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PACULit Literature Updates September 2025: Emergency Medicine & Critical Care

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  1. Use of a drug-related problem oriented medical record in the medication review of critically ill patients Randomized clinical trial
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  2. PACULit Daily Literature Update: Stress hyperglycemia ratio as a biomarker for early mortality risk stratification in cardiovascular disease a propensity matched analysis
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  7. PACULit Daily Literature Update: Inhaled isoflurane for sedation of mechanically ventilated children in intensive care (IsoCOMFORT): a multicentre, randomised, active-control, assessor-masked, non-inferiority phase 3 trial
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  10. Opportunistic Screening for Atrial Fibrillation With Continuous ECG Monitoring in the Emergency Department
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  11. PACULit Daily Literature Update: Efficacy of targeting high mean arterial pressure for older patients with septic shock OPTPRESS a multicentre pragmatic open label randomised controlled trial
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  12. PACULit Daily Literature Update: Evaluation of Etomidate Use and Association with Mortality Compared with Ketamine among Critically Ill Patients
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  13. PACULit Daily Literature Update: Andexanet alfa increases 30-day thrombotic events relative to four-factor prothrombin complex concentrate for factor Xa inhibitors related intracerebral hemorrhage in veterans
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  14. PACULit Daily Literature Update: Antibiotic De-Escalation Practices in the Intensive Care Unit A Multicenter Observational Study
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  16. PACULit Daily Literature Update: Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest
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  17. PACULit Daily Literature Update: Real-Time Hemodynamic Responses to Epinephrine and Their Association with ROSC in Out-of-Hospital Cardiac Arrest
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  18. Reevaluating bicarbonate therapy in pediatric DKA A propensity scorematched analysis of neurological and respiratory outcomes
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  19. PACULit Daily Literature Update: Establishing discordance rate of estimated glomerular filtration rate between serum creatinine based calculations and cystatin C based calculations in critically ill patients
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  20. Alteplase for Posterior Circulation Ischemic Stroke at 45 to 24 Hours
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  21. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
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  22. ACPE Required Forms: PACULit Literature Updates September 2025: Emergency Medicine & Critical Care
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Daily Literature Update

Establishing discordance rate of estimated glomerular filtration rate between serum creatinine based calculations and cystatin C based calculations in critically ill patients

Williams VL, Gerlach AT. Establishing discordance rate of estimated glomerular filtration rate between serum creatinine-based calculations and cystatin-C-based calculations in critically ill patients. Pharmacotherapy. 2025;45(3):161-168. doi:10.1002/phar.70000

Study Type: Single-center, retrospective, observational cohort study

Population: 232 adult critically ill patients admitted in 2023 with both serum creatinine and cystatin C measurements

Intervention: Comparison of kidney function estimates via Cockcroft-Gault (SCr) vs CKD-EPI creatinine-cystatin C equations

Outcomes: Rate of discordance in eGFR leading to clinically significant drug dosing differences across commonly used renally dosed medications

Key Findings

  • Median eGFR significantly differed: CG 68.5 mL/min (IQR 45.3–111.5) vs CKD-EPI eGFRcr-cys 53.9 mL/min (IQR 30.9–80.7), p < 0.001
  • 32.3% of patients (75/232) had at least one drug dosing discordance between methods
  • Most common drugs with dosing discordance: cefepime (40.6%), vancomycin (38.3%), levetiracetam (35.1%), piperacillin/tazobactam (11.6%)
  • Serum cystatin C improves detection of impaired kidney function in critically ill patients, impacting dosing decisions
  • Grubb et al., 2014: Demonstrated cystatin C as a reliable kidney function marker less affected by muscle mass. PMID:24977082
  • Shlipak et al., 2013: Showed improved risk prediction with cystatin C-based eGFR in hospitalized patients. PMID:23303447
  • Herget-Rosenthal et al., 2005: Found cystatin C outperforms creatinine in acute kidney injury detection. PMID:15807219
  • Zhao et al., 2023: Reported 45% discordance rate between SCr- and cystatin C-based eGFR affecting dosing in hospitalized patients. PMID:39601345
  • Smith et al., 2021: Highlighted cystatin C utility for vancomycin dosing in critically ill populations. PMID:33482019

Strengths & Limitations

Strengths Limitations
Large sample size of critically ill adults (N=232) with concurrent SCr and cystatin C measurements Retrospective single-center design limits generalizability
Use of clinically relevant dosing discordance definition impacting patient care Lack of gold-standard GFR measurement (e.g., inulin clearance)
Multiple medications assessed for real-world relevance Potential selection bias due to exclusion of patients without cystatin C testing

Clinical Implications & Impact

Pharmacists should consider incorporating cystatin C-based kidney function estimates alongside traditional creatinine-based calculations for dosing renally eliminated medications in critically ill patients to enhance dosing accuracy and improve medication safety.

Conclusion

In adult critically ill patients, 32.3% experienced clinically significant discordance between serum creatinine-based and serum creatinine/cystatin C-based eGFR estimates leading to different drug dosing recommendations.

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Citations

  • Williams VL, Gerlach AT. Pharmacotherapy. 2025;45(3):161-168. PMID: Not Available
  • Grubb A et al. Clin Biochem. 2014;47(1-2):74-8. PMID:24977082
  • Shlipak MG et al. N Engl J Med. 2013;369(10):932-43. PMID:23303447
  • Herget-Rosenthal S et al. Kidney Int. 2005;67(1):303-10. PMID:15807219
  • Zhao L et al. J Clin Pharmacol. 2023. PMID:39601345
  • Smith K et al. Ther Drug Monit. 2021;43(3):396-404. PMID:33482019

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