Pharmacists are essential drug experts on the health care team, providing clinical services related to safe distribution, optimal selection, and use of medications and patient education in the community, ambulatory care, and acute care pharmacy environments.
Pharmacists are trained at accredited schools of pharmacy that require a minimum of 2–4 years of undergraduate education before entering a 3- to 4-year doctorate training program (PharmD). During their doctorate training, they are licensed as pharmacy interns and begin gaining practice experience in the community and acute care settings, working under the supervision of a licensed pharmacist. After completing the PharmD degree, although not required, the majority of PharmD graduates pursue postgraduate residency or fellowship training. Pharmacy residency programs are accredited nationally and include 1-year general postgraduate training in the community and ambulatory or acute care environments. Beyond the first year, pharmacists may pursue a second year of residency specializing in a disease state, such as but not limited to infectious disease, critical care, or solid organ transplantation in acute care settings.
Currently, there are no accredited residency programs or fellowships in nephrology for pharmacists. Many pharmacists interested in nephrology pursue training in other areas, such as ambulatory care, critical care, or solid organ transplantation. Beyond residency training, pharmacists may pursue board certification from the Board of Pharmacy Specialties to gain qualifications for advanced practice; however, specialty boards in nephrology are not yet developed. The lack of specialty training in nephrology is a major contributor to the limited number of pharmacists specializing in nephrology.
In the United States, some states offer an advanced practice pharmacist designation and advanced pharmacist licensure, which expand the scope of practice for clinical pharmacists to perform patient assessments; order and interpret laboratory tests; refer patients; initiate, adjust, and discontinue drug therapy; and collaborate in the evaluation and management of diseases. However, insurers still do not routinely recognize pharmacists as health care providers for reimbursement of services. This has created a major barrier to the expansion of clinical pharmacist services.
Despite the limited pool of pharmacists specializing in nephology, studies have documented the positive impact of pharmacist services in the care of patients with acute kidney injury (AKI) or chronic kidney disease (CKD) or patients receiving chronic dialysis (Table 1) (1–10). Advocacy from professional organizations, such as ASN, is needed to improve insurance reimbursement of pharmacist services, improve the development of specialty programs in nephrology, and integrate the clinical pharmacist in the dialysis and CKD care teams, especially in light of the Advancing American Kidney Health Initiative (11).
Studies of clinical pharmacy services in nephrology
Barreto EF, et al. Development and feasibility of a multidisciplinary approach to AKI survivorship in care transitions: Research letter. Can J Kidney Health Dis 2022; 9:20543581221081258. doi: 10.1177/20543581221081258
Lalonde L, et al. Community pharmacist training-and-communication network and drug-related problems in patients with CKD: A multicenter, cluster-randomized, controlled trial. Am J Kidney Dis 2017; 70: 386–396. doi: 10.1053/j.ajkd.2017.05.008
Anderegg MD, et al. Pharmacist intervention for blood pressure control in patients with diabetes and/or chronic kidney disease. Pharmacotherapy 2018; 38: 309–318. doi: 10.1002/phar.2083
Awdishu L, et al. A primer on quality assurance and performance improvement for interprofessional chronic kidney disease care: A path to Joint Commission certification. Pharmacy (Basel) 2019; 7:E83. doi: 10.3390/pharmacy7030083
van Berlo-van De Laar IRF, et al. Pharmacist-led medication reviews in pre-dialysis and dialysis patients. Res Social Adm Pharm 2020; 16: 1718–1723. doi: 10.1016/j.sapharm.2020.02.006
Weinhandl ED, et al. Clinical outcomes associated with receipt of integrated pharmacy services by hemodialysis patients: A quality improvement report. Am J Kidney Dis 2013; 62: 557–567. doi: 10.1053/j.ajkd.2013.02.360
El Nekidy WS, et al. Role of nephrology pharmacists in the management of anemia in outpatient dialysis units: A Canadian model. Clin Nephrol 2020; 94: 36–42. doi: 10.5414/CN110066
Manley HJ, et al. Multidisciplinary medication therapy management and hospital readmission in patients undergoing maintenance dialysis: A retrospective cohort study. Am J Kidney Dis 2020; 76: 13–21. doi: 10.1053/j.ajkd.2019.12.002
Daifi C, et al. Implementation of a clinical pharmacist in a hemodialysis facility: A quality improvement report. Kidney Med 2021; 3: 241–247.e1. doi: 10.1016/j.xkme.2020.11.015
Dyer SA, et al. Impact of medication reconciliation by a dialysis pharmacist. Kidney360, May 2022; 3:922–925. https://doi.org/10.34067/KID.0007182021
Pai AB, et al. Medication reconciliation and therapy management in dialysis-dependent patients: Need for a systematic approach. Clin J Am Soc Nephrol 2013; 8: 1988–1999. doi: 10.2215/CJN.01420213