Rebecca Ritte

Progression of Kidney Disease in Indigenous Australians: The eGFR Follow-up Study

BACKGROUND AND OBJECTIVES Indigenous Australians experience a heavy burden of CKD. To address this burden, the eGFR Follow-Up Study recruited and followed an Indigenous Australian cohort from regions of Australia with the greatest ESRD burden. We sought to better understand factors contributing to the progression of kidney disease. Specific objectives were to assess rates of progression of eGFR in Indigenous Australians with and without CKD and identify factors associated with a decline in eGFR. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This observational longitudinal study of Indigenous Australian adults was conducted in >20 sites. The baseline cohort was recruited from community and primary care clinic sites across five strata of health, diabetes status, and kidney function. Participants were then invited to follow up at 2-4 years; if unavailable, vital status, progression to RRT, and serum creatinine were obtained from medical records. Primary outcomes were annual eGFR change and combined renal outcome (first of ≥30% eGFR decline with follow-up eGFR<60 ml/min per 1.73 m(2), progression to RRT, or renal death). RESULTS Participants (n=550) were followed for a median of 3.0 years. Baseline and follow-up eGFR (geometric mean [95% confidence interval], 83.9 (80.7 to 87.3) and 70.1 (65.9 to 74.5) ml/min per 1.73 m(2), respectively. Overall mean annual eGFR change was -3.1 (-3.6 to -2.5) ml/min per 1.73 m(2). Stratified by baseline eGFR (≥90, 60-89, <60 ml/min per 1.73 m(2)), annual eGFR changes were -3.0 (-3.6 to -2.4), -1.9 (-3.3 to -0.5), and -5.0 (-6.5 to -3.6) ml/min per 1.73 m(2). Across baseline eGFR categories, annual eGFR decline was greatest among adults with baseline albumin-to-creatinine ratio (ACR) >265 mg/g (30 mg/mmol). Baseline determinants of the combined renal outcome (experienced by 66 participants) were higher urine ACR, diabetes, lower measured GFR, and higher C-reactive protein. CONCLUSIONS The observed eGFR decline was three times higher than described in nonindigenous populations. ACR was confirmed as a powerful predictor for eGFR decline across diverse geographic regions.

Low rates of predominant breastfeeding in hospital after gestational diabetes, particularly among Indigenous women in Australia

Objectives: To investigate rates of ‘any’ and ‘predominant’ breastfeeding in hospital among Indigenous and non‐Indigenous women with and without gestational diabetes mellitus (GDM).

Chronic kidney disease and socio-economic status: a cross sectional study

ABSTRACT Objective: This cross-sectional study investigated the relationship between individual-level markers of disadvantage, renal function and cardio-metabolic risk within an Indigenous population characterised by a heavy burden of chronic kidney disease and disadvantage. Design: Using data from 20 Indigenous communities across Australia, an aggregate socio-economic status (SES) score was created from individual-level socio-economic variables reported by participants. Logistic regression was used to assess the association of individual-level socio-economic variables and the SES score with kidney function (an estimated glomerular function rate (eGFR) cut-point of <60 ml/min/1.73 m2) as well as clinical indicators of cardio-metabolic risk. Results: The combination of lower education and unemployment was associated with poorer kidney function and higher cardio-metabolic risk factors. Regression models adjusted for age and gender showed that an eGFR < 60 ml/min/1.73 m2 was associated with a low socio-economic score (lowest vs. highest 3.24 [95% CI 1.43–6.97]), remote living (remote vs. highly to moderately accessible 3.24 [95% CI 1.28–8.23]), renting (renting vs. owning/being purchased 5.76[95% CI 1.91–17.33]), unemployment (unemployed vs employed 2.85 [95% CI 1.31–6.19]) and receiving welfare (welfare vs. salary 2.49 [95% CI 1.42–4.37]). A higher aggregate socio-economic score was inversely associated with an eGFR < 60 ml/min/1.73 m2 (0.75 [95% CI 063–0.89]). Conclusion: This study extends upon our understanding of associations between area-level markers of disadvantage and burden of end stage kidney disease amongst Indigenous populations to a detailed analysis of a range of well-characterised individual-level factors such as overall low socio-economic status, remote living, renting, unemployment and welfare. With the increasing burden of end-stage kidney disease amongst Indigenous people, the underlying socio-economic conditions and social and cultural determinants of health need to be understood at an individual as well as community-level, to develop, implement, target and sustain interventions.

Nutritional predictors of chronic disease in a Central Australian Aboriginal cohort: A multi-mixture modelling analysis

BACKGROUND AND AIMS Chronic diseases (including diabetes, cardiovascular disease, hypertension and chronic kidney disease) are major contributors to the total burden of disease for Aboriginal people. Here we used novel epidemiological modelling to investigate nutritional profiles at a population level associated with chronic disease. METHODS AND RESULTS Multi-mixture modelling, was used to group members of a Central Australian Aboriginal population (n = 444) based on their nutritional profile from a risk factor prevalence survey in 1995. Multi-mixture modelling assigned % membership to four classes; Class 1 (young, low adiposity and lipids, low dietary antioxidants; n = 171.7); Class 2 (older, greater adiposity and lipids; n = 22.6); Class 3 (predominantly female, greater adiposity and antioxidants, low smoking; n = 134.3) and Class 4 (predominantly male, greater lipids and adiposity, low antioxidants, high smoking prevalence; n = 115.4). For persons free of chronic disease (n = 285), incident chronic disease for classes 1, 3 and 4 was determined using follow up hospital, primary health care and death records collected in 2004/05. Fifty-four percent of Class 4 had incident chronic disease, an excess of 3355 events per 100,000 person years relative to Class 1. Incident CVD, hypertension, or CKD was highest for Class 4 and incident diabetes highest for Class 3. CONCLUSION Multi-mixture modelling appears useful in identifying population subgroups of an Aboriginal population at risk of chronic conditions.

The impact of health promotion on trachoma knowledge, attitudes and practice (KAP) of staff in three work settings in remote Indigenous communities in the Northern Territory

Background Globally, trachoma is the leading cause of infectious blindness and Australia is the only developed country with endemic trachoma. It is found in remote Indigenous communities burdened with poverty, overcrowding and poor hygiene. Lack of culturally appropriate health promotion, a small trachoma workforce and lack of awareness and support for trachoma elimination in general, were early barriers. Methods A cross-sectional pre-post study using a convenience sample, was conducted in clinics, schools and community work-settings from 63 of the 82 remote Aboriginal communities identified as being at risk of trachoma in the Northern Territory (NT). The study assessed the effect of a multi-component health promotion strategy aimed at increasing knowledge, attitude and practice amongst health, education and community support settings staff. Data were collected between 2010 and 2012. The health promotion initiatives were introduced in communities in staggered delivery over a one-year period; 272 participants were surveyed at baseline and 261 at follow-up. Results Trachoma related knowledge, attitudes and practice increased across all settings and for all primary outcome measures. Across all settings, there was a significant increase in the proportion of participants reporting the most important thing to do if a child has a ‘dirty’ face is to ‘wash it every time its dirty’ (61.6% cf 69.7%; X2p = 0.047), a significant reduction in the proportion of respondents answering ‘no’ to the question “Is it normal for kids to have dirty faces in your community’ (40.5% cf 29.6%; X2p = 0.009) and a significant increase in reported capacity to teach others about trachoma prevention (70.8% cf 83.3%; X2p <0.001). Conclusion Health promotion was associated with increased trachoma knowledge, attitude and practice amongst health, education and community support staff working with children and in remote NT communities. In the early stages of the trachoma health promotion program, this increased trachoma awareness and improved local workforce capacity and support for trachoma elimination in three health promotion settings in remote communities in the NT.

Health and wellbeing outcomes of programs for Indigenous Australians that include strategies to enable the expression of cultural identities: a systematic review

Indigenous people have long maintained that strong cultural identities are critical to health and wellbeing. The purpose of this systematic review is to examine whether interventions that entail strategies to enable expression of cultural identities for Australian Indigenous peoples are associated with measurable improvements in health and wellbeing. Peer-reviewed articles that reported quantitatively expressed health and wellbeing outcomes involving Indigenous Australian participants only were included. The cultural intervention component was defined and assessed by Indigenous researchers on the team. A narrative analysis was conducted. The protocol was registered on PROSPERO (CRD42015027387). Thirteen articles describing eleven studies were identified, including one randomised control trial (RCT), one cluster RCT and two studies with non-randomised controls. Other studies reported on case series or cross-sectional studies. All except two studies described multiple intervention strategies. Eight studies showed significant improvement in at least one psychosocial, behavioural or clinical measure, with two showing a positive direction of effect and one showing no improvement. Publication bias may discourage researchers to report negative findings of these interventions. Although studies vary in quality, this review provides evidence that interventions that include opportunities for expression of cultural identities can have beneficial effects for Australian Indigenous peoples.

An Australian model of the First 1000 Days: an Indigenous-led process to turn an international initiative into an early-life strategy benefiting indigenous families

Internationally, the 1000 days movement calls for action and investment in improving nutrition for the period from a childs conception to their second birthday, thereby providing an organising framework for early-life interventions. To ensure Australian Indigenous families benefit from this 1000 days framework, an Indigenous-led year-long engagement process was undertaken linking early-life researchers, research institutions, policy-makers, professional associations and human rights activists with Australian Indigenous organisations and families. The resultant model, First 1000 Days Australia, broadened the international concept beyond improving nutrition. The First 1000 Days Australia model was built by adhering to Indigenous methodologies, a recognition of the centrality of culture that reinforces and strengthens families, and uses a holistic view of health and wellbeing. The First 1000 Days Australia was developed under the auspice of Indigenous peoples leadership using a collective impact framework. As such, the model emphasises Indigenous leadership, mutual trust and solidarity to achieve early-life equity.

Albuminuria Is a Critical Determinant of Ckd Progression Among Indigenous Australian Adults: the Egfr Follow-Up Study

021 CELL BASED THERAPY IN COMBINATION WITH SERELAXIN IS CRITICAL FOR PRESERVATION OF VASCULAR INTEGRITY VIA PROMOTION OF ANGIOGENESIS AND ANASTOMOSIS B HUUSKES1, A PINTO2, C SAMUEL3, S RICARDO1 1Department of Anatomy and Developmental Biology, Monash University, Clayton, Victoria; 2Australian Regenerative Medicine Institute, Monash University, Clayton, Victoria; 3Department of Pharmacology, Monash University, Clayton, Victoria

International comparisons of kidney transplantation rates – seeking a road to success

Insufficient supplies of donor kidneys continue to represent a major barrier to renal transplantation in many countries. Solutions to this problem lie not only in hotly anticipated scientific developments such as stem cell therapies, but also in the evolution of clinical practices and protocols, legislation, and sociocultural attitudes that will facilitate the identification of potential donors, encourage consent for donation, and enable timely procurement of available kidneys. Data from the Global Observatory on Donation and Transplantation showing vast inequalities in kidney transplantation rates (KTR) between countries and evidence of rapid improvements within countries such as Croatia suggest that identification of ingredients for – or impediments to – success could provide a road map to national self-sufficiency in kidney transplantation. In search of this knowledge, a number of national and international studies have examined the influence of specific variables on indicators of success such as KTR. In this issue, Bendorf et al. present an ambitious study that strives to analyse the influence of 15 socioeconomic and demographic factors on KTR from living and deceased donors in 53 countries. Their work highlights the utility of pooling knowledge, and learning from the international experience. However, it also reveals some of the hazards and limitations of ecological study design: drawing conclusions regarding the influence of particular variables, especially in the absence of data at the individual level, risks ecological fallacy. In addition, where key factors are overlooked, data may be confounded. For example, two of the countries studied, Iran and Saudi Arabia, provide financial incentives for donation. Setting aside the significant ethical concerns of this practice, it is difficult to understand the rationale for including data from these countries without taking incentives into account as a variable, given that payment is widely considered responsible for the high rates of KTR in Iran at least. Finally, although unexpected associations between variables may provide exciting avenues for new research through hypothesis generation, they may also produce speculative conclusions of uncertain benefit. With the exception of the negative association found between presumed consent legislation and KTR from living donors – previously reported and of uncertain cause – Bendorf et al. discovered no statistically significant factors influencing living donation (LD) KTR. From this, they conclude that, ‘efforts to increase KTR should regard LD and DD [deceased donation] as completely separate and distinct entities with factors influencing them unique to each.’ However, rather than considering policies governing LD and DD in isolation, a more united approach may be precisely what is needed. The positive association Bendorf et al. find between DD KTR, nationalized transplantation programmes, and economic development, is supported by evidence from the world’s most successful DD programmes: investment in the healthcare infrastructure necessary for DD and oversight of programmes by national authorities have been critical to the success of the famed ‘Spanish Model’ and similar strategic paradigms implemented in Portugal and Croatia, for example. Societal and political support for DD and transplantation may well manifest in the introduction of presumed consent legislation, leading to the strong association between DD KTR and presumed consent policies that Bendorf et al. report. In keeping with the findings of other studies exploring the influence of DD consent policies on rates of organ donation, they suggest this positive correlation is likely indicative of additional factors rather than evidence of a causal effect. The practical requirements for deceased donation are such that DD KTR will depend to a large extent upon societal commitment to – and investment in – the goal of meeting public needs for transplantation through DD. Living donation allows for a less communal approach, with individual donor-recipient pairs able to form on an ad hoc basis. In contrast to the collective, often nationally framed responses to DD issues, efforts to encourage and facilitate living kidney donation frequently fall within the purview of provinces, states, or even individual healthcare institutions. Strategies that have successfully increased LD KTR such as targeted education programmes and the use of laparoscopic nephrectomy are often confined to specific hospitals or regions. Although, like DD, LD often requires a highly sensitive and personalized approach in clinical practice, this should not discourage analysis of successful strategies that could be trialled on a larger scale, adapted to suit different healthcare systems, and subjected to international comparison. Systematic implementation of new strategies to enhance LD at the national level, using public health and educational resources, may prove as effective as international adoption and adaptation of the ‘Spanish model’. By correlating data across nations in a study such as this, researchers may be diverted from further exploration of important variables. For example, the apparent lack of statistically significant economic influences on LD KTR may be indicative of the need for more detailed data, especially given prior evidence that socioeconomic factors do play a role in facilitating or impairing access to living donor kidney bs_bs_banner