CKD in Australia Flashcards
Describe the distribution of CKD in Australia
Mortality and morbidity from CKD is associated with increasing age and is unevenly distributed across Australian population
- highest burden over 65
- uneven distribution: Indigenous status, remote and very remote areas, social disadvantage
- data from Indigenous patients:
- fewer dying, but incidence not really changing
- treatment approach greater prevention programs
Describe how life-course epidemiology unpacks development of disease
- chronic damage over time leads to CKD/ESRF
- effect is cumulative with multiple comorbidities
- CKD adn ESRF are result of additive of processes of acute and chronic insults
- acute insults contribute to cumulative damge over time, contributng to CKD and ESRF development
- chronic disease in background decreases threshold for acute injury, increasing progression
Describe how staging of disease can prevent progression
CKD is diagnosed between eGFR and ACR.
- intervening at first signs of albuminuria is critical to reducing progression to ESRF
- non-notifiable disease burden will be under-reported as only severe cases are counted
- despite this, majority of disease burden comes from non-notifiable disease
Describe deficit discourse
- disempowering patterns of thought, language and practice
- represents people in terms of deficiencies and failures
- places responsibility for problems with affected individuals or communities, overlooking the larger socio-economic structures in which they are embedded
- rejecting deficient discourse does not ignore challenges or downplays it but highlights it, ways to alleviate it
- consequence: identity becomes defined in negative terms
Describe how social determinants impact CKD burden
Social and not biological differences are the primary cause of uneven burden of CKD
Multiple different explanatory pathways have been proposed
- primary renal disease explanations: higher incidence and greater severity — reflect processes that cannot be explained by epigenetic and/or SDH
- genetic differences – evidence varies
- early development explanations: attributed to adverse intrauterine environment affecting kidney development and predisposing to ESRD– supported by evidence
- socio-economic disadvantage increases ESRD incidence: supported by evidence
CKD and ESRF are the result of an additive process of acute and chronic insults to the kidney
*Health and disease follow a social gradient, where lower socioeconomic status is associated worse health outcomes
*SDH are critical to the creation and maintenance of health inequities - unfair and avoidable differences in health status
*SDH can be more important than individual behavior or health care in influencing health outcomes
*SDH are often represented in a way that makes sense to social and public health researchers, but can be hard to apply in a clinical setting
Acute and chronic insults can be made more prevalent by issues of human security: food, water, housing, environment and health.
These are turn impacted by issues of transport, service availability and quality, continuity of care, accessibility, culturally appropriate and safe care, quality, affordability etc
Notably, education and income are important factors influencing the inequitable distribution of CKD in Indigenous Australian populations.
Broader issues of education access/quality, social/community context, exonomic stabiity, health access and workforce , neighbourhood and built environemnt - all ultimately influenced by inequality
Burden of CKD is
a product of significant social and environmental security challenges, exacerbated by remote geography.
actors affecting water security
Water security is one of five determinants of human security, a social determinant of health.
- contamination by microbes
- calcificaiton of pipes
- buying water
Factors affecting housing security
Another determinant of human security.
- energy insecure due to pre-payment
- no building permits or qualifications required
- required maintenance but no tradies
- few facilities e.g. washing machines
- overcrowding
Food security
- prevalence higher in remote Indigenous communities comapred to asustralian population (31%, and likely underestimate)
- choosing between food and energy
- cost in healthy food 52% higher
Note: not just a remote issue
- Alice Springs, flooded highway
#### Geography
- similar size to sizable NSW towns e.g. Bathurst, Queanbeyan
- fewer supermarkets
- 5-7 hours or longer for nearby, if local is out
Describe issues of service delivery for CKD patientes in resourece limtied settings
Services for CKD and ESRF require a complex network of nurses, doctors, community workers, and physical infrastructure
Renal care in Central Australia
*The Alice Springs Renal unit is the largest single dialysis complex in the Southern Hemisphere
*Over 400 dialysis patients and nearly 1000 patients with CKD (2020)
*Covers area of 872,861 Km2
*17 remote communities, 15 language groups
*Services by the Alice Springs “Renal Mob:
*Inpatient, community and home dialysis hubs
*Peritoneal dialysis
*Renal transplantation services
*Interventional nephrology
*Chronic kidney disease clinics
*Transportation
HD units
Four HD units in Alice Springs
*Kidney Dialysis Unit at Alice Springs Hospital: Inpatient and acute HD, unstable patients
Three community units:
Note: Purple House/Western Desert Dialysis: renal patients who find it hard to engage with Western models of care
Nurse-led units outside Alice Springs
- Tennant Creek: Largest satellite unit outside of Alice Springs
- Smaller remote units
Note:
Many of our patients live remotely prior to starting dialysis, which can make CKD follow up difficult.
many patients may not have reliable electricity, food or medication security or working fridges when prescribing outpatient management.
HOME DIALYSIS HUBS
We have home dialysis hubs where patient can do dialysis in a unit in their own community:
- requires the patient to undergo home dialysis training with a buddy
PERITONEAL DIALYSIS
PD is a major issues:
- lack of suitable resources in many remote communities to do dialysis in their own home
- high infection rate.
RENAL TRANSPLANTATION
Renal transplantation also has its complications:
- high burden of comorbidities
- lack of available living donors
- difficulties in complex follow up in the remote communities.
It is a unit priority to try to work up and list and suitable patients for a transplant.
INTERVENTIONAL NEPHROLOGY
Alice Springs Renal Unit is one of the few interventional nephrology units in Australia.
For many of our patients English is the second, third or fourth language and ALOs can be very helpful in providing interpretation services here.
Providing care in remote settings require flexibility, adaptability and commitment
Discuss health system/structural issues assocaited with inadequate or delayed care
Easy to fall into fixed biomedical lens, can limit understanding of our engagement with health care services
Haemodialysis is very difficult, to put it mildly.
Adherence can be broken down into:
- social and economic: work, income, transport
- health care system: access, follow-up
- condition-related: CKD, uremia, calciphylaxis
- therapy-related: regimen, effects and pill burden
- patient-related: priorities, commitments, preferences
Note: patients off-country
### Art: unify biomedical and patient priorities
Community led interventions can be very helpful in addressing SDH
- Purple house
- visiting patients on country
- Indigenous run and owned
Strategies for prevention and provision of adequate care include:
Strategies for kidney disease prevention and providing adequate care
- target levels of prevention
Notice the difference between levels of prevention and healthcare
Public health can tackle primordial prevention.
Orimary healthcare can tackle primary prevention
Recommendations
Recommendations developed in consultation with First Nations communities across metropolitan, regional and remote areas of Australia.
**Includes 15 recommendations under 4 areas:
*Cultural safe and responsive kidney health care
*Screening and referral of chronic kidney disease
*Public awareness, education and self-management
*Models of care (CKD, ESRF, transplant)
Under each recommendation, report includes:
*Description/background
*Community voice
*Clinical evidence (incl. certainty of evidence)
*Cultural safety considerations
*Cost, capacity, equity, and resource implications
