Between 1999 to 2009, the number of people from central Australia receiving renal replacement therapy (dialysis) more than tripled, from 62 to 209, according to ANZDATA Registry analysis. At present, there are some 558 Northern Territorians undergoing dialysis — 98% of whom are Aboriginal. Current estimates are that this number will grow by 4.5% a year. In simple terms, and all other things being equal, this means over 1000 territorian and tri-state Aboriginal people will be “on the machine” in the NT in 14 years. In central Australia alone, a worst-case scenario would involve 479 people undergoing dialysis by 2020.

The statistics around chronic kidney disease (CKD) among Aboriginal people are not pretty.

Chronic diseases and associated risk factors are responsible for approximately two-thirds of the life expectancy gap between Aboriginal and non-Aboriginal people. For males in the Northern Territory, this stands at around 17 years, with a national average of 11.

CKD is a big slice of the gap in life expectancy for Aboriginal people in the Northern Territory and remote areas of Western Australia, Queensland and South Australia.

From 2004 to 2006, Aboriginal people in these jurisdictions for males and females were, respectively, seven and 11 times more likely to die from CKD than non-Aboriginal Australians. The deaths occurred at a younger age than among non-Aboriginal Australians.

In the same period, CKD was directly attributed to 4% of deaths, and linked to a further 12% of deaths. Kidney disease is associated with an increased risk of death and disability, and is closely linked with cardiovascular disease — both acute myocardial infarction and stroke — along with diabetes.

More than 40% of adults attending Aboriginal primary healthcare services across the central Australian region have either proteinuria or reduced kidney function — the main indicators of the early stages of CKD.

Chronic disease, experienced at far higher levels among Aboriginal communities than that of the general Australian population, has devastating consequent effects on kin and country. CKD — and the apparently inevitable pathway to dialysis (and hopefully transplantation) as people progress to end-stage kidney disease (ESKD) — increasingly affects families and communities.

The rates of ESKD in remote areas are up to 30 times the national average. The ESKD toll falls largely between the ages of 35 and 65. These are, in Aboriginal terms, the years in which Aboriginal people — now and traditionally — have major responsibilities for family formation, traditional ceremonial responsibilities, and community leadership. Yet it is also a disease that affects people as young as the early 20s.

Unless you have access to renal replacement therapy through dialysis, or kidney transplantation, ESKD kills. There are two main forms of dialysis — Haemodialysis (HD) or Peritoneal Dialysis (PD). Dialysis is a “holding measure” until a renal transplant can be performed, or as the only life-prolonging procedure available for those who may not be well enough, or live long enough, for a transplant.

The “system”, such as it is, is constantly in “catch up” mode. While dialysis became available in Katherine and Tennant Creek in the first decade of the 2000s, the relentless expansion of ESKD continues to push the envelope of supply. Aboriginal communities and health organisations have been pushing for models of community-based, mobile and home dialysis. In many cases, these advances have been paid for out of art sales and mining royalties.

Why is CKD and ESKD so prevalent among Aboriginal people?

It’s complicated.

Family history, genetics and increasing age play a role — but probably no more than that of the general Australian population. In large part, we have to look at the social and cultural determinants of health.

These can be summed up by:

• factors such as poverty, economic inequality and social status;

• employment and job security;

• social exclusion — including isolation, poverty, discrimination, incarceration, trauma and racism;

• education and care in early life;

• food security and access to a balanced and adequate diet; and

• addictions, particularly to alcohol and tobacco.

For Aboriginal people, the social and cultural determinants of health are directly linked to low birth weight, diabetes, high blood pressure, obesity, tobacco smoking, physical inactivity and poor nutrition. Poor maternal health and low birth weight, childhood infection and chronic inflammation, have also been associated with increased risk of developing CKD.

Peter Fray

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Peter Fray
Editor-in-chief of Crikey