tag:theconversation.com,2011:/au/topics/chronic-kidney-disease-6537/articlesChronic kidney disease – The Conversation2023-05-25T00:43:48Ztag: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>
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<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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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>
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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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<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/1573292021-03-25T14:36:58Z2021-03-25T14:36:58ZKenyans with chronic kidney disease know diet is important. But many don’t follow the guidelines<figure><img src="https://images.theconversation.com/files/390388/original/file-20210318-13-fbo7ts.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Patients on dialysis struggle to follow strict diets. </span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>Chronic kidney disease is a condition that occurs when a person’s kidneys are damaged and can’t remove harmful waste from the blood. This can lead to high blood pressure and severe infections. The disease affects about <a href="https://doi.org/10.1007/978-981-13-8871-2_1">13.4%</a> of the population globally. Around <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30045-3/fulltext">1.23 million</a> people died of chronic kidney disease in 2017. </p>
<p>But this doesn’t have to be the outcome. Patients can be treated with <a href="https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/choosing-treatment">dialysis</a> to mechanically remove the waste material and excess fluid from the bloodstream. Or they could receive a kidney transplant to replace the damaged kidney. Patients and their caregivers can also <a href="https://doi.org/10.1093/ndt/gfaa336">minimise the symptoms</a> by carefully managing what they eat and drink.</p>
<p>For dialysis to succeed, it’s important to prevent overloading the kidneys. There is <a href="https://doi.org/10.1007/s11906-020-1020-1">convincing evidence</a> that following a healthy diet may lower the risk of disease complications and allow patients to live well despite having the disease.</p>
<p>The recommended diet involves keeping salt intake below <a href="https://doi.org/10.1016/j.jada.2003.12.028">5g per day</a> because damaged kidneys can’t excrete sodium very well. Retaining sodium in the body leads to fluid overload, which is bad for blood pressure and vascular health. Excluding table salt from the diet is a challenge for many patients, though. </p>
<p>It’s also important to reduce potassium content in food, because damaged kidneys aren’t good at excreting excess potassium in urine. Too much potassium can weaken the heart muscles, leading to irregular heartbeat and heart attack. One way to reduce potassium in the diet is by boiling vegetables and discarding the water. </p>
<p>Consumption of red meat is restricted as it leads to accumulation of toxic substances in the body. Patients can eat poultry and fish instead to get animal protein, but this may be expensive. Poor consumption of protein is likely to expose patients to <a href="https://doi.org/10.1053/j.jrn.2018.08.006">malnutrition</a>, which is a common feature in patients on dialysis. </p>
<p>Kenya has seen an increase in the number of patients undergoing dialysis. This is mainly because the service has become more widely <a href="https://doi.org/10.1016/j.kisu.2019.11.010">available</a>. We conducted a <a href="https://rrtjournal.biomedcentral.com/articles/10.1186/s41100-019-0237-4">study</a> with patients on dialysis to understand what factors influence their compliance or non compliance with dietary prescriptions for patients with kidney disease on dialysis.<br>
Understanding why it can be hard to follow the diet allows health practitioners to work with individual patients in finding solutions.</p>
<h2>Challenges with renal diet prescriptions</h2>
<p>The recommended diet can be <a href="https://www.jrnjournal.org/article/S1051-2276(18)30058-X/fulltext">difficult to follow</a> because patients and caregivers find it complex. And at times it may seem to contradict ideas about healthy eating, cultural norms, social functioning, and individuals’ sense of control.</p>
<p>We <a href="https://rrtjournal.biomedcentral.com/articles/10.1186/s41100-019-0237-4">found</a> that almost all participants (92.8%) in our study were aware of the dietary recommendations for patients with chronic kidney disease, but most of them were not following it. The main source of their information was the nutritionist (90.3%) at the health facility. More than half (61.8%) of them, however, had challenges in following the diet recommendations. Most of them considered the recommendations to be important, with health benefits. But 83.8% felt that the diets were restrictive and did not fit with their other ways of eating. </p>
<p>The main problems with the diets were the prescribed food types, preparation methods and sharing meals at social gatherings. Sometimes patients couldn’t avoid certain types of restricted foods, or the prescribed foods were costly or unavailable. Also, caregivers found it stressful, time consuming and expensive to prepare separate meals for the patient and other household members. </p>
<p>Respondents also said it was no longer possible to eat the foods they were most familiar with such as fried food, food with salt added, or locally accessible fruits like bananas or oranges. They couldn’t share family meals, or eat away from home because the foods served are what they are not allowed to eat. They sometimes withdrew from social gatherings for fear of explaining to people why they were avoiding certain foods. </p>
<p>A number of households were also constrained by the high cost of prescribed fruits, vegetables and white meat (chicken or fish) as well as cooking separate foods for the family. </p>
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Read more:
<a href="https://theconversation.com/lessons-from-a-diabetes-clinic-in-malawi-why-everyone-should-follow-a-healthy-diet-143909">Lessons from a diabetes clinic in Malawi: why everyone should follow a healthy diet</a>
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<p>About 39% of participants therefore found it difficult to give up certain foods and drinks. They considered renal diets unpalatable without salt, sugar, or cooking oil. They knew they should be eating boiled vegetables but found these didn’t taste good, or the cooking method seemed to contradict their idea of healthy food. Therefore, most were likely to consume food high in potassium, preferring not to eat food that had no taste and was less nutritious as the vitamins C and B-complex are removed in the preparation.</p>
<p>We observed that consuming unhealthy restricted foods that are palatable and affordable was common among more than half of the patients. This puts them at risk of disease complications, making dialysis less effective and increasing their risk of death. </p>
<p>Studies in developed countries have similarly found that more than half of adults on dialysis <a href="https://doi.org/10.2147/IJNRD.S76831">do not adhere</a> to their diet prescriptions.</p>
<h2>Way forward</h2>
<p>Nutritionists and dietitians can help patients by prescribing a more flexible, affordable, palatable, and nutritious diet. Patients should be involved in developing local recipes based on natural, locally available, and affordable whole foods that contain natural flavours and do not require additives. </p>
<p>To overcome nutrient loss, a variety of locally available vegetables and fruits with lower potassium and sodium content but high vitamins C and B-Complex should be encouraged. </p>
<p>Nutritional advice in chronic kidney disease is based on nutrient requirements linked to published evidence and guidelines. Where international guidelines are the main source of advice, development and use of national guidelines based on locally available foods should be a priority. A good starting point in Kenya would be developing local renal nutrition guidelines, which are currently lacking, based on the most recent, updated <a href="http://www.b4fn.org/resources/publications/publication-item/kenya-food-composition-tables-2018/">National Food Composition Database</a>.</p><img src="https://counter.theconversation.com/content/157329/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York, Sida, the DELTAS Africa Initiative. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) and the UK government. The statements made and views expressed are solely the responsibility of the authors.</span></em></p>Following a healthy diet may lower the risk of disease complications and allow patients to live well despite having the disease.Rose Okoyo Opiyo, Lecturer, University of NairobiLicensed 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>
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<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">
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<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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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>
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<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>
<hr>
<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>
</strong>
</em>
</p>
<hr>
<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>
<hr>
<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>
</strong>
</em>
</p>
<hr>
<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>
</figcaption>
</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>
</strong>
</em>
</p>
<hr>
<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>
<hr>
<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>
</strong>
</em>
</p>
<hr>
<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>
</figcaption>
</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>
</strong>
</em>
</p>
<hr>
<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>
</strong>
</em>
</p>
<hr>
<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>
<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/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/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>
<hr>
<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>
</strong>
</em>
</p>
<hr>
<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>
</strong>
</em>
</p>
<hr>
<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>
</strong>
</em>
</p>
<hr>
<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>
<hr>
<p>
<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>
</strong>
</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/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>
<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>
</strong>
</em>
</p>
<hr>
<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>
<hr>
<p>
<em>
<strong>
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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</em>
</p>
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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/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>
<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>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>
<hr>
<p>
<em>
<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>
</strong>
</em>
</p>
<hr>
<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>
<hr>
<p>
<em>
<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>
</strong>
</em>
</p>
<hr>
<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/563902016-04-01T04:23:01Z2016-04-01T04:23:01ZFour things parents can do to keep their kids’ kidneys healthy<figure><img src="https://images.theconversation.com/files/116244/original/image-20160323-28178-1v0hze3.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ensuring that children eat healthily can prevent them from developing kidney disease. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There has been an increase in kidney disease in children globally. In the developed world up to 5% of patients with chronic kidney disease are <a href="http://link.springer.com/article/10.1007/s004670050750">children</a>. But statistics are harder to come by in the developing world. </p>
<p>The overall increase in the incidence of kidney failure in children mimics that of adults. This is largely due to an increase in the incidence of obesity in children. Obese children develop hypertension and diabetes at a much younger age, which in turn affects their kidneys.</p>
<p>Kidneys perform vital functions. They rid the body of waste products and excess salts that would otherwise make people ill. They also:</p>
<ul>
<li><p>help the body maintain a good chemical balance; </p></li>
<li><p>control blood pressure; </p></li>
<li><p>keep bones healthy; and </p></li>
<li><p>help make red blood cells.</p></li>
</ul>
<p>Preventing kidney disease in children requires vigilance and awareness on the part of parents. Parents can do several things to help their children stay healthy and prevent chronic kidney disease. Four are listed below.</p>
<p><strong>1. A healthy diet:</strong> Parents should keep their children fit, active and eating well to ensure that they do not become overweight. As a start, children should be encouraged to take part in school sports, and families should become more active.</p>
<p>But parents should also ensure that their children eat healthy, well-balanced meals. Eating well helps children maintain a balanced weight. This will decrease their risk of obesity, which in turn decreases the risk of kidney failure. A healthy diet also helps to regulate blood pressure. </p>
<p>A balanced diet contains a mix of protein, fat and carbohydrates. It includes fresh fruit and vegetables instead of canned or refined foods. The refined carbohydrates found in processed foods, fizzy drinks, crisps and sweets result in children having both a sugar and salt overload. These should be kept to a minimum.</p>
<p>Salt is often “hidden” in foods and is not only found in crisps or other obvious snacks. Lower salt intake will decrease children’s risk of developing hypertension earlier in life and, in turn, kidney disease. If children complain of chronic headaches and fatigue, their blood pressure should be checked as they may be at risk of hypertension. Every time parents take their children to the doctor or nurse, they should ask for the child’s blood pressure to be checked. This can also be checked when immunisations are done.</p>
<p>In addition to checking the blood pressure, parents should also have their children’s blood glucose levels checked on at least an annual basis. Diabetes, like hypertension, is a silent disease. Only when a child’s blood sugar is extremely high, will he or she become symptomatic. An early sign of suspected diabetes in children is excessive thirst – not just drinking a lot of water when it is hot, but drinking large quantities of water with an extreme thirst. </p>
<p><strong>2. Sufficient fluid intake:</strong> Children need to drink enough healthy fluids, especially water. This allows the kidneys to stay healthy. Sugary drinks, including fruit juice, should be kept to a minimum.</p>
<p>Children’s kidneys can be affected after an infection or as part of a systemic illness, even as a result of something as simple as a throat infection (pharyngitis). When this happens there may be a change in their urine. They may pass less urine or their urine may change colour – the most common signs of trouble are urine that turns rose or red in colour, or the colour of black tea. </p>
<p>If a child is dehydrated and drinks large quantities of water, he or she should not pass a lot of urine. This is because the body has absorbed the water. Children who drink excessive amounts of water and pass urine frequently may be showing signs of diabetes.</p>
<p>Parents should ask for a urine dipstix test to be done when they take their child for a checkup. This is important because persistent protein in the urine is one of the earliest indications that a child’s kidneys might be taking strain. If a child is healthy, an annual checkup should be sufficient.</p>
<p><strong>3. No smoking:</strong> Smoking is another big no-no. Children should be dissuaded from smoking, especially during their teenage years, when they are more likely to experiment with cigarettes. Cigarettes contain toxins that can damage blood vessels and cause heart diseases that in turn damage kidneys.</p>
<p><strong>4. Beware of over-the-counter drugs:</strong> Parents tend to buy over-the-counter medicines for their children, but many drugs, especially anti-inflammatory medication and drugs used for fevers, can be harmful to their kidneys. </p>
<p>Aspirin, which is common in colds and flu medication, is not recommended for children under 12 due to the effect it has on their livers. Similarly, some anti-inflammatory drugs should be dispensed by a medical professional as they can cause acute kidney failure when children are dehydrated, ill and not taking in sufficient fluids. Paracetamol is a safe drug to use for fever in children, but it’s important that parents read the package insert to determine the dose and frequency for their children.</p><img src="https://counter.theconversation.com/content/56390/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christel du Buisson 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>An increase in child obesity is spurring on hypertension and diabetes among children, which may lead to chronic kidney disease.Christel du Buisson, Paediatric Nephrologist and Senior Specialist in the Department of Paediatrics and Child Health at the Faculty of Medicine and Health Sciences, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/447152015-08-02T20:09:56Z2015-08-02T20:09:56ZWe’re overdosing on medicine – it’s time to embrace life’s uncertainty<figure><img src="https://images.theconversation.com/files/90266/original/image-20150730-22657-182ybv9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Biomedical science has made our lives immeasurably better, but it’s time to accept that too much medicine can be as harmful as too little.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/kokopinto/1744766359/in/photolist-7FDNYM-5ybjn2-3EbofB-9KY9Wj-qGDS6F-qq5RWC-qGufbZ-qEniU1-bWUa8e-cegvz5-ccbHNh-ccbGqw-ccbELY-bUPoWR-4tMDXt-8F6wcv-9WQ3CY-wkUQc-6rSdnG-92T4Ew-cuCykW-9uQTvm-9KVkMX-8FmLAq-6gGE2m-9SfJSh-8FiCsV-8FiCcT-8FmNns-8FmN2A-8FiBoc-8FiB7D-8FmMjY-8FmM4y-8FiAig-8FmLfW-8Fizvc-8FiyXX-8FiyHP-8FiyuD-8FiybB-8FixWc-8FixJB-8Fixu8-hrtzAQ-hrtza9-hrtyV1-hrsXnD-hrtyfy-hrsWuM">Kathea Pinto/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The more we learn about the problem of <a href="http://www.bmj.com/too-much-medicine">too much medicine</a> and what’s driving it, the harder it seems to imagine effective solutions. Winding back unnecessary tests and treatments will require a raft of reforms across medical research, education and regulation. </p>
<p>But to enable those reforms to take root, we may need to cultivate a fundamental shift in our thinking about the limits of medicine. It’s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, ageing and death.</p>
<h2>We’re all ill now</h2>
<p>A growing body of evidence shows that when it comes to health care, we may simply be getting too much of a good thing. In the United States, <a href="http://jama.jamanetwork.com/article.aspx?articleid=1148376">it’s estimated that</a> more than US$200 billion a year is squandered on unnecessary tests and treatments. In the United Kingdom, senior medical groups are <a href="http://www.aomrc.org.uk/dmdocuments/Promoting%20value%20FINAL.pdf">calling on doctors</a> to reduce all the wasteful things they do. And in Australia, the <a href="http://www.choosingwisely.org.au/">Choosing Wisely</a> campaign recently kicked off with lists of unnecessary and harmful health care.</p>
<p>Not only are we overusing pills and procedures, we’re creating <a href="http://theconversation.com/preventing-over-diagnosis-how-to-stop-harming-the-healthy-8569">even more problems with “overdiagnosis”</a> by labelling more and more healthy people with diseases that will never harm them.</p>
<p>Screening programs targeting the healthy can detect potentially deadly cancers and extend lives. But they can also find many early abnormalities <a href="http://theconversation.com/whats-in-a-name-why-we-need-to-reconsider-the-word-cancer-16606">that are then treated as cancers</a>, even though they would never have caused anyone any symptoms if left undetected. </p>
<p>The common ups and downs of our sex lives are often re-labelled as medical dysfunctions. Older people who are simply at risk of future illness – those with high cholesterol, for instance, or reduced kidney function, or low bone mineral density – are portrayed as if they were diseased. </p>
<p>The doctors expanding disease definitions and lowering the thresholds at which diagnoses are made are <a href="https://www.plos.org/wp-content/uploads/2013/05/plme-10-08-Moynihan.pdf">often being paid directly</a> by the companies that stand to benefit from turning millions more people into patients.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.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">
<figcaption>
<span class="caption">It’s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, ageing and death.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/73381004@N00/59049213/in/photolist-6dDgT-as1b63-8VfiHg-pt1ZLD-4yvxmj-ayfZDT-57kwh9-bUSw6n-87uLL3-neJf4Y-uyrPfX-6wz4gq-4qJveT-nrmnqp-nHNFTA-nrm1Df-6NzzcH-f2o6hN-9oYe6J-ejVWBf-9KzFCs-4yNyBQ-5Z572r-n9uLQp-5Rpyvo-egsKjx-byjwTG-3wDidW-gi21pE-qRhU2a-fejVCN-3LBeAe-5XmMo3-4nJegS-qBxzPr-3THNtd-nEFYa-qG4X7s-6fNBQr-8mMsjZ-3TsZxy-iPkzVA-HqKUn-pVBG31-dguHFd-3WBzZh-71271F-4D7xVC-4Bradu-o6vq9">Javier ie/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
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<p>What’s driving all this excess is a toxic combination of good intentions, wishful thinking and vested interests – fuelled by sophisticated diagnostic technology that often offers the illusion of more certainty about the causes of our suffering. It’s as if we’re seeking technical fixes for the fundamental reality of human existence – uncertainty, ageing and death.</p>
<h2>Fundamental shifts in thinking</h2>
<p>Indeed, <a href="http://www.bmj.com/content/349/bmj.g5702">intolerance of uncertainty</a> has been suggested as among the most important drivers of medical excess. Doctors order ever more tests to try, often in vain, to be sure about what they’re seeing – to be more certain. But disease and the benefits and harms of treating it are inevitably fraught with uncertainty because we’re trying to apply knowledge derived from populations to unique individuals. </p>
<p>More broadly, <a href="http://www.bmj.com/content/349/bmj.g6123">uncertainty is the basis</a> of all scientific creativity, intellectual freedom and political resistance. We should nurture uncertainty, treasure it and teach its value, rather than be afraid of it.</p>
<p>No matter how much the marketers of medicines try to make us feel broken by the mere passing of time, ageing is not a disease. Disease definitions that equate “normal” with being young are fundamentally flawed and require urgent review. </p>
<p>The doctors who defined osteoporosis, for instance, arbitrarily decided the bones of a young woman were normal, automatically classifying millions of older women as “diseased”. Similarly, those who defined “chronic kidney disease” have classified the normal changes in kidney function that happen as many of us age as somehow abnormal. Brace yourself for the impending arrival of pre-dementia, the latest attempt to medicalise the ageing process. </p>
<p>In all cases, the people who wrote these definitions included those with ties to pharmaceutical companies – reinforcing the need for much greater independence between doctors and the industries that benefit from expanding medical empires.</p>
<h2>Rays of hope</h2>
<p>Everyone must die and everyone, patients and doctors alike, is more or less fearful of dying. So, it’s perhaps not surprising that we so often turn to biotechnical approaches rather than paying real attention to the care of the dying – a core purpose of medicine. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.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">The doctors who defined osteoporosis arbitrarily decided the bones of a young woman were normal, automatically classifying millions of older women as ‘diseased’.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/sandeepachetan/15258162923/">sandeepachetan.com travel photography/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>What we tend to forget is that medicine cannot save lives – it can only postpone death. Yet we persuade ourselves it might somehow keep extending our lives, and we come to view almost every death as a failure of medicine. </p>
<p>Doctors persist with treatments for the dying well after these have become obviously futile, often with the support of patients or their families. Deep, difficult and necessary conversations about death and dying are only possible in a context of trust, which becomes increasingly difficult as health-care systems are ever more fragmented.</p>
<p>But, there are many positive signs of change within medicine. The <a href="http://www.choosingwisely.org.au/">Choosing Wisely</a> campaign mentioned above is a partnership between doctors and wider civil society. And it’s now an international movement to wind back excess medicine. </p>
<p>A new approach called <a href="http://www.safetyandquality.gov.au/our-work/shared-decision-making/">shared decision making</a> is promoting much more honest conversations between doctors and the people they care for, embracing uncertainty about benefits and harms, rather than peddling false hopes. Another new approach among GPs called <a href="http://www.ncbi.nlm.nih.gov/pubmed/23062686">quaternary prevention</a> is urging doctors to protect people from unnecessary medical labels and unwarranted tests and treatments.</p>
<p>Perhaps all these new movements will re-establish doctor-patient trust, helping us reduce fear and embrace uncertainty, and end the pretence that medicine can cure ageing and even death. Biomedical science has made our lives immeasurably better, but it’s time to accept that too much medicine can be as harmful as too little.</p>
<hr>
<p><em>Former president of the UK Royal College of General Practitioners, Dr Iona Heath, co-authored this article. Dr Heath will deliver a <a href="http://sydney.edu.au/sydney_ideas/lectures/2015/iona_heath.shtml">free public lecture</a> on the problem of “Too Much Medicine” at the University of Sydney this Wednesday night, August 5.</em></p><img src="https://counter.theconversation.com/content/44715/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ray Moynihan is helping organise the Preventing Overdiagnosis conferences. He wrote this article in close collaboration with Dr Iona Heath.</span></em></p>By forgetting that medicine postpones death rather than saving lives, we persuade ourselves it might somehow keep extending our life and come to view death as a failure of medicine.Ray Moynihan, Senior Research Fellow, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/309662015-03-12T03:00:41Z2015-03-12T03:00:41ZKidneys are amazing for all they do, be sure to look after yours<figure><img src="https://images.theconversation.com/files/74555/original/image-20150311-24203-zjs59l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kidneys are a feature-packed, highly efficient filtration and waste elimination system.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/64958688@N00/3349943474">Helen Taylor/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Tucked away just below your ribcage near your spine are two bean-shaped organs known as the kidneys. And when they’re quietly getting on with their job, it’s easy to forget they’re there and how important they are. But their absence, or even less-than-optimal performance can have dire consequences. </p>
<p>Kidneys are a feature-packed, highly efficient filtration and waste elimination system as well as the source of some essential hormones and vitamins. When all is said and done, the “factory-fitted” system for all they do beats alternatives for efficiency and convenience. They’re compact, built-in, self-contained, portable and low maintenance. </p>
<p>About 1,500 litres of blood pass through the kidneys each day, through a series of highly-regulated pumps and channels. Essential nutrients and water are reabsorbed and the waste products created by our cells are removed in volumes ranging from as little as 500 millilitres to as much as ten litres, in the form of urine. </p>
<p>Together with the bladder, which acts as a mechanism to batch this output, kidneys are the ultimate personal waste disposal system, requiring little maintenance. In fact, you could say the greatest inconvenience they pose is the need to occasionally quickly locate “conveniences”.</p>
<h2>When things go wrong</h2>
<p>Although the list of <a href="http://www.anzdata.org.au/anzdata/AnzdataReport/36thReport/2013c02_newpatients_v1.7.pdf">conditions causing kidney disease</a> is long, dietary and other lifestyle issues are beginning to dominate. <a href="http://www.kidney.org.au/KidneyDisease/FastFactsonCKD/tabid/589/Default.aspx">More than a third of all new patients</a> are now reaching end-stage kidney disease due to diabetes and about one in eight as a result of high blood pressure. </p>
<p>In contrast, the most common genetic cause of kidney disease (polycystic kidney disease) only accounts for one in 20 patients. Less common causes include autoimmune diseases and the toxic side effects of some medicines. Not only are <a href="http://www.kidney.org.au/HealthProfessionals/QKidneyRiskAssessment/tabid/861/Default.aspx">many of the risk factors</a> for kidney disease the same as those for heart disease, kidney disease itself is considered a risk factor for developing heart disease. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/74556/original/image-20150311-24178-1e69j9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dietary and other lifestyle issues now dominate as causes of kidney disease.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/bijoubaby/6178847805">Heather Wizell/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
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<p>The development of kidney disease is often insidious, as symptoms are non-specific and occur late. Indeed, more than 90% of kidney function may be lost before any symptoms occur. </p>
<p>Common symptoms include nausea, a change in taste or loss of appetite, fatigue and itching, which reflect the build-up of toxins normally eliminated by the kidney. Less often patients may present due to swelling, or because they have noticed the presence of blood or protein in the urine (protein may cause urine to become frothy). </p>
<p>Thanks to advances in technology, kidneys are the only major organs that can completely fail but leave patients alive and reasonably healthy, even out of hospital. If your kidneys do fail, the first step is to get an alternative filtration system up and working. This is known as dialysis. </p>
<h2>Dialysis and transplants</h2>
<p>The <a href="https://www.renalreg.org/documents/patient-information/">two main types of dialysis</a> are peritoneal dialysis and haemodialysis. Both involve having some sort of permanent access point to enable regular dialysis. While these interventions keep people alive, they only provide at best about 10% to 15% of health kidney function. </p>
<p>Peritoneal dialysis, which can be done at home by patients themselves, involves having a tube surgically inserted into the abdominal cavity to enable fluid to enter.</p>
<p>Haemodialysis, which takes four to five hours and has to be performed three times a week, requires direct access into the bloodstream. This usually involves a surgical connection between an artery and a vein. Once these access points have been established, dialysis can begin. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/74557/original/image-20150311-24209-afqse3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Both kinds of dialysis involve having some sort of permanent access point into the body.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/newslighter/523392">Dan/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>For eligible patients, a <a href="https://www.renalreg.org/documents/patient-information/">kidney transplant</a> may avert the need for dialysis but it comes with its own problems. In addition to the risks of having an operation and general anaesthetic, unless the patient has an identical twin, the transplanted kidney will be seen by their immune system as foreign. </p>
<p>Left unchecked, transplanted kidneys are soon rejected, and fail. Immune-suppressing drugs can prevent this, but they have serious side effects and have to be taken for the rest of your life. The problem is that currently available immunosuppressants are relatively non-specific in their actions, and suppress the patient’s whole immune system. This makes them much more vulnerable to all sorts of infections, and also cancers. </p>
<p>Clearly, current treatments for kidney failure come with their own significant downsides. Life expectancy on dialysis, for instance, is considerably shorter than that of the general population.</p>
<h2>Love kidneys, yourself and others</h2>
<p>Chances are, if you are looking after your kidneys, you are also looking after the rest of your body. You’ve probably heard it all before but if you eat a balanced diet that’s low in salt, fat, and sugar, maintain a healthy weight, exercise regularly, drink sufficient water, restrict your alcohol intake and don’t smoke, you are caring for your kidneys. </p>
<p>There will be other benefits too. You’ll also be reducing your risk of diabetes, heart disease, high blood pressure and even cancer.</p>
<p>Despite the limitations of kidney transplants, they can transform and extend the lives of those with kidney failure. Only people with healthy kidneys can donate kidneys for transplantation. So looking after your kidneys may turn out to be an investment in someone else’s future and allow you to give the gift of life.</p><img src="https://counter.theconversation.com/content/30966/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christine Carson has in the past received funding from The Rural Industries Research & Development Corporation and companies in the natural products and complementary and alternative medicines industry.</span></em></p><p class="fine-print"><em><span>Aron Chakera receives funding from The University of Western Australia, Royal Australasian College of Physicians, Raine Foundation, Western Australian Department of Health.</span></em></p>Rather innocuous-looking and tucked away below the ribcage, kidneys are crucial for keeping us alive and well.Christine Carson, Research Associate at the University of Western Australia &, Harry Perkins Institute of Medical ResearchAron Chakera, Clinical senior lecturer, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/157702013-08-12T04:40:01Z2013-08-12T04:40:01ZStopping the silent epidemic of chronic kidney disease<figure><img src="https://images.theconversation.com/files/28245/original/r9fjb9r5-1375075951.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Despite a high global prevalence and inequities in treatment, kidney disease is not given priority in international health plans.</span> <span class="attribution"><span class="source">Daniel Oines</span></span></figcaption></figure><p><a href="http://www.kidney.org.au/LinkClick.aspx?fileticket=UZa5usbv2XE%3D&tabid=609&mid=850">One in nine Australians</a> over the age of 25 (that’s 1.7 million people) has chronic kidney disease. That’s more than the number living with <a href="http://www.lungfoundation.com.au/professional-resources/statistics/copd-the-statistics/">chronic lung disease</a>, <a href="http://strokefoundation.com.au/health-professionals/tools-and-resources/facts-and-figures-about-stroke/">stroke</a>, <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442453166">heart failure</a>, and all types of <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129542353">cancers combined</a>. </p>
<p>And the picture is just as bad in many other countries. But, for some reason, kidney disease hasn’t received the attention it ought in World Health Organization <a href="http://www.who.int/nmh/events/un_ncd_summit2011/political_declaration_en.pdf">priority documents</a> and <a href="http://www.nature.com/ki/journal/vaop/ncurrent/full/ki2012488a.html">national chronic disease programs</a>. </p>
<p>So what do kidneys do, and why is this disease worth prioritising?</p>
<h2>Chronic kidney disease</h2>
<p>Kidneys are essential organs involved in regulating blood pressure, bone quality, and red blood cell production (important for carrying oxygen in the bloodstream), control of essential electrolytes and removal of waste products from the blood. </p>
<p>Chronic kidney disease is a <a href="https://theconversation.com/a-quick-explanation-of-non-communicable-diseases-or-ncds-10923">non-communicable disease</a> involving a reduction in kidney function over time. It most commonly results from diabetes, high blood pressure or kidney inflammation. </p>
<p>Disease onset is frequently insidious (and often asymptomatic until late stages) so awareness and early identification can be difficult. </p>
<p>The term “end-stage kidney disease” refers to the stage of kidney failure (about less than 10% of normal function) wherein kidney replacement therapy, namely dialysis or transplantation, is required to sustain life.</p>
<p>Major risk factors for chronic kidney disease include hypertension, obesity, diabetes and ageing – all of which are <a href="http://www.who.int/topics/global_burden_of_disease/en/">on the rise</a> globally.</p>
<p>Importantly, kidneys are not the only organs damaged. Chronic kidney disease is a cause, consequence and risk multiplier for many other diseases, including heart disease. </p>
<p>And even after adjusting for traditional cardiovascular risk factors, such as high cholesterol and blood pressure, chronic kidney disease independently increases your risk of heart disease by between <a href="http://www.ncbi.nlm.nih.gov/pubmed/23727170">two and four times</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/27013/original/zyzyrp9b-1373207201.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/27013/original/zyzyrp9b-1373207201.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/27013/original/zyzyrp9b-1373207201.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/27013/original/zyzyrp9b-1373207201.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/27013/original/zyzyrp9b-1373207201.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/27013/original/zyzyrp9b-1373207201.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/27013/original/zyzyrp9b-1373207201.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">One in six people worldwide are affected by chronic kidney disease.</span>
<span class="attribution"><span class="source">Bhakua/Flickr</span></span>
</figcaption>
</figure>
<h2>The global picture</h2>
<p>The global prevalence of chronic kidney disease is estimated at between 8% and 16% of the population, meaning up to <a href="http://www.ncbi.nlm.nih.gov/pubmed/23727169">one in six people worldwide</a> are affected.</p>
<p>Health-care expenditure on chronic kidney disease totalled a staggering US$60 billion in the United States in 2007, representing <a href="http://www.ncbi.nlm.nih.gov/pubmed/23727169">27% of the total Medicare budget</a>. In the United Kingdom in 2009-10, more than <a href="http://www.ncbi.nlm.nih.gov/pubmed/23727169">AUS$2.4 billion</a> was spent on the illness - equalling $1,320 for each person diagnosed. </p>
<p>More than 50% of this money was spent on managing end-stage kidney disease, despite it accounting for only 2% of the affected population. In Australia, the cost of treating end-stage kidney disease between 2009 and 2020 is estimated at <a href="http://www.kidney.org.au/LinkClick.aspx?fileticket=vave4WFH73U%3d&tabid=635&mid=1837">A$12 billion</a>.</p>
<p>In low- and middle-income countries, often with more fragile health-care systems, these costs can be crippling for both governments and individuals.</p>
<h2>Kidney disease, equity and development</h2>
<p>A bi-directional relationship between poverty and chronic kidney disease means poverty makes you more likely to develop the illness, and poverty worsens the outcome once you have it.</p>
<p>Even in Australia, end-stage kidney disease is more common in <a href="http://ndt.oxfordjournals.org/content/27/11/4173.long">socioeconomically disadvantaged areas</a>. <a href="http://www.aihw.gov.au/ckd/end-stage-kidney-disease/">Regional and remote areas</a> have more cases of kidney disease and <a href="http://ndt.oxfordjournals.org/content/27/5/2069.long">poorer survival</a>.</p>
<p>In particular, Indigenous Australians carry a disproportionate burden of chronic kidney disease; they are <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737420068">four times more likely</a> to die from it than non-Indigenous Australians. </p>
<p>A similar picture is seen in Indigenous populations worldwide such as Native Americans, First Nation Canadians, South American Aborigines and New Zealand Maori.</p>
<p>Around <a href="http://www.ncbi.nlm.nih.gov/pubmed/23022428">1.4 million people globally</a> receive dialysis for end-stage kidney disease, a number which is increasing by 5% to 10% every year. </p>
<p>But number is limited by the financial costs of providing care; it’s likely that many more are dying of this preventable and treatable condition because they can’t afford treatment. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/27014/original/547s8rj5-1373207919.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/27014/original/547s8rj5-1373207919.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/27014/original/547s8rj5-1373207919.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/27014/original/547s8rj5-1373207919.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/27014/original/547s8rj5-1373207919.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/27014/original/547s8rj5-1373207919.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/27014/original/547s8rj5-1373207919.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">Kidney disease is a notable absentee from the WHO’s grouping of priority non-communicable diseases.</span>
<span class="attribution"><span class="source">US Mission Geneva/Flickr</span></span>
</figcaption>
</figure>
<p>Globally, over 80% of patients receiving treatment for end-stage disease live in high-income countries, which account for less than 20% of the world’s population. </p>
<p>Countries such as India are seeing increasing numbers of people suffering from chronic kidney disease but <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647401/">less than 10%</a> of the people who need dialysis receive it. </p>
<h2>Prioritising health</h2>
<p>Despite a high global prevalence, inequities in treatment, and being noted by the 2011 World Health Organization high-level meeting on non-communicable diseases as posing “<a href="http://www.who.int/nmh/events/un_ncd_summit2011/political_declaration_en.pdf">a major health burden for many countries</a>”, kidney disease is still a notable absentee from the grouping of priority non-communicable diseases.</p>
<p>Kidney disease is noted in the <a href="http://www.who.int/nmh/publications/ncd_action_plan2013.pdf">draft global action plan for controlling non-communicable diseases 2013-2020</a> as being “closely associated” with priority diseases. And therapy to prevent kidney disease progression is an aim within diabetes actions. </p>
<p>But the action plan still only focuses on the <a href="http://whqlibdoc.who.int/publications/2009/9789241597418_eng.pdf">four prioritised non-communicable diseases</a> – heart disease, diabetes, chronic respiratory disease and cancers.</p>
<p>Governments and health systems must develop strategies to both prevent kidney disease and provide treatment to everyone who needs it. </p>
<p>This involves implementing proven preventative measures globally, while developing low-cost dialysis methods that reduce financial barriers to care, and new effective treatments for chronic kidney disease.</p>
<p>We must be clear about the links and common origins of chronic diseases if we are to combat them. The burden of kidney disease should be recognised and it should be prioritised alongside other highlighted non-communicable diseases. This would galvanise action against their shared risk factors. </p>
<p>Whatever our future global health and development agenda looks like, kidney disease must be a priority within it.</p><img src="https://counter.theconversation.com/content/15770/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Georgina E Taylor is employed by Monash University in kidney research.</span></em></p><p class="fine-print"><em><span>Peter Kerr receives funding from National Health &Medical Research Council, Australia.</span></em></p><p class="fine-print"><em><span>Vlado Perkovic undertakes research on kidney disease, and is a practising nephrologist. He receives funding from the National Health and Medical Research Council, the Heart Foundation, and a range of commercial sources to fund his research. </span></em></p><p class="fine-print"><em><span>Brendon L Neuen and Sandro Demaio 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>One in nine Australians over the age of 25 (that’s 1.7 million people) has chronic kidney disease. That’s more than the number living with chronic lung disease, stroke, heart failure, and all types of…Sandro Demaio, Australian Medical Doctor; Postdoctoral Fellow in Global Health & NCDs, Harvard UniversityBrendon L Neuen, Medical student, James Cook UniversityGeorgina E Taylor, Medical student, University of TasmaniaPeter Kerr, Professor and Director of Nephrology, Monash UniversityVlado Perkovic, Executive Director, Professor of Medicine, George Institute for Global HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/165052013-07-31T04:57:27Z2013-07-31T04:57:27ZMaking people patients: chronic kidney disease over-diagnosis<figure><img src="https://images.theconversation.com/files/28394/original/8vmj2x9g-1375239547.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A newly-defined condition called 'chronic kidney disease' could turn many people unnecessarily into patients.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Kidneys are probably not a subject most of us think about too much – but right now they’re at the centre of a global medical controversy. In <a href="http://www.bmj.com/content/347/bmj.f4298">a paper published</a> in the British Medical Journal today, we explain how a newly-defined condition called “chronic kidney disease” could turn many people into patients. </p>
<p>The problem is that the boundaries of this “disease” have been set so wide and the threshold defining who is “sick” set so low, that there’s a risk a lot of folk might end up being over-diagnosed. People who are “over-diagnosed” are <a href="http://www.beacon.org/productdetails.cfm?PC=2174">labelled as having a condition</a> even though it would never harm them.</p>
<p>The over-diagnosis of disease was recently described as a “<a href="http://archinte.jamanetwork.com/article.aspx?articleid=1203523">modern epidemic</a>” in medicine and is attracting <a href="https://theconversation.com/preventing-over-diagnosis-how-to-stop-harming-the-healthy-8569">increasing scientific and public attention</a>.</p>
<h2>A wide net</h2>
<p>The new framework for the condition called chronic kidney disease was first launched in 2002 by the National Kidney Foundation in the United States. A key motivation was to bring a common language and a sense of order to kidney care – to replace a rather chaotic situation where there were different names for kidney problems, including renal insufficiency and renal impairment. </p>
<p>One of the main aims of the 2002 framework was to try and identify people with the early signs of kidney disease – before it developed into full-blown kidney failure. </p>
<p>A key measurement of the definition is based on a <a href="http://www.labtestsonline.org.au/understanding/analytes/egfr/tab/glance">common blood test</a> of kidney function. This measure tends to decline as we get older. And the thresholds used to define those with the disease and those without it, were somewhat arbitrarily decided (as they are with many diseases). </p>
<p>The problem here is that the way the definition was written automatically means that around one in eight adults – and around one in two people over the age of 70 – are defined as having chronic kidney disease. </p>
<p>But being treated for end-stage kidney disease is extremely rare, perhaps happening to only one in every 3,000 people in any given year. As <a href="http://www.revistanefrologia.com/modules.php?name=articulos&idarticulo=10501&idlangart=EN">others have noted</a>:</p>
<blockquote>
<p>the majority of those held to have CKD have no identifiable kidney disease.</p>
</blockquote>
<p>Understandably, there’s a lot of concern among some doctors and others that, for many people, the new definition of chronic kidney disease means the normal ageing of kidneys is being turned into a medical condition.</p>
<p>As we outline in <a href="http://www.bmj.com/content/347/bmj.f4298">our paper</a>, there’s a vigorous debate underway within the medical community about this new condition, and the risk of over-diagnosis. Our co-author, kidney specialist Richard Glassock, has observed elsewhere that chronic kidney disease is: </p>
<blockquote>
<p>like a fishing trawler, it catches many more innocent subjects than it should. </p>
</blockquote>
<p>Despite this, an international organisation of kidney disease experts confirmed the 2002 thresholds again in 2012. While some amendments added more complexity to the disease classification system, the fundamentals of the definition didn’t change. </p>
<h2>Growing concern</h2>
<p>For those of us studying the problem of over-diagnosis, chronic kidney disease appears to be another example of disease labels being given to some people who may not benefit from them. </p>
<p><a href="http://www.bmj.com/content/344/bmj.e3502?ijkey=tzRK2ncLto2JJ9I&keytype=ref">Other conditions</a> where this is of concern include <a href="https://theconversation.com/psa-screening-and-prostate-cancer-over-diagnosis-8568">prostate</a>, <a href="https://theconversation.com/growing-uncertainty-about-breast-cancer-screening-15997">breast</a> and thyroid cancer, <a href="https://theconversation.com/moving-the-diagnostic-goalposts-medicalising-adhd-8675">attention deficit disorder</a> and asthma. </p>
<p>It’s important to mention that the problem of over-diagnosis can exist alongside the problem of under-diagnosis, where some people miss out on much-needed care. </p>
<p>In fact, the changes in the definition of chronic kidney disease have led to a big increase in specialist referrals, potentially meaning fewer resources, over time, for those with genuine kidney disease.</p>
<p>Our paper on chronic kidney disease is <a href="http://www.bmj.com/content/347/bmj.f4247">part of a series</a> in the British Medical Journal, looking at the problem of expanding disease definitions and the risk of over-diagnosis. </p>
<p>The series was launched with a paper about the over-diagnosis of a condition called “<a href="http://www.bmj.com/content/347/bmj.f3368?ijkey=b80bf32d1ee7499092a645fbbf3aa536c87c05a0&keytype2=tf_ipsecsha&linkType=FULL&journalCode=bmj&resid=347/jul02_2/f3368&atom=/bmj/347/bmj.f4247.atom">pulmonary embolism</a>” (blood clots in the artery leading to the lungs). </p>
<p>That research showed that while these clots can be deadly, modern diagnostic technology – CT scans in particular – are finding smaller and smaller clots that are being diagnosed and treated earlier, even though they may never have caused any harm. </p>
<p>The world’s leading medical science journals are increasingly publishing articles on the problem of too much medicine. Recent articles focus on the over-treatment of <a href="http://archinte.jamanetwork.com/article.aspx?articleid=1687525">mild high blood pressure</a>, the lack of effectiveness and potential harms of <a href="http://jama.jamanetwork.com/article.aspx?articleid=1697948">general health checks</a>, and the <a href="http://jama.jamanetwork.com/article.aspx?articleid=1691913">over-diagnosis of breast cancer</a> arising from screening. </p>
<p>Just this week, a <a href="http://jama.jamanetwork.com/article.aspx?articleid=1722196">series of recommendations</a> from the National Cancer Institute called for much great awareness that “overdiagnosis is common”, and argued that some early forms of abnormalities should no longer be called cancer.</p>
<p>Our long-held cultural faith in early detection is being shaken as mounting scientific evidence suggests it can be a double-edged sword. </p>
<p>In our paper, we call for a review of the definition of chronic kidney disease to be conducted by a broad panel of people. We hope this will be part of a wider public debate about how many people we want to define as patients.</p><img src="https://counter.theconversation.com/content/16505/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ray Moynihan receives funding from an NHMRC STEP grant. He is helping organise an international scientific conference called Preventing Overdiagnosis, which will take place in the United States in September (<a href="http://www.preventingoverdiagnosis.net">www.preventingoverdiagnosis.net</a> ).</span></em></p><p class="fine-print"><em><span>Jenny Doust receives funding from the Screening and Test and Evaluation Program NHMRC grant. She is helping organise an international scientific conference called Preventing Overdiagnosis, which will take place in the United States in September (<a href="http://www.preventingoverdiagnosis.net">www.preventingoverdiagnosis.net</a> ).</span></em></p>Kidneys are probably not a subject most of us think about too much – but right now they’re at the centre of a global medical controversy. In a paper published in the British Medical Journal today, we explain…Ray Moynihan, Senior Research Fellow, Bond UniversityJenny Doust, Professor of Clinical Epidemiology, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.