EPIDEMIOLOGY

1. EPIDEMIOLOGY Epidemiology of chronic kidney injury, including prevalence and prognosis in various community groups. Screening of populations for kidney disease (as opposed to patient-centred care and screening) Knowledge of the issues/steps required to develop a screening or intervention program for renal disease in a particular population/population sub-group, and to follow-up and manage those who screen negative and those who screen positive.

2. 1.7 Million Australians have chronic kidney disease • >4.5 million Australians at risk (diabetes, hypertension) • Approx. 1 in 9 people over 25, who present to the GP, have CKD (have at least one clinical sign) … some don’t know it • 11.3% of all deaths in Australia are due to, or associated with, kidney failure • Every day about 6 Australians commence expensive dialysis or transplantation to stay alive • Indigenous Australians are overrepresented

3. Key Points- Indigenous • Kidney diseases, both acute and chronic are more common in Maori, Pacific Islander, Australian Aboriginal and Torres Strait Islander people. • The reasons are multiple and include genetic, environmental and socio-economic factors. • In childhood post streptococcal glomerulonephritis, haemolytic uraemic syndrome, renal stones and acute kidney injury all occur at higher frequency in at least some of the Indigenous populations.  (Diseases such as post streptococcal glomerulonephritis now occur almost exclusively in the Indigenous children of Australia) • Chronic kidney disease CKD occurs more commonly, and at a younger age in Indigenous than non Indigenous people. • Factors involved may include reduced nephron endowment at birth (?due to low birth weights), and subsequent insults including nephritis, obesity, and early onset type 2 diabetes, as well as underlying socioeconomic and environmental determinants. • Prognosis: End stage kidney disease is much more common in Indigenous than non Indigenous adults • Aboriginal people are less likely to be treated by peritoneal dialysis or transplantation, and transplant and patient survival is poorer than other Australians. • The higher incidence of ESKD is accounted for largely by diabetic (type II) nephropathy, glomerulonephritis and hypertensive renal disease. 

5. Social determinants Several pathways that could link disadvantage to renal disease have been suggested, including the following: • overcrowding leading to scabies, streptococcal skin infection PSGN and renal damage • stress-related to low income, unemployment and lack of control over one's life initiating or progressing renal disease • damaging health behaviours such as smoking and sedentary behaviour that occur at higher rates in socio-economically disadvantaged people leading to increased rates of diabetes and renal damage • health-care service differences leading to Indigenous people being less likely to receive optimal primary or secondary prevention of renal disease

6. Intervention • Remember there are 3 ‘Levels’ of Prevention – Interventions can be implemented at any/all levels. • Primary prevention measures aim to eliminate or reduce exposure to factors which cause ill health or disease. • For CKD this involves strategies to reduce the incidence and prevalence of risk factors such as diabetes and high blood pressure, in order to reduce the number of people at risk of developing CKD. • Secondary prevention consists of measures for early detection of disease to allow prompt and effective intervention to prevent the disease becoming established. • Early detection and effective intervention in the early stages of kidney damage are essential to prevent or delay the development of CKD. • Tertiary prevention strategies are focused on management of established disease to prevent progression and reduce or delay long-term complications, impairment or disability. • Management of CKD aims to prevent or delay further kidney damage and loss of kidney function, and hence reduce the incidence and prevalence of ESKD and other complications. In those who do develop ESKD, good management during kidney replacement therapy not only reduces suffering and death, but also improves quality of life.

7. Interventions for renal disease in Indigenous people

8. WHO criteria for screening The condition sought should be an important health problem for the individual and community. There should be an accepted treatment or useful intervention for patients with the disease. The natural history of the disease should be adequately understood. There should be a latent or early symptomatic stage.There should be a suitable and acceptable screening test or examination.Facilities for diagnosis and treatment should be available. There should be an agreed policy on whom to treat as patients. Treatment started at an early stage should be of more benefit than treatment started later. The cost should be economically balanced in relation to possible expenditure on medical care as a whole. Case finding should be a continuing process and not a once and for all project. • Screening should not occur as an activity on its own; it should only be implemented as part of a process of early intervention. However, too often inadequate thought is given to ensuring that the resources are available to follow-up and manage the problems identified in the screening. • There is currently no nationally coordinated, standardised screening program in Australia for renal disease and information on early detection among high-risk groups is limited. There is however national recommended

9. Screening Kidney Check Screen • BP • eGFR • Urine A:C ratio May be Appropriate to started screening of Indigenous during adolescents

10. References • Johnson.D. 2011. CKD- Lecture Notes and handouts • White A, Wong W, Sureshkumur P, Singh G. The burden of kidney disease in indigenous children of Australia and New Zealand, epidemiology, antecedent factors and progression to chronic kidney disease. J Paediatr Child Health. 2010 Sep;46(9):504-9 • Kidney Health Australia. FAST FACTS ON CKD IN AUSTRALIA. Accessed: http://www.kidney.org.au