Acute Kidney Injury and Augmented Renal Clearance Risk Factor Assessment in Patients with Covid-19

INTRODUCTION: While COVID19 was initially thought to only affect the lungs, the virus also affects other organs including the kidneys. This has led to reports of renal function alterations including impairment and enhancement. The incidence of acute kidney injury (AKI) and augmented renal clearance (ARC) has been reported to be 25-35% and 25-75%, respectively. Several risk factors for AKI and ARC have been reported with many overlapping. This study sought to identify which patients might experience AKI vs ARC. METHOD(S): Hospitalized, adult patients with laboratory confirmed COVID19 from the National COVID Cohort Collaborative (N3C) database were included in this retrospective study. Patients who had all data to calculate creatinine clearance (CrCl) via Cockroft-Gault were screened and excluded for pregnancy, body mass index < 18kg/m2, history of end-stage renal disease on dialysis or nephrectomy, or lacking data to determine exclusion criteria. AKI and ARC were defined using AKIN criteria and CrCl >130mL/min, respectively. Potential demographic and biomarker predictors of AKI or ARC were considered in univariate and multivariate logistic regression models. RESULT(S): 11,274 patients were included in univariate and multivariate logistic regression analysis. 20.1% developed AKI and 34.2% experienced ARC. Significant variables associated with AKI included age, weight, height, white race, male sex, Hispanic ethnicity, and diabetes (OR 0.996, 1.01, 0.73, 0.969, 1.1, 1.11, and 1.06, respectively). Age, weight, black race, male sex, Hispanic ethnicity, and hypertension were all associated with experiencing ARC (OR 0.973 1.01, 0.753, 0.945, 1.15, 0.911, respectively). No biomarker variables were available from N3C database. CONCLUSION(S): While a significant proportion of patients with COVID19 experience alterations in renal function, there are many overlapping risk factors for the development of AKI or ARC including age, weight, and Hispanic ethnicity, with male sex as the only differentiating patients at risk for AKI vs ARC. Thus, determining which patient may be at risk for renal dysfunction or enhancement based on their demographic is still unknown. Further investigation is needed to identify patients who are at risk for each of these renal function alterations.

Analysis of Renal Function in Patients Hospitalized with COVID19

Introduction: COVID19 was originally thought to be solely a respiratory disease, however, other organs, such as the kidneys, are often also affected. While acute kidney injury (AKI) and augmented renal clearance (ARC) have both been documented, the incidence, renal characteristics, and outcome of each derangement have not been fully elucidated. Research Question or Hypothesis: What are the incidences, characteristics, and outcomes of AKI, ARC, and no AKI/ARC in patients hospitalized with COVID19? Study Design: Retrospective, observational cohort study Methods: Inpatient data from the National COVID Cohort Collaborative database with laboratory confirmed COVID19 who were >18 years old were utilized. Patients who had all data to calculate creatinine clearance (CrCl) via Cockcroft-Gault equation were screened. Exclusion criteria were pregnancy, body mass index <18kg/m2, history of end-stage renal disease on dialysis or nephrectomy. Episodes of AKI and ARC were defined using AKIN criteria and CrCl >130mL/min, respectively. Renal function characteristics and outcomes included days with episode, hospital length of stay (LOS), and mortality. Descriptive statistics and Mann-Whitney U tests were used for statistical analysis where appropriate with p<0.05 indicating statistical significance. Result(s): 15,608 patients from 11 sites were included. Overall, 57.3% were male with median age 62.7[50.1-73.2] years. The incidence of No AKI/ARC, AKI, and ARC was 43.5%, 22.9%, and 33.6%, respectively. Episodes of ARC lasted longer than AKI (4[2-7] vs 3[1-6] days;p<0.0001) Patients with AKI and ARC both had longer LOS compared to no AKI/ARC (19[10-34] and 6[4-11] vs 6[4-10];p<0.001). Patients with AKI had the highest mortality followed by no AKI/ARC then ARC (41.7% vs 10.1% vs 5.4%;p<0.001). Conclusion(s): A significant proportion of patients with COVID19 exhibit altered renal function throughout hospitalization. Clinicians should be mindful of these alterations given their associations with increased LOS and mortality with AKI. Future research should explore the impact of ARC on medication therapy in patients with COVID19.

MeRIT Project: Scoping review of rational polytherapy in patients with drug resistant epilepsy

Introduction: There is a paucity of literature regarding the optimal selection of combination anti-seizure medications (ASMs) for drug resistant epilepsy (DRE). The aim of this scoping review is to evaluate current evidence related to "rational polytherapy" among adults with DRE. Research Question or Hypothesis: What is the current evidence of clinical and health-related humanistic and economic outcomes of rational polytherapy with ASMs in DRE? If DRE is mentioned, is the appropriate definition applied? What are the current gaps? Study Design: Scoping review Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-SCr) guidelines, PubMed, ProQuest, CINAHL, and Cochrane databases were searched using DRE- and polytherapy-related keywords. The exclusion criteria applied included: non-English;non-human studies;non-research studies;participants less than 18 years;status epilepticus;ASM monotherapy;and certain ASMs. In Covidence, two researchers independently reviewed articles for inclusion at each phase, with a third resolving conflicts. Data were extracted, with quality appraisal using the Mixed Methods Appraisal Tool (MMAT). Result(s): Of the 6477 studies imported for screening, 33 studies were included. Clinical, humanistic, and economic outcomes were reported by 26, 12, and one study, respectively. Common efficacyrelated clinical outcomes included >=50% reduction in seizure frequency (n=14), seizure freedom (n=13), and percent reduction in seizure frequency (n=8). Common humanistic outcomes included quality of life (n=4), medication adherence (n=2), sleep-related outcomes (n=2), and physician and patient global assessments (n=2). The economic study reported quality-adjusted life years. Two studies referenced the standard definition of DRE. Five studies did not specifically define DRE. Gaps in the literature include limited generalizability, minimal reports in pregnancy, and lack of optimal ASM combinations. Conclusion(s): Strengths of the evidence include addressing a variety of outcomes. Inconsistent definitions of DRE, small sizes, and heterogeneity among studies limit the ability to draw meaningful conclusions. Optimal combinations of ASMs for rational polytherapy for DRE is unclear.

Use of a clinical reasoning scaffolding tool improves future student clinical reasoning performance

Introduction: Clinical reasoning skills are arguably the most important skill set a healthcare professional can possess. Anecdotally, students in the latter half of pharmacotherapy course series were underachieving in developing medication-centric patient assessments and goals from collected patient data. Scaffolding is a pedagogy used to progressively advance students toward stronger understanding, skill acquisition, and independence in learning process. A clinical reasoning scaffolding tool (CRST) was designed to improve students' ability to collect pertinent information, assess patient medication therapy problems, and develop appropriate goals of therapy with specific monitoring parameters. Research Question or Hypothesis: Can a CRST improve student clinical reasoning performance? Study Design: Prospective observational cohort Methods: The CRST was implemented in Fall 2020. To assess its impact, student performance on pharmacotherapy clinical reasoning think-alouds (CRTA) in Spring 2021 were compared to historical 2020 CRTAs not exposed to CRST. Students were evaluated using entrustable professional activity-like (EPA) ratings on five CRTA sections (Findings, Assessment/Goals, Recommendations, Monitoring, Rationale) and a Percent Grade calculated. Median EPA ratings and Percent Grade were compared between 2020 and 2021 cohorts using Mann-Whitney U or Kruskal-Wallis test which were also conducted, when appropriate, to assess impact of covariates including experiential education and case progression. CRTA cases during the beginning of COVID19 were excluded from analysis. Results: Twenty-six CRTA from 2020 and 56 from 2021 were analyzed. To minimize the effect of case progression only the first two CRTAs were included. The CRST cohort had significantly higher Assessment/Goals (2[2-2.5] vs. 2[1.5-2],p=0.001) and Monitoring (2[2-2.5] vs 1.5[1.5-1.75],p<0.001) EPA-ratings, but there was no difference in Findings. Additionally, there was a significant improvement in Percent Grade in the CRST cohort (86% vs 83%, p<0.001). Conclusion: The implementation of a CRST in an early course significantly improved future student clinical reasoning performance in assessing MTPs, developing goals of therapy, and patient monitoring.

Forces driving change in pharmacy education: Opportunities to take academic, social, technological, economic, and political into the future

In pharmacy education, we are experiencing the “new normal” after an “inflection point” along with a host of other overused phrases. Yet, without doubt, there is pressing need to reconsider what was once standard operating procedure. When an inflection point is viewed as opportunity, it sparks a strategic boom. Indeed, the confluence of threats and opportunities caused—or revealed—by the COVID-19 pandemic is setting the stage for an acceleration of change in professional education. In this paper, we investigate the motivations and approaches to accelerate needed change in pharmacy education. Though prompted by the demand for rapid restructuring in response to the COVID-19 pandemic, these ideas transcend any one driver. We argue that now is the time to disrupt current practices through innovation leading to new educational models and present sample solutions. We consider academic, social, technological, economic, and political (ASTEP) forces driving the imperative to educational change.