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Clinical Pharmacist, Shands Jacksonville, Jacksonville, FL
Clinical Assistant Professor, College of Pharmacy, The Ohio State University, Columbus, OH
Clinical Assistant Professor, College of Pharmacy, The Ohio State University
Reprints: Dr. Patel, Shands Jacksonville, 655 W. 8th St., Jacksonville, FL 32209-6511, fax 904/244-4998, Harita_patel{at}hotmail.com
BACKGROUND: Chronic kidney disease (CKD) poses significant public health concerns. Early identification and interventions can help prevent or slow progression to end-stage renal disease.
OBJECTIVE: To characterize CKD in high-risk indigent patients in a primary care setting and evaluate opportunities for pharmacists to work collaboratively with physicians to improve medication use and CKD patient outcomes.
METHODS: Medical records of 200 patients with diabetes mellitus and/or hypertension were reviewed by the clinical pharmacist. Estimated glomerular filtration rate (creatinine clearance [Clcr]) and urinalysis were used to identify and stage CKD according to published guidelines. Glycosylated hemoglobin concentrations and blood pressures were recorded. The pharmacist evaluated medications for possible drug-related problems (DRPs), made therapeutic recommendations, and evaluated the acceptance rate by physicians.
RESULTS: One hundred nineteen patients met inclusion criteria, and a total of 68.9% met CKD criteria: stage 1, 16.0%; stage 2, 20.2%; stage 3, 25.2%; stage 4, 1.7%; stage 5, 0.8%; and not stageable, 5.0%. A total of 381 DRPs were identified, averaging 3.2 (1.7) per patient (range 0-11). The number of DRPs correlated with Clcr (r = -0.25; p = 0.007). Therapeutic recommendations included change of drug, dose and/or interval adjustment of the current drug, discontinuation of nonsteroidal antiinflammatory drugs, additional laboratory monitoring, meeting goal blood pressure and glycosylated hemoglobin, adding renoprotective drug and/or low-dose aspirin, and nephrologist referral. Fewer than half (40.9%) of the recommendations were accepted or accepted with modifications, and an approximately equal percentage were not accepted by the physicians.
CONCLUSIONS: CKD prevalence was high among the patients evaluated here. New guidelines are available to assist in managing CKD ambulatory patients. Pharmacist collaboration with physicians may optimize CKD screening in high-risk patients and improve medication usage.
Key Words: ambulatory care, chronic kidney disease, National Kidney Foundation
Published Online, November 16, 2004. www.theannals.com, DOI 10.1345/aph.1E269
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