Kane‐Gill, Sandra L.

Objectives: Consensus clinical criteria for refractory septic shock were recently developed, but the incidence and outcomes with these criteria are unknown. There were two aims: 1) to describe the incidence of refractory septic shock and 2) to assess outcomes of patients with septic shock meeting refractory septic shock criteria compared with those who did not. Design: Multicohort, retrospective study. For aim 1, a descriptive epidemiologic study was designed to ascertain the cumulative incidence of refractory septic shock in patients with septic shock. For aim 2, a cohort study was conducted to compare hospital mortality between patients meeting refractory septic shock clinical criteria compared with those who did not. Setting: Large U.S. health system from 2012 to 2024. Patients: Adults (age ≥ 18 yr) meeting both Centers for Disease Control and Prevention Adult Sepsis Event and Sepsis-3 clinical criteria for septic shock. Patients with missing hospital discharge disposition and incomplete vasopressor dosage information were excluded. Interventions: None. Measurements and Main Results: Clinical criteria for refractory septic shock were operationalized as concomitant occurrence of norepinephrine (base) equivalent greater than 0.5 µg/kg/min and lactate greater than 2 mmol/L. Risk-adjusted hospital mortality was assessed with a generalized linear mixed-effects model with a random effect for hospital and fixed effects for age, sex, Elixhauser Comorbidity Index, and Sequential Organ Failure Assessment (original description, without cardiovascular component). Of 35,914 patients assessed, 15,732 patients with septic shock were included. Refractory septic shock occurred in 3423 patients (21.8%), with a cumulative incidence of 218 cases (95% CI, 211–224) per 1000 patients with septic shock. Hospital mortality with refractory septic shock was 64.4%, and risk-adjusted hospital mortality odds were 4.87-fold higher (95% CI, 4.46–5.31) compared with patients without refractory septic shock. Conclusions: Clinical criteria for refractory septic shock were fulfilled in about one in five patients with septic shock and associated with substantially higher mortality.

ABSTRACT Pharmacists play a critical role in optimizing medication use, especially in vulnerable populations such as those with chronic kidney disease (CKD). Despite strong evidence and recent guideline endorsements, many pharmacists continue to rely on the Cockcroft–Gault (C‐G) equation for medication dosing. This opinion paper issues a call to action for the widespread adoption of a race‐free, body surface area–adjusted estimated glomerular filtration rate (eGFR BSAadj ) for medication‐related decision‐making, as endorsed by the 2024 Kidney Disease: Improving Global Outcomes CKD guidelines and the National Kidney Foundation and the American Society of Nephrology Taskforce. Persistent variability in pharmacy practice, institutional protocols, and pharmacy education underscores the need for coordinated change. We urge health systems to integrate eGFR BSAadj into electronic health records and clinical decision support to enhance medication decision‐making; institutions to align protocols with contemporary eGFR‐based prescribing standards; pharmacy educators to contemporize and standardize education on kidney function assessment and medication dosing; and regulatory bodies to update licensure and board examinations. The pharmacy profession must act decisively in order to align with evidence‐based, equitable kidney‐related dosing practices and ensure optimal medication management for all patients.

Key Points Pooled discrimination metrics were acceptable (area under the receiver operating characteristic curve >0.70) for all AKI risk classification categories in both internal and external validation. Better performance was observed in most recently published studies and those with a low or unclear risk of bias. Significant heterogeneity in patient populations, definitions, clinical predictors, and methods limit implementation in real-world clinical scenarios. Background Artificial intelligence through machine learning models seems to provide accurate and precise AKI risk classification in some clinical settings, but their performance and implementation in real-world settings has not been established. Methods PubMed, Excerpta Medica (EMBASE) database, Web of Science, and Scopus were searched until August 2023. Articles reporting on externally validated models for prediction of AKI onset, AKI severity, and post-AKI complications in hospitalized adult and pediatric patients were searched using text words related to AKI, artificial intelligence, and machine learning. Two independent reviewers screened article titles, abstracts, and full texts. Areas under the receiver operating characteristic curves (AUCs) were used to compare model discrimination and pooled using a random-effects model. Results Of the 4816 articles initially identified and screened, 95 were included, representing 3.8 million admissions. The Kidney Disease Improving Global Outcomes (KDIGO)-AKI criteria were most frequently used to define AKI (72%). We identified 302 models, with the most common being logistic regression (37%), neural networks (10%), random forest (9%), and eXtreme gradient boosting (9%). The most frequently reported predictors of hospitalized incident AKI were age, sex, diabetes, serum creatinine, and hemoglobin. The pooled AUCs for AKI onset were 0.82 (95% confidence interval, 0.80 to 0.84) and 0.78 (95% confidence interval, 0.76 to 0.80) for internal and external validation, respectively. Pooled AUCs across multiple clinical settings, AKI severities, and post-AKI complications ranged from 0.78 to 0.87 for internal validation and 0.73 to 0.84 for external validation. Although data were limited, results in the pediatric population aligned with those observed in adults. Between-study heterogeneity was high for all outcomes (I 2 >90%), and most studies presented high risk of bias (86%) according to the Prediction Model Risk of Bias Assessment Tool. Conclusions Most externally validated models performed well in predicting AKI onset, AKI severity, and post-AKI complications in hospitalized adult and pediatric populations. However, heterogeneity in clinical settings, study populations, and predictors limits their generalizability and implementation at the bedside.

AbstractBackgroundAccurately estimating glomerular filtration rate (GFR) is crucial for dosing medications in hospitalized patients. Due to limitations of serum creatinine for GFR estimation, serum cystatin C (CysC) has been explored as an alternative functional kidney biomarker. This study assessed discordance between eGFRCr and eGFRCysC in a large sample of hospitalized patients and examined the frequency of renally eliminated medications affected by eGFR discordance.MethodsThis multisite historical study included adults hospitalized between 2011 and 2023 with CysC and serum creatinine reported within 24 h of each other. The first concurrent biomarker pair for each patient was analyzed. eGFR discordance and use of renally eliminated medications were described.Results17,718 hospitalized patients with concurrent creatinine and CysC assessments were included. The median eGFRCr was 65 mL/min, and the eGFRCysC was 46 mL/min. The median absolute difference of eGFRCr−eGFRCysC was 15 mL/min, and 7972 patients (45%) had a > 30% absolute difference. There was a significantly greater percentage of patients with an eGFR <30 mL/min based on eGFRCysC (26%) compared to eGFRCr (15%) (p < 0.001). Patients were prescribed an average of 20 medications in the 24 h surrounding the concurrent biomarker assessment. Renally eliminated medications accounted for 39% ± 13% of medication orders, and 80% of patients with eGFR discordance were prescribed five or more renally eliminated medications.ConclusionSubstantial eGFR discordance between eGFRCysC and eGFRCr was observed in hospitalized patients, which directly affects the dosing of renally eliminated medications. Further research is needed to optimize the pharmacotherapy of renally eliminated medications with discordant GFR assessments to improve medication safety and effectiveness.

The objective of this project was to develop a standardized list of renally eliminated and potentially nephrotoxic drugs that will help inform initiatives to improve medication safety. Several available lists of medications from the published literature including original research articles and reviews, and from regulatory agencies, tertiary references, and clinical decision support systems were compiled, consolidated, and compared. Only systemically administered medications were included. Medication combinations were included if at least 1 active ingredient was considered renally dosed or potentially nephrotoxic. The medication list was reviewed for completeness and clinical appropriateness by a multidisciplinary team of individuals with expertise in critical care, nephrology, and pharmacy. An initial list of renally dosed and nephrotoxic drugs was created. After reconciliation and consensus from clinical experts, a standardized list of 681 drugs is proposed. The proposed evidence-based standardized list of renally dosed and potentially nephrotoxic drugs will be useful to harmonize epidemiologic and medication quality improvement studies. In addition, the list can be used for clinical purposes with surveillance in nephrotoxin stewardship programs. We suggest an iterative re-evaluation of the list with emerging literature and new medications on an approximately annual basis.

Objective: The objective was to explore and describe the role of pharmacists in providing postdischarge care to patients with kidney disease. Data Sources: PubMed, Embase (Elsevier), CINAHL (Ebscohost), Web of Science Core Collection, and Scopus were searched on January 30, 2023. Publication date limits were not included. Search terms were identified based on 3 concepts: kidney disease, pharmacy services, and patient discharge. Experimental, quasi-experimental, observational, and qualitative studies, or study protocols, describing the pharmacist’s role in providing postdischarge care for patients with kidney disease, excluding kidney transplant recipients, were eligible. Study Selection and Data Extraction: Six unique interventions were described in 10 studies meeting inclusion criteria. Data Synthesis: Four interventions targeted patients with acute kidney injury (AKI) during hospitalization and 2 evaluated patients with pre-existing chronic kidney disease. Pharmacists were a multidisciplinary care team (MDCT) member in 5 interventions and were the sole provider in 1. Roles commonly identified include medication review, medication reconciliation, medication action plan formation, kidney function assessment, drug dose adjustments, and disease education. Some studies showed improvements in diagnostic coding, laboratory monitoring, medication therapy problem (MTP) resolution, and patient education; prevention of hospital readmission was inconsistent. Limitations include lack of standardized reporting of kidney disease, transitions of care processes, and differences in outcomes evaluated. Relevance to Patient Care and Clinical Practice: This review identifies potential roles of a pharmacist as part of a postdischarge MDCT for patients with varying degrees of kidney disease. Conclusions: The pharmacist’s role in providing postdischarge care to patients with kidney disease is inconsistent. Multidisciplinary care teams including a pharmacist provided consistent identification and resolution of MTPs, improved patient education, and increased self-awareness of diagnosis.

Background: Goals of managing patients with acute kidney injury (AKI) are mitigating disease progression and ensuring safety while providing supportive care because no effective treatment exists. One strategy recommended in guidelines to meet these goals is optimizing medication management. Unfortunately, guideline implementation appears to be lacking as observed by the frequent occurrence of medication errors and adverse drug events. Objective: To address this performance gap in the care of hospitalized patients receiving nephrotoxins and renally eliminated drugs, we sought to provide a potential intervention based on theory-informed behavior change. Methods: Formative research with a qualitative analysis identifying what needs to change in patient care was completed by obtaining clinician opinion and expert opinion and reviewing the published literature. Frontline providers, including 8 physicians, 4 pharmacists, and a multiprofessional group of authors, provided insight into possible barriers to appropriate prescribing. Capability, Opportunity, Motivation and Behavior model and Theoretical Domain Framework were applied to characterize behavior change interventions and inform a potential implementation intervention for changing inappropriate prescribing behaviors. Results: Lack of knowledge about appropriate drug management in patients at risk for adverse outcomes was provided as a major barrier. Other reported barriers included a lack of: (1) tools to assist with drug management, (2) motivation to make changes, (3) routinization, and (4) an accountable clinician. Conclusions and Relevance: Assigning a designated clinician to execute a stepwise, routine care process following the checklist provided is a recommended intervention to overcome barriers. The intended impact is behavior change that reduces inappropriate prescribing.

AKI is a global concern with a high incidence among patients across acute care settings. AKI is associated with significant clinical consequences and increased health care costs. Preventive measures, as well as rapid identification of AKI, have been shown to improve outcomes in small studies. Providing high-quality care for patients with AKI or those at risk of AKI occurs across a continuum that starts at the community level and continues in the emergency department, hospital setting, and after discharge from inpatient care. Improving the quality of care provided to these patients, plausibly mitigating the cost of care and improving short- and long-term outcomes, are goals that have not been universally achieved. Therefore, understanding how the management of AKI may be amenable to quality improvement programs is needed. Recognizing this gap in knowledge, the 22nd Acute Disease Quality Initiative meeting was convened to discuss the evidence, provide recommendations, and highlight future directions for AKI-related quality measures and care processes. Using a modified Delphi process, an international group of experts including physicians, a nurse practitioner, and pharmacists provided a framework for current and future quality improvement projects in the area of AKI. Where possible, best practices in the prevention, identification, and care of the patient with AKI were identified and highlighted. This article provides a summary of the key messages and recommendations of the group, with an aim to equip and encourage health care providers to establish quality care delivery for patients with AKI and to measure key quality indicators.