US Pharm. 2017;42(6):29-31.

ABSTRACT: Incorporating pharmacists into multidisciplinary teams in the outpatient ambulatory care and inpatient acute care settings can circumvent major drug-related problems through the process of medication therapy management (MTM), in which the pharmacist’s care plan includes optimal evidence-based medication, goals of therapy, and, most important, ensuring that appropriate follow-up is carried out. Chronic kidney disease (CKD) patients present with comorbid disease states with often-complex pharmacotherapeutic regimens that can be difficult not only for the patient, but for the prescribers as well. This review evaluates medication-related problems associated with CKD, nonadherence issues, medication reconciliation, and the contributions pharmacists provide through MTM.

Care for the chronic kidney disease (CKD) patient poses unique challenges to prescribers and practitioners in terms of overall medication therapy management (MTM). Traditionally, the role of clinical pharmacists in both the ambulatory care and inpatient acute care practice has been to prospectively screen for major drug-related problems through careful laboratory monitoring, evaluate for possible drug interactions, and dose-adjust medications based on patients’ renal function.

In 2013, the American College of Clinical Pharmacy (ACCP) clarified its position statement in its description of clinical pharmacy services. In its definition, ACCP recognized the need for pharmacists in the provision of direct patient care, which involves a regular continuing collaboration or practice with other members of the healthcare team in the care of the patient.1 MTM includes a thorough review of the patient’s full medication list and an evaluation of therapies by screening for the safest and most effective use of medications. The development of a pharmaceutical care plan with evidence- and goal-based therapies and the ensuring of appropriate follow-up are the definition of MTM.2

Patients with CKD present with comorbid conditions such as diabetes, hypertension, anemia, osteodystrophy, and electrolyte disturbances. In fact, multiple physicians often prescribe a CKD patient’s medications. This can result in problematic situations due to gaps in communication between healthcare providers as well as unfamiliarity of disease-state management by the patient.3

The purpose of this review is to evaluate the role of the pharmacist in the management of CKD through the use of MTM services and to highlight areas of focus, such as identifying medication-related problems (MRPs) associated with CKD, medication nonadherence in CKD patients, importance of medication reconciliation, and enhancement of pharmacist roles on multidisciplinary teams.

Medication-Related Problems Associated With CKD

Patients with CKD may experience significant MRPs, including adverse drug reactions, drug interactions, and inappropriate dosing and laboratory monitoring.4 These MRPs are undesirable events that patients experience with their medication therapy and prevent them from reaching their desired goals. CKD patients, especially those with end-stage renal disease (ESRD) undergoing dialysis, have complex medication regimens and are at a higher risk for MRPs. Various surveys suggest that dialysis patients in the United States are prescribed about 11 to 12 medications per day and take about 17 to 25 doses each day, leading to a high medication burden for these patients and contributing to frequent MRPs in this patient population.5  

Some potential MRPs that CKD patients may experience include adverse drug reactions, inappropriate drug therapy and dosing, drug interactions, and inappropriate laboratory monitoring.4,5 Patients may be on drug therapy without a proper indication, or they may not be receiving proper therapy for their indicated condition.

These MRPs result in significant morbidity, mortality, and excessive cost to our healthcare system.6 They may lead to over 100,000 deaths annually and cost the U.S. healthcare system an estimated $175 billion or more.  At least one MRP is experienced by 25% of ambulatory care patients, and MRPs account for up to one in six hospital admissions.It has been found that >18% of patient deaths in medical wards are medication-related.6

Manley et al conducted a study looking at the number, type, severity, and rate of MRPs, specifically in ambulatory hemodialysis patients.6 It was found that the most common MRPs observed included problems with medication dosing (33.5%), adverse drug reactions (20.7%), and indication without treatment (13.5%). They found that MRPs are common and occur in high frequency within this patient population. It is important for pharmacists to be included in the care of these patients owing to their ability to identify and resolve these MRPs, thereby improving patient compliance and response to medication therapy.6

CKD and Medication Nonadherence

Patients with CKD typically also have multiple comorbidities and a high pill burden.7 These complex medication regimens have been found to impair adherence to medication therapy.8 Data suggest that more than half of the prescriptions dispensed in the U.S. are taken improperly, and about 14% to 21% of patients fail to fill their prescriptions.4 Medication nonadherence, particularly in the elderly and those with chronic comorbidities, can lead to increased costs, worsening disease progression, adverse effects, and hospitalizations.4,7 The cost associated with poor medication adherence, which accounts for one-third to two-thirds of annual medication-related hospital admissions in the U.S., is estimated to be about $100 billion.4

Rifkin et al conducted a study to understand medication use and adherence decisions in elderly CKD patients through the use of semistructured interviews addressing patients’ medication use, barriers to adherence, side effects, and medication prioritization.7 Patients expressed concerns about polypharmacy and their high pill burden. They were found to prioritize medications based on noticeable feedback, so medications that allow for symptomatic relief and more noticeable effects were considered to be more important than those without these effects, such as lipid-lowering agents. Despite being informed of the benefits of these medications, many of the patients weighed the risks of polypharmacy and the side effects associated with these medications heavier than the benefits.7

Factors that affect patient adherence can include barriers that are both intentional and unintentional.4,7 Intentional nonadherence may be due to patient beliefs, including prioritization and concerns about side effects and efficacy of medications. Some of the more unintentional factors may include forgetfulness, low health literacy, cost, and lack of information. Physicians and other healthcare providers may potentially contribute to patient nonadherence by prescribing complex medication regimens, inadequately providing proper communication and counseling on the risks and benefits of these medications, and failing to consider cost of therapy.4 Pharmacists have the opportunity to play a key role in educating patients and addressing these communication gaps between patients, physicians, and the healthcare system in order to help reduce MRPs and improve medication adherence.4

Medication Reconciliation

CKD patients are generally managed by a primary care provider, nephrologist, social worker, dietitian, nurse, and pharmacist.4,5 Although all healthcare providers share the same goal of preventing kidney disease progression and managing comorbidities in CKD and ESRD patients, gaps occur in the care of these patients in terms of discrepancies in medication records.9 There is a growing body of evidence that supports the involvement of a nephrology-trained clinical pharmacist in closing these gaps in this patient population by improving clinical and cost outcomes, such as a decrease in rate of glomerular filtration rate decline, mortality, hospitalization rates, and hospital days.4,9 Pharmacists have an extensive knowledge of the pharmacodynamics and pharmacokinetic properties of medications that enable them to provide medication reconciliation and comprehensive medication review effectively to reduce MRPs and the consequences associated with them.4,5,9

Ideally, medication reconciliation and a comprehensive medication review should be performed at every patient visit, including routine care and transitions of care, to lessen MRPs.5 Medication reconciliation is a process by which an accurate list of medications is created and then utilized to assess the patient’s regimen before making a clinical intervention.5 Comprehensive medication review is secondary to medication reconciliation, in which the patient’s medication regimen is evaluated for appropriateness and safety.5

Medication Therapy Management

Over the past several years, the pharmacist’s role has expanded beyond the traditional scope of pharmacy practice.10 Implementation of the Medicare Prescription Drug Improvement Modernization Act of 2003 mandated that MTM services be offered to Medicare beneficiaries.11 For the first time, this act enabled pharmacists to serve as MTM providers. As a result, pharmacists are reimbursed for services provided within an MTM program. Such services consist of patient counseling and assistance with specific chronic conditions defined by the Centers for Medicare and Medicaid Services. The nine chronic disease states identified as potential targets for MTM reviews include ESRD. Approximately 80% of CKD patients have at least two of the nine targeted chronic disease states, such as diabetes, dyslipidemia, heart failure, and hypertension. These chronic disease states require multiple Medicare Part D medications, leading to drug costs that exceed annual, predetermined thresholds; most CKD patients, therefore, meet eligibility requirements for MTM services.12,13

Several models have incorporated pharmacists into the multidisciplinary healthcare team to assist in the management of patients with CKD, which encompasses kidney transplant, nondialysis CKD, and hemodialysis. Clinical trials in CKD patients have demonstrated the positive impact pharmacists provide to improve healthcare-related outcomes in anemia, diabetes, hyperlipidemia, hypertension, and secondary hyperparathyroidism.9,14,15 Salgado et al conducted a systematic review evaluating CKD patients who received pharmacist interventions.15 This review identified 37 studies with various designs and primary outcomes. Among the studies, the main interventions consisted of adjusting medication doses to kidney function, laboratory monitoring, medication reconciliation, optimizing drug therapy, and patient education. Overall, the compiled data had variable qualities to assess different outcomes but were not robust in nature. Despite the known benefits of MTM services, none of the clinical trials in the review directly measured the impact of pharmacist-driven MTM outcomes.

As opposed to the large systematic review, smaller studies with pharmacist involvement that enrolled hemodialysis patients strongly support the benefit of MTM provided by pharmacists. In a 2-year randomized, controlled trial conducted by Pai et al, MTM interventions provided by pharmacists reduced hospitalization rates and patient drug costs.16 An observational study by Weinhandl et al provided evidence that telephonic MTM reduced the overall number of patient hospital days and the mortality rate.17

Increasing the role of pharmacists through medication reviews is a growing practice, not only in the U.S., but in countries around the world.18 The complexity of comorbid conditions requiring multiple medications associated with CKD provides the opportunity for a fee-for-service model. Under this model, pharmacists in community and primary care settings are able to be reimbursed for time spent during each encounter and for documented interventions. 


The role of the pharmacist can positively impact the overall care of the CKD patient through the provision of clinical services targeted toward safe and efficacious outcomes in terms of MTM. While studies are limited, incorporating pharmacists as part of an interdisciplinary approach in the care of the CKD patient can prove to be cost-effective to the healthcare system and beneficial to patients.


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