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1.10 Kidney disease

Why is it important?

The kidneys can be permanently damaged by various acute illnesses or by progressive damage from chronic conditions such as elevated blood pressure and long-standing high blood sugar levels (untreated diabetes). If the kidneys cease functioning entirely (known as end stage kidney disease, or kidney failure), waste products and excess water build up rapidly in the body. This can cause death within a few days or weeks unless a machine is used to filter the blood several times per week (kidney dialysis) or a new kidney is provided by transplant. Kidney failure was estimated to contribute 5% of the burden of disease for Indigenous Australians (Vos et al. 2007).

Indigenous Australians have very high levels of end stage kidney disease (ESKD) due to a range of risk factors (White et al. 2010). Among non-Indigenous Australians, ESKD usually occurs in older age, but for Indigenous Australians, it occurs more frequently in the middle adult years (White et al. 2010). Fewer Indigenous patients receive kidney transplants, so most must have dialysis three times a week for the rest of their lives, impacting quality of life and social and emotional wellbeing (McDonald et al. 2006; Devitt et al. 2008; AIHW 2014d).

Findings

Based on the 2012–13 Health Survey, nearly one in five (18%) Indigenous Australian adults had blood/urine test results showing signs of kidney problems (infection, acute or chronic condition) (ABS 2014a). The majority of these showed signs of being in Stage 1 (12%) with very few in Stages 4–5 (1%). Of those with signs of kidney disease, 89% did not have a diagnosis for chronic kidney disease. The prevalence of signs of kidney disease among Indigenous Australians began at a much earlier age than for non-Indigenous Australians, with rates steadily increasing from the age of 18, whereas rates for non-Indigenous Australians begin to climb from the age of 55. After adjusting for age differences in the two populations, Indigenous adults were twice as likely as non-Indigenous to have signs of kidney disease (3 times for Stage 1 and around 5 times for Stages 4–5). Among Indigenous Australians, rates for signs of kidney disease were highest in very remote areas (37%) compared with 12% in major cities.

In 2012–13, 38% of Indigenous Australians with kidney problems also had diabetes. Indigenous Australians with high blood pressure were twice as likely to have kidney problems as those with normal blood pressure (29% compared with 15%). Rates were also higher for those who were obese (20%) compared with underweight/normal weight (13%).

During 2008–12, 2.5% of deaths among Indigenous Australians (290) were due to kidney disease. After adjusting for the different age profiles of the two populations, the kidney disease mortality rate was 2.6 times the non-Indigenous rate. Kidney disease death rates significantly declined for Indigenous Australians between 2006 and 2012 (by 40%) and the gap halved with non-Indigenous Australians (declined by 53%). Often, kidney disease is listed as an associated cause of death rather than the principal cause (AIHW 2014k). In 2008–12, there were 1,795 deaths among Indigenous Australians where kidney disease was listed as an associated cause of death.

In 2011–13, care involving dialysis was the leading cause of hospitalisation (45%) for Indigenous Australians. Hospitalisation for dialysis was 10 times the non-Indigenous rate. Excluding dialysis there were also 4,120 hospitalisations for Indigenous Australians during this period for chronic kidney disease, 3 times the non-Indigenous rate.

The incidence of patients commencing ongoing kidney replacement therapy (KRT) (dialysis or kidney transplantation) for ESKD is higher for Indigenous Australians than for non-Indigenous Australians. Between 2010 and 2012, there were 716 new Indigenous patients registered as commencing KRT, accounting for 10% of all new registrations. The age-adjusted incidence rate of treated ESKD was 7 times as high for Indigenous Australians as for non-Indigenous Australians.

Indigenous Australians commencing KRT were younger than non-Indigenous Australians commencing KRT, with 60% aged less than 55 years compared with 31% of non-Indigenous Australians. Treated-ESKD incidence was higher for Indigenous Australians in all adult age groups, with the greatest gap seen in the 55–64 year age group. In the period 2010–12, treated-ESKD incidence rates among Indigenous Australians were highest in the NT (152 per 100,000) and lowest in NSW/the ACT (34 per 100,000). Treated-ESKD incidence rates were higher in remote (149 per 100,000) and very remote areas (97 per 100,000) than non-remote areas (33 per 100,000). For non-Indigenous Australians, rates were similar across all regions.

The incidence of treated-ESKD among Indigenous males has increased by 33% over the period 1996–2012. Treated-ESKD incidence for non-Indigenous males has also increased; therefore, the gap has not changed. Rates have remained stable over the period for both Indigenous and non-Indigenous females. The increase in the incidence of treated-ESKD among Indigenous males may reflect both real growth in the underlying disease, an increase in treatment and/or improved levels of identification of Indigenous Australians in the registry.

ESKD patients require either a kidney transplant or dialysis to maintain the functions normally performed by the kidneys. In December 2012, there were 1,617 Indigenous Australians registered for ongoing KRT. Of these, 88% were reliant on dialysis and 12% had received a kidney transplant. In comparison, 53% of non-Indigenous Australians with treated- ESKD were reliant on dialysis and 47% had a kidney transplant. After adjusting for differences in the age structure of the two populations, Indigenous Australians with treated-ESKD were 9 times as likely as non-Indigenous Australians with treated-ESKD to be reliant on dialysis.

Implications

The high level of ESKD among Indigenous Australians is associated with the high rates of diabetes, high blood pressure, obesity, low birthweight, and possibly the high rates of bacterial infections and glomerulonephritis in childhood (AIHW 2005a). These factors, in turn, are associated with issues of access to primary health care (see measure 3.14) and determinants of health (see Tier 2). Healthier nutrition and greater physical activity play a role in reducing risk, as well as early detection and diagnosis and appropriate and timely treatment of conditions associated with kidney disease.

A study of Australian nephrologists found that, in the absence of robust evidence on predictors of post-transplant outcomes, decisions on which patients to refer for kidney transplantation are not based on systematic formal approaches. Instead, decisions may be influenced by factors such as kidney shortages, compliance with dialysis as a predictor of compliance with transplant regimes (despite large differences in these factors), and anecdotal evidence suggests, experiences with other Indigenous patients. This is leading to Indigenous patients being more commonly identified as 'high-risk' transplant candidates (Anderson et al. 2012).

Mobile Dialysis Bus services offer respite dialysis to remote communities in the NT and SA, on a frequent basis. The Health and Hospitals Fund is providing funding of $56 million for 31 additional dialysis chairs throughout WA. These options are important for remote communities, where people with ESKD often need to travel long distances, or permanently relocate, to receive dialysis. Indigenous Australians have relatively poorer access to kidney transplants and addressing barriers is important (Cass et al. 2003; Yeates et al. 2009). A focus on improving primary prevention, detection and management is necessary to lessen the impact of chronic kidney disease on people with the condition and the cost to the health care system and to Indigenous Australians. The Department of Health, through the Indigenous Australians' Health Programme, sets a number of priorities aimed at chronic disease prevention, detection and management.

Figure 1.10-1 Age-standardised incidence rates for treated end stage kidney disease, by Indigenous status, 1996 to 2012
age-standardised incidence rates for treated end stage kidney disease

Figure 39 shows age-standardised registration rates for end stage renal disease among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians (rate per 100,000). Data is presented for each year from 1996 to 2012. Refer to the findings section of this measure for a description of key results found in this figure.

Source: AIHW analysis Australian and New Zealand Dialysis and Transplant Registry (ANZDATA)

Figure 1.10-2 Incidence of treated end stage kidney disease by Indigenous status and age group, 2010–12
chart showing Incidence of treated end stage kidney disease

Figure 1.10-2 shows the incidence of end stage renal disease among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians in 2010–2012 (rate per 100,000). Data is presented for the following age groups: 0-24 years; 25-44 years; 45-54 years; 55-64 years; 65 years and over. Refer to the findings section of this measure for a description of key results found in this figure.

Source: AIHW analysis of Australian and New Zealand Dialysis and Transplant Registry (ANZDATA)

Figure 1.10-3 Age-standardised incidence of treated end stage kidney disease by Indigenous status and remoteness, 2010–12
age-standardised incidence of treated end stage kidney disease

Figure 1.10-3 shows the age-standardised incidence of end stage renal disease among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians in 2010–2012 (rate per 100,000). Data is presented for major cities; inner regional areas; outer regional areas; remote areas; very remote areas; and Australia as a whole. Refer to the findings section of this measure for a description of key results found in this figure.

Source: AIHW analysis of Australian and New Zealand Dialysis and Transplant Registry (ANZDATA)

Table 1.10-1 Prevalence if treated end stage kidney disease, by Indigenous status and treatment, 31 December 2012
Treatment: Number
Indig.
Number
Non Indig.
Rate per 100,000 (age adjusted)
Indig.
Rate per 100,000 (age adjusted)
Non Indig.
Ratio
Dialysis 1,425 10,021 370 40 9.2*
Transplant 192 8,977 44 38 1.1
Total 1,617 18,998 414 78 5.3*

* Represents results with statistically significant differences in the Indigenous/non-Indigenous comparisons at the p<.05 level

Source: AIHW analysis of Australian and New Zealand Dialysis and Transplant Registry (ANZDATA)

Table 1.10-2 Incidence of treated end stage kidney disease among Indigenous Australians, by jurisdiction and sex, 2010–12
Male Female Persons
No. Rate(a) Ratio No. Rate(a) Ratio No. Rate(a) Ratio
NSW /ACT 52 29 2.4 62 37 5.3 114 34 4.0
Vic 20 51 3.8 15 n.p. n.p. 35 44 4.0
Qld 86 60 5.4 93 54 8.5 179 57 7.0
WA 61 82 6.8 74 98 16.0 135 91 10.0
SA 16 n.p. n.p. 29 86 13.5 45 73 8.0
Tas n.p. n.p. n.p. n.p. n.p. n.p. n.p. n.p. n.p.
NT 82 133 13.3 121 171 n.p. 203 152 16.0
Australia 319 57 4.7 397 66 9.8 716 62 7.0

n.p. refers to 'not published' as the rate is based on very small numbers. (a) Rates are age-standardised.

Source: AIHW analysis of Australian and New Zealand Dialysis and Transplant Registry (ANZDATA)