1. Daniel M. Goldstein, MPAS, PA-C LCDR, USPHS
2010 U.S. Public Health Service Scientific and Training Symposium San Diego, CA
Daniel M. Goldstein, MPAS, PA-C
LCDR, USPHS

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

3. 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

4. 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

6. Objectives 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

7. 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

9. 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

10. 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

11. 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) x (age) x (0.742 if female) x (1.210 if African American)
Labs calculate the GFR, report number if below 60

12. 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

13. 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

14. Other Causes CKD Hepatorenal disease- secondary to cirrhosis
HCV- membranous nephropathy
HIV
Vascular- Wegener’s granulomatosis

15. 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

16. 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

17. 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

18. Complications with Fistula
Aneurysm- arterial bleed, emergency
Clotted
Infected
Steel syndrome
Recirculation
Low access flow
- should be able to hear bruit, palpate thrill

19. 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: s: 15
- 40s: s: 1
52/82 African American

20. How to Prevent Dialysis
Early referral to nephrologist: when GFR < 60
Good management of risk factors:
- DM
- HTN
Education about NSAIDs

21. Nephrologist
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

22. 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

23. 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

24. Lab Details Hgb: above 10, goal 11-12
- if too high access site may clot, also risk MI/CVA
Ca+: (correct for low albumin)
PO4: < 5.5
Ca+ x PO4= < 55
PTH: (CKD4: < 110)
K: < 5.5
ALB: > 3.8
Iron saturation: 25-50%

25. Complications from CKD
Anemia
Hyperphosphatemia
Secondary Hyperparathyroidism

26. 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

27. 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 kidney
Causes of elevated PO4:
- inadequate binders
- missed dialysis sessions
- diet high in phosphorus

28. Complications CKD Secondary Hyperparathyroidism (SHPT)
- low vit D and low Ca+ and high PO high PTH
- high PTH SHPT bone disease
Renal osteodystrophy: rapid bone formation and resorption- not mineralized well
Hyperplasia of parathyroid glands
- 31/2 parathyroidectomy

29. Dietitian 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

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

31. Food Specifics High in potassium - orange juice - tomato juice
- bananas
- spinach
- squash
- beans
- potatoes

32. 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

33. 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

34. 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

35. 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

36. 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%

37. 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)

38. 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)

39. 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

40. 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
Martini FH, Timmons MJ. Human Anatomy. 2nd edition. Prentice Hall
Galley R. Improving Outcomes in Renal Disease. JAAPA. 2006;19(9):20-25.