Effectiveness of using STOPP/START criteria to identify potentially inappropriate medication in people aged ≥ 65 years with chronic kidney disease: a randomized clinical trial.

PURPOSE: Polypharmacy and inappropriate prescribing are common in elderly with chronic kidney disease (CKD). This study identified potentially inappropriate prescriptions (PIPs) and potential prescribing omissions (PPOs) using the Screening Tool of Older Persons' Prescriptions (STOPP) and the Screening Tool to Alert doctors to the Right Treatment (START) criteria in elderly with advanced CKD and determined the effect of a medication review on medication adherence and health-related quality of life (HRQoL). METHODS: The intervention consisted of a medication review using STOPP/START criteria with a recommendation to a nephrologist or similar review without a recommendation. End points were prevalence of PIP and PPO, medication adherence, and HRQoL. Group differences in outcomes were assessed using a generalized linear mixed model. The trial was registered under www.clinicaltrial.gov (ID: NCT02424786). RESULTS: We randomized 180 patients with advanced CKD (mean age 77 years, 23% female). The prevalence of PIPs and PPOs in the intervention group was 54% and 50%, respectively. The odds of PPOs were lower in the intervention than the control group (OR 0.42, 95% CI 0.19-0.92, p = 0.032), while there was no intergroup difference in the number of PIPs (OR 0.57, CI 0.27-1.20, p = 0.14). There was no difference in changes in medication adherence or HRQoL from baseline to 6 months between the groups. CONCLUSIONS: The intervention with the STOPP/START criteria identified a high prevalence of inappropriate medications in the elderly with advanced CKD and reduced the number of PPOs. However, there was no detectable impact of the intervention on medication adherence or HRQoL.

Medication regimen complexity and medication adherence in elderly patients with chronic kidney disease.

INTRODUCTION: Elderly patients with chronic kidney disease (CKD) stage 5 with or without dialysis treatment usually have concomitant comorbidities, which often result in multiple pharmacological therapies. This study aimed to identify factors associated with medication complexity and medication adherence, as well as the association between medication complexity and medication adherence, in elderly patients with CKD. METHODS: This prospective study involved elderly patients with CKD stage 5 (estimated glomerular filtration rate < 15 ml/min/1.73m2 ) recruited from three Norwegian hospitals. Most of the patients were receiving either hemodialysis or peritoneal dialysis. We used the Medication Regimen Complexity Index (MRCI) to assess the complexity of medication regimens, and the eight-item Morisky Medication Adherence Scale (MMAS-8) to assess medication adherence. Factors associated with the MRCI and MMAS-8 score were determined using either multivariable linear or ordinal logistic regression analysis. FINDINGS: In total, 157 patients aged 76 ± 7.2 years (mean ± SD) were included in the analysis. Their overall MRCI score was 22.8 ± 7.7. In multivariable linear regression analyses, female sex (P = 0.044), Charlson Comorbidity Index of 4 or 5 (P = 0.029) and using several categories of phosphate binders (P < 0.001 to 0.04) were associated with the MRCI. Moderate or high adherence (MMAS-8 score ≥ 6) was demonstrated by 83% of the patients. The multivariable logistic regression analyses found no association of medication complexity, age or other variables with medication adherence as assessed using the MMAS-8. DISCUSSION: Female sex, comorbidity and use of phosphate binders were associated with more-complex medication regimens in this population. No association was found between medication regimen complexity, phosphate binders or age and medication adherence. These findings are based on a homogeneous elderly group, and so future studies should test if they can be generalized to patients of all ages with CKD.

More potent lipid-lowering effect by rosuvastatin compared with fluvastatin in everolimus-treated renal transplant recipients.

BACKGROUND: Dyslipidemia is a risk factor for premature cardiovascular morbidity and mortality in renal transplant recipients (RTRs). Pharmacotherapy with mTOR inhibitors aggravates dyslipidemia, thus necessitating lipid-lowering therapy with fluvastatin, pravastatin, or atorvastatin. These agents may not sufficiently lower lipid levels, and therefore, a more potent agent like rosuvastatin maybe needed. METHODS: We have aimed to assess the lipid-lowering effect of rosuvastatin as compared with fluvastatin in RTR receiving everolimus. Safety was assessed as the pharmacokinetic (PK) interaction potential of a rosuvastatin/everolimus combination in RTR. A 12-hour everolimus PK investigation was performed in 12 stable RTR receiving everolimus and fluvastatin (80 mg/d). Patients were then switched to rosuvastatin (20 mg/d), and a follow-up 12/24-hour PK investigation of everolimus/rosuvastatin was performed after 1 month. All other drugs were kept unchanged. RESULTS: In RTR already receiving fluvastatin, switching to rosuvastatin further decreased LDL cholesterol and total cholesterol by 30.2±12.2% (P<0.01) and 18.2±9.6% (P<0.01), respectively. Everolimus AUC0-12 was not affected by concomitant rosuvastatin treatment, 80.3±21.3 µg*h/L before and 78.5±21.9 µg*h/L after, respectively (P=0.61). Mean rosuvastatin AUC0-24 was 157±61.7 ng*h/mL, approximately threefold higher than reported in the literature for nontransplants. There were no adverse events, and none of the patients had or developed proteinuria. CONCLUSION: Rosuvastatin showed a superior lipid-lowering effect compared to fluvastatin in stable RTR receiving everolimus. The combination of everolimus/rosuvastatin seems to be as safe as the everolimus/fluvastatin combination.

Lecithin: Cholesterol Acyltransferase (LCAT) Deficiency: renal lesions with early graft recurrence.

Familial lecithin:cholesterol acyltransferase (LCAT) deficiency is a rare metabolic disease with lipid deposition in several organs. The authors report a man with hypertension and proteinuria. Renal biopsy revealed glomerular changes, including peculiar thrombus-like deposits, consistent with LCAT deficiency. He was found to be compound heterozygous for two mutations of the LCAT gene. He received a kidney graft from his father. The authors also describe LCAT deficiency-related lesions in the explanted native kidneys and in biopsies at 2 days, 6 weeks, and 1 year after transplantation. The morphology of this disease is characteristic, and the diagnosis should be suspected from the ultrastructural findings.