Continuity of Care: Chronic Kidney Disease Across the Continuum

Drs. Chahine and Brown are bothassistant professors of pharmacypractice at Palm Beach AtlanticUniversity, Lloyd L. Gregory School ofPharmacy, West Palm Beach, Florida.

In general, kidney failure refers to anycircumstance that impacts the kidney'sability to function appropriately.Many conditions, diseases, and medicationscan instigate situations leading toeither acute or chronic kidney disease(CKD).

Acute renal failure is frequentlyreversible and associated with dehydration,blood loss from surgery, or exposureto contrast agents or medications suchas nonsteroidal anti-inflammatory drugs.CKD is predominantly nonreversible andis due to long-term, uncontrolled comorbidities,thus forcing patients with thiscondition to move through many facetsof the health care system.^1-4

CKD is a growing public health concernthat remains underdiagnosed in theUnited States.³ The early stages of CKDand the incidence and prevalence of kidneyfailure are escalating due in part toan aging American population and anincreasing rate of incidence of diabetes.⁵Data from the National Health andNutrition Examination Survey suggestthat the prevalence of CKD hasincreased, from 12.9% in the period between1988 and 1994, to 15.5% in theperiod between 1999 and 2004.^6,7 Presently,more than 30 million Americanshave been diagnosed with CKD, which isassociated with an increased risk for cardiovasculardisease, progression to endstagerenal disease (ESRD), and suddendeath. In fact, by 2030, more than 2.2 millionAmericans will warrant treatment forESRD, causing a significant burden on thehealth care system.⁶

CKD may be detected in either the outpatientor inpatient setting. In the ambulatorysetting, CKD is found as a result oftypical comprehensive management andscreening for diseases such as diabetes,heart failure, and hypertension. Whenthese conditions go uncontrolled, theycan lead to hospital admission for acutedecompensated heart failure, hypertensivecrises, diabetic ketoacidosis, oracute coronary syndromes, where CKD isthen diagnosed.⁴ The National KidneyFoundation Kidney Disease OutcomesQuality Initiative (KDOQI) Advisory Boarddefines CKD as either:

• Kidney damage for ≥3 months, indicatedby structural or functionalabnormalities of the kidney, with orwithout decreased glomerular filtrationrate (GFR), manifested byabnormalities or markers of kidneydamage, including abnormalities inthe composition of the blood orurine, or abnormalities in imagingtest results, or
• GFR <60 mL/min/1.73 m² for &#8805;3months, with or without kidneydamage

KDOQI also established a 5-stage classificationsystem of CKD progression,defined according to GFR and the presence or absence of kidney damage(Table).³

Once discharged from the hospital,patients diagnosed with CKD may be followedby their primary care providerand/or a consulting nephrologist, dependingupon the stage of disease. Inpatients with Stage 4 disease or higher, anephrologist typically manages care, asrenal replacement therapy (RRT) may bewarranted. All patients should receiveconsultations from a clinical dietitian,certified diabetes educator (if diabetes isa comorbidity), and case manager/socialworker who will coordinate overall care.Input from a cardiologist or endocrinologistalso may be needed, dependingupon the severity of cardiovascularcomorbidities and diabetes.⁸

For all patients with CKD, blood pressureshould be tightly controlled to a goalof <130/80 mm Hg; hemoglobin A1Creduced to <7%; a low-density lipoproteinconcentration decreased to <100mg/dL; and proteinuria significantlydiminished.³ Medications used to reachthese goals include an angiotensin-convertingenzyme inhibitor, angiotensinreceptor blocker, calcium channel blocker,and/or beta-blockers, sulfonylureas,insulin sensitizers and/or insulin, andlipid-lowering agents such as a statin.Selection of specific agents will dependupon comorbidities and drug contraindications.Lifestyle modifications, such assmoking cessation, exercise, and dietarychanges, which could include a diet lowin sodium and phosphorus, should becarefully implemented.

In patients with Stage 3 disease orhigher, drugs to treat anemia (eg, ironreplacement products,erythropoietin, or darbepoetinalfa), hyperparathyroidism/vitaminD deficiency (eg,vitamin-D sterol therapy),and/or hyperphosphatemia(eg, phosphatebinders) willneed to be considered.At Stage 4, patientswill need to considerthe possibility oftransplantation andbegin planning for dialysis.For Stage 5 orESRD, a surgeon shouldbe consulted for theplacement of a permanentvascular accessgraft so that RRT canbe started.

The pharmacist plays a crucial role, ashe or she is the only clinician whoremains the constant among all the differentproviders and consultants makingrecommendations of care for the CKDpatient. The pharmacist will need to payclose attention for drug?drug anddrug?disease interactions, drug duplications,and adverse drug reactions. Asmany patients tend to take nutritionalsupplements without informing theirproviders, the pharmacist will need toeducate the patient with CKD on whichnutritional supplements to avoid. Overall,pharmacists practicing in various healthsystems may be faced with many possibleconcerns as the patient movesthrough the health care system.

Stages and Prevalence of CKD Based on NKF-KDOQI and Possible Opportunities for Interventions

Stage

Description

GFR (mL/min/1.73 m²)

Prevalence(%)

Possible Interventions

1

Kidney damage with normal GFR or GFR >90

&#8805;90

3.3

Screening and identification; aggressive treatment of comorbid conditions (DM, HTN, hyperlipidemia)

2

Kidney damage with mild decrease in GFR

60 to 89

3.0

3

Moderate decrease in GFR

30 to 59

4.3

Testing and treatment for common complications of CKD (anemia, hyperparathyroidism, hyperphosphatemia)

4

Severe decrease in GFR

15 to 29

0.2

Planning for renal dialysis and transplantation

5 or ESRD

Kidney failure

<15 or dialysis

0.1

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.

References

• 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.