Safety of Medical Therapy in Patients With CKD and ESRD
Safety of Medical Therapy in Patients With CKD and ESRD
Purpose of review Maintaining patient safety is a necessary step to improve healthcare delivery. Patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) have an increased frequency of adverse safety events largely because of medication errors.
Recent findings CKD and ESRD have several features which threaten patient safety. Reduced glomerular filtration rate affects the clearance of many medications and is also associated with several comorbidities such as diabetes, cardiovascular disease, metabolic bone disease, and anemia. These comorbidities of CKD often increase the complexity of treatment regimens. Patients with ESRD, requiring dialysis or transplantation, have an even greater potential for adverse safety events because of the reliance on renal replacement modalities and the frequent requirements of polypharmacy and potential drug–drug interactions.
Summary There is an important need to develop strategies to provide inpatient and outpatient management plans to limit the risk of adverse medication errors across a wide range of educational and socioeconomic backgrounds, and a critical need to develop a uniform set of standards for evaluating patient safety in CKD and ESRD as well as appropriate descriptions of the prototypical safety profiles of patients who have CKD, a kidney transplant, or who are on dialysis.
An Institute of Medicine report in 1999 described in broad terms the extent to which medical errors and harm from medical care contributed to excess mortality and morbidity in hospitalized patients in the United States. A report entitled, 'To err is human: Building a Safer Health System' concluded that 44 000 to 98 000 inhospital deaths each year were due to medication errors. This report, which is nearly 15 years old, did not include information about a population which is at markedly increased risk for patient safety errors: the patient with chronic kidney disease (CKD) and end-stage renal disease (ESRD).
CKD is common. It affects more than 10% of the U.S. population. Of these, nearly 500 000 patients are on dialysis in the United States and more than 15 000 receive a kidney transplant annually, yielding a large prevalent population.
Patients with CKD are complex and have frequent medical comorbidity, including hypertension, diabetes, cardiovascular disease, and metabolic bone disease. Such patients require more frequent hospitalizations and encounters with healthcare providers. Polypharmacy is typical and the risk for drug–drug interactions is substantial.
Unfortunately, reduced glomerular filtration rate (GFR) is often underdiagnosed despite the widespread use of estimated GFR reporting with laboratory measurements. Inadequate treatment and late referral often leads to poor preparation for optimal treatment and management of ESRD or transplantation. In addition, the failure to recognize CKD often results in the failure to use proven therapeutic treatments to reduce the rate of progression of kidney disease. Medication dosing in patients with CKD and ESRD requires special consideration. A significant proportion of medications are either metabolized or cleared by the kidney. Despite the advantage of the use of electronic medical records (EMRs) as reminders for prescribing physicians, the likelihood of misuse of medications remains substantial. Chertow et al. evaluated the use of a computer-assisted order system in a U.S. hospital to alert healthcare providers of the medication orders requiring alterations because of impaired kidney function. As shown in Table 1, nearly 15% of all medications ordered were potentially nephrotoxic or required dose alterations. In a large European study, the investigators noted that of 1469 medication orders in 164 patients, nearly 85% had the potential for nephrotoxicity, and of these, more than 20% were not modified for the patient's level of renal function. Other reviews have similarly noted a high risk of adverse drug events with medication use in patients with CKD when hospitalized. However, what is most concerning about this information is that it likely underestimates the outpatient exposures, especially when there is no EMR to provide reminders for treating physicians.
Abstract and Introduction
Abstract
Purpose of review Maintaining patient safety is a necessary step to improve healthcare delivery. Patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) have an increased frequency of adverse safety events largely because of medication errors.
Recent findings CKD and ESRD have several features which threaten patient safety. Reduced glomerular filtration rate affects the clearance of many medications and is also associated with several comorbidities such as diabetes, cardiovascular disease, metabolic bone disease, and anemia. These comorbidities of CKD often increase the complexity of treatment regimens. Patients with ESRD, requiring dialysis or transplantation, have an even greater potential for adverse safety events because of the reliance on renal replacement modalities and the frequent requirements of polypharmacy and potential drug–drug interactions.
Summary There is an important need to develop strategies to provide inpatient and outpatient management plans to limit the risk of adverse medication errors across a wide range of educational and socioeconomic backgrounds, and a critical need to develop a uniform set of standards for evaluating patient safety in CKD and ESRD as well as appropriate descriptions of the prototypical safety profiles of patients who have CKD, a kidney transplant, or who are on dialysis.
Introduction
An Institute of Medicine report in 1999 described in broad terms the extent to which medical errors and harm from medical care contributed to excess mortality and morbidity in hospitalized patients in the United States. A report entitled, 'To err is human: Building a Safer Health System' concluded that 44 000 to 98 000 inhospital deaths each year were due to medication errors. This report, which is nearly 15 years old, did not include information about a population which is at markedly increased risk for patient safety errors: the patient with chronic kidney disease (CKD) and end-stage renal disease (ESRD).
CKD is common. It affects more than 10% of the U.S. population. Of these, nearly 500 000 patients are on dialysis in the United States and more than 15 000 receive a kidney transplant annually, yielding a large prevalent population.
Patients with CKD are complex and have frequent medical comorbidity, including hypertension, diabetes, cardiovascular disease, and metabolic bone disease. Such patients require more frequent hospitalizations and encounters with healthcare providers. Polypharmacy is typical and the risk for drug–drug interactions is substantial.
Unfortunately, reduced glomerular filtration rate (GFR) is often underdiagnosed despite the widespread use of estimated GFR reporting with laboratory measurements. Inadequate treatment and late referral often leads to poor preparation for optimal treatment and management of ESRD or transplantation. In addition, the failure to recognize CKD often results in the failure to use proven therapeutic treatments to reduce the rate of progression of kidney disease. Medication dosing in patients with CKD and ESRD requires special consideration. A significant proportion of medications are either metabolized or cleared by the kidney. Despite the advantage of the use of electronic medical records (EMRs) as reminders for prescribing physicians, the likelihood of misuse of medications remains substantial. Chertow et al. evaluated the use of a computer-assisted order system in a U.S. hospital to alert healthcare providers of the medication orders requiring alterations because of impaired kidney function. As shown in Table 1, nearly 15% of all medications ordered were potentially nephrotoxic or required dose alterations. In a large European study, the investigators noted that of 1469 medication orders in 164 patients, nearly 85% had the potential for nephrotoxicity, and of these, more than 20% were not modified for the patient's level of renal function. Other reviews have similarly noted a high risk of adverse drug events with medication use in patients with CKD when hospitalized. However, what is most concerning about this information is that it likely underestimates the outpatient exposures, especially when there is no EMR to provide reminders for treating physicians.
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