RENAL DISEASE IN CENTRAL AUSTRALIA. Dr Cheri Hotu Endocrinologist, General Physician, Postdoctoral Fellow Baker IDI Heart & Diabetes Institute, ASH

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1 RENAL DISEASE IN CENTRAL AUSTRALIA Dr Cheri Hotu Endocrinologist, General Physician, Postdoctoral Fellow Baker IDI Heart & Diabetes Institute, ASH

2 Kidney Disease in Central Australia High rates of kidney disease in Indigenous population 30% NT population are Indigenous 85% NT dialysis population are Indigenous Central Australia - 96% dialysis population - Indigenous Diabetes - most common cause of end-stage renal disease Australia-wide diabetes cause of ESRD in 35% Alice Springs diabetes cause of ESRD in 88%

3 End-stage renal disease Associated with: Low quality of life High hospitalization rates High mortality rates Dialysis - displacement from family and country Challenges passing on Tjukurpa (law) to next generation

4 RRT Incidence (pmp) State QLD 490 (113) 450 (102) 454 (101) 473 (104) 492 (106) NSW 766 (109) 726 (102) 790 (109) 811 (111) 783 (106) ACT 41 (116) 53 (147) 53 (144) 63 (168) 53 (139) Vic 549 (102) 575 (105) 603 (109) 634 (113) 651 (113) Tas 58 (115) 47 (92) 53 (104) 49 (96) 44 (86) SA 207 (129) 182 (112) 184 (112) 203 (123) 165 (99) NT 72 (319) 65 (283) 82 (355) 98 (415) 85 (351) WA 248 (111) 237 (103) 292 (124) 242 (99) 271 (108) Aust 2431 (112) 2335 (106) 2511 (112) 2573 (113) 2544 (110) NZ 584 (136) 515 (118) 487 (111) 517 (117) 546 (123) ANZDATA 2014

5 New patients by age group NSW Age ANZDATA 2014

6 400 New patients by age group VIC Age ANZDATA 2014

7 1500 New patients by age group NT Age ANZDATA 2014

8 Renal Dialysis Unit Flynn Drive Gap Road Dialysis Facilty/Nephrocare In Hospital at Alice Springs Hospital Purple House Tennant Renal Dialysis Facility Haemodialysis n = 350 patients Western Desert Dialysis Nurse led mini satellite facilities Yuendumu Santa Teresa Hermannsburg Kintore Kiwirrkura Warburton Home hemodialysis Patients

9 Kidney disease has an onset Can progress to end-stage renal disease Other less common causes of ESRD (glomerulonephritis, hypertensive nephrosclerosis, lupus nephritis) Concentrating on diabetic nephropathy Risk factors can drive onset + progression

10 Natural course of diabetic nephropathy Hyperfiltration - overdrive Microalbuminuria (ACR >3.5mg/mmol, >2.5mg/mmol ) Macroalbuminuria (ACR >25-35mg/mmol) egfr can begin to decline during microalbuminuric stage Without intervention, egfr declines at average rate of 6-12 ml/min/1.73m 2 /year

11 Risk Factors

12 Glycaemic control Smoking Ethnicity Family history of kidney disease History of previous kidney injury (AKI, GN) Obesity Lipids Hypertension

13 How do we deal with this?

14 Good surveillance methods

15 Reliable detection methods

16 Successful interventions

17 Clever delay tactics

18 Even better prevention strategies

19 What to check

20 Check urinary ACR Microalbuminuria (ACR >3.5mg/mmol, >2.5mg/mmol ) Macroalbuminuria (ACR >25-35mg/mmol) Check serum creatinine (egfr)

21 When to check

22 Screen for the presence of albuminuria and CKD (egfr) at diagnosis of diabetes Screen annually for albuminuria and egfr in the event of negative screening tests If ACR is positive for microalbuminuria, repeat test 1-2 times over next 3 months to confirm If ACR is positive for macroalbuminuria, repeat test to confirm (can be impractical to do 24-hour urine protein collection)

23 CARPA Manual Comprehensive + simple to follow Adult Health Check Includes urinary ACR BP serum creatinine

24 Interpreting egfr egfr ml/min/1.73m 2 may indicate mild kidney dysfunction optimise glycaemic, BP and lipid control egfr ml/min/1.73m 2 stage 3 CKD optimise above control, refer to renal or endocrine service egfr ml/min/1.73m 2 stage 4 CKD - refer to renal service egfr <15 ml/min/1.73m 2 stage 5 CKD urgent renal referral - admission

25 Albuminuria - check every 6 months egfr - 3 monthly for CKD 3 egfr - once a month for CKD 4 egfr 2-4 weekly for CKD 5

26 Modify the risk factors

27 Hypertension - strongly associated with development of albuminuria and progression of kidney disease to ESRD Good BP control is paramount Can delay + stop development and progression of kidney disease Can reduce risk of future cardiovascular disease Aim for BP <130/80mmHg Commence ACE I or A2RB for albuminuria (BP may be normal)

28 Central Australia - primary care/remote care clinics important hub for delivery of effective care in communities with good BP management, convincing evidence that antihypertensive use can delay renal + CV disease in diabetes what stops evidence-based treatments from working effectively in our communities? which factors of healthcare delivery can make BP care more effective to achieve better outcomes?

29 What stops this from working?

30 barriers to improved healthcare

31 clinical (therapeutic) inertia a lack of treatment intensification in a patient not at evidence-based goals of care Physician factors Patient factors System factors

32 What works?

33 nurse-led hypertension clinics

34 nurse-led care nurse-led hypertension clinics lead to reduction in BP, lipids, albuminuria, future CV and stroke risk in patients with T2DM + hypertension longer consultation times increases patient satisfaction of care nurse-led clinics demonstrate better adherence to stepwise treatment algorithms and protocol-driven systems results in a greater likelihood of medication adjustments

35 nurse-led care home-based or work-based visits increase effectiveness of attaining good BP control important point to note: effectiveness of nurse-led model dependent on authorising nurses to implement changes to patient s medication regimen (e.g dose adjustment, prescribing new antihypertensive agents) reviews by Oakeshott Clark shown little or no effect on BP if intervention does not allow for medication adjustments or prescribing new meds

36 pharmacist-led clinics

37 pharmacist-led care Similar effectiveness to nurse-led clinics

38 self monitoring of BP

39 Self-monitoring of BP Can result in more accurate monitoring of BP May increase compliance due to patient s greater participation in their healthcare

40 organisational interventions

41 organisational interventions robust systems that guarantee appropriate recall and regular follow-up of patients WORK hypertension detection follow-up programme (conducted >30 yrs ago) implemented an organisational intervention 10,940 patients led to significant reduction in SBP and DBP + decrease in 5-year mortality in interventional group Cochrane review of BP control in the community showed this was most effective intervention

42 community healthcare workers

43 community healthcare workers culturally-appropriate CHWs to monitor BP in community in Indigenous patients with diabetic nephropathy (NZ) 4 week home-based visits for BP monitoring of interventional group medication changed by clinical team according to stepwise protocol control group usual care with GP + diabetes/renal team at 12 months, significant improvements in systolic BP, proteinuria, and ECHO parameters (LV mass index and LA volume reduction)

44 Recipe for success

45 Common theme evident in all effective interventions to improve BP control and delay progression of kidney disease Robust system of patient registration and recall, coupled with Regular and frequent patient follow-up visits for BP monitoring and review of medications, compliance and side effects Home-based (work-based) visits

46 Adherence to stepwise algorithms to change antihypertensive medications if target BP is not met Culturally-appropriate health workforce bridge cultural gaps + language barriers Invitation, engagement, consultation, discussion, communication with community Invitation, engagement, consultation, discussion, communication with patient

47 Into the future we Go!

48 Better coordinated and collaborative management strategies multidisciplinary effort nutting out cases together play well together in the playground, share our toys IT, TeleHeatlh, shared electronic health records Pro-activity with care plans Data collection for quality improvement utilise it to show whether service effective More collaboration with other non-health service providers educationalists, power/water services..

49 Acknowledgements Traditional Owners + Custodians of Mparntwe Donors and sponsors Collaborative partners Symposium Organisers Heidi, Sienna, Shruti et al