Use of nephrotoxic medications in adults with chronic kidney disease in Swedish and US routine care

Abstract

Background: To characterize the use of nephrotoxic medications in patients with chronic kidney disease (CKD) Stages G3-5 in routine care.

Methods: We studied cohorts of adults with confirmed CKD G3-5 undergoing routine care from 1 January 2016 through 31 December 2018 in two health systems [Stockholm CREAtinine Measurements (SCREAM), Stockholm, Sweden (N = 57 880) and Geisinger, PA, USA (N = 16 255)]. We evaluated the proportion of patients receiving nephrotoxic medications within 1 year overall and by baseline kidney function, ranked main contributors and examined the association between receipt of nephrotoxic medication and age, sex, CKD G-stages comorbidities and provider awareness of the patient's CKD using multivariable logistic regression.

Results: During a 1-year period, 20% (SCREAM) and 17% (Geisinger) of patients with CKD received at least one nephrotoxic medication. Among the top nephrotoxic medications identified in both cohorts were non-steroidal anti-inflammatory drugs (given to 11% and 9% of patients in SCREAM and Geisinger, respectively), antivirals (2.5% and 2.0%) and immunosuppressants (2.7% and 1.5%). Bisphosphonate use was common in SCREAM (3.3%) and fenofibrates in Geisinger (3.6%). Patients <65 years of age, women and those with CKD G3 were at higher risk of receiving nephrotoxic medications in both cohorts. Notably, provider awareness of a patient's CKD was associated with lower odds of nephrotoxic medication use {odds ratios [OR] 0.85[95% confidence interval (CI) 0.80-0.90] in SCREAM and OR 0.80 [95% CI 0.72-0.89] in Geisinger}.

Conclusions: One in five patients with CKD received nephrotoxic medications in two distinct health systems. Strategies to increase physician's awareness of patients' CKD and knowledge of drug nephrotoxicity may reduce prescribing nephrotoxic medications and prevent iatrogenic kidney injury.

Keywords: chronic kidney disease; estimated glomerular filtration rate; nephrotoxicity.

Graphical Abstract

FIGURE 1:

Volume (in percentage) of dispensations (in SCREAM, Panel A) or prescriptions (in Geisinger, Panel B), grouped in drug classes, out of the total number of nephrotoxic medications identified (N = 33 964 dispensations in SCREAM, N = 8924 prescriptions in Geisinger). Shaded polygons are proportional to the total area within each diamond for the indicated percentage. Medications included in the ‘Others’ class are isotretinoin, amphotericin B, normal human immunoglobulins, deferasirox and palifermin for SCREAM (Panel A) and quinidine, isotretinoin, amphotericin B, normal human immunoglobulins, deferasirox and palifermin for Geisinger (Panel B). Differences are due to market availability in each country.

FIGURE 2:

Odds ratios of nephrotoxic medication use in SCREAM (in blue) or Geisinger (in brown) by baseline demographic and clinical characteristics. Charlson comorbidity index is a sum of item scores for comorbid conditions listed in the table except CKD. Covariates included in both cohorts included age, sex, baseline eGFR, history of AKI, Charlson comorbidity index and awareness of CKD; additional covariates in Geisinger include race and BMI.