Impact of a multidisciplinary approach involving clinical pharmacist on resolving drug related problems in chronic kidney patients: a prospective interventional study.

BACKGROUND: Chronic kidney disease (CKD) is a major public health concern due to its high mortality risk, high hospitalization rates and cost, and low life expectancy. Thus, CKD patients are among patient group that may benefit from clinical pharmacy services the most. METHODS: This was a prospective interventional study conducted between October 1, 2019, and March 18, 2020, in the nephrology ward of Ankara University School of the Medicine, Ibn-i Sina Hospital. DRPs were classified according to PCNE v8.03. The main outcomes were interventions proposed and the rate of acceptance by the physicians. RESULTS: 269 pre-dialysis patients were included to determine DRPs during the treatment process of the patients. 205 DRPs were found in 131 (48.7%) patients. Treatment efficacy was found to be the main type of DRPs (56.2%) followed by treatment safety (39.6%). When patients with and without DRPs were compared, it was found that the number of female patients (55.0%) was higher in the group with DRPs (p < 0.05). The length of hospital stays (11.3 ± 7.7) and the mean number of drugs used (9.6 ± 3.6) in the group with DRPs were significantly higher than those without DRPs (9.3 ± 5.9; 8.1 ± 3.5, respectively) (p < 0.05). 91.7% of the interventions were accepted by the physicians, and patients and found clinically beneficial. 71.7% of DRPs were fully resolved, 1.9% partially resolved and 23.4% could not be resolved. CONCLUSIONS: A high prevalence of DRPs in patients with chronic kidney disease was determined during therapy. Clinical pharmacist interventions were highly accepted by the physicians and patients. This may indicate implementation of clinical pharmacy services in the nephrology ward has a great impact on optimized therapy and prevention DRPs.

Potentially Inappropriate Medication Use in Older Adults with Chronic Kidney Disease.

Objectives: This study aimed to identify the prevalence of potentially inappropriate medication use (PIMU) in adults above the age of 65 with chronic kidney disease (CKD) according to the American Geriatric Society Beers Criteria (Beers), Screening Tool of Older People's Potentially Inappropriate Prescriptions Criteria (STOPP) and medication appropriateness index (MAI) 30 criteria and to compare them to justify their use in this specific patient group. Materials and Methods: This was a retrospective and descriptive study conducted between October 1st, 2019 and March 18th, 2020 at Ibni Sina Hospital, Nephrology Department, Faculty of Medicine, Ankara University. Results: Among 269 patients discharged from the hospital during the study period, 100 of them were eligible for the study. The mean age was 73.3 ± 6.9 years and 51.9% of them were male. The prevalence of 35 PIMU was 91%, 42%, and 70% according to the Beers, STOPP, and MAI criteria, respectively. There was a statistically significant difference in terms of prevalence among 3 criteria (p<0.001). Beer detected more PIMU (11.3% vs. 6.4%) and had higher sensitivity among older adults with CKD (0.97 vs. 0.56) compared to the STOPP criteria. Most patients had at least one drug-drug interaction (DDIs) in their discharge prescription (93%) and DDI was one of the main contributors of PIMU. Proton pump inhibitors were the most common medication associated with PIMU in all 3 criteria. Conclusion: The prevalence of PIMU was high among older adults with CKD at discharge according to these criteria. To improve the prescriptions after hospital discharge, it is considered appropriate to use Beers criteria under guidance of a clinical pharmacist.

Potential drug-drug interactions of immunosuppressants in kidney transplant recipients: comparison of drug interaction resources.

Background Drug-drug interactions are frequently observed in kidney transplant recipients due to polypharmacy and use of immunosuppressants. However, there is only one study evaluating clinically relevant potential drug-drug interactions of immunosuppressants specially in kidney transplant recipients by means of online databases and Stockleys Drug Interactions, as a gold standard. Aim This study aimed to compare four online databases used frequently to determined clinically relevant potential drug-drug interactions of immunosuppressants in kidney transplant recipients according to the Renal Drug Handbook. Method This was a descriptive cross-sectional study conducted between October 1, 2019, and March 18, 2020, in the nephrology ward of Ankara University School of the Medicine, Ibn-i Sina Hospital. In total, 52 adult patients' discharge prescriptions were retrieved from their medical records and analyzed retrospectively. Micromedex®, Lexicomp®, Medscape, and Drugs.com databases were used to evaluate drug interactions. The Renal Drug Handbook was used as a gold standard to do specificity and sensitivity analysis. Results A total of 127 potential drug-drug interactions between the immunosuppressants and co-medications were detected by at least one online database. 32 (25.2%) of these were approved as clinically relevant potential drug-drug interactions by the Renal Drug Handbook. Lexicomp® and Drugs.com have exhibited the highest sensitivity (0.72 and 0.75) while Micromedex® has shown the highest specifity (0.83). Furthermore, the highest positive predictive value has been observed in Micromedex® (0.53). Micromedex® and Medscape had the highest negative predictive value (0.83 and 0.82). However, the kappa value of all was low. The values of inter-rater agreement (Kappa index) between online databases and the Renal Drug Handbook were weak (range 0.05-0.36). In addition, only 11 (8.7%) of potential drug-drug interactions were identified by all online databases. Conclusion This study showed that there was a weak compatibility between each database examined and the Renal Drug Handbook to detect clinically relevant potential drug-drug interactions for immunosuppressants in kidney transplant recipients. Therefore, we suggest that although databases might be practical to take a quick glance in detection of potential drug-drug interactions between immunosuppressants and co-medications, the data should be evaluated in detail and interpreted with caution in combination with a reference book like Renal Drug Handbook.

Cytomegalovirus infection in patients with glomerular diseases treated with cyclophosphamide: a single-center prospective study.

PURPOSE: Cytomegalovirus infection is an important complication in immunocompromised patients. As few studies have shown that cyclophosphamide treatment is a risk factor for cytomegalovirus infection in patients with glomerulonephritis, we aimed to describe the frequency and risk factors of cytomegalovirus infection in glomerulonephritis patients treated with cyclophosphamide. METHODS: We prospectively recruited 43 cytomegalovirus seropositive patients with glomerulonephritis treated with cyclophosphamide. We screened all patients for viral DNA monthly during treatment. Patients were compared for age, sex, glomerular pathology, renal function and clinical status regarding development of cytomegalovirus infection before and after the treatment. RESULTS: Cytomegalovirus infection was detected in 10 (23.3%) patients, most commonly within the first 2 months of cyclophosphamide treatment. All patients recovered without any cytomegalovirus-related complications. Patients with cytomegalovirus infection had higher serum creatinine (4.2 ± 3.2 vs. 1.9 ± 1.8 mg/dl, p = 0.006) and lower estimated glomerular filtration rate (29 ± 11 vs. 65 ± 8 ml/min/1.73 m2, p = 0.016) at diagnosis compared with cytomegalovirus infection non-occurred patients. In addition, number of patients presented with rapidly progressive glomerulonephritis were higher in cytomegalovirus infection group (80.0% vs. 27.3%, p = 0.007). Moreover, cytomegalovirus infection was associated with prolonged hospital stay (54 ± 7 vs. 29 ± 6 days, p = 0.027). CONCLUSION: Cytomegalovirus infection is a common complication in glomerulonephritis patients treated with cyclophosphamide in this prospective study. Routine monitoring and prophylaxis should be considered for these high-risk patients.

A multicenter study of the clinical, laboratory characteristics, and potential prognostic factors in patients with amyloid A amyloidosis on hemodialysis.

INTRODUCTION: While light chain (AL) amyloidosis is more common in western countries, the most common type of amyloidosis is amyloid A (AA) amyloidosis in Eastern Mediterranean Region, including Turkey. Although worse prognosis has been attributed to the AL amyloidosis, AA amyloidosis can be related to higher mortality under renal replacement therapies. However, there are no sufficient data regarding etiology, clinical presentation, and prognostic factors of AA amyloidosis. The objective of our study is to evaluate the clinical, laboratory characteristics, and possible predictive factors related to mortality in patients with AA amyloidosis undergoing hemodialysis (HD). METHODS: This multicenter, cross-sectional study was a retrospective analysis of 2100 patients on HD. It was carried out in 14 selected HD centers throughout Turkey. Thirty-two patients with biopsy-proven AA amyloidosis and thirty-two control patients without AA amyloidosis undergoing HD were included between October 2018 and October 2019. There was no significant difference between the groups in terms of age and dialysis vintage. Causes of AA amyloidosis, treatment (colchicine and/or anti-interleukin 1 [IL] treatment), and the number of familial Mediterranean fever (FMF) attacks in the last year in case of FMF, systolic and diastolic blood pressures, biochemical values such as mean CRP, hemoglobin, serum albumin, phosphorus, calcium, PTH, ferritin, transferrin saturation, total cholesterol levels, EPO dose, erythropoietin-stimulating agents resistance index, interdialytic fluid intake, body mass indexes, heparin dosage, UF volume, and Kt/V data in the last year were collected by retrospective review of medical records. FINDINGS: Prevalence of AA amyloidosis was found to be 1.87% in HD centers. In amyloidosis and control groups, 56% and 53% were male, mean age was 54 ± 11 and 53 ± 11 years, and mean dialysis vintage was 104 ± 94 and 107 ± 95 months, respectively. FMF was the most common cause of AA amyloidosis (59.5%). All FMF patients received colchicine and the mean colchicine dose was 0.70 ± 0.30 mg/day. 26.3% of FMF patients were unresponsive to colchicine and anti-IL-1 treatment was used in these patients. In AA amyloid and control groups, erythropoietin-stimulating agents resistance index were 7.88 ± 3.78 and 5.41 ± 3.06 IU/kg/week/g/dl, respectively (p = 0.008). Additionally, higher CRP values (18.78 ± 18.74 and 10.61 ± 10.47 mg/L, p = 0.037), lower phosphorus (4.68 ± 0.73 vs. 5.25 ± 1.04 mg/dl, p = 0.014), total cholesterol (135 ± 42 vs. 174 ± 39 mg/dl, p < 0.01), and serum albumin (3.67 ± 0.49 mg/dl, 4.03 ± 0.22, p < 0.01) were observed in patients with AA amyloidosis compared to the control group. DISCUSSION: In this study, we found that long-term prognostic factors including higher inflammation, malnutritional parameters, and higher erythropoietin-stimulating agents resistance index were more frequent in AA amyloidosis patients under HD treatment.

Infectious Complications in Patients with Primary Glomerulonephritis over 10 Years: A Single-Center Experience in Turkey.

INTRODUCTION: Infections can play an important role in the mortality and morbidity of patients with glomerulonephritis. However, the frequency of infectious complications in primary glomerulonephritis and their burden to the healthcare managements are not clear. METHODS: We evaluated the infectious complications in patients with biopsy-proven focal segmental glomerulosclerosis, membranous glomerulonephritis, IgA nephropathy, minimal change disease, membranoproliferative glomerulonephritis, and chronic glomerulonephritis during the last 10 years in a single center. We recorded the demographic, clinical, and laboratory characteristics; treatment modalities; infectious episodes; and infection-related mortality and morbidity of the patients. RESULTS: Of the patients, 154 (63.6%) received immunosuppressive treatment and 88 (34.4%) were followed up under conservative treatment. Overall, 118 infectious episodes were noted in 64 patients, with an infection rate of 0.20 per patient-year. Total infectious complications were higher in the immunosuppressive group than in the conservative group (42.1 vs. 23.3%, p = 0.005). Infection-related hospitalizations were also higher in the immunosuppressive group (p = 0.01). The most frequently infected area was the lungs (15.7%). Although bacterial infections were the most common in both groups, 14.9% of the immunosuppressive group had cytomegalovirus (CMV) replication. Age >50 years (OR 2.19, p = 0.03), basal serum albumin <2.5 g/dL (OR 2.28, p = 0.02), cyclophosphamide (OR 2.43, p = 0.02), and cyclosporine (OR 2.30, p = 0.03) were independently associated with experiencing infectious episodes. CONCLUSIONS: Because of high seropositivity for CMV in Turkey, it might be a wise approach to use prophylactic antiviral drugs in patients treated with immunosuppressive treatments. Close monitoring of patients with primary glomerulonephritis, especially those treated with immunosuppressive therapy, is important for reducing infection-related morbidity and mortality.

Two patients, two viruses and multiple sites of injury in the kidney.

Viral nephropathy is a term defines glomerular, tubular and/or vascular injury in kidney caused by viruses itself or virus-induced immune mechanisms. It is difficult to prove causality between the renal disease and the viral infection, however, renal biopsy findings can help in this regard. Several viruses such as hepatitis B and C, Human immun deficiciency virus (HIV), Hantavirus, Cytomegalovirus (CMV), an recently Coronavirus are shown to affect the kidney. Treatment of viral nephropathies are unique regarding the diagnosis which can be made only with renal biopsy in most of the situations. We present two patients presented with acute kidney injury and thrombocytopenia caused by different viruses (Hantavirus and HIV) that affect multiple areas in kidney that revealed with kidney biopsy. Supportive treatment in the patient with Hantavirus nephropathy and HIV treatment along with eculizumab and supportive treatment in the patient with HIVAN were successfully implemented.

Outcomes of Canakinumab Treatment in Recipients of Kidney Transplant With Familial Mediterranean Fever: A Case Series.

Familial Mediterranean fever (FMF) is an important and preventable cause of chronic kidney disease due to secondary amyloidosis. Although colchicine is the first-line therapy in patients with FMF with 60% to 65% complete remission rates, 5% to 10% of patients are colchicine-resistant and 5% to 10% of them are intolerant to the therapy. Anti-interleukin-1 agents, such as anakinra and canakinumab, are safe and efficient therapeutic options in patients with colchicine resistance or intolerance. However, the data on management of these targeted agents is limited in recipients of kidney transplant (RKT). In this case series, we aim to share our experience on canakinumab therapy of 4 RKTs with FMF-related amyloidosis, who were followed up in our clinic between 2010 and 2017. All of the 4 patients with end-stage renal disease were colchicine- resistant and on other alternative therapies, which provided poor disease control. For efficient control of secondary amyloidosis, canakinumab therapy was initiated in 1 of the patients before the renal transplant, and for the remaining patients after renal transplant. Any serious adverse effect, development of proteinuria, or graft dysfunction has not been observed in any of the patients. Under the canakinumab treatment, complete clinical responses, prevent typical familial Mediterranean fever attacks with fever and arthritis and abdominal pain, normalized serum amyloid A and C-reactive protein levels were achieved in all patients. Canakinumab treatment is a safe and effective therapeutic option for RKTs with FMF who are resistant or intolerant to colchicine and anakinra.