Abstract

BackgroundMeasurement of albuminuria to stratify risk in chronic kidney disease (CKD) is not done universally in the primary care setting despite recommendation in KDIGO (Kidney Disease Improving Global Outcomes) guidelines. Pharmacist medication therapy management (MTM) may be helpful in improving CKD risk stratification and management.MethodsWe conducted a pragmatic, cluster-randomized trial using seven primary care clinic sites in the Geisinger Health System to evaluate the feasibility of pharmacist MTM in patients with estimated glomerular filtration rate (eGFR) 45–59 ml/min/1.73 m2 and uncontrolled blood pressure (≥150/85 mmHg). In the three pharmacist MTM sites, pharmacists were instructed to follow a protocol aimed to improve adherence to KDIGO guidelines on testing for proteinuria and lipids, and statin and blood pressure medical therapy. In the four control clinics, patients received usual care. The primary outcome was proteinuria screening over a follow-up of 1 year. A telephone survey was administered to physicians, pharmacists, and patients in the pharmacist MTM arm at the end of the trial.ResultsBaseline characteristics were similar between pharmacist MTM (n = 24) and control (n = 23) patients, although pharmacist MTM patients tended to be younger (64 vs. 71 y; p = 0.06) and less likely to have diabetes (17 % vs. 35 %; p = 0.2) or baseline proteinuria screening (41.7 % vs. 60.9 %, p = 0.2). Mean eGFR was 54 ml/min/1.73 m2 in both groups. The pharmacist MTM intervention did not significantly improve total proteinuria screening at the population level (OR 2.6, 95 % CI: 0.5–14.0; p = 0.3). However, it tended to increase screening of previously unscreened patients (78.6 % in the pharmacist MTM group compared to 33.3 % in the control group; OR 7.3, 95 % CI: 0.96–56.3; p = 0.05). In general, the intervention was well-received by patients, pharmacists, and providers, who agreed that pharmacists could play an important role in CKD management. A few patients contacted the research team to express anxiety about having a CKD diagnosis without prior knowledge.ConclusionsPharmacist MTM may be useful in improving risk stratification and management of CKD in the primary care setting, although implementation requires ongoing education and multidisciplinary collaboration and careful communication regarding CKD diagnosis. Future studies are needed to establish the effectiveness of pharmacist MTM on slowing CKD progression and improvement in cardiovascular outcomes.Trial registrationClinicalTrials.gov, NCT02208674 Registered August 1, 2014, first patient enrolled September 30, 2014

Highlights

  • Measurement of albuminuria to stratify risk in chronic kidney disease (CKD) is not done universally in the primary care setting despite recommendation in Kidney disease improving global outcomes (KDIGO) (Kidney Disease Improving Global Outcomes) guidelines

  • Patients were contacted by telephone if they needed proteinuria screening completed, and if needed, were scheduled for clinic visits with the pharmacist for medication initiation and/or titration

  • There were 73 patients eligible for the study (45 in clinics randomized to the pharmacist medication therapy management (MTM), 28 in control clinics) who were contacted from September 2014 to February 2015

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Summary

Introduction

Measurement of albuminuria to stratify risk in chronic kidney disease (CKD) is not done universally in the primary care setting despite recommendation in KDIGO (Kidney Disease Improving Global Outcomes) guidelines. Optimal screening and treatment strategies for CKD have been recommended by KDIGO (Kidney Disease: Improving Global Outcomes). Guidelines recommend using both estimated glomerular filtration rate (eGFR) and quantification of albuminuria (or proteinuria) to stratify renal and cardiovascular risk in CKD patients [3,4,5]. For patients with non-proteinuric CKD, KDIGO guidelines recommend treatment to a blood pressure goal of ≤140/90. For patients with proteinuric CKD, KDIGO guidelines recommend a lower blood pressure goal of ≤130/80,and the use of angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) [3]. KDIGO guidelines recommend treatment with statins for all adults ≥ 50 years with CKD, regardless of proteinuria status [3, 6]

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