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Saudi Journal of Kidney Diseases and Transplantation
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EDITORIAL Table of Contents   
Year : 2002  |  Volume : 13  |  Issue : 1  |  Page : 14-17
The Role of the Clinical Pharmacist in the Care of Renal Transplant Patients


Clinical Pharmacist, Secretary - Pharmacy & Therapeutics Committee, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

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How to cite this article:
Zolezzi M. The Role of the Clinical Pharmacist in the Care of Renal Transplant Patients. Saudi J Kidney Dis Transpl 2002;13:14-7

How to cite this URL:
Zolezzi M. The Role of the Clinical Pharmacist in the Care of Renal Transplant Patients. Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2020 Jan 19];13:14-7. Available from: http://www.sjkdt.org/text.asp?2002/13/1/14/33196

   Introduction Top


The profession of pharmacy continues to expand its involvement in patient care through the precepts of pharmaceutical care. In doing so, many pharmacists have implemented structured programs designed to enhance the outcomes of patients at high risk of developing drug-related problems. It is well known that the number of patients who are being diagnosed with end-stage renal disease (ESRD) is rapidly increasing worldwide, including Saudi Arabia. Most of these patients appear to develop ESRD as a result of long-standing, often overlooked, hypertension or diabetes mellitus. [1] Solid organ transplantation has become a well-accepted therapy for the treatment of ESRD. These patients often require complex pharmaco­-therapeutic regimens and tend to develop drug-related complications, which jeopardize graft and patient survival. [2] Multiple drug combinations are still required to obtain positive long-term outcomes and improve patient survival rates. Consequently, the input of pharmacists on a kidney transplant program can significantly improve the quality of care offered to these patients. [3],[4]


   Clinical Pharmacy Top


Pharmacists entered the 20 th century as apothecaries, procuring, preparing, evaluating, and selling medicinal drugs, but that role was gradually taken over by the pharma­ceutical industry. Thus, clinical pharmacy practice evolved around the mid-1960s, representing a period of professional transition in which pharmacists sought to execute fully their professional potential by performing significantly more patient ­oriented activities. The factors contributing to this evolution are many fold, but are primarily related to enhanced requirements of patients for optimization of increasingly complex drug treatments. [5] Clinical pharmacy activities which address various problems of drug therapy in individual patients include drug information for health care workers, patient counseling to increase the patients' knowledge of their treatment regimens, performing medication histories to obtain the correct drug usage by individual patients, providing pharmacokinetic interpretation of patients' drug therapy, and monitoring and reporting adverse drug reactions. [6],[7],[8] However, it was not until the mid-1980s that the concept of pharmaceutical care was introduced. This concept has revolutionized the practice of pharmacy and has solidified the clinical pharmacist's presence as part of the health-care team. [9],[10],[11]


   Pharmaceutical Care Top


Pharmaceutical care requires that the pharmacist engage in a systematic, compre­hensive process whereby he or she is able to accomplish three primary functions: (a) identify a patient's actual and potential drug­-related problems, (b) resolve the patient's drug related problems, and (c) prevent the patient's potential drug-related problems from becoming actual problems. Thus, by definition, pharmaceutical care involves provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life. The clinical activities described above, are considered tools that a pharmacist uses in order to help identify, prevent, and resolve drug-related problems. As a consequence, pharmaceutical care is the latest step in the pharmacy profession's evolution toward a patient-focused practice with direct responsibility and accountability for patient care. [9],[10]


   Nephrology Clinical Pharmacy Services Top


The role of the clinical pharmacist in the care of patients with kidney disease has also evolved over the past 25 years. Many hospital clinical pharmacy programs initiated their nephrology services with pharmacokinetic consultations, primarily targeted towards antibiotic monitoring (in particular for aminoglycosides); however, with the increased use of vancomycin in nephrology patients, these types of consul­tations has decreased dramatically. [4],[7] The later shift toward a pharmaceutical care approach over time has resulted in an expanded array of pharmacotherapy consul­tative services. [1],[3],[6]

Although not extensively found in the medical literature, various reports have described the type of consults and activities performed by clinical pharmacists in nephrology services. It appears that the vast majority of drug-related problems encoun­tered by post-renal transplant patients are in relation to antihypertensive, antimicrobial or immunosuppressant medications. [1],[3],[6],[12]

Drug-related admissions and non­compliance with medications are common in renal transplant patients. [3],[5],[11],[12] All these problems reflect the need for a constant review of medication regimens in this patient population, a need that is being addressed by clinical pharmacists.

Medication reviews and consultations specifically targeted at antihypertensive medication, which often complicates the treatment of renal transplant patients, assist clinicians in assessing drug response in patients suffering from treatment-resistant hypertension and help in the development of rational drug therapy. [3],[8] The clinical pharmacist establishes a patient specific pharmaceutical care plan for monitoring the effectiveness and the potential side effects from drug therapy, which is specially important in patients who are using combinations of antihypertensive medi­cations.

Because of the diversity of organisms affecting the immunosuppressed population, infections continue to be the single largest cause of post-transplantation morbidity and mortality. [2] Clinical pharmacists are a useful source of information and are often involved in antibiotic dosage recommendations that are based on pharmacokinetic values and are individualized according to the patient's renal function. [2],[4]

Most of the complications of transplant treatment are problems related to immuno­suppression, primarily due to a range of well-known and potentially catastrophic side effects, including nephrotoxicity, hyper­lipidemia, osteoporosis, obesity and diabetes. All these toxicities can lead to debilitating and life-threatening disease and graft failure. Therefore, optimizing immunosuppressive regimens, identifying and minimizing the risk for potential drug interactions, choosing suitable agents to treat the side effects of immunosuppressants, and seeking new anti­rejection agents and techniques are all goals that pharmacists help to achieve through their interventions. [1],[2],[3],[4],[5],[6],[7]

Another aspect of immunotherapy that should not be ignored is patient compliance. Studies have shown that a substantial proportion of the general population is non compliant with their medication. [5],[11],[12] Poor adherence with drug therapy can contribute to a future drug-induced admission. This emphasizes the importance of providing patients with a clear and consistent information about their medication regimens that are easily understood. If this is not done, the resulting confusion may affect patient compliance. Treatment follow-up is part of the total pharmaceutical care process, and this again seems to be a natural development of the pharmacist's role. As prescribing becomes more complex and the physician's workload increases, the pharmacist is in an ideal position to advise on subtle differences in action, side effects, monitoring and tailoring of individual therapy. Patients with previous drug-related admissions are often targeted by the pharmacist for counseling and compliance check after discharge. [5],[6]

Drugs represent a relatively small proportion of the overall costs of the initial transplant procedure, but they are one of the major costs after the first year post-transplant. [13] In today's health care environment, health-care providers and hospital administrators are demanding evidence of economic efficiency for drugs and other technologies. Pharmaco­economics is a tool to determine the value of drugs, a term that is being increasingly used by decision makers. Clinical pharmacists may be useful in interpreting results of economic analysis, some of which are often unclear or controversial to clinicians who have not had formal training in pharmaco-economics.


   Summary Top


The ESRD population has many unique issues, which puts them at special risk for drug-related problems and associated increased morbidity and mortality. Simple activities such as medication profile reviews have been shown to be successful in streamlining drug therapy. [8] Although limited data supports the presence of clinical pharmacists in renal transplant settings, the few studies available have clearly identified the ESRD population as one that is at high risk for drug-related problems. [5],[6] The presence of a clinical pharmacist in a renal transplant unit may lead to improved pharmacotherapy and to minimize medication related problems in this patient population. Further research in this area should be directed at demonstrating a positive effect on morbidity and mortality with reduction in drug-related problems.

 
   References Top

1.Matzke GR, St Peter WL, Comstock TJ, Foote EF. Nephrology pharmaceutical care preceptorship: a programmatic and clinical outcomes assessment. Ann Pharmacother 2000;34:593-9.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Shaefer MS. Current topics in immuno­therapy and the role of the pharmacist on a solid organ transplant service. Pharmaco­therapy 1991;11(6):136S-41S.  Back to cited text no. 2    
3.Chisholm MA, Vollenweider LJ, Mulloy LL, Jagadeesan M, Wade WE, DiPiro JT. Direct patient care services provided by a pharmacist on a multidisciplinary renal transplant team. Am J Health-Syst Pharm 2000;57:1994-6.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.St Peter W. Clinical pharmacy, nephrology consultation and documentation: a comp­rehensive approach. J Pharmac Prac 1993; 6(3):140-7.  Back to cited text no. 4    
5.Einarson TR. Drug-related hospital admis­sions. Ann Pharmacother 1993;27:832-40.  Back to cited text no. 5  [PUBMED]  
6.Grabe DW, Low CL, Bailie GR, Eisele G. Evaluation of drug-related problems in an outpatient hemodialysis unit and the impact of a clinical pharmacist. Clin Nephrol 1997;47:117-21.  Back to cited text no. 6  [PUBMED]  
7.Tang I, Vrahnos D, Hatoum H, Lau A. Effectiveness of clinical pharmacist inter­ventions in a hemodialysis unit. Clin Ther 1993;15:459-64.  Back to cited text no. 7  [PUBMED]  
8.Britton ML, Lurvey PL. Impact of medication profile review on prescribing in a general medicine clinic. Am J Hosp Pharm 1991;48:265-70.  Back to cited text no. 8  [PUBMED]  
9.Strand LM, Morley PC, Cipolle RJ, Ramsey R, Lamsam GD. Drug-related problems: their structure and function. DICP 1990;24:1093-7.  Back to cited text no. 9  [PUBMED]  
10.Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990;47:533-43.  Back to cited text no. 10  [PUBMED]  
11.Swanson MA, Palmeri D, Vossler ED, et al. Noncompliance in organ transplant recipients. Pharmacotherapy 1991;11:173S-4S.  Back to cited text no. 11  [PUBMED]  
12.De Geest S, Borgermans L, Gemoets H, et al. Incidence, determinants, and consequences of subclinical noncompliance with immuno­suppressive therapy in renal transplant recipients. Transplantation 1995;59:340-7.  Back to cited text no. 12  [PUBMED]  
13.Eggers PW, Kucken LE. Cost issues in transplantation. Surg Clin North Am 1994;74:1259-67.  Back to cited text no. 13  [PUBMED]  

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Correspondence Address:
Monica Zolezzi
Clinical Pharmacist, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159
Saudi Arabia
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PMID: 18209406

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    Introduction
    Clinical Pharmacy
    Pharmaceutical Care
    Nephrology Clini...
    Summary
    References
 

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