An expanded nationwide view of chronic kidney disease in Aboriginal Australians

Population pharmacokinetics of unbound cefazolin in infected hospitalized patients requiring intermittent high-flux haemodialysis: can a three-times-weekly post-dialysis dosing regimen provide optimal treatment?

OBJECTIVES

To describe the population pharmacokinetics of cefazolin in infected hospitalized patients requiring intermittent haemodialysis (IHD).

METHODS

This prospective population pharmacokinetic study was conducted in IHD patients prescribed cefazolin 2 g three times weekly. Plasma samples were collected at prespecified timepoints and assayed for total and unbound concentrations using validated LC. Pharmacokinetic modelling and dosing simulations were performed using Pmetrics®. PTA in plasma suitable for MSSA (unbound trough concentrations of ≥2 mg/L for the final 24 h of a 72 h interval) were simulated for different dosing regimens. A PTA of ≥95% was deemed acceptable.

RESULTS

A total of 260 cefazolin concentrations (130 total, 130 unbound) were collected from 16 patients (14 female) with a median age of 51 years. The median (IQR) pre-dialysis unbound cefazolin concentration for a 3 day dose interval trough was 17.7 (13.5-31.4) mg/L. The median (IQR) unbound fraction was 0.38 (0.32-0.46). The lowest pre-dialysis unbound concentration was 9.1 mg/L. A two-compartment model with a complex protein-binding component adequately described the data. The mean unbound cefazolin CL during IHD was 16.4 ± 4.26 L/h, compared with 0.40 ± 0.19 L/h when dialysis was off. Duration of time on haemodialysis (TOH) was the only covariate supported in the final model. The 2 g three-times-weekly regimen was associated with a PTA of 99.7% on dosing simulations to maintain unbound concentrations of ≥2 mg/L with TOH of 6 months. The 1 g three-times-weekly post-dialysis was associated with a PTA of 95.4%.

CONCLUSIONS

A 2 g three-times-weekly post-dialysis cefazolin regimen is supported for MSSA infections.

Vision loss and diabetic retinopathy prevalence and risk among a cohort of Indigenous and non-Indigenous Australians with type 2 diabetes receiving renal haemodialysis treatment: The retinopathy in people currently on renal dialysis (RiPCORD) study

AIMS

Diabetic nephropathy, vision loss and diabetic retinopathy (DR) are frequent comorbidities among individuals with type 2 diabetes (T2D). The Retinopathy in People Currently On Renal Dialysis (RiPCORD) study sought to examine the epidemiology and risk of vision impairment (VI) and DR among a cohort of Indigenous and non-Indigenous Australians with T2D currently receiving haemodialysis for end-stage renal failure (ESRF).

METHODS

A total of 106 Indigenous and 109 non-Indigenous Australians were recruited in RiPCORD across five haemodialysis centres in urban and remote settings. Clinical assessments, questionnaires and medical record data determined the rates of ocular complications and risk factor profiles.

RESULTS

Prevalence rates include unilateral VI, 23.5 %; bilateral VI, 11.7 %; unilateral blindness, 14.2 %; and bilateral blindness, 3.7 %, with no significant differences between sub-cohorts (p=0.30). DR prevalence rates were 78.0 % among non-Indigenous Australians and 93.1 % among Indigenous Australians (p=<0.001). Non-Indigenous ethnicity (OR: 0.28) and pre-dialysis diastolic blood pressure (OR: 0.84 per 10-mmHg) were protective, while peripheral vascular disease (OR: 2.79) increased DR risk.

CONCLUSIONS

Ocular complications among individuals with T2D and ESRF are disproportionately high, especially for Indigenous Australians, and beyond what can be accounted for by risk factor variation. Findings suggest a need to improve screening and preventative efforts within this high-risk population group.

Systemic lupus erythematosus in Aboriginal and Torres Strait Islander peoples in Australia: addressing disparities and barriers to optimising patient care

The first inhabitants of Australia and the traditional owners of Australian lands are the Aboriginal and Torres Strait Islander peoples. Aboriginal and Torres Strait Islander peoples are two to four times more likely to have systemic lupus erythematosus (SLE) than the general Australian population. Phenotypically, SLE appears distinctive in Aboriginal and Torres Strait Islander peoples and its severity is substantially increased, with mortality rates up to six times higher than in the general Australian population with SLE. In particular, Aboriginal and Torres Strait Islander peoples with SLE have increased prevalence of lupus nephritis and increased rates of progression to end-stage kidney disease. The reasons for the increased prevalence and severity of SLE in this population are unclear, but socioeconomic, environmental, and biological factors are all likely to be implicated, although there are no published studies investigating these factors in Aboriginal and Torres Strait Islander peoples with SLE specifically, indicating an important knowledge gap. In this Review, we summarise the data on the incidence, prevalence, and clinical and biological findings relating to SLE in Aboriginal and Torres Strait Islander peoples and explore potential factors contributing to its increased prevalence and severity in this population. Importantly, we identify health disparities and deficiencies in health-care provision that limit optimal care and outcomes for many Aboriginal and Torres Strait Islander peoples with SLE and highlight potentially addressable goals to improve outcomes.

Disease profiles in the Indigenous Australian population are suggestive of a common complement control haplotype

Aboriginal and Torres Strait Islander People (respectfully referred to as Indigenous Australians herein) are disparately burdened by many infectious and chronic diseases relative to Australians with European genetic ancestry. Some of these diseases are described in other populations to be influenced by the inherited profile of complement genes. These include complement factor B, H, I and complement factor H-related (CFHR) genes that can contribute to a polygenic complotype. Here the focus is on the combined deletion of CFHR1 and 3 to form a common haplotype (CFHR3-1Δ). The prevalence of CFHR3-1Δ is high in people with Nigerian and African American genetic ancestry and correlates to a higher frequency and severity of systemic lupus erythematosus (SLE) but a lower prevalence of age-related macular degeneration (AMD) and IgA-nephropathy (IgAN). This pattern of disease is similarly observed among Indigenous Australian communities. Additionally, the CFHR3-1Δ complotype is also associated with increased susceptibility to infection with pathogens, such as Neisseria meningitidis and Streptococcus pyogenes, which also have high incidences in Indigenous Australian communities. The prevalence of these diseases, while likely influenced by social, political, environmental and biological factors, including variants in other components of the complement system, may also be suggestive of the CFHR3-1Δ haplotype in Indigenous Australians. These data highlight a need to define the Indigenous Australian complotypes, which may lead to the discovery of new risk factors for common diseases and progress towards precision medicines for treating complement-associated diseases in Indigenous and non-Indigenous populations. Herein, the disease profiles suggestive of a common complement CFHR3-1Δ control haplotype are examined.

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.

Identifying disease progression in chronic kidney disease using proton magnetic resonance spectroscopy

Chronic kidney disease (CKD) affects approximately 10% of the world population, higher still in some developing countries, and can cause irreversible kidney damage eventually leading to kidney failure requiring dialysis or kidney transplantation. However, not all patients with CKD will progress to this stage, and it is difficult to distinguish between progressors and non-progressors at the time of diagnosis. Current clinical practice involves monitoring estimated glomerular filtration rate and proteinuria to assess CKD trajectory over time; however, there remains a need for novel, validated methods that differentiate CKD progressors and non-progressors. Nuclear magnetic resonance techniques, including magnetic resonance spectroscopy and magnetic resonance imaging, have the potential to improve our understanding of CKD progression. Herein, we review the application of magnetic resonance spectroscopy both in preclinical and clinical settings to improve the diagnosis and surveillance of patients with CKD.

Twenty years of real-world data to estimate chronic kidney disease prevalence and staging in an unselected population

Chronic kidney disease (CKD) represents a global public health burden, but its true prevalence is not fully characterized in the majority of countries. We studied the CKD prevalence in adult users of the primary, secondary and tertiary healthcare units of an integrated health region in northern Portugal (n = 136 993; representing ∼90% of the region's adult population). Of these, 45 983 (33.6%) had at least two estimated glomerular filtration rate (eGFR) assessments and 30 534 (22.2%) had at least two urinary albumin:creatinine ratio (UACR) assessments separated by at least 3 months. CKD was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines as a persistent decrease in eGFR (<60 ml/min/1.73 m2) and/or an increase in UACR (≥30 mg/g). The estimated overall prevalence of CKD was 9.8% and was higher in females (5.5%) than males (4.2%). From these, it was possible to stratify 4.7% according to KDIGO guidelines. The prevalence of CKD was higher in older patients (especially in patients >70 years old) and in patients with comorbidities. This is the first real-world-based study to characterize CKD prevalence in a large, unselected Portuguese population. It probably provides the nearest estimate of the true CKD prevalence and may help healthcare providers to guide CKD-related policies and strategies focused on prevention and on the improvement of cardiovascular disease and other outcomes.

Aboriginal patients driving kidney and healthcare improvements: recommendations from South Australian community consultations

OBJECTIVE

To describe the experiences, perceptions and suggested improvements in healthcare identified by Aboriginal patients, families and community members living with kidney disease in South Australia.

METHODS

Community consultations were held in an urban, rural and remote location in 2019 by the Aboriginal Kidney Care Together - Improving Outcomes Now (AKction) project and Kidney Health Australia. Consultations were co-designed with community members, using participatory action research, Yarning, Dadirri and Ganma Indigenous Methodologies. Key themes were synthesised, verified by community members and shared through formal and community reports and media.

RESULTS

Aboriginal participants identified the importance of: family and community and maintaining their wellbeing, strength and resilience; the need for prevention and early detection that is localised, engages whole families and prevents diagnosis shock; better access to quality care that ensures Aboriginal people can make informed choices and decisions about their options for dialysis and transplantation, and; more Aboriginal health professionals and peer navigators, and increased responsiveness and provision of cultural safety care by all kidney health professionals.

CONCLUSION

Aboriginal community members have strong and clear recommendations for improving the quality and responsiveness of health care generally, and kidney care specifically.

IMPLICATIONS FOR PUBLIC HEALTH

Aboriginal people with lived experience of chronic conditions wish to significantly inform the way care is organised and delivered.

Why Aboriginal and Torres Strait Islander Australians fall and fracture: the codesigned Study of Indigenous Muscle and Bone Ageing (SIMBA) protocol

OBJECTIVES

Aboriginal and Torres Strait Islander Australians have a substantially greater fracture risk, where men are 50% and women are 26% more likely to experience a hip fracture compared with non-Indigenous Australians. Fall-related injuries in this population have also increased by 10%/year compared with 4.3%/year in non-Indigenous Australians. This study aims to determine why falls and fracture risk are higher in Aboriginal and Torres Strait Islander Australians.

SETTING

All clinical assessments will be performed at one centre in Melbourne, Australia. At baseline, participants will have clinical assessments, including questionnaires, anthropometry, bone structure, body composition and physical performance tests. These assessments will be repeated at follow-up 1 and follow-up 2, with an interval of 12 months between each clinical visit.

PARTICIPANTS

This codesigned prospective observational study aims to recruit a total of 298 adults who identify as Aboriginal and Torres Strait Islander and reside within Victoria, Australia. Stratified sampling by age and sex will be used to ensure equitable distribution of men and women across four age-bands (35-44, 45-54, 55-64 and 65+ years).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is within-individual yearly change in areal bone mineral density at the total hip, femoral neck and lumbar spine assessed by dual energy X-ray absorptiometry. Within-individual change in cortical and trabecular volumetric bone mineral density at the radius and tibia using high-resolution peripheral quantitative computed tomography will be determined. Secondary outcomes include yearly differences in physical performance and body composition.

ETHICAL APPROVAL

Ethics approval for this study has been granted by the Monash Health Human Research Ethics Committee (project number: RES-19-0000374A).

TRIAL REGISTRATION NUMBER

ACTRN12620000161921.

INFERR-Iron infusion in haemodialysis study: INtravenous iron polymaltose for First Nations Australian patients with high FERRitin levels on haemodialysis-a protocol for a prospective open-label blinded endpoint randomised controlled trial

Background

The effectiveness of erythropoiesis-stimulating agents, which are the main stay of managing anaemia of chronic kidney disease (CKD), is largely dependent on adequate body iron stores. The iron stores are determined by the levels of serum ferritin concentration and transferrin saturation. These two surrogate markers of iron stores are used to guide iron replacement therapy. Most Aboriginal and/or Torres Islander Australians of the Northern Territory (herein respectfully referred to as First Nations Australians) with end-stage kidney disease have ferritin levels higher than current guideline recommendations for iron therapy. There is no clear evidence to guide safe and effective treatment with iron in these patients. We aim to assess the impact of intravenous iron treatment on all-cause death and hospitalisation with a principal diagnosis of all-cause infection in First Nations patients on haemodialysis with anaemia, high ferritin levels and low transferrin saturation

Methods

In a prospective open-label blinded endpoint randomised controlled trial, a total of 576 participants on maintenance haemodialysis with high ferritin (> 700 μg/L and ≤ 2000 μg/L) and low transferrin saturation (< 40%) from all the 7 renal units across the Northern Territory of Australia will be randomised 1:1 to receive intravenous iron polymaltose 400 mg once monthly (200 mg during 2 consecutive haemodialysis sessions) (Arm A) or no IV iron treatment (standard treatment) (Arm B). Rescue therapy will be administered when the ferritin levels fall below 700 μg/L or when clinically indicated. The primary outcome will be the differences between the two study arms in the risk of hospitalisation with all-cause infection or death. An economic analysis and several secondary and tertiary outcomes analyses will also be performed.

Discussion

The INFERR clinical trial will address significant uncertainty on the safety and efficacy of iron therapy in First Nations Australians with CKD with hyperferritinaemia and evidence of iron deficiency. This will hopefully lead to the development of evidence-based guidelines. It will also provide the opportunity to explore the causes of hyperferritinaemia in First Nations Australians from the Northern Territory.

Trial registration

This trial is registered with The Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12620000705987. Registered 29 June 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05854-w.

Sex differences in mortality among binational cohort of people with chronic kidney disease: population based data linkage study

OBJECTIVE

To evaluate sex differences in mortality among people with kidney failure compared with the general population.

DESIGN

Population based cohort study using data linkage.

SETTING

The Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), which includes all patients receiving kidney replacement therapy in Australia (1980-2019) and New Zealand (1988-2019). Data were linked to national death registers to determine deaths and their causes, with additional details obtained from ANZDATA.

PARTICIPANTS

Of 82 844 people with kidney failure, 33 329 were female (40%) and 49 555 were male (60%); 49 376 deaths (20 099 in female patients; 29 277 in male patients) were recorded over a total of 536 602 person years of follow-up.

MAIN OUTCOME MEASURES

Relative measures of survival, including standardised mortality ratios, relative survival, and years of life lost, using general population data to account for background mortality (adjusting for country, age, sex, and year). Estimates were stratified by dialysis modality (haemodialysis or peritoneal dialysis) and for the subpopulation of kidney transplant recipients.

RESULTS

Few differences in outcomes were found between male and female patients with kidney failure. However, compared with the general population, female patients with kidney failure had greater excess all cause deaths than male patients (female patients: standardised mortality ratio 11.3, 95% confidence interval 11.2 to 11.5, expected deaths 1781, observed deaths 20 099; male patients: 6.9, 6.8 to 6.9, expected deaths 4272, observed deaths 29 277). The greatest difference was observed among younger patients and those who died from cardiovascular disease. Relative survival was also consistently lower in female patients, with adjusted excess mortality 11% higher (95% confidence interval 8% to 13%). Average years of life lost was 3.6 years (95% confidence interval 3.6 to 3.7) greater in female patients with kidney failure compared with male patients across all ages. No major differences were found in mortality by sex for haemodialysis or peritoneal dialysis. Kidney transplantation reduced but did not entirely remove the sex difference in excess mortality, with similar relative survival (P=0.83) and years of life lost difference reduced to 2.3 years (95% confidence interval 2.2 to 2.3) between female and male patients.

CONCLUSIONS

Compared with the general population, female patients had greater excess deaths, worse relative survival, and more years of life lost than male patients, however kidney transplantation reduced these differences. Future research should investigate whether systematic differences exist in access to care and possible strategies to mitigate excess mortality among female patients.

Peritoneal dialysis in indigenous australians

Indigenous people in wealthy countries have outcomes of chronic disease that are comparable to those of patients in low socio-economic developing countries. This is not different for renal disease and outcomes of renal replacement therapy. This chapter addresses the dilemmas of using Peritoneal Dialysis in aboriginal patients in Australia. The focus is on aboriginal people in very remote areas and some personal views are presented as to the causes of the gap between outcomes for aboriginal and non-aboriginal patients and how the many failed attempts to close the gap could be addressed.

Comparison of clinical manifestation among Australian Indigenous and non- Indigenous patients presenting with pleural effusion

BACKGROUND

There is sparse evidence in the literature in relation to the nature and causes of pleural effusion among Australian Indigenous population.

METHODS

In this retrospective study, Indigenous and non-Indigenous adults diagnosed to have pleural effusion over a two-year study period were included for comparative analysis.

RESULTS

Of the 314 patients, 205 (65%) were non-Indigenous and 52% were males. In comparison to non-Indigenous, the Indigenous patients were younger (50 years (IQR 39,60) vs 63 years (IQR 52,72), p<0.001), females (61% vs 41%, p=0.001), have higher prevalence of renal and cardiovascular disease and tend to have exudative effusion (93% vs 76%, p=0.032). Infections was judged to be the most common cause for effusion in both groups, more so among the Indigenous cohort. Effusion secondary to renal disease was higher (13% vs 1%, p<0.001) among Indigenous Australians, in contrast malignant effusions were higher (13% vs 4%, p=0.004) among non-Indigenous. Length of hospital stay was longer for Indigenous patients (p=0.001), and a greater proportion received renal dialysis (13% vs 1%, p<0.001). Intensive care unit (ICU) admissions rates were higher with infective etiology of pleural effusion (82% vs. 53% Indigenous & 44% vs. 39% non-Indigenous respectively). Re-presentations to hospital were higher among Indigenous patients (46% vs 33%, p=0.046) and were associated with renal and cardiac disease and malignancy in non-Indigenous.

CONCLUSION

There are significant differences in the way pleural effusion manifests among Australian Indigenous patients. Understanding these differences may facilitate approaches to the management and to implement strategies to reduce morbidity and mortality in this population. This article is protected by copyright. All rights reserved.

Chronic disease prevention programs offered by Aboriginal Community Controlled Health Services in New South Wales, Australia

OBJECTIVES

To identify and describe chronic disease prevention programs offered by Aboriginal Community Controlled Health Services (ACCHSs) in New South Wales (NSW), Australia.

METHODS

ACCHSs were identified through the Aboriginal Health and Medical Research Council of NSW website. Chronic disease programs were identified from the Facebook page and website of each ACCHS. Characteristics, including regions, target population, condition, health behaviour, modality and program frequency were extracted and summarised.

RESULTS

We identified 128 chronic disease programs across 32 ACCHSs. Of these, 87 (68%) programs were broad in their scope, 20 (16%) targeted youth, three (2%) targeted Elders, 16 (12%) were for females only and five (4%) were for males only. Interventions included physical activity (77, 60%), diet and nutrition (74, 58%), smoking (70, 55%), and the Aboriginal and Torres Strait Islander Health Check (44, 34%), with 93 programs (73%) of ongoing duration.

CONCLUSIONS

Chronic disease prevention programs address chronic conditions by promoting physical activity, diet and nutrition, smoking cessation and health screening. Most target the general Aboriginal community, a few target specific groups based on gender and age, and more than one-quarter are time-limited. Implications for public health: Chronic disease programs that are co-produced with specific groups, based on age and gender, may be needed.

Narrative Review of Hyperferritinemia, Iron Deficiency, and the Challenges of Managing Anemia in Aboriginal and Torres Strait Islander Australians With CKD

Aboriginal and Torres Strait Islander Australians (Indigenous Australians) suffer some of the highest rates of chronic kidney disease (CKD) in the world. Among Indigenous Australians in remote areas of the Northern Territory, prevalence rates for renal replacement therapy (RRT) are up to 30 times higher than national prevalence. Anemia among patients with CKD is a common complication. Iron deficiency is one of the major causes. Iron deficiency is also one of the key causes of poor response to the mainstay of anemia therapy with erythropoiesis-stimulating agents (ESAs). Therefore, the effective management of anemia in people with CKD is largely dependent on effective identification and correction of iron deficiency. The current identification of iron deficiency in routine clinical practice is dependent on 2 surrogate markers of iron status: serum ferritin concentration and transferrin saturation (TSAT). However, questions exist regarding the use of serum ferritin concentration in people with CKD because it is an acute-phase reactant that can be raised in the context of acute and chronic inflammation. Serum ferritin concentration among Indigenous Australians receiving RRT is often markedly elevated and falls outside reference ranges within most national and international guidelines for iron therapy for people with CKD. This review explores published data on the challenges of managing anemia in Indigenous people with CKD and the need for future research on the efficacy and safety of treatment of anemia of CKD in patients with high ferritin and evidence iron deficiency.

Kidney failure in Samoa

BACKGROUND

There is limited literature on kidney disease in the Pacific Region, despite it being recognised as a leading cause of death in some Pacific Island nations. Kidney replacement therapy is only available in a handful of Pacific Islands. This paper reports the epidemiology of haemodialysis patients in Samoa.

METHODS

Registry data from the National Kidney Foundation of Samoa was analysed to estimate the incidence and prevalence rates of kidney failure from the rates of haemodialysis in Samoa and to explore some of the demographic features related to kidney failure in Samoa.

FINDINGS

In total, 393 patients have received long-term haemodialysis in the National Kidney Foundation of Samoa since its inception in 2005 until August 2019. 43% of the haemodialysis population were women and the mean age of people dialysed was 54.9 years. The crude mean incidence rate of kidney failure in Samoa, based on treated kidney failure cases, is 224 patients per million population with a crude prevalence of 629 patients per million population. Diabetic nephropathy (69.4%) was the leading cause of kidney failure.

INTERPRETATION

This is the first paper to report the epidemiology of haemodialysis patients in Samoa and reveals an urgent need for further studies on the extent of chronic kidney disease, and kidney failure, in Samoa to develop country specific prevention strategies to mitigate this growing burden and optimise care for kidney failure patients in Samoa.

FUNDING

: No funding was received for this study.

Baseline liver function tests and full blood count indices and their association with progression of chronic kidney disease and renal outcomes in Aboriginal and Torres Strait Islander people: the eGFR follow- up study

Background

Determination of risks for chronic kidney disease (CKD) progression could improve strategies to reduce progression to ESKD. The eGFR Study recruited a cohort of adult Aboriginal and Torres Strait Islander people (Indigenous Australians) from Northern Queensland, Northern Territory and Western Australia, aiming to address the heavy CKD burden experienced within these communities.

Methods

Using data from the eGFR study, we explored the association of baseline liver function tests (LFTs) (alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), bilirubin and albumin) and full blood count (FBC) indices (white blood cell and red blood cell counts and haemoglobin) with annual eGFR decline and renal outcomes (first of 30% decline in eGFR with a follow-up eGFR < 60 mL/min/1.73 m², initiation of renal replacement therapy, or renal death). Comparisons of baseline variables across eGFR categories were calculated using analysis of variance and logistic regression as appropriate. Linear and multivariable regression models were used to estimate the annual change in eGFR for changes in FBC indices and LFTs. Cox proportional hazard models were used to estimate the hazard ratio for developing renal outcome for changes in baseline FBC indices and LFTs.

Results

Of 547 participants, 540 had at least one baseline measure of LFTs and FBC indices. The mean age was 46.1 (14.7) years and 63.6% were female. The median follow-up was 3.1 (IQR 2.8–3.6) years. Annual decline in eGFR was associated with low serum albumin (p < 0.001) and haemoglobin (p = 0.007). After adjustment for age, gender, urine albumin/creatinine ratio, diabetes, BMI, CRP, WHR, alcohol consumption, cholesterol and triglycerides, low serum albumin (p < 0.001), haemoglobin (p = 0.012) and bilirubin (p = 0.011) were associated with annual decline in eGFR.

Renal outcomes were inversely associated with serum albumin (p < 0.001), bilirubin (p = 0.012) and haemoglobin (p < 0.001) and directly with GGT (p = 0.007) and ALP (p < 0.001). Other FBC indices and LFTs were not associated with annual decline in eGFR or renal outcomes.

Conclusions

GGT, ALP, bilirubin, albumin and haemoglobin independently associate with renal outcomes. Contrary to findings from other studies, no association was found between renal outcomes and other FBC indices. These findings may help focus strategies to prevent disease progression in this high-risk population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-020-02185-x.

Characteristics and outcomes of Aboriginal and Torres Strait Islander patients with dialysis-dependent kidney disease in Australian Intensive Care Units

BACKGROUND

In Australia, 531 people per million population have dialysis-dependent Chronic Kidney Disease (CKD5D). The incidence is four times higher for Aboriginal and Torres Strait Islander (Indigenous) people compared to non-Indigenous Australians. CKD5D increases the risk of hospitalisation, admission to the Intensive Care Unit (ICU) and mortality compared to patients without CKD5D. There is limited literature describing short-term outcomes of patients with CKD5D who are admitted to ICU, comparing Indigenous and non-Indigenous patients.

AIMS

This registry-based retrospective cohort analysis compared demographic and clinical data between Indigenous and non-Indigenous patients with CKD5D and tested whether Indigenous status predicted short-term outcomes independently of other contributing factors. Adjusted hospital mortality was the primary outcome measure.

METHODS

Data were from the Australian and New Zealand Intensive Care Society's Centre for Outcome and Resource Evaluation Adult Patient Database. Australian ICU admissions between 2010 and 2017 were included. Data from 173 ICUs (2,136 beds) include 1,051,697 ICU admissions of which 23,793 had a pre-existing diagnosis of CKD5D.

RESULTS

Indigenous patients comprised 11.9% of CKD5D patients in ICU. CKD5D was prevalent among 4.9% of Indigenous and 2.9% of non-Indigenous ICU admissions. Indigenous patients were 13.5 years younger, had fewer comorbidities and lower crude mortality despite equivalent calculated mortality risk. After adjusting for age, remoteness and severity of illness, Indigenous status did not predict mortality.

CONCLUSIONS

Socioeconomic disadvantage contributes to earlier development of CKD5D and the over representation in ICU of Indigenous people. Mortality is equivalent once correcting for confounders, but addressing inequality requires strengthening preventative care. This article is protected by copyright. All rights reserved.

Results From 16 Years of Quality Surveillance of Urine Albumin to Creatinine Ratio Testing for a National Indigenous Point-of-Care Testing Program

CONTEXT.—

The burden of chronic kidney disease in Indigenous Australians is 7.3 times higher than that of non-Indigenous Australians. If chronic kidney disease is detected early and managed, deterioration in kidney function can be reduced. Urine albumin to creatinine ratio is a key marker of early renal damage.

OBJECTIVE.—

To report on 16 years of analytic quality of urine albumin to creatinine ratio testing on Siemens DCA devices enrolled in the national Quality Assurance for Aboriginal and Torres Strait Islander Medical Services point-of-care testing program.

DESIGN.—

Quality Assurance for Aboriginal and Torres Strait Islander Medical Services participants are required to test 2 quality assurance samples each month across two 6-monthly testing cycles per year. Participants also test 2 quality control samples monthly.

RESULTS.—

The percentage of urine albumin, creatinine, and albumin to creatinine ratio results for quality assurance point-of-care testing that were within assigned allowable limits of performance averaged 96.9%, 95.9%, and 97.5%, respectively. The percentage acceptable quality control results for urine albumin and creatinine averaged 93.5% and 86.8%. The median imprecision for urine albumin, creatinine, and albumin to creatinine ratio quality assurance testing averaged 5.5%, 4.1%, and 3.3%, respectively, and the median within-site imprecision for quality control testing averaged 5.4%, 4.3%, and 5.7%, respectively, for the low sample and 4.0%, 4.1%, and 4.5%, respectively, for the high sample.

CONCLUSIONS.—

For 16 years the DCA system has proven to be reliable and robust and operators at Aboriginal medical services have demonstrated they are able to conduct point-of-care testing for urine albumin to creatinine ratio that consistently meets analytic performance standards.

Protocol and establishment of a Queensland renal biopsy registry in Australia

Background

Renal biopsy is often required to obtain information for diagnosis, management and prognosis of kidney disease that can be broadly classified into acute kidney injury (AKI) and chronic kidney disease (CKD). The most common conditions identified on renal biopsy are glomerulonephritis and tubulo-interstitial disorders. There is a paucity of information on management strategies and therapeutic outcomes in AKI and CKD patients. A renal biopsy registry will provide information on biopsy-proven kidney disorders to improve disease understanding and tracking, healthcare planning, patient care and outcomes.

Methods

A registry of patients, that includes biopsy-proven kidney disease, was established through the collaboration of nephrologists from Queensland Hospital and Health Services and pathologists from Pathology Queensland services. The registry is in keeping with directions of the Advancing Kidney Care 2026 Collaborative, established in September 2018 as a Queensland Health initiative. Phase 1 of the registry entailed retrospective acquisition of data from all adult native kidney biopsies performed in Queensland, Australia, from 2002 to 2018. Data were also linked with the existing CKD.QLD patient registry. From 2019 onwards, phase 2 of the registry involves prospective collection of all incident consenting patients referred to Queensland public hospitals and having a renal biopsy. Annual reports on patient outcomes will be generated and disseminated.

Discussion

Establishment of the Queensland Renal Biopsy Registry (QRBR) aims to provide a profile of patients with biopsy-proven kidney disease that will lead to better understanding of clinico-pathological association and facilitate future research. It is expected to improve patient care and outcomes.

Progressive Nephron Loss in Aging Kidneys: Clinical–Structural Associations Investigated by Two Anatomical Methods

Two major studies of structural changes associated with aging in human kidneys are reviewed and new information presented. The studies are the Monash University stereologically analyzed series of 319 autopsy kidneys from the United States in which 44% were white and the Mayo Clinic CT angiogram/biopsy analysis of 1,388 US kidney donors in which 97% were white. Hypertension rates in the Monash series were 48% and included moderate and severe hypertension. In the Mayo Clinic study, 12% had mild hypertension. The studies showed no relationship between glomerular number and hypertension except for a weak relationship with older white women in the Monash series. An inverse relationship was present between glomerular number and glomerular volume, a reciprocity that tended to enhance glomerular mass and by inference filtration capacity with lower nephron numbers. This relationship seemed to be present whether low nephron numbers were intrinsic or acquired. In the Mayo Clinic studies, pretransplant iothalamate clearances demonstrated that single nephron (SN) glomerular filtration rates (GFR) were similar throughout the range of glomerular number in subjects younger than 70 years, but that increased SNGFR correlated with nephron hypertrophy and increased nephrosclerosis particularly at 70 years of age and over. Hypertension at least through middle age cannot be related to a deficiency of glomeruli, but glomeruli are lost with later aging in association with adaptive nephron hypertrophy that can maintain GFR near normal. These studies help define an age‐related nephropathy that overlaps with hypertension as a potential cause of end‐stage renal disease when glomerulosclerosis is advanced.

Weight change trajectories in Aboriginal and Torres Strait islander Australians after kidney transplantation: a cohort analysis using the Australia and New Zealand Dialysis and Transplant registry (ANZDATA)

Background

Weight change post-kidney transplantation and its associations in Aboriginal and Torres Strait Islander Australians, a group known to have poor patient and graft outcomes, are unknown. Weight change based on body mass index in Aboriginal and Torres Strait Islander Australian recipients was compared to non- indigenous recipients.

Methods

We performed a cohort analysis of data from the Australia and New Zealand Dialysis and Transplant Registry for first deceased donor kidney transplant recipients between 1995 and 2014 in Australia. Weight change post-kidney transplantation was analysed by recipient ethnicity using multivariate mixed effect linear regression analysis.

Results

There were 343 (5.24%) Aboriginal and Torres Strait Islander Australian kidney transplants recipients from a total of 6550 recipients. They had higher pre-transplant BMI (p < 0.001), higher rates of current smokers (p < 0.001), diabetes (p < 0.001), coronary artery disease (p < 0.001), cerebrovascular disease (p = 0.011) and peripheral vascular disease (p = 0.013), ≥4 HLA mismatches (p < 0.001), graft loss (p < 0.001), mortality (p < 0.001) and rejection rates (p < 0.001). Weight increased in the first 2 years post-transplantation in both Aboriginal and Torres Strait Islander Australians and non-indigenous Australians. After adjusting for the baseline differences, weight change diverged significantly at 6, 12 and 24 months. The difference was most marked between 6 and 12 months. When stratified by pre-transplantation BMI, all groups except underweight reflected this pattern. Normal weight and obese Aboriginal and Torres Strait Islander Australian recipients had substantial increase at 12 and 24 months and overweight at 6, 12 and 24 months.

The difference in BMI trajectories between Aboriginal and Torres Strait Islander Australians and non- indigenous Australian transplant recipients persisted after adjustment in multivariate mixed effect linear regression analysis.

Conclusions

Post-kidney transplantation weight gain in this high-risk population is substantial and greater than in non-indigenous Australians. Further studies should assess the effect of treatment factors and weight gain on transplant and recipient outcomes.

Indigenous compared with non-Indigenous Australian patients at entry to specialist palliative care: Cross-sectional findings from a multi-jurisdictional dataset

BACKGROUND

There are few quantitative studies on palliative care provision to Indigenous Australians, a population known to experience distinctive barriers to quality healthcare and to have poorer health outcomes than other Australians.

OBJECTIVES

To investigate equity of specialist palliative care service provision through characterising and comparing Indigenous and non-Indigenous patients at entry to care.

METHODS

Using data (01/01/2010-30/06/2015) from all services participating in the multi-jurisdictional Palliative Care Outcomes Collaboration, Indigenous and non-Indigenous patients entering palliative care were compared on proportions vis-à-vis those expected from national statutory datasets, demographic characteristics, and entry-to-care status across fourteen 'problem' domains (e.g., pain, functional impairment) after matching by age, sex, and specific diagnosis.

RESULTS

Of 140,267 patients, 1,465 (1.0%, much lower than expected from statutory data) were Indigenous, 133,987 (95.5%) non-Indigenous, and 4,905 (3.5%) had a missing identifier. The proportion of patients with a missing identifier diminished markedly over the study period, without a corresponding increase in the proportion identified as Indigenous. Indigenous compared with non-Indigenous patients were younger (mean 62.8 versus 73.0 years, p<0.001), a higher proportion were female (51.5% versus 46.3%; p<0.001) or resided outside major cities (44.2% versus 21.5%, p<0.001). Across all domains, Indigenous compared with matched non-Indigenous patients had lower or equal risk of status requiring prompt intervention.

CONCLUSIONS

Indigenous patients (especially those residing outside major cities) are substantially under-represented in care by services participating in the nationwide specialist palliative care Collaboration, likely reflecting widespread access barriers. However, the similarity of status indicators among Indigenous and non-Indigenous patients at entry to care suggests that Indigenous patients who are able to access these services do not disproportionately experience clinically important impediments to care initiation.

Acute kidney injury in Indigenous Australians in the Kimberley: age distribution and associated diagnoses

OBJECTIVE

To describe the frequencies of acute kidney injury (AKI) and of associated diagnoses in Indigenous people in a remote Western Australian region.

DESIGN

Retrospective population-based study of AKI events confirmed by changes in serum creatinine levels.

SETTING, PARTICIPANTS

Aboriginal and Torres Strait Islander residents of the Kimberley region of Western Australia, aged 15 years or more and without end-stage kidney disease, for whom AKI between 1 June 2009 and 30 May 2016 was confirmed by an acute rise in serum creatinine levels.

MAIN OUTCOME MEASURES

Age-specific AKI rates; principal and other diagnoses.

RESULTS

324 AKI events in 260 individuals were recorded; the median age of patients was 51.8 years (IQR, 43.9-61.0 years), and 176 events (54%) were in men. The overall AKI rate was 323 events (95% CI, 281-367) per 100 000 population; 92 events (28%) were in people aged 15-44 years. 52% of principal diagnoses were infectious in nature, including pneumonia (12% of events), infections of the skin and subcutaneous tissue (10%), and urinary tract infections (7.7%). 80 events (34%) were detected on or before the date of admission; fewer than one-third of discharge summaries (61 events, 28%) listed AKI as a primary or other diagnosis.

CONCLUSION

The age distribution of AKI events among Indigenous Australians in the Kimberley was skewed to younger groups than in the national data on AKI. Infectious conditions were common in patients, underscoring the significance of environmental determinants of health. Primary care services can play an important role in preventing community-acquired AKI; applying pathology-based criteria could improve the detection of AKI.

A randomised controlled trial of potential for pharmacologic prevention of new-onset albuminuria, hypertension and diabetes in a remote Aboriginal Australian community, 2008-2013

Introduction

We conducted a double-blind randomised controlled trial in a remote-living Australian Aboriginal group at high risk for chronic disease to assess whether pharmacological treatment with angiotensin converting enzyme inhibitor (ACEi) could delay the onset of albuminuria, hypertension or diabetes in people currently free of those conditions.

Methods

Eligibility criteria in 2008 were age ≥18yr, blood pressure ≤140/90 mm/Hg, urinary albumin creatinine ratio (ACR) < 3.4 mg/mmol, normal levels of glycosylated haemoglobin, and, in females, infertility. A 2011 amendment allowed enrolment of fertile females using long-term contraception. “Treatment” was the ACEi perindopril arginine, or placebo, and participant events were ACR ≥3.4 mg/mmol and/or blood pressure >140/90 mm Hg and/or haemoglobin A1c >6.5%, and/or cardiovascular events. Results were analysed in 125 randomised participants who commenced treatment.

Results

Recruitment was low, especially of women, and dropout rates high: there were finally 60 and 65 people in the ACEi and placebo groups respectively. In females, there were no events among 10 in the ACEi group, versus 5 events among 17 in the placebo group, and longitudinal ACR, HbA1c and blood pressure levels supported probable benefit of ACEi. There was no benefit of ACEi in males, but a probable benefit on diabetes/hypertension events. With the genders combined, there was probable reduction of diabetes (zero vs 4 events, p = 0.068), and of diabetes or hypertension (zero vs 5 events, p = 0.037).

Discussion

In this high-risk population, ACEi probably delays development of albuminuria, diabetes and hypertension in females, and of non-ACR events overall. Repeat investigation with a larger sample size is warranted.

Long-term survival rates of patients undergoing vitrectomy for diabetic retinopathy in an Australian population: a population-based audit

IMPORTANCE

Five-year survival rates in patients undergoing vitrectomy for diabetic retinopathy (DR) vary from 68% to 95%. No study has been conducted in an Australian population.

BACKGROUND

We aimed to determine the survival rates of patients undergoing diabetic vitrectomy in an Australian population.

DESIGN

Retrospective audit, tertiary centre hospitals and private practices.

PARTICIPANTS

All individuals in South Australia and the Northern Territory who underwent their first vitrectomy for diabetic complications between January 1, 2007 and December 31, 2011.

METHODS

An audit of all eligible participants has been completed previously. Survival status as of July 6, 2018 and cause of death were obtained using SA/NT DataLink. Kaplan-Meier survival curves and multivariate cox-regressions were used to analyse survival rates and identify risk factors for mortality.

MAIN OUTCOME MEASURES

Five-, seven- and nine-year survival rates.

RESULTS

The 5-, 7- and 9-year survival rates were 84.4%, 77.9% and 74.7%, respectively. The most common cause of death was cardiovascular disease. Associated with increased mortality independent of age were Indigenous ethnicity (HR = 2.04, 95% confidence interval [CI]: 1.17-3.57, P = 0.012), chronic renal failure (HR = 1.76, 95% CI: 1.07-2.89, P = 0.026) and renal failure requiring dialysis (HR = 2.32, 95% CI: 1.25-4.32, P = 0.008).

CONCLUSIONS AND RELEVANCE

Long-term survival rates after diabetic vitrectomy in Australia are similar to rates reported in other populations. Indigenous ethnicity and chronic renal failure were the most significant factors associated with long-term mortality. This information can guide allocation of future resources to improve the prognosis of these high risk groups.

Female preterm indigenous Australian infants have lower renal volumes than males: A predisposing factor for end-stage renal disease?

Aim

Indigenous Australians have an increased risk of developing chronic kidney disease (CKD). Indigenous women have a higher rate of CKD than men. In a cohort of Indigenous and non‐Indigenous preterm neonates, we assessed total renal volume (TRV) (a proxy indicator for nephron number). We hypothesized that there would be no difference in renal volume between these two groups at term corrected (37 weeks gestation).

Methods

Normally grown preterm neonates less than 32 weeks of gestation were recruited and at term corrected dates, the neonates underwent renal ultrasonography (TRV measurements), urine microalbumin‐creatinine ratio and serum analysis for Cystatin C measurement for estimated glomerular filtration rate (eGFR) calculation.

Results

One hundred and five neonates (38 Indigenous; 67 non‐Indigenous) were recruited. Indigenous neonates were significantly more premature and of lower birth weight. At term corrected age, Indigenous neonates had a significantly smaller TRV (18.5 (4.2) vs 21.4 (5.1) cm³; P = 0.027) despite no significant difference in body weight. Despite having a smaller TRV, there was no significant difference in eGFR between Indigenous and Non‐indigenous neonates (47.8 [43.2–50.4] vs 46.2 [42.6–53.3] ml/min per 1.73 m²; P = 0.986). These infants achieve similar eGFR through hyperfiltration, which likely increases their future risk of CKD. There was no difference in microalbumin‐creatinine ratio. Female Indigenous neonates, however, had significantly smaller TRV compared with Indigenous male neonates (15.9 (3.6) vs 20.6 (3.6) cm³; P = 0.006), despite no difference in eGFR, birth weight, gestational age, and weight at term corrected.

Conclusion

The difference in TRV is likely to be an important risk factor for the difference in morbidity and mortality from renal disease reported between male and female Indigenous adults.

Indigenous Australians are known to have an increased risk of developing CKD. The authors examined total renal volume (TRV) in a cohort of Indigenous and non‐Indigenous preterm neonates, and found that female Indigenous neonates had significantly smaller TRV compared with Indigenous male neonates.

Musculoskeletal health of Indigenous Australians

INTRODUCTION

Research on non-communicable diseases (NCD) in Indigenous Australians has mostly focused on diabetes mellitus and chronic kidney or cardiovascular disease. Osteoporosis, characterised by low bone mass and structural deterioration of bone tissue, and sarcopenia, the age-related loss of muscle mass and strength, often co-exist with these common NCDs-the combination of which will disproportionately increase bone fragility and fracture risk and negatively influence cortical and trabecular bone. Furthermore, the social gradient of NCDs, including osteoporosis and fracture, is well-documented, meaning that specific population groups are likely to be at greater risk of poorer health outcomes: Indigenous Australians are one such group.

PURPOSE

This review summarises the findings reported in the literature regarding the muscle and bone health of Indigenous Australians.

FINDINGS

There are limited data regarding the musculoskeletal health of Indigenous Australians; however, areal bone mineral density (aBMD) measured by dual-energy X-ray absorptiometry (DXA) is reported to be greater at the hip compared to non-Indigenous Australians. Falls are the leading cause of injury-related hospitalisations in older Australians, particularly Indigenous Australians, with a great proportion suffering from fall-related fractures. Despite sparse data, it appears that Indigenous men and women have a substantially higher risk of hip fracture at a much younger age compared to non-Indigenous Australians.

CONCLUSION

Data on more detailed musculoskeletal health outcomes are required in Indigenous Australians to better understand fracture risk and to formulate evidence-based strategies for fracture prevention and to minimise the risk of falls.

The Barker hypothesis confirmed: association of low birth weight with all-cause natural deaths in young adult life in a remote Australian Aboriginal community

Barker et al. proposed that low birth weight predisposes to higher death rates in adult life. We previously confirmed this fact in a cohort of young adults who were born in a remote Australian Aboriginal community between 1956 and 1985. We now present data in these same people with four more years of follow-up and a greater number of deaths. The fates of participants were documented from age 15 years until death, start of dialysis, or until the end of 2010 and causes of death were derived from clinic narratives and dialysis records. Rates of natural deaths were compared by birth cohorts and birth weight, and hazard ratios were calculated using Cox proportional hazards methods, by birth weight and adjusted for birth cohort and sex. Over follow-up of 19,661 person-years, 61 people died of natural causes between age 15 and the censor date. Low birth weights (&lt;2.5 kg) were associated with higher rates of natural death, with HR (95% CI) 1.76 (1.1-2.9, P=0.03), after adjustment for year of birth and sex. The effect was particularly prominent for deaths at &lt;41 years of age, and with deaths from respiratory conditions/sepsis and unusual causes. A predisposing effect of low birth weight on adult deaths was confirmed. This phenomenon, occurring in the context of dramatically improved survivals of lower birth weight infants and children since the early 1960s, helps explain the current epidemic of chronic disease in Aboriginal people. Birth weights continue to improve, so excess deaths from this source should progressively be minimized.

CKD Screening and Surveillance in Australia: Past, Present, and Future

Chronic kidney disease (CKD) was largely a hidden health problem until the publication of an internationally agreed approach to its identification, monitoring, and treatment. The 2002 National Kidney Foundation CKD classification and the subsequent 2006 Kidney Disease Improving Global Outcomes (KDIGO) recommendations are powerful tools for translating thinking about CKD into clinical practice. These guidelines were strongly endorsed by the international community, including Australia, and were incorporated into CKD practice guidelines. In the past, CKD research studies in Australia focused on screening the general population, and more specifically, individuals at risk for CKD. Information from these studies led to the recognition that the CKD burden in Australia is a public health problem and contributed to the development of national health policies and priorities. At present, apart from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) that reports on CKD patients undergoing renal replacement therapy (RRT), long-term surveillance to describe the natural history of the CKD population not on RRT has only recently started. Entities such as CKD. Queensland and the Western Australian Nephrology Database are able to fill the gap and provide opportunities for collaborative research of CKD in Australia. Establishment of a National Health and Medical Research Centre-funded CKD Centre of Excellence in 2015 and the Better Evidence and Translation-Chronic Kidney Disease in 2016 are likely to change the future of CKD surveillance and research in Australia.

Transformation of mortality in a remote Australian Aboriginal community: a retrospective observational study

OBJECTIVES

To describe trends in ages and causes of death in a remote-living Australian Aboriginal group over a recent 50-year period.

DESIGN

A retrospective observational study, from 1960 to 2010, of deaths and people starting dialysis, using data from local clinic, parish, dialysis and birthweight registers.

SETTING

A remote island community in the Top End of Australia's Northern Territory, where a Catholic mission was established in 1911. The estimated Aboriginal population was about 800 in 1960 and 2260 in 2011.

PARTICIPANTS

All Aboriginal residents of this community whose deaths had been recorded.

OUTCOME MEASURES

Annual frequencies and rates of terminal events (deaths and dialysis starts) by age group and cause of death.

RESULTS

Against a background of high rates of low birth weight, 223 deaths in infants and children and 934 deaths in adults (age > 15 years) were recorded; 88% were of natural causes. Most deaths in the 1960s were in infants and children. However, over time these fell dramatically, across the birthweight spectrum, while adult deaths progressively increased. The leading causes of adult natural deaths were chronic lung disease, cardiovascular disease and, more recently, renal failure, and rates were increased twofold in those of low birth weight. However, rates of natural adult deaths have been falling briskly since 1986, most markedly among people of age ≥45 years. The population is increasing and its age structure is maturing.

CONCLUSIONS

The changes in death profiles, the expression of the Barker hypothesis and the ongoing increases in adult life expectancy reflect epidemiological and health transitions of astonishing rapidity. These probably flow from advances in public health policy and healthcare delivery, as well as improved inter-sectoral services, which are all to be celebrated. Other remote communities in Australia are experiencing the same phenomena, and similar events are well advanced in many developing countries.

An expanded nationwide view of chronic kidney disease in Aboriginal Australians

We summarize new knowledge that has accrued in recent years on chronic kidney disease (CKD) in Indigenous Australians. CKD refers to all stages of preterminal kidney disease, including end‐stage kidney failure (ESKF), whether or not a person receives renal replacement therapy (RRT). Recently recorded rates of ESKF, RRT, non‐dialysis CKD hospitalizations and CKD attributed deaths were, respectively, more than sixfold, eightfold, eightfold and threefold those of non‐Indigenous Australians, with age adjustment, although all except the RRT rates are still under‐enumerated. However, the nationwide average Indigenous incidence rate of RRT appears to have stabilized. The median age of Indigenous people with ESKF was about 30 years less than for non‐Indigenous people, and 84% of them received RTT, while only half of non‐Indigenous people with ESKF did so. The first‐ever (2012) nationwide health survey data showed elevated levels of CKD markers in Indigenous people at the community level. For all CKD parameters, rates among Indigenous people themselves were strikingly correlated with increasing remoteness of residence and socio‐economic disadvantage, and there was a female predominance in remote areas. The burden of renal disease in Australian Indigenous people is seriously understated by Global Burden of Disease Mortality methodology, because it employs underlying cause of death only, and because deaths of people on RRT are frequently attributed to non‐renal causes.

These data give a much expanded view of CKD in Aboriginal people. Methodologic approaches must be remedied for a full appreciation of the burden, costs and outcomes of the disease, to direct appropriate policy development.

Excellent review on the kidney health in the Aboriginal communities in Australia, describing the challenges and important priorities.