Pharmacist impact on CKD screening of HIV-infected patients

Purpose: It is estimated that 30% of HIV-infected patients have evidence of proteinuria on urinalysis.  As a result, practice guidelines recommend a urinalysis upon diagnosis of HIV and annually thereafter for high-risk patients to identify and appropriately manage CKD.  In 2010, a chart review (n=101) was conducted at an HIV clinic in Montgomery, Alabama to determine compliance with practice guidelines for CKD screening in HIV-infected patients. 

Results indicated an 11% compliance rate.  The primary objective of this study was to evaluate improvement in CKD screening at this clinic following a pharmacist intervention.  Secondary objectives included percentage of patients with proteinuria and appropriate management.

Methods: CKD screening reminders were placed in patient charts October 19 - December 31, 2011.  A retrospective chart review was performed in April 2012.  Data collected included demographics, serum creatinine, urinalysis, highly active antiretroviral therapy (HAART), current medications, viral load, CD4 count, concomitant disease states (HTN, hepatitis C, diabetes), and blood pressure.  Results:  Of 118 patients reviewed, 58% had orders for urinalysis.  Of those patients with a urinalysis, 40% had proteinuria (n=26).  Of all patients reviewed, 25% had CKD and 88% had at least 2 risk factors for CKD.  ACE-inhibitors were prescribed in only 46% of those with proteinuria. Of those patients reviewed with diabetes, 42% were not screened and 33% had proteinuria.  

Conclusion: The chart reminders had a positive impact improving CKD screening frequency from 11% to 58%.  The 40% incidence of proteinuria observed in this population is higher than previously published (30%) signaling the need for greater vigilance in this high risk population.  Optimization of pharmacotherapy in the primary care of these patients is needed.  This study prompted development of quality improvement measures implemented in the transition to an electronic medical record. Routine CKD screening and appropriate management is imperative to limit progression.