Kidney Res Clin Pract > Volume 43(4); 2024 > Article
Wang, Kang, Wu, Wu, Huang, and Wu: The effect of pharmacist-led medication therapy management in the multidisciplinary care of acute kidney injury survivors

Abstract

Background

The Acute Disease Quality Initiative advocates multidisciplinary care for the survivors of acute kidney injury (AKI). The bundled care strategy recognizes the role of pharmacists. However, their specific contributions in this context remain underexplored.

Methods

This retrospective study examined the efficacy of pharmacist-led post-AKI pharmaceutical care in outpatient settings at a single center. Adults with recent AKI during hospitalization, maintaining an estimated glomerular filtration rate <45 mL/min/1.73 m2 postdischarge, were enrolled in a multidisciplinary team care program from March 2022 to January 2023, with a 6-month follow-up period. Pharmacist-delivered care adhered to international multidisciplinary consensus guidelines. Efficacy was evaluated by analyzing medication-related recommendations, medication adherence, nephrotoxic drug utilization, and renoprotective medication usage before and after the intervention.

Results

A total of 40 patients were referred to the pharmacist-managed clinic. Of these, 33 patients (mean age, 63 ± 15 years; 60.6% male) attended the clinic. Nineteen patients completed follow-up visits. The pharmacist provided 14 medication-related recommendations to relevant physicians, with 10 of these recommendations (71.4%) being accepted. There was a significant decrease in the use of modifiable nephrotoxic drugs (p = 0.03). However, no significant improvements were noted in medication adherence or the utilization of renoprotective medications.

Conclusion

Our study underscores the potential benefits of pharmacist-led post-AKI bundled care strategy in outpatient settings. We observed a significant reduction in the utilization of modifiable nephrotoxic drugs, indicating the effectiveness of pharmacist interventions in optimizing medication regimens to mitigate renal harm.

Introduction

Acute kidney injury (AKI) is a common and complex clinical syndrome, frequently manifesting as a complication in hospital settings, and its etiology involves diverse underlying factors [1]. The transitional phase between AKI and the onset of chronic kidney disease (CKD) is medically defined as acute kidney disease (AKD) [2]. A comprehensive systematic review has revealed that approximately 33.6% of all patients with AKI subsequently develop AKD [3]. AKI survivors have elevated risks of recurrent AKI incidents and adverse drug reactions [4,5]. Meticulous reconciliation of medications following discharge is paramount given the likely alterations in patients’ current medication regimens due to AKI [4]. Medications that undergo renal processing, possess renoprotective attributes, or have nephrotoxic potential are modifiable elements that can substantially affect post-AKI outcomes [68]. Consequently, the management of medications for AKI survivors must be optimized.
In 2018, the Acute Disease Quality Initiative recommended the inclusion of a comprehensive care bundle for AKI survivors. This bundle, denoted as “KAMPS” (an acronym for kidney function check, advocacy, medication, pressure, and sick-day protocols) (Table 1), pertains to the careful evaluation and subsequent intervention in the context of medications [9]. Recently, the evolving roles and prospective contributions of pharmacists in post-AKI care have garnered increasing attention [1013]. Pharmacists play crucial roles, such as educating patients on medication management throughout the course of AKD; calibrating drug dosages; ensuring no unnecessary nephrotoxic drug exposure in the post-AKI phase; exercising caution in reintroducing indispensable drugs with potential nephrotoxic effects during acute illness settings, such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs); managing comorbidities; and monitoring patients and collaborating with their care teams [10,13]. Pharmacist interventions have been effective in enhancing medication adherence among both patients with CKD and those with AKD [14,15]. A pioneering pilot study in the United States that included pharmacists in post-AKI care teams in primary care settings highlighted pharmacists’ engagement in discerning medication-related problems (MRPs) and offering effective recommendations [13].
In 2006, Taiwan initiated a multidisciplinary team care program for pre-end-stage renal disease (pre-ESRD) patients. By 2021, the program expanded its ambit to include patients with AKD and integrated pharmaceutical care services. However, the precise scope of pharmacists’ contributions within this evolving landscape remains unclear. To date, very few studies have investigated the efficacy of multidisciplinary post-AKI care; moreover, limited data are available on pharmacist-led outpatient pharmaceutical care for AKI survivors, particularly in Asian populations. Therefore, the present study aimed to evaluate the efficacy of pharmacist-delivered outpatient pharmaceutical care for AKI survivors by assessing pharmacist-provided MRP recommendations, changes in patient medication adherence, and the usage of renoprotective and nephrotoxic medications during their AKD period.

Methods

Patients

This retrospective study was conducted at a single medical center and involved survivors of AKI who were enrolled in a multidisciplinary outpatient AKI care program and subsequently referred to a pharmacist-managed clinic (PMC) at National Taiwan University Hospital between March 2022 and January 2023. The participants were followed up for 6 months after enrollment. Eligible participants included adults (≥18 years) who had developed AKI during hospitalization and exhibited an estimated glomerular filtration rate of <45 mL/min/1.73 m2 within 1 month after discharge. AKI was defined and graded by a nephrologist following the KDIGO (Kidney Disease: Improving Global Outcomes) framework, with criteria including an increase in serum creatinine (SCr) by ≥0.3 mg/dL within 48 hours or an increase in SCr to ≥1.5 times baseline [2]. Baseline SCr was defined as the lowest value within the preceding 180 days before hospital admission, or if this information was lacking, as the lowest SCr level during hospitalization. In addition, individuals requiring dialysis for less than 3 months due to AKI and deemed by physicians to have the potential to discontinue dialysis were eligible for inclusion. To alleviate the risk of information bias, individuals who had previously participated in our institution’s pre-ESRD program or similar multidisciplinary care programs for multidisciplinary CKD care before AKI onset were excluded from the study.
This study was approved by the Research Ethics Committee of National Taiwan University Hospital (No. 202207142RINB; 2022). Written informed consent was waived due to the retrospective nature of the study.

Multidisciplinary team

The AKD multidisciplinary team comprised various specialized professionals, such as nephrologists, nurses, dietitians, and a pharmacist. Each specialist conducted an initial consultation with patients within 30 days after discharge, with all specialists meeting on the same day; this was followed by a revisit after 3 months. The nephrologists assumed a central role in the team, offering advanced kidney disease treatment. The nurses coordinated patient care within the team, and the dietitians offered personalized dietary guidance for the patients. The pharmacist, in accordance with the KAMPS framework (Table 1), engaged in medication therapy management (MTM), which included tasks such as ensuring medication reconciliation, performing comprehensive assessments, evaluating medication adherence, and delivering medication-related education [9]. Pharmaceutical care was provided before or after physician consultations. Following each consultation, a succinct personal medication record was generated, outlining current medications, MRPs, and action plans for each patient. Notably, each care session was meticulously documented within the patients’ electronic medical records.

Outcomes of pharmaceutical care

Pharmaceutical care outcomes were assessed across four key dimensions: MRP recommendations, changes in patient medication adherence, usage of renoprotective medications, and exposure to nephrotoxic agents. MRP recommendations provided by pharmacists were quantified and organized, while medication adherence was evaluated using the Adherence to Refills and Medications Scale (ARMS) [16], with scores ranging from 12 (optimal adherence) to 48 (extremely poor adherence). Instances of nonadherence, particularly regarding renoprotective medications and nephrotoxic drugs, were documented. Renoprotective medication evaluation encompassed ACEIs, ARBs, and sodium-glucose cotransporter 2 (SGLT2) inhibitors. The assessment of nephrotoxic drug usage was guided by previous literature [17], with a comprehensive list provided in Table 2. Nephrotoxic agents were categorized into modifiable and non-modifiable types based on patient usage circumstances. Modifiable agents encompassed medications for which non-nephrotoxic alternatives were available, those lacking clear indications, and drugs that patients self-administered. On the other hand, non-modifiable nephrotoxic agents referred to medications deemed essential for treatment, for which substitutions or alterations were not feasible. The assessment of both nephroprotective and nephrotoxic agents was conducted across four stages (pre-AKI, before discharge, first visit, and second visit), tracking patients’ medication profiles before and after AKI onset and during subsequent follow-up visits.

Statistical analysis

Data on the patients’ characteristics and clinical outcomes were manually extracted from their electronic medical records. Categorical data are presented as the number and percentage values, whereas continuous data are presented as the mean ± standard deviation or median (interquartile range) values. The change in ARMS score was assessed using a paired t test, while categorical variables, such as ARMS categorization (=12 or >12), as well as the utilization of nephrotoxic and renoprotective medications, were analyzed using the McNemar test. Statistical significance was set at p < 0.05. All statistical analyses were performed using STATA (version 14.0; StataCorp).

Results

Patient attendance and characteristics

During the study period, 40 patients were referred to the PMC. Of them, 33 adults (82.5%) attended the PMC. Nineteen patients (57.6%) completed the follow-up visits (Fig. 1). The patients’ absence at follow-up visits was attributed to various factors, including loss to follow-up at a nephrology clinic (21.4%), admission or referral to an emergency department (14.3%), death within 3 months (7.1%), administrative oversight (14.3%), and patient-related factors (42.9%).
The demographic characteristics of the cohort are summarized in Table 3. The mean age was 63 years, with 60.6% being men. Notably, 20 patients (60.6%) had CKD before the onset of AKI. Common comorbidities associated with AKI included diabetes mellitus (54.5%), heart failure (39.4%), and malignancy (24.2%). Among the cohort, 25 patients (75.8%) had stage 3 AKI, with 14 patients requiring dialysis during hospitalization and three patients remaining on dialysis upon discharge. The primary etiological factors contributing to AKI were categorized as cardiorenal syndrome (33.3%), infection (27.3%), and medication-related causes (21.2%). Duplicates of etiology were allowed, indicating that patients might have more than one contributing factor to their AKI. After 6 months of follow-up, 17 individuals achieved a SCr level lower than 1.3 times the baseline, two patients discontinued dialysis, three patients were on long-term dialysis, and three patients passed away. Additionally, 14 patients were still receiving multidisciplinary pharmaceutical care for CKD under the purview of the nephrology department.

Pharmacist intervention

The pharmacist involved in this study provided 14 medication-related recommendations to relevant physicians, of which 10 recommendations (71.4%) were accepted and implemented (Table 4; Supplementary Table 1, available online). These recommendations primarily centered on medication reconciliation, comprising 57% of all suggestions. Specifically, these medication reconciliation-related suggestions predominantly pertained to the cessation and resumption of chronic disease medications prescribed long-term for patients during their hospitalization for AKI. Other MRPs included inappropriate dosage based on current renal function, indication (requiring additional therapy), nephrotoxic medication usage, and inadequate medication efficacy (due to low dosage). Four recommendations were not accepted, likely due to concerns regarding the resumption of ezetimibe and valsartan, management of a potential overdose of erythropoiesis-stimulating agents such as methoxy polyethylene glycol-epoetin beta, and an increase in the dosage of valsartan. For the 19 individuals who completed follow-up visits, the average ARMS score before and after the pharmacist’s consultation showed a nonsignificant change (from 13.4 ± 1.5 to 13.2 ± 1.3, p = 0.72) (Fig. 2). Specifically, among those with an ARMS score of 12 (indicating full adherence to the medication regimen and prescription refills in the past month), the number of patients decreased from 9 (47.4%) to 8 (42.1%). Four individuals showed an improvement in adherence (ARMS score decreased to 12), while five individuals exhibited worsened adherence (ARMS score changed from 12 to >12). The findings suggest no significant difference in adherence change (p = 0.99) (Fig. 2). Further exploration of characteristics associated with poor adherence (ARMS >12) based on AKI stage, PMC visit frequency, and polypharmacy (number of medications ≥5) revealed that individuals with AKI stage 1, those who visited the PMC only once, and those using five or more medications had poorer medication adherence (Supplementary Fig. 1, available online). Additionally, the pharmacist identified 16 instances of medication nonadherence among all the 33 patients, including one patient who self-administered a nephrotoxic drug (nonsteroidal anti-inflammatory drug, NSAID) and three patients who voluntarily reduced their intake of renoprotective medications, specifically ARBs. After the pharmacist-led MTM, nonsignificant increases were observed in the numbers of patients using ACEIs or ARBs (p = 0.13) and those using SGLT2 inhibitors (p = 0.99) (Fig. 3). Two patients refrained from resuming ACEIs or ARBs due to low blood pressure or unstable kidney function after AKI, while one patient refrained from resuming SGLT2 inhibitors because of poor kidney function. Overall, there was no reduction observed in the number of patients who had been exposed to at least one nephrotoxic drug before and after AKI, with a usage rate of 63.6% before AKI and 60.6% to 63.6% during the follow-up period after discharge (Fig. 4). The highest proportion of nephrotoxic drug usage was seen in the antibiotic category (particularly beta-lactam drugs) and proton-pump inhibitors. When analyzing modifiable nephrotoxic agents alone, a significant reduction was observed between pre-AKI and after pharmacist intervention (p = 0.03), with the decrease in NSAID usage being the primary contributing factor (reduced from 27.3% to 3.0%).

Discussion

Our findings highlighted that pharmacists involved in caring for AKI survivors can assist in postdischarge medication reconciliation, provide recommendations for minimizing medication discrepancies, and reduce nephrotoxic drug exposure. Our care team is consistent with multidisciplinary teams formed in other post-AKI studies [11,12]. Our pharmacist delivered post-AKI pharmaceutical care in line with the international consensus, offering services similar to those described in other studies [1113].
Pharmacists bring a wealth of expertise to the realm of health care. They recognize potential drug interactions, determine necessary drug dosage adjustments, formulate monitoring plans, and limit nephrotoxic drug exposure, thereby optimizing the selection and dosage of medications [18]. Key components of pharmaceutical care encompass vital tasks such as ensuring medication reconciliation, performing comprehensive medication assessments with a focus on drugs eliminated through the renal route and those known to be nephrotoxic, and providing drug-related education. Notably, our unique approach integrates the routine evaluation of medication adherence.
Previous studies assessing the efficacy of multidisciplinary post-AKI care have predominantly focused on team-based interventions with results of optimizing blood pressure management, reducing the urine albumin-to-creatinine ratio, and enhancing patient knowledge [11,12]. However, limited data are available on the efficacy of interventions targeting medication-related behaviors and MRPs. A Mayo Clinic study on post-AKI pharmaceutical care reported that pharmacists, when working closely with primary care providers, can identify and address MRPs [13]. However, in our study, a relatively low number of medication-related recommendations were provided by the pharmacist. This discrepancy may be attributable to the timing of pharmacist consultation in our study, which predominantly occurred after physician consultation; by contrast, in the aforementioned Mayo Clinic study, pharmacist consultation preceded physician consultation. In this study, a substantial proportion of MRPs was associated with medication discrepancies before and after AKI. However, a considerable percentage of omitted medications were not medications that undergo renal processing or have nephrotoxic potential, such as lipid-lowering agents, levothyroxine, and febuxostat. This underscores the importance of comprehensive assessment.
Research on medication adherence in AKI survivors or patients with AKD is either limited or of low quality [15]. CKD studies have indicated that poor adherence increases the risks of kidney function deterioration and mortality [19,20]. Medication adherence is crucial, regardless of the advancement of kidney disease. In our study, we focused on short-term postdischarge adherence since we included patients within the first month after discharge. Most patients demonstrated good adherence, making it challenging to discern the effects of pharmacist intervention. Upon further investigation, we observed that individuals with lower clinic attendance and those with polypharmacy exhibited poorer adherence, consistent with previous findings [21]. However, the subset of individuals who did not attend follow-up visits after 3 months could not be evaluated for differences before and after pharmacist intervention, potentially introducing selection bias into the interpretation of results. Additionally, there was a slight increase in the proportion of individuals with suboptimal adherence (ARMS >12) at the second visit, suggesting a decline in adherence over time since discharge, highlighting the potential necessity for more frequent interventions and longer follow-up periods. Future research should focus on assessing sustained intervention impact and employ larger sample sizes for comprehensive understanding.
An observational post-AKI study revealed that 87% of all AKI survivors were exposed to at least one nephrotoxin; these individuals had higher risks of de novo or progressive CKD, readmission for AKI, and mortality than nonexposed individuals [22]. Few post-AKI outpatient studies have evaluated the rate of success for nephrotoxin avoidance. In our study, approximately 60% of patients had used at least one nephrotoxic medication, and pharmacist-delivered MTM led to a significant reduction in the use of modifiable nephrotoxic drugs, such as NSAIDs. However, the overall rate of nephrotoxic exposure did not decrease significantly due to the use of essential nephrotoxic drugs such as antibiotics, proton-pump inhibitors, immunosuppressants, and cancer therapies. Extended observation is necessary to assess the sustainability of the effects of pharmacist intervention.
Patients with AKI typically discontinue long-term prescription medications, such as ACEIs, ARBs, and SGLT2 inhibitors, during their hospital stay [5,23]. Observational studies have reported a reduction in the mortality rate among AKI survivors using renin-angiotensin-aldosterone system (RAAS) inhibitors, without any increase in the rate of AKI recurrence [6,24]. Nonetheless, the risks of hyperkalemia and hemodynamically mediated AKI necessitate the personalized assessment of medication re-administration [6,10,17,24]. The effects of SGLT2 inhibitors on post-AKI or AKD outcomes remain unclear; however, long-term studies conducted in high-risk patients, such as those with type 2 diabetes, heart failure, or CKD, have demonstrated that SGLT2 inhibitors can delay kidney function decline and reduce AKI risk [25,26]. Hence, pharmacist-mediated postdischarge medication reconciliation is indispensable for AKI survivors. In the pharmaceutical care for AKI survivors, the pharmacist routinely assessed the usage of these medications. At the second visit, there were increases in the number of users of RAAS inhibitors and SGLT2 inhibitors. However, the resumption of medication use could not be solely attributed to pharmacist intervention. Pharmacists’ assistance in educating patients on monitoring blood pressure, blood sugar, and fluid status might have had an indirect impact. Furthermore, since the number of individuals using these two types of medications before AKI was low, it was challenging to observe significant differences in this regard.
Individuals with a history of AKI are at high risk of unfavorable kidney-related outcomes and adverse drug reactions; therefore, effective MTM is crucial [7,9,27,28]. In Taiwan, post-AKI care is an emerging domain of health care. This study presents a practical model for AKD pharmaceutical care and has yielded preliminary results. However, the small sample size, retrospective study design, and lack of a control group may limit the generalizability of our findings. Therefore, extensive studies are required to elucidate the advantages and multifaceted implications of outpatient pharmacist interventions.
In conclusion, the role of pharmacists in AKD bundled care strategy is paramount given the high risks of kidney-related complications and adverse drug reactions in AKI survivors. Our study clarifies the potential benefits of outpatient pharmacist intervention. Further studies are warranted to comprehensively assess the long-term advantages and implications of pharmacist involvement in AKD care.

Supplementary Materials

Supplementary data are available at Kidney Research and Clinical Practice online (https://doi.org/10.23876/j.krcp.23.306).

Notes

Conflicts of interest

All authors have no conflicts of interest to declare.

Data sharing statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Authors’ contributions

Conceptualization, Formal analysis, Investigation, Methodology: TW

Resources: TLW, CFH

Writing–original draft: TW

Writing–review & editing: HCK, CCW, VCW

All authors read and approved the final manuscript.

Acknowledgments

We would like to express our gratitude to the staff at the National Health Insurance for their support in reimbursing post-AKI care, thereby facilitating optimal pharmaceutical management. Furthermore, we acknowledge valuable support from the following members of the multidisciplinary acute kidney disease care team at National Taiwan University Hospital: Szu-Yu Pan, Thomas Tao-Min Huang, I-Jung Tsai, Yu-Feng Lin, Chih-Yi Hsu, Hui-Chuen Chen.

Figure 1.

Flowchart of patient selection.

AKI, acute kidney injury; PMC, pharmacist-managed clinic; ESRD, end-stage renal disease; ED, emergency department.
j-krcp-23-306f1.jpg
Figure 2.

Comparing medication adherence before and after pharmacist intervention using the ARMS.

ARMS, Adherence to Refills and Medications Scale.
j-krcp-23-306f2.jpg
Figure 3.

Trends in renoprotective medication utilization: prevalence of renoprotective medications at pre-AKI, discharge, and follow-up stages.

(A) Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. (B) Sodium-glucose cotransporter 2 inhibitor. PMC 1 represents patients who attended the PMC only once (n = 14); PMC 2 represents patients who attended the PMC twice (n = 19).
AKI, acute kidney injury; PMC, pharmacist-managed clinic.
j-krcp-23-306f3.jpg
Figure 4.

Nephrotoxic medication trends: prevalence of nephrotoxic medications at pre-AKI, discharge, and follow-up stages.

AKI, acute kidney injury.
j-krcp-23-306f4.jpg
Table 1.
KAMPS framework and MTM for AKI survivors
Action Description
KAMPS framework
 Kidney function check Measure kidney function
 Advocacy Educate patients and caregivers on AKI and CKD
Communicate with other care providers
 Medication Reconcile, review, and manage medications
Discuss the risks and benefits of medications, particularly angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, and diuretics
Review KENDs and over-the-counter medications
 Pressure Ensure patients’ understanding of blood pressure goals and targets
Discuss fluid status, ideal weight, and diuretics’ functions
 Sick-day protocols Educate patients on medications that require monitoring during acute illness
Consider protocols to withhold KENDs
Focal points of MTM for AKI survivors
 Medication reconciliation Review current prescription, nonprescription medications, herbal medicines, and dietary supplements
Identify medication discrepancies before and after admission
 Comprehensive medication assessment Assess renally processed or eliminated drugs, renoprotective medications, and potential drug interactions
Identify medication-related problems
Identify potentially harmful drugs
 Medication adherence Assess medication adherence using the Adherence to Refills and Medications Scale
Describe medication nonadherence in detail
 Education Provide information on AKI, avoiding nephrotoxic agents, and sick-day protocols

AKI, acute kidney injury; CKD, chronic kidney disease; KAMPS, kidney function check, advocacy, medication, pressure, and sick-day protocols; KEND, kidney-eliminated and nephrotoxic drug; MTM, medication therapy management.

Table 2.
List of potentially nephrotoxic medications
Medication class Individual medicationsa
Antibiotics Aminoglycosides Fluoroquinolones TMP/SMX
Beta-lactam drugs Macrolides Vancomycin
Colistin Rifampin
Antifungals Amphotericin B
Antivirals Abacavir Darunavir Tenofovir
Acyclovir Foscarnet
Anticonvulsants Carbamazepine Phenobarbital Phenytoin
Antiangiogenetic drugs Bevacizumab Sorafenib
Chemotherapeutic agents Cisplatin Ifosfamide Pemetrexed
Gemcitabine Methotrexate
Immunosuppressants Cyclosporine Tacrolimus
Immunotherapies Atezolizumab Nivolumab Ipilimumab
Avelumab Pembrolizumab Tremelimumab
Durvalumab
NSAIDs Celecoxib Indomethacin Naproxen
Diclofenac Ketorolac Piroxicam
Etoricoxib Meloxicam Sulindac
Ibuprofen Mefenamic acid Tenoxicam
Proton-pump inhibitors Dexlansoprazole Lansoprazole Pantoprazole
Esomeprazole Omeprazole Rabeprazole
Others Allopurinol Iodinated radiocontrast agents Lithium
Bisphosphonates Mesalamine

NSAID, nonsteroidal anti-inflammatory drugs; TMP/SMX, Trimethoprim/sulfamethoxazole.

a All medications investigated were in systemic formulations. Topical routes and inhalation were not evaluated.

Table 3.
Patient demographics
Characteristic Summary Patients with 1 visit Patients with 2 visits
No. of patients 33 14 19
Age (yr) 63 ± 16 66 ± 15 61 ± 16
Male sex 20 (60.6) 7 (50.0) 13 (68.4)
Comorbidities
 CKD 20 (60.6) 9 (64.3) 11 (57.9)
 Diabetes 18 (54.5) 9 (64.3) 9 (47.4)
 Hypertension 23 (69.7) 9 (64.3) 14 (73.7)
 Heart failure 13 (39.4) 4 (28.6) 9 (47.4)
 Coronary artery disease 6 (18.2) 2 (14.3) 4 (21.1)
 Liver dysfunction 4 (12.1) 2 (14.3) 2 (10.5)
 Malignancy 8 (24.2) 3 (21.4) 5 (26.3)
eGFRa (mL/min/1.73 m2)
 Baseline 44.9 ± 31.0 45.6 ± 31.5 44.5 ± 33.9
 At the time of discharge 23.7 ± 11.7 26.1 ± 14.8 22.1 ± 9.3
 At inclusion (1st visit) 23.3 ± 9.8 23.6 ± 11.6 23.1 ± 8.7
 After 3 mo (2nd visit) 29.1 ± 18.6 26.9 ± 10.4 30.2 ± 21.8
 After 6 mo (follow-up) 30.8 ± 21.0 28.0 ± 5.7 31.9 ± 24.6
No. of medications used at inclusion 9 (7–11) 10 (7–11) 9 (7–10)
AKI staging
 KDIGO stage 1 6 (18.2) 4 (28.6) 2 (10.5)
 KDIGO stage 2 2 (6.1) 1 (7.1) 1 (5.3)
 KDIGO stage 3 25 (75.8) 9 (64.3) 16 (84.2)
Received RRT due to AKI during admission 14 (42.4) 7 (50.0) 7 (36.8)
Still under RRT at inclusion 3 (9.1) 2 (14.3) 1 (5.3)
Etiology of AKIb
 Cardiorenal syndrome 11 (33.3) 4 (28.6) 7 (36.8)
 Infection 9 (27.3) 4 (28.6) 5 (26.3)
 Drug 7 (21.2) 3 (21.4) 4 (21.1)
 Obstructive nephropathy 4 (12.1) 1 (7.1) 3 (15.8)
 Underlying diseases 4 (12.1) 2 (14.3) 2 (10.5)
 Dehydration 1 (3.0) 1 (7.1) 0 (0)
 Hepatorenal syndrome 1 (3.0) 1 (7.1) 0 (0)
Hospital length of stay (day) 19 (9–30) 21 (13–27) 15 (8–30)
Days from onset of AKI to follow-up visit 41 (33–51) 40 (34–47) 41 (31–53)
Days from hospital discharge to follow-up visit 19 (14–24) 16 (14–22) 20 (14–24)

Data are expressed as number only, mean ± standard deviation, number (%), or median (interquartile range).

AKI, acute kidney injury; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; KDIGO, Kidney Disease: Improving Global Outcomes; RRT, renal replacement therapy.

a Exclude patients undergoing dialysis from the calculation.

b Duplicates of etiology were permitted.

Table 4.
Medication-related recommendations to physicians
Medication-related problem Summary Acceptance
Medication reconciliationa 8 6 (75.0)
 Lipid-lowering agents 4 3 (75.0)
 Anti-hypertensives (including RASi) 2 1 (50.0)
 Aspirin 1 1 (100)
 Levothyroxine 1 1 (100)
 Oral hypoglycemic agents 1 1 (100)
 Urate lowing therapy 1 1 (100)
Dosage or frequency 2 1 (50.0)
Indication (need additional therapy) 1 1 (100)
Contraindication (nephrotoxic medication) 1 1 (100)
Efficacy of medication (dose too low) 2 1 (50.0)
Total 14 10 (71.4)

Data are expressed as number only or number (%).

RASi, renin-angiotensin system inhibitors.

a A single medication recommendation may encompass multiple categories of drugs.

References

1. Hoste EA, Kellum JA, Selby NM, et al. Global epidemiology and outcomes of acute kidney injury. Nat Rev Nephrol 2018;14:607–625.
crossref pmid pdf
2. Kellum JA, Lameire N, Aspelin P, et al. Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl 2012;2:1–138.
3. Su CC, Chen JY, Chen SY, et al. Outcomes associated with acute kidney disease: a systematic review and meta-analysis. EClinicalMedicine 2023;55:101760.
crossref pmid
4. Gameiro J, Marques F, Lopes JA. Long-term consequences of acute kidney injury: a narrative review. Clin Kidney J 2021;14:789–804.
crossref pmid pdf
5. Siew ED, Liu KD, Bonn J, et al. Improving care for patients after hospitalization with AKI. J Am Soc Nephrol 2020;31:2237–2241.
crossref pmid pmc
6. Chen JY, Tsai IJ, Pan HC, et al. The impact of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers on clinical outcomes of acute kidney disease patients: a systematic review and meta-analysis. Front Pharmacol 2021;12:665250.
crossref pmid pmc
7. Ostermann M, Bellomo R, Burdmann EA, et al. Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference. Kidney Int 2020;98:294–309.
pmid pmc
8. Goldstein SL, Mottes T, Simpson K, et al. A sustained quality improvement program reduces nephrotoxic medication-associated acute kidney injury. Kidney Int 2016;90:212–221.
crossref pmid
9. Kashani K, Rosner MH, Haase M, et al. Quality improvement goals for acute kidney injury. Clin J Am Soc Nephrol 2019;14:941–953.
crossref pmid pmc
10. Kane-Gill SL, Bauer SR. AKD: the time between AKI and CKD. What is the role of the pharmacist? Hosp Pharm 2017;52:663–665.
crossref pmid pmc pdf
11. Thanapongsatorn P, Chaikomon K, Lumlertgul N, et al. Comprehensive versus standard care in post-severe acute kidney injury survivors, a randomized controlled trial. Crit Care 2021;25:322.
crossref pmid pmc pdf
12. Ortiz-Soriano V, Alcorn JL, Li X, et al. A survey study of self-rated patients’ knowledge about AKI in a post-discharge AKI clinic. Can J Kidney Health Dis 2019;6:2054358119830700.
crossref pmid pmc pdf
13. Herges JR, May HP, Meade L, et al. Pharmacist-provider collaborative visits after hospital discharge in a comprehensive acute kidney injury survivor model. J Am Pharm Assoc (2003) 2023;63:909–914.
crossref pmid
14. Al Raiisi F, Stewart D, Fernandez-Llimos F, Salgado TM, Mohamed MF, Cunningham S. Clinical pharmacy practice in the care of chronic kidney disease patients: a systematic review. Int J Clin Pharm 2019;41:630–666.
crossref pmid pmc pdf
15. Gayatri RM, Ujwala M, Madhur AS, Viriti US. Evaluation of risk factors for the prevalence of kidney failure (CKD & AKD) and the impact of clinical pharmacists role in improving the medication adherence in kidney disease patients of a tertiary care teaching hospital. World J Curr Med Pharm Res 2020;2:171–177.
crossref
16. Kripalani S, Risser J, Gatti ME, Jacobson TA. Development and evaluation of the Adherence to Refills and Medications Scale (ARMS) among low-literacy patients with chronic disease. Value Health 2009;12:118–123.
crossref pmid
17. Perazella MA, Rosner MH. Drug-induced acute kidney injury. Clin J Am Soc Nephrol 2022;17:1220–1233.
crossref pmid pmc
18. Phipps DL, Morris RL, Blakeman T, Ashcroft DM. What is involved in medicines management across care boundaries? A qualitative study of healthcare practitioners’ experiences in the case of acute kidney injury. BMJ Open 2017;7:e011765.
crossref pmid pmc
19. Hu EA, Coresh J, Anderson CA, et al. Adherence to healthy dietary patterns and risk of CKD progression and all-cause mortality: findings from the CRIC (Chronic Renal Insufficiency Cohort) study. Am J Kidney Dis 2021;77:235–244.
crossref pmid
20. Cedillo-Couvert EA, Ricardo AC, Chen J, et al. Self-reported medication adherence and CKD progression. Kidney Int Rep 2018;3:645–651.
crossref pmid pmc
21. Seng JJ, Tan JY, Yeam CT, Htay H, Foo WY. Factors affecting medication adherence among pre-dialysis chronic kidney disease patients: a systematic review and meta-analysis of literature. Int Urol Nephrol 2020;52:903–916.
crossref pmid pdf
22. Schreier DJ, Rule AD, Kashani KB, et al. Nephrotoxin exposure in the 3 years following hospital discharge predicts development or worsening of chronic kidney disease among acute kidney injury survivors. Am J Nephrol 2022;53:273–281.
crossref pmid pdf
23. Alwagdani A, Awad AS, Abdel-Rahman EM. Optimum post-discharge care of acute kidney injury (AKI) survivors. J Clin Med 2022;11:6277.
crossref pmid pmc
24. Siew ED, Parr SK, Abdel-Kader K, et al. Renin-angiotensin aldosterone inhibitor use at hospital discharge among patients with moderate to severe acute kidney injury and its association with recurrent acute kidney injury and mortality. Kidney Int 2021;99:1202–1212.
crossref pmid
25. Bailey CJ, Day C, Bellary S. Renal protection with SGLT2 inhibitors: effects in acute and chronic kidney disease. Curr Diab Rep 2022;22:39–52.
crossref pmid pmc pdf
26. Nuffield Department of Population Health Renal Studies Group; SGLT2 inhibitor Meta-Analysis Cardio-Renal Trialists’ Consortium. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials. Lancet 2022;400:1788–1801.
pmid pmc
27. Macedo E, Bihorac A, Siew ED, et al. Quality of care after AKI development in the hospital: consensus from the 22nd Acute Disease Quality Initiative (ADQI) conference. Eur J Intern Med 2020;80:45–53.
crossref pmid pmc
28. Chawla LS, Bellomo R, Bihorac A, et al. Acute kidney disease and renal recovery: consensus report of the Acute Disease Quality Initiative (ADQI) 16 Workgroup. Nat Rev Nephrol 2017;13:241–257.
crossref pmid pdf


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