Tag Archives: Chronic Kidney Disease

Hot oil baths and other things to do on World Kidney Day 2015

“In ancient times the Persian philosopher Avicenna [Ibn Sina] noted that urine may be retained in crisis of fever (s393) and prescribed hot oil baths (s413)(1). Unfortunately, apart from the supportive therapy of dialysis, there has been little progress since in the treatment of acute kidney injury (AKI).”(2)

Given that getting AKI at least doubles your chance of dying in hospital “no progress” is a major health issue.

Today is World Kidney Day and I get to post quite possibly the first blog post in the world on this day. I believe Avicenna would be thrilled with the attention paid to the organ which delivers urine. He may not be so thrilled that hot oil baths have been abandoned. Of course there is the obvious safety issues of scalding and drowning. Also, as Herod the Great found out, syncope (sudden loss of consciousness) is also a possible side effect (probably just because the heat constricted his blood flow [vasoconstriction] causing too little oxygen to reach his brain [cerebral anoxaemia].(3) Nevertheless, I think Avicenna is the type of person who would have welcomed a randomised controlled trial of hot oil baths verse today’s standard treatment.

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The statue of Avicenna (Ibd Sina) to be found in Hamaden, Iran. http://www.panoramio.com/photo/91467137

If you don’t fancy a hot oil bath this World Kidney Day, then there are other things to do to minimise the possibility of Acute Kidney Injury. Have you got high blood pressure, diabetes or Chronic Kidney Disease? Be warned, ~10% of the adult population have Chronic Kidney Disease, many of whom are not aware, and many more are at risk of developing it. All add to your risk of multiple illnesses any one of which can trigger acute kidney injury. If you happen to have a heart attack or sepsis (very serious infection) you are more likely to get AKI and more likely to die because of these underlying conditions.

So, on the assumption that readers of this blog are smarter than the average bear, I shall give you some sound advice – for the sake of yourselves and your family LOOK AFTER YOURSELF (yes, I’m shouting and therefore sinning against the internet protocol police – but this is important). Cut the sugar intake, quit smoking, take a walk around the block. It ain’t rocket science (one of the simpler sciences that involves cylinders with fins and lots of explosives) – it’s easier than that.

Former World Kidney Day posts

2014 A day to celebrate https://100dialysis.wordpress.com/2014/03/13/a-day-to-celebrate/

2013 Happy WKD https://100dialysis.wordpress.com/2013/03/14/happy-wkd/

2012 I am a pee scientist https://100dialysis.wordpress.com/2012/03/07/i-am-a-pee-scientist/

References

  1. Avicenna: The Canon of Medicine [Internet]. 2nd ed. New Yourk: AMS Press; 1973. Available from: http://archive.org/stream/AvicennasCanonOfMedicine/9670940-Canon-of-Medicine_djvu.txt
  2. Pickering JW, Endre ZH: The definition and detection of acute kidney injury. Journal of Renal Injury Prevention 2014; 3:19–23 http://www.journalrip.com/Archive/3/1
  3. Retief FP, Cilliers JFG: Illnesses of Herod the Great. S Afr Med J 2003; 93:300–303

A taste of success

Some recent successes of University of Otago Christchurch researchers:

Chlorine bleach key in disease?

Professor Tony Kettle from the Centre for Free Radical Research has won a prestigious Marsden Fund grant to better understand a ‘Jekyll and Hyde’ chemical with a role in heart disease, cancer, cystic fibrosis, and rheumatoid arthritis.

Professor Kettle will investigate chlorine bleach’s role in strengthening collagen by linking to form a resilient mesh. Without this mesh people can develop cataracts and an autoimmune disease that destroys the kidneys and causes the lungs to hemorrhage. However bleach can also have negative effects.

“Chlorine bleach should be viewed as a natural chemical with a Jekyll and Hyde personality. It helps us to fight infections and form strong connective tissue but also endangers our health during uncontrolled inflammation.”

Professor Kettle and his team will work with researchers from Vienna and Budapest on the project.

Improving the treatment and experience for dialysis patients

Chronic kidney disease is common, affecting about 500,000 New Zealanders. It is important because it increases chances of heart disease and death and may lead to needing treatment with dialysis or a kidney transplant. Dialysis therapy is a heavy and costly burden for patients and their families and the health system. However, there is a lack of reliable evidence to improve patient outcomes.

Dr Suetonia Palmer has just been awarded a prestigious Rutherford Discovery Fellowship valued at $800,000 over five years for research project called: “Improving evidence for decision-makers in chronic kidney disease.”

Dr Palmer’s research aims to to provide rigorous overviews of existing research and participant-led enquiry to provide better and more useable information for clinicians, consumers and policy-makers in the field of chronic kidney disease.

Recovering from food addiction

Professor Doug Sellman and his team from the National Addiction Centre have just been granted funding to trial a new treatment for those with obesity called Kia Akina.

“There is a serious need to develop new non-surgical ways of treating obesity because obesity-related diseases are expensive for New Zealand, traditional non-surgical methods are not working, and surgery is very costly,” says Professor Sellman.

Kia Akina uses a ‘food addiction’ approach to obesity. Professor Sellman says the project will test the feasibility, short-term effectiveness and participant satisfaction ofKia Akina within a primary health care setting.

If shown to be effective, Kia Akina will be developed as a non-commercial, low cost network for obesity recovery throughout New Zealand.

Innovation in Indigenous Health

Christchurch’s Maori/Indigenous Health Institute (MIHI) recently won the Australasian award for ‘innovation in Indigenous health curriculum implementation’ at the Leaders in Indigenous Medical Education (LIME) conference.

The LIME conference brings together all 20 medical schools throughout Australia and New Zealand, and hosts attendees from the United States and Canada.

Staff and students of the University of Otago, Christchurch, in Darwin at the Leaders in Indigenous Medical Education (LIME) conference

Staff and students of the University of Otago, Christchurch, in Darwin at the Leaders in Indigenous Medical Education (LIME) conference

MIHI director Suzanne Pitama says she and her team were thrilled to receive the award. As there is much collaboration between indigenous teaching teams at University of Otago’s Christchurch, Wellington and Dunedin campuses, the award recognises the innovation of all these teams.  It also recognised the systemic support within the University of Otago to prioritise indigenous health within the curriculum.

MIHI oversees the Maori health component of the medical curriculum at the University of Otago, Christchurch.

Award nominees are judged on how well their teaching programmes demonstrate their commitment and experience to understanding and furthering the health of Maori and Indigenous peoples.

The award has been presented for four years, says Pitama. MIHI also won it in the inaugural year.

A review panel of academic peers and members of indigenous medical doctors associations judge the award, Pitama says.

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This guest post was written by Kim Thomas,  Senior Communications Advisor, University of Otago, Christchurch, www.uoc.otago.ac.nz.

Two new Health Research Council grants worth crowing about

This week’s announcement by the HRC of Feasibility Study and Emerging Researcher grants have many great projects.  Two in particular are worth crowing about (because they have some relationship to kidneys and they involve two excellent people).  I have put summaries in their own words below, but first my comments.

Dr Palmer (Department of Medicine, University of Otago Christchurch), who has appeared on this blog site before, conducts what in the trade are called “meta-analyses” and “systematic reviews.”  Simply put, these are methods to extract the best possible evidence from all the studies that have been done for the effectiveness of a treatment.  Just as one person may toss a coin 4 times in a row and get 4 heads, so too can any one trial give a mistaken impression that a treatment is efficacious (or not) when it really isn’t (or is).  By pooling together many treatments Suetonia provides the very best quality evidence available.  Given that Chronic Kidney Disease affects a large and growing proportion of us, knowing which treatments have the best outcomes is of national significance, not merely to our health but also to the national budget.  A particular problem is that after a trial it can be many many years until meaningful health outcomes are know (e.g. if the treatment delays dialysis need or reduces mortality).  Suetonia’s study will assess the effectiveness of surrogate endpoints for clinical trials.  Surrogate endpoints, such as plasma creatinine which I’ve discussed many time in this blog, are physiologically related to the functioning of an organ or to a disease state as well as statistically associated with future hard outcomes.  However, their use in trials is limited by how well they are associated and how they are used.  I look forward to finding out what Suetonia discovers.

Mrs Rachael Parke (Auckland DHB) is an experienced nurse undertaking a PhD. Ensuring patients have adequate fluids on board is particularly crucial to the kidneys and other organs. Obviously with surgery any blood loss needs to be compensated for. However, there are also physiological changes in where fluid is distributed throughout the body.  Cardiopulmonary bypass, used in cardiac surgery, is a particular risk factor for Acute Kidney Injury. In the past the practice has been to give large amounts of fluid in order to ensure adequate fluid is given.  However, recent research has shown that too much fluid can have a negative impact (increased mortality).  A more restrictive fluid regime may have very meaningful outcomes.  Rachael is investigating, in a randomised controlled trial, if restricting fluid improves outcomes.  The outcome she is most interested in is how long patients stay in the hospital.  This is a very practical outcome for both patient and budget.  I am particularly pleased that this study is nurse-led.  Nurses play an incredibly important role in research as well as patient management.

In their own words:

Dr Suetonia Palmer: Making better clinical decisions to prevent kidney disease

More than ten percent of adults will develop chronic kidney disease. The effectiveness of many treatments used to improve outcomes in kidney disease is tested against surrogate (indirect) markers of health (e.g., cholesterol levels or blood pressure).

Unexpectedly, subsequent systematic analysis has identified little evidence to show that treatment strategies based on these surrogate markers translate to improved health for patients. Serum creatinine and proteinuria levels are commonly-used markers of kidney function to guide treatment.

The research involves using systematic review methods to summarise the quality of evidence for using proteinuria and serum creatinine as markers of treatment effectiveness in clinical trials. It will be determined whether using these markers to guide clinical care improves patient health or, conversely, leads to treatment-related harm or excessive use of ineffective medication.

These summaries will help clinicians and patients make better shared decisions about which therapeutic strategies actually improve clinical outcomes in kidney disease.

Mrs Rachel Parke: Fluid therapy after cardiac surgery – A feasibility study

Following cardiac surgery, patients receive large amounts of fluid in the intensive care unit. This may cause problems with wound healing and delay hospital discharge. A planned randomised controlled trial of a restrictive fluid regime as compared to a more liberal approach utilising advance hemodynamic monitoring, aims to reduce the amount of fluid patients receive and reduce hospital length of stay. This feasibility study aims to determine whether this nurse-led protocol is practicable and feasible and will help answer the research question. This study is simple and inexpensive and if it demonstrates a decreased length of hospital stay then this will represent a significant benefit for both individual patients and the health system.

Diabetes in NZ – new scary data

If this doesn’t scare you, you are an Ostrich.  Otago University researcher Dr Kirsten Coppell has released new data on the prevalence of diabetes in New Zealand.  See here for the press release.

Basic data:

  • 7% of New Zealanders over the age of 15 have diabetes
  • 18.6% have pre-diabetes which typically leads to Type II diabetes (therefore the prevalence is likely to go higher than 7%).
  • The pre-diabetes prevalence increases with age – it was 45% in 55-64 year age group.

For those interested in reading the research, it can be found in the NZ Medical Journal.  NZMJ 1 March 2013, Vol 126 No 1370; ISSN 1175 8716  URL: http://journal.nzma.org.nz/journal/126-1370/5555/  Dr Coppell kindly sent me a copy (*I’ve made a few more observations about the details of the study for those who are interested below).

In the meantime, this is rightly hitting the headlines.  We should be afraid, very afraid.  Our politicians must stop arguing over that which is petty (like selling less than half of a small fraction of our assets) and get focussed on what matters.  Next year is election year – we should demand a comprehensive diabetes policy from each political party.  Below is a letter I wrote to the Christchurch Press prior to the last election – not much has changed.  As for you – you can stop attacking the sugar – you don’t need it and it may kill you.  Beware of “fat free” food which substitutes sugar instead.  Get some advice – see your doctor.  Don’t become a statistic in the next survey.

As for the link with my work (Kidney Attack a.k.a. Acute Kidney Injury), the little diagram explains.Diabetes AKI

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*  The study was a representative sample of New Zealanders.  The study size was large (for an NZ study) – 4,721.

From the results

Overall the prevalence of diabetes was 7.0% (95% CI: 6.0, 8.0). Diabetes was more common among men (8.3%; 95% CI: 6.4, 10.1) compared with women (5.8%; 95% CI: 4.7, 7.0). The prevalence of diagnosed diabetes was 6.0% (95% CI: 4.5, 7.5) among men and 4.0% (95% CI: 3.1, 4.8) among women, and the prevalence of undiagnosed diabetes was 2.1% (95% CI: 1.2, 3.0) among men and 1.5% (95% CI: 1.0, 2.0) among women.

Scary for me is the percentage of undiagnosed diabetes.  This represents tens of thousands of New Zealanders!

Tables in the paper show how the prevalence increases with age and body mass index and that there are marked differences according to ethnicity.  One third of Pacific people over the age of 45 had diabetes, yet about 40% of this was undiagnosed diabetes!

By the way – 95% CI with two numbers following means a that the 95% confidence interval for the prevalence is between the two numbers.  What this means is that there is a 95% chance that confidence interval contains the true prevalence (which can only be known if everyone is measured).  Eg There is a 95% chance that the 6% to 8% confidence interval contains the true prevalence of diabetes (note – 7% should be thought of as an estimate).

How many times do you wash your blood each day?

Stop Kidney Attack.  See this great short video from last year’s World Kidney Day as to why it is so very very important to look after your kidneys. Or as Fred Dagg may sing “If it weren’t for your kidneys, where would you be? You’d be in the hospital or infirmary.”

An implantable artificial kidney

$100 Dialysis is my vision.  University of California San Francisco researchers are doing some exciting research that may well be a step on the way.  They are developing an implantable artificial kidney .  They have a facebook page http://www.facebook.com/ArtificialKidney for those wishing to follow progress.  $13M is needed to bring it clinical trials – I think they should try Kickstarter.  With 400,000 on dialysis in the US alone there will be plenty of contributors (If you are feeling generous now you can contribute by going to their website).  Alternatively, $13M is a drop in the bucket of the $29Bn that Medicaid (6% of its budget)* spends on dialysis every year!

A few interesting facts about UCSF’s artificial kidney:

  • No pumps and no power supply.  It relies on the body’s blood pressure to perform filtration.
  • The key to cleaning the blood is a good filter – they have developed nano technology to produce a silicon based filter with pores small enough and a structure that does not induce blood clotting.  See http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607036/
  • Beyond simply filtering the nasties, the kidney’s role is to regulate salt and water reabsorption and blood pressure.  This is being achieved by using bioengineered grown tissue – that is real cells from inside the kidney. They call this the bioreactor.
  • They are currently in the “pre-clinical” stage where they are miniaturising the machine and preparing it for implantation into humans.

* If you want to know why this is so high and the practices in the US then see http://www.propublica.org/series/dialysis.  You may be shocked (a must read for every for anyone in the US making choices about dialysis).

How can donor rates be increased? : guest post

I read the following in Kidney Health New Zealand’s annual report and with KHNZ and Paula Martin’s permission I have reproduced her great report.  I am thrilled to see such important research being undertaken and as you’ll read, Paula has great motivation.  Paula is a PhD Candidate in the Health Services Research Centre, School of Government, Victoria University, Wellington, New Zealand.

Kidney Health New Zealand Research Grant

Paula Martin

In 2006 I donated a kidney to my husband. At the time, I was just focusing on getting through the year long donor work up and supporting my husband while we coped with the impacts on our lives of him being on peritoneal dialysis. Only after the transplant did I realise just how few living donor transplants are done each year in New Zealand. In 2006, only 46 other live donors gave a kidney to someone; last year the number had climbed to 57 live donors, but the number of people needing a transplant had also increased dramatically, with around 600 on the official waiting list.

What could be done to increase the current rate of kidney donations? The low number of transplants is a concern because we know that for most people with end stage renal failure, a transplant is the best treatment. In addition, it is cheaper than keeping people on dialysis. In order to develop solutions, we needed research to tell us what the barriers to living donor kidney transplantation are in New Zealand; how similar to, or different from, barriers in other countries these are; and what people involved in the renal community here think could be done about those barriers, so that more people wanting a transplant can get one.

In 2010, I decided to do some research on this topic to fill this gap. Supported by a research grant from Kidney Health New Zealand, I’m currently undertaking a PhD in Public Policy based at the Health Services Research Centre in the School of Government, at Victoria University of Wellington. My focus is solely on living donation, not deceased. Around half of all kidney transplants now come from living donors and with the increasing demand for kidney transplants and the shortage of deceased donors, living transplantation has to be a critical part of solving the problem. The barriers to living donation and deceased donation are different so it’s important to think about them separately.

We know from overseas research that there can be many different barriers: for example, patients needing a transplant often find it difficult to approach their family and friends about whether they might consider living donation; people who want to be donors can face practical barriers such as loss of income while they take time off to recover from the surgery; and many people who would like to be donors discover that they aren’t compatible with the person they want to donate to, or that they have a medical problem of their own which makes them unsuitable. A particular problem in NZ is that Maori and Pacific people often find it harder to get a transplant than European/Pakeha. There are likely to be many different reasons for this. Cultural attitudes to organ donation may be one factor, but a bigger issue may be that it can be harder for these patients to find a donor who meets the strict medical suitability criteria because of things like the high rates of Type II diabetes in these populations.

There is no single solution to this problem – this is an extremely complex issue and we’ll need a variety of different initiatives to make a difference to it. So, I’ve been looking at our legislation and current policies as well as how renal services operate on the ground, and talking to a range of different people – patients, renal specialists, transplant coordinators, patient support groups, managers in District Health Boards and senior government officials and politicians – to find out what they think the issues are.

Finding out what the issues are from a patient perspective has been a big part of the research. With the assistance of the three renal transplant units, I carried out a postal survey last year of all the people on the kidney transplant waiting list and received nearly 200 replies. I’ve followed that up with a small number of in-depth patient interviews. The early results of this part of the research suggest that, as in other countries, patients find it very difficult to “ask” someone to be a kidney donor which often stops them talking to their family and friends about living donation. Furthermore, patients that do get offers from people to be kidney donors often find they are incompatible or the potential donor is medically unsuitable for some reason. Health professionals I’ve interviewed have provided valuable insights into what the issues are from their perspective inside the health system.

I’m aiming to finish this research in 2013. I hope it will be of use to practitioners, policy makers, patient groups and anyone else interested in making a difference to this problem.

Thanks to Kidney Health New Zealand for supporting this work with a grant towards the costs of doing research.