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2010 U.S. Public Health Service Scientific and Training Symposium San Diego, CA. Daniel M. Goldstein, MPAS, PA-C LCDR, USPHS. Title. Medical Management and Prevention of Chronic Kidney Disease at a Federal Medical Center in the Federal Bureau of Prisons (BOP). BOP Overview.

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2010 U.S. Public Health Service Scientific and Training Symposium San Diego, CA

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2010 u s public health service scientific and training symposium san diego ca

2010 U.S. Public Health Service Scientific and Training Symposium San Diego, CA

Daniel M. Goldstein, MPAS, PA-C



Medical Management and Prevention of Chronic Kidney Disease at a Federal Medical Center in the Federal Bureau of Prisons (BOP)

bop overview
BOP Overview
  • Institutions: 119
  • Federal inmates: approx 210,000
  • Staff: approx 37,000
  • Security levels: min, low, med, high, admin
  • Institution types: FPC, FCI, USP, FCC, Admin

- Admin: FMC

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

fmc devens
FMC Devens
  • Population: approx 1100
  • Location: Ayer, MA, 40 miles northwest of Boston
  • Specialized focus: mental health and dialysis
  • Medical Referral Center (MRC): inmates with complex medical problems
  • Affiliated with UMASS Medical Center
  • Stages of CKD
  • Causes of CKD
  • Prevention of CKD
  • Complications seen with CKD
  • Types of dialysis- HD and PD
  • Multi-team approach
  • Lab results
  • Medication treatment
  • Unique challenges
kidney function
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
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
Chronic Kidney Disease
  • 20 million Americans
  • Not 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
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
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 1.0
  • Once serum Cr is 2.0: 50% renal function loss
  • Serum Cr is 3.0: 75% renal function loss
causes of ckd
Causes of CKD
  • Major causes: HTN and DM
  • Medications: NSAIDs (e.g. ibuprofen, Advil, Motrin)
  • Polycystic Kidney Disease
  • Glomerular Disease

- glomerulonephritis

- minimal change disease

- lupus nephropathy

- Goodpasture’s syndrome

other causes ckd
Other Causes CKD
  • Hepatorenal disease- secondary to cirrhosis
  • HCV- membranous nephropathy
  • HIV
  • Vascular- Wegener’s granulomatosis
when is dialysis needed
When is Dialysis Needed?
  • CKD stage V: GFR < 15
  • Uremia: 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
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

  • 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
Complications with Fistula
  • Aneurysm- arterial bleed, emergency
  • Clotted
  • Infected
  • Steel syndrome
  • Recirculation
  • Low access flow

- should be able to hear bruit, palpate thrill

devens inmates
Devens Inmates
  • 82 hemodialysis inmates
  • Average current age: 48 yrs old
  • Youngest: 24 yrs old
  • Oldest: 74 yrs old
  • Breakdown age:

- 20s: 2 50s: 21

- 30s: 23 60s: 15

- 40s: 20 70s: 1

  • 52/82 African American
how to prevent dialysis
How to Prevent Dialysis
  • Early referral to nephrologist: when GFR < 60
  • Good management of risk factors:

- DM


  • Education about NSAIDs
  • Management of all dialysis, kidney transplant inmates, also sees pre-dialysis per referral
  • Every Wednesday- entire day at Devens
  • Order labs before inmate seen by nephrologist: CMP, CBC, Ca+, PO4, Mg, intact PTH, vitamin D, urine protein studies, iron panel
  • Renal ultrasound
  • Sometimes kidney biopsy
multi team
  • Once inmate on dialysis many involved in care

- dietitian

- social worker


- nephrologist (in-house)

- dialysis nurses

- vascular surgeon at UMASS

- kidney transplant clinic at UMASS

dialysis inmates
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
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: < 5.5
  • Ca+ x PO4= < 55
  • PTH: 150-300 (CKD4: < 110)
  • K: < 5.5
  • ALB: > 3.8
  • Iron saturation: 25-50%
complications from ckd
Complications from CKD
  • Anemia
  • Hyperphosphatemia
  • Secondary Hyperparathyroidism
complications ckd
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 ckd27
Complications CKD


- peripheral vascular calcification

- coronary artery and heart valve calcification

- increased risk of MI, CVA, sudden death

  • 70% of ingested PO4 excreted by healthy kidney
  • Causes of elevated PO4:

- inadequate binders

- missed dialysis sessions

- diet high in phosphorus

complications ckd28
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

  • Very important part of management CKD

- Restriction PO4 foods

- Low potassium foods (hyperkalemia with CKD)

- Supplemental protein drinks: monitor albumin

  • Makes PO4 binders recommendations
  • Diabetic diet: glycemic index
  • Dietary weight loss
food specifics
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 specifics31
Food Specifics
  • High in potassium

- orange juice

- tomato juice

- bananas

- spinach

- squash

- beans

- potatoes

treatment phosphate
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 phosphate33
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
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 pth35
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
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 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 insulin
  • Side effects meds (e.g. N/V, constipation)
  • Pain control (e.g. no NSAIDs)
custody challenges
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
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
  • 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.