Hyperkalemia affects up to 10% of patients with CKD. Sodium polystyrene sulfonate has long been prescribed for this condition, although evidence is lacking on its efficacy for the treatment of mild ...hyperkalemia over several days. This study aimed to evaluate the efficacy of sodium polystyrene sulfonate in the treatment of mild hyperkalemia.
In total, 33 outpatients with CKD and mild hyperkalemia (5.0-5.9 mEq/L) in a single teaching hospital were included in this double-blind randomized clinical trial. We randomly assigned these patients to receive either placebo or sodium polystyrene sulfonate of 30 g orally one time per day for 7 days. The primary outcome was the comparison between study groups of the mean difference of serum potassium levels between the day after the last dose of treatment and baseline.
The mean duration of treatment was 6.9 days. Sodium polystyrene sulfonate was superior to placebo in the reduction of serum potassium levels (mean difference between groups, -1.04 mEq/L; 95% confidence interval, -1.37 to -0.71). A higher proportion of patients in the sodium polystyrene sulfonate group attained normokalemia at the end of their treatment compared with those in the placebo group, but the difference did not reach statistical significance (73% versus 38%; P=0.07). There was a trend toward higher rates of electrolytic disturbances and an increase in gastrointestinal side effects in the group receiving sodium polystyrene sulfonate.
Sodium polystyrene sulfonate was superior to placebo in reducing serum potassium over 7 days in patients with mild hyperkalemia and CKD.
Background Explicit criteria for judging medication safety and use issues in patients with chronic kidney disease (CKD) are lacking. Study Design Quality improvement report. Setting & Participants ...Nephrologists (n = 4), primary care physicians (n = 2), hospital pharmacists with expertise in nephrology (n = 4), and community pharmacists (n = 2). The PAIR (Pharmacotherapy Assessment in Chronic Renal Disease) criteria were applied retrospectively to 90 patients with CKD in a randomized study. Quality Improvement Plan Development of an explicit set of criteria to enable rapid and systematic detection of drug-related problems (DRPs). Using a RAND method, experts judged the clinical significance of DRPs and the appropriateness of a community pharmacist intervention. The PAIR criteria include 50 DRPs grouped into 6 categories. Outcomes DRPs detected using the PAIR criteria compared with implicit clinical judgment by nephrology pharmacists. Measurements Prevalence of DRPs and reliability, validity, and responsiveness of the PAIR criteria. Results A mean of 2.5 DRPs/patient (95% CI, 2.0-3.1) was identified based on the PAIR criteria compared with 3.9 DRPs/patient (95% CI, 3.4-4.5) based on clinical judgment of nephrology pharmacists. Inter-rater reliability coefficients (κ) by PAIR category varied from 0.80-1.00, with an intraclass correlation coefficient (ICC) of 0.93 (95% CI, 0.89-0.95) for total DRPs per patient. Test-retest reliability coefficients by category varied from 0.74-1.00, with an ICC of 0.91 (95% CI, 0.82-0.96) for total DRPs per patient. During the study, the mean number of DRPs per patient did not change significantly when assessed using the PAIR criteria and clinical judgment. Limitation The prevalence of PAIR DRPs may be underestimated due to the retrospective nature of the validation. Conclusion The prevalence of DRPs requiring the intervention of community pharmacists is high in patients with CKD. The PAIR criteria are reliable, but their responsiveness remains to be shown.
The aim of this study was to compare the validity of an integrated objective structured clinical examination (OSCE) station assessing both oral and written components with that of an OSCE station ...assessing 1 single skill (oral only), both targeted at assessing taking a best possible medication history.
A convergent mixed-methods design that used the 4 inferences of Kane’s validity framework (scoring, generalization, extrapolation, and implications) as a scaffold to integrate qualitative data (post-OSCE reflections) and quantitative data (assessment grades and categories of medication errors) was applied.
In 2022, 216 students completed the OSCE station with the oral component alone, while in 2023, 254 students completed the integrated (oral and written) OSCE station. Students in 2023 performed significantly better, with a median score of 88% vs 80% in 2022. There was a greater proportion of commission errors in the integrated assessment (20.4% vs 15.3%), but fewer omission errors (29.9% vs 31.8%) and patient profile errors (5.1% vs 69.4%). Student reflections revealed that conversations were rushed in the integrated assessment, with a greater focus on written formatting, but an appreciation for the authenticity and structured format of the integrated OSCE compared with the single-skill OSCE alone.
Students completing the integrated OSCE (with oral and written components) had fewer patient profile and medication omission errors than students who completed the oral-only OSCE. Considering Kane’s validity framework, there was a stronger argument for the more authentic integrated OSCE in terms of the inferences of extrapolation and implications.
Introduction:
Chronic kidney disease (CKD) patients are multimorbid elderly at high risk of drug‐related problems. A Web‐based training program was developed based on a list of significant ...drug‐related problems in CKD patients requiring a pharmaceutical intervention. The objectives were to evaluate the impact of the program on community pharmacists' knowledge and skills and their satisfaction with the training.
Methods:
Pharmacists were randomized to the training program or the control group. Training comprised a 60‐minute Web‐based interactive session supported by a clinical guide. Pharmacists completed a questionnaire on knowledge (10 multiple‐choice questions) and skills (2 clinical vignettes) at baseline and a second time within 1 month. Trained pharmacists completed a written satisfaction questionnaire. Semidirected telephone interviews were conducted with 8 trained pharmacists. Changes in knowledge and skills scores were compared between the groups.
Results:
Seventy pharmacists (training: 52; control: 18) were recruited; the majority were women with <15 years' experience. Compared with the control group, an adjusted incremental increase in the knowledge score (22%; 95% confidence interval CI: 16%–27%) and skills score (24%; 95% CI: 16%–33%) was observed in the training group. Most pharmacists (87%–100%) rated each aspect of the program “excellent'' or “very good.” Additional training and adding a discussion forum were suggested to complement the program.
Discussion:
Pharmacists like the Web‐based continuing education program. Over a short time span, the program improved their knowledge and skills. Its impact on their clinical practices and quality of medication use in CKD patients remains to be assessed.
Background
Fractures have serious health consequences in older adults. While some medications are individually associated with increased risk of falls and fractures, it is not clear if this holds ...true for the use of many medications (polypharmacy). We aimed to identify what is known about the association between polypharmacy and the risk of fractures in adults aged ≥65 and to examine the methods used to study this association.
Methods
We conducted a systematic review with narrative synthesis of studies published up to October 2023 in PubMed, Embase, CINAHL, PsychINFO, Cochrane Library, Web of Science, and the grey literature. Two independent reviewers screened titles, s, and full texts, then performed data extraction and quality assessment.
Results
Among the 31 studies included, 11 different definitions of polypharmacy were used and were based on three medication counting methods (concurrent use 15/31, cumulative use over a period 6/31, daily average 3/31, and indeterminate 7/31). Overall, polypharmacy was frequent and associated with higher fracture risk. A dose–response relationship between increasing number of medications and increased risk of fractures was observed. However, only seven studies adjusted for major confounders (age, sex, and chronic disease). The quality of the studies ranged from poor to high.
Conclusions
Polypharmacy appears to be a relevant modifiable risk factor for fractures in older individuals that can easily be used to identify those at risk. The diversity of medication calculation methods and definitions of polypharmacy highlights the importance of a detailed methodology to understand and compare results.
New drugs to prevent and treat hyperkalemia Lepage, Laurence; Desforges, Katherine; Lafrance, Jean-Philippe
Current opinion in nephrology and hypertension,
2016-November, 2016-Nov, 2016-11-00, 20161101, Letnik:
25, Številka:
6
Journal Article
Recenzirano
PURPOSE OF REVIEWHyperkalemia is frequent, but occurs mostly in patients with chronic kidney disease and is often the cause of discontinuation or omission of renin–angiotensin–aldosterone system ...inhibitors in patients with diabetes, chronic kidney disease and heart failure.
RECENT FINDINGSWithout much evidence in the literature on its efficacy, sodium polystyrene sulfonate is being used frequently in the clinical setting to treat hyperkalemia. In the last few years, two new promising agents have been developed to treat hyperkalemia – patiromer and sodium zirconium cyclosilicate 9 (ZS-9). Both patiromer and ZS-9 have been shown to decrease potassium in patients with hyperkalemia and then to maintain normokalemia. Gastrointestinal adverse events were more frequent with patiromer, and edema occurred in patients using high doses of ZS-9, possibly due to its high sodium content.
SUMMARYAlthough patiromer and ZS-9 are very promising in terms of safety and efficacy, many questions remain, mostly in terms of selection of patients, long-term effects and costs.
Appropriate training for community pharmacists may improve the quality of medication use. Few studies have reported the impact of such programs on medication management for patients with chronic ...kidney disease (CKD).
Multicenter, cluster-randomized, controlled trial.
Patients with CKD stage 3a, 3b, or 4 from 6 CKD clinics (Quebec, Canada) and their community pharmacies.
Each cluster (a pharmacy and its patients) was randomly assigned to either ProFiL, a training-and-communication network program, or the control group. ProFiL pharmacists completed a 90-minute interactive web-based training program on use of medications in CKD and received a clinical guide, patients’ clinical summaries, and facilitated access to the CKD clinic.
Drug-related problems (primary outcome), pharmacists’ knowledge and clinical skills, and patients’ clinical attributes (eg, blood pressure and glycated hemoglobin concentration).
Drug-related problems were evaluated the year before and after the recruitment of patients using a validated set of significant drug-related problems, the Pharmacotherapy Assessment in Chronic Renal Disease (PAIR) criteria. Pharmacists’ questionnaires were completed at baseline and after 1 year. Clinical attributes were documented at baseline and after 1 year using available information in medical charts.
207 community pharmacies, 494 pharmacists, and 442 patients with CKD participated. After 1 year, the mean number of drug-related problems per patient decreased from 2.16 to 1.60 and from 1.70 to 1.62 in the ProFiL and control groups, respectively. The difference in reduction of drug-related problems per patient between the ProFiL and control groups was −0.32 (95% CI, −0.63 to −0.01). Improvements in knowledge (difference, 4.5%; 95% CI, 1.6%-7.4%) and clinical competencies (difference, 7.4%; 95% CI, 3.5%-11.3%) were observed among ProFiL pharmacists. No significant differences in clinical attributes were observed across the groups.
High proportion of missing data on knowledge and clinical skills questionnaire (34.6%) and clinical attributes (11.1%).
Providing community pharmacists with essential clinical data, appropriate training, and support from hospital pharmacists with expertise in nephrology increases pharmacists’ knowledge and reduces drug-related problems in patients with CKD who are followed up in clinics incorporating a multidisciplinary health care team.
Purpose
The optimal vitamin D
3
therapy for the treatment of secondary hyperparathyroidism (SHPT) in chronic hemodialysis patients is still controversial. Recent studies suggest that uremia in ...end-stage renal disease is associated with enzymatic hepatic dysfunction altering 25-hydroxylation of vitamin D
3
. The goal of our study was to compare the efficacy of calcitriol, the fully hydroxylated active form of vitamin D
3
, to alfacalcidol which needs 25-hydroxylation to be effective, for the treatment of SHPT in chronic hemodialysis patients.
Methods
We retrospectively reviewed 45 chronic hemodialysis patients who were switched from oral alfacalcidol to oral calcitriol for the treatment of SHPT. Parathyroid hormone (PTH), serum calcium and serum phosphorus levels were compared pre- and post-conversion using paired Student’s
t
tests.
Results
The mean dose of active vitamin D
3
decreased from 3.50 mcg/week at baseline to 2.86 mcg (
P
< 0001) after the switch from alfacalcidol to calcitriol. PTH significantly decreased from 94.4 to 82.6 pmol/L (−11.8 pmol/L,
P
= 0.02). The mean corrected calcium increased from 2.17 to 2.25 mmol/L (+0.08 mmol/L,
P
< 0.001) without any clinically significant hypercalcemia, and phosphorus levels were stable. Results were similar in a subgroup of patients (
n
= 17) for whom the medication was administrated during the hemodialysis session, ensuring a complete compliance.
Conclusions
According to our study, calcitriol in equal dosage is more effective than alfacalcidol in lowering serum PTH level in chronic hemodialysis patients. This suggests that calcitriol may be the optimal active vitamin D
3
for the treatment of SHPT in chronic hemodialysis patients.
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