Study shows value of community pharmacists screening patients for chronic kidney disease

Community pharmacists can play a key role in diagnosing patients with unrecognised chronic kidney disease (CKD), suggests new research published in the Canadian Pharmacists Journal
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(2016;149:14–17).

A team of researchers from the University of Alberta, Canada, used an online tool — the ‘CKD Clinical Pathway’ — based on clinical pathways developed by England’s National Institute for Health and Care Excellence (NICE), to demonstrate that community pharmacists could successfully facilitate early diagnosis of CKD at community level. The tool helps clinicians to decide which patients to test, as well as identify cases and give affected patients lifestyle advice, medication or a referral to a nephrologist.

“Pharmacists… see patients with and at risk of CKD frequently and therefore could systematically identify these individuals and assist in their management,” say the researchers. “Pharmacists’ scope of practice has expanded in Alberta, allowing them to order and view laboratory tests.”

The researchers, led by Yazid Al Hamarneh, a scientific officer at the university’s department of medicine, note that 1 in 10 people in Canada has CKD but that early diagnosis is difficult as the disease remains asymptomatic in the early stages.

In the study, Al Hamarneh and colleagues assessed community pharmacists’ application of the CKD Clinical Pathway for the screening and detection of patients with previously unrecognised CKD in 55 community pharmacies across Alberta. The assessment was carried out as a part of a randomised controlled trial, the Alberta Vascular Risk Reduction Community Pharmacy Project – known as the RxEACH study – which looked at cardiovascular risk reduction intervention by pharmacists compared with usual care.

The pharmacists identified patients at risk of CKD by reviewing recent prescriptions and laboratory test reports. Where necessary, pharmacists could order new tests. They screened at-risk patients by looking at their blood (serum creatinine and estimated glomerular filtration rate) and urine tests (random urine albumin-to-creatinine ratio) and by putting the test results into the CKD Clinical Pathway. Study participants were also asked whether they had been previously diagnosed with CKD.

Among the 720 at-risk patients who participated in the RxEACH study, 39% had CKD (other co-morbidities included diabetes [79%] and vascular disease [30%]). Among patients with CKD, 60% had previously diagnosed disease, whereas in 40% of patients (n=113) the condition had not been previously recognised.

“A targeted screening approach for CKD can help identify patients with unrecognised CKD, when such an approach focuses on screening patients who are at high risk for CKD (such as patients with diabetes, hypertension or previous vascular disease) and tests for kidney function using serum creatinine/estimated glomerular filtration rate as well as random urine albumin creatinine ratio,” says Al Hamarneh.

Fellow author Ross Tsuyuki, a cardiologist and director of the Epidemiology Coordinating and Research (EPICORE) Centre at the University of Alberta, says the study results are exciting for two reasons. “Nephrologists have known for many years that the early to mid-stages of CKD are under-detected. We have shown that pharmacists, using a screening tool, can uncover CKD,” he says. “Second, as far as I know, this is the first validation of the value of pharmacists ordering laboratory tests. This evidence should be important for policymakers who are considering this avenue to expand the scope of practice of pharmacists.”

Mark Segal, chief of the division of nephrology, hypertension and renal transplantation at the University of Florida, who was not involved in the study, highlights two important findings from the study. “One is that a large portion of patients with CKD do not know they have it,” he says. “Second, kidney disease is relatively inexpensive to screen for.”