Evaluation of renal drug dosing adjustment in chronic kidney disease patients at two university hospitals in Lebanon
Background: Inappropriate medication dosing in patients with chronic kidney disease can cause toxicity or ineffective therapy. Patients are at a high risk of developing related adverse events caused by the altered effect of drugs in conjunction with the use of polypharmacy to treat comorbid conditions. This necessitates adequate renal dosing adjustments.
Objective: The current study aims at assessing whether appropriate dosing adjustments were made in hospitalized patients with chronic kidney disease.
Methods: A retrospective descriptive study was conducted at two university hospitals in Beirut between January and December 2016. All adult CKD patients with creatinine clearance less than 60 ml/min and receiving at least one medication that require renal dosing adjustment were included. Kidney function was estimated from serum creatinine using Cockcroft-Gault equation, and dose appropriateness was determined by comparing practice with specific guidelines. The rates of renal drug dosing adjustment were investigated, in addition to the influence of possible determinants, such as the severity of renal impairment, reason of hospital admission, and other patient characteristics.
Results: 2138 patients admitted in 2016 were screened. 223 adults receiving 578 drug orders that require adjustment were included. Among the 578 orders, 215 (37%) were adjusted adequately, 284 (49%) were adjusted inadequately, and 79 (14%) were not adjusted at all. Beta-blockers were the most inadequately dosed (83.6%) class of medication, whereas lipid-lowering agents had the highest percentage of adequate dosing (65.1%). As per patient, 84.3% of patients appeared to be receiving at least one inappropriate drug dose.
Conclusions: Our study confirms that physicians are not prescribing appropriate dosing adjustments in chronic kidney disease inpatients, which may have deleterious effects. This highlights the need for more nephrology consultation and the implementation of physician education programs.
Luyckx VA, Tonelli M, Stanifer JW. The global burden of kidney disease and the sustainable development goals. Bull World Health Organ. 2018;96(6):414D-422D. https://dx.doi.org/10.2471/BLT.17.206441
Matzke GR. Drug therapy individualization for patients with chronic kidney disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 9th ed. New York, NY: McGraw-Hill; 2014.
Ponticelli C, Sala G, Glassock RJ. Drug management in the elderly adult with chronic kidney disease: a review for the primary care physician. Mayo Clin Proc. 2015;90(5):633-645. https://dx.doi.org/10.1016/j.mayocp.2015.01.016
Doogue MP, Polasek TM. Drug dosing in renal disease. Clin Biochem Rev. 2011;32(2):69-73.
Battistella M, Matzke GR. Drug Therapy Individualization for Patients with Chronic Kidney Disease. In: Pharmacotherapy: A Pathophysiologic Approach, 10ed. DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, Eds. New York, NY: McGraw-Hill; 2017.
Fink JC, Chertow GM. Medication errors in chronic kidney disease: one piece in the patient safety puzzle. Kidney Int. 2009;76(11):1123-1125. https://dx.doi.org/10.1038/ki.2009.315
Drenth-van Maanen AC, van Marum RJ, Jansen PA, Zwart JE, van Solinge WW, Egberts TC. Adherence with Dosing Guideline in Patients with Impaired Renal Function at Hospital Discharge. PLoS One. 2015;10(6):e0128237. https://dx.doi.org/10.1371/journal.pone.0128237
Hassan Y, Al-Ramahi R, Abd Aziz N, Ghazali R. Drug use and dosing in chronic kidney disease. Ann Acad Med Singapore. 2009;38(12):1095-1103.
Andrassy KM. Comments on ‘KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease’. Kidney Int. 2013;84(3):622-623. https://dx.doi.org/10.1038/ki.2013.243
Getachew H, Tadesse Y, Shibeshi W. Drug dosage adjustment in hospitalized patients with renal impairment at Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia. BMC Nephrol. 2015;16:158. https://dx.doi.org/10.1186/s12882-015-0155-9
Munar MY, Singh H. Drug dosing adjustments in patients with chronic kidney disease. Am Fam Physician. 2007;75(10):1487-1496.
Aronoff G, Bennett W, Berns J, Brier M, Kasbekar N, Mueller B. Drug prescribing in renal failure: Dosing guidelines for adults and children. Philadelphia, PA: American College of Physicians; 2007.
Cockcroft DW, Gault H. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31-41.
Lessard BA, Zaiken K. Comparison of equations for dosing of medications requiring renal adjustment. J Am Pharm Assoc (2003). 2013;53(1):54-57. https://dx.doi.org/10.1331/JAPhA.2013.11241
Wilhelm SM, Kale-Pradhan PB. Estimating creatinine clearance: a meta-analysis. Pharmacotherapy. 2011;31(7):658-664. https://dx.doi.org/10.1592/phco.31.7.658
Decloedt E, Leisegang R, Blockman M, Cohen K. Dosage adjustment in medical patients with renal impairment at Groote Schuur Hospital. S Afr Med J. 2010;100(5):304-306.
Alahdal AM, Elberry AA. Evaluation of applying drug dose adjustment by physicians in patients with renal impairment. Saudi Pharm J. 2012;20(3):217-220. https://dx.doi.org/10.1016/j.jsps.2011.12.005
Salomon L, Deray G, Jaudon MC, Chebassier C, Bossi P, Launay-Vacher V, Diquet B, Ceza JM, Levu S, Brücker G, Ravaud P. Medication misuse in hospitalized patients with renal impairment. Int J Qual Health Care. 2003;15(4):331-335.
Altunbas G, Yazc M, Solak Y, Gul EE, Kayrak M, Kaya Z, Akilli H, Aribas A, Gaipov A, Yazc R, Ozdemir K. Renal drug dosage adjustment according to estimated creatinine clearance in hospitalized patients with heart failure. Am J Ther. 2016;23(4):e1004-e1008. https://dx.doi.org/10.1097/01.mjt.0000434042.62372.49
Sweileh WM, Janem SA, Sawalha AF, Abu-Taha AS, Zyoud SH, Sabri IA, Al-Jabi SW, Jaradat NA, Zaid AA. Medication dosing errors in hospitalized patients with renal impairment: a study in Palestine. Pharmacoepidemiol Drug Saf. 2007;16(8):908-912. https://dx.doi.org/10.1002/pds.1412
Solak Y, Biyik Z, Gaipov A, Kayrak M, Ciray H, Cizmecioglu A, Tonbul HZ, Turk S. Drug dose adjustment in dialysis patients admitted in clinics other than internal medicine. Am J Ther. 2016;23(1):e68-e73. https://dx.doi.org/10.1097/MJT.0b013e3182a4ef81
Modig S, Lannering C, Ostgren CJ, Molstad S, Midlov P. The assessment of renal function in relation to the use of drugs in elderly in nursing homes; a cohort study. BMC Geriatr. 2011;11:1. https://dx.doi.org/10.1186/1471-2318-11-1
Bailie GR, Eisele G, Liu L, Roys E, Kiser M, Finkelstein F, Wolfe R, Port F, Burrows-Hudson S, Saran R. Patterns of medication use in the RRI-CKD study: focus on medications with cardiovascular effects. Nephrol Dial Transplant. 2005;20(6):1110-1115. https://dx.doi.org/10.1093/ndt/gfh771
Matzke GR, Aronoff GR, Atkinson AJ Jr, Bennett WM, Decker BS, Eckardt KU, Golper T, Grabe DW, Kasiske B, Keller F, Kielstein JT, Mehta R, Mueller BA, Pasko DA, Schaefer F, Sica DA, Inker LA, Umans JG, Murray P. Drug dosing consideration in patients with acute and chronic kidney disease-a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2011;80(11):1122-1137. https://dx.doi.org/10.1038/ki.2011.322
Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med. 2006;166(9):955-964. https://dx.doi.org/10.1001/archinte.166.9.955
Martinez-Anton A, Sanchez JI, Casanueva L. Impact of an intervention to reduce prescribing errors in a pediatric intensive care unit. Intensive Care Med. 2012 Sep;38(9):1532-8. https://dx.doi.org/10.1007/s00134-012-2609-x
El-Jardali F, El Bawab L, Fadlallah R. Addressing medical errors in the Lebanese healthcare system. Beirut: Knowledge to Policy (K2P) Center; 2016.
The authors hereby transfer, assign or otherwise convey to Pharmacy Practice (1) the right to grant permission to republish or reprint the stated material, in whole or in part, without a fee; (2) the right to print or epublish copies for free distribution or sale; and (3) the right to republish the stated material in any format (electronic or printed). In addition, the undersigned affirms that the article described above has not previously been published, in whole or part, is not subject to copyright or other rights except by the author(s), and has not been submitted for publication elsewhere, except as communicated in writing to Pharmacy Practice with this document.
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License (CC-BY-NC-ND) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
Author Self-Archiving Policy
Pharmacy Practice permits and encourages authors to post and archive the final PDFs of their respective articles submitted to the journal on personal websites or institutional repositories after publication, while providing bibliographic details that credit its publication in this journal.