Clinical pharmacy activities in chronic kidney disease and end-stage renal disease patients: a systematic literature review

<p>Abstract</p> <p>Background</p> <p>Chronic kidney disease (CKD) and end-stage renal disease (ESRD) represent worldwide health problems with an epidemic extent. Therefore, attention must be given to the optimisation of patient care, as gaps in the care of CKD and ESRD patients are well documented. As part of a multidisciplinary patient care strategy, clinical pharmacy services have led to improvements in patient care. The purpose of this study was to summarise the available evidence regarding the role and impact of clinical pharmacy services for these patient populations.</p> <p>Methods</p> <p>A literature search was conducted using the <it>Medline</it>, <it>Embase </it>and <it>International Pharmaceutical Abstracts </it>databases to identify relevant studies on the impact of clinical pharmacists on CKD and ESRD patients, regarding disease-oriented and patient-oriented outcomes, and clinical pharmacist interventions on drug-related problems.</p> <p>Results</p> <p>Among a total of 21 studies, only four (19%) were controlled trials. The majority of studies were descriptive (67%) and before-after studies (14%). Interventions comprised general clinical pharmacy services with a focus on detecting, resolving and preventing drug-related problems, clinical pharmacy services with a focus on disease management, or clinical pharmacy services with a focus on patient education in order to increase medication knowledge. Anaemia was the most common comorbidity managed by clinical pharmacists, and their involvement led to significant improvement in investigated disease-oriented outcomes, for example, haemoglobin levels. Only four of the studies (including three controlled trials) presented data on patient-oriented outcomes, for example, quality of life and length of hospitalisation. Studies investigating the number and type of clinical pharmacist interventions and physician acceptance rates reported a mean acceptance rate of 79%. The most common reported drug-related problems were incorrect dosing, the need for additional pharmacotherapy, and medical record discrepancies.</p> <p>Conclusions</p> <p>Few high-quality trials addressing the benefit and impact of clinical pharmacy services in CKD and ESRD patients have been published. However, all available studies reported some positive impact resulting from clinical pharmacist involvement, including various investigated outcome measures that could be improved. Additional randomised controlled trials investigating patient-oriented outcomes are needed to further determine the role of clinical pharmacists and the benefits of clinical pharmacy services to CKD and ESRD patients.</p

Doctor can I buy a new kidney? I've heard it isn't forbidden: what is the role of the nephrologist when dealing with a patient who wants to buy a kidney?

Organ trafficking is officially banned in several countries and by the main Nephrology Societies. However, this practice is widespread and is allowed or tolerated in many countries, hence, in the absence of a universal law, the caregiver may be asked for advice, placing him/her in a difficult balance between legal aspects, moral principles and ethical judgments. In spite of the Istanbul declaration, which is a widely shared position statement against organ trafficking, the controversy on mercenary organ donation is still open and some experts argue against taking a negative stance. In the absence of clear evidence showing the clinical disadvantages of mercenary transplantation compared to chronic dialysis, self-determination of the patient (and, with several caveats, of the donor) may conflict with other ethical principles, first of all non-maleficence. The present paper was drawn up with the participation of the students, as part of the ethics course at our medical school. It discusses the situation in which the physician acts as a counselor for the patient in the way of a sort of “reverse” informed consent, in which the patient asks advice regarding a complex personal decision, and includes a peculiar application of the four principles (beneficence, non-maleficence, justice and autonomy) to the donor and recipient parties

Effects of water immersion on renal function in the nephrotic syndrome

Effects of water immersion on renal function in the nephrotic syndrome. Nine adult patients with the nephrotic syndrome were studied during 4 hours of water immersion (WI) to the level of the neck in the seated position and under control conditions. During WI, sodium excretion (UNaV) rose from a mean prestudy level of 45.9 ± 18.7 µEq/min to a mean peak level of 242.2 ± 42.8 µEq/min during the 4th hour. During control studies, UNaV was unchanged. During WI, urine volume rose from 1.1 ± 0.4ml/min and reached a peak level of 7.5 ± 0.8ml/min during the 2nd hour. There were also marked increases in free water clearance and potassium excretion. Plasma renin activity fell from a prestudy level of 5.1 ± 1.3 ng/ml/hr to a nadir of 1.9 ± 0.4 ng/ml/hr during the 2nd hour of WI. Levels were unchanged during control studies. There was a considerable variation in the magnitude of the natriuretic effect of WI between the individual patients. Peak levels of UNaV varied from 55.3 to 488 µEq/min, and net negative sodium balance varied from 12.8 to 105mEq. These variations were found to be directly related to the patient's estimated plasma volume, such that y = 19.2x - 211 (r = 0.84) represented the relationship between the plasma volume and the peak UNaV, and y = 1.9x - 41 (r = 0.81) represented the relationship between plasma volume and net negative sodium balance. These studies indicate that in patients with nephrotic syndrome, as in normal subjects, WI provides a potent natriuretic stimulus that results from expansion of the central blood volume. The magnitude of the natriuresis in nephrotic patients is related to their plasma volume, an observation that might help predict therapeutic benefit of the procedure in the individual patient.Effets de l'immersion dans l'eau sur la fonction rénale dans le syndrome néphrotique. Neuf malades adultes atteints de syndrome néphrotique ont été étudiés au cours de 4 heures d'immersion dans l'eau (WI) jusqu'au cou en position assise et dans des conditions contrôles. Au cours de l'immersion l'excrétion de sodium (UNaV) a augmenté d'une valeur moyenne contrôle de 45,9 ± 18,7 µEq/mn à une valeur moyenne de pic de 242,2 ± 42,8 µEq/mn au cours de la quatrième heure. Au cours des études contrôles UNaV était inchangée. Au cours de l'immersion le débit urinaire a augmenté de 1,1 ± 0,4ml/mn et a atteint une valeur de pic de 7,5 ± 0,8ml/mn au cours de la deuxième heure. Une augmentation importante de la clearance de l'eau libre et de l'excrétion de potassium a été observée. L'activité rénine plasmatique a diminué d'une valeur de 5,1 ± 1,3 ng/ml/h avant l'étude à un minimum de 1,9 ± 0,4 ng/ml/h au cours de la deuxième heure de l'immersion. Au cours des études contrôles les valeurs ont été inchangées. Des variations individuelles considérables dans l'amplitude de l'effet natriurétique de l'immersion ont été observées. La valeur de pic de UNaV a varié de 55,3a488a varié de µEq/min, et net négative l'equilibre sodium 12,8mEq à 105mEq. Ces variations ont été corrélées au volume plasmatique estimé des malades de telle sorte que y = 19,2x - 211 (r = 0,84) a représenté la relation entre le volume plasmatique et la valeur de pic de UNaV, et que y = 1,9x - 41 (r = 0,81) a représenté la relation entre le volume plasmatique et le bilan négatif net de sodium. Ces études indiquent que chez des malades atteints de syndrome néphrotique comme chez les sujets normaux l'immersion produit un stimulus natriurétique puissant qui résulte d'une expansion du volume sanguin central. L'importance de la natriurèse chez les malades atteints de syndrome néphrotique était en relation avec leur volume plasmatique, une observation qui peut aider à prédire l'effet thérapeutique de cette manoeuvre pour un malade donné