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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 l.jpg

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

Daniel M. Goldstein, MPAS, PA-C

LCDR, USPHS


Title l.jpg
Title Symposium

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


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BOP Overview Symposium

  • 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


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FMC Devens Symposium

  • 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


Objectives l.jpg
Objectives Symposium

  • 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


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Kidney Function Symposium

  • 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


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Anatomy Kidney Symposium

  • 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


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Chronic Kidney Disease Symposium

  • 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


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Determine GFR Symposium

  • 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


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Serum Creatinine Symposium

  • 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


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Causes of CKD Symposium

  • 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 l.jpg
Other Causes CKD Symposium

  • Hepatorenal disease- secondary to cirrhosis

  • HCV- membranous nephropathy

  • HIV

  • Vascular- Wegener’s granulomatosis


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When is Dialysis Needed? Symposium

  • 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


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Which Type of Dialysis? Symposium

  • 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


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Fistula Symposium

  • 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


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Complications with Fistula Symposium

  • Aneurysm- arterial bleed, emergency

  • Clotted

  • Infected

  • Steel syndrome

  • Recirculation

  • Low access flow

    - should be able to hear bruit, palpate thrill


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Devens Inmates Symposium

  • 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


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How to Prevent Dialysis Symposium

  • Early referral to nephrologist: when GFR < 60

  • Good management of risk factors:

    - DM

    - HTN

  • Education about NSAIDs


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Nephrologist Symposium

  • 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


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Multi-Team Symposium

  • 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 l.jpg
Dialysis Inmates Symposium

  • 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


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Lab Details Symposium

  • 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%


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Complications from CKD Symposium

  • Anemia

  • Hyperphosphatemia

  • Secondary Hyperparathyroidism


Complications ckd l.jpg
Complications CKD Symposium

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 l.jpg
Complications CKD Symposium

Hyperphosphatemia

- 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


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Complications CKD Symposium

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


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Dietitian Symposium

  • 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 l.jpg
Food Specifics Symposium

  • High in PO4

    - dairy products: milk, yogurt, cheese

    - Soft drinks: colas

    - Some fruit juices: punch

    - Nuts

    - Processed meats

    - Beans

    - All brand cereals


Food specifics31 l.jpg
Food Specifics Symposium

  • High in potassium

    - orange juice

    - tomato juice

    - bananas

    - spinach

    - squash

    - beans

    - potatoes


Treatment phosphate l.jpg
Treatment: Phosphate Symposium

  • 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 l.jpg
Treatment: Phosphate Symposium

  • 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 l.jpg
Treatment: PTH Symposium

  • 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 l.jpg
Treatment: PTH Symposium

  • 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 l.jpg
Treatment: Anemia Symposium

  • 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 l.jpg
Medication Challenges Symposium

  • 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 l.jpg
Custody Challenges Symposium

  • 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 l.jpg
Important Points Symposium

  • 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 l.jpg
References Symposium

  • 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.