Polypharmacy and medication use in patients with chronic kidney disease with and without kidney replacement therapy compared to matched controls

Comparative Effectiveness of Cinacalcet Taken at-Home Versus Three Times Weekly In-Center on Controlling Calcium, Phosphate, and Parathyroid Hormone Levels

INTRODUCTION

Chronic kidney disease-mineral and bone disorder (CKD-MBD), is a common syndrome in end stage kidney disease (ESKD) patients, is marked by dysregulation of electrolytes and hormones, including calcium, phosphorus and parathyroid hormone (PTH). Calcimemetics are a cornerstone of PTH lowering therapy; cinacalcet, an oral calcimemetic, is the most used and typically prescribed as a daily administration, thus contributing to the high total pill burden of this population. Recent clinical trials have provided evidence that administration of cinacalcet at the dialysis unit three times a week might be a safe and effective treatment option. In this study we sought to evaluate the comparative effectiveness of cinacalcet delivered daily at-home versus three times weekly in-center.

METHODS

This was a retrospective matched cohort study of 2894 adult in-center hemodialysis patients a between January 01, 2008 and September 30, 2022 who were started on cinacalcet for the first time (group 1: at-home use or group 2: in-center administration). Patients were matched (1:1) on: age, body mass index, cinacalcet dose, and baseline phosphorous, calcium, and PTH. Patients were followed until censoring (i.e., lost to follow up) or 12 months after baseline, whichever occurred first. The primary outcome was achieving triple control of PTH, phosphorous, and calcium.

RESULTS

Overall, the patients had a median patient age of 63 (IQR: 55, 71) years, were predominately Black (41.6%) and male (56.5%), and well matched on other baseline clinical and demographic characteristics, including etiology of ESKD. Fitted proportion model results show no statistical difference between the intermittent in-center or daily at home cinacalcet use group in achieving the primary outcome (triple control). The secondary outcomes of control of phosphorous or PTH, showed similar results. Calcium control was the same for 9 of 12 months, and better controlled in the in-center group during the remaining months.

CONCLUSION

In a well-matched cohort, no clinical difference exists between administering cinacalcet thrice weekly in-center and prescribing cinacalcet daily at-home.

Combination therapy as a new standard of care in diabetic and non-diabetic chronic kidney disease

Combination therapy, involving the use of multiple medications together, is becoming a new standard of care for chronic kidney disease (CKD). For people with CKD, combination therapy offers the promise of preventing kidney failure and reducing the risk of heart problems. This approach is appealing because different drugs target distinct mechanisms involved in CKD progression. For instance, some target immune responses, others reduce kidney inflammation and scarring, while others improve blood pressure within the kidneys. Data from large clinical trials suggest that each treatment works effectively on its own, regardless of other medications people are taking. Combining therapies can also reduce the risk of side effects of individual medications. This review highlights the evidence for combination therapy in CKD, explores how to improve its use, and discusses how future studies may answer remaining questions.

ABSTRACT

A range of therapies now exists to reduce the risk of kidney failure and cardiovascular events in people with type 2 diabetes, including renin-angiotensin system blockade, sodium-glucose cotransporter 2 (SGLT2) inhibitors, non-steroidal mineralocorticoid receptor antagonists, and glucagon-like peptide-1 receptor agonists. With multiple clinical trials underway, it is likely that at least some of these therapies-as well as additional agents such as endothelin receptor antagonists-will further demonstrate kidney-protective effects in people with CKD who do not have diabetes in the near future. For conditions such as IgA nephropathy, several therapies have recently been approved or are being evaluated in late phase trials. Thus combination therapy is emerging as a new standard for diabetic and non-diabetic chronic kidney disease (CKD). This approach is supported by randomized data suggesting that each therapeutic class offers independent and additive benefits in diabetic kidney disease, regardless of background therapy. Notably, the reduction in hyperkalaemia and fluid retention with SGLT2 inhibitors may enhance the tolerability and safety of other treatments. In this review, we present the rationale for combination therapy with evidence-based kidney therapies in diabetic and non-diabetic CKD. We also summarize randomized evidence supporting a multi-medicine approach, address safety considerations, review ongoing trials, and propose frameworks for implementing treatments aligned with patient risk to optimize person-centred care and reduce long-term risks of kidney failure and related complications.

Prescribing patterns and medication costs in patients on maintenance haemodialysis and peritoneal dialysis

BACKGROUND

Polypharmacy is a significant clinical issue for patients on dialysis but has been incompletely studied. We investigated the prevalence and costs of polypharmacy in a population-based cohort of participants treated with haemodialysis (HD) or peritoneal dialysis (PD).

METHODS

We studied adults ≥20 years of age in Alberta, Canada receiving maintenance HD or PD as of 31 March 2019. We characterized participants as users of 0-29 drug categories of interest and those ≥65 years of age as users/non-users of potentially inappropriate medications (PIMs). We calculated the number of drug categories, daily pill burden, total annual cost and annual cost per participant and compared this to an age- and sex-matched cohort from the general Alberta population.

RESULTS

Among 2248 participants (mean age 63 years; 39% female) on HD (n = 1781) or PD (n = 467), the median number of prescribed drug categories was 6 [interquartile range (IQR) 4-8] and the median daily pill burden was 8.0 (IQR 4.6-12.6), with 5% prescribed ≥21.7 pills/day and 16.5% prescribed ≥15 pills/day. Twelve percent were prescribed at least one drug that is contraindicated in kidney failure. The median annual per-participant cost was ${\$}$3831, totalling ≈${\$}$11.6 million annually for all participants. When restricting to the 1063 participants ≥65 years of age, the median number of PIM categories was 2 (IQR 1-2), with a median PIM pill burden of 1.2 pills/day (IQR 0.5-2.4). Compared with PD participants, HD participants had a similar daily pill burden, higher use of PIMs and higher annual per-participant cost. Pill burden and associated costs for participants on dialysis were >3-fold and 10-fold higher, respectively, compared with the matched participants from the general population.

CONCLUSION

Participants on dialysis have markedly higher use of prescription medications and associated costs than the general population. Effective methods to de-prescribe in the dialysis population are needed.

The impact of medication regimen complexity on patient-related and clinical outcomes in kidney failure: a systematic review

INTRODUCTION

Kidney failure is a life-limiting condition that profoundly impacts an individual's quality of life. The significant medication burden on patients required to manage the comorbidities and complications of kidney failure can have implications for patient-reported and clinical outcomes.

METHODS

This work systematically reviewed methods used to assess medication regimen complexity amongst adults with kidney failure, the associated patient-reported and clinical outcomes, and the effectiveness of interventions to address regimen complexity. A comprehensive search of PubMed, Embase, Web of Science, and Scopus covering all relevant literature up until November 2023 was performed.

RESULTS

The findings of this review suggest that patients with kidney failure are prescribed complex medication regimens, which have implications for both clinical and patient-related outcomes. A significant link was found between regimen complexity and poor health outcomes, particularly in the dialysis-dependent patient population. These outcomes included poor quality of life, medication adherence, frailty, hospitalization, and mortality. Interventions to improve medication regimen complexity included de-prescribing tools and pharmacist-led medication management services.

CONCLUSION

Future research should consider well-designed prospective longitudinal studies that develop more comprehensive and standardized definitions of medication regimen complexity. Additionally, multifaceted interventions are needed to address the complex medication regimen to improve outcomes in patients with kidney failure.

Recipients of public assistance with advanced chronic kidney disease: insights into receiving a presentation of kidney replacement therapy options and polypharmacy from Japanese investigators with innovative network about kidney disease study

BACKGROUND

The characteristics of patients with advanced chronic kidney disease (CKD) who are recipients of public assistance in Japan, and the adequacy of their medical care have not been reported previously.

METHODS

The records of patients with CKD stage G5 who visited nine facilities in Japan from April to June 2013 were retrospectively reviewed to compare the characteristics and care of recipients of public assistance with those of non-recipients. Receiving a presentation of kidney replacement therapy (KRT) options and polypharmacy were used as indicators of suboptimal medical care.

RESULTS

Of the 592 patients included in this analysis (mean age, 69.6 years; male, 59.3%), 56 (9.5%) were recipients of public assistance and 536 (90.5%) were non-recipients of public assistance. The prevalence of diabetes mellitus, unmarried status, and living alone were higher in recipients of public assistance. In multivariable logistic regression analysis, compared with non-recipients of public assistance, recipients of public assistance were less likely to receive a presentation of KRT options (adjusted odds ratio [aOR], 0.31; 95% confidence interval [CI], 0.17-0.56), and were more likely to receive ≥ 10 (aOR, 1.92; 95% CI, 1.05-3.51), and ≥ 15 (aOR, 2.78; 95% CI, 1.23-6.26) types of medication.

CONCLUSIONS

Patients with advanced CKD receiving public assistance were less likely to receive a presentation of KRT options and more likely to receive ≥ 10 and ≥ 15 types of medication, suggesting that recipients of public assistance are more likely to receive suboptimal medical care.

Medication burden in patients with dialysis-dependent CKD: a systematic review

This systematic review aimed to statistically profile the medication burden and associated influencing factors, and outcomes in patients with dialysis-dependent chronic kidney disease (DD-CKD). Studies of medication burden in patients with DD-CKD in the last 10 years from 1 January 2013 to 31 March 2024 were searched from PubMed, Embase, and Cochrane databases. Newcastle-Ottawa Scale (NOS) or Agency for Healthcare Research and Quality (AHRQ) methodology checklist was used to evaluate quality and bias. Data extraction and combining from multiple groups of number (n), mean, and standard deviation (SD) were performed using R programming language (version4.3.1; R Core Team, Vienna, Austria). A total of 10 studies were included, and the results showed a higher drug burden in patients with DD-CKD. The combined pill burden was 14.57 ± 7.56 per day in hemodialysis (HD) patients and 14.63 ± 6.32 in peritoneal dialysis (PD) patients. The combined number of medications was 9.74 ± 3.37 in HD and 8 ± 3 in PD. Four studies described the various drug classes and their proportions, in general, antihypertensives and phosphate binders were the most commonly used drugs. Five studies mentioned factors associated with medication burden. A total of five studies mentioned medication burden-related outcomes, with one study finding that medication-related burden was associated with increased treatment burden, three studies finding that poor medication adherence was associated with medication burden, and another study finding that medication complexity was not associated with self-reported medication adherence. Limitations: meta-analysis was not possible due to the heterogeneity of studies.

Prescribing patterns in older people with advanced chronic kidney disease towards the end of life

Background

Advancing age and chronic kidney disease (CKD) are risk factors for polypharmacy. Polypharmacy is associated with negative healthcare outcomes. Deprescribing, the systematic rationalization of potentially inappropriate medications, is a proposed way of addressing polypharmacy. The aim of this study was to describe longitudinal prescribing patterns of oral medications in a cohort of older people with advanced CKD in their last years of life.

Methods

The European QUALity (EQUAL) study is a European, prospective cohort study of people ≥65 years with an incident estimated glomerular filtration rate (eGFR) of ≤20 mL/min/1.73 m2. We analysed a decedent subcohort, using generalized additive models to explore trends in the number and types of prescribed oral medications over the years preceding death.

Results

Data from 563 participants were analysed (comprising 2793 study visits) with a median follow-up time of 2.2 years (interquartile range 1.1-3.8) pre-death. Participants' numbers of prescribed oral medications increased steadily over the years approaching death-7.3 (95% confidence interval 6.9-7.7) 5 years pre-death and 8.7 (95% confidence interval 8.4-9.0) at death. Over the years pre-death, the proportion of people prescribed (i) proton-pump inhibitors and opiates increased and (ii) statins, calcium-channel blockers and renin-angiotensin-aldosterone system inhibitors decreased, whilst (iii) beta-blockers, diuretics and gabapentinoids remained stable. At their final visits pre-death 14.6% and 5.1% were prescribed opiates and gabapentinoids, respectively.

Conclusion

Elderly people with advanced CKD experienced persistent and increasing levels of polypharmacy as they approached the end of life. There was evidence of cessation of certain classes of medications, but at a population level this was outweighed by new prescriptions. This work highlights the potential for improved medication review in this setting to reduce the risks associated with polypharmacy. Future work should focus at the individual patient-clinician level to better understand the decision-making process underlying the observed prescribing patterns.

Magnitude of multiple drug use and determinants of vulnerability among chronic kidney disease inpatients in Ethiopia: a multi-center study

BACKGROUND

Patients with chronic kidney disease frequently face various nutritional and metabolic problems that necessitate the use of multiple medications. This multiple drug use can lead to several drug-related problems including adverse drug events, hospital admissions, poor medication adherence, harmful drug interactions, inadequate therapeutic outcomes, and death. Despite these challenges, there is a notable lack of studies on the extent of multiple drug use and its determinants among patients with chronic kidney disease in Ethiopia. This study aims to assess the magnitude of multiple drug use and identify the determinants of vulnerability among patients with chronic kidney disease in Ethiopia.

METHOD

A hospital-based cross-sectional study was conducted among patients with chronic kidney disease. Eligible participants were selected using a simple random sampling technique. Frequency and percentage calculations were performed for categorical variables, while means and standard deviations were used for continuous variables. The chi-square test and t-test were used to compare the proportions and means, respectively. Binary logistic regression was used to identify the determinants of multiple drug use, with statistical significance determined by a p-value of less than 0.05 and a 95% confidence interval. Guidelines and previous literature were utilized to assess the magnitude of multiple drug use.

RESULTS

A total of 230 patients were enrolled, with more than half being male. The overall magnitude of multiple drug use was 83.0%. Diuretics being the most frequently prescribed medication class followed by angiotensin converting enzyme inhibitors. Patients aged 65 years and above (AOR = 4.91 (95% CI 1.60-15.03)), CKD stage five (AOR) = 5.48 (95% CI 1.99-15.09)), and the presence of comorbid conditions (AOR) = 3.53 (95% CI 1.55-8.06)) were significantly associated with multiple drug use.

CONCLUSION

Chronic kidney disease patients exhibited a high rate of multiple drug use. The presence of comorbid conditions, disease progression and older age are significant determinates of this vulnerability. Health care providers should pay particular attention to these factors to manage and mitigate the risks associated with multiple drug use.

Late pregnancy in women with renal transplants: A multidisciplinary guide

Kidney transplant recipients are at risk of complications in late pregnancy, with increased rates of pre-eclampsia, intrauterine growth restriction and preterm birth. It is recommended that these women receive more intensive monitoring after 20 weeks' gestation, ideally provided by a multidisciplinary team in a tertiary centre. This review focuses on the management of late pregnancy in kidney transplant recipients, from the perspective of different members of the multidisciplinary team. This includes evidence and guidance to inform the nephrologist, obstetrician, obstetric anaesthetist, transplant surgeon, midwife, and a summary of the woman's perspective. The review outlines a late pregnancy and early postnatal care pathway as a common algorithm to be used by the whole multidisciplinary team.

Use of drugs with pharmacogenomics (PGx)-based dosing guidelines in a Danish cohort of persons with chronic kidney disease, both on dialysis and not on dialysis: Perspectives for prescribing optimization

AIM

The objective of this registry study is to assess the utilization of pharmacogenomic (PGx) drugs among patients with chronic kidney disease (CKD).

METHODS

This study was a retrospective study of patients affiliated with the Department of Nephrology, Aalborg University Hospital, Denmark in 2021. Patients diagnosed with CKD were divided into CKD without dialysis and CKD with dialysis. PGx prescription drugs were retrieved from the Patient Administration System. Actionable dosing guidelines (AG) for specific drug-gene pairs for CYP2D6, CYP2C9, CYP2C19 and SLCO1B1 were retrieved from the PharmGKB homepage.

RESULTS

Out of 1241 individuals, 25.5% were on dialysis. The median number of medications for each patient was 9 within the non-dialysis group and 16 within the dialysis group. Thirty-one distinct PGx drugs were prescribed. Altogether, 76.0% (943 individuals) were prescribed at least one PGx drug and the prevalence of prescriptions of PGx drugs was higher in the dialysis group compared to the non-dialysis group. The most frequently prescribed drugs with AG were metoprolol, pantoprazole, atorvastatin, simvastatin and warfarin.

CONCLUSION

This study demonstrated that a substantial proportion of patients with CKD are exposed to drugs or drug combinations for which there exists AG related to PGx of CYP2D6, CYP2C19, CYP2C9 and SLCO1B1.

Proton Pump Inhibitors Use in Kidney Transplant Recipients: A Population-Based Study

Background

Kidney transplant recipients are commonly prescribed proton-pump inhibitors (PPIs), but due to concern for polypharmacy, chronic use should be limited.

Objective

The objective was to describe PPI use in kidney transplant recipients beyond their first year of transplant to better inform and support deprescribing initiatives.

Design

We conducted a retrospective, population-based cohort study using linked health care databases.

Setting

This study was conducted in Alberta, Canada.

Patients

We included all prevalent adult, kidney-only transplant recipients between April 2008 and December 2017 who received their transplant between May 2002 and December 2017.

Measurements

The primary outcome was ongoing or new PPI use and patterns of use, including frequency and duration of therapy, and assessment of indication for PPI use.

Methods

We ascertained baseline characteristics, covariate information, and outcome data from the Alberta Kidney Disease Network (AKDN). We compared recipients with evidence of a PPI prescription in the 3 months prior to study entry to those with a histamine-2-receptor antagonist (H2Ra) fill and those with neither.

Results

We identified 1823 kidney transplant recipients, of whom 868 (48%) were on a PPI, 215 (12%) were on an H2Ra, and 740 (41%) were on neither at baseline. Over a median follow-up of 5.4 years (interquartile range [IQR] = 2.6-9.3), there were almost 45 000 unique PPI prescriptions dispensed, the majority (80%) of which were filled by initial PPI users. Recipients who were on a PPI at baseline would spend 91% (IQR = 70-98) of their graft survival time on a PPI in follow-up, and nephrologists were the main prescribers. We identified an indication for ongoing PPI use in 54% of recipients with the most common indication being concurrent antiplatelet use (26%).

Limitations

Our kidney transplant recipients have access to universal health care coverage which may limit generalizability. We identified common gastrointestinal indications for PPI use but did not include rare conditions due to concerns about the validity of diagnostic codes. In addition, symptoms suggestive of reflux may not be well coded as the focus of follow-up visits is more likely to focus on kidney transplant.

Conclusions

Many kidney transplant recipients are prescribed a PPI at, or beyond, the 1-year post-transplant date and are likely to stay on a PPI in follow-up. Almost half of the recipients in our study did not have an identifiable indication for ongoing PPI use. Nephrologists frequently prescribe PPIs to kidney transplant recipients and should be involved in deprescribing initiatives to reduce polypharmacy.

The Effects of Pharmacist-Led Medication Therapy Management on Medication Adherence and Use of Non-Steroidal Anti-Inflammatory Drug in Patients with Pre-End Stage Renal Disease

Purpose

Patients with chronic kidney disease (CKD) are particularly vulnerable to the risks of polypharmacy, largely owing to various comorbid conditions. This vulnerability is further compounded by an escalated risk of renal function deterioration when exposed to nephrotoxic medications. As part of the national health insurance program in Taiwan, the pre-end-stage kidney disease patient care and education plan has included pharmaceutical care since October 2021. This study aims to explore the effect of pharmacist involvement in a multidisciplinary care team for patients with kidney disease in outpatient settings.

Patients and Methods

This retrospective observational study was conducted at a single center. It analyzed data from May 2022 to May 2023, focusing on patients who received medication therapy management in the kidney disease pharmacist-managed clinic. The study assessed changes in patient medication adherence, non-steroidal anti-inflammatory drugs (NSAIDs) usage, CKD stage, and urine protein-to-creatinine ratio (UPCR) after pharmacist intervention. It also documented pharmacists' medication recommendations and the rate of acceptance by physicians.

Results

A total of 202 patients who had at least two clinic visits were included in the study. After pharmacist intervention, the proportion of poor medication adherence reduced significantly from 67.8% to 43.1% (p<0.001). The proportion of NSAID users also decreased significantly from 19.8% to 8.4% (p=0.001). CKD stage showed a significant reduction (p=0.007), and the average UPCR improved from 2828.4 to 2111.0 mg/g (p<0.001). The pharmacists provided a total of 56 medication recommendations, with an acceptance rate of 86%.

Conclusion

The involvement of pharmacists in the multidisciplinary care team can effectively provide medication-related recommendations, ensuring the effectiveness and safety of patients' medication use, and lead to better kidney function and lower proteinuria.

Medication Adherence Among Patients With Kidney Disease: An Umbrella Review

Chronic kidney disease (CKD) imposes a significant medication burden on patients due to the necessity of multiple treatments to slow disease progression, manage coexisting conditions, and address complications. The complex medication regimen, in turn, has implications for clinical and patient-centered outcomes. This umbrella review provides comprehensive evidence on extent of medication nonadherence among adults with CKD, as well as associated risk factors, outcomes, and the effectiveness of interventions by synthesizing evidence from published systematic reviews and/or meta-analyses. We identified 37 works that met our inclusion criteria. These reviews covered various aspects of treatment adherence in people with CKD, which can be categorized into four main themes: (i) prevalence of treatment nonadherence; (ii) factors associated with (non)adherent behaviors; (iii) outcomes associated with treatment (non)adherence; and (iv) interventions to improve treatment adherence or overall self-management practices. Approximately half of the included studies (15/34) focused on interventions aimed at improving medication adherence or overall CKD management, while outcomes associated with medication (non)adherence were relatively underexplored in the literature. The reported prevalence rates of medication nonadherence varied widely among reviews and stages of CKD. The determinants of adherence identified included socioeconomic variables, disease or clinical conditions, and psychosocial factors. Common interventions to improve adherence included nurse-led interventions, pharmaceutical services, and eHealth technologies, which had varying effects on medication adherence or dialysis sessions.

[Polypharmacy in acute and chronic kidney diseases]

The prevalence for chronic kidney disease (CKD) has steadily increased over the past decades. It is a gradually progressive disease that is associated with several comorbidities including cardiovascular diseases, hypertension, anemia, disorders of bone and mineral metabolism, electrolyte imbalance and acid-base abnormalities. All these comorbidities require adequate medication. Therefore, patients with CKD have a high risk for polypharmacy, which is defined as five or more medications daily. Polypharmacy causes a greatly increased risk for adverse drug effects and severe drug-drug interactions, which if not closely controlled and the individual doses adapted to the decreased renal function during the progression of the CKD, can result in increased morbidity and mortality. Therefore, several aspects of the medication need to be considered and constantly addressed. This article summarizes the problems arising from inadequate polypharmacy in CKD patients, including undesired adverse drug effects, drug interactions, the complexity of medication plans, treatment burden and nonadherence to the treatment. Furthermore, the most important steps to identify patients with inadequate polypharmacy are discussed, whereby complications can also be avoided and the benefits of the medication can be increased. Finally, the polypharmacy in acute kidney injury is dealt with.

The association between polypharmacy and health-related quality of life among non-dialysis chronic kidney disease patients

BACKGROUND AND OBJECTIVE

The United States government spends over $85 billion annually on treating non-dialysis chronic kidney disease (CKD). Patients with CKD are prescribed a multitude of medications to manage numerous comorbidities associated with CKD. Thus, this study aims to investigate the association between polypharmacy and health-related quality of life (HRQoL) in non-dialysis CKD patients.

METHODS

This cross-sectional study utilized data from the Medical Expenditure Panel Survey (MEPS) from 2010 through 2019. We classified polypharmacy into three groups based on the number of medication classes: ≤ 4 (minor polypharmacy), 5 through 9 (major polypharmacy), and ≥ 10 (hyperpolypharmacy). To measure HRQoL, a Physical Component Summary (PCS) and a Mental Component Summary (MCS) were obtained from the 12-item Short-Form Health Survey version 2 and Veteran's Rand 12 item. We applied multivariable ordinary least squares regression to assess the association between polypharmacy and HRQoL in non-dialysis CKD patients.

RESULTS

A total of 649 CKD patients (weighted n = 667,989) were included. Patients with minor polypharmacy, major polypharmacy, and hyperpolypharmacy were 22.27%, 48.24%, and 29.48%, respectively. Major polypharmacy and hyperpolypharmacy were significantly and negatively associated with lower PCS scores when compared with minor polypharmacy [Beta = -3.12 (95% CI: -3.62, -2.62), p-value<0.001; Beta = -4.13 (95CI: -4.74, -3.52), p-value<0.001]. Similarly, major polypharmacy and hyperpolypharmacy were significantly and negatively associated with lower MCS scores when compared to minor polypharmacy [Beta = -0.38 (95% CI: -0.55, -0.20), p-value<0.001; Beta = -1.70 (95% CI: -2.01, -1.40), p-value<0.001]. The top 5 classes of medications used by CKD patients were antihyperlipidemic (56.31%), beta-adrenergic blockers (49.71%), antidiabetics (42.14%), analgesics (42.17%), and diuretics (39.65%).

CONCLUSION

Our study found that both major polypharmacy and hyperpolypharmacy were associated with lower HRQoL among non-dialysis CKD patients. This study highlights the need for further evaluation of the combination of medications taken by non-dialysis CKD patients to minimize unnecessary and inappropriate medication use.

Trends and perspectives for improving quality of chronic kidney disease care: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Chronic kidney disease (CKD) affects over 850 million people globally, and the need to prevent its development and progression is urgent. During the past decade, new perspectives have arisen related to the quality and precision of care for CKD, owing to the development of new tools and interventions for CKD diagnosis and management. New biomarkers, imaging methods, artificial intelligence techniques, and approaches to organizing and delivering healthcare may help clinicians recognize CKD, determine its etiology, assess the dominant mechanisms at given time points, and identify patients at high risk for progression or related events. As opportunities to apply the concepts of precision medicine for CKD identification and management continue to be developed, an ongoing discussion of the potential implications for care delivery is required. The 2022 KDIGO Controversies Conference on Improving CKD Quality of Care: Trends and Perspectives examined and discussed best practices for improving the precision of CKD diagnosis and prognosis, managing the complications of CKD, enhancing the safety of care, and maximizing patient quality of life. Existing tools and interventions currently available for the diagnosis and treatment of CKD were identified, with discussion of current barriers to their implementation and strategies for improving the quality of care delivered for CKD. Key knowledge gaps and areas for research were also identified.

Phenotypes of Symptom, Function, and Medication Burden in Older Adults with Nondialysis Advanced Kidney Disease

Key Points

There are three distinct classes of symptoms, functional impairment, and medication burden among older adults with advanced kidney disease. One class with Complex Needs with pain and psychological symptoms, functional difficulties, and polypharmacy may benefit from tailored multidisciplinary care.

Background

Older adults with advanced CKD (stages 4 and 5) have significant symptoms, polypharmacy, and functional difficulties, and previous studies evaluated these burdens separately. Identifying subgroups with similar patterns of burdens could help clinicians optimize care for these individuals.

Methods

We conducted a secondary analysis of 377 older participants (70 years and older) with stage 4 and 5 CKD at high risk of hospitalization enrolled in a national Veterans Affairs prospective cohort study. Adults on dialysis or with prior kidney transplant were excluded. We used latent class analysis to identify participants with similar patterns across symptoms, medication burden, and function. Sixteen variables were included: symptoms (anxiety, depression, appetite, pain, shortness of breath, fatigue, dizziness, leg weakness, constipation, and stiffness using the Symptom Burden Score), polypharmacy (≥10 medications and potentially inappropriate medications), and function (activities of daily living [ADLs], physical and cognitive instrumental ADLs [IADLs], and falls in the past year). We also compared 12-month hospitalization and mortality rates between the three classes.

Results

Three classes of participants with similar functional impairment, medication burden, and symptom phenotypes were identified. The largest participant class (N =208) primarily had difficulties with physical IADLs and polypharmacy. The second participant class (N =99) had shortness of breath, constipation, and dizziness. The third participant class (N =70) had complex needs with daily pain, psychological symptoms (anxiety and depression), functional limitations (ADLs and physical and cognitive IADLs), and polypharmacy. The three classes had significantly different levels of comorbidities, financial stress, and social support. There were no significant differences in mortality and hospitalization among the three classes.

Conclusion

There are distinct classes of older adults with advanced CKD who have physical and psychological symptoms, functional impairment, and medication burden. Tailoring care for this population should include a multidisciplinary team to address these overlapping symptoms, medication, and functional needs.

The Value of Pharmacogenomics for White and Indigenous Americans after Kidney Transplantation

BACKGROUND

There is a paucity of evidence to inform the value of pharmacogenomic (PGx) results in patients after kidney transplant and how these results differ between Indigenous Americans and Whites. This study aims to identify the frequency of recommended medication changes based on PGx results and compare the pharmacogenomic (PGx) results and patients' perceptions of the findings between a cohort of Indigenous American and White kidney transplant recipients.

METHODS

Thirty-one Indigenous Americans and fifty White kidney transplant recipients were studied prospectively. Genetic variants were identified using the OneOme RightMed PGx test of 27 genes. PGx pharmacist generated a report of the genetic variation and recommended changes. Pre- and post-qualitative patient surveys were obtained.

RESULTS

White and Indigenous American subjects had a similar mean number of medications at the time of PGx testing (mean 13 (SD 4.5)). In the entire cohort, 53% received beta blockers, 30% received antidepressants, 16% anticoagulation, 47% pain medication, and 25% statin therapy. Drug-gene interactions that warranted a clinical action were present in 21.5% of patients. In 12.7%, monitoring was recommended. Compared to the Whites, the Indigenous American patients had more normal CYP2C19 (p = 0.012) and CYP2D6 (p = 0.012) activities. The Indigenous American patients had more normal CYP4F2 (p = 0.004) and lower VKORC (p = 0.041) activities, phenotypes for warfarin drug dosing, and efficacy compared to the Whites. SLC6A4, which affects antidepressant metabolism, showed statistical differences between the two cohorts (p = 0.017); specifically, SLC6A4 had reduced expression in 45% of the Indigenous American patients compared to 20% of the White patients. There was no significant difference in patient perception before and after PGx.

CONCLUSIONS

Kidney transplant recipients had several drug-gene interactions that were clinically actionable; over one-third of patients were likely to benefit from changes in medications or drug doses based on the PGx results. The Indigenous American patients differed in the expression of drug-metabolizing enzymes and drug transporters from the White patients.

Association of Potentially Inappropriate Medication Classes with Mortality Risk Among Older Adults Initiating Hemodialysis

BACKGROUND AND OBJECTIVE

Older adults initiating dialysis have a high risk of mortality and that risk may be related to potentially inappropriate medications (PIMs). Our objective was to identify and validate mortality risk associated with American Geriatrics Society Beers Criteria PIM classes and concomitant PIM use.

METHODS

We used US Renal Data System data to establish a cohort of adults aged ≥ 65 years initiating dialysis (2013-2014) and had no PIM prescriptions in the 6 months prior to dialysis initiation. In a development cohort (40% sample), adjusted Cox proportional hazards models were performed to determine which of 30 PIM classes were associated with mortality (or "high-risk" PIMs). Adjusted Cox models were performed to assess the association of the number of "high-risk" PIM fills/month with mortality. All models were repeated in the validation cohort (60% sample).

RESULTS

In the development cohort (n = 15,570), only 13 of 30 PIM classes were associated with a higher mortality risk. Compared with those with no "high-risk" PIM fills/month, patients having one "high-risk" PIM fill/month had a 1.29-fold (95% confidence interval 1.21-1.38) increased risk of death; those with two or more "high-risk" PIM fills/month had a 1.40-fold (95% confidence interval 1.24-1.58) increased risk. These findings were similar in the validation cohort (n = 23,569).

CONCLUSIONS

Only a minority of Beers Criteria PIM classes may be associated with mortality in the older dialysis population; however, mortality risk increases with concomitant use of "high-risk" PIMs. Additional studies are needed to confirm these associations and their underlying mechanisms.

Polypharmacy in US Medicare beneficiaries with antineutrophil cytoplasmic antibody vasculitis

BACKGROUND: Treatment requirements of antineutrophil cytoplasmic autoantibody vasculitis (AV) and high comorbidity burden among patients with AV may lead to higher potential for polypharmacy and its associated adverse outcomes, including adverse drug events, nonadherence, drug-drug interactions, and higher costs. Medication burden and risk factors associated with polypharmacy in patients with AV have not been well-characterized. OBJECTIVE: To characterize medication burden and examine prevalence of and risk factors for polypharmacy in the first year after diagnosis with AV. METHODS: We conducted a retrospective cohort study using 2015-2017 Medicare claims to identify incident cases of AV. We counted the number of unique generic products dispensed to patients in each of the 4 quarters after diagnosis and categorized medication count as high (≥10 medications), moderate (5-9 medications), or minimal or no polypharmacy (<5 medications). We used multinomial logistic regression to examine associations of predisposing, enabling, and medical need factors with having high or moderate polypharmacy. RESULTS: In 1,239 Medicare beneficiaries with AV, high or moderate polypharmacy was most common in the first quarter after diagnosis (83.7%), with 43.2% taking 5 - 9 medications and 40.5% taking at least 10. The odds of high polypharmacy were greater in all quarters for patients with eosinophilic granulomatosis with polyangiitis compared with granulomatosis with polyangiitis, ranging from 2.02 (95% CI = 1.18 - 3.46) in the third quarter to 2.96 (95% CI = 1.64-5.33) in the second quarter. Older age, diabetes, chronic kidney disease, obesity, a higher Charlson Comorbidity Index score, coverage with Medicaid/Part D low-income subsidy, and living in areas with low education or persistent poverty were risk factors for high or moderate polypharmacy. CONCLUSIONS: Medicare beneficiaries with newly diagnosed AV experienced a high medication burden, with more than 40% taking at least 10 medications and the highest rates among those with eosinophilic granulomatosis with polyangiitis. Patients with AV may benefit from medication therapy management interventions to manage complex drug regimens and reduce risks associated with polypharmacy. DISCLOSURES: Dr Derebail receives personal fees from Travere Therapeutics, Pfizer, Bayer, Forma Therapeutics, UpToDate, outside of the submitted work. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health or the Department of Veterans Affairs. Dr Thorpe receives royalties from SAGE Publishing for activities unrelated to the submitted work. This research is supported by internal funds from the University of North Carolina, as well as the National Institute of Allergy and Infectious Diseases of the National Institutes of Health under award number R21AI160606 (PI: C. Thorpe).

Pill-Burden and its Association with Treatment Burden among Patients with Advanced Stages of Chronic Kidney Disease

Introduction

Chronic kidney disease (CKD) is associated with multimorbidity and high treatment burden. Pill-burden is one component of the overall treatment burden. However, little is known about its magnitude and contribution to the overall treatment burden among patients with advanced stages of CKD. This study aimed to quantify the magnitude of pill-burden in dialysis-dependent vs. non-dialysis-dependent advanced-stage CKD patients and its association with treatment burden.

Methods

This was a cross-sectional study for the assessment of pill-burden and treatment burden among non-dialysis and hemodialysis (HD)-dependent CKD patients. Pill-burden was quantified as "number of pills/patient/week" through electronic medical record, while treatment burden was assessed using the "Treatment Burden Questionnaire (TBQ)". Furthermore, oral and parenteral medication burden was also quantified. Data were analyzed using both descriptive and inferential analysis, including Mann - Whitney U test and two-way between groups analysis of variance (ANOVA).

Results

Among the 280 patients included in the analysis, the median (IQR) number of prescribed chronic medications was 12 (5.7) oral and 3 (2) parenteral medications. The median (IQR) pill-burden was 112 (55) pills/week. HD patients experienced higher pill-burden than non-dialysis patients [122 (61) vs. 109 (33) pills/week]; however, this difference did not reach statistical significance (p = 0.81). The most commonly prescribed oral medications were vitamin D (90.4%), sevelamer carbonate (65%), cinacalcet (67.5%), and statins (67.1%). Overall, patients who had high pill-burden (≥112 pills/week) had significantly higher perceived treatment burden compared to low pill-burden patients (<112 pills/week) [47(36.2) vs. 38.5(36.7); p = 0.0085]. However, two-way ANOVA showed that dialysis status is the significant contributor to the treatment-burden in the high overall pill-burden group (p < 0.01), the high oral-medication-burden group (p < 0.01), and the high parenteral-medication-burden group (p = 0.004).

Conclusions

Patients with advanced CKD experienced a high pill-burden, which increases the treatment burden; however, the dialysis status of the patient is the main factor affecting the overall treatment burden. Future intervention studies should target this population with an aim to reduce polypharmacy, pill-burden, and treatment burden, which may ultimately improve CKD patients' quality of life.

Decreasing microbiota-derived uremic toxins to improve CKD outcomes

Chronic kidney disease (CKD) is set to become the fifth-leading global cause of death by 2040. This illustrates the many unknowns regarding its pathogenesis and therapy. A key unknown relates to the therapeutic impact of the interaction between CKD and the gut microbiome. The normal gut microbiome is essential for body homeostasis. There is evidence for multiple interactions between the microbiota and CKD—its causes, comorbidities and therapeutic interventions—that are only starting to be unraveled. Thus uremic retention products, such as urea itself, modify the gut microbiota biology and both dietary and drug prescriptions modify the composition and function of the microbiota. Conversely, the microbiota may influence the progression and manifestations of CKD through the production of biologically active compounds (e.g. short-chain fatty acids such as butyrate and crotonate) and precursors of uremic toxins. The present review addresses these issues and their relevance for novel therapeutic approaches ranging from dietary interventions to prebiotics, probiotics, synbiotics and postbiotics, to the prevention of the absorption of microbial metabolites and to increased clearance of uremic toxins of bacterial origin through optimized dialysis techniques or blockade of tubular cell transporters.

Polypharmacy Predicts Onset and Transition of Frailty, Malnutrition, and Adverse Outcomes in Peritoneal Dialysis Patient

BACKGROUND

Polypharmacy, frailty and malnutrition are known predictors of adverse outcomes in dialysis patients. Little has reported about their interaction and composite prognostic values. We aimed to describe the interaction between polypharmacy, frailty, nutrition, hospitalization, and survival in peritoneal dialysis patients.

METHODS

In this prospective cohort study, we recruited 573 peritoneal dialysis patients. Drug burden was measured by medication number and daily pill load. Frailty and nutrition were assessed by the validated Frailty Score (FQ) and Subjective Global Assessment (SGA) respectively. All patients were followed for two years. Primary outcome was all-cause mortality. Secondary outcomes were fall and fracture episodes, hospitalization, change in FQ and SGA.

RESULTS

At baseline, each patient took 7.5 ± 2.6 medications with 15.5 ± 8.5 tablets per day. Medication number, but not daily pill load predicted baseline FQ (p = 0.004) and SGA (p = 0.03). Over 2 years, there were 69 fall and 1,606 hospitalization episodes. In addition, 148 (25.8%) patients died, while FQ and SGA changed by 0.73 ± 4.23 and -0.07 ± 1.06 respectively in survivors. Medication number (hospitalization: p = 0.02, survival: p = 0.005), FQ (hospitalization: p < 0.001; survival: p = 0.01) predicted hospitalization and survival. Medication number also predicted fall episodes (p = 0.02) and frailty progression (p = 0.002). Daily pill load did not predict any of these outcomes.

CONCLUSIONS

Drug burden is high in peritoneal dialysis patients, and it carries important prognostic implication. Medication number but not pill load significantly predicted onset and progression of frailty, malnutrition, fall, hospitalization, and mortality.

Chronic prescription of antidepressant medication in patients with chronic kidney disease with and without kidney replacement therapy compared with matched controls in the Dutch general population

Background

Chronic kidney disease (CKD) is associated with a higher prevalence of depression, neuropathic pain and insomnia. These conditions are often treated pharmaceutically. In this study we aimed to determine the prevalence of chronic antidepressant use among CKD patients with and without kidney replacement therapy (KRT).

Methods

By using the Dutch health claims database, we were able to determine the prevalence, type and dosage of chronic antidepressant prescriptions in patients with CKD Stage G4/G5 without KRT (n = 14 905), patients on dialysis (n = 3872) and patients living on a functioning graft (n = 8796) and compared these to age-, sex- and socio-economic status (SES)-matched controls from the general population.

Results

Our data show that the prevalence of chronic antidepressant prescription is 5.6%, 5.3% and 4.2% in CKD Stage G4/G5, dialysis and kidney transplant patients, respectively, which is significantly higher than in matched controls. Although our data revealed more prescriptions in female patients and in the age category 45–64 years, our data did not show any association between antidepressant prescriptions and SES. Selective serotonin reuptake inhibitors were the most prescribed drugs in all patient groups and controls. Tricyclic antidepressants were more often used in patients compared with controls.

Conclusion

This nationwide analysis revealed that chronic antidepressant prescription in the Netherlands is higher in CKD patients with and without KRT than in controls, higher in middle-aged patients and women, unrelated to socio-economic status and lower than chronic use reported in other countries.