tag:theconversation.com,2011:/africa/topics/kidney-failure-5748/articleskidney failure – The Conversation2024-02-05T22:24:10Ztag:theconversation.com,2011:article/2209412024-02-05T22:24:10Z2024-02-05T22:24:10ZThe uncertain fate of patients needing life-saving dialysis treatment in Gaza<p>More than 100 days into the brutal assault on Gaza, over <a href="https://news.un.org/en/story/2024/02/1146157">27,000 Palestinians have been killed — of whom 60 per cent have been children and women</a> — and 66,000 injured, according to the World Health Organization (WHO).</p>
<p>The destruction of Gaza’s health-care system has been catastrophic. The <a href="https://news.un.org/en/story/2024/01/1145317#:%7E:text=Hundreds%20of%20facilities%20hit,seven%20deaths%20and%2052%20injuries.">WHO says</a> that, as of Jan. 5, there have been more than 600 attacks on health-care facilities, with 26 out of 36 hospitals in Gaza severely damaged and 79 ambulances targeted. Over <a href="https://doi.org/10.1136/bmj.q203">300 health-care workers have been killed and over 200 have been detained by Israeli forces</a>. </p>
<p><a href="https://www.msf.org/letter-gaza-un-security-council">In an open letter</a> to the United Nations Security Council, Médecins Sans Frontières (MSF) president Christos Christou wrote: </p>
<blockquote>
<p>“Israel has shown a blatant and total disregard for the protection of Gaza’s medical facilities. We are watching as hospitals are turned into morgues and ruins. These supposedly protected facilities are being bombed, are being shot at by tanks and guns, encircled and raided, killing patients and medical staff.”</p>
</blockquote>
<p>Most of the resources within the collapsing health-care system in Gaza are directed towards treating acute trauma victims, such as the injured <a href="https://www.reuters.com/world/middle-east/baby-saved-gaza-rubble-after-mother-killed-israeli-strike-2023-12-29/">babies pulled from rubble</a>, the toddlers requiring <a href="https://www.reuters.com/world/middle-east/gazas-child-amputees-face-further-risks-without-expert-care-2024-01-04/">limb amputations</a> and the civilians suffering from <a href="https://reliefweb.int/report/occupied-palestinian-territory/gaza-strip-msf-treating-patients-severe-burns-following-airstrike">severe burn injuries</a>. This leaves patients with chronic life-threatening diseases, such as cancer, heart failure and end-stage kidney disease, with severely limited access to the ongoing medical care they need to survive.</p>
<h2>Patients unable to access care for chronic conditions</h2>
<p>As nephrologists and internal medicine physicians, we are gravely concerned about patients in Gaza with chronic diseases who are unable to access care. There are more than <a href="https://www.aljazeera.com/features/2023/10/25/terrifying-hope-shrinks-for-gazas-dialysis-patients-at-packed-hospitals">1,100 dialysis patients, including 38 children, in Gaza</a>. </p>
<p><a href="https://kidney.ca/Kidney-Health/Living-With-Kidney-Failure/Dialysis">Hemodialysis</a> is a treatment for patients with kidney failure that involves removing blood from the patient’s circulation and circulating it through a dialysis machine that clears toxins and removes excess fluid. Without adequate dialysis, fluid and toxins accumulate and patients typically die within days to weeks from respiratory failure or cardiac arrest. </p>
<p>Dialysis is a resource-intensive therapy that requires a dialysis facility, dialysis machines, filters, water supply and fuel, along with a team of technicians, nurses and nephrologists. Each one of these components has been severely and directly compromised since Israel’s assault on Gaza. </p>
<p>Israel’s complete blockade of food, fuel and water has left over <a href="https://abcnews.go.com/International/500000-people-gaza-face-catastrophic-hunger-unrwa/story?id=106593939">500,000 Gazans facing catastrophic hunger</a> according to the United Nations Relief and Works Agency (UNRWA), and Gazan children face a <a href="https://www.unicef.org/press-releases/barely-drop-drink-children-gaza-strip-do-not-access-90-cent-their-normal-water-use">90 per cent reduction in access to water</a>.</p>
<p>Several hospitals, including Al-Aqsa, reported being completely out of fuel, putting all patients in grave danger, <a href="https://www.aljazeera.com/news/2024/1/13/blackout-in-gazas-al-aqsa-hospital-as-fuel-runs-out-babies-at-high-risk">particularly those on life support, babies in incubators and those requiring dialysis</a>. </p>
<p>Even before the current conflict, the 16-year blockade of Gaza put the lives of kidney failure patients at risk due to chronic shortages of fuel and medical supplies. Al Jazeera reports that since Oct. 7, <a href="https://www.aljazeera.com/features/2023/10/25/terrifying-hope-shrinks-for-gazas-dialysis-patients-at-packed-hospitals">the number of patients at Al-Aqsa Hospital requiring dialysis has more than doubled</a> from 143 to about 300, including 11 children, who have just 24 dialysis machines between them. </p>
<p>This has forced dialysis units to significantly cut treatments, with patients receiving two-hour sessions rather than the typically prescribed 3.5-hour treatments. Treatment frequency, typically prescribed three times weekly, are now only available one or two times per week. </p>
<p>This decrease in treatment time and frequency is grossly insufficient to sustain life. But in a health-care system under assault, patients are fortunate to receive any dialysis at all. </p>
<h2>Patients needing life-saving treatment</h2>
<p>Ismail Al Tawil was a 44-year-old patient in Gaza who died of kidney failure after he was unable to access dialysis. In an interview with Al-Jazeera’s AJ+ social media arm, <a href="https://www.instagram.com/ajplus/reel/C15bdLAOVVi/">his widow described desperately trying to get him to dialysis at Al-Shifa hospital</a>, but being shot at by Israeli snipers who surrounded the hospital. </p>
<p>She then attempted to access dialysis at Al-Awda and Kamal Adwan hospitals, but both facilities had insufficient capacity to treat him. </p>
<p>Since Oct. 7, <a href="https://www.hrw.org/news/2023/12/20/most-gazas-population-remains-displaced-and-harms-way">1.9 million people or 85 per cent of the population of Gaza have been internally displaced</a>, according to Human Rights Watch. This is a tremendous challenge for dialysis patients who are faced with the uncertainty of when, where or if they will access their life-saving therapy. </p>
<p>Anssam, age 12, was displaced from Jabaliya in northern Gaza to seek treatment in Deir El Balah in central Gaza. She had gone 15 days without dialysis and had to leave with her mother to receive life-saving medical treatment. <a href="https://www.thenationalnews.com/mena/palestine-israel/2023/12/18/gaza-dialysis-patients-hospital/">In an interview with <em>The National News</em></a>, Anssam said: </p>
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<p>“I hope for this war to end and for us to go back to the way we were, happy and playing, and to go back to doing dialysis three times a week… Now, without filters, I cannot have dialysis and so I will die. My life depends on dialysis.” </p>
</blockquote>
<h2>Loss of medical personnel</h2>
<p>Beyond the destruction of health-care facilities and a critical shortage of supplies, the loss of medical personnel may have the most devastating and longest-lasting impact on the health-care system in Gaza. </p>
<p>Dr. Hammam Alloh was one of the only nephrologists in Gaza, <a href="https://www.democracynow.org/2023/11/13/medical_workers_killed_colleagues_mourn_hammam">described as a committed physician and a beacon of light by his colleagues</a>. He was 36 years old and a father of two young children. He had hopes to expand dialysis care in Gaza and build a nephrology educational training program.</p>
<p><a href="https://www.cbc.ca/news/world/gaza-hamman-alloh-killed-1.7027623">He was killed on Nov. 12</a> by an <a href="https://www.frontlinedefenders.org/en/profile/hammam-alloh">Israeli airstrike to his family’s home</a>, where he was taking a short rest after a busy shift at Al Shifa Hospital. His loss resonated far beyond his family, patients and colleagues in Gaza. Dr. Alloh’s <a href="https://www.presstv.ir/Detail/2023/11/19/714879/humans-of-gaza-hammam-alloh-nephrologist-alshifa-hospital">courage and dedication has become a powerful source of inspiration</a> for physicians and health-care workers around the world. </p>
<p>Multiple sources have reported the number of civilians who have been killed by the bombs and bullets during the assault on Gaza. We may never know how many cancer patients will die from lack of chemotherapy; or diabetics from lack of insulin; or kidney failure patients from inadequate dialysis. The consequences of the collapsed health-care system in Gaza will be felt for years to come. </p>
<p>The <a href="https://www.cbc.ca/news/canada/chilling-effect-pro-palestinian-1.7064510">attempts to silence, intimidate and smear health-care workers</a> for calling out the atrocities in Gaza have been well documented. These efforts not only attempt to rob us of our freedom of speech, but of our professional and moral duty as physicians to promote global health and protect the vulnerable. </p>
<p>As physicians, we will not be silent as our colleagues in Gaza are being killed, as hospitals are being targeted and attacked, and as vulnerable patients are endangered. We <a href="https://news.un.org/en/story/2024/01/1145462">join the UN</a>, the <a href="https://doi.org/10.1016/S0140-6736(23)02627-2">WHO</a>, <a href="https://www.doctorswithoutborders.ca/msf-immediate-ceasefire-is-needed-in-gaza-to-stop-the-bloodshed/">MSF</a> and the <a href="https://www.bma.org.uk/what-we-do/working-internationally/our-international-work/bma-position-israel-gaza-conflict">British Medical Association</a>, along with millions around the world, who call for an immediate ceasefire and unimpeded humanitarian aid. </p>
<p>We stand in solidarity with the true health-care heroes of Gaza who continue to work in harrowing conditions, and we honour the legacies of those like Dr. Alloh who lost their lives while upholding the highest values of our profession.</p><img src="https://counter.theconversation.com/content/220941/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Patients with kidney failure need regular dialysis treatments to survive. However, the equipment, supplies and medical staff needed for dialysis have been largely destroyed by the assault on Gaza.Ali Iqbal, Transplant Nephrologist, Assistant Professor of Medicine, McMaster UniversityAliya Khan, Clinical professor, Faculty of Health Sciences, McMaster UniversityBen Thomson, Masters of Public Health student, Bloomberg School of Public Health, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2063922023-05-25T00:43:48Z2023-05-25T00:43:48ZTina Turner had a history of high blood pressure and kidney disease. Here’s how one leads to the other<p>Legendary singer Tina Turner, who <a href="https://www.abc.net.au/news/2023-05-25/singer-tina-turner-has-died-aged-83/102389716">died this week</a> at the age of 83 after a long illness, has <a href="https://www.showyourkidneyslove.com/articles/tina-turner/">written about</a> her history of high blood pressure and kidney disease, leading to a kidney transplant.</p>
<p>Turner should be applauded for her willingness to share her <a href="https://www.instagram.com/p/CpkhvaFBS0K/?utm_source=ig_web_copy_link&igshid=MzRlODBiNWFlZA%3D%3D">medical history</a> to publicise the importance of looking after your kidneys, just months before she died.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CpkhvaFBS0K/?utm_source=ig_web_copy_link\u0026igshid=MzRlODBiNWFlZA%3D%3D","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<p>Turner’s family has not confirmed how she died. But Turner’s openness with her long-standing illness is a reminder for us all to keep an eye on our blood pressure, and to control it, if we are to avoid complications.</p>
<p>Here’s why controlling your blood pressure is so important and what can happen if we don’t.</p>
<h2>Why is high blood pressure linked to kidney disease?</h2>
<p>There’s a bi-directional relationship between blood pressure and kidney disease. </p>
<p>That means high blood pressure increases the risk for kidney disease and once you have kidney disease, it further promotes high blood pressure. It’s a vicious cycle.</p>
<p>In some cases, it’s hard to determine which one came first. </p>
<p>Uncontrolled blood pressure exerts a lot of pressure on the kidney. That leads to scarring and damage. If we looked inside the kidney, we’d see large areas of scarring. Once you have scarring, that tissue isn’t working properly and can start to leak protein into the urine. That then pushes up the risk of progressive kidney disease, leading to kidney failure, heart disease and premature death.</p>
<p>The kidney itself is integral to maintaining blood pressure. Kidneys obviously maintain fluid balance by passing urine, but they also have important hormonal jobs which are vital to maintaining blood pressure.</p>
<p>So, once you get kidney disease, blood pressure can be really hard to manage. It’s like a hammer and nail, and the nail is the kidney. If you have high blood pressure, the hammer is hitting the nail really, really hard.</p>
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Read more:
<a href="https://theconversation.com/health-check-what-do-my-blood-pressure-numbers-mean-29212">Health Check: what do my blood pressure numbers mean?</a>
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<h2>Are there certain symptoms to look out for?</h2>
<p>Both high blood pressure and kidney disease are what we call “clinically silent”, so many people don’t realise they have problems until it is very far along. </p>
<p>Often a person with high blood pressure has no symptoms. There are times, in extreme cases, where people may get headaches or a feeling of thumping in the head. But their first sign may be a stroke or heart attack or some other major complication. That’s why checking blood pressure on a regular basis is smart.</p>
<p>For kidney disease, you can lose up 90% of kidney function before symptoms develop. They can be clinically silent right up until kidney failure. When symptoms do arrive, they can be very vague – things like poor concentration or feeling tired. </p>
<p>Often people just put it down to winter, being busy or getting older. </p>
<p>So we recommend screening for kidney disease if you have high blood pressure, diabetes, heart disease, excess abdominal weight, a history of smoking, acute kidney injury or a family history of kidney disease. This should be done on a one- to two-year basis.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/kidneys-are-amazing-for-all-they-do-be-sure-to-look-after-yours-30966">Kidneys are amazing for all they do, be sure to look after yours</a>
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<h2>What are the treatments?</h2>
<p>In the past five years, there have been a swathe of newer medicines that bring down blood pressure and protect the kidney. For around 20 years, we have had a class of drugs called renin-angiotensin system blockade (usually just shortened to RAS blockade).</p>
<p>But more recently, we have a new group of medicines called <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/sodium-glucose-cotransporter-2-sglt2-inhibitors#:%7E:text=SGLT2%20inhibitors%20are%20a%20class,canagliflozin%2C%20dapagliflozin%2C%20and%20empagliflozin.">SGLT2 inhibitors</a>, which have really changed the landscape of kidney disease. The Therapeutic Goods Administration has just approved another medicine called finerenone, which is a non-steroidal MRA. </p>
<p>These have all been shown to protect the kidney, as opposed to just treating symptoms. They slow the progression of the disease and have shifted the paradigm to kidney preservation. </p>
<p>And it’s really crucial you address the lifestyle factors that increase your risk.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-chronic-kidney-disease-and-why-are-one-in-three-at-risk-of-this-silent-killer-81942">Explainer: what is chronic kidney disease and why are one in three at risk of this silent killer?</a>
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<h2>How can I reduce my risk?</h2>
<p>Don’t smoke. Being a smoker significantly increases your risk of high blood pressure and kidney disease.</p>
<p>Eat a nutrient-dense diet, including fresh, whole foods that are in season and avoid ultra-processed food and sugar. This approach will help to control blood pressure and protect the kidney. </p>
<p>Do all the usual things – get good sleep, maintain an active lifestyle and manage your stress. If you have a family history of kidney disease, that may prompt you to get checked. </p>
<p>Do the <a href="https://kidney.org.au/kidneyrisktest/">Kidney Health Australia quiz</a> and if you are deemed to be at risk, go to your GP to get a kidney health check. That involves a blood pressure check, urine test and a blood test.</p>
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Read more:
<a href="https://theconversation.com/health-check-what-can-your-doctor-tell-from-your-urine-74990">Health Check: what can your doctor tell from your urine?</a>
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<h2>Kidney disease is becoming more common</h2>
<p>The number of people with kidney failure is increasing dramatically. <a href="https://www.aihw.gov.au/news-media/media-releases/2021/august/recipients-of-kidney-replacement-therapy-more-than">According</a> to the Australian Institute of Health and Welfare, the number of Australians receiving kidney replacement therapy (either on dialysis or living with a transplant) more than doubled between 2000 and 2020, from 11,700 to 27,700. Over half of those receiving kidney replacement therapy were on dialysis.</p>
<p>While a kidney transplant improves quality of life and can extend a person’s life, it’s important to remember that high blood pressure can still persist and often requires ongoing treatment.</p><img src="https://counter.theconversation.com/content/206392/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karen Dwyer is Clinical Director of Kidney Health Australia. She has received honorarium from AstraZeneca, Boehringer Ingelheim and Bayer. She is on the clinical advisory committee for GMHBA. She has a current research grant through Servier.</span></em></p>What’s the relationship between high blood pressure and kidney disease, and how can they be prevented?Karen Dwyer, Professor, School of Medicine, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1808252022-04-12T17:22:42Z2022-04-12T17:22:42ZHemodialysis: New research could vastly improve this life-sustaining treatment for kidney failure patients<figure><img src="https://images.theconversation.com/files/457580/original/file-20220412-21-ir72f2.jpg?ixlib=rb-1.1.0&rect=384%2C118%2C4273%2C2974&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hemodialysis treatment can be efficient at replacing some lost kidney function, but patients can experience complications and side-effects.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Around <a href="https://kidney.ca/KFOC/media/images/PDFs/Facing-the-Facts-2020.pdf">one in 10 Canadians has kidney disease</a> and millions more are at risk. According to the Kidney Foundation of Canada, the number of people living with end-stage kidney disease or <a href="https://kidney.ca/KFOC/media/images/PDFs/Facing-the-Facts-2020.pdf">kidney failure has grown 35 per cent since 2009, with 46 per cent of new patients under the age of 65</a>. </p>
<p>Hemodialysis is a life-sustaining treatment for kidney failure patients to clean and filter their blood of waste products, salts and excess fluid. However, this membrane-based therapy is not perfect, and hemodialysis patients experience acute side-effects, life-threatening chronic conditions and unacceptably high morbidity and mortality rates. </p>
<p>While hemodialysis treatment can be efficient at replacing some lost kidney function, patients experience some complications such as <a href="https://www.healthline.com/health/kidney-health/dialysis-side-effects">blood clots, heart conditions, cardiac arrest</a>, <a href="https://www.nhs.uk/conditions/dialysis/side-effects/">blood poisoning</a>, <a href="https://www.mayoclinic.org/tests-procedures/hemodialysis/about/pac-20384824">anemia, high/low blood pressure, bone diseases, itching, sleep problems, heart inflammation, fluid overload, infections and muscle cramps</a>. </p>
<p>As a membrane science researcher, I am working on creating hemodialysis membranes that are more compatible with the human body than current membranes. My short-term aim is to achieve reduced patient side-effects and increase quality of life. </p>
<p>My long-term goal is to design an artificial wearable kidney based on a membrane with greatly improved performance compared to those in use in hospitals today. This is the only research program in Canada to address key problems associated with dialysis membranes.</p>
<h2>Problems and challenges with hemodialysis</h2>
<p>First, dialysis treatment is expensive, <a href="https://kidney.ca/KFOC/media/images/PDFs/Facing-the-Facts-2020.pdf">costing the Canadian health-care system more than $100,000 per patient per year</a>. And while it does prolong life, it presents a number of challenges. </p>
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<a href="https://images.theconversation.com/files/457583/original/file-20220412-16-crw4w8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A patient's arm attached to tubes transporting blood to a machine" src="https://images.theconversation.com/files/457583/original/file-20220412-16-crw4w8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/457583/original/file-20220412-16-crw4w8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/457583/original/file-20220412-16-crw4w8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/457583/original/file-20220412-16-crw4w8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/457583/original/file-20220412-16-crw4w8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/457583/original/file-20220412-16-crw4w8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/457583/original/file-20220412-16-crw4w8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">In a hemodialysis session, a patient’s blood is diverted to a machine to remove waste products and excess fluid.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>In a hemodialysis session, a patient’s blood is diverted to a machine to remove waste products and excess fluid. A typical patient requires three dialysis sessions per week, each taking four to five hours, so even mild interactions between a patient’s blood and the dialysis membrane may lead to big problems over time. </p>
<p>Because the membranes in use today cannot perfectly mimic the function of a healthy kidney, some toxins can be poorly filtered from the blood, new ones can arise from blood-membrane interactions and blood clotting can occur. </p>
<p>The <a href="https://www.medscape.com/answers/238798-105284/what-are-the-mortality-rates-associated-with-chronic-kidney-disease-ckd#:%7E:text=Mortality%20then%20tends%20to%20improve,25%25%20in%20patients%20with%20diabetes.">five-year survival rate for hemodialysis patients is 35 per cent, and only 25 per cent for hemodialysis patients with diabetes</a>; both values are considerably worse than the <a href="https://cancer.ca/en/research/cancer-statistics/cancer-statistics-at-a-glance">five-year survival rate for cancer patients of approximately 64 per cent</a>. </p>
<p>Additional kidney failure patients are now requiring treatment as <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-kidney-damage-caused-by-covid19">more than 30 per cent of patients hospitalized with COVID-19 develop kidney injury</a>. Some studies in Canada showed that around <a href="https://doi.org/10.1177/20543581211027759">54 per cent of the Canadian patients who were hospitalized with COVID-19 developed acute kidney injury</a>. Although the rates of acute kidney injury have fallen from the early months of the pandemic, <a href="https://doi.org/10.1093/ndt/gfab303">high-risk patients should have their kidney function and fluid status monitored closely</a>.</p>
<h2>Research program progress</h2>
<p>My research group is working on creating hemodialysis membranes that are more compatible with the human body than current membranes. The first step was to conduct <a href="https://doi.org/10.1038/s41598-020-71755-8">in-depth investigations of the membranes available in Canadian hospitals</a> to determine how patient side-effects are related to the characteristics of the membranes and the clinical practices employed. We are getting answers to several key questions and taking steps towards new designs and new membrane materials.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/457266/original/file-20220410-21-z8jc37.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C579%2C504&q=45&auto=format&w=1000&fit=clip"><img alt="A woman adjusting equipment in a lab" src="https://images.theconversation.com/files/457266/original/file-20220410-21-z8jc37.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C579%2C504&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/457266/original/file-20220410-21-z8jc37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=582&fit=crop&dpr=1 600w, https://images.theconversation.com/files/457266/original/file-20220410-21-z8jc37.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=582&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/457266/original/file-20220410-21-z8jc37.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=582&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/457266/original/file-20220410-21-z8jc37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=731&fit=crop&dpr=1 754w, https://images.theconversation.com/files/457266/original/file-20220410-21-z8jc37.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=731&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/457266/original/file-20220410-21-z8jc37.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=731&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Amira Abdelrasoul uses Canadian Light Source synchrotron to get answers to several key questions about hemodialysis.</span>
<span class="attribution"><span class="source">(Amira Abdelrasoul)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Innovative imaging techniques available at the <a href="https://www.lightsource.ca/index.php">Canadian Light Source</a> (CLS) synchrotron at the University of Saskatchewan have allowed my team to visualize and track the behaviour and deposits <a href="https://doi.org/10.1016/j.seppur.2020.118136">of blood proteins inside the membrane channels</a>. This is important because these protein deposits can bring about severe inflammation and are undesirable. Imaging at the CLS allows real-time 3D visualization at high speeds. </p>
<p>We are currently using customized gold nanoparticles to label and track specific blood proteins, which have different shapes and sizes, through the filtration process. This is a huge advance over other imaging techniques that only allow us to see the top layer of the membrane. </p>
<p>We can now monitor the flow at every layer of both new and existing hemodialysis membranes, which means we can assess protein deposits on the dialysis membrane surface, accumulation and blockage of the membrane pores at all points in the process. </p>
<p>Using advanced software, the 3D images we obtain are being converted into valuable models that can predict how these blood proteins behave when they interact with different types of membranes. These models also enable us to understand when, how and why proteins accumulate and block the membranes for different clinical conditions. </p>
<h2>Impact for patients</h2>
<figure class="align-right ">
<img alt="A black square with a wide yellow diagonal streak and a narrow yellow streak" src="https://images.theconversation.com/files/457493/original/file-20220411-24-ezm039.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/457493/original/file-20220411-24-ezm039.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=584&fit=crop&dpr=1 600w, https://images.theconversation.com/files/457493/original/file-20220411-24-ezm039.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=584&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/457493/original/file-20220411-24-ezm039.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=584&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/457493/original/file-20220411-24-ezm039.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=734&fit=crop&dpr=1 754w, https://images.theconversation.com/files/457493/original/file-20220411-24-ezm039.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=734&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/457493/original/file-20220411-24-ezm039.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=734&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Photo A, showing protein deposit on current clinical membranes.</span>
<span class="attribution"><span class="source">(Amira Abdelrasoul)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<figure class="align-right ">
<img alt="A black square with very faint streaks of yellow particles" src="https://images.theconversation.com/files/457494/original/file-20220411-10942-8ujlex.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/457494/original/file-20220411-10942-8ujlex.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=581&fit=crop&dpr=1 600w, https://images.theconversation.com/files/457494/original/file-20220411-10942-8ujlex.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=581&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/457494/original/file-20220411-10942-8ujlex.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=581&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/457494/original/file-20220411-10942-8ujlex.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=731&fit=crop&dpr=1 754w, https://images.theconversation.com/files/457494/original/file-20220411-10942-8ujlex.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=731&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/457494/original/file-20220411-10942-8ujlex.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=731&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Photo B shows significantly lower protein deposits on newly developed membranes.</span>
<span class="attribution"><span class="source">(Amira Abdelrasoul)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>We are using this information to provide doctors with tools to optimize clinical practice and minimize the patients’ side-effects. For example, one recent study was the first to be able to predict the <a href="https://doi.org/10.1038/s41598-020-71755-8">inflammation that patients may experience after a dialysis session</a>. </p>
<p>Importantly, we are using all of this information to develop new membranes that better mimic the filtration ability of a healthy kidney. Again using gold nanoparticles to track blood proteins, imaging techniques at the CLS show the amount of attachment on <a href="https://doi.org/10.1016/j.surfin.2021.101505">current clinical membranes (Photo A) is greater than on membranes we developed with our new coating (Photo B)</a>. </p>
<p>The information from all of our studies is being integrated to allow us to tune membrane characteristics for individual patient characteristics, which directly works towards our goal of improving patient quality of life. </p>
<p>The results of our work will reduce acute side-effects and life-threatening chronic conditions, and increase the quality of life and survival of the millions of people who suffer from kidney failure.</p><img src="https://counter.theconversation.com/content/180825/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Amira Abdelrasoul receives funding from Social Sciences and Humanities Research Council, Natural Sciences and Engineering Research Council of Canada, and Saskatchewan Health Research Foundation.</span></em></p>Hemodialysis filters kidney patients’ blood through a machine. Improving the membranes that mimic kidney function could reduce complications and side-effects, with better treatment results.Amira Abdelrasoul, Assistant Professor, Chemical and Biomedical Engineering, University of SaskatchewanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1450882020-09-09T21:23:40Z2020-09-09T21:23:40ZAn opt-out organ donor system could address Canada’s shortage of organs for transplant<figure><img src="https://images.theconversation.com/files/357316/original/file-20200909-24-1r85pz3.jpg?ixlib=rb-1.1.0&rect=498%2C188%2C4430%2C3175&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Eighty-five per cent of Ontarians support organ donation, but only one-third have opted in under the current system.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>In 2018, there were <a href="https://www.cihi.ca/en/organ-replacement-in-canada-corr-annual-statistics-2019#:%7E:text=At%20the%20end%20of%202018,while%20waiting%20for%20a%20transplant">4,351 Canadians on waiting lists</a> for an organ transplant. In the same year, 223 Canadians died while awaiting organ transplants. </p>
<p>These numbers have been growing over the last decade. For example, between 2009 and 2019, the number of <a href="https://www.cihi.ca/sites/default/files/document/corr-snapshot-2019-en.pdf">Canadians in end-stage renal failure increased by 35 per cent</a>, significantly raising the number of individuals requiring kidney transplants. The situation is only expected to worsen, as it is anticipated that <a href="https://doi.org/10.1186/s12882-017-0699-y">more Canadians will require organ transplants over the coming years</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cross-sectional illustration of a human kidney" src="https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=911&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=911&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=911&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1144&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1144&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1144&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">End-stage kidney disease increased by more than 35 per cent in Canada between 2009 and 2019.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>In the backdrop of these sobering statistics, Nova Scotia is set to become the first jurisdiction in North America to enact legislation to tackle the shortage of organs for transplant. Passed on April 2, 2019, the <a href="https://nslegislature.ca/legc/bills/63rd_2nd/1st_read/b133.htm">Human Organ and Tissue Act</a> is scheduled to come into effect on Jan. 18, 2021. </p>
<p>The act institutes an “opt-out” system to organ donation, which functions on the idea of presumed consent. In its essence, this idea presumes that individuals have consented to having their organs harvested upon their death for transplantation into others in need of those organs. </p>
<p>Nova Scotia’s opt-out system goes against prevailing practice in Canada. Currently, organ donation is based on the “opt-in” system, in which individuals must sign up to be organ donors while they are alive in order for their organs to be harvested for transplantation upon their death.</p>
<h2>The case for presumed consent</h2>
<p>There is ample evidence to substantiate the effectiveness of presumed consent policy. Take the case of Spain, the country with the most robust opt-out system, which it established over 40 years ago. In 2019, <a href="https://www.healio.com/news/nephrology/20200605/presumed-consent-helpful-for-increasing-transplants-in-spain-but-challenges-remain">Spain had 49 deceased organ donors per million population</a> — by far the highest in the world. This compares to Canada’s paltry rate of 20.6 per million population on the same measure.</p>
<p>Despite Canada’s lagging donation indicators, most Canadians support organ donation. For example, <a href="https://www.giftoflife.on.ca/en/">85 per cent of Ontarians support donation</a>, although only one-third have opted-in to the current system. </p>
<p>This discrepancy has been attributed to apathy in registering as a donor rather than <a href="https://dx.doi.org/10.1177%2F1751143718777171">serious moral objections to donating posthumously</a>. If surveys of public opinion are correct, then an opt-out system would get it right more times than it gets it wrong when making assumptions about individuals’ wishes. </p>
<h2>Moral objections</h2>
<p>Those who object to organ donation for religious or other reasons are more likely to make their wishes known in an opt-out system as compared to those wishing to donate for altruistic reasons, who are <a href="https://doi.org/10.1076/jmep.29.1.37.30412">less likely to make their preferences clear in an opt-in system</a>. </p>
<p>In a system designed to save more lives, putting the onus on those who object to donation to opt-out is not only morally justified, but follows other initiatives in which public interest is placed at the forefront of policy. For instance, the introduction of mandatory seat-belt laws have often come under fire for infringing on individual autonomy, but the prevailing benefit to public interest has resulted in a now <a href="https://doi.org/10.1093/phe/phz014">widely accepted legal and social norm</a>. </p>
<figure class="align-center ">
<img alt="Illustration of kidneys, heart, lungs and liver with a green ribbon, symbol for organ donation support" src="https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=140&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=140&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=140&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=176&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=176&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=176&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Eighty-five per cent of Ontarians support organ donation, but only one-third have opted in to the current system.</span>
<span class="attribution"><span class="source">(Canva)</span></span>
</figcaption>
</figure>
<p>Policy debates over whether a jurisdiction ought to have an opt-out versus on opt-in system to organ transplantation are replete with thorny ethical questions. There are usually no simple, clear-cut answers and not all members of the public will be satisfied with any decision reached. </p>
<p>But given the number of Canadians detrimentally affected by types of organ failure that can be medically remedied through transplantation, the country has an ethical responsibility to consider how best to approach the ongoing shortage of donor organs.</p>
<h2>Lowering costs while saving lives</h2>
<p>Beyond the moral reasons for instituting an opt-out system, there are financial incentives too. For example, where it concerns end-stage renal failure, the British Columbia Renal Agency found that the <a href="http://www.bcrenalagency.ca/resource-gallery/Documents/Transplant%20and%20recipient%20eligibility.pdf">annual cost of dialysis treatment is $50,000 per person</a>. This is meaningfully higher than the cost of kidney transplantation, which has a <a href="http://www.bcrenalagency.ca/resource-gallery/Documents/Transplant%20and%20recipient%20eligibility.pdf">one-time associated price tag of $15,000 and $5,500 per year for anti-rejection drugs</a>. </p>
<p>To be sure, it would be wholly unreasonable to expect Nova Scotia’s new act to be implemented without any hiccups. There will likely be unforeseen, complex and difficult issues that emerge as the province begins to put the act into operation in the coming weeks. Moreover, as evidence from jurisdictions that have established presumed consent policy reveals, the effects of the opt-out policy are tenuous unless <a href="https://doi.org/10.3399/bjgp18X694445">sufficient financial and political support buttress it</a>. </p>
<p>While there may be challenges, instituting policy on organ harvesting based on presumed consent could be an important initial step in addressing the ever-growing shortage of organ donors in the country. Other provinces in Canada ought to pay close attention to the forthcoming experiment in Nova Scotia, and consider how their own jurisdictions might respond to the shortage of organ donors — a phenomenon that is causing many avoidable deaths and much unnecessary suffering to Canadians.</p>
<p><em>This is a corrected version of a story originally published Sept. 9, 2020. The earlier story incorrectly stated that the opt-out program would take effect on Oct. 1, 2020.</em></p><img src="https://counter.theconversation.com/content/145088/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ajnesh Prasad receives funding from the Social Sciences and Humanities Research Council and the Canada Research Chairs program. </span></em></p><p class="fine-print"><em><span>Karly Nygaard-Petersen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Thousands of Canadians are on waiting lists for life-saving organ transplants. An opt-out organ donor system, like the one Nova Scotia is implementing, could reduce avoidable deaths and suffering.Ajnesh Prasad, Professor & Canada Research Chair, School of Business, Royal Roads UniversityKarly Nygaard-Petersen, Doctoral student, School of Business, Royal Roads UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1295012020-01-24T13:37:34Z2020-01-24T13:37:34ZThe serious consequence of exercising too much, too fast<figure><img src="https://images.theconversation.com/files/310351/original/file-20200115-134789-u1mhwl.jpg?ixlib=rb-1.1.0&rect=152%2C781%2C5748%2C3098&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Exercising too much, too hard can lead not only to burnout but sometimes to a serious condition that can harm the kidneys.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/tired-man-exhausted-after-extreme-exercise-1009020748">Thayut Sutheeravut/Shutterstock.com</a></span></figcaption></figure><p>Every 365.25 days, when the Earth completes a full orbit around the Sun, we humans have the opportunity to hit the reset button and become fitter, finer versions of ourselves. As usual for January, social media is humming with advice on how to eat better, exercise regularly, lose weight and remain healthy. We feel particularly invincible at this time of year, armed with renewed vigor and motivation to purge ourselves from previous indulgences and our couch-potato ways. </p>
<p>The New Year is also the time when our overzealous, instant-gratification selves emerge, and we do too much exercise too soon to make up for lost time. Exhaustive muscular work, especially following a period of inactivity, can cause mechanical and chemical disruptions to muscle cell membranes which trigger the muscle cells to burst. </p>
<p>I am an <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=%22Hew-Butler+T%22">exercise physiologist and sports medicine specialist</a> who studies exercise-associated collapse. I am seeing and hearing of more incidents of skeletal muscle ruptures that are causing harm in other parts of the body.</p>
<p>This information is not designed to scare people back onto the couch. The key take-away from highlighting these cases is to remind athletes, coaches and mere mortals that the desired physiological response to a training stimulus requires both a gradual buildup period and period of recovery in between training sessions.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/310352/original/file-20200115-134797-1ef1tie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/310352/original/file-20200115-134797-1ef1tie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=466&fit=crop&dpr=1 600w, https://images.theconversation.com/files/310352/original/file-20200115-134797-1ef1tie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=466&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/310352/original/file-20200115-134797-1ef1tie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=466&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/310352/original/file-20200115-134797-1ef1tie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=585&fit=crop&dpr=1 754w, https://images.theconversation.com/files/310352/original/file-20200115-134797-1ef1tie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=585&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/310352/original/file-20200115-134797-1ef1tie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=585&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A cross-section of the human kidneys, which can be injured when muscle cells rupture and send toxic chemicals into the bloodstream.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/human-kidney-cross-section-on-scientific-532563151">crystal light/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>More than muscle injury</h2>
<p>The medical term for skeletal muscle cell rupture is “<a href="https://doi.org/10.1056/NEJMra0801327">rhabdomyolysis</a>,” or “rhabdo” for short. When muscle cells rupture or explode, the intracellular contents are released into the bloodstream. These cellular contents include enzymes, such as creatine kinase; electrolytes, such as potassium; and proteins, such as myoglobin. </p>
<p><a href="https://doi.org/10.1056/NEJMra0801327">Myoglobin</a>, in particular, is a big, red protein that can block the kidney filtration system, or renal tubules, that serve as kidney plumbing. It also can dissociate into toxic byproducts that injure kidneys. In rare cases, too much myoglobin in the bloodstream can stop kidney function altogether, as happened with a <a href="https://doi.org/%2010.1080/10245330701255254">27-year old marathon runner</a> who died from kidney failure. </p>
<p>In a study we conducted on college swimmers, we saw a cluster of rhabdomyolysis, in which <a href="http://dx.doi.org/10.1097/JSM.0000000000000736">six out of 34 swimmers</a> were hospitalized after participating in a 20-minute or so “arm competition” to see how many pull-ups, rows and bench presses they could complete. Cases of “symptomatic rhabdo,” or those needing medical treatment, appear to be increasing within collegiate sports teams at an alarming rate, with the characteristic appearance seen in <a href="https://doi.org/10.1249/JSR.0000000000000484">football players returning to January practice</a> after a season-ending holiday layoff. </p>
<p>To date, <a href="https://doi.org/10.1249/JSR.0000000000000484">17 cases</a> of team rhabdo have occurred from doing “too much, too soon, too fast” and include a variety of sports such as football, swimming, lacrosse, soccer, track, basketball, softball, volleyball and golf. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/V99UtzJCKSc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">University of Houston women’s soccer players suffered from rhabdomyolosis after grueling workouts.</span></figcaption>
</figure>
<h2>Noncompetitive athletes affected too</h2>
<p>So, what about us mere mortals trying to get back in shape? Any physical activity that is either new or excessive can cause symptomatic rhabdo. Excessive <a href="https://doi.org/10.1155/2015/174892">gardening</a>, <a href="https://doi.org/10.1186/1757-1626-1-173">weightlifting</a>, <a href="https://doi.org/10.1002/mus.24784">CrossFit type</a> activities and even a routine <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=%22Tietjen+DP%22+rhabdomyolysis">Army physical fitness test</a> have triggered symptomatic rhabdo with kidney injury. </p>
<p>Over <a href="https://doi.org/10.1249/JSR.0000000000000311">90 cases</a> of rhabdo have been documented after spinning, while <a href="https://doi.org/10.1136/bjsm.2004.013235">119 high school students</a> in Taiwan ended up in the emergency room after their teacher made them complete 120 push-ups within five minutes. Thus, harmful muscle cell rupture can occur after any degree <a href="https://doi.org/10.1136/bjsm.2004.013235">five minutes</a> to <a href="https://doi.org/10.1249/01.mss.0000222831.35897.5f">36 hours</a> of exuberant and/or unaccustomed physical activity. </p>
<p>In combination, gradual training and appropriate recovery allow beneficial muscular, cardiovascular and body composition adaptations to occur, such as building muscle, increasing fitness and losing body fat. Our research confirms that a <a href="https://doi.org/10.1097/JSM.0000000000000736">two-week gradual introduction</a> into training after a layoff is required for muscle cell membranes to fully adapt to training stress. </p>
<p><a href="https://doi.org/10.1249/01.mss.0000210192.49210.fc">Subclinical rhabdo</a>, or muscle breakdown without acute kidney injury or debilitating symptoms, is common and represents the typical response to training which does not require medical treatment. However, hard exercise, especially following a layoff, with the following signs or symptoms within one to two days requires an appropriate medical examination: </p>
<ul>
<li>excruciating muscle pain that does not resolve over time</li>
<li>muscle swelling with limitations in movement</li>
<li>nausea or vomiting, or both</li>
<li>very dark (looks like Coca-Cola) or sparse urine. </li>
</ul>
<p>There are risk factors which increase the likelihood of developing rhabdo following a workout. These risk factors include exercising in the <a href="https://doi.org/10.1016/0002-9343(67)90196-9">heat</a>, <a href="https://doi.org/10.1159/000181723">dehydration</a> or <a href="https://doi.org/10.1007/s00421-015-3324-4">overhydration</a>, <a href="https://doi.org/10.1016/j.ajem.2007.09.003">binge drinking</a>, <a href="https://doi.org/10.1177/0960327113510536">excessive coffee</a> consumption, extreme <a href="https://doi.org/10.1097/PHM.0b013e3181ae107f">dietary</a> practices (<a href="https://doi.org/10.1097/PHM.0b013e3181ae107f">vegetarian</a> or high <a href="https://doi.org/10.1097/JSM.0000000000000310">protein</a>) and possessing the <a href="https://doi.org/10.1097/JSM.0b013e3182625a37">sickle cell</a> trait. Both men and women can develop symptomatic rhabdo, although we see more cases in men. Smaller <a href="https://doi.org/10.1097/JSM.0000000000000310">arm</a> muscles appear more susceptible to rupture after five to 30 minutes of exercise than bigger <a href="https://doi.org/10.1001/jama.1960.03020230019005">leg</a> muscles for reasons that remain unclear.</p>
<p>Although symptomatic rhabdomyolysis is uncommon, this emergent complication of exercise should be on everyone’s radar since cases are on the rise. We coaches, trainers, scientists, practitioners and others encourage everyone to reap the joys and benefits of regular exercise training. However, we caution against exercising too much too soon. Self- (or coach-) inflicted skeletal muscle cell explosions are fully preventable with adherence to smart, physiologically sound approaches to training. </p>
<p>[ <em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/129501/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tamara Hew-Butler does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When it comes to exercise, there’s no month like January, when resolutions kick into gear and call us to the gym. And while physical activity is good, you can injure yourself by overdoing.Tamara Hew-Butler, Associate Professor of Exercise and Sports Science, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/739772017-11-05T08:57:40Z2017-11-05T08:57:40ZChronic kidney disease is still a major health challenge in Africa<figure><img src="https://images.theconversation.com/files/167721/original/file-20170503-21630-oieauo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In Africa, many patients with kidney failure either incur catastrophic out of pocket medical bills or die. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Close to <a href="http://ac.els-cdn.com/S0140673614616019/1-s2.0-S0140673614616019-main.pdf?_tid=f8b4e8d6-03fb-11e7-9f66-00000aab0f01&acdnat=1488976820_5379aaf2200a299d73269e2b7a23e5d9">three million people</a> suffering from chronic kidney failure across the world receive renal replacement therapy every year. But between <a href="http://mema.aub.edu.lb/wp-content/uploads/2017/06/VARIANCE-AND-SCOPE-OF-DESTRUCTION-IN-DELIVERY-OF-RENAL-CARE-DURING-CONFLICTS-Mohamad-Sukkarie.pdf">4.9 million and 9.7 million</a> more still need treatment. And at least two million die because they cannot access it. </p>
<p>Kidneys filter wastes and excess fluids from the blood which are then excreted in the urine. When someone has chronic kidney disease, their kidneys are unable to perform these tasks and they require renal replacement therapy in the form of dialysis or kidney replacement. </p>
<p>Chronic kidney disease is a global problem with about <a href="https://www.kidney.org/kidneydisease/global-facts-about-kidney-disease">10% of the world’s population</a> suffering from the disease. </p>
<p>But in <a href="http://www.kisupplements.org/article/S2157-1716(15)31135-7/pdf">sub-Saharan Africa</a>, about 14% of the adult population suffers from chronic kidney disease . Between 1999 and 2006 South Africa saw a <a href="http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000300034">67% rise in deaths</a> as a result of chronic kidney disease.</p>
<p>There are three main challenges with managing chronic kidney disease on the continent. Firstly lifestyle changes have resulted in increasing obesity rates which in turn increases the risk of kidney disease. Secondly, there is the link between HIV and kidney failure and thirdly, there are treatment failures.</p>
<p>Many patients with kidney failure either incur catastrophic out of pocket medical bills, or they die. If the underlying challenges aren’t addressed the problems that come with expected increases in chronic kidney disease on the continent will only get worse.</p>
<h2>Obesity’s role</h2>
<p>Obesity is one of the most potent risk factors for people developing kidney disease. This is because it increases the risk of people developing diabetes and hypertension – two of the major risks for chronic kidney disease. </p>
<p>The rise in <a href="https://academic.oup.com/heapro/article/28/1/4/579695/Obesity-in-sub-Saharan-Africa-development-of-an">obesity rates</a> has been rapid, substantial and widespread. As a result, obesity has become a major public health epidemic in both the developed and developing world.</p>
<p>The estimations are that by 2025, obesity will affect 18% of men and more than 21% of women worldwide while severe obesity will affect 6% of men and 9% of women.</p>
<p>On the continent South Africa has the highest number of overweight and obese people. Close to <a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)30054-X.pdf">70%</a> of South Africa’s women are overweight or obese, according to a study by The Lancet. More 25% of girls are also overweight or obese. </p>
<p>The Lancet study found that 70% of South African women are overweight and 42% are obese. The problem is also acute in children. There is combined overweight and obesity prevalence of 13.5% for South African children aged six to 14 years. This is higher than the global prevalence of 10% in schoolchildren, but lower than current levels in the US.</p>
<p>If action is not taken to halt this epidemic, the expected increase in overweight and obese South African children will become a major concern.</p>
<p>There are very specific dietary and lifestyle changes that are linked to obesity. This includes patterns of increased eating, drinking and smoking along with reduced physical activity, and a shift to a diet high in sugar, salt and saturated fat.</p>
<p>Evidence shows that people with a higher weight-to-height ratio – more commonly known as a body mass index – have a higher risk of developing cardiovascular disease, cancer, diabetes, osteoarthritis and chronic kidney disease. </p>
<h2>Expensive treatment</h2>
<p>Treatment of chronic kidney disease on the African continent is dire. Of the world’s population that needed renal replacement therapy, only 1% of those who received treatment lived in Africa.</p>
<p>There are two main problems: </p>
<ul>
<li><p>dialysis is costly, and </p></li>
<li><p>there are too few facilities to perform transplants.</p></li>
</ul>
<p>In South Africa, more than half of potentially eligible patients are turned down for dialysis as a result of cost. But dialysis not a cure, it is a lifeline while patients wait for a transplant. </p>
<p>In South Africa there only three public hospitals that offer kidney transplants. And on the rest of the continent, there are very few countries offering routine transplants. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5325483/">Nigeria</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/8991246">Kenya</a> have started up programmes. </p>
<h2>The link between kidney failure and HIV</h2>
<p>Africa carries the world’s highest burden of HIV: In 2013, more than <a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/overview">24.7 million</a> people were living with the disease, accounting for 71% of the total caseload on the globe. </p>
<p>Studies have also shown that <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362304/">severe immunosuppression</a> – or CD4 counts less than 200 – are a predominant risk factor for acute kidney infection.</p>
<p>The extent of the HIV epidemic and its associated burden of chronic kidney disease on the continent make it a challenging problem. </p>
<p>The main challenge is that there are no measures to prevent renal disease in people living with HIV or to detect it early enough to treat it. As a result, most clinicians deal with advanced stages of chronic kidney failure in people living with HIV.</p>
<h2>Making changes</h2>
<p>The underlying causes that lead to chronic kidney disease need to be tackled as a matter of urgency.</p>
<p>Firstly, the challenge of a rise in diet-related non-communicable diseases – such as obesity and hypertension – which accounts for 28% of the burden of disease in South Africa, must be addressed.</p>
<p>One critical intervention would be to get people to eat healthier. For obese individuals sustained moderate weight loss by itself is definitely beneficial in obesity, especially “morbid” obesity, but also in diabetes, hypertension, hyperlipidaemia, cardiorespiratory diseases and other chronic degenerative diseases associated with any degree of excess body fat.</p>
<p>Reducing salt intake would also make a dramatic difference. Excessive salt leads to increased risk of stomach cancer, kidney failure, dehydration, high blood pressure and hypertension, which in turn can contribute to heart disease and strokes. </p>
<p>Another critical intervention is education: people need to understand the causes and risks. Action and clear strategies are needed. South Africa’s Department of Health realises the significance of the obesity crisis, and has included this in the national non-communicable diseases strategic goals to assist with the obesity problem in the country: </p>
<ul>
<li><p>Increase physical activity by 10% by 2020;</p></li>
<li><p>Reduce the consumption of alcohol by 20% by 2020; and</p></li>
<li><p>Reduce the percentage of people who are obese and overweight by 10% by 2020.</p></li>
</ul>
<p>But there’s only so much that governments can do. It’s up to the individuals to improve their health and quality of life.</p><img src="https://counter.theconversation.com/content/73977/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Chronic kidney disease is a global problem with about 10% of the world’s population suffering from the disease.Irene Labuschagne, Principle dietitian at the Nutrition Information Centre, Stellenbosch UniversityJohan Nel, Senior specialist in the Division of Nephrology, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/638502016-08-16T15:41:04Z2016-08-16T15:41:04ZFour things you should know before starting that exercise regime<figure><img src="https://images.theconversation.com/files/134267/original/image-20160816-13003-vg50s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Let me hear your body talk ...</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-379979383/stock-photo-attractive-young-muscular-man-working-out-on-a-fitness-station-in-gym-pumping-iron.html?src=AprLWf6JPL_HjpTenZbMXQ-1-95">Yurly Rudyy</a></span></figcaption></figure><p>The debate about how much is the right amount of exercise can seem never-ending. The <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213740/dh_128145.pdf">minimum recommendation</a> in the UK is 30 minutes of “moderate” exercise five times per week, not that most adults are meeting it. Some health specialists think alternative regimes will do us more good, such as <a href="https://www.acsm.org/docs/brochures/high-intensity-interval-training.pdf">shorter bouts</a> of very intense exercise three to four times a week; or <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3404815/">limiting</a> periods of inactivity to a maximum of 60 minutes at any one time. </p>
<p>The trouble with this debate is that it risks assuming that exercise is always good for you. In reality, this is not always the case. Most of us know about the need to warm up properly and avoid exercising when we are under the weather, but some risks may not yet have reached the public consciousness. What follows is a few words of caution for anyone working themselves into a sweat. You never know, they may just save your life. </p>
<h2>1. Easy does it</h2>
<p>People who are unaccustomed to exercise and throw themselves in at the deep end <a href="http://www.ncbi.nlm.nih.gov/pubmed/10953894">can develop</a> an unpleasant condition called delayed onset muscle soreness. It involves aching and tender muscles and a reduced range of motion of the joint at the affected area. It can last for several days and peaks about 48 hours after exercise. </p>
<p>The condition is caused by the body reacting to the trauma of sudden exercise: white blood cells infiltrate the muscles and digest damaged tissue, causing acute inflammation. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7481277">How to</a> avoid this experience? Anyone starting an exercise programme should build it up gradually.</p>
<h2>2. Don’t overstimulate</h2>
<p>In extreme cases of delayed onset muscle soreness, the enzymes released by the muscles from the digestion of damaged tissue can induce a condition called <a href="https://medlineplus.gov/ency/article/000473.htm">rhabdomyolysis</a> in which enzymes from damaged muscle cells are released into the blood. In severe cases this can lead to kidney failure but fortunately this appears to be relatively rare. </p>
<p>Using electrical stimulation devices as a substitute or supplement to exercise can also <a href="http://www.bbc.co.uk/news/magazine-35959206">reportedly</a> induce rhabdomyolysis. These devices work by attaching electrodes to different muscle groups and have become increasingly popular in recent years. Now, however, clinicians <a href="https://www.statnews.com/2016/04/07/fitness-electrical-muscle-stimulation/">are issuing</a> warnings about the dangers of using them excessively. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/134269/original/image-20160816-13037-j0fooc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/134269/original/image-20160816-13037-j0fooc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/134269/original/image-20160816-13037-j0fooc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134269/original/image-20160816-13037-j0fooc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134269/original/image-20160816-13037-j0fooc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134269/original/image-20160816-13037-j0fooc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134269/original/image-20160816-13037-j0fooc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134269/original/image-20160816-13037-j0fooc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The shock doctrine.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-114814000/stock-photo-electrical-muscle-stimulation-ems-training.html?src=zezqLJHH5mjrfPRIE62Nmg-1-14">Javier Brosch</a></span>
</figcaption>
</figure>
<h2>3. Hey, Ironman …</h2>
<p>If you are thinking about seriously pushing yourself, a brief lesson on the function of the heart is in order. The heart works in two phases, a contraction phase and a relaxation phase. In the contraction phase, blood is ejected from the right and left ventricles into the arteries through contraction of the heart muscle. In the relaxation phase, blood fills the ventricles to prepare for the next contraction. </p>
<p>The average human heart contracts about 70 times per minute, 24 hours per day and accumulates about 3 billion contractions over a 75-year period. It is considered that the heart can cope with even strenuous exercise, rising to about 200 beats per minute to pump enough blood and oxygen around the body. </p>
<p>Yet studies investigating the effects of prolonged intensive exercise such as an Ironman triathlon <a href="http://www.ncbi.nlm.nih.gov/pubmed/12402180">have shown</a> a temporary decline in the heart’s relaxation function after the athlete has stopped exercising. This effect has been termed “cardiac stunning”. </p>
<p>Perhaps more worrying, some participants in these gruelling events <a href="http://www.ncbi.nlm.nih.gov/pubmed/12774593">have displayed</a> biomarkers of cardiac damage usually only found after a heart attack – albeit the levels tend to be only just over the threshold to indicate damage and the effects appear to be short term. Yet subsequent studies <a href="http://www.ncbi.nlm.nih.gov/pubmed/15377277">also suggest</a> it could be detrimental to cardiac function in the longer term. </p>
<p>Having said all that, it is worth stressing that not all exercise is detrimental to the heart. Exercise maintains heart function and in the case of heart-attack patients following a rehab programme, can substantially improve it. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/134271/original/image-20160816-13007-1t4ta7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/134271/original/image-20160816-13007-1t4ta7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/134271/original/image-20160816-13007-1t4ta7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134271/original/image-20160816-13007-1t4ta7l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134271/original/image-20160816-13007-1t4ta7l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134271/original/image-20160816-13007-1t4ta7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134271/original/image-20160816-13007-1t4ta7l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134271/original/image-20160816-13007-1t4ta7l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Wot no Tony Stark?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-87947212/stock-photo-barcelona-oct-16-brenton-cabello-of-spain-in-action-finishing-swimming-at-barcelona-garmin-triathlon-event-at-barcelona-beach-on-october-16-2011-in-barcelona-spain.html?src=AprLWf6JPL_HjpTenZbMXQ-1-7">Maxisport</a></span>
</figcaption>
</figure>
<h2>4. Immunity care</h2>
<p>A bout of moderate exercise is considered to boost our immune function by prompting an increase in the number of white blood cells in our blood. In contrast, completing three or four hours of strenuous exercise – par for the course for professional athletes – has been <a href="http://www.ncbi.nlm.nih.gov/pubmed/23899753">linked to</a> a decline in immune function over the next 24 hours. </p>
<p>After that it would return to normal, however for people like athletes doing this on a daily basis, longer-term studies have <a href="http://www.ncbi.nlm.nih.gov/pubmed/21584686">demonstrated that</a> repeated strenuous exercise over several weeks can suppress immune function by lowering the number of white blood cells and making them function less effectively. It would then take considerably longer for the immune system to correct itself. </p>
<p>What to do about this? You can alleviate some of the effects with a good diet (or exacerbate them by eating poorly). Better still, you can also keep the bugs at bay with good personal hygiene. It is no coincidence that this message is drilled into athletes competing in the Olympics nowadays. </p>
<h2>The take-home</h2>
<p>None of this is intended to suggest that moderate exercise is not good for us. Doctors and sports scientists would agree that it maintains and promotes good heart, muscle, immune and also metabolic function. We might still be debating the best regime, but it’s still rightly a major goal for health professionals to educate the public about the beneficial effects of exercise. </p>
<p>That said, there are limits. People need to be more aware of the risks of doing too much too soon – and of taking things to extremes. Exercise is good for you, but take the wrong approach and you might wish you had stayed on the couch.</p><img src="https://counter.theconversation.com/content/63850/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Derek Ball receives funding from Medical Research Scotland.</span></em></p>Working out is always good for you – until it’s not.Derek Ball, Associate Professor of Applied and Intergrative Physiology, Heriot-Watt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/578742016-06-09T20:09:48Z2016-06-09T20:09:48ZHow Australians Die: cause #5 – diabetes<figure><img src="https://images.theconversation.com/files/121843/original/image-20160510-20717-n8wmk9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Diabetes is characterised by higher than normal levels of glucose in the blood.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/FZeiyMSWsn8">Leon Ephraim/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p><em>This is the final in the <a href="https://theconversation.com/au/topics/how-australians-die">How Australians Die</a> series that focuses on the country’s top five causes of death and how we can drive down rates of these illnesses. Previous series articles were on <a href="https://theconversation.com/how-australians-die-cause-1-heart-diseases-and-stroke-57423">heart diseases</a> and stroke, <a href="https://theconversation.com/how-australians-die-cause-2-cancers-58063">cancers</a>, <a href="https://theconversation.com/how-australians-die-cause-3-dementia-alzheimers-57341">dementia</a> and <a href="https://theconversation.com/how-australians-die-cause-4-chronic-lower-respiratory-diseases-58926">chronic lower respiratory</a> diseases.</em></p>
<hr>
<p>Diabetes is rapidly emerging as a <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2014%7EMain%20Features%7ELeading%20Causes%20of%20Death%7E10001">leading cause of death</a> among Australians. It is also a leading cause of heart attacks, strokes, amputations, kidney failure, depression, dementia and severe infections – all of which themselves contribute to premature death. </p>
<p>It never used to be this way. Thirty years ago, around 250,000 Australians had diabetes. Today that figure is around <a href="https://www.diabetesaustralia.com.au/diabetes-in-australia">two million</a>. </p>
<p>Around the world in 2013, <a href="http://www.diabetesatlas.org">more than five million people</a> between the ages of 20 and 79 died from diabetes, accounting for 8.4% of deaths among people in this age group. This translates to one death due to diabetes every six seconds. Tragically, nearly <a href="http://www.diabetesatlas.org">half of these</a> were in people under 60.</p>
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<p>These figures likely underestimate the major role of diabetes in death as it frequently goes unreported as a cause of death. One study showed that only 35% to 40% of people with diabetes who died had the disease listed on their death certificate, while only about 10% to 15% had diabetes listed as the <a href="http://www.diabetes.org/diabetes-basics/statistics">underlying cause of death</a>.</p>
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<img alt="" src="https://images.theconversation.com/files/123909/original/image-20160525-25231-7yojbi.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/123909/original/image-20160525-25231-7yojbi.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=192&fit=crop&dpr=1 600w, https://images.theconversation.com/files/123909/original/image-20160525-25231-7yojbi.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=192&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/123909/original/image-20160525-25231-7yojbi.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=192&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/123909/original/image-20160525-25231-7yojbi.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=241&fit=crop&dpr=1 754w, https://images.theconversation.com/files/123909/original/image-20160525-25231-7yojbi.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=241&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/123909/original/image-20160525-25231-7yojbi.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=241&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<h2>Which type of diabetes is worst?</h2>
<p>Diabetes is characterised by higher than normal levels of glucose in the blood, caused by having insufficient insulin production or function to keep glucose levels under control.</p>
<p>This can come about if the immune system inadvertently destroys the insulin producing cells of the pancreas. This is called <a href="http://theconversation.com/explainer-what-is-diabetes-11842">type 1 diabetes</a>. It can occur at any age, but is most common in children and young adults.</p>
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<p>Ectopic fat – fat that accumulates outside the typical stores underneath your skin – can also reduce insulin production and cause resistance to its glucose lowering effects. This is called <a href="http://theconversation.com/explainer-what-is-diabetes-11842">type 2 diabetes</a> and accounts for 95% of all diabetes cases. It can occur at any age, but is most common in older adults.</p>
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<p>Because of its substantially higher frequency and the older age of its sufferers, type 2 diabetes kills many more people than type 1 . However, both kinds of diabetes can shorten lives. </p>
<p>For example, the life expectancy of someone with type 1 diabetes in Australia is <a href="http://link.springer.com/article/10.1007/s00125-015-3857-4/fulltext.html">12 years less</a> than observed in the general population. </p>
<p>Equally, a man in his fifties with type 2 diabetes is <a href="http://care.diabetesjournals.org/content/37/9/2579.long">twice as likely</a> to die in the next five years than one without diabetes. </p>
<p>Deaths due to diabetes are substantially higher in some settings and populations. For instance, the impact of diabetes on mortality may be at least <a href="http://www.aihw.gov.au/diabetes-indicators/deaths">five times higher</a> in Aboriginal and Torres Strait Islander people as in non-Indigenous Australians.</p>
<h2>Pre-diabetes</h2>
<p>On average, the higher the blood glucose, the greater the risk from complications of diabetes and premature mortality. Consequently, lowering glucose levels is an essential component of diabetes care and can substantially improve the <a href="http://jama.jamanetwork.com/article.aspx?articleid=2088851">survival of people with diabetes</a> in the long term. </p>
<p>However, the <a href="http://www.bmj.com/content/343/bmj.d4169">lack of success</a> in short to medium-term studies shows the <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMe0807625">long shadow</a> of diabetic complications and the importance of both early identification and long-term treatment.</p>
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<img alt="" src="https://images.theconversation.com/files/121840/original/image-20160510-20721-52qfta.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/121840/original/image-20160510-20721-52qfta.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/121840/original/image-20160510-20721-52qfta.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/121840/original/image-20160510-20721-52qfta.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/121840/original/image-20160510-20721-52qfta.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/121840/original/image-20160510-20721-52qfta.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/121840/original/image-20160510-20721-52qfta.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Diabetes is characterised by higher than normal levels of glucose in the blood.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<p>One in five Australians have moderately high glucose levels; not high enough to be called diabetic but still <a href="http://circ.ahajournals.org/content/116/2/151.abstract">enough to increase their risk</a> of dying too soon. This is called pre-diabetes and well over 60% of these people will ultimately develop diabetes without intervention. </p>
<p>Because there are many more people with pre-diabetes than have diabetes, it has been <a href="http://www.ncbi.nlm.nih.gov/pubmed/17098083">estimated that most deaths</a> due to elevated blood glucose levels actually don’t occur in people with diabetes. Such data further suggests the true ranking of elevated blood glucose levels as a cause of death in Australians is likely much higher than number five.</p>
<h2>Changing causes of death in diabetes</h2>
<p>Diabetes has always been a killer. In the second century AD, Greek physician <a href="http://www.ncbi.nlm.nih.gov/pubmed/22450352">Aretaeus of Cappadocia described diabetes mellitus</a> as a rare but fatal disease characterised by “the wasting of flesh and limbs into urine”. </p>
<p>Modern diabetes treatment has now abolished the idea of emaciation caused by the excessive loss of glucose into the urine. In its place, diabetes has transformed into a wholly different kind of killer.</p>
<p>Heart disease and stroke account for about a <a href="http://care.diabetesjournals.org/content/37/9/2579.long">third of deaths</a> in people with diabetes. Consequently, <a href="http://care.diabetesjournals.org/content/38/Supplement_1/S49.full">reducing risk factors for heart disease</a> – including cholesterol and blood pressure levels, stopping smoking, dietary change, increasing physical activity and weight reduction – are cornerstones of diabetes care.</p>
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<img alt="" src="https://images.theconversation.com/files/125817/original/image-20160609-3513-1j82d61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/125817/original/image-20160609-3513-1j82d61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/125817/original/image-20160609-3513-1j82d61.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/125817/original/image-20160609-3513-1j82d61.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/125817/original/image-20160609-3513-1j82d61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/125817/original/image-20160609-3513-1j82d61.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/125817/original/image-20160609-3513-1j82d61.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Increasing physical activity as a cornerstone of diabetes care.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<p>There is evidence that improvements in the management of diabetes have led to a <a href="http://care.diabetesjournals.org/content/early/2016/04/20/dc15-2308.full.pdf+html">substantial reduction</a> in the frequency of deaths from heart disease and strokes over the past 30 years. Unfortunately, the rising prevalence of diabetes has outstripped much of these gains, the result of which is that diabetes is now the leading cause of heart disease in many countries, including Australia.</p>
<p>With the decline of deaths due to heart disease, cancer has now emerged as the <a href="http://care.diabetesjournals.org/content/early/2016/04/20/dc15-2308.full.pdf+html">leading cause of death in Australians with diabetes</a>. Indeed, diabetes is now considered an important <a href="http://care.diabetesjournals.org/content/33/7/1674">risk factor</a> for many cancers such as liver, pancreatic, endometrial, colon, breast, and bladder cancers. </p>
<h2>Where to from here?</h2>
<p>At least <a href="http://www.thelancet.com/journals/landia/article/PIIS2213-8587,70161-5/abstract">two out of every five adults</a> will develop type 2 diabetes in their lifetime. Yet it is preventable and may even be reversible in its earliest stages.</p>
<p>It is clear that simple measures, such as improving diet, weight loss and regular physical activity, can have profound and ongoing effects to not only <a href="http://www.ncbi.nlm.nih.gov/pubmed/24731674">reduce the risk of developing type 2 diabetes</a>, but also subsequent mortality.</p>
<p>Given the importance of diabetes, it is up to every person, society and country to recognise the disease as a major threat to well-being and actively take opportunities for diabetes prevention or face an overwhelming health crisis. Here in Australia, the recently released <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/nds-2016-2020">National Diabetes Strategy</a> outlines many of the first steps needed.</p><img src="https://counter.theconversation.com/content/57874/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Merlin Thomas receives funding from NHMRC and JDRF</span></em></p><p class="fine-print"><em><span>Paul Zimmet does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Diabetes is a leading cause of death as well as of heart attacks, strokes, amputations, kidney failure, depression and severe infections – all of which themselves contribute to premature death.Merlin Thomas, Adjunct Professor of Preventive Medicine, Baker Heart and Diabetes InstitutePaul Zimmet, Professor (Hon) at Monash University, Baker Heart and Diabetes InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/309662015-03-12T03:00:41Z2015-03-12T03:00:41ZKidneys are amazing for all they do, be sure to look after yours<figure><img src="https://images.theconversation.com/files/74555/original/image-20150311-24203-zjs59l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kidneys are a feature-packed, highly efficient filtration and waste elimination system.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/64958688@N00/3349943474">Helen Taylor/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Tucked away just below your ribcage near your spine are two bean-shaped organs known as the kidneys. And when they’re quietly getting on with their job, it’s easy to forget they’re there and how important they are. But their absence, or even less-than-optimal performance can have dire consequences. </p>
<p>Kidneys are a feature-packed, highly efficient filtration and waste elimination system as well as the source of some essential hormones and vitamins. When all is said and done, the “factory-fitted” system for all they do beats alternatives for efficiency and convenience. They’re compact, built-in, self-contained, portable and low maintenance. </p>
<p>About 1,500 litres of blood pass through the kidneys each day, through a series of highly-regulated pumps and channels. Essential nutrients and water are reabsorbed and the waste products created by our cells are removed in volumes ranging from as little as 500 millilitres to as much as ten litres, in the form of urine. </p>
<p>Together with the bladder, which acts as a mechanism to batch this output, kidneys are the ultimate personal waste disposal system, requiring little maintenance. In fact, you could say the greatest inconvenience they pose is the need to occasionally quickly locate “conveniences”.</p>
<h2>When things go wrong</h2>
<p>Although the list of <a href="http://www.anzdata.org.au/anzdata/AnzdataReport/36thReport/2013c02_newpatients_v1.7.pdf">conditions causing kidney disease</a> is long, dietary and other lifestyle issues are beginning to dominate. <a href="http://www.kidney.org.au/KidneyDisease/FastFactsonCKD/tabid/589/Default.aspx">More than a third of all new patients</a> are now reaching end-stage kidney disease due to diabetes and about one in eight as a result of high blood pressure. </p>
<p>In contrast, the most common genetic cause of kidney disease (polycystic kidney disease) only accounts for one in 20 patients. Less common causes include autoimmune diseases and the toxic side effects of some medicines. Not only are <a href="http://www.kidney.org.au/HealthProfessionals/QKidneyRiskAssessment/tabid/861/Default.aspx">many of the risk factors</a> for kidney disease the same as those for heart disease, kidney disease itself is considered a risk factor for developing heart disease. </p>
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<img alt="" src="https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Dietary and other lifestyle issues now dominate as causes of kidney disease.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/bijoubaby/6178847805">Heather Wizell/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
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<p>The development of kidney disease is often insidious, as symptoms are non-specific and occur late. Indeed, more than 90% of kidney function may be lost before any symptoms occur. </p>
<p>Common symptoms include nausea, a change in taste or loss of appetite, fatigue and itching, which reflect the build-up of toxins normally eliminated by the kidney. Less often patients may present due to swelling, or because they have noticed the presence of blood or protein in the urine (protein may cause urine to become frothy). </p>
<p>Thanks to advances in technology, kidneys are the only major organs that can completely fail but leave patients alive and reasonably healthy, even out of hospital. If your kidneys do fail, the first step is to get an alternative filtration system up and working. This is known as dialysis. </p>
<h2>Dialysis and transplants</h2>
<p>The <a href="https://www.renalreg.org/documents/patient-information/">two main types of dialysis</a> are peritoneal dialysis and haemodialysis. Both involve having some sort of permanent access point to enable regular dialysis. While these interventions keep people alive, they only provide at best about 10% to 15% of health kidney function. </p>
<p>Peritoneal dialysis, which can be done at home by patients themselves, involves having a tube surgically inserted into the abdominal cavity to enable fluid to enter.</p>
<p>Haemodialysis, which takes four to five hours and has to be performed three times a week, requires direct access into the bloodstream. This usually involves a surgical connection between an artery and a vein. Once these access points have been established, dialysis can begin. </p>
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<img alt="" src="https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Both kinds of dialysis involve having some sort of permanent access point into the body.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/newslighter/523392">Dan/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>For eligible patients, a <a href="https://www.renalreg.org/documents/patient-information/">kidney transplant</a> may avert the need for dialysis but it comes with its own problems. In addition to the risks of having an operation and general anaesthetic, unless the patient has an identical twin, the transplanted kidney will be seen by their immune system as foreign. </p>
<p>Left unchecked, transplanted kidneys are soon rejected, and fail. Immune-suppressing drugs can prevent this, but they have serious side effects and have to be taken for the rest of your life. The problem is that currently available immunosuppressants are relatively non-specific in their actions, and suppress the patient’s whole immune system. This makes them much more vulnerable to all sorts of infections, and also cancers. </p>
<p>Clearly, current treatments for kidney failure come with their own significant downsides. Life expectancy on dialysis, for instance, is considerably shorter than that of the general population.</p>
<h2>Love kidneys, yourself and others</h2>
<p>Chances are, if you are looking after your kidneys, you are also looking after the rest of your body. You’ve probably heard it all before but if you eat a balanced diet that’s low in salt, fat, and sugar, maintain a healthy weight, exercise regularly, drink sufficient water, restrict your alcohol intake and don’t smoke, you are caring for your kidneys. </p>
<p>There will be other benefits too. You’ll also be reducing your risk of diabetes, heart disease, high blood pressure and even cancer.</p>
<p>Despite the limitations of kidney transplants, they can transform and extend the lives of those with kidney failure. Only people with healthy kidneys can donate kidneys for transplantation. So looking after your kidneys may turn out to be an investment in someone else’s future and allow you to give the gift of life.</p><img src="https://counter.theconversation.com/content/30966/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christine Carson has in the past received funding from The Rural Industries Research & Development Corporation and companies in the natural products and complementary and alternative medicines industry.</span></em></p><p class="fine-print"><em><span>Aron Chakera receives funding from The University of Western Australia, Royal Australasian College of Physicians, Raine Foundation, Western Australian Department of Health.</span></em></p>Rather innocuous-looking and tucked away below the ribcage, kidneys are crucial for keeping us alive and well.Christine Carson, Research Associate at the University of Western Australia &, Harry Perkins Institute of Medical ResearchAron Chakera, Clinical senior lecturer, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.