Cystatin C–Guided Vancomycin Dosing in Critically Ill Patients: A Quality Improvement Project

Frazee, Erin; Rule, Andrew D.; Lieske, John C.; Kashani, Kianoush; Barreto, Jason N.; Virk, Abinash; Kuper, Philip J; Dierkhising, Ross A.; Leung, Nelson

doi:10.1053/j.ajkd.2016.11.016

Cited by 64 publications

(66 citation statements)

References 36 publications

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“…In this historical cohort study, we evaluated the SI as a predictor of malnutrition and outcomes in critically ill adults (≥18 years of age) hospitalized in a Mayo Clinic (Rochester, Minnesota) medical or surgical ICU between 2008 and 2015. Eligible individuals were obtained from 2 previously collected cohorts of patients with both serum creatinine and serum cystatin C drawn during their ICU admission . Briefly, included patients were those with sepsis, shock, or major trauma hospitalized in the ICU.…”

Section: Methodsmentioning

confidence: 99%

Sarcopenia Index Is a Simple Objective Screening Tool for Malnutrition in the Critically Ill

Barreto

Kanderi

DiCecco

et al. 2018

J Parenter Enteral Nutr

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Background Reliable and valid tools to screen for malnutrition in the intensive care unit (ICU) remain elusive. The sarcopenia index (SI) [(serum creatinine/serum cystatin C) × 100], could be an inexpensive, objective tool to predict malnutrition. We evaluated the SI as a screening tool for malnutrition in the ICU and compared it with the modified‐NUTRIC score. Materials and Methods This was a historical cohort study of ICU patients with stable kidney function admitted to Mayo Clinic ICUs between 2008 and 2015. Malnutrition was defined by the Subjective Global Assessment. Diagnostic performance was evaluated with the area under the receiver operating characteristic curve (AUC) and multivariable logistic regression. Results Of the 398 included patients, 181 (45%) had malnutrition, with 34 (9%) scored as severely malnourished. The SI was significantly lower in malnourished patients than in well‐nourished patients (64 ± 27 vs 72 ± 25; P = 0.002), and reductions in SI corresponded to increased malnutrition severity (P = 0.001). As a screening tool, the SI was an indicator of malnutrition risk (AUC 0.61) and performed slightly better than the more complex modified‐NUTRIC score (AUC = 0.57). SI cutoffs of 101 and 43 had >90% sensitivity and >90% specificity, respectively, for the prediction of malnutrition. Patients with a low SI (≤43) had a significantly higher risk of mortality (HR = 2.61, 95% CI 1.06–6.48, P = 0.038). Conclusion The frequency of malnutrition was high in this critically ill population, and it was associated with a poor prognosis. The SI could be used to assess nutrition risk in ICU patients.

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Section: Methodsmentioning

confidence: 99%

Sarcopenia Index Is a Simple Objective Screening Tool for Malnutrition in the Critically Ill

Barreto

Kanderi

DiCecco

et al. 2018

J Parenter Enteral Nutr

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“…This model was converted into a bedside applicable algorithm (Figure ). A similar model using the CKD‐EPI eGFR creatinine performed less well ( R 2 = 0.39) . After approval from local multidisciplinary practice groups, a quality‐improvement project was undertaken to implement the new dosing algorithm in critically ill patients and compare performance with historical controls dosed based on creatinine clearance.…”

Section: Practical Models Of Biomarker Utilizationmentioning

confidence: 99%

“…The results of this study indicated, that despite the use of significantly lower weight‐based and absolute doses, target vancomycin trough attainment improved from 28% in historical control patients to 50% in patients treated with the new algorithm, and overall concentration variability was reduced significantly. This was largely driven by a reduction in subtherapeutic trough concentrations through the use of more frequent dosing intervals in the intervention group …”

Section: Practical Models Of Biomarker Utilizationmentioning

confidence: 99%

“…Cells reflect doses of vancomycin (milligrams) and recommended dosing interval (hours). (Adapted from reference ).…”

Section: Practical Models Of Biomarker Utilizationmentioning

confidence: 99%

“…A similar model using the CKD-EPI eGFR creatinine performed less well (R 2 = 0.39). 13,36 After approval from local multidisciplinary practice groups, a quality-improvement project was undertaken to implement the new dosing algorithm in critically ill patients and compare performance with historical controls dosed based on creatinine clearance. Nonobese patients, with a weight greater than 40 kg, stable renal function, and newly initiated on vancomycin, were eligible for use of the algorithm.…”

Section: Practical Models Of Biomarker Utilizationmentioning

confidence: 99%

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Innovative Use of Novel Biomarkers to Improve the Safety of Renally Eliminated and Nephrotoxic Medications

et al. 2018

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Over the last decade, the discovery of novel renal biomarkers and research on their use to improve medication effectiveness and safety has expanded considerably. Pharmacists are uniquely positioned to leverage this new technology for renal assessment to improve medication dosing and monitoring. Serum cystatin C is a relatively new, inexpensive, functional renal biomarker that responds more quickly to changing renal function than creatinine and is not meaningfully affected by age, sex, skeletal muscle mass, dietary intake, or deconditioning. Cystatin C has been proposed as an adjunct or alternative to creatinine for glomerular filtration rate assessment and estimation of drug clearance. Tissue inhibitor of metalloproteinase-2·insulin-like growth factor-binding protein 7 ([TIMP-2]·[IGFBP7]) is a composite of two damage biomarkers released into the urine at a checkpoint in mitosis when renal cells undergo stress or sense a future risk of damage. Concentrations of [TIMP-2]·[IGFBP7] increase before a rise in serum creatinine is evident, thus providing insightful information for evaluation in the context of other patient data to predict the risk for impending kidney injury. This article provides a brief overview of novel renal biomarkers being used as a mechanism to improve medication safety including a discussion of cystatin C, as part of drug-dosing algorithms and specifically for vancomycin dosing, and the use of [TIMP-2]·[IGFBP7] for risk prediction in acute kidney injury and drug-induced kidney disease. Select cases of clinical experience with novel renal biomarkers are outlined, and lessons learned and future applications are described.

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Recommendations on Acute Kidney Injury Biomarkers From the Acute Disease Quality Initiative Consensus Conference

et al. 2020

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IMPORTANCE In the last decade, new biomarkers for acute kidney injury (AKI) have been identified and studied in clinical trials. Guidance is needed regarding how best to incorporate them into clinical practice. OBJECTIVE To develop recommendations on AKI biomarkers based on existing data and expert consensus for practicing clinicians and researchers. EVIDENCE REVIEW At the 23rd Acute Disease Quality Initiative meeting, a meeting of 23 international experts in critical care, nephrology, and related specialties, the panel focused on 4 broad areas, as follows: (1) AKI risk assessment; (2) AKI prediction and prevention; (3) AKI diagnosis, etiology, and management; and (4) AKI progression and kidney recovery. A literature search revealed more than 65 000 articles published between 1965 and May 2019. In a modified Delphi process, recommendations and consensus statements were developed based on existing data, with 90% agreement among panel members required for final adoption. Recommendations were graded using the Grading of Recommendations, Assessment, Development and Evaluations system. FINDINGS The panel developed 11 consensus statements for biomarker use and 14 research recommendations. The key suggestions were that a combination of damage and functional biomarkers, along with clinical information, be used to identify high-risk patient groups, improve the diagnostic accuracy of AKI, improve processes of care, and assist the management of AKI. CONCLUSIONS AND RELEVANCE Current evidence from clinical studies supports the use of new biomarkers in prevention and management of AKI. Substantial gaps in knowledge remain, and more research is necessary.

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Cystatin C–Guided Vancomycin Dosing in Critically Ill Patients: A Quality Improvement Project

Cited by 64 publications

References 36 publications

Sarcopenia Index Is a Simple Objective Screening Tool for Malnutrition in the Critically Ill

Sarcopenia Index Is a Simple Objective Screening Tool for Malnutrition in the Critically Ill

Innovative Use of Novel Biomarkers to Improve the Safety of Renally Eliminated and Nephrotoxic Medications

Recommendations on Acute Kidney Injury Biomarkers From the Acute Disease Quality Initiative Consensus Conference

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