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Daniel M. Goldstein, MPAS, PA-C LCDR, USPHS

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Presentation on theme: "Daniel M. Goldstein, MPAS, PA-C LCDR, USPHS"— Presentation transcript:

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.

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