Analgesic Use in Patients With Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Barriers and facilitators to using a clinical decision support tool for the management of osteoarthritis pain in patients undergoing hemodialysis: a qualitative study

BACKGROUND

While osteoarthritis is a significant issue within the hemodialysis population and contributes to reduced quality of life, pain related to osteoarthritis is poorly managed by healthcare professionals (HCPs) in hemodialysis settings due to the absence of clinical guidance applicable to this population. The purpose of this study was to explore the perceptions of HCPs on the barriers and facilitators to using a clinical decision support tool for osteoarthritis pain management in the hemodialysis setting.

METHODS

A qualitative descriptive study was conducted. Purposeful and snowball sampling techniques were used to recruit hemodialysis clinicians from academic and community settings across multiple Canadian provinces. One-to-one interviews were conducted with clinicians using a semi-structured, open ended interview guide informed by the Theoretical Domains Framework, a behavior change framework. A general inductive approach was applied to identify the main themes of barriers and facilitators.

RESULTS

A total of 11 interviews were completed with 3 nephrologists, 2 nurse practitioners and 6 pharmacists. Findings revealed 6 main barriers and facilitators related to the use of the clinical decision support tool. Alignment of the tool with practice roles emerged as a key barrier and facilitator. Other barriers included challenges related to the dialysis environment, varying levels of clinician comfort with pain medications, and limited applicability of the tool due to patient factors. An important facilitator was the intrinsic motivation among clinicians to use the tool.

CONCLUSIONS

Most participants across the included hemodialysis settings expressed satisfaction with the clinical decision support tool and acknowledged its overall potential for improving osteoarthritis pain management among patients on hemodialysis. Future implementation of the tool may be limited by existing roles and practices at different institutions. Increased collaboration among hemodialysis and primary care teams may promote uptake of the tool.

Drug stewardship in chronic kidney disease to achieve effective and safe medication use

People living with chronic kidney disease (CKD) often experience multimorbidity and require polypharmacy. Kidney dysfunction can also alter the pharmacokinetics and pharmacodynamics of medications, which can modify their risks and benefits; the extent of these changes is not well understood for all situations or medications. The principle of drug stewardship is aimed at maximizing medication safety and effectiveness in a population of patients through a variety of processes including medication reconciliation, medication selection, dose adjustment, monitoring for effectiveness and safety, and discontinuation (deprescribing) when no longer necessary. This Review is aimed at serving as a resource for achieving optimal drug stewardship for patients with CKD. We describe special considerations for medication use during pregnancy and lactation, during acute illness and in patients with cancer, as well as guidance for the responsible use of over-the-counter drugs, herbal remedies, supplements and sick-day rules. We also highlight inequities in medication access worldwide and suggest policies to improve access to quality and essential medications for all persons with CKD. Further strategies to promote drug stewardship include patient education and engagement, the use of digital health tools, shared decision-making and collaboration within interdisciplinary teams. Throughout, we position the person with CKD at the centre of all drug stewardship efforts.

Development and Validation of a Treatment Algorithm for Osteoarthritis Pain Management in Patients With End-Stage Kidney Disease Undergoing Hemodialysis

Background

Although osteoarthritis is common in the hemodialysis population and leads to poor health outcomes, pain management is challenged by the absence of clinical guidance. A treatment algorithm was developed and validated to aid hemodialysis clinicians in managing osteoarthritis pain.

Objective

The objective was to develop and validate a treatment algorithm for managing osteoarthritis pain in patients undergoing hemodialysis.

Design

A validation study was conducted based on Lynn's method for content validation.

Setting

To develop and validate a treatment algorithm, interviews were conducted virtually by the primary researcher with clinicians from various institutions across the Greater Toronto and Hamilton Area in Ontario.

Patients

The treatment algorithm was developed and validated for the management of osteoarthritis pain in patients on hemodialysis. Patients were not involved in the development or validation of the tool.

Measurements

The algorithm was measured for content and face validity. Content validity was measured by calculating the content validity index of each component (I-CVI) of the algorithm and the overall scale validity index (S-CVI). Face validity was assessed by calculating the percentage of positive responses to the face validity statements.

Methods

A draft algorithm was developed based on literature searches and expert opinion and validated by interviewing nephrology and pain management clinicians. Through consecutive rounds of 1:1 interviews, content and face validity were assessed by asking participants to rate the relevance of each component of the algorithm and indicate their level of agreeability with a series of statements. Following each round, the I-CVI of the algorithm as well as the S-CVI was calculated and the percentage of positive responses to the statements was determined. The research team revised the algorithm in response to the findings. The final algorithm provides a stepwise approach to the non-pharmacologic and pharmacologic management of pain, including topical, oral, and opioid use.

Results

A total of 18 clinicians from 7 institutions across the Greater Toronto and Hamilton Area were interviewed (10 pharmacists, 5 nurse practitioners, and 3 physicians). The average S-CVI of the algorithm across all 3 rounds was 0.93. At least 78% of participants provided positive responses to the face validity statements.

Limitations

An algorithm was developed based on input from clinicians working in the province of Ontario, limiting the generalizability of the algorithm across provinces. In addition, the algorithm did not include the perspectives of primary care providers or patients/caregivers.

Conclusions

An algorithm for the management of osteoarthritis pain in the hemodialysis population was developed and validated through expert review to standardize practices and encourage clinicians to use evidence-based treatments and address the psychosocial symptoms of pain. As the algorithm possesses a high degree of content and face validity, it may improve osteoarthritis pain management among patients undergoing hemodialysis. Future research will assess the implementation of the algorithm across hemodialysis settings.

Scoping review of interventions to de-implement potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) in healthcare settings

OBJECTIVES

Potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) utilisation persists at undesirable rates worldwide. The purpose of this paper is to review the literature on interventions to de-implement potentially harmful NSAIDs in healthcare settings and to suggest directions for future research.

DESIGN

Scoping review.

DATA SOURCES

PubMed, CINAHL, Embase, Cochrane Central and Google Scholar (1 January 2000 to 31 May 2022).

STUDY SELECTION

Studies reporting on the effectiveness of interventions to systematically reduce potentially harmful NSAID utilisation in healthcare settings.

DATA EXTRACTION

Using Covidence systematic review software, we extracted study and intervention characteristics, including the effectiveness of interventions in reducing NSAID utilisation.

RESULTS

From 7818 articles initially identified, 68 were included in the review. Most studies took place in European countries (45.6%) or the USA (35.3%), with randomised controlled trial as the most common design (55.9%). Interventions were largely clinician-facing (76.2%) and delivered in primary care (60.2%) but were rarely (14.9%) guided by an implementation model, framework or theory. Academic detailing, clinical decision support or electronic medical record interventions, performance reports and pharmacist review were frequent approaches employed. NSAID use was most commonly classified as potentially harmful based on patients' age (55.8%), history of gastrointestinal disorders (47.1%), or history of kidney disease (38.2%). Only 7.4% of interventions focused on over-the-counter (OTC) NSAIDs in addition to prescription. The majority of studies (76.2%) reported a reduction in the utilisation of potentially harmful NSAIDs. Few studies (5.9%) evaluated pain or quality of life following NSAIDs discontinuation.

CONCLUSION

Many varied interventions to de-implement potentially harmful NSAIDs have been applied in healthcare settings worldwide. Based on these findings and identified knowledge gaps, further efforts to comprehensively evaluate the effectiveness of interventions and the combination of intervention characteristics associated with effective de-implementation are needed. In addition, future work should be guided by de-implementation theory, focus on OTC NSAIDs and incorporate patient-focused strategies and outcomes, including the evaluation of unintended consequences of the intervention.

Pain and Its Management in Patients Referred to a Geriatric Outpatient Clinic

(1) Background: A major problem affecting geriatric patients is pain. In addition to pain, a significant problem of old age is dementia and depression, which can hinder the diagnosis and treatment of pain. The aim of this study was to analyse the prevalence of pain in patients treated in a geriatric outpatient clinic and the treatment used. (2) Methods: The analysis was based on the records of 937 patients who visited the Geriatric Outpatient Clinic in Dobre Miasto between 2015 and 2020. Based on records containing data dating back to their first visit to the hospital, patients' experiences of pain, the presence of depressive symptoms and dementia, and the pharmacological treatment used for pain (analgesics and coanalgesics) were analysed. (3) Results: Pain complaints were reported by 311 patients (33.2% of the study group), 76% of the complaints were from females. The mean age of the patients was 78 years (SD = 8.45). At least one analgesic drug was taken by 107 patients (34.4%). The most commonly used analgesics were opioids (63 patients, 58.87%), especially tramadol. Of the potential coanalgesics, the largest number of patients used an antidepressant. (4) Conclusions: Despite the widespread prevalence of pain among the elderly, only about one-third of them were taking pain medication, mainly in the form of weak opioids. Patients with symptoms of dementia were found to report pain less frequently.

A Scoping Review of Interventions to De-implement Potentially Harmful Nonsteroidal Anti-inflammatory Drugs (NSAIDs) in Healthcare Settings

Objectives

Potentially harmful nonsteroidal anti-inflammatory drugs (NSAIDs) utilization persists at undesirable rates throughout the world. The purpose of this paper is to review the literature on interventions to de-implement potentially harmful NSAIDs in healthcare settings and to suggest directions for future research.

Design

Scoping review.

Data Sources

PubMed, CINAHL, Embase, Cochrane Central, and Google Scholar (2000-2022).

Study Selection

Studies reporting on the effectiveness of interventions to systematically reduce potentially harmful NSAID utilization in healthcare settings.

Data Extraction

Using Covidence systematic review software, we extracted study and intervention characteristics, including the effectiveness of interventions in reducing NSAID utilization.

Results

From 7,818 articles initially identified, 68 were included in the review. Most studies took place in European countries (45.6%) or the U.S. (35.3%), with randomized controlled trial as the most common design (55.9%). The majority of studies (76.2%) reported a reduction in the utilization of potentially harmful NSAIDs. Interventions were largely clinician-facing (76.2%) and delivered in primary care (60.2%). Academic detailing, clinical decision support or electronic medical record interventions, performance reports, and pharmacist review were frequent approaches employed. NSAID use was most commonly classified as potentially harmful based on patients' age (55.8%) or history of gastrointestinal disorders (47.1%) or kidney disease (38.2%). Only 7.4% of interventions focused on over-the-counter NSAIDs in addition to prescription. Few studies (5.9%) evaluated pain or quality of life following NSAIDs discontinuation.

Conclusion

Many varied interventions are effective in de-implementing potentially harmful NSAIDs in healthcare settings. Efforts to adapt, scale, and disseminate these interventions are needed. In addition, future interventions should address over-the-counter NSAIDs, which are broadly available and widely used. Evaluating unintended consequences of interventions, including patient-focused outcomes, is another important priority.

[Development of quality indicators for the care of patients with chronic kidney disease : Results of a structured consensus process using the Delphi technique]

BACKGROUND

Chronic kidney disease (CKD) is a common condition, especially in the elderly. In order to prevent progression and complications of the disease, guideline-adherent outpatient care of patients with CKD should be prioritized. Quality indicators (QIs) can be used to measure and evaluate the quality of ambulatory care for patients with CKD. QIs specifically made for evaluating CKD care in Germany are not yet available. The goal of this work was to develop QIs for the quality assessment of outpatient care for patients over the age of 70 with CKD not requiring dialysis.

MATERIALS AND METHODS

QIs were operationalized from the recommendations of the German national guideline for CKD and others were proposed based on a published review of international QIs. The resulting QIs were divided into sets based on routine data (e.g., health insurance billing data) and data collection in practices (chart review). A panel of experts from various disciplines as well as a patient representative evaluated the proposed QIs in a two-stage Delphi process via online survey in October 2021 and January 2022 and a final consensus conference in March 2022. In addition, ranking lists of the most important QIs from each set were created.

RESULTS

An incidence indicator and a prevalence indicator were established; these were not subject to vote. Further, 21 QIs were voted upon by the expert panel. The seven most important QIs in each set (billing data or chart review) were selected. Only one QI was rated by the expert panel as not suitable for additional use in adults under the age of 70 years.

DISCUSSION

The QIs will enable the evaluation of the quality of outpatient care for patients with CKD with the long-term aim of optimizing guideline-adherent outpatient care.

An Updated Review on the Metabolite (AM404)-Mediated Central Mechanism of Action of Paracetamol (Acetaminophen): Experimental Evidence and Potential Clinical Impact

Paracetamol remains the recommended first-line option for mild-to-moderate acute pain in general population and particularly in vulnerable populations. Despite its wide use, debate exists regarding the analgesic mechanism of action (MoA) of paracetamol. A growing body of evidence challenged the notion that paracetamol exerts its analgesic effect through cyclooxygenase (COX)-dependent inhibitory effect. It is now more evident that paracetamol analgesia has multiple pathways and is mediated by the formation of the bioactive AM404 metabolite in the central nervous system (CNS). AM404 is a potent activator of TRPV₁, a major contributor to neuronal response to pain in the brain and dorsal horn. In the periaqueductal grey, the bioactive metabolite AM404 activated the TRPV₁ channel-mGlu5 receptor-PLC-DAGL-CB1 receptor signaling cascade. The present article provides a comprehensive literature review of the centrally located, COX-independent, analgesic MoA of paracetamol and relates how the current experimental evidence can be translated into clinical practice. The evidence discussed in this review established paracetamol as a central, COX-independent, antinociceptive medication that has a distinct MoA from non-steroidal anti-inflammatory drugs (NSAIDs) and a more tolerable safety profile. With the establishment of the central MoA of paracetamol, we believe that paracetamol remains the preferred first-line option for mild-to-moderate acute pain for healthy adults, children, and patients with health concerns. However, safety concerns remain with the high dose of paracetamol due to the NAPQI-mediated liver necrosis. Centrally acting paracetamol/p-aminophenol derivatives could potentiate the analgesic effect of paracetamol without increasing the risk of hepatoxicity. Moreover, the specific central MoA of paracetamol allows its combination with other analgesics, including NSAIDs, with a different MoA. Future experiments to better explain the central actions of paracetamol could pave the way for discovering new central analgesics with a better benefit-to-risk ratio.

Non-steroidal anti-inflammatory drugs in chronic kidney disease and risk of acute adverse kidney events according to route of administration

BACKGROUND

Topical non-steroidal anti-inflammatory drugs (NSAIDs) have lower risks for cardiovascular disease and gastrointestinal adverse effects compared to oral NSAIDs, but there are little data regarding their kidney risks in chronic kidney disease (CKD). We evaluated the risk of adverse acute kidney outcomes in CKD according to route of NSAID administration.

METHODS

Retrospective cohort study of adults with CKD (eGFR less than 60 ml/min/1.73 m²) who received prescriptions between 2015 and 2017 from a major healthcare cluster in Singapore. The adverse acute kidney outcomes were acute kidney injury (AKI) and need for nephrology specialist consult within 30 days.

RESULTS

Among 6298 adults with CKD (mean age 72.1 ± 13.3 years and eGFR 41.9 ± 12.2 ml/min/1.73 m²), systemic and topical NSAIDs were prescribed in 16.7% and 32.0%, respectively. Incident AKI (any severity), KDIGO Stage 2 or 3 AKI, and need for nephrology specialist consult occurred in 16.7%, 2.6%, and 10.6% of the study cohort, respectively. After adjusting for age, diabetes, recent cardiovascular hospitalization, baseline eGFR, RAAS blocker and diuretic, systemic NSAIDs, and topical NSAIDs, compared with the no-NSAID group, were independently associated with incident AKI [adjusted OR 1.77 (95% CI 1.46-2.15) and 1.38 (1.18-1.63), respectively]. Moderate and severe AKI (adjusted OR 1.68, 95% CI 1.09-2.58, p = 0.02) and need for nephrology consults (adjusted OR 1.41, 95% CI 1.09-1.82, p = 0.008) were also increased in systemic NSAIDs.

CONCLUSION

Among adults with CKD, both systemic and topical NSAIDs were independently associated with acute adverse kidney outcomes.

Population-Based Analysis of Nonsteroidal Anti-inflammatory Drug Prescription in Subjects With Chronic Kidney Disease

Background

Pain is a prevalent symptom experienced by patients with chronic kidney disease (CKD) and appropriate management of pain is an important element of comprehensive care. Nonsteroidal anti-inflammatory drugs (NSAID) are known to be nephrotoxic in persons with CKD.

Objective

This study examined the pattern of NSAID prescribing practices in a population based-cohort of patients with CKD.

Design

Retrospective cohort study using linked population-based health care data.

Setting

Entire province of Alberta, Canada.

Participants

All adults in Alberta with eGFR defined CKD G3 or greater between 2009 and 2017 were included.

Measurements

CKD was defined using at least 2 outpatient serum creatinine (SCr) greater than 90 days apart; the date of second SCr measurement was used as index date. We determined the incidence of hyperkalemia using the peak serum potassium. Prescription drug information was obtained from the Pharmaceutical Information Network (PIN) database.

Methods

All patients were followed from the index date until March 31, 2019, with a minimum follow-up of 2 years. Prescription drug information and the follow-up laboratory testing of serum creatinine and serum potassium were obtained. Patients with kidney failure defined as eGFR < 15 mL/min per 1.73 m², receiving chronic dialysis, or prior kidney transplant at baseline were excluded.

Results

A total of 170 574 adults (mean age 76.3; 44% male) with CKD were identified and followed for a median of 7 years; 27% were dispensed at least 1 NSAID prescription. While there was a trend toward fewer prescriptions in patients with more advanced CKD (P < .001), 16% of those with CKD G4 were prescribed an NSAID. Primary care providers provided 79% of the prescriptions. Among NSAID users, 21% had a follow-up serum creatinine (SCr) within 30 days of the index prescription.

Limitations

Data collected were from clinical and administrative databases not created for research purposes. The study cohort is limited to subjects who sought medical care and had a serum creatinine measurement obtained. Measurement of NSAID use is limited to those who were dispensed a prescription, over-the-counter NSAIDs use is not captured.

Conclusions

Despite guidelines advocating cautious use of NSAIDs in patients with CKD, this study indicates that there is a discrepancy from best practice recommendations. Effective strategies to better support and educate prescribers, as well as patients, may help reduce inappropriate prescribing and adverse events.

Why paracetamol (acetaminophen) is a suitable first choice for treating mild to moderate acute pain in adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, or who are older

Acute pain is among the most common reasons that people consult primary care physicians, who must weigh benefits versus risks of analgesics use for each patient. Paracetamol (acetaminophen) is a first-choice analgesic for many adults with mild to moderate acute pain, is generally well tolerated at recommended doses (≤4 g/day) in healthy adults and may be preferable to non-steroidal anti-inflammatory drugs that are associated with undesirable gastrointestinal, renal, and cardiovascular effects. Although paracetamol is widely used, many patients and physicians still have questions about its suitability and dosing, especially for older people or adults with underlying comorbidities, for whom there are limited clinical data or evidence-based guidelines. Inappropriate use may increase the risks of both overdosing and inadequate analgesia. To address knowledge deficits and augment existing guidance in salient areas of uncertainty, we have researched, reviewed, and collated published evidence and expert opinion relevant to the acute use of paracetamol by adults with liver, kidney, or cardiovascular diseases, gastrointestinal disorders, asthma, or/and who are older. A concern is hepatotoxicity, but this is rare among adults who use paracetamol as directed, including people with cirrhotic liver disease. Putative epidemiologic associations of paracetamol use with kidney or cardiovascular disease, hypertension, gastrointestinal disorders, and asthma largely reflect confounding biases and are of doubtful relevance to short-term use (<14 days). Paracetamol is a suitable first-line analgesic for mild to moderate acute pain in many adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, and/or who are older. No evidence supports routine dose reduction for older people. Rather, dosing for adults who are older and/or have decompensated cirrhosis, advanced kidney failure, or analgesic-induced asthma that is known to be cross-sensitive to paracetamol, should be individualized in consultation with their physician, who may recommend a lower effective dose appropriate to the circumstances.

Assessment of glycemia in chronic kidney disease

Reliable assessment of glycemia is central to the management of diabetes. The kidneys play a vital role in maintaining glucose homeostasis through glucose filtration, reabsorption, consumption, and generation. This review article highlights the role of the kidneys in glucose metabolism and discusses the benefits, pitfalls, and evidence behind the glycemic markers in patients with chronic kidney disease. We specifically highlight the role of continuous glucose monitoring as an emerging minimally invasive technique for glycemic assessment.

Analgesic use and associated adverse events in patients with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Treating pain in the context of chronic kidney disease (CKD) is challenging because of altered pharmacokinetics and pharmacodynamics, with an increased risk of toxicity and drug adverse events in this population. The aims of this systematic review and meta-analysis were to assess the prevalence of analgesic use and establish the risk of analgesics-related adverse events, in patients with CKD.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Medline, Embase, CINAHL, and CENTRAL were searched until January 2021. Random-effects meta-analyses and meta-regression were conducted to pool and summarise prevalence data and measures of association between analgesic use and adverse events.

RESULTS

Sixty-two studies relevant to the prevalence of analgesic use and 33 to analgesic-related adverse events were included, combining data on 2.3 and 3 million individuals, respectively. Pooled analyses found that 41% (95% confidence interval [CI], 35-48) of the CKD population regularly use analgesia. The annual period prevalence was estimated at 50% for opioids and 21% for nonsteroidal anti-inflammatory drugs (NSAID). Overall, 20% and 7% of patients with CKD are on chronic opioid or NSAID therapy, respectively. Opioid use was associated with an increased risk of death (1.61; 95% CI, 1.12-2.31; n= 7, I²= 91%), hospitalisation (1.38; 95% CI, 1.32-1.45; n=2, I²=0%), and fractures (1.51; 95% CI, 1.16-1.96; n=3, I²=54%).

CONCLUSION

High levels of analgesic consumption and related serious adverse outcomes were found in patients with CKD. Consideration needs to be given to how these patients are assessed and managed in order to minimise harms and improve outcomes.

CLINICAL TRIAL REGISTRATION

CRD42019156491 (PROSPERO).

Short-Course Systemic and Topical Non-Steroidal Anti-Inflammatory Drugs: Impact on Adverse Renal Events in Older Adults with Co-Morbid Disease

BACKGROUND

Prolonged systemic non-steroidal anti-inflammatory drugs (NSAIDs) have been associated with adverse renal outcomes among older adults. However, there is scant data regarding the renal safety of topical and short-course systemic NSAIDs. We aimed to evaluate the risk of acute adverse renal outcomes among older adults prescribed topical and short-term systemic NSAIDs.

METHODS

We conducted a retrospective cohort study of all older adults, age 60 years and above, who received prescriptions between July 2015 and December 2017 from the largest tertiary hospital and a major public primary care institution in Singapore. Data from 6 months before until 30 days after the first prescription were retrieved from electronic medical records. The primary outcome was the incidence of acute kidney injury (serum creatinine increased >26.5 µmol/L or >50% from baseline) and/or hyperkalemia within 30 days. A multi-variate analysis taking into account age, sex, co-morbidities, baseline-estimated glomerular filtration rate and serum potassium, NSAID route of administration, and concurrent renin-angiotensin-aldosterone system blocker and diuretic prescription was performed to evaluate factors associated with the primary outcome.

RESULTS

We identified 12,773 older adults with incident prescriptions: 3982 (31.2%) received short-course systemic NSAIDs, 3784 (29.6%) received topical NSAIDs, and 5007 (39.2%) did not receive any NSAID. Both short-course systemic NSAIDs (adjusted odds ratio [OR] 1.59, 95% confidence interval [CI] 1.41-1.80, p < 0.001) and topical NSAIDs (adjusted OR 1.48, 95% CI 1.31-1.67, p < 0.001), compared with the no-NSAID group, were independently associated with the primary outcome. Among older adults with co-morbid conditions and prescribed NSAIDs, topical NSAIDs had a reduced odds of 30-day incident acute kidney injury and/or hyperkalemia in diabetes mellitus (adjusted OR 0.78, 95% CI 0.65-1.06, p = 0.007), chronic kidney disease (adjusted OR 0.74, 95% CI 0.60-0.90, p = 0.003), and cardiovascular disease (adjusted OR 0.54, 95% CI 0.37-0.79, p < 0.001), compared with short-course systemic NSAIDs.

CONCLUSIONS

NSAIDs increased the risk of acute adverse renal events. Topical NSAIDs, compared with short-course systemic NSAIDs, were associated with a reduced incidence of acute kidney injury and/or hyperkalemia among older adults with additional risk factors.