Welcome to the latest edition of Renal News — the first to beproduced in collaboration with the team at Clinical Pharmacist.This year has been incredibly busy for the Renal PharmacyGroup and I would like to take this opportunity to thank all

those across the UK who have worked so hard for the organisation. One focus has been joined-up working, which we plan to build on further.

We saw an example of this earlier in the year when the RPG and the UnitedKingdom Clinical Pharmacy Association’s diabetes group co-hosted a studyday. Furthermore, in April, several of the RPG’s special interest groups tookpart in the Clinical Pharmacy Congress held in London; as well as giving twowell attended lectures, the RPG hosted a stand as part of the medicalexhibition, which attracted a great deal of interest. We also exhibited at theUKCPA autumn symposium in Chester, to let their members know moreabout the RPG’s activities.RPG members continue to raise the profile of the organisation beyond the

sphere of pharmacy. A notable example is an RPG-badged session on HIVand the renal patient pathway that was held at the British Renal SocietyConference in Manchester in May. Hayley Wells, principal renal, transplantand urology pharmacist at Guy’s and St Thomas’ NHS Foundation Trust,chaired the session, which featured Andrea Devaney, consultant pharmacistfor transplantation and renal services at Oxford University Hospitals NHSTrust, Esther Gathogo, HIV research group, Guy’s and St Thomas’ School ofMedicine, and Rachel Hilton, consultant nephrologist at Guy’s and StThomas’ NHS Foundation Trust. The lectures were well received and nextyear we have been asked to host a pre-symposium CPD session aroundnon-medical prescribing.The RPG’s acute kidney injury (AKI) working group has developed a toolkit

to help healthcare professionals manage issues around medicines managementfor patients with AKI (see p4). This work feeds into that of the national AKIdelivery group. A learning package to support pharmacists using the toolkit hasbeen developed in collaboration with the Centre for Postgraduate PharmacyEducation. This Learning@Lunch flex programme is underpinned by twoarticles published in Clinical Pharmacist (2012;4:98–106), and was launchedin April with a workshop at the aforementioned Clinical Pharmacy Congress.And so to the future. Those of you who attended our conference in

September will know of the plans to restructure the RPG and the way itoperates. In her article (p5), Liz Lamerton, senior renal pharmacist at SalfordRoyal NHS Foundation Trust, describes these changes in more depth. Wewould like more members, even inexperienced ones, to become involvedwith the work of the RPG, to contribute to its continued success and toallow it to expand its activities to suit the changing NHS landscape. Ifanyone would like to be involved, please don’t be shy, let us know — wewould love to have you on board.I hope that you enjoy this issue of Renal News and, as always, if you have

any comments or would like to submit an article, please contact ClareMorlidge (claremorlidge@nhs.net), who leads our new publications sub-group. I wish you all the best for 2013, and I look forward to “seeing” youagain in the next edition.

Caroline Ashley, Renal Pharmacy Group chairman

Winter 2012/13 Renal News

Collaboration is the key to success

Renal News is sponsored by Takeda UK Ltd, which had no editorial input into or controlover the content

U K R E N A L P H A R M A C Y G R O U P

p2 conference reports

p3 lupus nephritis evidence

p5 changes at the RPG

p6 award-winning abstracts

ISSN 2045-7073

RENAL NEWSISSUE 4 WINTER 2012/13

“We wouldlike moremembersto becomeinvolvedwith thework ofthe RPG

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Challenges around the treatment of patientswith HIV and renal impairment were thefocus of session a run by Esther Gathogo,clinical pharmacist, HIV research group,Guy’s and St Thomas’ School of Medicine,at this year’s Renal Pharmacy Groupconference (see Box). Setting the scene, Ms Gathogo spoke

about the substantial improvements thathave come about in HIV treatment, enablingpatients with the condition to live longer.Like all people, she pointed out, patientswith HIV are prone to the illnessesassociated with ageing, including renaldysfunction. Moreover, although a rareoccurrence, antiretroviral medicines caninduce kidney injury through a range ofmechanisms, she said. Specifically about the use of antiretroviral

medicines in patients with renal dysfunction,Ms Gathogo said that dose adjustments are

required for the nucleoside reversetranscriptase inhibitors (NRTIs), such aslamivudine and abacavir. However, this isnot the case for the non-nucleoside reversetranscriptase inhibitors (NNRTIs), such asefavirenz or nevirapine, or proteaseinhibitors, such as lopinavir.An important point for pharmacists to

remember, she said, is that there are severalpatient groups in whom eGFR readings areunreliable estimates of renal function, forexample, those who are malnourished and,conversely, those using creatinesupplements for bodybuilding.Specific guidance around dose

adjustments can be found in the RenalDrugs Handbook and on the HIV InSitewebsite (www.hivinsite.org). She alsodirected the audience to guidelinespublished by the British HIV Association(www.bhiva.org).

Renal transplant Renal transplant forpatients with HIV was also discussed in thissession. Ms Gathogo presented interimresults of her study into thepharmacokinetics of immunosuppressantdrugs when used by patients with HIV whohave undergone renal transplant. Initial results point to very good

outcomes for HIV patients who receive renal transplants. She said that most

patients have few HIV-related problems ifthey are managed correctly — in particular,ensuring that patients are trialled ontacrolimus before transplant to ensure thattherapeutic levels can be maintained and, ifthis is successful, ensuring that their HIVregimen does not change between this trialand transplantation. This is especiallyimportant for patients taking proteaseinhibitors, which can increase levels ofcalcineurin inhibitors.

An interesting and thorough overview of themetabolic, bone and soft tissueabnormalities associated with chronickidney disease (CKD), and their implicationsfor patient morbidity and mortality, waspresented by Alastair Hutchison, consultantnephrologist at Central ManchesterUniversity Hospitals NHS Foundation Trust,on day 1 of the conference (see Box). Dr Hutchison explained that phosphate

retention is evident once renal functiondeclines beyond a glomerular filtration rateof 60–80ml/min, stimulating hypocalcaemia,parathyroid cell hyperplasia and, ultimately,hyperparathyroid activity. He pointed outthat evidence now suggests that it is raisedphosphate, rather than an abnormal serumcalcium, that underpins the physiologicalchanges seen in CKD-bone and mineraldisorder (CKD-BMD). He went on to discuss the proposed

links between raised phosphate (and theassociated parathyroid abnormalities) onvascular ossification — calcification and/or phosification — vessel contractilityand the increased cardiovascular mortality associated with end-stage renaldisease.

Dr Hutchinson also spoke about ongoingresearch around CKD-BMD, focusing ontwo main areas, the fibroblast growth factorFGF23 and the Klotho gene and protein,and their roles in vascular calcification andatherosclerosis. FGF23 inhibits sodium-dependent

phosphate reabsorption and 1-alpha-hydroxylase in the proximal tubules,according to Dr Hutchison. He explained thatFGF23 therefore increases urinary excretionof phosphate and decreases serum 1.25-vitamin D3 levels. Patients with CKD haveelevated serum FGF23 levels relative to theirserum phosphate levels, he told the audience. The Klotho gene and protein have been

studied extensively in both mice andhumans, with polymorphisms associatedwith longevity, risk of vascular calcificationand bone mineral density inpostmenopausal women, he said. Dr Hutchinson finished by asking: is the

control of phosphate in patients with CKDmore important than previously thought, andshould it therefore be more tightly managedusing binding therapy or increased dialysis?He certainly made a strong argument for thecase.

Pharmacists should be looking foropportunities to change and improve,according to Chris Green, chief pharmacistat Countess of Chester Hospital NHSFoundation Trust. Speaking at the RPG conference (see

Box) about the challenges facing pharmacyin the NHS, Dr Green, who was thenchairman of the United Kingdom ClinicalPharmacy Association, said thatpharmacists are facing reduced resourcesand increasing demands for services. Theanswer, he believes, is working moreefficiently, for example, through automationof prescribing and dispensing. He also thinks that the profession needs

to engage the public and other healthcareprofessionals, and to become more handson with patients. Look for opportunities inoptimising medicines use and makingsavings in prescribing budgets, he urged. Dr Green’s take home message was

simple: pharmacists should not bury theirheads in the sand; they should be lookingfor the ways to improve and make thesehappen.

Winter 2012/13 Renal News

CONFERENCE 2

Tackle renal impairment in patients with HIV

Is phosphate the key to CKD-BMD? Look for ways tochange and improve

conference details

The UK Renal Pharmacy Groupconference was held in Manchester on28–29 September 2012. In 2013 the RPG conference will be

held on 27–28 September in Birmingham.Put the date in your diary!

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CommentaryLupus nephritis is part of the autoimmunedisorder systemic lupus erythematosus(commonly known as lupus). It is thought toaffect at least 50% of all people with lupus,with around 5% of these patients expectedto develop renal failure. Prompt treatment oflupus nephritis can resolve renaldysfunction and induce disease remission. This recent study by Dooley and

colleagues, known as “ALMSMaintenence”, builds on previous researcharound induction and maintenancetreatment of lupus nephritis. For induction, one of the initial pieces of

research was the National Institutes ofHealth (NIH) study, which demonstratedthat intravenous cyclophosphamidetherapy, in monthly doses of 0.5–1g/m2,was superior to glucocorticoid therapy forinduction treatment of lupus nephritis.1 Thisbecame the gold-standard inductiontreatment. Later, the Euro Lupus Nephritis Trial

showed that low-dose cyclophosphamide(500mg every two weeks, for six weeks)demonstrated similar renal and extra-renaloutcomes as the higher-dosecyclosphosphamide regimen in NIH, with alower incidence of toxicity.2 However,patients with severe lupus nephritis wereexcluded from this study; these patientsmay benefit from the higher-dose regimen.Then ALMS (Aspreva Lupus

Management Study) compared inductionwith oral mycophenolate mofetil (MMF; upto 3g/day) with the gold-standard NIHintravenous cyclophosphamide regimen.3

Equivalent response rates were seen at 24weeks (56.2% versus 52%, respectively). Inlight of these results MMF is considered asuitable alternative to intravenouscyclophosphamide for induction therapy inlupus nephritis; moreover, MMF can beused in all classes and disease severity. With regard to maintenance treatment for

lupus nephritis, the MAINTAIN trialcompared oral MMF (2g/day) with oralazathioprine (2mg/kg/day).4 No significantdifferences were seen in rates of diseaserelapse (the primary outcome) despite anumerical reduction in the number of renalflares in the MMF group (25% versus 19%).MAINTAIN was smaller than this latest

ALMS maintenance investigation (n=105and 227, respectively) and patients receiveddifferent induction therapy. All patients inMAINTAIN received the Euro LupusNephritis Trial cyclophosphamide regimenfor 10 weeks and were randomised to

Winter 2012/13 Renal News

JOURNAL CLUB 3

Should mycophenolate be used firstline for lupus nephritis maintenance?expanded abstractDooley MA et al. Mycophenolate versusazathioprine as maintenance therapy forlupus nephritis. New England Journal ofMedicine 2011;365:1886–95.

BackgroundAfter the initial induction therapy in lupusnephritis, maintenance immunosuppressionis recommended to avoid disease relapses.Azathioprine and mycophenolate can beused for this indication.

MethodsObjectives To compare the use of oralmycophenolate mofetil versus azathioprinefor the maintenance of remission of lupusnephritis.

Design A prospective, double-blind,randomised controlled trial with a three-year follow-up.

Subjects Patients 12 to 75 years of agewith active class III, IV, or V lupus nephritiswho have been treated to remission witheither oral mycophenolate mofetil (MMF) orintravenous cyclophosphamide (n=227).86% of the study group was female andthe majority of the participants were fromAsia (32%) or Latin America (26%) with18% of the patients from Europe.

Intervention Participants received oralMMF (2g/day) or azathioprine(2mg/kg/day). Patients unable to tolerateMMF at a minimum dose of 1g/day wereexcluded from the trial. Concurrentprednisolone (10mg or less) wasadministered to most patients (90.4% and86.5% in the MMF and azathioprinegroups, respectively).

Outcomes The primary efficacy endpointwas the time to treatment failure, measuredas sustained doubling of baselinecreatinine, renal flare (proteinuric ornephritic), the use of rescue therapy ordeath.

ResultsOf the 227 patients enrolled, a total of 127 patients completed the 36-monthfollow-up. A higher incidence of treatment

withdrawal was seen in the azathioprine

group (39% due to adverse events, 13%due to other reasons for withdrawal and48% completed), compared with the MMFgroup (25% due to adverse events, 12%due to other reasons for withdrawal and62% completed). No statistically significant differences in

baseline characteristics were evident. Meandoses of MMF and azathioprine were1.87+0.43g and 119.7+47.91mg,respectively and there was no dosedifference for either drug in the treatmentfailure subgroup. Although greater than 85% of the study

population had at least class IV biopsy-proven lupus nephritis, the baseline eGFRwas exceptional following inductiontherapy (104+43 vs 98.6+38 ml/min/1.73m2

for MMF and azathioprine, respectively). MMF was significantly better than

azathioprine with regard to treatmentfailure — 16.4% for MMF and 32.4% forazathioprine (hazard ratio 0.44; 95%confidence interval 0.25–0.77; P=0.003).This superiority was confirmed regardlessof induction therapy, race and geographicalarea. Renal flares and the requirements for

rescue therapy were lower in the MMFgroup compared with the azathioprinegroup (12.9% versus 23.4% for renal flares;7.8% versus 17.1% requiring rescuetherapy). Serological monitoring of the disease

demonstrated equivocal results, with c3and c4 lower in the azathioprine group buthigher anti-DsDNA antibodies seen in theMMF group. Infection was the most commonly

experienced adverse effect, with similarrates seen in both groups (around 78% forall infections and around 10% for severeinfections).

LimitationsThe study is limited by the fact that it wasnot powered to draw conclusions about theEuropean population.

ConclusionIn patients with lupus nephritis who havereceived successful induction therapy withintravenous cyclophosphamide or oralmycophenolate, maintenance treatmentwith MMF is superior to azathioprine inpreventing disease relapse.

Winter 2012/13 Renal News

JOURNAL CLUB 4receive MMF or azathioprine irrespective oftheir renal function and whether the diseasewas in remission. Baseline renal function was lower in the

MAINTAIN trial and maintenance therapywas initiated in patients not successfully indisease remission. The study howeverfollowed up patients for an additional year(four years) and was based on Europeanpractice. Similar glucocorticoid therapy wasadministered in both studies. ALMSmaintenance was open-label and thereforeclinician bias may have affected results.

The bottom line Individual patientcharacteristics may help decide whichmaintenance therapy to use. Overall, ratesof adverse effects are similar, but gastro-intestinal adverse effects are moreproblematic with MMF (dose reduction mayhelp to minimise this) and azathioprine isassociated with more leucopenia.Thiopurine methyltransferase (TPMT) activityshould be measured before startingazathioprine, since patients with enzymeunderactivity are at higher risk of toxicityand require lower doses.Because lupus affects women of child-

bearing age predominantly, non-teratogenicmedicines should be used where possible.Cyclophosphamide causes ovarian failure in38–52% of women. Although someevidence suggests that gonadotrophin-releasing hormone analogues can preventthis, the risk of gonadal dysfunction limitsuse of this drug. MMF is preferred forinduction in this population. However, in pregnancy, MMF is strictly

contraindicated due to concerns over fetaltoxicity; azathioprine can be safely used inpregnancy. An argument could therefore bemade to use azathioprine in this largelychild-bearing group to avoid suchcomplications. Additionally, azathioprine isless expensive than MMF — although the

cost differential has lessened now thatgeneric MMF is available. The ALMS maintenance trial

demonstrates that MMF (at doses up to2g/day) is superior to azathioprine (2mg/kg)for the prevention of renal flares in patientsin remission of lupus nephritis. Individualpatient characteristics should influenceprescribing, for example, for womenplanning pregnancy azathioprine is thepreferred treatment option.

By Stephen Hughes, specialist renalpharmacist, and Marc Vincent, lead renalpharmacist, Central Manchester UniversityHospitals NHS Foundation Trust

REFERENCES1. Boumpas DT, Austin HA, Vaughn EM, et al. Controlled

trial of pulse methylprednisolone versus two regimensof pulse cyclophosphamide in severe lupus nephritis.Lancet 1992;340:741–5.

2. Houssiau FA, Vasconcelos C, D’Cruz D, et al.Immunosuppressive therapy in lupus nephritis: theEuro-Lupus Nephritis Trial, a randomized trial of low-dose versus high-dose intravenous cyclophosphamide.Arthritis and Rheumatology 2002;46: 2121–31

3. Appel G, Contreras G, Dooley MA, et al.Mycophenolate mofetil versus cyclophosphamide forinduction treatment of lupus nephritis. Journal of theAmerican Society of Nephrology 2005;20:1103–12.

4. Houssiau FA, D’Cruz D, Sangle S, et al. Azathioprineversus mycophenolate mofetil for long-termimmunosuppression in lupus nephritis: results fromthe MAINTAIN Nephritis Trial. Annals of RheumaticDiseases 2010;69:2083–9.

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Acute kidney injury (AKI) affects around20% of patients admitted acutely tohospital. Moreover, the condition isassociated with substantial mortality (some10 –80% of patients will not survive) andconsiderable cost to the NHS (in 2009–10between £434m and £620m was spent onmanaging the condition in England). The condition is largely preventable and

up to 30% of all cases are thought to becaused by medicines. To help tackle theproblem of medicines-induced AKI theRenal Pharmacy Group has developed atoolkit, designed to promote medicinesoptimisation for patients with AKI. The medicines optimisation toolkit

(available at www.renalpharmacy.org.uk)

provides a list of medicines that are deemed“high-risk” in patients with AKI and providesrecommendations for how to manage therisk (eg, through dose adjustment ortemporary cessation of the drug). To help improve pharmacists’

understanding of AKI and promote thetoolkit two articles about AKI werepublished in Clinical Pharmacist (2012;4:98and 2012;4:103) and a Centre for PharmacyPostgraduate Education learning@lunch flexprogramme was developed.

� Acute kidney injury is also the themeof World Kidney Day 2013, which takesplace on 14 March. More information canbe found at www.worldkidneyday.org

Help your patients avoid acute kidney injury with the RPG toolkit

Primarily, the Renal Pharmacy Group(RPG) is a special interest group forpharmacy staff with an interest inrenal medicine, and has strong

links with other pharmacy groups, such asthe Royal Pharmaceutical Society, and withother renal groups, for example the BritishRenal Society.

Over the past 18 months the RPGcommittee has been considering theorganisation, and future direction, of theRPG. The result of these discussions is arestructure, the details of which werepresented at the Annual General Meetingand conference in September 2012.

Why is change needed? The RPG is anactive organisation. Currently, our memberactivities range from participation indevelopment of technology appraisals andguidelines for the National Institute forHealth and Clinical Excellence to educationand training for pharmacists and the widerhealthcare team. In addition, members havepublished a range of articles and books onbehalf of the RPG.

The RPG annual conference provideseducation, training and networkingopportunities for people with an interest inrenal pharmacy. Members also use online

Winter 2012/13 Renal News

ARTICLE 5

Restructure aims to prepare theRenal Pharmacy Group for the future

new organisational structure

forums, such as the RPG email questionand answer cascades, to share experienceand provide support.

However, the NHS has changed over thepast few years, and change is set tocontinue. The introduction of the quality,innovation, productivity and prevention(QIPP) challenge means that everyoneworking in the NHS is striving to improvequality, while making efficiency savings.

To adapt to the new NHS climate, theRPG needs to ensure that more membersare given opportunities to become activelyinvolved in RPG initiatives. Our challenge isto ensure that our activity remains relevantfor the new NHS, and for our members, andhelps us deliver high standards ofmedicines management.

Aim of restructure The RPG needs to beproactive in issuing opinions, alerts andposition statements for our members andthe wider healthcare community, whilecontinuing to support and promote renalpharmacy. The RPG committee haveproposed a new structure (below), whichaims to:

� Promote collaborative working within theRPG membership

Executive boardChair — Caroline Ashley

Deputy chair — Andrea Devaney Secretary (including treasurer, corporate sponsorship and membership) — Aileen Dunleavy

Strategic lead — Stephen AshmoreBritish Renal Society and Renal Association representative — Hayley Wells

Generalclinical subgroup

Lead — Marc Vincent

� General nephrology� Acute kidney injury� Chronic kidney disease� Dialysis� Transplantation� Paediatrics� End of life

Education andtraining subgroup

Lead — Rob Bradley

� Conference� Study days

Research anddevelopmentsubgroup

Lead — Sue Shaw

� Research� Research publications� Workforce planning

Communicationsand publications

subgroup

Lead — Clare Morlidge

� Communications� Publications (eg, Renal

Drug Handbook) � Renal News� Website, Twitter,

Facebook

� Encourage high quality clinical pharmacywork and increase productivity ofmembers by sharing good practice

� Provide an opportunity for RPGmembers to have experience ofcommittee work and national projects,and to be encouraged to take on a rolein the executive committee in the future

� Increase the political awareness ofmembers

� Enable RPG members to be co-opted in and out of subgroups depending onthe current work requirements and level of individual commitment available; for example, members may wish to participate in discussionsabout a specific topic on a short-termbasis

For an initial transition period of oneyear, existing elected members of the RPGcommittee will fulfil the roles on theexecutive board, and as the subgroupleads. After this time, members will beelected to the RPG executive committeeand as leads for subgroups. The membersof the subgroups will be RPG membervolunteers, as detailed in the Terms ofReference (available online atwww.renalpharmacy.org.uk).

Desensitisation ofpatients unable totolerate co-trimoxazoleAllen J,* Lamerton E* *Salford Royal NHS Foundation Trust

BackgroundFollowing a sudden increase in confirmedcases of Pneumocystis carinii pneumonia(PCP) in Salford Royal transplant patients, adecision was made to commence alltransplant patients on prophylactic co-trimoxazole.

Several patients were unable to tolerateco-trimoxazole prophylaxis, experiencingnausea or headache. Others had previouslybeen “unwell” while taking co-trimoxazoleand another experienced a black tonguewhile taking the drug.

Renal pharmacists found publishedevidence of successful co-trimoxazoledesensitisation in patients with HIV, and ledan initiative to try desensitisation in theserenal transplant patients. A pharmacist-leddesensitisation plan was agreed with therenal team and offered to suitable patients.

PurposeTo describe the successful desensitisationto co-trimoxazole of five renal transplantpatients.

MethodPatients were reviewed in the pharmacist-led drug monitoring clinic. A medicinesreconciliation and allergy history weretaken. Patients with anaphylaxis wereexcluded from the programme. Six suitablepatients were consequently prescribed adesensitisation programme by the renalpharmacist. The desensitisation protocolused co-trimoxazole paediatric suspension(240mg/5ml) as follows:

� Day 1 — 1.25ml once only� Day 2 — 1.25ml twice daily� Day 3 — 1.25ml three times daily� Day 4 — 2.5ml twice daily� Day 5 — 2.5ml three times daily

On day 6, patients took one 480mg tablet.

ResultsA total of six patients were suitable for atrial of the desensitisation regimen. Ofthese, five patients tolerated the co-trimoxazole and were able to continue withthe full adult prophylactic dose. One patient

Winter 2012/13 Renal News

ABSTRACTS 6

Award-winning abstracts from the RPG conference 2012

first prize

second prize

developed a rash during the desensitisationprogramme and co-trimoxazole wasimmediately discontinued and a yellow cardsubmitted.

ConclusionUsing the desensitisation regimen allowspatients with non life-threateningintolerances to tolerate co-trimoxazole, thusproviding them with prophylaxis againstPCP during the period of outbreak at SalfordRoyal. Without the desensitisation, patientswould have been prescribed a second-lineoption, such as dapsone, with a potentiallyhigher incidence of adverse effects.

Further, utilising the clinical andprescribing skills of the renal pharmacists inthis manner ensured patients receivedoptimisation of medicines management.

REFERENCES1. Tietjen PA et al. Prophylaxis against Pneumocystis

carinii (P jirovecii) in HIV-infected patients.www.uptodate.com (accessed 20 January 2011).

Drug-related problemson an inpatientpaediatric renal wardIbrahim N,* Wong ICK,*† Patey S,‡ Rees L,‡

Jani Y**Centre for Paediatric Pharmacy Research, UCLSchool of Pharmacy; †Department ofPharmacology and Pharmacy, Li Ka Shing Facultyof Medicine, University of Hong Kong;‡Department of Pharmacy/Nephrology, GreatOrmond Street Hospital for Children NHSFoundation Trust

BackgroundA drug-related problem (DRP) is defined as:“an event or circumstance involving drugtherapy that actually or potentially interfereswith desired health outcomes”.1 There is asignificant lack of research on drugproblems in this patient group.2

PurposeThis study aims to describe thecharacteristics of DRPs in a paediatric renalward at a tertiary care NHS hospital inLondon, UK.

MethodThis prospective observational study wasconducted from 1 September 2011 to 30April 2012 at a renal ward of a NHSpaediatric hospital in London. The study

site has an established pharmaceutical carepractice based on standard care at thetime. All children aged 18 years and belowat all stages of chronic kidney disease(CKD) who were admitted to the wardduring the observational period wereincluded into the study.

All DRPs identified by the pharmacistwere recorded into a specific pro forma.The nature and characteristics of each casewere evaluated by a panel of two members,and disagreements were re-evaluated by athird member.

The drugs related to the occurrence ofDRP were categorised based on the WorldHealth Organization Anatomical TherapeuticChemical (ATC) classification system. Datawere analysed using the Statistical Packagefor the Social Sciences (SPSS) version 19.0for Windows. This study was approved bythe Westminster-London Research EthicalCommittee.

ResultsA total of 107 admissions involving 72subjects were followed up. The median ageof subjects was 4.81 years (interquartilerange [IQR] = 9.27). The median length ofhospitalisation was seven days (IQR = 11).A majority of hospitalisations were CKDcases not on any renal replacementtherapy, followed by dialysis (35.5%) andpost kidney transplant (23.4%).

There was no significant difference in thenumber of DRPs identified at differentstages of CKD, length-of-stay or gender. Atotal number of 171 DRPs were identifiedinvolving 3,520 prescribed items. Themedian number of prescribed items duringhospitalisation was 22 (IQR = 29). Morethan half (64.9%) of the cases admitted tothe renal ward developed at least one drugproblem (median = 1; IQR = 1.9).

Most of the identified DRPs had thepotential to cause unnecessary treatment(23.4%), toxic reaction (18.1%) anduntreated indication (11.1%). This studyalso discovered frequent drugadministrative problems due to difficulty indosage measurement (11.1%). The threedrug groups most associated with DRPswere antibacterials for systemic use(16.4%), analgesics (13%) and intestinalanti-inflammatory agents (8.5%).

ConclusionCurrent understanding on the managementof DRPs in renal failure is based on studiesin the adult population and does notrepresent the paediatric group. Moreepidemiology research on DRPs inpaediatric group is essential to develop aDRP classification scheme for thepaediatric population.

Winter 2012/13 Renal News

ABSTRACTS 7

Impact of a clinicalpharmacist attendingnephrology andneurology wardrounds: a one-yearretrospective study

Captur C,* Captur G,† Farrugia E,* Vella NR**Mater Dei Hospital, Malta; †University CollegeLondon

BackgroundThere are various US studies evaluating theimpact of pharmacists attending “rounds”.1–4

In UK hospitals, ward pharmacy servicesare traditionally provided by pharmacistsundertaking daily visits to their allocatedwards.5

During these ward visits, pharmacistsdiscuss medication-related issues andmake recommendations to medical staff,nursing staff and patients as necessary.These contributions to patient care aretypically termed “interventions”.

MethodA clinical pharmacist regularly monitorednephrology and neurology ward rounds anddocumented interventions at a hospital inMalta. Data were recorded for eachinteraction, during each ward round, withstrict control for variables, so as to ensurethe scientific validity.

For the purposes of this study, apharmacist intervention was defined as:“any verbal or written communicationbetween a pharmacist and a physician,undertaken with the intention on influencingprescribing”.6

third prize

Pharmacist interventions were categorisedas follows:

� Untreated Indication � Improper medicine selection� Sub-therapeutic dose� Overdose � Failure to receive medicines

appropriately � Adverse drug reaction � Medicine Interaction � Medicine use without indication � Duplication of therapy� Monitoring need� Counselling need � Seamless care

ResultsData were collected for a one-year period(1 November 2010 to 30 November 2011).During this one-year timeframe, 5,441patients’ situations were evaluated duringward rounds. This included screening oftheir drug charts and any other clinicalpharmacist interventions. In total, 12,509interventions were recorded (see Figure,below).

ConclusionBased on the results of this study, clinicalpharmacists should attend ward rounds formedical specialisms for two critical reasons:

� To instill a procedure which ensurespatient safety

� To make hospitals run more efficiently

Further research is needed to evaluatethe benefit of clinical pharmacists attendingward rounds for other specialisms.Nevertheless medical consultants andpharmacy departments should worktogether to include clinical pharmacists ontheir multidisciplinary ward rounds.

REFERENCES1. Kucukarslan S, Peters M, Mlynarek M, et al.

Pharmacists on rounding teams reduce preventableadverse drug events in hospital general medicineunits. Archives of Internal Medicine2003;163:2014–8.

2. Leape L, Cullen D, Clapp M, et al. Pharmacistparticipation on physician rounds and adverse drugevents in the intensive care unit. JAMA1999;281:267–70.

3. Scarsi K, Fotis M, Noskin G. Pharmacistsparticipation in medical rounds reduces medicationerrors. American Journal of Health-System Pharmacy2002;59:2089–92.

4. Rollins G. Having pharmacists participate in medicalrounds reduces medication errors. Report on medicalguidelines & outcomes research 2002;13:9–10, 12.

5. Stebbing C, Jacklin A, Barber N, et al. A comparisonof the US and UK inpatient medication systems.European Journal of Hospital Pharmacy Practice2006;12:36–40.

6. Brady D, Franklin BD. An evaluation of thecontribution of the medical admissions pharmacist ata London teaching hospital. International Journal ofPharmacy Practice 2004;12:1–6.

REFERENCES1. Pharmaceutical Care Network Europe. Classification

of drug-related problems, version 6.2. January 2010.www.pcne.org/sig/drp/drug-related-problems.php

2. Ibrahim N, Wong ICK, Patey S, et al. Drug-relatedproblems in children with chronic kidney disease.Pediatric Nephrology 2012; DOI 10.1007/s00467-012-2149-1.

Renal News is produced onbehalf of the UK RenalPharmacy Group by ClinicalPharmacist (PJ Publications). PJ Publications is a division ofPharmaceutical Press, a wholly

owned subsidiary of the Royal Pharmaceutical Society, 1 Lambeth High Street, London SE1 7JN (tel 020 7572 2425;email clinicalpharmacist@pharmj.org.uk).

The content of and information contained in this publication isthe responsibility of the Renal Pharmacy Group. The sponsorTakeda UK Ltd had no editorial input into or control over thecontent. For editorial enquiries contact Clare Morlidge (emailclaremorlidge@nhs.net). Copyright © UK Renal PharmacyGroup 2012. All rights reserved. No copying, distribution,adaptation, extraction or reuse of any material in thispublication (print or digitally) may take place except with theexpress permission of the Renal Pharmacy Group.

Figure: number of interventions

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Intravenous treatment of iron de� ciency anaemia in adult patients with chronic kidney disease1

Short course1

High dose1 Rapid bolus injection1

RIENSO®▼ (ferumoxytol) PRESCRIBING INFORMATIONRefer to Summary of Product Characteristics before prescribing. Presentation: 30mg/ml solution for injection. 1 ml of solution contains 30 mg of iron as ferumoxytol. Each vial of 17 ml solution contains 510 mg of iron as ferumoxytol. Available in 1 x 17ml vial (£65) and 6 x 17 ml vial (£390) packs. EU/1/12/774/001 and 004. Indications: Rienso is indicated for the intravenous (IV) treatment of iron de� ciency anaemia in adult patients with chronic kidney disease (CKD). Dosage and Administration: Each 510 mg dose is administered as an IV injection. For patients receiving two doses, the second 510 mg IV injection is to be administered 2 to 8 days later. The recommended course and dose is based on the patient’s pre-treatment haemoglobin (Hb) and body weight. Refer to table in SmPC. Patients should be observed for signs and symptoms of hypersensitivity for at least 30 minutes following each injection . Re-treatment: May be given after the patient has been re-assessed and con� rmed to be iron de� cient. Children and adolescents (under 18 years): Not recommended. Special population – patients receiving haemodialysis: Administer once the blood pressure is stable and the patient has completed at least one hour of haemodialysis. Hepatic Impairment: Parenteral iron should only be administered after careful risk / bene� t assessment. No change in dosage is recommended. Contraindications: Hypersensitivity to active substance, excipients or other iron preparations. Evidence of iron overload. Anaemia not caused by iron de� ciency. Warnings and precautions: Hypersensitivity Reactions; Can cause hypersensitivity reactions including serious and life-threatening anaphylactic /anaphylactoid reactions. Hypersensitivity reactions presenting with cardiac / cardiorespiratory arrest, clinically signi� cant hypotension, syncope, and unresponsiveness have been reported in post-marketing experience. The product should only be administered when sta� trained to evaluate and manage

anaphylactic reactions are immediately available. If any signs of hypersensitivity reaction or intolerance are detected, administration must be stopped immediately. In patients with multiple substance allergies, the need for alternative treatment options should be carefully considered. Hypotension; Hypotension may follow administration with or without accompanying signs of hypersensitivity. Patients should be monitored for hypotension following each Rienso administration. Iron Overload; Should not be administered to patients with iron overload and must not be given to patients if their Hb is greater than 12 g/dl, serum Transferrin Saturation (TSAT) is greater than 50% or ferritin is greater than 800 ng/ml (see section 4.2). Immunologic Disease or Infection; Parenteral iron should be used with caution in cases of immunologic disease or acute or chronic infection. It is not recommended to administer to patients with ongoing bacteraemia. Re-treatment / Long term use; Limited clinical study data is available regarding re-treatment and no clinical study data is available for repeated long term use. Magnetic Resonance (MR) Imaging; Administration may transiently a� ect the diagnostic ability of MR imaging. Conduct MR imaging prior to Rienso administration. Interference with Serological Testing; In the 24 hours following administration laboratory assays may overestimate serum iron and transferrin bound iron by also measuring the iron in the Rienso complex. Fertility, Pregnancy and lactation: Do not use. Potential risk unknown. Undesirable e� ects: In clinical trials involving 1562 subjects with CKD, adverse reactions were seen in 7.9% of patients who received Rienso, of which 0.2% were considered serious. Common (1-10%): injection site reactions. Uncommon (0.1-1%): Hypersensitivity including anaphylaxis, decreased appetite, increased appetite, dizziness, dysgeusia, headache, somnolence, burning sensation, hypotension, � ushing, hypertension, dyspnoea, diarrhoea, constipation, nausea, abdominal pain, vomiting, faeces discloured, rash, ecchymosis, sweating, skin hyperpigmentation,

skin reaction, muscle / joint pain or sti� ness, back pain, muscle spasms, fatigue, chest pain, chills, fever, serum ferritin increased, contusion. Frequency unknown: Life-threatening anaphylactic / anaphylactoid reactions, syncope, unresponsiveness, loss of consciousness, arrhythmia / tachycardia, cardiac arrest, cardio-respiratory arrest, myocardial Infarction, cyanosis, bronchospasm, respiratory failure, laryngeal / pharyngeal oedema, angioedema, congestive heart failure, respiratory arrest, pulse absent. PI Date: August 2012. PI code: FE120702a. Legal category: POM. MARKETING AUTHORISATION HOLDER: Takeda Global R & D Centre (Europe) Limited. Takeda UK Ltd. are responsible for the sale and supply of RIENSO in the UK. RIENSO is a registered trademark owned by Takeda Pharmaceutical Company Ltd. For further information contact: Takeda UK Ltd. Takeda House, Mercury Park, Wycombe Lane, Wooburn Green, High Wycombe, Bucks HP10 0HH. Tel: 01628-537900, Fax: 01628-526617.

Reference1. Rienso SmPC. Available at: http://www.medicines. org.uk/EMC/medicine/26773/

SPC/Rienso.

October 2012 Code: FE120914c

Please refer to the Summary of Product Characteristics for details on the full side e� ect pro� le of RIENSO. Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Takeda UK Ltd.

anaemiazone.co.uk

28130 Rienso SP 297x210 GroupNEWS aw4.indd 1 20/11/2012 10:18