Wendy E. Hoy

Protein catabolism during the postoperative course after renal transplantation.

Protein catabolic rate (PCR) was measured daily by computerized mass balance studies in 50 subjects during hospitalization after renal transplant. All subjects received 60 mg prednisone per day. PCR rose over the first 3 to 4 postoperative days and then stabilized at an accelerated level, which was sustained through the third posttransplant week. Rejection therapy with either 3 mg/kg/d prednisone or 15 mg/kg/d of methylprednisolone for 3 days further increased PCR, but there was no difference in PCR between these two regimens. Protein restriction did not decrease PCR and subjects offered a higher protein diet did not have further acceleration of PCR. We conclude that 60 mg/kg/d prednisone produces an obligatory acceleration of PCR that is further accentuated by higher steroid doses. The use of minimal maintenance doses of prednisone consistent with adequate immunosuppression seems wise. Protein balance may be improved if protein intake is increased to match individual rates of accelerated protein catabolism.

Disorders of glucose regulation in adults and birth weight: results from the Australian Diabetes, Obesity and Lifestyle (AUSDIAB) Study.

OBJECTIVE—The purpose of this study was to examine the association of birth weight with indexes of glycemia in a population-based survey. RESEARCH DESIGN AND METHODS—A total of 10,788 participants in the Australian Diabetes, Obesity and Lifestyle (AusDiab) Study were asked to complete a birth weight questionnaire. Fasting plasma glucose (FPG), postload glucose (PLG), and A1C were modeled against birth weight. World Health Organization criteria were used to define impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and diabetes. RESULTS—Among 7,157 participants who responded to the questionnaire, 4,502 reported their birth weights, with a mean ± SD of 3.4 ± 0.7 kg. FPG, PLG, and A1C were strongly and inversely correlated with birth weight. The odds ratios (95% CI) for high (>90th sex-specific percentile) FPG, PLG, and A1C were 0.83 (0.71–0.96), 0.74 (0.65–0.84), and 0.81 (0.70–0.94), respectively, for a 1-kg increase in birth weight after adjustment for age and sex. In those with low birth weight (LBW), the risks for having IFG, IGT, and diabetes and for all abnormalities combined were increased by 1.75, 2.22, 2.76, and 2.28, respectively, for women and by 1.40, 1.32, 1.98, and 1.49 for men compared with risks for those with normal birth weight. These trends applied across categories of age and BMI. CONCLUSIONS—In an affluent Western country with a good adult health profile, birth weight has an inverse relationship with indexes of glycemia, and individuals with LBW were predisposed to higher rates of glycemic dysregulation in adult life. These associations were independent of BMI and of other factors significantly correlated with glycemic dysregulation.

Body mass index and mortality in aboriginal Australians in the Northern Territory.

Objective: To assess the association between body mass index and the risk of all‐cause and disease‐specific mortalities in Australian Aborigines in a remote community.

MARKERS FOR CARDIOVASCULAR AND RENAL MORBIDITY: EXPECTATIONS FOR AN INTERVENTION PROGRAMME IN AN AUSTRALIAN ABORIGINAL COMMUNITY

1 Australian Aborigines have high rates of both cardiovascular mortality and renal failure and the usual male dominance in these conditions is respectively reduced and effaced. 2 In one Aboriginal community, we have demonstrated a strong association between albuminuria and cardiovascular risk factors and a relationship of both with insulin resistance, which is more pronounced in females than males. 3 We propose that albuminuria is a component of Syndrome X and that reduction in levels of albuminuria should prove to be a useful marker of effectiveness in treatment programmes targeting cardiovascular risk as well as renal disease.

Towards a definition of glomerulomegaly: clinical–pathological and methodological considerations

Background. Glomerulomegaly, the abnormal enlargement of glomeruli, has been related to an increased risk of glomerulosclerosis, but the degree of enlargement that constitutes glomerulomegaly has not been defined. Methods. The principal stereological methods for estimating glomerular volume are [1] the disector/Cavalieri method that is considered the ‘gold standard’ for measuring individual glomerular volume (IVglom) and [2] the disector/fractionator technique that estimates average glomerular volume (Vglom) together with total glomerular number (Nglom) for the entire kidney. The two methods produce different estimates with Vglom consistently exceeding IVglom. This study compares glomerular volumes obtained by the two methods in autopsy kidneys of 39 African American and 34 US white adult males, and correlates the values with Nglom, body mass index (BMI), hypertension, glomerulosclerosis and race, factors known or thought to influence glomerular volume. Results. For the smallest glomeruli, Vglom was 25% larger than IVglom with the difference increasing to over 50% for kidneys with the largest glomeruli. Both Vglom and IVglom showed significant inverse correlations with Nglom and significant direct correlations with BMI and hypertension. African Americans had larger IVglom and Vglom than whites, but only IVglom was significant. The 90th percentile for IVglom was 6.81 μm3 × 106 and 13.10 μm3 × 106 for Vglom, but larger glomerular size did not separate hypertensive from non-hypertensive subjects nor did it show any significant relationship to glomerulosclerosis. While Vglom overestimated glomerular size compared with IVglom, both measurements demonstrated similar relationships to factors influencing glomerular volume. Conclusions. With neither method could glomerulomegaly, the abnormal enlargement of glomerular size predisposing to glomerulosclerosis, be determined.

CKD.QLD: chronic kidney disease surveillance and research in Queensland, Australia

Background Chronic kidney disease (CKD) is recognized as a major public health problem in Australia with significant mortality, morbidity and economic burden. However, there is no comprehensive surveillance programme to collect, collate and analyse data on CKD in a systematic way. Methods We describe an initiative called CKD Queensland (CKD.QLD), which was established in 2009 to address this deficiency, and outline the processes and progress made to date. The foundation is a CKD Registry of all CKD patients attending public health renal services in Queensland, and patient recruitment and data capture have started. Results We have established through early work of CKD.QLD that there are over 11 500 CKD patients attending public renal services in Queensland, and these are the target population for our registry. Progress so far includes conducting two CKD clinic site surveys, consenting over 3000 patients into the registry and initiation of baseline data analysis of the first 600 patients enrolled at the Royal Brisbane and Womens Hospital (RBWH) site. In addition, research studies in dietary intake and CKD outcomes and in models of care in CKD patient management are underway. Conclusions Through the CKD Registry, we will define the distribution of CKD patients referred to renal practices in the public system in Queensland by region, remoteness, age, gender, ethnicity and socioeconomic status. We will define the clinical characteristics of those patients, and the CKD associations, stages, co-morbidities and current management. We will follow the course and outcomes in individuals over time, as well as group trends over time. Through our activities and outcomes, we are aiming to provide a nidus for other states in Australia to join in a national CKD registry and network.

Chronic Kidney Disease Management – What Can We Learn from South African and Australian Efforts?

Background: The prevalence of chronic kidney disease is on the rise. Our objective is to describe two programs to improve the awareness and management of hypertension, renal disease, and diabetes in remote Australian Aboriginal and urban and periurban South African communities. We focus on how the Australian Aboriginal and South African Chronic Disease Outreach Programs have worked together. Methods: The establishment of prevention programs in developing countries is a challenge. The paper evaluates these challenges, including accessing international aid. The programs advocate that regular integrated checks for chronic disease and their risk factors are essential elements of regular adult health care. Programs should be run by primary health workers, following algorithms for testing and treatment, and a backup provided by nurse coordinators. Constant evaluation is essential to develop community health profiles and adapt program structure. Results: Both programs are discussed, including how they are organized to deliver preventative and treatment strategies. The challenges and adaptations required are outlined. Conclusions: It is the aim of the international kidney commu- nity to prevent chronic kidney disease. The South African and Australian groups highlight the need for a systematic and sustained approach to the management of chronic diseases to achieve this goal.

CIRRHOSIS AND DEATH AFTER JEJUNOILEAL SHUNT FOR OBESITY

Cirrhosis following small-bowel bypass with jejunocolic anastomosis for obesity is well recognized (1-7). Opinions differ concerning permanent liver damage following jejunoileal bypass, but most of the evidence supports jejunoileal bypass as being relatively safe (816) and there are only one or two well documented cases of death from cirrhosis following jejunoileal shunt (15, 17). We report another such case.

Kidney disease in Aboriginal Australians: a perspective from the Northern Territory.

This article outlines the increasing awareness, service development and research in renal disease in Aboriginal people in Australias Northern Territory, among whom the rates of renal replacement therapy (RRT) are among the highest in the world. Kidney failure and RRT dominate the intellectual landscape and consume the most professional energy, but the underlying kidney disease has recently swung into view, with increasing awareness of its connection to other chronic diseases and to health profiles and trajectories more broadly. Albuminuria is the marker of the underlying kidney disease and the best treatment target, and glomerulomegaly and focal glomerulosclerosis are the defining histologic features. Risk factors in its multideterminant genesis reflect nutritional and developmental disadvantage and inflammatory/infectious milieu, while the major putative genetic determinants still elude detection. A culture shift of “chronic disease prevention” has been catalyzed in part by the human pain, logistic problems and great costs associated with RRT. Nowadays chronic disease management is the central focus of indigenous primary care, with defined protocols for integrated testing and management of chronic diseases and with government reimbursed service items and free medicines for people in remote areas. Blood pressure, cardiovascular risk and chronic kidney disease (CKD) are all mitigated by good treatment, which centres on renin-angiotensin system blockade and good metabolic control. RRT incidence rates appear to be stabilizing in remote Aboriginal people, and chronic disease deaths rates are falling. However, the profound levels of disadvantage in many remote settings remain appalling, and there is still much to be done, mostly beyond the direct reach of health services.

Indigenous mortality in remote Queensland, Australia

Objectives: To quantify Indigenous mortality, compare it with non‐Indigenous mortality, and identify causes of excess Indigenous mortality by remoteness in Queensland, 1997–2000.