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

1. 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)-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

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: 23 60s: 15 - 40s: 20 70s: 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+: 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%

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 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

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. 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.