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Burns KA, Robbins LM, LeMarr AR, Morton DJ, Wilson ML. Chronic kidney disease increases cost of care and readmission risk after shoulder arthroplasty. J Shoulder Elbow Surg 2024; 33:e208-e214. [PMID: 37777047 DOI: 10.1016/j.jse.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 08/01/2023] [Accepted: 08/20/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with adverse outcomes and higher costs after lower extremity arthroplasty from higher rates of infection, aseptic loosening, and transfusion and longer hospital length of stay (LOS). The purpose of this study was to compare health care utilization and 90-day encounter charges after shoulder arthroplasty (SA) in patients with and without renal disease. A secondary aim was to define the characteristics of patients with renal disease. METHODS We conducted a retrospective cohort study of all patients who underwent primary SA from January 2015 to December 2019 by a single surgeon at a single institution. Patients without a baseline glomerular filtration rate (GFR) were excluded. We evaluated results for patients with CKD (GFR ≤59 mL/min/1.73 m2) and without CKD (GFR ≥60 mL/min/1.73 m2). Univariate regression was performed to assess the influence of CKD on health care utilization, including LOS, transfusion, and risk for emergency department (ED) revisit or readmission during the 90-day postoperative period. In addition, 90-day encounter charges, revisit charges, and ED charges for patients with CKD were compared with those for patients with normal renal function. Last, multivariable linear regression models were used to assess the effect of estimated GFR on total 90-day encounter charges. RESULTS A total of 514 patients met the study inclusion criteria, with 125 having CKD and 389 having normal GFR. Patients with CKD were more likely to require transfusion (odds ratio: 16.2 [confidence interval: 1.9, 139.7], P = .011) despite similar intraoperative estimated blood loss (156.9 ± 132.5 mL vs. 153.8 ± 89.7 mL; P = .768). In addition, patients with CKD had longer LOS (2.8 ± 1.3 days vs. 2.3 ± 1.0 days; P < .001), had higher 90-day readmission rates (P = .001), were more likely to visit the ED within 90 days after SA (P = .018), and had higher total 90-day encounter charges ($37,769 ± $6901 vs. $35,684 ± $5312; P = .001). Each unit increase in eGFR independently reduced total encounter charges by $67 (-$132, -$2; P = .043); dialysis patients incurred higher total 90-day encounter charges compared with patients with less severe renal disease ($42,733 ± $8985 vs. $37,531 ± $6749; P = .002). Also, patients with CKD were older (73.2 ± 8.9 vs. 68.1 ± 9.4 years; P < .001); had a lower preoperative hemoglobin level (12.4 ± 1.5 g/dL vs. 13.4 ± 1.5 g/dL; P < .001), higher American Society of Anesthesiologists score (P < .001), and more preoperative comorbidities (5.9 ± 2.9 vs. 5.0 ± 3.1; P < .001); and were more likely to use opioids preoperatively (P = .043). CONCLUSION Patients with CKD have a higher risk for blood transfusion, ED visits, and readmission after SA, with higher total 90-day encounter charges. Identifying and optimizing this patient population before surgery can reduce costs and improve outcomes, which benefits patients, physicians, institutions, and payors.
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Affiliation(s)
| | - Lynn M Robbins
- Department of Orthopaedics, SSM Health, St. Louis, MO, USA
| | | | - Diane J Morton
- Department of Orthopaedics, SSM Health, St. Louis, MO, USA
| | - Melissa L Wilson
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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2
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Dowsett T, Awan S, McWilliam S. Prescribing in paediatric kidney impairment. Arch Dis Child Educ Pract Ed 2022; 107:460-464. [PMID: 34880072 DOI: 10.1136/archdischild-2021-322781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/24/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Thomas Dowsett
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Samiah Awan
- Pharmacy, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Stephen McWilliam
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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3
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New L, Goodridge D, Kappel J, Lawson J, Dobson R, Penz E, Groot G, Gjevre J. Improving hospital safety for patients with chronic kidney disease: a mixed methods study. BMC Nephrol 2021; 22:318. [PMID: 34556044 PMCID: PMC8461959 DOI: 10.1186/s12882-021-02499-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 08/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People living with chronic kidney disease (CKD) require complex medical management and may be frequently hospitalized. Patient safety incidents during hospitalization can result in serious complications which may negatively affect health outcomes. There has been limited examination of how these patients perceive their own safety. OBJECTIVES This study compared the safety perceptions of patients hospitalized with CKD using two approaches: (a) the Patient Measure of Safety (PMOS) questionnaire and (b) qualitative interviews. The study objectives were to: (1) assess concordance between qualitative and quantitative data on safety perceptions and (2) better understand safety as perceived by study participants. METHODS A cross-sectional convergent mixed methods design was used. Integration at the reporting level occurred by weaving together patient narratives and survey domains through the use of a joint display. Interview data were merged with results of the PMOS on a case-by-case basis for analysis to assess for concordance or discordance between these approaches to safety data collection. RESULTS Of the 30 inpatients with CKD, almost one quarter (23.3 %) of participants reported low levels of perceived safety in hospitals. Four major themes emerged from the interviews: receiving safe care; expecting to be taken care of; expecting to be cared for; and reporting safety concerns. Suboptimal communication, delays in care and concerns about technical aspects of care were common to both forms of data collection. Concordance was noted between qualitative and quantitative data with respect to communication/teamwork, respect and dignity, staff roles, and ward type/lay-out. While interviews allowed for participants to share specific concerns related to safety about quality of interpersonal interactions, use of the questionnaire alone did not capture this concern. CONCLUSIONS Safety issues are a concern for in-patients with CKD. Both quantitative and qualitative approaches provided important and complementary insights into these issues. Narratives were mostly concordant with questionnaire scores. Findings from this mixed methods study suggest that communication, interpersonal interactions, and delays in care were more concerning for participants than technical aspects of care. Eliciting the concerns of people with CKD in a systematic fashion, either through interviews or a survey, ensures that hospital safety improvement efforts focus on issues important to patients.
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Affiliation(s)
- Lucia New
- Health Sciences Program, College of Medicine, University of Saskatchewan, Saskatoon, SK Canada
| | - Donna Goodridge
- Department of Medicine, College of Medicine, University of Saskatchewan, 103 Hospital Drive, SK S7N OW8 Saskatoon, Canada
| | - Joanne Kappel
- Department of Medicine, Saskatchewan Health Authority, Saskatoon, Saskatchewan Canada
| | - Joshua Lawson
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan Canada
| | - Roy Dobson
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK Canada
| | - Erika Penz
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan Canada
| | - Gary Groot
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan Canada
| | - John Gjevre
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan Canada
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Belkin MD, Doerfler RM, Wagner LA, Zhan M, Fink JC. Associations of Performance-Based Functional Assessments and Adverse Outcomes in CKD. KIDNEY360 2021; 2:629-638. [PMID: 35373040 PMCID: PMC8791312 DOI: 10.34067/kid.0005802020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/18/2021] [Indexed: 02/04/2023]
Abstract
Background The comparative utility of performance-based functional assessments in predicting adverse outcomes in CKD is unknown. To examine their relative utility, we examined three performance-based functional assessments in an observational cohort of patients with CKD. Methods We recruited 350 participants with stage II-V, predialysis CKD. Participants were administered three performance-based functional assessments: Short Physical Performance Battery (SPPB), Modified Mini-Mental Status Exam (M3SE), and Lawton Instrumental Activities of Daily Living (IADL). Scores were dichotomized on the basis of the median and combined into a summary score. Outcomes included 50% GFR reduction, ESKD, and death. We used Cox proportional hazards to assess the association of performance-based functional assessments with outcomes. Results Compared with high performers, low SPPB performers had the highest adjusted rate of death, ESKD, or 50% reduction in GFR (HR, 1.96; 95% CI, 1.28 to 2.99). Low SPPB had the strongest association with death when adjusted for multiple covariates (HR, 2.43; 95% CI, 1.36 to 4.34). M3SE performance was not associated with any adverse outcome. None of the performance-based functional assessments were associated with ESKD, but a low IADL score was associated with a lower hazard ratio for ESKD or 50% decline GFR (HR, 0.49; 95% CI, 0.24 to 1.00). Conclusions Low SPPB score was the strongest predictor of death and all adverse outcomes as a composite. Future trials should determine if outcomes for patients with CKD who have poor physical performance and low SPPB scores are improved by targeted interventions. Clinical Trial registry name and registration number Safe Kidney Care Cohort Study, NCT01407367.
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Affiliation(s)
- Mitchell D. Belkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rebecca M. Doerfler
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lee-Ann Wagner
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Min Zhan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jeffrey C. Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Trevisan M, Fu EL, Xu Y, Jager K, Zoccali C, Dekker FW, Carrero JJ. Pharmacoepidemiology for nephrologists (part 1): concept, applications and considerations for study design. Clin Kidney J 2020; 14:1307-1316. [PMID: 34221367 PMCID: PMC8247736 DOI: 10.1093/ckj/sfaa244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/12/2020] [Indexed: 12/15/2022] Open
Abstract
Randomized controlled trials on drug safety and effectiveness are the foundation of medical evidence, but they may have limited generalizability and be unpowered to detect rare and long-term kidney outcomes. Observational studies in routine care data can complement and expand trial evidence on the use, safety and effectiveness of medications and aid with clinical decisions in areas where evidence is lacking. Access to routinely collected large healthcare data has resulted in the proliferation of studies addressing the effect of medications in patients with kidney diseases and this review provides an introduction to the science of pharmacoepidemiology to critically appraise them. In this first review we discuss the concept and applications of pharmacoepidemiology, describing methods for drug-utilization research and discussing the strengths and caveats of the most commonly used study designs to evaluate comparative drug safety and effectiveness.
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Affiliation(s)
- Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Edouard L Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yang Xu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Kitty Jager
- Department of Medical Informatics, ERA-EDTA Registry, Amsterdam University Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
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Abstract
Importance Chronic kidney disease (CKD) is the 16th leading cause of years of life lost worldwide. Appropriate screening, diagnosis, and management by primary care clinicians are necessary to prevent adverse CKD-associated outcomes, including cardiovascular disease, end-stage kidney disease, and death. Observations Defined as a persistent abnormality in kidney structure or function (eg, glomerular filtration rate [GFR] <60 mL/min/1.73 m2 or albuminuria ≥30 mg per 24 hours) for more than 3 months, CKD affects 8% to 16% of the population worldwide. In developed countries, CKD is most commonly attributed to diabetes and hypertension. However, less than 5% of patients with early CKD report awareness of their disease. Among individuals diagnosed as having CKD, staging and new risk assessment tools that incorporate GFR and albuminuria can help guide treatment, monitoring, and referral strategies. Optimal management of CKD includes cardiovascular risk reduction (eg, statins and blood pressure management), treatment of albuminuria (eg, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers), avoidance of potential nephrotoxins (eg, nonsteroidal anti-inflammatory drugs), and adjustments to drug dosing (eg, many antibiotics and oral hypoglycemic agents). Patients also require monitoring for complications of CKD, such as hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia. Those at high risk of CKD progression (eg, estimated GFR <30 mL/min/1.73 m2, albuminuria ≥300 mg per 24 hours, or rapid decline in estimated GFR) should be promptly referred to a nephrologist. Conclusions and Relevance Diagnosis, staging, and appropriate referral of CKD by primary care clinicians are important in reducing the burden of CKD worldwide.
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Affiliation(s)
- Teresa K Chen
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Daphne H Knicely
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Morgan E Grams
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Haase A, Stracke S, Chenot JF, Weckmann G. Nephrologists' perspectives on ambulatory care of patients with non-dialysis chronic kidney disease - A qualitative study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:e438-e448. [PMID: 30945392 DOI: 10.1111/hsc.12744] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 01/09/2019] [Accepted: 02/25/2019] [Indexed: 06/09/2023]
Abstract
Little is known on the perspectives of nephrologists on managing non-dialysis patients with chronic kidney disease (CKD). The purpose of this qualitative study was to explore the experiences and perspectives of nephrologists regarding the interface with general practitioners (GP) and GPs' management of patients with non-dialysis CKD, so that barriers to cooperation and need for improved management can be identified. Twenty semi-structured interviews were conducted for this qualitative study. The interviews were audio-recorded and coded to be analysed. The concept of knowledge systems served as a sensitising concept. Optimising underlying diseases, medication adaptation and patient awareness of CKD were regarded as the most important treatment measures in CKD management. Differing views exist on who should be responsible for lifestyle interventions, patient education and timing of referral. Nephrologists generally preferred the referral of patients with high progression risk and co-treatment models in which daily care was performed by GP, but some preferred referral of all patients with early CKD and some nephrologists stated that patient care should be in the hands of nephrologists entirely in case of CKD. Doctor-patient communication predominantly remained within the medical-scientific knowledge system whereas patients' everyday knowledge systems were rarely considered. While stressing optimisation of laboratory values, diabetes and hypertension, patients' perspectives and shared decision-making to identify and prioritise patients' individual health goals were rarely considered by nephrologists. Instead, most nephrologists regarded educating patients and GPs as an important part of their professional role. Defining the interface between GPs and nephrologists, with specific recommendations on when to refer and which tasks each professional group should perform can lead to standardisation and improved interdisciplinary management of CKD patients. Addressing patients' everyday knowledge systems can be valuable in formulating and prioritising health goals with patients.
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Affiliation(s)
- Annekathrin Haase
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
- DRK Hospital Grimmen GmbH, Süderholz, Germany
| | - Sylvia Stracke
- Nephrology, Dialysis and Hypertension, Internal Medicine A, University Medicine Greifswald, Greifswald, Germany
- KfH Kidney Center Greifswald, University Medicine Greifswald, Germany
| | - Jean-François Chenot
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Gesine Weckmann
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
- Faculty of Applied Health Sciences, European University of Applied Sciences, Rostock, Germany
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New L, Goodridge D, Kappel J, Groot G, Dobson R. "I just have to take it" - patient safety in acute care: perspectives and experiences of patients with chronic kidney disease. BMC Health Serv Res 2019; 19:199. [PMID: 30922299 PMCID: PMC6437896 DOI: 10.1186/s12913-019-4014-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 03/15/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Frequent hospitalizations and dependency on technology and providers place individuals with chronic kidney disease (CKD) at high risk for multiple safety events. Threats to their safety may be physical, emotional, or psychological. This study sought to explore patient safety from the perspectives and experiences of patients with CKD in acute care settings, and to describe willingness to report incidents utilizing an existing safety reporting system. METHODS This study was conducted using a qualitative interpretive descriptive approach. Face to face interviews were conducted with 30 participants at their bedside during their current hospital admission. The majority of the participants were 50 years or older, of which 75% had a confirmed diagnosis of end stage renal disease with the remainder at stages 3 or 4 of CKD. Eighty percent of the participants were either on hemo- or peritoneal dialysis. RESULTS Participants expected to receive safe care, to be taken care of, and to be cared for. Safety threats included: sharing a room with patients who were on precautions; lack of cleanliness; and roommates perceived to be threatening. The concepts of being taken care of and being cared for constituted the safety threats identified within the interpersonal environment. Participants felt taken care of when their physical needs are met and cared for when their psychological and emotional needs are met. There was a general lack of awareness of the presence of a safety reporting system that was to be accessible to patients and families by telephone. There was also an overall unwillingness to report perceived safety incidents, although participants did distinguish between speaking up and reporting. CONCLUSIONS A key finding was the unwillingness to report incidents using the safety reporting system. Fear of reprisals was the most significant reporting impediment expressed. Actively inviting patients to speak up may be more effective when combined with a psychologically safe environment in order to encourage the involvement of patients in patient safety. System-wide organizational changes may be necessary to mitigate emotional and physical harm for this client population.
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Affiliation(s)
- Lucia New
- College of Medicine Health Sciences Program, University of Saskatchewan, Saskatoon, SK Canada
| | - Donna Goodridge
- Department of Medicine, College of Medicine, University of Saskatchewan, Room 543 Ellis Hall, 108 Hospital Drive, Saskatoon, SK S7N 0W8 Canada
| | - Joanne Kappel
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan Canada
| | - Gary Groot
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan Canada
| | - Roy Dobson
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK Canada
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Lee MJ, Park JH, Moon YR, Jo SY, Yoon D, Park RW, Jeong JC, Park I, Shin GT, Kim H. Can we predict when to start renal replacement therapy in patients with chronic kidney disease using 6 months of clinical data? PLoS One 2018; 13:e0204586. [PMID: 30286208 PMCID: PMC6171856 DOI: 10.1371/journal.pone.0204586] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 09/11/2018] [Indexed: 11/19/2022] Open
Abstract
Purpose We aimed to develop a model of chronic kidney disease (CKD) progression for predicting the probability and time to progression from various CKD stages to renal replacement therapy (RRT), using 6 months of clinical data variables routinely measured at healthcare centers. Methods Data were derived from the electronic medical records of Ajou University Hospital, Suwon, South Korea from October 1997 to September 2012. We included patients who were diagnosed with CKD (estimated glomerular filtration rate [eGFR] < 60 mL·min–1·1.73 m–2 for ≥ 3 months) and followed up for at least 6 months. The study population was randomly divided into training and test sets. Results We identified 4,509 patients who met reasonable diagnostic criteria. Patients were randomly divided into 2 groups, and after excluding patients with missing data, the training and test sets included 1,625 and 1,618 patients, respectively. The integral mean was the most powerful explanatory (R2 = 0.404) variable among the 8 modified values. Ten variables (age, sex, diabetes mellitus[DM], polycystic kidney disease[PKD], serum albumin, serum hemoglobin, serum phosphorus, serum potassium, eGFR (calculated by Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]), and urinary protein) were included in the final risk prediction model for CKD stage 3 (R2 = 0.330). Ten variables (age, sex, DM, GN, PKD, serum hemoglobin, serum blood urea nitrogen[BUN], serum calcium, eGFR(calculated by Modification of Diet in Renal Disease[MDRD]), and urinary protein) were included in the final risk prediction model for CKD stage 4 (R2 = 0.386). Four variables (serum hemoglobin, serum BUN, eGFR(calculated by MDRD) and urinary protein) were included in the final risk prediction model for CKD stage 5 (R2 = 0.321). Conclusion We created a prediction model according to CKD stages by using integral means. Based on the results of the Brier score (BS) and Harrel’s C statistics, we consider that our model has significant explanatory power to predict the probability and interval time to the initiation of RRT.
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Affiliation(s)
- Min-Jeong Lee
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Joo-Han Park
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Yeo Rae Moon
- Department of Biostatistics, Ajou University School of Medicine, Suwon, Korea
| | - Soo-Yeon Jo
- Department of Medical Informatics, Ajou University School of Medicine, Suwon, Korea
| | - Dukyong Yoon
- Department of Medical Informatics, Ajou University School of Medicine, Suwon, Korea
| | - Rae Woong Park
- Department of Medical Informatics, Ajou University School of Medicine, Suwon, Korea
| | - Jong Cheol Jeong
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
| | - Inwhee Park
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
| | - Gyu-Tae Shin
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
| | - Heungsoo Kim
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
- * E-mail:
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10
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Sobrinho A, da Silva LD, Perkusich A, Pinheiro ME, Cunha P. Design and evaluation of a mobile application to assist the self-monitoring of the chronic kidney disease in developing countries. BMC Med Inform Decis Mak 2018; 18:7. [PMID: 29329530 PMCID: PMC5767024 DOI: 10.1186/s12911-018-0587-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 01/05/2018] [Indexed: 12/13/2022] Open
Abstract
Background The chronic kidney disease (CKD) is a worldwide critical problem, especially in developing countries. CKD patients usually begin their treatment in advanced stages, which requires dialysis and kidney transplantation, and consequently, affects mortality rates. This issue is faced by a mobile health (mHealth) application (app) that aims to assist the early diagnosis and self-monitoring of the disease progression. Methods A user-centered design (UCD) approach involving health professionals (nurse and nephrologists) and target users guided the development process of the app between 2012 and 2016. In-depth interviews and prototyping were conducted along with healthcare professionals throughout the requirements elicitation process. Elicited requirements were translated into a native mHealth app targeting the Android platform. Afterward, the Cohen’s Kappa coefficient statistics was applied to evaluate the agreement between the app and three nephrologists who analyzed test results collected from 60 medical records. Finally, eight users tested the app and were interviewed about usability and user perceptions. Results A mHealth app was designed to assist the CKD early diagnosis and self-monitoring considering quality attributes such as safety, effectiveness, and usability. A global Kappa value of 0.7119 showed a substantial degree of agreement between the app and three nephrologists. Results of face-to-face interviews with target users indicated a good user satisfaction. However, the task of CKD self-monitoring proved difficult because most of the users did not fully understand the meaning of specific biomarkers (e.g., creatinine). Conclusion The UCD approach provided mechanisms to develop the app based on the real needs of users. Even with no perfect Kappa degree of agreement, results are satisfactory because it aims to refer patients to nephrologists in early stages, where they may confirm the CKD diagnosis.
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Affiliation(s)
- Alvaro Sobrinho
- Federal Rural University of the Semiarid, Rodovia BR-226, Pau dos Ferros, 59900-000, Brazil.
| | - Leandro Dias da Silva
- Federal University of Alagoas, Av. Lourival Melo Mota, S/N Tabuleiro do Martins, Maceió, 57072-900, Brazil
| | - Angelo Perkusich
- Federal University of Campina Grande, R. Aprígio Veloso, 882, Universitário, Paraíba, 58429-900, Brazil
| | - Maria Eliete Pinheiro
- Federal University of Alagoas, Av. Lourival Melo Mota, S/N Tabuleiro do Martins, Maceió, 57072-900, Brazil
| | - Paulo Cunha
- Federal Institute of Alagoas, R. Prof. Domingos Correia, 1207, Ouro Preto, Alagoas, 57300-010, Brazil
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11
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Ozieh MN, Bishu KG, Dismuke CE, Egede LE. Trends in healthcare expenditure in United States adults with chronic kidney disease: 2002-2011. BMC Health Serv Res 2017; 17:368. [PMID: 28532412 PMCID: PMC5441091 DOI: 10.1186/s12913-017-2303-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 05/11/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND This study examines trends in healthcare expenditure in adults with chronic kidney disease (CKD) and other kidney diseases (OKD) in the U.S. from 2002 to 2011. METHODS One hundred and eighty-seven thousand, three hundred and fourty-one adults aged ≥18 from the Medical Expenditure Panel Survey (MEPS) Household Component were analyzed. CKD and OKD were based on ICD-9 or CCC codes. A novel two-part model was used to estimate the likelihood of any healthcare use and total expenditures. Covariates included individual demographics and comorbidities. RESULTS Approximately 711 adults surveyed from 2002 to 2011 had CKD and 3693 had OKD. CKD was more likely among Non-Hispanic Blacks (NHB), Midwest and Western residents while OKD was more likely among Non-Hispanic Whites (NHW), Hispanics, married and Northeast residents. Both CKD and OKD were more likely in ≥45 years, males, widowed/divorced/single, ≤high school educated, publicly insured, Southern residents, poor and low income individuals. All comorbidities were more likely among people with CKD and OKD. Unadjusted analysis for mean expenditures for CKD and OKD vs. no kidney disease was $39,873 and $13,247 vs. $5411 for the pooled sample. After adjusting for covariates as well as time, individuals with CKD had $17,472 and OKD $5014 higher expenditures, while adjusted mean expenditures increased by $293 to $658 compared to the reference year group. Unadjusted yearly expenditures for CKD and OKD in the US population were approximately $24.6 and $48.1 billion, while adjusted expenditures were approximately $10.7 and $18.2 billion respectively. CONCLUSION CKD and OKD are significant cost-drivers and impose a profound economic burden to the US population.
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Affiliation(s)
- Mukoso N Ozieh
- Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA.,Center for Health Disparities Research, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA.,Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA
| | - Kinfe G Bishu
- Center for Health Disparities Research, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Clara E Dismuke
- Center for Health Disparities Research, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA.,Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA
| | - Leonard E Egede
- Center for Patient Care and Outcomes Research (PCOR), Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA. .,Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
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12
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Grams ME, Wilson FP. Lifetime Probabilities of ESRD: A Decade of Disparity. Am J Kidney Dis 2016; 68:831-832. [DOI: 10.1053/j.ajkd.2016.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/09/2016] [Indexed: 11/11/2022]
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13
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Yang P, Chen N, Wang RR, Li L, Jiang SP. Inappropriateness of medication prescriptions about chronic kidney disease patients without dialysis therapy in a Chinese tertiary teaching hospital. Ther Clin Risk Manag 2016; 12:1517-1524. [PMID: 27785039 PMCID: PMC5066999 DOI: 10.2147/tcrm.s116789] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background With the increasing incidence rate of chronic kidney disease (CKD), inappropriate use of medicine in CKD patients is an important issue, as it may cause adverse effects in patients and progression to chronic renal failure. Objective The aim of this study is to assess the frequency of inappropriate medicine use among CKD patients. Methods A cross-sectional study was conducted from November 1 to December 1, 2014 in a Chinese teaching tertiary hospital. All medication prescriptions for CKD patients with serum creatinine level above normal value were enrolled. The prescriptions, including unreasonable dosage, contraindicated, and cautiously used medicines in CKD patients, were evaluated and the related medications were also analyzed and classified. Results Two hundred and two patients were included, and a total of 1,733 lines of medication prescriptions were evaluated. The prevalence of inappropriate medication prescriptions in CKD patients was 15.18%, of which, unreasonable dosage (n=56), contraindicated (n=46), and cautiously used medicines (n=161) accounted for 3.23%, 2.65%, and 9.29%, respectively. Spearman’s rank correlation coefficient implied that there was a significant correlation between the severity of renal insufficiency and frequency of inappropriate medication prescriptions (P=0.02, r=0.056). Among the inappropriate medication prescriptions, nutraceutical and electrolytes (n=65, 24.71%), cardiovascular drugs (n=61, 23.19%), and antimicrobial drugs (n=55, 20.91%) represented the top three medicine categories in CKD patients. Conclusion The study confirmed that inappropriate medication prescriptions were prevalent in CKD patients. Improving the quality of medication prescriptions in CKD patients is necessary.
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Affiliation(s)
- Ping Yang
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Na Chen
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Rong-Rong Wang
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Lu Li
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Sai-Ping Jiang
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
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14
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Offurum A, Wagner LA, Gooden T. Adverse safety events in patients with Chronic Kidney Disease (CKD). Expert Opin Drug Saf 2016; 15:1597-1607. [PMID: 27648959 DOI: 10.1080/14740338.2016.1236909] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Chronic kidney disease (CKD) confers a higher risk of adverse safety events as a result of many factors including medication dosing errors and use of nephrotoxic drugs, which can cause kidney injury and renal function decline. CKD patients may also have comorbidities such as hypertension and diabetes for which they require more frequent care from different providers, and for which standard, but countervailing treatments, may put them at risk for adverse safety events. Areas covered: In addition to the well-known agents such as iodinated radiocontrast, antimicrobials, diuretics and angiotensin converting enzyme (ACE) inhibitors which can directly affect renal function, safety considerations in the treatment of common CKD complications such as anemia, diabetes, analgesia and thrombosis will also be discussed. Expert opinion: Better outcomes in CKD may be achieved by alerting care providers to the special care needs of kidney patients and encouraging patients to self-manage their disease with the decision support of multidisciplinary patient care teams.
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Affiliation(s)
- Ada Offurum
- a General Internal Medicine , University of Maryland Medical System Ringgold standard institution , Baltimore , MD , USA
| | - Lee-Ann Wagner
- a General Internal Medicine , University of Maryland Medical System Ringgold standard institution , Baltimore , MD , USA
| | - Tanisha Gooden
- a General Internal Medicine , University of Maryland Medical System Ringgold standard institution , Baltimore , MD , USA
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15
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Tan TL, Kheir MM, Tan DD, Filippone EJ, Tischler EH, Chen AF. Chronic Kidney Disease Linearly Predicts Outcomes After Elective Total Joint Arthroplasty. J Arthroplasty 2016; 31:175-179.e2. [PMID: 27067757 DOI: 10.1016/j.arth.2016.03.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/18/2016] [Accepted: 03/07/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Kidney disease is associated with increased complications in total joint arthroplasty (TJA). The purpose of this study was to determine the association of kidney disease severity as measured by the chronic kidney disease (CKD) staging system with complications after TJA. METHODS A retrospective review of 12,308 primary TJAs (6361 hips and 5947 knees) from 2008 to 2013 was performed. The following preoperative variables were obtained from medical records: chemistry 7 panel, Elixhauser comorbidities, and demographic factors. CKD stages were defined based on estimated glomerular filtration rate (eGFR) in mL/min/1.73m(2): (1) 90+, (2) 60-89, (3A) 45-59, (3B) 30-44, (4) 15-29, and (5) <15. Multivariate analysis was performed to assess the independent influence of CKD stage on the aforementioned end points. RESULTS Patients with CKD stage greater than 2 demonstrated an increased odds of receiving transfusions (P = .001), length of stay >3 days (P = .010), acute kidney injury (P < .001), septic revisions (P = .002), and in-hospital complications (P < .001) compared with all patients with eGFR ≥60 when controlling for potential confounders. Only CKD stage 3A was significantly associated with septic revisions (90 days, P = .004; 2 years P = .002). In addition, the relationship between eGFR and the previously mentioned complications increased linearly rather than demonstrating a clear threshold at which the risk increased substantially. CONCLUSION Severe CKD is associated with increased transfusion, length of stay, and in-hospital complications; and complications increased linearly with disease severity. Surgeons should be cognizant of this increase when evaluating TJA patients with renal disease.
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Affiliation(s)
- Timothy L Tan
- The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michael M Kheir
- The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Dean D Tan
- The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Edward J Filippone
- The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Eric H Tischler
- The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Antonia F Chen
- The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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16
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Hemsley B, Georgiou A, Hill S, Rollo M, Steel J, Balandin S. An integrative review of patient safety in studies on the care and safety of patients with communication disabilities in hospital. PATIENT EDUCATION AND COUNSELING 2016; 99:501-511. [PMID: 26566195 DOI: 10.1016/j.pec.2015.10.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/29/2015] [Accepted: 10/28/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To review the research literature on the experiences of patients with communication disabilities in hospital according to the Generic Model of patient safety. METHODS In 2014 and 2015, we searched four scientific databases for studies with an aim or result relevant to safety of hospital patients with communication disabilities. The review included 27 studies. RESULTS A range of adverse event types were outlined in qualitative research. Little detail was provided about contributing or protective factors for safety incidents in hospital for these patients or the impact of the incidents on the patient or organisations involved. CONCLUSION Further research addressing the safety of patients with communication disabilities is needed. Sufficient detail is required to identify the nature, timing, and detection of incidents; factors that contribute to or prevent adverse events; and detail the impact of the adverse events. PRACTICE IMPLICATIONS In order to provide safe and effective care to people with communication disabilities in hospital, a priority for health and disability services must be the design and evaluation of ecologically appropriate and evidence-based interventions to improve patient care, communication, and reduce the risk of costly and harmful patient safety incidents.
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Affiliation(s)
- Bronwyn Hemsley
- Faculty of Education and Art, The University of Newcastle, Newcastle, Australia.
| | - Andrew Georgiou
- Australian Institute for Health Innovation, Macquarie University, Sydney, Australia
| | - Sophie Hill
- Department of Public Health, La Trobe University, Australia
| | - Megan Rollo
- Faculty of Education and Art, The University of Newcastle, Newcastle, Australia
| | - Joanne Steel
- Faculty of Education and Art, The University of Newcastle, Newcastle, Australia
| | - Susan Balandin
- Faculty of Health, Deakin University, Melbourne, Australia
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17
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Hsu KL, Fink JC, Ginsberg JS, Yoffe M, Zhan M, Fink W, Woods CM, Diamantidis CJ. Self-reported Medication Adherence and Adverse Patient Safety Events in CKD. Am J Kidney Dis 2015; 66:621-9. [PMID: 25979348 PMCID: PMC4586079 DOI: 10.1053/j.ajkd.2015.03.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/06/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Promoting medication adherence is a recognized challenge for prescribers. In this study, we examine whether lower medication adherence is associated with adverse safety events in individuals with decreased estimated glomerular filtration rates (eGFRs). STUDY DESIGN Cross-sectional baseline analysis of prospective cohort. SETTING & PARTICIPANTS Baseline analysis of the Safe Kidney Care (SKC) Cohort Study, a prospective study of individuals with eGFRs<60 mL/min/1.73 m(2) intended to assess the incidence of disease-specific safety events. Kidney transplant recipients were excluded. PREDICTOR Self-reported medication adherence based on responses to 3 questions ascertaining degree of medication regimen adherence. OUTCOMES Adverse safety events were self-reported at baseline (class I events), such as hypoglycemia or fall thought to be related to a medication, or detected incidentally during the baseline visit (class II events), for example, hypotension or hyperkalemia. Potential drug-related problems (DRPs) were determined by analyzing participants' medications with respect to dosing guidelines based on their screening eGFRs at the time of medication reporting. MEASUREMENTS Relationship between medication adherence and disease-specific patient safety events. RESULTS Of 293 SKC participants, 154 (53%) were classified as having lower medication adherence. After multivariable adjustment, lower medication adherence was significantly associated with a class I or II safety event (prevalence ratio [PR], 1.21; 95% CI, 1.04-1.41) and potential DRPs (PR, 1.29; 95% CI, 1.02-1.63). Lower medication adherence was also significantly associated with multiple (≥2) class I events (PR, 1.71; 95% CI, 1.18-2.49), multiple class I or II events (PR, 1.35; 95% CI, 1.04-1.76), and multiple potential DRPs (PR, 2.11; 95% CI, 1.08-2.69) compared with those with higher medication adherence. LIMITATIONS Use of self-reported medication adherence rather than pharmacy records. Clinical relevance of detected safety events is unclear. CONCLUSIONS Lower medication adherence is associated with adverse safety events in individuals with eGFRs<60 mL/min/1.73 m(2).
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Affiliation(s)
- Kailin L Hsu
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Jeffrey C Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; Department of Medicine, Veterans Affairs Maryland Health Care System, Baltimore, MD
| | - Jennifer S Ginsberg
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Marni Yoffe
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Min Zhan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Wanda Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | | | - Clarissa J Diamantidis
- Department of Medicine, Duke University School of Medicine, Durham, NC; Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC.
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18
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Weir MR, Gravens-Muller L, Costa N, Ivanova A, Manitpisitkul W, Bostom AG, Diamantidis CJ. Safety events in kidney transplant recipients: results from the folic Acid for vascular outcome reduction in transplant trial. Transplantation 2015; 99:1003-8. [PMID: 25393158 DOI: 10.1097/tp.0000000000000454] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Kidney transplant recipients are at increased risk for adverse safety events related to their reduced renal function and many medications. METHODS We determined the incidence of adverse safety events based on previously defined Agency for Healthcare and Research Quality (AHRQ) International Classification of Diseases-9 (ICD-9) code-derived patient safety indicators (PSI) in the Folic Acid for Vascular Outcome Reduction in Transplant trial participants who had a hospitalization stratified by tertiles of estimated glomerular filtration rate (GFR). We also examined the frequency of Micromedex defined two precautionary drug-drug interactions, and two medications whose use may be contraindicated because of reduced GFR from the Folic Acid for Vascular Outcome Reduction in Transplant trial medication thesaurus at baseline, and annually among 4,110 participants. Logistic regression was used to examine the relationship between patient safety events and baseline demographic and clinical variables at a participant level. Event rates were estimated at participant and visit levels. RESULTS Of the 2,514 patients with a hospitalization, 978 (38.9%) experienced an AHRQ PSI. Factors which were associated with more common AHRQ PSI included: U.S. location, history of cardiovascular disease or diabetes, and lower tertile of estimated GFR. At a participant level, 2,524 of the 4,110 participants (61.4%) were taking calcineurin inhibitor and statin, 378 (9.2%) were taking azathioprine and an angiotensin-converting enzyme inhibitor, 171 (12.9%) were taking a sulfonylurea), 45 (3.4%) were taking metformin despite a baseline GFR below 40 mL per min per 1.73 m. CONCLUSION We conclude that patient safety events are not uncommon in kidney transplant recipients. Careful monitoring is necessary to prevent adverse outcomes.
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Affiliation(s)
- Matthew R Weir
- 1 Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD. 2 Department of Biostatistics, University of North Carolina, Chapel Hill, NC. 3 Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD. 4 Rhode Island Hospital, Brown University School of Medicine, Providence, RI
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Mahalingaiah PKS, Ponnusamy L, Singh KP. Chronic oxidative stress leads to malignant transformation along with acquisition of stem cell characteristics, and epithelial to mesenchymal transition in human renal epithelial cells. J Cell Physiol 2015; 230:1916-28. [PMID: 25546616 DOI: 10.1002/jcp.24922] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/24/2014] [Accepted: 12/18/2014] [Indexed: 12/30/2022]
Abstract
Oxidative injury to cellular macromolecules has been suggested as a common pathway shared by multiple etiological factors for kidney cancer. Whether the chronic oxidative stress alone is sufficient to induce malignant transformation in human kidney cells is not clear. Therefore, the objective of this study was to evaluate the effect of H2O2-induced chronic oxidative stress on growth, and malignant transformation of HK-2 normal kidney epithelial cells. This study revealed that chronic oxidative stress causes increased growth and neoplastic transformation in normal kidney epithelial cells at non-cytotoxic dose and increased adaptation to cytotoxic level. This was confirmed by gene expression changes, cell cycle analysis, anchorage independent growth assay and in vivo tumorigenicity in nude mice. Stem cells characteristics as revealed by up-regulation of stem cell marker genes, and morphological changes indicative of EMT with up regulation of mesenchymal markers were also observed in cells exposed to chronic oxidative stress. Antioxidant NAC did not reverse the chronic oxidative stress-induced growth, and adaptation suggesting that perturbed biological function in these cells are permanent. Partial reversal of oxidative stress-induced growth, and adaptation by silencing of Oct 4 and Snail1, respectively, suggest that these changes are mediated by acquisition of stem cell and EMT characteristics. In summary, this study for the first time suggests that chronic exposure to elevated levels of oxidative stress is sufficient to induce malignant transformation in kidney epithelial cells through acquisition of stem cell characteristics. Additionally, the EMT plays an important role in increased adaptive response of renal cells to oxidative stress.
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Affiliation(s)
- Prathap Kumar S Mahalingaiah
- Department of Environmental Toxicology, The Institute of Environmental and Human Health (TIEHH), Texas Tech University, Lubbock, Texas
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20
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Colantonio LD, Baber U, Banach M, Tanner RM, Warnock DG, Gutiérrez OM, Safford MM, Wanner C, Howard G, Muntner P. Contrasting Cholesterol Management Guidelines for Adults with CKD. J Am Soc Nephrol 2015; 26:1173-80. [PMID: 25395432 PMCID: PMC4413767 DOI: 10.1681/asn.2014040400] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 07/24/2014] [Indexed: 11/03/2022] Open
Abstract
The Kidney Disease Improving Global Outcomes Lipid Work Group recommends statins for adults ≥50 years old with CKD. The American College of Cardiology/American Heart Association endorses statins for adults with atherosclerotic cardiovascular disease, adults with LDL cholesterol≥190 mg/dl, and adults 40-79 years old with LDL cholesterol=70-189 mg/dl and diabetes or a 10-year predicted risk for atherosclerotic cardiovascular disease ≥7.5% estimated using the Pooled Cohort risk equations. Using data from the Reasons for Geographic and Racial Differences in Stroke Study, we calculated the agreement for statin treatment between these two guidelines for adults 50-79 years old with CKD (eGFR<60 ml/min per 1.73 m(2) or albuminuria≥30 mg/g) not on dialysis. We assessed the validity of the Pooled Cohort risk equations in individuals with CKD. Study participants were enrolled between 2003 and 2007, and we report incident cardiovascular disease events (stroke and coronary heart disease) through December of 2010. Among 4726 participants with CKD, 2366 (50%) were taking statins, and 1984 (42%) were recommended statins by the American College of Cardiology/American Heart Association guideline but not taking them. Overall, 376 (8%) participants did not meet the American College of Cardiology/American Heart Association criteria for initiating statin treatment. Cardiovascular disease incidence was low (3.0/1000 person-years; 95% confidence interval, 0.1 to 5.9) among these participants. The Pooled Cohort risk equations were well calibrated (Hosmer-Lemeshow chi-squared=2.7, P=0.45) with moderately good discrimination (C index, 0.71; 95% confidence interval, 0.65 to 0.77). In conclusion, these guidelines show high concordance for statin treatment for adults with CKD.
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Affiliation(s)
| | - Usman Baber
- Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York
| | - Maciej Banach
- Department of Hypertension, Medical University of Lodz, Lodz, Poland; and
| | | | | | | | | | - Christoph Wanner
- Department of Medicine, Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
| | - George Howard
- Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
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Perotte A, Ranganath R, Hirsch JS, Blei D, Elhadad N. Risk prediction for chronic kidney disease progression using heterogeneous electronic health record data and time series analysis. J Am Med Inform Assoc 2015; 22:872-80. [PMID: 25896647 PMCID: PMC4482276 DOI: 10.1093/jamia/ocv024] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 03/08/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND As adoption of electronic health records continues to increase, there is an opportunity to incorporate clinical documentation as well as laboratory values and demographics into risk prediction modeling. OBJECTIVE The authors develop a risk prediction model for chronic kidney disease (CKD) progression from stage III to stage IV that includes longitudinal data and features drawn from clinical documentation. METHODS The study cohort consisted of 2908 primary-care clinic patients who had at least three visits prior to January 1, 2013 and developed CKD stage III during their documented history. Development and validation cohorts were randomly selected from this cohort and the study datasets included longitudinal inpatient and outpatient data from these populations. Time series analysis (Kalman filter) and survival analysis (Cox proportional hazards) were combined to produce a range of risk models. These models were evaluated using concordance, a discriminatory statistic. RESULTS A risk model incorporating longitudinal data on clinical documentation and laboratory test results (concordance 0.849) predicts progression from state III CKD to stage IV CKD more accurately when compared to a similar model without laboratory test results (concordance 0.733, P<.001), a model that only considers the most recent laboratory test results (concordance 0.819, P < .031) and a model based on estimated glomerular filtration rate (concordance 0.779, P < .001). CONCLUSIONS A risk prediction model that takes longitudinal laboratory test results and clinical documentation into consideration can predict CKD progression from stage III to stage IV more accurately than three models that do not take all of these variables into consideration.
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Affiliation(s)
- Adler Perotte
- Biomedical Informatics Department, Columbia University, New York, NY, USA
| | - Rajesh Ranganath
- Computer Science Department, Princeton University, Princeton, NJ, USA
| | - Jamie S Hirsch
- Biomedical Informatics Department, Columbia University, New York, NY, USA Division of Nephrology, Columbia University, New York, NY, USA
| | - David Blei
- Statistics Department, Columbia University, New York, NY, USA
| | - Noémie Elhadad
- Biomedical Informatics Department, Columbia University, New York, NY, USA
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22
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Weir MR, Fink JC. Safety of medical therapy in patients with chronic kidney disease and end-stage renal disease. Curr Opin Nephrol Hypertens 2014; 23:306-13. [PMID: 24670404 DOI: 10.1097/01.mnh.0000444912.40418.45] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Maintaining patient safety is a necessary step to improve healthcare delivery. Patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) have an increased frequency of adverse safety events largely because of medication errors. RECENT FINDINGS CKD and ESRD have several features which threaten patient safety. Reduced glomerular filtration rate affects the clearance of many medications and is also associated with several comorbidities such as diabetes, cardiovascular disease, metabolic bone disease, and anemia. These comorbidities of CKD often increase the complexity of treatment regimens. Patients with ESRD, requiring dialysis or transplantation, have an even greater potential for adverse safety events because of the reliance on renal replacement modalities and the frequent requirements of polypharmacy and potential drug-drug interactions. SUMMARY There is an important need to develop strategies to provide inpatient and outpatient management plans to limit the risk of adverse medication errors across a wide range of educational and socioeconomic backgrounds, and a critical need to develop a uniform set of standards for evaluating patient safety in CKD and ESRD as well as appropriate descriptions of the prototypical safety profiles of patients who have CKD, a kidney transplant, or who are on dialysis.
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Affiliation(s)
- Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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23
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Zhu L, Fox A, Chan YC. Enhancing collaborative pharmaceutical care for patients with chronic kidney disease: survey of community pharmacists. Can J Hosp Pharm 2014; 67:268-73. [PMID: 25214657 DOI: 10.4212/cjhp.v67i4.1370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The Kidney Care Clinic at Sunnybrook Health Sciences Centre provides multidisciplinary care for patients with stage 4 or 5 chronic kidney disease. These patients are at high risk of drug therapy problems. Clinic pharmacists review medications and provide recommendations at each visit, but potential gaps in care exist between clinic visits. Community pharmacists are ideally situated to identify and resolve drug therapy problems between visits. OBJECTIVES To determine community pharmacists' confidence in managing care for patients with chronic kidney disease; to identify opportunities for improving collaboration between clinic and community pharmacists; and to determine the key clinical information that community pharmacists would use when caring for these patients. METHODS An anonymous survey was sent by mail and electronically to community pharmacies that were providing prescription medications for clinic patients. A total of 318 surveys were sent to 96 pharmacies. Data analysis was based on descriptive statistics, including frequencies, ranges, and measures of central tendency. RESULTS Fifty-one completed surveys were returned (response rate 16%). Thirty-five (69%) of the responding pharmacists were not aware or were unsure that a patient from the Kidney Care Clinic was a client of their pharmacy. Forty-six (90%) were confident in providing counselling about medications used to manage chronic kidney disease, and 32 (63%) indicated confidence in recommending drug dosing changes based on kidney function. Forty-five (88%) of the pharmacists indicated a willingness to play a greater role in reviewing medications for patients with chronic kidney disease, and all agreed that they would benefit from education about the complications of this disease and their management. Clinical information ranked most useful included an updated medication list with indications and details regarding recent medication changes. CONCLUSIONS Community pharmacists indicated willingness to have greater involvement in the care of patients with chronic kidney disease. The survey results revealed a need to increase awareness of clinic patients among community providers. Participants were receptive to continuing education, and initial efforts should focus on dosing adjustments of renal drugs and the complications of chronic kidney disease. Tools for transferring clinical information must be developed.
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Affiliation(s)
- Lisa Zhu
- BScPhm, ACPR, PharmD, is a Clinical Pharmacist in the Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Andrea Fox
- BSc, BScPhm, is a Clinical Pharmacist in the Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Yu Chun Chan
- BSc, BScPhm, was, at the time the study was conducted, a pharmacy research student at Sunnybrook Health Sciences Centre, Toronto, Ontario. He is now a Clinical Pharmacist with North York General Hospital, Toronto, Ontario
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Khanal A, Castelino RL, Peterson GM, Jose MD. Dose adjustment guidelines for medications in patients with renal impairment: how consistent are drug information sources? Intern Med J 2014; 44:77-85. [PMID: 24112311 DOI: 10.1111/imj.12291] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 09/09/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is known that patients with renal disease are often administered inappropriate dosages of drugs. A lack of quantitative data in the available drug information sources and inconsistency in dosing information may augment the problem of dosing error. AIMS To determine the concordance among five drug information sources regarding the dosing recommendations provided for drugs considered problematic in patients with renal impairment and to determine the consistency among the sources regarding the definition of renal impairment and categorisation of chronic kidney disease. METHODS Five standard drug information sources were reviewed for 61 drugs recommended to be used with caution in renal impairment. Information on recommendations for dosage adjustment in renal impairment was extracted and analysed. Further, the definition and classification of renal impairment were recorded. The recommendation for each drug was coded into six different categories and the intersource reliability was calculated. RESULTS Only slight agreement was observed among the sources (Fleiss Kappa: 0.3). Qualitative data were not well defined, and there was a lack of consistency in quantitative values. Some drugs marked as contraindicated in one source were not mentioned as such in others. Also, drugs considered as not requiring dosage adjustment in one source had explicit recommendations in other sources. The definition and classification of renal impairment differed among the five information sources. CONCLUSIONS There should be an evidence-based approach to drug dosage adjustment in order to bring uniformity to the recommendations. Regular updating of the content of the drug information sources is also important.
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Affiliation(s)
- A Khanal
- School of Pharmacy, University of Tasmania, Hobart, Tasmania, Australia
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Stengel B, Combe C, Jacquelinet C, Briançon S, Fouque D, Laville M, Frimat L, Pascal C, Herpe YE, Deleuze JF, Schanstra J, Pisoni RL, Robinson BM, Massy ZA. The French Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort study. Nephrol Dial Transplant 2014; 29:1500-7. [PMID: 24064325 PMCID: PMC4106639 DOI: 10.1093/ndt/gft388] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 08/05/2013] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND While much has been learned about the epidemiology and treatment of end-stage renal disease (ESRD) in the last 30 years, chronic kidney disease (CKD) before the end-stage has been less investigated. Not enough is known about factors associated with CKD progression and complications, as well as its transition to ESRD. We designed the CKD-renal epidemiology and information network (REIN) cohort to provide a research platform to address these key questions and to assess clinical practices and costs in patients with moderate or advanced CKD. METHODS A total of 46 clinic sites and 4 renal care networks participate in the cohort. A stratified selection of clinic sites yields a sample that represents a diversity of settings, e.g. geographic region, and public versus for-profit and non-for-profit private clinics. In each site, 60-90 patients with CKD are enrolled at a routine clinic visit during a 12-month enrolment phase: 3600 total, including 1800 with Stage 3 and 1800 with Stage 4 CKD. Follow-up will continue for 5 years, including after initiation of renal replacement therapy. Data will be collected from medical records at inclusion and at yearly intervals, as well as from self-administered patient questionnaires and provider-level questionnaires. Patients will also be interviewed at baseline, and at 1, 3 and 5 years. Healthcare costs will also be determined. Blood and urine samples will be collected and stored for future studies on all patients at enrolment and at study end, and at 1 and 3 years in a subsample of 1200. CONCLUSIONS The CKD-REIN cohort will serve to improve our understanding of the biological, clinical and healthcare system determinants associated with CKD progression and adverse outcomes as well as of international variations in collaboration with the CKD Outcome and Practice Pattern Study (CKDopps). It will foster CKD epidemiology and outcomes research and provide evidence to improve the health and quality of life of patients with CKD and the performances of the healthcare system in this field.
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Affiliation(s)
- Bénédicte Stengel
- Inserm, U1018, CESP Centre for Research in Epidemiology and Population Health, Team 10, Diabetes, Obesity, and Chronic Kidney Disease Epidemiology Team, Villejuif, France
- Paris Sud Univ, UMRS 1018, Villejuif, France
| | - Christian Combe
- Department of Nephrology Transplantation Dialysis, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Inserm, U1026, Univ Bordeaux Segalen, Bordeaux, France
| | | | - Serge Briançon
- Clinical Epidemiology, Inserm CIC-EC, CHU de Nancy, Vandoeuvre-lès-Nancy, France
| | - Denis Fouque
- Nephrology Department, Centre Hospitalier LYON-SUD, Pierre-Bénite, France
- CarMeN, CENS and Univ Lyon, Lyon, France
| | - Maurice Laville
- Nephrology Department, Centre Hospitalier LYON-SUD, Pierre-Bénite, France
- CarMeN, CENS and Univ Lyon, Lyon, France
| | - Luc Frimat
- Clinical Epidemiology, Inserm CIC-EC, CHU de Nancy, Vandoeuvre-lès-Nancy, France
- Nephrology Department, CHU de Nancy, Vandoeuvre-lès-Nancy
| | - Christophe Pascal
- Jean Moulin Lyon 3 University, The Institute for Education and Research in Health Care and Social Service, Lyon, France
| | - Yves-Edouard Herpe
- Biobanque de Picardie, Amiens, France
- Centre Hospitalier Universitaire, Amiens, France
| | | | - Joost Schanstra
- Institute of Cardiovascular and Metabolic Disease, Inserm U1048, Toulouse, France
- Université Toulouse III Paul-Sabatier, Toulouse, France
| | - Ron L. Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Ziad A. Massy
- Centre Hospitalier Universitaire, Amiens, France
- Inserm U1088, Amiens University Hospital, Amiens, France
- Nephrology Department, CHU Ambroise Pare, Boulogne, France
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Ginsberg JS, Zhan M, Diamantidis CJ, Woods C, Chen J, Fink JC. Patient-reported and actionable safety events in CKD. J Am Soc Nephrol 2014; 25:1564-73. [PMID: 24556352 DOI: 10.1681/asn.2013090921] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Patients with CKD are at high risk for adverse safety events because of the complexity of their care and impaired renal function. Using data from our observational study of predialysis patients with CKD enrolled in the Safe Kidney Care study, we estimated the baseline frequency of adverse safety events and determined to what extent these events co-occur. We examined patient-reported adverse safety incidents (class I) and actionable safety findings (class II), conditioned on participant use of drugs that might cause such an event, and we used association analysis as a data-mining technique to identify co-occurrences of these events. Of 267 participants, 185 (69.3%) had at least one class I or II event, 102 (38.2%) had more than one event, and 48 (18.0%) had at least one event from both classes. The adjusted conditional rates of class I and class II events ranged from 2.9 to 57.6 per 100 patients and from 2.2 to 8.3 per 100 patients, respectively. The most common conditional class I and II events were patient-reported hypoglycemia and hyperkalemia (serum potassium>5.5 mEq/L), respectively. Reporting of hypoglycemia (in patients with diabetes) and falling or severe dizziness (in patients without diabetes) were most frequently paired with other adverse safety events. We conclude that adverse safety events are common and varied in CKD, with frequent association between disparate events. Further work is needed to define the CKD "safety phenotype" and identify patients at highest risk for adverse safety events.
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Affiliation(s)
| | - Min Zhan
- Department of Epidemiology and Public Health, School of Medicine, and
| | | | - Corinne Woods
- Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, Maryland
| | | | - Jeffrey C Fink
- Department of Medicine and Department of Epidemiology and Public Health, School of Medicine, and
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Greer RC, Crews DC, Boulware LE. Challenges perceived by primary care providers to educating patients about chronic kidney disease. J Ren Care 2013; 38:174-81. [PMID: 23176576 DOI: 10.1111/j.1755-6686.2012.00323.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To identify primary care providers' (PCPs) perceived barriers to educating patients about chronic kidney disease (CKD) during routine clinical visits. METHODS We conducted three focus groups of eighteen PCPs in Baltimore, Maryland (MD), USA. Focus groups began with the presentation of a hypothetical case of a patient with CKD, followed by open-ended questions to assess providers' perceived barriers to delivering education about CKD. Groups were audiotaped, transcribed and coded independently by two investigators who identified major themes. RESULTS PCPs reported on several patient, provider and system level barriers contributing to poor education about CKD in primary care that were both common and unique to barriers previously reported in educating patients regarding other chronic diseases. CONCLUSIONS Interventions designed to address barriers to CKD education identified by PCPs could improve the delivery of education about CKD in primary care settings.
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Affiliation(s)
- Raquel C Greer
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Hartley IR, Ginsberg JS, Diamantidis CJ, Zhan M, Walker L, Rattinger GB, Fink JC. Consideration of ICD-9 code-derived disease-specific safety indicators in CKD. Clin J Am Soc Nephrol 2013; 8:2123-31. [PMID: 24052221 DOI: 10.2215/cjn.12671212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The Agency for Healthcare and Research Quality patient safety indicators track adverse safety events in hospitalized patients but overlook safety incidents specific to CKD. This study considers candidate CKD-pertinent patient safety indicators and compares them with the Agency for Healthcare and Research Quality patient safety indicators. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using a national Veterans Health Administration database of hospitalized veterans from fiscal year 2005, 247,160 hospitalized veterans with prehospitalization measures of renal function were retrospectively examined for proposed CKD patient safety indicators versus Agency for Healthcare and Research Quality patient safety indicators using International Classification of Diseases, Ninth Revision diagnosis codes. Candidate CKD-pertinent patient safety indicators included in-hospital acute kidney failure; in-hospital congestive heart failure (and related diagnostic codes); electrolyte disturbances; and medication errors, poisoning, and intoxication. Patients with a prehospital estimated GFR<60 ml/min per 1.73 m(2) (CKD group) were compared with a non-CKD group. For CKD patient safety indicators, hospitalizations were excluded if the admitting condition was a potential cause of the secondary condition. Regression methods were used to present adjusted rates in study groups of interest. RESULTS The CKD patient safety indicators were generally more common than the Agency for Healthcare and Research Quality patient safety indicators in all groups, tended to occur in different patients than those patients who experienced Agency for Healthcare and Research Quality patient safety indicators, and were more common in the CKD group than the non-CKD group, except for hypoglycemia, hypokalemia, and hyponatremia. The adjusted composite CKD patient safety indicators rate (per 1000 patient-hospitalizations) was 398.0 (95% confidence interval, 391.2 to 405.0) for patients in the CKD group and 250.0 (95% confidence interval, 247.4 to 252.7) for patients in the non-CKD group. The prevalence ratio of CKD patient safety indicators to Agency for Healthcare and Research Quality patient safety indicators was 23.4 (95% confidence interval, 21.9 to 25.0). CONCLUSION The candidate CKD patient safety indicators that occur in hospitalized patients are distinct from the Agency for Healthcare and Research Quality patient safety indicators and tend to be more common in CKD than non-CKD patients. These measures have the potential to serve as sentinel tools for identifying patients with CKD who warrant examination for disease-pertinent safety events.
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Affiliation(s)
- Iris R Hartley
- Departments of Medicine and, †Epidemiology and Public Health, School of Medicine and, ‡Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, Maryland, §Fairleigh Dickinson University, Pharmacy Practice Division, School of Pharmacy, Florham Park, New Jersey
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Pippias M, Tomson CRV. Patient safety in chronic kidney disease: time for nephrologists to take action. Nephrol Dial Transplant 2013; 29:473-5. [PMID: 23975749 DOI: 10.1093/ndt/gft364] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Maria Pippias
- Specialist Registrar in Nephrology, Richard Bright Renal Unit, Southmead Hospital, Bristol BS10 5NB, UK
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Vassalotti JA, Piraino B. Loss of kidney function with aging is a patient safety hazard. Am J Kidney Dis 2013; 62:217-9. [PMID: 23883657 DOI: 10.1053/j.ajkd.2013.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 06/07/2013] [Indexed: 11/11/2022]
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Reilly JB, Marcotte LM, Berns JS, Shea JA. Handoff Communication Between Hospital and Outpatient Dialysis Units at Patient Discharge: A Qualitative Study. Jt Comm J Qual Patient Saf 2013; 39:70-6. [DOI: 10.1016/s1553-7250(13)39010-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Joosten H, Drion I, Boogerd KJ, van der Pijl EV, Slingerland RJ, Slaets JPJ, Jansen TJ, Schwantje O, Gans ROB, Bilo HJG. Optimising drug prescribing and dispensing in subjects at risk for drug errors due to renal impairment: improving drug safety in primary healthcare by low eGFR alerts. BMJ Open 2013; 3:e002068. [PMID: 23355668 PMCID: PMC3563134 DOI: 10.1136/bmjopen-2012-002068] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Revised: 12/09/2012] [Accepted: 12/19/2012] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To assess the risk of medication errors in subjects with renal impairment (defined as an estimated glomerular filtration rate (eGFR) ≤40 ml/min/1.73 m(2)) and the effectiveness of automatic eGFR ≤40-alerts relayed to community pharmacists. DESIGN Clinical survey. SETTING The city of Zwolle, The Netherlands, in a primary care setting including 22 community pharmacists and 65 general practitioners. PARTICIPANTS All adults who underwent ambulatory creatine measurements which triggered an eGFR ≤40-alert. PRIMARY AND SECONDARY OUTCOME MEASURES The total number of ambulatory subjects with an eGFR ≤40-alert during the study period of 1 year and the number of medication errors related to renal impairment. The type and number of proposed drug adjustments recommended by the community pharmacist and acceptance rate by the prescribing physicians. Classification of all medication errors on their potential to cause an adverse drug event (ADE) and the actual occurrence of ADEs (limited to those identified through hospital record reviews) 1 year after the introduction of the alerts. RESULTS Creatine measurements were performed in 25 929 adults. An eGFR ≤40-alert was indicated for 5.3% (n=1369). This group had a median (IQR) age of 78 (69, 84) years, and in 73% polypharmacy (≥5 drugs) was present. In 15% (n=211) of these subjects, a medication error was detected. The proportion of errors increased with age. Pharmacists recommended 342 medication adjustments, mainly concerning diuretics (22%) and antibiotics (21%). The physicians' acceptance rate was 66%. Of all the medication errors, 88% were regarded as potential ADEs, with most classified as significant or serious. At follow-up, the ADE risk (n=40) appeared highest when the proposed medication adjustments were not implemented (38% vs 6%). CONCLUSIONS The introduction of automatic eGFR-alerts identified a considerable number of subjects who are at risk for ADEs due to renal impairment in an ambulatory setting. The nationwide implementation of this simple protocol could identify many potential ADEs, thereby substantially reducing iatrogenic complications in subjects with impaired renal function.
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Affiliation(s)
- Hanneke Joosten
- University of Groningen, University Medical Centre Groningen, Department of Internal Medicine, Groningen, The Netherlands
| | - Iefke Drion
- Isala Clinics, Department of Internal Medicine, Diabetes Centre, Zwolle, The Netherlands
| | - Kees J Boogerd
- Pharmacy De Fenix (previously Boogerd Kluin), Zwolle, The Netherlands
| | | | - Robbert J Slingerland
- Isala Clinics, Department of Clinical Chemistry and Laboratory Medicine, Zwolle, The Netherlands
| | - Joris P J Slaets
- University of Groningen, University Medical Centre Groningen, Department of Internal Medicine, Groningen, The Netherlands
- University of Groningen, University Medical Centre Groningen, Department of Internal Medicine, University Center for Geriatric Medicine, Groningen, The Netherlands
| | | | | | - Reinold O B Gans
- University of Groningen, University Medical Centre Groningen, Department of Internal Medicine, Groningen, The Netherlands
| | - Henk J G Bilo
- Isala Clinics, Department of Internal Medicine, Diabetes Centre, Zwolle, The Netherlands
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Harel Z, Wald R, Liu JJ, Bell CM. Lapses in safety in end-stage renal disease patients admitted to surgical services. Hemodial Int 2013; 16:286-93. [PMID: 22098634 DOI: 10.1111/j.1542-4758.2011.00633.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Chronic dialysis patients are a vulnerable population that may be highly susceptible to medical errors, particularly when they are hospitalized. We performed a chart review of chronic hemodialysis patients admitted to surgical services at a tertiary care center in order to characterize lapses in patient safety. We conducted a retrospective chart review of admissions of patients receiving chronic hemodialysis to various surgical services at St. Michael's Hospital from January 1, 2009 to December 31, 2010. For each hospitalization, we collected data on four process of care indicators of potential safety lapses. When these lapses were identified, we sought to determine whether: (i) the lapse was detected and remedied; and (ii) the lapse resulted in an adverse event. Among the 41 patients, 96 process of care lapses were identified. Multiple lapses were detected in 83% of the cohort. Failure to order a renal diet (72%) occurred most often. There was one adverse event. Process of care lapses were detected 39% of the time, usually within 1.5 days of their occurrence. Patients receiving chronic hemodialysis admitted to surgical services experience multiple lapses in patient safety, which often remain undetected. As such, it is imperative that these patients be closely monitored in order to mitigate against potential adverse events.
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Affiliation(s)
- Ziv Harel
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada.
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Richardson MM, Nolin TD. A decade after the KDOQI CKD guidelines: impact on medication safety. Am J Kidney Dis 2012; 60:713-5. [PMID: 23067638 DOI: 10.1053/j.ajkd.2012.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 08/10/2012] [Indexed: 11/11/2022]
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Reardon G, Wasserman MR, McKenzie RS, Hord RS, Kilpatrick B, Bailey RA. The Prevalence and Recognition of Chronic Kidney Disease and Anemia in Long-Term Care Residents. ACTA ACUST UNITED AC 2012; 27:627-40. [DOI: 10.4140/tcp.n.2012.627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Kuske S, Maass C, Weingärter V, Pöhlmann S, Schrappe M. Patient-safety indicators: a systematic review, criteria-based characterization and prioritization. J Public Health (Oxf) 2012. [DOI: 10.1007/s10389-012-0532-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Patel K, Diamantidis C, Zhan M, Hsu VD, Walker LD, Gardner J, Weir MR, Fink JC. Influence of creatinine versus glomerular filtration rate on non-steroidal anti-inflammatory drug prescriptions in chronic kidney disease. Am J Nephrol 2012; 36:19-26. [PMID: 22699456 DOI: 10.1159/000339439] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 05/10/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs), including cyclooxygenase-2 (COX-2) inhibitors, are generally contraindicated in chronic kidney disease (CKD). This investigation sought to identify the frequency of NSAID/COX-2 prescription and to determine the influence of serum creatinine (Cr) versus estimated glomerular filtration rate (eGFR) on this practice pattern. METHODS An established Veterans Health Administration CKD safety cohort (n = 70,154) was examined to determine the frequency of NSAID/COX-2 in fiscal year 2005 (FY05) for up to 30 days preceding the index hospitalization and as many as 365 days during that year. Binomial regression was used to determine adjusted prevalence ratios for prescription of NSAID/COX-2 with respect to continuous eGFR measurement and serum Cr categories. CKD was defined as eGFR <60 ml/min/1.73 m(2). RESULTS 15.4% of the subjects had an NSAID/COX-2 prescription during the observation period. The proportion of these prescribed agents decreased with declining renal function, but remained significant at any stage of CKD given the renal harm related to these medications. At specific GFR estimates, serum Cr remained a significant predictor of NSAID/COX-2 prescription. At GFR set at 42 ml/min/1.73 m(2), the predicted proportion of prescribed NSAID/COX-2 was 0.29 (95% CI 0.24, 0.36), 0.23 (95% CI 0.22, 0.26), 0.20 (95% CI 0.19, 0.22), and 0.12 (95% CI 0.10, 0.14) for Cr strata of ≤1.3, 1.4-1.6, 1.7-2.1, and ≥2.2 mg/dl, respectively (all p < 0.05). CONCLUSION A significant proportion of individuals with CKD continue to be prescribed NSAID/COX-2 and serum Cr remains an influential guide to NSAID/COX-2 prescription, even in GFR ranges where these agents are ill advised.
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Affiliation(s)
- Krupa Patel
- Department of Medicine, University of Maryland School of Medicine, Baltimore, 21201, USA
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Fink JC, Joy MS, St. Peter WL, Wahba IM. Finding a Common Language for Patient Safety in CKD. Clin J Am Soc Nephrol 2012; 7:689-95. [DOI: 10.2215/cjn.12781211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Chronic kidney disease is a general term for heterogeneous disorders affecting kidney structure and function. The 2002 guidelines for definition and classification of this disease represented an important shift towards its recognition as a worldwide public health problem that should be managed in its early stages by general internists. Disease and management are classified according to stages of disease severity, which are assessed from glomerular filtration rate (GFR) and albuminuria, and clinical diagnosis (cause and pathology). Chronic kidney disease can be detected with routine laboratory tests, and some treatments can prevent development and slow disease progression, reduce complications of decreased GFR and risk of cardiovascular disease, and improve survival and quality of life. In this Seminar we discuss disease burden, recommendations for assessment and management, and future challenges. We emphasise clinical practice guidelines, clinical trials, and areas of uncertainty.
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Affiliation(s)
- Andrew S Levey
- William B Schwartz Division of Nephrology, Tufts Medical Center, Boston, MA 02111, USA.
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Breton G, Froissart M, Janus N, Launay-Vacher V, Berr C, Tzourio C, Helmer C, Stengel B. Inappropriate drug use and mortality in community-dwelling elderly with impaired kidney function--the Three-City population-based study. Nephrol Dial Transplant 2011; 26:2852-9. [PMID: 21292816 PMCID: PMC3907357 DOI: 10.1093/ndt/gfq827] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Glomerular filtration rate (GFR) decline with age increases the risk of inappropriate dosing of drugs. We investigated the determinants and the mortality associated with the use of drugs that are contraindicated or require dose adjustment according to kidney function among the community-dwelling elderly. METHODS The Three-City population-based study included 8701 participants ≥65 years from 1999 to 2001. Exposure to the risk of inappropriate drug dosage was defined as reported use of either a contraindicated drug or one requiring dose adjustment according to the individual baseline glomerular filtration rate estimated (eGFR) with the Modification of Diet in Renal disease study equation. Six-year mortality was analysed using Cox models adjusted for several sociodemographic, biologic and clinical risk factors. RESULTS The overall percentage of exposure to the risk of inappropriate drug use was 13.3% (contraindication, 0.8%): it was 52.5% (4.5%) in those with an eGFR of 30-59 and 96% (48%) in those <30 mL/min/1.73 m(2). Antihypertensive agents, fibrates and psycholeptics accounted for most of the drugs with dosing recommendations and antidiabetic agents and antihistamines for those contraindicated. Individuals at risk were more likely to be men, older, and under treatment for hypertension or hypercholesterolemia. Exposure to either risk was independently related to higher all-cause mortality (hazard ratio 1.4, 95% confidence interval 1.0-1.9) in participants with eGFR <60 mL/min/1.73 m(2). CONCLUSIONS Contraindicated drug prescription was uncommon but >10% of the population took drugs requiring renal dosing adjustments. Regular monitoring of eGFR may prevent excess mortality associated with inappropriate drug prescription in the elderly.
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Affiliation(s)
- Gaëlle Breton
- CESP, Centre de Recherche en Epidémiologie et Santé des Populations
INSERM : U1018Université Paris XI - Paris SudHôpital Paul BrousseAssistance Publique - Hôpitaux de Paris (AP-HP)16 Avenue Paul Vaillant Couturier 94807 Villejuif Cedex, FR
| | - Marc Froissart
- CESP, Centre de Recherche en Epidémiologie et Santé des Populations
INSERM : U1018Université Paris XI - Paris SudHôpital Paul BrousseAssistance Publique - Hôpitaux de Paris (AP-HP)16 Avenue Paul Vaillant Couturier 94807 Villejuif Cedex, FR
- Service de Physiologie, Explorations Fonctionnelles et Radioisotopes
Hôpital européen Georges PompidouAssistance Publique - Hôpitaux de Paris (AP-HP)Université Paris V - Paris Descartes20 Rue Leblanc 75015 Paris, FR
| | - Nicolas Janus
- Pharmacie
Hôpital Pitié-SalpêtrièreAssistance Publique - Hôpitaux de Paris (AP-HP)Université Pierre et Marie Curie (UPMC) - Paris VI47-83 Boulevard de l'Hôpital 75013 Paris, FR
| | - Vincent Launay-Vacher
- Pharmacie
Hôpital Pitié-SalpêtrièreAssistance Publique - Hôpitaux de Paris (AP-HP)Université Pierre et Marie Curie (UPMC) - Paris VI47-83 Boulevard de l'Hôpital 75013 Paris, FR
| | - Claudine Berr
- Pathologies du Système Nerveux : Recherche Epidémiologique et Clinique
INSERM : U888IFR76Université Montpellier IHôpital la colombiere 39 Avenue charles Flahault BP 34493 -pav 42 Calixte Cavalier 34093 MONTPELLIER CEDEX 5, FR
| | - Christophe Tzourio
- Neuroépidémiologie
INSERM : U708Université Pierre et Marie Curie (UPMC) - Paris VIGH Pitie-Salpetriere 47, Boulevard de L'Hopital 75651 PARIS CEDEX 13, FR
| | - Catherine Helmer
- Epidémiologie et Biostatistique
INSERM : U897Université Victor Segalen - Bordeaux IIInstitut de Santé Publique, d'Épidémiologie et de Développement (ISPED)146 Rue Léo-Saignat 33076 Bordeaux, FR
| | - Benedicte Stengel
- CESP, Centre de Recherche en Epidémiologie et Santé des Populations
INSERM : U1018Université Paris XI - Paris SudHôpital Paul BrousseAssistance Publique - Hôpitaux de Paris (AP-HP)16 Avenue Paul Vaillant Couturier 94807 Villejuif Cedex, FR
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Rifkin DE, Winkelmayer WC. Medication issues in older individuals with CKD. Adv Chronic Kidney Dis 2010; 17:320-8. [PMID: 20610359 DOI: 10.1053/j.ackd.2010.03.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 03/13/2010] [Accepted: 03/16/2010] [Indexed: 01/10/2023]
Abstract
Older US adults bear a substantial burden of chronic disease and take an average of five prescription and non-prescription medications per day. Recent data suggest that over 20% of older adults have chronic kidney disease (CKD) as defined by an impaired glomerular filtration rate. These individuals often have multiple comorbidities, including diabetes, hypertension, and cardiovascular disease. Although patients with CKD may receive substantial benefits from prescribed medications, they are also at high risk for adverse drug events and polypharmacy. In this review, we outline the risks and benefits of medication use in the CKD population as a specific case within geriatric pharmacoepidemiology as a framework.
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Stevens LA, Viswanathan G, Weiner DE. Chronic kidney disease and end-stage renal disease in the elderly population: current prevalence, future projections, and clinical significance. Adv Chronic Kidney Dis 2010; 17:293-301. [PMID: 20610356 DOI: 10.1053/j.ackd.2010.03.010] [Citation(s) in RCA: 170] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 03/29/2010] [Accepted: 03/31/2010] [Indexed: 01/07/2023]
Abstract
The world's population is aging, with the number of older adults projected to increase dramatically over the next 2 decades. This trend poses major challenges to health care systems, reflecting the greater health care use and more comorbid conditions among elderly adults. Chronic kidney disease (CKD) is a substantial concern in the elderly population, with both an increasing incidence of treated kidney failure with dialysis as well as a high prevalence of earlier stages of CKD. Given the high burden of risk factors for CKD, the high prevalence of CKD in the elderly population is not surprising, with the rise in obesity, diabetes, and hypertension in middle-aged adults likely foreshadowing further increases in CKD prevalence among the elderly population. It is now commonly agreed that the presence of CKD identifies a higher risk state in the elderly population, with increased risk for multiple adverse outcomes, including kidney failure, cardiovascular disease, cognitive impairment, and death. Accordingly, CKD in older adults is worthy of attention by both health care providers and patients, with the presence of a reduced glomerular filtration rate or albuminuria in the elderly potentially informing therapeutic and diagnostic decisions for these individuals.
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Abstract
Chronic kidney disease, as defined by albuminuria or decreased estimated glomerular filtration rate (eGFR), affects 11.6% of the adult population in the United States. CKD frequently occurs in association with diabetes and hypertension, suggesting that vascular disease is a likely cause in many people. We provide data on the frequency of diabetes, hypertension, or both, according to albumin-to-creatinine ratio and eGFR, and review the rationale for retaining the current name.
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Medication errors in chronic kidney disease: one piece in the patient safety puzzle. Kidney Int 2010; 76:1123-5. [PMID: 19910946 DOI: 10.1038/ki.2009.315] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Patients with chronic kidney disease (CKD) are at increased risk of harm as a consequence of errors in medical care. Hug and colleagues highlight the significance of adverse drug events in hospitalized patients with CKD. Their findings demonstrate the role adverse drug events play in the safety of patients with CKD and underscore the importance of novel strategies intended to reduce such medical errors.
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Zaza G, Granata S, Sallustio F, Grandaliano G, Schena FP. Pharmacogenomics: a new paradigm to personalize treatments in nephrology patients. Clin Exp Immunol 2009; 159:268-80. [PMID: 19968662 DOI: 10.1111/j.1365-2249.2009.04065.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Although notable progress has been made in the therapeutic management of patients with chronic kidney disease in both conservative and renal replacement treatments (dialysis and transplantation), the occurrence of medication-related problems (lack of efficacy, adverse drug reactions) still represents a key clinical issue. Recent evidence suggests that adverse drug reactions are major causes of death and hospital admission in Europe and the United States. The reasons for these conditions are represented by environmental/non-genetic and genetic factors responsible for the great inter-patient variability in drugs metabolism, disposition and therapeutic targets. Over the years several genetic settings have been linked, using pharmacogenetic approaches, to the effects and toxicity of many agents used in clinical nephrology. However, these strategies, analysing single gene or candidate pathways, do not represent the gold standard, being the overall pharmacological effects of medications and not typically monogenic traits. Therefore, to identify multi-genetic influence on drug response, researchers and clinicians from different fields of medicine and pharmacology have started to perform pharmacogenomic studies employing innovative whole genomic high-throughput technologies. However, to date, only few pharmacogenomics reports have been published in nephrology underlying the need to enhance the number of projects and to increase the research budget for this important research field. In the future we would expect that, applying the knowledge about an individual's inherited response to drugs, nephrologists will be able to prescribe medications based on each person's genetic make-up, to monitor carefully the efficacy/toxicity of a given drug and to modify the dosage or number of medications to obtain predefined clinical outcomes.
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Affiliation(s)
- G Zaza
- Renal, Dialysis and Transplant Unit, Department of Emergency and Transplantation, University of Bari, Bari, Italy.
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