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Risk of Potentially Inappropriate Medications in Adults With CKD: Findings From the Chronic Renal Insufficiency
Rasheeda K Hall1, Jacob B Blumenthal2, Rebecca M Doerfler3
1Renal Section, Department of Medicine, School of Medicine, Duke University, and Durham Veterans Affairs Healthcare System, Durham, North Carolina.
Insights
Potentially inappropriate medications (PIMs) increase hospitalization, mortality, and fall risks in adults with chronic kidney disease (CKD). The risk escalates with multiple PIM prescriptions, but PIMs do not affect CKD progression.
Area of Science:
- Nephrology
- Geriatrics
- Pharmacology
Background:
- Adults with chronic kidney disease (CKD) face heightened risks from potentially inappropriate medications (PIMs).
- Understanding the independent association of PIM exposure with adverse outcomes in CKD is crucial for patient safety.
Purpose of the Study:
- To assess the independent association between PIM exposure and CKD progression, hospitalizations, mortality, and falls in adults with CKD.
Main Methods:
- Retrospective observational study of 3,929 adults with CKD from the Chronic Renal Insufficiency Cohort (CRIC) study.
- PIM exposure defined using the 2015 American Geriatrics Society Beers Criteria.
- Logistic and Poisson regression analyses were used to evaluate associations with outcomes.
Main Results:
- PIM exposure was associated with increased hospitalization rates and mortality, with a graded association observed with increasing numbers of PIMs.
- Prescriptions for three or more PIMs were linked to a significantly higher risk of falls in a subset of participants.
- No significant association was found between PIM use and CKD progression or the initiation of kidney replacement therapy (KRT).
Conclusions:
- PIMs are associated with increased risks of hospitalization, mortality, and falls in adults with CKD, irrespective of age.
- The risk of these adverse events increases with the number of PIM prescriptions, highlighting the importance of medication review.
Rationale & Objective:
Adults with chronic kidney disease (CKD) may be at increased risk of adverse effects from use of potentially inappropriate medications (PIMs). Our objective was to assess whether PIM exposure has an independent association with CKD progression, hospitalizations, mortality, or falls.
Study Design:
Retrospective observational study.
Setting & Participants:
Chronic Renal Insufficiency Cohort (CRIC) study; 3,929 adults with CKD enrolled 2003-2008 and followed prospectively until December 2011.
Exposure:
PIM exposure was defined as prescriptions for any medications to be avoided in older adults as defined by the 2015 American Geriatrics Society Beers Criteria.
Outcome:
Hospitalization count, death, a composite kidney disease end point of CKD progression or initiation of kidney replacement therapy (KRT), KRT, and fall events assessed 1 year after PIM exposure.
Analytical Approach:
Logistic regression and Poisson regression to estimate the associations of PIM exposure with each outcome.
Results:
The most commonly prescribed PIMs were proton pump inhibitors and α-blockers. In unadjusted models, any PIM exposure (compared to none) was associated with hospitalizations, death, and fall events. After adjustment, exposure to 1, 2, or≥3 PIMs had a graded association with a higher hospitalization rate (rate ratios of 1.09 [95% CI, 1.01-1.17], 1.18 [95% CI, 1.07-1.30], and 1.35 [95% CI, 1.19-1.53], respectively) and higher odds of mortality (odds ratios of 1.19 [95% CI, 0.91-1.54], 1.62 [95% CI, 1.21-2.17], and 1.65 [95% CI, 1.14-2.41], respectively). In a cohort subset reporting falls (n=1,109), prescriptions for≥3 PIMs were associated with an increased risk of falls (adjusted OR, 2.85 [95% CI, 1.54-5.26]). PIMs were not associated with CKD progression or KRT. Age did not modify the association between PIM count and outcomes.
Limitations:
Measurement bias; confounding by indication.
Conclusions:
Adults of any age with CKD who are prescribed PIMs have an increased risk of hospitalization, mortality, and falls with the greatest risk occurring after more than 1 PIM prescription.
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