The Center for Acute Care Nephrology Drug Induced Kidney Injury: Prevention and Management Strategies Stuart L. Goldstein, MD Clark D. West Endowed Chair Professor of Pediatrics University of Cincinnati College of Medicine Director, Center for Acute Care Nephrology Medical Director, Pheresis Service Cincinnati Children’s Hospital Medical Center
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The Center for Acute Care Nephrology
Drug Induced Kidney Injury:Prevention and Management Strategies
Stuart L. Goldstein, MDClark D. West Endowed Chair
• One of the most common causes of AKI in non-critically ill hospitalized children
• A portion of NTMx-AKI goes unnoticed due to lack of systematic kidney function surveillance in exposed children
• Multiple studies show SCr measured at least every four days only 50% of the time in children receiving multiple NTMx
• NTMx-AKI may be a potentially modifiable adverse safety event if• At-risk patients are identified• Systematic SCr monitoring is instituted reliably in at-risk patients• AKI is avoided and/or mitigated by reducing unnecessary NTMx exposure
The Center for Acute Care Nephrology
NINJA Vision Statement
Children should only get the nephrotoxic medications they need
for the duration they need them
The Center for Acute Care Nephrology
• Patients receiving IV AG > 5 days• Primary renal diagnoses excluded• One year of study
• 557 children• 95% > 3 months of age• AKI occurred in
• SCr measured at least q4 days only 50% of the time
The Center for Acute Care Nephrology
• 350 non-critically ill children with AKI by pRIFLE• 350 matched children without AKI• 38 potential NTMx• Compared NTMx exposure rate between AKI vs. non-
AKI patients• 86% exposed to at least 1 NTMx• Patients with AKI had 1.7 OR for exposure to a NTMx• PPV for AKI doubles for patient with 3+ NTMx
The Center for Acute Care Nephrology
Background
Nephrotoxic medication (NTMx)-associated Acute Kidney Injury (AKI) is one of the most common causes of AKI in hospitalized children.
The Center for Acute Care Nephrology
Background
Nephrotoxic medication (NTMx)-associated Acute Kidney Injury (AKI) is one of the most common causes of AKI in hospitalized children.
Recent studies demonstrate that NTMx-AKI occurs at higher than previously recognized rates.
The Center for Acute Care Nephrology
Background
Nephrotoxic medication (NTMx)-associated Acute Kidney Injury (AKI) is one of the most common causes of AKI in hospitalized children.
Recent studies demonstrate that NTMx-AKI occurs at higher than previously recognized rates.
A portion of NTMx-AKI goes unnoticed due to lack of kidney function surveillance in susceptible children.
The Center for Acute Care Nephrology
Background
Nephrotoxic medication (NTMx)-associated Acute Kidney Injury (AKI) is one of the most common causes of AKI in hospitalized children.
Recent studies demonstrate that NTMx-AKI occurs at higher than previously recognized rates.
A portion of NTMx-AKI goes unnoticed due to lack of kidney function surveillance in susceptible children.
The Center for Acute Care Nephrology
Objectives of NINJA
• Develop and EHR-based AKI screening intervention to assess changes in AKI prevalence, or duration (intensity)
• RELIABLY QUANTIFY the rate of High NTMx exposure and NTMx-AKI in the non-critical care population.
The Center for Acute Care Nephrology
High NTMx-exposure Criteria
Patient receiving 3 or more nephrotoxic medications (NTMx) concomitantly*
orOn an aminoglycoside for 3 or more days
*IV radiology contrast, amphotericin, or cidofovir in previous week is counted for the week following administration
The Center for Acute Care Nephrology
Nephrotoxic Medication List
The Center for Acute Care Nephrology
AKI Definition
The Center for Acute Care Nephrology
Outcome Measures
The Center for Acute Care Nephrology
The Process
Pharmacists create/receive daily reports,
verify & validate
Provide SCr screening
suggestions if necessary
Data Analyst compiles
registry from Pharmacist reports…
…and generate
metrics, run charts
Share with AKI team,
leadership, other
stakeholders
The Center for Acute Care Nephrology
AKI Surveillance Algorithm
Meets High NTMx Exposure Criteria
Exposure surveillance loop
Injury surveillance loop
End Surveillance
The Center for Acute Care Nephrology
The Center for Acute Care Nephrology
The Center for Acute Care Nephrology
Inclusion Flowchart
Data span June 2, 2011 – June 4, 2012
99% compliance with daily SCrmonitoring in all
high NTMx-exposed patients
The Center for Acute Care Nephrology
The Center for Acute Care Nephrology
Initial AKI prevalence rates 10-fold higher than CAUTI rates and 3-fold higher than CLBSI rates at CCHMC
The Center for Acute Care Nephrology
AKI intensity decreases in Year 1 of the project by 42%
*Data presented for partial year. Annualized values represent if data were extrapolated to full time period. Study period in 2011 (Sept – Dec), in 2015 (January – March). All aggregate data are actual count.
Adverse Events Avoided
The Center for Acute Care Nephrology
Cost Implications – A Theoretical Model
• Costs incurred• Daily creatinine• Prolonged hospital admission for AKI detection• Follow up clinic and labs since AKI detected• Medications to slow CKD progression
High NTMx Exposured Patients per 1000 Patient Days Oncology/Hematology Patients
Monthly High NTMx Exposure Patients Average Monthly High NTMx Expsoure Rate Control Limits
(Hospital Rate - 7.5/1000 Days)
The Center for Acute Care Nephrology
Contr
ast P
rotec
tion P
rotoc
olPh
arma
cist R
ound
ing/N
TMx I
mpac
t Aler
t
Vanc
omyc
in St
ewar
dship
Phar
macy
Sma
rtPhr
ase
Cefep
ime v
s Zos
yn16.08
11.19
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
Jul-1
3Au
g-13
Sep-
13Oc
t-13
Nov-1
3De
c-13
Jan-
14Fe
b-14
Mar-1
4Ap
r-14
May-1
4Ju
n-14
Jul-1
4Au
g-14
Sep-
14Oc
t-14
Nov-1
4De
c-14
Jan-
15Fe
b-15
Mar-1
5Ap
r-15
May-1
5Ju
n-15
Jul-1
5Au
g-15
Sep-
15Oc
t-15
Nov-1
5De
c-15
Jan-
16Fe
b-16
Mar-1
6Ap
r-16
May-1
6Ju
n-16
Jul-1
6Au
g-16
Sep-
16Oc
t-16
Nov-1
6De
c-16
Jan-
17Fe
b-17
Mar-1
7
High
NTM
x Exp
osur
e Pat
ients
Monthly
High NTMx Exposured Patients per 1000 Patient Days Oncology/Hematology Patients
Monthly High NTMx Exposure Patients Average Monthly High NTMx Expsoure Rate Control Limits
(Hospital Rate - 7.5/1000 Days)
The Center for Acute Care Nephrology
Contr
ast P
rotec
tion P
rotoc
olPh
arma
cist R
ound
ing N
TMx I
mpac
t Aler
t
Vanc
omyc
in St
ewar
dship
Phar
macy
Sma
rtPhr
ase
Cefep
ime v
s Zos
yn
3.48
1.92
0.0
2.0
4.0
6.0
8.0
10.0
12.0Ju
l-13
Aug-
13Se
p-13
Oct-1
3No
v-13
Dec-1
3Ja
n-14
Feb-
14Ma
r-14
Apr-1
4Ma
y-14
Jun-
14Ju
l-14
Aug-
14Se
p-14
Oct-1
4No
v-14
Dec-1
4Ja
n-15
Feb-
15Ma
r-15
Apr-1
5Ma
y-15
Jun-
15Ju
l-15
Aug-
15Se
p-15
Oct-1
5No
v-15
Dec-1
5Ja
n-16
Feb-
16Ma
r-16
Apr-1
6Ma
y-16
Jun-
16Ju
l-16
Aug-
16Se
p-16
Oct-1
6No
v-16
Dec-1
6Ja
n-17
Feb-
17Ma
r-17
AKI P
atien
ts
Monthly
AKI associated with High NTMX Exposure Rate per 1000 Patient Days Oncology/Hematology Patients
Monthly AKI Patients Average Monthly AKI Rate Control Limits
(Hospital Rate - 1.06/1000 days)
The Center for Acute Care Nephrology
Contr
ast P
rotec
tion P
rotoc
ol Ph
arma
cist R
ound
ing; N
TMx I
mpac
t Aler
t
Vanc
omyc
in St
ewar
dship
Phar
macy
Sma
rtPhr
ase
Cefep
ime v
s Zos
yn
21.61
0%
20%
40%
60%
80%
100%Ju
l/13
Aug/1
3Se
p/13
Oct/1
3No
v/13
Dec/1
3Ja
n/14
Feb/1
4Ma
r/14
Apr/1
4Ma
y/14
Jun/1
4Ju
l/14
Aug/1
4Se
p/14
Oct/1
4No
v/14
Dec/1
4Ja
n/15
Feb/1
5Ma
r/15
Apr/1
5Ma
y/15
Jun/1
5Ju
l/15
Aug/1
5Se
p/15
Oct/1
5No
v/15
Dec/1
5Ja
n/16
Feb/1
6Ma
r/16
Apr/1
6Ma
y/16
Jun/1
6Ju
l/16
Aug/1
6Se
p/16
Oct/1
6No
v/16
Dec/1
6Ja
n/17
Feb/1
7Ma
r/17
Perc
ent w
ith A
KI
Monthly
Percent of High NTMx Exposed Patients with AKI Oncology/Hematology Patients
Monthly Percent of patients with AKI Average Percent of patients with AKI Control Limits
(Using P chart)
%
(Hospital Rate - 15.4%)
The Center for Acute Care Nephrology
Contr
ast P
rotec
tion P
rotoc
ol Ph
arma
cist R
ound
ing; N
TMx I
mpac
t Aler
t
Vanc
omyc
in St
ewar
dship
Phar
macy
Stew
ards
hip
Cefep
ime v
s Zos
yn
34.30
5.350.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
180.0
200.0
Jul-1
3Au
g-13
Sep-
13Oc
t-13
Nov-1
3De
c-13
Jan-
14Fe
b-14
Mar-1
4Ap
r-14
May-1
4Ju
n-14
Jul-1
4Au
g-14
Sep-
14Oc
t-14
Nov-1
4De
c-14
Jan-
15Fe
b-15
Mar-1
5Ap
r-15
May-1
5Ju
n-15
Jul-1
5Au
g-15
Sep-
15Oc
t-15
Nov-1
5De
c-15
Jan-
16Fe
b-16
Mar-1
6Ap
r-16
May-1
6Ju
n-16
Jul-1
6Au
g-16
Sep-
16Oc
t-16
Nov-1
6De
c-16
Jan-
17Fe
b-17
Mar-1
7
AKI D
ays
Monthly
AKI Days per 100 High-NTMx Exposure Days (Intensity) Oncology/Hematology Patients
Monthly AKI Days Mean Monthly AKI Days Control Limits
(Hospital Rate -19.13/100 Days)
The Center for Acute Care Nephrology
Can NINJA work in the ICU?
The Center for Acute Care Nephrology
So….. CAN NINJA WORK IN THE ICU?• NO!
• NINJA raised awareness of NTMx-AKI by increasing surveillance in at-risk non-ICU patients
• AKI risk is already high in the ICU• Aren’t we already monitoring for AKI daily anyway in the ICU?• Don’t all ICU patients get at least 3 NTMx the femptosecond they roll
in the door?
• MAYBE!• Are pharmacists in the ICU armed and supported to
• Make medication recommendations/dosing adjustments based on risk?
• Highlight the need to minimize “unnecessary” NTMx?• Look up organism antimicrobial susceptibility?
The Center for Acute Care Nephrology
Acknowledgements
• Eric Kirkendall, MD, MBI• Stephen Muething, MD• Theresa Mottes, RN, BSN• Devesh Dahale• Cynthia Barclay, PharmD