Couzos, S., Thomas, M., and Cass, A. (2008) Chronic kidney disease. In: Couzos, Sophia, and Murray, Richard, (eds.) Aboriginal Primary Health Care: an evidence-based approach. An evidence based approach . UNSPECIFIED, South Melbourne, VIC, Australia, pp. 575-621.

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Abstract

Driven as the tragic consequence of poverty, a heavy community burden of diabetes, hypertension and obesity, and inadequate access to health services relative to need, kidney disease rates among Aboriginal populations continue to increase. New cases of end-stage kidney disease (ESKD) occur at 2 to 30 times the rate of non-Indigenous Australians. A 'whole of government' response will be required to address the root causes of this excess chronic disease burden.

There is evidence that kidney disease is often unrecognised and that a lack of preparation (including delayed referral) for the management of chronic kidney disease (CKD) and ESKD may be responsible for the poor outcomes of tertiary level care. Dipstick testing for proteinuria should be undertaken annually to screen Aboriginal adults for early indicators of kidney disease. People with abnormal findings on dipstick testing should undergo further assessment of kidney function, including serum creatinine and calculated glomerular filtration rate (GFR).

In the primary prevention of CKD, social factors such as diet and exercise, combined with minimisation of nicotine and alcohol use, are most important. Environmental factors such as appropriate housing and community measures to reduce skin infections will reduce the risk of acute glomerulonephritis and possibly contribute to a reduction in CKD. Among people with early CKD, hypertension is one of the major factors contributing to a decline in kidney function. Blood pressure should be kept below 130/85, or 125/75 in the presence of proteinuria. The optimal antihypertensive choices are the angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (alone or in combination), to delay the progression of diabetic and non-diabetic-related kidney disease by as much as twofold, and reduce proteinuria by 50%. The key aspects of CKD management are lowering blood pressure, reducing proteinuria, and avoiding nephrotoxic drugs.

CKD is an independent risk factor for cardiovascular disease and there is a very high risk of concurrent generalised vascular disease. People with CKD who have established cardiovascular disease should receive lipid-lowering therapy. Among people with CKD who have not had a prior vascular event, evidence supporting a role for the statin-class of cholesterol-lowering drugs in cardio-renal protection is inconclusive.

All patients with CKD should be monitored at least every 3-6 months with serum creatinine, for hypertension, diabetic control, dyslipidaemia, weight, diet, and level of physical activity. Involvement of Aboriginal Health Workers (AHWs), point-of-care testing, and immediate feedback of results all assist in management. Patients with progressive kidney disease should be referred to a nephrologist at or before reaching a calculated GFR of 30mL/min. Specialist nephrology management will involve correction of anaemia, treatment of renal bone disease and electrolyte disturbances, education regarding ESKD options, and timely preparation for kidney replacement therapy, including creation of vascular access. As much as possible, Aboriginal patients, whether in urban, rural, or remote settings, should be given the same opportunities for ESKD treatment as non-Aboriginal patients.

Following the recommendations of the USA Kidney Disease Quality Initiative, the term 'renal disease' has been replaced by 'kidney disease' throughout this chapter (see box 15.2).

Item ID:	34141
Item Type:	Book Chapter (Research - B1)
ISBN:	978-0-19-555138-9
Date Deposited:	16 Nov 2014 22:34
FoR Codes:	11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111717 Primary Health Care @ 100%
SEO Codes:	92 HEALTH > 9203 Indigenous Health > 920399 Indigenous Health not elsewhere classified @ 100%
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