Pharmacists Find Satisfaction in Dialysis Clinics

[March 15, 2010, AJHP News]

Kate Traynor

BETHESDA, MD 26 February 2010—For pharmacists who work in dialysis clinics, satisfaction comes from meeting daily technical challenges and finding ways to improve patients' lives.

"I enjoy it so much I can't really see ever giving it up," said Ronald Abrahams.

Abrahams retired five years ago from full-time work as a clinical pharmacist at Hartford Hospital in Connecticut. But he still comes in, on a half-time basis, to prepare and adjust medication regimens for patients undergoing dialysis—work that he hopes will one day be done by pharmacists at all dialysis clinics.

Last year, Abrahams launched a one-week ambulatory care rotation that allows staff pharmacists and pharmacy residents to learn about the clinic's work. Three people have finished the weeklong rotation since it was created, and several others have completed portions of the program.

Abrahams said the participants are "totally amazed" by what they learn while in the dialysis clinic.

The clinic serves about 180 patients who require periodic hemodialysis and 20 who undergo peritoneal dialysis, he said. Patients typically come in for their procedures three times a week. The clinic also offers low-density lipoprotein (LDL) apheresis and plasmapheresis, Abrahams said.

Before the rotation was established, Abrahams said, Hartford's pharmacists and pharmacy residents knew little about the clinic other than that medication doses were prepared and used there.

"Nobody ever had any idea what goes on behind that," he said. "And I finally convinced them that we need to do more than just say, 'here's the dialysis pharmacy.'"

Abrahams said his colleagues—the nurses, dietitians, social workers, and nephrologists who work with the clinic patients—were "very enthusiastic" about the opportunity to host pharmacists.

He said the pharmacists go on rounds with a clinic dietitian to learn about patients' nutritional needs and problems following strict dietary regimens. The pharmacists also spend an afternoon with a social worker who deals with psychosocial, transportation, family, and financial issues that patients face.

Abrahams said the pharmacists spend part of the rotation with different nephrologists and with the nurses, who explain the setup and operation of the dialysis apparatus. The rotation includes time in the peritoneal dialysis clinic, and the participants observe an LDL apheresis procedure.

The pharmacists also spend two days with Abrahams observing his work, which includes preparing and adjusting i.v. therapy under a collaborative practice protocol.

Health issues faced by patients with kidney failure include anemia, bone disease, and serious electrolyte imbalances. Abrahams said medications used in the clinic include epoetin alfa and i.v. iron to manage anemia, paricalcitol to help control osteodystrophy, phosphate binders to lower blood phosphorus levels, and L-carnitine, which can be deficient in patients undergoing dialysis.

To manage the complex therapy, he said, "I order labs, I review all the labs, make the dosing changes, and actually write the orders."

Abrahams said those who complete the rotation "come away with a pretty good understanding" of the needs of dialysis patients. He hopes that participants realize the clinical benefits pharmacists can provide to dialysis patients as well as the potential cost savings that can arise from well-managed therapy.

Rochelle Castro, who recently completed the postgraduate year 1 residency program at California's Santa Clara Valley Medical Center in San Jose, likewise sees a need for pharmacists in dialysis clinics.

For her residency project, Castro examined whether the implementation of a medication therapy management (MTM) program at the hospital's dialysis clinic could improve specific clinical values. Ninety days after the MTM intervention, patients who received counseling had a statistically significant improvement in the amount of serum calcium– phosphorus product and possible improvements in systolic blood pressure and hemoglobin A_1c levels, Castro said.

To qualify for the study, patients had to be 18 years of age or older and take at least eight medications for the treatment of chronic conditions. Exclusion criteria included HIV infection, psychosis, pregnancy, chronic kidney disease other than end-stage renal disease (ESRD), and receipt of a kidney transplant.

Castro said the renal care center serves 240 patients who require hemodialysis and 37 who undergo peritoneal dialysis. The 60 patients who met the inclusion criteria and agreed to participate in the study were asked a series of questions about their medications, medical history, and demographics.

During a subsequent dialysis session, the participants brought in their medications brown-bag style for Castro to examine and discuss with the patients, a process that took about 30–60 minutes.

In all, Castro examined 571 patient medications and counseled patients about 121 instances in which the drugs were not being taken as prescribed.

"I would tell them what each of the medications did for them and why they were taking it," she said. "My hopes were that this would increase compliance; that they would see the need and understand the consequences."

A follow-up survey was administered 90 days after the intervention to reassess patients' understanding of their medication regimen.

Castro said people have trouble complying with phosphate binder regimens, which are used in dialysis patients to reduce serum phosphate levels.

Compliance means "taking as many as six huge tablets with every meal," Castro said, adding that the medications produce uncomfortable gastrointestinal effects.

She said clearly explaining to patients the benefits of taking a phosphate binder can improve compliance. Another option is to prescribe a chewable formulation, which Castro said some patients find easier to ingest.

She called phosphate binder compliance "a good place for a pharmacist to intervene and talk to the patients, because a lot of times, the physicians are looking at the problems of the patient, not necessarily the problems of the treatment."

Castro said that the dialysis process is very difficult for patients.

"They feel very exposed, because they're hooked up to needles in a big room with a bunch of other people. And it's loud, and they want to sleep, and they're tired, and they don't feel good," she said.

But even in that stressful environment, she said, most of those she queried about enrolling in the study were enthusiastic about participating and learning about their therapy.

"The best part of this project was working face-to-face with the patients, and being able to see their face change when you tell them what their medication does, and seeing their numbers change and that they're actually taking their medications," Castro said.

More than 350,000 Americans received hemodialysis or peritoneal dialysis for the management of ESRD in 2006, according to the National Institute of Diabetes and Digestive and Kidney Diseases. The institute estimates that more than 500,000 Americans suffer from ESRD, and 23 million have physiologic evidence of kidney disease.

The Centers for Medicare and Medicaid Services (CMS) decided in 2008 not to require Medicare-participating dialysis facilities to include a pharmacist as a member of the interdisciplinary team. But CMS, in issuing its new conditions for coverage for ESRD facilities, encouraged those facilities to use pharmacists' expertise as appropriate.