Beating the smiling assassin
One of the cornerstones of general medicine is the speciality of nephrology. Intense and bustling with activity, it is fuelled here by four dedicated consultants. It is a busy division, one of high patient throughput and providing dynamic healthcare for hundreds of medical and kidney patients each year.
Chronic kidney disease (CKD) is an umbrella term for any condition that instigates reduced kidney function over a period of time. Alas, it is also a silent condition, meaning that, oftentimes, patients come forward when they already have established end-stage renal injury. Some will go on to require renal replacement therapy.
The morbidity and mortality associated with CKD is considerable. From the time of first diagnosis of CKD, as many as 60-70 per cent of patients will have succumbed to the disease in the ensuing five years.
The condition is common and epidemiological studies show a very high prevalence, rendering CKD to be the second most frequent non-communicable disease worldwide. Moreover, the incidence of CKD is on the increase, particularly in people aged 65 and older. Because CKD is such an important medical problem, hospital trusts around the world, and here too, have been investing heavily in improving the screening, diagnosis and management of the disease.
The renal pharmacist has become an integral part of this exercise.
This article outlines the contributions that renal pharmacists are making to the daily battle with this smiling assassin.
The main objective of any renal pharmacist is to maximise the clinical effect of medicines by: recommending the most effective treatment for each type of patient; minimising the risk of treatment-induced adverse events; monitoring drug therapy and patient compliance and, finally, minimising expenditure for pharmacological treatments, usually financed by finite health budgets or by the patients themselves.
All these interventions translate into more effective expenditure of the national healthcare budget. This naturally means better treatment for a greater number of patients with less wastage.
Renal pharmacists seek to ensure that all patients are receiving the optimum medication dose and ideal drug type for their particular condition. This applies to inpatients, renal patients visiting the hospital as part of their renal replacement regime and transplanted subjects.
On the wards, pharmacists are responsible for adjusting doses, halting unnecessary treatment and commencing new medication following close liaison with the caring consultant. Inappropriate treatment and drug duration is carefully reviewed during every ward round.
These interventions are especially important at the time of discharge, when the pharmacist generally cautions patients about what to expect from the novel medication.
These procedures serve to reduce the incidence of potentially harmful drug-related side effects during the post-discharge period.
The Renal Unit at Mater Dei Hospital is specifically dedicated to the nation’s renal patients. Here, patients attend for haemodialysis (HD), usually with a frequency of three sessions per week. Every session is generally four hours long but substantial variation exists. At any given time, the Renal Unit houses some 30 patients.
The Peritoneal Dialysis (PD) Unit is geared to educate CKD patients on the conduct of PD, a form of renal replacement therapy that may be carried out in the comfort of one’s own home.
A PD patient typically performs four exchanges per day, with each exchange lasting about four hours.
In both HD and PD patients, the renal pharmacist is particularly vigilant about adjusting drug doses in accordance with urine output and weight.
Both deceased and living-related renal transplants are carried out in Malta, an average of 12 every year. In the post-operative period, these patients require close surveillance by the renal transplant physician and his team, which includes the renal pharmacist, to ensure the long-term success of the transplant. This care extends well beyond discharge and is maintained through all subsequent post-discharge clinic reviews.
Every renal pharmacist understands that the patients under their care are, by their very nature, fragile. Inappropriate treatment decisions could be catastrophic, so extreme rigour and care at the time of prescribing is key.
But renal pharmacy is more than just about the clinically difficult; it is also about the excitement of medical innovation and the joys of battles won. It’s also about the rich armamentarium of bespoke renal drugs and the every improving guidelines.
Slowly, we will overcome the smiling assassin.
Clarissa Captur, a senior pharmacist at Mater Dei Hospital’s Clinical Pharmacy Section, conducts renal research.