 10.1111/jcpt.13371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/20/2021] [Indexed: 12/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Renal impairment (RI) and renal drug-related problems (rDRP) often remain unrecognized in the community setting. A "renal pharmacist consultant service" (RPCS) at hospital admission can support patient safety by detecting rDRP. However, the efficient information sharing from pharmacists to physicians is still discussed. The aim of the study was to test the implementation of a RPCS and its effectiveness on prescription changes and to evaluate two ways of written information sharing with physicians. METHODS Urological patients with eGFRnon-indexed of 15-59 ml/min and ≥1 drug were reviewed for manifest and potential rDRP at admission by a pharmacist. Written recommendations for dose or drug adaptation were forwarded to physicians comparing two routes: July-September 2017 paper form in handwritten chart; November 2017-January 2018 digital PDF document in the electronic patient information system and e-mail alert. Prescription changes regarding manifest rDRP were evaluated and compared with a previous retrospective study without RPCS. RESULTS AND DISCUSSION The RPCS detected rDRP in 63 of 234 (26.9%) patients and prepared written recommendations (median 1 rDRP (1-5) per patient) concerning 110 of 538 (20.5%) drugs at admission. For manifest rDRP, acceptance rates of recommendations were 62.5% (paper) vs 42.9% (digital) (P = 0.16). Compared with the retrospective study without RPCS (prescription changes in 21/76 rDRP; 27.6%), correct prescribing concerning manifest rDRP significantly increased by 27.1%. WHAT IS NEW AND CONCLUSION A RPCS identifies patients at risk for rDRP and significantly increases appropriate prescribing by physicians. In our hospital (no electronic order entry, electronic chart or ward pharmacists), consultations in paper form seem to be superior to a digital PDF document.
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Affiliation(s)
- Sarah Seiberth
- Hospital Pharmacy, University Hospital, LMU Munich, Munich, Germany.,Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - Dominik Bauer
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - Ulf Schönermarck
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Hanna Mannell
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - Christian Stief
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Joerg Hasford
- Institute of Medical Data Processing, Biometrics and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Munich, Germany
| | - Dorothea Strobach
- Hospital Pharmacy, University Hospital, LMU Munich, Munich, Germany.,Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
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