Association between First Nations ethnicity and progression to kidney failure by presence and severity of albuminuria

Understanding the Current Landscape of Kidney Disease in Canada to Advance Precision Medicine Guided Personalized Care

Purpose of Review

To understand the impact of kidney disease in Canada and the priority areas of kidney research that can benefit from patient-oriented, precision medicine research using novel technologies.

Sources of Information

Information was collected through discussions between health care professionals, researchers, and patient partners. Literature was compiled using search engines (PubMed, PubMed central, Medline, and Google) and data from the Canadian Organ Replacement Register.

Methods

We reviewed the impact, prevalence, economic burden, causes of kidney disease, and priority research areas in Canada. After reviewing the priority areas for kidney research, potential avenues for future research that can integrate precision medicine initiatives for patient-oriented research were outlined.

Key Findings

Chronic kidney disease (CKD) remains among the top causes of morbidity and mortality in the world and exerts a large financial strain on the health care system. Despite the increasing number of people with CKD, funding for basic kidney research continues to trail behind other diseases. Current funding strategies favor existing clinical treatment and patient educational strategies. The identification of genetic factors for various forms of kidney disease in the adult and pediatric populations provides mechanistic insight into disease pathogenesis. Allocation of resources and funding toward existing high-yield personalized research initiatives have the potential to significantly affect patient-oriented research outcomes but will be difficult due to a constant decline of funding for kidney research.

Limitations

This is an overview primarily focused on Canadian-specific literature rather than a comprehensive systematic review of the literature. The scope of our findings and conclusions may not be applicable to health care systems in other countries.

Reported sources of health inequities in Indigenous Peoples with chronic kidney disease: a systematic review of quantitative studies

BACKGROUND

To summarise the evidentiary basis related to causes of inequities in chronic kidney disease among Indigenous Peoples.

METHODS

We conducted a Kaupapa Māori meta-synthesis evaluating the epidemiology of chronic kidney diseases in Indigenous Peoples. Systematic searching of MEDLINE, Google Scholar, OVID Nursing, CENTRAL and Embase was conducted to 31 December 2019. Eligible studies were quantitative analyses (case series, case-control, cross-sectional or cohort study) including the following Indigenous Peoples: Māori, Aboriginal and Torres Strait Islander, Métis, First Nations Peoples of Canada, First Nations Peoples of the United States of America, Native Hawaiian and Indigenous Peoples of Taiwan. In the first cycle of coding, a descriptive synthesis of the study research aims, methods and outcomes was used to categorise findings inductively based on similarity in meaning using the David R Williams framework headings and subheadings. In the second cycle of analysis, the numbers of studies contributing to each category were summarised by frequency analysis. Completeness of reporting related to health research involving Indigenous Peoples was evaluated using the CONSIDER checklist.

RESULTS

Four thousand three hundred seventy-two unique study reports were screened and 180 studies proved eligible. The key finding was that epidemiological investigators most frequently reported biological processes of chronic kidney disease, particularly type 2 diabetes and cardiovascular disease as the principal causes of inequities in the burden of chronic kidney disease for colonised Indigenous Peoples. Social and basic causes of unequal health including the influences of economic, political and legal structures on chronic kidney disease burden were infrequently reported or absent in existing literature.

CONCLUSIONS

In this systematic review with meta-synthesis, a Kaupapa Māori methodology and the David R Williams framework was used to evaluate reported causes of health differences in chronic kidney disease in Indigenous Peoples. Current epidemiological practice is focussed on biological processes and surface causes of inequity, with limited reporting of the basic and social causes of disparities such as racism, economic and political/legal structures and socioeconomic status as sources of inequities.

Evidence-Based Decision Making 6: Administrative Databases as Secondary Data Source for Epidemiologic and Health Service Research

Health-care systems require reliable information on which to base health-care planning and make decisions, as well as to evaluate their policy impact. Administrative data, predominantly captured for non-research purposes, provide important information about health services use, expenditures, and clinical outcomes and may be used to assess quality of care. With increased digitalization and accessibility of administrative databases, this data is more readily available for health service research purposes, aiding evidence-based decision making. This chapter discusses the utility of administrative data for population-based studies of health and health care.

Systemic Disease and Ocular Comorbidity Analysis of Geographically Isolated Federally Recognized American Indian Tribes of the Intermountain West

BACKGROUND

The American Indian Navajo and Goshute peoples are underserved patient populations residing in the Four Corners area of the United States and Ibupah, Utah, respectively.

METHODS

We conducted a cross-sectional study of epidemiological factors and lipid biomarkers that may be associated with type II diabetes, hypertension and retinal manifestations in tribal and non-tribal members in the study areas (n = 146 participants). We performed multivariate analyses to determine which, if any, risk factors were unique at the tribal level. Fundus photos and epidemiological data through standardized questionnaires were collected. Blood samples were collected to analyze lipid biomarkers. Univariate analyses were conducted and statistically significant factors at p < 0.10 were entered into a multivariate regression.

RESULTS

Of 51 participants for whom phenotyping was available, from the Four Corners region, 31 had type II diabetes (DM), 26 had hypertension and 6 had diabetic retinopathy (DR). Of the 64 participants from Ibupah with phenotyping available, 20 had diabetes, 19 had hypertension and 6 had DR. Navajo participants were less likely to have any type of retinopathy as compared to Goshute participants (odds ratio (OR) = 0.059; 95% confidence interval (CI) = 0.016-0.223; p < 0.001). Associations were found between diabetes and hypertension in both populations. Older age was associated with hypertension in the Four Corners, and the Navajo that reside there on the reservation, but not within the Goshute and Ibupah populations. Combining both the Ibupah, Utah and Four Corners study populations, being American Indian (p = 0.022), residing in the Four Corners (p = 0.027) and having hypertension (p < 0.001) increased the risk of DM. DM (p < 0.001) and age (p = 0.002) were significantly associated with hypertension in both populations examined. When retinopathy was evaluated for both populations combined, hypertension (p = 0.037) and living in Ibupah (p < 0.001) were associated with greater risk of retinopathy. When combining both American Indian populations from the Four Corners and Ibupah, those with hypertension were more likely to have DM (p < 0.001). No lipid biomarkers were found to be significantly associated with any disease state.

CONCLUSIONS

We found different comorbid factors with retinal disease outcome between the two tribes that reside within the Intermountain West. This is indicated by the association of tribe and with the type of retinopathy outcome when we combined the populations of American Indians. Overall, the Navajo peoples and the Four Corners had a higher prevalence of chronic disease that included diabetes and hypertension than the Goshutes and Ibupah. To the best of our knowledge, this is the first study to conduct an analysis for disease outcomes exclusively including the Navajo and Goshute tribe of the Intermountain West.

Ethnic minority disparities in progression and mortality of pre-dialysis chronic kidney disease: a systematic scoping review

Background

There are a growing number of studies on ethnic differences in progression and mortality for pre-dialysis chronic kidney disease (CKD), but this literature has yet to be synthesised, particularly for studies on mortality.

Methods

This scoping review synthesized existing literature on ethnic differences in progression and mortality for adults with pre-dialysis CKD, explored factors contributing to these differences, and identified gaps in the literature. A comprehensive search strategy using search terms for ethnicity and CKD was taken to identify potentially relevant studies. Nine databases were searched from 1992 to June 2017, with an updated search in February 2020.

Results

8059 articles were identified and screened. Fifty-five studies (2 systematic review, 7 non-systematic reviews, and 46 individual studies) were included in this review. Most were US studies and compared African-American/Afro-Caribbean and Caucasian populations, and fewer studies assessed outcomes for Hispanics and Asians. Most studies reported higher risk of CKD progression in Afro-Caribbean/African-Americans, Hispanics, and Asians, lower risk of mortality for Asians, and mixed findings on risk of mortality for Afro-Caribbean/African-Americans and Hispanics, compared to Caucasians. Biological factors such as hypertension, diabetes, and cardiovascular disease contributed to increased risk of progression for ethnic minorities but did not increase risk of mortality in these groups.

Conclusions

Higher rates of renal replacement therapy among ethnic minorities may be partly due to increased risk of progression and reduced mortality in these groups. The review identifies gaps in the literature and highlights a need for a more structured approach by researchers that would allow higher confidence in single studies and better harmonization of data across studies to advance our understanding of CKD progression and mortality.

Burden, access, and disparities in kidney disease

Kidney disease is a global public health problem, affecting over 750 million persons worldwide. The burden of kidney disease varies substantially across the world, as does its detection and treatment. In many settings, rates of kidney disease and the provision of its care are defined by socio-economic, cultural, and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here, we highlight that many countries still lack access to basic diagnostics, a trained nephrology workforce, universal access to primary health care, and renal replacement therapies. We point to the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage worldwide by 2030 is one of the World Health Organization's Sustainable Development Goals. While universal health coverage may not include all elements of kidney care in all countries, understanding what is feasible and important for a country or region with a focus on reducing the burden and consequences of kidney disease would be an important step towards achieving kidney health equity.

Preventing CKD in Developed Countries

Chronic kidney disease (CKD) is an important public health concern in developed countries because of both the number of people affected and the high cost of care when prevention strategies are not effectively implemented. Prevention should start at the governance level with the institution of multisectoral polices supporting sustainable development goals and ensuring safe and healthy environments. Primordial prevention of CKD can be achieved through implementation of measures to ensure healthy fetal (kidney) development. Public health strategies to prevent diabetes, hypertension, and obesity as risk factors for CKD are important. These approaches are cost-effective and reduce the overall noncommunicable disease burden. Strategies to prevent nontraditional CKD risk factors, including nephrotoxin exposure, kidney stones, infections, environmental exposures, and acute kidney injury (AKI), need to be tailored to local needs and epidemiology. Early diagnosis and treatment of CKD risk factors such as diabetes, obesity, and hypertension are key for primary prevention of CKD. CKD tends to occur more frequently and to progress more rapidly among indigenous, minority, and socioeconomically disadvantaged populations. Special attention is required to meet the CKD prevention needs of these populations. Effective secondary prevention of CKD relies on screening of individuals at risk to detect and treat CKD early, using established and emerging strategies. Within high-income countries, barriers to accessing effective CKD therapies must be recognized, and public health strategies must be developed to overcome these obstacles, including training and support at the primary care level to identify individuals at risk of CKD, and appropriately implement clinical practice guidelines.

Kidney disease and care among First Nations people with diabetes in Ontario: a population-based cohort study

BACKGROUND

End-stage kidney disease is a serious complication of diabetes. We describe the prevalence of chronic kidney disease, prevalence and incidence of end-stage kidney disease and quality of care of early-stage chronic kidney disease for First Nations people with diabetes compared to other Ontarians with diabetes.

METHODS

We conducted a retrospective cohort study in Ontario using linked administrative data at ICES. We included adults with incident diabetes between 1994 and 2014, and used laboratory values to identify kidney disease and quality indicators for care for early-stage disease. We compared measures in First Nations people to those in other people in Ontario, and used direct age and sex standardization. We used Cox proportional hazards regression to compare the incidence of end-stage kidney disease between groups.

RESULTS

Our study included 21 968 First Nations people with diabetes. The age- and sex-standardized prevalence of chronic kidney disease was higher for First Nations people than for other Ontarians (20.7% v. 18.4%), as was the prevalence of end-stage kidney disease (2.9% v. 1.0%). The incidence of end-stage kidney disease was higher among First Nations people than among other people in Ontario (9.3 v. 4.7 events per 10 000 person-years; age- and sex-adjusted hazard ratio 2.23, 95% confidence interval 1.72-2.89). The 2 groups were similarly likely to receive recommended medications, but First Nations people were less likely to receive laboratory tests for their kidney disease.

INTERPRETATION

Despite receiving similar quality of care for early-stage kidney disease, First Nations people with diabetes had higher rates of end-stage kidney disease than other Ontarians. Further research is needed to better understand contributing factors to help inform future interventions.

Burden, access, and disparities in kidney disease

For the World Kidney Day Steering Committee Kidney disease is a global public health problem that affects more than 750 million persons worldwide. The burden of kidney disease varies substantially across the world, as does its detection and treatment. Although the magnitude and impact of kidney disease is better defined in developed countries, emerging evidence suggests that developing countries have a similar or even greater kidney disease burden. In many settings, rates of kidney disease and the provision of its care are defined by socioeconomic, cultural, and political factors, leading to significant disparities in disease burden, even in developed countries. These disparities exist across the spectrum of kidney disease - from preventive efforts to curb development of acute kidney injury or chronic kidney disease, to screening for kidney disease among persons at high risk, to access to subspecialty care and treatment of kidney failure with renal replacement therapy. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. In this editorial, we highlight these disparities and emphasize the role of public policies and organizational structures in addressing them. We outline opportunities to improve our understanding of disparities in kidney disease, the best ways for them to be addressed, and how to streamline efforts toward achieving kidney health equity across the globe.

A Holistic Approach to Risk for Early Kidney Injury in Indigenous Youth With Type 2 Diabetes: A Proof of Concept Paper From the iCARE Cohort

Background:

Indigenous youth with type 2 diabetes (T2D) are disproportionately affected by early onset albuminuria and are at high risk of kidney failure in early adulthood. Traditional biological approaches have failed to fully explain the renal morbidity seen in this population. The improving renal Complications in Adolescents with type 2 diabetes through REsearch cohort (iCARE) study was therefore designed in collaboration with patients, to more holistically evaluate risk factors for renal morbidity. We hypothesize that both biological factors and mental health influence renal outcomes, mediated via inflammatory pathways.

Objective:

The objective of this study was to evaluate the iCARE analytic framework which evaluates relationships between biological factors, mental health, inflammation, and albuminuria utilizing a structural equation modeling (SEM) approach.

Methods:

The first 187 youth with T2D (10-25 years) from the Manitoba iCARE cohort are presented here to evaluate our theoretical and analytic framework. An SEM was chosen to evaluate the statistical significance of proposed associations. The primary outcome was a nonorthostatic urine albumin:creatinine ratio ≥2 mg/mmol. Main exposures (ie, latent factors) included psychological health (distress, perceived stress, positive mental health and resilience), hypertension (24 hour monitored), and inflammatory markers (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], fibrinogen). Hemoglobin A1c (HbA1c) and duration of diabetes were covariates.

Results:

Within the initial cohort (median age = 15 years, duration of diabetes = 2.3 years, 66.8% female), 30.5% (n = 57) had nonorthostatic albuminuria (ALB), and the majority of ALB was persistent (confirmed in 2/3 samples over a 6-month period; n = 47). Youth with ALB had higher HbA1c (10.9% vs 8.9%; P < .001), more hypertension (94.2% vs 78·2%; P = .02), longer duration of diabetes (3.4 vs 2.4 years; P = .01), higher distress (9.2 vs 7.3; P = .02), and stress scores (28.7 vs 26.4; P = .03), and elevated inflammatory markers (CRP: 4.9 vs 3.1 mg/L; P = .01, fibrinogen: 3.7 vs 3.3 µmol/L; P = .02). Factors directly associated with ALB in the SEM were hypertension (0.28; P = .001), inflammation (0.41; P < .001), and HbA1c (0.50; P < .001). Psychological health was independently associated with inflammation (−0.20; P < .001) but not directly associated with ALB.

Conclusions:

Albuminuria is highly prevalent in Indigenous youth with T2D. This preliminary analysis supports a theoretical framework linking glycemic control, hypertension, and inflammation, potentially mediated by psychological factors with albuminuria. These data support the need for more holistic models of evaluation and care for youth with T2D and multifactorial interventions to prevent complications.

Burden, access, and disparities in kidney disease

This article was published in Kidney International volume 95, pages 242–248, https://doi.org/10.1016/j.kint.2018.11.007, Copyright World Kidney Day 2019 Steering Committee (2019) and is reprinted concurrently in several journals. The articles cover identical concepts and wording, but vary in minor stylistic and spelling changes, detail, and length of manuscript in keeping with each journal's style. Any of these versions may be used in citing this article. Note that all authors contributed equally to the conception, preparation, and editing of the manuscript.

Kidney disease is a global public health problem, affecting over 750 million persons worldwide. The burden of kidney disease varies substantially across the world, as does its detection and treatment. In many settings, rates of kidney disease and the provision of its care are defined by socio-economic, cultural, and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here, we highlight that many countries still lack access to basic diagnostics, a trained nephrology workforce, universal access to primary health care, and renal replacement therapies. We point to the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage worldwide by 2030 is one of the World Health Organization's Sustainable Development Goals. While universal health coverage may not include all elements of kidney care in all countries, understanding what is feasible and important for a country or region with a focus on reducing the burden and consequences of kidney disease would be an important step towards achieving kidney health equity.

Burden, Access, and Disparities in Kidney Disease

Kidney disease is a global public health problem, affecting more than 750 million persons worldwide. The burden of kidney disease varies substantially across the world, as does its detection and treatment. In many settings, rates of kidney disease and the provision of its care are defined by socioeconomic, cultural, and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here, we highlight that many countries still lack access to basic diagnostics, a trained nephrology workforce, universal access to primary health care, and renal replacement therapies. We point to the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage worldwide by 2030 is one of the World Health Organization’s Sustainable Development Goals. Although universal health coverage may not include all elements of kidney care in all countries, understanding what is feasible and important for a country or region with a focus on reducing the burden and consequences of kidney disease would be an important step toward achieving kidney health equity.

Burden, Access, and Disparities in Kidney Disease

Kidney disease is a global public health problem, affecting over 750 million persons worldwide. The burden of kidney disease varies substantially across the world. In many settings, rates of kidney disease and the provision of its care are defined by socioeconomic, cultural, and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here, we highlight the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage worldwide by 2030 is a World Health Organization Sustainable Development Goal. While universal health coverage may not include all elements of kidney care in all countries, understanding what is locally feasible and important with a focus on reducing the burden and consequences of kidney disease would be an important step towards achieving kidney health equity.

Burden, Access, and Disparities in Kidney Disease

Kidney disease is a global public health problem, affecting over 750 million persons worldwide. The burden of kidney disease varies substantially across the world. In many settings, rates of kidney disease and the provision of its care are defined by socioeconomic, cultural, and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here, we highlight the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage worldwide by 2030 is a World Health Organization Sustainable Development Goal. While universal health coverage may not include all elements of kidney care in all countries, understanding what is locally feasible and important with a focus on reducing the burden and consequences of kidney disease would be an important step towards achieving kidney health equity.

Burden, access and disparities in kidney disease

Kidney disease is a global public health problem, affecting over 750 million persons worldwide. The burden of kidney disease varies substantially across the world, as does its detection and treatment. In many settings, rates of kidney disease and the provision of its care are defined by socio-economic, cultural, and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here, we highlight that many countries still lack access to basic diagnostics, a trained nephrology workforce, universal access to primary health care, and renal replacement therapies. We point to the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage worldwide by 2030 is one of the World Health Organization's Sustainable Development Goals. While universal health coverage may not include all elements of kidney care in all countries, understanding what is feasible and important for a country or region with a focus on reducing the burden and consequences of kidney disease would be an important step towards achieving kidney health equity.

Burden, Access, and Disparities in Kidney Disease

Kidney disease is a global public health problem, affecting over 750 million persons worldwide. The burden of kidney disease varies substantially across the world. In many settings, rates of kidney disease and the provision of its care are defined by socioeconomic, cultural, and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here, we highlight the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage worldwide by 2030 is a World Health Organization Sustainable Development Goal. While universal health coverage may not include all elements of kidney care in all countries, understanding what is locally feasible and important with a focus on reducing the burden and consequences of kidney disease would be an important step towards achieving kidney health equity.

2019 World Kidney Day Editorial - burden, access, and disparities in kidney disease

Kidney disease is a global public health problem, affecting over 750 million persons worldwide. The burden of kidney disease varies substantially across the world, as does its detection and treatment. In many settings, rates of kidney disease and the provision of its care are defined by socio-economic, cultural, and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here, we highlight that many countries still lack access to basic diagnostics, a trained nephrology workforce, universal access to primary health care, and renal replacement therapies. We point to the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage worldwide by 2030 is one of the World Health Organization's Sustainable Development Goals. While universal health coverage may not include all elements of kidney care in all countries, understanding what is feasible and important for a country or region with a focus on reducing the burden and consequences of kidney disease would be an important step towards achieving kidney health equity.

Contribution of cardiometabolic risk factors to estimated glomerular filtration rate decline in Indigenous Australians with and without albuminuria - the eGFR Follow-up Study

AIM

We assessed associations between cardiometabolic risk factors and estimated glomerular filtration rate (eGFR) decline according to baseline albuminuria to identify potential treatment targets in Indigenous Australians.

METHODS

The eGFR Follow-up Study is a longitudinal cohort of 520 Indigenous Australians. Linear regression was used to estimate associations between baseline cardiometabolic risk factors and annual Chronic Kidney Disease Epidemiology Collaboration eGFR change (mL/min per 1.73m² /year), among those classified with baseline normoalbuminuria (urine albumin-to-creatinine ratio (uACR) <3 mg/mmol; n = 297), microalbuminuria (uACR 3-30 mg/mmol; n = 114) and macroalbuminuria (uACR ≥30 mg/mmol; n = 109).

RESULTS

After a median of 3 years follow-up, progressive declines of the age- and sex-adjusted mean eGFR were observed across albuminuria categories (-2.0 [-2.6 to -1.4], -2.5 [-3.7 to -1.3] and -6.3 [-7.8 to -4.9] mL/min per 1.72m² /year). Although a borderline association was observed between greater baseline haemoglobin A_1c and eGFR decline in those with macroalbuminuria (P = 0.059), relationships were not significant in those with microalbuminuria (P = 0.187) or normoalbuminuria (P = 0.23). Greater baseline blood pressure, C-reactive protein, waist-to-hip ratio and lower high-density lipoprotein cholesterol showed non-significant trends with greater eGFR decline in the presence of albuminuria.

CONCLUSION

Over a 3 year period, marked eGFR decline was observed with greater baseline albuminuria. Cardiometabolic risk factors were not strong predictors for eGFR decline in Indigenous Australians without albuminuria. Longer follow-up may elucidate the role of these predictors and other mechanisms in chronic kidney disease progression in this population.

Screening for kidney disease in Indigenous Canadian children: The FINISHED screen, triage and treat program

Background

Indigenous populations are disproportionately affected by kidney failure at younger ages than other ethnic groups in Canada. As symptoms do not occur until disease is advanced, early kidney disease risk is often unrecognized.

Objectives

We sought to evaluate the yield of community-based screening for early risk factors for kidney disease in youth from rural Indigenous communities in Canada.

Methods

The FINISHED project screened 11 rural First Nations communities in Manitoba, Canada after community and school engagement. The results for the 10- to 17-year olds are reported here. Body mass index (BMI), blood pressure, estimated glomerular filtration rate (eGFR), hemoglobin A1c's (HbA1c) and urine albumin-to-creatinine ratios (ACR) were assessed. All children were triaged and referred to either primary or tertiary care, depending on risk.

Results

A total of 353 were screened (estimated 22.4% of population). The median age was 12 years (IQR 10 to 13), 55% were female and 55% were overweight or obese. Overall, 21.8% of children had at least one abnormality. Hypertension was identified in 5.4% and 11.9% had prehypertension. None of the children had an eGFR < 60 ml/min/1.73 m² however 10.5% had an ACR > 3 mg/mmol and 6.2% had an eGFR < 90 ml/min/1.73 m² suggestive of early kidney disease. Diabetes was identified in 1.4%, and 1.4% had HbA1c's between 6.1% and 6.49%.

Conclusions

Risk factors for chronic kidney disease are highly prevalent in rural Indigenous children. More research is required to confirm the persistence of these findings, and to evaluate the efficacy of screening children to prevent or delay progression to kidney failure.

Remote Dwelling Location Is a Risk Factor for CKD Among Indigenous Canadians

Introduction

Rural and remote indigenous individuals have a high burden of chronic kidney disease (CKD) when compared to the general population. However, it has not been previously explored how these rates compare to urban-dwelling indigenous populations.

Methods

In a recent cross-sectional screening study, 1346 adults 18 to 80 years of age were screened for CKD and diabetes across 11 communities in rural and remote areas in Manitoba, Canada, as part of the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) program. An additional 284 Indigenous adults who resided in low-income areas in the city of Winnipeg, Manitoba, Canada were screened as part of the NorWest Mobile Diabetes and Kidney Disease Screening and Intervention Project.

Results

Our findings indicate that a gradient of CKD and diabetes prevalence exists for Indigenous individuals living in different geographic areas. Compared to urban-dwelling Indigenous individuals, rural-dwelling individuals had more than a 2-fold (2.1, 95% CI = 1.4-3.1) increase in diabetes whereas remote-dwelling individuals had a 4-fold (4.1, 95% CI = 2.8-6.0) increase, and more than a 3-fold (3.1, 95% CI = 2.2-4.5) increase in CKD prevalence.

Conclusion

Although these results highlight the relative importance of geography in determining the prevalence of diabetes and CKD in Indigenous Canadians, geography is but an important surrogate of other determinants, such as poverty and access to care.

Exploring structural barriers to diabetes self-management in Alberta First Nations communities

BACKGROUND

Type 2 diabetes is highly prevalent in Canadian First Nations (FN) communities. FN individuals with diabetes are less likely to receive guideline recommended care and access specialist care. They are also less likely to be able to engage in optimal self-management behaviours. While the systemic and racial contributors to this problem have been well described, individuals' experiences with structural barriers to care and self-management remain under-characterized.

METHODS

We utilized qualitative methods to gain insight into the structural barriers to self-management experienced by FN individuals with diabetes. We conducted a qualitative descriptive analysis of a subcohort of patients with diabetes from FN communities (n = 5) from a larger qualitative study. Using detailed semi-structured telephone interviews, we inquired about participants' diabetes and barriers to diabetes self-management. Inductive thematic analysis was performed in duplicate using NVivo 10.

RESULTS

The structural barriers faced by this population were substantial yet distinct from those described by non-FN individuals with diabetes. For example, medication costs, which are usually cited as a barrier to care, are covered for FN persons with status. The barriers to diabetes self-management that were commonly experienced in this cohort included transportation-related difficulties, financial barriers to uninsured health services, and lack of accessible diabetes education and resultant knowledge gaps.

CONCLUSIONS

FN Albertans with diabetes face a myriad of barriers to self-management, which are distinct from the Non-FN population. In addition to the barriers introduced by colonialism and historical injustices, finances, geographic isolation, and lack of diabetes education each impede optimal management of diabetes. Programs targeted at addressing FN-specific barriers may improve aspects of diabetes self-management in this population.

Screening for chronic kidney disease in Canadian indigenous peoples is cost-effective

Canadian indigenous (First Nations) have rates of kidney failure that are 2- to 4-fold higher than the non-indigenous general Canadian population. As such, a strategy of targeted screening and treatment for CKD may be cost-effective in this population. Our objective was to assess the cost utility of screening and subsequent treatment for CKD in rural Canadian indigenous adults by both estimated glomerular filtration rate and the urine albumin-to-creatinine ratio. A decision analytic Markov model was constructed comparing the screening and treatment strategy to usual care. Primary outcomes were presented as incremental cost-effectiveness ratios (ICERs) presented as a cost per quality-adjusted life-year (QALY). Screening for CKD was associated with an ICER of $23,700/QALY in comparison to usual care. Restricting the model to screening in communities accessed only by air travel (CKD prevalence 34.4%), this ratio fell to $7,790/QALY. In road accessible communities (CKD prevalence 17.6%) the ICER was $52,480/QALY. The model was robust to changes in influential variables when tested in univariate sensitivity analyses. Probabilistic sensitivity analysis found 72% of simulations to be cost-effective at a $50,000/QALY threshold and 93% of simulations to be cost-effective at a $100,000/QALY threshold. Thus, targeted screening and treatment for CKD using point-of-care testing equipment in rural Canadian indigenous populations is cost-effective, particularly in remote air access-only communities with the highest risk of CKD and kidney failure. Evaluation of targeted screening initiatives with cluster randomized controlled trials and integration of screening into routine clinical visits in communities with the highest risk is recommended.

Kidney Disease Among Registered Métis Citizens of Ontario: A Population-Based Cohort Study

Background:

Indigenous peoples in Canada have higher rates of kidney disease than non-Indigenous Canadians. However, little is known about the risk of kidney disease specifically in the Métis population in Canada.

Objective:

To compare the prevalence of chronic kidney disease and incidence of acute kidney injury and end-stage kidney disease among registered Métis citizens in Ontario and a matched sample from the general Ontario population.

Design:

Population-based, retrospective cohort study using data from the Métis Nation of Ontario’s Citizenship Registry and administrative databases.

Setting:

Ontario, Canada; 2003-2013.

Patients:

Ontario residents ≥18 years.

Measurements:

Prevalence of chronic kidney disease and incidence of acute kidney injury and end-stage kidney disease. Secondary outcomes among patients hospitalized with acute kidney injury included non-recovery of kidney function and mortality within 1 year of discharge.

Methods:

Database codes and laboratory values were used to determine study outcomes. Métis citizens were matched (1:4) to Ontario residents on age, sex, and area of residence. The analysis included 12 229 registered Métis citizens and 48 916 adults from the general population.

Results:

We found the prevalence of chronic kidney disease was slightly higher among Métis citizens compared with the general population (3.1% vs 2.6%, P = 0.002). The incidence of acute kidney injury was 1.2 per 1000 person-years in both Métis citizens and the general population (P = 0.54). Of those hospitalized with acute kidney injury, outcomes were similar among Métis citizens and the general population except 1-year mortality, which was higher for Métis citizens (24.5% vs 15.3%, P = 0.03). The incidence of end-stage kidney disease did not differ between groups (<3.0 per 10 000 person-years, P = 0.73).

Limitations:

The Métis Nation of Ontario Citizenship Registry only captures about 20% of Métis people in Ontario. Administrative health care codes used to identify kidney disease are highly specific but have low sensitivity.

Conclusions:

Rates of kidney disease were similar or slightly higher for Métis citizens in Ontario compared with the matched general population.

The Prevalence of CKD in Rural Canadian Indigenous Peoples: Results From the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) Screen, Triage, and Treat Program

BACKGROUND

Indigenous Canadians have high rates of risk factors for chronic kidney disease (CKD), in particular diabetes. Furthermore, they have increased rates of complications associated with CKD, such as kidney failure and vascular disease. Our objective was to describe the prevalence of CKD in this population.

STUDY DESIGN

Cross-sectional cohort.

SETTING & PARTICIPANTS

Indigenous (First Nations) Canadians 18 years or older screened as part of the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) project, an initiative completed in 2015 that accomplished community-wide screening in 11 rural communities in Manitoba, Canada.

PREDICTORS

Indigenous ethnicity and geographic location (communities accessible by road compared with those accessible only by air).

OUTCOME

Prevalence of CKD, presumed based on a single ascertainment of urine albumin-creatinine ratio (UACR) ≥ 30mg/g and/or estimated glomerular filtration rate (eGFR)<60mL/min/1.73m(2).

MEASUREMENTS

Kidney function measured by eGFR (CKD-EPI creatinine equation) and UACR.

RESULTS

1,346 adults were screened; 25.5% had CKD, defined as UACR≥30mg/g or eGFR<60mL/min/1.73m(2). Communities accessible by road had a lower prevalence of CKD (17.6%) than more remote communities accessible only by air (34.4%). Of those screened, 3.3% had reduced kidney function (defined as eGFR<60mL/min/1.73m(2)). Severely increased albuminuria was present in 5.0% of those screened.

LIMITATIONS

Presumption of chronicity based on a single ascertainment. There is a possibility of sampling bias, the net direction of which is uncertain.

CONCLUSIONS

We found a 2-fold higher prevalence of CKD in indigenous Canadians in comparison to the general population and a prevalence of severely increased albuminuria that was 5-fold higher. This is comparable to patients with diabetes and/or hypertension. Public health strategies to screen, triage, and treat all Canadian indigenous peoples with CKD should be considered.

Back to the basics: Identifying and addressing underlying challenges in achieving high quality and relevant health statistics for indigenous populations in Canada

Canada is known internationally for excellence in both the quality and public policy relevance of its health and social statistics. There is a double standard however with respect to the relevance and quality of statistics for Indigenous populations in Canada. Indigenous specific health and social statistics gathering is informed by unique ethical, rights-based, policy and practice imperatives regarding the need for Indigenous participation and leadership in Indigenous data processes throughout the spectrum of indicator development, data collection, management, analysis and use. We demonstrate how current Indigenous data quality challenges including misclassification errors and non-response bias systematically contribute to a significant underestimate of inequities in health determinants, health status, and health care access between Indigenous and non-Indigenous people in Canada. The major quality challenge underlying these errors and biases is the lack of Indigenous specific identifiers that are consistent and relevant in major health and social data sources. The recent removal of an Indigenous identity question from the Canadian census has resulted in further deterioration of an already suboptimal system. A revision of core health data sources to include relevant, consistent, and inclusive Indigenous self-identification is urgently required. These changes need to be carried out in partnership with Indigenous peoples and their representative and governing organizations.

Evidence-based decision-making 6: Utilization of administrative databases for health services research

Health-care systems require reliable information on which to base health-care planning and make decisions, as well as to evaluate their policy impact. Administrative data provide important information about health services use, expenditures, clinical outcomes, and may be used to assess quality of care. With increased digitalization and accessibility of administrative databases, these data are more readily available for health service research purposes, aiding evidence-based decision-making. This chapter discusses the utility of administrative data for population-based studies of health and health care.

Disparities in the burden, outcomes, and care of chronic kidney disease

PURPOSE OF REVIEW

Racial, ethnic and socioeconomic disparities in chronic kidney disease (CKD) have been documented for decades, yet little progress has been made in mitigating them. Several recent studies offer new insights into the root causes of these disparities, point to areas in which future research is warranted, and identify opportunities for changes in policy and clinical practice.

RECENT FINDINGS

Recently published evidence suggests that geographic disparities in CKD prevalence exist and vary by race. CKD progression is more rapid for racial and ethnic minority groups compared with whites and may be largely, but not completely, explained by genetic factors. Stark socioeconomic disparities in outcomes for dialysis patients exist and vary by race, place of residence, and treatment facility. Disparities in access to living kidney donation may be driven primarily by the socioeconomic status of the donor as opposed to recipient factors.

SUMMARY

Recent studies highlight opportunities to eliminate disparities in CKD, including efforts to direct resources to areas and populations where disparities are most prevalent, efforts to understand how to best use emerging information on the contribution of genetic factors to disparities, and continued work to identify modifiable environmental, social, and behavioral factors for targeted interventions among high-risk populations.