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A risk factor for the development of acute kidney injury (AKI) in hospitalized patients is exposure to nephrotoxic medications (NTMx). Cystic fibrosis (CF) patients admitted for pulmonary exacerbations (PEx) are commonly exposed to NTMx. There is limited data on the development, implementation and outcomes of a hydration protocol (HP) for CF patients admitted for a PEx to prevent AKI.
An electronic survey was submitted to 13 providers at Children’s Mercy Kansas City (CMKC) and the CF pharmacist listserv to gather baseline interest and center practices. Based on the survey results and evaluation of published literature, a standard HP was developed to be utilized for all CF patients admitted for a PEx. Baseline exposure rates to NTMx and AKI rates were analyzed from January 2017 to July 2017. The HP was implemented in July 2018. Post-implementation data was analyzed from July 2018 to February 2019. AKI rates were evaluated while on NTMx defined as ≥50% increase from baseline (admission SCr) or an absolute increase of 0.3 mg/dL within 48 hours. The hydration protocol entails initiating IV fluids for the first 48 hours while on NTMx and includes a consult to Child Life to make individualized fluid charts.
All 10 (77%) respondents to the CMKC survey supported the implementation of a standardized HP. Prior to HP implementation, 45 individuals were exposed to NTMx comprising an exposure rate of 54.48 and an AKI rate of 7.26 per 1000 non-ICU days. Post-implementation of the HP, 61 individuals were exposed to NTMx with an exposure rate of 58.15 and AKI rate of 6.67 per 1000 non-ICU days. The mean duration of AKI was 1.17 ±0.41 days pre-implementation compared to 1.57 ±0.98 days post-implementation. The most common NTMx associated with AKI were tobramycin, vancomycin, colistimethate and piperacillin/tazobactam. There were 14 (23%) HP deviations primarily because the individuals did not receive intravenous fluids for 48 hours while on two NTMx. Of 61 encounters, 32 (52.5%) declined a fluid chart. Of those 32 encounters, 6 (19%) developed AKI, while only 1 (3%) individual that utilized a fluid chart developed AKI.
Implementation of the HP decreased AKI rate of CF patients admitted for PEx while receiving NTMx. This data demonstrates a need for a larger study over a longer duration and suggests the potential need for a standardized HP for patients exposed to NTMx hospital-wide.
Duehlmeyer, Stephanie; Elson, Claire; and Escobar, Hugo, "Development and Implementation of a Hydration Protocol for Cystic Fibrosis Patients Receiving Nephrotoxic Medications" (2019). Research at Children's Mercy Month 2019. 11.