| Summary: | INTRODUCTION. Renal disease is a worldwide health problem. The prevalence of chronic disease is between 10-16% in the general population and rises to 30% in hospitalized patients. Patients with renal disease have increased morbidity, mortality and costs. Chronic kidney disease(CKD) is defined as
abnormalities of kidney structure or function, for more than three months, with implications for health. There are different type of factors that promote the development of this disease including the use of nephrotoxic drugs. GFR is generally accepted as the best overall index of kidney function and is estimated by different equations. The hypothesis for this research is that clinical decision support system(CDSS) which provides patients specific recommendations in real time would improve drug selection and the quality of drug prescribing, reducing adverse drugs events in patients with renal insufficiency.
OBJECTIVES. To characterize inpatients according to renal function and determine the prescription habits of nephrotoxic drugs and drugs with renal elimination. To design a CDSS aids to guide drug prescription in renal impairment. To assess the impact of a CDSS in drug prescribing for patient with renal disease.
PATIENTS AND METHODS. The setting for this study was an academic medical centre with an electronic medical record system including integrated computerized physician order entry(CPOE). The study was designed as an intervention study comparing pre and post implementation phases. Inclusion criteria were inpatients older than 18 years old with at least one reported SCr level. Patients were classified according to their GFR in the categories of CKD of the NKF guidelines (2002). AKI was defined as increase in SCr by 0,3 mg/dl within 48 hours or increase in SCr to 1,5 times baseline which is known or presumed to have occurred within the prior 7 days (KDIGO 2012). Drugs cleared by kidney and/or nephrotoxic drugs were selected from the hospital formulary. Four alert categories were defined and assigned to these drugs in corresponding renal stages: precaution, adjustment, contraindication and nephrotoxicity. A dosing guideline was drawn for drugs with adjustment alerts. The CDSS was designed and implemented in the hospital CPOE system after its diffusion among its users.
RESULTS. 399 active substances where classified as renally cleared and 68 as nephrotoxic. The CDSS identified patients with potential acute or chronic renal disease and patients receiving nephrotoxic drugs. In these patients, it displayed a renal report with their renal function values and the corresponding alerts for the drugs prescribed. Alerts for precaution and adjustment had an informative design whereas alerts for contraindication or nephrotoxic in AKI were interruptive. More than 30% of inpatients included in the analysis suffered renal insufficiency and 7% presented at least an AKI episode. Patients with renal disease were older, had suffered any kind of renal damage previously and had other associated chronic diseases such as hypertension or diabetes mellitus. Every patient with renal impairment received drugs with precaution or adjustment alerts. More than 25% of patients were prescribed contraindicated drugs and one out of four nephrotoxic drugs. Alerts for nephrotoxic drugs in patients suffering AKI decreased the prescription of these drugs.
CONCLUSIONS. Renal disease is a major health problem in hospitalized patients. CDSS implemented helps identifying these patients and eases the control of renally eliminated and nephrotoxic drugs use. Drug adjustment neglecting is more frequent during the prescription of antimicrobials drugs and in patients with cancer. Patients with chronic disease, patients undergoing renal therapy replacement, patients with worse renal function and patients who die during hospitalization receive more frequently drugs that should be avoided. Alerts for nephrotoxic drugs in patients suffering AKI have been the most effective alerts.
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