Transcript Medical Management and Prevention of Chronic Kidney Disease at

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
 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
 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
 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
 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 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
 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
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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
HTN and DM
 Medications: NSAIDs (e.g. ibuprofen, Advil, Motrin)
 Major causes:
 Polycystic Kidney Disease
 Glomerular Disease
- glomerulonephritis
- minimal change disease
- lupus nephropathy
- Goodpasture’s syndrome
Other Causes CKD
 Hepatorenal disease- secondary to cirrhosis
 HCV- membranous nephropathy
 HIV
 Vascular- Wegener’s granulomatosis
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?
 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, emergency
 Clotted
 Infected
 Steel syndrome
 Recirculation
 Low access flow
- should be able to hear bruit, palpate thrill
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
 Early referral to nephrologist: when GFR < 60
 Good management of risk factors:
- DM
- HTN
 Education about NSAIDs
Nephrologist
 Management of all dialysis, kidney transplant
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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
- 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
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- 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
 Anemia
 Hyperphosphatemia
 Secondary 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 kidney
 Causes 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 recommendations
 Diabetic diet: glycemic index
 Dietary 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 insulin
 Side 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.