Modules

The prevalence of Chronic Kidney Disease (CKD) is rising in the United States. National efforts have been implemented to improve the quality of care and outcomes of people with CKD. For the first time in decades, there are exciting new therapies available that have been proven to slow the progression of CKD. This module on Chronic Kidney Disease and Management will discuss the evaluation of kidney function, management of CKD and opportunities for Pharmacists; and you will apply concepts to a patient case.

By the end of this module, learners will be able to:

• Asses Kidney Function
• Describe Chronic Kidney Disease (CKD) and its epidemiology
• Describe management of CKD
• Define value-based Care
• Identify opportunities for Pharmacists

Claretha Lyas, MD

Estimated glomerular filtration rate (eGFR) equations are used for kidney disease staging, to assess kidney disease progression, and drug dosing. Which equation to use is a controversial area. This module will discuss the newest equations that removed race as a variable.. This module focuses on the basis for these changes, compares accuracy of these new equations to the older equations and demonstrates the rationale for using non-indexed results from this new equation for drug-related decision making.

By the end of this module, learners will be able to:

• Articulate rationale for replacing older raced based equations with non-race-based ‘race-less’ estimated glomerular filtration rate (eGFR) equations
• Explain limitations of older raced based methods to estimate kidney function for the purpose of drug-related decision-making
• Identify benefits and limitations for using serum creatinine and cystatin-C based methods to estimate kidney function
• Justify use of non-indexed vs indexed results in underweight and overweight individuals for drug-related decision-making

Time: 30 minutes

Wendy St. Peter, PharmD, FCCP, FASN, FNKF

This is an important topic for pharmacists and health care providers who see people with kidney disease. This module will cover the evaluation of kidney function part 2, focusing on the application of the race-less eGFR equation to stage Chronic Kidney Disease, evaluate when evidence-based medication therapy is warranted and determine a drug dosing regimen. It is recommended to review Evaluation of Kidney Function – Part 1: Use of Race-Less eGFR before taking this module.

By the end of this module, learners will be able to:

• Review the recommended race-less eGFR equations covered in Part 1 and their clinical application
• Determine when kidney function is stable and the race-less eGFR equations are appropriate for CKD staging
• Use information from eGFR assessment to determine necessary evidence-based therapies to address kidney and cardiometabolic outcomes

Joanna Q Hudson, PharmD, BCPS, FASN, FCCP, FNKF

A majority of medications are primarily eliminated by the kidneys. As kidney function declines in chronic kidney disease, altered pharmacokinetics necessitate dosage adjustment to minimize toxicity risk while ensuring optimal efficacy. This module will provide the underpinning pharmacokinetic rationale for these medication dosage adjustments, using practical examples of commonly used medications in clinical practice.

By the end of this module, learners will be able to:

1. Describe clinically relevant changes in pharmacokinetics (PK) and pharmacodynamics (PD) that occur as kidney function declines.
2. Differentiate data derived from PK studies and outcomes studies to make drug therapy decisions.
3. Design a medication regimen and monitoring plan for high-risk medications in patients with chronic kidney disease (CKD).
4. Design strategies to engage patients and caregivers in the design of their medication regimen to promote efficacy and safety.

Joanna Q Hudson, PharmD, BCPS, FASN, FCCP, FNKF

ACE inhibitors and ARBs have benefits beyond blood pressure control in people with kidney disease. These include slowing kidney disease progression, reducing albuminuria, and reducing cardiovascular risk. But data shows only a fraction of patients who are eligible for an ACEi or an ARB receive one. This module focuses on the evidence behind the role of ACEis and ARBs in patients living with kidney disease, and will also discuss how to safely initiate and monitor ACEis and ARBs in patients with kidney disease.

By the end of this module, learners will be able to:

1. Summarize the evidence to support use of ACEIs/ARBs for slowing CKD progression, reducing albuminuria and reducing cardiovascular risk
2. Determine the  goals of therapy for critical effectiveness and safety endpoints for use of ACEIs/ARBs in patients with kidney disease
3. Using a patient case, apply guideline-directed medication therapy (or evidence-based medication practice) for ACEi/ARB  use to reduce CKD progression, albuminuria and cardiovascular risk
4. Using a patient case, appropriately initiate and monitor ACEi/ARB for safety and effectiveness  in a patient with CKD

Emily Ashjian, PharmD, BCPS, BCACP, CDCES

SGLT2 inhibitors are an addition to our pharmacotherapy toolkit that have cardio- and kidney-protective benefits for individuals with kidney disease. New information from clinical trials has prompted guideline updates from leading diabetes and nephrology organizations. In this module, we will review the supporting evidence and guidelines in addition to discussing clinical considerations for the optimal use of SGLT inhibitors in improving cardiometabolic and kidney outcomes.

By the end of this module, learners will be able to:

1. Describe current recommendations/guidance for SGLT-2i use
2. Review proposed mechanisms of cardio- and  kidney-protective effects of SGLT-2is
3. Summarize supporting evidence for SGLT-2is in slowing CKD progression, reducing albuminuria & cardiovascular  risk
4. Apply guideline-directed medication therapy to initiate, monitor, and modify SGLT-2i use
5. Outline strategies to improve pharmacoequity in use of SGLT-2is

Time: 30 minutes

Katherine H. Cho, PharmD, BCACP

The cardiovascular benefits of GLP1 RAs have been well characterized in several large cardiovascular outcome trials. The benefits of secondary kidney outcomes in those with diabetes have been observed in these trials. In this module, we will review current evidence supporting the benefits of GLP-1 RAs in the patients with kidney disease. We will also review current clinical guidelines and recommendations for their use and discuss medication and patient-specific efficacy and safety considerations when using them in people with type 2 diabetes and chronic kidney disease.

By the end of this module, learners will be able to:

1. Summarize the evidence to support use of GLP1RAs for slowing CKD progression, reducing albuminuria and cardiovascular risk
2. Determine the  goals of therapy for critical effectiveness and safety endpoints for use of GLP1RAs in patients with kidney disease
3. Design care plans to facilitate pharmacoequity for the use of GLP4RAs by ensuring access and optimal use across populations
4. Using a patient case:
   • Apply guideline-directed medication therapy (or evidence-based medication practice) for GLP1RAs use to reduce CKD progression, albuminuria and cardiovascular risk
   • Create a monitoring plan for GLP1RAs safety and effectiveness  in a patient with CKD
   • Describe potential complications of GLP1RAs in patients with CKD stages 4-5

Time: 30 minutes

Joshua J. Neumiller, PharmD, CDCES, FASCES, FASCP

A new non-steroidal  mineralocorticoid receptor antagonist (MRA), finerenone, is FDA-approved for kidney and heart protection in patients with type 2 diabetes. In this module, we will be introducing the different MRAs that are commercially available and discussing the evidence to support their use in patients with kidney disease. This will include a focus on criteria for use of finerenone in our patients with type 2 diabetes, and the patient-specific considerations of when to use this medication.

By the end of this module, learners will be able to:

1. Summarize the evidence to support use of finerenone, a non-steroidal mineralocorticoid receptor antagonist (MRA), compared to other steroidal MRAs for slowing CKD progression, reducing albuminuria and cardiovascular risk.
2. Determine the  goals of therapy for critical effectiveness and safety endpoints for use of MRAs in patients with kidney disease
3. Design care plans to facilitate pharmacoequity for the use of GLP4RAs by ensuring access and optimal use across populations
4. Using a patient case:
   • Apply guideline-directed medication therapy (or evidence-based medication practice) for MRA use to reduce CKD progression, albuminuria and cardiovascular risk
   • Create a monitoring plan for MRAs safety and effectiveness  in a patient with CKD
5. Describe the risk of hyperkalemia with MRAs and finerenone in patients with CKD stages 4-5 and apply strategies to reduce hyperkalemia if it occurs

Time: 30 minutes

Allissa Long, PharmD, BCACP

The management of chronic heart failure in the setting of chronic kidney disease is an important topic, particularly for pharmacists, because the cornerstone for the treatment of heart failure is pharmacotherapy. Heart failure also remains the leading discharge diagnosis among patients greater than 65, and anywhere from 40 to 45% of individuals who have chronic heart failure also have some form of chronic kidney disease. In this module, we will cover the importance of guideline-directed medical therapy (GDMT), pharmacologic diuresis, and altering GDTM for those with CKD.

By the end of this module, learners will be able to:

1. Discuss pharmacologic and non-pharmacologic strategies to monitor and maintain euvolemia in a patient with heart failure and CKD
2. Apply guideline-directed medication management in a patients with heart failure and CKD
3. Describe complications of guideline directed medical therapy for heart failure in a patient with CKD

Time: 60 minutes

Robert Page, PharmD, MSPH, BCPS, BCGP, FAHA, FHFSA, FCCP, FASHP

Anxiety and depression are highly prevalent in chronic kidney disease. In recent years, we’ve learned that response to antidepressants is different in patients with kidney disease. This, coupled with altered medication risk profiles due to declining kidney function, makes management of anxiety and depression a considerable challenge. This module provides an overview of pharmacologic and non-pharmacologic treatment options for anxiety and depression unique to patients with kidney disease.

By the end of this module, learners will be able to:

1. Describe prevalence of depression compared to the general population
2. Review risk factors for depression
3. Discuss non-pharmacologic and preferred pharmacologic options for treating depression and anxiety
4. Review the pharmacokinetics and pharmacodynamics of commonly used antidepressants
5. Create a treatment plan to select, initiate, adjust, and/or modify pharmacologic agents used in management of depression and anxiety

Heather Legris, PharmD, BCPS

Hyperkalemia is a significant risk of medications  that slow progression of chronic kidney disease. Oftentimes these medications or their optimal doses are avoided as a means to mitigate the risk of hyperkalemia, withholding the full potential benefit for our patients. Complicating this problem is the reality that evidence-based guidelines for managing hyperkalemia in patients with chronic kidney disease are sparse. In this module, we will cover risks of hyperkalemia, describe current guidelines that discuss hyperkalemia in CKD, and summarize a patient-centered approach to prevent and treat hyperkalemia.

By the end of this module, learners will be able to:

• Describe risk factors for hyperkalemia in patients with CKD and the pharmacologic therapies associated with development of hyperkalemia
• Differentiate the mechanism of action, timing of the effect on potassium lowering, and drug interactions with patiromer and sodium zirconium cyclosilicate
• Develop a plan to prevent and manage hyperkalemia that includes dietary considerations and use of potassium binding agents using a patient case
• Analyze the advantages and disadvantages of a low potassium diet for the treatment and prevention of hyperkalemia in a patient with CKD

Calvin Meaney, PharmD, BCPS

Patients with chronic kidney disease are often prescribed numerous medications to treat comorbidities, slow the progression of their kidney disease, and to minimize morbidity and mortality. These complex medication regimens  lead to an increased potential for medication therapy problems. This module discusses common medication therapy problems associated with chronic kidney disease, medication reconciliation for this population, and the contributions that pharmacists can provide in medication therapy management.

By the end of this module, learners will be able to:

• Identify medications that can accelerate kidney function decline both acutely and chronically
• Define prescribing cascades and determine when it is appropriate to deprescribe medications in patients with CKD to minimize pill burden and potential for adverse events
• Utilize a medication financial assistance tool to improve patient access to guideline directed medication therapy
• Develop a plan to address medication therapy problems given a patient case

Marisa Battistella, PharmD

Pain is one of the most prevalent and problematic somatic symptoms in patients with kidney disease that contributes to poor quality of life. Medication options are limited by declining kidney function. This module is designed to equip clinicians with the tools needed to adequately address pain management in patients with chronic kidney disease using a holistic approach.

By the end of this module, learners will be able to:

1. Describe etiologies and types of pain in patients with CKD
2. Discuss the pharmacokinetics and pharmacodynamics of analgesics that could be altered in patients with reduced kidney function
3. Discuss non-pharmacologic and preferred pharmacologic options to manage pain in CKD, and develop an individualized plan to manage pain in CKD
4. Design a monitoring plan to evaluate the efficacy and side effects of therapeutic options 

Laurie Willhite, PharmD, CPHQ, CSPI

Summary

There are significant health and medication-related disparities in black persons with CKD that need to be addressed. In Part 1, we will address some of the history and current experiences that have led to Black community and/or Black individual distrust in the US Health system and healthcare practitioners.

Objectives

1. Review the historical context for distrust of Black persons in the US health system
2. Discuss current health and medication-related disparities that Black persons with chronic kidney disease are experiencing
3. Characterize different types of bias that affect equitable health care
4.  Identify resources for  health care professionals to educate themselves and others on how to address various biases to improve health equity and pharmacoequity in Black persons

Glenda Roberts

Wendy St. Peter, PharmD, FCCP, FASN, FNKF

Summary

In Part 2, we use patient voices to show their health care and medication-related experiences, we discuss challenges that interfere with medication adherence and address microaggression by healthcare professionals that can erode patient trust.

Objectives

1. Discover challenges, fears and frustrations that Black persons with CKD have experienced with their own illness and medication-related experiences
2. Identify health priorities of Black persons patients with CKD from their own stories of health care encounters
3. Assess your patient for social determinants of health, health literacy and autonomy in decision-making
4. Apply practitioner strategies to reduce microaggression and medication-related disparities

Curtis Warfield

Wendy St. Peter, PharmD, FCCP, FASN, FNKF

Summary

As discussed in Part 1 and Part 2, there is a disproportionate impact of CKD on Black persons. Individuals need to have CKD identified and diagnosed as early as possible in the disease process to attain desired health outcomes. This successful management of CKD and its complications requires an awareness and understanding of the diagnosis. Without awareness, patients are unlikely to become informed and adequately participate in their care and become motivated to adopt healthy behaviors.

Objectives

1. Develop strategies for screening Black persons at high risk for CKD with serum creatinine (eGFR) and urine albumin to creatinine ratio
2. Focus on pharmacoequity when creating a medication-related plan
3. Identify key medication-related facts and medication alternatives that Black patients with CKD want to know
4. Apply successful practitioner strategies to improve pharmacoequity

Glenda Roberts

Lisa Hillman, PharmD

Summary

Part 4 looks at building trustful and respectful relationships with Black person’s with CKD and empowering them in their care.

Objectives

1. Create respectful and trusting relationships with your individual patient
2. Utilize resources to improve health literacy in Black persons with CKD
3. Build respect and trust within Black persons' communities
4. Avoid microaggression (tie back to implicit bias in module 1)
5. Be visibly consistent
6. Sustain your commitment (to show that team is committed to the cause for the long-term and not as a ‘photo-op’ or ‘part of a checklist for the office’
7. Apply successful practitioner strategies

Curtis Warfield

Lisa Hillman, PharmD

Summary

In Part 5, we will present strategies to overcome the barriers presented in Part 1-4. These strategies include: multidisciplinary team-based care that can provide comprehensive medication management, or CMM; overcoming barriers to access medications; using a shared decision making, patient-centered model of care; and patient / caregiver tools to improve medication use.

Objectives

1. Assemble and train a multidisciplinary team with well-defined roles
2. Describe the importance and impact of hiring people that look like those in the community they serve for positions in the public eye (when possible)
3. Incorporate a pharmacist on the multidisciplinary team to provide comprehensive medication management utilizing AKHOMM resources
4. Develop a process to address insurance, medication access and refill issues
5. Create an environment for the shared decision-making process with the patient in the center

Glenda Roberts

Calvin Meaney, PharmD, BCPS

While hypertension is the second leading cause of CKD in the US, we also know that CKD can cause hypertension. Controlling blood pressure becomes more difficult as kidney disease progresses. In this module, we will cover pharmacologic and nonpharmacologic approaches to help individuals with late stage chronic kidney disease control their blood pressure.

By the end of this module, learners will be able to:

1. Discuss the goal blood pressure for kidney and cardiovascular benefits and the controversies with defining target blood pressure
2. Optimize blood pressure management in stage 4 and 5 CKD with use of thiazide,  loop diuretics and their combination
3. Recommend appropriate diuretic therapy to control volume status and the necessary monitoring parameters
4. Identify patients that may benefit from addition  of a mineralocorticoid receptor antagonist to improve blood pressure management in stage 4 and 5 CKD and determine an appropriate monitoring plan

Time: 45 minutes

Rebecca Maxson, PharmD, BCPS

Implementation of kidney protective medications in patients with diabetes is challenging. This module highlights the complexities of managing diabetes, including medication access and addressing disparities in care to provide practical guidance for the pharmacist to optimize medication management. This module supplements the previous medication focused modules that more comprehensively review the contemporary management of diabetes.

By the end of this module, learners will be able to:

• Recommend preferred oral anti-diabetic agents based on the benefits and risks in patients with diabetes and CKD
• Describe the disparities that exist with prescribing and access to preferred oral anti-diabetic medications in patients with CKD
• Determine the appropriate insulin agent and regimen for a patient with advanced CKD based on goals of therapy and concomitant therapies

Katie Cardone, PharmD, BCACP, FNKF, FASN, FCCP