1
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Dai N, Jiang C, Wang Y. Relationship between vancomycin-induced nephrotoxicity and vancomycin trough concentration in older adults: A retrospective observational study. Indian J Pharmacol 2023; 55:155-161. [PMID: 37555409 PMCID: PMC10501546 DOI: 10.4103/ijp.ijp_634_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 04/10/2023] [Accepted: 07/13/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVES The objective of the study is to investigate the risk factors of vancomycin-induced renal toxicity in older adults, especially in those with chronic kidney disease (CKD) Stages 3-5. METHODS In this retrospective observational study, serum vancomycin trough concentrations (VTCs) in patients aged g65 years treated with vancomycin were analyzed, and independent risk factors of vancomycin-induced nephrotoxicity (VIN) were determined by logistic regression analysis. RESULTS In total, 321 patients were included in this study. Serum VTC was an independent risk factor for vancomycin-induced renal toxicity in total cohort (odds ratio [OR], 1.07; P = 0.004) as well as in the cohort with CKD Stages 3-5 (OR, 1.09; P = 0.010). A daily dose of vancomycin and Charlson comorbidity index was an independent risk factor for vancomycin-induced renal toxicity in total cohort (OR, 3.63; P = 0.006) and in the cohort with CKD Stage 3-5 (OR, 1.83; P = 0.002), respectively. In older adults with CKD Stages 3a and 3b-5, the VTCs associated with higher risk for vancomycin-induced renal toxicity were 21.5 mg/L and 16.5 mg/L, respectively. CONCLUSIONS In older adults, serum VTC is an independent risk factor for VIN. VTCs over 21.5 mg/L and 16.5 mg/L are associated with increased risk of VIN in this population with CKD Stage 3a and 3b-5, respectively.
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Affiliation(s)
- Ning Dai
- Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chunyan Jiang
- Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yunchao Wang
- Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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2
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Abdelmessih E, Patel N, Vekaria J, Crovetto B, SanFilippo S, Adams C, Brunetti L. Vancomycin area under the curve versus trough only guided dosing and the risk of acute kidney injury: Systematic review and meta-analysis. Pharmacotherapy 2022; 42:741-753. [PMID: 35869689 PMCID: PMC9481691 DOI: 10.1002/phar.2722] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/25/2022] [Accepted: 06/27/2022] [Indexed: 12/30/2022]
Abstract
Vancomycin is commonly used to treat methicillin-resistant Staphylococcus aureus infections and is known to cause nephrotoxicity. Previous Vancomycin Consensus Guidelines recommended targeting trough concentrations but the 2020 Guidelines suggest monitoring vancomycin area under the curve (AUC) given the reduced risk of acute kidney injury (AKI) at similar levels of efficacy. This meta-analysis compares vancomycin-induced AKI incidence using AUC-guided dosing strategies versus trough-based monitoring. Literature was queried from Medline (Ovid), Web of Science, and Google Scholar from database inception through November 5, 2021. Interventional or observational studies reporting the incidence of vancomycin-induced AKI between AUC- and trough-guided dosing strategies were included. In the primary analysis, the Vancomycin Consensus Guidelines definition for AKI was used if reported; otherwise, the Risk, Injury, and Failure; and Loss, and End-stage kidney disease (RIFLE) or Kidney Disease Improving Global Outcomes (KDIGO) definitions were used. The incidence of nephrotoxicity was evaluated between the two strategies using a Mantel-Haenszel random-effects model, and odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Subgroup analyses for adjusted ORs and AKI definitions were performed. Heterogeneity was identified using Cochrane's Q test and I2 statistics. A total of 10 studies with 4231 patients were included. AUC-guided dosing strategies were associated with significantly less vancomycin-induced AKI than trough-guided strategies [OR 0.625, 95% CI (0.469-0.834), p = 0.001; I2 = 25.476]. A subgroup analysis of three studies reporting adjusted ORs yielded similar results [OR 0.475, 95% CI (0.261-0.863), p = 0.015]. Stratification by AKI definition showed a significant reduction in AKI with the Vancomycin Consensus Guidelines definition [OR 0.552, 95% CI (0.341-0.894), p = 0.016] but failed to find significance in the alternative definitions. Area under the curve-guided dosing strategies are associated with a lower incidence of vancomycin-induced AKI versus trough-guided dosing strategies (GRADE, low). Limitations included the variety of AKI definitions and the potential for confounding bias.
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Affiliation(s)
- Emily Abdelmessih
- Ernest Mario School of Pharmacy, RutgersThe State University of New JerseyPiscatawayNew JerseyUSA
| | - Nandini Patel
- Ernest Mario School of Pharmacy, RutgersThe State University of New JerseyPiscatawayNew JerseyUSA
| | - Janaki Vekaria
- Ernest Mario School of Pharmacy, RutgersThe State University of New JerseyPiscatawayNew JerseyUSA
| | - Brynna Crovetto
- Touro College of PharmacyNew YorkNew YorkUSA,Department of PharmacyMount Sinai HospitalNew YorkNew YorkUSA
| | - Savanna SanFilippo
- Tabula Rasa HealthcareMoorestownNew JerseyUSA,Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, RutgersThe State University of New JerseyPiscatawayNew JerseyUSA,Robert Wood Johnson University Hospital SomersetSomervilleNew JerseyUSA
| | - Christopher Adams
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, RutgersThe State University of New JerseyPiscatawayNew JerseyUSA,Robert Wood Johnson University Hospital SomersetSomervilleNew JerseyUSA,La Jolla Pharmaceutical CompanyWalthamMassachusettsUSA
| | - Luigi Brunetti
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, RutgersThe State University of New JerseyPiscatawayNew JerseyUSA,Robert Wood Johnson University Hospital SomersetSomervilleNew JerseyUSA
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3
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Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Beringer AW, Rodvold KA, Maples HD. Validity of 2020 vancomycin consensus recommendations and further guidance for practical application. Am J Health Syst Pharm 2021; 78:1364-1367. [PMID: 33764403 DOI: 10.1093/ajhp/zxab123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael J Rybak
- Anti-Infective Research Laboratory Department of Pharmacy Practice Eugene Applebaum College of Pharmacy & Health Sciences Wayne State University Detroit, MI, USA.,School of Medicine Wayne State University Detroit, MI, USA
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences University of California San Diego La Jolla, CA, USA
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences Albany, NY, USA
| | - Donald P Levine
- School of Medicine Wayne State University Detroit, MI, USA.,Detroit Receiving Hospital Detroit, MI, USA
| | - John S Bradley
- Department of Pediatrics Division of Infectious Diseases University of California at San Diego La Jolla, CA, USA.,Rady Children's Hospital San Diego San Diego, CA, USA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases University of Washington Seattle, WA, USA
| | - Bruce A Mueller
- University of Michigan College of Pharmacy Ann Arbor, MI, USA
| | - Manjunath P Pai
- University of Michigan College of Pharmacy Ann Arbor, MI, USA
| | | | | | - Holly D Maples
- University of Arkansas for Medical Sciences College of Pharmacy & Arkansas Children's Hospital Little Rock, AR, USA
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4
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Scheetz MH, Lodise TP, Downes KJ, Drusano G, Neely M. The case for precision dosing: medical conservatism does not justify inaction. J Antimicrob Chemother 2021; 76:1661-1665. [PMID: 33843994 DOI: 10.1093/jac/dkab086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The need for precision dosing has been challenged on the basis of insufficient evidence. Herein, we argue that adequate evidence exists to conduct therapeutic drug monitoring (TDM) and precisely target antibiotic exposures. While achievement of any antibiotic concentration does not guarantee efficacy sans toxicity for any single patient, stochastic control optimizes the probability of achieving favourable responses across patients. We argue that variability in targets (such as the organism's MIC) can be considered with models. That is, complexity alone does not relegate the decision-making framework to 'clinician intuition'. We acknowledge the exposure-response relationships are modified by patient-specific factors (other drugs, baseline organ functional status etc.) and describe how precision dosing can inform clinical decision making rather than protocolize it. Finally, we call for randomized, controlled trials; however, we suggest that these trials are not necessary to make TDM standard of care for multiple classes of antibiotics.
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Affiliation(s)
- Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Pharmacometric Center of Excellence, Midwestern University, Downers Grove, IL, USA.,College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
| | - Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Kevin J Downes
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - George Drusano
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Orlando, FL, USA
| | - Michael Neely
- Children's Hospital Los Angeles and University of Southern California, Los Angeles, CA, USA
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5
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Lodise TP, Drusano G. Vancomycin Area Under the Curve–Guided Dosing and Monitoring for Adult and Pediatric Patients With Suspected or Documented Serious Methicillin-Resistant Staphylococcus aureus Infections: Putting the Safety of Our Patients First. Clin Infect Dis 2021; 72:1497-1501. [DOI: 10.1093/cid/ciaa1744] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Indexed: 12/12/2022] Open
Abstract
Abstract
The revised vancomycin consensus guidelines recommended area under the curve (AUC)–guided dosing/monitoring for patients with serious invasive methicillin-resistant Staphylococcus aureus (MRSA) infections as a measure to minimize vancomycin-associated acute kidney injury (VA-AKI) while maintaining similar effectiveness. Data indicate that the intensity of vancomycin exposure drives VA-AKI risk. Troughs of 15–20 mg/L will ensure an AUC ≥400 mg × hr/L but most patients will have daily AUCs >600. VA-AKI increases as a function of AUC, especially when >600. In addition to minimizing VA-AKI risk while maintaining similar efficacy, AUC-guided dosing/monitoring is a more precise way to conduct therapeutic drug monitoring for vancomycin relative to trough-only control.
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Affiliation(s)
- Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - George Drusano
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
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6
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Lodise TP, Hall RG, Scheetz MH. Vancomycin Area Under the Curve-guided Dosing and Monitoring: "Is the Juice Worth the Squeeze"? Pharmacotherapy 2020; 40:1176-1179. [PMID: 33368454 DOI: 10.1002/phar.2482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Ronald G Hall
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, Jerry H. Hodge School of Pharmacy, Amarillo, Texas, USA.,Dose Optimization and Outcomes Research (DOOR) Program, Dallas, Texas, USA
| | - Marc H Scheetz
- Pharmacometrics Center of Excellence, Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Downers Grove, Illinois, USA.,Department of Pharmacology, College of Graduate Studies, Midwestern University, Downers Grove, Illinois, USA.,Department of Pharmacy, Northwestern Medicine, Chicago, Illinois, USA
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7
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Cost-benefit analysis comparing trough, two-level AUC and Bayesian AUC dosing for vancomycin. Clin Microbiol Infect 2020; 27:1346.e1-1346.e7. [PMID: 33221430 DOI: 10.1016/j.cmi.2020.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/08/2020] [Accepted: 11/14/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Area under the time-concentration curve (AUC) -guided dosing provides better estimates of exposure than vancomycin trough concentrations. Though clinical benefits have been reported, the costs of AUC-guided dosing are uncertain. The objective of this study was to quantify the costs of single-sample Bayesian or two-sample AUC strategies versus trough-guided dosing. METHODS A cost-benefit analysis from the institutional perspective was conducted using a decision tree to model the probabilities and costs of acute kidney injury (AKI) associated with vancomycin administered over 48 hours up to 21+ days. Costs included vancomycin concentrations, Bayesian software and AKI hospitalization costs, and probabilities were obtained from primary literature. Robustness was assessed via both one-way and probabilistic sensitivity analyses. RESULTS In the base-case model, two-sample AUC versus trough dosing saved an average of US$ 846 per patient encounter, and single-sample Bayesian AUC versus trough dosing saved an average of US$ 2065 per patient encounter. This translates into annual cost-savings of US$ 846 810 and US$ 2 065 720 for two-sample and single-sample Bayesian methods versus trough dosing, respectively, assuming 1000 vancomycin-treated patients per year. Assuming a budget of US$ 100 000 per year for Bayesian software, an institution would need to treat ≥41 patients with vancomycin for at least 48 hours to break even. CONCLUSIONS There are significant institutional cost benefits using two-sample AUC or single-sample Bayesian methods over trough dosing, even after accounting for the annual costs of Bayesian programs. The potential to decrease rates of AKI, improve clinical outcomes and reduce costs to the institution strongly warrants consideration of improved dosing methods for vancomycin.
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8
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Effect of Vancomycin-Associated Acute Kidney Injury on Incidence of 30-Day Readmissions among Hospitalized Veterans Affairs Patients with Skin and Skin Structure Infections. Antimicrob Agents Chemother 2020; 64:AAC.01268-20. [PMID: 32718970 DOI: 10.1128/aac.01268-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/22/2020] [Indexed: 12/22/2022] Open
Abstract
Among hospitalized adults who received vancomycin for their skin and skin structure infection (SSSI), patients who experienced acute kidney injury (AKI) had considerably higher 30-day readmission rates. Nearly half of the observed 30-day readmissions were due to non-SSSI-related reasons, which is consistent with the persistent organ dysfunction observed among patients with AKI.
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9
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Jorch SK, Surewaard BG, Hossain M, Peiseler M, Deppermann C, Deng J, Bogoslowski A, van der Wal F, Omri A, Hickey MJ, Kubes P. Peritoneal GATA6+ macrophages function as a portal for Staphylococcus aureus dissemination. J Clin Invest 2020; 129:4643-4656. [PMID: 31545300 DOI: 10.1172/jci127286] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 08/01/2019] [Indexed: 12/20/2022] Open
Abstract
Essentially all Staphylococcus aureus (S. aureus) bacteria that gain access to the circulation are plucked out of the bloodstream by the intravascular macrophages of the liver - the Kupffer cells. It is also thought that these bacteria are disseminated via the bloodstream to other organs. Our data show that S. aureus inside Kupffer cells grew and escaped across the mesothelium into the peritoneal cavity and immediately infected GATA-binding factor 6-positive (GATA6+) peritoneal cavity macrophages. These macrophages provided a haven for S. aureus, thereby delaying the neutrophilic response in the peritoneum by 48 hours and allowing dissemination to various peritoneal and retroperitoneal organs including the kidneys. In mice deficient in GATA6+ peritoneal macrophages, neutrophils infiltrated more robustly and reduced S. aureus dissemination. Antibiotics administered i.v. did not prevent dissemination into the peritoneum or to the kidneys, whereas peritoneal administration of vancomycin (particularly liposomal vancomycin with optimized intracellular penetrance capacity) reduced kidney infection and mortality, even when administered 24 hours after infection. These data indicate that GATA6+ macrophages within the peritoneal cavity are a conduit of dissemination for i.v. S. aureus, and changing the route of antibiotic delivery could provide a more effective treatment for patients with peritonitis-associated bacterial sepsis.
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Affiliation(s)
- Selina K Jorch
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bas Gj Surewaard
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mokarram Hossain
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Moritz Peiseler
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carsten Deppermann
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Deng
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ania Bogoslowski
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fardau van der Wal
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abdelwahab Omri
- Department of Chemistry and Biochemistry, Laurentian University, Sudbury, Ontario, Canada
| | - Michael J Hickey
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Paul Kubes
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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10
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Dasta JF, Kane-Gill S. Review of the Literature on the Costs Associated With Acute Kidney Injury. J Pharm Pract 2020; 32:292-302. [PMID: 31291842 DOI: 10.1177/0897190019852556] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute kidney injury (AKI) develops in 8% to 16% of hospital admissions. These patients exhibit a 4- to 10-fold increase in mortality and prolonged hospital stays. There is a dearth of information on the economics of AKI, especially in critically ill patients whose health-care costs are already high. It is important that pharmacists understand the economic impact of AKI to optimally prevent and treat AKI occurrence, thus reducing total hospital costs. Authors used MEDLINE, PubMed, and Google Scholar searches up to April 2019. Inpatient AKI affects an estimated 498 000 patients in the United States with its annual cost from $4.7 to $24.0 billion. Average patient costs of AKI in the intensive care unit are generally double than those of non-AKI patients. High AKI severity portends a higher cost. Total hospital costs in patients with AKI ranged from $29 700 in cardiac surgery patients to $80 400 in cardiogenic shock. Incremental increases of cost range from $9400 in major surgery patients and up to $81 000 in nonsurviving dialysis patients. The enormity of the clinical and economic impact of AKI should be a call to action by pharmacists to expeditiously select patient-specific therapies to prevent and treat AKI, and thus reduce its economic burden on an already fragile health-care system.
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Affiliation(s)
- Joseph F Dasta
- 1 Division of Practice and Science, The Ohio State University, Columbus, OH, USA
| | - Sandra Kane-Gill
- 2 Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
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