Pharmacist‐led, technology‐assisted study to improve medication safety, cardiovascular risk factor control, and racial disparities in kidney transplant recipients (original) (raw)
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Hypertension, 2016
Although outcome inequalities for non-Hispanic black (NHB) kidney transplant recipients are well documented, there is paucity in data assessing the impact of cardiovascular disease (CVD) risk factors on this disparity in kidney transplantation. This was a longitudinal study of a national cohort of veteran kidney recipients transplanted between January 2001 and December 2007. Data included baseline characteristics acquired through the United States Renal Data System linked to detailed clinical follow-up information acquired through the Veterans Affairs electronic health records. Analyses were conducted using sequential multivariable modeling (Cox regression), incorporating blocks of variables into iterative nested models; 3139 patients were included (2095 non-Hispanic whites [66.7%] and 1044 NHBs [33.3%]). NHBs had a higher prevalence of hypertension (100% versus 99%; P<0.01) and post-transplant diabetes mellitus (59% versus 53%; P<0.01) with reduced control of hypertension (bl...
Clinical Transplantation, 2012
Background-Kidney transplant recipients (KTRs) have increased risk for cardiovascular disease (CVD). Our objective is to describe the prevalence of CVD risk factors applying standard criteria and use of CVD risk factor lowering medications in contemporary KTRs. Methods-The Folic Acid for Vascular Outcome Reduction in Transplantation study enrolled and collected medication data on 4,107 KTRs with elevated homocysteine and stable graft function an average of 5 years post-transplant. Results-CVD risk factors were common (hypertension or use of blood pressure lowering medication in 92%, borderline or elevated LDL or use of lipid-lowering agent in 66%, history of diabetes mellitus in 41%, and obesity in 38%); prevalent CVD was reported in 20% of study participants. National Kidney Foundation blood pressure (BP) guidelines (BP < 130/80 mm Hg) were not met by 69% of participants. Uncontrolled hypertension (BP of 140/90 mm Hg or higher) was present in 44% of those taking anti-hypertension medication; 18% of participants had borderline or elevated LDL, of which 60% were untreated, and 31% of the participants with prevalent CVD were not using an anti-platelet agent. Conclusion-There is opportunity to improve treatment and control of traditional CVD risk factors in kidney transplant recipients.
Use of Cardioprotective Medications in Kidney Transplant Recipients
American Journal of Transplantation, 2009
Death with function causes half of late kidney transplant failures, and cardiovascular disease (CVD) is the most common cause of death in these patients. We examined the use of potentially cardioprotective medications in a prospective observational study at seven transplant centers in the United States and Canada. Among 935 patients, 87% received antihypertensive medications at both 1 and 6 months after transplantation. Similar antihypertensive regimens were used for patients with and without diabetes and CVD, but with wide variability among centers. In contrast, while 44% of patients were on angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) at the time of transplantation, the proportion taking these agents dropped to 12% at month 1, then increased to 24% at 6 months. Fewer than 30% with CVD or diabetes received ACEI/ARB therapy 6 months posttransplant. Aspirin use was uncommon (<40% of patients). Even among those with diabetes and/or CVD, fewer than 60% received aspirin and only half received a statin at 1 and 6 months. This study demonstrates marked variability in the use of cardioprotective medications in kidney transplant recipients, a finding that may reflect, among several possible explanations, clinical uncertainty due the lack of randomized trials for these medications in this population.
Patterns of antihypertensive medication use in kidney transplant recipients
Herz, 2016
Aim. This study analyzed the prevalence of hypertension and the pattern of antihypertensive treatment before and after kidney transplantation. Patients and methods. The prevalence of hypertension and the class and daily dosage load of antihypertensive medications were analyzed in 116 patients before kidney transplantation and 1, 6, and 12 months after transplantation (67.2 % males, mean age 45.9 ± 11.4 years). Two patients died and eight had the allograft explanted, leaving 106 patients in the final analysis. Blood pressure (BP) was recorded on the day of transplantation and at every follow-up; it was considered uncontrolled at values > 130/80 mmHg.
Cardiovascular Risk Estimates and Risk Factors in Renal Transplant Recipients
Transplantation Proceedings, 2005
Cardiovascular morbidity, including coronary artery disease and left ventricular hypertrophy, and mortality are high in patients following renal transplantation. Cardiovascular disease is thought to be due to traditional (hypertension, hyperlipidemia, diabetes mellitus and smoking) as well as nontraditional cardiovascular risk factors (microinflammation). Furthermore, immunosuppressive drugs, namely, calcineurin inhibitors, sirolimus, and steroids, have been reported to adversely affect cardiovascular risk factors (e.g., hypertension, hyperlipidemia, hyperglycemia). Evidence from comparative trials and from conversion studies suggest that blood pressure, hyperlipidemia, and hyperglycemia after renal transplantation may be differentially affected by the calcineurin inhibitors cyclosporine and tacrolimus. In the European Tacrolimus versus Cyclosporin A Microemulsion Renal Transplantation Study, 557 patients were randomly allocated to therapy with tacrolimus (n ϭ 286) versus cyclosporine (n ϭ 271). In addition, to blood pressure, serum cholesterol, HDL cholesterol, triglycerides, and blood glucose, we estimated the 10-year risk of coronary heart disease (Framingham risk score). Tacrolimus resulted in a significantly lower time-weighted average of serum cholesterol (P Ͻ .001), and mean arterial blood pressure (P Ͻ .05), but a higher time-weighted average of blood glucose (P Ͻ .01) than cyclosporine. Mean 10-year coronary artery disease risk estimate was significantly lower in men treated with tacrolimus, (10.0% versus 13.2%; P Ͻ .01) but was unchanged in women (4.7% versus 7.0%). Tacrolimus and cyclosporine microemulsion have compound-specific effects on cardiovascular risk factors that differentially affect the predicted rate of coronary artery disease.
PURPOSE: The implementation and outcomes of a program combining electronic home blood pressure monitoring (HBPM) and pharmacist-provided medication therapy management (MTM) services in a renal transplantation clinic are described. SUMMARY: Patients enrolled in the program were provided with a computer-enabled blood pressure monitor. A dedicated renal transplantation pharmacist was integrated into the renal transplantation team under a collaborative care practice agreement. The collaborative care agreement allowed the pharmacist to authorize medication additions, deletions, and dosage changes. Comprehensive disease and blood pressure education was provided by a clinical pharmacist. In the pretransplantation setting, the pharmacist interviewed the renal transplant candidate and documents allergies, verified the patient's medication profile, and identified and assessed barriers to medication adherence. A total of 50 renal transplant recipients with at least one recorded home blood pressure reading and at least one year of follow-up were included in our analysis. A significant reduction in mean systolic and diastolic blood pressure values were observed at 30, 90, 180, and 360 days after enrollment in the program (p < 0.05). Pharmacist interventions were documented for 37 patients. Medication-related problems accounted for 46% of these interventions and included dosage modifications, regimen changes, and mitigation of barriers to medication access and adherence. CONCLUSION: Implementation of electronic HBPM and pharmacist-provided MTM services implemented in a renal transplant clinic was associated with sustained improvements in blood pressure control. Incorporation of a pharmacist in the renal transplant clinic resulted in the detection and resolution of medication-related problems.
Transplantation, 2008
Death with function causes half of late kidney transplant failures, and cardiovascular disease (CVD) is the most common cause of death in these patients. We examined the use of potentially cardioprotective medications in a prospective observational study at seven transplant centers in the United States and Canada. Among 935 patients, 87% received antihypertensive medications at both 1 and 6 months after transplantation. Similar antihypertensive regimens were used for patients with and without diabetes and CVD, but with wide variability among centers. In contrast, while 44% of patients were on angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) at the time of transplantation, the proportion taking these agents dropped to 12% at month 1, then increased to 24% at 6 months. Fewer than 30% with CVD or diabetes received ACEI/ARB therapy 6 months posttransplant. Aspirin use was uncommon (<40% of patients). Even among those with diabetes and/or CVD, fewer than 60% received aspirin and only half received a statin at 1 and 6 months. This study demonstrates marked variability in the use of cardioprotective medications in kidney transplant recipients, a finding that may reflect, among several possible explanations, clinical uncertainty due the lack of randomized trials for these medications in this population.
Nephrology Dialysis Transplantation, 2022
BACKGROUND AND AIMS: Although improvement in histocompatibility matching, immunosuppressive therapy and antimicrobial treatment have led to improved longterm allograft survival, cardiovascular diseases (CVD) remain the major cause of morbidity and mortality in kidney transplant recipients (KTR). In addition to the accumulated risks due to chronic kidney disease and dialysis, kidney transplantation conveys its own unique risk factors for CVD. These include the metabolic effects of immunosuppressive treatments such as post-transplant hyperglycaemia, dyslipidaemia and hypertension as well as the effects of suboptimal kidney function including volume overload, anaemia, mineral bone disease and left ventricular hypertrophy. The predictors of cardiovascular diseases in KTR, however, have not been clearly defined. This study aimed to first ascertain the incidence of post-transplant CVD in those KTR without a prior confirmed history of CVD, then identify the predictors of CVD transplant associated CVD risk factors and finally evaluate the impact of CVD on graft and patient survival in this era of modern immunosuppressive medications. METHOD: We evaluated 962 KTR transplanted between 2000 and 2020 and followed in a single centre. About 328 KTR with a history of pre transplant CVD were excluded. CVD was defined as a composite of Ischaemic heart disease, myocardial infarction, heart failure, stroke or peripheral vascular disease. Logistic regression analyses were performed to identify the risk predictors of post-transplant CVD. Kaplan-Meier plots
Metabolic Profile and Cardiovascular Risk in a Population of Renal Transplant Recipients
Transplantation Proceedings, 2015
Introduction. Cardiovascular disease is more common in renal transplant recipients (RTRs) than in the general population, and is the major cause of both graft loss and patient death in RTRs. Objectives. This study aimed to characterize the cardiovascular risk factors, calculate the 7-year risk for major adverse cardiac events and the 7-year risk for death in a population of RTRs using a cardiovascular risk calculator, and determine the main cardiovascular risk factors associated with increased prediction of major adverse cardiac event (MACE) and death. Patients. This is a retrospective review of clinical data from 121 RTRs who are in followup programs at our institution, and who had a functioning and stable graft for longer than 6 months. Results. Among 121 adult patients followed at our institution (59.5% males, mean age of 49.6 AE 13.8 years, mean times for functioning grafts were 105 AE 73.5 mo), 86.8% had hypertension, 19.8% had diabetes, 24.8% were current or former smokers, 61.9% had increased body mass index, and 71% had dyslipidemia. The 7-year risk for MACE was more than 10% in 38 (31.4%) patients with age, diabetes, and smoke being independent risk predictors. The 7-year risk for death was more than 10% in 56 (46.3%) patients with age, diabetes, blood pressure, smoking, and male gender being independent risk predictors. Conclusion. There is a high prevalence of cardiovascular risk factors in a population of RTRs, and there is increased risk for MACE and death. Accurate risk prediction is important for physician decision support and patient education, promoting improved cardiovascular health of RTRs, and thus prolonging the survival of both patients and graft.
Transplantation Proceedings, 2009
The prevalence of traditional cardiovascular risk factors in renal transplantation is high. Studying the evolution of cardiovascular risk factors over time may help us to design better strategies to control them. The relative impact of traditional cardiovascular risk factors on allograft survival and mortality in transplant recipients is not clear. This study was performed to determine the incidence and risk factors for allograft survival and mortality among renal transplant patients. We enrolled 250 patients who had undergone transplantation between 1980 and 2004. They were followed for various periods, and we analyzed the impact of traditional and nontraditional risk factors on renal allograft survival. The prevalence of hypertension was &amp;gt;80% during all the follow-up periods. Blood pressure diminished, antihypertensive drug prescription increased, and 15% of patients had adequate blood pressure control during follow-up. The prevalence of pretransplant diabetes mellitus was 6.8%; the incidence of posttransplant diabetes mellitus (PTDM) was 14.2%. The prevalence of PTDM increased over the course of patient evolution. The prevalence of dyslipidemia was in all cases &amp;gt;70%; total cholesterol and low-density lipoprotein (LDL)-cholesterol decreased; prescription of statins increased; and the percentage of patients with good lipid control also increased. The 25% prevalence of active smoking at the time of transplantation decreased to 13.6% at 10 years posttransplantation. The mean patient follow-up was 8 +/- 4.6 years. Sixty-five patients (26%) lost their grafts and 40 (16%) died during follow-up. Donor age, exercise, diastolic blood pressure, renal function, and albumin levels were independent risk factors for graft loss. Charlson comorbidity index at transplantation, recipient and donor ages, exercise, diastolic blood pressure, and LDL-cholesterol posttransplantation were independent risk factors for mortality among renal transplant recipients. Blood pressure and lipid control improved during follow-up, however, insufficiently among renal transplant patients. The prevalence of diabetes gradually increased, and the incidence of smoking cessation was low. Diastolic blood pressure, exercise, and albuminemia were the most significant modifiable cardiovascular risk factors for renal allograft survival. Diastolic blood pressure, LDL-cholesterol level, and exercise were the most relevant modifiable cardiovascular risk factors for the survival of renal transplant patients.