Appropriate prescription review based on kidney function is essential to ensure safe and effective pharmacotherapy. As a simple tool to convey kidney function, the chronic kidney disease (CKD) sticker has been utilized in clinical practice. In a survey conducted by the CKD Sticker Promotion Working Group of the Japanese society of Nephrology and pharmacotherapy, CKD stickers were identified in 62 regions. The scale of implementation varied widely, ranging from prefecture-wide programs to initiatives at individual facilities. A variety of organizations—including local governments, medical associations, and pharmaceutical associations—were involved in their implementation, suggesting that CKD stickers serve not merely as a tool but as part of an organized program.

In many regions, the primary purpose of CKD stickers was to promote appropriate use of medications by pharmacists, but some areas also used them to facilitate information sharing with primary care physicians or to encourage behavioral changes in patients. The thresholds for estimated glomerular filtration rate (eGFR) at which the stickers were applied appeared to be set according to the objectives of each region, such as early intervention and efficient allocation of medical resources. Both phased replacement formats and versions requiring manual entry of eGFR values were observed. Physicians and pharmacists were the primary professionals responsible for applying the stickers, while in some areas, nurses, public health nurses, dentists, and local government staff were also involved. Certain regions limited sticker application to nephrologists or hospital pharmacists to ensure accuracy, while others later broadened the range of eligible professionals to promote wider adoption. From a design perspective, many regions customized the information displayed on the sticker according to the intended audience, and some even included direct messages to CKD patients.

Challenges identified included limited spread, leading to uneven application within regions, and the coexistence of multiple types of CKD stickers within the same or neighboring areas. Early-adopter regions reported an increase in prescription queries from pharmacist to physician prompted by CKD stickers and a decrease in hospitalizations due to drug-induced kidney injury. However, there have been no reports of hard endpoints, such as reductions in dialysis initiation or improvements in eGFR slope, indicating the need for future outcome-based studies.

It is important for patients with end-stage CKD to understand their options for renal replacement therapy; however, 95% of end-stage CKD patients in Japan currently choose hemodialysis. In response to the increasing number of patients undergoing hemodialysis, various associations have established pharmacist certification programs. Yet, it is unclear how these certifications affect pharmacist involvement in patients’ choice of treatment. To identify the effects of certification, we compared awareness and knowledge regarding renal transplantation between certified and non-certified pharmacists.

The study included 607 members enrolled in the Kansai Society of Nephrology and Pharmacotherapy between December 1, 2020, and August 23, 2023. After surveying the participants’ awareness of renal replacement therapies and knowledge of renal transplantation, a short video was presented to communicate the dangers of stereotypes and the need for more widespread knowledge about renal transplantation. Then, another awareness survey was conducted.

Certified pharmacists had significantly higher levels of understanding of post-transplant pregnancy and delivery, donor conditions, and blood group incompatibility than non-certified pharmacists. However, there were no significant differences between the two groups in their use of the phrase “to avoid dialysis” during medication instruction, knowledge of the donor’s insurance, awareness of the donor registry’s priority donation intentions needed for renal replacement therapy options, or organ donation intention rates. Non-certified pharmacists were significantly more aware of the need to learn after watching videos, and the misassumption that the term “renal replacement therapy” is interchangeable with the term “hemodialysis” was reduced. After viewing the video, certified pharmacists were significantly less willing to avoid using the phrase “to avoid dialysis” in the future than non-certified pharmacists.

Short video viewing was effective for non-certified pharmacists. In contrast, certified pharmacists had an understanding of the choice of renal replacement therapy but may not have been fully aware of the importance of being “properly involved in the choice.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are essential for the treatment of diabetes, chronic kidney disease, and heart failure. Prescription rates continue to increase. However, multiple professional societies have prompted warnings about the initial dip in eGFR observed shortly after the initiation of SGLT2 inhibitors. Despite these concerns, associated risk factors remain unclear. This study aimed to identify the risk factors associated with the initial dip in patients with heart failure.

This retrospective study used electronic medical records. We conducted research on heart failure patients who were prescribed SGLT2 inhibitors (dapagliflozin or empagliflozin) at Kido Hospital between December 1, 2020, and September 30, 2023.

In total, 184 patients were included in this study. A multivariate analysis was performed to identify independent risk factors. The analysis revealed that baseline eGFR (beta coefficient: 0.317, p < 0.001) and loop diuretic use (beta coefficient: -0.227, p = 0.001) were significantly associated with the initial decrease in eGFR. These findings suggest that baseline eGFR and loop diuretic use independently influence the extent of the initial dip.

In patients with heart failure, the baseline renal function and loop diuretic use may be independent risk factors for the initial decrease following SGLT2 inhibitor initiation. Given the high prevalence of renal impairment and loop diuretic use in this population, the initial decrease may be more pronounced. Therefore, careful monitoring and management of adverse effects by pharmacists is crucial to ensuring the long-term efficacy and safety of SGLT2 inhibitors in clinical practice.

【Background】Dialysis patients are prone to zinc deficiency. However, excessive zinc supplementation can lead to copper deficiency, which may cause cytopenia, including anemia. In this study, we evaluated the appropriate zinc dosage in dialysis patients from the perspective of the risk of copper deficiency.

【Method】Ten hemodialysis patients who newly started zinc supplementation with zinc acetate hydrate (Nobelzin^® tablets) and had measurable serum zinc and copper concentrations were included. Changes in serum zinc and copper levels were monitored for up to one year after the start of treatment. Data are presented as medians [minimum – maximum].

【Results】Five patients each received a daily dose of 25 mg or 50 mg of zinc acetate hydrate. Serum zinc concentrations increased from 58 [45 – 84] µg/dL before treatment to 114 [46 – 155] µg/dL after treatment, while serum copper concentrations changed from 83 [58 – 121] µg/dL to 91 [8 – 113] µg/dL (N=10).

When analyzed by dosage group, the serum zinc levels were 106.5 [87.0 – 126.0] µg/dL in the 25 mg/day group and 114.0 [46.0 – 155.0] µg/dL in the 50 mg/day group. Within one year of starting zinc acetate hydrate, treatment was discontinued in one patient from the 25 mg/day group and in all five patients from the 50 mg/day group.

After initiating zinc acetate hydrate, the serum copper concentrations were 103.0 [91.0 – 113.0] µg/dL in the 25 mg/day group and 12.0 [8.0 – 92.0] µg/dL in the 50 mg/day group. Treatment was discontinued in four patients from the 50 mg/day group due to decreased serum copper levels, whereas no such cases were observed in the 25 mg/day group. In the 50 mg/day group, copper deficiency was observed as early as three months after starting supplementation. In one patient from the 50 mg/day group, treatment was discontinued at nine months due to suspected copper deficiency-related cytopenia, which subsequently improved.

【Conclusion】From the perspective of copper deficiency risk, when initiating zinc acetate hydrate at doses of 50 mg/day or more in dialysis patients, monitoring of the serum copper levels within at least three months is necessary. The results indicated that zinc supplementation was effective even at 25 mg/day, suggesting that initiating treatment at a lower dose is reasonable.

Proteinuria and thrombotic microangiopathy (TMA) are representative adverse events associated with angiogenesis inhibitors, such as bevacizumab (BEV) and ramucirumab (RAM).

We managed a patient who developed systemic TMA with severe thrombocytopenia 2 weeks after discontinuing RAM and starting BEV. The patient was a female in her 50s undergoing chemotherapy for recurrent lung metastasis after rectal cancer surgery. She developed hypertension when undergoing treatment with an angiogenesis inhibitor, for which she was prescribed two antihypertensive drugs.

On the first day of hospitalization, 2 weeks after the last administration of RAM,

BEV + trifluridine/tipiracil (FTD/TPI) therapy was initiated. On the 15th day of treatment, when the patient returned to the hospital for a scheduled BEV treatment, lower extremity edema, abdominal distension, weight gain (+5 kg), and hypertension of several days’ duration were noted. Based on a urine protein/creatinine ratio (UPCR) of 1.52 g/g creatinine, a platelet count of 30,000/µL, anemia, elevated LDH level, low haptoglobin level, and the appearance of schistocytes in the peripheral blood, all of which are signs of microangiopathic hemolytic anemia (MAHA), the patient was diagnosed with systemic TMA induced by BEV and was hospitalized for treatment. BEV was discontinued and fluid and blood pressure management was initiated. There was no evidence of acute kidney injury (AKI) and the serum creatinine level was not increased. On the 28th day of hospitalization, the platelet count and UPCR improved, and the patient was discharged to home.

The differential diagnosis for thrombocytopenia during cancer chemotherapy includes myelosuppression caused by cytotoxic anticancer drugs and septic disseminated intravascular coagulation (DIC) caused by febrile neutropenia. However, severe thrombocytopenia caused by FTD/TPI is rare and TMA was diagnosed based on the MAHA findings.

Systemic TMA can present with proteinuria equivalent to that of nephrotic syndrome and can become severe if complicated by AKI. We were able to avoid AKI by early discontinuation of the suspected drug.