Kidney Disease State Management

Chronic Kidney Disease and the Pharmacist’s Role
by Darrell Hulisz, RPh, PharmD
Associate Professor
Case Western Reserve University School of Medicine

Chronic kidney disease, also known as chronic renal failure (CRF) affects nearly 19 million people in the United States. The incidence of CRF is four times higher in African Americans and twofold higher in Native Americans and Hispanics, as compared to Caucasians. A majority of patients who develop CRF do so secondary to diabetes or undetected or poorly controlled hypertension. Other causes include congenital disease, rheumatic disease (e.g. lupus) and chronic exposure to nephrotoxic medications, such as nonsteroidal anti-inflammatory drugs. Patients with baseline renal impairment may develop chronic kidney disease from acute disease processes, such as renal ischemia, septic or cardiogenic shock, and exposure to pharmacologic and diagnostic nephrotoxins, such as amphotericin and radiocontrast media, respectively.

Numerous complications arise from CRF, including fluid and electrolyte abnormalities, such as fluid overload, hyperkalemia, hyperphosphatemia, and metabolic acidosis. Anemia often results in these patients as a result of diminished endogenous erythropoietin production. Comorbidities are often seen in patients with CRF, such as hypertension, hyperlipidemia and secondary hyperparathyroidism. Latent manifestations of CRF include dependence of kidney dialysis, pruritus (itching), anorexia, uremic bleeding and uremic encephalopathy.

The pharmacist is ideally suited to provide a myriad of interventions that may improve the quality of care of patients with chronic kidney disease. This may occur early on to prevent or delay the onset of CRF in high-risk patients. Examples include screening for diabetes and hypertension, the two leading causes of CRF. Pharmacists can provide diabetic patient education and can work collaboratively with physicians by providing medication therapy management for both disease states. Improvement of blood sugar and blood pressure control has been shown to decrease the progression of kidney disease in patients with diabetes and hypertension, respectively. Other examples include assuring that diabetic patients are treated with angiotensin converting enzyme inhibitors or other appropriate therapies to decrease the progression of diabetic nephropathy.

Pharmacists are frequently consulted to provide dosing recommendations for patients with CRF, with or without dialysis and can advise patients and providers about medications that may contribute to nephrotoxicity. Pharmacists can work to reduce the many complications and comorbidities of renal disease. Examples include assisting patients with selection of appropriate nutritional supplements, such as iron therapy in patients receiving erythropoietin, and help with selecting OTC phosphate binders, such as aluminum, calcium and magnesium preparations. The pharmacists can collaborate with the prescriber to improve the management of lipid abnormalities which often coexist in patients with CRF. Thus, it is important to note any history of chronic kidney disease, be aware of precipitating factors and co-morbid conditions associated with CRF, and advise patients and providers about drugs to avoid and recommend the necessary dosing adjustments in these patients.

Links - Kidney Disease