Alcoholic Liver Disease Pathophysiology

hello, i'm norman swan. welcome to this program on chronickidney disease, a silent condition. it's often preventable,and it's said to be silent because up to 90% of kidney functioncan be lost before symptoms are evident. with ageing and the diabetes epidemic, more and more australians are havingeither dialysis or transplantation for end-stage kidney disease. one in seven australian adultsover the age of 25 has some degree of kidney disease,

and chronic kidney diseaseconstitutes nearly 10% of all deaths and more than 1.1 millionhospitalisations. it's commonamongst indigenous australians, who are six times as likely as otheraustralians to be receiving dialysis or to have had a kidney transplant. death rates from chronic kidney diseaseare between 7 and 11 times higher in indigenous men and women compared tonon-indigenous australians. this program will emphasise the needfor a targeted approach to prevention, detectionand the management of people

with chronic kidney disease. it also examines the needfor early detection and the deliveryof chronic kidney disease care, which is not necessarilystraightforward, with a specific focuson indigenous and rural populations. there area number of useful resources available on the rural health foundation'swebsite - now let's meet our panel. david harris is a nephrologistand professor of medicine

at the university of sydney. - welcome, david.- evening. tim mathew is the medical directorof kidney health australia. - tim.- evening, norman. paul snelling is a renal physician atroyal prince alfred hospital in sydney. - welcome, paul.- good evening, norman. beres joyner is a gp anda specialist in public health medicine, and is basedin rockhampton in queensland. - welcome, beres.- good evening.

anne blong is currently the chronickidney disease nurse practitioner for townsville health service district. - welcome, anne.- thank you. are there many nurse practitionersaround in townsville? about 11, i think. 11? that's more than i thoughtthere were in the whole of australia. they're not all doingchronic kidney disease. last but not least is anothernurse practitioner, lesley salem. lesley is a nurse practitionerfor the integrated chronic care

for aboriginal people programat hunter new england health. lesley is a descendant ofthe wonnarua nation in new south wales. - welcome, lesley.- thank you very much, norman. lesley, tell me about the impact you see of chronic kidney diseaseon aboriginal communities. it's a two-edged swordhere in new south wales. i see the overall incidenceand prevalence across australia as being very high. in new south wales,because of the vast distances,

we have large groups of missions,small towns, that have no gp servicesor very limited gp services. so i think we have poor recognition, and we underestimatethe impact in new south wales of kidney disease andthe consequential cardiovascular disease on aboriginal people. what personal and family impact,and community impact, do you see? personally, i have a fatherwho never smoked or drank and still had a heart attack at 49,

so i've always been quite passionateabout the health of aboriginal people. but i've been working in nephrologyfor 26 years, and what i see is a lot of aboriginal peoplenot coming to the major town centres when they're referredfor treatment of kidney disease. i think there's a paucity of treatmentgoing on in rural and remote areas. anne, do you agree? yes. i think that sometimes remoteaboriginal people don't attend hospitals because they see it as some placethat you go if you're going to die. what are we talking about here, tim?

what is chronic kidney disease?is it one disease? we talk about itas though it was one disease. in truth, there are manydifferent types of diseases which cause damage to the kidney. but it's a useful concept to consider -chronic kidney disease as an entity - to find there's either a reductionin the efficiency of the kidney or the presence of kidney damage, asevidenced by abnormalities in the urine. and causes, david? the most common cause in australiaand worldwide now is diabetes.

number two is glomerulonephritisand number three hypertension. norman: glomerulonephritis? yep, different varieties.iga is the most common. norman: in aboriginal communities, paul,what's the commonest cause? increasingly, it's probably diabetesor a metabolic syndrome, but that's a bit simplisticin some ways. our thinking is it's probablya whole-of-life disease in many ways, from early-childhood damage rightthrough to accumulating risk factors as one ages.

i don't think it's as simple as sayingone disease. it's a whole-of-life story. and, of course, beres, what we miss with chronic kidney diseaseis the impact on the heart. most certainly. i see chronic kidney diseaseas being a very important risk factor for cardiovascular disease. while i think chronic kidney diseaseis important as a singular concept, i think it's most importantthat we actually consider it as one of the vascular risk factors.

do you think that's generally known,anne? no, i don't think it is. i think that people thinkthat if they've got kidney problems, they probably have diabetes,and if they get that under control, there's no other problems. but i think evenearly chronic kidney disease causes 10 to 20 timesthe cardiac risk factors. do we know why, paul? it's certainly through acceleratedcardiovascular disease the risk comes.

and it's probably through bothan association with kidney disease being accelerated byvascular risk factors - hypertension, diabetes,hyperglycerolemia - but also with reductionin kidney function there are probably other changesthat affect blood vessels - changes in inflammation, oxidant stress, changes in the different lipid profiles. - but it is an independent risk factor?- it's an independent risk factor, yeah. how strong an independent risk factor,tim?

it's probablyabout as strong as cholesterol. it probably increases the riskby three to five times, depending on how you assess itand look at it. it is one of the necessary preclusions to using the new absolute-risk toolassessment. you must measure kidney function first, because if you have a reductionor you have some important ckd, you shoot to the top of the treeas a high-risk person. so how much of it is around, david?

well, chronic kidney diseaseis in fact a very common disease. it's not recognised how common it is. so one in seven australians havesome evidence of chronic kidney disease, and up to one in three australiansare at risk of having chronic kidney diseasein the future. that's a substantial proportion,and getting bigger. the contribution of ageingand type 2 diabetes? as i mentioned, type 2 diabetesis the commonest cause in australia and worldwide.

it's now over 30%, getting up to 40%of cases are due to type 2 diabetes. certainly, ageing does contribute a lot. one of the difficulties in this area is distinguishingageing, the normal ageing, from abnormal ageing of the kidney. norman: tell me more. well, as you get older, your glomerularfiltration rate declines with age, and so it becomes difficult to knowwhether a reduction in gfr in the older age group isjust part of the normal ageing process

or whether that patientin fact has chronic kidney disease. and what are the risk factors, tim? because people talk about smoking. yes, there are seven risk factors whichwe would like everybody to be aware of, and they feed into thosewho need to have kidney tests done, so they're very important. smoking, obesity,family history of kidney disease, anyone with diabetes,anyone with high blood pressure, anyone who's over the age of 60

and anyone, of course, who's anaboriginal or torres strait islander. so they are people who merit, what,screening? they merit,according to all the guidelines and the red bookand every way you look at it, a kidney health check, probablyon an annual or biannual basis. beres, what do you understandby a kidney health check? i'd actually wrap it up, again, in a health check looking atcardiovascular risk factors. but specifically looking at the kidneys,

we're looking at an egfrand also looking at a urine test, and, in a general practice setting, if you can get a dipstick urine,looking for protein or blood. we've just done a series of programson diabetes, and they raised the sign of the crossto the idea of doing dipsticks - that this is unreliable,not a way of measuring kidney disease, you may as well not bother. i think there would besome differing opinions on that, but i think that one of the challengesin general practice

is actually getting a urine testin the clinic at the time at which you require it. norman: anne, what's your view on that? i think people find it very difficultto give you a urine sample on demand. paul, what's the evidence here? there's not much point in doing a testif it's not going to be worth a lot. if it's not going to changeyour management? certainly, for diabetes, the guidelineis to quantitate albuminuria, with albuminuria being the markerof damage in the glomerulus.

proteinuria has a few other bits andpieces that slough off along the way, so albuminuria is better. for the general populationthat guideline is not there, but it's useful and easy to do. in fact, in america and other countries,as tim might say, albuminuria has been integrated into thecardiovascular risk algorithms as well as a marker of vascular risk, probably because the glomerulusis a blood vessel, it's a filter, and damage in thatreflects damage elsewhere.

i personally think a quantitativealbumin or something along those lines gives you at least a numberthat allows you to stratify risk. and we know that if it's significantand you can regress that, it actually will allow you to tell yourpatient there's a better outcome. lesley salem, what's your practicein aboriginal communities? even though the focus for meis identifying kidney disease, i approach it asa cardiovascular risk assessment. so, one, i'm looking at how manynon-modifiable things they have wrong - you know, age, aboriginality, familyhistory, gender, things like that.

and for aboriginal people, of course,the age is lower. and then i'd lookat the modifiable things that i can deal within remote or rural areas - smoking, dyslipidemia,hypertension, diabetes. abdominal obesity - very important. psychological factors that may inhibitthem taking on management or treatment. nutrition,lack of daily vegetables or fruit. alcohol intake, physical activity,microalbuminuria, of course. and then, if they're in later stages,i look at anaemia,

any sort of vascular calcification,looking at ecgs and that, and any metabolic bone disorderor any inflammatory problems. so they're the key things i'm looking atin assessing. either identifying initiallyor following through. i think even though it's kidney disease, i'm constantly looking atcardiovascular risk and what can be modified. and how easy, in the environment of anaboriginal community, is that to do? i mean, that's a long list of stuff.

a lot of that is point-of-care testing. icrs or hba1cs on point-of-care testing,i just need a couple of drops of blood and i can do lipid panels,haemoglobins and that. i had to base the practiceon point-of-care testing - portable ecg equipment that could be used under a treewith a laptop, things like that. one of my clinics is actuallyunder the trees. patients are reluctant to comein to the clinics because of deaths and inappropriate smoking ceremonies.

so one of the clinicsis under the trees, and using some point-of-caretesting equipment. david, once your egfr's dropped, once you've got a creatininethat's detectably raised, what, you've lost something like 40%of your kidney function? yeah, or even more. so once you're outside the normal range,you've lost half, at least. we're saying herewe've got to do screening tests. the screening tests come in,and the screening tests are crude.

there might be more sophisticated onesin years to come, but they're crude. if they come up positive, almost halfyour kidney function's already gone. what's the impact of intervening then? your blood pressure is up a little, and you get in hard with blood pressureand lose a bit of weight. can you return your creatinineto normal? you may not return it to normal,but at any stage of kidney impairment, you can have an effecton the rate of progression of disease with treatment, and you can reducethe cardiovascular risk.

lesley is workingin an aboriginal community. we're all working with peoplewith busy lives. they don't know they've gotkidney disease, and you want me to take major treatment. can you promise me an effect? beres, what do you tell your patients - we're putting you on these drugsand you've got to stay on them for life. what's the promisein terms of my kidneys? what does the evidence say?

i suppose my first priority, again,is reducing cardiovascular risk, because i think that's goingto kill these people before their kidneys, in many cases. if you've got kidney disease, doyou take the same approach as diabetes - you go onto a statin regardless, yougo onto an antihypertensive regardless. it doesn't matter what your levels are - we're going to hit you hardfor your risk factors. that's probably summing upfairly tightly. certainly, one has to work withthe individual patient

and look at the whole picture,address the lifestyle risk factors as well as pharmacological approaches. and in some cases it really takes a bit of stepping through,prioritising medications and working with patients to help themunderstand the targets of therapy. paul, what's the evidence? there's a number epidemiologicalcohort studies that have shown the tight correlationbetween reductions in kidney function or egfrand increased cardiovascular risk.

norman: no, but intervening. intervention studies both in diabeticand non-diabetic studies. usually the one that we've looked at are looking at reductionsin progression of in-stage disease. it can show a halvingof the rate of progression with tight blood pressure control. predominantly it's the blood pressurecontrol people that have looked at. as with anything, people with greatestrisk derive the greatest benefits. so, those with the worst degreeof blood pressure or proteinuria,

if you can get that under control,derive the greatest benefit. there's strong evidence that you canslow rates of progression of disease. it probably ties intocardiovascular events as well, though most of the trialsaren't powered to show that. i've got a question here which isasking about low-protein diets. if you're starting to register high, you're coming up positiveon your kidney screen, straight onto a low-protein diet? no. in australia, the consensus is

that low-protein diets have no part toplay in stopping progression of disease. there are pockets of belief overseaswhere that is practised. we certainly practiseavoiding excessive protein intake, but going to a low-protein diet,the answer is no. can i just take us back brieflyto the urine testing? i would like to get across the point that conventional dipstick testingfor urine protein is still ok, and it's still the areawhere the best evidence exists in terms of the importance of thatin long-term outcome studies.

it's cheap and it's reasonably accurate. i don't want people to feelthey shouldn't do it. but there's no question,as paul was indicating, that we're moving progressively towardsalbumin as a more accurate measure and as one which can be donein the laboratory more easily. so stand by to watchfor the next 6 to 12 months. new recommendations may well becoming out in that direction. another online question -'how does one investigate someone suspected of havingchronic kidney disease?' david?

well, do the initial screening testto prove it. so, doing their egfr and then lookingat their urine, as we've just said. and then the investigations that you dodepend on the stage of kidney disease. so if it's very early,you may not do too much more than that. norman: as defined by? by the level of gfr. so once your gfr falls below 60, so you're into stage-3chronic kidney disease, that's when you start to look atother things, such as haemoglobin,

to see if the patient is anaemic, start to look at calcium and phosphateto see if there's any imbalances there. david, you'd also agreethat at any stage of gfr reduction, if there is proteinuriaor albuminuria present, that adds greatly to the riskof progression? yes, you're quite right. so the gfr and the proteinuriaare independent risk factors. the new staging is going to take accountof proteinuria at every stage. and what's the place - ouronline viewer asks - of renal biopsy?

- when do you start doing that, paul?- oh, it depends... this goes to when the gpwould actually refer on. it probably dependswhat school you went to. people are changing. we do a lot lessbiopsies now than we used to. most people would biopsy ifthere's definite nephrotic syndrome... norman: you've got oedema, proteinuria. proteinuria of greater than 3g a day,low albumin, swelling, all the rest. those diseases may benefitfrom specific treatment. if you've got significant proteinuria,which we define as over a gram a day,

and acr roughly of about 100,protein-creatinine ratio of about 100, people may biopsy there, looking to seeif they can treat with other agents than our standard therapy, which isaggressive blood pressure lowering. there's a debate about that,and we can discuss that, but that's really for nephrologists. for the majority of patients,we wouldn't think of biopsy without rapidlyprogressive loss of kidney function with haematuriaor significant proteinuria. let's go to our first case study.

lily is a non-indigenous 40-year-old woman on her first visit to you, beres. she has three children, and tells you in her first pregnancy she had swollen ankles and high blood pressure. you measure her blood pressure and it's 160/90. she says, 'that's what other doctors

got for me recently.' she says she doesn't smoke and has one or two drinks at the weekend. this lady has come for a check-up, and i'd actually clarifywhat her expectations are. in the general practice setting, a check-up means a bit morethan just checking blood pressure and honing immediately inonto that issue.

we'd certainly discuss other preventivehealth aspects, lifestyle aspects, looking at risk factorsfor cardiovascular disease and screening for cancers in particular,pap-smear screening. for this context, i supposethe hypertension is significant. certainly that historyof pregnancy-related hypertension will contributeto her risk of kidney disease. she should actually also be screenedat this point in time for kidney disease, particularly looking at her egfrand at her urine test.

i'd also probably want to checka little bit further regarding her blood pressure, and make sure it's not due tosome other cause. i'd do routine electrolytes, i'd do a full blood count on herat that point in time as well. i'd then start certainly to addressher cardiovascular risk factors also. i'd probably do her cholesterolat this point in time and fasting sugar. what if she had blood in her urine, tim? you would need to establishif it's persistent,

and there's an algorithmwhich we can distribute but i think we're not planningto talk about tonight, which would demand investigation. persistent dipstick-positive haematuriais abnormal and should always be investigated. norman: would you send offfor microscopy on the first occasion? yes, you'd certainly send itfor culture. norman: are we still old-fashionedenough to look for casts in urine? no, casts don't get mentioned muchanymore.

but the presence of what we callglomerular haematuria or dysmorphic cellshas replaced that. we have got a reliable servicethat does that well. that's a very useful help in determining whether the haematuria is coming fromthe kidneys or from the urinary tract. lesley salem, if this was an aboriginalwoman, part of your community, you'd be thinking about blood sugar? yes. i'd be looking at loss or riskor urinary tract infections if she had haematuria.

sorry, the line was going a bit blankthere. i missed some of it. i'd be looking at further sampling to confirmthat it was consistent haematuria and looking at her diabetesand those sort of risk factors. anne, what should be challenges hereof this woman, moving forward? let's assume that she's really justbeginning to show a reduced egfr and maybe just a little bit of proteinin the urine. what's the whole picture that gpsand others have got to look at? i think you need to look ather social situation.

i think a multidisciplinary teamis really important. if you have a dietician who canspeak with this lady, you've got... i don't think she smoked. norman: no, she's not a smoker.- no. looking at her bloods and urine testsover time, you can demonstrate to her her progression or improvementof her results depending on her treatment, and whethershe's adhering to the treatment. so, beres, she comes back to see you.

the only tests that have come up trumpsare... the egfr is down a little bit. a little bit of protein in the urine,not a lot. what are you going to do now for her? well, certainly,i'd want to control her blood pressure. she's actually a relatively young woman, and i would probably have a brief chatto a renal physician about her. i suspect that the proteinuriais related to hypertension. certainly,in controlling her hypertension, i'd use an ace inhibitor or an arb.

i'd usually use an ace inhibitor first. but i'd probably just have a briefdiscussion with a nephrologist. norman: well, you've got three here.take your pick. i suppose the question is, is there anything more i needto do for her at this point in time? ok, lads, fight over this patient here. she needs an ultrasound andher proteinuria/albuminuria quantitated, and she needs to be watched over timeto see what the trends are. norman: an ultrasound to seeif she's got an obstructive uropathy?

yes, to be sureyou won't have a red face in two years. otherwise, time will sort this out. if, in three months,her blood pressure is under control, her albuminuria has gone awayand her gfr is stable, then you know you're on top of things, and you can just continue to managewithout referral. let's change the story a little bit. she's 38.she wants to have a fourth child. what are we going to tell her now,david?

well, it dependson the level of her egfr. if her blood pressure is under controland her egfr is above 50, then probably she's going to be okwith the pregnancy. it probably won't have much extra riskfor her kidney. but once her egfr gets lower than that, there's a risk that her renal functionwill get worse during her pregnancy. is there a risk of eclampsia? yeah, there is an increased risk of hypertension getting worseduring the pregnancy.

what's the eclampsia story here,pre-eclampsia story, paul? she's had it in the first pregnancy,with hypertension and swelling. her second pregnancies, i think,were ok. generally, if you get throughthe second and third without pre-eclampsia, it's less likely. she may well have sustained hypertensionduring the pregnancy and transient hypertensiontowards the end. it'd be unlikely she'd developpre-eclampsia based on previous history. only thing to point out -she can't be on an ace

if she's wanting to get pregnant'cause it's foetotoxic. she needs to be off that agentin the first trimester. but there would be no problemwith her being pregnant. she'd be at slightly increased risk.you'd just watch her. to what extentdo we look for other causes of her hypertensionand her kidney disease? tim? if the hypertension is controlledand her kidney function is stable, then one... i would not go beyondan ultrasound. so we'd just say it's idiopathic kidneydamage, we don't know why she's got it?

well, you may well be missingsome mild nephritis, but it's not going to be treatable,so you would just treat expectantly. so you don't go hunting hardfor autoimmune kidney disease? if you think there'san underlying nephritis, at some stage, if you thengo to referral to a nephrologist, then most of us would do a screening for nephritis with anfs,immunoglobulins, et cetera, but the yield on those is quite low. it would very much depend on the degreeof her albinuria and proteinuria.

if there's lots, it wouldn't fitwith simple hypertension. if it was very mild,you probably wouldn't chase it, or if she had haematuria and proteinuriasuggesting it. anne, as a nurse practitioner,sit back from this, take a whole view of the system, when is it appropriateif a gp does have a specialist nurse practitionerin the town, when does the nurse practitionersee a patient? when should a patient be referredto a specialist?

what's the story there? give usa systemwide view from where you sit. i get some direct referrals from gps for people who have very mildkidney impairment, stage 2s, people that they're very worried abouttheir diabetes, for example, or people who are becoming anaemic,and i will help them manage... norman:so, control slipping away from the gp? i think they just want...they don't think it's serious enough to contact a nephrologist because theyknow nephrology services are very busy. i'm like an extra linkthat they can access.

if i'm worried, i'll just flick themstraight into the nephrologist's clinic. when do you refer on, beres? a number of people in stage 3,people with glomerular haematuria, i'd certainly want a discussionregarding them, and certainly anybody beyond stage 3or people who have got complications. a question herefrom one of our online viewers, michael nixonfrom the northern territory. '95% of my patients are aboriginaland torres strait islanders. issues around diabetes, hyperlipidaemiaand hypertension,

together with helping people understandthe implications of compliance to the medication regimeare always uppermost in my mind and in my interactions with patients.' in other words, taking the holistic...it's more of a comment than a question. do you have a comment, lesley?would you concur with those views? absolutely. that's where the nursepractitioner role has come into play, in that we can givelonger consultations, we can go to different areaswhere it may not be feasible for a gp because gps are private practice

and they need numbers and thatto sustain their own business. we can be employed under differentmethods and go into different areas. we can case-manage a little bitmore frequently and follow people upin their own communities. that's one of the benefitswe're able to provide, like anne and i,and why we get referrals from gps who may have lost a patientwho hasn't followed up with them. we can actually seek people outin their community. and i get referrals also from thematernity services on aboriginal clients

who really don't have a locationor a gp. i can follow them upand track them into more... and work with the gpand a collaborative team arrangement. that's a take on how we'll do it. norman: let's go to our next case study. vivian is a 46-year-oldnon-indigenous woman. a bmi of 25.5,so she's not really overweight. she's had type 2 diabetes and beenon insulin for the last four years. she's high blood pressure,she's got high cholesterol.

a biopsy has detecteddiabetic nephropathy. vivian is a single motherwith a 17-year-old daughter. she works full-time as a casual. she's a social smoker,about a pack a week, and a rare social drinker. she can't afford all her medications and wonders what meds she can miss. she's stressed, and had a few hypos while exercising.

her current medications are - her hba1c is 8 at the moment. her blood pressure is 130/80. her albumin-creatinine ratio is 360. her urea 8, her creatinine is 80, and her egfr is 71. certainly... we have comparable... we have resultsthere from previous times as well, and we can certainly seethat there's been

some improvement in her hba1c,which reflects control of her diabetes. there's certainly been some improvement in her blood pressure and some improvement in her acr and improvement in her egfr. although we note on those resultsthat her hba1c is not yet to target, and her blood pressureis also not yet to target. so there certainlyis some more work to be done, but it's good to see that improvement.

norman: which of her drugs can she ditchbecause she can't afford them? ah. i actually wouldn't immediatelyhave thought about ditching any. i would probably have to work with herfairly hard, though, to work through these issuesof enabling her to... ..you know, to convince her thatwe think that these are all necessary. norman: but she's not gottype 2 diabetes. she's 46, she's not fat andshe's been on insulin for four years. this is a woman with type 1.5, isn't it? tim: that's not unreasonable.

she's a very interesting case, in that she's continuing to haveheavy albuminuria despite having a combinationof ace and arb. yet her creatinine has improvedover some period of time. so there are some good things happeningand some not-so-good things happening. i think all the drugs are essential,as beres said. but she continues to smoke, norman,and i think that's a major issue. she should save her moneyby giving up the cigarettes? absolutely.

nice of you to say it, doctor. i'm surethat's extremely effective advice. anne, how would you be approaching this?it's obviously not an easy situation for a womanliving in difficult circumstances. she does need to cut down smokingas much as possible. it's an independent risk factor for chronic kidney diseaseand cardiovascular disease. that will save her a lot of moneybecause they're very expensive. and possibly change herto the combination polypills appearing on the market now.

this is the sort of ladyyou can have a really good win with. we should be able to keep this lady far,far from dialysis all of her life. given that she's not got type 2 andshe's got insulin-dependent diabetes, what's the impact of betterdiabetes control on her kidney function? not as much asbetter blood pressure control would be, we nephrologists would say. we'd focus probably on blood pressurereduction. recent articles suggest... just pretend you're a real doctor andyou look after more than the kidneys. even for her othervascular risk factors,

even the ukpds showed thatthe blood pressure reduction was the greater... driverof improved cardiovascular outcomes, apart from renal analysis. we'd focus on blood pressure,try and get that down. you can rationalise the medications. we do aim to target an hba1c of 7%, but i don't think the risk reduction isas great as with blood pressure control. i can't quote you a percentage -i just don't know - but it's not as great asacross the board for all vascular risk.

just coming back to the smoking,norman, the evidence is that if you smokein the presence of kidney disease, you'll go onto dialysis twice as early - that is, you're half the timeto dialysis as though you don't smoke. that's a very useful figure to usewith patients. given that she's probably got type 1, what will you doabout the 17-year-old daughter? i think she still does have type 2. norman: do you?

we're seeing type 2 diabeticsat an earlier age. but they're fat. she's not fat. - you don't have to be fat.tim: she's lost weight. norman: oh, has she? ok. that was a quick save there, dr mathew. you brought up the questionof her family history, and that's very important. she's got kidney disease, so her familyis at risk of kidney disease as well. norman: so, regardless of cause?

yes, regardless of cause,but particularly with diabetes. and if this was an aboriginal woman,lesley? as much as you can, looking atdrugs that are on a pbs system, or looking at where you could hookin to the aboriginal s100 schemes so it becomes affordable for themto stay on medication, using aboriginal health educationofficers and health workers to case-manage and follow and help. a really good education,ensuring the person understands the issues involvedin their particular case.

often, health literacy,it is so poor in so many people, aboriginal and non-aboriginal. let's go to our next case study. sandra is a 56-year-oldaboriginal woman. she's a bit overweight,with a bmi of 27.4. she's got type 2 diabetesand is on insulin. she's got also high blood pressureand high cholesterol levels. she's an ex-smoker and an ex-drinker. she's got lots of work to dowith her family, and works part-time.

she's confused about whethershe's taken her pills or not and forgets to refill her scripts. she is on - lesley, do you want to comment? lifestyle. you'd have to look at this lady's lifestyle, changes that could be modifiedto start with - weight, exercise, and, once again,i lead back into education. it is culturally appropriate to see ifshe's a decision-maker on her health,

whether other peoplehelp to make decisions, whether she has control over whethershe gets her medications or not. the social dynamics of the familyare really important here. but, before you do anything else, you'd be encouraging exercise,nutrition and weight loss, and looking at secondary smokingwithin the house as a key start with this lady, to tidy up before you even starton helping her with her medications. let's have a look at her pathology,beres.

her hba1c is 14.6. her blood pressure is up a little bit at 128/85. albumin-creatinine ratio is 880. urea, 12.1. creatinine, 197. egfr, 23. pth, 12. tim: i've amended her blood pressure, norman, to 170/95.

norman: sorry? oh, sorry. i'm looking at an old measure of her blood pressure. she is still hypertensive. and we're not doing a great job about controlling her blood sugar. your patient. certainly, not only is her diabetesand hypertension poorly controlled, but her renal functionis also not flash. i agree with the previous commentsregarding lifestyle.

certainly we've got to get thosereinstated. it's also time to actually have a chatabout medications. i think... well, we know thatshe's not been getting scripts filled. but we've actually got to go backand work through the reasons for that and see if we can actually findsome common ground, so we can move forward with her to encourage her to get her scriptsfilled and actually take her medication. it's difficult to go adjusting doses if you don't knowwhat the patient is already taking.

one really has to ascertainwhat's been taken lately before you even change doses. how bad is her kidney function, david? it's bad. as we can see on her results,she's down to a quarter of normal. if she continues in the same way,she'll need dialysis in the mid-future. norman: how soon? hard to predict, but when she gets toan egfr of... certainly less than 15 but as low as 5 - it depends onthe individual patient -

she'll be needing dialysis. so she's got a while to go,maybe a couple of years from 23. tim: the red lights are flashing here,aren't they? yeah. there's a number of thingsof concern here. it looks as though her kidney functionhas actually improved, but in fact what's happened is she'snot taking her blood pressure tablets, so it's a false impression. norman: explain what's going on. she's got a higher blood pressure, somore blood pumping through her kidneys.

- squeezing through the dying kidney?- she's not taking her ace inhibitor. so the gfr looks better than it should. one comment i wanted to makeon her treatment - we're assuming her poor blood pressureis due to non-compliance. it may be also her diet. one thing we haven't discussed in a dietso far is salt. if she's having too much salt, it could make her blood pressurea lot more difficult to treat. norman: anne?

it's really important that peopleare seen by a multidisciplinary team involving the gp, the nephrologist -if they're at that stage - nursing staff,practice nurses in the gp's. dieticians are very important becausethey can spend the time with people. they can go throughand do a food diary with them and make very small changes. the earlier the dieticiancan see a patient, the smaller the changesthat person has to make. norman: are they oftenquite salt-sensitive?

a lot of people in rural and remotecommunities add a lot of salt, not only aboriginal people. some of us don't need to live remotelyto do that. you'll go to a barbecuein a remote place, and everybody at the sausage sizzle tips the salt onbefore they taste anything. it's just the habit there. a couple of other things aboutblood pressure control in these people - the number of tablets you needto achieve your target blood pressure

goes up as your gfr declines. at a level of 20,you're probably on four or five, sometimes even six medications,to reach a target blood pressure. generally, everybody who hassome salt and water retention, requires diuretics, which she's not on,but she probably does require them. that would be a general mantra, i guess,and probably a loop with a low gfr, although thiazides do work. you could probably have heron some combinations that are long-acting, once a day, thatmight make it easier for her to comply,

rather than the twice-a-day metoprololand those sorts of drugs. norman: what combinations,without giving away brand names? you could use ace thiazideor accb combinations. actually, out next year, there will bean ace thiazide-ccb combination drug. that will be useful. we were talking before thatthe ideal would be a depo that you could inject for several monthsthat would work. but something that's long-acting,once a day. you can mix and match combinationsto make drugs easier.

lesley, it's all very well for uspontificating here about the idealised careof someone like sandra. how do you make it effective bybeing culturally sensitive, if you like? keeping the person in their community. so, visiting specialists,people who visit the areas, linking them in as much as you can. realising that manywon't leave their community to go and seek specialist help. so, getting support from as manyof those teams anne was talking about

to come to a close locationor to those communities to help. for this lady as well, you're looking atthe complications of kidney disease - the anaemia and the bone disease. so, doing as much of the pathologyor testing within the community, so that person stays with family. a lot of them have a deep fear that once they're removed fromthat community for treatment or help that they don't come back. what we haven't told you, lesley,is that her cholesterol is up, 8.5.

triglycerides, 5.2. her ldl is up a little bit too. she's not anaemic. one wonders why, but she's not. she's going to need statins or a fibrate or something like that as well. this is a bundle of pills, which is hard enough for somebody with full control of their life to get,

much less with the huge demands of living in an aboriginal community. that's a huge issue that we face. one, they will not travel 100km or 200km or they don't have transport,to go and fill a prescription, and can't afford prescriptionswhen they get there. linking in with programslike we're running, we have health workerswho will pick up the prescriptions and take them out and monitor whetherthat prescription is being taken.

once again, i use point-of-careto monitor a blood-sugar level or to help the patient see the gainsfrom taking medications. and education - education in a mannerthat is not as wordy as we see in many of the pamphletsthat come out. looking at artwork or figuresor language that suits the community. and there can be discrepanciesbetween different communities. a question, anne, is how aggressivelydo you monitor someone like this, given the controversy over monitoring -that you can overmonitor and get into a picklebecause you're testing too much?

we're on a slippery dip with sandra,but how actively do you... if we're trying to keep this ladyaway from dialysis, she needs to be closely monitored. i would say she should see theendocrinology team or the renal team every monthwhen they come over to her community. i think she needs to... the indigenous health workersare invaluable. if you've got indigenous health workersthat she trusts that are spreading the same messagethat the teams are spreading,

then you get continuity of that messagewhen you're not there. what are the different models of carethat are available for indigenous communities? you need to find out what people want. in the past,it's been very paternalistic. clinics have been builtand patients don't go to them because it's notwhat they would have chosen or it's not where they feel safe. so you have to havecommunity engagement.

i think you need to bring... the caredoes need to come to the communities because people can't afford to travel. in a lot of cases, in north queensland,they have to fly. it could be 1,000km, 2,000km to get to the nearest nephrologistor vascular surgeon. and that's a big ask for people. a gp in queensland asks,'what's the current state of knowledge between haemodialysisand peritoneal dialysis?' what's the benefits, what arethe downsides and the upsides?

let's take it living in a cityversus living in an aboriginal community or living in a rural townwithout a lot of support. david? the choice between the two is very muchup to what suits the patient. if there's a medical contraindication toone or the other, that will guide you. but usually that's not the issue.it's usually a patient choice. if the patient is well dialysedwith either peritoneal or haemodialysis, they can do equally well. you run statewide dialysis services,paul, in new south wales. what's your view on this?

the bean counters want youto do pd all the time, do they? it's no more cost-effectivethan home haemodialysis in our state. so there's no cost benefit to pd. so, we have it as a patient choice. either modality has its problems. with pd,it's peritonitis and infections. the average time on pd in australiais two to three years is how long the modality works before people shift off to haemo,on the whole.

haemodialysis, if they can do it -it's a greater technical burden for patients and their families to learnand manage - but if they can do it, it has a good outcome. the major problems are related tomaintenance of vascular access. both put a burdenon the person and their carer. and, in remote communities,if you're doing home haemo there, it puts a burdenon the local health staff to look after these patients. in some places where it wasn'tin the territory when we set it up,

there were concerns about beingheld responsible for health workers if things went wrong. so there was a degree ofreluctance or fear about having home-or community-based dialysis. the benefits to the patientsand the community were great, but there were concerns that neededto be weighed up in those settings. the pathway by which people finish upon peritoneal or haemodialysis is poorly understood in this country. kidney health australia is doinga national consumer or patient survey

on everyone on dialysis,be it at hospital or home, trying to better understandthat pathway. we're encouraging all patientswho will get a form to fill it in and let us know what their pathwayhas been, what their feelings are,what their successes, and to help us guide this very importantquestion of which is the preferred way. an online viewer asks, 'what are the hallmarksof a good satellite dialysis? how do you make it work remotely?'

lesley, do you want to comment on that?do you have much experience of that? we can't ignore the patientswho are in satellite units. previous to this position, i looked after 360 patientsin satellite and home dialysis. once again, it was a focus oncardiovascular risk for these patients. so constantly looking atthe issues around dry weight and their medications,timing of medications. so even thoughthey were in satellite units, with nurse practitioner support,working with the gps in the community,

you can create very stable,well patients. so very much a health-promotion view of looking at patientsin the satellite units is important. david appletonfrom mallacoota medical centre asks, 'what's the role of combinationace/arbs and at what doses? in proteinuric kidney disease,there's a role for both of them. the combination appears to be betterthan one by itself. that's a little bit controversial. in fact, if you push the dose up of anace inhibitor or a receptor antagonist,

you can probably get as good an effect as you will fromcombining the two together. the main drawback, of course,to the combination in patients with renal impairment is whether they become hyperkalemicor not. you need to watch for that. an important trial came out earlier looking at the hypertensive vascularrisk patient, the ontarget trial, which showed ace/arb combinationshad no benefit in reducing cardiovascular events

and had a greater degreeof adverse effects, with decreased gfr and hyperkalemia. so, it's only in a small group -significant proteinuria, renal disease - that you might consider them. the other thing is, i guess - we shouldfess up that the trial that suggested that the combination halved the rate ofprogression was shown to be fraudulent. norman: (laughs) right. dr appleton, you might just want to bea little careful about how you're throwing aroundthis combination.

you might want a nephrologist with youjust in case something goes wrong. i wouldn't use the combinationroutinely. the most important thing is the achievedblood pressure, not the drug you use. an ace/arb won't give you the degreeof blood pressure lowering you'll get with an ace thiazideor an accb generally. i'd go for those combinationsthese days. beres, what about the challengesof the elderly? that could be definedin any way you like. since we're all approachingthe elderly age group,

let's be loose about the age wherewe define someone as elderly. kidney disease in the elderly - what's the story from your point of viewas a gp? certainly, there is an increasedrate of kidney disease in the elderly. there are two different perspectiveson this. one is that, really,we shouldn't be ageist. we must continue to look forthe condition and manage it. the other side of itis really to have a look at the person and look at all of their comorbidities,and have the discussion with them.

i suppose i frame that, really thinkingabout at what stage of ckd they're at. norman: tim? the only really contentious issueis whether you consider dialysis for someone, say, in their mid-80sand beyond, which i would call elderly. apart from that, all the treatment plans to do with hypertension and cholesterolreduction and things should apply. certainly, the evidence is now in that treating hypertensionin the elderly is effective. and i don't see any reasonfor not offering elderly people

epo and phosphate reductionand all the things for complications. whether you offer them dialysisis a very difficult issue. it has to be considered individually. australia offers about a quarter ofthe rate of dialysis to that age group as other oecd countries, so we're probably underdeliveringby international standards. but you talk to a lotof australian nephrologists, and they would say maybewe've got the balance right here. there is some recent evidence showing

that if you don't offer dialysisto that population that they tend to do about as wellas those that do get dialysis. and is age a strong enough risk factor to be a trigger for screeningin its own right? we teach that over the age of 50 is the cut point above which the riskof having kidney disease, or yield, is sufficient to justify the screening,so the answer is yes. paul? i'll stick with tim on that.(laughter)

norman: oh, you chicken. it might cut out at 70 or 80 or 75. there is an upper age, above which... why would you cut it out? you've told me you'd havethe same criteria as everybody else. you might get peoplean extra four or five years if you treat kidney diseaseaggressively. for the same reasonthat the absolute-risk tool is not applied above the age of 75 -everyone is so high-risk for everything

that justifies treatment. anne, do you have any comment on lookingafter the elderly with kidney disease? i think it's our growth industry,really. this is your future we're talking about. most of the patients i seewould be over 65. there's very few that would be under 50. lesley, you should be so lucky that you see somebody who's elderlyin an aboriginal community. exactly. two issues here -elderly in aboriginals is a lot younger.

the median-age deaths from ckd is 60in aboriginal people as opposed to 82 in non-aboriginals. so age is relative, i guess,and a lot younger for aboriginal people. the important issue here isif you identify ckd you can link into palliation programs. i'm not talking about end-of-lifepalliation, but symptom control. there's new clinics coming on boardfor control of itch and control of pain and things associated with ckd. so i think it's important to identifyat any age,

whether you're going toactively dialyse them or link into appropriate palliationservices to make the person comfortable. norman: pain, anne?anne: mm. what pain do they get? a lot of people have quite severearthritis, and we're telling them they can't take any ofthe non-steroidal anti-inflammatories. panadol osteo and glucosaminedon't always do it, and so there's a lot of pain. they get metabolic bone disorders.

if they've got high pths, they've gotheadache, bone pain, muscle aches, which goes along withall the complications of ckd. interesting, and disturbing. what medicare items help in all this,beres? it's really good that we... norman:a question from an online viewer. there certainly aremedicare item numbers. i'm not going to list them specifically. there are two separate structures -one is the gp management plan.

there's a rebate for actually workingwith the person to clarify what the problems are, determine the goals of care,and then to determine who does what - you know,what the patient's responsibilities are and what the gp links them into. there's also an item for reviewingthe gp management plan. there are also itemsfor team-care arrangements, where one actually coordinates carewith other health practitioners. most of the divisionshave actually put a lot of work

into supporting and teaching gpshow to use these item numbers, and are aware that more and morepractice nurses are actually having a major role in building these management plansinto general practice and helping keep the plans on-track. what about nursing item numbers? i think there's six for allied health. there is no medicare provider numbersfor nurse practitioners currently, but that's before the senate.

tim: there are for practice nurses.- but not nurse practitioners. in the practice of nephrology, the apnahave got teaching modules now online that the government have arrangedfor all the chronic diseases. we strongly encourage gpsto use those item numbers to make a business case in favour ofemploying practice nurses. employing a practice nurseto help with screening. i think there's ten visits for follow-upwith a practice nurse, so that if you put something in placelike a medication, it can be followed up,and blood pressure is checked,

urine is checked, things like that. there is a lot more access to numbersfor follow-up after you've identified somebody. and now,just before we finish our program, we'll get you the resultsof the last question on the poll - and you all do in your practice.well done. lesley, what's your takeaway messagefor viewers? it's that i think initial screeningand identifying problems in communities, and the extent of that,and then pulling teams in to help.

so, getting people to visit thecommunity or an area close to that and linking in with aboriginalhealth workers and local services and particularly lifestyle services, such as smoking cessationor exercise programs. the team moves beyond a clinical teamto an education and a lifestyle team. that's very important,as much as the pharmaceutical treatment. lesley, thanks for staying on the linefor the entire program. it's been really good of you. anne?

my take-home message would be -we have to get screening out there for people who are at increased risk,because it is silent. there are no symptoms until up to 90%of your renal function is gone. your kidneys are deteriorating at thesame rate as your cardiovascular system and your eyes and whatever. if we can screen people earlier,the interventions are so much smaller to make such a big difference. norman: beres? i'm somewhat reductionistin my thinking.

i think that we really need to recognise that this is a very importantcardiovascular risk factor, and it's worth looking for. norman: paul? that declining gfr andincreasing proteinuria or albuminuria independently and progressively predictvascular events and risk of renal disease. hopefully we'll give you one way ofthinking about albuminuria/proteinuria in the next year or twoso that people know better

how to assess and use itas a clinical tool. the number of patients on dialysisin this country has doubled in the last nine years and is destined to double againin the next ten years. the only way that kidney healthaustralia thinks that's going to change is by finding kidney disease earlier anddoing something appropriate about it. it is silent, andtherefore we must go looking for it. norman: david? that it's definitely harmful, but it'salso preventable and treatable.

thank you all very much indeed. an illuminating program.i hope you found it too. chronic kidney disease:a silent condition. if you're interested in obtaining moreinformation about the issues raised, there are a number of resourcesavailable on the rural health education foundationwebsite - don't forget to completeand send in your evaluation forms and register for cpd pointsby completing the attendance sheet. i'm norman swan.from all of us, goodnight.

captions bycaptioning & subtitling international funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�