Chronic Kidney Disease Management in General Practice: A Focus on Inappropriate Drugs Prescriptions

Nephrotoxic drugs prescriptions are often prescribed inappropriately by general practitioners (GPs), increasing the risk of chronic kidney disease (CKD). The aim of this study was to detect inappropriate prescriptions in patients with CKD and to identify their predictive factors. A retrospective study on patients with creatinine values recorded in the period 2014–2016 followed by 10 GPs was performed. The estimated glomerular filtration rate (eGFR) was used to identify CKD patients. The demographic and clinical characteristics and drugs prescriptions were collected. A descriptive analysis was conducted to compare the characteristics and logistic regression models to estimate the predictive factors of inappropriate prescriptions. Of 4098 patients with creatinine values recorded, 21.9% had an eGFR <60 mL/min/1.73 m2. Further, 56.8% received inappropriate prescriptions, with a significantly lower probability in subjects with at least a nephrologist visit (Adj OR 0.54 (95% CI 0.36–0.81)) and a greater probability in patients treated with more active substances (1.10 (1.08–1.12)), affected by more comorbidities (1.14 (1.06–1.230)), or with serious CKD (G4/G5 21.28 (7.36–61.57)). Nonsteroidal anti-inflammatory drugs (NSAIDs) were the most used contraindicated drugs (48.5%), while acetylsalicylic acid was the most inappropriately prescribed (39.5%). Our results highlight the inappropriate prescriptions for CKD authorized by GPs and underline the need of strategies to improve prescribing patterns.

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A Descriptive Analysis of Prescribing Patterns of Drugs in Chronic Kidney Disease Patients on Maintenance Hemodialysis

Journal of Medical Science And clinical Research ◽

10.18535/jmscr/v7i5.126 ◽

2019 ◽

Vol 7 (5) ◽

Author(s):

Bhargava Jyotsna ◽

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Descriptive Analysis ◽

Prescribing Patterns ◽

Maintenance Hemodialysis

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FC 070USE OF POTENTIALLY NEPHROTOXIC MEDICATIONS IN PERSONS WITH CHRONIC KIDNEY DISEASE: PARALLEL COHORT STUDIES IN SWEDISH AND U.S ROUTINE CARE

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfab122.004 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

Alessandro Bosi ◽

Juan Jesus Carrero ◽

Jung-Im Shin ◽

Yunwen Xu ◽

Morgan Grams ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Adverse Drug Events ◽

Medication Use ◽

Kidney Injury ◽

Routine Care ◽

Clinical Predictors ◽

Nephrotoxic Drugs ◽

Study Inclusion ◽

Swedish Cohort

Abstract Background and Aims Many adverse drug events are preventable, such as those potentially resulting from the prescription of nephrotoxic drugs to persons with chronic kidney disease (CKD). We here quantify the extent of contemporary nephrotoxic medication use in patients with CKD. Method In two observational cohorts of Swedish (Stockholm CREAtinine Measurements [SCREAM] project, Stockholm, Sweden) and U.S. (Geisinger Health System, Pennsylvania) adults with confirmed CKD stages G3-G5 undergoing routine care during 2016-2018, we explored the prescription (in U.S.) and dispensation (in Sweden) of 115 different ambulatory drugs with proven or purported nephrotoxicity during the 12 months following study inclusion. We evaluated the proportion of participants receiving nephrotoxic drugs, ranked main contributors and identified clinical predictors. Results In the Swedish cohort, there were 57880 patients (54.6% women) with median age of 80.00 (inter-quartile range [IQR]: 73.0-86.0) years and eGFR 48.9 ([IQR]: 39.9-55.0) mL/min/1.73 m2. In the U.S. cohort, there were 16255 patients (59% women) with median age of 76 years and eGFR 44 mL/min/1.73 m2. During observation, 20% (Sweden) and 17% (U.S.) of patients received at least one nephrotoxic drug. The top 3 potentially inappropriate nephrotoxic drugs identified were NSAIDs (9% and 11% of participants in U.S. and Sweden received it), antivirals (2.0% and 2.5%) and immunosuppressants (1.5% and 2.7%). Bisphosphonate use was common in Sweden (3.3% of participants), but not in U.S. (0.5%). Conversely, fenofibrates were common in U.S. (3.6%), but not in Sweden (0.13%). In adjusted analyses, patients with young age (<65 years old), women, or with CKD G3 were at higher risk of receiving nephrotoxic medications in both cohorts (P>0.05 for all). Notably, patients aware of their CKD (identified either by issued diagnosis or recent visit to a nephrologist), were at lower risk of nephrotoxic drug use (OR 0.87, 95% CI 0.82-0.92 in Sweden and 0.89, 95% CI 0.81-1.01 in U.S.). Conclusion In two geographically distinct health systems, one in five patients with CKD received potentially inappropriate nephrotoxic medications, mainly NSAIDs. Strategies to increase CKD awareness and physician’s knowledge of drug nephrotoxicity may reduce inappropriate ambulatory prescriptions and prevent iatrogenic kidney injury.

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Racial Disparities in Invasive Management for Patients With Acute Myocardial Infarction With Chronic Kidney Disease

Circulation Cardiovascular Interventions ◽

10.1161/circinterventions.121.011171 ◽

2021 ◽

Author(s):

Jennifer A. Rymer ◽

Shuang Li ◽

Patrick H. Pun ◽

Laine Thomas ◽

Tracy Y. Wang

Keyword(s):

Myocardial Infarction ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Racial Disparities ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Logistic Regression Models ◽

Black Patients ◽

Invasive Management ◽

White Patients

Background: Due to increased risks of contrast nephropathy, chronic kidney disease (CKD) can deter consideration of invasive management for patients with myocardial infarction (MI). Black patients have a higher prevalence of CKD. Whether racial disparities exist in the use of invasive MI management for patients with CKD presenting with MI is unknown. Methods: We examined 717 012 White and 99 882 Black patients with MI treated from 2008 to 2017 at 914 hospitals in the National Cardiovascular Data Registry Chest Pain—MI Registry. CKD status was defined as estimated glomerular filtration rate (eGFR) ≥90 mL/(min·1.73 m 2 ; no CKD), eGFR <90 but ≥60 (mild), eGFR <60 but ≥30 (moderate), and eGFR <30 or dialysis (severe). We used multivariable logistic regression models to examine the interaction of race and CKD severity in invasive MI management. Results: Among those with MI, Black patients were more likely than White patients to have CKD (eGFR <90; 61.4% versus 58.5%; P <0.001). Among those with MI and CKD, Black patients were more likely than White patients to have severe CKD (21.2% versus 12.4%; P <0.001). Patients with CKD were more likely than those without CKD to have diabetes or heart failure; Black patients with CKD were more likely to have these comorbidities when compared with White patients with CKD (all P <0.0001). Black race and CKD were associated with a lower likelihood of invasive management (adjusted odds ratio, 0.78 [95% CI, 0.75–0.81]; adjusted odds ratio, 0.72 [95% CI, 0.70–0.74]; P <0.001 for both). At eGFR levels ≥10, Black patients were significantly less likely than White patients to undergo invasive management. Conclusions: Black patients with MI and mild or moderate CKD were less likely to undergo invasive management compared with White patients with similar CKD severity. National efforts are needed to address racial disparities that may remain in the invasive management of MI.

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Potentially inappropriate prescribing in people with chronic kidney disease: cross-sectional analysis of a large population cohort

British Journal of General Practice ◽

10.3399/bjgp.2020.0871 ◽

2020 ◽

pp. BJGP.2020.0871

Author(s):

Clare Elizabeth MacRae ◽

Stewart Mercer ◽

Bruce Guthrie

Keyword(s):

Chronic Kidney Disease ◽

High Risk ◽

Kidney Disease ◽

Large Population ◽

Inappropriate Prescribing ◽

Prescribing Patterns ◽

Potentially Inappropriate Prescribing ◽

Cross Sectional ◽

Stage 4 ◽

Ckd Stage

Background: Many drugs should be avoided or require dose-adjustment in chronic kidney disease (CKD). Previous estimates of potentially inappropriate prescribing rates have been based on data on a limited number of drugs and mainly in secondary care settings. Aim: To determine the prevalence of contraindicated and potentially inappropriate primary care prescribing in a complete population of people with CKD. Method: Cross-sectional study of prescribing patterns in a complete geographical population of people with CKD defined using laboratory data. Drugs were organised by British National Formulary advice. Contraindicated (CI) drugs: “avoid”. Potentially high risk (PHR) drugs: “avoid if possible”. Dose inappropriate (DI) drugs: dose exceeded recommended maximums. Results: 28,489 people with CKD were included in analysis, of whom 70.0% had CKD 3a, 22.4% CKD 3b, 5.9% CKD 4, and 1.5% CKD 5. 3.9% (95%CI 3.7-4.1) of people with CKD stages 3a-5 were prescribed one or more CI drug, 24.3% (95%CI 23.8-24.8) PHR drug, and 15.2% (95% CI 14.8-15.62) DI drug. CI drugs differed in prevalence by CKD stage, and were most commonly prescribed in CKD stage 4 with a prevalence of 36.0% (95%CI 33.7–38.2). PHR drugs were commonly prescribed in all CKD stages ranging from 19.4% (95%CI 17.6-21.3) in stage 4 to 25.1% (95%CI 24.5–25.7) in stage 3b. DI drugs were most commonly prescribed in stage 4, 26.4% (95%CI 24.3-28.6). Conclusion: Potentially inappropriate prescribing is common at all stages of CKD. Development and evaluation of interventions to improve prescribing safety in this high-risk populations are needed.

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Increasing Body Mass Index Predicts Rapid Decline in Renal Function: A 5 Year Retrospective Study

Hormone and Metabolic Research ◽

10.1055/a-0599-6360 ◽

2018 ◽

Vol 50 (07) ◽

pp. 556-561 ◽

Cited By ~ 2

Author(s):

Xiaojing Ma ◽

Chengyin Zhang ◽

Hong Su ◽

Xiaojie Gong ◽

Xianglei Kong

Keyword(s):

Body Mass Index ◽

Chronic Kidney Disease ◽

Renal Function ◽

Retrospective Study ◽

Kidney Disease ◽

Body Mass ◽

Adult Population ◽

Rapid Decline ◽

Logistic Regression Models ◽

Baseline Bmi

AbstractWhile obesity is a recognized risk factor for chronic kidney disease, it remains unclear whether change in body mass index (ΔBMI ) is independently associated with decline in renal function (evaluated by the change in estimated glomerular filtration rate, ΔeGFR) over time. Accordingly, to help clarify this we conducted a retrospective study to measure the association of ΔBMI with decline in renal function in Chinese adult population. A total of 4007 adults (aged 45.3±13.7 years, 68.6% male) without chronic kidney disease at baseline were enrolled between 2008 and 2013. Logistic regression models were applied to explore the relationships between baseline BMI and ΔBMI, and rapid decline in renal function (defined as the lowest quartile of ΔeGFR ). During 5 years of follow-up, the ΔBMI and ΔeGFR were 0.47±1.6 (kg/m2) and –3.0±8.8 (ml/min/1.73 m2), respectively. After adjusted for potential confounders, ΔBMI (per 1 kg/m2 increase) was independently associated with the rapid decline in renal function [with a fully adjusted OR of 1.12 (95% CI, 1.05 to 1.20). By contrast, the baseline BMI was not associated with rapid decline in renal function [OR=1.05 (95% CI, 0.98 to 1.13)]. The results were robust among 2948 hypertension-free and diabetes-free participants, the adjusted ORs of ΔBMI and baseline BMI were 1.14 (95% CI, 1.05 to 1.23) and 1.0 (95% CI, 0.96 to 1.04) for rapid decline in renal function, respectively. The study revealed that increasing ΔBMI predicts rapid decline in renal function.

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P0755CALCIUM/MAGNESIUM RATIO: NEW PREDICTOR OF INCREASED PULSE PRESSURE IN CHRONIC KIDNEY DISEASE PATIENTS

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p0755 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Eduarda Carias ◽

Filipa Mendes ◽

André Fragoso ◽

Pedro Leão Neves ◽

Ana Silva

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Pulse Pressure ◽

Descriptive Analysis ◽

Risk Groups ◽

T Test ◽

Chaid Analysis ◽

Stage 4 ◽

Significant Difference ◽

Calcium Magnesium

Abstract Background and Aims Cardiovascular disease (CVD) is the main cause of death in chronic kidney patient. Increase pulse pressure (PP) is associated with adverse cardiovascular outcomes and is an independent risk factor of progression of chronic kidney disease. In this study we aim to identify the risk factors associated with increased PP in a population with severely decreased glomerular filtration rate. Method This was a prospective analysis conducted in an outpatient nephropathy clinic between 2005-2018, enrolling 692 patients with stage 4 CKD. Patients were divided into two groups according to their pulse pressure. Group 1 mean PP< 50 mmHg, Group2 mean PP >50 mmHg. Based on the calcium/magnesium ratio (rCaMg), the subjects were also divided into 4 risk groups according to the following criteria: <25th percentile (rCaMg < 3.8mg/dl; n=168) – G1; 25-50th percentile (rCaMg: 3.8-4.7; n=171) – G2; 50-75th percentile (rCaMg: 4.7-8.6; n=188) – G3; and >75th percentile (rCaMg: > 8.6; n=165) - G4. We used descriptive analysis, Student's t test, Univariate logistics regression analysis and CHAID analysis to determine the relationship between variables and PP. Results Total of 682 patients, with mean age 70 (SD 12.5), female 54%. An independent t-test was conducted to compare groups. There was a significant difference in mean hemoglobin level (p=0.005), calcium (p=0.029), phosphorus (p=0.017), magnesium (p<0.001), Ca/Mg ratio (p<0.001) and eGFR (p=0.034). Phosphorus OR 1.906 (CI 1.338-2.715) p<0.001, eGFR OR 1.440 (CI 1.023-2.027) p=0.037 were all associated with increased PP. We also compared PP with the subjects of the 4 groups based on calcium/magnesium ratio. Results: G2= OR 7.003 (CI 4.162-11.783) p<0.001; G3= OR 5.136 (CI 3.205-8.230) p<0.001; G4= OR 6.695 (CI 3.999-11.208) p<0.001. After adjusting for confounding variables only sex OR 0.613 (CI 0.420-0.896) p=0.012 and rCa/Mg groups: G1 OR 7.392 (CI 4.362-12.527) p<0.001, G2 OR 6.436 (CI 3.361-12.323) p<0.001 and G3 OR 8.485 (CI 4.009-17.957) p<0.001, showed significant differences. CHAID analysis identified rCa/Mg G2, G3, G4 (82.4%) as the more likely significant predictor to PP> 50 mmHg (p<0.001) in association with male gener (86.2%) (p=0.037). The model correctly classified 76.2% of patients and the estimate of the risk misclassification of events was 0.238±0.016. Conclusion These results suggest increased calcium/magnesium rate and male gender were associated with increased pulse pressure in a population with stage 4 CKD. Further studies are needed to understand this relationship.

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Predictive factors of rapid linear renal progression and mortality in patients with chronic kidney disease

BMC Nephrology ◽

10.1186/s12882-020-01982-8 ◽

2020 ◽

Vol 21 (1) ◽

Cited By ~ 1

Author(s):

Ibrahim Ali ◽

Rajkumar Chinnadurai ◽

Sara T. Ibrahim ◽

Darren Green ◽

Philip A. Kalra

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Predictive Factors ◽

Renal Progression

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The effect of comorbidities on glycemic control among Colombian adults with diabetes mellitus: a longitudinal approach with real-world data

BMC Endocrine Disorders ◽

10.1186/s12902-021-00791-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Manuel Urina-Jassir ◽

Lina Johana Herrera-Parra ◽

Juliana Alexandra Hernández Vargas ◽

Ana María Valbuena-García ◽

Lizbeth Acuña-Merchán ◽

...

Keyword(s):

Diabetes Mellitus ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Glycemic Control ◽

Early Onset ◽

National Registry ◽

Real World Data ◽

Logistic Regression Models ◽

Statistical Interaction ◽

Longitudinal Approach

Abstract Background Achieving an optimal glycemic control has been described to reduce the incidence of diabetes mellitus (DM) related complications. The association between comorbidities and glycemic control remains unclear. Our aim is to evaluate the effect of comorbidities on glycemic control in people living with DM. Methods A retrospective longitudinal study on data from the National Registry of Chronic Kidney Disease from 2014 to 2019 in Colombia. The outcome was poor glycemic control (PGC = HbA1c ≥7.0%). The association between each comorbidity (hypertension (HTN), chronic kidney disease (CKD) or obesity) and PGC was evaluated through multivariate mixed effects logistic regression models. The measures of effect were odds ratios (OR) and their 95% confidence intervals (CI). We also evaluated the main associations stratified by gender, insurance, and early onset diabetes as well as statistical interaction between each comorbidity and ethnicity. Results From 969,531 people at baseline, 85% had at least one comorbidity; they were older and mostly female. In people living with DM and CKD, the odds of having a PGC were 78% (OR: 1.78, CI 95%: 1.55-2.05) higher than those without CKD. Same pattern was observed in obese for whom the odds were 52% (OR: 1.52, CI 95%: 1.31-1.75) higher than in non-obese. Non-significant association was found between HTN and PGC. We found statistical interaction between comorbidities and ethnicity (afro descendant) as well as effect modification by health insurance and early onset DM. Conclusions Prevalence of comorbidities was high in adults living with DM. Patients with concomitant CKD or obesity had significantly higher odds of having a PGC.

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