Pharmaceutical care program for patients with chronic kidney disease in the community pharmacy: Detection of nephrotoxic drugs and dose adjustment. Viability study

Point-of-Care Testing Glucometer in Rapid Assessment Settings: Comparison of 2 Network-Capable Devices in a Referral Hospital

BACKGROUND

Point-of-care testing (POCT) glucose meters are essential for rapid glucose monitoring. This study aimed to evaluate the analytical performance of 2 novel network-capable POCT glucometers, CobasPulse (Roche Diagnostic) and StatStrip (Nova Biomedical), in comparison to the Atellica CH 930 Analyzer (Siemens Healthcare), a central laboratory clinical chemistry analyzer, as a reference method.

METHODS

A cohort of 150 patients' venous whole blood samples were analyzed. Method comparison was performed using Passing-Bablok regression and Bland-Altman plots. Precision studies were conducted using commercial controls, with assessment of within-run and between-run imprecision by experienced laboratory technicians. Performance was assessed against FDA 2020 benchmarks.

RESULTS

Passing-Bablok regression showed accurate overlap for both POCT devices. CobasPulse exhibited a bias of -0.17 mmol/L and Pearson r of 0.982, while StatStrip showed a bias of -0.35 mmol/L and Pearson r of 0.959. Within-run CV for Cobas Pulse (3.3 mmol/L control) was 2.4%, and for StatStrip (3.44 mmol/L control) was 5.2%. Between-run CVs were 2.1% for Cobas Pulse and 3.2% for StatStrip at comparable glucose concentrations.

CONCLUSIONS

Both CobasPulse and StatStrip demonstrated acceptable concordance with the Atellica CH 930 Analyzer. While Cobas Pulse showed slightly better agreement and precision, both devices are suitable for glucose measurements in healthcare settings, providing reliable results and reduced turnaround time, supporting timely clinical decisions for rapid glycemic assessment.

Risk Factor-Based Screening for Early Detection of Chronic Kidney Disease in Primary Care Settings: A Systematic Review

Rationale & Objective

Kidney failure can be prevented or delayed if chronic kidney disease (CKD) is detected and treated early. Targeted screening has been shown effective in detecting CKD worldwide, but a recently updated summary of evidence is lacking. We synthesized up-to-date evidence of the effectiveness of risk factor-based screening for the early detection of CKD among adults in primary care.

Study Design

We retrieved articles from Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Scopus. Relevant gray literature and hand-searching bibliographies of key articles were also performed.

Setting & Study Populations

Adult patients (age ≥ 18 years) with at least 1 known CKD risk factor in primary care.

Selection Criteria for Studies

Prospective studies applying CKD screening in adults based on at least 1 CKD risk factor.

Data Extraction

Data were abstracted from full texts and the risk of bias was assessed using the Joanna Briggs Institute critical appraisal tools.

Analytical Approach

No meta-analysis was conducted.

Results

In total, 24 studies from 11 countries fulfilled the inclusion criteria. Diverse screening tests, CKD definitions, formulas for estimating kidney function, and positive screening test cutoffs were used. Most studies (n = 22) employed estimated glomerular filtration rate (eGFR), albumin-creatinine ratio (ACR) (n = 14), and dipstick urinalysis (n = 9) for screening. The prevalence of reduced kidney function and/or kidney damage was between 2.9% and 56%, and confirmed CKD varied from 4.4% to 17.1%. Increased patient referrals and physician visits, higher patient satisfaction, and some form of patient willingness to pay for the services were reported because of screening.

Limitations

Meta-analysis was not conducted, and the findings might not be generalized to resource-limited settings.

Conclusions

Risk factor-based screening effectively identifies a substantial proportion of people with undiagnosed CKD, but there is still scope for improvement. We recommend future studies have robust designs and multidimensional interventions to establish the effectiveness of targeted CKD screening in primary care.

Medications for community pharmacists to dose adjust or avoid to enhance prescribing safety in individuals with advanced chronic kidney disease: a scoping review and modified Delphi

BACKGROUND

Community pharmacists commonly see individuals with chronic kidney disease (CKD) and are in an ideal position to mitigate harm from inappropriate prescribing. We sought to develop a relevant medication list for community pharmacists to dose adjust or avoid in individuals with an estimated glomerular filtration rate (eGFR) below 30 mL/min informed through a scoping review and modified Delphi panel of nephrology, geriatric and primary care pharmacists.

METHODS

A scoping review was undertaken to identify higher risk medications common to community pharmacy practice, which require a dose adaptation in individuals with advanced CKD. A 3-round modified Delphi was conducted, informed by the medications identified in our scoping review, to establish consensus on which medications community pharmacists should adjust or avoid in individuals with stage 4 and 5 CKD (non-dialysis).

RESULTS

Ninety-two articles and 88 medications were identified from our scoping review. Of which, 64 were deemed relevant to community pharmacy practice and presented for consideration to 27 panel experts. The panel consisted of Canadian pharmacists practicing in nephrology (66.7%), geriatrics (18.5%) and primary care (14.8%). All participants completed rounds 1 and 2 and 96% completed round 3. At the end of round 3, the top 40 medications to adjust or avoid were identified. All round 3 participants selected metformin, gabapentin, pregabalin, non-steroidal anti-inflammatory drugs, nitrofurantoin, ciprofloxacin and rivaroxaban as the top ranked medications.

CONCLUSION

Medications eliminated by the kidneys may accumulate and cause harm in individuals with advanced chronic kidney disease. This study provides an expert consensus of the top 40 medications that community pharmacists should collaboratively adjust or avoid to enhance medication safety and prescribing for individuals with an eGFR below 30 mL/min.

[Screening for Chronic Kidney Disease in the Community Pharmacy. CRIERFAC Study: Description of the Methodology]

Abstract

Chronic kidney disease (CKD) is the existence of abnormalities in renal structure or function with an impact on health. This is usually considered when estimated glomerular filtration (eGF) falls under 60 mL/min/1.73m2. Its clinical course leads to renal replacement therapy (dialysis or transplant) when eGF falls under 15 mL/min/1.73m2. Screening in at risk populations has been proven to be cost-effective. The aim of this work is to perform CKD screening in the community pharmacy. In this publication we report and justify the methodology in detail.

Methodology

Pharmacists from the community pharmacies taking part selected patients who complied with inclusion and not exclusion criteria. Creatinine was measured by means of a finger prick and eGF calculated with the formula CKD-EPI. If this is lower than a set value, which depends on age, referral to the general practitioner takes place.

Results

A total of 141 out of 200 pharmacies took part in the study. In all 2116 patients were recruited and 116 patients were lost. The final sample size was 2000 patients.

Discussion

The protocol was successfully implemented by community pharmacists and was extremely well received by community pharmacy users. The age adjustment for eGF thresholds provides a novel additional filter. The aim is not to overburden primary care centres with potential referrals of false positives. Confirmation of the diagnosis is subject to voluntary communication by the patient to the pharmacist.

Fibrosis in Chronic Kidney Disease: Pathophysiology and Therapeutic Targets

Chronic kidney disease (CKD) is a slowly progressive condition characterized by decreased kidney function, tubular injury, oxidative stress, and inflammation. CKD is a leading global health burden that is asymptomatic in early stages but can ultimately cause kidney failure. Its etiology is complex and involves dysregulated signaling pathways that lead to fibrosis. Transforming growth factor (TGF)-β is a central mediator in promoting transdifferentiation of polarized renal tubular epithelial cells into mesenchymal cells, resulting in irreversible kidney injury. While current therapies are limited, the search for more effective diagnostic and treatment modalities is intensive. Although biopsy with histology is the most accurate method of diagnosis and staging, imaging techniques such as diffusion-weighted magnetic resonance imaging and shear wave elastography ultrasound are less invasive ways to stage fibrosis. Current therapies such as renin-angiotensin blockers, mineralocorticoid receptor antagonists, and sodium/glucose cotransporter 2 inhibitors aim to delay progression. Newer antifibrotic agents that suppress the downstream inflammatory mediators involved in the fibrotic process are in clinical trials, and potential therapeutic targets that interfere with TGF-β signaling are being explored. Small interfering RNAs and stem cell-based therapeutics are also being evaluated. Further research and clinical studies are necessary in order to avoid dialysis and kidney transplantation.

Impact of a pharmacy-led screening and intervention in people at risk of or living with chronic kidney disease in a primary care setting: a cluster randomised trial protocol

INTRODUCTION

Chronic kidney disease (CKD) is increasingly recognised as a growing global public health problem. Early detection and management can significantly reduce the loss of kidney function. The proposed trial aims to evaluate the impact of a community pharmacy-led intervention combining CKD screening and medication review on CKD detection and quality use of medicines (QUM) for patients with CKD. We hypothesise that the proposed intervention will enhance detection of newly diagnosed CKD cases and reduce potentially inappropriate medications use by people at risk of or living with CKD.

METHODS AND ANALYSIS

This study is a multicentre, pragmatic, two-level cluster randomised controlled trial which will be conducted across different regions in Australia. Clusters of community pharmacies from geographical groups of co-located postcodes will be randomised. The project will be conducted in 122 community pharmacies distributed across metropolitan and rural areas. The trial consists of two arms: (1) Control Group: a risk assessment using the QKidney CKD risk assessment tool, and (2) Intervention Group: a risk assessment using the QKidney CKD plus Point-of-Care Testing for kidney function markers (serum creatinine and estimated glomerular filtration rate), followed by a QUM service. The primary outcomes of the study are the proportion of patients newly diagnosed with CKD at the end of the study period (12 months); and rates of changes in the number of medications considered problematic in kidney disease (number of medications prescribed at inappropriate doses based on kidney function and/or number of nephrotoxic medications) over the same period. Secondary outcomes include proportion of people on potentially inappropriate medications, types of recommendations provided by the pharmacist (and acceptance rate by general practitioners), proportion of people who were screened, referred, and took up the referral to visit their general practitioners, and economic and other patient-centred outcomes.

ETHICS AND DISSEMINATION

The trial protocol has been approved by the Human Research Ethics Committee at the University of Sydney (2022/044) and the findings of the study will be presented at scientific conferences and published in peer-reviewed journal(s).

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12622000329763).

[Detection of nephrotoxics and dose adjustment in patients with low glomerular filtration rate in community pharmacy: methodology]

Abstract

Chronic kidney disease is a prevalent problem without specific treatment. Early detection is important and estimated glomerular filtration rate (eGFR) is a very affordable test that can be performed in community pharmacies. If present, it is very important not to further damage the kidney by avoiding the use of nephrotoxic drugs and adjusting the doses of other renal elimination drugs and the community pharmacy is very well positioned to do this.

Objective

To describe the methodology used to detect nephrotoxic drugs and adjust doses of other drugs in community pharmacies for subsequent referral to primary care.

Method

Multicentre experimental multicentre uncontrolled follow-up study carried out in community pharmacies in 4 autonomous communities in Spain. Patients who met the inclusion criteria and signed the informed consent form were included. Those with eGFR <60 ml/min/1.73m2 were studied and their medication was analysed using the BOT Plus and 4 other sources of information.

Result

670 patients were included, 215 of them with eGFR<60ml/min/1.73m2. Of these 90 (41.9%) needed some type of adjustment in the pharmacist's judgement. Of these 90, 43.3% (39) had some kind of change after the pharmacist's intervention.

Conclusion

In patients with low glomerular filtration rate, with the appropriate methodology, the community pharmacist is able to detect the use of nephrotoxic drugs or the use of drugs at doses higher than those recommended according to their renal status.