Publications by authors named "Marisa Battistella"

59 Publications

A retrospective study of antithrombotic therapy use in an outpatient haemodialysis unit.

J Clin Pharm Ther 2021 Jun 15. Epub 2021 Jun 15.

Department of Pharmacy, University Health Network, Toronto, Ontario, Canada.

What Is Known And Objective: Patients on haemodialysis (HD) are at increased risk of both bleeding and thrombotic events, due to comorbidities and nature of dialysis treatment. However, there is a lack of research on evidence-based treatment strategies and prescribing patterns for antithrombotic therapies (ATT) in this population. To characterize ATT use and its main indications in an outpatient HD unit.

Methods: A single-centre retrospective chart review was conducted in a Toronto outpatient HD unit (n = 329). Medical histories, number of ATTs and corresponding indications were collected from adult patients prescribed at least one ATT from 1 October 2019 to 31 December 2019, inclusive.

Results And Discussion: Of 329 patients in the unit, a total of 135 (41%) patients were on at least one ATT. Of these 135 patients, 80% were on monotherapy (55% antiplatelet, 25.1% anticoagulant), 12.6% were on dual antiplatelet therapy (DAPT), and 7.4% were on a antiplatelet and anticoagulant combination. Primary indications for ATT in our cohort were coronary artery disease (CAD; 55%), atrial fibrillation (18.5%) and venous thromboembolism (VTE; 17%). Described ATT use was in-line with current clinical guidelines. Monotherapy was primarily used in our HD cohort, whereas few patients were on dual therapy. Low-dose aspirin was the most common antiplatelet prescribed for secondary prevention of cardiovascular events. Warfarin monotherapy was primarily indicated for VTE, and DAPT aspirin/clopidogrel was the most commonly prescribed for CAD.

What Is New And Conclusion: Our characterization of ATT use in this HD cohort demonstrates that ATT is often prescribed for a number of different CVD reasons. Overlapping and confounding indications for prescribing ATTs, lack of randomized controlled trials and unclear clinical guidelines mean that individualized risk-benefit assessments for ATT use are still needed to provide care for these high-risk patients. More research to address the safety and efficacy of ATTs is warranted to develop more robust evidence-based treatment guidelines for the HD population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jcpt.13467DOI Listing
June 2021

Management of Diabetes 100 Years After the Discovery of Insulin: Nuances for the Kidney.

Kidney Med 2021 Mar-Apr;3(2):159-161. Epub 2021 Mar 4.

Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.xkme.2021.02.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8039405PMC
March 2021

Development and Validation of Nine Deprescribing Algorithms for Patients on Hemodialysis to Decrease Polypharmacy.

Can J Kidney Health Dis 2020 29;7:2054358120968674. Epub 2020 Oct 29.

Department of Pharmacy, University Health Network, Toronto, ON, Canada.

Background: Polypharmacy is ubiquitous in patients on hemodialysis (HD), and increases risk of adverse events, medication interactions, nonadherence, and mortality. Appropriately applied deprescribing can potentially minimize polypharmacy risks. Existing guidelines are unsuitable for nephrology clinicians as they lack specific instructions on how to deprescribe and which safety parameters to monitor.

Objective: To develop and validate deprescribing algorithms for nine medication classes to decrease polypharmacy in patients on HD.

Design: Questionnaires and materials sent electronically.

Participants: Nephrology practitioners across Canada (nephrologists, nurse practitioners, renal pharmacists).

Methods: A literature search was performed to develop the initial algorithms via Lynn's method for development of content-valid clinical tools. Content and face validity of the algorithms was evaluated over three interview rounds using Lynn's method for determining content validity. Canadian nephrology clinicians each evaluated three algorithms (15 clinicians per round, 45 clinicians in total) by rating each algorithm component on a four-point Likert scale for relevance; face validity was rated on a five-point scale. After each round, content validity index of each component was calculated and revisions made based on feedback. If content validity was not achieved after three rounds, additional rounds were completed until content validity was achieved.

Results: After three rounds of validation, six algorithms achieved content validity. After an additional round, the remaining three algorithms achieved content validity. The proportion of clinicians rating each face validity statement as "Agree" or "Strongly Agree" ranged from 84% to 95% (average of all five questions, across three rounds).

Limitations: Algorithm development was guided by existing deprescribing protocols intended for the general population and the expert opinions of our study team, due to a lack of background literature on HD-specific deprescribing protocols. There is no universally accepted method for the validation of clinical decision-making tools.

Conclusions: Nine medication-specific deprescribing algorithms for patients on HD were developed and validated by clinician review. Our algorithms are the first medication-specific, patient-centric deprescribing guidelines developed and validated for patients on HD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2054358120968674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605037PMC
October 2020

Direct Oral Anticoagulant Use in Chronic Kidney Disease and Dialysis Patients With Venous Thromboembolism: A Systematic Review of Thrombosis and Bleeding Outcomes.

Ann Pharmacother 2021 06 19;55(6):711-722. Epub 2020 Oct 19.

University of Toronto, Toronto, ON, Canada.

Objective: To evaluate how treatment with DOACs for VTE affects thrombosis and bleeding outcomes compared to warfarin in CKD and dialysis patients.

Data Sources: A literature search was conducted for studies evaluating VTE and bleeding outcomes with DOAC use in CKD and dialysis patients. Searches conducted through EMBASE, MEDLINE/PubMed, Scopus, and Cochrane Central Register of Controlled Trials, from inception to September 22, 2020.

Study Selection And Data Extraction: Randomized controlled trials, cohort studies, and case series with ≥10 patients included.

Data Synthesis: From 7286 studies, nine studies met inclusion criteria. There was no significant difference between DOACs (dabigatran, rivaroxaban, apixaban) and warfarin for reducing recurrent VTE and bleeding events in moderate CKD patients. The risk of overall major bleeding increased when the degree of kidney impairment increased. There was no significant difference between apixaban and warfarin for VTE outcomes in dialysis patients.

Relevance To Patient Care And Clinical Practice: There continues to be a controversial debate whether it may be more beneficial to use DOACs versus warfarin in CKD/dialysis patients with venous thromboembolism (VTE). The risk vs benefit of using DOACs in the CKD/ESKD population should continue to be evaluated for each individual patient.

Conclusion: Apixaban may be used cautiously as an alternative in acute VTE treatment in severe CKD patients. Insufficient evidence is available to suggest the use of dabigatran and rivaroxaban in this patient population. The benefit of using DOACs in this population for VTE treatment should be weighed against the potential bleeding risk in patients with CKD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1060028020967635DOI Listing
June 2021

Canadian Society of Nephrology Commentary on the Kidney Disease Improving Global Outcomes 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder.

Can J Kidney Health Dis 2020 4;7:2054358120944271. Epub 2020 Aug 4.

Division of Nephrology, Department of Medicine, Department of Health Research, Evidence and Impact, McMaster University, Hamilton, ON, Canada.

Purpose Of Review: (1) To provide commentary on the 2017 update to the Kidney Disease Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD); (2) to apply the evidence-based guideline update for implementation within the Canadian health care system; (3) to provide comment on the care of children with chronic kidney disease (CKD); and (4) to identify research priorities for Canadian patients.

Sources Of Information: The KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD.

Methods: The commentary committee co-chairs selected potential members based on their knowledge of the Canadian kidney community, aiming for wide representation from relevant disciplines, academic and community centers, and different geographical regions.

Key Findings: We agreed with many of the recommendations in the clinical practice guideline on the diagnosis, evaluation, prevention, and treatment of CKD-MBD. However, based on the uncommon occurrence of abnormalities in calcium and phosphate and the low likelihood of severe abnormalities in parathyroid hormone (PTH), we recommend against screening and monitoring levels of calcium, phosphate, PTH, and alkaline phosphatase in adults with CKD G3. We suggest and recommend monitoring these parameters in adults with CKD G4 and G5, respectively. In children, we agree that monitoring for CKD-MBD should begin in CKD G2, but we suggest measuring ionized calcium, rather than total calcium or calcium adjusted for albumin. With regard to vitamin D, we suggest against routine screening for vitamin D deficiency in adults with CKD G3-G5 and G1T-G5T and suggest following population health recommendations for adequate vitamin D intake. We recommend that the measurement and management of bone mineral density (BMD) be according to general population guidelines in CKD G3 and G3T, but we suggest against routine BMD testing in CKD G4-G5, CKD G4T-5T, and in children with CKD. Based on insufficient data, we also recommend against routine bone biopsy in clinical practice for adults with CKD or CKD-T, or in children with CKD, although we consider it an important research tool.

Limitations: The committee relied on the evidence summaries produced by KDIGO. The CSN committee did not replicate or update the systematic reviews.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2054358120944271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7412914PMC
August 2020

Potentially inappropriate prescribing in older adults with advanced chronic kidney disease.

PLoS One 2020 20;15(8):e0237868. Epub 2020 Aug 20.

Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

Background: Older adults with chronic kidney disease (CKD) are at heightened risk for polypharmacy. We examined potentially inappropriate prescribing in this population and whether introducing pharmacists into the ambulatory kidney care model was associated with improved prescribing practices.

Methods: Retrospective cohort study using linked administrative databases. We included patients with an eGFR ≤30 mL/min/1.73 m2 ≥66 years of age followed in multidisciplinary kidney clinics in Ontario, Canada (n = 25,016 from 28 centres). The primary outcome was the absence of a statin prescription or the receipt of a potentially inappropriate prescription defined by the American Geriatric Society Beers Criteria® and a modified Delphi panel that identified key drugs of concern in CKD. We calculated the crude cumulative incidence and incidence rate for the primary outcome and used change-point regression to determine if a change occurred following pharmacist introduction.

Results: There were 6,007 (24%) and 16,497 patients (66%) not prescribed a statin and with ≥1 potentially inappropriate prescription, respectively. The rate of potentially inappropriate prescribing was 125.6 per 100 person-years and was higher in more recent years. The change-point regression analysis included 2,275 patients from two centres. No immediate change was detected at pharmacist introduction, but potentially inappropriate prescribing was increasing pre-pharmacist introduction, and this rising trend was reversed post-pharmacist introduction. The incidence of potentially inappropriate prescribing still remained high post-pharmacist introduction.

Conclusions: Potentially inappropriate prescribing practices were common. Incorporating pharmacists into the kidney care model may improve prescribing practices. The role of pharmacists in the ambulatory kidney care team warrants further investigation in a randomized controlled trial.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0237868PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7444541PMC
October 2020

Addressing Polypharmacy in Outpatient Dialysis Units.

Clin J Am Soc Nephrol 2020 12 13;16(1):144-146. Epub 2020 Aug 13.

Pharmacy Department, University Health Network, Toronto, Ontario, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2215/CJN.05270420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792641PMC
December 2020

Effect of Therapeutic Drug Monitoring and Cytochrome P450 2C19 Genotyping on Clinical Outcomes of Voriconazole: A Systematic Review.

Ann Pharmacother 2021 04 8;55(4):509-529. Epub 2020 Aug 8.

University of Toronto, ON, Canada.

Objectives: To examine current knowledge on the clinical utility of therapeutic drug monitoring (TDM) in voriconazole therapy, the impact of genotype on voriconazole plasma concentrations, and the role of genotyping in voriconazole therapy.

Data Sources: Three literature searches were conducted for original reports on (1) TDM and voriconazole outcomes and (2) voriconazole and polymorphisms. Searches were conducted through EMBASE, MEDLINE/PubMed, Scopus, and Cochrane Central Register of Controlled Trials from inception to June 2020.

Study Selection And Data Extraction: Randomized controlled trials, cohort studies, and case series with ≥10 patients were included. Only full-text references in English were eligible.

Data Synthesis: A total of 63 studies were reviewed. TDM was recommended because of established concentration and efficacy/toxicity relationships. Voriconazole trough concentrations ≥1.0 mg/L were associated with treatment success; supratherapeutic concentrations were associated with increased neurotoxicity; and hepatotoxicity associations were more prevalent in Asian populations. polymorphisms significantly affect voriconazole metabolism, but no relationship with efficacy/safety were found. Genotype-guided dosing with TDM was reported to increase chances of achieving therapeutic range.

Relevance To Patient Care And Clinical Practice: Genotype-guided dosing with TDM is a potential solution to optimizing voriconazole efficacy while avoiding treatment failures and common toxicities.

Conclusions: Voriconazole plasma concentrations and TDM are treatment outcome predictors, but research is needed to form a consensus target therapeutic range and dosage adjustment guidelines based on plasma concentrations. polymorphisms are a predictor of voriconazole concentrations and metabolism, but clinical implications are not established. Large-scale, high-methodological-quality trials are required to investigate the role for prospective genotyping and establish -guided voriconazole dosing recommendations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1060028020948174DOI Listing
April 2021

Lower opioid and higher adjuvant analgesic use in patients on haemodialysis: A single-centre cross-sectional study.

J Clin Pharm Ther 2020 Dec 22;45(6):1295-1300. Epub 2020 Jul 22.

Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.

What Is Known: Opioids are often used to treat chronic non-cancer pain (CNCP) in patients on haemodialysis. Altered pharmacokinetics in this population increases risk for opioid-related adverse events. Although useful in pain management, there is a lack of opioid prescribing guidance for end-stage kidney disease.

Objective: To characterize opioid usage for CNCP in an outpatient haemodialysis unit.

Methods: Cross-sectional, single-centre, retrospective cohort study of 272 patients receiving outpatient haemodialysis between 01 June and 31 December 2017. Prevalence of prescription or non-prescription opioids, formulation, indication, dosing, prescriber type and therapeutic effectiveness were evaluated.

Results: A total of 27 (10%, aged 58 + 12.1 years, 59% women) patients received opioids for CNCP during the study period. Pain aetiology was diverse; 14 (52%) patients experienced multiple concurrent chronic pain conditions. Hydromorphone (55%) and oxycodone (37%) were the most common prescriptions. A majority (85%) of patients used non-opioid analgesics as adjunct therapy, while half (48%) used benzodiazepines or zopiclone concurrently. Patients who completed a pain scale (n = 10) reported a median pain intensity of 6.8/10 ([IQR], 4.5-7.3).

Discussion: Opioid usage was lower than expected despite a higher prevalence of concurrent chronic pain conditions. Though this was within opioid usage guidelines, pain may not be sufficiently controlled. High concomitant use of benzodiazepines and Z-drugs introduces the potential for additive adverse effects. Judicious opioid usage can be facilitated with stewardship to effectively treat pain while avoiding associated harms and manage potential drug-drug interactions with common concomitant medications.

What Is New And Conclusion: The prevalence of chronic opioid use for non-cancer pain in haemodialysis patients was lower than expected at our centre. Despite following the recommended guidelines, pain management was relatively ineffective, and concomitant use of non-opioid analgesics was widespread. Opioid stewardship is recommended to optimize pain treatment and mitigate drug interaction risks.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jcpt.13208DOI Listing
December 2020

Principles of Drug Dosing in Sustained Low Efficiency Dialysis (SLED) and Review of Antimicrobial Dosing Literature.

Pharmacy (Basel) 2020 Mar 9;8(1). Epub 2020 Mar 9.

Pharmacy Department, University Health Network, Toronto, ON M4G 2C4, Canada.

The use of sustained low-efficiency dialysis (SLED) as a renal replacement modality has increased in critically ill patients with both acute kidney injury (AKI) and hemodynamic instability. Unfortunately, there is a paucity of data regarding the appropriate dosing of medications for patients undergoing SLED. Dose adjustment in SLED often requires interpretation of pharmacodynamics and pharmacokinetic factors and extrapolation based on dosing recommendations from other modes of renal replacement therapy (RRT). This review summarizes published trials of antimicrobial dose adjustment in SLED and discusses pharmacokinetic considerations specific to medication dosing in SLED. Preliminary recommendation is provided on selection of appropriate dosing for medications where published literature is unavailable.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/pharmacy8010033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7151685PMC
March 2020

Quality Improvement Program Improves Time in Therapeutic Range for Hemodialysis Recipients Taking Warfarin.

Kidney Int Rep 2020 Feb 6;5(2):159-164. Epub 2019 Nov 6.

Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada.

Introduction: Studies have shown that achieving a time in therapeutic range (TTR) for warfarin of greater than 60% is associated with a lower risk of bleeding. However, many patients on hemodialysis (HD) do not achieve this target.

Methods: We audited TTR achievement at the in-center HD unit of our hospital in 2017 and found that only 40% of patients had achieved a TTR >60%. We aimed to improve the percentage of HD patients achieving target TTR within 2 years. We reported each patient's individualized trend in quarterly TTR to their primary warfarin prescriber as an audit-feedback report. These reports were generated, disseminated, and subsequently improved following a series of plan-do-study-act cycles. We then used statistical process control to assess for changes in the percentage of HD patients achieving target TTR over time.

Results: In the primary analysis, 28 patients were included in the baseline period, and 46 were included in the intervention period. At baseline, the percentage of patients achieving a TTR >60% varied between 33% and 45% (mean ± SD, 40% ± 5%); post-intervention, this metric improved and varied between 52% and 71% (mean ± SD, 61% ± 8%). In time-series analysis, there was evidence of statistically significant variation between the 2 periods and evidence of sustained improvement.

Conclusions: A quality improvement program consisting of an audit-feedback report that raises awareness of the quality gap in TTR achievement can result in substantial improvement in the safe and efficacious administration of warfarin to patients receiving maintenance hemodialysis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ekir.2019.10.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000800PMC
February 2020

Cultivating Innovative Pragmatic Cluster-Randomized Registry Trials Embedded in Hemodialysis Care: Workshop Proceedings From 2018.

Can J Kidney Health Dis 2019 26;6:2054358119894394. Epub 2019 Dec 26.

ICES, ON, Canada.

Hemodialysis is a life-sustaining treatment for persons with kidney failure. However, those on hemodialysis still face a poor quality of life and a short life expectancy. High-quality research evidence from large randomized controlled trials is needed to identify interventions that improve the experiences, outcomes, and health care of persons receiving hemodialysis. With the support of the Canadian Institutes of Health Research and its Strategy for Patient-Oriented Research, the Innovative Clinical Trials in Hemodialysis Centers initiative brought together Canadian and international kidney researchers, patients, health care providers, and health administrators to participate in a workshop held in Toronto, Canada, on June 2 and 3, 2018. The workshop served to increase knowledge and awareness about the conduct of innovative, pragmatic, cluster-randomized registry trials embedded into routine hemodialysis care and provided an opportunity to discuss and build support for new trial ideas. The workshop content included structured presentations, facilitated group discussions, and expert panel feedback. Partnerships and promising trial ideas borne out of the workshop will continue to be developed to support the implementation of future large-scale trials.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2054358119894394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6933546PMC
December 2019

Medications Used Routinely in Primary Care to be Dose-Adjusted or Avoided in People With Chronic Kidney Disease: Results of a Modified Delphi Study.

Ann Pharmacother 2020 07 2;54(7):625-632. Epub 2020 Jan 2.

Ontario Renal Network, Cancer Care Ontario, Toronto, Ontario, Canada.

Chronic kidney disease (CKD) affects up to 18% of those over the age of 65 years. Potentially inappropriate medication prescribing in people with CKD is common. Develop a pragmatic list of medications used in primary care that required dose adjustment or avoidance in people with CKD, using a modified Delphi panel approach, followed by a consensus workshop. We conducted a comprehensive literature search to identify potential medications. A group of 17 experts participated in a 3-round modified Delphi panel to identify medications for inclusion. A subsequent consensus workshop of 8 experts reviewed this list to prioritize medications for the development of point-of-care knowledge translation materials for primary care. After a comprehensive literature review, 59 medications were included for consideration by the Delphi panel, with a further 10 medications added after the initial round. On completion of the 3 Delphi rounds, 66 unique medications remained, 63 requiring dose adjustment and 16 medications requiring avoidance in one or more estimated glomerular filtration rate categories. The consensus workshop prioritized this list further to 24 medications that must be dose-adjusted or avoided, including baclofen, metformin, and digoxin, as well as the newer SGLT2 inhibitor agents. We have developed a concise list of 24 medications commonly used in primary care that should be dose-adjusted or avoided in people with CKD to reduce harm. This list incorporates new and frequently prescribed medications and will inform an updated, easy to access source for primary care providers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1060028019897371DOI Listing
July 2020

Development and Validation of a Uremic Pruritus Treatment Algorithm and Patient Information Toolkit in Patients With Chronic Kidney Disease and End Stage Kidney Disease.

J Pain Symptom Manage 2020 02 11;59(2):279-292.e5. Epub 2019 Oct 11.

University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada. Electronic address:

Context: Uremic pruritus (UP) affects up to half of all patients with kidney disease and has been independently associated with poor patient outcomes. UP is a challenging symptom for clinicians to manage as there are no validated guidelines for its treatment.

Objectives: The study aimed to develop and validate an algorithm and patient information toolkit for the treatment of UP in patients with kidney disease.

Methods: The study involved a literature search and development of an initial draft algorithm, followed by content and face validation of this algorithm. Validation entailed three rounds of interviews with six nephrology clinicians per round. Participants assessed the relevance of each component of the algorithm and then rated a series of statements on a scale of 1-5 to assess face validity of the algorithm. After each round, the content validity index (CVI) of each algorithm component was calculated, and the algorithm was revised by the study team in response to findings. This process was followed by a second study that developed and validated a patient information pamphlet and video.

Results: Algorithm validation participants were affiliated with three institutions and included seven physicians, four registered nurses, three nurse practitioners, three pharmacists, and a dietician. The average CVI of the algorithm components across all three rounds was 0.89, with 0.80 commonly cited as the lower acceptable limit for content validation. More than 78% of participants rated each face validity statement as "Agree" or "Strongly Agree". For the patient information tools, five clinicians and 15 patients were included in validation. The average CVI was 1.00 for both tools, and the average face validity was 92%.

Conclusion: A treatment algorithm and patient information toolkit for managing UP in patients with kidney disease were developed and validated through expert review. Further research will be conducted on implementation of the treatment algorithm and evaluating patient-reported outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpainsymman.2019.10.003DOI Listing
February 2020

Cardiologists' and nephrologists' management of atrial fibrillation in hemodialysis patients
.

Clin Nephrol 2019 Nov;92(5):226-232

Background: Antithrombotic therapy for stroke prevention in atrial fibrillation (AF) is considered a standard of care, but for hemodialysis (HD) patients the benefits are unclear, and bleeding risks are high. Our study objective was to compare cardiologists' and nephrologists' stroke prevention practices in different patient risk scenarios.

Materials And Methods: A cross-sectional, online survey was distributed to members of three Canadian physician societies (Nephrology, Cardiovascular, Heart Rhythm), and to cardiologists affiliated with three Canadian Universities. The questionnaire included four AF scenarios in HD patients with varying stroke and bleeding risks. Physicians selected one of six antithrombotic therapy options for each scenario.

Results: Cardiologists were 3 times more likely than nephro-logists to choose anticoagulant therapy over both antiplatelet and no drug therapy, regardless of stroke or bleeding risk (p < 0.001). Physicians' drug therapy choices in regards to level of stroke and bleeding risk reflected the expected pattern based on current evidence.

Conclusion: Cardiologists were more likely to prescribe anticoagulant therapy for AF in the HD population compared to nephrologists, regardless of patient stroke or bleeding risk.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5414/CN109724DOI Listing
November 2019

Clinical Outcomes of Failing to Dose-Reduce Cephalosporin Antibiotics in Older Adults with CKD.

Clin J Am Soc Nephrol 2019 02 10;14(2):197-205. Epub 2019 Jan 10.

Institute for Clinical Evaluative Sciences, Ontario, Canada;

Background And Objectives: Current dosing recommendations for cephalosporin antibiotics are on the basis of pharmacokinetic studies and are frequently ignored in practice. This study was undertaken to investigate the clinical outcomes of failing to dose-reduce cephalosporin antibiotics in CKD.

Design, Setting, Participants, & Measurements: Retrospective cohort study conducted in Ontario, Canada using linked population-based health care databases. Nine thousand three hundred forty-seven outpatients (median age 83; interquartile range, 77-88 years; 57% women) with an eGFR<30 ml/min per 1.73 m and no prior history of dialysis were dispensed oral cephalexin, cefuroxime, or cefprozil between April of 2007 and March of 2016. Two thirds of the patients (6253 of 9347) received a higher than recommended daily dose of cephalexin (>1000 mg), cefuroxime (>500 mg), or cefprozil (>500 mg). The primary outcome was a hospital encounter (emergency room visit or hospital admission) with a condition listed as a possible side-effect of cephalosporins. Secondary outcomes were antibiotic treatment failure and all-cause mortality. All measures were assessed in the 30 days after cephalosporin initiation.

Results: Patients who received a higher than recommended dose of a cephalosporin antibiotic were similar in multiple indicators of baseline health to patients who received a reduced dose. Overall, 6% of patients presented to hospital with a possible cephalosporin side-effect, 13% failed antibiotic treatment, and 3% died. Compared with a reduced dose, receiving a higher dose of antibiotic was not associated with a different rate of side-effects (adjusted odds ratio, 1.00; 95% confidence interval, 0.84 to 1.20), treatment failure (1.01; 0.88 to 1.15), or death (0.99; 0.76 to 1.29).

Conclusions: In this study we failed to demonstrate any association between the dose of cephalosporin antibiotic administered to elderly patients with CKD and the risk of side-effects leading to hospitalization, treatment failure, or mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2215/CJN.10710918DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6390923PMC
February 2019

Pharmacokinetic Study of Cefazolin in Short Daily Hemodialysis.

Ann Pharmacother 2019 04 20;53(4):348-356. Epub 2018 Oct 20.

1 University Health Network, Toronto, ON, Canada.

Background: A number of centers across the world offer short daily hemodialysis (SDHD) treatments. To date, cefazolin pharmacokinetics have not been described in patients undergoing SDHD.

Objective: The purpose of this study was to investigate the effect of SDHD on the pharmacokinetics of cefazolin.

Methods: This was a prospective, open-label, pharmacokinetic study of cefazolin during SDHD in 10 noninfected patients. Participants received a 1-g intravenous (IV) infusion of cefazolin after SDHD on study day 1 and a second dose after SDHD on study day 2. To determine the concentration of cefazolin, 6 blood samples were drawn at 0, 1, 2, 2.3, 4, and 24 hours after initiation of dialysis on day 2, and 2 dialysate samples were drawn at 1 and 2 hours after initiation of dialysis on day 2. Samples were analyzed using high-performance liquid chromatography, and pharmacokinetic parameters were determined.

Results: Median interdialysis clearance was 0.16 L/h (interquartile range [IQR]: 0.11-0.21 L/h), and median intradialysis clearance was 1.95 L/h (IQR: 1.66-2.45 L/h). Median interdialysis half-life was 28.2 hours (IQR: 23.5-59.3 hours) as compared with a median intradialysis half-life of 2.3 hours (IQR: 1.7-2.7 hours). The median percentage removal of cefazolin during dialysis was 41% (IQR: 35%-53%). Conclusion and Relevance: Estimated cefazolin dialysis clearance is similar to previous estimates with conventional thrice-weekly regimens. Current dosing recommendations of 1 g IV post-SDHD achieve total serum drug concentrations greater than 40 mg/L in all patients, which is the total drug concentration required for bactericidal activity against Staphylococcus species.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1060028018809695DOI Listing
April 2019

A Province-wide, Cross-sectional Study of Demographics and Medication Use of Patients in Hemodialysis Units Across Ontario.

Can J Kidney Health Dis 2018 13;5:2054358118760832. Epub 2018 Mar 13.

Institute for Clinical Evaluative Sciences, London, Ontario, Canada.

Background: Hemodialysis patients are at an increased risk of polypharmacy as they have the highest pill burden of all chronically ill patient populations, with an estimated average of 12 medications per day.

Objectives: The aim of this study was to evaluate prescribing patterns of outpatient medications in patients receiving in-center hemodialysis. This was done to identify potential candidate medications for future quality improvement initiations to optimize prescribing.

Design: We conducted a descriptive retrospective cross-sectional study in the province of Ontario, Canada, using several linked health care databases housed at the Institute for Clinical Evaluative Sciences (ICES).

Setting: We considered outpatient medications dispensed to patients eligible for the Ontario Drug Benefit program.

Patients: Patients were receiving chronic in-center hemodialysis at one of the 69 facilities in the province of Ontario, Canada as of October 1, 2013.

Measurements: We assessed whether any of our 28 study medications of interest were recently dispensed (within the prior 120 days), the type of prescribing physician, and the associated medication costs. The 28 included medications of interest (ie, proton pump inhibitors, benzodiazepines) were selected because they may not have a true indication for dialysis patients and/or there are safety concerns with their use in this population. Results are presented as median (25th, 75th percentile).

Methods: We conducted this study at ICES according to a prespecified protocol approved by the Research Ethics Board at Sunnybrook Health Sciences Centre (Toronto, Ontario).

Results: A total of 3094 patients on chronic in-center hemodialysis received a study drug of interest (age: 76.5 years [SD: 7.3]), 44% women). Patients were dispensed 11 (8, 14) unique medication products with more than two-thirds of patients dispensed 9 or more different medications. The median number of annual health care visits was 7 (3-15) with more than half the cohort receiving prescriptions from 3 or more specialists. The 10 most commonly dispensed study medications cost more than 3 million dollars in direct costs in 1 year.

Limitations: Our study was also subjected to some limitations of health care databases.

Conclusions: Polypharmacy is frequent in in-center hemodialysis patients. To decrease polypharmacy and its associated negative outcomes, health care providers need to implement tools to optimize medication use and deprescribe medications that lack evidence for efficacy and safety in hemodialysis patients. Therefore, strategies to improve prescribing and discontinue ineffective medications warrant testing for better patient outcomes and reduced health care costs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2054358118760832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858734PMC
March 2018

A systematic review of direct oral anticoagulant use in chronic kidney disease and dialysis patients with atrial fibrillation.

Nephrol Dial Transplant 2019 02;34(2):265-277

Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.

Background: There is a lack of clear benefit and a potential risk of bleeding with direct oral anticoagulant (DOAC) use in chronic kidney disease (CKD) and dialysis patients with atrial fibrillation. The objective of this study was to evaluate how treatment with DOACs affects stroke and bleeding outcomes compared with warfarin or aspirin.

Methods: We conducted a systematic review of randomized controlled trials, cohort studies and case series, and searched electronic databases from 1946 to 2017. Studies evaluating stroke and bleeding outcomes with DOAC use in CKD and dialysis patients were included.

Results: From 8008 studies, 10 met the inclusion criteria. For moderate CKD patients (estimated glomerular filtration rate  <60 mL/min/1.73 m2), there was no difference in stroke outcomes between dabigatran 110 mg [hazard ratio (HR) 0.78, 95% confidence interval (95% CI) 0.51-1.21], rivaroxaban (HR 0.82-0.84, 95% CI 0.25-2.69) and edoxaban (HR 0.87, 95% CI 0.65-1.18) versus warfarin. Dabigatran (150 mg twice daily) and apixaban reduced risk of stroke or systemic embolism significantly more than warfarin for moderate CKD patients (HR 0.55, 95% CI 0.34-0.89 and HR 0.61, 95% CI 0.39-0.94, respectively). Edoxaban and apixaban were associated with reduced major bleeding events (HR 0.50-0.76) compared with warfarin. Rivaroxaban and dabigatran 110 mg and 150 mg showed no significant difference in major bleeding versus warfarin. In hemodialysis (HD) patients, there was no difference in stroke outcomes between apixaban, dabigatran [relative risk (RR) 1.71, 95% CI 0.97-2.99] or rivaroxaban (RR 1.8, 95% CI 0.89-3.64) versus warfarin. In HD patients, rivaroxaban and dabigatran were associated with an increased major bleeding risk (RR 1.45-1.76), whereas there was no major bleeding difference with apixaban compared to warfarin.

Limitations: The heterogeneity of major bleeding and stroke definitions of the 10 included studies.

Conclusions: Clinicians should continue to weigh the risk of stroke versus bleeding before prescribing DOACs in the CKD and dialysis population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ndt/gfy031DOI Listing
February 2019

Acute kidney injury secondary to lymphoma.

CANNT J 2017 Jan-Mar;27(1):19-22

View Article and Find Full Text PDF

Download full-text PDF

Source
January 2018

Warfarin Use in Hemodialysis Patients With Atrial Fibrillation: A Systematic Review of Stroke and Bleeding Outcomes.

Can J Kidney Health Dis 2017 20;4:2054358117735532. Epub 2017 Oct 20.

Leslie Dan Faculty of Pharmacy, University of Toronto, Ontario, Canada.

Background: Given the lack of clear indications for the use of warfarin in the treatment of atrial fibrillation (AF) in patients on hemodialysis and the potential risks that accompany warfarin use in these patients, we systematically reviewed stroke and bleeding outcomes in hemodialysis patients treated with warfarin for AF.

Objective: To systematically review the stroke and bleeding outcomes associated with warfarin use in the hemodialysis population to treat AF.

Design: Systematic review.

Setting: All adult hemodialysis patients.

Patients: Patients on hemodialysis receiving warfarin for the management of AF.

Measurements: Any type of stroke and/or bleeding outcomes.

Methods: MEDLINE(R) In-Process & Other Non-Indexed Citations and MEDLINE(R) via OVID (1946 to January 11, 2017), and EMBASE via OVID (1974 to January 11, 2017) were searched for relevant literature. Inclusion criteria were randomized controlled trials, observational studies, and case series in English that examined stroke and bleeding outcomes in adult population of patients (over 18 years old) who are on hemodialysis and taking warfarin for AF. Studies with less than 10 subjects, case reports, review articles, and editorials were excluded. Quality of selected articles was assessed using Newcastle-Ottawa Scale (NOS).

Results: Of the 2340 titles and abstracts screened, 7 met the inclusion criteria. Two studies showed an association between warfarin use and an increased risk of stroke (Hazard Ratio: 1.93-3.36) but no association with an increased risk of bleed (HR: 0.85-1.04), while 4 studies showed no association between warfarin and stroke outcomes (HR: 0.12-1.17) but identified an association between warfarin and increased bleeding outcome (HR: 1.41-3.96). And 1 study reported neither beneficial nor harmful effects associated with warfarin use.

Limitations: The major limitation to this review is that the 7 included studies were observational cohort studies, and thus the outcome measures were not specified and predetermined in a research protocol.

Conclusion: Our systematic review demonstrated that for patients with AF who are on hemodialysis, warfarin was not associated with reduced outcomes of stroke but was rather associated with increased bleeding events.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2054358117735532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5652660PMC
October 2017

Targeted Deprescribing in an Outpatient Hemodialysis Unit: A Quality Improvement Study to Decrease Polypharmacy.

Am J Kidney Dis 2017 Nov 14;70(5):611-618. Epub 2017 Apr 14.

Department of Pharmacy, University Health Network, Toronto, Ontario, Canada; Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Background: Polypharmacy in hemodialysis patients can result in adverse patient outcomes. Deprescribing tools can reduce polypharmacy, yet no method exists for an outpatient hemodialysis population.

Design: Quality improvement study.

Setting & Participants: 240 patients in a tertiary-care outpatient hemodialysis unit.

Quality Improvement Plan: We aimed to: (1) develop a deprescribing tool for target medications with poor evidence for efficacy and safety, (2) determine its effectiveness in decreasing polypharmacy, and (3) monitor patient safety and satisfaction.

Outcomes: The primary outcome was the proportion of target medications completely deprescribed after 4 weeks. Secondary outcomes were the proportion of target medications completely deprescribed after 6 months, average number of medications per patient before and after deprescription, and proportion of successful deprescriptions for each target medication.

Measurements: Number of medications deprescribed at 4 weeks and 6 months. Patient safety and satisfaction were monitored using drug-specific monitoring parameters.

Results: A deprescribing tool for specific medications was developed and implemented in the hemodialysis unit. 5 medication classes were selected: quinine, diuretics, α-blockers, proton pump inhibitors, and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins). All 240 patients in the unit were screened using the deprescribing tool. There were 171 of 240 (71%) patients prescribed at least 1 of the 5 target medications, and after applying the tool, 35 of 40 (88%) eligible patients had the medications deprescribed. There were 31 of 40 (78%) target medications completely deprescribed. 6 months after the study, only 5 of 31 (16%) medications discontinued were represcribed. At the end of the study, 57% of patients were taking fewer medications than at baseline. No adverse events were observed.

Limitations: Single-center study that relied on patient self-reporting of medication use and adherence to our recommendations.

Conclusions: Deprescribing tools can be applied successfully in an outpatient hemodialysis unit to reduce polypharmacy while maintaining patient safety and satisfaction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.ajkd.2017.02.374DOI Listing
November 2017

An Observational Case Study of Near-peer Teaching in Medical and Pharmacy Experiential Training.

Am J Pharm Educ 2016 Sep;80(7):114

University of Toronto, Toronto, Ontario, Canada.

To compare peer teaching in a medical and a pharmacy clinical teaching unit and to provide suggestions for future research in pharmacy near-peer teaching. This exploratory observational study used principles of ethnographic methodology for data collection and analysis. Observations were collected in a large downtown teaching hospital. An average of 4-6 hours per day were spent observing a team of medical trainees from the Faculty (School) of Medicine in the general internal medicine (unit for two weeks, followed by a team of pharmacy trainees in an ambulatory hemodialysis (HD) unit for two weeks. Data was collected through field notes and informal interviews that were audiotaped and subsequently transcribed. Data was interpreted by the observer and reviewed weekly by two impartial pharmacists. Five major themes emerged: (1) influence of peer teaching hierarchy; (2) educational distance between peer learners and teachers; (3) effect of the clinical teaching unit size on peer learning; (4) trainees' perception of their teaching role in the clinical teaching unit; and (5) influence of daily schedule and workload on peer teaching. As opposed to pharmacy, a hierarchy and pyramidal structure of peer teaching was observed in medical experiential training. There appeared to be no effect of educational distance on near peer teaching; however, perception of teaching role and influence of daily schedule affected near-peer teaching. Through initial comparisons of medical and pharmacy clinical teaching units, this study provides a reflection of elements that may be necessary to successfully implement near-peer teaching in pharmacy experiential training. Future studies in this area should assess learning outcomes and participant satisfaction, preceptor workload, and impact on patient care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5688/ajpe807114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5066917PMC
September 2016

Update on phosphate binders: The old and the new.

CANNT J 2016 Jan-Mar;26(1):17-21; quiz 22-3

View Article and Find Full Text PDF

Download full-text PDF

Source
June 2016

An introduction to chemotherapy-associated nephrotoxicity.

CANNT J 2015 Oct-Dec;25(4):19-23; quiz 24-5

View Article and Find Full Text PDF

Download full-text PDF

Source
April 2016

Delusional parasitosis in patients on dialysis.

CANNT J 2015 Apr-Jun;25(2):40-3; quiz 44-5

View Article and Find Full Text PDF

Download full-text PDF

Source
April 2016

Deprescribing: Is there a role in hemodialysis?

CANNT J 2015 Jan-Mar;25(1):21-3; quiz 24-5

View Article and Find Full Text PDF

Download full-text PDF

Source
April 2016

Development, validation, and implementation of a medication adherence survey to seek a better understanding of the hemodialysis patient.

Clin Nephrol 2016 Jan;85(1):12-22

Background: Factors contributing to non-adherence have become a priority for clinicians, healthcare policy makers, and healthcare payers alike. Patients who are non-adherent to their medication regimen appear to have poor health outcomes, with evidence of both high mortality rates and high morbidity in the form of more frequent emergency room admissions, recurrent exacerbations of disease, and poor overall well-being. The primary objective of this study was to identify and describe patient-identified factors associated with non-adherence in patients maintained on chronic hemodialysis.

Methods: A 23-item questionnaire was developed and validated for use in the hemodialysis population. This questionnaire was administered to patients undergoing chronic hemodialysis in a single center during the period of October to December 2013.

Results: A total of 156/183 eligible patients consented. Of these 156 patients, 36 (23%) patients reported being non-adherent. The most common non-adherent behaviors were changing the frequency of taking medications and skipping doses. Patients identified information gaps around medication interactions, the flexibility around drug timings, and how best to manage medications that needed to be taken apart from, with, or without food.

Conclusions: Our study shows that, despite an intensive drug education program, almost one quarter of patients continue to have problems with taking medication and that traditional education around medications is insufficient. We propose that clinicians customize education to the patient-driven gaps in knowledge, in particular focusing on the education needed to empower patients to recognize which aspects of their care they can and should modify and which aspects require further clinician input.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5414/CN108654DOI Listing
January 2016

Measuring pain in patients undergoing hemodialysis: a review of pain assessment tools.

Clin Kidney J 2014 Aug 1;7(4):367-72. Epub 2014 Jul 1.

Pharmacy , University Health Network, University of Toronto , Toronto, ON , Canada.

Background: Patients undergoing hemodialysis frequently report pain with multifactorial causes, not limited to that experienced directly from hemodialysis treatment. Their pain may be nociceptive, neuropathic, somatic or visceral in nature. Despite this, pain in this population remains under-recognized and under-treated. Although several tools have been used to measure pain in patients undergoing hemodialysis as reported in the literature, none of them have been validated specifically in this population. The objective for this review was to compare and contrast these pain assessment tools and discuss their clinical utility in this patient population.

Methods: To identify pain assessment tools studied in patients undergoing hemodialysis, a literature search was performed in PubMed and Medline. An expert panel of dialysis and pain clinicians reviewed each tool. Each pain assessment tool was assessed on how it is administered and scored, its psychometric properties such as reliability, validity and responsiveness to change, and its clinical utility in a hemodialysis population. Brief Pain Inventory, McGill Pain Questionnaire, Pain Management Index, Edmonton Symptom Assessment System, Visual Analogue Scale and Faces Pain Scale were evaluated and compared.

Results: This assessment will help clinicians practicing in nephrology to determine which of these pain assessment tools is best suited for use in their individual clinical practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ckj/sfu067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4377812PMC
August 2014
-->