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DANIEL M. GOLDSTEIN, MPAS, PA-C LCDR, USPHS 2010 U.S. Public Health Service Scientific and Training...
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Transcript of DANIEL M. GOLDSTEIN, MPAS, PA-C LCDR, USPHS 2010 U.S. Public Health Service Scientific and Training...
DANIEL M. GOLDSTEIN, MPAS, PA-CLCDR, USPHS
2010 U.S. Public Health Service Scientific and Training
Symposium San Diego, CA
Title
Medical Management and Prevention of Chronic
Kidney Disease at a Federal Medical Center in the
Federal Bureau of Prisons (BOP)
BOP Overview
Institutions: 119Federal inmates: approx 210,000Staff: approx 37,000Security levels: min, low, med, high, adminInstitution types: FPC, FCI, USP, FCC, Admin
- Admin: FMC- FMC: 6 total: Butner, Carswell, Devens, Lexington, Rochester, Springfield
FMC Devens
Population: approx 1100Location: Ayer, MA, 40 miles northwest of
BostonSpecialized focus: mental health and dialysisMedical Referral Center (MRC): inmates with
complex medical problemsAffiliated with UMASS Medical Center
Objectives
Stages of CKDCauses of CKDPrevention of CKDComplications seen with CKDTypes of dialysis- HD and PDMulti-team approachLab resultsMedication treatmentUnique 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 AmericansNot 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 used to calculate GFR
Serum Creatinine (Cr): affected by muscle mass, which could give inaccurate picture of renal function
Normal serum Cr is approx 1.0Once serum Cr is 2.0: 50% renal function lossSerum Cr is 3.0: 75% renal function loss
Causes of CKD
Major causes: HTN and DMMedications: NSAIDs (e.g. ibuprofen, Advil,
Motrin)
Polycystic Kidney DiseaseGlomerular Disease
- glomerulonephritis- minimal change disease- lupus nephropathy- Goodpasture’s syndrome
Other Causes CKD
Hepatorenal disease- secondary to cirrhosisHCV- membranous nephropathyHIVVascular- Wegener’s granulomatosis
When is Dialysis Needed?
CKD stage V: GFR < 15Uremia: 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, emergencyClottedInfectedSteel syndromeRecirculationLow access flow
- should be able to hear bruit, palpate thrill
Devens Inmates
82 hemodialysis inmatesAverage current age: 48 yrs oldYoungest: 24 yrs oldOldest: 74 yrs oldBreakdown 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 inmates, also sees pre-dialysis per referral
Every Wednesday- entire day at DevensOrder labs before inmate seen by
nephrologist: CMP, CBC, Ca+, PO4, Mg, intact PTH, vitamin D, urine protein studies, iron panel
Renal ultrasoundSometimes 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- if too high access site may clot, also risk MI/CVA
Ca+: 8.5-10 (correct for low albumin)PO4: < 5.5Ca+ x PO4= < 55PTH: 150-300 (CKD4: < 110)K: < 5.5ALB: > 3.8Iron saturation: 25-50%
Complications from CKD
AnemiaHyperphosphatemiaSecondary 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 kidneyCauses 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 recommendationsDiabetic diet: glycemic indexDietary 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 insulinSide 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.