Opportunities and responsibilities for pharmacists on short-term medical mission teams.

BACKGROUND: American medical mission teams commonly travel to developing countries for short-term provision of clinical services. Although medications play an important role in the work of these teams, how to plan and organize a mission field pharmacy has been seldom described in the literature. OBJECTIVE: To describe pharmacist participation in medical mission work. SUMMARY: Global standards and policies, as well as traditional best practices, should be applied to the selection, acquisition, use, and disposition of medications taken into a host country. This report describes the roles and responsibilities of pharmacists in planning and organizing a mission pharmacy and in delivering quality pharmacy services in the field. CONCLUSION: Pharmacists have an important contribution to make to medical mission teams. Pharmacist knowledge of drug products, regulatory issues, medication storage, dispensing, patient consultation, therapeutic substitution, and pharmacy organization and workflow is ideally suited for mission field work.

Increasing hematocrit reduces early posttransplant cardiovascular risk in diabetic transplant recipients.

BACKGROUND: Cardiovascular disease remains epidemic in transplant recipients, despite aggressive treatment of cardiovascular risk factors. Thus, novel risk factors could play a role in the genesis of cardiovascular events in this population. METHODS: We evaluated the impact of early posttransplant anemia on cardiovascular events. We examined rolling average hematocrit values at 30-day intervals and determined the effect of increasing hematocrit on the risk for cardiovascular (CV) events in a single-center population of 404 type 1 diabetic end-stage renal disease patients who underwent either cadaveric kidney transplantation alone or simultaneous pancreas-kidney transplantation. RESULTS: Greater than 60% of the individuals in the study cohort had hematocrit less than or equal to 30% at least once during the first 30 days posttransplant. Forty-two individuals (10.4% of the study population) had at least one 30-day rolling hematocrit less than or equal to 30% and a CV event (myocardial infarction, CV death, angina, congestive heart failure) during the first 26 weeks of the posttransplant course. Increasing hematocrit (>30%) led to a reduction in the risk ratio (RR) for a CV event compared with hematocrit less than or equal to 30% (RR, 0.237; P=0.015). The association between anemia and CV events remained statistically significant in a multivariate analysis (RR, 0.65; P=0.022) that also included age and a history of pretransplant ischemic heart disease. CONCLUSIONS: These data suggest that anemia is an important risk factor for early posttransplant CV events in a high-risk population. Prospective studies of anemia management therapy in this setting are warranted to determine whether this will reduce early posttransplant CV risk.

Anemia in pediatric hemodialysis patients: results from the 2001 ESRD Clinical Performance Measures Project.

BACKGROUND: Despite improvements in dialysis care, anemia remains a problem in pediatric hemodialysis patients. METHODS: To assess possible explanations for the anemia, clinical data were obtained from the Centers for Medicare and Medicaid Services on all hemodialysis patients ages 12 to <18 years between October and December 2000. Complete data were available for 435 of the 516 patients (84%). RESULTS: A total of 160 (37%) patients had a mean hemoglobin of <11 g/dL (anemic). The mean (+/- SD) age for these patients was 15.5 +/- 1.8 years compared to 15.9 +/- 1.5 years for the target hemoglobin patients (P < 0.05). Mean time on chronic dialysis was similar for both the anemic and target hemoglobin patients (>/=100 g/dL) ( approximately 3 years) but patients on dialysis <6 months were more likely to be anemic (67%). While nearly all patients were treated with erythropoietin, anemic patients received greater weekly erythropoietin doses (intravenous, anemia 374 +/- 232 units/kg/week vs. target hemoglobin 246 +/- 196 units/kg/week, P < 0.001; and subcutaneous, 304 +/- 238 units/kg/week vs. 167 +/- 99 units/kg/week, P < 0.05). A total of 59% of anemic patients had a mean transferrin saturation (TSAT) >/=20% compared to 71% of patients with a target hemoglobin (P < 0.01). A mean serum ferritin >/=100 ng/mL was present in approximately two thirds of the anemic and target hemoglobin patients. Approximately 60% of all children were treated with intravenous iron. The mean Kt/V values were lower for anemic patients (1.46 +/- 0.4 vs. 1.53 +/- 0.3, P < 0.05). Anemic patients were less likely to have a normal serum albumin (29% anemic vs. 52% target hemoglobin patients, P < 0.001). CONCLUSION: In the final multivariable regression model, dialyzing <6 months, a low albumin, and a mean TSAT <20% remained significant predictors of anemia in children.

Regional variability in anaemia management and haemoglobin in the US.

BACKGROUND: Regional differences in haemoglobin values and process care measures were examined using data from the Centers for Medicare & Medicaid Services' End-Stage Renal Disease (ESRD) Clinical Performance Measures Project. It was posited that regional differences in haemoglobin values are consequent upon differences in components of clinical practice. METHODS: A national random sample of 8336 adult, in-centre haemodialysis patients, stratified by the 18 regional ESRD Networks, was drawn. Information was collected for October-December 1998. Multivariable stepwise linear and logistic regression analyses were performed to identify variables associated with haemoglobin. Linear regression analysis was used to identify variables associated with Epo/Hb index (mean weight-adjusted treatment level erythropoietin (Epo) dose divided by mean haemoglobin). RESULTS: The percentage of patients with haemoglobin concentration < 11 g/dl ranged from 34 to 52% across ESRD Networks. In addition to haemoglobin there was significant, non-random variation among ESRD Networks with regard to prescribed Epo dose and administration route, intravenous (IV) iron prescription and dialyser flux (high flux = KUf > or = 20 ml/mmHg/h) (all P-values < 0.001). Higher haemoglobin was associated with older age, male gender, higher serum albumin, higher transferrin saturation, higher Kt/V, lower serum ferritin and lower prescribed Epo dose (all P-values < 0.01). Diabetes mellitus as cause of ESRD, high-flux dialyser use, IV iron prescription or subcutaneous Epo prescription were not associated with haemoglobin. Male gender, diabetes as cause of ESRD, older age, higher transferrin saturation and higher albumin concentrations were associated with lower Epo/Hb index. Prescription of IV iron and IV Epo were associated with higher Epo/Hb index. CONCLUSIONS: Regional mean haemoglobin levels vary considerably across the US and the variation in haemoglobin is explained by both non-modifiable factors and modifiable clinical practice-derived variables.

Comparative review of the pharmacokinetics of vitamin D analogues.

This article reviews the pharmacokinetic characteristics of calcitriol, paricalcitol, and doxercalciferol, and provides an overview of the metabolism of vitamin D. Calcitriol and paricalcitol have similar pharmacokinetic profiles, with terminal half-lives ranging from 5 to 10 hours in healthy subjects to 15-30 hours in patients undergoing dialysis. Both are active on intravenous administration and little of the active agent remains in the circulation after 24 hours, although they are normally given every 48-72 hours. Doxercalciferol is a prohormone, requiring hepatic metabolism to the active metabolite 1alpha,25-(OH)2D2. The half-life of 1alpha,25-(OH)2D2 is about 34 hours in healthy subjects and about 45 hours in dialysis patients, resembling physiologic blood concentrations of endogenous vitamin D. More studies are warranted to determine the disposition of the vitamin D analogues, especially in selected populations such as pediatric and geriatric dialysis patients.

The nephrology nurse's role in improved care of patients with chronic kidney disease.

The care of chronic kidney disease (CKD) patients is suboptimal. This article discusses how nephrology nurses can contribute to multidisciplinary clinics that work in collaboration with primary care providers to identify and manage patients with early CKD. This article will describe the importance of the nephrology nurse as a resource for improved patient outcomes and for the implementation of federal, professional, and corporate CKD initiatives.

Analysis of renal bone disease treatment in dialysis patients.

End-Stage Renal Disease Network 11 initiated a renal osteodystrophy quality improvement activity in 1999. One component was the collection and assessment of dialysis facility renal osteodystrophy protocols, whereas another component was the analysis of bone disease-related medication use. Two hundred eighty-eight facilities were invited to submit protocols. A model bone disease and mineral metabolism protocol was developed as the standard for comparison. From the model protocol, an instrument was created to evaluate eight key areas (baseline screening of key laboratory data, dietary intervention, phosphate-binder use, vitamin D use, monitoring of key laboratory indicators, management of hypercalcemia, oversuppression of parathyroid hormone [PTH], and guidelines for both hemodialysis and peritoneal dialysis patients). A bone disease-related prescription survey was completed for 749 randomly selected patients. Survey information included vitamin D and phosphate-binder use and related laboratory values (calcium, phosphorus, intact PTH [iPTH], and calcium x phosphorus product). Although 45% of facilities had six or more points on the evaluation tool, protocols were still incomplete compared with the model. Mean facility-specific scores among the five states in the Network ranged from 1.0 to 5.9 (possible scores, 0 to 8). Most patients were prescribed a phosphate binder; however, 31.8% had average phosphorus levels greater than 6.0 mg/dL during the 3-month period. Only 58% of patients with average iPTH concentrations greater than 260 pg/mL were prescribed vitamin D. Of patients treated with vitamin D, 39% had iPTH concentrations less than 130 pg/mL. There is opportunity to improve renal osteodystrophy protocols in Network 11 and reinforce potential hazards of sustained hyperphosphatemia and hyperparathyroidism.

Trends in anemia management among US hemodialysis patients.

This study was undertaken to describe the relationship between hematocrit (Hct) and changes in the prescribed dose of erythropoietin (EPO) as well as selected patient and process care measures across annual national samples of hemodialysis patients from 1994 to 1998. This study uses the cohorts identified in the ESRD Core Indicators Project, random samples of 6181, 6241, 6364, 6634, and 7660 patients, stratified by ESRD Networks drawn for each year from 1994 to 1998. Patient demographic and clinical information was collected from October to December for each year. Surrogates of iron stores and patterns of iron and EPO administration were profiled from 1996 to 1998. Multivariable stepwise linear regression analyses were performed to adjust for potential confounding variables and to identify independent variables associated with Hct and EPO dose. Mean Hct and EPO dose increased each year from 31.1 +/- 5.2% to 34.1 +/- 3.7% and from 58.2 +/- 41.8 U/kg to 68.2 +/- 55.0 U/kg, respectively (P = 0.0001). Increasing Hct was positively associated with male gender, more years on dialysis, older age, higher urea reduction ratio and transferrin saturation, prescription of intravenous iron, and lower ferritin and EPO dose in multivariable models (all P = 0.0001). Male gender, older age, diabetes, higher Hct, and increasing weight, urea reduction ration, and transferrin saturation were associated with lower EPO doses (all P < 0.01). Conversely, intravenous EPO and iron were associated with higher prescribed EPO doses (all P = 0.0001). Although increasing Hct is associated with decreasing EPO dose at the patient level, the increase in Hct seen across years among the cohorts of hemodialysis patients in the United States has been associated with increasing doses of EPO at the population level.

Current management of anemia in adult hemodialysis patients with end-stage renal disease.

The management of anemia in adult end-stage renal disease (ESRD) patients receiving hemodialysis in dialysis facilities is examined. Clinical information was collected for a random sample of adult (age > or = 18 years) patients who received hemodialysis for ESRD between October and December 1999 and included hemoglobin concentrations, epoetin alfa doses and routes of administration, iron prescribing patterns, transferrin saturation levels, and serum ferritin concentrations. Patients whose data did not include hemoglobin concentrations with the weekly epoetin dose were excluded from the analysis. Associations by patient characteristics and geographic region were examined for clinical intermediate outcomes and epoetin alfa and iron prescribing practice patterns. Data were submitted for 8154 patients, and hemoglobin values linked to weekly epoetin alfa doses were available for 7573 of those patients. The mean hemoglobin concentration for patients in the sample was 11.4 +/- 1.3 g/dL. Sixty-seven percent of patients had mean hemoglobin values > or = 11 g/dL. Females, blacks, patients 18-44 years old, and patients receiving hemodialysis for less than six months exhibited significantly lower mean hemoglobin values despite being prescribed, on average, significantly higher epoetin alfa doses than males, whites, older patients, and patients receiving hemodialysis for six months or more (p < 0.001). There was significant regional variation in the prescribing patterns for s.c. epoetin alfa and i.v. iron (p < 0.001). Multivariable logistic regression analysis found significant associations between mean hemoglobin values > 11 g/dL and certain patient characteristics, including white race, hemodialysis for six months or longer, lower prescribed weekly epoetin alfa doses, prescription of i.v. iron, mean transferrin saturation levels > or = 20%, mean Kt/V > or = 1.2, and higher mean serum albumin values. Prescribing patterns for i.v. iron did not vary by the status of patients' iron stores. Regional and patient-specific variations in parameters of anemia management provide pharmacists with the opportunity to contribute to a multidisciplinary team approach to improve the care of hemodialysis patients.