Discordance Between Using Estimated and Measured Glomerular Filtration Rate for Drug Dosing in Kidney Transplant Recipients.

INTRODUCTION: Estimating glomerular filtration rate (eGFR) using different formulas is common clinical practice for evaluating kidney function and drug dosing. But, the performance of available eGFR equations is questionable during early days after kidney transplantation. METHODS: This study compared the performance of three common eGFR equations (Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)) in relation with measured GFR (mGFR) using clearance of Tc-99m-diethylenetriaminepentaacetic acid, 7 to 10 days post kidney transplantation. Agreement of mGFR and different eGFR equations in the staging of kidney function and dosing of 8 common antimicrobials were assessed. RESULT: Thirty kidney and 5 simultaneous pancreas-kidney transplant recipients were included. CG applying total body weight (CGTBW) had the lowest bias (-12 mL/min/ 1.73 m2) and the highest percentage of estimation within 30% of mGFR (71.4%). MDRD showed the best precision (13.14 mL/min/ 1.73m2) and linear correlation with mGFR. CKD-EPI and MDRD acted better than CG for staging the level of kidney function. CGTBW had the lowest discordance rate with mGFR for antimicrobials dosing (33.6%). Discordance rates of drug dosing between mGFR and eGFR formulas were greater for drugs that have higher dosing levels such as (val)-ganciclovir (≥ 54.3%). CONCLUSION: Until developing more accurate methods for estimating kidney function during first 1 to 2 weeks after kidney transplantation, CGTBW method is suggested for drug dose adjustment and MDRD or CKD-EPI equation for the staging of kidney function in these patients, keeping in mind that these formulas underestimate the level of kidney function in new transplant recipients.

Comparing the Effect of Immediate versus Delayed Initiation of Tacrolimus on Delayed Graft Function in Kidney Transplant Recipients: A Randomized Open-label Clinical Trial.

OBJECTIVE: Delayed graft function (DGF) is an early complication after kidney transplantation with negative impact on allograft outcomes. This study assessed the effect of delayed initiation of tacrolimus as a nephrotoxic drug, on DGF occurrence and allograft function. METHODS: This randomized, open-label clinical trial was conducted on kidney transplant recipients with the age of at least 14 years who underwent the first kidney transplantation from deceased or living donor. Patients were randomly allocated to immediate (n = 26) or delayed tacrolimus (n = 27) groups. All patients received thymoglobulin as induction therapy and similar maintenance immunosuppression including tacrolimus, mycophenolate, and prednisolone with the difference in the time of initiation of tacrolimus either on the day of transplantation (immediate tacrolimus group) or day 3 after transplant (delayed tacrolimus group). FINDINGS: DGF incidence (46.15% vs. 37.04%; P = 0.501) and duration (9.75 ± 6.41 vs. 8.6 ± 6.16 days; P = 0.675) were not different between the immediate and delayed tacrolimus groups. Estimated creatinine clearance using Cockcroft-Gault equation (63.14 ± 18.81 vs. 58.19 ± 19.42 mL/min in immediate and delayed tacrolimus groups respectively; P = 0.373) and estimated acute rejection-free survival were also comparable between the groups over the 3 months of follow-up. Compared with the immediate group, the delayed tacrolimus group showed higher estimated 3-month grafts' survival (100% vs. 84.27%; P = 0.072). CONCLUSION: Delayed initiation of tacrolimus after kidney transplantation under the umbrella of thymoglobulin induction did not result in either lower incidence or duration of DGF or improved the level of graft function in kidney transplant recipients but non-statistically significant increased 3-month grafts' survival.

Impact of clinical pharmacy services on stress ulcer prophylaxis prescribing and related cost in patients with renal insufficiency.

OBJECTIVES: Compared to the general population, chronic kidney disease patients are more vulnerable to gastrointestinal haemorrhage and its morbidity and mortality. Due to the fear of gastrointestinal bleeding consequences in these patients on the one hand, and the perception of general safety of acid suppressive medications on the other hand, inappropriate stress ulcer prophylaxis (SUP) seems to be encountered in nephrology wards. The objectives of this study were to evaluate appropriateness of acid suppression therapy in kidney disease patients and to assess the role of clinical pharmacists to decrease inappropriate SUP prescribing and related costs for these patients. METHODS: All inpatients at nephrology wards of a teaching hospital were assessed regarding appropriate SUP prescribing during a 6-month pre-intervention phase of the study without any clinical pharmacists' involvement in patients' management. Thereafter, during a 6-month post-intervention phase clinical pharmacists provided local SUP protocol and educational classes for physicians regarding appropriate SUP prescribing and participated actively in the patient-care team. MAIN FINDINGS: The results showed significant relative reduction in inappropriate SUP prescribing and related cost in patients with renal insufficiency by about 44% and 67% respectively. CONCLUSION: This study showed that implementing institutional guidelines, and active involvement of clinical pharmacists in the nephrology healthcare team, could reduce inappropriate SUP prescribing and related costs for these patients.

The use of pharmaceutical care to improve health-related quality of life in hemodialysis patients in Iran.

BACKGROUND: Compared with the general population, hemodialysis patients suffer from worse health-related quality of life (HRQoL). Poor HRQoL results in the higher risk of hospitalization and mortality. OBJECTIVE: This study was designed to assess the impact of pharmaceutical care on HRQoL of hemodialysis patients. SETTING: This study was performed in a university hemodialysis center in Iran. METHODS: At the initiation of the study HRQoL of dialysis patients were assessed using SF-36 instrument and patients' demographic and laboratory data were gathered. Hemodialysis patients were randomized to receive either only standard care of the ward consisted of brief medication review by nurses and monthly visits by nephrology fellow and attending physicians as the control group or receive clinical pharmacist-led pharmaceutical care in addition to the standard care of the ward as the case group. Finally patients' HRQoL were assessed at the end of the month six of the study in both groups. MAIN OUTCOME MEASURE: Quality of life as measured with the SF-36 was compared between case and control groups and within each group at the initiation and at the end of 6 months study. RESULTS: During this study, median (IQR) of HRQoL improved significantly from 56.9 (37.7-71.7) at the initiation of the study to 72.2 (55.3-83.7) at the end of the study in the case group (P = 0.001) especially in the role-emotional [from 66.6 (33.3-66.6) to 100.0 (100.0-100.0); P = 0.001], mental health [from 54.2 (40.8-73.5) to 68.3 (58.9-90.2); P = 0.007], social functioning [from 73.6 (37.5-100.0) to 93.4 (75.0-100.0); P = 0.01], and general health [from 45.0 (30.0-70.0) to 65.0 (48.8-75.0); P = 0.001] dimensions. Conversely, HRQoL did not change or decreased in the control group. This decrease was statistically significant in the general health domain [from 47.5 (33.8-56.3) to 40.0 (23.7-51.2); P = 0.04]. CONCLUSION: Providing pharmaceutical care significantly improved HRQoL of hemodialysis patients especially in the role-emotional, mental health, social functioning, and general health dimensions.