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  Table of Contents 
REVIEW ARTICLE
Year : 2016  |  Volume : 32  |  Issue : 3  |  Page : 192-198
 

The role of the pharmacist in the management of kidney transplant recipients


1 Department of Pharmacy Services, Oregon Health and Science University, Portland, OR 97239, USA, India
2 Department of Pharmacy Services, Oregon Health and Science University, Portland, OR 97239; Department of Pharmacy Services, College of Pharmacy, Oregon State University, Corvallis, OR 97331, USA

Date of Web Publication1-Jul-2016

Correspondence Address:
Joshua J Wiegel
3181 SW Sam Jackson Park Road, Mail Code CR 9-4, Portland, OR 97239
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.185108

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   Abstract 

Pharmacists may play a key role on the multidisciplinary transplant team. This article describes the development and current status of pharmacists in the management of transplant recipients in the United States. Traditionally, pharmacists played an important support role in transplant medicine. This role has been expanded to include direct patient care for the avoidance, detection, and/or treatment of side effects from the polypharmacy necessary in the management of these complex patients. Pharmacists provide pre- and post-transplant education to transplant recipients to enhance adherence to complicated medical regimens and thereby reduce readmission to hospital and unscheduled, costly visits to urgent care centers and/or hospital emergency departments.


Keywords: Collaboration, compliance, pharmacist


How to cite this article:
Wiegel JJ, Olyaei AJ. The role of the pharmacist in the management of kidney transplant recipients. Indian J Urol 2016;32:192-8

How to cite this URL:
Wiegel JJ, Olyaei AJ. The role of the pharmacist in the management of kidney transplant recipients. Indian J Urol [serial online] 2016 [cited 2019 Sep 21];32:192-8. Available from: http://www.indianjurol.com/text.asp?2016/32/3/192/185108



   Introduction Top


Because of their extensive knowledge of pharmacology, pharmacists may play key roles on multidisciplinary transplant teams. In the USA, the United Network for Organ Sharing (UNOS) administers the Organ Procurement and Transplantation Network. It is responsible for setting standards for all USA Transplant Programs, and it requires that all transplant programs identify at least one pharmacist to be responsible for providing pharmaceutical care to solid organ transplant recipients.[1] In 2007, the Center for Medicare and Medicaid Services, the government agency responsible for administration of several key federal health-care programs, followed suit and now requires that every transplant center identify an individual trained in pharmacology.[2] Although they do not specifically state that the individual trained in pharmacology must be a pharmacist, it is generally accepted that this role is best filled by a pharmacist.

The role of pharmacists as part of the multidisciplinary transplant team has been well documented for four decades. In 1976, Mitchell described pharmacists as an integral part of the transplant team attending daily rounds, providing medication instruction, following patients, and counseling at discharge.[3] With the increasing recognition of pharmacists as members of the transplant team since the updated UNOS regulations of 2004, the role of pharmacists in transplant has increased significantly. This article describes the development and current status of pharmacists in the management of transplant recipients.


   Transplant Pharmacy Practice Top


Traditionally, pharmacists played an important supporting role in transplant medicine, with a focus on dispensing medications and providing tools to improve adherence. Today, however, the role of pharmacists has expanded to include responsibilities in the pretransplant, perioperative, and posttransplant periods. In daily practice, USA pharmacists are responsible for monitoring and managing complications of immunosuppressive medications. Some of the important components of the job are recognizing drug–drug and drug-disease interactions, monitoring and managing toxicities of immunosuppressants, antimicrobials, and other essential posttransplant medications. Pharmacists provide extensive pre- and post-transplant education to patients to enhance adherence and minimize unscheduled and costly visits to an urgent care center and/or hospital emergency department.

Drug–drug interactions are very important to consider in the posttransplant setting. For example, calcineurin inhibitors (tacrolimus and cyclosporine) and mammalian target of rapamycin inhibitors (sirolimus and everolimus) are substrates of cytochrome P450 (CYP) isoenzyme 3A and p-glycoprotein and are subject to numerous drug interactions with commonly used posttransplant medications. Of particular importance are interactions with anti-infectives, human immunodeficiency virus and hepatitis C virus protease inhibitors, statins, psychiatric medications, antiseizure medications, and some antihypertensives [Table 1]a,[Table 1]b,[Table 1]c.[4],[5],[6],[7],[8] There are also numerous drug-disease interactions that must be monitored closely posttransplant. Mental status changes from immunosuppressants such as prednisone, cyclosporine, and tacrolimus may adversely affect patients with preexisting mental health issues.[9],[10],[11],[12],[13] Medication absorption may be altered in patients who have undergone gastric bypass or other gastrointestinal surgeries, patients with short gut syndrome, or patients with gastroparesis from diabetes mellitus.[14],[15],[16],[17],[18],[19] More frequent monitoring of immunosuppressant blood levels, dose adjustments, and modification of immunosuppressive regimens to alternative agents with fewer drug-disease interactions may be assessed by a clinical pharmacist to optimize the management of these patients.
Table 1a: Cyclosporine and tacrolimus drug-drug interactions

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{Table 2}{Table 3}


   Resources for Pharmacists Top


Pharmacists have many resources available to them through various online and mobile references and clinical decision support (CDS) systems within electronic health records (EHRs) to assist in analyzing drug–drug and drug-disease interactions, therapeutic duplication, and monitoring therapeutic drug levels. Many institutions, especially larger health systems and hospitals associated with a university, purchase drug information resources such as Micromedex, Lexicomp, PubMed, Ovid, DynaMed, and UpToDate for physicians, pharmacists, and nurses to use in their daily practice. Micromedex, Lexicomp, and UpToDate also have mobile applications that can be downloaded and used on smartphones and tablets which can be convenient to use when rounding on patients or in an ambulatory clinic. There are many other drug information resources available via mobile applications including Medscape, Johns Hopkins ABX Guide, and Epocrates; however, a comprehensive list of all available mobile drug information resources is outside of the scope of this review. CDS systems within EHRs utilize multiple tools, including customizable drug databases, to enhance clinical decision-making for pharmacists and other healthcare providers. CDS systems can include alerts, workflow support, and process-based decision support.[20] Alerts can be a helpful tool to assist pharmacists in identifying drug–drug and drug-disease interactions, specific laboratory requirements before initiation of a medication, or need for alternative medication decisions due to drug shortages or formulary restrictions. CDS workflow support may include order sets with preselected medication orders or note templates that are meant to improve efficiency in data entry and documentation. Process-based decision support can enhance the comprehensive care of the patient by identifying follow-up tests that may be needed for a patient such as therapeutic drug levels. These tools do have their limitations: False positive alerts may lead to alert fatigue, note templates may not include all pertinent up-to-date information, and process-based support may lead to ordering unnecessary laboratory tests. The American Society of Health-System Pharmacists has recently published guidelines on the design of database-driven CDS systems which include recommendations on the essential capabilities that all CDS systems should possess.[21] These systems offer tools that pharmacists need in their daily practice to improve quality, safety, and cost of health care.


   Medication Management Top


Pharmacists may provide medication therapy management (MTM) through collaborative drug therapy management (CDTM) agreements under the direction or supervision of a licensed physician or nurse practitioner through a written protocol for patient- and disease-specific medication therapy. MTM activities under CDTMs may include ordering, changing, and/or substituting therapies and/or ordering laboratory tests to monitor drug safety, effectiveness, or therapeutic levels. CDTMs provide pharmacists with increased autonomy and offset some of the work traditionally performed by physicians.

In transplant medicine, compliance plays an important role in allograft survival, especially in younger recipients. Noncompliance to immunosuppressive therapy is a significant cause of graft failures in kidney transplant patients.[22] In a recent study by Gaynor et al., noncompliance to immunosuppressive therapy was found to be the cause of graft failure in approximately 10% of kidney transplant recipients, and as high as one-third of patients in high-risk groups, for example, teenagers.[23] In general, compliance is defined as the extent a patient correctly follows medical advice. In pharmacotherapy, compliance is described as the degree of adherence to a prescribed medication regimen. The implementation of a clinical pharmacy intervention service in an outpatient transplant clinic for postrenal transplant patients is an essential part of pharmacist activities to improve pharmacotherapy compliance. The clinical pharmacist reviews and optimizes medication therapy, encourages adherence, provides instructions on how to take the medications, assists with enrollment into medication assistance programs, and provides recommendations to the health-care team. In a study by Chisholm-Burns et al., patients were randomized to receive traditional care from the interdisciplinary group (control group) or traditional care in combination with clinical pharmacy services (the intervention group) (N = 12 for each group).[24] The majority of patients (66.7%) received kidney transplants from a deceased donor, and approximately 88% were prescribed cyclosporine. The intervention group had a higher overall adherence rate (mean 96.1% vs. 81.6%, P < 0.001) and a longer period of adherence time until the 1st nonadherent month, defined as ≤80% adherence (mean 11 months vs. 9 months, P < 0.05). There were fewer adverse drug reactions, lower costs, increased patient satisfaction, and improved health outcomes in patients that had a clinical pharmacist as part of their team.[25],[26],[27],[28],[29],[30]

Pharmacists are well educated about therapy unrelated to transplantation. Maldonado et al. reported that pharmacologic and nonpharmacologic risks are important when evaluating patients on the transplantation waitlist.[31] Their study reviewed the pertinent literature regarding pharmacologic and nonpharmacologic risks that need to be mitigated before receiving a transplant including anticoagulation concerns, mental health medications, chronic pain medication use, allergies, hormonal contraception, history of immunosuppressant use, medication absorption issues, alcohol and tobacco use, illicit substance use, herbal substance use, vaccine delivery, infection prophylaxis and treatment, medication compliance issues, communication barriers, and financial, insurance, or transportation challenges. After reviewing the literature, the authors concluded, based on practitioner consensus, that all of the above-mentioned pharmacologic and nonpharmacologic factors influence outcomes in kidney transplant patients and should be assessed before transplantation. This can be done by the clinical pharmacist.

Taber et al. demonstrated that medication use and safety are believed to be the core issues causing delayed discharge and early readmissions of kidney transplant recipients.[32] To improve these common issues, a multidisciplinary quality improvement program was initiated to improve clinical outcomes. These services included improved medication reconciliation, development of a diabetes management service, and improved discharge medication dispensing, delivery, education, and scrutiny. The results showed a reduction in medication discrepancies by >2 per patient and 100% adherence with reconciliation. A 40% reduction in medication safety issues was documented as a result of pharmacists reviewing discharge medications. Short length of stay, a 14% reduction in delayed discharges, and a 50% reduction in 7-day readmission rates were noticeable outcomes. In this study, pharmacists provided comprehensive medication reviews to identify drug–drug, drug-lab, and drug-nutrition interactions for a given therapeutic regimen and to design appropriate plans, along with other health-care team members, to minimize the chance of significant medication problems. Clinical improvement in medication safety in kidney transplant patients was the result of having a multidisciplinary quality improvement initiative.

Martinet al. assessed the expanding roles of transplant pharmacists across each aspect of the care of transplant recipients.[33] In a survey to 118 transplant centers, 36 out of 41 responding centers had incorporated pharmacists into the transplant team. These pharmacists were involved in kidney (86%), liver (71%), pancreas (50%), heart (25%), and lung (7%) transplants. Pharmacists were salaried through the department of pharmacy (74%), college of pharmacy (12%), transplant center (8%), and the department of surgery (6%). Posttransplant care was the primary focus of these transplant pharmacists. The average percentage of the pharmacists' time was spent as follows: Inpatient service (43%), outpatient clinic (15%), research (14%), other transplant-related (6%), and nontransplant-related (22%). According to the responding centers, the average number of organs transplanted was 99 kidneys, 45 livers, 28 pancreata, 14 hearts, and 26 lungs. The number of transplants was not correlated with the presence or absence of a clinical pharmacist.


   Conclusion Top


Transplant clinical pharmacists have expertise in patient education, detection of major drug adverse events and interactions, and improvement of adherence. Pharmacists play a vital role in patient monitoring to determine whether or not a specific event was caused by a specific medication. In the field of transplantation, pharmacists are integral members of the transplant patient care team as experts in medication-use safety and quality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
United Network for Organ Sharing [UNOS]. Attachment 1 to Appendix B of UNOS Bylaws: Designated Transplant Program Criteria; 2007. Available from: . [Last accessed on 2016 Mar 02].  Back to cited text no. 1
    
2.
Centers for Medicare and Medicaid Services (CMS), HHS. Medicare program; hospital conditions of participation: Requirements for approval and re-approval of transplant centers to perform organ transplants; final rule. Fed Regist. 2007;72(61):15197-279.  Back to cited text no. 2
    
3.
Mitchell JF. Pharmacist involvement as a member of a renal transplant team. Am J Hosp Pharm 1976;33:55-8.  Back to cited text no. 3
    
4.
Trofe-Clark J, Lemonovich TL; AST Infectious Diseases Community of Practice. Interactions between anti-infective agents and immunosuppressants in solid organ transplantation. Am J Transplant 2013;13 Suppl 4:318-26.  Back to cited text no. 4
    
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van Maarseveen EM, Rogers CC, Trofe-Clark J, van Zuilen AD, Mudrikova T. Drug-drug interactions between antiretroviral and immunosuppressive agents in HIV-infected patients after solid organ transplantation: A review. AIDS Patient Care STDS 2012;26:568-81.  Back to cited text no. 5
    
6.
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7.
Manitpisitkul W, McCann E, Lee S, Weir MR. Drug interactions in transplant patients: What everyone should know. Curr Opin Nephrol Hypertens 2009;18:404-11.  Back to cited text no. 7
    
8.
House RM, Thompson TL 2nd. Psychiatric aspects of organ transplantation. JAMA 1988;260:535-9.  Back to cited text no. 8
    
9.
Micromedex 2.0. Greenwood Village, CO. Truven Health Analytics, Inc. Available from: http://www.micromedexsolutions.com. [Last accessed on 2016 Apr 20].  Back to cited text no. 9
    
10.
Wise MG, Brannan SK, Shanfield SB, Moeller FG. Psychiatric aspects of organ transplantation. JAMA 1988;260:3437.  Back to cited text no. 10
    
11.
Plosker GL, Foster RH. Tacrolimus: A further update of its pharmacology and therapeutic use in the management of organ transplantation. Drugs 2000;59:323-89.  Back to cited text no. 11
    
12.
Soi V, Karthikeyan V, Parasuraman R. Altered mental status in a kidney transplant recipient receiving tacrolimus. Am J Kidney Dis 2008;51:A29-30.  Back to cited text no. 12
    
13.
Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41:263-306.  Back to cited text no. 13
    
14.
Titus R, Kastenmeier A, Otterson MF. Consequences of gastrointestinal surgery on drug absorption. Nutr Clin Pract 2013;28:429-36.  Back to cited text no. 14
    
15.
Marterre WF, Hariharan S, First MR, Alexander JW. Gastric bypass in morbidly obese kidney transplant recipients. Clin Transplant 1996;10:414-9.  Back to cited text no. 15
    
16.
Rogers CC, Alloway RR, Alexander JW, Cardi M, Trofe J, Vinks AA. Pharmacokinetics of mycophenolic acid, tacrolimus and sirolimus after gastric bypass surgery in end-stage renal disease and transplant patients: A pilot study. Clin Transplant 2008;22:281-91.  Back to cited text no. 16
    
17.
Edwards A, Ensom MH. Pharmacokinetic effects of bariatric surgery. Ann Pharmacother 2012;46:130-6.  Back to cited text no. 17
    
18.
Miller AD, Smith KM. Medication and nutrient administration considerations after bariatric surgery. Am J Health Syst Pharm 2006;63:1852-7.  Back to cited text no. 18
    
19.
Dostalek M, Akhlaghi F, Puzanovova M. Effect of diabetes mellitus on pharmacokinetic and pharmacodynamic properties of drugs. Clin Pharmacokinet 2012;51:481-99.  Back to cited text no. 19
    
20.
Richardson JE, Ash JS, Sittig DF, Bunce A, Carpenter J, Dykstra RH, et al. Multiple perspectives on the meaning of clinical decision support. AMIA Annu Symp Proc 2010;2010:1427-31.  Back to cited text no. 20
    
21.
Troiano D, Jones MA, Smith AH, Chan RC, Laegeler AP, Le T, et al. ASHP guidelines on the design of database-driven clinical decision support: Strategic directions for drug database and electronic health records vendors. Am J Health Syst Pharm 2015;72:1499-505.  Back to cited text no. 21
    
22.
Gaston RS, Hudson SL, Ward M, Jones P, Macon R. Late renal allograft loss: Noncompliance masquerading as chronic rejection. Transplant Proc 1999;31:21S-3S.  Back to cited text no. 22
    
23.
Gaynor JJ, Ciancio G, Guerra G, Sageshima J, Hanson L, Roth D, et al. Graft failure due to noncompliance among 628 kidney transplant recipients with long-term follow-up: A single-center observational study. Transplantation 2014;97:925-33.  Back to cited text no. 23
    
24.
Chisholm-Burns MA, Spivey CA, Garrett C, McGinty H, Mulloy LL. Impact of clinical pharmacy services on renal transplant recipients' adherence and outcomes. Patient Prefer Adherence 2008;2:287-92.  Back to cited text no. 24
    
25.
Chisholm MA, Vollenweider LJ, Mulloy LL, Jagadeesan M, Martin BC, DiPiro JT. Pharmaceutical care services reduce adverse drug reactions in renal transplant patients. Pharmacotherapy 2000b; 20(10):1270.  Back to cited text no. 25
    
26.
Vollenweider LJ, DiPiro JT, Chisholm MA. Economic evaluation of direct patient care pharmacy services to renal transplant clinic patients. Am J Transplant 2001;1 Suppl 1:273.  Back to cited text no. 26
    
27.
Chisholm MA, Reinhardt BO, Vollenweider LJ, Mulloy L, Jagadeesan M, Rogers HE, et al. Renal transplant clinic patients' satisfaction with health care quality: Effect of pharmaceutical care services. Pharmacotherapy 1999a; 19(10):1228.  Back to cited text no. 27
    
28.
Chisholm MA, Vollenweider LJ, Reinhardt BO, Martin BC, Rogers HE, May JR, et al. Effect of pharmaceutical care services on the blood pressure of renal transplant patients. Pharmacotherapy 1999b;19 (10):1222.  Back to cited text no. 28
    
29.
Chisholm MA, Mulloy LL, Jagadeesan M, Martin BC, DiPiro JT. Effect of clinical pharmacy services on the blood pressure of African-American renal transplant patients. Ethn Dis 2002;12:392-7.  Back to cited text no. 29
    
30.
Chisholm MA, Reinhardt BO, Vollenweider LJ, Jagadeesan M, Martin BC, DiPiro JT, et al. Effect of pharmaceutical care services on renal transplant patients' blood glucose levels. Int Pharm Abstr 1999c; 36:2180-1.  Back to cited text no. 30
    
31.
Maldonado AQ, Tichy EM, Rogers CC, Campara M, Ensor C, Doligalski CT, et al. Assessing pharmacologic and nonpharmacologic risks in candidates for kidney transplantation. Am J Health Syst Pharm 2015;72:781-93.  Back to cited text no. 31
    
32.
Taber DJ, Pilch NA, McGillicuddy JW, Bratton CF, Chavin KD, Baliga PK. Improved patient safety and outcomes with a comprehensive interdisciplinary improvement initiative in kidney transplant recipients. Am J Med Qual 2013;28:103-12.  Back to cited text no. 32
    
33.
Martin JE, Zavala EY. The expanding role of the transplant pharmacist in the multidisciplinary practice of transplantation. Clin Transplant 2004;18 Suppl 12:50-4.  Back to cited text no. 33
    



 
 
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