DANIEL M. GOLDSTEIN, MPAS, PA-CLCDR, USPHS

2010 U.S. Public Health Service Scientific and Training

Symposium San Diego, CA

Title

Medical Management and Prevention of Chronic

Kidney Disease at a Federal Medical Center in the

Federal Bureau of Prisons (BOP)

BOP Overview

Institutions: 119Federal inmates: approx 210,000Staff: approx 37,000Security levels: min, low, med, high, adminInstitution types: FPC, FCI, USP, FCC, Admin

- Admin: FMC- FMC: 6 total: Butner, Carswell, Devens, Lexington, Rochester, Springfield

FMC Devens

Population: approx 1100Location: Ayer, MA, 40 miles northwest of

BostonSpecialized focus: mental health and dialysisMedical Referral Center (MRC): inmates with

complex medical problemsAffiliated with UMASS Medical Center

Objectives

Stages of CKDCauses of CKDPrevention of CKDComplications seen with CKDTypes of dialysis- HD and PDMulti-team approachLab resultsMedication treatmentUnique challenges

Kidney Function

Normal kidney- 150 grams- 10 cm x 5.5 cm x 3 cm- filters blood to remove metabolic waste- produces hormones - regulates BP, electrolytes, fluids

Anatomy Kidney

Nephron: functional unit of kidney responsible for the formation of urine- each kidney: > 1 million nephron- a long renal tubule with straight & convoluted areas

Renal corpuscle PCT loop of Henle DCT collection duct- filtrate produced, reabsorption, secretion

Renal artery afferent arteriole efferent arteriole peritubular cap/vasa recta renal vein

Chronic Kidney Disease

20 million AmericansNot reversible like Acute Renal Failure (ARF)Stages: I-V

- I: kidney damage with normal GFR, ≥ 90- II: mild decrease in GFR, 60-89-III: moderate decrease in GFR, 30-59- IV: severe decrease in GFR, 15-29- V: kidney failure, GFR< 15, dialysis if symptomatic

Determine GFR

Glomerular Filtration Rate (GFR): - calculated from the Modification of Diet in Renal Disease (MDRD) - complicated equation that requires 4 variables: serum creatinine, age, sex, and whether or not patient is African American- GFR (ml/min/1.73 m2)= 186 x (Cr)-1.154 x (age)-

0.203 x (0.742 if female) x (1.210 if African American)

Labs calculate the GFR, report number if below 60

Serum Creatinine

For many years, the Cockcroft-Gault equation was used to calculate GFR

Serum Creatinine (Cr): affected by muscle mass, which could give inaccurate picture of renal function

Normal serum Cr is approx 1.0Once serum Cr is 2.0: 50% renal function lossSerum Cr is 3.0: 75% renal function loss

Causes of CKD

Major causes: HTN and DMMedications: NSAIDs (e.g. ibuprofen, Advil,

Motrin)

Polycystic Kidney DiseaseGlomerular Disease

- glomerulonephritis- minimal change disease- lupus nephropathy- Goodpasture’s syndrome

Other Causes CKD

Hepatorenal disease- secondary to cirrhosisHCV- membranous nephropathyHIVVascular- Wegener’s granulomatosis

When is Dialysis Needed?

CKD stage V: GFR < 15Uremia: accumulation of nitrogenous waste

products in the blood that usually is excreted in the urine

Uremic symptoms:- loss of appetite, fatigue, cognitive impairment, muscle cramps and twitches, shortness of breath

Uremic signs: - pericarditis, pericardial effusion, pulmonary edema, uremic fetor (urine-like odor to breath), uremic frost on skin

Which Type of Dialysis?

Hemodialysis (HD)- most inmates, 4 hours long, 3 days/week- M/W/F or T/R/Sat- contract nurses run dialysis machines- fistula, graft, catheter

Peritoneal Dialysis (PD)- about 8 inmates, done in their cells- disadvantage: daily, peritonitis, poor compliance- advantage: portable, freedom, done while sleeping

Fistula

Definition: a communication between artery and vein that is used as an access site for hemodialysis

Vascular surgeon:- vein mapping- surgery one week later- follow-up surgery in 10 days- follow-up 3 months after surgery and clear for use

Done before needing dialysis

Complications with Fistula

Aneurysm- arterial bleed, emergencyClottedInfectedSteel syndromeRecirculationLow access flow

- should be able to hear bruit, palpate thrill

Devens Inmates

82 hemodialysis inmatesAverage current age: 48 yrs oldYoungest: 24 yrs oldOldest: 74 yrs oldBreakdown age:

- 20s: 2 50s: 21- 30s: 23 60s: 15- 40s: 20 70s: 1

52/82 African American

How to Prevent Dialysis

Early referral to nephrologist: when GFR < 60

Good management of risk factors: - DM - HTN

Education about NSAIDs

Nephrologist

Management of all dialysis, kidney transplant inmates, also sees pre-dialysis per referral

Every Wednesday- entire day at DevensOrder labs before inmate seen by

nephrologist: CMP, CBC, Ca+, PO4, Mg, intact PTH, vitamin D, urine protein studies, iron panel

Renal ultrasoundSometimes kidney biopsy

Multi-Team

Once inmate on dialysis many involved in care- dietitian- social worker- PCPT- nephrologist (in-house)- dialysis nurses- vascular surgeon at UMASS- kidney transplant clinic at UMASS

Dialysis Inmates

Labs drawn during the first week of each month

Important labs: albumin, Hgb/HCT, iron panel, Ca+, PO4, K, intact PTH

Labs reviewed by nephrologist, PA/NP, dietitian, chief dialysis nurse last week of month

Medication changes, referrals as needed

Lab Details

Hgb: above 10, goal 11-12- if too high access site may clot, also risk MI/CVA

Ca+: 8.5-10 (correct for low albumin)PO4: < 5.5Ca+ x PO4= < 55PTH: 150-300 (CKD4: < 110)K: < 5.5ALB: > 3.8Iron saturation: 25-50%

Complications from CKD

AnemiaHyperphosphatemiaSecondary Hyperparathyroidism

Complications CKD

Anemia: low H/H If controlled- will slow down progression of

CKD- erythropoietin production in renal tubules declines- decreased oxygen-carrying capacity- increased cardiac work load LVH heart failure- increased mortality and poor quality life

Complications CKD

Hyperphosphatemia- peripheral vascular calcification- coronary artery and heart valve calcification- increased risk of MI, CVA, sudden death

70% of ingested PO4 excreted by healthy kidneyCauses of elevated PO4:

- inadequate binders - missed dialysis sessions - diet high in phosphorus

Complications CKD

Secondary Hyperparathyroidism (SHPT)- low vit D and low Ca+ and high PO4 high PTH - high PTH SHPT bone disease

Renal osteodystrophy: rapid bone formation and resorption- not mineralized well

Hyperplasia of parathyroid glands- 31/2 parathyroidectomy

Dietitian

Very important part of management CKD - Restriction PO4 foods - Low potassium foods (hyperkalemia with CKD)- Supplemental protein drinks: monitor albumin

Makes PO4 binders recommendationsDiabetic diet: glycemic indexDietary weight loss

Food Specifics

High in PO4- dairy products: milk, yogurt, cheese- Soft drinks: colas- Some fruit juices: punch- Nuts- Processed meats- Beans- All brand cereals

Food Specifics

High in potassium- orange juice- tomato juice- bananas- spinach- squash- beans- potatoes

Treatment: Phosphate

Calcium-based phosphate binders: - Calcium Carbonate: (if Ca+ low & PO4 normal)- Calcium Acetate: (if Ca+ low & PO4 high)

Calcium-free, metal-free binder- Sevelamer Carbonate: (if Ca+ normal & PO4 high)- often 3 tabs with meals and 2 with snacks- may reduce LDL, less coronary calcification

Treatment: Phosphate

Metal-based binder- Lanthanum Carbonate: (if Ca+ normal & PO4 high)- GI discomfort side effect- chewable- expensive

Aluminum-based binder: (no longer used)- was primary binder until mid-1980s- aluminum was found in toxic levels - aluminum levels checked yearly

Treatment: PTH

SHPT (high PTH)- Goal: PTH 150-300 - if PTH > 300 start vitamin D analog - if PO4 is high, then improve PO4 first before vitamin D analog- if vitamin D causes too high Ca+ or PO4, consider adding cinacalcet

Treatment: PTH

Cinacalcet: binds to calcium sensing receptor on parathyroid gland- results in lower serum Ca+, lower PO4 - allows to suppress PTH- decrease need for parathyroidectomy- start at 30 mg daily- increase by 30 to max 180 mg- common side effect: N/V

Treatment: Anemia

Anemia: Darbepoetin 1st choice - given subcut. weekly, often 40 mcg to start- weekly to monthly CBC needed- goal: Hgb: 11-12- not responding- change darbepoetin to epoetin alfa

Iron: given IV in dialysis if low, goal iron sat > 25%

Medication Challenges

Medication compliance (e.g. PO4 binders)Meds need renal dose adjustment (e.g.

antibiotics)Some meds contraindicated (e.g. metformin) Risk hypoglycemia for DM inmates on insulinSide effects meds (e.g. N/V, constipation)Pain control (e.g. no NSAIDs)

Custody Challenges

Many scheduled outside trips to UMASS needed (e.g. biopsy, ultrasound, vascular surgeon)

Many emergency trips to UMASS needed (e.g. cardiac events, fistula complications, sepsis)

BOP staffing, security concerns (some inmates max custody)

Handcuffs (can not place over fistula)

Important Points

Controlling HTN, DM, avoid chronic NSAIDs will prevent most common cases of CKD

Once GFR < 60 patient needs CKD management including referral to nephrologist

Once on dialysis: need to control PO4, PTH, to prevent vascular calcification, bone disease, and early death- follow advice of nephrologist & dietitian

References

Daugirdas JT, Blake PG, Ing TS. Handbook of Dialysis. 4th edition. Lippincott Williams & Wilkins. 2007

Van De Graaff KM. Human Anatomy. 4th edition. Wm. C. Brown Publishers. 1995. 638-646.

Martini FH, Timmons MJ. Human Anatomy. 2nd edition. Prentice Hall. 1997. 663-675.

Galley R. Improving Outcomes in Renal Disease. JAAPA. 2006;19(9):20-25.