Integrating pharmacists into kidney care team can provide better outcomes for patients

BUFFALO, N.Y. — Approximately 35 million adults in the United States suffer from chronic kidney disease (CKD), and that number is growing.

Meanwhile, there’s a critical shortage of nephrologists to manage these patients, according to Calvin Meaney, PharmD, clinical associate professor of pharmacy practice who specializes in nephrology at the University at Buffalo School of Pharmacy and Pharmaceutical Sciences.

Meaney touts the benefit of integrating pharmacists into kidney disease treatment teams in a recent commentary he co-authored that appeared in the American Journal of Kidney Diseases. The five other authors include a nephrologist from Geisinger College of Health Sciences and pharmacy clinicians and researchers from the University of Tennessee, Fresenius Medical Care North America, Auburn University; and the University of Minnesota. They are all part of the Advancing Kidney Health through Optimal Medication Management Initiative.

Meaney, who also works as a clinical pharmacist at Erie County Medical Center, shares some of the main issues facing the nephrology profession and kidney patients right now and how pharmacists are well-equipped to help, especially by optimizing comprehensive medication management (CMM).

More than one in seven adults in the United States live with chronic kidney disease, and this number is growing. Why is that?

CKD is growing because the major causes are diabetes and hypertension, which are both on the rise, especially in the U.S. And it’s a silent disease — 90% of people do not realize they have kidney disease until it’s progressed to a serious level.

What are problems you see in regard to diagnosis and treatment?

There’s an effort nationally to screen people, especially those who have diabetes, for protein in the urine, which can indicate kidney damage. In the U.S., adherence to that test is less than 30%. It’s a cheap, non-invasive test, and we need to do a better job of increasing the percentage of patients getting it. It’s so important to identify kidney disease early on. You’re never going to stop kidney function from declining, but you can slow it down.

At the same time, there needs to be better monitoring of cardiometabolic health because people with kidney disease tend to die from heart disease. When caught early enough, a medical team can intensify treatments and improve the patient’s chance of living a longer, healthier life.

What is comprehensive medication management (CMM), and how does it help kidney patients?

CMM ensures that each patient’s medications are individually assessed to determine that they are appropriate, safe and taken as intended. It encompasses medication reconciliation and medication reviews, but also deals with more complex medical problems, including the patient’s beliefs and goals regarding their care and health disparities.

Studies have also shown that having pharmacists use CMM as part of the care team leads to decreased hospitalizations and ER visits. Also, because disadvantaged patients are disproportionately likely to have kidney disease, it’s important to have pharmacists on board who can help with things like health literacy and navigating insurance.

What is the Advancing Kidney Health through Optimal Medication Management Initiative?

It started in 2020, following the Advancing American Kidney Health Initiative that focused on shifting care for patients who have kidney disease more upstream before patients need dialysis or a kidney transplant.

Also, payments in the kidney disease space have shifted from fee for service to more value-based care to try to incentivize higher-quality care earlier in the disease process. It also incentivizes patients with kidney failure to get a transplant over dialysis because transplants produce a much better quality of life as well as longevity for patients.

Currently, how involved are pharmacists with kidney disease treatment?

Nationally, it’s very inconsistent. In pharmacy, we don't have a kidney disease training pathway. That specialty training happens in cardiology, oncology, infectious diseases, critical care and more but doesn’t exist for kidney disease.

Organizations including the National Kidney Foundation and the American Society of Nephrology now include specific programming for pharmacists, noting the importance of pharmacists in kidney care. Yet, pharmacists are still greatly underused.

We work with colleagues in Canada who have a standard that for every 300 non-dialysis patients and every 200 dialysis patients, you must have one pharmacist on the care team. In Alberta and Toronto, it’s well accepted that if you’re in a kidney clinic, there’s a pharmacist. Our ultimate vision for a kidney care team is to include a nephrologist, pharmacist, nurse, dietitian and a social worker.

What are the main benefits of following this model?

We know that we can improve patient outcomes, patient satisfaction and physician satisfaction, all while reducing costs.

You see that in transplant work. Transplant patients know their pharmacist. Their pharmacist manages their medications, and patients can call them with questions. Patients come to us and say, “I never knew what a pharmacist could do until I had a transplant. Why didn’t I have that person before my transplant? They could have helped me manage all the medications that I’m on.”

On average, patients requiring dialysis are taking 9 to 12 different medications, with 12-19 pills per day, while non-dialysis kidney patients take 7 to 9 medications, averaging 10 to 19 pills per day. Most medications are cleared by the kidneys and because their kidneys don’t work, the doses all have to be adjusted.

With that number of medications, there’s drug interactions, there’s overlapping adverse effects, and there’s risks of medication errors. These patients often see multiple providers, so there’s a lack of coordination. And that’s a gap pharmacists can fill.

There are a lot of medications that now slow kidney disease progression. There’s a workforce shortage in nephrology, and there’s the change to value-based care. All these things together point to now being the time to fit pharmacists into the care team and address a lot of these deficiencies.