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Hello, I'm Norman Swan.
Welcome to this program on chronic kidney disease, a silent condition.
It's often preventable, and it's said to be silent
because up to 90% of kidney function can be lost before symptoms are evident.
With ageing and the diabetes epidemic,
more and more Australians are having either dialysis or transplantation
for end-stage kidney disease.
One in seven Australian adults over the age of 25
has some degree of kidney disease,
and chronic kidney disease constitutes nearly 10% of all deaths
and more than 1.1 million hospitalisations.
It's common amongst Indigenous Australians,
who are six times as likely as other Australians to be receiving dialysis
or to have had a kidney transplant.
Death rates from chronic kidney disease are between 7 and 11 times higher
in Indigenous men and women compared to non-Indigenous Australians.
This program will emphasise the need for a targeted approach
to prevention, detection and the management of people
with chronic kidney disease.
It also examines the need for early detection
and the delivery of chronic kidney disease care,
which is not necessarily straightforward,
with a specific focus on Indigenous and rural populations.
There are a number of useful resources available
on the Rural Health Foundation's website -
Now let's meet our panel.
David Harris is a nephrologist and professor of medicine
at the University of Sydney.
- Welcome, David. - Evening.
Tim Mathew is the medical director of Kidney Health Australia.
- Tim. - Evening, Norman.
Paul Snelling is a renal physician at Royal Prince Alfred Hospital in Sydney.
- Welcome, Paul. - Good evening, Norman.
Beres Joyner is a GP and a specialist in public health medicine,
and is based in Rockhampton in Queensland.
- Welcome, Beres. - Good evening.
Anne Blong is currently the chronic kidney disease nurse practitioner
for Townsville Health Service District.
- Welcome, Anne. - Thank you.
Are there many nurse practitioners around in Townsville?
About 11, I think.
11? That's more than I thought there were in the whole of Australia.
They're not all doing chronic kidney disease.
Last but not least is another nurse practitioner, Lesley Salem.
Lesley is a nurse practitioner for the Integrated Chronic Care
for Aboriginal People program at Hunter New England Health.
Lesley is a descendant of the Wonnarua Nation in New South Wales.
- Welcome, Lesley. - Thank you very much, Norman.
Lesley, tell me about the impact you see
of chronic kidney disease on Aboriginal communities.
It's a two-edged sword here in New South Wales.
I see the overall incidence and prevalence
across Australia as being very high.
In New South Wales, because of the vast distances,
we have large groups of missions, small towns,
that have no GP services or very limited GP services.
So I think we have poor recognition,
and we underestimate the impact in New South Wales
of kidney disease and the consequential cardiovascular disease
on Aboriginal people.
What personal and family impact, and community impact, do you see?
Personally, I have a father who never smoked or drank
and still had a heart attack at 49,
so I've always been quite passionate about the health of Aboriginal people.
But I've been working in nephrology for 26 years, and what I see
is a lot of Aboriginal people not coming to the major town centres
when they're referred for treatment of kidney disease.
I think there's a paucity of treatment going on in rural and remote areas.
Anne, do you agree?
Yes. I think that sometimes remote Aboriginal people don't attend hospitals
because they see it as some place that you go if you're going to die.
What are we talking about here, Tim?
What is chronic kidney disease? Is it one disease?
We talk about it as though it was one disease.
In truth, there are many different types of diseases
which cause damage to the kidney.
But it's a useful concept to consider - chronic kidney disease as an entity -
to find there's either a reduction in the efficiency of the kidney
or the presence of kidney damage, as evidenced by abnormalities in the urine.
And causes, David?
The most common cause in Australia and worldwide now is diabetes.
Number two is glomerulonephritis and number three hypertension.
NORMAN: Glomerulonephritis?
Yep, different varieties. IgA is the most common.
NORMAN: In Aboriginal communities, Paul, what's the commonest cause?
Increasingly, it's probably diabetes or a metabolic syndrome,
but that's a bit simplistic in some ways.
Our thinking is it's probably a whole-of-life disease in many ways,
from early-childhood damage right through to accumulating risk factors
as one ages.
I don't think it's as simple as saying one disease. It's a whole-of-life story.
And, of course, Beres,
what we miss with chronic kidney disease is the impact on the heart.
Most certainly.
I see chronic kidney disease as being a very important risk factor
for cardiovascular disease.
While I think chronic kidney disease is important as a singular concept,
I think it's most important that we actually consider it
as one of the vascular risk factors.
Do you think that's generally known, Anne?
No, I don't think it is.
I think that people think that if they've got kidney problems,
they probably have diabetes, and if they get that under control,
there's no other problems.
But I think even early chronic kidney disease
causes 10 to 20 times the cardiac risk factors.
Do we know why, Paul?
It's certainly through accelerated cardiovascular disease the risk comes.
And it's probably through both an association with kidney disease
being accelerated by vascular risk factors -
hypertension, diabetes, hyperglycerolemia -
but also with reduction in kidney function
there are probably other changes that affect blood vessels -
changes in inflammation, oxidant stress,
changes in the different lipid profiles.
- But it is an independent risk factor? - It's an independent risk factor, yeah.
How strong an independent risk factor, Tim?
It's probably about as strong as cholesterol.
It probably increases the risk by three to five times,
depending on how you assess it and look at it.
It is one of the necessary preclusions
to using the new absolute-risk tool assessment.
You must measure kidney function first,
because if you have a reduction or you have some important CKD,
you shoot to the top of the tree as a high-risk person.
So how much of it is around, David?
Well, chronic kidney disease is in fact a very common disease.
It's not recognised how common it is.
So one in seven Australians have some evidence of chronic kidney disease,
and up to one in three Australians are at risk
of having chronic kidney disease in the future.
That's a substantial proportion, and getting bigger.
The contribution of ageing and type 2 diabetes?
As I mentioned, type 2 diabetes is the commonest cause
in Australia and worldwide.
It's now over 30%, getting up to 40% of cases are due to type 2 diabetes.
Certainly, ageing does contribute a lot.
One of the difficulties in this area
is distinguishing ageing, the normal ageing,
from abnormal ageing of the kidney.
NORMAN: Tell me more.
Well, as you get older, your glomerular filtration rate declines with age,
and so it becomes difficult to know whether a reduction in GFR
in the older age group is just part of the normal ageing process
or whether that patient in fact has chronic kidney disease.
And what are the risk factors, Tim?
Because people talk about smoking.
Yes, there are seven risk factors which we would like everybody to be aware of,
and they feed into those who need to have kidney tests done,
so they're very important.
Smoking, obesity, family history of kidney disease,
anyone with diabetes, anyone with high blood pressure,
anyone who's over the age of 60
and anyone, of course, who's an Aboriginal or Torres Strait Islander.
So they are people who merit, what, screening?
They merit, according to all the guidelines
and the Red Book and every way you look at it,
a kidney health check, probably on an annual or biannual basis.
Beres, what do you understand by a kidney health check?
I'd actually wrap it up, again,
in a health check looking at cardiovascular risk factors.
But specifically looking at the kidneys,
we're looking at an eGFR and also looking at a urine test,
and, in a general practice setting,
if you can get a dipstick urine, looking for protein or blood.
We've just done a series of programs on diabetes,
and they raised the sign of the cross to the idea of doing dipsticks -
that this is unreliable, not a way of measuring kidney disease,
you may as well not bother.
I think there would be some differing opinions on that,
but I think that one of the challenges in general practice
is actually getting a urine test in the clinic
at the time at which you require it.
NORMAN: Anne, what's your view on that?
I think people find it very difficult to give you a urine sample on demand.
Paul, what's the evidence here?
There's not much point in doing a test if it's not going to be worth a lot.
If it's not going to change your management?
Certainly, for diabetes, the guideline is to quantitate albuminuria,
with albuminuria being the marker of damage in the glomerulus.
Proteinuria has a few other bits and pieces that slough off along the way,
so albuminuria is better.
For the general population that guideline is not there,
but it's useful and easy to do.
In fact, in America and other countries, as Tim might say,
albuminuria has been integrated into the cardiovascular risk algorithms as well
as a marker of vascular risk,
probably because the glomerulus is a blood vessel, it's a filter,
and damage in that reflects damage elsewhere.
I personally think a quantitative albumin or something along those lines
gives you at least a number that allows you to stratify risk.
And we know that if it's significant and you can regress that,
it actually will allow you to tell your patient there's a better outcome.
Lesley Salem, what's your practice in Aboriginal communities?
Even though the focus for me is identifying kidney disease,
I approach it as a cardiovascular risk assessment.
So, one, I'm looking at how many non-modifiable things they have wrong -
you know, age, Aboriginality, family history, gender, things like that.
And for Aboriginal people, of course, the age is lower.
And then I'd look at the modifiable things
that I can deal with in remote or rural areas -
smoking, dyslipidemia, hypertension, diabetes.
Abdominal obesity - very important.
Psychological factors that may inhibit them taking on management or treatment.
Nutrition, lack of daily vegetables or fruit.
Alcohol intake, physical activity, microalbuminuria, of course.
And then, if they're in later stages, I look at anaemia,
any sort of vascular calcification, looking at ECGs and that,
and any metabolic bone disorder or any inflammatory problems.
So they're the key things I'm looking at in assessing.
Either identifying initially or following through.
I think even though it's kidney disease,
I'm constantly looking at cardiovascular risk
and what can be modified.
And how easy, in the environment of an Aboriginal community, is that to do?
I mean, that's a long list of stuff.
A lot of that is point-of-care testing.
ICRs or HbA1cs on point-of-care testing, I just need a couple of drops of blood
and I can do lipid panels, haemoglobins and that.
I had to base the practice on point-of-care testing -
portable ECG equipment
that could be used under a tree with a laptop, things like that.
One of my clinics is actually under the trees.
Patients are reluctant to come in to the clinics because of deaths
and inappropriate smoking ceremonies.
So one of the clinics is under the trees,
and using some point-of-care testing equipment.
David, once your eGFR's dropped,
once you've got a creatinine that's detectably raised,
what, you've lost something like 40% of your kidney function?
Yeah, or even more.
So once you're outside the normal range, you've lost half, at least.
We're saying here we've got to do screening tests.
The screening tests come in, and the screening tests are crude.
There might be more sophisticated ones in years to come, but they're crude.
If they come up positive, almost half your kidney function's already gone.
What's the impact of intervening then?
Your blood pressure is up a little,
and you get in hard with blood pressure and lose a bit of weight.
Can you return your creatinine to normal?
You may not return it to normal, but at any stage of kidney impairment,
you can have an effect on the rate of progression of disease
with treatment, and you can reduce the cardiovascular risk.
Lesley is working in an Aboriginal community.
We're all working with people with busy lives.
They don't know they've got kidney disease,
and you want me to take major treatment.
Can you promise me an effect?
Beres, what do you tell your patients -
we're putting you on these drugs and you've got to stay on them for life.
What's the promise in terms of my kidneys?
What does the evidence say?
I suppose my first priority, again, is reducing cardiovascular risk,
because I think that's going to kill these people
before their kidneys, in many cases.
If you've got kidney disease, do you take the same approach as diabetes -
you go onto a statin regardless, you go onto an antihypertensive regardless.
It doesn't matter what your levels are -
we're going to hit you hard for your risk factors.
That's probably summing up fairly tightly.
Certainly, one has to work with the individual patient
and look at the whole picture, address the lifestyle risk factors
as well as pharmacological approaches.
And in some cases it really takes
a bit of stepping through, prioritising medications
and working with patients to help them understand the targets of therapy.
Paul, what's the evidence?
There's a number epidemiological cohort studies
that have shown the tight correlation between reductions in kidney function
or eGFR and increased cardiovascular risk.
NORMAN: No, but intervening.
Intervention studies both in diabetic and non-diabetic studies.
Usually the one that we've looked at
are looking at reductions in progression of in-stage disease.
It can show a halving of the rate of progression
with tight blood pressure control.
Predominantly it's the blood pressure control people that have looked at.
As with anything, people with greatest risk derive the greatest benefits.
So, those with the worst degree of blood pressure or proteinuria,
if you can get that under control, derive the greatest benefit.
There's strong evidence that you can slow rates of progression of disease.
It probably ties into cardiovascular events as well,
though most of the trials aren't powered to show that.
I've got a question here which is asking about low-protein diets.
If you're starting to register high,
you're coming up positive on your kidney screen,
straight onto a low-protein diet?
No. In Australia, the consensus is
that low-protein diets have no part to play in stopping progression of disease.
There are pockets of belief overseas where that is practised.
We certainly practise avoiding excessive protein intake,
but going to a low-protein diet, the answer is no.
Can I just take us back briefly to the urine testing?
I would like to get across the point
that conventional dipstick testing for urine protein is still OK,
and it's still the area where the best evidence exists
in terms of the importance of that in long-term outcome studies.
It's cheap and it's reasonably accurate.
I don't want people to feel they shouldn't do it.
But there's no question, as Paul was indicating,
that we're moving progressively towards albumin as a more accurate measure
and as one which can be done in the laboratory more easily.
So stand by to watch for the next 6 to 12 months.
New recommendations may well be coming out in that direction.
Another online question - 'How does one investigate someone
suspected of having chronic kidney disease?' David?
Well, do the initial screening test to prove it.
So, doing their eGFR and then looking at their urine, as we've just said.
And then the investigations that you do depend on the stage of kidney disease.
So if it's very early, you may not do too much more than that.
NORMAN: As defined by?
By the level of GFR.
So once your GFR falls below 60,
so you're into stage-3 chronic kidney disease,
that's when you start to look at other things, such as haemoglobin,
to see if the patient is anaemic,
start to look at calcium and phosphate to see if there's any imbalances there.
David, you'd also agree that at any stage of GFR reduction,
if there is proteinuria or albuminuria present,
that adds greatly to the risk of progression?
Yes, you're quite right.
So the GFR and the proteinuria are independent risk factors.
The new staging is going to take account of proteinuria at every stage.
And what's the place - our online viewer asks - of renal biopsy?
- When do you start doing that, Paul? - Oh, it depends...
This goes to when the GP would actually refer on.
It probably depends what school you went to.
People are changing. We do a lot less biopsies now than we used to.
Most people would biopsy if there's definite nephrotic syndrome...
NORMAN: You've got oedema, proteinuria.
Proteinuria of greater than 3g a day, low albumin, swelling, all the rest.
Those diseases may benefit from specific treatment.
If you've got significant proteinuria, which we define as over a gram a day,
and ACR roughly of about 100, protein-creatinine ratio of about 100,
people may biopsy there, looking to see if they can treat with other agents
than our standard therapy, which is aggressive blood pressure lowering.
There's a debate about that, and we can discuss that,
but that's really for nephrologists.
For the majority of patients, we wouldn't think of biopsy
without rapidly progressive loss of kidney function
with haematuria or significant proteinuria.
Let's go to our first case study.
Lily is a non-Indigenous 40-year-old
woman on her first visit to you, Beres.
She has three children,
and tells you in her first pregnancy
she had swollen ankles
and high blood pressure.
You measure her blood pressure
and it's 160/90.
She says, 'That's what other doctors
got for me recently.'
She says she doesn't smoke
and has one or two drinks
at the weekend.
This lady has come for a check-up,
and I'd actually clarify what her expectations are.
In the general practice setting,
a check-up means a bit more than just checking blood pressure
and honing immediately in onto that issue.
We'd certainly discuss other preventive health aspects, lifestyle aspects,
looking at risk factors for cardiovascular disease
and screening for cancers in particular, pap-smear screening.
For this context, I suppose the hypertension is significant.
Certainly that history of pregnancy-related hypertension
will contribute to her risk of kidney disease.
She should actually also be screened at this point in time
for kidney disease,
particularly looking at her eGFR and at her urine test.
I'd also probably want to check a little bit further
regarding her blood pressure,
and make sure it's not due to some other cause.
I'd do routine electrolytes,
I'd do a full blood count on her at that point in time as well.
I'd then start certainly to address her cardiovascular risk factors also.
I'd probably do her cholesterol at this point in time and fasting sugar.
What if she had blood in her urine, Tim?
You would need to establish if it's persistent,
and there's an algorithm which we can distribute
but I think we're not planning to talk about tonight,
which would demand investigation.
Persistent dipstick-positive haematuria is abnormal
and should always be investigated.
NORMAN: Would you send off for microscopy on the first occasion?
Yes, you'd certainly send it for culture.
NORMAN: Are we still old-fashioned enough to look for casts in urine?
No, casts don't get mentioned much anymore.
But the presence of what we call glomerular haematuria
or dysmorphic cells has replaced that.
We have got a reliable service that does that well.
That's a very useful help in determining
whether the haematuria is coming from the kidneys or from the urinary tract.
Lesley Salem, if this was an Aboriginal woman, part of your community,
you'd be thinking about blood sugar?
Yes. I'd be looking at loss or risk or urinary tract infections
if she had haematuria.
Sorry, the line was going a bit blank there. I missed some of it.
I'd be looking at further sampling
to confirm that it was consistent haematuria
and looking at her diabetes and those sort of risk factors.
Anne, what should be challenges here of this woman, moving forward?
Let's assume that she's really just beginning to show a reduced eGFR
and maybe just a little bit of protein in the urine.
What's the whole picture that GPs and others have got to look at?
I think you need to look at her social situation.
I think a multidisciplinary team is really important.
If you have a dietician who can speak with this lady, you've got...
I don't think she smoked.
NORMAN: No, she's not a smoker. - No.
Looking at her bloods and urine tests over time,
you can demonstrate to her
her progression or improvement of her results
depending on her treatment, and whether she's adhering to the treatment.
So, Beres, she comes back to see you.
The only tests that have come up trumps are... The eGFR is down a little bit.
A little bit of protein in the urine, not a lot.
What are you going to do now for her?
Well, certainly, I'd want to control her blood pressure.
She's actually a relatively young woman,
and I would probably have a brief chat to a renal physician about her.
I suspect that the proteinuria is related to hypertension.
Certainly, in controlling her hypertension,
I'd use an ACE inhibitor or an ARB.
I'd usually use an ACE inhibitor first.
But I'd probably just have a brief discussion with a nephrologist.
NORMAN: Well, you've got three here. Take your pick.
I suppose the question is,
is there anything more I need to do for her at this point in time?
OK, lads, fight over this patient here.
She needs an ultrasound and her proteinuria/albuminuria quantitated,
and she needs to be watched over time to see what the trends are.
NORMAN: An ultrasound to see if she's got an obstructive uropathy?
Yes, to be sure you won't have a red face in two years.
Otherwise, time will sort this out.
If, in three months, her blood pressure is under control,
her albuminuria has gone away and her GFR is stable,
then you know you're on top of things,
and you can just continue to manage without referral.
Let's change the story a little bit.
She's 38. She wants to have a fourth child.
What are we going to tell her now, David?
Well, it depends on the level of her eGFR.
If her blood pressure is under control and her eGFR is above 50,
then probably she's going to be OK with the pregnancy.
It probably won't have much extra risk for her kidney.
But once her eGFR gets lower than that,
there's a risk that her renal function will get worse during her pregnancy.
Is there a risk of eclampsia?
Yeah, there is an increased risk
of hypertension getting worse during the pregnancy.
What's the eclampsia story here, pre-eclampsia story, Paul?
She's had it in the first pregnancy, with hypertension and swelling.
Her second pregnancies, I think, were OK.
Generally, if you get through the second and third
without pre-eclampsia, it's less likely.
She may well have sustained hypertension during the pregnancy
and transient hypertension towards the end.
It'd be unlikely she'd develop pre-eclampsia based on previous history.
Only thing to point out - she can't be on an ACE
if she's wanting to get pregnant 'cause it's foetotoxic.
She needs to be off that agent in the first trimester.
But there would be no problem with her being pregnant.
She'd be at slightly increased risk. You'd just watch her.
To what extent do we look for other causes
of her hypertension and her kidney disease? Tim?
If the hypertension is controlled and her kidney function is stable,
then one... I would not go beyond an ultrasound.
So we'd just say it's idiopathic kidney damage, we don't know why she's got it?
Well, you may well be missing some mild nephritis,
but it's not going to be treatable, so you would just treat expectantly.
So you don't go hunting hard for autoimmune kidney disease?
If you think there's an underlying nephritis,
at some stage, if you then go to referral to a nephrologist,
then most of us would do a screening
for nephritis with ANFs, immunoglobulins, et cetera,
but the yield on those is quite low.
It would very much depend on the degree of her albinuria and proteinuria.
If there's lots, it wouldn't fit with simple hypertension.
If it was very mild, you probably wouldn't chase it,
or if she had haematuria and proteinuria suggesting it.
Anne, as a nurse practitioner, sit back from this,
take a whole view of the system,
when is it appropriate if a GP does have
a specialist nurse practitioner in the town,
when does the nurse practitioner see a patient?
When should a patient be referred to a specialist?
What's the story there? Give us a systemwide view from where you sit.
I get some direct referrals from GPs
for people who have very mild kidney impairment, stage 2s,
people that they're very worried about their diabetes, for example,
or people who are becoming anaemic, and I will help them manage...
NORMAN: So, control slipping away from the GP?
I think they just want... they don't think it's serious enough
to contact a nephrologist because they know nephrology services are very busy.
I'm like an extra link that they can access.
If I'm worried, I'll just flick them straight into the nephrologist's clinic.
When do you refer on, Beres?
A number of people in stage 3, people with glomerular haematuria,
I'd certainly want a discussion regarding them,
and certainly anybody beyond stage 3 or people who have got complications.
A question here from one of our online viewers,
Michael Nixon from the Northern Territory.
'95% of my patients are Aboriginal and Torres Strait Islanders.
Issues around diabetes, hyperlipidaemia and hypertension,
together with helping people understand the implications
of compliance to the medication regime are always uppermost in my mind
and in my interactions with patients.'
In other words, taking the holistic... It's more of a comment than a question.
Do you have a comment, Lesley? Would you concur with those views?
Absolutely. That's where the nurse practitioner role has come into play,
in that we can give longer consultations,
we can go to different areas where it may not be feasible for a GP
because GPs are private practice
and they need numbers and that to sustain their own business.
We can be employed under different methods and go into different areas.
We can case-manage a little bit more frequently
and follow people up in their own communities.
That's one of the benefits we're able to provide,
like Anne and I, and why we get referrals from GPs
who may have lost a patient who hasn't followed up with them.
We can actually seek people out in their community.
And I get referrals also from the maternity services on Aboriginal clients
who really don't have a location or a GP.
I can follow them up and track them into more...
And work with the GP and a collaborative team arrangement.
That's a take on how we'll do it.
NORMAN: Let's go to our next case study.
Vivian is a 46-year-old non-Indigenous woman.
A BMI of 25.5, so she's not really overweight.
She's had type 2 diabetes and been on insulin for the last four years.
She's high blood pressure, she's got high cholesterol.
A biopsy has detected diabetic nephropathy.
Vivian is a single mother with a 17-year-old daughter.
She works full-time as a casual.
She's a social smoker, about a pack a week,
and a rare social drinker.
She can't afford all her medications
and wonders what meds she can miss.
She's stressed,
and had a few hypos while exercising.
Her current medications are -
Her HbA1c is 8 at the moment.
Her blood pressure is 130/80.
Her albumin-creatinine ratio is 360.
Her urea 8, her creatinine is 80,
and her eGFR is 71.
Certainly...
We have comparable... we have results there from previous times as well,
and we can certainly see that there's been
some improvement in her HbA1c, which reflects control of her diabetes.
There's certainly been some improvement
in her blood pressure
and some improvement in her ACR
and improvement in her eGFR.
Although we note on those results that her HbA1c is not yet to target,
and her blood pressure is also not yet to target.
So there certainly is some more work to be done,
but it's good to see that improvement.
NORMAN: Which of her drugs can she ditch because she can't afford them?
Ah. I actually wouldn't immediately have thought about ditching any.
I would probably have to work with her fairly hard, though,
to work through these issues of enabling her to...
..you know, to convince her that we think that these are all necessary.
NORMAN: But she's not got type 2 diabetes.
She's 46, she's not fat and she's been on insulin for four years.
This is a woman with type 1.5, isn't it?
TIM: That's not unreasonable.
She's a very interesting case,
in that she's continuing to have heavy albuminuria
despite having a combination of ACE and ARB.
Yet her creatinine has improved over some period of time.
So there are some good things happening and some not-so-good things happening.
I think all the drugs are essential, as Beres said.
But she continues to smoke, Norman, and I think that's a major issue.
She should save her money by giving up the cigarettes?
Absolutely.
Nice of you to say it, Doctor. I'm sure that's extremely effective advice.
Anne, how would you be approaching this? It's obviously not an easy situation
for a woman living in difficult circumstances.
She does need to cut down smoking as much as possible.
It's an independent risk factor
for chronic kidney disease and cardiovascular disease.
That will save her a lot of money because they're very expensive.
And possibly change her to the combination polypills
appearing on the market now.
This is the sort of lady you can have a really good win with.
We should be able to keep this lady far, far from dialysis all of her life.
Given that she's not got type 2 and she's got insulin-dependent diabetes,
what's the impact of better diabetes control on her kidney function?
Not as much as better blood pressure control would be,
we nephrologists would say.
We'd focus probably on blood pressure reduction. Recent articles suggest...
Just pretend you're a real doctor and you look after more than the kidneys.
Even for her other vascular risk factors,
even the UKPDS showed that the blood pressure reduction
was the greater... driver of improved cardiovascular outcomes,
apart from renal analysis.
We'd focus on blood pressure, try and get that down.
You can rationalise the medications.
We do aim to target an HbA1c of 7%,
but I don't think the risk reduction is as great as with blood pressure control.
I can't quote you a percentage - I just don't know -
but it's not as great as across the board for all vascular risk.
Just coming back to the smoking, Norman,
the evidence is that if you smoke in the presence of kidney disease,
you'll go onto dialysis twice as early -
that is, you're half the time to dialysis as though you don't smoke.
That's a very useful figure to use with patients.
Given that she's probably got type 1,
what will you do about the 17-year-old daughter?
I think she still does have type 2.
NORMAN: Do you?
We're seeing type 2 diabetics at an earlier age.
But they're fat. She's not fat.
- You don't have to be fat. TIM: She's lost weight.
NORMAN: Oh, has she? OK.
That was a quick save there, Dr Mathew.
You brought up the question of her family history,
and that's very important.
She's got kidney disease, so her family is at risk of kidney disease as well.
NORMAN: So, regardless of cause?
Yes, regardless of cause, but particularly with diabetes.
And if this was an Aboriginal woman, Lesley?
As much as you can, looking at drugs that are on a PBS system,
or looking at where you could hook in to the Aboriginal S100 schemes
so it becomes affordable for them to stay on medication,
using Aboriginal health education officers and health workers
to case-manage and follow and help.
A really good education, ensuring the person understands
the issues involved in their particular case.
Often, health literacy, it is so poor in so many people,
Aboriginal and non-Aboriginal.
Let's go to our next case study.
Sandra is a 56-year-old Aboriginal woman.
She's a bit overweight, with a BMI of 27.4.
She's got type 2 diabetes and is on insulin.
She's got also high blood pressure and high cholesterol levels.
She's an ex-smoker and an ex-drinker.
She's got lots of work to do with her family, and works part-time.
She's confused about whether she's taken her pills or not
and forgets to refill her scripts.
She is on -
Lesley, do you want to comment?
Lifestyle. You'd have to look at
this lady's lifestyle,
changes that could be modified to start with -
weight, exercise, and, once again, I lead back into education.
It is culturally appropriate to see if she's a decision-maker on her health,
whether other people help to make decisions,
whether she has control over whether she gets her medications or not.
The social dynamics of the family are really important here.
But, before you do anything else,
you'd be encouraging exercise, nutrition and weight loss,
and looking at secondary smoking within the house
as a key start with this lady,
to tidy up before you even start on helping her with her medications.
Let's have a look at her pathology, Beres.
Her HbA1c is 14.6.
Her blood pressure is up a little bit
at 128/85.
Albumin-creatinine ratio is 880.
Urea, 12.1. Creatinine, 197.
eGFR, 23.
PTH, 12.
TIM: I've amended her blood pressure,
Norman, to 170/95.
NORMAN: Sorry? Oh, sorry. I'm looking at
an old measure of her blood pressure.
She is still hypertensive.
And we're not doing a great job about
controlling her blood sugar.
Your patient.
Certainly, not only is her diabetes and hypertension poorly controlled,
but her renal function is also not flash.
I agree with the previous comments regarding lifestyle.
Certainly we've got to get those reinstated.
It's also time to actually have a chat about medications.
I think... Well, we know that she's not been getting scripts filled.
But we've actually got to go back and work through the reasons for that
and see if we can actually find some common ground,
so we can move forward with her
to encourage her to get her scripts filled and actually take her medication.
It's difficult to go adjusting doses
if you don't know what the patient is already taking.
One really has to ascertain what's been taken lately
before you even change doses.
How bad is her kidney function, David?
It's bad.
As we can see on her results, she's down to a quarter of normal.
If she continues in the same way, she'll need dialysis in the mid-future.
NORMAN: How soon?
Hard to predict, but when she gets to an eGFR of... certainly less than 15
but as low as 5 - it depends on the individual patient -
she'll be needing dialysis.
So she's got a while to go, maybe a couple of years from 23.
TIM: The red lights are flashing here, aren't they?
Yeah. There's a number of things of concern here.
It looks as though her kidney function has actually improved,
but in fact what's happened is she's not taking her blood pressure tablets,
so it's a false impression.
NORMAN: Explain what's going on.
She's got a higher blood pressure, so more blood pumping through her kidneys.
- Squeezing through the dying kidney? - She's not taking her ACE inhibitor.
So the GFR looks better than it should.
One comment I wanted to make on her treatment -
we're assuming her poor blood pressure is due to non-compliance.
It may be also her diet.
One thing we haven't discussed in a diet so far is salt.
If she's having too much salt,
it could make her blood pressure a lot more difficult to treat.
NORMAN: Anne?
It's really important that people are seen by a multidisciplinary team
involving the GP, the nephrologist - if they're at that stage -
nursing staff, practice nurses in the GP's.
Dieticians are very important because they can spend the time with people.
They can go through and do a food diary with them
and make very small changes.
The earlier the dietician can see a patient,
the smaller the changes that person has to make.
NORMAN: Are they often quite salt-sensitive?
A lot of people in rural and remote communities add a lot of salt,
not only Aboriginal people.
Some of us don't need to live remotely to do that.
You'll go to a barbecue in a remote place,
and everybody at the sausage sizzle
tips the salt on before they taste anything.
It's just the habit there.
A couple of other things about blood pressure control in these people -
the number of tablets you need to achieve your target blood pressure
goes up as your GFR declines.
At a level of 20, you're probably on four or five,
sometimes even six medications, to reach a target blood pressure.
Generally, everybody who has some salt and water retention,
requires diuretics, which she's not on, but she probably does require them.
That would be a general mantra, I guess, and probably a loop with a low GFR,
although thiazides do work.
You could probably have her on some combinations
that are long-acting, once a day, that might make it easier for her to comply,
rather than the twice-a-day metoprolol and those sorts of drugs.
NORMAN: What combinations, without giving away brand names?
You could use ACE thiazide or aCCB combinations.
Actually, out next year, there will be an ACE thiazide-CCB combination drug.
That will be useful.
We were talking before that the ideal would be a depo
that you could inject for several months that would work.
But something that's long-acting, once a day.
You can mix and match combinations to make drugs easier.
Lesley, it's all very well for us pontificating here
about the idealised care of someone like Sandra.
How do you make it effective by being culturally sensitive, if you like?
Keeping the person in their community.
So, visiting specialists, people who visit the areas,
linking them in as much as you can.
Realising that many won't leave their community
to go and seek specialist help.
So, getting support from as many of those teams Anne was talking about
to come to a close location or to those communities to help.
For this lady as well, you're looking at the complications of kidney disease -
the anaemia and the bone disease.
So, doing as much of the pathology or testing within the community,
so that person stays with family.
A lot of them have a deep fear
that once they're removed from that community for treatment or help
that they don't come back.
What we haven't told you, Lesley, is that her cholesterol is up, 8.5.
Triglycerides, 5.2.
Her LDL is up a little bit too.
She's not anaemic.
One wonders why, but she's not.
She's going to need statins or a fibrate
or something like that as well.
This is a bundle of pills, which is
hard enough for somebody
with full control of their life to get,
much less with the huge demands
of living in an Aboriginal community.
That's a huge issue that we face.
One, they will not travel 100km or 200km
or they don't have transport, to go and fill a prescription,
and can't afford prescriptions when they get there.
Linking in with programs like we're running,
we have health workers who will pick up the prescriptions
and take them out and monitor whether that prescription is being taken.
Once again, I use point-of-care to monitor a blood-sugar level
or to help the patient see the gains from taking medications.
And education - education in a manner that is not as wordy
as we see in many of the pamphlets that come out.
Looking at artwork or figures or language that suits the community.
And there can be discrepancies between different communities.
A question, Anne, is how aggressively do you monitor someone like this,
given the controversy over monitoring - that you can overmonitor
and get into a pickle because you're testing too much?
We're on a slippery dip with Sandra, but how actively do you...
If we're trying to keep this lady away from dialysis,
she needs to be closely monitored.
I would say she should see the endocrinology team or the renal team
every month when they come over to her community.
I think she needs to...
The Indigenous health workers are invaluable.
If you've got Indigenous health workers that she trusts
that are spreading the same message that the teams are spreading,
then you get continuity of that message when you're not there.
What are the different models of care that are available
for Indigenous communities?
You need to find out what people want.
In the past, it's been very paternalistic.
Clinics have been built and patients don't go to them
because it's not what they would have chosen
or it's not where they feel safe.
So you have to have community engagement.
I think you need to bring... The care does need to come to the communities
because people can't afford to travel.
In a lot of cases, in north Queensland, they have to fly.
It could be 1,000km, 2,000km
to get to the nearest nephrologist or vascular surgeon.
And that's a big ask for people.
A GP in Queensland asks, 'What's the current state of knowledge
between haemodialysis and peritoneal dialysis?'
What's the benefits, what are the downsides and the upsides?
Let's take it living in a city versus living in an Aboriginal community
or living in a rural town without a lot of support. David?
The choice between the two is very much up to what suits the patient.
If there's a medical contraindication to one or the other, that will guide you.
But usually that's not the issue. It's usually a patient choice.
If the patient is well dialysed with either peritoneal or haemodialysis,
they can do equally well.
You run Statewide dialysis services, Paul, in New South Wales.
What's your view on this?
The bean counters want you to do PD all the time, do they?
It's no more cost-effective than home haemodialysis in our State.
So there's no cost benefit to PD.
So, we have it as a patient choice.
Either modality has its problems.
With PD, it's peritonitis and infections.
The average time on PD in Australia is two to three years
is how long the modality works
before people shift off to haemo, on the whole.
Haemodialysis, if they can do it - it's a greater technical burden
for patients and their families to learn and manage - but if they can do it,
it has a good outcome.
The major problems are related to maintenance of vascular access.
Both put a burden on the person and their carer.
And, in remote communities, if you're doing home haemo there,
it puts a burden on the local health staff
to look after these patients.
In some places where it wasn't in the territory when we set it up,
there were concerns about being held responsible for health workers
if things went wrong.
So there was a degree of reluctance or fear
about having home- or community-based dialysis.
The benefits to the patients and the community were great,
but there were concerns that needed to be weighed up in those settings.
The pathway by which people finish up on peritoneal or haemodialysis
is poorly understood in this country.
Kidney Health Australia is doing a national consumer or patient survey
on everyone on dialysis, be it at hospital or home,
trying to better understand that pathway.
We're encouraging all patients who will get a form to fill it in
and let us know what their pathway has been,
what their feelings are, what their successes,
and to help us guide this very important question of which is the preferred way.
An online viewer asks,
'What are the hallmarks of a good satellite dialysis?
How do you make it work remotely?'
Lesley, do you want to comment on that? Do you have much experience of that?
We can't ignore the patients who are in satellite units.
Previous to this position,
I looked after 360 patients in satellite and home dialysis.
Once again, it was a focus on cardiovascular risk for these patients.
So constantly looking at the issues around dry weight
and their medications, timing of medications.
So even though they were in satellite units,
with nurse practitioner support, working with the GPs in the community,
you can create very stable, well patients.
So very much a health-promotion view
of looking at patients in the satellite units is important.
David Appleton from Mallacoota Medical Centre asks,
'What's the role of combination ACE/ARBs and at what doses?
In proteinuric kidney disease, there's a role for both of them.
The combination appears to be better than one by itself.
That's a little bit controversial.
In fact, if you push the dose up of an ACE inhibitor or a receptor antagonist,
you can probably get as good an effect
as you will from combining the two together.
The main drawback, of course, to the combination
in patients with renal impairment
is whether they become hyperkalemic or not. You need to watch for that.
An important trial came out earlier
looking at the hypertensive vascular risk patient, the ONTARGET trial,
which showed ACE/ARB combinations had no benefit
in reducing cardiovascular events
and had a greater degree of adverse effects,
with decreased GFR and hyperkalemia.
So, it's only in a small group - significant proteinuria, renal disease -
that you might consider them.
The other thing is, I guess - we should fess up that the trial that suggested
that the combination halved the rate of progression was shown to be fraudulent.
NORMAN: (Laughs) Right.
Dr Appleton, you might just want to be a little careful
about how you're throwing around this combination.
You might want a nephrologist with you just in case something goes wrong.
I wouldn't use the combination routinely.
The most important thing is the achieved blood pressure, not the drug you use.
An ACE/ARB won't give you the degree of blood pressure lowering you'll get
with an ACE thiazide or an aCCB generally.
I'd go for those combinations these days.
Beres, what about the challenges of the elderly?
That could be defined in any way you like.
Since we're all approaching the elderly age group,
let's be loose about the age where we define someone as elderly.
Kidney disease in the elderly -
what's the story from your point of view as a GP?
Certainly, there is an increased rate of kidney disease in the elderly.
There are two different perspectives on this.
One is that, really, we shouldn't be ageist.
We must continue to look for the condition and manage it.
The other side of it is really to have a look at the person
and look at all of their comorbidities, and have the discussion with them.
I suppose I frame that, really thinking about at what stage of CKD they're at.
NORMAN: Tim?
The only really contentious issue is whether you consider dialysis
for someone, say, in their mid-80s and beyond, which I would call elderly.
Apart from that, all the treatment plans
to do with hypertension and cholesterol reduction and things should apply.
Certainly, the evidence is now in
that treating hypertension in the elderly is effective.
And I don't see any reason for not offering elderly people
EPO and phosphate reduction and all the things for complications.
Whether you offer them dialysis is a very difficult issue.
It has to be considered individually.
Australia offers about a quarter of the rate of dialysis to that age group
as other OECD countries,
so we're probably underdelivering by international standards.
But you talk to a lot of Australian nephrologists,
and they would say maybe we've got the balance right here.
There is some recent evidence showing
that if you don't offer dialysis to that population
that they tend to do about as well as those that do get dialysis.
And is age a strong enough risk factor
to be a trigger for screening in its own right?
We teach that over the age of 50
is the cut point above which the risk of having kidney disease, or yield,
is sufficient to justify the screening, so the answer is yes.
Paul?
I'll stick with Tim on that. (Laughter)
NORMAN: Oh, you chicken.
It might cut out at 70 or 80 or 75.
There is an upper age, above which...
Why would you cut it out?
You've told me you'd have the same criteria as everybody else.
You might get people an extra four or five years
if you treat kidney disease aggressively.
For the same reason that the absolute-risk tool
is not applied above the age of 75 - everyone is so high-risk for everything
that justifies treatment.
Anne, do you have any comment on looking after the elderly with kidney disease?
I think it's our growth industry, really.
This is your future we're talking about.
Most of the patients I see would be over 65.
There's very few that would be under 50.
Lesley, you should be so lucky
that you see somebody who's elderly in an Aboriginal community.
Exactly. Two issues here - elderly in Aboriginals is a lot younger.
The median-age deaths from CKD is 60 in Aboriginal people
as opposed to 82 in non-Aboriginals.
So age is relative, I guess, and a lot younger for Aboriginal people.
The important issue here is if you identify CKD
you can link into palliation programs.
I'm not talking about end-of-life palliation, but symptom control.
There's new clinics coming on board for control of itch and control of pain
and things associated with CKD.
So I think it's important to identify at any age,
whether you're going to actively dialyse them
or link into appropriate palliation services to make the person comfortable.
NORMAN: Pain, Anne? ANNE: Mm.
What pain do they get?
A lot of people have quite severe arthritis, and we're telling them
they can't take any of the non-steroidal anti-inflammatories.
Panadol Osteo and glucosamine don't always do it,
and so there's a lot of pain.
They get metabolic bone disorders.
If they've got high PTHs, they've got headache, bone pain, muscle aches,
which goes along with all the complications of CKD.
Interesting, and disturbing.
What Medicare items help in all this, Beres?
It's really good that we...
NORMAN: A question from an online viewer.
There certainly are Medicare item numbers.
I'm not going to list them specifically.
There are two separate structures - one is the GP management plan.
There's a rebate for actually working with the person
to clarify what the problems are,
determine the goals of care, and then to determine who does what -
you know, what the patient's responsibilities are
and what the GP links them into.
There's also an item for reviewing the GP management plan.
There are also items for team-care arrangements,
where one actually coordinates care with other health practitioners.
Most of the divisions have actually put a lot of work
into supporting and teaching GPs how to use these item numbers,
and are aware that more and more practice nurses
are actually having a major role
in building these management plans into general practice
and helping keep the plans on-track.
What about nursing item numbers?
I think there's six for allied health.
There is no Medicare provider numbers for nurse practitioners currently,
but that's before the Senate.
TIM: There are for practice nurses. - But not nurse practitioners.
In the practice of nephrology, the APNA have got teaching modules now online
that the government have arranged for all the chronic diseases.
We strongly encourage GPs to use those item numbers
to make a business case in favour of employing practice nurses.
Employing a practice nurse to help with screening.
I think there's ten visits for follow-up with a practice nurse,
so that if you put something in place like a medication,
it can be followed up, and blood pressure is checked,
urine is checked, things like that.
There is a lot more access to numbers for follow-up
after you've identified somebody.
And now, just before we finish our program,
we'll get you the results of the last question on the poll -
And you all do in your practice. Well done.
Lesley, what's your takeaway message for viewers?
It's that I think initial screening and identifying problems in communities,
and the extent of that, and then pulling teams in to help.
so, getting people to visit the community or an area close to that
and linking in with Aboriginal health workers and local services
and particularly lifestyle services,
such as smoking cessation or exercise programs.
The team moves beyond a clinical team to an education and a lifestyle team.
That's very important, as much as the pharmaceutical treatment.
Lesley, thanks for staying on the line for the entire program.
It's been really good of you.
Anne?
My take-home message would be - we have to get screening out there
for people who are at increased risk, because it is silent.
There are no symptoms until up to 90% of your renal function is gone.
Your kidneys are deteriorating at the same rate as your cardiovascular system
and your eyes and whatever.
If we can screen people earlier, the interventions are so much smaller
to make such a big difference.
NORMAN: Beres?
I'm somewhat reductionist in my thinking.
I think that we really need to recognise
that this is a very important cardiovascular risk factor,
and it's worth looking for.
NORMAN: Paul?
That declining GFR and increasing proteinuria or albuminuria
independently and progressively predict vascular events
and risk of renal disease.
Hopefully we'll give you one way of thinking about albuminuria/proteinuria
in the next year or two so that people know better
how to assess and use it as a clinical tool.
NORMAN: Tim?
The number of patients on dialysis in this country
has doubled in the last nine years
and is destined to double again in the next ten years.
The only way that Kidney Health Australia thinks that's going to change
is by finding kidney disease earlier and doing something appropriate about it.
It is silent, and therefore we must go looking for it.
NORMAN: David?
That it's definitely harmful, but it's also preventable and treatable.
Thank you all very much indeed.
An illuminating program. I hope you found it too.
Chronic Kidney Disease: A Silent Condition.
If you're interested in obtaining more information about the issues raised,
there are a number of resources available
on the Rural Health Education Foundation website -
Don't forget to complete and send in your evaluation forms
and register for CPD points by completing the attendance sheet.
I'm Norman Swan. From all of us, goodnight.
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