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Pharmacists and Chronic Kidney Disease

Table of Contents

About Pharmacists and Chronic Kidney Disease

Traditionally, the pharmacist’s role in caring for people living with chronic kidney disease (CKD) has been to ensure safe and effective medication use (i.e. adjusting medication doses based on a patient’s estimated kidney function).1,2 More recently, pharmacists are getting increasingly involved in broader aspects of CKD care, including screening, prevention, risk mitigation, and complication management, in collaboration with other members of the healthcare team.3–6

Pharmacists are well positioned to help improve overall CKD outcomes by leveraging their role and expertise at multiple steps along the CKD screening, risk stratification, treatment, and education continuum.7 Within the NKF’s CKDintercept initiative, pharmacists are recognized as essential members of the care team who support improved recognition and the effective management of early CKD and its associated cardiovascular risk.

Conceptual framework of a chronic kidney disease (CKD) screening, risk stratification, and treatment program.
Shlipak MG, Tummalapalli SL, Boulware LE, et al. The case for early identification and intervention of chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2021;99:34-47.

Screening for CKD
  • Identify patients who are at high risk for CKD (e.g. diabetes, hypertension, heart disease)
  • Facilitate initial CKD screening with eGFR and uACR by leveraging collaborative practice agreements, protocols, referral processes, and/or other arrangements
  • Opportunities for education at this phase:
    • Explain the importance of timely CKD screening and the benefits of catching it early in the disease process
    • Describe what each test is looking for (eGFR vs. uACR)
    • Discuss patient’s modifiable and nonmodifiable risk factors for CKD

Diagnosis & Risk Stratification
  • Refer patients for confirmatory testing and diagnosis
  • Facilitate the completion of additional testing as necessary
  • Opportunities for education:
    • Educate on the importance of looking at both numbers (eGFR and uACR) for awareness and risk stratification
    • Discuss with patients their modifiable and nonmodifiable risk factors for CKD and corresponding risks for cardiovascular events and/or other complications of CKD

Treatment
  • Facilitate patient access and utilization of guideline-directed medical therapy for CKD and its associated cardiovascular risk by leveraging collaborative practice agreements, protocols, referral processes, and/or other arrangements
  • Opportunities for education:
    • Educate patients about the role of medications in slowing CKD progression and reducing cardiovascular risk
    • Discuss with patients the importance of medication persistence and the long-term benefits of these chronic therapies
    • Ask patients about side effects they may be experiencing or any concerns they may have (and help identify solutions/mitigation strategies when possible)
    • Emphasize the importance of lifestyle interventions to promote overall health and wellbeing
    • Encourage strategies to avoid or minimize the use of NSAIDs
interaction between patient and healthcare professional

Missouri Ending Disparities in CKD Leadership Summit

Learn about an NKF initiative focused on increasing the early diagnosis and management of CKD, including a demonstration project leveraging community pharmacies to promote CKD testing, patient education, and medication optimization.

Read more

Chronic Kidney Disease in the United States

Low recognition of CKD is a serious public health problem. Approximately 37 million Americans have CKD, representing more than 1 in 7 adults. Only 10% of people with CKD are aware of their condition. Furthermore, 1 in 3 adults in the U.S. is at risk for CKD.8

Increasing routine screening rates for people at high risk for CKD is critical and can be done with two simple laboratory tests: estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (uACR). Both tests are needed to obtain a complete picture of a patient’s kidney health status.9 In addition, repeat testing is usually required to confirm CKD (as opposed to acute kidney injury) and/or rule out potential false positives/negatives or other anomalies.

 

Blood test is for eGFR, urine test is for uACR

When appropriate testing occurs in a timely manner, CKD is more likely to be detected at an earlier stage when more can be done to prevent CKD progression and reduce the risk of cardiovascular events, since the two are very closely linked.10 Furthermore, albuminuria and reduced eGFR have each been shown to be independent risk factors for CKD progression and cardiovascular events/mortality, emphasizing the need for both tests.11 Lastly, the leading cause of death among people living with CKD is cardiovascular disease, so while preventing CKD progression is important, a similar focus on reducing cardiovascular risk is also essential.10 

 

Frequency of monitoring GFR and uACR in people with CKD. Higher GFR and/or lower uACR are lower risk; lower GFR and/or higher uACR are higher risk.
KDIGO. KDIGO 2024 Clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2024;105(4S):S197.

Removing Race from eGFR Equations and CKD Care

In 2020, the National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) established a Task Force to reassess the inclusion of race in the estimation of GFR and its implications for diagnosis and management of patients with, or at risk for, kidney diseases.12 Race is a social construct, not a biological one, and its use in calculating a patient’s eGFR does not improve test accuracy or kidney disease management.  In fact, it perpetuates kidney health inequity and adversely impacts diagnosis and treatment, particularly in advanced stages of CKD.

Many labs have made the switch to the Task Force-recommended CKD-EPI 2021 creatinine equation refit without the race variable to calculate eGFR.13 However, some laboratories continue to use the older CKD-EPI 2009 creatinine or MDRD equation, both of which include an adjustment for race. If you are working with a laboratory that has not yet implemented the race-free equation, consider initiating a conversation about making the switch. Additionally, there is an online calculator available to calculate eGFR in adults using any of the race-free equations.

Tools and Resources for Pharmacists

The following resources can be incorporated by pharmacists in their practice to support improved testing and early management of CKD.

Clinical Practice Resources

Operational Resources

Estimating GFR

Calculators

Additional Resources

Doctor holding pipette

CE Program: CKD Overview for Community Pharmacy Teams

A focused update on CKD screening, classification, and treatment strategies – specifically designed for community pharmacists & pharmacy technicians. (Available until 5/21/25)

Enroll Now

Tools and Resources for Patients

Patients also need information and tools to understand their condition and build the motivation to set and achieve goals to protect their kidney health. The NKF can help here, too. Pharmacists can refer patients to Kidney Pathways, an online resource to help patients understand their condition and steps they can take to slow or stop its progression. This site uses a very brief questionnaire to help patients interact with their own lab results so they can access a custom course that walks them through important topics in plain language. 

Educational Resources for Patients About CKD

Educational Resources for Patients About CKD

Below is a comprehensive inventory of tools and resources pharmacists can use when interacting with patients: 

Many of these valuable resources are also available in Spanish with some of the 2-sided flyers additionally available in Arabic, Bosnian, Dari, Farsi, Kinyarwanda, Nepali, Pashto, Somali, Swahili, and Vietnamese. 

Other Patient Resources

  • NKF Cares is our Patient Help Line, offering support for people affected by kidney disease, organ donation or transplantation. Patients, family members and caregivers can speak with a trained professional ready to answer questions and address concerns. Support, assistance, and resources are provided in English and Spanish. The toll-free phone number is 1-855-NKF-Cares (855.653.2273) or email  nkfcares@kidney.org.
  • NKF Peers is a national, telephone-based peer support program that connects people who want support with someone who has been there before. This program is designed to help people adjust to living with stage 4 or 5 CKD, kidney failure, a kidney transplant or those interested in living donation. People interested in receiving support or becoming a mentor can complete an online application or email nkfpeers@kidney.org, or call 1-855-NKF-PEERS (855.653.7337). 
  • NKF Council on Renal Nutrition CKD Kidney Dietitian Directory and the Academy of Nutrition and Dietetics “Find a Nutrition Expert” Database are excellent resources to help patients find a registered dietitian in your area who specializes in kidney disease.
  • Kidney Risk Quiz - a tool to aid in early detection of kidney disease. 
  • Kidney Learning Center - designed for patients to better understand and care for kidney disease, it features educational activities on an array of carefully selected topics by well-known health experts on the subject.
  • NKF Online Communities - a safe and supportive place where patients and caregivers can share experiences, ask questions, and get answers related to kidney health, kidney disease, transplantation and living organ donation. Participation is free and anonymous.

References

  1. Al Raiisi F, Stewart D, Fernandez-Llimos F, Salgado TM, Mohamed MF, Cunningham S. Clinical pharmacy practice in the care of Chronic Kidney Disease patients: a systematic review. Int J Clin Pharm. 2019;41(3):630-666. doi:10.1007/s11096-019-00816-4
  2. Stemer G, Lemmens-Gruber R. Clinical pharmacy activities in chronic kidney disease and end-stage renal disease patients: a systematic literature review. BMC Nephrol. 2011;12:35. doi:10.1186/1471-2369-12-35
  3. Johns TS, Yee J, Smith-Jules T, Campbell RC, Bauer C. Interdisciplinary care clinics in chronic kidney disease. BMC Nephrol. 2015;16(1):161. doi:10.1186/s12882-015-0158-6
  4. Nicoll R, Robertson L, Gemmell E, Sharma P, Black C, Marks A. Models of care for chronic kidney disease: A systematic review. Nephrology (Carlton). 2018;23(5):389-396. doi:10.1111/nep.13198
  5. Vu A, Nicholas SB, Waterman AD, et al. “Positive Kidney Health”: Implementation and design of a pharmacist-led intervention for patients at risk for development or progression of chronic kidney disease. J Am Pharm Assoc (2003). 2023;63(2):681-689. doi:10.1016/j.japh.2022.11.007
  6. Gheewala PA, Peterson GM, Zaidi STR, Jose MD, Castelino RL. Australian Community Pharmacists’ Experience of Implementing a Chronic Kidney Disease Risk Assessment Service. Prev Chronic Dis. 2018;15:E81. doi:10.5888/pcd15.170485
  7. Shlipak MG, Tummalapalli SL, Boulware LE, et al. The case for early identification and intervention of chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2021;99(1):34-47. doi:10.1016/j.kint.2020.10.012
  8. Centers for Disease Control and Prevention. Chronic Kidney Disease in the United States, 2021. In: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2021.
  9. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314. doi:10.1016/j.kint.2023.10.018
  10. Jankowski J, Floege J, Fliser D, Böhm M, Marx N. Cardiovascular Disease in Chronic Kidney Disease: Pathophysiological Insights and Therapeutic Options. Circulation. 2021;143(11):1157-1172. doi:10.1161/CIRCULATIONAHA.120.050686
  11. Van Der Velde M, Matsushita K, Coresh J, et al. Lower estimated glomerular filtration rate and higher albuminuria are associated with all-cause and cardiovascular mortality. A collaborative meta-analysis of high-risk population cohorts. Kidney International. 2011;79(12):1341-1352. doi:10.1038/ki.2010.536
  12. Delgado C, Baweja M, Crews DC, et al. A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. American Journal of Kidney Diseases. 2022;79(2):268-288.e1. doi:10.1053/j.ajkd.2021.08.003
  13. Inker LA, Eneanya ND, Coresh J, et al. New Creatinine- and Cystatin C-Based Equations to Estimate GFR without Race. N Engl J Med. 2021;385(19):1737-1749. doi:10.1056/NEJMoa2102953

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