In the Journals

Children with CKD prescribed nephrotoxic medications at high rates in primary care practices

A recently published study found primary care physicians prescribed nephrotoxic medications to children with chronic kidney disease at a rate four-times greater than they did to those without the disease.

“One strategy for preventing CKD progression is limiting nephrotoxic medication exposure,” Claire E. Lefebvre, MD, of the department of pediatrics at Centre Hospitalier Universitaire Saine-Justine, in Canada, and colleagues wrote. “Studies of outpatient nephrotoxic medication prescriptions in CKD are currently limited to adults, reporting prescription prevalences of 13% to 70%. This raises concerns about whether children with CKD are also at risk for inappropriate nephrotoxic medication prescribing.”

As general practitioners “play an important role” in caring for children with CKD, researchers used a U.K. database comprising patient demographics, diagnoses and general practitioner prescriptions. Focusing on the years between 1997 and 2017, investigators matched 1,018 children with CKD 1:4 to patients without CKD (mean age, 9.8 years; 52% were boys).

Patients were followed for a mean of 3.3 years. During this time, researchers observed that 26% of patients with CKD were prescribed one or more potentially nephrotoxic medication vs. 15% of those without CKD. Overall, the rate of nephrotoxic medication prescriptions was determined to be 71 prescriptions per 100 person-years in patients with CKD and eight prescriptions per 100 person-years in patients without CKD (adjusted rate ratio: 4.1).

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Primary care physicians prescribed nephrotoxic medications to children with CKD at a rate four-times greater than they did to those without.
Source: Adobe Stock

Researchers noted that, when determining which medications to prescribe, there are additional factors to consider beyond nephrotoxicity.

They wrote, “It is also important to recognize that in the face of an opioid epidemic, the avoidance of medications such as NSAIDs may have important implications for individuals with pain in whom alternative medications, although safe from a kidney point of view, may carry other important risks.”

In a related editorial, Stuart L. Goldstein, MD, of Cincinnati Children’s Hospital Medical Center, argued that caution should also be taken when prescribing nephrotoxic medications to children who do not yet have kidney disease, because reliance on these medications can lead to acute kidney injury, which can subsequently increase risk for CKD.

“The American Society of Nephrology AKI Working Group has highlighted a broader association of AKI to CKD and admonished clinicians regarding the 10% and 40% rates of follow-up for CKD after an AKI episode in adults and children, respectively,” he wrote.

As for prescribing patterns of nephrotoxic medications in children who do have CKD, he added, “These results are of great concern for the pediatric CKD population ... Clearly, many of these patients with CKD could have other underlying systemic illnesses that require the use of nephrotoxic medications; yet, in their secondary analyses, the investigators demonstrate that some medications classes, such as NSAIDs and proton pump inhibitors, have suitable less nephrotoxic alternatives and are therefore potentially avoidable.” Goldstein suggested the pediatric medical community develop systems “to identify appropriate and inappropriate nephrotoxic-medication prescribing to children with CKD, with the goal of protecting children from the latter.” – by Melissa J. Webb

Disclosures: Lefebvre reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

A recently published study found primary care physicians prescribed nephrotoxic medications to children with chronic kidney disease at a rate four-times greater than they did to those without the disease.

“One strategy for preventing CKD progression is limiting nephrotoxic medication exposure,” Claire E. Lefebvre, MD, of the department of pediatrics at Centre Hospitalier Universitaire Saine-Justine, in Canada, and colleagues wrote. “Studies of outpatient nephrotoxic medication prescriptions in CKD are currently limited to adults, reporting prescription prevalences of 13% to 70%. This raises concerns about whether children with CKD are also at risk for inappropriate nephrotoxic medication prescribing.”

As general practitioners “play an important role” in caring for children with CKD, researchers used a U.K. database comprising patient demographics, diagnoses and general practitioner prescriptions. Focusing on the years between 1997 and 2017, investigators matched 1,018 children with CKD 1:4 to patients without CKD (mean age, 9.8 years; 52% were boys).

Patients were followed for a mean of 3.3 years. During this time, researchers observed that 26% of patients with CKD were prescribed one or more potentially nephrotoxic medication vs. 15% of those without CKD. Overall, the rate of nephrotoxic medication prescriptions was determined to be 71 prescriptions per 100 person-years in patients with CKD and eight prescriptions per 100 person-years in patients without CKD (adjusted rate ratio: 4.1).

#
Primary care physicians prescribed nephrotoxic medications to children with CKD at a rate four-times greater than they did to those without.
Source: Adobe Stock

Researchers noted that, when determining which medications to prescribe, there are additional factors to consider beyond nephrotoxicity.

They wrote, “It is also important to recognize that in the face of an opioid epidemic, the avoidance of medications such as NSAIDs may have important implications for individuals with pain in whom alternative medications, although safe from a kidney point of view, may carry other important risks.”

In a related editorial, Stuart L. Goldstein, MD, of Cincinnati Children’s Hospital Medical Center, argued that caution should also be taken when prescribing nephrotoxic medications to children who do not yet have kidney disease, because reliance on these medications can lead to acute kidney injury, which can subsequently increase risk for CKD.

“The American Society of Nephrology AKI Working Group has highlighted a broader association of AKI to CKD and admonished clinicians regarding the 10% and 40% rates of follow-up for CKD after an AKI episode in adults and children, respectively,” he wrote.

As for prescribing patterns of nephrotoxic medications in children who do have CKD, he added, “These results are of great concern for the pediatric CKD population ... Clearly, many of these patients with CKD could have other underlying systemic illnesses that require the use of nephrotoxic medications; yet, in their secondary analyses, the investigators demonstrate that some medications classes, such as NSAIDs and proton pump inhibitors, have suitable less nephrotoxic alternatives and are therefore potentially avoidable.” Goldstein suggested the pediatric medical community develop systems “to identify appropriate and inappropriate nephrotoxic-medication prescribing to children with CKD, with the goal of protecting children from the latter.” – by Melissa J. Webb

Disclosures: Lefebvre reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.