Treating kidney disease in the Indigenous communities
Associate Professor Rob Baird, Director of Pathology, Territory Pathology and Infectious Diseases Physician at Royal Darwin Hospital, discusses the complexities of treating kidney disease effectively in remote rural communities.
“I’m located in the Northern Territory. I would estimate that chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are at least ten times more prevalent in the
Indigenous community, in comparison to the non-Indigenous population. Providing effective treatment and monitoring kidney disease can pose its own set of complications in the remote
Indigenous communities, as dialysis treatment or undergoing a renal transplant often requires extensive travel.
“Currently, there are not dialysis units in every small community, the dialysis units are centralised; and if a patient is on dialysis and needs to be dialysed three times per week, a
roundtrip from a remote community is a long way. Therefore, families usually move off their homeland and come to town for dialysis treatment. Consequently, communities can be left
without elder leadership, and community culture is weakened. Patients suffer from isolation and depression, restricted by a dialysis machine for their foreseeable future,” says A/Prof
In 2014, a survey of around 3,300 Aboriginal and Torres Strait Island adults (aged 18 years and over) across Australia, revealed that nearly one in five (17.9%) had chronic kidney
disease. When compared with those in urban areas, Aboriginal and Torres Strait Islander adults in remote areas were two and a half times as likely to have signs of chronic kidney
disease (33.6% compared with 13.1%). When compared with the non-Indigenous population, Aboriginal and Torres Strait Islander people were twice as likely to have signs of
chronic kidney disease (rate ratio of 2:1). In 2011–13, care involving dialysis was the leading cause of hospitalisation (45%) for Indigenous Australians. Hospitalisation for dialysis
was 10 times the non-Indigenous rate.
“In some cases, a patient may not seek out a level of medical intervention if the result is moving away from their community and land. The option to move to a large city to seek
treatment might even be rejected by the patient, even when the reality of that decision means the patient won’t survive. When health services are available locally, there can still
be complexities to providing these services, due to socio economic factors, such as housing, education, unemployment and poverty.
“The issues are well recognised and, looking forward, solutions may include mobile dialysis units (https://www.westerndesertdialysis.com/communities/the-purple-truck), changing the funding models for regional dialysis centres and, in the future, technology improvements may advance to the level that portable dialysis machines can be offered to patients.
However, the best current option is successful renal transplantation.
“Kidney transplants are fantastic - a patient’s whole life changes for the better. The patient’s overall wellbeing improves, as they’re off dialysis and mobile again. A/Prof Baird explains that there has been a shortage of organs in the Indigenous communities. “Ideally you want a good tissue match, but that’s not quite as important as it once was due to improved drugs”.
Unfortunately, the rates of renal transplantation in Indigenous patients are far lower than in other groups. Kidneys for transplantation are largely from deceased donors, as there are
very few living kidney donors in Aboriginal and Torres Strait Islander communities.
According to an article in the Australian Medical Association, the reasons for poor access to transplantation experienced by Aboriginal and Torres Strait Islander Australians are complex. Some of those can be attributed to
- The greater burden of comorbid illness amongst Aboriginal and Torres Strait Islander dialysis patients, leading to fewer patients being judged medically suitable;
- The shortage of living and deceased donors from within Aboriginal and Torres Strait Islander communities;
- The challenges in delivering appropriate health services to people living in remote areas who might also have low health literacy and not speak English as a first
- The dislocation that follows from moving to transplant centres in distant capital cities; and
- The high complication rate, particularly in terms of early infectious complications leading to poor transplant outcomes, including substantially higher death and graft
“Prior to transplantation, significant work up tests and assessments require visits to major centres. After transplantation there is the prospect of a post-operative stay and side effects away from home and supports. The number of medications usually increases, and there is an increased risk of infections and cancers. In summary, this is a highly challenging area
with much still to be done,” says A/Prof Baird.
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This article appeared in the April 2018 Edition of ePathWay which is an online magazine produced by the Royal College of Pathologists of Australasia (http://www.rcpa.edu.au/Library/Publications/ePathway).
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