Kidney Disease in Aboriginal Australians - Case Study Example

Kidney disease in Aboriginal Australians Kidney disease in Aboriginal Australians [The name of the writer appears here] [The name of institution appears here] Introduction Australian Aborigines are a disadvantaged and marginalized people struggling to survive in a crisis of social and cultural transition. Most Aborigines in the Northern Territory live in remote areas, in serious poverty and disadvantage, with inadequate services of all sorts. Health services are uneven: excellent care for acute and advanced illnesses and for catastrophes is rendered in centralized hospitals, but at the community level, environmental health, health education and primary care are poorly resourced, and ‘lifestyle’ or non-communicable adult diseases have been relatively neglected. Mortality rates reflect this sociological disaster. Standardized mortality rates in Aboriginal adults actually rose between 1981 and 1992, to a level more than five times that of non-Aboriginal Australians. Premature death in young and middle-age adults is contributing to family, community and cultural breakdown. Most major conditions are represented in this excess mortality, including intoxications, trauma, cardiovascular disease, diabetes, lung disease and infections, (Cunningham et al, 1996) as well as renal disease and renal failure. Deaths from renal disease have increased 18- to 30-fold, and the incidence of treated end-stage renal disease (ESRD) is approaching 1000 per million, and, until recently, has been doubling every 3–4 years. (Hoy, 1996) The number of indigenous people treated with renal replacement therapy (RRT) for end-stage renal disease (ESRD) in Australia has risen dramatically over the past 20 years. This is now a major health problem not only for the individuals affected but also the local communities and health service providers. The rise in numbers of people receiving treatment for ESRD in the early and mid-1980s is probably due, in part, to increased ascertainment and referral, but later increases have been real. Currently, 96% of persons on dialysis are Aboriginal, although Aborigines constitute only 28% of the population. The costs of ESRD treatment have attracted especial concern, with the annual maintenance of a person on haemodialysis (the main form of treatment) plus their intercurrent hospitalizations estimated at more than $100 000 in 1996–8. (Hoy et al, 1999) Quality of life on ESRD treatment is poor, and survival is often short. (Spencer, 1998) History and Prevalence of kidney disease in Aboriginal Australians Indigenous Australians, overall, have eight times the rate of treated end-stage kidney disease compared with non-indigenous Australians. (McDonald et al, 2003) A steep gradient from urban areas leads to some remote regions with a 25 times higher incidence. (McDonald et al, 2003) The crude national incidence rate of treated end-stage kidney disease of 94 per million per year in 2002 (Cass, 2003) compares with rates higher than 1,000 per million per year in certain remote regions. Indigenous Australians with treated end-stage kidney disease are known to have earlier onset of disease, a multiplicity of barriers to receiving equitable treatment and a worse prognosis than the general population. Compared with the general population, Indigenous Australians are more likely to live in rural and remote regions; however, renal specialist services and dialysis facilities tend to be situated in larger centres. Despite a recent increase in renal services and facilities in rural and remote areas, there remains a substantial discrepancy between areas of high need and renal replacement therapy service provision. In 1998, a study of Indigenous Australians starting dialysis in remote northern Australia between 1978 and 1996 reported treated end-stage kidney disease incidence to be doubling every four years. (Spencer, 1998) If this pattern were to continue, the social, economic and cultural consequences for patients and their families, health services, and governments would be devastating. According to a study conducted the rates of treated end-stage kidney disease in Indigenous patients are high and rising, particularly in remote areas, and demonstrates the high proportion of these patients who must leave their homes and communities in order to access life-saving treatment. Analysis by smaller regions (ATSIC regions) accentuates the extremely high rates in the most remote regions. (Preston, 2007) The significant implications for planning for the provision of appropriate renal services have been recognized by the Australian Health Ministers’ Conference through the publication of National Service Guidelines for the management of dialysis and transplantation in remote Australia in July 2006. (Australian Health Ministers, 2006) This study also conclude that the rate of increase in treated end-stage kidney disease incidence might be slowing, consistent with a slowing in mortality rate rises that has been demonstrated for some chronic diseases among Indigenous Australians. (Thomas, 2006) However, in the Australian Indigenous population, not enough is known about the extent of early chronic kidney disease – the common clinical pathway that can lead to premature cardiovascular mortality or end-stage kidney disease. The AUSDIAB study found that approximately one-in-seven Australian adults have markers chronic kidney disease. (Chadban, 2003) Cultural impact Health and community services exert a powerful influence on the expression of renal (and other chronic) diseases, by influencing risk factors, natural history and survival. Risk is reduced by environmental improvements, better infant and childhood nutrition, anti-scabies programmes and containment of epidemics of post-streptococcal glomerulonephritis, while a vaccine against nephritogenic streptococci is eagerly awaited. Paradoxically, however, improved services can facilitate disease expression. Dramatic reductions in infant mortality since the 1960s, due to better hospital management of sick babies, have resulted in large cohorts of low-birthweight infants now surviving to adult life (Hoy, 1998) who are at high risk of renal and other chronic diseases. This phenomenon will abate if birthweights continue to improve. In addition, better management of infections, diabetes, cardiovascular morbidity (angioplasties, bypass procedures, etc.) in high-risk patients, and progressive effacement of the 20+ year mean survival differential between Aborigines and non-Aboriginal Australians through general improvements in health will lend more opportunity for nephropathy to run its fairly slow course to renal failure. These considerations underpin arguments to systematically detect and modify disease progression in people already afflicted, the ultimate deliberate environmental influence. To this end, we introduced a treatment programme into the study community in late 1995, using the long-acting angiotensin-converting enzyme (ACE) inhibitor perindopril (Coversyl, Servier, Australia) as the primary agent. 21–25 Eligibility criteria were hypertension (systolic blood pressure ≥ 140 or diastolic blood pressure ≥ 90 mmHg), diabetes with ACR 3.4+ (microalbuminuria threshhold) regardless of blood pressure and overt albuminuria (ACR 34+) that was progressing regardless of blood pressure and diabetes status. The high rates of relocation to access renal replacement therapy, particularly in remote regions, represent a heavy toll for their communities. Remote Indigenous people are most affected, with 78% having to relocate, compared with 39% of those who live in rural areas and 15% of urban Indigenous end-stage kidney disease patients. (Preston, 2007) Until the mid 1990s, high rates of withdrawal from dialysis by Indigenous patients in the north of the NT indicated poor acceptance of treatment. Relocation affects patients’ quality of life and their ability and willingness to maintain treatment regimens, and often results in financial difficulties and extreme social and cultural isolation. The issue has motivated Indigenous groups to consider trading a land claim for dialysis machines and to auction local art to fund a dialysis program in their community. These examples support the contention that many Indigenous Australians developing end-stage kidney disease might have chosen (and perhaps still choose) not to opt for dialysis treatment. (Cass, 2004) The heavy burden of end-stage kidney disease, especially in remote areas, presents complex public health challenges. Given that people with chronic kidney disease have high rates of mortality from non-renal causes, and that it is only a small proportion of them who survives to develop end-stage kidney disease, this is also a reminder of the burden of non-renal disease in these communities. Long-term strategies must be developed to address the socio-economic, cultural, health system and medical factors that contribute to high rates of chronic kidney disease and associated chronic diseases among Indigenous Australians. Nevertheless, Indigenous communities demand access to treatment services for kidney disease. Conclusion Renal disease in this population is multi-determinant, with the excess of disease associated with a high density and multiplicity of nephropathic factors operating in a high-risk environment. Renal disease is intimately related to the general health profile and other chronic ‘disease’ states, and tightly correlated with overall mortality. Risk factors derive from, or are exacerbated by, rapid transition, poverty and disadvantage, and the deficiencies and successes of health services. Environmental factors have undoubtedly also influenced genotypes over time. Prevention depends on sustained improvements in socio-economic circumstances, infrastructure and health services. Concerns over ESRD treatment costs might yet prompt such changes. For persons already afflicted, disease is easily diagnosed and progression is dramatically altered by interventions within our reach. Control of blood pressure, adult weight and infections are especially important. Pharmacological intervention will postpone ESRD and reduce premature death in early and middle adult life, and might postpone renal failure beyond reasonable life expectancies in many people. Meanwhile, we must advocate for intersectoral initiatives to improve the environmental and socio-economic circumstances of high-risk populations. In our academic domains, we should foster interspecialty collaboration with the aim of developing a coherent unified approach to these health issues. We must redirect significant intellectual and material resources from expensive high-technology, diagnostic and interventional tracks in metropolitan hospitals towards issues of prevention and disease modification. Sociological, public health and community perspectives should be incorporated into specialist training, and mentorship and granting arrangements fostered in these disciplines. We should develop community-based health protocols, with defined goals, and accountability for outcomes. Improved health, greater longevity and reduced health care costs can probably be achieved over a shorter term than ever imagined. Read More