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

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

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

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

Value-based care has the potential to revolutionize the way pharmacists practice. The success of value-based programs are contingent upon patient outcomes, which are often influenced by the medication therapy problems. Thus, pharmacists are well positioned to be key members of value-based care teams to address complex medication therapy problems in patients with CKD. Value-based kidney care is in its infancy, so it is vital for the pharmacy workforce to be prepared and integrate into these programs.

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

• Describe value-based models of care in nephrology practice
• Identify opportunities for pharmacists to provide patient centered CMM to patients with CKD
• Utilize reimbursement strategies to integrate a pharmacist into nephrology practices to optimize medication management in patients with CKD

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

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

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