Aileen Currie
MRPharmS
Senior Pharmacist Renal Services
Queen Margaret Hospital NHS Trust
Dunfermline, UK
Renal medicine covers many different areas, treating several different patient groups, including dialysis-dependent outpatients (either on haemodialysis or peritoneal dialysis), predialysis patients, transplanted patients, inpatients with chronic or acute renal failure, and general nephrology patients.
The renal population is expanding as patients of increasing age are being admitted onto dialysis programmes,(1) in some instances even up to the age of 90 years old. Therefore more pharmacists with renal specialist knowledge are required. Renal medicine is a multidisciplinary specialty and there are many different roles for the clinical pharmacist.
As expected, renal pharmacists govern renal drug expenditure, which can be a considerable amount owing mainly to treatment for anaemia and immuno-suppression. They also have a high-profile clinical role in anaemia management, renal bone disease and hypertension, as well as in outpatient clinics and training of all grades of staff. There are increasing interactions with patients, not only at ward and clinic level but also within the structure of group patient education sessions at renal support group meetings.
Anaemia
The prevention of anaemia in renal patients stimulates a lot of interest within renal units, not only because of the benefit for the patients, but also because of its effects on the drug budget. Anaemia is common in patients with renal failure due to epoetin and iron deficiency, blood loss due to haemodialysis, infections, hyperparathyroidism and increased red blood cell breakdown.(2) Before the introduction of epoetin and darbepoetin patients were treated with blood transfusions. However, the production of antibodies from the blood led to difficulties in finding a suitable kidney donor, as well as poor quality of life for the patient with fluctuating haemoglobin concentrations. Since the introduction of epoetin and intravenous iron, and more recently darbepoetin, it is possible to maintain patients with a constant haemoglobin concentration over 10–11g/dl. The Renal Association standards recommend that at least 85% of patients should achieve a haemoglobin concentration >10g/dl after 3 months on dialysis,(3) unless there are exceptional circumstances. Using intravenous iron and closely monitoring the patient’s blood results can reduce the amount of epoetin(4) and probably darbepoetin required, and can lead to savings of up to £1,000 per patient per year. Some renal pharmacy positions in the UK have even been funded from the savings made from good anaemia management.
Renal bone disease
Renal bone disease is another debilitating effect of failing kidneys, which leads to raised phosphate levels, reduced calcium levels and a decreased production of 1,25-dihydroxycholecalciferol, resulting in hyperparathyroidism.(5) As pharmacists we can help by encouraging patients to comply with their medication and educate them about the problems associated with renal bone disease, such as fractures, bone pain, painful calcium deposits in joints or even surgery if the parathyroid hormone is not controllable by medication.
Alfacalcidol or calcitriol are used in combination with phosphate binders to control renal bone disease.
Medicines information
This is an integral part of the renal pharmacist’s daily tasks. The renal pharmacist must work closely with their medicine information colleagues to provide a research service, especially as patients have increased accessibility to the internet and complementary medicines. Some of the queries I have been asked include whether glucosamine is suitable for a haemodialysis patient (he read about it in a dog breeder’s magazine!) and shark cartilage capsules for a renal transplant patient.
The renal pharmacist can also help keep medical and nursing staff up to date with any advances in renal pharmaceuticals. Few clinical trials include renal patients, so usually additional research into the pharmacokinetics of the drug is required to determine its suitability for patients with renal failure and on various dialysis modalities.
Other duties
Discharge planning is a major part of my everyday duties. This involves ensuring that the patient knows how to take their medication and why they are taking it, and also liaising with the community pharmacist to ensure a continued supply of medication or introduction of a compliance aid, such as nomad and dosette compliance boxes for the patient once they are home.
Within transplantation there is not only the above- mentioned roles, but also participation in self-medication schemes to aid transplant patients’ understanding of their medication regimen for their discharge home. The usefulness of a pharmacist in transplant clinics to optimise pharmaceutical care is well documented.(6)
The UK Renal Pharmacy Group
As renal pharmacy is such a specialised area there is a UK Renal Pharmacy Group, which is affiliated to the British Renal Society and Hospital Pharmacists’ Group. The Renal Pharmacy Group was founded in 1984, and at present has approximately 100 members. Membership is open to all pharmacists and pharmacy technicians with an interest in renal medicine, excluding those working for the pharmaceutical industry.
The group organises a number of events throughout the year, all largely based on feedback and requests from the membership. There is an annual conference, which this year is titled “2001 – A Renal Pharmacy Odyssey”. Keynote lectures over the weekend include: autoimmune renal diseases, transplant immunology and a pharmacist from the Department of Health covering the “NHS plan for pharmacy and medicines management” and its implications for pharmacists working within the renal specialty. The conference is being held in Birmingham on 21–22 September.
Management courses are organised according to membership needs. Other benefits to membership are twice-yearly newsletters, Beginner’s Guide to Renal Pharmacy, which is a very useful resource to new members, and a Renal Pharmacists’ Directory,(*) which lists all the renal units in the UK. Other key projects that the group are currently working on include:
- A UK Renal Pharmacy Group standards document for pharmaceutical care of renal patients.
- Workforce planning guidelines for renal pharmacists, as part of a multidisciplinary and Department of Health review for all professionals involved in the care of a renal patient. This review has been orchestrated by the British Renal Society. A final document will be published in late 2002 and it will coincide with the target publication date of the renal National Service Framework document. Theses two documents will complement each other and are integral for future service provision.
*Both of these are available from the Renal Pharmacy Group.
Peer review
Peer review is another area of interest at the moment and has already been undertaken in both Wales and Scotland by their respective renal associations. It is hoped that the English peer review process will take place in the near future. In Scotland, implementation involved not only the doctors and nurses being interviewed but also related staff, such as pharmacists and dieticians, and even patients. The interview panel consisted of two consultant nephrologists, a nurse and a patient representative. In Scotland, the Clinical Standards Board is in the process of preparing multidisciplinary clinical standards for renal medicine and repeating the peer review process. These factors may have an impact on how we treat our patients, and pharmacists should be prepared to increase their involvement in the renal ward and with clinical audit.
Conclusion
The role of the renal pharmacist is challenging, forward thinking and varied, and we are treated as an integral part of the multidisciplinary team. We are always striving for excellence, and, with a combination of renal pharmacy standards and peer review, we are aiming to achieve the same high-quality care for our patients irrespective of what area of the country we work in. It is to be hoped that more funding will become available for renal pharmacy posts as people are made aware of the impact a pharmacist can make in a renal unit.
References
- Rodger RSC, Briggs JD. Renal replacement therapy in the elderly. Scot Med J 1997;42:143-4.
- Harper A. Use of human erythropoietin in end stage chronic renal failure. Pharm J 1989;243:293-5.
- The Renal Association and Royal College of Physicians of London. Treatment of adult patients with renal failure: recommended standards and audit measures. 2nd edn. Sudbury: Lavenham Press; 1997.
- Currie A, Wilson M, Jenkins D. Anaemia: monitoring renal patients’ quality of life. Br J Renal Med1997;2:12.
- Cassidy MJD. Renal osteodystrophy. Medicine 1999;27:37-40.
- Chisolm MA, Vollenweider LJ, Mulloy LL, Jagadeesan M, Wade WE, Dipiro JT. Direct patient care services provided by a pharmacist on a multidisciplinary renal transplant team.Am J Health-Syst Pharm 2000;57:1994-6.
Resources
British Renal Society
W:www.britishrenal.org
European Renal Association – European Dialysis and Transplant Association
W:www.era-edta.org/ erafset.htm
Nephronline
W:www.nephronline.org
Renal Pharmacy Group
W:www.renalpharmacy.org.uk
Further reading
Daugirdas JT, Ing TS. Handbook of dialysis. 2nd edn. London: Little, Brown and Co; 1994
Weatherall DJ, et al. Oxford textbook of medicine. Oxford: OUP; 1995
Bunn R, Ashley C. The renal drug handbook. Oxford: Radcliffe Medical Press; 1999
Stein A, Wild J. Kidney failure explained. London: Class Publishing; 1999
Forthcoming events
13–17 Oct 2001
World Congress of Nephrology
San Francisco, USA
Contact:
ASN Headquarters Office, 2025 M Street NW #800 Washington, DC 20036, USA
T:+1 202 367 1190
F:+1 202 367 2190
E:[email protected]
14–17 July 2002
XXXIX Congress of the ERA–EDTA
Copenhagen Denmark
W:www.unipr.it/%7Eeraedta/2002.htm
