Kidney disease is easily missed but vital to identify, writes Jarrod McMaugh
When it comes to organ function and pharmacy, there are two that impact on our day-to-day clinical roles more than any other; the liver and the kidney. Excretion of the vast majority of medications occur through one (or both) of these organs.
As such, it is important for pharmacists to be mindful of kidney health in all aspects of clinical practice, be it dispensing, medication reviews, or offering clinical services as primary care.
Impact on patient interactions
Before we get in to the impact of kidney health on the clinical roles of pharmacists, it’s important to consider the way in which kidney function loss will manifest itself in patient interactions.
Kidney function decline is a standard part of ageing, but the rate of kidney function loss can vary greatly between individuals due to comorbidities or medication use. Common conditions and medications that can impact on kidney function decline are shown in Table 1.
ACE Inhibitors and AR2Bs
Pyelonephritis (especially recurrent)
Since pharmacists are so accessible for patients, and a patient with regular medication of any kind will see us more often than any other health professional, it is important that pharmacists are looking for signs of kidney function loss. It may be months before anyone realises that there is an issue. It is important for pharmacists to be mindful of these signs and symptoms. Kidney Health Australia lists the following signs and symptoms of declining kidney function:
- high blood pressure;
- changes in the amount and number of times urine is passed;
- changes in the appearance of your urine (for example, frothy or foaming urine);
- blood in your urine;
- puffiness in your legs, ankles or around your eyes;
- pain in your kidney area;
- loss of appetite;
- difficulty sleeping;
- lack of concentration;
- shortness of breath;
- nausea and vomiting;
- bad breath and a metallic taste in your mouth;
- muscle cramps; and/or
- pins and needles in your fingers or toes.
Few of these symptoms are exclusive to kidney disease, so clinical picture of each patient is important. If kidney function loss is suspected, have a conversation with the patient and refer them to their GP for assessment.
Impact in clinical role (dispensing)
The clinical role of dispensing medications requires pharmacists to assess the appropriateness of medications being supplied to the patient. Kidney function will impact on both new and existing medications.
As mentioned earlier, many medications are excreted from the body via the renal system, or the kidney is their site of action. When patients have kidney function decline (or are diagnosed with Chronic Kidney Disease, CKD), dose adjustments will be necessary for some medications.
Pharmacists in all settings need to be mindful of the impact of kidney function decline on existing and new medications, and apply their clinical knowledge to all prescriptions – never assume that the prescriber has accounted for renal function. When in doubt, use your references to determine appropriate doses. If a dose should be adjusted, contact the GP and discuss the situation.
This process needs to be applied to all new medications, and to all existing medications to ensure that the current dose is still appropriate.
Impact on accredited role (HMR)
Kidney function is a key consideration for all pharmacists in an accredited role performing HMR and DMMR services. This article will not go in the level of detail that is required for these roles; all pharmacists performing this role should already be intimately familiar with the impact of renal function on patient medications.
A useful resource for accredited pharmacists is the CKD Management in General Practice Handbook, available from http://kidney.org.au/cms_uploads/docs/ckd-management-in-gp-handbook-3rd-edition.pdf. This resource outlines the guidelines for management of a patient with CKD (lifestyle, medication, nutrition, etc), and can be invaluable when making recommendations to a GP.
Impact on clinical services
Clinical services offered in pharmacy can be designed to help identify patients at risk of renal disease, or who may have accelerated renal function decline. Discussion about kidney function should be a part of clinical services that deal with diabetes, hypertension, heart disease, or conditions that require chronic use of medications known to affect the kidney (chronic use of antiinflammatories, for instance).
There are some products available in pharmacy that can identify renal function loss, such as Kidney Check available from Amcal and Guardian Pharmacies. This product is a take-home test that identifies the presence of protein in the urine, which may be a sign of glomerular damage.
Point of Care Testing devices that are currently used in pharmacy can also be used to detect kidney function loss. The Alere Afinion device (used in some pharmacies for HbA1c and full lipid panel screening) can detect albumin, creatinine, and albumin/creatinine ratio.
Pharmacists can design services around the use of these tests, assuming patients have access to a restroom in the pharmacy. Of critical importance is the relevance of the information gathered – there is little point performing screening tests without a clinical need. The service should be offered to those patients who are at greatest risk of developing Chronic Kidney Disease, or those patients taking medications that are greatly impacted by, or cause, loss of renal function.
Communication with other health professionals about such a service is essential. The results gathered in pharmacy are not diagnostic, and the patient’s GP will need to follow up and confirm any issues identified. Send a referral letter to the GP outlining the results and your concerns, and be prepared to discuss your findings with them.
Jarrod McMaugh is a community pharmacy practitioner with Capital Chemist in the northern suburbs of Melbourne. He has extensive experience in developing and delivering professional services in the community pharmacy setting.