1
|
Kaplan HC, Goldstein SL, Rubinson C, Daraiseh N, Zhang F, Rodgers IM, Dahale DS, Askenazi DJ, Somers MJG, Zaritsky JJ, Misurac J, Chadha V, Yonekawa KE, Sutherland SM, Weng PL, Walsh KE. Prospective Study of the Multisite Spread of a Medication Safety Intervention: Factors Common to Hospitals With Improved Outcomes. Am J Med Qual 2024; 39:21-32. [PMID: 38127682 DOI: 10.1097/jmq.0000000000000161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Context and implementation approaches can impede the spread of patient safety interventions. The objective of this article is to characterize factors associated with improved outcomes among 9 hospitals implementing a medication safety intervention. Nephrotoxic Injury Negated by Just-in-Time Action (NINJA) is a pharmacist-driven intervention that led to a sustained reduction in nephrotoxic medication-associated acute kidney injury (NTMx-AKI) at 1 hospital. Using qualitative comparative analysis, the team prospectively assessed the association between context and implementation factors and NTMx-AKI reduction during NINJA spread to 9 hospitals. Five hospitals reduced NTMx-AKI. These 5 had either (1) a pharmacist champion and >2 pharmacists working on NINJA (Scon 1.0, Scov 0.8) or (2) a nephrologist-implementing NINJA with minimal competing organizational priorities (Scon 1.0, Scov 0.2). Interviews identified ways NINJA team leaders obtained pharmacist support or successfully implemented without that support. In conclusion, these findings have implications for future spread of NINJA and suggest an approach to study spread of safety interventions more broadly.
Collapse
Affiliation(s)
- Heather C Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Claude Rubinson
- Department of Social Sciences, University of Houston-Downtown, Houston, TX
| | - Nancy Daraiseh
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Fang Zhang
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | | | - Devesh S Dahale
- Operational Effectiveness Department, Southeast Health, Dothan, AL
| | - David J Askenazi
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Jason Misurac
- Department of Pediatrics, University of Iowa, Stead Family Children's Hospital, Iowa City, IA
| | - Vimal Chadha
- Division of Nephrology, Children's Mercy Hospital, Kansas City, MO
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Karyn E Yonekawa
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA
| | - Scott M Sutherland
- Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
- Division of Nephrology, Lucille Packard Stanford Children's Hospital, Palo Alto, CA
| | - Patricia L Weng
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, CA
| | - Kathleen E Walsh
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA
- Department of General Pediatrics, Harvard Medical School, Boston, MA
| |
Collapse
|
2
|
Sun H, Weidner J, Allamargot C, Piper RC, Misurac J, Nester C. Dynein-Mediated Trafficking: A New Mechanism of Diabetic Podocytopathy. Kidney360 2023; 4:162-176. [PMID: 36821608 PMCID: PMC10103215 DOI: 10.34067/kid.0006852022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
Key Points The expression of dynein is increased in human and rodent models of diabetic nephropathy (DN), eliciting a new dynein-driven pathogenesis. Uncontrolled dynein impairs the molecular sieve of kidney by remodeling the postendocytic triage and homeostasis of nephrin. The delineation of the dynein-driven pathogenesis promises a broad spectrum of new therapeutic targets for human DN. Background Diabetic nephropathy (DN) is characterized by increased endocytosis and degradation of nephrin, a protein that comprises the molecular sieve of the glomerular filtration barrier. While nephrin internalization has been found activated in diabetes-stressed podocytes, the postinternalization trafficking steps that lead to the eventual depletion of nephrin and the development of DN are unclear. Our work on an inherited podocytopathy uncovered that dysregulated dynein could compromise nephrin trafficking, leading us to test whether and how dynein mediates the pathogenesis of DN. Methods We analyzed the transcription of dynein components in public DN databases, using the Nephroseq platform. We verified altered dynein transcription in diabetic podocytopathy by quantitative PCR. Dynein-mediated trafficking and degradation of nephrin was investigated using an in vitro nephrin trafficking model and was demonstrated in a mouse model with streptozotocin (STZ)-induced DN and in human kidney biopsy sections. Results Our transcription analysis revealed increased expression of dynein in human DN and diabetic mouse kidney, correlated significantly with the severity of hyperglycemia and DN. In diabetic podocytopathy, we observed that dynein-mediated postendocytic sorting of nephrin was upregulated, resulting in accelerated nephrin degradation and disrupted nephrin recycling. In hyperglycemia-stressed podocytes, Dynll1 , one of the most upregulated dynein components, is required for the recruitment of dynein complex that mediates the postendocytic sorting of nephrin. This was corroborated by observing enhanced Dynll1-nephrin colocalization in podocytes of diabetic patients, as well as dynein-mediated trafficking and degradation of nephrin in STZ-induced diabetic mice with hyperglycemia. Knockdown of Dynll1 attenuated lysosomal degradation of nephrin and promoted its recycling, suggesting the essential role of Dynll1 in dynein-mediated mistrafficking. Conclusions Our studies show that hyperglycemia stimulates dynein-mediated trafficking of nephrin to lysosomes by inducing its expression. The decoding of dynein-driven pathogenesis of diabetic podocytopathy offers a spectrum of new dynein-related therapeutic targets for DN.
Collapse
Affiliation(s)
- Hua Sun
- Division of Nephrology, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, Iowa
- Carver College of Medicine, The University of Iowa, Iowa City, Iowa
| | - Jillian Weidner
- Division of Nephrology, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, Iowa
- Carver College of Medicine, The University of Iowa, Iowa City, Iowa
| | - Chantal Allamargot
- Central Microscopy Research Facility, The University of Iowa, Iowa City, Iowa
| | - Robert C. Piper
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, The University of Iowa, Iowa City, Iowa
| | - Jason Misurac
- Division of Nephrology, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, Iowa
- Carver College of Medicine, The University of Iowa, Iowa City, Iowa
| | - Carla Nester
- Division of Nephrology, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, Iowa
- Carver College of Medicine, The University of Iowa, Iowa City, Iowa
| |
Collapse
|
3
|
Griffin BR, Wendt L, Vaughan-Sarrazin M, Hounkponou H, Reisinger HS, Goldstein SL, Jalal D, Misurac J. Nephrotoxin Exposure and Acute Kidney Injury in Adults. Clin J Am Soc Nephrol 2023; 18:163-172. [PMID: 36754005 PMCID: PMC10103278 DOI: 10.2215/cjn.0000000000000044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/30/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Rates of nephrotoxic AKI are not well described in adults due to lack of a clear definition, debate over which drugs should be considered nephrotoxins, and illness-related confounding. Nephrotoxic Injury Negated by Just-in Time Action (NINJA), a program that reduces rates of nephrotoxic AKI in pediatric populations, may be able to address these concerns, but whether NINJA can be effectively applied to adults remains unclear. METHODS In this retrospective cohort study conducted at the University of Iowa Hospital, we included adult patients admitted to a general hospital floor for ≥48 hours during 2019. The NINJA algorithm screened charts for high nephrotoxin exposure and AKI. After propensity score matching, Cox proportional hazard modeling was used to evaluate the relationship between nephrotoxic exposure and all-stage AKI, stage 2-3 AKI, or death. Additional analyses evaluated the most frequent nephrotoxins used in this population. RESULTS Of 11,311 patients, 1527 (16%) had ≥1 day of high nephrotoxin exposure. Patients with nephrotoxic exposures subsequently developed AKI in 29% of cases, and 22% of all inpatient AKI events met nephrotoxic AKI criteria. Common nephrotoxins were vancomycin, iodinated contrast dye, piperacillin-tazobactam, acyclovir, and lisinopril. After propensity score matching, Cox proportional hazard models for high nephrotoxin exposure were significantly associated with all AKI (hazard ratio [HR] 1.43, 1.19-1.72, P<0.001), stage 2-3 AKI (HR 1.78, 1.18-2.67, P=0.006), and mortality (HR 2.12, 1.09-4.11, P=0.03). CONCLUSIONS Nephrotoxin exposure in adults is common and is significantly associated with AKI development, including stage 2-3 AKI.
Collapse
Affiliation(s)
- Benjamin R Griffin
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
| | - Linder Wendt
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Mary Vaughan-Sarrazin
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
| | - Hermann Hounkponou
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Heather S Reisinger
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Diana Jalal
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
| | - Jason Misurac
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| |
Collapse
|
4
|
Engen RM, Weng PL, Shih W, Patel HP, Richardson K, Dowdrick SL, Ashoor IF, Misurac J, Traum AZ, Semanik MG, Jain NG, Mansuri A, Sreedharan R. Outcomes of granulocyte colony-stimulating factor use in pediatric kidney transplant recipients: A Pediatric Nephrology Research Consortium study. Pediatr Transplant 2022; 26:e14202. [PMID: 34967072 DOI: 10.1111/petr.14202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/02/2021] [Accepted: 11/15/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Neutropenia is common in the first year after pediatric kidney transplant and is associated with an increased risk of infection, allograft loss, and death. Granulocyte colony-stimulating factor (G-CSF) increases neutrophil production, but its use in pediatric solid organ transplant recipients remains largely undescribed. METHODS We performed a multicenter retrospective cohort study of children with neutropenia within the first 180 days after kidney transplant. Multivariable linear regression and Poisson regression were used to assess duration of neutropenia and incidence of hospitalization, infection, and rejection. RESULTS Of 341 neutropenic patients, 83 received G-CSF during their first episode of neutropenia. Median dose of G-CSF was 5 mcg/kg for 3 (IQR 2-7) doses. G-CSF use was associated with transplant center, induction immunosuppression, steroid-free maintenance immunosuppression, hospitalization, and decreases in mycophenolate mofetil, valganciclovir, and trimethoprim-sulfamethoxazole dosing. Absolute neutrophil count nadir was also significantly lower among those treated with G-CSF. G-CSF use was not associated with a shorter duration of neutropenia (p = .313) and was associated with a higher rate of neutropenia relapse (p = .002) in adjusted analysis. G-CSF use was associated with a decreased risk of hospitalization (aIRR 0.25 (95%CI 0.12-0.53) p < .001) but there was no association with incidence of bacterial infection or rejection within 90 days of neutropenic episode. CONCLUSION G-CSF use for neutropenia in pediatric kidney transplant recipients did not shorten the overall duration of neutropenia but was associated with lower risk of hospitalization. Prospective studies are needed to determine which patients may benefit from G-CSF treatment.
Collapse
Affiliation(s)
- Rachel M Engen
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patricia L Weng
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Weiwen Shih
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Hiren P Patel
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kelsey Richardson
- Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Shauna L Dowdrick
- Department of Pediatric Nephrology and Hypertension, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, USA
| | - Isa F Ashoor
- Department of Pediatrics, Louisiana State University Health Sciences Center, New Orleans, Louisina, USA
| | - Jason Misurac
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Avram Z Traum
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael G Semanik
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Namarata G Jain
- Department of Pediatrics, Columbia University, New York City, New York, USA
| | | | - Rajasree Sreedharan
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
5
|
Hooper DK, Misurac J, Blydt-Hansen T, Chua AN. Multicenter data to improve health for pediatric renal transplant recipients in North America: Complementary approaches of NAPRTCS and IROC. Pediatr Transplant 2021; 25:e13891. [PMID: 33142362 DOI: 10.1111/petr.13891] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/15/2020] [Accepted: 09/23/2020] [Indexed: 11/30/2022]
Abstract
Kidney transplantation increases life expectancy and improves quality of life for children with end-stage kidney disease, yet sequelae of transplantation and treatment make it difficult for transplant recipients to enjoy health and quality of life similar to their healthy peers. The NAPRTCS network was among the first to use multicenter data to inform improvements in care and outcomes for children with a kidney transplant through observational research. Now, with new technologies and unprecedented access to data, it is possible to create learning health systems as envisioned by the US National Academy of Sciences to seamlessly integrate research and continuous improvement of clinical care. In this review, we present two pre-eminent North American networks focused on using multicenter data to drive improved care and outcomes for children with a kidney transplant. Whereas, for the past 30 years NAPRTCS has focused on discovery of best practices through observational research and clinical trials, the Improving Renal Outcomes Collaborative, established in 2016, engages patients, families, clinicians, and researchers in redesigning the healthcare delivery system to enable practice change and continuous improvement of health outcomes. We discuss the history and past contributions of these networks, as well as current activities, barriers, and potential future solutions to more fully realize the vision of a true learning health system for pediatric kidney transplant recipients.
Collapse
Affiliation(s)
- David K Hooper
- Division of Nephrology (MLC-7022) and James M Anderson Center for Health Systems Excellence (MLC-7014), Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Jason Misurac
- Division of Pediatric Nephrology, Dialysis, and Transplantation, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Tom Blydt-Hansen
- Division of Nephrology, BC Children's Hospital, University of British Colombia, Vancouver, BC, Canada
| | - Annabelle N Chua
- Division of Pediatric Nephrology, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
6
|
Seifert ME, Dahale DS, Kamel M, Winterberg PD, Barletta GM, Belsha CW, Chaudhuri A, Flynn JT, Garro R, George RP, Goebel JW, Kershaw DB, Matossian D, Misurac J, Nailescu C, Nguyen CR, Pearl M, Pollack A, Pruette CS, Singer P, VanSickle JS, Verghese P, Warady BA, Warmin A, Weng PL, Wickman L, Wilson AC, Hooper DK. The Improving Renal Outcomes Collaborative: Blood Pressure Measurement in Transplant Recipients. Pediatrics 2020; 146:peds.2019-2833. [PMID: 32518170 PMCID: PMC7329257 DOI: 10.1542/peds.2019-2833] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Hypertension is highly prevalent in pediatric kidney transplant recipients and contributes to cardiovascular death and graft loss. Improper blood pressure (BP) measurement limits the ability to control hypertension in this population. Here, we report multicenter efforts from the Improving Renal Outcomes Collaborative (IROC) to standardize and improve appropriate BP measurement in transplant patients. METHODS Seventeen centers participated in structured quality improvement activities facilitated by IROC, including formal training in quality improvement methods. The primary outcome measure was the proportion of transplant clinic visits with appropriate BP measurement according to published guidelines. Prospective data were analyzed over a 12-week pre-intervention period and a 20-week active intervention period for each center and then aggregated as of the program-specific start date. We used control charts to quantify improvements across IROC centers. We applied thematic analysis to identify patterns and common themes of successful interventions. RESULTS We analyzed data from 5392 clinic visits. At baseline, BP was measured and documented appropriately at 11% of visits. Center-specific interventions for improving BP measurement included educating clinic staff, assigning specific team member roles, and creating BP tracking tools and alerts. Appropriate BP measurement improved throughout the 20-week active intervention period to 78% of visits. CONCLUSIONS We standardized appropriate BP measurement across 17 pediatric transplant centers using the infrastructure of the IROC learning health system and substantially improved the rate of appropriate measurement over 20 weeks. Accurate BP assessment will allow further interventions to reduce complications of hypertension in pediatric kidney transplant recipients.
Collapse
Affiliation(s)
- Michael E. Seifert
- Department of Pediatrics, University of Alabama and Children’s of Alabama, Birmingham, Alabama
| | - Devesh S. Dahale
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Margret Kamel
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Pamela D. Winterberg
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Craig W. Belsha
- Department of Pediatrics, Saint Louis University, St Louis, Missouri
| | - Abanti Chaudhuri
- Department of Pediatrics, Stanford University, Stanford, California
| | | | - Rouba Garro
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Roshan P. George
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - David B. Kershaw
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Debora Matossian
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Jason Misurac
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Corina Nailescu
- Riley Hospital for Children, Indiana University Health, Indianapolis, Indiana
| | - Christina R. Nguyen
- Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Meghan Pearl
- Mattel Children’s Hospital, University of California Los Angeles Health, Los Angeles, California
| | - Ari Pollack
- Seattle Children’s Hospital, Seattle, Washington
| | | | - Pamela Singer
- Cohen Children’s Medical Center, New Hyde Park, New York
| | | | - Priya Verghese
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | | | - Andrew Warmin
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Patricia L. Weng
- Mattel Children’s Hospital, University of California Los Angeles Health, Los Angeles, California
| | - Larysa Wickman
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Amy C. Wilson
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - David K. Hooper
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | | |
Collapse
|
7
|
Goswami E, Ogden RK, Bennett WE, Goldstein SL, Hackbarth R, Somers MJG, Yonekawa K, Misurac J. Evidence-based development of a nephrotoxic medication list to screen for acute kidney injury risk in hospitalized children. Am J Health Syst Pharm 2020; 76:1869-1874. [PMID: 31665764 DOI: 10.1093/ajhp/zxz203] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Medications are commonly associated with acute kidney injury (AKI). However, in both clinical practice and research, consideration of specific medications as nephrotoxic varies widely. The Nephrotoxic Injury Negated by Just-in-time Action quality improvement collaborative was formed to focus on prevention or reduction of nephrotoxic medication-associated AKI in noncritically ill hospitalized children. However, there were discrepancies among institutions as to which medications should be considered nephrotoxic. The collaborative convened a Nephrotoxic Medication (NTMx) Subcommittee to develop a consensus for the classification of nephrotoxic medications. SUMMARY The NTMx Subcommittee initially included pediatric nephrologists, a pharmacist, and a pediatric intensivist. The committee reviewed NTMx lists from the collaborative and identified changes from the initial NTMx list. The NTMx Subcommittee conducted a literature review of the disputed medications and assigned an evidence grade based on the reported association with nephrotoxicity and the quality of the data. The association between medication exposure and AKI was also determined using administrative data from the Pediatric Health Information Systems database. The NTMx Subcommittee then came to a majority consensus regarding which medications should be included on the list. The subcommittee's recommendations were presented to the larger collaborative for approval, and consensus was achieved. The list continues to be reviewed and updated annually. CONCLUSION Formation of a multicenter quality-improvement initiative exposed current limitations as to which medications are considered nephrotoxic in clinical and research settings and presented an opportunity to approach this problem using an evidence-based process. A consensus definition of nephrotoxic-medication exposure was achieved.
Collapse
Affiliation(s)
| | - Richard K Ogden
- Pharmacy Department, Children's Mercy Hospital and Clinics, Kansas City, MO
| | - William E Bennett
- Department of Pediatrics, Division of Pediatric and Adolescent Comparative Effectiveness Research, Indiana University School of Medicine, Indianapolis, IN
| | | | | | | | - Karyn Yonekawa
- Department of Pediatrics, Division of Nephrology, University of Washington, Seattle, WA
| | - Jason Misurac
- University of Iowa Stead Family Children's Hospital, Iowa City, IA
| |
Collapse
|
8
|
Goldstein SL, Dahale D, Kirkendall ES, Mottes T, Kaplan H, Muething S, Askenazi DJ, Henderson T, Dill L, Somers MJG, Kerr J, Gilarde J, Zaritsky J, Bica V, Brophy PD, Misurac J, Hackbarth R, Steinke J, Mooney J, Ogrin S, Chadha V, Warady B, Ogden R, Hoebing W, Symons J, Yonekawa K, Menon S, Abrams L, Sutherland S, Weng P, Zhang F, Walsh K. A prospective multi-center quality improvement initiative (NINJA) indicates a reduction in nephrotoxic acute kidney injury in hospitalized children. Kidney Int 2019; 97:580-588. [PMID: 31980139 DOI: 10.1016/j.kint.2019.10.015] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/26/2019] [Accepted: 10/03/2019] [Indexed: 10/25/2022]
Abstract
Nephrotoxic medication (NTMx) exposure is a common cause of acute kidney injury (AKI) in hospitalized children. The Nephrotoxic Injury Negated by Just-in time Action (NINJA) program decreased NTMx associated AKI (NTMx-AKI) by 62% at one center. To further test the program, we incorporated NINJA across nine centers with the goal of reducing NTMx exposure and, consequently, AKI rates across these centers. NINJA screens all non-critically ill hospitalized patients for high NTMx exposure (over three medications on the same day or an intravenous aminoglycoside over three consecutive days), and then recommends obtaining a daily serum creatinine level in exposed patients for the duration of, and two days after, exposure ending. Additionally, substitution of equally efficacious but less nephrotoxic medications for exposed patients starting the day of exposure was recommended when possible. The main outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) serum creatinine criteria (increase of 50% or 0.3 mg/dl over baseline). The primary outcome measure was AKI episodes per 1000 patient-days. Improvement was defined by statistical process control methodology and confirmed by Autoregressive Integrated Moving Average (ARIMA) modeling. Eight consecutive bi-weekly measure rates in the same direction from the established baseline qualified as special cause change for special process control. We observed a significant and sustained 23.8% decrease in NTMx-AKI rates by statistical process control analysis and by ARIMA modeling; similar to those of the pilot single center. Thus, we have successfully applied the NINJA program to multiple pediatric institutions yielding decreased AKI rates.
Collapse
Affiliation(s)
- Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| | - Devesh Dahale
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Eric S Kirkendall
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Theresa Mottes
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Heather Kaplan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stephen Muething
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David J Askenazi
- Division of Nephrology, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | - Traci Henderson
- Division of Nephrology, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | - Lynn Dill
- Division of Nephrology, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | | | - Jessica Kerr
- Division of Nephrology, Children's Hospital, Boston, Massachusetts, USA
| | - Jennifer Gilarde
- Division of Nephrology, Children's Hospital, Boston, Massachusetts, USA
| | - Joshua Zaritsky
- Division of Nephrology, A.I. Dupont Children's Hospital, Wilmington, Delaware, USA
| | - Valerie Bica
- Division of Nephrology, A.I. Dupont Children's Hospital, Wilmington, Delaware, USA
| | - Patrick D Brophy
- Division of Nephrology, Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Jason Misurac
- Division of Nephrology, Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Richard Hackbarth
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Julia Steinke
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Joann Mooney
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Sara Ogrin
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Vimal Chadha
- Division of Nephrology, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Bradley Warady
- Division of Nephrology, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Richard Ogden
- Division of Nephrology, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Wendy Hoebing
- Division of Nephrology, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Jordan Symons
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Karyn Yonekawa
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Shina Menon
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Lisa Abrams
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Scott Sutherland
- Division of Nephrology, Lucille Packard Stanford Children's Hospital, Palo Alto, California, USA
| | - Patricia Weng
- Division of Nephrology, Mattel Children's Hospital, Los Angeles, California, USA
| | - Fang Zhang
- Division of Biostatistics, Harvard Medical School, Boston, Massachusetts, USA; Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Kathleen Walsh
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
9
|
Kizilbash S, Claes D, Ashoor I, Chen A, Jandeska S, Matar RB, Misurac J, Sherbotie J, Twombley K, Verghese P. Bortezomib in the treatment of antibody-mediated rejection in pediatric kidney transplant recipients: A multicenter Midwest Pediatric Nephrology Consortium study. Pediatr Transplant 2017; 21. [PMID: 28092129 DOI: 10.1111/petr.12873] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 01/18/2023]
Abstract
Antibody-mediated rejection leads to allograft loss after kidney transplantation. Bortezomib has been used in adults for the reversal of antibody-mediated rejection; however, pediatric data are limited. This retrospective study was conducted in collaboration with the Midwest Pediatric Nephrology Consortium. Pediatric kidney transplant recipients who received bortezomib for biopsy-proven antibody-mediated rejection between 2008 and 2015 were included. The objective was to characterize the use of bortezomib in pediatric kidney transplant recipients. Thirty-three patients received bortezomib for antibody-mediated rejection at nine pediatric kidney transplant centers. Ninety percent of patients received intravenous immunoglobulin, 78% received plasmapheresis, and 78% received rituximab. After a median follow-up of 15 months, 65% of patients had a functioning graft. The estimated glomerular filtration rate improved or stabilized in 61% and 36% of patients at 3 and 12 months post-bortezomib, respectively. The estimated glomerular filtration rate at diagnosis significantly predicted estimated glomerular filtration rate at 12 months after adjusting for chronic histologic changes (P .001). Fifty-six percent of patients showed an at least 25% reduction in the mean fluorescence intensity of the immune-dominant donor-specific antibody, 1-3 months after the first dose of bortezomib. Non-life-threatening side effects were documented in 21 of 33 patients. Pediatric kidney transplant recipients tolerated bortezomib without life-threatening side effects. Bortezomib may stabilize estimated glomerular filtration rate for 3-6 months in pediatric kidney transplant recipients with antibody-mediated rejection.
Collapse
Affiliation(s)
| | - Donna Claes
- Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Isa Ashoor
- Children's Hospital New Orleans, New Orleans, LA, USA
| | - Ashton Chen
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | | | | | | | | | | |
Collapse
|
10
|
Abstract
Neonatal chronic kidney disease (CKD) occurs with an estimated incidence of 1 in 10,000 live births, whereas the incidence of neonatal end-stage renal disease (ESRD) is about 7.1 per million age-related population. The most frequent etiologies are renal hypoplasia/dysplasia, posterior urethral valves, and other congenital anomalies of the kidney and urinary tract. Other etiologies include polycystic kidney disease, cortical necrosis, and renal vascular thrombosis. Management of CKD focuses primarily on replacing renal functions such as erythropoietin, 1,25-hydroxylation of vitamin D, electrolyte homeostasis/excretion, and, in ESRD, waste product removal. Nutrition and growth monitoring are of utmost importance, with the majority of ESRD infants requiring gastrostomy tube for nutrition. Outcomes of neonates (<31 days) started on dialysis continue to improve, with large cohort studies showing 2-3-year survival rates of 79-81%. As in other neonatal disciplines, the gestational age and size limits for safe provision of dialysis continue to decrease.
Collapse
Affiliation(s)
- Jason Misurac
- Pediatric Nephrology, University of Iowa Children's Hospital, Iowa City, IA, USA.
| |
Collapse
|
11
|
Abstract
Hypertension in children is common, and the prevalence of primary hypertension is increasing with the obesity epidemic and changing dietary choices. Careful measurement of blood pressure is important to correctly diagnose hypertension, as many factors can lead to inaccurate blood pressure measurement. Hypertension is diagnosed based on comparison of age-, sex-, and height-based norms with the average systolic and diastolic blood pressures on three separate occasions. In the absence of hypertensive target organ damage (TOD), stage I hypertension is managed first by diet and exercise, with the addition of drug therapy if this fails. First-line treatment of stage I hypertension with TOD and stage II hypertension includes both lifestyle changes and medications. First-line agents include angiotensin-converting enzyme (ACE) inhibitors, thiazide diuretics, and calcium-channel blockers. Hypertensive emergency with end-organ effects requires immediate modest blood pressure reduction to alleviate symptoms. This is usually accomplished with IV medications. Long-term reduction in blood pressure to normal levels is accomplished gradually. Specific medication choice for outpatient hypertension management is determined by the underlying cause of hypertension and the comparative adverse effect profiles, along with practical considerations such as cost and frequency of administration. Antihypertensive medication is initiated at a starting dose and can be gradually increased to effect. If ineffective at the recommended maximum dose, an additional medication with a complementary mechanism of action can be added.
Collapse
Affiliation(s)
- Jason Misurac
- Department of Pediatrics, Section of Pediatric Nephrology, Indiana University School of Medicine, 699 Riley Hospital Dr., Room 230, Indianapolis, IN, 46202, USA.
| | - Kristen R Nichols
- Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN, USA
- Department of Pharmacy, Riley Hospital for Children, Indiana University Health, Indianapolis, IN, USA
| | - Amy C Wilson
- Department of Pediatrics, Section of Pediatric Nephrology, Indiana University School of Medicine, 699 Riley Hospital Dr., Room 230, Indianapolis, IN, 46202, USA
| |
Collapse
|