A pharmacist based intervention to improve the care of patients with CKD: a pragmatic, randomized, controlled trial

Background Primary care providers do not routinely follow guidelines for the care of patients with chronic kidney disease (CKD). Multidisciplinary efforts may improve care for patients with chronic disease. Pharmacist based interventions have effectively improved management of hypertension. We performed a pragmatic, randomized, controlled trial to evaluate the effect of a pharmacist based quality improvement program on 1) outcomes for patients with CKD and 2) adherence to CKD guidelines in the primary care setting. Methods Patients with moderate to severe CKD receiving primary care services at one of thirteen community-based Veterans Affairs outpatient clinics were randomized to a multifactorial intervention that included a phone-based pharmacist intervention, pharmacist-physician collaboration, patient education, and a CKD registry (n = 1070) or usual care (n = 1129). The primary process outcome was measurement of parathyroid hormone (PTH) during the one year study period. The primary clinical outcome was blood pressure (BP) control in subjects with poorly controlled hypertension at baseline. Results Among those with poorly controlled baseline BP, there was no difference in the last recorded BP or the percent at goal BP during the study period (42.0% vs. 41.2% in the control arm). Subjects in the intervention arm were more likely to have a PTH measured during the study period (46.9% vs. 16.1% in the control arm, P <0.001) and were on more classes of antihypertensive medications at the end of the study (P = 0.02). Conclusions A one-time pharmacist based intervention proved feasible in patients with CKD. While the intervention did not improve BP control, it did improve guideline adherence and increased the number of antihypertensive medications prescribed to subjects with poorly controlled BP. These findings can inform the design of quality improvement programs and future studies which are needed to improve care of patients with CKD. Trial registration ClinicalTrials.gov: NCT01290614. Electronic supplementary material The online version of this article (doi:10.1186/s12882-015-0052-2) contains supplementary material, which is available to authorized users.


CKD and My Health
How does my health care provider know I have CKD?
Chances are, you feel normal and were surprised to hear that you have CKD. It is called a "silent" disease, because many people don't have any symptoms until their kidneys are about to fail. The only way to know is to get your kidneys checked with blood and urine tests.

A blood test checks your GFR, which tells how
well your kidneys are filtering. GFR stands for glomerular filtration rate.

A urine test checks for albumin.
Albumin is a protein that can pass into the urine when the kidneys are damaged. See picture below.

Inside a healthy kidney Inside a damaged kidney
These two tests are used to monitor CKD and make sure that treatment is working. See pages 9 and 10 to learn more about these tests and track your results. 3

What causes CKD?
Diabetes and high blood pressure are the most common causes of CKD. There are other causes, too.
Your provider will look at your health history and may do other tests. You need to know why you have CKD, so your treatment can also address the cause of the CKD.

What medicines are used to treat CKD?
People with CKD often take medicines to lower blood pressure, control blood glucose, and lower blood cholesterol. Two types of blood pressure medicines-ACE inhibitors and ARBs-may slow CKD and delay kidney failure, even in people who don't have high blood pressure. Many people need to take two or more medicines for their blood pressure. They also may need to take a diuretic (water pill). The goal is to keep your blood pressure below 130/80.

Do I need to change my medicines?
Some medicines are not safe for people with CKD.
Other medicines need to be taken in smaller doses.
Tell your provider about all the medicines you take, including over-the-counter medicines (those you get without a prescription), vitamins, and supplements.

Can CKD affect my health in other ways?
People with CKD often have high blood pressure. They can also develop anemia (low number of red blood cells), bone disease, malnutrition, and heart and blood vessel diseases.

What tests will help track my CKD?
The blood and urine tests used to check for CKD are also used to monitor CKD. You need to keep track of your test results to see how you're doing. 5 Track your blood pressure. In most cases, you should keep it below 130/80.
If you have diabetes, monitor your blood glucose and keep it in your target range. Like high blood pressure, high blood glucose can be harmful to your kidneys.
See page 9 of this booklet for more information on tracking your test results.

Will I have to go on dialysis?
Some people live with CKD for years without going on dialysis. Others progress quickly to kidney failure. You may delay dialysis if you follow your provider's advice on medicine, diet, and lifestyle changes.
If your kidneys fail, you will need dialysis or a kidney transplant. Most people with kidney failure are treated with dialysis.

Will I be able to get a kidney transplant instead of going on dialysis?
Some people with kidney failure may be able to receive a kidney transplant. The donated kidney can come from someone you don't know who has recently died, or from a living person-a relative, spouse, or friend. A kidney transplant isn't for everyone. You may have a condition that makes the transplant surgery dangerous or not likely to succeed.

CKD and My Lifestyle
People with CKD can and should continue to live their lives in a normal way: working, enjoying friends and family, and staying active. They also need to make some changes as explained here.

Do I need to change what I eat?
What you eat may help to slow down CKD and keep your body healthier. Some points to keep in mind: Choose and prepare foods with less salt (sodium). Use less salt at the table.
Select the right kinds and smaller amounts of protein.
Choose foods that are healthy for your heart, like lean cuts of meat, skinless chicken, fish, fruits, vegetables, and beans.
Read the Nutrition Facts Label, especially for sodium, to help you pick the right foods and drinks.
7 Your provider may refer you to a dietitian. Your dietitian will teach you how to choose foods that are easier on your kidneys. You will also learn about the nutrients that matter for CKD.

Do I need to change what I drink?
n W ater -You don't need to drink more water unless you have kidney stones. Drink as much water as you normally do. n S oda and other drinks -If you are told to limit phosphorus, choose light-colored soda (or pop), like lemon-lime, and homemade iced tea and lemonade. Dark-colored sodas, fruit punch, and some bottled and canned iced teas can have a lot of phosphorus.
n Juice -If you are told to limit potassium, drink apple, grape, or cranberry juice instead of orange juice.
n A lcohol -You may be able to drink small amounts of alcohol. Drinking too much can damage the liver, heart, and brain and cause serious health problems.

Is smoking cigarettes bad for my kidneys?
Take steps to quit smoking as soon as you can. Cigarette smoking can make kidney damage worse. Urine albumin -Albumin is a protein in your blood that can pass into the urine when kidneys are damaged. You can't undo kidney damage, but you may be able to lower the amount of albumin in your urine with treatment.

CKD: Tracking My Test Results
Lowering your urine albumin is good for your kidneys.
A1C -A1C test is a lab test that shows your average blood glucose level over the last 3 months. The goal is less than 7 for most people with diabetes. Lowering your A1C can help you to stay healthy. (For people with diabetes only.) Where can I get more information?