Evaluating Pharmacist Medication Interventions in Emergency Admissions with Community-Acquired Acute Kidney Injury in a Large Teaching Hospital

This study, selected for presentation as a poster at the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) meeting, Madrid, Spain, looked at key initial recommendations and interventions by a pharmacy team for patients with community-acquired acute kidney injury (CA-AKI). Over 60% of AKI starts in the community.¹ The National Health Service (NHS) England’s AKI programme ‘Think Kidneys’ supports patients in understanding the risks of AKI and educating them in protection against it.² This includes medication management known as ‘Sick Day Guidance’. The aim of this study was to evaluate the role of secondary care pharmacists in the management of community acquired AKI and to explore the dissemination of sick day guidance.

Prospective data were collected from 50 consecutive emergency medical admissions with AKI <48 hours from admission over a 4-week period in 2016 using a piloted data collection form and interview questions. Using the electronic patient records, patients’ pre-admission medications were screened and split into five categories: angiotensin converting enzyme inhibitors, angiotensin receptor blockers, nonsteroidal anti-inflammatory drugs, diuretics, and metformin. These were considered to have nephrotoxic potential or pose further risk to patients’ health in AKI, and the following elements were reviewed:

1. The number, nature, and timing of recommendations made by pharmacists via the AKI Pharmacy Review document.
2. The number of patients with AKI admitted with a history of taking medicines that have nephrotoxic potential.
3. The proportion of pharmacist recommendations implemented by the medical team.
4. AKI progression after the medication intervention.
5. The number of patients with AKI who have been given sick day guidance.
6. Pharmacist AKI reviews were indicated for 46 patients of the 50 admitted with CA-AKI. Pharmacists reviewed 44 of these patients (96%); 35 (76%) within 24 hours and 42 (91%) within 48 hours of the AKI alert. Dose adjusting or withholding of medications was recommended for 38 (80.9%), of which 34 recommendations (89.5%) were to withhold the medication. Changes were also recommended for 14 ‘other’ medications.
7. The study found 29 patients (63%) were taking ≥1 medication from 1 of the 5 categories. Diuretics were the most common category, with 4 (14%) patients on 2 diuretics.
8. Pharmacist recommendations were adhered to for 36 medications (95%); recommendations for ‘other’ medications were followed for 11 (79%).
9. Results showed that 34 patients (77.3%) showed no AKI progression following pharmacist review.
10. Finally, 35 patients were identified as suitable for interview and 28 were interviewed. No patient in this group recalled sick day guidance or had been counselled that any medications they were taking could affect their kidneys.

This study suggests that the dissemination of sick day guidance to at risk patients has not been maximally implemented thus far, a point which, in particular, was discussed at the poster presentation. At the congress, there was debate over the formation of the agreement for sick day guidance itself and then the subsequent responsibility for tailoring advice and restarting medication. Pharmacist reviews in AKI are crucial in the early recognition and cessation of potentially nephrotoxic mediations. Reviews could be fundamental to optimal medical management of AKI and preventing AKI progression.