Iatrogenic Kidney Injury: Cases and Learnings
Inappropriate prescribing of medications occurs often in patients with chronic kidney disease (CKD). In a 2015 analysis of data from more than 83,000 Veterans Affairs outpatients nationwide, nearly one-sixth (13%) of veterans with stage 3 CKD (creatinine clearance [CrCl] of 30 to 49 mL/min) and nearly one-third (29%) of those with stage 4 CKD (CrCl of 15 to 29 mL/min) received one or more drugs that were contraindicated or prescribed at an excessive dose given the patient’s kidney function.1 Medications are a common cause of iatrogenic adverse drug reactions in patients with CKD. More than two-thirds (69.3%) of patients with CKD (n=267) in the Safe Kidney Care study developed either an adverse safety incident that the patient attributed to medication or a hazardous clinical disturbance that move the potential correction with treatment or medication modification.2
Antibiotics are a frequent culprit; two-thirds of 1,464 antibiotic prescriptions written for ambulatory older patients (≥66 years old) with CKD stage 4 or 5 reflected treatment in excess of kidney dose adjustment guidelines, according to a database analysis.3
The physician assistants (PAs) and nurse practitioners of the National Kidney Foundation have shared the following true stories of the consequences of inappropriate medication dosing in patients with CKD. For medication dosing purposes, a CrCl and a GFR are interchangeable.Sam, a 45-year-old, wheelchair-bound man with hypertension, diabetes, CKD (stage 4), peripheral vascular disease (PVD), hyperkalemia, edema, right leg amputation below the knee, and left foot ulcer, was diagnosed with pneumonia by a pharmacy clinic. Not knowing the patient’s stage of CKD, the clinic used a standard dose of levofloxacin, which caused prolongation of the QT interval and Sam’s death. All fluoroquinolones, including levofloxacin, can prolong the QT interval. Renal dosing for levofloxacin can either be managed at a lower dose or with a loading dose for the first day, followed by a less frequent and/or lower doses.4 The author often uses levofloxacin 250 mg every other day in patients with CKD stage 4/5.
This supplement is intended for physicians, nurses, nurse practitioners, physician assistants, CDEs, and other clinicians involved in the diagnosis and management of metabolic and endocrine disorders.
DONNA L. JORNSAY, MS, CPNP, CDE, CDTC
CHRISTINE KESSLER, CNS, ANP, BC-ADM, CDTC, FAANP
DAVIDA F. KRUGER, MSN, APRN-BC, BC-ADM
ELLEN D. MANDEL, DMH, MPA, PA-C, RDN, CDE
LUCIA M. NOVAK, MSN, ANP-BC, BC-ADM, CDTC
JOYCE ROSS, MSN, ANP, CRNP, FPCNA, FNLA
SCOTT URQUHART, PA-C, DFAAPA
KIM ZUBER, PA-C
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Primary care providers are often the first point of care for diabetes and kidney disease. The Metabolic & Endocrine Disease Summit 2016, a CME/CE conference, explored the latest advances in the management of these conditions. Obesity raises the risk of many other conditions. Providers would benefit from a discussion of how to address this frequently encountered problem in clinical practice. Lipoprotein (Lp) (a) is an inherited, independent risk factor for atherosclerotic cardiovascular disease. New therapies show some promise for addressing this form of dyslipidemia. Diabetes raises the risk of major depressive disorder, and depression increases the risk of diabetic complications. Psychosocial intervention can improve glycemic control and symptoms of diabetes-related distress. Nephropathy is a common complication of diabetes but glycemic control, careful choice of medications, and regular monitoring can promote renoprotection.
Diabetes presents issues throughout a patient’s life; three touchpoints are the transition of a young adult from pediatrics to adult care, the detection and management of diabetes during pregnancy, and diabetes in the older adult. Anticipation of the relevant issues and implementation of a transition program can contribute to retaining young adults in care. Preconception counseling and early detection of diabetes can reduce the risk of adverse outcomes. Clinicians must be knowledgeable about how to balance the many complex issues to consider when establishing glycemic targets and selecting a treatment plan for an older adult with diabetes. At this writing, four new insulin-only preparations have been approved by the US Food and Drug Administration (FDA) since February 2015. The ability to differentiate these options is important for clinicians.
After reading and studying this journal supplement, participants should be better able to:
- Differentiate the many insulin options available to treat people with diabetes, and their applications in clinical practice
- Display an understanding of the contributors to and consequences of obesity, and interventions to address unhealthy weight
- Evaluate the contribution of elevated Lp (a) to vascular risk and its influence on treatment
- Apply the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) glycemic goals and pharmacologic recommendations in the context of individual patient concerns and practical limitations.
- Incorporate consideration of renal function in monitoring, medication choice, and general management of diabetes
- Understand common errors in medication choice and dosing that are associated with kidney injury, and plan how to avoid them
- Demonstrate an understanding of the effect of depression—and its treatment—on diabetes
- List tools to assess and manage depression in patients with diabetes
- Identify risks of transition of young adults with diabetes from pediatric to adult services, and list elements of successful transition
- Demonstrate familiarity with assessment and treatment recommendations for older adults with diabetes
- Detect and manage pregestational and gestational diabetes mellitus to reduce risk of complications for the mother and child during and after pregnancy
In accordance with the ACCME Standards for Commercial Support of CME, the speakers for this course have been asked to disclose to participants the existence of any financial interest and/or relationship(s) (e.g., paid speaker, employee, paid consultant on a board and/or committee for a commercial company) that would potentially affect the objectivity of his/her presentation or whose products or services may be mentioned during their presentation. The following disclosures were made:
Planning Committee Members
Susan P. Tyler No Relevant Relationships
Rick Ricer, MD No Relevant Relationships
Eileen McCaffrey No Relevant Relationships
Sylvia Reitman No Relevant Relationships
Shirley Jones No Relevant Relationships
The following PIM planners and managers, Judi Smelker-Mitchek, RN, BSN, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, and Jan Schultz, RN, MSN, CHCP, hereby state that they or their spouse/ life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
Donna L. Jornsay, MS, CPNP, CDE, CDTC, has indicated that she is a Consultant for Becton, Dickinson and Company and Eli Lilly; a Shareholder of Medtronic Diabetes; and is on the Speaker’s Bureau for Insulet.
Christine Kessler, CNS, ANP, BC-ADM, CDTC, FAANP, is a Consultant for AstraZeneca, Medtronic, and Novo Nordisk; and is on the Speaker’s Bureau for Novo Nordisk.
Davida F. Kruger, MSN, APRN-BC, BC-ADM, has indicated that she is on the Advisory Board of Abbott, Dexcom, Eli Lilly, Janssen Pharmaceuticals, Novo Nordisk; and Intarcia; on the Speaker’s Bureau for Abbott, Astra Zeneca, Boehringer Ingelheim, Dexcom, Eli Lilly, Janssen Pharmaceuticals, Novo Nordisk, Valeritas; has stock in Dexcom; and received grants/research support from Astra Zeneca, Dexcom, Eli Lilly, Helmsley Foundation, Lexicon, and Novo Nordisk, and receives research support of 40% salary from NIH.
Ellen D. Mandel, DMH, MPA, PA-C, RDN, CDE, has nothing to disclose.
Lucia M. Novak, MSN, ANP-BC, BC-ADM, CDTC, has indicated that she is on the Speaker’s Bureau for AstraZeneca, Janssen Pharmaceuticals, and Novo Nordisk.
Joyce Ross, MSN, ANP, CLS, CRNP, FPCNA, FNLA, has indicated that she is a on the Advisory Board for Akcea Therapeutics, Kaneka America, Kastle Pharma; and on the Speaker’s Bureau for AbbVie, Amarin, Amgen, Kaneka America, KOWA, and Sanofi/Regeneron.
Scott Urquhart, PA-C, DFAAPA, has indicated that he is on the Advisory Board for AstraZeneca and Shire; a Consultant for Abbott and Acella Pharma; and on the Speaker’s Bureau for Abbott and AstraZeneca.
Kim Zuber, PA-C, has indicated that she is on the Speaker’s Bureau for Amgen and Janssen Pharmaceuticals.
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The faculty acknowledge the editorial assistance of Global Academy for Medical Education, LLC, and Eileen McCaffrey, medical writer, in the development of this supplement. It has been reviewed and approved by the faculty as well as the editors of Clinical Endocrinology News.
Neither the editors of Clinical Endocrinology News nor the Editorial Advisory Board nor the reporting staff contributed to its content. The opinions expressed are those of the faculty and do not necessarily reflect the views of the supporter or of the Publisher.
Copyright © 2017 by Global Academy for Medical Education, LLC, Frontline Medical Communications Inc., and its Licensors. All rights reserved. No part of this publication may be reproduced or transmitted in any form, by any means, without prior written permission of the Publisher. Global Academy for Medical Education, LLC, will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned This continuing medical education (CME) supplement was developed from faculty presentations at the Metabolic & Endocrine Disease Summit October 5 - 8, 2016.
1. Chang F, O’Hare AM, Miao Y, Steinman MA. Use of renally inappropriate medications in older veterans: A national study. J Amer Geriatr Soc. 2015; 63(11):2290-2297.
2. Ginsberg JS, Zhan M, Diamantidis CJ, Woods C, Chen J, Fink JC. Patient- reported and actionable safety events in CKD. JASN. 2014;25(7):1564-1573.
3. Farag A, Garg AX, Li L, Jain AK. Dosing errors in prescribed antibiotics for older persons with CKD: A retrospective time series analysis. Am J Kidney Dis. 2014;63(3):422-428.
4. Levaquin [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; 2017. 5. Zovirax [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2005.
6. KDIGO clinical practice guideline for acute kidney injury. Kidney Int. 2012;2(Suppl 1):1-138.