Risk of Acute Kidney Injury Associated With Medication Administration in the Emergency Department

Jeremiah S Hinson; Michael R Ehmann; Nour Al Jalbout; Melinda J Ortmann; Juliana Zschoche; Eili Y Klein

doi:10.1016/j.jemermed.2019.11.034

Risk of Acute Kidney Injury Associated With Medication Administration in the Emergency Department

J Emerg Med. 2020 Mar;58(3):487-496. doi: 10.1016/j.jemermed.2019.11.034. Epub 2020 Jan 15.

Authors

Jeremiah S Hinson¹, Michael R Ehmann², Nour Al Jalbout², Melinda J Ortmann³, Juliana Zschoche³, Eili Y Klein⁴

Affiliations

¹ Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Johns Hopkins Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, Maryland.
² Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
³ Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland.
⁴ Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Center for Disease Dynamics, Economics and Policy, Washington, District of Columbia.

PMID: 31952871
DOI: 10.1016/j.jemermed.2019.11.034

Abstract

Background: Patients who develop acute kidney injury (AKI) have a 2-fold increased risk for major adverse events within 1 year. An estimated 19-26% of all cases of hospital-acquired AKI may be attributable to drug-induced kidney disease (DIKD). Patients evaluated in the emergency department (ED) are often prescribed potentially nephrotoxic drugs, yet the role of ED prescribing in DIKD is unknown.

Objective: We sought to measure the association between ED medication administration and development of AKI.

Methods: This was a retrospective 5-year cohort analysis at a single center. Patients with a serum creatinine measurement at presentation in the ED and 24-168 h later were included. Outcome was incidence of AKI as defined by Kidney Disease Improving Global Outcomes criteria in the 7 days after ED evaluation. Medication administration risk was estimated using Cox proportional hazards model.

Results: There were 46,965 ED encounters by 30,407 patients included in the study, of which 6461 (13.8%) patients met the criteria for AKI. For hospitalized patients, administration of a potentially nephrotoxic medication was associated with increased risk of AKI (hazard ratio [HR] 1.30 [95% confidence interval {CI} 1.20-1.41]). Diuretics were associated with the largest risk of AKI (HR 1.64 [95% CI 1.52-1.78]), followed by angiotensin-converting enzyme inhibitors (HR 1.39 [95% CI 1.26-1.54]) and antibiotics (HR 1.13 [95% CI 1.05-1.22]). For discharged patients, administration of antibiotics was strongly associated with increased risk of AKI (HR 3.19 [95% CI 1.08-9.43]).

Conclusion: ED administration of potentially nephrotoxic medications was associated with an increased risk of AKI in the following 7 days. Diuretics, angiotensin-converting enzyme inhibitors, and antibiotics were independently associated with increased risk of AKI. Nephroprotective practices in the ED may mitigate kidney injury and long-term adverse outcomes.

Keywords: acute kidney injury; drug-induced kidney disease; emergency department; nephrotoxins.

MeSH terms

Acute Kidney Injury* / chemically induced
Acute Kidney Injury* / epidemiology
Drug-Related Side Effects and Adverse Reactions*
Emergency Service, Hospital
Humans
Pharmaceutical Preparations*
Retrospective Studies
Risk Factors

Substances

Pharmaceutical Preparations