Background To characterize use of nephrotoxic medications in patients with CKD Stage G3-5 in routine care. Methods Cohorts of adults with confirmed CKD G3-5 undergoing routine care during January 1, 2016 through December 31, 2018 in two health systems (Stockholm CREAtinine Measurements [SCREAM], Stockholm, Sweden [N = 57,880]; and Geisinger, Pennsylvania, U.S. [N = 16,255]). We evaluated the proportion of patients receiving nephrotoxic medications within one year overall and by baseline kidney function, ranked main contributors, and examined the association between receipt of nephrotoxic medication and age, sex, CKD G-stages, comorbidities and provider awareness of the patient's CKD using multivariable logistic regression. Results During a one-year period, 20% (SCREAM) and 17% (Geisinger) of patients with CKD received at least one nephrotoxic medication. Among the top nephrotoxic medications identified in both cohorts were NSAIDs (given to 11% and 9% of patients in SCREAM and Geisinger, respectively), antivirals (2.5% and 2.0%) and immunosuppressants (2.7% and 1.5%). Bisphosphonate use was common in SCREAM (3.3%), and fenofibrates in Geisinger (3.6%). Patients with age < 65 years, women, or with CKD G3 were at higher risk of receiving nephrotoxic medications in both cohorts. Notably, provider awareness of a patient's CKD was associated with lower odds of nephrotoxic medication use (OR, 0.85; 95% CI, 0.80–0.90 in SCREAM and OR, 0.80; 95% CI, 0.72–0.89 in Geisinger). Conclusions One in five patients with CKD received nephrotoxic medications in two distinct health systems. Strategies to increase physician's awareness of patients’ CKD and knowledge of drug nephrotoxicity may reduce prescribing nephrotoxic medications and prevent iatrogenic kidney injury.

Thrombosis in patients with thrombocytopenia has several risk factors, both disease-related and treatment-associated. Recently, COVID-19 infection was recognized as an additional risk factor, further complicating the delicate balance between thrombosis and bleeding in these patients. Here we describe the case of a patient with aplastic anaemia on eltrombopag who developed pulmonary embolism during COVID-19 pneumonia, despite receiving oral anticoagulation with edoxaban. Notably, he was also carrying a large paroxysmal nocturnal haemoglobinuria clone, although without evidence of haemolysis. The presented case recapitulates some of the open questions in thrombotic risk management of cytopenic patients, such as the management of thrombopoietin receptor agonists and the choice of anticoagulation in PNH, while also accounting for the additional thrombotic risk linked to COVID-19.

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