Chronic Kidney Disease in Disadvantaged Populations

Chronic Kidney Disease in Disadvantaged Populations investigates the increased incidence and prevalence of kidney disease in vulnerable populations world-wide. The volume explores the complex interactions of genetic, biologic, cultural and socioeconomic factors such as the environment, and specific health behaviors that seem to be responsible for a significant proportion of the health disparities in these communities. Each chapter is written by leading experts in the field and analyzes the prevalence and incidence of pre-dialysis kidney disease in disadvantaged populations across both developed and developing countries. In addition, each contribution analyzes differentiated risk factors and compares the disparities in access to screening, prevention strategies, treatment protocols and renal replacement therapies. Chronic Kidney Disease in Disadvantaged Populations is essential reading for residents, fellows, clinicians and biomedical researchers working in nephrology, internal medicine, and epidemiology, especially those working in areas with high concentrations of disadvantaged populations.

• Presents a comprehensive account of both traditional and non-traditional risk factors for kidney disease
• Explores the mechanisms by which poverty increases the burden of kidney disease in these populations, barriers to access to renal health care, including renal replacement therapies, organ donation, and organ commercialization
• Offers the latest perspectives on outcomes in renal replacement therapies as well as prevention strategies

• Language: English
• Publisher: Academic Press
• Release date: Jul 8, 2017
• ISBN: 9780128043820

Book preview

Chronic Kidney Disease in Disadvantaged Populations

Edited by

Guillermo García-García, MD, FACP, FASN

Nephrology Service, Hospital Civil de Guadalajara

University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico

International Society of Nephrology Committee on Kidney Health in Disadvantaged Populations

Lawrence Y. Agodoa, MD

National Institutes of Health; and National Institute of Diabetes and

Digestive and Kidney Diseases (NIDDK), Bethesda, MD, United States

International Society of Nephrology Committee on Kidney Health in Disadvantaged Populations

Keith C. Norris, MD, PhD, FACP, FASN

David Geffen School of Medicine at

UCLA, Los Angeles, CA, United States

International Society of Nephrology Committee on Kidney Health in Disadvantaged Populations

Table of Contents

Cover

Title page

Copyright

Contributors

Foreword

Part I: Introduction

Chapter 1: Introduction

Summary

Part II: Burden of Disease: Prevalence of Predialysis Kidney Disease in Disadvantaged Populations in Developed Countries

Chapter 2: Prevalence of Predialysis Kidney Disease in Disadvantaged Populations in Developed Countries: Canada

Summary

1. The Canadian population

2. Canada’s health care system

3. Who is disadvantaged?

4. Prevalence of predialysis chronic kidney disease in disadvantaged populations in Canada

5. Immigrants and refugees

6. Canada’s Aboriginal people

7. Conclusions

Chapter 3: Prevalence of Predialysis Kidney Disease in Disadvantaged Populations in Developed Countries: United States

Summary

1. Racial/ethnic disparities in chronic kidney disease and the impact of low socioeconomic status

2. Racial/ethnic disparities in the prevalence of chronic kidney disease in the United States

3. Conclusions

Acknowledgment

Chapter 4: Chronic Kidney Disease in China

Summary

1. Prevalence of predialysis CKD in China

2. Prevalence and incidence of dialysis patients in China

3. Affordability and accessibility of dialysis in China

4. Treatment and prognosis of dialysis patients in China

5. Spectrum of CKD in China

Part III: Burden of Disease: Prevalence and Incidence of Predialysis Kidney Disease in Disadvantaged Populations in Developing Countries

Chapter 5: Prevalence of CKD in Uruguay

Summary

1. Introduction

2. Methodology

3. Analytical determinations for screening CKD in Preventive Medicine Clinics

4. Results

5. Discussion

6. Conclusions

Chapter 6: Prevalence of Chronic Kidney Disease and Associated Risk Factors in Cuba

Summary

1. Introduction

2. Social determinants and health system indicators regarding the development of kidney disease in Cuba: year 2014

3. Patients with end-stage renal disease on renal replacement therapy

4. Isle of Youth Study (ISYS)

5. Methodology

6. Results

Part IV: Disparities in ESRD Among Disadvantaged Populations

Chapter 7: End-Stage Renal Disease Among Indigenous Populations in Canada

Summary

1. Introduction

2. Terminology

3. Health of Aboriginal people in Canada

4. Prevalence and causes of end-stage renal disease among Aboriginal adults

5. Prevalence and causes of end-stage renal disease among Aboriginal children

6. Survival and quality of care for Aboriginal adults treated with dialysis

7. Survival and quality of care for Aboriginal children treated with dialysis

8. Kidney transplantation among Aboriginal adults

9. Kidney transplantation among Aboriginal children

10. Conclusions

Chapter 8: Racial Differences in Kidney Disease and End-Stage Kidney Disease in the USA

Summary

1. Introduction

2. Causes of ESRD in the US population

3. Racial and ethnic disparities in dialysis care

4. Racial and ethnic disparities in kidney transplantation

5. Survival paradox

6. Conclusions

Acknowledgments

Chapter 9: End-Stage Renal Disease in Mexico

Summary

1. Introduction

2. Epidemiology of treated ESRD

3. Dialysis

4. Dialysis outcomes

5. Kidney transplantation

6. Kidney transplantation outcomes

7. Nephrology manpower

8. Disparities in renal care

9. Conclusions

Chapter 10: End-Stage Renal Disease in Latin America

Summary

1. Introduction

2. The development of nephrology and dialysis and transplantation registries in Latin America

3. Burden of ESRD in LA

Acknowledgments

Conflicts of interest statement

Chapter 11: Kidney Disease in Ethnic Minority Populations in the United Kingdom

Summary

1. Introduction

2. General issues around health/societal inequality in the United Kingdom

3. The epidemiology of chronic kidney disease in different ethnic groups in the United Kingdom

4. The epidemiology of end-stage kidney disease in different ethnic groups in the United Kingdom

5. Conclusions

Chapter 12: End-Stage Renal Disease in the Middle East

Summary

1. Introduction

Chapter 13: End Stage Renal Disease (ESKD) in Egypt and North Africa

Summary

1. Introduction

2. Kidney disease in North Africa

3. Burden of end-stage kidney disease

4. Facing the challenge

5. Human resources

6. Conclusions

Chapter 14: End Stage Renal Disease in Sub-Saharan Africa

Summary

1. Introduction

2. Chronic kidney disease

3. Healthcare resources for CKD

4. Causes of chronic kidney disease in Sub-Saharan Africa

5. Renal replacement therapy

6. Prevention of CKD

7. Conclusions

Acknowledgments

Chapter 15: Kidney Disease in South Asia

Summary

1. South Asia: why is the Population Disadvantaged?

2. Epidemiology of kidney disease in South Asia

3. Burden of CKD in South Asia

4. CKD care in South Asia

5. Improving CKD care: looking forward

Chapter 16: ESRD in South-East Asia

Summary

1. Introduction

2. Status in individual countries

3. Public–private partnership—a new incentive within Southeast Asia

4. Conclusions

Acknowledgments

Chapter 17: Kidney Disease in Maori and Pacific people in New Zealand

Summary

1. Background

2. Geography and climate

3. Polynesian and European arrival

4. Health inequality in New Zealand

5. Mortality rates

6. Diabetes

7. Albuminuria and blood pressure in those without diabetes

8. Glomerulonephritis

9. Dialysis

10. Transplantation

11. Disparities in health care outcomes in nonrenal disease

12. Pacific people

13. Reasons for differences in incidence or ESKD and outcomes for Māori and Pacific people

14. Conclusions

Chapter 18: Kidney Disease Among Aboriginal and Torres Strait Islander People in Australia

Summary

1. Background

2. Chronic kidney disease

3. Pathological basis of CKD

4. Management of kidney disease among indigenous people

Part V: Current View on Risk Factors

Chapter 19: Current View on CKD Risk Factors: Traditional, Noncommunicable Diseases—Diabetes, Hypertension, and Obesity

Summary

1. Introduction

2. Diabetes

3. Hypertension

4. Obesity

5. The interrelated nature of obesity, diabetes, and hypertension

6. The way forward

7. Conclusions

Acknowledgment

Chapter 20: Risk Factors for Kidney Disease in Disadvantaged Populations—Communicable Diseases, Environmental Factors, and Pollutants

Summary

1. Introduction

2. Communicable diseases and the kidney

3. Kidney disease and environmental factors

4. Kidney disease and pollutants

5. Conclusion

Chapter 21: Poverty and Renal Disease

Summary

1. Introduction

2. Poverty and prevalent chronic kidney disease

3. Poverty and progressive chronic kidney disease

4. Poverty and consequences of CKD

5. Why might poverty lead to CKD?

6. Conclusions

Part VI: Unique Issues in Kidney Disease Among Disadvantaged Populations

Chapter 22: Mesoamerican Nephropathy or Chronic Kidney Disease of Unknown Origin

Summary

1. Introduction

2. Epidemiology

3. Clinical and laboratory characteristics

4. Histopathology

5. Potential risk factors and causes of MeN

6. Prevention and treatment

7. Conclusions

Chapter 23: Prematurity, Low Birth Weight, and CKD

Summary

1. Chronic kidney disease

2. Inequalities around the world: LBW, prematurity and the Human Development Index (HDI)

3. Causes of low birth weight and preterm birth

4. Changing death rates around the world

5. Postnatal health in relation to LBW and prematurity

6. Impaired kidney development in the context of LBW and prematurity and CKD

7. Disadvantaged groups within countries and regions

8. Some supporting observations

9. Conclusions

Chapter 24: Hypovitaminosis D and Progression of CKD

Summary

1. Introduction

2. Vitamin D and progression of kidney disease

3. Racial differences in hypovitaminosis D and as an explanatory factor for racial disparities in progression of kidney disease

4. Conclusions

Chapter 25: Renal Care in an Unequal World: Anthropological Reflections

Summary

1. Introduction: fieldwork reflections

2. Focus and scope

3. Anthropology and the transplant complex

4. Organ transplantation and the cultural encounter

5. Ethnographic research: the problems of specificity and scale

6. Conclusions

Chapter 26: Developing Nephrology Programs in Low Resource Settings

Summary

1. Introduction

2. Understanding the local burden of disease: information and research

3. Developing competent renal healthcare practitioners: healthcare workforce

4. Delivering sustainable and effective renal care

5. Delivering sustainable and effective renal care

6. Developing appropriate policies and financial planning for a sustainable and affordable renal program

7. Developing appropriate policies and financial planning for a sustainable and affordable renal program

8. Conclusions

Chapter 27: Renal Transplantation in Low Resource Settings

Summary

1. Introduction

2. Economic indications

3. End stage renal disease and access to RRT

4. Renal transplantation

5. Organ donation

6. Commercialism

7. Conclusions

Chapter 28: Renal Transplantation, the Iranian Model

Summary

1. Introduction

2. Country overview

3. ESRD profile of Iran

4. How renal replacement therapy in Iran started?

5. Historical background of renal transplantation in Iran

6. Why governmental incentive for donation?

7. Final link in the transplantation program chain: Legislation of Brain Death Organ Donation Act (2000)

8. Controversial issues in Iranian model

9. Conclusions

Part VII: CKD Screening and Prevention Strategies in Disadvantaged Populations

Chapter 29: Developing a Rational Approach for Chronic Kidney Disease Identification: Population Based Versus Targeted Screening Studies

Summary

1. Introduction

2. The debate regarding screening for chronic kidney disease

3. Findings from screening for chronic kidney disease

4. The kidney early evaluation program and related programs

5. Screening in low- and middle-income countries

6. Conclusions

Acknowledgments

Chapter 30: CKD Screening in Mexico

Summary

1. Introduction

2. CKD screening approaches

3. Population-based screening

4. Targeted-screening

5. Opportunistic-screening

6. Involvement of primary care physicians in CKD detection

7. Conclusions

Chapter 31: The Role of Primary Health Care Professionals

Summary

1. Introduction

2. Prevalence of chronic kidney disease at an early stage

3. Recommendation for screening of chronic kidney disease

4. Prevention strategies and role of primary health care professionals

5. Conclusions

Chapter 32: Chronic Kidney Disease in Disadvantaged Populations: Online Educational Programs for NCD Prevention and Treatment

Summary

1. e-Learning

2. PIEENSO

3. The CASALUD model

4. Chronic kidney disease

5. e-Learning diploma for the prevention and integrated care of noncommunicable diseases

6. Conclusions

Chapter 33: Integration of Chronic Kidney Disease Prevention into the Uruguayan National Program for Noncommunicable Diseases

Summary

1. Introduction

2. The Uruguayan context

3. Noncommunicable diseases in Uruguay

4. Surveillance of noncommunicable diseases

5. Risk factors for noncommunicable diseases

6. Programs for prevention of noncommunicable diseases

7. Prevalence and treatment of CKD; end-stage renal disease

8. National Renal Healthcare Program

9. Inclusion of CKD screening in the mandatory health check-up

10. Evaluation of the CKD Program; The CKD Registry

11. Universalization of the CKD Program and regional expansion

12. Conclusions

Chapter 34: Integration of Chronic Kidney Disease Prevention into Noncommunicable Diseases Programs in Cuba

Summary

1. Introduction

2. Republic of Cuba—demographic characteristics

3. Healthcare for CKD patients in Cuba

4. The Cuban National Program for the Prevention of Chronic Kidney Disease

5. CKD mortality

6. CKD prevalence

7. Prevalence of CKD risk factors

8. Conclusions

Chapter 35: Raising Awareness: The World Kidney Day Initiative

Summary

1. Background

2. Results

3. WKD editorials

4. WKD themes

5. WKD champions

6. Activation ideas

7. Conclusions

Index

Copyright

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Contributors

Lawrence Y. Agodoa,     National Institutes of Health; and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, United States

Ejaz Ahmed,     Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi, Pakistan

Fazal Akhtar,     Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi, Pakistan

Luz Alcantar-Vallin,     Guadalajara Civil Hospital, Guadalajara, Jalisco, Mexico

Miguel Almaguer-López,     Nephrology Institute, Havana, Cuba

Gloria Ashuntantang,     University of Yaounde I, Yaounde, Cameroon

Tahir Aziz,     Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi, Pakistan

Rashad S. Barsoum,     Cairo University, The Cairo Kidney Center, Cairo, Egypt

Aminu K. Bello,     University of Alberta, Edmonton, AB, Canada

Miguel Betancourt-Cravioto,     Carlos Slim Foundation, Mexico City, Mexico

Hugo Breien-Coronado,     Regional Hospital Valentin Gomez Farias, Guadalajara, Jalisco, Mexico

Fergus Caskey

Southmead Hospital

Canynge Hall, University of Bristol, Bristol, England

Jonathan S. Chavez-Iñiguez,     Nephrology Service, Hospital Civil de Guadalajara, University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico

José A. Chipi-Cabrera,     Héroes del Baire Hospital, Nueva Gerona, Cuba

John F. Collins,     University of Auckland, Auckland City Hospital, Auckland, New Zealand

Ricardo Correa-Rotter,     Salvador Zubirán National Institute of Health Sciences and Nutrition, Mexico City, Mexico

Laura Cortés-Sanabria,     Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México

Deidra C. Crews

Welch Center for Prevention, Epidemiology and Clinical Research

Hopkins Center to Eliminate Cardiovascular Health Disparities, Johns Hopkins University School of Medicine, Baltimore, MD, United States

Alfonso M. Cueto-Manzano,     Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México

Ana M. Cusumano,     CEMIC University Institute, Buenos Aires, Argentina

Jorge P.O. Díaz,     Institute of Nephrology, Cuba

Librado de la Torre-Campos,     Guadalajara Civil Hospital, Guadalajara, Jalisco, Mexico

Gavin Dreyer,     Barts Health NHS Trust, London, United Kingdom

Arogundade F. Abiola,     Obafemi Awolowo University, Ife, Osun State, Nigeria

Liliana Gadola,     Centro de Nefrología, Universidad de la República, Montevideo, Uruguay

Héctor Gallardo-Rincón,     Carlos Slim Foundation, Mexico City, Mexico

Hector García-Bejarano,     Regional Hospital, Jalisco Health Secretariat, Guadalajara, Jalisco, Mexico

Guillermo García-García,     Nephrology Service, Hospital Civil de Guadalajara, University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico

María C. González-Bedat,     Executive Board of the Latin American Dialysis and Transplantation Registry, Montevideo, Uruguay

Alfonso Gutierrez-Padilla,     Hospital Civil Foundation, Guadalajara, Mexico

Altaf Hashmi,     Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi, Pakistan

A.S. Hassan,     Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi, Pakistan

Brenda Hemmelgarn,     Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

Raúl Herrera-Valdés,     Nephrology Institute, Havana, Cuba

Wendy E. Hoy,     NHMRC CKD Centre for Research Excellence and Centre for Chronic Disease, UQCCR, The University of Queensland, Herston, QLD, Australia

Wendy Hoy,     Royal Brisbane and Women’s Hospital, The University of Queensland, Brisbane, QLD, Australia

Manzoor Hussain,     Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi, Pakistan

Zafar Hussain,     Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi, Pakistan

Margarita Ibarra-Hernandez,     Hospital Civil Foundation, Guadalajara, Mexico

Vivekanand Jha

George Institute for Global Health India, New Delhi, India

University of Oxford, Oxford, United Kingdom

Ciara Kierans,     The University of Liverpool, Liverpool, England

Kajiru G. Kilonzo,     Kilimanjaro Christian Medical University College, Kilimanjaro Christian Medical Centre, Moshi, Tanzania

Vivek Kumar,     Postgraduate Institute of Medical Education and Research, Chandigarh, India

Miguel A. López,     Institute of Nephrology, Cuba

Zuo Li,     Peking University People’s Hospital, Beijing, China

Valerie A. Luyckx,     Institute of Biomedical Ethics, University of Zurich, Zurich, Switzerland

Mitra Mahdavi-Mazdeh,     Tehran University of Medical Sciences, Iranian Tissue Bank & Research Center, Tehran, Iran

Héctor R. Martínez-Ramírez,     Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México

Anna Mathew,     Hofstra Northerly School of Medicine, Great Neck, NY, United States

Stephen McDonald

Central Northern Adelaide Renal and Transplantation Service

Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute

The University of Adelaide, Adelaide, SA, Australia

Rajnish Mehrotra,     Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, WA, United States

Rehan Mohsin,     Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi, Pakistan

Susan A. Mott,     NHMRC CKD Centre for Research Excellence and Centre for Chronic Disease, UQCCR, The University of Queensland, Herston, QLD, Australia

Saraladevi Naicker,     University of the Witwatersrand, Johannesburg, South Africa

Mirza Naqi Zafar,     Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi, Pakistan

Syed A. Anwar Naqvi,     Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi, Pakistan

Robert Nee,     Walter Reed National Military Medical Center, Bethesda, MD, United States

Susanne B. Nicholas,     David Geffen School of Medicine at UCLA, Los Angeles, CA, United States

Jennifer L. Nicol,     NHMRC CKD Centre for Research Excellence and Centre for Chronic Disease, UQCCR, The University of Queensland, Herston, QLD, Australia

Keith C. Norris,     David Geffen School of Medicine at UCLA, Los Angeles, CA, United States

Jorge F. Pérez-Oliva-Díaz,     Nephrology Institute, Havana, Cuba

Leonardo Pazarin-Villaseñor,     Civil Hospital Dr. Juan I. Menchaca, Guadalajara, Jalisco, Mexico

Gustavo Perez-Cortez,     Civil Hospital Dr. Juan I. Menchaca, Guadalajara, Jalisco, Mexico

Pablo G. Ríos Sarro,     Fondo Nacional de Recursos, Montevideo, Uruguay

Karina Renoirte-Lopez,     Hospital Civil Foundation, Guadalajara, Mexico

Raul Reyna-Raygoza,     Hospital Civil Foundation, Guadalajara, Mexico

Syed A.H. Rizvi,     Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi, Pakistan

Orlando L. Rodríguez,     Ministry of Public Health, Cuba

Enrique Rojas-Campos,     Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México

Guillermo J. Rosa Diez,     Executive Board of the Latin American Dialysis and Transplantation Registry, Buenos Aires, Argentina

Carlos Rosales-Galindo,     Hospital Civil Foundation, Guadalajara, Mexico

Alireza H. Rouchi,     Tehran University of Medical Sciences, Iranian Tissue Bank & Research Center, Tehran, Iran

Susan Samuel,     Alberta Children’s Hospital, Calgary, AB, Canada

Nestor J. Santiago-Hernandez,     Nephrology Service, Hospital Civil de Guadalajara, University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico

Faissal A.M. Shaheen,     Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia

Laura Sola,     University of the Republic, Montevideo, Uruguay

Manish Sood,     The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada

John W. Stanifer

Duke University

Duke Clinical Research Institute

Duke Global Health Institute, Durham, NC, United States

Sydney C.W. Tang,     The University of Hong Kong, Queen Mary Hospital, Hong Kong, China

Philip K. Tao Li,     Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong

Roberto Tapia-Conyer,     Carlos Slim Foundation, Mexico City, Mexico

Marcello Tonelli,     Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

Viliame Tutone,     Middlemore Hospital, Auckland, New Zealand

Raúl H. Valdés,     Institute of Nephrology, Cuba

Curtis Walker,     Palmerston North Hospital, Palmerston North, New Zealand

Sandra F. Williams

Cleveland Clinic, Weston

Florida Atlantic University, Boca Raton, FL, United States

Karen Yeates,     Queen’s University, Kingston, ON, Canada

Luxia Zhang,     Peking University First Hospital, Beijing, China

Foreword

The publication of a new book devoted to contemporary problems associated with kidney disease in disadvantaged nations and communities is both welcome and timely. Although not the first such endeavor, it is certainly the most comprehensive, and has the advantage that the authors of many of the chapters are themselves working under the conditions that they describe. As such it should serve as the default reference source for nephrologists and other professionals whose practice brings them into contact with the problems associated with acute and chronic progressive renal disease.

And there are indeed problems, many of them, such as prioritization of resources, which are beyond the capacity of nephrologists to resolve. Given that limitation, renal physicians, most of who work in association with metropolitan academic institutions, should not ignore the fact that much of the world’s renal disease burden is occurring in these disadvantaged communities. This inconvenient paradox should throw up clues to the etiology of these diseases. Clinical research, on the ground, importantly, may lead to useful evidence in the search for disease prevention. Such an approach coupled with a renal education component ought to provide the impetus for younger trained nephrologists to acquaint themselves directly in the field. This, though, could only happen if it obtained the support of senior influential nephrologists.

Nephrology as a specialty is barely 75 years old, but it has seen spectacular advances in that time, particularly in the areas of histopathology and in the treatment of end-stage disease. Sadly, these advances have really only been applicable in developed countries with mature health services. Elsewhere, in the absence of such services or private insurance, progressive renal disease has been and largely remains a death sentence. Our understanding of the pathophysiological mechanisms which result in renal failure is still rudimentary, and the fact that the incidence of chronic renal disease is so high within disadvantaged communities suggests that the etiological net should be cast much wider. Thus the main focus needs to be on prevention.

Not that preventive programs can be introduced without difficulty, or with any easy optimism about beneficial outcomes. While a screening diagnosis of important renal disease, justified on the grounds that renal disease is highly prevalent, may rest with certainty on the simple finding of persistent proteinuria, backed up by simple blood tests and blood pressure readings, one has to ask the question, what next? If the anticipated answer is surveillance of identified cases, how are they to be followed, and is it not morally reprehensible if consequential necessary treatment is not offered?

The widespread availability of computing technology, and simple statistical programs has led to a mushrooming of mostly retrospective studies in this area, often presented at conferences and symposia. In many instances the material presented is not fit for purpose and the results are likely to benefit the researcher rather more than the population under study, and this, as well as being wasteful of scarce resources, simply produces data rather than knowledge. Again, there is an ethical dilemma.

Nephrology has tended to operate in an exclusive fashion with day-to-day activities and professional meetings largely confined to the discipline. So, a tick for the fact that this book has broadened the investigational frontier, with chapters referring to dietary concerns, and consideration of anthropological aspects of renal disease, as well as health economics. Disadvantaged communities continue to need help from the wider nephrological community, and they remain fertile ground for the work of nephrologists in the efforts to resolve as yet unanswered questions regarding the genesis of renal disease and its adequate treatment.

David Pugsley

Adelaide, Australia

Part I

Introduction

Chapter 1: Introduction

Chapter 1

Introduction

Guillermo García-García*

Lawrence Y. Agodoa**

Keith C. Norris†

*    Nephrology Service, Hospital Civil de Guadalajara, University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico

**    National Institutes of Health; and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, United States

†    David Geffen School of Medicine at UCLA, Los Angeles, CA, United States

Summary

Chronic kidney disease (CKD) is increasingly recognized as a global public health problem, and it is a key determinant of the poor health outcomes. While Although the magnitude of CKD has been better defined in developed countries, increasing evidence indicates that the burden of CKD is as great or even greater in developing countries. Disadvantaged communities, iethat is, those from low resource, racial and ethnic minority, and/or indigenous backgrounds, suffer from marked increases in the incidence, prevalence, and/or complications of CKD. The fact that even in developed countries racial and ethnic minorities bear a disproportionate burden of the disease suggests there is much to learn beyond the traditional risk factors contributing to CKD-associated complications.

Keywords

CKD

developed countries

developing countries

Chronic kidney disease (CKD) is increasingly recognized as a global public health problem, and it is a key determinant of the poor health outcomes [1]. Although the magnitude of CKD has been better defined in developed countries, increasing evidence indicates that the burden of CKD is as great or even greater in developing countries. Disadvantaged communities, that is, those from low resource, racial and ethnic minority, and/or indigenous backgrounds, suffer from marked increases in the incidence, prevalence, and/or complications of CKD. The fact that even in developed countries racial and ethnic minorities bear a disproportionate burden of the disease suggests there is much to learn beyond the traditional risk factors contributing to CKD-associated complications [2].

Poverty-related factors, such as infectious diseases secondary to poor sanitation, inadequate supply of safe water, environmental pollutants, and high concentrations of disease-transmitting vectors, continue to play an important role in the development of CKD in low-income countries. The poor are more susceptible to disease because of lack of access to goods and services, in particular, clean water and sanitation, information about preventive behaviors, and adequate nutrition, and have reduced access to health care [3]. In addition, genetic or biologic predisposition may be involved in cases with accelerated CKD progression in the setting of poverty, like in nondiabetic patients with focal segmental glomerulosclerosis [4]. The elevated prevalence of CKD of unspecified cause in various developing countries reminds us of the relationship between poverty and ill-health, in which among other factors, environmental exposures to heavy metals or other toxins and pollutants may play a significant role in the development of CKD [5]. An association between low birth weight due primarily to nutritional factors and kidney disease has been described in most populations, including the aboriginal community of Australia, African American and whites in the United States, Indian, and South Asian populations [6–8].

In addition to having a higher disease burden, the poor have limited access to resources for meeting treatment costs. A large proportion of patients, who are forced to meet the expensive End Stage Renal Disease (ESRD) treatment costs by incurring out-of-pocket expenditure, get pushed into extreme poverty [9]. Likewise, disadvantaged populations have low transplantation rates because of a combination of low levels of infrastructure; geographical remoteness; lack of legislation governing brain death; religious, cultural, and social constraints; and commercial incentives that favor dialysis [10]. Mortality rates among those who receive Replacement Therapy (RRT) are often higher in indigenous minority and disproportionately uninsured populations even after adjustment for comorbid conditions [11–13]. However, it should be noted that despite these excess adversities racial/ethnic minorities in more developed nations treated with dialysis have lower mortality rates than their white peers [14–18].

The book highlights the complex interactions of genetic, biologic, and cultural and socioeconomic factors, such as the environment and specific health behaviors, that seem to be responsible for a significant proportion of the health disparities in these communities.

References

[1] Couser WG, Remuzzi G, Mendis S, Tonelli M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int. 2011;80(12):1258–1270.

[2] Pugsley D, Norris KC, Garcia-Garcia G, Agodoa L. Global approaches for understanding the disproportionate burden of chronic kidney disease. Ethn Dis. 2009;19(1 Suppl. 1): S1-1-2.

[3] García-García G, Jha V. World Kidney Day 2015: CKD in disadvantaged populations. Am J Kidney Dis. 2015;65(3):349–353.

[4] Kao WH, Klag MJ, Meoni LA, et al. MYH9 is associated with nondiabetic end-stage renal disease in African Americans. Nat Genet. 2008;40(10):1185–1192.

[5] Almaguer M, Herrera R, Orantes CM. Chronic kidney disease of unknown etiology in agricultural communities. MEDICC Rev. 2014;16(2):9–15.

[6] Hoy WE, Hughson MD, Zimanyi M, et al. Distribution of volumes of individual glomeruli in kidneys at autopsy: association with age, nephron number, birth weight and body mass index. Clin Nephrol. 2010;74(Suppl. 1):S105–S112.

[7] Lackland DT, Bendall HE, Osmond C, Egan BM, Barker DJ. Low birth weights contribute to high rates of early-onset chronic renal failure in the Southeastern United States. Arch Intern Med. 2000;160(10):1472–1476.

[8] Jafar TH, Chaturvedi N, Hatcher J, et al. Proteinuria in South Asian children: prevalence and determinants. Pediatr Nephrol. 2005;20(10):1458–1465.

[9] Ramachandran R, Jha V. Kidney transplantation is associated with catastrophic out of pocket expenditure in India. PLoS One. 2013;8(7):e67812.

[10] Garcia G, Harden P, Chapman J. World Kidney Day Steering Committee 2012 The global role of kidney transplantation. Lancet. 2012;379(9820):E36–E38.

[11] McDonald SP, Russ GR. Burden of end-stage renal disease among indigenous peoples in Australia and New Zealand. Kidney Int Suppl. 2003;(83):S123–S127.

[12] Rodriguez RA, Sen S, Mehta K, Moody-Ayers S, Bacchetti P, O’Hare AM. Geography matters: relationships among urban residential segregation, dialysis facilities, and patient outcomes. Ann Intern Med. 2007;146(7):493–501.

[13] Chou SH, Tonelli M, Bradley JS, Gourishankar S, Hemmelgarn BR. Alberta Kidney Disease Network Quality of care among Aboriginal hemodialysis patients. Clin J Am Soc Nephrol. 2006;1(1):58–63.

[14] Agodoa L, Eggers P. Racial and ethnic disparities in end-stage kidney failure-survival paradoxes in African-Americans. Semin Dial. 2007;20(6):577–585.

[15] Kucirka LM, Grams ME, Lessler J, et al. Association of race and age with survival among patients undergoing dialysis. JAMA. 2011;306(6):620–626.

[16] Kalantar-Zadeh K, Golan E, Shohat T, Streja E, Norris KC, Kopple JD. Survival disparities within American and Israeli dialysis populations: learning from similarities and distinctions across race and ethnicity. Semin Dial. 2010;23(6):586–594.

[17] Rhee CM, Kalantar-Zadeh K, Norris KC. Why minorities live longer on dialysis: an in-depth examination of the Danish nephrology registry. Nephrol Dial Transplant. 2016;31(7):1027–1030.

[18] van den Beukel TO, Hommel K, Kamper AL, et al. Differences in survival on chronic dialysis treatment between ethnic groups in Denmark: a population-wide, national cohort study. Nephrol Dial Transplant. 2016;31(7):1160–1167.

Further reading

Hall YN, Xu P, Chertow GM, Himmelfarb J. Characteristics and performance of minority-serving dialysis facilities. Health Serv Res. 2014;49(3):971–991.

Nicholas SB, Kalantar-Zadeh K, Norris KC. Socioeconomic disparities in chronic kidney disease. Adv Chronic Kidney Dis. 2015;22(1):6–15.

Part II

Burden of Disease: Prevalence of Predialysis Kidney Disease in Disadvantaged Populations in Developed Countries

Chapter 2: Prevalence of Predialysis Kidney Disease in Disadvantaged Populations in Developed Countries: Canada

Chapter 3: Prevalence of Predialysis Kidney Disease in Disadvantaged Populations in Developed Countries: United States

Chapter 4: Chronic Kidney Disease in China

Chapter 2

Prevalence of Predialysis Kidney Disease in Disadvantaged Populations in Developed Countries: Canada

John W. Stanifer*,**,†

Anna Mathew‡

Kajiru G. Kilonzo¶

Karen Yeates||

*    Duke University, Durham, NC, United States

**    Duke Clinical Research Institute, Durham, NC, United States

†    Duke Global Health Institute, Durham, NC, United States

‡    Hofstra Northerly School of Medicine, Great Neck, NY, United States

¶    Kilimanjaro Christian Medical University College, Kilimanjaro Christian Medical Centre, Moshi, Tanzania

||    Queen’s University, Kingston, ON, Canada

Summary

Canada is a geographically large, high-income country with a population of approximately 35 million. Canada’s population is ethnically diverse and is growing annually due to strong immigration policies. Canadians enjoy a health system that is based on the principle of universality and is made up of a series of socialized health plans that differ by the province where a person lives. In addition, a person who lives in Canada (e.g., rural vs. urban) has an impact on health status. Rural Canadians have poorer health status relative to other Canadians, which includes lifestyle-related illnesses, injuries, cardiovascular diseases, poisoning, infant mortality, and life expectancy. There are many people and communities in Canada that are considered vulnerable and at risk. These populations are very heterogeneous and predominantly consist of people living in rural and remote parts of Canada, those who are homeless or with intermittent shelter, Aboriginal peoples, immigrants and refugees, isolated seniors, and the poor, including both low-income individuals and families. Although we can classify these groups of Canadians as disadvantaged, the level of disadvantage and health disparities that come with this classification are harder to quantify. Moreover, understanding how these groups experience relative disadvantage within Canadian society and within the health system is challenging, especially with respect to predialysis kidney disease prevalence and care. With respect to chronic kidney disease (CKD), Canada ostensibly has a comprehensive system of nephrology care that is guideline-driven and embedded in both specialized (secondary and tertiary) and within a network of provincial primary health care systems. Despite the availability of nephrology care, challenges exist with respect to identification of risk factors for CKD in these disadvantaged groups. As these populations are often marginalized from the mainstream health care system, provision of preventive services is challenging. In the context of CKD, the data are limited for these populations; however, current evidence suggests that these disadvantaged populations experience disparate outcomes related to CKD and other health domains. Unlike other disadvantaged populations, there is marginally more evidence regarding predialysis CKD prevalence and outcomes among Aboriginal Canadians. This population may have been the subject of more research due to the disproportionally high burden of end-stage kidney disease requiring dialysis and transplantation. Evidence suggests that this disparity may be mostly driven by the lack of Aboriginals receiving the appropriate predialysis care. In the context of CKD, and particularly in predialysis CKD, the data are limited for these populations; however, current evidence suggests that these disadvantaged populations experience disparate outcomes related to CKD and other health domains.

Keywords

dialysis

chronic kidney disease

Aboriginal

immigrant

refugee

disadvantaged population

health disparities

Chapter Outline

1 The Canadian Population

2 Canada’s Health Care System

3 Who is Disadvantaged?

4 Prevalence of Predialysis Chronic Kidney Disease in Disadvantaged Populations in Canada

5 Immigrants and Refugees

6 Canada’s Aboriginal People

7 Conclusions

References

1. The Canadian population

On July 1, 2015, Canada’s estimated population was 35,851,800. This increase (calculated for the 2014–15 period) was the lowest population increase since 1998–99, but was the largest increase among the G7 countries over the most recent comparable annual period in each country. In 2015, the number of persons aged 65 years and older exceeded the number of children aged 0–14 years.

In 1971, Canada became the first country in the world to adopt multiculturalism as an official policy. The underlying principles included the rights of Aboriginal peoples. In 1988 the policy became law as the Canadian Multiculturalism Act. The Act continues to uphold the principles of recognizing diversity and promoting understanding, equality of opportunity, and the elimination of barriers. The Act forms part of a broader legislative framework that also includes other protective legislation, such as (but not limited to) the Canadian Charter of Rights and Freedoms, the Canadian Human Rights Act, and the Immigration and Refugee Protection Act.

In the spirit of strong policies surrounding multiculturalism, Canada is a country that has relied on strong immigration policies to promote healthy population growth. Government figures show that between July 1, 2014 and June 30, 2015, Canada received 239,800 immigrants, which was lower than the estimate of 267,900 in 2013–14.

Although international migration growth slowed relative to years before, it still remains an important stimulus of population growth, accounting for 60.8% of the population growth in 2014–15. This is in contrast to the contribution of the national birth rate, which accounted for only 39% of population growth in that same time period. [1].

The 2011 census highlighted Canada’s diverse ethnic origins within the population. In 2011, nearly 6,264,800 people identified themselves as a member of the visible minority population on the National Household Survey (NHS) questionnaire. They represented about one out of every five people (19.1%) in Canada’s total population. Combined, the three largest visible minority groups in 2011 were South Asians, Chinese, and Blacks, with these three minority groups accounting for 61.3% of the visible minority population [1].

The NHS and 2011 census highlighted Canada’s multicultural policy in action. Although most immigrants historically came from Europe, the largest group of recent newcomers to Canada have come from Asia (including the Middle East). The NHS found that Canada is home to people from over 200 ethnic origins. The multicultural nature and diversity of the Canadian population is shown in Fig. 2.1.

Figure 2.1   Percentage of the population by Broad Population Group Categories in Canadian Provinces and Territories.

Canadians enjoy very good life expectancies when ranked among the world’s developed countries. In 2017 the life expectancy for the total Canadian population is projected to be 79 years for men and 83 years for women [2]. Among the Aboriginal population, the Inuit have the lowest projected life expectancy in 2017, 64 years for men and 73 years for women. The Métis and First Nations populations have similar life expectancies, 73–74 years for men and 78–80 years for women. Life expectancy projections show an average increase of 1–2 years from the life expectancy that was recorded for the Aboriginal population in 2001 [3]. People living below the poverty line, in poorer neighborhoods, also tend to have shorter life expectancies than do other Canadians [4–6].

A person who lives in Canada (e.g., rural vs. urban) has an impact on health status. Rural Canadians have poorer health status relative to other Canadians, which includes lifestyle-related illnesses, injuries, cardiovascular diseases, poisoning, infant mortality, and life expectancy [7]. As such, there is an increased need for all health services. Concurrently, rural populations have greater barriers to accessing these much-needed health services.

The Canadian population is aging. In 2015, the median age in Canada was 40.5 years, whereas in 1971 the median age was 26.2 years. Seniors (>65 years) make up the fastest-growing age group. This trend is expected to continue for the next several decades due mainly to a below-replacement fertility rate (i.e., average number of children per woman), an increase in life expectancy, and the aging of the baby boom generation. In 2011, an estimated 5.0 million Canadians were 65 years of age or older, a number that is expected to be double in the next 25 years to reach 10.4 million seniors by 2036. By 2051, about one in four Canadians is expected to be 65 years or over [8].

2. Canada’s health care system

Canada’s health care system is a group of socialized health insurance plans that provide coverage to all Canadian citizens. It is publicly funded and administered on a provincial or territorial basis, within guidelines set by the federal government with universality at its core.

Canada’s health system provides comprehensive care to individual citizens that includes preventative care, medical treatments from primary care physicians, access to hospitals, dental surgery, and other additional medical services depending on the jurisdiction and health programs. Health care in Canada is funded at both the provincial and federal levels. The financing of health care is provided via taxation both from personal and corporate income taxes. The system is also funded through other financial sources, such as sales tax and lottery proceeds, if mandated in some provinces [9].

Although there are a few exceptions, all citizens qualify for health coverage regardless of medical history, personal income, lifestyle, or location of residence. The Canada Health Act is a federal legislation that puts in place conditions by which individual provinces and territories in Canada may receive funding for health care services. The five leading principles in the Canada Health Act are the concept of public administration which requires that administration of provincial health insurance must be carried out by a public authority on a nonprofit basis. The program must be comprehensive with all necessary health services, including hospitals, physicians, and surgical dentists insured under the Act. The system must be universal with all insured residents are entitled to the same level of health care and portable such that a resident that moves to a different province or territory is still entitled to coverage from their home province during a minimum waiting period. Lastly, the system must be accessible with all insured persons having reasonable access to health care facilities [10].

3. Who is disadvantaged?

There are many people and communities in Canada that are considered vulnerable and at risk. These populations are very heterogeneous and predominantly consist of people living in rural and remote parts of Canada, those who are homeless or with intermittent shelter, Aboriginal peoples, immigrants and refugees, isolated seniors, and the poor, including both low-income individuals and families [11]. Although we can classify these groups of Canadians as disadvantaged, the level of disadvantage and health disparities that come with this classification are harder to quantify. Moreover, understanding how these groups experience relative disadvantage within Canadian society and within the health system is challenging, especially with respect to predialysis kidney disease prevalence and care.

Despite a publicly funded Universal health care system, disadvantaged populations face health disparities in access to health care. With respect to chronic kidney disease (CKD), Canada ostensibly has a comprehensive system of nephrology care that is guideline-driven and embedded in both specialized (secondary and tertiary) and within a network of provincial primary health care systems. Despite the availability of nephrology care, challenges exist with respect to identification of risk factors for CKD in these disadvantaged groups. As these populations are often marginalized from the mainstream health care system, provision of preventive services is challenging. Aboriginal people, immigrants and refugees, and the poor have higher rates of chronic disease, such as hypertension, type 2 diabetes, and cardiovascular disease. Considering the barriers to accessing mainstream health care and preventive care, we can expect that identification and treatment (and prevention of chronic diseases that lead to CKD) will be underrecognized and undertreated [12].

In addition, evidence shows that there are a number of factors that determine health beyond availability of and access to health care. These social determinants of health typically occur well before a person becomes ill or seeks out health care. These determinants include access to food (and healthy food), availability of safe housing, poverty, education, the physical and social environment, cultural practices, and access to supportive social networks [13,14]. These social determinants weigh heavily on the health of disadvantaged populations and have a significant impact on the development of CKD, especially in the setting of other chronic diseases.

4. Prevalence of predialysis chronic kidney disease in disadvantaged populations in Canada

The prevalence of CKD among adults in Canada is 12.5%, or roughly 3 million people [15]. In Canada, CKD may be most burdensome among the economically disadvantaged, including immigrants, Aboriginal people, refugees, ethnic minorities, and the urban and rural poor [16,17]. These populations, which experience significant poverty rates with more limited health care access, not only have a high prevalence of CKD, but also experience disproportionately worse outcomes [18,19]. For example, individuals identified as First Nations have a significantly increased risk of death due to kidney disease or developing advanced or end-stage kidney disease (ESKD) compared with the general population [20,21]. In addition, refugees have shown to suffer from high rates of hypertension and diabetes which portends a high prevalence of CKD especially when juxtaposed with more limited health care access [22].

Canada’s geography also presents unique challenges and structural barriers for the rural poor. Physician supply imbalances and lower income have significant effects on the health of rural populations [23,24]. Furthermore, individuals living in remote areas also often travel long distances (>200 km) to access specialized medical care centered in larger, urban settings, and this dramatically affects the quality, frequencies, and type of health care individuals receive [25]. In Canada, these individuals receive fewer preventative therapies and recommended screenings for chronic disease [26,27]. For CKD, this means that individuals who live in rural settings far from nephrology care are much more likely to experience adverse health outcomes including hospitalization and death [26,28]. Even among those rural populations receiving nephrology care in the form of dialysis, mortality rates are disproportionately higher and transplantation rates lower [29–31].

5. Immigrants and refugees

International migration is estimated at 200 million people worldwide [32], with the largest ongoing increases in numbers in developed countries. In Canada, recent foreign nationals originate most commonly from China, followed by India and the Philippines [33]. From an administrative standpoint, foreign nationals arriving to Canada can be classified as either temporary or permanent residents. Temporary residents are workers, international students, or refugee claimants (humanitarian migrants who claim refugee status upon arrival to Canada). Permanent residents are classified as immigrants (selected through a regulated process) and refugees (selected from outside Canada). Approximately 250,000 immigrants, 11,200 refugees, and another 12,000 refugee claimants arrive annually in Canada [34]. In contrast, the United States has a population 10 times larger than Canada and accepts 1 million international immigrants annually as legal permanent residents and 100,000 refugees [35]. In addition, the nonstatus or irregular migrant population is estimated at approximately 200,000 within Canada [36]. These people have no official immigration status or access to government health insurance or programs.

Migrants to Canada come from around the world, and many represent vulnerable populations that are socioeconomically disadvantaged, of racial and/or ethnic minority, and uninsured. Health status of migrants depends on the complex interplay of environmental, economic, genetic, and sociocultural factors. Health status in the home country, circumstances around migration, postmigration socioeconomic status, and access to health care all affect migrant health [34]. Overall, most new migrants to Canada (>90%) are in very good to excellent health [37–39], with age-standardized mortality ratio or 0.34–0.58 compared with the Canadian population [40]. Research has supported this healthy immigrant effect, and purports that immigrants are healthier than native born persons for many reasons, including sociocultural differences in diet, activity and nutrition, and the physical and mental requirements to successfully move from one country to another [34,41,42]. In addition, Canadian immigration screening procedures can deny admission for certain health conditions [43]. Beneficial health indicators seen in migrants decline with longer duration of residence in Canada. One study reported that type 2 diabetes mellitus increased when examining two cross-sectional time points in nonrecent immigrants [37]. Development or increasing severity of these cardiometabolic risk factors could place immigrants and refugees at higher risk of developing kidney disease with migration to Canada.

Migrants to Canada must undergo a mandatory medical screening which is used to document the health of migrants to Canada. These screens have traditionally focused on infectious diseases; therefore, longitudinal data on the prevalence of noncommunicable diseases, including kidney disease, are lacking in migrant cohorts to Canada. However, given the growing focus on migration in research, recent epidemiologic studies have shifted focus to the prevalence of noncommunicable diseases and lifestyle factors, such as alcohol and tobacco use. The current Canadian immigration medical examination (IME) includes a physical examination with a focus on end-organ consequences of noncommunicable diseases, and for high-risk migrants such as those with comorbid conditions, the IME also includes a mandatory screening for kidney disease with serum creatinine, urinalysis, and microalbumin-to-creatinine ratio [44].

Despite this recent focus on chronic disease screening among migrants, data on the prevalence of kidney disease in new Canadian immigrants and refugees remain scarce. The Canadian Collaboration for Immigrant and Refugee Health recently conducted a comprehensive evidence review to inform the development of evidence-based clinical guidelines for immigrants and refugees [45,46]. Diabetes, anemia, dental, and vision health were the only chronic diseases with data available to systematically review, with no report on the prevalence of CKD. Allan and Szafran [47] reported a retrospective review of medical screening examinations on illegal immigrants from China to Canada in 1999. Of 589 subjects, 7.6% were documented to have urogenital disease, with dermatologic conditions (55.2%) being most prevalent. Redditt et al. conducted retrospective chart review of 1063 newly arrived refugee patients to a Toronto medical clinic from 2011 to 2014. Refugees were most commonly from Hungary, North Korea, and Nigeria. Of all patients, 30% had elevated blood pressure with men, seniors (60 years or older) and African descent subgroups having the highest prevalence. Forty-three percent of patients aged 60 years or older had impaired glycemic control [23]. Other studies have compared the prevalence of CKD risk factors in a Canadian-born populations to new immigrants. Compared with native Canadians, immigrants from South East Asia are at higher risk for mortality from stroke [48], those from the Caribbean are at higher risk for diabetes [40], and Africans for hypertension [49]. Although the prevalence of kidney disease was not reported in any of these studies, development of diabetes, hypertension, or cardiovascular disease in these individuals places them at high risk for CKD.

6. Canada’s Aboriginal people

The Aboriginal peoples of Canada, as defined by the Constitution Act, 1982, comprise the Indian, Inuit, and Métis peoples. These distinct groups have unique heritages, languages, and cultures [50]. In the 2011 NHS, 1,400,685 people identified as Aboriginal persons, representing 4.3% of the total Canadian population. Aboriginal people accounted for 3.3% of the population enumerated in the 2001 Census. Of the 1,400,685 people who identified themselves as Aboriginal, 851,560 [58] identified as First Nations (North American Indian) only; 451,795 (32%) identified as Métis only; and 59,445 (4%) identified as Inuit only. An additional 26,475 (2%) reported other Aboriginal identities and 11,415 (<1%) reported more than one Aboriginal identity. Among the 637,660 First Nations people who reported being registered Indians, nearly half (49%) lived on an Indian reserve or Indian settlement [51].

Aboriginal Canadians have received significant attention in nephrology due to the disproportionally high burden of ESKD requiring dialysis and transplantation. Evidence suggests that this disparity may be mostly driven by the lack of Aboriginals receiving the appropriate predialysis care [55].

Aboriginal Canadians face unique challenges related to kidney disease care. Economically, they represent a designated group that is considered disadvantaged as noted from the Canadian employment equity plan [52]. These disparities extend to health care and health outcomes as well [12]. Approximately 50% of Canada’s Aboriginal population live in rural and remote locations. This brings challenges with lack of transportation infrastructure, long wait times, and inadequate human health resources. Many of these rural and remote dwelling populations speak traditional languages which can act as a further barrier in accessing the health care system [53]. Long distances and low population density can also mean higher service delivery costs which can result in reduced access to health services and health professionals [54].

Type 2 diabetes also plays a significant role in the health of Canada’s Aboriginal people. Prior to 1940, type 2 diabetes was very rare among this population, but following the national demographic transition diabetes has become a major disease burden. Rates of type 2 diabetes increased rapidly after 1950 and have now reached epidemic levels in some communities [55,56]. Higher rates of type 2 diabetes in children and youth and of gestational diabetes in females have also been observed. Moreover, earlier age at onset and high rates of complications amplify the problem within many First Nations and Métis communities.

Canada’s Aboriginal population is young, and when accounting for prevalence rates it is important to adjust for the younger age structure in the First Nations, Inuit, and Métis populations when comparing the prevalence of diabetes to that of the non-Aboriginal population. After adjusting for this difference in age structure, the prevalence of diabetes was 17.2% among First Nations individuals living on-reserve, 10.3% among First Nations individuals living off-reserve, and 7.3% among Métis. Although the crude prevalence of diabetes among Inuit has historically been well below the national average, after adjusting for the difference in age structure, the prevalence of diabetes among Inuit was comparable to the general Canadian population [57].

Despite limited evidence, it would be expected that the burden of diabetes in such a young population will have significant consequences for the future among those with type 2 diabetes. Significant efforts to reduce diabetes in Canada’s Aboriginal people have already taken place [58], but the impact on future generations remains unclear.

Despite ample evidence regarding ESKD in Aboriginal Canadians, there are limited studies on the prevalence of predialysis kidney disease and regarding access to care or barriers to care in Canada. It appears from several studies that CKD prevalence may be lower because evidence shows it is lower among minorities in the United States [58] and in Aboriginal people in Canada. In data from outpatient visits in Canada, Gao et al. demonstrated a prevalence among First Nations of 59.5 per 1000 population compared with 67.5 per 1000 population among non-First Nation people [59].

Community-based studies are limited; however, Garg et al. [60] estimated a CKD prevalence of 5% among the general population in Canada using data from laboratories. However, among First Nations people, in a community-based study from Manitoba, the prevalence of albuminuria was 20% [61]. This higher prevalence of early kidney disease suggests there are new opportunities for intervention to counter the high burden of ESKD.

7. Conclusions

Canada is a high-income country with a large and diverse population. Despite the positive aspects of a health care system that considers universality at its core, high-quality Universal health care system that includes preventative services and specialized services, numerous disparities in access and health outcomes still exist. These disparities are most prominent among the economically disadvantaged, including immigrants, Aboriginal people, refugees, ethnic minorities, and the urban and rural poor.

In the context of CKD, the data are limited for these populations; however, the current evidence suggests that these disadvantaged populations experience disparate outcomes related to CKD and other health domains.

The burden of CKD is expected to continue to rise in Canada, especially with the demographic transition. Further research is needed to understand these disparities and the reasons for their existence. Epidemiologic studies are urgently needed, but individual- and community-based research that seeks to understand and subsequently intervene upon these poor health outcomes for predialysis CKD is most urgently needed, so that better preventive care and improved heath care access can occur.

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Further reading

Rivera B, Casal B, Currais