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Kiberd J, Quinn RR, Ravani P, Lentine KL, Clarke A, Jeong R, Faruque L, Lam NN. Proton Pump Inhibitors Use in Kidney Transplant Recipients: A Population-Based Study. Can J Kidney Health Dis 2024; 11:20543581241228723. [PMID: 38356921 PMCID: PMC10865938 DOI: 10.1177/20543581241228723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 12/12/2023] [Indexed: 02/16/2024] Open
Abstract
Background Kidney transplant recipients are commonly prescribed proton-pump inhibitors (PPIs), but due to concern for polypharmacy, chronic use should be limited. Objective The objective was to describe PPI use in kidney transplant recipients beyond their first year of transplant to better inform and support deprescribing initiatives. Design We conducted a retrospective, population-based cohort study using linked health care databases. Setting This study was conducted in Alberta, Canada. Patients We included all prevalent adult, kidney-only transplant recipients between April 2008 and December 2017 who received their transplant between May 2002 and December 2017. Measurements The primary outcome was ongoing or new PPI use and patterns of use, including frequency and duration of therapy, and assessment of indication for PPI use. Methods We ascertained baseline characteristics, covariate information, and outcome data from the Alberta Kidney Disease Network (AKDN). We compared recipients with evidence of a PPI prescription in the 3 months prior to study entry to those with a histamine-2-receptor antagonist (H2Ra) fill and those with neither. Results We identified 1823 kidney transplant recipients, of whom 868 (48%) were on a PPI, 215 (12%) were on an H2Ra, and 740 (41%) were on neither at baseline. Over a median follow-up of 5.4 years (interquartile range [IQR] = 2.6-9.3), there were almost 45 000 unique PPI prescriptions dispensed, the majority (80%) of which were filled by initial PPI users. Recipients who were on a PPI at baseline would spend 91% (IQR = 70-98) of their graft survival time on a PPI in follow-up, and nephrologists were the main prescribers. We identified an indication for ongoing PPI use in 54% of recipients with the most common indication being concurrent antiplatelet use (26%). Limitations Our kidney transplant recipients have access to universal health care coverage which may limit generalizability. We identified common gastrointestinal indications for PPI use but did not include rare conditions due to concerns about the validity of diagnostic codes. In addition, symptoms suggestive of reflux may not be well coded as the focus of follow-up visits is more likely to focus on kidney transplant. Conclusions Many kidney transplant recipients are prescribed a PPI at, or beyond, the 1-year post-transplant date and are likely to stay on a PPI in follow-up. Almost half of the recipients in our study did not have an identifiable indication for ongoing PPI use. Nephrologists frequently prescribe PPIs to kidney transplant recipients and should be involved in deprescribing initiatives to reduce polypharmacy.
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Affiliation(s)
- James Kiberd
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Robert R. Quinn
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Pietro Ravani
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | | | - Alix Clarke
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rachel Jeong
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Labib Faruque
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ngan N. Lam
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Jeong R, James MT, Quinn RR, Ravani P, Bagshaw SM, Stelfox HT, Pannu N, Clarke A, Wald R, Harrison TG, Niven DJ, Lam NN. Follow-up Care of Critically Ill Patients With Acute Kidney Injury: A Cohort Study. Kidney Med 2023; 5:100685. [PMID: 37538394 PMCID: PMC10394002 DOI: 10.1016/j.xkme.2023.100685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023] Open
Abstract
Rationale & Objective To evaluate follow-up care of critically ill patients with acute kidney injury (AKI). Study Design Retrospective cohort study. Setting & Participants Patients admitted to the intensive care unit (ICU) with AKI in Alberta, Canada from 2005 to 2018, who survived to discharge without kidney replacement therapy or estimated glomerular filtration rate <15 mL/min/1.73 m2. Exposure AKI (defined as ≥50% or ≥0.3 mg/dL serum creatinine increase). Outcomes The primary outcome was the cumulative incidence of an outpatient serum creatinine and urine protein measurement at 3 months postdischarge. Secondary outcomes included an outpatient serum creatinine or urine protein measurement or a nephrologist visit at 3 months postdischarge. Analytical Approach Patients were followed from hospital discharge until the first of each outcome of interest, death, emigration from the province, kidney replacement therapy (maintenance dialysis or kidney transplantation), or end of study period (March 2019). We used non-parametric methods (Aalen-Johansen) to estimate the cumulative incidence functions of outcomes accounting for competing events (death and kidney replacement therapy). Results There were 29,732 critically ill adult patients with AKI. The median age was 68 years (IQR, 57-77), 39% were female, and the median baseline estimated glomerular filtration rate was 72 mL/min/1.73 m2 (IQR, 53-90). The cumulative incidence of having an outpatient creatinine and urine protein measurement at 3 months postdischarge was 25% (95% CI, 25-26). At 3 months postdischarge, 64% (95% CI, 64-65) had an outpatient creatinine measurement, 28% (95% CI, 27-28) had a urine protein measurement, and 5% (95% CI, 4-5) had a nephrologist visit. Limitations We lacked granular data, such as urine output. Conclusions Many critically ill patients with AKI do not receive the recommended follow-up care. Our findings highlight a gap in the transition of care for survivors of critical illness and AKI.
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Affiliation(s)
- Rachel Jeong
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Matthew T. James
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Robert R. Quinn
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Pietro Ravani
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Henry T. Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Neesh Pannu
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Alix Clarke
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital and the University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
| | - Tyrone G. Harrison
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Daniel J. Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ngan N. Lam
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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3
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Lam NN, Quinn RR, Clarke A, Al-Wahsh H, Knoll GA, Tibbles LA, Kamar F, Jeong R, Kiberd J, Ravani P. Progression of Kidney Disease in Kidney Transplant Recipients With a Failing Graft: A Matched Cohort Study. Can J Kidney Health Dis 2023; 10:20543581231177203. [PMID: 37313362 PMCID: PMC10259097 DOI: 10.1177/20543581231177203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/26/2023] [Indexed: 06/15/2023] Open
Abstract
Background Few studies have assessed outcomes in transplant recipients with failing grafts as most studies have focused on outcomes after graft loss. Objective To determine whether renal function declines faster in kidney transplant recipients with a failing graft than in people with chronic kidney disease of their native kidneys. Design Retrospective cohort study. Setting Alberta, Canada (2002-2019). Patients We identified kidney transplant recipients with a failing graft (2 estimated glomerular filtration rate [eGFR] measurements 15-30 mL/min/1.73 m2 ≥90 days apart). Measurements We compared the change in eGFR over time (eGFR with 95% confidence limits, LCLeGFRUCL) and the competing risks of kidney failure and death (cause-specific hazard ratios [HRs], LCLHRUCL). Methods Recipients (n = 575) were compared with propensity-score-matched, nontransplant controls (n = 575) with a similar degree of kidney dysfunction. Results The median potential follow-up time was 7.8 years (interquartile range, 3.6-12.1). The hazards for kidney failure (HR1.101.331.60) and death (HR1.211.592.07) were significantly higher for recipients, while the eGFR decline over time was similar (recipients vs controls: -2.60-2.27-1.94 vs -2.52-2.21-1.90 mL/min/1.73 m2 per year). The rate of eGFR decline was associated with kidney failure but not death. Limitations This was a retrospective, observational study, and there is a risk of bias due to residual confounding. Conclusions Although eGFR declines at a similar rate in transplant recipients as in nontransplant controls, recipients have a higher risk of kidney failure and death. Studies are needed to identify preventive measures to improve outcomes in transplant recipients with a failing graft.
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Affiliation(s)
- Ngan N. Lam
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Robert R. Quinn
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Alix Clarke
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Huda Al-Wahsh
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Greg A. Knoll
- Department of Medicine (Nephrology) and The Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Lee Anne Tibbles
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Fareed Kamar
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Rachel Jeong
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - James Kiberd
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Pietro Ravani
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, AB, Canada
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Fox DE, Quinn RR, Ronksley PE, Harrison TG, Quan H, Bigam D, Shapiro AMJ, Jeong R, Lam NN. Perioperative Outcomes Following Kidney-Pancreas Transplantation in Alberta, Canada: Research Letter. Can J Kidney Health Dis 2021; 8:20543581211029389. [PMID: 34290878 PMCID: PMC8274095 DOI: 10.1177/20543581211029389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 05/17/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Simultaneous kidney-pancreas transplantation (SPK) has benefits for patients with kidney failure and type I diabetes mellitus, but is associated with greater perioperative risk compared with kidney-alone transplantation. Postoperative care settings for SPK recipients vary across Canada and may have implications for patient outcomes and hospital resource use. Objective: To compare outcomes following SPK transplantation between patients receiving postoperative care in the intensive care unit (ICU) compared with the ward. Design: Retrospective cohort study using administrative health data. Setting: In Alberta, the 2 transplant centers (Calgary and Edmonton) have different protocols for routine postoperative care of SPK recipients. In Edmonton, SPK recipients are routinely transferred to the ICU, whereas in Calgary, SPK recipients are transferred to the ward. Patients: 129 adult SPK recipients (2002-2019). Measurements: Data from the Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) were used to identify SPK recipients (procedure codes) and the outcomes of inpatient mortality, length of initial hospital stay (LOS), and the occurrence of 16 different patient safety indicators (PSIs). Methods: We followed SPK recipients from the admission date of their transplant hospitalization until the first of hospital discharge or death. Unadjusted quantile regression was used to determine differences in LOS, and age- and sex-adjusted marginal probabilities were used to determine differences in PSIs between centers. Results: There were no perioperative deaths and no major differences in the demographic characteristics between the centers. The majority of the SPK transplants were performed in Edmonton (n = 82, 64%). All SPK recipients in Edmonton were admitted to the ICU postoperatively, compared with only 11% in Calgary. There was no statistically significant difference in the LOS or probability of a PSI between the 2 centers (LOS for Edmonton vs Calgary:16 vs 13 days, P = .12; PSIs for Edmonton vs Calgary: 60%, 95% confidence interval [CI] = 0.50-0.71 vs 44%, 95% CI = 0.29-0.59, P = .08). Limitations: This study was conducted using administrative data and is limited by variable availability. The small sample size limited precision of estimated differences between type of postoperative care. Conclusions: Following SPK transplantation, we found no difference in inpatient outcomes for recipients who received routine postoperative ICU care compared with ward care. Further research using larger data sets and interventional study designs is needed to better understand the implications of postoperative care settings on patient outcomes and health care resource utilization.
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Affiliation(s)
- Danielle E Fox
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Robert R Quinn
- Department of Community Health Sciences, University of Calgary, AB, Canada.,Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Tyrone G Harrison
- Department of Community Health Sciences, University of Calgary, AB, Canada.,Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, AB, Canada.,Center for Health Informatics, University of Calgary, AB, Canada
| | - David Bigam
- Department of Surgery, Division of Transplantation, University of Alberta, Edmonton, Canada
| | - A M James Shapiro
- Department of Surgery, Division of Transplantation, University of Alberta, Edmonton, Canada
| | - Rachel Jeong
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada
| | - Ngan N Lam
- Department of Community Health Sciences, University of Calgary, AB, Canada.,Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada
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Jeong R, Lentine KL, Quinn RR, Ravani P, Wiebe N, Davison SN, Barr B, Lam NN. NSAID prescriptions in kidney transplant recipients. Clin Transplant 2021; 35:e14405. [PMID: 34174784 DOI: 10.1111/ctr.14405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/03/2021] [Accepted: 06/21/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Guidelines recommend that non-steroidal anti-inflammatory drugs (NSAIDs) be avoided in kidney transplant recipients due to potential nephrotoxicity. It is unclear whether physicians are following these recommendations. METHODS We conducted a retrospective cohort study of adult kidney transplant recipients from 2008 to 2017 in Alberta, Canada. We determined the frequency and prescriber of NSAID prescriptions, the proportion with serum creatinine and potassium testing post-fill, and the incidence of acute kidney injury (AKI, serum creatinine increase of ≥ 50% or ≥ 26.5 μmol/L from baseline) and hyperkalemia (potassium ≥ 5.5 mmol/L) within 14 and 30 days. RESULTS Of the 1730 kidney transplant recipients, 189 (11%) had at least one NSAID prescription over a median follow-up of 5 years (IQR 2-9) (280 unique prescriptions). The majority were prescribed by family physicians (67%). Approximately 25% and 50% of prescriptions had serum creatinine and potassium testing within 14 and 30 days, respectively. Of those with lab measurements within 14 days, 13% of prescriptions were associated with AKI and 5% had hyperkalemia. CONCLUSIONS Contrary to guidelines, one in 10 kidney transplant recipients are prescribed an NSAID, and most do not get follow-up testing of graft function and hyperkalemia. These findings call for improved education of patients and primary care providers.
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Affiliation(s)
- Rachel Jeong
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Calgary, Alberta, Canada
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Robert R Quinn
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Natasha Wiebe
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Sara N Davison
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Bryce Barr
- Department of Medicine, Section of Nephrology, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Ngan N Lam
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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6
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Lam N N, Jeong R, Quinn R R, Ravani P, Xiao H, McAdams-DeMarco M, Axelrod D, Lentine L K. POS-744 CLINICAL CORRELATES AND OUTCOMES OF DUAL BASILIXIMAB AND THYMOGLOBULIN INDUCTION IN KIDNEY TRANSPLANT RECIPIENTS: A NATIONAL STUDY. Kidney Int Rep 2021. [DOI: 10.1016/j.ekir.2021.03.776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Jeong R, Quinn RR, Lentine KL, Ravani P, Ye F, Campbell P, Wen K, Broscheit C, Gourishankar S, Lam NN. Incidence, Risk Factors, and Outcomes of Kidney Transplant Recipients Treated With Both Basiliximab and Antithymocyte Globulin. Can J Kidney Health Dis 2020; 7:2054358120964061. [PMID: 33117549 PMCID: PMC7573718 DOI: 10.1177/2054358120964061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Kidney transplant recipients are given induction therapy to rapidly reduce the immune response and prevent rejection. Guidelines recommend that an interleukin-2 receptor antibody (basiliximab) be the first-line agent and that a lymphocyte-depleting agent (antithymocyte globulin [ATG]) be reserved for those at high immunologic risk. Objective: To determine the incidence, risk factors, and outcomes for patients who receive both basiliximab and ATG for induction compared to either agent alone. Design: Retrospective cohort study. Setting: We used the transplant electronic medical record at the University of Alberta Hospital in Edmonton, Canada. Patients/samples/participants: We included incident adult kidney transplant recipients from 2013 to 2018. Measurements: We measured baseline characteristics, type, and dose of induction therapy used, estimated glomerular filtration rate (eGFR) at 1-year posttransplant, and outcomes of all-cause graft failure, death-censored graft failure, all-cause mortality, and death with a functioning graft. Methods: Differences between induction groups were compared using chi-square test for categorical variables and Kruskal-Wallis tests for continuous variables. We performed multivariable logistic regression modeling with type of induction therapy as the dependent variable and the case-level factors as the predictors (adjusted odds ratio). We estimated the Kaplan-Meier failure functions and used log-rank tests to assess statistical significance of differences in unadjusted incidence across induction therapy types. We compared cumulative incidence functions using a Fine and Gray competing risk regression model. Results: In all, 430 kidney transplant recipients were followed for a mean of 3.9 years (standard deviation 1.5). Of these, 71% (n = 305) received basiliximab alone, 22% (n = 93) received ATG alone, and 7% (n = 32) received both basiliximab and ATG. After adjusting for age and sex, compared to the basiliximab alone group, patients were more likely to receive dual-induction therapy if they were sensitized (calculated panel reactive antibody ≥80%), had diabetes mellitus or peripheral vascular disease, or experienced delayed graft function. Compared to the ATG alone group, the dual-induction therapy group had worse graft function at 1 year (mean eGFR 42 vs. 59 mL/min/1.73 m2, P = .0008) and an increased risk of all-cause graft failure (31% vs. 13%, P = .02) and death-censored graft failure (16% vs. 4%, P = .03). Limitations: There is a risk of confounding by indication, as patients who received dual-induction therapy likely had worse outcomes due to the indication for dual-induction therapy (such as delayed graft function). Conclusions: In our study, 1 out of 10 recipients who were treated with basiliximab also received ATG for induction therapy. These patients experienced worse outcomes than those treated with ATG alone. Trial registration: Not applicable (cohort study).
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Affiliation(s)
- Rachel Jeong
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada
| | - Robert R Quinn
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University, MO, USA
| | - Pietro Ravani
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Feng Ye
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Patricia Campbell
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Kevin Wen
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Chris Broscheit
- Department of Pharmacy, University of Alberta Hospital, Edmonton, Canada
| | - Sita Gourishankar
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Ngan N Lam
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
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Jeong R, Quinn RR, Ravani P, Ye F, Sood MM, Massicotte-Azarniouch D, Tonelli M, Hemmelgarn BR, Lam NN. Graft Function, Albuminuria, and the Risk of Hemorrhage and Thrombosis After Kidney Transplantation. Can J Kidney Health Dis 2020; 7:2054358120952198. [PMID: 33101697 PMCID: PMC7549159 DOI: 10.1177/2054358120952198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/22/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Compared to the general population, kidney transplant recipients are at
increased risk of hemorrhage and thrombosis. Whether this risk is affected
by graft function and albuminuria is unknown. Objective: To determine the association between graft function and albuminuria and the
risk of post-transplant hemorrhage and thrombosis. Design: Retrospective cohort study. Setting: We used linked health care databases in Alberta, Canada. Patients/sample/participants: We included adult kidney transplant recipients from 2002 to 2015 with a
functioning graft at 1 year. Measurements: Estimated glomerular filtration rate (eGFR) and albuminuria measurements at 1
year post-transplant were used to categorize recipients (eGFR: ≥45 vs.
<45 mL/min/1.73 m2; albuminuria: absence vs. presence). We
determined the rates of post-transplant hemorrhage and venous thrombosis
based on validated diagnostic and procedural codes. Methods: We determined the association between categories of eGFR and albuminuria and
post-transplant hemorrhage and venous thrombosis using Poisson regression
with log link. Results: Of 1284 kidney transplant recipients, 21% had an eGFR <45 mL/min/1.73
m2 and 40% had presence of albuminuria at 1 year
post-transplant. Over a median follow-up of 6 years, there were 100
hemorrhages (12.6 events per 1000 person-years) and 57 venous thrombosis
events (7.1 events per 1000 person-years). The age- and sex-adjusted rate of
hemorrhage and thrombosis was over 2-fold higher in recipients with lower
eGFR and presence of albuminuria compared to higher eGFR and no albuminuria
(hemorrhage: incidence rate ratio, IRR, 2.6, 95% confidence interval [CI]:
1.5-4.4, P = .001; thrombosis: IRR, 2.3, 95% CI: 1.1-5.0,
P = .046). Limitations: Complete relevant medication information, such as anticoagulants, were not
available in our datasets. Due to sample size, this study was underpowered
to conduct a fully adjusted analysis. Conclusion: Among kidney transplant recipients, lower eGFR and presence of albuminuria at
1 year post-transplant were associated with an over 2-fold higher risk of
hemorrhage and venous thrombosis. Graft function and albuminuria at 1 year
post-transplant are important prognostic factors in determining risk of
post-transplant hemorrhage and venous thrombosis. Further research,
including medication data, are needed to further delineate outcomes and
safety. Trial registration: Not applicable (cohort study).
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Affiliation(s)
- Rachel Jeong
- Division of Nephrology, Cumming School of Medicine and the Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Robert R Quinn
- Division of Nephrology, Cumming School of Medicine and the Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Pietro Ravani
- Division of Nephrology, Cumming School of Medicine and the Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Feng Ye
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Manish M Sood
- Department of Medicine and the School of Epidemiology and Public Health, University of Ottawa, ON, Canada
| | | | - Marcello Tonelli
- Division of Nephrology, Cumming School of Medicine and the Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Brenda R Hemmelgarn
- Division of Nephrology, Cumming School of Medicine and the Department of Community Health Sciences, University of Calgary, AB, Canada.,Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Ngan N Lam
- Division of Nephrology, Cumming School of Medicine and the Department of Community Health Sciences, University of Calgary, AB, Canada
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Jeong R, Quinn RR, Lentine KL, Lloyd A, Ravani P, Hemmelgarn B, Braam B, Garg AX, Wen K, Wong-Chan A, Gourishankar S, Lam NN. Outcomes Following Macrolide Use in Kidney Transplant Recipients. Can J Kidney Health Dis 2019; 6:2054358119830706. [PMID: 30815270 PMCID: PMC6385328 DOI: 10.1177/2054358119830706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/15/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Calcineurin inhibitors (CNI; cyclosporine, tacrolimus) are critical for kidney transplant immunosuppression, but have multiple potential drug interactions, such as with macrolide antibiotics. Macrolide antibiotics (clarithromycin, erythromycin, and azithromycin) are often used to treat atypical infections. Clarithromycin and erythromycin inhibit CNI metabolism and increase the risk of CNI nephrotoxicity, while azithromycin does not. OBJECTIVE To determine the frequency of CNI-macrolide co-prescriptions, the proportion who receive post-prescription monitoring, and the risk of adverse drug events in kidney transplant recipients. DESIGN Retrospective cohort study. SETTING We used linked health care databases in Alberta, Canada. PATIENTS We included 293 adult kidney transplant recipients from 2008-2015 who were co-prescribed a CNI and macrolide. MEASUREMENTS The primary outcome was a composite of all-cause hospitalization, acute kidney injury (creatinine increase ≥0.3 mg/dL or 1.5 times baseline), or death within 30 days of the macrolide prescription. METHODS We identified CNI-macrolide co-prescriptions and compared outcomes in those who received clarithromycin/erythromycin versus azithromycin. We used a linear mixed-effects model to examine the mean change in serum creatinine and estimated glomerular filtration rate (eGFR). RESULTS Of the 293 recipients who were co-prescribed a CNI and a macrolide, 38% (n = 112) were prescribed clarithromycin/erythromycin while 62% (n = 181) were prescribed azithromycin. Compared with azithromycin users, clarithromycin/erythromycin users were less likely to have outpatient serum creatinine monitoring post-prescription (56% vs 69%, P = .03). There was no significant difference in the primary outcome between the 2 groups (17% vs 11%, P = .11); however, the risk of all-cause hospitalization was higher in the clarithromycin/erythromycin group (10% vs 3%, P = .02). The mean decrement in eGFR was significantly greater in the clarithromycin/erythromycin versus azithromycin group (-5.4 vs -1.9 mL/min/1.73 m2, P < .05). LIMITATIONS We did not have CNI levels to correlate with the timing of CNI-macrolide co-prescriptions. We also did not have information regarding the indications for macrolide prescriptions. CONCLUSION Clarithromycin and erythromycin were frequently co-prescribed in kidney transplant recipients on CNIs despite known drug interactions. Clarithromycin/erythromycin use was associated with a higher risk of hospitalization compared with azithromycin users. Safer prescribing practices in kidney transplant recipients are warranted.
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Affiliation(s)
- Rachel Jeong
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, AB, Canada
| | - Robert R. Quinn
- Departments of Community Health Sciences and Medicine, University of Calgary, Calgary, AB, Canada
| | - Krista L. Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Anita Lloyd
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, AB, Canada
| | - Pietro Ravani
- Department of Medicine, Division of Nephrology, University of Calgary, Calgary, AB, Canada
| | - Brenda Hemmelgarn
- Department of Medicine, Division of Nephrology, University of Calgary, Calgary, AB, Canada
| | - Branko Braam
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, AB, Canada
| | - Amit X. Garg
- Department of Medicine, Division of Nephrology, Western University, London, ON, Canada
| | - Kevin Wen
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, AB, Canada
| | - Anita Wong-Chan
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, AB, Canada
| | - Sita Gourishankar
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, AB, Canada
| | - Ngan N. Lam
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, AB, Canada
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Ip S, Jeong R, Schaeffer DF, Yoshida EM. Unusual case of drug-induced cholestasis due to glucosamine and chondroitin sulfate. World J Hepatol 2015; 7:2559-2562. [PMID: 26527309 PMCID: PMC4621470 DOI: 10.4254/wjh.v7.i24.2559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 07/13/2015] [Accepted: 09/18/2015] [Indexed: 02/06/2023] Open
Abstract
Glucosamine (GS) and chondroitin sulfate (CS) are common over-the-counter (OTC) supplements used in the treatment of osteoarthritis. These medications are seemingly safe, but there are increasing reports of hepatotoxicity with these supplements. We reported a unique case of drug-induced cholestasis caused by GS and CS in a combination tablet. The etiology of the jaundice was overlooked despite extensive investigations over a three-month period. Unlike drug-induced hepatocellular injury, drug-induced cholestatic jaundice with GS and CS has only been reported twice before. This case emphasizes the importance of a complete medication history, especially OTC supplements, in the assessment of cholestasis.
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Lee H, Lee YS, Jeong R, Kim YJ, Ahn S. Predictive factors of bacteremia in patients with febrile urinary tract infection: an experience at a tertiary care center. Infection 2014; 42:669-74. [PMID: 24677052 DOI: 10.1007/s15010-014-0615-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 03/15/2014] [Indexed: 12/16/2022]
Abstract
PURPOSE To investigate the clinical features in adult patients with febrile urinary tract infection (UTI) who visited the emergency department (ED) and to determine the predictive factors of bacteremia among the initial presenting clinical features. METHODS This retrospective cohort study was conducted at the ED of a tertiary hospital in Korea from 1 January 2012 to 31 December 2012. All adult patients who were diagnosed with febrile UTI and for whom data on blood and urine cultures were available were included in the study. Clinical examinations and laboratory tests were performed at the initial presentation. RESULTS A total of the 325 patients with febrile UTI (median age: 60 years) were included for analysis, of whom 82 % were female. Bacteremia was detected in 106 of the 325 patients (32.6 %), with Escherichia coli the most frequent pathogen detected (59.7 % of cases). Between the bacteremic and non-bacteremic groups, there was significant difference in age (67 vs. 57 years, respectively), flank pain (16 vs. 7.8 %), suprapubic discomfort (0 vs. 4.6 %), body temperature (38.8 vs. 38.3 °C), respiratory rate (21 vs. 20/min), platelet count (170 vs. 186 × 10(3)/μL), C-reactive protein (10.2 vs. 8.3 mg/dL), and procalcitonin (1.5 vs. 0.3 ng/mL) (P < 0.05 for all). In the multivariate logistic regression analysis, age [odds ratio (OR) 1.03; 95 % confidence interval (CI) 1.01-1.05], systolic blood pressure of <90 mmHg (OR 3.27; 95 % CI 1.13-9.45), body temperature of >39 °C (OR 4.26; 95 % CI 2.28-7.96), and procalcitonin level of >0.5 ng/dL (OR 2.03; 95 % CI 1.07-3.86) were significantly associated with bacteremia. CONCLUSION Among our adult patients with febrile UTI, age, systolic blood pressure, body temperature, and procalcitonin were significantly associated with bacteremia. We therefore suggest that these factors should be considered when deciding upon treatment options for febrile UTI patients at the ED.
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Affiliation(s)
- H Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736, Korea
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Kim D, Jung M, Jeong R, Kim H. Needle-type multi-electrode array fabricated by MEMS technology for the hypodermic continuous glucose monitoring system. Conf Proc IEEE Eng Med Biol Soc 2007; 2004:1987-9. [PMID: 17272106 DOI: 10.1109/iembs.2004.1403586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A needle-type multi-electrode array for the hypodermic continuous glucose monitoring sensor was fabricated using MEMS technology. The developed multielectrode sensor has 4 electrodes of two working(Pt) electrodes, one counter(Pt) electrode, and one reference(Ag/AgCl) electrode. Two working electrodes are for the enzyme and nonenzyme electrodes which measure glucose concentration and the background current (I(0)), respectively. The developed integrated sensor system is adequate to accomplish our prereported new two-point calibration method using only one-point sample measurement. Results of in vitro performance test are also provided.
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Affiliation(s)
- D Kim
- Interdisciplinary Program, Seoul National University, South Korea
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