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Sanz Solutions

Concierge pharmacy

Playbook

CKD/ESRD playbook

Research phase

CKD/ESRD Playbook

Owner: Derek Sanz
Status: Research phase
Last updated: 2026‑02‑16

1. Strategic Objectives

  1. Slow progression: aggressive risk-factor control (BP, A1C, proteinuria) and evidence-based pharmacotherapy.
  2. Dialysis preparedness: early modality education, vascular access planning, and payer coordination.
  3. Medication stewardship: reconcile nephrotoxic risks, dose-adjust therapies, optimize anemia/mineral-bone regimens.

2. Core Workflows

Workflow Trigger Owner
CKD dashboard sweep eGFR <45, UACR >30, rapid decline Analytics + pharmacy
Med review cadence Every visit + within 48h of hospitalization Pharmacist
Dialysis transition huddle eGFR <20 or RRT within 9 months Nephrology + care coordination
SDOH escalation Missed labs, transportation barriers Social work

3. Pharmacy Playbook

  • Layered pharmacotherapy:
    • ACEi/ARB at maximally tolerated dose for all albuminuric patients.
    • SGLT2 inhibitor if eGFR ≥20; GLP‑1 receptor agonist for metabolic/ASCVD benefit.
    • Finerenone consideration when persistent albuminuria despite ACEi/ARB.
  • Anemia protocols: Hb <10 → evaluate iron, B12, folate; IV iron first-line if TSAT <30%. ESA initiation per KDIGO.
  • Mineral bone disease: standardize calcitriol/calcimimetic titration and phosphorus binder algorithm.
  • Drug safety: global flag for NSAIDs, contrast, metformin hold when eGFR <30 unless supervised.

4. Monitoring Matrix

Metric Target Frequency Owner
BP <130/80 ≥70% of panel Every visit/home monitoring RN/Pharmacy
A1C 6.5–7.5% individualized Quarterly PCP/Endocrine
UACR reduction ≥30% from baseline Semiannual Pharmacy
eGFR slope <5 mL/min/yr decline Quarterly review Nephrology
ESA/IV iron documentation 100% dosing captured Each infusion Infusion team

5. Dialysis & Transplant Readiness

  1. Access planning: referral to vascular surgery when eGFR <25 (fistula first).
  2. Modality education: home hemo vs. PD vs. in-center within 6 months of expected RRT.
  3. Transplant fast-track: HLA typing + psychosocial eval early; maintain vaccination series.
  4. Payer coordination: confirm MA vs. traditional Medicare billing rules, secondary coverage for supplies.

6. Patient-Facing Toolkit

  • “Kidney Protect” cheat sheet: med list, NSAID avoidance, sick-day rules (hold SGLT2/ACEi if dehydrated).
  • Dietitian script: sodium <2g/day, protein goals by stage, phosphorus additive education.
  • Transportation + infusion concierge: dialysis center mapping, rideshare credits, home phlebotomy partners.

7. Action Items

  1. Analytics: deploy CKD trend dashboard + eGFR velocity alerts by Mar 1.
  2. Pharmacy: standing order set for IV iron + ESA with labs embedded.
  3. Care coordination: build dialysis/transplant checklist in EHR (goal: pilot by Apr 15).
  4. Quality: align KPI reporting with CMS Star measures (KED, KED follow-up) and state ESRD metrics.

Contact: kidneycare@sanzsolutions.com | 813‑XXX‑XXXX