tag:theconversation.com,2011:/us/topics/kidney-disease-489/articlesKidney disease – 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>
<blockquote>
<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/2025952023-05-05T12:14:19Z2023-05-05T12:14:19ZObesity in children is rising dramatically, and it comes with major – and sometimes lifelong – health consequences<figure><img src="https://images.theconversation.com/files/524166/original/file-20230503-24-l7rhni.jpg?ixlib=rb-1.1.0&rect=22%2C33%2C7326%2C4869&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Knowing how to talk to kids about healthful eating is key.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/xtd3zYWxEs4">MI PHAM/Unsplash</a></span></figcaption></figure><p>In the past two decades, <a href="https://doi.org/10.1542/peds.2021-053708">children have become more obese</a> and have developed obesity at a younger age. A 2020 report found that <a href="https://www.cdc.gov/obesity/data/childhood.html#">14.7 million</a> children and adolescents in the U.S. live with obesity. </p>
<p>Because <a href="https://childhoodobesityfoundation.ca/what-is-childhood-obesity/complications-childhood-obesity/">obesity is a known risk factor</a> for <a href="https://www.mayoclinic.org/diseases-conditions/childhood-obesity/symptoms-causes/syc-20354827">serious health problems</a>, its <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7037a3.htm">rapid increase during the COVID-19 pandemic</a> raised alarms.</p>
<p>Without intervention, many obese <a href="https://doi.org/10.1111/obr.12334">adolescents will remain obese</a> as adults. Even before adulthood, some children will have serious health problems beginning in their preteen years.</p>
<p>To address these issues, in early 2023, the American Academy of Pediatrics released its <a href="https://www.aap.org/en/news-room/news-releases/aap/2023/american-academy-of-pediatrics-issues-its-first-comprehensive-guideline-on-evaluating-treating-children-and-adolescents-with-obesity/">first new obesity management guidelines</a> in 15 years.</p>
<p>I am a <a href="https://www.scvmc.org/find-provider-result?field_specialties_target_id=536&field_spoken_language_target_id=All&title=&field_gender_target_id=All&sort_bef_combine=field_last_name_value_ASC">pediatric gastroenterologist</a> who sees children in the largest public hospital in California, and I have witnessed a clear trend over the last two decades. Early in my practice, I only occasionally saw a child with a complication of obesity; now I see multiple referrals each month. Some of these children have severe obesity and several health complications that require multiple specialists.</p>
<p>These observations prompted my reporting for the <a href="https://centerforhealthjournalism.org/2023/03/06/pandemic-made-childhood-obesity-even-worse-how-can-we-help-children-most-risk">California Health Equity Fellowship</a> at the University of Southern California. </p>
<p>It’s important to note that not all children who carry extra weight are unhealthy. But evidence supports that obesity, especially severe obesity, requires further assessment.</p>
<h2>How obesity is measured</h2>
<p>The <a href="https://www.who.int/health-topics/obesity#tab=tab_1">World Health Organization defines obesity</a> as “abnormal or excessive fat accumulation that presents a risk to health.” </p>
<p>Measuring fat composition requires specialized equipment that is not available in a regular doctor’s office. Therefore most clinicians use body measurements to screen for obesity. </p>
<p>One method is body mass index, or BMI, a calculation based on a child’s height and weight compared to age- and sex-matched peers. BMI doesn’t measure body fat, but when <a href="https://www.cdc.gov/healthyweight/assessing/bmi/index.html">BMI is high</a>, it correlates with total body fat.</p>
<p>According to the <a href="https://doi.org/10.1542/peds.2022-060640">American Academy of Pediatrics</a>, a child qualifies as overweight at a BMI between the <a href="https://www.cdc.gov/growthcharts/clinical_charts.htm">85th and 95th percentile</a>. Obese is defined as a <a href="https://www.cdc.gov/obesity/basics/childhood-defining.html">BMI above the 95th percentile</a>. Other screens for obesity include <a href="https://www.nccor.org/nccor-tools/a-guide-to-methods-for-assessing-childhood-obesity/">waist circumference and skin-fold thickness</a>, but these methods are less common. </p>
<p>Because many children exceeded the limits of existing growth charts, in 2022 the Centers for Disease Control and Prevention introduced <a href="https://www.cdc.gov/growthcharts/extended-bmi.htm">extended growth charts</a> for severe obesity. Severe obesity occurs when a child reaches the 120th percentile or has a BMI over 35. For instance, a 6-year-old boy who is 48 inches tall and is 110 pounds would meet criteria for severe obesity because his BMI is 139th percentile.</p>
<p><a href="https://doi.org/10.1161/cir.0b013e3182a5cfb3">Severe obesity</a> carries a heightened risk of liver disease, cardiovascular disease and metabolic problems such as diabetes. As of 2016, almost <a href="https://doi.org/10.1542%2Fpeds.2017-3459">8% of children ages 2 to 19 had severe obesity</a>.</p>
<p>Other health problems associated with severe obesity include <a href="https://doi.org/10.1155%2F2012%2F134202">obstructive sleep apnea</a>, <a href="https://orthoinfo.aaos.org/en/diseases--conditions/slipped-capital-femoral-epiphysis-scfe">bone and joint problems</a> that can cause early arthritis, <a href="https://doi.org/10.5527%2Fwjn.v4.i2.223">high blood pressure</a> and <a href="https://doi.org/10.1159/000492826">kidney disease</a>. Many of these problems occur together.</p>
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<figcaption><span class="caption">More and more children are developing diseases that have traditionally only been seen in adults.</span></figcaption>
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<h2>How obesity affects the liver</h2>
<p>The liver disease associated with obesity is called nonalcoholic <a href="https://www.niddk.nih.gov/health-information/liver-disease/nafld-nash-children#">fatty liver disease</a>. To store excess dietary fat and sugar, the liver’s cells fill with fat. Excess carbohydrates in particular get processed into substances similar to the <a href="https://doi.org/10.3945%2Fan.112.002998">breakdown products of alcohols</a>. Under the microscope, a pediatric fatty liver looks similar to a liver with alcohol damage.</p>
<p>Occasionally children with fatty liver are not obese; however, the <a href="https://doi.org/10.1002/cld.1027">greatest risk factor for fatty liver</a> is obesity. At the same BMI, Hispanic and Asian children are more susceptible to fatty liver disease than Black and white children. Weight reduction or reducing the consumption of fructose, a naturally occurring sugar and common food additive – even without significant weight loss – improves fatty liver.</p>
<p>Fatty liver is the most common chronic liver disease in children and adults. In Southern California, <a href="https://doi.org/10.1542%2Fpeds.2020-0771">pediatric fatty liver doubled</a> from 2009 to 2018. The disease can progress rapidly in children, and <a href="https://doi.org/10.1136/gut.2008.171280">some will have liver scarring</a> after only a few years. </p>
<p>Although few children currently require liver transplants for fatty liver, it is the most <a href="https://doi.org/10.1097/mcg.0000000000000925">rapidly increasing reason for transplantation in young adults</a>. Fatty liver is the second-most common reason for liver transplantation in the U.S., and it will be the <a href="https://liverfoundation.org/about-your-liver/facts-about-liver-disease/fatty-liver-disease/">leading cause in the future</a>.</p>
<figure class="align-center ">
<img alt="A light micrograph image of fatty liver, with large vacuoles of triglyceride fat accumulated inside liver cells." src="https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.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">
<figcaption>
<span class="caption">A light micrograph image of fatty liver, with large vacuoles of triglyceride fat inside liver cells.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/light-micrograph-of-a-fatty-liver-royalty-free-image/851075118?phrase=fatty+liver&adppopup=true">Dr_Microbe/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<h2>Links between obesity and diabetes</h2>
<p><a href="https://doi.org/10.1016/S2213-8587(14)70032-4">Fatty liver is implicated</a> in <a href="https://www.nhlbi.nih.gov/health/metabolic-syndrome">metabolic syndrome</a>, a group of conditions that cluster together and increase the risk of cardiovascular disease and diabetes.</p>
<p>In a telephone interview, Dr. Barry Reiner, a pediatric endocrinologist, voiced his concerns to me about obesity and diabetes.</p>
<p>“When I started my practice, I had never heard of type 2 diabetes in children,” says Reiner. “Now, depending on which part of the U.S., between a quarter and a third of new cases of diabetes are type 2.”</p>
<p><a href="https://www.mayoclinic.org/diseases-conditions/type-1-diabetes/symptoms-causes/syc-20353011">Type 1 diabetes</a> is an autoimmune disease previously called juvenile-onset diabetes. Conversely, <a href="https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193">type 2 diabetes</a> was historically considered an adult disease. </p>
<p>However, type 2 diabetes is increasing in children, and obesity is the <a href="https://www.endocrine.org/news-and-advocacy/news-room/2017/childhood-obesity-quadruples-risk-of-developing-type-2-diabetes">major risk factor</a>. While both types of diabetes have genetic and lifestyle influences, type 2 is more modifiable through diet and exercise. </p>
<p>By 2060, the number of people under 20 with type 2 diabetes will <a href="https://doi.org/10.2337/dc22-0945">increase by 700%</a>. Black, Latino, Asian, Pacific Islander and Native American/Alaska Native children will have more type 2 diabetes diagnoses than white children. </p>
<p>“The seriousness of type 2 diabetes in children is underestimated,” says Reiner. He added that many people express a misconception that type 2 diabetes is a mild, slow-moving disease.</p>
<p>Reiner pointed to an important study showing that type 2 diabetes acquired in childhood <a href="https://www.adameetingnews.org/live-updates/session-coverage/today2-study-youth-onset-type-2-diabetes-more-severe-than-adult-onset-disease">can rapidly progress</a>. As early as 10 to 12 years after their childhood diagnosis, patients developed nerve damage, kidney problems and vision damage. By 15 years after diagnosis, at an average age of 27, almost <a href="https://doi.org/10.1056/NEJMoa2100165">70% of the patients had high blood pressure</a>.</p>
<p>Most patients had more than one complication. Although rare, a few patients experienced heart attacks and strokes. When people with childhood onset diabetes became pregnant, 24% delivered premature infants, over <a href="https://www.marchofdimes.org/peristats/reports/united-states/prematurity-profile#">double the rate in the general population</a>.</p>
<h2>Heart health</h2>
<p>Cardiovascular changes associated with obesity and severe obesity can also increase a child’s lifetime chance of heart attacks and strokes. Carrying extra weight at 6 to 7 years old can result in higher blood pressure, cholesterol and artery stiffness by <a href="https://doi.org/10.1542/peds.2019-3666">11 to 12 years of age</a>. Obesity <a href="https://doi.org/10.1093/eurheartj/ehv089">changes the structure of the heart</a>, making the muscle thicken and expand. </p>
<p>Although still uncommon, more people in their 20s, 30s and 40s <a href="https://doi.org/10.1161/STROKEAHA.119.024156">are having strokes</a> and <a href="https://www.acc.org/about-acc/press-releases/2019/03/07/08/45/heart-attacks-increasingly-common-in-young-adults">heart attacks</a> than a few decades ago. Although many factors may contribute to heart attack and stroke, obesity adds to that risk.</p>
<h2>Talk about being healthy, not focusing on weight</h2>
<p>Venus Kalami, a registered dietitian, spoke with me about the environmental and societal influences on childhood obesity.</p>
<p>“Food, diet, lifestyle and weight are often a proxy for something greater going on in someone’s life,” says Kalami.</p>
<p>Factors beyond a child’s control, including <a href="https://med.stanford.edu/news/all-news/2018/04/pediatric-obesity-depression-connected-in-the-brain.html">depression</a>, <a href="https://doi.org/10.1542/peds.2021-055571">access to healthy food</a> and <a href="https://doi.org/10.1210/endrev/bnac005">walkable neighborhoods</a>, contribute to obesity.</p>
<p>Parents may wonder how to help children without introducing shame or blame. First, conversations about weight and food should be age appropriate.</p>
<p>“A 6-year-old does not need to be thinking about their weight,” says Kalami. She adds that even preteens and teenagers should not be focusing on their weight, though they likely already are. </p>
<p>Even <a href="https://doi.org/10.1542/peds.2016-1649">“good-natured” teasing</a> is harmful. Avoid diet talk, and instead discuss health. Kalami recommends that adults explain how healthy habits can improve mood, focus or kids’ performance in a favorite activity.</p>
<p>“A 12-year-old isn’t always going to know what is healthy,” Kalami said. “Help them pick what’s available and make the best choice, which may not be the perfect choice.”</p>
<p>Any weight talk, either criticism or compliments for weight loss, may backfire, she adds. Praising a child for their weight loss can reinforce a negative cycle of disordered eating. Instead, cheer the child’s better health and good choices.</p>
<p>Dr. Muneeza Mirza, a pediatrician, recommends that parents model healthful behavior.</p>
<p>“Changes should be made for the whole family,” says Mirza. “It shouldn’t be considered a punishment for that kid.”</p><img src="https://counter.theconversation.com/content/202595/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christine Nguyen 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>The American Academy of Pediatrics has recently released new obesity management guidelines in order to help address the growing obesity crisis in children.Christine Nguyen, 2023 California Health Equity Fellow, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2005582023-03-20T12:57:03Z2023-03-20T12:57:03ZBeans are a favourite food in Nigeria - 4 safe ways to preserve them<figure><img src="https://images.theconversation.com/files/514224/original/file-20230308-28-ivbp2d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Pius Utomi Ekpei/AFP via Getty Images </span></span></figcaption></figure><p>The beans known as <em>oloyin</em> in Yoruba, or as cowpeas (<em>Vigna unguiculata</em>),
are a favourite food among Nigerians, who eat them in a variety of dishes including soups and stews or as a standalone side dish. </p>
<p>This is great news for Nigerians’ nutritional health. Beans are an excellent source of <a href="https://www.healthline.com/nutrition/beans-101">fibre and protein</a>, as well as <a href="https://www.healthline.com/nutrition/foods-with-minerals#:%7E:text=Beans,which%20can%20decrease%20nutrient%20absorption.">minerals</a> like copper, potassium and magnesium, which have <a href="https://www.naturemade.com/blogs/health-articles/can-you-take-magnesium-and-potassium-together#:%7E:text=Both%20magnesium%20and%20potassium%20are%20important%20minerals%20that%20support%20your,activity%20of%20the%20heart%20muscle.">health benefits for people</a>. That’s a lot of nutrition packed into a small food. What’s more, beans contain a lot of <a href="https://www.healthline.com/nutrition/foods-high-in-antioxidants#TOC_TITLE_HDR_11">antioxidants</a>, which help shield your body from cancer-causing free radicals. </p>
<p>But there are potential dangers lurking in your tins or bags of beans. They’re so tiny you might not easily spot them: bean beetles (<em>Callosobruchus maculatus</em>), also known as weevils. The adult’s body is about 2mm to 5.4mm long and they can be identified by the brownish and black markings on the elytra or wing covers. </p>
<p>Consuming the bugs can lead to digestive issues because the adult bean beetle <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174668/">harbours a gut bacterial community</a>. The bacteria get into the human gut and upset the balance of the human gut bacteria. Imbalances in gut bacteria have been linked to a number of human health problems including <a href="https://genomemedicine.biomedcentral.com/articles/10.1186/s13073-016-0303-2">metabolic and immune disorders</a>.</p>
<p>And even if you don’t swallow them, the weevils can spoil your meal – they cause beans to rot.</p>
<p>Unfortunately Nigeria has turned to dangerous chemicals to tackle the weevil problem. A pesticide called Phostoxin – a trade name for aluminium phosphide and ammonium carbonate – <a href="https://pubmed.ncbi.nlm.nih.gov/7761363/#:%7E:text=Phostoxin%20is%20a%20mixture%20of,abrupt%20digestive%20and%20nervous%20disorders.">is highly poisonous to humans</a>.</p>
<p>Nigeria used to export its dried beans. In 2013, the European Union <a href="https://www.researchgate.net/publication/330888314_Preserving_or_Poisoning_A_Case_of_Dried-Beans_from_Nigeria">placed a ban</a> on dried beans originating from the country. Moves by the Nigerian government and farmers since then to get the ban lifted have been futile and <a href="https://punchng.com/fg-wants-eu-ban-on-nigerian-beans-exports-lifted/">it remains in place</a>. This is due to the discovery of <a href="https://www.researchgate.net/publication/322113141_Controlled_atmosphere_storage_of_brown_cowpea_under_nitrogen">high residues of pesticide found in bags of dried beans</a>. The chemical is stored in tablets, which are then placed into the bags. Rinsing or boiling the beans doesn’t get rid of the highly toxic chemical. </p>
<p>As an agricultural entomologist who has <a href="https://www.researchgate.net/publication/271101492_Occurrence_Abundance_and_Control_of_the_Major_Insect_Pests_Associated_with_Amaranths_in_Ibadan_Nigeria">studied</a> the <a href="http://www.esxpublishers.com/images/IJRT-0514-0216.pdf">impact of pests on different crops</a>, I would like to suggest four safe techniques that Nigerians can use to protect their beans from beetles without using toxic materials. These methods can preserve beans for up to a year and you won’t waste money by losing beans to weevils. </p>
<h2>Freezing</h2>
<p><a href="https://www.mdpi.com/2304-8158/10/4/869">Freezing</a> is a well-established preservation method used to maintain the freshness of perishable food products. It is a great way to preserve beans against weevils. You can simply put the beans in a freezer bag in the freezer. Beans can also be frozen in ice cube trays. Freezing has the capacity to prevent clean beans from being infested as well as salvaging beans already infested with bean beetle. All the beetles and any eggs on the bean will be killed by freezing. </p>
<h2>Add pepper</h2>
<p>The ratio here is 10 beans to one dried pepper.</p>
<p>Put the beans with the pepper in an airtight container and keep it in a safe place. The bean beetles and their immature stages, including eggs, will be suffocated and die. This method is useful where there is an irregular supply of electricity – a situation most Nigerians know too well. Using pepper <a href="https://www.researchgate.net/publication/311736248_Effects_of_inclusion_of_local_pepper_powder_or_salt_to_cowpea_seeds_during_storage">retard</a> the growth of adult and larva weevils during storage period.</p>
<p>You could also use the same storage method with three spoonfuls of orange peel powder to 15kg of beans. </p>
<h2>Drying</h2>
<p><a href="https://www.scielo.br/j/rbeaa/a/zrxQKBy977pqLZDYmvVcgNr/?lang=en">Drying</a> reduces the moisture content of beans and makes them easier to store for future use. Simply put the beans in a <a href="https://agris.fao.org/agris-search/search.do?recordID=XS2021036669">heat accumulator dryer</a> and reduce the moisture content below 12%. For those who don’t have a heat accumulator dryer, solar drying will help too. Sun-dry the beans periodically in a thin layer for periods of up to four hours. Solar heaters or transparent bags of seeds left in the sun can provide excellent control of bean beetle infestations. This method can be used to <a href="https://infonet-biovision.org/PlantHealth/Pests/Cowpea-seed-beetle">control bean beetle infestations without affecting seed germination</a> when small lots are stored. Sun-drying can also give beans substantial protection.</p>
<h2>Preserve them in oil</h2>
<p>Beans can be preserved in oil and stored for future use. Heat the oil and add the beans. I must add that an organoleptic test is yet to be carried out to ascertain the taste of beans preserved in oil after cooking. Organoleptic testing <a href="https://www.sqa.org.uk/files/aq/H3GY04.pdf">involves</a> the assessment of flavour, odour, appearance and mouthfeel of a food product. While there has been no formal lab test of taste, it’s a method people use to preserve beans.</p>
<h2>Next steps</h2>
<p>No matter what storage method you use, it’s important to check your beans before cooking. You can do this by sniffing them or looking for anything that looks out of place or doesn’t look like a bean. Sometimes you can perceive the odour of the chemicals used in preserving the beans. Another method is to put a few beans in water; any chemicals will float to the surface as an oil film. You should discard such beans as rinsing does not help: they are contaminated.</p><img src="https://counter.theconversation.com/content/200558/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ismaila Aderolu 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>Nigerians are fond of beans but they need to preserve them without using toxic chemicals.Ismaila Aderolu, Lecturer , Federal University of Agriculture, AbeokutaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1713272021-11-10T14:43:18Z2021-11-10T14:43:18ZExtreme heat hurts human health. Its effects must be mitigated – urgently<figure><img src="https://images.theconversation.com/files/430752/original/file-20211108-19-1tn54mx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Higher temperatures cause drought, and can lead to food insecurity
</span> <span class="attribution"><span class="source">Guido Dingemans, De Eindredactie/GettyImages</span></span></figcaption></figure><p>The African continent is heating up more, and faster, than other regions in the world according to the recently released <a href="https://www.uneca.org/stories/state-of-climate-in-africa-report-2020">State of Climate in Africa Report</a>. By 2030, the report says up to 118 million extremely poor people will be subject to the devastating impacts of drought and intense heat.</p>
<p>Many of the temperatures presently being recorded in Africa, and those projected in the next decade, are <a href="https://doi.org/10.1038/s41558-018-0145-6">already close</a> to the limits of human survival, or “liveability”. </p>
<p>The general limit of heat we should live in is 35°C wet-bulb temperature, which is a measure of both air temperature and humidity. Beyond this, the body struggles to cool itself.</p>
<p>In northern Mali, for example, many communities <a href="https://www.cifor.org/knowledge/publication/3524/">have to make do</a> with a rainy season of just three months, from July to September. For the rest of the year, temperatures approach 50°C. The consequences have been catastrophic, impacting health and agriculture and livestock activities. Younger generations have no option but to leave as they cannot survive in these conditions.</p>
<p>Extreme heat is a serious health hazard. It can have very negative health effects on the human body. The body responds to <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01208-3/fulltext">heat stress by</a> redistributing blood flow to the skin and producing sweat, thus cooling the body. These blood flow changes increase the demand on the heart, making it work harder. Additional sweat production can also lead to dehydration, reducing blood volume which strains the heart further and also causes damage to organs such as the kidney.</p>
<p>Despite this, extreme heat has drawn less attention than other climate risks, such as flooding and drought. </p>
<p>The 26th UN Climate Change Conference of the Parties (COP26) provides an opportunity to focus in more detail on the health effects of extreme heat in African countries and elsewhere. Particular attention should be paid to how vulnerable groups like women, newborn children and poorer people can be helped to deal with or mitigate against these effects.</p>
<h2>How heatwaves affect people</h2>
<p>There are various ways in which rising temperatures will affect people. </p>
<p>Heatwaves – generally considered to be several days of excessively hot weather, which may be accompanied by high humidity – <a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30274-6/fulltext">worsen</a> the risk of death from heatstroke. This happens when the body is unable to control its temperature which then rises rapidly to 40°C or more causing internal organ damage. </p>
<p>It also means more people with certain ailments – such as kidney or respiratory diseases – are at a higher risk of dying.</p>
<p>As temperatures rise, there’ll be an <a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-51962100132-7/fulltext">increased spread</a> of infectious diseases, such as malaria and dengue fever. This is because more areas will become suitable for vectors, like mosquitoes that carry malaria.</p>
<p>Increased heat will also result in more drought which will result in crop failure and livestock deaths. This will lead to under- and malnutrition, especially in children, with higher rates of stunting or worse a result. Projections using temperature changes in sub-Saharan Africa <a href="https://pubmed.ncbi.nlm.nih.gov/33139856/">suggest</a> considerable increases in malnutrition. For instance, it’s expected that by 2100 there’ll be an increase in prevalence of wasting in western Africa by 37%, and 25% for central and eastern Africa. </p>
<p>More heat also means <a href="https://icpac.medium.com/wildfires-in-eastern-africa-will-climate-change-increase-the-intensity-of-wildfires-573ba35a5e10">more wildfires</a>. Wildfires affect humans in several ways including burns, pollutants from smoke and psychological trauma. Increased vulnerability to wildfires is <a href="https://icpac.medium.com/wildfires-in-eastern-africa-will-climate-change-increase-the-intensity-of-wildfires-573ba35a5e10">expected</a> in East Africa due to a combination of temperature change and unsustainable land management practices, such as clearing and setting fire to land to plant crops.</p>
<h2>Most at risk</h2>
<p>It is important to understand which groups are most at risk from the negative effects of extreme heat. </p>
<p><a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30274-6/fulltext">A review</a> of climate change and health literature earlier this year found a greater mortality risk from heatwaves for children, especially infants. Children are more at risk as they have smaller surface to body ratios than adults (increasing dehydration and heat stress risk) and they are still growing with underdeveloped systems, such as respiratory and immune systems.</p>
<p>Older people are more vulnerable to heat stress because their bodies are less able to adapt to changes in body temperature and they may have chronic medical conditions.</p>
<p>Extreme heat is also a high risk factor for pregnant women and their babies. A summary of evidence on the obstetric risks of heat reported many associated adverse effects <a href="https://www.bmj.com/content/371/bmj.m3811.long">including</a> maternal hypertension <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/ijgo.13958">and</a> placental abruption (the separation of the placenta from the uterus which can cause pregnancy complications), stillbirths, preterm birth, and low birth weight. Some of these complications could be because extreme heat causes dehydration and may lead to contractions and fainting. Exposure to extreme heat in a woman’s first trimester may also cause foetal heart and neural tube defects.</p>
<p>Finally, heat is expected to have worse outcomes for more vulnerable members of society. </p>
<p>A <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1908064">review</a> of the effects of climate change – in low- and middle-income countries found that residents of informal urban settlements are particularly at risk. That’s because of vulnerabilities like limited access to healthcare, poor sanitation and overcrowding. A <a href="https://www.sciencedirect.com/science/article/abs/pii/S0048969720348841?via%3Dihub">case study</a> of informal settlements in Dar es Salaam, Tanzania, reinforces the review’s findings: it shows that higher temperatures pose a significant risk to health – for instance because tin roofs exacerbate heat stress – even if the city doesn’t reach extreme temperatures.</p>
<p>As for those living in rural areas, such as pastoralists, aside from the stress extreme heat puts on their bodies, pastoralists will be vulnerable to drought and food insecurity. </p>
<h2>Moving forward</h2>
<p>These are not problems for the future. As the examples above and many others highlight, Africa is already feeling the reality of heat stress. All the projections suggest it will only get worse, yet nearly all heat-related adverse health outcomes and deaths are preventable. </p>
<p>But the continent has limited research capacity to examine these challenges and inform policy. Most of the research has focused on current impacts and that risks will continue to increase with additional climate change. Moving beyond this to identify solutions that are effective in the African context is an essential step.</p>
<p>There’s <a href="http://www.mdpi.com/2071-1050/13/9/5312">low scientific growth</a> in publications output and a large evidence gap both in understanding heat stress and relevant interventions to adapt to these changing environmental circumstances. </p>
<p>The research that needs to be done includes vulnerability assessments, urban heat island evaluation and studies that focus on heat adaptation measures that might prevent the worst effects of extreme heat.</p>
<p>In addition to more research, the continent needs immediate financial and technological assistance to adapt to the warming environment and to support research. </p>
<p>Heat risks are complex. They require strong research foundations and integrated planning, for example across health systems and urban planning. Early warning systems are also needed that actively involve communities to avoid or mitigate at least some adverse effects.</p>
<p>It is imperative that people from different disciplinary backgrounds work on climate and health issues together, coordinate, and develop new ideas together. One example is the new network – <a href="https://eur03.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.enbel-project.eu%2Fevents-page%2Fchance-a-new-network-for-climate-and-health-in-africa&data=04%7C01%7CAbdu.Mohiddin%40aku.edu%7Cacbe54b343f94fe4726c08d99916dbc1%7Ca5d4252a02f94e6096f09733baae4919%7C0%7C0%7C637709145716788230%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=VWDh8MSO5qIxtQ34DTNHgCSqnfZeGcnj7Lj%2F2IYkNpE%3D&reserved=0">CHANCE (Climate-Health Africa Network for Collaboration and Engagement)</a> – which is funded by the European Commission EU’s Horizon 2020 programme. It aims to facilitate interactions and create greater coherence between these, sometimes, siloed communities of practice. </p>
<p>It’s imperative that all of this happens fast. People are already living with the effects of a warming environment, with devastating effects. </p>
<p>_Caroline Gichuki, an emerging researcher in the field of climate change and health, helped in the writing of this article. _</p><img src="https://counter.theconversation.com/content/171327/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Jack receives funding from NERC, EU Commission, and the NIH</span></em></p><p class="fine-print"><em><span>Evans Kituyi consults for UNEP and GIZ.</span></em></p><p class="fine-print"><em><span>Kristie Ebi receives funding from the World Health Organization and the US National Institutes of Health.</span></em></p><p class="fine-print"><em><span>Matthew Chersich receives funding from the EU, NIH and Belmont Forum </span></em></p><p class="fine-print"><em><span>Stanley Luchters receives funding from the Belmont Forum, European Commission and the US NIH.</span></em></p><p class="fine-print"><em><span>Abdu Mohiddin 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>Many of the temperatures presently being recorded in Africa, and those projected in the next decade, are already close to the limits of human survival, or “liveability”.Abdu Mohiddin, Assistant Professor, Aga Khan University Christopher Jack, Researcher, University of Cape TownEvans Kituyi, Associate, Institute for Climate Change & Adaptation, University of NairobiKristie Ebi, Professor of Global Health and Environmental and Occupational Health Sciences, University of WashingtonMatthew Chersich, Professor, University of the WitwatersrandStanley Luchters, Professor, Aga Khan University HospitalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1671552021-09-23T10:00:51Z2021-09-23T10:00:51ZDiabetes targets would cost more but the impact would be worth it: here’s how<figure><img src="https://images.theconversation.com/files/421845/original/file-20210917-15-1alo6s0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Early detection of diabetes is important in setting treatment targets </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/nov-14-2019-a-doctor-makes-free-blood-sugar-test-on-world-news-photo/1182443866?adppopup=true">Xinhua/Mohamed Khidir via Getty Images</a></span></figcaption></figure><p>Setting global health targets, which is often done by multinational organisations, such as the United Nations or World Health Organisation (WHO), is commonly used to improve health outcomes. For example, the United Nations <a href="https://www.avert.org/global-hiv-targets">target</a> to improve access to treatment for HIV has resulted in many more people receiving the treatment that they need, which has <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2020/july/20200706_global-aids-report">saved</a> lives. </p>
<p>Now, the WHO <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00111-X/fulltext">Diabetes Compact</a> to support people living with diabetes is under development. The content of the Compact will not be finalised until 2022. However, to help inform whether targets should be part of the Compact, we asked what the health benefits from achieving various targets for people with diabetes would be, and whether these could be cost-effective over the next 10 years. </p>
<p>The WHO is considering whether targets should be set, and our <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00340-5/fulltext">analysis</a> feeds into that process as there was little previous evidence to inform what the targets should be. We were involved in some of the WHO processes for the Compact, and our results have been shared with WHO, but the analysis we did was independent. Similar to the UN targets for HIV/AIDS, the targets we considered were the percentages of people with diabetes and its associated cardiovascular disease risk factors (for example high blood pressure and choesterol) who were diagnosed, treated and controlled.</p>
<p>Our study was based on data from 23,678 people with diabetes living in 67 low- or middle-income countries. These countries were chosen as they had data available and they are home to <a href="http://www.healthdata.org/gbd/data">80% of the world’s people</a> with diabetes. </p>
<p>We found that setting targets for 80% of people with diabetes to have the condition (and other risk factors) diagnosed, treated, and controlled would substantially reduce death and improve healthy-years lived. And it would also be highly cost effective. </p>
<h2>Diabetes is often overlooked</h2>
<p>The most common form of diabetes, type 2 diabetes, is often associated with obesity and usually starts in later life. It is seldom noticed unless picked up by a medical professional. Over time it causes complications such as cardiovascular diseases (like heart attacks and strokes), kidney disease and blindness. These complications are far more likely to happen if a person with diabetes also has high blood pressure (hypertension), another condition that often goes unnoticed. </p>
<p>Treating diabetes and raised blood pressure markedly reduces the risk of future complications. Whether or not cholesterol is raised, giving a medication called a statin to lower it also <a href="https://journals.plos.org/plosmedicine/peerReview?id=10.1371/journal.pmed.1003485.r005">reduces</a> risk. These treatments to reduce risk in people with diabetes are also <a href="https://www.who.int/nmh/publications/essential_ncd_interventions_lr_settings.pdf">recommended</a> by the WHO. </p>
<p>However, our research has <a href="https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(21)00089-1/fulltext">previously shown</a> that fewer than 6% of people with diabetes get all the treatment they need to reduce risk of future complications.</p>
<h2>Three targets</h2>
<p>We therefore asked two questions. How would achieving certain targets reduce future complications from diabetes? And, in looking at costs relative to the health benefits, could achieving these targets be cost effective?</p>
<p>Reducing complications from diabetes requires interventions to reduce elevated blood sugar, blood pressure and cholesterol. We asked what benefits would be seen, and at what cost, for all three of these interventions combined.</p>
<p>We studied combinations of three targets. The first is that patients with diabetes are actually diagnosed, and their high blood pressure, if present, is also diagnosed. Second, that they are on treatment for blood sugar, blood pressure and cholesterol using a statin medication. And third, that their blood sugar and blood pressure are controlled to below internationally recommended levels. We tested these at targets of 60%, 70%, or 80% for each of diagnosis, treatment, or control. In other words, what would happen if 80% of people with diabetes and high blood pressure were diagnosed, 80% of those patients were treated and 80% of them were controlled.</p>
<p>We compared this to a baseline scenario in which diagnosis, treatment and control continued at current levels. </p>
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Read more:
<a href="https://theconversation.com/how-changing-blood-pressure-targets-in-south-africa-could-save-costs-and-lives-153674">How changing blood pressure targets in South Africa could save costs and lives</a>
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<p>We found that achieving each of these targets dramatically reduced deaths and improved the number of years people could live in good health. The number of years that people can live in good health is captured by a measure called <a href="https://www.who.int/data/gho/indicator-metadata-registry/imr-details/158">Disability Adjusted Life Years or DALYs</a>. One DALY is equivalent to the loss of a year in full health, hence it captures both early death and being unwell due to a disease.</p>
<p>We found that the greatest impact of achieving the targets would be from reducing the risk of cardiovascular diseases. Other risks like blindness and kidney diseases would be less affected by achieving the targets. </p>
<p>In addition, most of the benefits came from improving treatment of high blood pressure and giving a statin for cholesterol, rather than from treating or controlling high blood sugar.</p>
<p>Overall, at the highest target of 80% diagnosis, 80% treatment, and 80% control, we found that healthy-years-lived were improved by around 6%. This means that around 6% more people with diabetes would be expected to live healthier lives. Even achieving the lower targets of 60% resulted in substantial improvements. </p>
<p>We also showed that achieving the 80% targets would greatly reduce deaths, especially those from cardiovascular diseases.</p>
<p>There was substantial variation in benefits by world regions. For example, reduction in deaths due to cardiovascular diseases was greatest in east sub-Saharan Africa. In this region, deaths would fall from around 46 per 1,000 people in the baseline scenario to 27 per 1,000 with a target of 80% for diagnosis, treatment, and control. In central Latin America deaths fell from around 18 per 1,000 people at baseline to 14 per 1,000 with this target.</p>
<h2>Achieving targets is cost effective</h2>
<p>In our <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00340-5/fulltext">study</a>, we considered the costs of diagnosing and treating diabetes and hypertension, and giving a statin, and the costs of treating the complications of diabetes, for the baseline scenario (current diagnosis, treatment, and control levels continued for the next 10 years) and each of the targets. </p>
<p>In the baseline scenario, the costs of managing diabetes in the countries in the study would be $2,222,882 per 1,000 people with diabetes over the next 10 years. </p>
<p>If diagnosis, treatment, and control were scaled up to achieve 80% targets for each, the costs would increase by a small amount, to $2,832,000 per 1,000 people with diabetes. Most of the increased costs would come from achieving the target for increasing treatment of hypertension. But the costs of treating cardiovascular disease complications would fall. </p>
<p>Overall this gave an incremental cost-effectiveness ratio (effectively the costs per extra healthy-life-year lived, or DALY averted) of $1,362. These costs are well below the WHO <a href="https://www.valueinhealthjournal.com/article/S1098-3015(15)00574-4/fulltext#relatedArticles">thresholds</a> for cost effectiveness of three times GDP per capita for each country. So, each extra year of healthy life would cost $1,362, but the WHO has a benchmark of three times GDP per capita as a worthwhile investment in a year of healthy life. For example, GDP per capita in Angola is $2,790, therefore an intervention would be considered cost effective (by WHO) if it cost less than $8,370 per DALY.</p>
<p>We have shown that targets for diabetes would improve healthy lives and reduce deaths, and that they would be cost effective. But these targets should not be for managing the blood sugar element of diabetes alone; they must include treating hypertension and giving statins to patients with diabetes. </p>
<p><em>This study was done by multiple co-investigators, and this article is written on behalf of the co-investigator team.</em></p><img src="https://counter.theconversation.com/content/167155/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justine Ina Davies receives funding from the UK National Institute for Health Research, the UK Medical Research Council, and the US National Institute of Health. </span></em></p><p class="fine-print"><em><span>David Flood receives funding from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). He also serves as an unpaid Staff Physician for Maya Health Alliance and GlucoSalud, which are two non-governmental health organizations in Guatemala; in his role with these organizations, he occasionally carries out diabetes advocacy and solitics funding for clinical diabetes programs.</span></em></p><p class="fine-print"><em><span>Sanjay Basu receives funding from the US Centers for Disease Control and Prevention, the Clinton Global Health Access Initiative, and the US National Institutes of Health.</span></em></p><p class="fine-print"><em><span>Jennifer Manne-Goehler 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>Targets for diabetes would improve healthy lives, reduce deaths, and be cost effective. But they should not be for managing diabetes alone; they must include treating hypertension.Justine Ina Davies, Professor of Global Health, Institute for Applied Research, University of BirminghamDavid Flood, Research Fellow, University of MichiganJennifer Manne-Goehler, Research Fellow in Medicine, Harvard UniversitySanjay Basu, Director of Research, Center for Primary Care, Harvard UniversityLicensed 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>
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<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>
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<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">
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<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/1370972020-05-04T11:04:21Z2020-05-04T11:04:21ZCoronavirus: what risks do people with kidney disease face?<figure><img src="https://images.theconversation.com/files/331963/original/file-20200501-42946-cuvuhk.jpg?ixlib=rb-1.1.0&rect=27%2C0%2C5979%2C4007&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Patients with kidney disease may develop more severe symptoms.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/waist-portrait-female-medical-worker-protective-1197022831">Olena Yakobchuk/ Shutterstock</a></span></figcaption></figure><p>The coronavirus pandemic is causing major healthcare issues for patients with kidney diseases throughout the world. Not only are these patients more likely to have severe complications if infected with COVID-19, anxiety because of the pandemic is also causing many patients not to seek medical care or advice for fear of contracting the virus.</p>
<p>Patients with chronic kidney disease are recognised by the NHS as being at a <a href="https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk-from-coronavirus/whos-at-higher-risk-from-coronavirus/">high risk from coronavirus</a>. Recent data also shows that patients needing dialysis <a href="https://renal.org/covid-19/data/">have higher mortality from COVID-19</a> than patients who don’t have kidney disease.</p>
<p>There are a number of potential reasons why patients with kidney disease are more likely to suffer severe complications if they contract COVID-19. </p>
<p>First, they’re more likely to have a <a href="https://www.niddk.nih.gov/health-information/kidney-disease/heart-disease">cardiovascular disease</a> caused by their kidney disease, including high blood pressure and susceptibility to heart attacks and strokes. Cardiovascular disease is known to <a href="https://www.world-heart-federation.org/covid-19-and-cvd/">increase your risk of death</a> if you contract COVID-19. This is likely due to the increased stress the patient’s damaged cardiovascular system is subjected to, and unable to cope with, when the lungs are no longer able to provide enough oxygen to the body. </p>
<p>Patients with advanced kidney disease are also <a href="https://cjasn.asnjournals.org/content/clinjasn/12/12/2032.full.pdf">more likely to be diabetic</a>. Diabetes can cause severe cardiovascular issues and has also been found to put patients at <a href="https://digital.nhs.uk/coronavirus/shielded-patient-list">risk of developing complications</a> from COVID-19.</p>
<p>Second, patients with kidney disease are commonly immunosuppressed – meaning they are less able to fight infections. This can be due to their underlying kidney disease or because they need to take medicines to treat their on-going kidney disease by suppressing their immune system. These drugs are crucial after a kidney transplant to ensure the <a href="https://www.nice.org.uk/guidance/ta481/resources/immunosuppressive-therapy-for-kidney-transplant-in-adults-pdf-82605021450181">body’s immune system</a> doesn’t reject the new kidney.</p>
<p>A suppressed immune system may make the body less able to clear the virus when infected. However, there’s also some evidence that an <a href="https://theconversation.com/coronavirus-cytokine-storm-this-over-active-immune-response-could-be-behind-some-fatal-cases-of-covid-19-136878">“over-active” immune system</a> after the first few days of infection causes more severe COVID-19 complications. Lessening the immune system’s response using immunosuppressive drugs may be beneficial – which is why <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144665/pdf/main.pdf">multiple clinical trials</a> are currently investigating this.</p>
<p>Finally, there’s a higher proportion of men and people from black, Asian and minority ethnic (BAME) groups with <a href="https://kidneyresearchuk.org/wp-content/uploads/2019/09/Health_Inequalities_lay_report_FINAL_WEB_20190311.pdf">severe kidney issues</a>, requiring kidney dialysis or a transplant. These factors have been shown to <a href="https://globalhealth5050.org/covid19/">predict a worse outcome</a> with COVID-19 infection.</p>
<p>Current data from <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30198-5/fulltext">China</a>, <a href="https://www.statista.com/statistics/1105061/coronavirus-deaths-by-region-in-italy/">Italy</a> and <a href="https://www.statista.com/statistics/1105061/coronavirus-deaths-by-region-in-italy/">Spain</a> shows children are much less likely to die of a COVID-19 infection compared to adults. This may possibly be due to the younger, evolving immune system being better at dealing with and clearing new viral infections.</p>
<p>However, children with kidney diseases may still be at <a href="https://pkdcharity.org.uk/news-events/blogs/404-coronavirus-covid-19-and-children-with-arpkd">higher risk of getting severely ill</a> from coronavirus. But their risk may be lower compared to adults, as many children with kidney disease don’t have a coexisting cardiovascular disease or other risk factors. Currently, in the UK, there are no reports of children with kidney disease experiencing severe complications from COVID-19.</p>
<h2>Healthcare changes</h2>
<p>Given that many adults with kidney disease face increased risk of contracting severe COVID-19 infections, it’s important that patients try to protect themselves from the virus as much as possible. Children with advanced kidney disease or who are heavily immunosuppressed are advised to take similar precautions.</p>
<p>It’s especially important to find ways to protect patients with kidney failure who need to regularly attend hospital for haemodialysis (or blood cleaning) treatment, often three to four times per week. Careful planning is needed to minimise unsafe human contact during dialysis delivery.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/331966/original/file-20200501-42962-1fmr6m0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/331966/original/file-20200501-42962-1fmr6m0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/331966/original/file-20200501-42962-1fmr6m0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/331966/original/file-20200501-42962-1fmr6m0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/331966/original/file-20200501-42962-1fmr6m0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/331966/original/file-20200501-42962-1fmr6m0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/331966/original/file-20200501-42962-1fmr6m0.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">
<figcaption>
<span class="caption">Changes to dialysis delivery will be important to minimise risk.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-monitored-by-electronic-sphygmomanometer-during-22262149">Picsfive/ Shutterstock</a></span>
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<p>The current pandemic has caused widespread anxiety and changes to the ways in which healthcare is being delivered. There’s been a dramatic decrease in <a href="https://www.thelancet.com/pdfs/journals/lanchi/PIIS2352-4642(20)30108-5.pdf">patients attending hospital</a> or seeking medical advice if unwell due to a fear of contracting COVID-19. This could have a detrimental cost to those with kidney disease. Many <a href="https://www.hsj.co.uk/commissioning/exclusive-nhs-trusts-suspend-life-saving-organ-transplants/7027301.article">kidney transplant programmes</a> have even been suspended, limiting treatment options for people with severely impaired kidney function (particularly those on dialysis). </p>
<p>Patients with kidney disease may also be worried about taking their regular medications, in case they may put them at greater risk of contracting COVID-19. An example of this are angiotensin converting enzyme (ACE) inhibitors, a drug that treats hypertension and reduces levels of protein in urine. These are both key to maintaining good cardiovascular and kidney health. ACE inhibitors block the stimulation of a receptor that is found on cells called the ACE2 receptor. The coronavirus, which causes COVID-19, gains entry to cells by <a href="https://doi.org/10.1016/j.cell.2020.02.052">going through this receptor</a>.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-we-know-about-ace-inhibitors-high-blood-pressure-and-covid-19-133970">What we know about ACE inhibitors, high blood pressure and COVID-19</a>
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<p>Currently, there’s no evidence that <a href="https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang">taking ACE inhibitors</a> is beneficial or detrimental to coronavirus. Patients should know that stopping these medicines could have detrimental consequences for kidney and cardiovascular disease health. </p>
<p><a href="https://renal.org/covid-19/data/">Current evidence</a> suggests that adult patients with significant kidney disease are highly susceptible to the effects of COVID-19. People with kidney conditions should take more stringent precautions to protect themselves from the virus and prevent infection, such as staying at home, properly washing hands and avoiding direct human contact as much as is possible.</p><img src="https://counter.theconversation.com/content/137097/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Coward currently receives research funding from the Medical Research Council (MRC), Wellcome Trust, Kidney Research UK, and and the European Union. He has previously been awarded Research Funding from the charities Diabetes UK, British Heart Foundation and Wellchild. In the past he has also received science research funding from the companies Takeda and Novo Nordisk. </span></em></p>Patients with kidney disease may also have heart problems or diabetes – both of which have been linked with more severe COVID-19 infections.Richard Coward, Clinical professor, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1270202019-12-19T19:06:42Z2019-12-19T19:06:42ZHow a rethink of emergency care is closing the gap, one person at a time<figure><img src="https://images.theconversation.com/files/307569/original/file-20191218-11919-1epy5bl.JPG?ixlib=rb-1.1.0&rect=2%2C10%2C987%2C722&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Walpiri Transient Camp, Katherine: Western medicine can't be expected to work for disadvantaged Indigenous Australians unless housing and social disadvantage are also addressed.</span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p><em>This is one of our occasional <a href="https://theconversation.com/au/topics/essays-on-health-32828">Essays on Health</a>, about one community’s attempt at closing the gap between Indigenous and non-Indigenous health in the Northern Territory. It’s a long read.</em></p>
<p>You can see <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/BriefingBook44p/ClosingGap">the gap</a> driving through the main street of Katherine in the Northern Territory.</p>
<p>The broken shop windows, the dust, the wheelchairs and crutches and bandaged bodies sing out poor health and inequity.</p>
<p>Overcrowding and homelessness are pervasive, and there is very little reprieve from the oppressive heat.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1204986670711558144"}"></div></p>
<p>Like many towns of its size, Katherine has its own hospital. Here, social and environmental determinants drive hospital attendance. </p>
<p>For instance, the town has <a href="https://www.katherinetimes.com.au/story/6419712/in-the-top-league-of-homelessness-rates-katherine-needs-a-plan/">some of the highest rates of homelessness</a> in Australia, in a jurisdiction with the <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4517.0%7E2018%7EMain%20Features%7ENorthern%20Territory%7E27">highest incarceration rates</a>, <a href="https://digitallibrary.health.nt.gov.au/prodjspui/bitstream/10137/572/1/Mortality_in_the_NT_1967_2006_web.pdf">lowest life expectancy</a> and the <a href="https://nap.edu.au/docs/default-source/resources/2018-naplan-national-report.pdf?sfvrsn=2">poorest educational outcomes</a>. The gap in Katherine is a chasm.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/three-reasons-why-the-gaps-between-indigenous-and-non-indigenous-australians-arent-closing-91561">Three reasons why the gaps between Indigenous and non-Indigenous Australians aren't closing</a>
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<h2>Who’s who in the emergency department?</h2>
<p>The hospital is a busy place, made even more so by the <a href="https://www.mja.com.au/journal/2008/189/10/frequent-attenders-emergency-departments-linked-data-population-study-adult">emergency department frequent attenders</a> who come and go through a constantly revolving door of admission and discharge. </p>
<p>Frequent attenders fall into two broad categories.</p>
<p>Roughly one-third are very sick, wracked by illness or chronic conditions, almost all underpinned by great social challenges. Despite stereotypes, this is a group that rarely drinks alcohol. </p>
<p>By contrast, grog is a driving force for the other two-thirds, often as a direct result of alcohol and its complications. Once again, illness and social exclusion are pervasive.</p>
<p>Most frequent attenders <a href="https://www.mja.com.au/journal/2016/204/3/factors-contributing-frequent-attendance-emergency-department-remote-northern#tbox1">are Indigenous</a>. They come from <a href="https://www.mdpi.com/1660-4601/16/22/4306/htm">around 30 different tribal nations</a>, each with unique language. Most are just three or four generations away from the first wave of colonisation.</p>
<p>Just over two-thirds are homeless, a situation shaped by subtle and ongoing forces of colonisation and subsequent displacement.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/making-space-how-designing-hospitals-for-indigenous-people-might-benefit-everyone-122550">Making space: how designing hospitals for Indigenous people might benefit everyone</a>
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<p>Only one-fifth of frequent attenders have access to a car in a town with no public transport (other than school buses). This affects people’s health in the tropics where it’s a long, hot walk from where most Indigenous people live to the pharmacy. </p>
<p>It is really no wonder more than half of frequent attenders have not taken their medicines, contributing to their presentation to the emergency department.</p>
<p>For frequent presenters to Katherine Hospital, poverty and illness go hand in hand. When you are living in an over-crowded house, and the <a href="https://www.jacanaenergy.com.au/residential/metering/prepaid_meters">A$20 power card</a> feeding the air conditioner expires on a 43°C tropical day, when your heart, lungs and kidneys are chronically malfunctioning and the insulin in the fridge slowly warms, the only free number you can call for help is “000” for an ambulance trip to hospital.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1206693515377467392"}"></div></p>
<p>These are some of the real-world challenges of closing the gap in Indigenous health. But these challenges can be overcome. </p>
<h2>Here’s what worked</h2>
<p>We have <a href="https://www.mdpi.com/1660-4601/16/22/4306/htm">recently published evidence</a> of how a locally driven program can make a difference.</p>
<p>When some of the town’s most vulnerable people attend the emergency department, the program connects them to primary care and other supports. It also tackles underlying drivers of hospitalisation such as homelessness or inadequate housing.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=797&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=797&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=797&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1001&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1001&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1001&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">At the emergency department, people are supported to move away from inadequate housing, as well as being treated for their physical or mental illness.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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</figure>
<p>The referral point taps into a critical moment when people choose to turn up to hospital, asking for help.</p>
<p>This is an opportunity to do things differently. As such, the program re-defines “help” beyond the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750953/">biomedical paradigm</a>, to both improve health and use limited resources more efficiently. </p>
<p>This contrasts with past approaches grounded in <a href="https://www.abc.net.au/news/2017-04-21/nt-mandatory-alcohol-rehab-has-little-health-impact-report-finds/8459998">discipline and law</a> that have failed to meaningfully help people who suffer the combined disharmony of sickness, homelessness and alcohol. </p>
<p>Among the 109 people supported in the first ten months of the program, there was a 23% reduction in emergency department presentations.</p>
<h2>More GP visits</h2>
<p>A <a href="https://grattan.edu.au/wp-content/uploads/2018/07/906-Mapping-primary-care.pdf">Grattan Institute report</a> found the most disadvantaged people living in the remotest areas are the least likely to see or have access to a GP.</p>
<p>In Katherine, many of the people presenting frequently to the emergency department with chronic diseases would benefit from being managed by their GP or other primary care provider.</p>
<p>As a result of the program, there was a 90% increase in GP attendance.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-the-housing-shortage-exacerbates-scabies-in-indigenous-communities-71337">Why the housing shortage exacerbates scabies in Indigenous communities</a>
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</em>
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<h2>Community support is vital</h2>
<p>The program has been developed gradually over the past five years, first with an understanding of <a href="https://www.mja.com.au/journal/2016/204/3/factors-contributing-frequent-attendance-emergency-department-remote-northern">who the hospital’s frequent attenders are</a>, and then getting the community on board. </p>
<p>Central to the program’s success is this community support. The four main partners include the hospital, the <a href="https://www.wurli.org.au/">Wurli-wurlinjang</a> local Aboriginal health service, the <a href="http://kalano.org.au/">local Aboriginal housing organisation</a> and <a href="http://www.krahrs.org.au/">Katherine Regional Aboriginal Health and Related Services</a>. </p>
<p>Other partners including the <a href="https://www.shelterme.org.au/katherine-doorways-hub">first ever homeless hub in Katherine</a> (a drop-in centre and community space for homeless people), as well as St John Ambulance, Mission Australia, Red Cross and the territory housing department.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/refugees-in-their-own-land-how-indigenous-people-are-still-homeless-in-modern-australia-55183">Refugees in their own land: how Indigenous people are still homeless in modern Australia</a>
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<h2>The harsh reality of the town camp</h2>
<p>Just off Katherine’s main drag is a patch of thick scrub that shields visitors from seeing the harsh realities of <a href="https://theconversation.com/refugees-in-their-own-land-how-indigenous-people-are-still-homeless-in-modern-australia-55183">Warlpiri Transient Camp</a>. This is where many people who frequently present to the emergency department live.</p>
<p>This <a href="https://dlghcd.nt.gov.au/town-camps/about-town-camps">“temporary” camp</a>, set up over 40 years ago, houses some of the sickest people in what is one of the sickest towns in Australia. </p>
<p>Up to 20 people live in small dwellings bursting at the seams. These structures often provide meagre refuge to people on dialysis, with failing hearts from rheumatic heart disease, and to the elderly and frail.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=640&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=640&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=640&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=804&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=804&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=804&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Up to 20 people live in small dwellings bursting at the seams, some without electricity never mind air-conditioning.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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</figure>
<p>Only a handful of these dwellings are air conditioned; some don’t even have electricity. Often it is sickness that drives people from ancestral lands into bigger towns like Katherine to access health services like kidney dialysis.</p>
<p>But <a href="https://www.katherinetimes.com.au/story/6434194/dialysis-patients-forced-onto-housing-waiting-list/">housing is less available than dialysis</a>. And the camp is not a destination of choice.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/want-to-improve-the-nations-health-start-by-reducing-inequalities-and-improving-living-conditions-64434">Want to improve the nation's health? Start by reducing inequalities and improving living conditions</a>
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<p><a href="https://www.mdpi.com/1660-4601/16/22/4306/htm">Our analysis of the program</a> demonstrates some striking features of people who live in the camp and who frequently attend the emergency department.</p>
<p>First, they are very sick. Almost 10% had died before the end of the first year of the program. Participants had an average of 2.8 significant health problems, many fold higher than the <a href="https://www.aihw.gov.au/getmedia/666de2ad-1c92-4db3-9c01-1368ba3c8c98/ah16-3-3-chronic-disease-comorbidities.pdf.aspx">Australian average</a>.</p>
<p>Three out of five didn’t have reliable access to enough affordable, nutritious food. Almost one-third had chronic kidney disease, and 10% were on dialysis. Of the 11 people needing dialysis three times a week, eight met the <a href="https://www.abs.gov.au/websitedbs/censushome.nsf/home/factsheetsh">Australian Bureau of Statistics’ definition of homelessness</a>; three were living in a tent.</p>
<p>Needless to say, nowhere else in Australia is it imaginable that someone sick enough to require dialysis has to live in a tent in temperatures <a href="https://www.katherinetimes.com.au/story/6548992/tuesday-was-australias-hottest-day-ever/?cs=9397">regularly above 40°C</a>.</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>A safe home, a working fridge and a good education</h2>
<p>Modern western medicine is the icing on the cake of a healthy and meaningful life. For people who do not have even the most fundamental building blocks of a normal urban existence, like the vast majority of people in this trial, applying western medicine is like icing a cake that has not yet been baked.</p>
<p>A safe home, a fridge that remains powered and relatively stocked, access to transport, and a good education, are ingredients that need to be slowly and systematically put together over a lifetime for western medicine to be an appropriate first step in resolving an individual health problem. </p>
<p>Applying a biomedical model of emergency care is nothing more than a very expensive band aid. But emergency departments can be structured in innovative ways to make a much bigger difference.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/to-close-the-health-gap-we-need-programs-that-work-here-are-three-of-them-91482">To close the health gap, we need programs that work. Here are three of them</a>
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<img src="https://counter.theconversation.com/content/127020/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Quilty set up and designed the project mentioned in the article.</span></em></p><p class="fine-print"><em><span>Lisa Wood evaluated the program mentioned in the article.</span></em></p>A safe home, a working fridge and access to transport are all needed before western medicine has a chance of working in the long term. But a new way of providing care can help.Simon Quilty, Senior Staff Specialist, Alice Springs Hospital. Honorary, Australian National UniversityLisa Wood, Associate Professor, School of Population and Global Health, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1214412019-09-13T03:27:35Z2019-09-13T03:27:35ZPolycystic kidney disease, the most common genetic kidney disorder you’ve probably never heard of<figure><img src="https://images.theconversation.com/files/290811/original/file-20190904-175700-vq8d1k.jpg?ixlib=rb-1.1.0&rect=53%2C0%2C6000%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If one parent has ADPKD, their child has a one in two chance of getting it.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Autosomal-dominant polycystic kidney disease (<a href="https://pkdaustralia.org/adpkd/">ADPKD</a>) is the most common genetic kidney disorder, and the <a href="https://www.anzdata.org.au/report/anzdata-41st-annual-report-2018-anzdata/">fourth most common</a> cause of kidney failure in Australian adults. It affects about <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/imj.13143">one in 1,000 Australians</a>. </p>
<p>In people with ADPKD, a mutation in one or two genes leads to the development and progressive growth of cysts in the kidneys, causing a decline in kidney function.</p>
<p>Labor senator Malarndirri McCarthy, a Yanyuwa woman, recently spoke publicly about having ADPKD after <a href="https://www.smh.com.au/politics/federal/senator-reveals-kidney-disease-that-saw-her-leave-question-time-for-hospital-20190802-p52d8w.html">she became unwell</a> with a kidney infection and had to leave the Senate. </p>
<p>But a newly available treatment for ADPKD shows promise for people with the disease.</p>
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<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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</em>
</p>
<hr>
<h2>What is ADPKD?</h2>
<p>If one parent has ADPKD, the children have a 50% chance of inheriting the gene (though <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/imj.13143">up to 10%</a> of patients don’t have a family history).</p>
<p>Where it is inherited, the age of diagnosis and rate of progression to kidney failure in the parent gives some indication of how the disease will develop in affected children. </p>
<p>The cysts are like balloons filled with water, which start small in childhood and increase in size over time.</p>
<p>Typically, the cysts don’t start to cause problems until later in life. The average age at diagnosis is <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1402685">27 years</a>. </p>
<p>As the cysts grow, normal working tissue in the kidney is replaced with enlarging cysts. So with time, the kidneys don’t work as well.</p>
<p>For about <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/imj.13143">half of people with ADPKD</a>, their condition will eventually progress to kidney failure, which may be treated with dialysis or a transplant. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/288676/original/file-20190820-170918-1foruju.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288676/original/file-20190820-170918-1foruju.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=442&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288676/original/file-20190820-170918-1foruju.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=442&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288676/original/file-20190820-170918-1foruju.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=442&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288676/original/file-20190820-170918-1foruju.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=556&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288676/original/file-20190820-170918-1foruju.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=556&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288676/original/file-20190820-170918-1foruju.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=556&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cysts grow on the kidneys of a person with polycystic kidney disease, often impacting kidney function.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>While the loss of kidney function is paramount, the cysts may cause other symptoms and complications too. </p>
<p>Symptoms can include high blood pressure and chronic pain or heaviness in the back, sides and abdomen. The growth of cysts means the kidneys can grow to as large as <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1464-410X.2007.07229.x">5-6kg in size</a>.</p>
<p>Blood in the urine, urinary tract infections, kidney stones and infections in the cysts are not uncommon in people with ADKPD, and can all impact quality of life. </p>
<p>Other organs may also be affected. People with ADPKD can develop cysts in the liver, pancreas and bowel, and about 10% will experience balloon dilations of the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26260542">blood vessels in the brain</a>, called aneurysms.</p>
<h2>Treatment</h2>
<p>Until recently, treatment of ADPKD was directed towards early detection, control of blood pressure, lifestyle measures such as quitting smoking, weight control and diet, antibiotics for infections, analgesics for pain and the management of progressive kidney dysfunction via dialysis and transplantation. None of these therapies however directly slowed the growth of cysts. </p>
<p>But on January 1, 2019, tolvaptan <a href="https://pkdaustralia.org/news/">was listed</a> on the Pharmaceutical Benefits Scheme. Australia now joins the United States, the European Union, and several other countries where this drug was already available. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/kidney-disease-in-aboriginal-australians-perpetuates-poverty-15031">Kidney disease in Aboriginal Australians perpetuates poverty</a>
</strong>
</em>
</p>
<hr>
<p>Tolvaptan, which is taken in tablet form, slows the growth of cysts by <a href="https://www.ncbi.nlm.nih.gov/pubmed/28379536">blocking a hormone called vasopressin</a>. Vasopressin is critical in triggering the formation of cysts. In this way, tolvaptan prolongs the time to kidney failure.</p>
<p>In one study, three years of treatment with tolvaptan <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1205511">reduced the rate of cyst growth</a> by around 50% in comparison to a placebo treatment. The authors suggested tolvaptan may delay dialysis or the need for a transplant for six to nine years for patients with ADPKD, particularly if started early. </p>
<p>People who took tolvaptan in this study also had lower incidence of ADPKD-related complications including urinary tract infections and kidney pain.</p>
<h2>Kidney disease and Indigenous Australians</h2>
<p>ADPKD is not actually more common in Aboriginal and Torres Strait Islander communities, as other causes of <a href="https://www.menzies.edu.au/page/Research/Indigenous_Health/Diabetes_and_kidney_disease/Kidney/">chronic kidney disease</a> are. This may be because ADPKD is inherited. </p>
<p>The majority of chronic kidney disease develops as a complication of diabetes, which affects Aboriginal and Torres Strait Islander populations more commonly and typically <a href="https://www.menzies.edu.au/page/Research/Indigenous_Health/Diabetes_and_kidney_disease/Diabetes/">at a younger age</a> than the overall Australian population.</p>
<p>Kidney disease, whatever the cause, remains a significant issue for Aboriginal and Torres Strait Islander communities. People in remote Indigenous communities in particular face challenges around accessing treatments in large urban centres, and have poorer access to organ transplants.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-simple-school-sores-often-lead-to-heart-and-kidney-disease-in-indigenous-children-86066">Why simple school sores often lead to heart and kidney disease in Indigenous children</a>
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</em>
</p>
<hr>
<p>There are several nationally targeted activities and proposals aimed at reducing the burden of chronic kidney disease in Indigenous Australians.</p>
<p>The <a href="https://www.menzies.edu.au/icms_docs/281923_Roundtable_Towards_Roadmap_For_Renal_Health_-_Media_Release.pdf">Renal Health RoadMap</a> is designed to support health systems in early detection and management of diabetes and chronic kidney disease. It also seeks to address the social determinants of poor health in Indigenous communities, including housing quality and availability, and health infrastructure.</p>
<p>In 2018, Minister for Indigenous Australians Ken Wyatt commissioned <a href="https://www.tsanz.com.au/TSANZ%20Performance%20Report%20-%20Improving%20Indigenous%20Transplant%20Outcomes%20(Final%20edited)-1.pdf">a report</a> detailing how access to and outcomes of kidney transplants could be improved among Indigenous Australians. He also established a <a href="https://www.anzdata.org.au/anzdata/for-information-2/tsanz/">National Indigenous Kidney Transplantation Taskforce</a> to implement the recommendations from this report. </p>
<p>Some key recommendations include improving the communication between health-care teams, patients and their families, addressing cultural bias in the delivery of health care, and improving the quality of data around transplant access and outcomes.</p>
<p>Addressing transplant and treatment inequities will benefit Indigenous Australians with kidney failure sustained from ADPKD and chronic kidney disease more broadly. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/to-close-the-health-gap-we-need-programs-that-work-here-are-three-of-them-91482">To close the health gap, we need programs that work. Here are three of them</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/121441/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jaquelyne Hughes receives funding from the National Health and Medical Research Council, is the convener of the Aboriginal and Torres Strait Islander Health Working Group of the Australia and New Zealand Dialysis and Transplantation Registry (ANZDATA), and the Deputy Chair of the TSANZ National Indigenous Kidney Transplantation Taskforce.</span></em></p><p class="fine-print"><em><span>Karen Dwyer 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>You might have heard of polycystic ovary syndrome, but what about polycystic kidney disease? This genetic disorder sees cysts growing in the kidneys.Karen Dwyer, Deputy Head, School of Medicine, Deakin UniversityJaquelyne Hughes, Senior Research Fellow, Menzies School of Health ResearchLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1164112019-07-12T19:44:45Z2019-07-12T19:44:45ZTrump’s order for more action on kidney disease may shrink organ transplant waitlists<p>Every year, thousands of Americans with kidney failure who could benefit from life-saving transplants <a href="https://doi.org/10.1111/ajt.15274">can’t get the organs they need</a>. </p>
<p>A record number of people are dying while waiting for an organ to become available that might have saved their lives. An <a href="https://www.hhs.gov/about/news/2019/07/10/hhs-launches-president-trump-advancing-american-kidney-health-initiative.html">executive order</a> President Donald Trump signed on July 10, 2019 could help some of them.</p>
<p>It calls for taking steps to <a href="https://www.vox.com/future-perfect/2019/7/10/20687507/triump-kidney-disease-transplant">increase the number of kidney donors</a>, improve care for <a href="https://www.kidney.org/atoz/content/kidney-transplant">people with kidney disease</a>, encourage the development of <a href="https://www.nibib.nih.gov/news-events/newsroom/artificial-kidney-development-advances-thanks-collaboration-nibib-quantum">artificial kidneys</a> and more. The intent is to drastically and quickly reduce the number of patients with end-stage kidney disease.</p>
<p>Among other things, the executive order outlines plans to compensate living donors for many of their expenses, make the bureaucracy controlling deceased organ donations more efficient and encourage <a href="https://www.healthcaredive.com/news/trump-executive-order-seeks-to-overhaul-us-kidney-care/558455/">more preventive care</a>.</p>
<p>As a <a href="https://www.researchgate.net/scientific-contributions/38447668_Amit_D_Tevar">transplant surgeon</a>, I believe that the new policy could increase incentives Americans have to become organ donors. Coupled with more public awareness about the need, doctors like me could be saving hundreds of thousands more people.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/283740/original/file-20190711-173360-14cxqoa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/283740/original/file-20190711-173360-14cxqoa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/283740/original/file-20190711-173360-14cxqoa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/283740/original/file-20190711-173360-14cxqoa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/283740/original/file-20190711-173360-14cxqoa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/283740/original/file-20190711-173360-14cxqoa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/283740/original/file-20190711-173360-14cxqoa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/283740/original/file-20190711-173360-14cxqoa.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">Nearly half a million Americans are on dialysis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hemodialysis-machines-tubingtransplantationmedical-equipment-concept-1152229250?src=Mt7E59K3ty6nOgMhIFvJ9A-2-39&studio=1">KANOWA/shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Supply and demand</h2>
<p>About <a href="https://www.kidney.org/news/newsroom/factsheets/KidneyDiseaseBasics">37 million Americans</a>, more than 10% of the entire population, have some form of kidney disease. The most common causes of this disease are <a href="https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/causes">high blood pressure and diabetes</a>. Nearly 500,000 of these patients <a href="https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease">require dialysis</a>, using a machine to carry out the function of the kidneys by filtering toxins out of their blood. Approximately <a href="https://www.cdc.gov/kidneydisease/basics.html">340 people start using dialysis every day</a> – a big inconvenience because it’s usually done three times a week, for three to four hours at a time.</p>
<p>Only half of those people beginning dialysis today will <a href="https://www.srtr.org/media/1331/a-calculator-for-kidney-transplant-waitlist-outcomes.pdf">survive for more than five years</a>. Transplants lead to better long-term survival rates: About 86% of the patients who get a donated kidney live for at least <a href="https://doi.org/10.1053/j.ackd.2016.07.001">five more years</a>, but each year only about 20% of the Americans <a href="https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/#">waiting for kidney transplants</a> will get one.</p>
<p>Having a transplant from a living donor remains the best option for many patients, as the wait time for a deceased donor organ can be long. But the number of living donor transplants is rising very slowly. </p>
<p>Based on my experience, I believe that a lack of physician and patient awareness of the benefits for the recipient and the minimal risks for the donor may be one reason why kidneys are in short supply. Another issue is the <a href="https://www.doi.org/10.1111/ajt.14949">financial burden</a> on donors, who must undergo surgery. They don’t pay for operating costs – that is currently covered by recipient’s insurance – but having the procedure leads to lost wages, and spending on child care, travel and even pet care. That is one problem Trump’s order is designed to alleviate.</p>
<p><iframe id="4yL93" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/4yL93/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Record numbers</h2>
<p>Another problem is that there just aren’t enough kidneys to go around. Kidneys for transplantation are distributed based on the number of years a patient has been on dialysis or how long they have been waiting. </p>
<p>Even though a record 21,167 kidney transplants were performed in 2018, <a href="https://www.doi.org/10.1111/ajt.14124">most kidney-disease patients currently waiting for an organ</a> won’t ultimately get one because the average wait times exceed their life expectancy.</p>
<p>The <a href="https://optn.transplant.hrsa.gov/">federal government</a> oversees the distribution of donated kidneys through <a href="https://unos.org/about/">United Network of Organ Sharing</a>, an independently run nonprofit, and spends <a href="https://www.healthcaredive.com/news/trump-executive-order-seeks-to-overhaul-us-kidney-care/558455/">US$114 billion a year</a> on patients with kidney disease through Medicare.</p>
<p>In 2018, transplants from a total of <a href="https://scrubsmag.com/long-time-nurse-donates-multiple-organs-after-suffering-fatal-medical-incident/">10,722 deceased organ donors</a> resulted in just <a href="https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/">14,725 kidney transplants and 7,849 liver transplants</a>. Many procured organs are discarded because they are not suitable for transplants. </p>
<p>The need for lifesaving organs for transplant far exceeds the demand and the gap has been growing for years.</p>
<p><iframe id="HENVi" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/HENVi/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Liver disease</h2>
<p>If the number of organ donors rises as a result of new federal policies, it will also benefit people who need other organs.</p>
<p>For example, roughly <a href="https://www.cdc.gov/nchs/fastats/liver-disease.htm">4.5 million Americans have liver disease</a>. This is primarily due to cirrhosis, a condition in which your liver is scarred and permanently damaged – typically from developing long-term <a href="https://www.fda.gov/patients/get-illnesscondition-information/hepatitis-b-c">hepatitis B or C</a>, <a href="https://www.mayoclinic.org/diseases-conditions/alcohol-use-disorder/symptoms-causes/syc-20369243">alcoholic liver disease</a> or <a href="https://www.mayoclinic.org/diseases-conditions/nonalcoholic-fatty-liver-disease/symptoms-causes/syc-20354567">non-alcoholic fatty liver disease</a>. </p>
<p>Early detection, treatment and referrals for a transplant has improved the outcomes for people who do get transplants – either an entire liver from someone who has died or a partial liver transplant from a living donor. Currently 90% of the people who get liver transplants survive for at least one more year and <a href="https://srtr.transplant.hrsa.gov/annual_reports/2017/Liver.aspx">75% live at least another five years</a>. Yet the death rate for patients with liver disease and cirrhosis who do not get transplants has <a href="http://dx.doi.org/10.15585/mmwr.mm6638a9">increased 31% in the past decade</a>.</p>
<p>As more patients and their doctors are understanding the benefits of organ transplantation, greater numbers of patients are being evaluated and placed on waitlists. Today there are more than <a href="https://optn.transplant.hrsa.gov/data/">121,000 patients waiting for a transplant</a>. Roughly 103,000 need a kidney transplant and more than 13,400 require a liver transplant. Most of the rest require a heart, lung or pancreas.</p>
<p><iframe id="q5kuy" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/q5kuy/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p><img src="https://counter.theconversation.com/content/116411/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amit Tevar receives funding from
National Institutes of Health
National Kidney Foundation - Medical Advisory Board
</span></em></p>The need for organs to transplant far exceeds the supply.Amit Tevar, Associate Professor of Surgery; Director, Kidney and Pancreas Transplant Program, Starzl Transplant Institute, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1146212019-04-08T20:08:13Z2019-04-08T20:08:13ZWe need new rules for defining who is sick. Step 1: remove vested interests<figure><img src="https://images.theconversation.com/files/267270/original/file-20190403-177167-yakeo4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Early detection of disease can be a double-edged sword.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Did you know the definition of high blood pressure (hypertension) in the United States was recently greatly expanded? Overnight, tens of millions of people were reclassified, leaving one in every two adults with a diagnosis of hypertension. </p>
<p>The move has been welcomed by some but also <a href="https://www.aafp.org/afp/2018/0315/p372.html">widely criticised</a>, amid concerns the expanded definition may <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2678449">bring more harm than good</a> to many people, from unnecessary illness labels and unneeded drugs. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-blood-pressure-guidelines-may-make-millions-anxious-that-theyre-at-risk-of-heart-disease-93349">New blood pressure guidelines may make millions anxious that they're at risk of heart disease</a>
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<p>What about the condition called “chronic kidney disease” (CKD), diagnosed by measuring blood levels to estimate kidney function? Because it does not account for normal ageing, the current definition labels up to one in two older people as having “CKD”. </p>
<p>But many of those labelled will never have any kidney symptoms, chronic or otherwise, and there’s been <a href="https://www.bmj.com/content/347/bmj.f4298">repeated criticism within the medical literature</a>. That broad new “disease” was created at a conference sponsored by a major drug company.</p>
<p>Then there are the recent changes to the definition of gestational diabetes which mean up to one in five pregnant women may now be diagnosed. But it’s <a href="https://theconversation.com/are-you-at-risk-of-being-diagnosed-with-gestational-diabetes-it-depends-on-where-you-live-112515">unclear</a> whether many among the newly diagnosed mothers or their babies might benefit from this expansion.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/are-you-at-risk-of-being-diagnosed-with-gestational-diabetes-it-depends-on-where-you-live-112515">Are you at risk of being diagnosed with gestational diabetes? It depends on where you live</a>
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<p>It’s time for a major change in how disease definitions and diagnostic thresholds are set. We outline a proposal for how this might happen today in the the journal <a href="https://ebm.bmj.com/content/early/2019/04/11/bmjebm-2018-111148">BMJ Evidence-Based Medicine</a>.</p>
<h2>The growing problem of overdiagnosis</h2>
<p>In all these examples, the danger is that more and more people may be <a href="https://theconversation.com/preventing-over-diagnosis-how-to-stop-harming-the-healthy-8569">overdiagnosed</a>. Overdiagnosis means receiving a diagnosis that isn’t likely to benefit you. </p>
<p>Supporters of expanded definitions often have the best of intentions, motivated to diagnose ever milder problems and treat them early. </p>
<p>But early detection can be a double-edged sword. For some people you prevent serious illness, for others you overdiagnose and overtreat things that would never progress and never cause any harm.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.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">
<figcaption>
<span class="caption">Panels of experts determining where to set the threshold for the diagnosis of disease often have financial ties to drug companies.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/619218203?size=huge_jpg">Africa Studio/Shutterstock</a></span>
</figcaption>
</figure>
<p>One common example is prostate cancer. Researchers <a href="https://bmjopen.bmj.com/content/9/3/e022457">recently estimated</a> that more than 40% of all the prostate cancer now detected via testing healthy men in Australia may be overdiagnosed. In other words, those cancers would not have caused symptoms or problems during a man’s lifetime, yet they are now being detected and treated with surgery or radiotherapy, often with major complications.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/most-people-want-to-know-risk-of-overdiagnosis-but-arent-told-41889">Most people want to know risk of overdiagnosis, but aren't told</a>
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<p>Our <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">research</a> a few years ago studied the panels of experts who actually change the definitions of common conditions, such as high blood pressure or depression. </p>
<p>We found three things. When they made changes, panels tended to expand definitions and label more previously healthy people as ill. </p>
<p>Second, they did not appear to rigorously investigate the downsides of that expansion. </p>
<p>And third, these panels tended to be dominated by doctors with multiple financial ties to drug companies with interests in expanding markets.</p>
<h2>A proposal to reform how diseases are defined</h2>
<p>Today, an international group of influential researchers and family doctors launch a proposal to address this problem of expanding disease definitions. Published in <a href="https://ebm.bmj.com/content/early/2019/04/11/bmjebm-2018-111148">BMJ Evidence-Based Medicine</a>, our proposal is for new processes and new people.</p>
<p>The new processes include rigorously examining evidence for benefits and potential harms, before reclassifying millions of healthy people as diseased. This was proposed in a world-first <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2626860">checklist</a> for groups seeking to change definitions, developed by the Guidelines International Network.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/five-commonly-over-diagnosed-conditions-and-what-we-can-do-about-them-82319">Five commonly over-diagnosed conditions and what we can do about them</a>
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</em>
</p>
<hr>
<p>As for new people, today’s article suggests new multidisciplinary panels led by generalists, rather than specialists. It calls for strong representation from consumer or citizen groups, and all members being free of financial ties to drug and other interested companies.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.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">
<figcaption>
<span class="caption">Overdiagnosis can lead to the overtreatment of things that would never progress and never cause any harm.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/521751805?src=YyMFtMJUoJy-6i72m0aOog-1-1&size=huge_jpg">Ronald Rampsch/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Where to from here?</h2>
<p>Responding to overdiagnosis remains a complex and uncertain challenge, both for individuals, and those who run health systems. </p>
<p>But it’s clearly being taken more and more seriously. The World Health Organisation is co-sponsor of the <a href="https://www.preventingoverdiagnosis.net/">Preventing Overdiagnosis</a> conference in Sydney this year, where the science of the problem and solutions will be debated.</p>
<p>And just last week, leadership of the Nordic Federation of General Practitioners endorsed this proposal to reform the way diseases are defined. It’s likely others will follow suit, against strong resistance from vested interests.</p>
<p>But as we conclude in <a href="https://ebm.bmj.com/content/early/2019/04/11/bmjebm-2018-111148">today’s BMJ Evidence-Based Medicine article</a>, the time for change is now. We shouldn’t treat people as an ever-expanding marketplace for diseases, for the benefit of professional and commercial interests. We can no longer ignore the great harm to those unnecessarily diagnosed. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/influential-doctors-arent-disclosing-their-drug-company-ties-110888">Influential doctors aren't disclosing their drug company ties</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/114621/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ray Moynihan receives funding from Australia's, National Health and Medical Research Council for an Early Career Fellowship. He is co-chair of the scientific committee organising the international scientific conference, Preventing Overdiagnosis, co-sponsored by the WHO. </span></em></p><p class="fine-print"><em><span>Paul Glasziou receives funding from an NHMRC program grant on overdiagnosis and overtreatment.</span></em></p>The threshold for diagnosing common conditions such as high blood pressure, chronic kidney disease and gestational diabetes have all lowered in recent years. But for whose benefit?Ray Moynihan, Assistant Professor, Bond UniversityPaul Glasziou, Professor of Medicine, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1123462019-04-02T10:41:42Z2019-04-02T10:41:42ZKids exposed to flame retardant PBDE are at risk for lifelong liver or cardiovascular problems<figure><img src="https://images.theconversation.com/files/266586/original/file-20190329-70986-1q75yi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most baby clothes, toys, bedding and furniture are treated with flame-retardant chemicals.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/baby-clothes-newborn-pastel-colors-326694860">vkuslandia/SHutterstock.com</a></span></figcaption></figure><p>What factors determine if you will experience healthy and cheerful aging or if it will turn into an endless chain of suffering from numerous health conditions? </p>
<p>Many factors shape our health, including genetics, diet, physical activity, smoking and stress. Some other factors may be as powerful but may not yet be recognized. </p>
<p>I am an environmental toxicologist studying how man-made chemicals affect our health. I was always interested in understanding how our current health is shaped by chemical exposures during the embryonic and early postnatal period – life stages that are particularly sensitive to environmental stressors. </p>
<p>To address these questions, I focused on the analysis of long-term health effects induced by a family of chemicals used as flame retardants called <a href="https://www.epa.gov/sites/production/files/2014-03/documents/ffrrofactsheet_contaminant_perchlorate_january2014_final_0.pdf">polybrominated diphenyl ethers (PBDEs)</a>. The first patent for PBDE use as a flame retardant was issued in 1960, and manufacturing of commercial products containing PBDEs, such as building materials, electronics, furnishings, motor vehicles, plastics, polyurethane foams, baby pajamas and others, <a href="https://doi.org/10.1016/j.scitotenv.2008.05.003">began in 1965</a>. PBDEs were first detected by scientists in <a href="https://doi.org/10.1016/0045-6535(87)90291-8">animal tissues in the 1980s</a>. </p>
<p>Later studies showed that concentrations of these chemicals in human blood, milk and tissues were <a href="http://doi.org/10.1021/es035082g">increasing exponentially over the past 30 years, doubling every five years</a>, while their health effects were poorly understood.</p>
<h2>Early exposures trigger lifelong changes in blood lipids</h2>
<p>In one of my experiments, I fed mice one of the PBDEs most often found in human blood and milk – BDE-47. The <a href="http://doi.org/10.1210/js.2016-1011">female mice received it</a> from day 8 of their pregnancy until the end of nursing (postpartum day 21). </p>
<p>We exposed mice to 0.2 milligrams of this chemical per kilogram of body weight. This caused BDE-47 concentrations in the fat of experimental animals to reach similar levels to concentrations found in humans living in big American cities. This comparison is used in toxicology to ensure that laboratory experiments use doses relevant for human exposures. </p>
<p>We were surprised to find that triglyceride levels were significantly altered in the offspring of exposed mothers, even though exposure to BDE-47 ceased three months earlier. Triglycerides are main constituents of body fat and cell membranes in humans and other animals.</p>
<p>To understand how BDE-47 changes blood triglycerides and other lipids, <a href="http://doi.org/10.3389/fendo.2018.00548">my laboratory conducted another experiment</a> with mice. Lipids are insoluble molecules that are used to store energy and as structural components of cell membranes. </p>
<p>We hypothesized that changes in blood lipids result from changes in liver function. It is well-known that the liver regulates composition of lipids in blood. The liver can synthesize new lipids, destroy them, secrete lipids to blood and absorb them from blood. </p>
<p>To test our hypothesis, we exposed female mice to BDE-47 daily during pregnancy or during the period of lactation and analyzed health outcomes in offspring when they reached one year old – roughly equivalent to 50 years in humans. </p>
<p>This experiment again demonstrated that short-term exposure to BDE-47 during early steps of development results in long-lasting effects on blood lipids in mice. These effects were very similar in animals that were exposed during the embryonic period or during nursing. </p>
<h2>Reprogramming the balance of lipid in blood and liver</h2>
<p>In exposed animals, levels of blood triglycerides fell by half, and <a href="http://doi.org/10.3389/fendo.2018.00548">livers accumulated 20 percent to 40 percent more lipids than in mice that were never exposed to the chemical</a>. Activity of many liver genes encoding enzymes important for lipid metabolism was altered in exposed mice. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&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">Stages of liver damage. In severe cases, high levels of fat in the liver can lead to liver cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/stages-liver-damage-disease-healthy-fatty-1071451652">wowow/Shutterstock.com</a></span>
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</figure>
<p>Among key proteins involved in lipid metabolism, one was particularly high. This protein – CD36 – is responsible for pumping lipids from blood to the liver. Increased amount of CD36 in exposed animals is likely responsible for lowering lipids in blood and raising them in the liver, resulting in increased accumulation of these fats in the liver. </p>
<p>We observed that lower-exposure dose (0.2 mg/kg) and higher-exposure dose (1.0 mg/kg) regulated CD36 in opposite directions. Lower dose resulted in decreased CD36 and elevated blood triglycerides, while higher dose raised CD36 and decreased blood triglycerides. We think it is important to note that both tested doses were in the range of human exposures. </p>
<h2>Do changes in CD36 pose health risks?</h2>
<p>Our findings demonstrate that exposure to BDE-47 during early development can alter the levels of CD36 in either direction in mice and that both increase and decrease in CD36 may be deleterious. </p>
<p>When we exposed mice to high doses of BDE-47, this increased levels of the CD36 protein, which causes excessive accumulation of fat in liver cells. This condition is called nonalcoholic fatty liver disease. It is the <a href="http://doi.org/10.1002/hep.20701">most common form of chronic</a> <a href="http://doi.org/10.1097/01.mpg.0000239995.58388.56">liver disease among adults and children</a>. </p>
<p>Around <a href="https://doi.org/10.1002/hep.20466">one-third of the American population has</a> nonalcoholic fatty liver disease, and it is a risk factor for <a href="https://doi.org/10.1038/nrgastro.2013.41">Type 2 diabetes, hypertension, cardiovascular and kidney disease</a>, <a href="https://doi.org/10.1016/j.jhep.2011.10.027">liver cirrhosis and liver cancer</a>.</p>
<p>On the other hand, decreased activity of CD36 will lead to higher lipid levels in the blood and result in <a href="https://medlineplus.gov/atherosclerosis.html">atherosclerosis</a> – a disease in which plaques of lipids build on the walls of vessels. Atherosclerosis is the primary risk factors for <a href="https://healthmetrics.heart.org/wp-content/uploads/2017/06/Heart-Disease-and-Stroke-Statistics-2017-ucm_491265.pdf">heart attack, which causes around 800,000 deaths annually</a> in the U.S. alone. Thus, early life exposure to this environmental chemical may completely reprogram lifelong health trajectory.</p>
<p>Studies published by other laboratories confirm that <a href="https://doi.org/10.1007/s00204-018-2292-y">PBDEs disrupt lipid metabolism in rats</a> and <a href="https://doi.org/10.1007/s00204-018-2177-0">increase risk of nonalcoholic fatty liver disease</a> in mice exposed during early steps of development.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=280&fit=crop&dpr=1 600w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=280&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=280&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=352&fit=crop&dpr=1 754w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=352&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=352&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">High levels of blood triglycerides can cause the buildup of fatty plaques that eventually block blood flow.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/closeup-atherosclerosis-3d-rendering-1036109620">Crevis/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Still at risk?</h2>
<p><a href="https://doi.org/10.1021/es303879n">PBDEs were banned in Europe by 2008</a> and <a href="https://www.epa.gov/sites/production/files/2014-03/documents/ffrrofactsheet_contaminant_perchlorate_january2014_final_0.pdf">voluntarily withdrawn by industry in North America by 2013</a>. It is likely that PBDEs’ production ceased all over the world, although data are missing for many regions. However these chemicals are still present in products used in U.S. households and cars. PBDEs are very stable compounds. Once released into the environment, they accumulate in sediments and in fatty tissues of wildlife and humans and stay there for many years. For example, the <a href="https://doi.org/10.1021/es1035046">half-life of different PBDEs</a> in the human body is between one and seven years. In the environment they found their way to fatty tissues of animals, many of which represent important sources of food for us.</p>
<p>Although production of PBDEs has ceased in developed countries, some studies report that concentrations of PBDEs in human tissues in the U.S. <a href="http://doi.org/10.1021/acs.est.7b00565">continue to grow</a>. </p>
<p>People born in the U.S. and Canada during the last 15 to 20 years were exposed during their early life to environmental concentrations of PBDE, comparable to those that reprogrammed lipid metabolism in our experiments with mice. Thus, we believe that about 20 percent of the North American population may be at risk of conditions associated with altered lipid concentrations in blood and liver. </p>
<p>Will these people develop aging-related conditions more readily than previous generations? The answer is yet to come. It is likely that PBDEs are not the only culprit. Many other ubiquitous pollutants, such as <a href="https://doi.org/10.1016/j.tox.2012.07.007">polychlorinated biphenyls (PCBs)</a>, <a href="https://www.toxicology.org/pubs/docs/Tox/2018Tox.pdf">dioxin (TCDD) and perfluorinated compounds (PFOS, PFNA)</a>, are known today to affect CD36 in mice. </p>
<p>It is not yet clear if effects of these other chemicals are as long-lasting as effects of PBDE. It is also not yet clear if effects of chemical exposures observed in mice are the same in humans. Mice are the most widely used animal model for testing the toxicity of pharmaceuticals and industrial chemicals, and animal toxicology studies generally are applicable to humans, <a href="https://www.ncbi.nlm.nih.gov/books/NBK215893/">although responses of laboratory animals</a> and humans to chemicals may differ in type and severity.</p><img src="https://counter.theconversation.com/content/112346/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexander Suvorov receives funding from:
1. University of Massachusetts - Amherst (startup funding), expired
2. Institute of general Genetics of the Russian Academy of Sciences (research contract), expired
3. USA Department of State (research grant), expired
4. USA National Institutes of Health (research grant), current</span></em></p>Brief exposure to a family of chemicals used as flame retardants early in life can permanently alter fat levels in the blood and liver, raising the risk of liver cancer and heart disease.Alexander Suvorov, Assistant Professor, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/947102018-05-30T10:38:17Z2018-05-30T10:38:17ZOrgans-on-chips: Tiny technology helping bring safe new drugs to patients faster<figure><img src="https://images.theconversation.com/files/220515/original/file-20180525-90281-17z2fmg.jpg?ixlib=rb-1.1.0&rect=46%2C84%2C4087%2C3038&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It doesn't look like a kidney, but this 'kidney-on-a-chip' is a breakthrough for new drug testing.</span> <span class="attribution"><span class="source">Alex Levine</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>Getting a new pharmaceutical from an <a href="https://www.fda.gov/ForPatients/Approvals/Drugs/default.htm">idea in the chemistry lab to market</a> takes many years and billions of dollars. Each year just <a href="https://www.fda.gov/Drugs/DevelopmentApprovalProcess/DrugInnovation/ucm537040.htm">several dozen new drugs are approved</a> for use in the United States. </p>
<p>Human “organs-on-chips” are leading a revolution in drug safety testing. These devices use human cells to model the structure and function of human organs and tissues. By testing the potential effects of drugs on different organs faster than traditional methods, organs-on-chips can reduce the need for animal studies and better predict which new drugs will effectively treat human disease.</p>
<p><a href="https://scholar.google.com/citations?user=dHBPovIAAAAJ&hl=en&oi=ao">As part</a> of an interdisciplinary research <a href="http://depts.washington.edu/kellylab/">team</a> with funding support from the National Center for Advancing Translational Sciences, we’re working on a kidney-on-a-chip to improve our understanding of how kidney diseases begin and which drugs can safely treat them. </p>
<h2>Quicker and better testing</h2>
<p>Historically, laboratory testing for new drugs is performed in cells grown in dishes or flasks. If a drug passes initial screening tests in vitro, researchers next test it in vivo in live animals to determine the effects of a new drug on a whole system instead of just one cell type at a time. Finally, after many years of laboratory investigation, researchers will test a promising new drug in people to see if it is safe and effective. </p>
<p>The problem is <a href="https://www.pharmaceutical-technology.com/features/featurecounting-the-cost-of-failure-in-drug-development-5813046/">9 out of 10 of these drugs</a> never make it from small-scale human tests to the patient because they turn out to be ineffective or toxic, even if they showed promising results in early testing.</p>
<p>Organs-on-chips have the potential to completely transform that system. Ranging from the size of a fingernail to that of a credit card, they’re composed of fluid channels and tiny chambers that contain human cell samples. Organs-on-chips <a href="https://ncats.nih.gov/tissuechip/about">in development in labs around the country</a> include kidney, lung, liver, intestine, skin, brain, heart, bone and reproductive systems.</p>
<p>In an organ-on-a-chip, flowing liquid supplies the cells with oxygen and nutrients, similar to the way blood sustains cells in the human body. It’s this constant flow that makes these devices special. Cells grown in organs-on-chips devices act more like cells in a human organ than do cells grown in flat dishes without flow.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/220361/original/file-20180524-51141-1z0jvvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/220361/original/file-20180524-51141-1z0jvvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/220361/original/file-20180524-51141-1z0jvvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220361/original/file-20180524-51141-1z0jvvy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220361/original/file-20180524-51141-1z0jvvy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220361/original/file-20180524-51141-1z0jvvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220361/original/file-20180524-51141-1z0jvvy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220361/original/file-20180524-51141-1z0jvvy.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"></a>
<figcaption>
<span class="caption">Fluid circulates through a kidney-on-a-chip.</span>
<span class="attribution"><span class="source">Alex Levine</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>Case of the kidney-on-a-chip</h2>
<p><a href="https://www.niddk.nih.gov/health-information/kidney-disease/kidneys-how-they-work">Kidneys are incredibly important</a> to overall human health. The two fist-sized kidneys remove drugs and unwanted compounds from the body and play a critical role in maintaining proper salt and water balance, blood pressure and vitamin D and bone health. Genetic conditions and even commonly administered medications can, in some circumstances, damage the kidneys.</p>
<p>In the U.S., <a href="https://www.cdc.gov/kidneydisease/pdf/kidney_factsheet.pdf">15 percent of adults have kidney diseases</a>. But most don’t even know it, because kidney diseases often display no symptoms until the condition is very advanced. There’s a pressing need to understand how kidney disease begins, and to develop new safe and effective treatments.</p>
<p>Here at the University of Washington, our kidney-on-a-chip research team is composed of scientists from many different disciplines, including pharmacy, pharmaceutical sciences, nephrology (kidney medicine), toxicology, biochemistry and bioengineering.</p>
<p>In partnership with <a href="https://www.nortisbio.com">Nortis, Inc.</a>, a local biotechnology company, our team has created a small device — the size of a business card — with up to three tiny tubes, each one-thousandth the size of a drop of water, containing 5,000 human kidney cells. When tiny amounts of fluid are pumped through the tubes, the <a href="https://doi.org/10.1016/j.kint.2016.06.011">kidney cells are exposed to important signals</a> that help the cells in the chip behave as if they were in a live kidney.</p>
<p>We’ve found that the kidney cells release signals – called biomarkers – of injury when exposed to known kidney toxins. Our research showed that cells on the chip released markers of injury commonly seen in the urine of people with kidney damage. Testing with the older method, using cells on plates, did not show any damage with the same treatment. This suggests that the <a href="https://doi.org/10.1681/ASN.2015010060">kidney-on-a-chip may be better</a> than existing methods at predicting if a new drug will cause kidney damage in humans.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/215467/original/file-20180418-163975-nzy7ci.jpg?ixlib=rb-1.1.0&rect=60%2C68%2C892%2C589&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/215467/original/file-20180418-163975-nzy7ci.jpg?ixlib=rb-1.1.0&rect=60%2C68%2C892%2C589&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/215467/original/file-20180418-163975-nzy7ci.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/215467/original/file-20180418-163975-nzy7ci.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/215467/original/file-20180418-163975-nzy7ci.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/215467/original/file-20180418-163975-nzy7ci.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/215467/original/file-20180418-163975-nzy7ci.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/215467/original/file-20180418-163975-nzy7ci.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"></a>
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<span class="caption">These devices do a better job of testing how molecules affect living human cells.</span>
<span class="attribution"><span class="source">Alex Levine</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<h2>Connecting organs-on-chips to mimic systems</h2>
<p>Now that we’ve had these promising results, scientific teams across the country are starting to connect different organs together to replicate a more complex, multi-organ system, to give greater insights into how drugs affect people. For example, we were able to connect a <a href="https://doi.org/10.1172/jci.insight.95978">liver-on-a-chip to a kidney-on-a-chip</a> to learn how a plant extract used in some herbal medicines, called aristolochic acid, damages kidney cells. This chip-to-chip investigation reinforces the need for interconnected organs-on-a-chip to replicate the complex mechanics in the human body.</p>
<p>In the coming year, our kidney-on-a-chip project will be one of several <a href="https://ncats.nih.gov/tissuechip/projects/space">sent to the International Space Station</a> where low gravity speeds up changes in cells, sometimes causing health problems for astronauts. The Space Station could be the perfect place to find out more about kidney diseases in weeks, rather than years or decades.</p>
<p>Organs-on-chips can also be used to discover new drug targets. Our team is evaluating the kidney-on-a-chip as a tool to personalize drug selection and dosing in people with kidney cancer, polycystic kidney disease and chronic kidney disease. Other organs-on-chips labs around the country are studying diseases of the immune system, brain, lungs, heart and blood vessels. By working together, dozens of research teams are developing this new technology to revolutionize drug discovery, leading to the development of better and safer medications for all.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/CYBrpCUkdVQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A pocket-size revolution in kidney research.</span></figcaption>
</figure><img src="https://counter.theconversation.com/content/94710/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Yeung receives funding from The National Institutes of Health (NCATS, NIGMS)</span></em></p><p class="fine-print"><em><span>Edward Kelly receives funding from National Institutes of Health, Environmental Protection Agency and Center for Advancing Science in Space.</span></em></p><p class="fine-print"><em><span>Jonathan Himmelfarb has received relevant grant funding from the U.S. National Institutes of Health and the Center for Advancement of Science in Space.</span></em></p>Researchers who’ve created a kidney-on-a-chip explain why these kinds of devices are an improvement over traditional ways to test new drugs.Catherine Yeung, Research Assistant Professor of Pharmacy, University of WashingtonEdward Kelly, Associate Professor of Pharmaceutics, University of WashingtonJonathan Himmelfarb, Director of the Kidney Research Institute and Professor of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/914822018-02-11T19:11:25Z2018-02-11T19:11:25ZTo close the health gap, we need programs that work. Here are three of them<figure><img src="https://images.theconversation.com/files/205783/original/file-20180210-51697-1r3qj3x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While death rates from heart and kidney disease have dropped among Indigenous people, death rates from cancer are on the rise.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>The tenth Closing the Gap report to be tabled in Parliament today is expected to show progress in the two health targets – to close the gap in life expectancy by 2031 and halve the child mortality (death) gap by 2018. But only the latter is on track.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=751&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=751&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=751&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=944&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=944&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=944&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">The gap in life expectancy between Indigenous and non-Indigenous Australians won’t be closed by 2031.</span>
<span class="attribution"><a class="source" href="https://www.aihw.gov.au/getmedia/5d39a104-a2d5-4ab5-900c-697ee0e5a1d8/ah16-5-8-main-contributors-indigenous-life-expectancy-gap.pdf.aspx">AIHW (screenshot)</a></span>
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<p>The Indigenous death rate has dropped by 15% (from 1998-2015), but <a href="https://closingthegap.pmc.gov.au/">we’re not on track</a> to meet the deadline. Chronic diseases such as diabetes, heart disease and cancer are <a href="https://www.aihw.gov.au/getmedia/5d39a104-a2d5-4ab5-900c-697ee0e5a1d8/ah16-5-8-main-contributors-indigenous-life-expectancy-gap.pdf.aspx">responsible for the majority of this gap</a>. </p>
<p>While <a href="https://closingthegap.pmc.gov.au/healthy-lives">death rates</a> from heart and kidney disease have dropped among Indigenous people, death rates from cancer are on the rise, and the gap here is widening.</p>
<p>The child death rate has dropped by 33% for the 1998-2015 period, and is reportedly on track to meet the target.</p>
<p>But overall, progress is slow. As governments talk about “refreshing” targets, three experts – in diabetes, maternal and infant health care, and rheumatic heart disease – provide evidence for how giving more support, funding and control to the Indigenous community leads to actual results.</p>
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Read more:
<a href="https://theconversation.com/closing-the-gap-is-failing-and-needs-a-radical-overhaul-72961">Closing the Gap is failing and needs a radical overhaul</a>
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<h2>Remote diabetes services</h2>
<p>Diabetes is <a href="https://www.pmc.gov.au/sites/default/files/publications/Aboriginal_and_Torres_Strait_Islander_HPF_2014%20-%20edited%2016%20June2015.pdf">three times more prevalent</a> in Aboriginal and Torres Strait islander people compared with non-Indigenous Australians. Rates in remote communities are even higher – up to 30% in some. The reasons are complex and include lifestyle factors such as poor diet and lack of exercise, poverty, and poor access to medical care and health literacy. Genetics and epigenetics also <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1753-4887.1999.tb01782.x/full">play a major role</a>, but aren’t yet well defined.</p>
<p>Over the past eight years, the Baker Heart and Diabetes Institute has been involved in remote diabetes services – as part of our <a href="https://www.baker.edu.au/impact/aboriginal-health">outreach health services</a>. </p>
<p>We’ve been shocked by the extreme levels of ill health associated with poorly controlled diabetes in these communities. The remote clinical services we visit are generally ill-equipped to manage complex chronic disease and the type of diabetes we see is aggressive and unusually resistant to treatment. </p>
<p>Diabetes contributes to illness and death through its complications, which include heart disease, kidney failure and limb amputations. Control of blood glucose (sugar) levels is central to managing complications.</p>
<p>Our service is made up of five doctors, and two diabetes educators. We visit eight communities in central Australia and intensively manage patients with poorly controlled diabetes. The doctors, based in Melbourne and Alice Springs, work closely with the nurse educators based in Alice Springs. The educators frequently visit the communities. Their follow-up and feedback are critical to overall management.</p>
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<strong>
Read more:
<a href="https://theconversation.com/type-2-diabetes-increasingly-affects-the-young-and-slim-heres-what-we-should-do-about-it-61283">Type 2 diabetes increasingly affects the young and slim; here's what we should do about it</a>
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<p>The program’s evaluation (not yet published) has shown significant improvements in glucose levels and cholesterol in more than 100 patients. We’ve also had success in finding effective medications for these types of diabetes and initiated a <a href="http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=indigenous+exenatide&conditionCategory=&conditionCode=&interventionCodeOperator=&interventionCode=&ageGroup=&healthyVolunteers=&gender=&allocationToIntervention=&dateOfRegistrationFrom=&dateOfRegistrationTo=&trialStartDateFrom=&trialStartDateTo=&recruitmentCountryOperator=&countryOfRecruitment=&primarySponsorType=&fundingSource=&healthCondition=&interventionDescription=&phase=&recruitmentStatus=&registry=&ethicsReview=&studyType=&isBasic=True&postcode=&distance">clinical trial</a> of a once-weekly diabetes medication in these communities. This less frequent dosage helps with adherence rates and we have so far seen improvements in patients involved in the trial. </p>
<p>With more funding and resources for remote clinical services, and greater involvement and feedback from the communities and community leaders, the impact of diabetes and its complications can be greatly reduced. – <strong>Neale Cohen</strong></p>
<h2>Birthing on Country</h2>
<p>Birthing on Country – a movement that has been benefiting Indigenous women in <a href="https://www.saxinstitute.org.au/wp-content/uploads/Birthing-on-Country1.pdf">Canada</a> for decades – is about <a href="https://www.saxinstitute.org.au/wp-content/uploads/Birthing-on-Country1.pdf">bringing birth back to community</a> and back to country. It’s also about offering safe and culturally appropriate maternity services for Aboriginal and Torres Strait Islander mothers and babies. </p>
<p>In Australia, we’ve been running a Birthing On Country service in Brisbane since 2013, but tailoring it to an urban setting. We call it <a href="http://www.iuih.org.au/Services/Child_and_Maternal_Health">Birthing in Our Community</a>. </p>
<p>Key aspects of our program include an Indigenous governance framework and 24/7 midwifery care in pregnancy to six weeks postnatal care by a named midwife. This is supported by Indigenous health workers and an Indigenous team coordinator. Our program also offers support for Indigenous student midwives through cadetships and placement.</p>
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<figcaption><span class="caption">Birthing on Country has been shown to be effective, and is strongly supported by Indigenous organisations.</span></figcaption>
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<p>Evaluation of <a href="https://espace.library.uq.edu.au/view/UQ:435004">Birthing in Our Community</a> has shown significant reductions in preterm birth, caesarean sections, and low birth weight infants and babies being admitted to the neonatal nursery. We’ve seen more women coming to us in early pregnancy, as they feel safe to do so. There has been an increase in antenatal care, normal birth and breastfeeding rates. </p>
<p>Currently, Birthing in Our Community is run and <a href="https://espace.library.uq.edu.au/view/UQ:435004">funded through a partnership</a> between the Institute for Urban Indigenous Health, the Aboriginal and Torres Strait Islander Community Health Service Brisbane and the Mater Mothers’ Hospital. Evaluation of the program is funded by the National Health and Medical Research Council.</p>
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<p>
<em>
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Read more:
<a href="https://theconversation.com/birthing-on-country-could-deliver-healthier-babies-and-communities-31180">Birthing on Country could deliver healthier babies and communities</a>
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<p>We recommend scaling up the Birthing in Our Community program to address the preterm birth rate, which hasn’t changed since Closing the Gap targets were released in 2008. This would also impact positively on infant and child mortality in Australia. </p>
<p>We also recommend full implementation of Birthing On Country in urban, rural and remote areas, with dedicated funding for Indigenous organisations to establish their own Birth Centres and structural barriers to this (regarding insurance and regulation) removed by government. </p>
<p>Birthing On Country was recommended by the <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/8AF951CE492C799FCA257BF0001C1A4E/$File/maternityplan.pdf">national maternal services policy</a>, released in 2010. It is also supported by international evidence, the <a href="https://health.act.gov.au/sites/default/files/Birthing%20on%20Country%20Workshop%20Report,%204%20July%202012.pdf">Indigenous community</a> and <a href="http://catsinam.org.au/static/uploads/files/birthing-on-country-position-statement-endorsed-march-2016-wfaxpyhvmxrw.pdf">professional organisations</a>. – <strong>Sue Kildea and Ms Jody Currie (CEO of Aboriginal and Torres Strait Islander Community Health Service, Brisbane and a Yugambeh woman).</strong></p>
<h2>Rheumatic heart disease</h2>
<p>Rheumatic heart disease is a rarity in mainstream Australia. But in remote communities of northern and central Australia, it continues largely unabated. The <a href="https://www.ncbi.nlm.nih.gov/pubmed/25169025">average age of death</a> from the disease in Aboriginal people is 40. Many children and adolescents are among those who die. Rheumatic heart disease is responsible for the <a href="http://www.aihw.gov.au/publication-detail/?id=6442467995">highest gap in life expectancy</a> between Indigenous and non-Indigenous Australians; higher than diabetes or kidney failure.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-are-aboriginal-children-still-dying-from-rheumatic-heart-disease-63814">Why are Aboriginal children still dying from rheumatic heart disease?</a>
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<p>Yet, it is preventable. It’s caused by an abnormal immune reaction to infections by the <em>group A Streptococcus</em> bacterium (that causes strep throat and <a href="https://theconversation.com/why-simple-school-sores-often-lead-to-heart-and-kidney-disease-in-indigenous-children-86066">skin sores</a>). The reaction causes inflammation in heart valves (part of the condition known as rheumatic fever). If left untreated, this can progress to rheumatic heart disease. </p>
<p>The disease can result in heart failure, and causes death and disability in children, adolescents and young adults.</p>
<p>Until now, rheumatic heart disease has been largely tackled entirely within the health system. That doesn’t work for a disease that is inherently complex and made up of many factors. And for one that starts as an infectious disease in childhood but ends up as a chronic disease of adolescents and young adults.</p>
<p>There are medical approaches to treatment and prevention, such as regular penicillin injections to prevent strep A infections. But housing, living conditions and education are core determinants for preventing infection.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=493&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=493&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=493&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=619&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=619&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=619&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"><span class="source">The Conversation</span>, <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 <a href="https://endrhd.telethonkids.org.au/">END RHD Centre for Research Excellence</a> – that began in 2014 (through funding by the National Health and Medical Research Council) – is developing a strategy to eliminate rheumatic heart disease in Australia. A critical aspect is <a href="https://endrhd.telethonkids.org.au/globalassets/subsite-media/subsite-documents/end-rhd/briefing-note-secondary-prophylaxis-delivery--lessons-learnt-to-date.pdf">to help communities take ownership</a> of ways to target rheumatic heart disease as a condition requiring attention, provide leadership and training within health services, connect the health service with clients, families and communities, and engage other services outside of the health system. </p>
<p>We recently <a href="https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-016-1166-y">conducted research</a> in ten remote communities in the Northern Territory, trialling a number of ways to assist local clinics to improve care and prevention of rheumatic heart disease. We found the communities that did best were those that tackled multiple aspects of prevention and treatment of the disease. </p>
<p>This meant delivering preventive treatments through streamlining systems at the clinic, and embracing ways to connect community members to the health service in culturally sensitive and appropriate ways.</p>
<p>Rheumatic heart disease is almost uniquely a disease of Aboriginal people in Australia. It deserves particular attention as part of closing the gap. To eliminate it from Australia, we need to identify it as a priority, and equip communities with the information and tools they need to tackle it. – <strong>Jonathan Carapetis</strong></p><img src="https://counter.theconversation.com/content/91482/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neale Cohen receives funding from Astra Zeneca for a clinical trial in remote communities. The Baker Institute recieves Federal government funding for their outrech clinical diabetes service. </span></em></p><p class="fine-print"><em><span>Jonathan Carapetis receives funding from the National Health and Medical Rearch Council, the Telethon Perth Childrens Hospital Fund, AusTrade, Novartis Institute for Biomedical Research.</span></em></p><p class="fine-print"><em><span>Sue Kildea receives funding from the National Health and Medical Research Council, the Canadian Institutes of Health Research, the National Institute of Health, the Mater Foundation and the Queensland Government. She has undertaken funded consultancy work on 'Birthing On Country' for the Sax Institute, State and Commonwealth governments. She works in partnership with Indingeous and other Organisations to establish and evaluate Birthing on Country services and they have their own funding sources: the Institute for Urban Indigenous Health, the Aboriginal and Torres Strait Islander Community Health Service Brisbane the South Coast Women’s Health and Welfare Aboriginal Corporation (Waminda); the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, the Australian College of Midwives and Rhodanthe Lipsett Indigenous Midwifery Charitable Fund with colleagues from University Queensland and Sydney University.</span></em></p>Politicians make sweeping statements on how to close the gap. But here’s advice from people working directly with Indigenous communities who have evidence for what actually works.Neale Cohen, General Manager Diabetes Services, Baker Heart and Diabetes InstituteJonathan Carapetis, Professor, Paediatrics, Telethon Kids InstituteSue Kildea, Professor of Midwifery, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/860662017-12-11T01:49:16Z2017-12-11T01:49:16ZWhy simple school sores often lead to heart and kidney disease in Indigenous children<figure><img src="https://images.theconversation.com/files/195398/original/file-20171120-18528-ltzud6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Impetigo happens when itching causes the skin to break and let in disease-causing bacteria.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Impetigo, also known as school sores, is a highly contagious bacterial skin infection that occurs in children far more frequently than adults. It is one of the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26317533">most common bacterial infections</a> in children aged two to five years. Impetigo happens when a break in the skin, from scratching an insect bite for instance, lets in disease-causing bacteria.</p>
<p>The bacteria responsible for impetigo are <em>Staphylococcus aureus</em> (<em>S. aureus</em> or staph) and <em>Streptococcus pyogenes</em> (<em>S. pyogenes</em> or group A strep). People with diabetes or other conditions that may affect the immune system, such as HIV infection, and those on medications that suppress immunity, are more susceptible.</p>
<p>While the infection itself is treatable, if left untreated it can lead to more serious conditions such as <a href="https://www.healthdirect.gov.au/cellulitis">cellulitis</a> (infection of the inner layers of skin) or <a href="https://www.healthdirect.gov.au/abscesses">abscess</a> (painful collections of pus that build up under the skin). It can also progress to kidney disease, or it could <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0000467">cause acute rheumatic fever</a>, which can affect the heart, joints, brain or skin.</p>
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<p>
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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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<p>Around 162 million children worldwide <a href="https://www.ncbi.nlm.nih.gov/pubmed/26317533">suffer from impetigo</a> at any one time. They mostly live in resource-poor tropical countries or underprivileged populations in developed countries. In Australia, about 15,000 Indigenous children are <a href="https://www.ncbi.nlm.nih.gov/pubmed/26317533">estimated to suffer</a> from impetigo – representing 40% of children in Indigenous communities.</p>
<h2>Causes and symptoms</h2>
<p>Impetigo can occur on top of other skin conditions, particularly itchy ones like eczema, scabies, insect bites, and head lice. Scratching the skin can break it and let the disease-causing bacteria in. A sore can be infectious for as long as it is weeping fluid, as the fluid and crusts of the sore contain infectious bacteria. </p>
<p>The time between becoming infected and developing symptoms is around four to ten days. Contact with the sore, or with things that have been in contact with the sore, can spread the infection to other people. </p>
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Read more:
<a href="https://theconversation.com/health-check-how-do-you-catch-and-get-rid-of-head-lice-43699">Health Check: how do you catch – and get rid of – head lice?</a>
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<p>There are two forms of impetigo: non-bullous and bullous. Non-bullous, also known as the crusted form of impetigo, accounts for about 70% of all cases and can be <a href="http://www.aafp.org/afp/2014/0815/p229.html">caused by both</a> <em>S. aureus</em> and <em>S. pyogenes</em>. It has a thick, soft, yellow crust below which is often a wet, red area. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=552&fit=crop&dpr=1 754w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=552&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=552&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Crusted forms of impetigo are the most common.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Impetigo_crouteux_jambes.jpg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>Non-bullous <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1470.1994.tb00092.x/abstract">impetigo spots grow slowly</a> and are smaller than the fully grown spots of bullous, or blistering, impetigo. They are not usually painful but can be itchy. The lesions generally appear on the face and extremities, often at the location of already broken skin, such as an insect bite or eczema.</p>
<p>The bullous (blistering) form of impetigo is <a href="http://www.mdedge.com/jfponline/dsm/1310/infectious-diseases/impetigo">characterised by the formation</a> of a large, fluid-filled irritating blister under the skin. It is caused exclusively by <em>S. aureus</em> and <a href="http://www.aafp.org/afp/2014/0815/p229.html">usually occurs</a> where two skin surfaces touch or rub together, such as the armpits. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=884&fit=crop&dpr=1 600w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=884&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=884&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1111&fit=crop&dpr=1 754w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1111&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1111&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Blistering impetigo infections usually occur where two skin surfaces touch, like the armpits.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Impetigo.jpg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>The blisters grow rapidly in size and number. They burst quickly and leave slightly wet or shiny areas with a brown crust at the edge. Those spots continue to grow quickly even after they break open and can be many centimetres wide. They are not usually painful but can be itchy. </p>
<h2>What are the treatments?</h2>
<p>As impetigo is highly contagious, good <a href="https://www.ncbi.nlm.nih.gov/pubmed/16253886">hygiene practices are essential</a> for stopping the spread of infection. These include washing hands with soap, washing of infected clothes and towels, and covering the sore with a sticking plaster. </p>
<p>It’s also recommended that the infected child be <a href="https://www.ncbi.nlm.nih.gov/pubmed/21976576">kept away from other children</a> and school for 24 hours after starting treatment. </p>
<p>Impetigo is generally considered a mild disease that can resolve without treatment after a few weeks. But because it can cause more serious conditions, the child should be examined by a doctor and treated with appropriate antibiotics. </p>
<p>Topical antibiotics (creams) like mupirocin are recommended for mild forms of the infection. Oral antibiotics are used in more <a href="https://www.mayoclinic.org/diseases-conditions/impetigo/symptoms-causes/syc-20352352">severe cases of impetigo</a>, such as when multiple sores are present, or when topical treatments have been ineffective. The treatment should continue until all sores are completely healed. With treatment, symptoms are likely to be improved or cleared up after seven days.</p>
<h2>What happens if it’s not treated?</h2>
<p>A possible consequence of untreated impetigo is an autoimmune kidney disease called acute post-streptococcal glomerulonephritis (APSGN). It’s not frequently seen in developed countries but one <a href="https://www.ncbi.nlm.nih.gov/pubmed/16253886">estimate suggests</a> that more than 390,000 children in less developed countries are affected, compared with about 13,000 children in more developed countries.</p>
<p>In Australia, data collected from 1991-2008 in the Northern Territory revealed that 95% of cases occurred in <a href="https://www.ncbi.nlm.nih.gov/pubmed/21976576">Indigenous Australians</a>, with 98% of affected individuals living in remote locations. The average age was seven years old, with children younger than 15 accounting for 88% of all cases. </p>
<p>Given the association between APSGN and chronic kidney disease, it is important that predisposing skin infections are treated promptly and appropriately, and the risk of transmission or recurrences is minimised. Around 97% of deaths from APSGN occur in resource-poor countries or communities.</p>
<p>Acute rheumatic fever is another potential consequence of untreated impetigo. It is an autoimmune response to an untreated group A strep infection, and repeated episodes can <a href="https://www.ncbi.nlm.nih.gov/pubmed/19962028">damage the heart</a>, leading to rheumatic heart disease. </p>
<p>Both rheumatic fever and rheumatic heart disease are preventable and generally not seen in industrialised countries. But rates of <a href="https://www.aihw.gov.au/reports/heart-stroke-vascular-disease/rheumatic-heart-disease-and-acute-rheumatic-fever/contents/table-of-contents">rheumatic fever and rheumatic heart diseases</a> in Indigenous communities are up to 26 times those in non-Indigenous populations.</p>
<hr>
<p><strong><em><a href="https://theconversation.com/why-are-aboriginal-children-still-dying-from-rheumatic-heart-disease-63814">Why are Aboriginal children still dying from rheumatic heart disease?</a></em></strong></p>
<hr>
<p>Between 1997 and 2013, <a href="http://www.aafp.org/afp/2014/0815/p229.html">97% of patients</a> diagnosed with acute rheumatic fever in the NT were Indigenous, despite Indigenous Australians <a href="http://digitallibrary.health.nt.gov.au/prodjspui/bitstream/10137/649/1/NT%20Demography%20Factsheet%202015.pdf">representing about 30%</a> of the NT population. Similarly, 94% of people diagnosed with rheumatic heart disease during this time were Indigenous, and Indigenous patients were younger than the non-Indigenous patients.</p>
<p>Poor hygiene, close living and lack of access to medical care are associated with impetigo and its related complications. Resources that help lessen these risk factors will also reduce the burden of impetigo and the diseases that can develop as a consequence.</p>
<hr>
<p><em>Dr Kavya E. Baby, a basic physician trainee with ACT health, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/86066/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jackson Thomas received funding from government e.g. RIRDC, ACT Gov, NSW Pharmacy Council, Goodwin aged care facilities, and consultant fee and/or grants from biotech companies</span></em></p><p class="fine-print"><em><span>Asha Bowen receives research funding from the National Health and Medical Research Council of Australia for research to reduce the burden of skin sores in remote Indigenous Australians. </span></em></p><p class="fine-print"><em><span>Erin Walker, Gregory Peterson, Julia K. Christenson, and Nathan M D'Cunha 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>While school sores – or impetigo – is a treatable condition, if left untreated it can lead to much more serious illness such as kidney and heart disease.Jackson Thomas, Assistant Professor/Senior Lecturer in Pharmacy, University of CanberraErin Walker, Medical Science Research Fellow, University of CanberraGregory Peterson, Deputy Dean (Research) Faculty of Health, University of TasmaniaNathan M D'Cunha, Sessional Academic, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/862712017-11-13T02:55:20Z2017-11-13T02:55:20ZWhy it can make sense to believe in the kindness of strangers<figure><img src="https://images.theconversation.com/files/193806/original/file-20171108-14182-1p5f2ol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When rain from Hurricane Harvey flooded Houston and surrounding areas, some people were more eager to volunteer than others.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/missouri-city-texas-august-29-2017-705372118?src=nmRy7Xx5DSFf5uJFfD-VTw-1-0">michelmond/Shutterstock.com</a></span></figcaption></figure><p>Would you risk your life for a total stranger?</p>
<p>While you might consider yourself incapable of acts of altruism on that scale, it happens again and again. During <a href="http://www.cnn.com/2017/09/03/us/houston-texas-harvey-heroes-trnd/index.html">hurricanes</a> and <a href="http://www.cnn.com/2017/10/05/us/las-vegas-shooting-jonathan-smith-tom-mcgrath-hero-intv/index.html">mass shootings</a>, some people go to great lengths to help people they don’t even know while everyone else flees.</p>
<p>To learn whether this behavior comes more naturally to some of us than others, I partnered with Abigail Marsh and other neuroscientists working at the <a href="http://www.abigailmarsh.com/">Laboratory on Social and Affective Neuroscience</a> at Georgetown University. We studied the brains and behavior of some extraordinary altruists: people who have donated one of their own kidneys to a total stranger, known as nondirected donors. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/x7EglP5A2Hg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Vox journalist Dylan Matthews explains in this video why he donated his left kidney to save a stranger’s life.</span></figcaption>
</figure>
<h2>Unusually altruistic</h2>
<p>These kidney donors may never learn anything about the recipient. That means they are not making this personal sacrifice because a relative or someone they may interact with in the future would benefit.</p>
<p>What’s more, this act of altruism is costly in multiple ways. It is a major, painful surgery. Many donors end up <a href="http://onlinelibrary.wiley.com/doi/10.1111/ajt.13591/abstract">paying thousands of dollars</a> out of pocket for medical and travel expenses, and they can lose out on salary and other earnings. </p>
<p>For the most part, there’s nothing to be gained in terms of the donor’s reputation. Many people, including some medical professionals, are skeptical about the motives of altruistic donors – even <a href="http://onlinelibrary.wiley.com/doi/10.1034/j.1600-6143.2003.00019.x/abstract">questioning their sanity</a>. </p>
<p>These drawbacks help explain why altruistic kidney donation is extremely rare. Fewer than 2,000 people have done this to date in the United States since 1988, the first year with a recorded altruistic donor. That makes it something a mere one out of every 163,133 Americans have ever done.</p>
<p>And the norm is for living friends and family to donate kidneys to their loved ones. That was the case when celebrity Selena Gomez, who has lupus, got a new kidney from <a href="http://people.com/music/selena-gomez-kidney-donor-francia-raisa-all-about/">her best friend</a>, the actress Francia Raisa. </p>
<p>Most commonly, the kidneys of deceased organ donors are used in transplants for strangers. There are about twice as many transplants from deceased donors as transplants from living ones. </p>
<p>Deceased donors and living friends and family account for a total of 99.5 percent of all kidney transplants performed over the past three decades.</p>
<p></p><hr><p></p>
<p><iframe id="LHG0m" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/LHG0m/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
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<h2>Mammalian brains</h2>
<p>Deep in the brains of all mammals – whether squirrel, bonobo or human – the same regions respond to distress and vulnerability. This response is especially common when babies cry out or appear threatened. In our <a href="https://doi.org/10.1098/rspb.2017.1731">most recent study</a>, we investigated whether those brain systems, which are responsible for making all mammals care about helpless youngsters, play a key role in making some people extremely altruistic. </p>
<p>There are two major regions in what brain scientists call the “offspring care neural network,” evolutionarily old structures deep in the brain called the amygdala and the periaqueductal gray.</p>
<p>The amygdala is a small almond-shaped structure in both hemispheres tucked below the cortex. (Amygdala means almond in Greek.) One of its main roles in the brain is picking up on important emotional cues.</p>
<p>Research has long established that the amygdala is largely responsible for <a href="http://www.jneurosci.org/content/15/9/5879">recognizing</a> and <a href="https://doi.org/10.1016/j.cub.2010.11.042">feeling</a> fear. </p>
<p>The periaqueductal gray is another small u-shaped structure at the base of the brain. It plays an important role in controlling basic behaviors like the impulse to cuddle a baby or the instinct to avoid predators. </p>
<p>Many studies have shown these structures and the connections between them are responsible for, say, motivating <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1460-9568.2009.06875.x/abstract">female rats to take care of their pups</a> or making <a href="https://doi.org/10.1016/j.pnpbp.2010.10.017">humans want to console crying babies</a>.</p>
<p>Responding to distressed offspring is such a strong survival instinct that it can even cross species. A deer, for example, will respond when it <a href="http://www.journals.uchicago.edu/doi/10.1086/677677">hears a crying human infant</a>.</p>
<p>Other research by Marsh’s lab has studied how people respond when they sense that <a href="https://doi.org/10.1037/emo0000054">others are afraid</a> and feel an urge to comfort them. </p>
<p>The sight of <a href="http://www.tandfonline.com/doi/abs/10.1080/02699930600652234">frightened faces can evoke helping behavior</a>. And people who are good at <a href="https://doi.org/10.1037/1528-3542.7.2.239">noticing that someone is afraid</a> just by seeing their face tend to be more altruistic than the rest of us.</p>
<p>Scientists have long hypothesized that the care people extend to strangers may be a sort of extension of our most basic impulses to take care of our own kids. Scientists also believe that the ancient brain structures humans share with other mammals trigger these responses.</p>
<h2>A test</h2>
<p>To learn more about the brains of extremely altruistic people, we <a href="https://doi.org/10.1098/rspb.2017.1731">did an experiment</a> with people who had donated one of their kidneys to someone they didn’t know. In our study, we asked these extreme altruists to read scenarios, some of which described people who were the target of harmful or callous behavior, and rate how much sympathy they felt. We did the same thing with a control group of people who had not donated a kidney. </p>
<p>Before reading some of these scenarios, we presented photos of fearful faces. These images were fleeting, lasting only 27 milliseconds. That means the participants couldn’t consciously recognize what they saw. Meanwhile, we scanned their brains.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/193810/original/file-20171108-14177-13vdbwh.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/193810/original/file-20171108-14177-13vdbwh.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/193810/original/file-20171108-14177-13vdbwh.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=624&fit=crop&dpr=1 600w, https://images.theconversation.com/files/193810/original/file-20171108-14177-13vdbwh.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=624&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/193810/original/file-20171108-14177-13vdbwh.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=624&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/193810/original/file-20171108-14177-13vdbwh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=785&fit=crop&dpr=1 754w, https://images.theconversation.com/files/193810/original/file-20171108-14177-13vdbwh.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=785&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/193810/original/file-20171108-14177-13vdbwh.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=785&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Brain scan made by the researchers showing how the amygdalas of altruistic kidney donors respond more strongly than average.</span>
<span class="attribution"><span class="source">Kristin Brethel-Haurwitz</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>We found some interesting effects while reviewing images captured during this experiment. Most notably, the amygdalas and their periaqueductal gray were more active for kidney donors than people in our control group, with stronger reactions to fearful and distressed stimuli. </p>
<p>What we found suggests that these two regions might be communicating or otherwise working together. We further tested this finding by looking at another aspect of our brain scans that allowed us to analyze how these two regions are connected by nerve cells.</p>
<p>My colleague <a href="https://aamarsh.wordpress.com/lab/">Katherine O'Connell</a>, a doctoral student, found that there seemed to be greater structural connections between these two regions too. These connections may help nerve impulses travel between them.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/193812/original/file-20171108-14209-1wy0fqj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/193812/original/file-20171108-14209-1wy0fqj.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/193812/original/file-20171108-14209-1wy0fqj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=526&fit=crop&dpr=1 600w, https://images.theconversation.com/files/193812/original/file-20171108-14209-1wy0fqj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=526&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/193812/original/file-20171108-14209-1wy0fqj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=526&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/193812/original/file-20171108-14209-1wy0fqj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=661&fit=crop&dpr=1 754w, https://images.theconversation.com/files/193812/original/file-20171108-14209-1wy0fqj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=661&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/193812/original/file-20171108-14209-1wy0fqj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=661&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Altruists have stronger-than-average structural connections between the amygdala and periaqueductal gray, the parts of the brain shown here.</span>
<span class="attribution"><span class="source">Katherine O'Connell</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Understanding altruism</h2>
<p>To be sure, more studies will have to be done to confirm our results before we can be sure how the offspring care neural network contributes to human altruism.</p>
<p>But our findings reinforce earlier neuroscience research that found that the amygdala and periaqeuductal gray, and communication between them, play an important role in caring for distressed and vulnerable others across all mammals – including humans.</p>
<p>These findings also build on our own prior research with altruistic kidney donors. In those earlier studies, we detected <a href="https://doi.org/10.1073/pnas.1408440111">stronger amygdala responses</a> when the donors glimpsed the faces of people who were feeling fear and that while altruistic kidney donors value friends and family as others do, they <a href="http://rdcu.be/rJ93">tend to be more generous</a> toward strangers.</p>
<p>Our study of the brains of real-world altruists backs up these theories. Caring about someone you have never met, what we learned suggests, may have a lot in common with caring about the people you love. </p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/BZBHr4Pg5Wd/?taken-by=selenagomez","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p><img src="https://counter.theconversation.com/content/86271/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>A grant from the John Templeton Foundation supported research on the neuroscience of altruism conducted by Kristin Brethel-Haurwitz and her colleagues at Georgetown University.</span></em></p>Caring about someone you have never met, this new brain research suggests, may have a lot in common with caring about the people you love.Kristin Brethel-Haurwitz, Postdoctoral Researcher in Cognitive Neuroscience, University of PennsylvaniaLicensed 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/819422017-08-30T20:05:56Z2017-08-30T20:05:56ZExplainer: what is chronic kidney disease and why are one in three at risk of this silent killer?<figure><img src="https://images.theconversation.com/files/182897/original/file-20170822-5178-7hj97i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If you have high blood pressure, smoke or have diabetes, you're at risk of chronic kidney disease.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/548566606?src=x-GEGjPymnWjtBM2loJSTw-1-7&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>A 42-year-old man – a father, a husband, a son – has come to the emergency department with a splitting headache. It’s been there for months, slowly getting worse. Today it’s unbearable. </p>
<p>He has no significant past medical history to explain the headaches and takes no regular medications. But he smokes and his <a href="https://www.heartfoundation.org.au/your-heart/know-your-risks/blood-pressure/is-my-blood-pressure-normal">blood pressure</a> is sky high – 210/100 mmHg (good blood pressure is <a href="https://www.heartfoundation.org.au/your-heart/know-your-risks/blood-pressure/is-my-blood-pressure-normal">considered under</a> 120/80 mmHg).</p>
<p>A series of investigations including blood and urine tests reveal significant kidney damage – stage four chronic kidney disease. Stage five kidney disease would mean he needs dialysis or a kidney transplant. This is serious.</p>
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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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<p>Kidney disease is silent. Currently <a href="http://kidney.org.au/cms_uploads/docs/state-of-the-nation--kidney-health-week-2016--chronic-kidney-disease-hot-spots.pdf">one in ten Australian adults</a> have evidence of chronic kidney disease, with many unaware of it. It’s not <a href="http://www.aihw.gov.au/chronic-kidney-disease/what-is-ckd/">until 90%</a> of kidney function is lost that symptoms become apparent.</p>
<p>While symptoms like nausea, loss of appetite, lethargy and poor concentration are hallmarks of kidney failure, they are quite non-specific. Most people will have had these symptoms at some stage.</p>
<p>Fluid retention - swollen ankles and puffiness around the eyes - can be a marker of kidney disease. That’s because the kidneys are key to regulating fluid in the body and a diseased kidney cannot do that as efficiently.</p>
<p><a href="https://theconversation.com/blood-tests-and-diagnosing-illness-what-can-blood-tell-us-about-whats-happening-in-our-body-80327">Doctors confirm kidney disease</a> using a blood and urine test. The blood test (serum electrolyes) gives you a “percent of kidney function”. And the urine test (urinanalysis) tests for blood and protein in the urine, markers of damage and inflammation.</p>
<h2>What happens when your kidneys don’t work well?</h2>
<p>Kidneys are responsible for removing fluid and waste from your body that accumulate each day. </p>
<p>But when kidney function declines, fluid accumulates in the body. So, your legs can swell, and fluid can build up in the lungs, making it difficult to breathe.</p>
<p>Impaired kidneys also mean you cannot efficiently get rid of waste products, so these accumulate too. Such toxins in the body account for much of the symptoms of fatigue, nausea and loss of appetite.</p>
<p>Loss of kidney function and the build-up of fluid may lead to high blood pressure, which in turn may further speed up decline in kidney function. High pressures pulsating through the kidney damages their delicate filters and cause scar tissue to form.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/182898/original/file-20170822-5328-19avxg4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/182898/original/file-20170822-5328-19avxg4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/182898/original/file-20170822-5328-19avxg4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=325&fit=crop&dpr=1 600w, https://images.theconversation.com/files/182898/original/file-20170822-5328-19avxg4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=325&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/182898/original/file-20170822-5328-19avxg4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=325&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/182898/original/file-20170822-5328-19avxg4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=408&fit=crop&dpr=1 754w, https://images.theconversation.com/files/182898/original/file-20170822-5328-19avxg4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=408&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/182898/original/file-20170822-5328-19avxg4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=408&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Loss of kidney function can lead to high blood pressure, which in turn can further speed up kidney disease.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/623268185?src=hOUHJYLNjSQ_6L_Pk8mtqA-1-26&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>People with chronic kidney disease are <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/216833">20-times</a> more likely to die from a heart attack or stroke. So, many people will die from heart disease before reaching end-stage kidney disease, the final stage of chronic kidney disease in which the kidneys no longer function well enough to meet your body’s daily needs.</p>
<p>When healthy, kidneys secrete the hormone erythropoietin (or EPO), which stimulates red blood cells to form. But as kidney function declines, production of this hormone is impaired and anaemia (a low red blood cell count), follows. So, patients need to be injected with EPO to restore their red blood cell count. </p>
<p>The kidneys are also pivotal in maintaining calcium and phosphate levels in the blood. As phosphate builds up, severe itchiness can develop; calcium levels drop and, without attention, this can lead to fragile bones.</p>
<h2>Who is at risk?</h2>
<p>Kidney disease is related to and caused by a number of different factors and conditions. As many as <a href="http://kidney.org.au/your-kidneys/prevent/check-your-kidneys">one in three Australians</a> have at least one risk factor for chronic kidney disease.</p>
<p>Indigenous Australians are at risk with this risk increasing the more remotely they live. People with a family history of kidney disease are particularly vulnerable to it. Diabetes, high blood pressure, smoking, obesity, high cholesterol, heart disease, stroke and being over 60 are additional risks.</p>
<p>The number of people with chronic (long-term) kidney disease is forecast to increase by <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129547200">60% by 2020</a>, largely due to diabetes and obesity becoming more common.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/kidney-disease-in-aboriginal-australians-perpetuates-poverty-15031">Kidney disease in Aboriginal Australians perpetuates poverty</a>
</strong>
</em>
</p>
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<p>Anyone who has had an episode of acute kidney injury is also at risk of later developing chronic kidney disease. </p>
<p>Less common causes of kidney disease are inflammation of the kidney, or glomerulonephritis. We don’t known what causes many forms of glomerulonephritis. But sometimes an infection triggers it.</p>
<p>For instance, while streptococcal infection that leads to glomerulonephritis is rarely seen in non-Indigenous people, this is a <a href="https://espace.library.uq.edu.au/view/UQ:275287/UQ275287_preprint.pdf">significant concern</a> in Indigenous Australian children living in remote communities, with 15-20% suffering from it.</p>
<p>In other cases, someone’s own immune system damages the kidney tissue (an autoimmune disease) to cause glomerulonephritis. This may be triggered by an infection such as hepatitis B or C or from a yet unidentified source.</p>
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<strong>
Read more:
<a href="https://theconversation.com/dr-g-yunupingus-legacy-its-time-to-get-rid-of-chronic-hepatitis-b-in-indigenous-australia-81672">Dr G. Yunupingu's legacy: it's time to get rid of chronic hepatitis B in Indigenous Australia</a>
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<p>Taking certain medications for a long time can cause or hasten progressive kidney decline. That’s what happened with <a href="https://medicalsciences.med.unsw.edu.au/node/302500715">Bex</a>, the painkiller popular in the 1960s, advertised widely with the slogan:</p>
<blockquote>
<p>Have a cup of tea, a Bex and a good lie down.</p>
</blockquote>
<p>Bex was ultimately associated with <a href="http://www.news.com.au/national/cancer-council-nsw-bex-powder-killed-more-than-pain/news-story/7637adcfe85ce4aa20e1bc267b8113ac">serious kidney injury (and cancer)</a> and is no longer in use.</p>
<p>Anti-inflammatory medications are the current curse of people with kidney disease as they restrict blood flow to the kidney, possibly leading to acute kidney failure.</p>
<p>Other less well known causes for kidney disease include the growth of cysts on the kidneys (polycystic kidney disease), congenital abnormalities of the
kidney or urinary tract and damage due to the backward flow of urine into the kidneys (reflux nephropathy).</p>
<h2>How is kidney disease managed?</h2>
<p>Chronic kidney disease cannot be cured. And once started, it’s difficult to halt its progression. So, awareness of kidney disease and its <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4089661/">early detection</a> offers the best opportunity to alter it course.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/183685/original/file-20170829-1590-1ltn0a7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/183685/original/file-20170829-1590-1ltn0a7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183685/original/file-20170829-1590-1ltn0a7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183685/original/file-20170829-1590-1ltn0a7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183685/original/file-20170829-1590-1ltn0a7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183685/original/file-20170829-1590-1ltn0a7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183685/original/file-20170829-1590-1ltn0a7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183685/original/file-20170829-1590-1ltn0a7.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">The number of people needing dialysis in Australia is forecast to increase.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Making lifestyle changes including losing weight, stopping smoking, controlling blood sugar levels and making healthy dietary choices cannot be emphasised enough as these factors slow progression of kidney disease, mainly through improved blood pressure control.</p>
<p>Reducing levels of protein in the diet <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4089661/">may slow disease progression</a>. However, people can have trouble sticking to a low-protein diet.</p>
<p>People with chronic kidney disease also need to be monitored, not just for declining kidney function but also so they don’t develop complications such as anaemia, bone disease, malnutrition and heart disease.</p>
<h2>Dialysis or a transplant is the only hope for some</h2>
<p>Concern of progressive kidney decline to end-stage kidney disease is real. It’s at this point that some people will receive dialysis or a kidney transplant, which is estimated to <a href="http://kidney.org.au/cms_uploads/docs/state-of-the-nation--kidney-health-week-2016--chronic-kidney-disease-hot-spots.pdf">cost Australia A$1 billion a year</a>.</p>
<p>And the number of people requiring dialysis or a kidney transplant is forecast to increase by <a href="http://kidney.org.au/cms_uploads/docs/state-of-the-nation--kidney-health-week-2016--chronic-kidney-disease-hot-spots.pdf">60% by the year 2020</a>.</p>
<p><a href="https://www.healthdirect.gov.au/dialysis">Dialysis</a> is needed when kidney disease has progressed to the point where toxins cannot be cleared from the blood and fluid builds up. A machine essentially cleans the blood of excess wastes and removes fluid. Although a lifesaving treatment, its demands and impact on quality of life are significant.</p>
<p>Compared to the general population, the life expectancy of people on dialysis is significantly compromised. The <a href="http://kidney.org.au/cms_uploads/docs/state-of-the-nation--kidney-health-week-2016--chronic-kidney-disease-hot-spots.pdf">five-year survival</a> on dialysis is only 46% - a much grimmer outlook compared to a lot of common cancers.</p>
<p>End-stage kidney disease can also lead to a kidney transplant. But there continues to be a shortage of donor organs. In 2015, despite 949 transplants being performed, <a href="http://www.anzdata.org.au/anzdata/AnzdataReport/39thReport">over 1,000 people</a> remained on the transplant waiting list. The median time to receive a transplant was 2.4 years then. An increasing demand coupled with static supply suggests this waiting time will increase substantially.</p>
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<strong>
Read more:
<a href="https://theconversation.com/a-quarter-of-kidney-donors-are-living-what-you-need-to-know-to-be-a-donor-78041">A quarter of kidney donors are living: what you need to know to be a donor</a>
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<p>Transplantation improves both quality and quantity of life compared to those who remain on dialysis. However the life expectancy of people who have had a transplant <a href="http://www.anzdata.org.au/v1/report_2016.html">still lags behind</a> an age matched population. People who have had a kidney transplant are at increased risk of heart disease and cancer afterwards.</p>
<p>So, if you are the one in three Australians with at least one risk factor for kidney disease, discuss this with your doctor. It could save your life.</p><img src="https://counter.theconversation.com/content/81942/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karen Dwyer is a member of the Australian and New Zealand Society of Nephrology (ANZSN) and the Transplantation Society of Australia and New Zealand (TSANZ).</span></em></p><p class="fine-print"><em><span>Ashani Lecamwasam is a member of the Australian New Zealand Society of Nephrology (ANZSN) and member of the International Society of Nephrology (ISN).
Currently on a partial PhD scholarship through the Medical Faculty of Deakin University.</span></em></p>The number of Australians with chronic kidney disease is set to rise, but there’s no cure for most people. Here’s what you need to know about this silent killer.Karen Dwyer, Deputy Head, School of Medicine, Deakin UniversityAshani Lecamwasam, PhD student, Faculty of Health, School of Medicine, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/818932017-08-03T02:48:37Z2017-08-03T02:48:37ZWeekly Dose: methylprednisolone, a drug for treating inflammation but not rare kidney disease<figure><img src="https://images.theconversation.com/files/180649/original/file-20170802-11374-1dpcm62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Methylprednisolone, the corticosteroid that's used to treat serious asthma attacks, works by reducing inflammation.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/518348707?size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Methylprednisolone is a prescription drug used to treat conditions involving inflammation, like asthma, arthritis, gout, tendinitis, transplant rejection, allergic reactions, and the skin conditions eczema and psoriasis.</p>
<p>It’s in the news because doctors have been trialling the drug to see if it helped treat a rare kidney condition called IgA nephropathy, also known as <a href="http://kidney.org.au/cms_uploads/docs/rrc-iga-nephropathy.pdf">Berger’s disease</a>.</p>
<p>A study <a href="http://dx.doi.org/10.1001/jama.2017.9362">published this week</a> reported an international trial of oral methylprednisolone involving 262 patients (including Australians) was stopped early due to safety concerns. Although the drug resulted in an almost three fold lower risk of kidney failure, there was an almost five fold higher risk of serious infection. The researchers reported two patients had died from these trial-related infections.</p>
<p><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1415463#t=article">Other clinical trials</a> have also reported higher rates of adverse effects, like serious infections, from oral use of methylprednisolone when treating IgA nephropathy.</p>
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<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>
</strong>
</em>
</p>
<hr>
<p>However, for people prescribed the drug for other reasons side effects are rare. And methylprednisolone should not to be confused with similarly sounding medicines in the same drug family, like prednisolone or prednisone.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=812&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=812&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=812&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1021&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1021&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1021&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>Use and formulations</h2>
<p>Methylprednisolone is a type of <a href="http://www.medicinenet.com/corticosteroids-oral/article.htm">corticosteroid</a>, the same drug family containing hydrocortisone, dexamethasone, prednisone, prednisolone and triamcinolone.</p>
<p>Corticosteroids are not the same as <a href="https://www.drugabuse.gov/publications/drugfacts/anabolic-steroids">anabolic steroids</a>, which some athletes and body builders use illegally to build muscle and help performance.</p>
<p>Corticosteroids suppress inflammation and the immune system by <a href="https://www.yourgenome.org/facts/what-is-gene-expression">regulating how genes are expressed</a>.</p>
<p>In Australia, methylprednisolone is indicated for acute severe asthma, arthritis (including both rheumatoid and osteoarthritis), <a href="http://www.move.org.au/Conditions-and-Symptoms/Gout?gclid=CjwKCAjwzYDMBRA1EiwAwCv6JrreALKZbjLvlHyyzXDXWtCMQOCcowEcp8TXDGQdja2F9fdUaZrfMBoCAxMQAvD_BwE">gout</a> (an arthritis-like condition due to the build up of uric acid in the bloodstream), <a href="http://www.webmd.com/fitness-exercise/arthritis-tendinitis#1">tendinitis</a>, acute transplant rejection, and some autoimmune diseases, like allergies, <a href="https://www.allergy.org.au/patients/skin-allergy/eczema">eczema</a> and <a href="http://www.psoriasisxplained.com.au/psoriasis-app-page/?utm_source=Adwords&utm_medium=Advert&utm_campaign=launch&gclid=CjwKCAjwzYDMBRA1EiwAwCv6JjRBx5XwiFqZA1GsBO0BCy0UJxbKAu9WRRk1c54r0Dl0u6lQgUAp0hoCTS0QAvD_BwE">psoriasis</a>.</p>
<p>Methylprednisolone is also on the <a href="http://www.who.int/topics/essential_medicines/en/">World Health Organisation’s list of essential medicines</a> that:</p>
<blockquote>
<p>… satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness.</p>
</blockquote>
<p>The most <a href="http://www.who.int/medicines/publications/essentialmedicines/20th_EML2017.pdf?ua=1">up-to-date list</a> published in March 2017 includes methylprednisolone for the treatment of acute lymphoblastic leukaemia. The list also includes the related drug, <a href="https://beta.nhs.uk/medicines/prednisolone/">prednisolone</a>, to treat different types of leukaemia and lymphoma.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-can-go-wrong-in-the-blood-a-brief-overview-of-bleeding-clotting-and-cancer-76400">What can go wrong in the blood? A brief overview of bleeding, clotting and cancer</a>
</strong>
</em>
</p>
<hr>
<p>While methylpredisolone is available in other countries in tablet form, in Australia it is only available by prescription as an injection or as skin cream or ointment. As an <a href="http://www.pharmexec.com/what-happens-when-product-loses-its-patent">off-patent</a> medicine, it is available from a variety of companies in different brands. </p>
<h2>Safety and side effects</h2>
<p>The <a href="https://amhonline.amh.net.au/">Australian Medicines Handbook</a> (subscription required) says side effects should be rare (have a rate less than 0.1%), the most common of which is liver toxicity. It is safe for women to use immediately after breastfeeding, but they should avoid using it within four hours before breastfeeding. This is because very small amounts of the drug can be transferred into the milk.</p>
<p><a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2014-CMI-02603-1">Other side-effects</a> depend on the dose and the formulation used. When used on the skin, side effects can include: thinning of the skin, appearance of fine blood vessels, acne, infection of hair follicles, excessive or unwanted hair growth, redness around the mouth, skin discolouration and allergic skin reactions.</p>
<h2>In a nutshell</h2>
<p>Methylprednisolone is an effective and safe medicine for treating inflammatory and autoimmune conditions. Recent studies into its use for IgA nephropathy have indicated an unacceptably high risk of serious infection. </p>
<p>Despite this, you should not be at risk if you use the medication as directed and prescribed by your doctor. However, if you have any concerns, you should speak to your local pharmacist.</p><img src="https://counter.theconversation.com/content/81893/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is affiliated with the Royal Australian Chemical Institute.</span></em></p>A trial of methylprednisolone in kidney patients was halted recently because of safety concerns. But this doesn’t affect people taking the drug for asthma, arthritis or other inflammatory conditions.Nial Wheate, BPharm Coordinator and Senior Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/790412017-07-25T00:39:42Z2017-07-25T00:39:42ZThe most used method of measuring blood pressure is often inaccurate, study finds<figure><img src="https://images.theconversation.com/files/174659/original/file-20170620-24878-ozsxsy.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3494%2C2326&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">You've probably had your blood pressure measured using the "cuff method". But how accurate was the reading? </span> <span class="attribution"><span class="source">from shutterstock.com </span></span></figcaption></figure><p>The most common method of measuring blood pressure is often inaccurate, a new study has found. This could mean people at risk of serious conditions such as heart disease are missing diagnosis and potentially life-saving treatment.</p>
<p>The so-called “cuff method” involves strapping an inflatable cuff over the upper arm to temporarily cut off the blood supply; then calculating the blood pressure once the cuff is relaxed.</p>
<p>In our study, published in the <a href="http://www.onlinejacc.org/content/70/5/572?sso=1&sso_redirect_count=1&access_token=">Journal of the American College of Cardiology</a>, we found the method, which is more than a century old, is inaccurate when monitoring people with mid-range blood pressure. This is the range <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62036-3/abstract">most common</a> among people worldwide. </p>
<p><a href="http://circ.ahajournals.org/content/111/5/697.long">Accurate measurement</a> of blood pressure is regarded among the most important of all medical tests. A misdiagnosis of low blood pressure can be a missed opportunity for lowering a person’s risk of cardiovascular disease, which often presents as a stroke, heart attack or kidney disease. A misdiagnosis of high blood pressure, on the other hand, could lead to people being prescribed unnecessary medication. </p>
<h2>What is blood pressure?</h2>
<p>Blood pressure is the force exerted in the large arteries – vessels that carry blood away from the heart – with every heartbeat. Blood pressure measurement provides a high (systolic) and a low (diastolic) value. The high value represents the peak pressure during heart contraction; the low value represents the pressure during heart relaxation.</p>
<p>Healthy levels of blood pressure are typically <a href="https://www.heartfoundation.org.au/images/uploads/publications/PRO-167_Hypertension-guideline-2016_WEB.pdf">less than 120/80 mmHg</a> (the 120 mmHg is systolic, and 80 mmHg diastolic). <a href="http://www.sciencedirect.com/science/article/pii/S0140673602119118?via%3Dihub">Decades of research</a> clearly tell us if a person’s blood pressure is raised they are at higher risk of cardiovascular disease. The higher the blood pressure, the higher the risk.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/174404/original/file-20170619-5835-16multz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/174404/original/file-20170619-5835-16multz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=621&fit=crop&dpr=1 600w, https://images.theconversation.com/files/174404/original/file-20170619-5835-16multz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=621&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/174404/original/file-20170619-5835-16multz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=621&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/174404/original/file-20170619-5835-16multz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=781&fit=crop&dpr=1 754w, https://images.theconversation.com/files/174404/original/file-20170619-5835-16multz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=781&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/174404/original/file-20170619-5835-16multz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=781&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Blood pressure readings include a systolic and a diastolic value, with the normal healthy range less than 120/80 mmHg.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>About one in three adults <a href="https://www.heartfoundation.org.au/about-us/what-we-do/heart-disease-in-australia/high-blood-pressure-statistics">have high blood pressure</a>. <a href="http://jamanetwork.com/journals/jama/article-abstract/195419">Lifestyle factors</a> such as regular exercise, normal body weight and healthy dietary choices, as well as <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01225-8/abstract">medications</a>, can lower blood pressure and prevent cardiovascular disease. </p>
<p>Although there are many factors to consider when assessing if someone has high blood pressure, the conventional threshold at which doctors might consider giving medication to lower pressure is 140/90 mmHg. </p>
<h2>How is blood pressure measured?</h2>
<p>The method to measure blood pressure is based on a technique <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1543468/">invented in 1896</a>, then refined in 1905, but the basic principal has remained virtually unchanged.</p>
<p>A broad cuff is placed over the upper arm and inflated until the main artery in the arm is completely occluded and blood flow is stopped. The cuff is then slowly deflated until blood flow returns into the lower arm. </p>
<p>A series of signals can then be measured that represent the systolic and diastolic blood pressure. These are measured by either listening with a stethoscope or, more often, using <a href="http://circ.ahajournals.org/content/111/5/697.long">automated</a> devices.</p>
<h2>Our study</h2>
<p>It’s uncertain whether cuff blood pressure accurately measures the pressure in the arteries of the arm or the major artery just outside the heart, called the aorta. This is important as <a href="https://academic.oup.com/eurheartj/article-abstract/11/2/138/503539/Nitroglycerin-has-more-favourable-effects-on-left?redirectedFrom=PDF">blood pressure readings can be different</a> in these two spots – a potential difference of 25 mmHg or more. </p>
<p>The central aorta blood pressure is a <a href="https://academic.oup.com/eurheartj/article/31/15/1865/690304/Prediction-of-cardiovascular-events-and-all-cause">better indicator of the pressure</a> experienced by organs, such as the heart and brain, so it is more clinically relevant.</p>
<p>The possibility of big blood pressure differences between the arm and the aorta could result in <a href="http://hyper.ahajournals.org/content/early/2013/09/23/HYPERTENSIONAHA.113.02001">very different clinical decisions</a> on diagnosis and treatment. So it is important to resolve the uncertainty as to what cuff blood pressure actually measures. </p>
<p>We retrieved data from studies from the 1950s until now that compared cuff blood pressure of more than 2,500 people with that of the gold standard method, called invasive blood pressure. Here, a catheter that measures pressure is inserted inside the artery either at the arm (same site as the cuff) or at the aorta.</p>
<p>Readings from this method were used as a reference and compared with those of the cuff method to determine the accuracy of cuff measurements.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/174623/original/file-20170620-9968-fzg7i8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/174623/original/file-20170620-9968-fzg7i8.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=495&fit=crop&dpr=1 600w, https://images.theconversation.com/files/174623/original/file-20170620-9968-fzg7i8.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=495&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/174623/original/file-20170620-9968-fzg7i8.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=495&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/174623/original/file-20170620-9968-fzg7i8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=623&fit=crop&dpr=1 754w, https://images.theconversation.com/files/174623/original/file-20170620-9968-fzg7i8.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=623&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/174623/original/file-20170620-9968-fzg7i8.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=623&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Research has found there can be significant differences between the blood pressure measured in the arm and in the aorta.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<h2>What did we find?</h2>
<p>Cuff blood pressure had reasonable accuracy compared with the reference standard, at either the arm or aorta, among people with low cuff blood pressure (lower than 120/80 mmHg) and high cuff blood pressure (the same or higher than 160/100 mmHg). These people are at the extreme ends of the blood pressure risk spectrum. </p>
<p>We found the accuracy when compared to invasive blood pressure was up to 80%.</p>
<p>But for the rest of the population with blood pressure in the middle range – systolic 120 to 159, and diastolic 80 to 99 mmHg – accuracy compared with invasive blood pressure at the arm or the aorta was quite low: only 50% to 57%.</p>
<h2>Why is this important?</h2>
<p>If people have their blood pressure measured using the cuff method and the values are either low (under 120/80 mmHg) or high (over 160/100 mmHg), we can have reasonable confidence the values are a good representation of the true (invasive) blood pressure.</p>
<p>But for people whose blood pressure is in the <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62036-3/abstract">most common mid-range</a> of 120 to 160 mmHg systolic or 80 to 100 mmHg diastolic, there is much less certainty as to whether the cuff blood pressure is truly representative of the actual blood pressure.</p>
<p>Our findings do not mean people should stop taking their medication or stop having their blood pressure measured using the cuff device. While this study reveals accuracy issues, the <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01225-8/abstract">evidence from many</a> <a href="http://www.sciencedirect.com/science/article/pii/S0140673603147393?via%3Dihub">large clinical trials</a> <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61212-5/abstract">clearly shows</a> taking medication to lower blood pressure from high levels reduces the chances of stroke, heart attack and vascular disease. </p>
<p>Cuff blood pressure measurements are still useful, but we could help more people if we could measure blood pressure more accurately. The problem is that some people in the mid blood pressure range may fall through the diagnosis cracks.</p>
<p>Until the accuracy standards of pressure-measuring devices are improved, the best available confirmation of blood pressure levels comes from an average of many repeated measures over time. This is better than one or two measures, as is often the way in busy daily clinical practice, and was closest to the method examined in this study.</p>
<p>People can have repeated measures of blood pressure undertaken in consultation with their general practitioners or at specialist centres. These can include <a href="http://www.racgp.org.au/afp/2016/januaryfebruary/how-to-measure-home-blood-pressure-recommendations-for-healthcare-professionals-and-patients/">self-measured home</a> blood pressure, <a href="http://aabpmc.org/attachments/Head_J_Hypertens_2012.pdf">24-hour ambulatory</a> blood pressure and <a href="http://hyper.ahajournals.org/content/55/2/195.long">automated unobserved</a> blood pressure.</p><img src="https://counter.theconversation.com/content/79041/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Sharman is a medical research scientist and has received funding to undertake blood pressure research from government, industry and non-government organisations. This includes fellowships and grant funding from the National Health and Medical Research Council of Australia, grants from the National Heart Foundation of Australia, Diabetes Australia Research Trust and the High Blood Pressure Research Council of Australia. Research funding has also been provided by blood pressure device manufacturers including AtCor Medical, IEM GmbH and Pulsecor.</span></em></p>A blood pressure test can say a lot about your health, but new research says not all readings are correct.James Sharman, Professor of Medical Research and Deputy Director, Menzies Institute for Medical Research., University of TasmaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/780412017-06-18T19:53:14Z2017-06-18T19:53:14ZA quarter of kidney donors are living: what you need to know to be a donor<figure><img src="https://images.theconversation.com/files/172669/original/file-20170607-11330-15z6fwj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People undergoing dialysis would have a better quality of life if they had a kidney transplant.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>At any one time, <a href="http://www.donatelife.gov.au/sites/default/files/Facts%20and%20Stats%20Fact%20Sheet%20-Feb%202017.pdf">more than 1,400 Australians</a> are on an organ transplant waiting list. The most common organs in demand are kidneys, followed by the liver and lung. </p>
<p>While the number of deceased organ donors in Australia has <a href="http://www.donatelife.gov.au/sites/default/files/Australian%20Donation%20and%20Transplantation%20Activity%20Report%202016.pdf">doubled since 2009</a>, rates of live donor transplantation – where a person donates one kidney or, rarely, a portion of their liver – are relatively static.</p>
<p>In 2016, 265 Australians <a href="http://www.donatelife.gov.au/sites/default/files/OTA%20Factsheet%20-%20Living%20Donation%20and%20AKX_05%20V2.pdf">donated a kidney</a> to a friend or relative, making up about a quarter of all kidney transplants. Live donor liver transplants are rare (only two occurred in Australia last year) and often donated from a parent to a child.</p>
<iframe src="https://datawrapper.dwcdn.net/DbcyM/2/" scrolling="no" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="403"></iframe>
<h2>Who needs a kidney?</h2>
<p>Kidneys filter toxins from the blood and regulate fluid balance. When kidneys are functioning so poorly a person needs dialysis to do the work for them, we say the person has “end stage kidney disease”. </p>
<p>In 2015, there were <a href="http://www.anzdata.org.au/brochures/brochure_2016v4.0_20170102.pdf">nearly 12,500 Australians</a> undergoing dialysis. End stage kidney disease often occurs gradually and is commonly a result of diabetes, high blood pressure and types of autoimmune kidney disease called glomerulonephritis. </p>
<p>Many patients with end stage kidney disease <a href="https://www.ncbi.nlm.nih.gov/pubmed/10580071">would live longer</a> and have a better quality of life following a kidney transplant compared to staying on dialysis. But the shortage of donor organs means preference is given to those likely to have better outcomes and reasonable life expectancy after transplantation. </p>
<p>Australian <a href="http://www.donatelife.gov.au/sites/default/files/TSANZ%20Clinical%20Guidelines%20for%20Organ%20Transplantation%20from%20Deceased%20Donors_Version%201.0_April%202016.pdf">guidelines require</a> patients have an 80% likelihood of survival at five years after transplantation to be eligible for the wait list. Tests are done to ensure the potential transplant recipient has acceptable heart health to undergo the operation, and that there are no cancers or infections that will be made worse by medications that suppress the immune system (“anti-rejection drugs”). </p>
<p>The donor’s kidney function is assessed, and the risk of them developing a kidney disease in future is evaluated. This is both to ensure the donor enjoys good kidney function after removal of their kidney, and that the recipient receives a well-functioning kidney. Donors also routinely undergo psychological evaluation.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.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">Kidneys work by filtering out toxins from the blood and regulating a person’s fluid balance.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Where do donors come from?</h2>
<p>A potential recipient is encouraged to ask friends and family if they would be willing to donate a kidney. If not, the potential recipient can go on the deceased donor list to wait for a compatible kidney.</p>
<p>People often donate organs to their blood relatives, but it’s also possible to give a kidney to someone who is not related, such as a spouse or close friend. Some people <a href="https://www.ncbi.nlm.nih.gov/pubmed/23600791">use social media</a> to solicit organ donations, and some have been successful. Specific matching sites also exist in countries such as the US, with the aim of getting healthy volunteers to altruistically donate a kidney. </p>
<p>But methods of acquiring a donor who is previously unknown to the recipient <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2011.03765.x/full">are controversial</a> and generally discouraged in Australia for ethical reasons. In Australia, a person could donate a kidney altruistically to someone on the waiting list. In this situation, the donor and recipient do not find out each other’s identity. </p>
<p>The Australian <a href="http://www.donatelife.gov.au/about-us/kidney-exchange-programme">paired-exchange program</a> allows greater numbers of live donor transplants to occur through paired kidney donor swaps. For example, if Jane’s potential donor John is unsuitable to give her a kidney because of matching issues, and Bob’s potential donor Barbara is unsuitable to give him a kidney, Barbara can donate a kidney to Jane, and John can donate a kidney to Bob. </p>
<p>Last year, an altruistic donation <a href="http://www.abc.net.au/news/2015-12-16/altruistic-kidney-donation-saves-seven-lives-in-one-day/7032292">kicked off a domino chain</a> of six paired-exchange donations, with the final kidney from a paired exchange donor going to a patient on the deceased donor waiting list.</p>
<p>Live donors must be over 18, but it’s preferable if they are over 30 as older age at donation minimises their chance of developing an unexpected condition that threatens their kidney health down the track. </p>
<h2>Do you need to be a ‘match’?</h2>
<p>Different people have different combinations of proteins on the surface of their cells that allow the immune system to determine what is part of the body (self) and what are foreign agents (non-self). These proteins are determined by genes called human leukocyte antigens (HLA). </p>
<p>The immune system is designed to recognise self HLA so it doesn’t target its own tissues. It is <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1399-0012.2012.01654.x/abstract;jsessionid=88CCDD1F42E1C2E3747A57660F0D7DA7.f02t04">advantageous to have high degrees</a> of HLA match (also called tissue match) between a donor and recipient, but it’s not absolutely necessary. A closer degree of HLA match means the immune system is less likely to reject the kidney.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.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>
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<span class="caption">Blood relatives are most likely to donate an organ.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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</figure>
<p>Usually people need to be the same blood group to donate a kidney. But some living donor transplants can occur across different blood groups. These are called ABO incompatible transplantation. For this to happen, the recipient must <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5338156">undergo plasmapheresis</a> – a process in which antibodies (proteins that attack foreign invaders) are removed from their blood and they are given strong medication to suppress the immune system. </p>
<p>Only people with end stage kidney disease can be listed for deceased donor transplantation. But living donor transplants can be “pre-emptive”, taking place before the need for dialysis. </p>
<p>This has advantages, such as not having to take time away from work or study to do dialysis. People who undergo pre-emptive transplantion have a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384698/">lower risk of death</a> and loss of kidney transplant function compared to people who spend time on dialysis before getting a transplant.</p>
<h2>Are there risks to donors?</h2>
<p>Kidney donors usually remain in hospital for a few days after surgery, which is usually conducted as “keyhole surgery”. This involves a camera and instruments being inserted through a small incision and the kidney being pulled out through it.</p>
<p>Full recovery time is around six to eight weeks. Complications, such as bleeding or blood clots, <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/20215610/">related to the operation</a> are rare. There is a very <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/20215610/">small risk of death</a> around the time of the operation, estimated at 3.1 in 10,000 donors, or 0.031%. Although the patient populations differ, this is less than for other minor operations such appendicectomy (estimated in a <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/27535664/">recent study</a> at 0.21%). </p>
<p>There is no long-term <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/20215610/">increased risk of death</a> or heart disease. Donating a kidney is likely to cause a <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/16880460/?i=5&from=/11502974/related">slight increase in blood pressure</a> over time. </p>
<p>After donation, the remaining kidney increases its capacity to filter blood, and <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/11502974/">kidney function usually returns</a> to 70-80% of the previous level. This is adequate, and does not result in any symptoms related to kidney disease.</p>
<p>Studies comparing kidney donors to equivalently healthy non-donors found kidney donation <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/26544982/">increases risk</a> of end stage kidney disease about three- to five-fold. But the risk is very <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/26544982/">low to begin with</a> (around 0.06% for a white US man and 0.04% for a white US woman).</p>
<p>The kidney donation experience is usually positive. In one study, 95% of <a href="http://www.ajkd.org/article/S0272-6386%2812%2900003-0/abstract">kidney donors in the US</a> rated their experience as good to excellent. They reported an improvement in their sense of meaning in life and self-esteem. But a degree of psychological stress related to donation was common, and 20% reported a financial burden. </p>
<p>The Australian government <a href="http://www.immunise.health.gov.au/internet/budget/publishing.nsf/Content/budget2017-factsheet44.htm">gives A$4.1 million to run</a> the Supporting Living Organ Donors program. This scheme includes reimbursing employers for sick leave for those who donate an organ, as well as other initiatives that aim to remove financial barriers to organ donation.</p>
<hr>
<p><em>More information about living kidney donation is available at <a href="http://www.donatelife.gov.au/donor-family-support/living-donors">Donate Life</a>, <a href="http://kidney.org.au/your-kidneys/support/organ-donation/living-donors">Kidney Health Australia</a>, and the <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/leave-for-living-organ-donors">Supporting Living Organ Donors program</a>.</em></p><img src="https://counter.theconversation.com/content/78041/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Holly Hutton is the recipient of an NHMRC postgraduate scholarship. (Grant number 1075304)</span></em></p>Many patients with end stage kidney disease would live longer and have a better quality of life with a kidney transplant compared to staying on dialysis.Holly Hutton, Nephrologist, PhD candidate at Centre for Inflammatory Diseases, Monash University., Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/756232017-04-06T19:18:02Z2017-04-06T19:18:02ZExplainer: what is rhabdomyolysis and what’s its connection to CrossFit?<figure><img src="https://images.theconversation.com/files/163994/original/image-20170405-5702-1cd4fdp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Overworking a muscle can have serious consequences for our health. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Rhabdomyolysis (often abbreviated to “rhabdo”) is a condition that causes our muscles to break down or leak, releasing the muscle cells’ contents into the bloodstream. Those contents contain a protein, myoglobin, which can cause injury to the kidneys.</p>
<p>If there is pre-existing kidney disease, this can result in kidney failure and death. Other problems include those caused by changes to blood chemicals (electrolytes), which can affect muscles, the heart and the brain. An additional consequence is compartment syndrome, where the pressure from swollen muscles can cut the blood supply, depriving tissues of their nourishment.</p>
<p>The three major symptoms of rhabdo are pain, weakness and tea-coloured urine owing to filtered myoglobin. Patients may also experience nausea and lethargy.</p>
<h2>What causes it?</h2>
<p>There are two main ways enough cells can be damaged to cause systemic problems. The first way is crush injuries from direct rupture of the cell walls. This is often associated with motor vehicle accidents and blunt trauma such as building collapse.</p>
<p>The second principal cause is from depleted energy levels in the cells. If the cells lack the energy to perform necessary functions such as maintaining the electrolyte balance, the cell walls are injured and leak. This is the type of muscle breakdown seen in elderly people who have a fall and are not found for some time, and in people following major surgery and after extreme exercise. This last cause is referred to as “exercise-induced” and “exertional” rhabdo.</p>
<p>A little more than a decade ago exertional rhabdo was rarely reported and was mostly associated with marathon runners and army training camps. However, with the popularity of high-intensity resistance training, increasing numbers of these patients are presenting to doctors and hospital emergency departments.</p>
<p>One form of high-intensity resistance training, CrossFit, seems to have a particularly strong association with exertional rhabdo online and in the popular press. <a href="http://journals.sagepub.com/doi/abs/10.1177/2165079916685568?journalCode=whsd">Studies have shown</a> the association is similar to that of other forms of high intensity training. This association was <a href="http://journal.crossfit.com/2005/10/crossfit-induced-rhabdo-by-gre.tpl">acknowledged by the program’s founder</a>, his blog on the topic also included the creepy clown motif “Uncle Rhabdo” associated with CrossFit.</p>
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<a href="https://images.theconversation.com/files/163987/original/image-20170405-5725-1lxo1o5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163987/original/image-20170405-5725-1lxo1o5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163987/original/image-20170405-5725-1lxo1o5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=751&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163987/original/image-20170405-5725-1lxo1o5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=751&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163987/original/image-20170405-5725-1lxo1o5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=751&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163987/original/image-20170405-5725-1lxo1o5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=944&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163987/original/image-20170405-5725-1lxo1o5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=944&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163987/original/image-20170405-5725-1lxo1o5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=944&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Uncle Rhabdo has been linked with the Crossfit community.</span>
<span class="attribution"><a class="source" href="http://journal.crossfit.com/2005/10/crossfit-induced-rhabdo-by-gre.tpl">Screenshot from Crossfit.com</a></span>
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<p>There is a lively online community posting selfies from hospital and who consider a rhabdo diagnosis as a badge of honour, showing their dedication to exercise.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/163990/original/image-20170405-5702-ucrwib.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163990/original/image-20170405-5702-ucrwib.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/163990/original/image-20170405-5702-ucrwib.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=929&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163990/original/image-20170405-5702-ucrwib.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=929&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163990/original/image-20170405-5702-ucrwib.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=929&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163990/original/image-20170405-5702-ucrwib.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1167&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163990/original/image-20170405-5702-ucrwib.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1167&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163990/original/image-20170405-5702-ucrwib.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1167&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sufferers posting pictures on social media.</span>
<span class="attribution"><a class="source" href="http://www.link.com">Screenshot Instarix.com</a></span>
</figcaption>
</figure>
<h2>How is it diagnosed?</h2>
<p>Diagnosis is usually based on the levels of an enzyme called creatine kinase (CK) in the blood, which is released when cells are damaged. </p>
<p>CK, which is involved in energy production and cell transport, is itself not harmful, but is a useful marker of cell destruction. </p>
<p>There is no consensus as to what level of creatine qualifies as a diagnosis. But it ranges from five times to more than 400 times the upper normal limit. </p>
<p>It’s not uncommon for those with exertional rhabdo to share stories and even boast about their CK values on social media.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/163991/original/image-20170405-5739-1j8j6z5.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163991/original/image-20170405-5739-1j8j6z5.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/163991/original/image-20170405-5739-1j8j6z5.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1027&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163991/original/image-20170405-5739-1j8j6z5.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1027&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163991/original/image-20170405-5739-1j8j6z5.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1027&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163991/original/image-20170405-5739-1j8j6z5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1291&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163991/original/image-20170405-5739-1j8j6z5.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1291&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163991/original/image-20170405-5739-1j8j6z5.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1291&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">CK levels aren’t something to boast about on social media.</span>
<span class="attribution"><a class="source" href="http://instarix.com/tag/rhabdomyolysis">Screenshot, instarix</a></span>
</figcaption>
</figure>
<p>Studies suggest younger males are more likely to develop exertional rhabdo. <a href="http://dx.doi.org/10.1016/j.jshs.2015.01.012">One suggested reason for this</a> is the higher male muscle mass. Another is that female hormones have a protective effect.</p>
<p>Our ongoing review of a decade of exertional rhabdo presentations to a leading Brisbane emergency department also noted more males than females. </p>
<p>The top three activities causing the rhabdo were gym workouts, long-distance running, and manual labour. </p>
<p>But if we take out the manual labourers, the male versus female statistics are almost equal.</p>
<h2>How dangerous is it?</h2>
<p>While rhabdo due to other causes can be fatal, exertional rhabdo without pre-existing disease normally follows quite a benign course. </p>
<p>Most people recover from exertional rhabdo relatively quickly. They require intravenous fluids and rest, and only suffer from a setback in their training. </p>
<p>However, as reported in a <a href="http://doi.org/10.1177/1941738114523544">recent review of exertional rhabdo</a>, there are rare and extreme cases where exertional rhabdo has caused kidney failure, irregular heart rhythm, and death. </p>
<h2>How is it treated?</h2>
<p>Usual treatment is by oral or IV fluids. These help the kidneys flush the myoglobin into the urine. Creatine levels are monitored until they go back to normal. </p>
<p>When there is co-existing kidney disease or the patient is otherwise unwell, dialysis (where a machine does the work of the kidneys) may be required to remove the toxic products from the blood and re-establish normal electrolytes.</p>
<h2>Is it on the rise?</h2>
<p>In our review of cases presenting to our emergency department, the number of people with exertional rhabdo each year has risen steadily since 2005. In the past five years there has been a 20-fold increase in cases compared to the previous five years. </p>
<p>We think this is a result of both changing exercise habits and increased awareness by patients and GPs. It could be that people engaging in activities that lead to exertional rhabdo are often aware of the symptoms – leading them to present to an emergency department where previously they would have recovered at home without medical intervention. </p>
<p>Doctors are also more aware of exertional rhabdo due to the increased presentations and diagnosis. The scientific literature has contributed to this with <a href="http://doi.org/10.1177/1941738114523544">two recent</a> <a href="http://dx.doi.org/10.1016/j.jshs.2015.01.012">literature reviews</a>.</p>
<p><a href="http://doi.org/10.1177/1941738114523544">Some contributory factors</a> may make someone more likely to get exertional rhabdo. These include use of amphetamines and alcohol, extreme temperatures, dehydration and infections.</p>
<p>An appreciation of the condition, knowledge of one’s limits, avoidance of the factors above, and using common sense when performing high-intensity resistance training will go a long way towards reducing your chance of seeing us in emergency.</p>
<hr>
<p><em>Update: amendments were made to the article to reflect the association between CrossFit and exertional rhabdomyolysis compared to other forms of high intensity resistance training.</em></p><img src="https://counter.theconversation.com/content/75623/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rob Eley 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>A condition where our muscles break down and leak into the bloodstream is usually caused by trauma. But high-intensity resistance training, like Crossfit, means it’s on the rise.Rob Eley, Academic Research Manager, Princess Alexandra Hospital Southside Clinical Unit, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/509382015-11-19T15:41:24Z2015-11-19T15:41:24ZExplainer: what is the kidney disorder that Jonah Lomu had?<figure><img src="https://images.theconversation.com/files/102517/original/image-20151119-18418-1ms6r53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rugby legend Jonah Lomu had a rare kidney disorder</span> </figcaption></figure><p>All Blacks rugby player Jonah Lomu <a href="https://theconversation.com/legend-hero-gentleman-jonah-lomu-changed-the-face-of-rugby-50940">has died</a>, aged 40. Lomu died of a heart attack, thought to have been a complication of the rare kidney disorder he’d been suffering from for most of his adult life. </p>
<p>The disorder, nephrotic syndrome, is a fairly rare disease with just two or three new cases <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2394708/">per 100,000 of the population</a> each year. But what exactly is it?</p>
<p>A nephron is a functioning unit within the kidney. Each nephron has a filter (called a glomerulus) and a drainpipe (a tubule), and there are about a million nephrons in a kidney, each acting in concert to clean the blood and regulate the body’s salt and water content. </p>
<p>The kidney cleans the blood over and over, at an incredible rate <a href="http://www.worldkidneyday.co.uk/kidney-facts/">of 180 litres a day</a>. Most of us have two kidneys which normally allows a lifetime’s worth of blood filtering to be performed.</p>
<h2>Nephrotic syndrome</h2>
<p>There are several diseases of the kidney where the filters of the nephron become damaged. This leads to a loss of large amounts of protein in the urine (when there should normally be very little), which leads to low blood protein levels and body swelling, known as oedema. It is this combination of symptoms and signs that is called nephrotic syndrome. It was first described in 1821, yet we are still learning new features of this condition.</p>
<p>There may be many different underlying causes, which include rare inherited forms, specific diseases of the glomerulus and secondary causes due to other medical conditions, such as diabetes, and drugs, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2218757/">such as Gold</a>, which is used to treat rheumatoid arthritis. </p>
<p>The consequences of nephrotic syndrome are severe. Complications that commonly occur include blood clotting problems (due to urinary loss of key proteins that prevent blood clotting), risk of serious infections (due to low blood protein levels) and kidney failure. </p>
<p>There are treatments for nephrotic syndrome, but no cure. Treatment often includes high dose steroid therapy and anticoagulants to prevent blood clots as well as diuretic tablets to control body swelling.</p>
<h2>Dialysis</h2>
<p>Certain underlying causes of nephrotic syndrome will eventually lead to complete kidney failure. This has devastating consequences and often means the patient has to rely on renal dialysis - where a machine does the job of the kidneys - until a kidney transplant can be performed. People can survive for many years on dialysis, but survival is often a long way from full health. </p>
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<img alt="" src="https://images.theconversation.com/files/102482/original/image-20151119-18413-1fkge46.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/102482/original/image-20151119-18413-1fkge46.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/102482/original/image-20151119-18413-1fkge46.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/102482/original/image-20151119-18413-1fkge46.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/102482/original/image-20151119-18413-1fkge46.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/102482/original/image-20151119-18413-1fkge46.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/102482/original/image-20151119-18413-1fkge46.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">People can survive for many years on dialysis.</span>
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<p>Dialysis may be performed by cleaning the blood three times a week using an artificial kidney (haemodialysis) or by using the abdominal cavity on a daily basis (peritoneal dialysis). Both treatments can be performed at home with the support of a healthcare professional.</p>
<p>However, life expectancy of a dialysis patient is severely limited, with the average being <a href="https://www.kidney.org/atoz/content/dialysisinfo">just five to ten years</a>. It is possible to live for 20 or more years on dialysis but this is the exception rather than the rule.</p>
<p>A <a href="http://www.nhs.uk/Conditions/Kidney-transplant/Pages/Introduction.aspx">kidney transplant</a> is the best treatment for kidney failure. A transplant returns life expectancy to <a href="https://www.kidneyresearchuk.org/health-information/kidney-transplantation">near normal values</a>. But transplanted kidneys tend to wear out faster than the kidneys you were born with and sometimes the original cause of nephrotic syndrome can recur after the kidney transplant. Often a second kidney transplant is needed when this happens. </p>
<p>It seems that, over several years, Lomu’s own kidneys failed and he received a transplant at the age of 29, which went on to function for the next seven years before failing. </p>
<h2>Understanding the genetic causes</h2>
<p><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4310431/pdf/sfu129.pdf">Research at Newcastle University</a> aims to understand the genetic causes of nephrotic syndrome. This is where an inherited change in a gene predisposes patients to kidney disease resulting in a protein leak. Although we are born with our set of genes, often it isn’t until adult life that these conditions appear. Knowing the underlying genetic condition can allow early detection of the disease in other family members and allow treatments to be developed. It also gives information about whether the condition will recur in a kidney transplant. </p>
<p>The Genomics England <a href="http://www.genomicsengland.co.uk/">100,000 genomes project</a>, which has been piloted at our university over the past few years, is a platform to study inherited kidney conditions such as nephrotic syndrome. Here, the genome is sequenced and analysed to identify disease causing variants. It was through this project that whole genome sequencing successfully identified the underlying genetic cause <a href="http://www.genomicsengland.co.uk/first-patients-diagnosed-through-the-100000-genomes-project/">in a Newcastle family</a> with an inherited form of nephrotic syndrome and kidney failure. </p>
<p>Knowing the underlying genetic predisposition for rare kidney disorders such as nephrotic syndrome is the starting point for developing a better understanding of the disease and developing treatments that can prevent the ongoing kidney damage that leads to kidney failure and all its devastating consequences.</p><img src="https://counter.theconversation.com/content/50938/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span><a href="mailto:john.sayer@ncl.ac.uk">john.sayer@ncl.ac.uk</a> receives funding from MRC, Kidney Research UK, Kids Kidney Research, Northern Counties Kidney Research Fund and Newcastle Hospitals Healthcare Charity. </span></em></p>All Blacks legend, Jonah Lomu, suffered from nephrotic syndrome for most of his adult life. Here is what we know about the rare condition.John Sayer, Senior clinical lecturer in nephrology, Newcastle UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/469652015-10-02T12:39:25Z2015-10-02T12:39:25ZWhy people with kidney disease opt for palliative care over dialysis<figure><img src="https://images.theconversation.com/files/95574/original/image-20150921-31500-1x74kip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hard going and not for everyone. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-171182189/stock-photo-side-view-of-male-patients-undergoing-renal-dialysis-in-hospital-room.html?src=d1tLHLyZ1rA_QkILdJngSQ-6-44">Dialysis by Shutterstock</a></span></figcaption></figure><p>End-stage renal disease is a devastating illness that happens when the kidneys stop working. It is primarily caused by diabetes and high blood pressure and is on the increase. When the kidneys fail, people have to make a stark choice: take up treatment or a transplant, or die. </p>
<p>Treatments include haemodialysis, a demanding intervention that removes waste products and fluid which accumulate in the blood when the kidneys fail. It is usually carried out in hospital three times a week, indefinitely, with each session lasting around four hours. Peritoneal dialysis is another treatment where the lining of the abdomen acts as a filter and waste is removed by means of a cleansing fluid called dialysate, washed in and out of the abdomen in cycles. It is home-based and requires a level of dexterity, training and an ability to perform the treatment steps safely. </p>
<p>Kidney transplantation is the treatment of choice, but is not available <a href="http://www.nhs.uk/conditions/kidney-disease-chronic/Pages/Treatment.aspx">to many patients</a> who are frail and often suffering other illnesses such as advanced cardiac failure. These patients would likely not survive a transplant and may also find dialysis challenging. One problem with opting for dialysis is that it can also shorten life, particularly for those people with other problems such as heart disease. It is physically and emotionally draining, causes complications such as nerve problems, anaemia, bone disease and infection. In addition, an arduous regime of three days a week on dialysis can lead to symptoms including nausea, vomiting, cramps and depression. Subsequently some people end up in very poor health and others will die. </p>
<p>This has led to a fourth choice for patients – the “no dialysis” option where people opt for a supportive and palliative care provided by the multidisciplinary team, usually in liaison with a community palliative care team and their GP. For some patients this decision is easy to make, particular those who are old and frail and don’t wish to attend hospital three times a week, but for many it is a complex, multi-faceted choice, fraught with difficulty. </p>
<p>Some patients may be advised against dialysis while others remain undecided for some time – though we know that if dialysis is not started (and we can’t always be sure it will extend life) certain death will ensue.</p>
<h2>The best care</h2>
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<p>Models of multidisciplinary care for supporting and providing palliative care for those with end-stage renal disease have developed <a href="http://www.ncpc.org.uk/sites/default/files/EndOfLifeCareInAdvancedKidneyDisease.pdf">mainly in England</a> and <a href="http://www.healthnetworks.health.wa.gov.au/modelsofcare/docs/RenalPalliativeCarePathway.pdf">in Australia</a>
and the approach <a href="http://www.isrctn.com/ISRCTN06857980">is being developed in Northern Ireland</a>. Yet we don’t know how many people are opting for this kind of care in preference to dialysis. Other parts of Europe have been slow to adopt this practice and it is likely that some people are advised to take up dialysis in order to prolong life, when it may not be the best option for them. </p>
<p>It is starting <a href="http://www.renalmed.co.uk/database/supportive-and-palliative-care">to be recognised</a> that some people with ESRD will not benefit from dialysis, particularly because it can shorten life. The difficulty is in identifying those for whom dialysis might hasten death. Increasing frailty, additional co-morbidities and poor functional status is likely to reduce your chance of effective dialysis.</p>
<p>Quality of life is another important issue. In order to help people make informed heath decisions we need to understand how quality of life is affected by treatments such as haemodialysis, peritoneal dialysis or palliative care with more research undertaken to explore these important questions – we can start by comparing these populations by following them over time in order to observe experiences and changes that happen. </p>
<p>Also key is the impact on carers when people opt out of dialysis. Carers, an often forgotten group, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23652841">may be as frail as, or frailer</a> than the person they are caring for as they are often spouses – and people opting not to use dialysis are usually in an older age-group. Sometimes carers die before the person with renal disease. </p>
<p>Many carers sacrifice social and personal health needs in order to care for their loved one and we know little about how they cope and what interventions might help improve the experience. </p>
<h2>More than counting costs</h2>
<p>The other important thing to bear in mind is that when making decisions about healthcare treatments, costs cannot be ignored in an impoverished NHS. Haemodialysis costs about £35,000 and peritoneal dialysis £20,000-a-year per patient. We do not know how much it costs to manage a patient in palliative care as this has not been studied, but it is likely to be much cheaper. That said, prices shouldn’t dictate treatment decisions but should be made based on the best interests of the patient. Many patients making decisions about treatments for ESRD are also frail, have poor performance scores <a href="http://www.renalmed.co.uk/database/supportive-and-palliative-care">and impaired cognition</a>, and may not do well on a dialysis machine. </p>
<p><a href="http://www.biomedcentral.com/1471-2369/16/104">The PACKS study</a>, of which I’m a contributor, is a welcome piece of research. The study aims to examine quality of life, decision making, costs and mortality in patients with ESRD who have opted for palliative care. It will also explore care decisions made by patients from the perspective of the patient, carer and healthcare professionals, from the start of palliative care. An economic analysis gives greater transparency of how resources are allocated for people with ESRD, and it will lay the ground work for further work which should ultimately compare patients who opt for dialysis with those who opt for palliative care. When we’re better able to compare outcomes in these two groups, it will help us make sure that the options people have are the best ones for them.</p><img src="https://counter.theconversation.com/content/46965/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Noble receives funding from an NIHR Post-Doctoral Fellowship funded by HSC Research & Development Division</span></em></p>Palliative care is a choice and for some the preferable option.Helen Noble, Lecturer in the School of Nursing and Midwifery, Queen's University BelfastLicensed as Creative Commons – attribution, no derivatives.