The Long-Term Risks of End Stage Renal Disease and Mortality among First Nations and Non-First Nations People with Youth-Onset Diabetes

Aboriginal and Torres Strait Islander Attitudes to Organ Donation in Central Australia: A Qualitative Pilot Study

Background

Organ transplantation is a well-established intervention but is reliant on the donation of organs and tissues, mostly from deceased donors. The proportion of Australians proceeding to organ donation (OD) has increased, but the proportion of Indigenous Australians proceeding remains two-thirds that of non-Indigenous Australians. We sought to explore perceived barriers and enablers for the involvement of Indigenous peoples in the OD process.

Methods

Qualitative methodology centered around focus groups was used to capture the experiences and perspectives of Indigenous people regarding OD. A purposively sampled group of Aboriginal Liaison Officers working within the Alice Springs Hospital Intensive Care Unit (ASH ICU) participated in up to 6 focus groups during 2021 with subsequent thematic analysis of the enablers and barriers to Indigenous participation in the OD process. The ASH ICU is the only ICU servicing Central Australia, and 70% of admissions are Indigenous patients.

Results

Four primary themes emerged: OD is a new and culturally taboo topic; conversations related to OD are confronting; education is needed (both about OD and cultural education for clinicians); and lack of trust in the healthcare system.

Conclusions

There are cultural barriers to engaging in the OD process and clinicians need more training on the delivery of culturally safe communication is needed. Despite this, there was a recognition that OD is important. Education about OD needs to be place based, culturally and linguistically appropriate, informed by local knowledge, delivered in community, and occur before a family member is admitted to ICU.

Effectiveness of RADAR on diabetes processes of care for First Nations communities in Alberta, Canada

The epidemic of type-2 diabetes in First Nations communities is tragic. Culturally-appropriate approaches addressing multiple components, focusing beyond glycemic control, are urgently needed. Using an intention-to-treat framework, 13 processes of care indicators were assessed to compare proportions of patients who received care at baseline relative to 2-year follow-up. Clinical improvements were demonstrated across major process of care indicators (e.g. screening, education, and vaccination activities). We found RADAR improved reporting for most diabetes processes of care across seven FN communities and was effective in supporting diabetes care for FN communities, in Alberta Canada.

Participation and Outcomes among Disabled and Non-Disabled People in the Diabetes Pay-for-Performance Program

OBJECTIVES

This study's objectives were to compare the participation rates of people with and without disabilities who had type 2 diabetes in a diabetes pay-for-performance (DM P4P) program, as well as their care outcomes after participation.

METHODS

This was a retrospective cohort study. The data came from the disability registry file, cause of death file, and national health insurance research database of Taiwan. The subjects included patients newly diagnosed with type 2 diabetes between 2001 and 2013 who were followed up with until 2014 and categorized as disabled and non-disabled patients. The propensity score matching method was used to match the disabled with the non-disabled patients at a 1:1 ratio. Conditional logistic regression analysis was used to determine the odds ratio between the disabled and non-disabled patients who joined the P4P program. The Cox hazard model was used to compare the risk of dialysis and death between the disabled and non-disabled patients participating in the P4P program.

RESULTS

There were 110,645 disabled and 110,645 non-disabled individuals after matching. After controlling for confounding factors, it was found that the disabled individuals were significantly less likely (odds ratio = 0.89) to be enrolled in the P4P program than the non-disabled individuals. The risk of dialysis was 1.08 times higher for people with disabilities than those without, regardless of their participation in the P4P program. After enrollment in the P4P program, the risk of death for people with disabilities decreased from 1.32 to 1.16 times that of persons without disabilities. Among the people with disabilities, the risk of death for those enrolled in the P4P program was 0.41 times higher than that of those not enrolled. The risk of death was reduced to a greater extent for people with disabilities than for those without disabilities upon enrollment in the DM P4P program.

CONCLUSION

People with disabilities are less likely to be enrolled in the P4P program in Taiwan and have unequal access to care. However, the P4P program was more effective at reducing mortality among people with disabilities than among those without.

Validating a novel three-times-weekly post-hemodialysis ceftriaxone regimen in infected Indigenous Australian patients-a population pharmacokinetic study

OBJECTIVES

To describe the total and unbound population pharmacokinetics of a 2 g three-times-weekly post-dialysis ceftriaxone regimen in Indigenous Australian patients requiring hemodialysis.

METHODS

A pharmacokinetic study was carried out in the dialysis unit of a remote Australian hospital. Adult Indigenous patients on intermittent hemodialysis (using a high-flux dialyzer) and treated with a 2 g three-times-weekly ceftriaxone regimen were recruited. Plasma samples were serially collected over two dosing intervals and assayed using validated methodology. Population pharmacokinetic analysis and Monte Carlo simulations were performed using Pmetrics in R. The probability of pharmacokinetic/pharmacodynamic target attainment (unbound trough concentrations ≥1 mg/L) and toxicity [trough concentrations (total)  ≥100 mg/L] were simulated for various dosing strategies.

RESULTS

Total and unbound concentrations were measured in 122 plasma samples collected from 16 patients (13 female) with median age 57 years. A two-compartment model including protein-binding adequately described the data, with serum bilirubin concentrations associated (inversely) with ceftriaxone clearance. The 2 g three-times-weekly regimen achieved 98% probability to maintain unbound ceftriaxone concentrations ≥1 mg/L for a serum bilirubin of 5 µmol/L. Incremental accumulation of ceftriaxone was observed in those with bilirubin concentrations >5 µmol/L. Three-times-weekly regimens were less probable to achieve toxic exposures compared with once-daily regimens. Ceftriaxone clearance was increased by >10-fold during dialysis.

CONCLUSIONS

A novel 2 g three-times-weekly post-dialysis ceftriaxone regimen can be recommended for a bacterial infection with an MIC ≤1 mg/L. A 1 g three-times-weekly post-dialysis regimen is recommended for those with serum bilirubin ≥10 µmol/L. Administration of ceftriaxone during dialysis is not recommended.

Risk of kidney disease following a pregnancy complicated by diabetes: a longitudinal, population-based data-linkage study among Aboriginal women in the Northern Territory, Australia

AIMS/HYPOTHESIS

The aim of this work was to investigate the risk of developing chronic kidney disease (CKD) or end-stage kidney disease (ESKD) following a pregnancy complicated by gestational diabetes mellitus (GDM) or pre-existing diabetes among Aboriginal women in the Northern Territory (NT), Australia.

METHODS

We undertook a longitudinal study of linked healthcare datasets. All Aboriginal women who gave birth between 2000 and 2016 were eligible for inclusion. Diabetes status in the index pregnancy was as recorded in the NT Perinatal Data Collection. Outcomes included any stage of CKD and ESKD as defined by ICD-10 coding in the NT Hospital Inpatient Activity dataset between 2000 and 2018. Risk was compared using Cox proportional hazards regression.

RESULTS

Among 10,508 Aboriginal women, the mean age was 23.1 (SD 6.1) years; 731 (7.0%) had GDM and 239 (2.3%) had pre-existing diabetes in pregnancy. Median follow-up was 12.1 years. Compared with women with no diabetes during pregnancy, women with GDM had increased risk of CKD (9.2% vs 2.2%, adjusted HR 5.2 [95% CI 3.9, 7.1]) and ESKD (2.4% vs 0.4%, adjusted HR 10.8 [95% CI 5.6, 20.8]). Among women with pre-existing diabetes in pregnancy, 29.1% developed CKD (adjusted HR 10.9 [95% CI 7.7, 15.4]) and 9.9% developed ESKD (adjusted HR 28.0 [95% CI 13.4, 58.6]).

CONCLUSIONS/INTERPRETATION

Aboriginal women in the NT with GDM or pre-existing diabetes during pregnancy are at high risk of developing CKD and ESKD. Pregnancy presents an important opportunity to identify kidney disease risk. Strategies to prevent kidney disease and address the social determinants of health are needed.

The Effects of COVID-19 Pandemic and Lockdown on Pediatric Nutritional and Metabolic Diseases: A Narrative Review

SARS-CoV-2 was the first pathogen implied in a worldwide health emergency in the last decade. Containment measures have been adopted by various countries to try to stop infection spread. Children and adolescents have been less clinically involved by COVID-19, but the pandemic and consequent containment measures have had an important influence on the developmental ages. The COVID-19 pandemic and the subsequent lockdown periods have influenced the nutrition and lifestyles of children and adolescents, playing an epigenetic role in the development of nutrition and metabolic diseases in this delicate age group. The aim of our review is to investigate the effects of the COVID-19 pandemic on nutrition and metabolic diseases in the developmental ages. Moreover, we have analyzed the effect of different containment measures in children and adolescents. An increase in being overweight, obesity and type 2 diabetes mellitus has been detected. Concerning type 1 diabetes mellitus, although a validated mechanism possibly linking COVID-19 with new onset type 1 diabetes mellitus has not been yet demonstrated, barriers to the accessibility to healthcare services led to delayed diagnosis and more severe presentation of this disease. Further studies are needed to better investigate these relationships and to establish strategies to contain the nutritional and metabolic impact of new pandemics in the developmental ages.

Kidney Health of Indigenous Children: Insights from Australia, Aotearoa New Zealand, and Canada

Purpose of Review

This review seeks to highlight the common and unique factors that impact the kidney health of Indigenous children in Australia, Aotearoa New Zealand, and Canada with a particular interest on efforts to improve their kidney health outcomes and the framework to pursue future efforts.

Recent Findings

In the period since the adoption of the United Nations (UN) Declaration on the Rights of Indigenous People (UNDRIP) there has been a number of studies documenting poorer renal health outcomes and potential causes amongst Indigenous paediatric populations in Australia, Aotearoa New Zealand, and Canada. There is a shortage of studies that look at interventions to improve these outcomes.

Summary

Poorer kidney health outcomes amongst Indigenous children are rarely genetic and appear to be more related to societal inequities. Reported efforts to improve outcomes are few but have demonstrated the ability to make change and with sustained focus on reducing inequities there is hope to improve the renal health of Indigenous children.

The impact of community-based non-pharmacological interventions on cardiovascular and kidney disease outcomes in remote dwelling Indigenous communities: A scoping review protocol

Introduction

Indigenous people represent approximately 5% of the world’s population. However, they often have a disproportionately higher burden of cardiovascular disease (CVD) risk and chronic kidney disease (CKD) than their equivalent general population. Several non-pharmacological interventions (e.g., educational) have been used to reduce CVD and kidney disease risk factors in Indigenous groups. The aim of this paper is to describe the protocol for a scoping review that will assess the impact of non-pharmacological interventions carried out in Indigenous and remote dwelling populations to reduce CVD risk factors and CKD.

Materials and methods

This scoping review will be guided by the methodological framework for conducting scoping studies developed by Arksey and O’Malley. Both empirical (Medline, Embase, Cochrane Library, CINAHL, ISI Web of Science and PsycINFO) and grey literature references will be assessed if they focused on interventions targeted at reducing CVD or CKD among Indigenous groups. Two reviewers will independently screen references in consecutive stages of title/abstract screening and then full-text screening. Impact of interventions used will be assessed using the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework. A descriptive overview, tabular summaries, and content analysis will be carried out on the extracted data.

Ethics and dissemination

This review will collect and analyse evidence on the impact of interventions of research carried out to reduce CVD and CKD among Indigenous populations. Such evidence will be disseminated using traditional approaches that includes open-access peer-reviewed publication, scientific presentations, and a report. Also, we will disseminate our findings to the government and Indigenous leaders. Ethical approval will not be required for this scoping review as the data used will be extracted from already published studies with publicly accessible data.

Spectrum of Phenotypes and Causes of Type 2 Diabetes in Children

Several factors, including genetics, family history, diet, physical activity, obesity, and insulin resistance in puberty, appear to increase the risk of type 2 diabetes in youth. Youth-onset type 2 diabetes is often thought of as a single entity but rather exists as a spectrum of disease with differences in presentation, metabolic characteristics, clinical progression, and complication rates. We review what is currently known regarding the risks associated with developing type 2 diabetes in youth. Additionally, we focus on the spectrum of phenotypes of pediatric type 2 diabetes, discuss the pathogenic underpinnings and potential therapeutic relevance of this heterogeneity, and compare youth-onset type 2 diabetes with type 1 diabetes and adult-onset type 2 diabetes. Finally, we highlight knowledge gaps in prediction and prevention of youth-onset type 2 diabetes.

Derivation and Validation of a Prediction Model of End-Stage Renal Disease in Patients With Type 2 Diabetes Based on a Systematic Review and Meta-analysis

OBJECTIVES

To develop and validate a model for predicting the risk of end-stage renal disease (ESRD) in patients with type 2 diabetes.

METHODS

The derivation cohort was from a meta-analysis. Statistically significant risk factors were extracted and combined to the corresponding risk ratio (RR) to establish a risk assessment model for ESRD in type 2 diabetes. All risk factors were scored according to their weightings to establish the prediction model. Model performance is evaluated using external validation cohorts. The outcome was the occurrence of ESRD defined as eGFR<15 ml min^-1 1.73 m^-2 or received kidney replacement therapy (dialysis or transplantation).

RESULTS

A total of 1,167,317 patients with type 2 diabetes were included in our meta-analysis, with a cumulative incidence of approximately 1.1%. The final risk factors of the prediction model included age, sex, smoking, diabetes mellitus (DM) duration, systolic blood pressure (SBP), hemoglobin A1c (HbA1c), estimated glomerular filtration rate (eGFR), and triglyceride (TG). All risk factors were scored according to their weightings, with the highest score being 36.5. External verification showed that the model has good discrimination, AUC=0.807(95%CI 0.753-0.861). The best cutoff value is 16 points, with the sensitivity and specificity given by 85.33% and 60.45%, respectively.

CONCLUSION

The study established a simple risk assessment model including 8 routinely available clinical parameters for predicting the risk of ESRD in type 2 diabetes.

Impact of point-of-care screening for hypertension, diabetes and progression of chronic kidney disease in rural Manitoba Indigenous communities

BACKGROUND

In 2013-2015, we conducted point-of-care screening for hypertension, diabetes and chronic kidney disease in rural and remote Indigenous communities in Manitoba, Canada. In this study, we aimed to determine whether optimal follow-up care was provided, defined as proportion of individuals with appropriate kidney disease laboratory testing, medication prescriptions and physician visits.

METHODS

We linked screening data from participants to provincial administrative data sets to evaluate whether frequencies of laboratory testing, prescriptions of disease-modifying medications, and primary care and nephrology visits differed in the 18 months before and after screening. We also conducted a propensity score matching analysis to compare outcomes between screened and unscreened adults.

RESULTS

Of 1353 adults who received the screening intervention and who had complete administrative data available, 44% were at risk of kidney failure at screening. Among these individuals, frequencies of comprehensive laboratory testing (estimated glomerular filtration rate and urine albumin to creatinine ratio) improved by 17.0% (95% confidence interval [CI] 11.5 to 22.5), anti-hyperglycemic medications improved by 4.4% (95% CI 1.0 to 7.8), and nephrology visits for participants meeting referral criteria improved by 5.9% (95% CI 3.4 to 8.5). We observed significant improvements in laboratory testing, antihyperglycemic medications and nephrology visits in the screened group compared with the 1:1 matched comparison group.

INTERPRETATION

Point-of-care screening programs in rural and remote Indigenous communities are adaptable methods for increasing awareness, monitoring risk and treating chronic diseases. Interventions such as the development of a national screening program could improve chronic disease care in high-risk populations.

Critical review of social, environmental and health risk factors in the Mexican indigenous population and their capacity to respond to the COVID-19

The objective of this study was to conduct a critical analysis of the social, environmental and health risk factors in the Mexican indigenous population in the context of the COVID-19 disease pandemic, and to propose strategies to mitigate the impacts on these communities. Regarding social factors, we identified the return of indigenous people to their communities, poor access to water, language barriers, and limited access to the Internet, as factors that will not allow them to take the minimum preventive measures against the disease. Additionally, environmental risk factors associated with pollutants from biomass burning were identified. In health, the lack of coverage in these areas and comorbidities such as diabetes mellitus, hypertension, respiratory tract infections, and chronic pulmonary diseases were identified. Some existing government programmes were identified that could be supported to address these social, environmental and health gaps. We believe that the best way to address these issues is to strengthen the health system with a community-based approach. Health is the best element of cohesion for inserting development and progress proposals in indigenous communities, given the vulnerability to which they are exposed in the face of the COVID-19 pandemic. In this review, all information is provided (as possible) on risk factors and potential solutions in indigenous communities in the hope of providing solutions to this pandemic and providing a reference for future studies.

Assessment of kidney health and exposure to mixture pollutants in the Mexican indigenous population

The indigenous population is one of the most vulnerable to suffer from contaminated environments. One of the target organs to suffer early deterioration from exposure to toxins is the kidney. The objective of this article was to evaluate biomarkers of exposure to organic and inorganic toxins and biomarkers of early kidney damage in urine from an indigenous Tenek population in Mexico. The biomarkers of exposure were Li, Be, Al, V, Cr, Mn, Fe, Ni, Cu, Zn, As, Se, Mo, Sn, Ba, and Pb evaluated by ICP-MS and hippuric acid for toluene exposure evaluated by UV-coupled with liquid chromatography; the biomarkers of kidney damage were cystatin C (Cys-C), osteopontin (OPN), retinol-binding protein-4 (RPB-4), and neutrophil gelatinase-associated lipocalin (NGAL). Thirty-one urine samples were obtained from indigenous people; 16, 42, 45.1, and 45.2% of the population exceeded the reference values for Pb, Zn, As, and hippuric acid respectively. Our results demonstrate significant correlations between the metals tested and the proteins associated with renal damage; Cys-C, OPN, and RPB4 showed a significant correlation with Li, B, and Mo, as well as hippuric acid in the case of Cys-C and Zn in OPN and RPB-4; NGAL did not present significant correlations with any of the pollutants of the study. This pilot study contributes to the evidence of great inequity in health associated to environmental pollution matters faced by indigenous people and addresses the need of initiatives for mitigation under the perspective that health is a fundamental human right.

Young-onset type 2 diabetes mellitus - implications for morbidity and mortality

Accumulating data suggest that type 2 diabetes mellitus (T2DM) in younger people (aged <40 years), referred to as young-onset T2DM, has a more rapid deterioration of β-cell function than is seen in later-onset T2DM. Furthermore, individuals with young-onset T2DM seem to have a higher risk of complications than those with type 1 diabetes mellitus. As the number of younger adults with T2DM increases, young-onset T2DM is predicted to become a more frequent feature of the broader diabetes mellitus population in both developing and developed nations, particularly in certain ethnicities. However, the magnitude of excess risk of premature death and incident complications remains incompletely understood; likewise, the potential reasons for this excess risk are unclear. Here, we review the evidence pertaining to young-onset T2DM and its current and future burden of disease in terms of incidence and prevalence in both developed and developing nations. In addition, we highlight the associations of young-onset T2DM with premature mortality and morbidity.

Examining the Impact of First Nations Status on the Relationship Between Diabetes and Cancer

Purpose: This population-based study examined the relationship between diabetes and cancer and determined if this relationship was influenced by First Nations (FN) status.

Methods: In a matched case–cohort study, individuals 30–74 years of age diagnosed with diabetes during 1984–2008 in the province of Manitoba, Canada, with no cancer diagnosis before their diabetes diagnosis were matched to one diabetes-free control by age, sex, FN status, and residence. Flexible competing risk and Royston–Parmar regression models were used to compare cancer rates.

Results: Overall, 72,715 individuals diagnosed with diabetes were matched to controls. In all age groups, diabetes was related to an increased risk of cancer. The relationship between diabetes and any type of cancer was not influenced by FN status (i.e., there was no interaction between the diagnosis of diabetes and people's FN status for any age group). The only significant interaction between diabetes and FN status was for kidney cancer for individuals 60–74 years of age; diabetes increased the risk of kidney cancer for all other Manitobans (AOMs) but not for FN.

Conclusions: Diabetes increased the risk of cancer. The association was not modified by FN status except for kidney cancer where diabetes increased the risk for AOMs but not for FN.

Prevalence of chronic kidney disease and cardiovascular comorbidities in adults in First Nations communities in northwest Ontario: a retrospective observational study

BACKGROUND

The prevalence of adult chronic kidney disease and cardiovascular comorbidities in Canadian Indigenous communities is largely unknown. We conducted a study to document the prevalence of chronic kidney disease and concurrent diabetes mellitus, hypertension and dyslipidemia in a First Nations population in northwest Ontario.

METHODS

In this observational study, we used retrospective data collected from regional electronic medical records of 16 170 adults (age ≥ 18 yr) from 26 First Nations communities in northwest Ontario from May 2014 to May 2017. Demographic and laboratory data included age, gender, prescribed medications, estimated glomerular filtration rate, urine albumin:creatinine ratio, low-density lipoprotein cholesterol (LDL-C) level and glycated hemoglobin (HbA1c) concentration. We identified patients with diabetes by an HbA1c concentration of 6.5% or higher, or the use of a diabetic medication, those with dyslipidemia by an elevated LDL-C level (≥ 2.0 mmol/L) or use of lipid-lowering medication, and those with hypertension by use of antihypertensive medication.

RESULTS

Of the 16 170 adults residing in the communities, 5224 unique patients (32.3%) had renal testing (albumin:creatinine ratio and/or estimated glomerular filtration rate). The age-adjusted prevalence of chronic kidney disease was 14.5%, and the prevalence of stage 3-5 chronic kidney disease (estimated glomerular filtration rate < 60 mL/min) was 7.0%. Most patients with chronic kidney disease (1487 [80.0%]) had at least 1 cardiovascular comorbidity. A total of 1332 patients (71.6%) had diabetes, 1313 (70.6%) had dyslipidemia, and 1098 (59.1%) had hypertension; all 3 comorbidities were present in 716 patients (38.5%).

INTERPRETATION

We document a high prevalence of advanced chronic kidney disease in this First Nations population, 7.0%, double the rate in the general population. High rates of cardiovascular comorbidities were also common in these patients with chronic kidney disease, which places them at increased risk for cardiovascular disease.

Prediabetes: An emerging public health concern in adolescents

OBJECTIVES

To identify the presence of risk factors for type 2 diabetes (ethnicity, body mass index, blood glucose tolerance and blood pressure) and to determine the prevalence of prediabetes and type 2 diabetes in Canadian adolescents attending two multicultural urban high schools.

METHODS

A total of 266 multicultural urban high school students who live in a mid-sized Western Canadian city, aged 14-21, were screened for risk factors of prediabetes and type 2 diabetes in March-April 2018. Data with respect to demographics, family history of diabetes, anthropometrics, blood pressure and haemoglobin A1c (HbA1c) were collected. Data analysis was done using descriptive and inferential statistics in addition to chi-square analyses.

RESULTS

Based on body mass index, 38% of the adolescents were classified as either overweight or obese. Overweight rates for females (69.8%) were double than males (30.2%); however, males (52.2%) were more likely to obese than the females (47.8%). Based on HbA1c levels, 29.3% were at high risk to develop either diabetes or prediabetes and 2.6% were classified in the prediabetes range. Prehypertension/hypertension rates of 47% in the sample increased to 51% in those adolescents with elevated HbA1c; the majority of these prehypertensive/hypertensive participants were male.

CONCLUSION

High rates of overweight/obesity and prehypertension/hypertension were found in the adolescents studied and indicated the presence of prediabetes and an increased risk to develop type 2 diabetes and associated complications. Obesity and hypertension are major risk factors for developing type 2 diabetes, resulting in earlier exposure to metabolic consequences and, ultimately, long-term complications. Thus, timely research is needed to identify age-appropriate strategies that address risks and to develop recommendations for routine screening of adolescents for prediabetes.

Widening the lens to childhood: relevance and lifetime risk of kidney failure

PURPOSE OF REVIEW

Lifetime risk of outcomes is emerging as a highly relevant health indicator, even in the context of low absolute risk of disease progression in short time frames. Evidence to support this concept for kidney failure is increasing, with growing emphasis on the long-term impact of risk factors occurring early in life.

RECENT FINDINGS

Proteinuria and stage of chronic kidney disease (CKD) are now established predictors of CKD progression in children, and youth with type 2 diabetes are emerging as a group at significant risk. Recent population-based studies have also examined the lifetime risk of end-stage renal disease in individuals with any childhood CKD. A recent study found that even in the absence of biomarkers of renal injury, childhood CKD can increase the lifetime risk of end-stage renal disease four-fold, and up to 10-fold in adults less than 40 years of age.

SUMMARY

Children with CKD are at high lifetime risk of kidney failure and require follow-up. Identifying children at highest lifetime risk through the use of biomarkers and risk equations, and determining the optimal duration and intensity of follow-up requires further research.

Projecting prevalence, costs and evaluating simulated interventions for diabetic end stage renal disease in a Canadian population of aboriginal and non-aboriginal people: an agent based approach

BACKGROUND

Diabetes-related end stage renal disease (DM-ESRD) is a devastating consequence of the type 2 diabetes epidemic, both of which disproportionately affect Indigenous peoples. Projecting case numbers and costs into future decades would help to predict resource requirements, and simulating hypothetical interventions could guide the choice of best practices to mitigate current trends.

METHODS

An agent based model (ABM) was built to forecast First Nations and non-First Nations cases of DM-ESRD in Saskatchewan from 1980 to 2025 and to simulate two hypothetical interventions. The model was parameterized with data from the Canadian Institute for Health Information, Saskatchewan Health Administrative Databases, the Canadian Organ Replacement Register, published studies and expert judgement. Input parameters without data sources were estimated through model calibration. The model incorporated key patient characteristics, stages of diabetes and chronic kidney disease, renal replacement therapies, the kidney transplant assessment and waiting list processes, costs associated with treatment options, and death. We used this model to simulate two interventions: 1) No new cases of diabetes after 2005 and 2) Pre-emptive renal transplants carried out on all diabetic persons with new ESRD.

RESULTS

There was a close match between empirical data and model output. Going forward, both incidence and prevalence cases of DM-ESRD approximately doubled from 2010 to 2025, with 250-300 new cases per year and almost 1300 people requiring RRT by 2025. Prevalent cases of First Nations people with DM-ESRD increased from 19% to 27% of total DM-ESRD numbers from 1990 to 2025. The trend in yearly costs paralleled the prevalent DM-ESRD case count. For Scenario 1, despite eliminating diabetes incident cases after 2005, prevalent cases of DM-ESRD continued to rise until 2019 before slowly declining. When all DM-ESRD incident cases received a pre-emptive renal transplant (scenario 2), a substantial increase in DM-ESRD prevalence occurred reflecting higher survival, but total costs decreased reflecting the economic advantage of renal transplantation.

CONCLUSIONS

This ABM can forecast numbers and costs of DM-ESRD in Saskatchewan and be modified for application in other jurisdictions. This can aid in resource planning and be used by policy makers to evaluate different interventions in a safe and economical manner.

Type 2 Diabetes in Canadian Aboriginal Adolescents: Risk Factors and Prevalence

PURPOSE

To identify the risk factors and prevalence rates of prediabetes and type 2 diabetes among northern Canadian Aboriginal adolescents.

DESIGN AND METHODS

In this novel exploratory, quantitative study, 160 high school students (aged 13-21) from three northern, predominantly Canadian Aboriginal communities were screened for risk for prediabetes and type 2 diabetes including demographic data, family medical history, anthropometric measurements, blood pressure, and hemoglobin A1c (HbA1c). Descriptive and inferential statistics, in addition to chi-square analysis, were used to establish risk and prevalence rates for prediabetes and type 2 diabetes in Aboriginal adolescents.

RESULTS

At least half of the adolescents presented with multiple risk factors for type 2 diabetes. In this sample, 10% had an HbA1c>5.7%, 22.5% were overweight, 17.5% were obese, and 26.6% had prehypertension or hypertension.

CONCLUSIONS

Prediabetes and type 2 diabetes are emerging as serious health concerns for young Aboriginal Canadians. This is troubling because both result from modifiable risk factors. As this study is the first to examine the prevalence of prediabetes in Canadian Aboriginal adolescents in the last decade, the findings underscore the necessity for early screening of Aboriginal adolescents for both prediabetes and type 2 diabetes.

PRACTICE IMPLICATIONS

Recommendations toward positive health outcomes include the introduction of early age screening programs, followed by culturally relevant interventions, specific to the modifiable risk factors (overweight/obesity and hypertension), and developed in collaboration with the communities. Such approaches have the potential to prevent the progression of prediabetes to diabetes and reduce complications related to type 2 diabetes.

Call to action: A new path for improving diabetes care for Indigenous peoples, a global review

Diabetes has reached epidemic proportions in Indigenous populations around the globe, and there is an urgent need to improve the health and health equity of Indigenous peoples with diabetes through timely and appropriate diabetes prevention and management strategies. This review describes the evolution of the diabetes epidemic in Indigenous populations and associated risk factors, highlighting gestational diabetes and intergenerational risk, lifestyle risk factors and social determinants as having particular importance and impact on Indigenous peoples. This review further describes the impact of chronic disease and diabetes on Indigenous peoples and communities, specifically diabetes-related comorbidities and complications. This review provides continued evidence that dramatic changes are necessary to reduce diabetes-related inequities in Indigenous populations, with a call to action to support programmatic primary healthcare transformation capable of empowering Indigenous peoples and communities and improving chronic disease prevention and management. Promising strategies for transforming health services and care for Indigenous peoples include quality improvement initiatives, facilitating diabetes and chronic disease registry and surveillance systems to identify care gaps, and prioritizing evaluation to build the evidence-base necessary to guide future health policy and planning locally and on a global scale.

The Incidence of End-Stage Renal Disease in the Diabetic (Compared to the Non-Diabetic) Population: A Systematic Review

End-stage renal disease (ESRD) in diabetes is a life threatening complication resulting in a poor prognosis for patients as well as high medical costs. The aims of this systematic review were (1) to evaluate the incidence of ESRD due to all causes and due to diabetic nephropathy in the diabetic population and differences between incidences of ESRD with respect to sex, ethnicity, age and regions, (2) to compare incidence rates in the diabetic and non-diabetic population, and (3) to investigate time trends. The systematic review was conducted according to the PRISMA group guidelines by performing systematic literature searches in the biomedical databases until January 3rd 2015; thirty-two studies were included. Among patients with incident type 1 diabetes the 30-year cumulative incidence ranged from 3.3% to 7.8%. Among patients with prevalent diabetes, incidence rates of ESRD due to all causes ranged from 132.0 to 167.0 per 100,000 person-years, whereas incidence rates of ESRD due to diabetic nephropathy varied from 38.4 to 804.0 per 100,000 person-years. The incidence of ESRD in the diabetic population was higher compared to the non-diabetic population, and relative risks varied from 6.2 in the white population to 62.0 among Native Americans. The results regarding time trends were inconsistent. The review conducted demonstrates the considerable variation of incidences of ESRD among the diabetic population. Consistent findings included an excess risk when comparing the diabetic to the non-diabetic population and ethnic differences. We recommend that newly designed studies should use standardized methods for the determination of ESRD and population at risk.

Persistent Albuminuria in Children with Type 2 Diabetes: A Canadian Paediatric Surveillance Program Study

OBJECTIVE

To determine the prevalence and the clinical features associated with persistent albuminuria in Canadian children aged <18 years with type 2 diabetes.

STUDY DESIGN

This national prospective surveillance study involved a network of pediatricians and pediatric endocrinologists. Cases of persistent albuminuria in children with type 2 diabetes were reported during a 24-month period from 2010 to 2012. Persistent albuminuria was defined as an elevated albumin-to-creatinine ratio in a minimum of 2 out of 3 urine samples obtained at least 1 month apart over 3-6 months and confirmed with a first morning sample. Descriptive statistics were used to illustrate demographic and clinical features of the population. The prevalence of persistent albumuria was estimated using data from a previous national surveillence study of type 2 diabetes in children.

RESULTS

Fifty cases were reported over the 24-month study period. The estimated prevalence of persistent albuminuria in children with type 2 diabetes in Canada was 5.1%. The median duration of diabetes at the time of diagnosis of albuminuria was 21 days (IQR, 0-241 days). Almost two-thirds (64%) were female, 80% were of Canadian First Nations heritage, and 76% were from Manitoba. Exposure to gestational or pregestational diabetes in utero occurred in 65%, and 48% had a family history of diabetes-related renal disease. Structural anomalies of the kidney were found in 37%.

CONCLUSION

Persistent albuminuria occurs in youths with type 2 diabetes in the first year after diagnosis, demonstrates regional variation, and is associated with First Nations heritage and exposure to maternal diabetes during pregnancy.

Morbidity and mortality in young-onset type 2 diabetes in comparison to type 1 diabetes: where are we now?

Increasingly, we recognise that type 2 diabetes in youth is a disease with an aggressive time course and a significant complication risk. On the other hand, outcomes for youth with type 1 diabetes appear generally to be improving. With increasing numbers of both types of diabetes in youth, it is timely that a comparative perspective is offered to help clinicians prognosticate more appropriately. Contemporary comparative studies add a new perspective to a consistent story, that for youth-onset type 2 diabetes, the development and progression of cardio-renal complications are increased and the survival prognosis is significantly worse than for type 1 diabetes. Here, we review this mounting evidence, highlight the importance of metabolic syndrome factors in the excess risk and underscore that there remains a significant mortality gap for youth with either type of diabetes, to be addressed as a matter of urgency.