Drs. Chahine and Brown are both
assistant professors of pharmacy
practice at Palm Beach Atlantic
University, Lloyd L. Gregory School of
Pharmacy, West Palm Beach, Florida.
In general, kidney failure refers to any
circumstance that impacts the kidney's
ability to function appropriately.
Many conditions, diseases, and medications
can instigate situations leading to
either acute or chronic kidney disease
Acute renal failure is frequently
reversible and associated with dehydration,
blood loss from surgery, or exposure
to contrast agents or medications such
as nonsteroidal anti-inflammatory drugs.
CKD is predominantly nonreversible and
is due to long-term, uncontrolled comorbidities,
thus forcing patients with this
condition to move through many facets
of the health care system.1-4
CKD is a growing public health concern
that remains underdiagnosed in the
United States.3 The early stages of CKD
and the incidence and prevalence of kidney
failure are escalating due in part to
an aging American population and an
increasing rate of incidence of diabetes.5
Data from the National Health and
Nutrition Examination Survey suggest
that the prevalence of CKD has
increased, from 12.9% in the period between
1988 and 1994, to 15.5% in the
period between 1999 and 2004.6,7 Presently,
more than 30 million Americans
have been diagnosed with CKD, which is
associated with an increased risk for cardiovascular
disease, progression to endstage
renal disease (ESRD), and sudden
death. In fact, by 2030, more than 2.2 million
Americans will warrant treatment for
ESRD, causing a significant burden on the
health care system.6
CKD may be detected in either the outpatient
or inpatient setting. In the ambulatory
setting, CKD is found as a result of
typical comprehensive management and
screening for diseases such as diabetes,
heart failure, and hypertension. When
these conditions go uncontrolled, they
can lead to hospital admission for acute
decompensated heart failure, hypertensive
crises, diabetic ketoacidosis, or
acute coronary syndromes, where CKD is
then diagnosed.4 The National Kidney
Foundation Kidney Disease Outcomes
Quality Initiative (KDOQI) Advisory Board
defines CKD as either:
- Kidney damage for ≥3 months, indicated
by structural or functional
abnormalities of the kidney, with or
without decreased glomerular filtration
rate (GFR), manifested by
abnormalities or markers of kidney
damage, including abnormalities in
the composition of the blood or
urine, or abnormalities in imaging
test results, or
- GFR <60 mL/min/1.73 m2 for ≥3
months, with or without kidney
KDOQI also established a 5-stage classification
system of CKD progression,
defined according to GFR and the presence or absence of kidney damage
Once discharged from the hospital,
patients diagnosed with CKD may be followed
by their primary care provider
and/or a consulting nephrologist, depending
upon the stage of disease. In
patients with Stage 4 disease or higher, a
nephrologist typically manages care, as
renal replacement therapy (RRT) may be
warranted. All patients should receive
consultations from a clinical dietitian,
certified diabetes educator (if diabetes is
a comorbidity), and case manager/social
worker who will coordinate overall care.
Input from a cardiologist or endocrinologist
also may be needed, depending
upon the severity of cardiovascular
comorbidities and diabetes.8
For all patients with CKD, blood pressure
should be tightly controlled to a goal
of <130/80 mm Hg; hemoglobin A1C
reduced to <7%; a low-density lipoprotein
concentration decreased to <100
mg/dL; and proteinuria significantly
diminished.3 Medications used to reach
these goals include an angiotensin-converting
enzyme inhibitor, angiotensin
receptor blocker, calcium channel blocker,
and/or beta-blockers, sulfonylureas,
insulin sensitizers and/or insulin, and
lipid-lowering agents such as a statin.
Selection of specific agents will depend
upon comorbidities and drug contraindications.
Lifestyle modifications, such as
smoking cessation, exercise, and dietary
changes, which could include a diet low
in sodium and phosphorus, should be
In patients with Stage 3 disease or
higher, drugs to treat anemia (eg, iron
erythropoietin, or darbepoetin
D deficiency (eg,
vitamin-D sterol therapy),
need to be considered.
At Stage 4, patients
will need to consider
the possibility of
begin planning for dialysis.
For Stage 5 or
ESRD, a surgeon should
be consulted for the
placement of a permanent
graft so that RRT can
The pharmacist plays a crucial role, as
he or she is the only clinician who
remains the constant among all the different
providers and consultants making
recommendations of care for the CKD
patient. The pharmacist will need to pay
close attention for drug?drug and
drug?disease interactions, drug duplications,
and adverse drug reactions. As
many patients tend to take nutritional
supplements without informing their
providers, the pharmacist will need to
educate the patient with CKD on which
nutritional supplements to avoid. Overall,
pharmacists practicing in various health
systems may be faced with many possible
concerns as the patient moves
through the health care system.
Stages and Prevalence of CKD Based on NKF-KDOQI and Possible Opportunities for Interventions
GFR (mL/min/1.73 m2)
Kidney damage with normal GFR or GFR >90
Screening and identification; aggressive treatment of comorbid conditions (DM, HTN, hyperlipidemia)
Kidney damage with mild decrease in GFR
60 to 89
Moderate decrease in GFR
30 to 59
Testing and treatment for common complications of CKD (anemia, hyperparathyroidism, hyperphosphatemia)
Severe decrease in GFR
15 to 29
Planning for renal dialysis and transplantation
5 or ESRD
<15 or dialysis
Permanent vascular access and initiation of RRT
CKD = chronic kidney disease; NKF-KDOQI = National Kidney Foundation Kidney Disease Outcome Quality Initiative; GFR = glomerular filtration rate; DM = diabetes mellitus;
HTN = hypertension; ESRD = end-stage renal disease; RRT = renal replacement therapy.
Adapted from references 3 and 4.
Unique Continuity of Care Concerns
- Once the patient is admitted to the hospital, the inpatient pharmacist should make recommendations for aggressive pharmacotherapy of comorbidities and adjustment in medication doses per the patient's renal function; evaluation of objective findings for common complications of CKD, such as anemia and hyperphosphatemia, will be crucial. Nurses may need to be educated regarding appropriate scheduling of medications to avoid possible drug?drug interactions.
- After stabilization and prior to discharge, the patient may have questions regarding side effects of medications, appropriate medication dosing schedules, pharmacotherapy goals, and diet. The pharmacist should work with the medical team to find cost-effective medication regimens to which the patient can adhere. Questions also may arise regarding appointments with specialists, such as cardiologists, nephrologists, and endocrinologists.
- Once discharged to home, the community-based pharmacist can work with the patient to enhance adherence to medications, explain therapeutic goals, select appropriate smoking cessation strategies (if needed), and answer additional questions regarding diet and supplements to avoid.
- In some cases, patients may require dialysis; the pharmacist practicing in this setting will need to make recommendations regarding medication scheduling and dosing, especially for medications not familiar to the nephrologist, around the patient's dialysis regimen.
- It will be crucial that the primary care provider knows all the specialty clinicians who are providing consultations; the pharmacist can inform the primary provider if duplications in pharmacotherapy exist.
- Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Am J Kidney Dis. 2003;41(1):1-12.
- St Peter WL, Khan SS, Ebben JP, Pereira BJ, Collins AJ. Chronic kidney disease: the distribution of health care dollars. Kidney Int. 2004;66:313-321.
- KDOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39:S1-266.
- Chen RA, Scott S, Mattern WD, Mohini R, Nissenson AR. The case for disease management in chronic kidney disease. Dis Manag. 2006;9:86-92.
- Foley RN, Murray AM, Li S, et al. Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999. J Am Soc Nephrol. 2005;16:489-495.
- Bakris GL. Protecting renal function in the hypertensive patient: clinical guidelines. Am J Hypertens. 2005;18:112S-119S.
- Kopyt NP. Chronic kidney disease: the new silent killer. J Am Osteopath Assoc. 2006;106:133-136.
- Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351:1296-305.