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Plain language review of the kidney health of Indigenous peoples

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Preface

This Plain language review of kidney disease and urologic disorders among Indigenous people is based on the Review of kidney disease and urologic disorders among Indigenous people (2013) by Sasha Stumpers and Neil Thomson.

Introduction

Kidney disease is a significant health problem that can affect all Australians. Kidney disease shares many of the same risk factors as some other chronic diseases including:

and often occurs at the same time as these other chronic diseases.

People with chronic kidney disease (CKD) require extensive hospital services such as dialysis. Diseases of the kidneys and urinary system are in the top ten leading causes of death for all Australians [1].

This review provides an overview of the burden of kidney disease among Indigenous Australians and the factors contributing to the high rates of kidney disease.

Kidney diseases

‘Kidney disease’, ‘renal disease’ and ‘renal disorder’ are all terms that refer to diseases that involve damage to the kidneys [2]. The kidneys have a variety of functions including:

Chronic kidney disease

Chronic kidney disease (CKD) is defined as kidney damage or reduced kidney function that lasts for three months or more [2][3][4]. The most common causes of CKD are:

Other causes include:

The most severe form of CKD is known as end-stage kidney disease (ESKD). It occurs when kidney function has decreased to the point where kidney replacement therapy (KRT) is necessary to avoid death. KRT involves either dialysis or transplantation (see Box 1). CKD is expensive to treat and has a marked impact on the quality of life of those who suffer from the disease as well as those who care for them [3][4].

Box 1: Dialysis and transplantation [2]

Dialysis is the mechanical filtering of the blood to help maintain functions normally performed by the kidneys. There are two types of dialysis:

  • haemodialysis (HD): blood passes through tubes from the body to a dialysis machine where it is filtered (cleaned) before being returned to the body. Haemodialysis is usually performed at a hospital or medical centre
  • peritoneal dialysis (PD): the dialysis solution (a fluid containing a type of sugar that draws waste products and extra fluid out of the blood) is pumped into the patient’s abdomen. After a couple of hours the fluid is drained out, taking the wastes with it. Peritoneal dialysis can be performed by patients in their own homes.

Transplantation: a healthy kidney from either a living or recently deceased donor is implanted in a patient. The diseased kidneys are usually left in place. Living donors are often relatives of the patient.

What is known about the kidney health of Indigenous people?

Kidney disease is a significant health problem for all Australians, but severe kidney disease is more common among Indigenous people than among non-Indigenous people [5][6]. In particular, CKD [5][7][8][9][10] and ESKD are consistently reported at significantly higher levels among Indigenous people than among other Australians [3][8].

In 2004-2005, kidney disease:

Figure 1 Prevalence (%) of kidney disease, by Indigenous status and age, Australia 2004-2005

Prevalence of kidney disease, by Indigenous status and age, Australia 2004-2005

Source: Australian Bureau of Statistics (2006) [6]

What do we know about hospitalisation of Indigenous people for CKD?

Indigenous people are admitted to hospital much more frequently for CKD and ESKD than are non-Indigenous people [12]. In 2009-10, care involving dialysis was the most common reason for hospitalisation for kidney disease among the whole Australian population. Indigenous people were hospitalised 11 times more often than were non-Indigenous people [13].

The more detailed information available for 2007-08 show that hospitalisations of people for CKD:

What do we know about deaths of Indigenous people with CKD?

In 2004-2008, death rates from CKD were five times higher among Indigenous people than among non-Indigenous people [15]. Deaths from CKD among Indigenous people increased by 102% over the eight-year period 2001-2008, compared with a 23% increase for deaths from CKD among non-Indigenous people [9].

More detailed information for the four-year period January 2001 to December 2005 show that deaths from CKD among Indigenous people were:

Individuals with CKD often have other chronic diseases as well (comorbidities), particularly diabetes and cardiovascular disease (CVD). Chronic kidney disease may be recorded as an underlying or associated cause of death1, however it may not be recorded as a cause of death if it does not fit into the criteria for either of these categories - this can underestimate the contribution of CKD to the number of deaths for Indigenous people [3][16]. Between 2003 and 2007 the most frequent underlying causes of death where CKD was an associated cause of death were:

What is known about other kidney health conditions among Indigenous people?

Glomerulonephritis

Recent information on morbidity (illness) and mortality (deaths) associated with glomerulonephritis is not available, but it is known that the condition may occasionally cause acute kidney failure and that high blood pressure is the most frequent major complication [17].

Box 2: Glomerulonephritis

Glomerulonephritis occurs when there has been inflammation of the glomerulus (a network of tiny blood vessels in the kidney that help filter blood), and subsequent damage to the filtration process of the kidney [18][19]. Acute post-streptococcal glomerulonephritis (APSGN) is the most important contributor to high levels of CKD and continues to pose a major problem in developing countries and among Indigenous populations of the developed world [18][20].

The symptoms of APSGN are generally mild, with complete recovery within days or weeks [17][21][22][23]. The long-term outlook is regarded as excellent [22]. Despite this, APSGN has also been associated with significant morbidity (illness), hospitalisation and occasional mortality (death) [24][25].

Earlier research investigating the morbidity associated with APSGN in Far North Queensland reported that of 100 people identified with the condition (of which 96 were Indigenous):

Disorders of the urinary tract

Urinary tract infections (UTIs) are generally caused by bacteria, but fungi, parasites and some viruses may also cause infection [26]. UTIs are one of the most common reasons for people visiting a doctor about an infection [26]. Risk factors include:

Box 3: Disorders of the urinary tract

Disorders of the urinary tract include those of the bladder (the organ that collects urine), ureters (the tubes that carry urine from the kidney to the bladder) and the urethra (tube that connects the bladder to the outside of the body). The disorders generally present as mild cases, but they can cause severe illnesses, and may even lead to kidney damage and kidney disease [18][26].

In Australia, about one in three women and one in twenty men will have a UTI at some time in their life. Women tend to be more susceptible to UTIs for several reasons:

The health impact of diseases of the urinary tract upon Indigenous people has received very little attention in recent years, but information from the 1980s suggests that the pattern of UTI among Indigenous people tends to differ from that among non-Indigenous people [27]. A hospital-based study in Darwin found that:

Easily treated UTIs were often not detected, particularly in Indigenous children, which increased the individual’s risk of developing more serious kidney disease [29]. Poor living conditions and environmental settings are thought to contribute to the high levels of UTI observed in some Indigenous communities [18][29].

For pregnant Indigenous women, it has been shown that:

These studies suggest that the screening, treatment and follow-up of UTIs among Indigenous people was often inadequate [29][30][31][32]. The occurrence of acute pyelonephritis (a severe infection of the kidneys) in women during pregnancies (who showed no symptoms and were undiagnosed) highlights the importance of screening, particularly for women living in rural and remote Indigenous communities.

Urolithiasis (kidney stones)

Very little attention has been spent on urolithiasis among Indigenous people since the 1990s, but the presence of a pattern among Indigenous children that is different to that of non-Indigenous children has been confirmed recently [33].

Box 4: Urolithiasis

The formation of one or more small pebble-like objects (usually referred to as stones or calculi) in the kidney or urinary tract [34][35].

Evidence from 2003 [33] is consistent with the reports from the 1980s and 1990s that Indigenous children with urolithiasis:

This pattern contrasts with that reported among non-Indigenous people and other populations of the developed world, where the incidence is much higher among adults than children [33][36][37][38][40].

A review of patient records collected between 1972 and 1986 from the major children’s hospital in Western Australia (WA) reported that the number of Indigenous children presenting with urolithiasis was more than double that of non-Indigenous children [36].

The high rates of urolithiasis seen among some Indigenous children [33] have been attributed to:

What do we know about the factors contributing to CKD in Indigenous people?

Many factors contribute to the high levels of CKD among Indigenous people. These are complex and reflect a combination of broad historical, social, cultural, and economic factors including: colonisation and displacement by European settlers - this led to a reduction in activity levels and nutritional status of Indigenous people, which have carried through the generations and are often still occurring [19]

In many Indigenous communities, the prevention, control and management of kidney disorders will depend not only on effective, culturally appropriate treatment, but also on action to address the poor socioeconomic conditions that contribute to these disorders [44][45][46][47][46][48].

As well as the broad factors, the following behavioural (those based on an individual’s behaviour) and biomedical (those based on genetics and lifestyle) risk factors, individually or in combination, can contribute to kidney disease among Indigenous people:

Efforts (by health care providers as well as patients) to reduce these risk factors can help to reduce the level of kidney disease and its impacts.

What do we know about the care received by Indigenous people with CKD?

Kidney disease is expensive to treat and has a huge impact on the quality of life of those who suffer from the disease and of those who care for them [4][11]. Medical intervention is necessary to prevent deaths among individuals with CKD and ESKD.

Box 5: Treatment for CKD

Treatment for CKD (before it progresses to ESKD) is only able to delay progression of the disease – it cannot be cured. If CKD progresses to ESKD, KRT becomes necessary [2]. KRT cannot cure failing kidneys, but dialysis, which filters the blood using a machine, helps maintain the functions normally performed by the kidneys [2][3][5]. Most dialysis occurs in hospitals or special clinics, but can be conducted from home and by the patient themselves [3][54].

Dialysis

The following statistics show that Indigenous people suffer a greater burden from CKD than non-Indigenous people:

When dialysis facilities are not available near to where the Indigenous patient lives, they are forced to move to regional centres or major cities to undertake dialysis. The lack of treatment available in remote areas and the limited availability of transplant facilities create geographical barriers to treatment. From 1999-2001 relocation was necessary for:

There are significant biological, psychological, social and economic consequences to the forced relocation of Indigenous patients for KRT [55][56], including:

In an attempt to avoid relocation, efforts have been made to deliver self-care peritoneal dialysis and haemodialysis (HD) services close to, or in, the home [58]. This means that Indigenous people remain in their own communities, with their own family and social supports, and the costs of re-housing and supporting relocated dialysis patients are avoided. However, challenges facing home HD in remote communities include:

HD is the most common form of dialysis treatment for Indigenous people with ESKD [8][11][48][60][61]:

Miscommunication between Indigenous patients and health care workers can occur because of differences in cultural and social beliefs on health, and in the understanding of the patient’s situation and ongoing treatment [19][63][64]. Appropriate information and the understanding of the patient and their family are key for the patient – and their family and community – to make the important decisions about treatment choice [57][63][65].

Transplantation

Transplantation is the ideal form of treatment for most ESKD patients, but there is a noticeable difference in transplantation rates between Indigenous people and non-Indigenous people for this treatment [54]. At the end of 2008:

In the four-year period 2006-2009:

There are many reasons why Indigenous ESKD patients do not receive the same level of opportunity for transplants as non-Indigenous ESKD patients [54]. Indigenous ESKD patients:

What are the main problems faced by Indigenous people living with CKD?

There has been much research in recent years into the causes, consequences and management of ESKD in the Indigenous population [10][47][48][51][52][63][67][68][69][70][71][72].

The following measures will also go a long way towards reducing the incidence of kidney disease, and improving the outcomes of those with kidney disease:

Reduction in the inequalities in treatment will require changes within the healthcare system and by healthcare providers [63][73][76][77] such as:

The advantage of wide-ranging action is that it will reduce not just kidney disease, but also other chronic and communicable conditions [73][75][78].

Key developments

In 2006 the Australian Government released the National Chronic Disease Strategy (NCDS) [79]. The NCDS includes kidney health but is not specific to kidney health, taking an overarching approach to chronic diseases as these conditions often occur at the same time and share many of the same risk factors.

In the same year, Kidney Health Australia released the National Chronic Kidney Disease Strategy (NCKDS) [16]. These two policies are complementary in their recommended action areas:

As a response to these policies, the National Centre for Monitoring Chronic Kidney Disease was established at the Australian Institute of Health and Welfare (AIHW) in 2007 [80].

In 2010 the National Consumer Council of Kidney Health Australia released a position statement calling for the Australian Government to take action on the lack of services for CKD [81]. The main components of the position statement include:

The Renal Division of the George Institute for Global Health, based in Sydney, has been conducting studies aimed at improving kidney health:

The Australian Government has funded specific initiatives to reduce the incidence and spread of kidney diseases including:

Summary

Disorders of the kidneys and urologic system are a major and frequently serious threat for many Indigenous people [3][10][85]. ESKD, which accounts for much of the sickness and death from kidney disease seen in Indigenous communities, is a clear priority for the health system. Continuing high rates of ESKD, the negative social consequences that accompany treatment, and the high cost of medical care are all factors that highlight the need for a health care approach that addresses not only the medical but also the social and economic factors underlying this major problem [63][73][77].

Poverty, poor living conditions, limited access to medical care, and inadequate environmental sanitation contribute to high rates of kidney health disorders in many Indigenous communities [3][43][42]. The prevention, management and control of renal-urologic disorders will depend not only on effective, acceptable medical and surgical treatment, but, importantly, on preventive action to address the poor socioeconomic circumstances that underlie these conditions. Forward planning must take into consideration service needs, service availability, and workforce projections [8][86]. A comprehensive approach that addresses both the medical and socioeconomic features of these health conditions is an immediate priority.

Endnotes

  1. The underlying cause of death is the disease or condition that triggered the death. An associated cause of death can be what caused the underlying cause, or it can be something that contributed to the death but was unrelated to the disease or condition that caused the death.
  2. When a patient leaves hospital it is called a separation. Hospital separations can be because of discharge (going back home or into the community), transfer to another health facility or death.

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