Purpose Two to seven percent of the German adult population has a renal impairment (RI) with an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m 2. This often remains unrecognized and adjustment of drug therapy is lacking. To determine renal function in clinical routine, the CKD-EPI equation is used to calculate an indexed eGFR (ml/min/1.73m 2). For drug dosing, it has to be individualized to a non-indexed eGFR (ml/min) by the patient's body surface area. Here, we investigated the number of patients admitted to urological wards of a teaching hospital with RI between July and December 2016. Additionally, we correctly used the eGFR non-indexed for drug and dosage adjustments and to analyse the use of renal risk drugs (RRD) and renal drug-related problems (rDRP). Methods In a retrospective observational study, urological patients with pharmacist-led medication reconciliation at hospital admission and eGFR indexed (CKD-EPI) of 15-59 ml/min/1.73m 2 were identified. Indexed eGFR (ml/min/1.73m 2) was recalculated with body surface area to non-indexed eGFR (ml/min) for correct drug dosing. Medication at admission was reviewed for RRD and based on the eGFR non-indexed for rDRP, e.g. inappropriate dose or contraindication. Results Of 1320 screened patients, 270 (20.5%) presented with an eGFR indexed of 15-59 ml/min/1.73m 2. After readjustment, 203 (15.4%) patients had an eGFR non-indexed of 15-59 ml/min. Of these, 190 (93.6%) used ≥ 1 drugs at admission with 660 of 1209 (54.7%) drugs classified as RRD. At least one rDRP was identified in 115 (60.5%) patients concerning 264 (21.8%) drugs. Conclusion Renal impairment is a common risk factor for medication safety in urologic patients admitted to a hospital. Considerable shifts were seen in eGFR-categories when correctly calculating eGFR non-indexed for drug dosing purposes. The fact that more than half of the study patients showed rDRP at hospital admission underlines the need to consider this risk factor appropriately.

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Purpose Estimated glomerular filtration rate (eGFR) as calculated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is used for detection of chronic kidney disease and drug dose adjustment. The purpose of the present study was to investigate the accuracy of freely available eGFR online calculators. Methods All identified CKD-EPI online calculators were run with five reference cases differing in age, sex, serum creatinine, and ethnicity. Conversion from eGFRindexed (unit ml/min per 1.73 m2) to eGFRnon-indexed (unit ml/min) and creatinine unit from milligramme/decilitre to micromole/litre was checked, if available. Results Only 36 of 47 calculators (76.6%) produced accurate eGFR results for all reference cases. Eight of 47 (17.0%) calculators were considered as faulty because of errors relating to ethnicity (4 calculators), to conversion of the eGFR unit (2 calculators), to erroneous eGFR values without obvious explanation (2 calculators), to conversion of the creatinine unit (1 calculator), and to an error in the eGFR unit displayed (1 calculator). Overall, 28 errors were found (range 59 to 147% of the correct eGFR value), the majority concerning calculation of eGFRindexed and the conversion to eGFRnon-indexed. Only 7 of 47 (14.9%) calculators offered conversion of the eGFR unit. Conclusions Erroneous calculations that might lead to inappropriate clinical decision-making were found in 8 of 47 calculators. Thus, online calculators should be evaluated more thoroughly after implementation. Conversion of eGFR units that might be needed for drug dose adjustments should be implemented more often.

What Is Known and Objective A ‘renal pharmacist consultant service’ (RPCS) reviewing patients' charts with renal impairment (RI) for drug‐related problems (DRP) can foster patient safety. However, the benefit of this service in the new setting of a computerized physician order entry (CPOE)‐system with a clinical decision support (CDS)‐system is unknown. The aim of our study was to evaluate the general need for an RPCS on wards with a CPOE‐CDS‐system already in use and its effectiveness on prescription changes to ensure in‐hospital patient safety. Methods Over a period of 3 months (02‐04/2021), elective orthopaedic and trauma patients with eGFRabsolute/CrCl <60 ml/min at a German University Hospital received a medication review by a renal pharmacist for all medication entered into the CPOE‐system (Meona®) by the treating physicians. Written consultations explaining identified DRP and recommending interventions to solve them, for example, dose or drug adaptation, were shared with the physicians directly in the drug chart tab of Meona®. In complex cases, DRP were additionally discussed via phone. The prescription changes were evaluated retrospectively. Results and Discussion During 53 working days, 712 (30.5%) of 2331 screened patients were included with an eGFRnon‐indexed/CrCl <60 ml/min and a pharmacist‐led medication review was performed for all medication presented in the CPOE‐system (Meona®). In 79 of 712 (11.1%) patients, one or more DRP were detected (median 1 DRP (1–3) per patient) and written recommendations concerning 106 of 1090 (9.7%) drugs were shared via Meona®. In total, 104 DRP were identified, mostly caused by ‘dosage too high’ (n = 55, 52.9%), ‘dosage regime wrong’ (n = 13, 12.5%), and ‘contraindication’ (n = 9, 8.7%). Acceptance rate of recommendations was 74.0% (n = 77/104). In nine cases (8.7%), despite of specific recommendations, no adjustment of drugs was made because of lack of alternatives. In 11 (10.6%) cases, prescription remained unchanged for unknown reasons and in seven (6.7%) cases, the result was unknown due to discharge. What Is New and Conclusion In the setting of prescribing in a CPOE‐CDS‐system, that provides physicians with advice for drug or dose adaption, the pharmacist‐led medication reviews still identified DRP in orthopaedic and trauma patients with RI. A RPCS forwarding recommendations to solve DRP via the electronic medical record increased appropriate prescribing by physicians and, thus, may further improve patient safety.

methods From June until December 2020, a clinical pharmacist (CP) provided CPS, which included medication reviews and subsequent ward round participations (A: haemato-oncology, 11 beds; B: HSCT unit, 10 beds). The CP and an independent expert panel consisting of two clinical pharmacists and two paediatric haemato-oncologists assessed the PI for clinical significance. 1 Economic benefit was estimated retrospectively by drug therapy cost reductions and avoided follow-up costs based on prevention and management of adverse drug reactions (ADR). 2 Results During 32 ward rounds, 230 DRP were addressed in 36 children (median age 7 (0.4-17) years). The acceptance rate for PI was 73.5%. The most common DRP concerned need for drug monitoring, need for information/therapy discussion and drug-drug interactions; the most common PI were drug-monitoring, drug-information and dose adjustments. The CP assessed 66% of PI as very significant or significant and correlation with the expert rating was significant (p£0.0001). Costs of CPS were C¼ 7200. PI led to estimated drug therapy cost reductions of C ¼ 5500. Prevention of 11 and identification of 24 ADR led to estimated avoided follow-up costs of C ¼ 14 300-C ¼ 27 500 and C ¼ 31 200, respectively. Conclusion and relevanceThis evaluation showed that CPS for a tertiary care centre specialising in paediatric haemato-oncology is capable of identifying and preventing DRP by clinically significant PI. The estimated economic benefit of CPS was at least six-fold higher than its costs. Based on the results, CPS were expanded in our hospital.