Chronic Kidney Disease and End Stage Renal Disease

Abstract

This chapter will describe the practice essentials that are considered standard of care, common conditions and their treatments. While many might consider nephrology pharmacy is all about the “dose”, it is far more encompassing than that. The practicalities of obtaining a best possible medication history, reconciling discrepancies and removing barriers to adherence will be discussed as part of good pharmacy practice. Further, opportunities for pharmacists to develop or coordinate population-based interventions will be discussed. Pharmacists develop evidence-based prescribing algorithms that both support best practice and the deprescribing of less effective therapies. The benefits of deprescribing include less cost, tablet burden and likely a reduced falls risk. This “medication management” is patient-centred care that optimizes safe, effective, appropriate drug therapy.

The typical goals of care for a patient with advanced kidney disease (under 30 mL/min estimated glomerular filtration rate (eGFR)) include achieving target blood pressure, target weight, normalizing most bloodwork and reducing symptom burden. In so doing, we hope to improve quality of life, slow the progression of kidney disease and reduce the risk of falls. An important goal is to smooth transitions in care, should a patient go on to transplant or dialysis. Finally, if a patient chooses not to transition and their journey ends, we want to improve their quality of death.

The patient journey through kidney disease may take place over many years. Initially the health care system screens the patient for chronic kidney disease risk factors such as diabetes, hypertension, age over 60 and family history. If the patient is at risk, we try to reduce the risk through modifiable factors. Initial kidney disease is diagnosed and treated as are comorbid conditions. As kidney disease progresses, as identified by serial eGFR measurements and albumin creatinine ratios, the team will treat complications and prepare the patient for renal replacement therapy. This may include a transplant workup, informed decision around dialysis modality, creating a vascular access or choosing conservative care. For the individual patient, any one of these may be a valid informed choice. Our job is to advocate for our patient, optimize and align drug therapy to that choice. It is quite possible for a patient to have a 30 year life expectancy once in renal failure whereas for others it could be considerably shorter.