Pattern of acute renal failure in a tertiary hospital in the United Arab Emirates

Drug-drug interaction and acute kidney injury development: A correlation-based network analysis

BACKGROUND

Drug-induced nephrotoxicity is a relatively common preventable cause of acute kidney injury (AKI), providing early recognition and management. The pharmacokinetics or pharmacodynamics of drug-drug interactions may lead to additive or synergistic toxicity. The influx of new medications or off-label use of medications in the critical care setting can lead to additional nephrotoxicities, often challenging to predict or detect. This study evaluates the patterns of medication utilization, their combinations, and the related associations with AKI.

METHODS

We utilized correlation-based network analysis (CNA) to investigate the relationship between medications or their combinations with AKI in a large cohort of critically ill patients in a tertiary medical center between 2007 and 2018. Pairwise medication-AKI correlation analysis was performed to evaluate drug synergistic or additive effects. To investigate the inherent nephrotoxicity of medications, we further analyzed medications that were not paired with any other medications within 24 hours before or after their administration time (isolated medication analysis).

RESULTS

Among 147,289 ICU admissions, we identified 244 associations among 1,555 unique medication types. In pairwise analysis, 233 significant correlations were found among 13,150,198 medication pair instances. In isolated medication analysis, ten significant AKI associations were noted. When stratified by eGFR level, substantial differences between eGFR<90 vs. eGFR≥90 patients were observed. This highlights a need to determine eGFR as a risk factor for nephrotoxicity assessment when drug interactions are considered.

CONCLUSIONS

This large-scale cohort study identified an artificial intelligence model to identify patient-agnostic relationships between medication or their pairs with AKI incidence among critically ill patients. It could be used as a continuous quality assurance tool to monitor drug-associated risk nephrotoxicity.

Drug therapy and other factors associated with the development of acute kidney injury in critically ill patients: a cross-sectional study

BACKGROUND

Acute kidney injury (AKI) is associated with a significant increase in morbidity, mortality, and health care costs. In intensive care units (ICU), AKI is commonly multifactorial and frequently involves diverse factors, such as hypovolemia, sepsis, and the use of nephrotoxic drugs. We aimed to investigate drug therapy and other factors associated with the development of AKI in a Brazilian public hospital.

METHODS

This is a cross-sectional study involving critically ill patients at an ICU of a tertiary hospital. All data on sequential serum creatinine (SCr) level, glomerular filtration rate (GFR), and urine output were collected during ICU stay. The primary outcome was the occurrence of AKI assessed by the Acute Kidney Injury Network (AKIN) criterion. Sociodemographics, clinical data and drug therapy were considered as covariates. Factors associated with AKI were assessed using logistic regression.

RESULTS

Overall, 122 participants were included in the study. Median age was 46.0 (interquartile range, IQ = 29.0-69.0) years, with a predominance of men (58.2%). Mean number of prescribed drugs throughout ICU stay was 22.0 ± 9.4. The number of potentially nephrotoxic drugs ranged from two to 24 per patient. A total of 29 (23.8%) ICU patients developed AKI. In the AKI-group, patients were older and showed higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores at admission, higher rates of sedation, mechanical ventilation, and infection. More drugs in general and specifically more vasoactive drugs were prescribed for AKI group. Patients who developed AKI tended to have extended stays in the ICU and a lower probability of being discharged alive than patients with no AKI development. Model adjustments of logistic regression showed that the number of medications (OR 1.15; 95% CI [1.05-1.27]) was the only factor associated with AKI in this study. This association was independent of drug nephrotoxicity.

DISCUSSION

Intensive care is characterized by its complexity that combines unstable patients, severe diseases, high density of medical interventions, and drug use. We found that typical risk factors for AKI showed statistical association on bivariate analysis. The contribution of drug therapy in the occurrence of AKI in medical ICUs reinforces the need for prevention strategies focused on early recognition of renal dysfunction and interventions in drug therapy. These actions would help improve the quality of patient care and ensure progress towards medication safety.

Multi-morbidity of non communicable diseases and equity in WHO Eastern Mediterranean countries

Introduction

Non communicable diseases are the biggest cause of death worldwide. Beside mortality, these diseases also cause high rates of morbidity and disability. Their high prevalence is generally associated to multi-morbidity. Because they need costly prolonged treatment and care, non communicable diseases have social and economical consequences that affect individuals, households and the whole society. They raise the equity problem between and within countries.

Methods and limitations

This annotated bibliography is a systematic review on multimorbidy of non communicable diseases and health equity in WHO Eastern Mediterranean countries. Medline/PubMed, EMBASE and other sources were used to get peer reviewed papers dealing with the review theme. The words/strings used for search and inclusion criteria were: multimorbidity, comorbidity, equity, non communicable diseases, chronic diseases, WHO Eastern Mediterranean and Arab countries.

Bibliography with annotations

According to the inclusion criteria, 26 papers were included in the present review. Generally, lack or paucity of publications was encountered in themes like headache, cancer and respiratory diseases. Of the 26 contributions selected, twelve dealt with comorbidity of depression and mental disorders with other chronic diseases. Another set of 11 publications was devoted to multimorbidity of diabetes, cardiovascular diseases (CVDs), hypertension, metabolic syndrome and obesity. Considering association of multimorbidity and social determinants, this review shows that female gender, low income, low level of education, old age and unemployed/retired are the most exposed to multimorbidity. It should also be stressed that, geographically, no contribution was issued from North African countries.

Non communicable diseases are one of the biggest challenges facing health decision makers in WHO Eastern Mediterranean countries where the multidimensional transition is boosting increases in multimorbidity of depression and mental diseases, cardiovascular diseases, diabetes, cancer and respiratory diseases among the whole population but with the highest burden among the least disadvantaged individuals or subpopulations. Health ministries in WHO Eastern Mediterranean countries should pay a particular attention to the association between equity and multimorbidity and opt for cost effective strategies based on early diagnosis and sensitisation for healthy diet, physical activity, no smoking and no alcohol.

Acute renal failure in the State of Qatar: presentation and outcome

Despite major improvements in health care, acute renal failure is still one of the main prognostic factors in terms of patient mortality and long-term morbidity. This cohort prospective study to evaluate the patterns and outcomes of renal failure in Qatar was performed between January and June 2005. Of the 213 patients followed prospectively from referral to the end of their hospitalization, 66.7% were males and 33.3% females. Their overall mean age was 60 years; the majority were referred from critical care units. Comorbidity was present in 87% of all patients. Volume depletion, hypotension, and sepsis were the main predisposing factors for renal failure. Eighty three patients (39%) needed renal replacement treatment and 130 (61%) were treated conservatively. The majority of critical care patients needed dialysis. Overall mortality was 23.9%, 7% needed chronic dialysis, and 69.1% were discharged with normal or mild renal impairment. This study showed that acute renal failure was a major factor affecting patient mortality in Qatar. Early treatment of predisposing factors may improve overall patient outcomes.

Effect of endoplasmic reticulum stress preconditioning on cytotoxicity of clinically relevant nephrotoxins in renal cell lines

The cytoprotection of LLC-PK1 cells afforded by endoplasmic reticulum (ER) stress preconditioning suggests that the ER plays an important role during drug-induced renal toxicity. However, in vitro studies have been largely limited to LLC-PK1 cells and model toxins. Therefore, we tested the hypothesis that cytoprotection following ER stress preconditioning is a common property of renal cell lines (LLC-PK1 (pig), NRK-52E (rat), HEK293 (human), MDCK (dog)) and extends to clinically relevant nephrotoxins. ER stress inducers (tunicamycin, thapsigargin and oxidized dithiothreitol (DTTox)) resulted in a dose-dependent increase in GRP78 and GRP94 stress protein expression, but the magnitude of induction was cell line- and inducer-dependent. Toxicity of the model toxins iodoacetamide and tert-butylhydroperoxide was modified by preconditioning. DTTox was effective in decreasing the toxicity in all cell lines, but protection was variable with tunicamycin and thapsigargin. Toxicity of clinically relevant drugs (cisplatin, gentamicin, glyoxylate, cyclosporine A, p-aminophenol) was significantly decreased in cells preconditioned by tunicamycin or DTTox. These results demonstrate that ER stress preconditioning offers cytoprotection against clinically relevant nephrotoxins in renal cell lines from multiple species, although there were qualitative and quantitative differences between the cell lines. These results support the hypothesis that ER is involved in drug-induced renal toxicity.

Drug-Associated Renal Dysfunction

Acute renal failure (ARF) in patients in the ICU is associated with a high mortality. Drug-induced renal dysfunction is an important, yet often overlooked, cause of ARF in this patient population. A drug use evaluation at the authors' institution, to assess the prescribing patterns of potential nephrotoxins in the adult and pediatric ICUs, found that antibiotics (aminoglycosides, amphotericin B, penicillins, cephalosporins, acyclovir), nonsteroidal anti-inflammatory drugs, contrast dye, and various other nephrotoxic medications are used widely in all of the ICUs. By focusing on several commonly prescribed classes of nephrotoxic medications in the ICU, this article reviews the general mechanisms of drug-associated renal dysfunction.