Chronic Kidney Disease and renal replacement therapy in the Kimberley Webinar-20250327_000138-Meeting Recording
March 27, 2025, 11:01PM
59m 58s
Sara Hennessy 0:08
Excellent.
OK.
So we have started our little online session.
So welcome everybody.
Thank you very much for giving up this time for this is such a lovely man and father to be. There you go.
For letting me know about this because obviously we this is a huge issue.
In Kimberly Ragston and his man is extremely busy.
Then it just came back from Luma. Yesterday, Lumi yesterday.
So you travels around the countryside.
With his job with picking my radio centre.
Hi there everybody. That’s tuning in from around the Kimberley or wherever you are and those big Cal, a lot of people that are tuning in today.
So thank you very much and pen bullying it to Mr. Mckittrick. Nothing, thank you. Thanks for coming.
My name is Dean.
I’m one of the remain GPS. I’m a General practitioner with the advanced skills in emergency medicine.
Quickly got this job, so I haven’t really used my any skills for a little while, but.
In the interest of time, I’m gonna wheeze through it.
Wasn’t sure what the.
Clientele, or the hunters that were coming today. So kind of based it from everything from student to medical practitioner and everything in between.
So it may or may not be applicable to you in certain areas. Just trying to catch also.
Have today chronic kidney disease and ring replacement therapy.
In the Kimberley, suck. Give me that.
So the was dialysis all about and how it’s done the lead up to getting the chair, fishing care, the general overview would be great info and kidney health would also be great and relevant discussion point there to unpack their announce. I’ll do my best.
I’ll try and whist through this, but if you have to go tail ended it, I won’t make your way out.
I’ve kind of put the things that are more applicable to everyone at the start and it gets a bit nuanced at the end.
So you’re finding it’s less and less applicable.
Gotta go.
Feel free.
So here we go.
No. To start off with, I rely very heavily on this resource.
And if you don’t know about it, I would recommend that you give it a look.
This is the kidney health strata kidney, chronic kidney disease management primary Care handbook released in 2024.
So it’s very up to date.
It’s a big addition.
You literally just Google CKD management.
It’s the first bit you go in there and you can download your electronic copy.
It’s about 88 pages, so it’s not the 150 or 80 or whatever it is the diabetes management.
Which is horrendous.
Really completing some flow charts and templates really, really nicely laid out.
That’s the dude on the front. If I’m him doing the right place.
So let’s do a little bit of overview of CKD.
So why do we worry about CK?
Well, it’s common.
Over 2,000,000 Australians currently living in CKD.
It’s twice as common as diabetes in Australia, 3 out of four Australian adults have at least one factor increasing their risk soipated.
One in five names First Nations Australians aged 18 years and over a living, signs of cpad and if you compare this to the one in 10 non Indigenous Australians, it’s pretty stark contrast.
Burden of disease increasing the number of CPD cases doubled in the last 20 years, and it’s not really slowing down.
People seek out 20 times more likely to die from a heart attack or stroke than they are to progress to advanced end stage reinfor. Around 20,000 Australians die every year in CKD and the burden of Ckd’s greatest in low socioeconomic backgrounds in rural remote areas and.
In First Nations Australas which I mean, we’re ticking lots of boxes there. We’ve Kimberley.
Cka continues to contribute contribute rather to one in six hospitalisations nationwide and cpad not only has negative physical effect in the health, but also to your family life and psychosocial health.
You know, it’s equally important to our patients.
Importantly, CKD is treatable.
We can slow progression of disease by up to 15 years if we start therapy early enough at the right time and it detect and match appropriately, we can produce up to 50% of renal deterioration.
Before it gets too late.
So, he says often overlooked less than 10% of people are aware they have cpad and late referrals are common.
17% of patients are referred to nephrologists and commence dialysis within 90 days of the referral.
That’s a nationwide statistic we call that crash landing to dialysis.
It’s pretty scary stuff. 9% of kidney function can be lost before the patient experience any symptoms of CKD.
So you’ll find that awful lot of comparisons to diabetes because in some ways it’s similar.
It’s a chronic disease.
It’s quite insidious.
You can have it for a long, long time and feel no different to anyone else in the room until all of a sudden bang everything starts to come undone.
So heading back to the students in here, just three of the rooms.
So what’s everyone’s background? You know, we got some medical students.
Yeah.
Practic students.
Back then accidentally. OK so.
Quick definition of CKD.
It’s a little bit wishy washy but I’ll try and make it digestible so it’s two caveats so you can either have an EGFR that’s reduced.
Below 60, but it’s going to be present for equal to 1 three months.
So that’s a really important point because it’s less than that.
It’s an AAI, so we need to prove that it’s there.
So you can either have them reduce EGFR or evidence of kidney damage without reducing HFR, and you’re kind of going what, what does that mean?
So if you have any form of proteinuria, structural abnowal imaging, any biopsy issues or immature after urological causes excluded, we would call that CKD as well.
I will go into this a little bit more in a grant that makes a bit clearer as follow each of, but bear with me. Just plant that seed.
Seek any risk factors.
By golly, there’s lots of them.
So anyone with diabetes, hypertension, established cardiovascular disease, a family history of kidney failure, obese with ABI 30, current or past smoker slash vapor, that’s a new one.
History of acute kidney injury pump smoking the bacon run.
History of kidney injuries. Anyone age at 60 and 1st place Australian age 18 years or older at higher risk. So you have a look at that and think about what people you work with.
That’s why that’s covering good line share of the people and the patients that we deal with on a day-to-day basis up or at least one or two if not more risk factors for chronic kidney disease which is quite scary.
Causes of kidney failure in our community, diabetes and hypertension by far.
The lion’s share of the 51% of that pie chart is diabetic, hypertensive.
I like to divide this graph in half side closest to me as what we do at KRS. That’s our GP work and our Primary Health inputs.
The other half, the familial, the familiar, the genetic, the autoimmune stuff, is what the nephrologist in the bottoms get really excited about and that.
Requires specialist input, but you can see just over half of their workload.
Can be done in the primary care then.
So that’s why it’s important that we’re all aware of it and actively.
CKD screen a kidney check is really, really easy.
It’s just a blood pressure check and you’re an ACR, and that stands for albumin creatinine ratio, which.
And in Egypt, so your biochemistry on the blood test, we can get so much information from these three basic tests to establish a risk factor and management plan for patients.
It’s just that is the mainstay of what we wanted. The information we want.
So going back to our Med school days for some of us, we remember that’s tkd stage in five different stages, stage 1 to the left of screen.
Miles for minimal damage to the kidney all the way to stage five to the far right, which is North stage, meeting dialysis.
I always tell people that it’s like a fuel tank in mocha.
It fills up and it goes down as you get older.
There’s some things that make you run out of fuel quicker.
But the important thing that Kim is you can’t refill it once you’re out of fuel, you’re outside the road and you’re stuck. And that means dialysis or other things.
So important to remember, you can go from left to right on the screen. You can’t go from right to left once kidney disease has settled in.
There’s no regeneration of it.
It is.
That is the number you’re stuck with.
So this is just a little bit of the story that so staging is easy enough.
123 a 3B45.
Sure, that’s sounds pretty straightforward.
But it’s only have a picture, so if you remember, I was telling you about your Egypt bar or your glomerular filtration rate or filtration rates, just the easy way to say it.
Is it can be normal and it can be reduced in chronic utilis. And that’s like what makes sense.
I only know it as a reduced kidney function equals CKD.
So what I mean by that is, if you only go by this part of the graph then you can see that things don’t look too bad.
So this is actually not telling you where your kidney function is at right now.
It’s telling you the risk of you developing end stage kidney disease.
Brain means you’ve got a very low risk of getting to stage 5.
Yellow is a moderate.
Orange is a high and red is a very high risk of progressing to CKD 5.
So if you.
Had no protein low low risk.
It’s a good thing, but you can see you can have a normal egg bar, but as soon as you got heavy protein in your urine, you’re at a high risk of going to see K5. And that’s what. That’s what I’m trying to get pub 3 to like.
With the CKD definition doesn’t always just mean an easy bar drop.
That’s only half the story.
We had a young lady in Fritzroy crossing that had of greater than 90 but.
Proteinuria.
Be thousands. Some of the highest ACR levels I’ve seen within 12 months, she declined.
All the way down to the bottom of this route and zone dialysis as we speak.
So that’s 12 months.
So from the end of 2023 to the end of 2024, her kidney function just tanked. And that was because it was poorly controlled. Diabetes, non engaging, the clinic non compliant with medication start coming in for checks and it’s just kind of all unwritten so.
Again, this colorful chart is not about where your kidney function is at.
Now it’s your risk of an alpha down the line of kidney disease can get to a.
So going back to that little bylaws, Tonya, if you do your blood pressure, ACR, e.g. Fr. Do your kidney checks and you work out where your patient is on this chart, that little Bible I told you has all the clinical management plans if they.
In the yellow part of the graph, there it is.
It’s all there.
How frequency you review?
What are your assessments?
What are you checking in on?
What you should be considering and then you can see it’s like a puzzle. So yellow just tacks on a few extra.
Tacks on a few extra lab.
And all then this really nice book.
So if students it’s not so important. It’s just about knowing that cpad in addition.
But for US practitioners, this is.
Guy in front of me with a low E chip bar and I’m going. What can I do for 3rd and nephrologist, what can I do now?
And this is where this is going to be very helpful. So.
Ultimately, we’re going to break down BRAF or that table into the five goals of CKD.
Once slavery decline Ngfr avoid further damage to the kidneys.
Maintain healthy blood pressure, lower CBD levels and reduce.
Slowing the defici how do we fight what we don’t know about?
You need to know the etiology of what your CKD is.
The big hitters, I’ve mentioned diabetes and high blood pressure. If it’s still unclear, we get the net team involved, we can do a glimerion of screen.
We can do renal biopsies.
It’s all about finding out who your enemy is.
It’s fighting appropriately.
Then it’s just the blow hanging fruit. Your lifestyle modifications, SNAP criteria stands for smoking nutrition.
Alcohol and physical activity.
So if you can cover those 3 four things and maintain a healthy weight because we know obesity is at high risk for CKD and that’s all low hanging fruit that you can don’t need much training to sort of pass that information on to your patient and slow the.
Decline in EGFR.
We do our regular monitoring and our kidney checks that I’ve let you know about, and with that we can do additional Bloods to make sure that we’re fine tuning things. And that’s where us at the ringleton can chime in.
We can.
We can help you address the anemia of chronic disease acidosis, hyperkalemia, bone, mineral disease, muscle cramps, weakness, fatigue, edema, restless legs, and all the other things that go with it.
Imagine you’ve been given this label of CKD, chronic kid disease, and I tell you we can’t cure it.
Probably not going to get better. The best we can do is to stop it in its tracks. Now, that would weigh pretty heavily on your mind, and depending on what number I put with it, if it was a three or A4 or A5, that’s going to.
Have huge ramifications on your mental health that you’re being given this label, so we’ve got to bear that in mind as well. When we talk to our patients.
Avoiding further damage to the kidneys.
Well, worked hard on the problem with that.
So prescribing renal adjusted doses when relevant and avoiding what we call nephrot toxic medication.
Medications that hurt the kidneys. When I have HFL or Fltation right falls less than 30.
There’s also importantly sick day medication plans so sick day.
I really don’t like the name of sick day medication plans because sick day is like I didn’t go to school for that, you know, like that’s that’s not what talking about sick day.
We’re talking about you’ve got horrendous nausea and vomiting and diarrhea, and you’re not keeping food down and you’re losing fluids and not able to replace it.
These medications.
Sad Man’s is the moniker for.
All of these medications are ones that will put your kidneys at risk with having those sick days.
Avoiding acute kidney injuries so infections are a big fire up here.
Skin sores, particularly, and tonsillitis and things like that.
Medications, as I mentioned, and dehydration and we live in very hot and humid environments.
So dehydration is a big player and safety need patients to present and giving an advice about their medications.
If they do kind of really unwell and of course linking in with the nephrology and Chaos team for support.
This is just a little snapshot from that little Bible I was telling you about.
It just gives you a handful of things to think about, like, hey, you know, if you get to the orange part of your graph, just bear in mind that these medications are not an exhaustive list, but things to bear in mind that you might need to pull the.
Reins in a little bit if you’re charting them, OK.
So lowering cardiovascular disease risk, we all know that there’s a CBD calculator that we can use and stratify. The new part of the CBD calculator as soon as you know that the patient has CKD, they go up to step.
So even if they’ve got a low risk on their CBD calculator soon they’ve got CKD. They go up a step because we know that cardiovascular disease is a huge risk factor for CKD. How I explain to patients is everyone understands that if they got high cholesterol, they’re at.
Risk of a heart attack.
That’s pretty a pretty straightforward concept, and most people get that through, whether it’s movies or from people they know or whatever.
I’d like to tell them is the blood vessels in your kidneys are even smaller than the ones in your heart?
And if you’ve got really high cholesterol, what you’re causing is mini heart attack of the kidney.
You’re not.
You’re knocking off clusters of nephrons or the little filter mole units of the kidney with your high cholesterol. So treating that is a really, really good thing.
There’s a new drug called Spinanero, which I won’t name.
It’s there but.
We we guide it.
We use it on the guidance of nephrologist because it’s quite a specialized medication at the moment.
It’s quite new.
And novel.
There’s lots of criteria for the PBS to get access to it. You need to be on an ace.
Need to be combined with other sglt twos and won’t be details, but it’s a new agent that we can use in CKD and it’s quite effective.
There is a risk of hyperplania, but a bit lower than spironolactone, so OK reducing Albania or protein in the urine.
There’s four drugs.
That we have at our disposal.
Ice and I have aids which if we not using Aces RAM approvals but any other ones that end in prel.
Then there’s something wrong, because that is our kidneys. Kimberley Standard Drug list agent.
This is probably less applicable to you guys in the room, but there are lots of agents that we kind of come in, do a clinic like I was at Loma chiming with, hey, have you thought about this agent because this patient has heavy protein in their urine if?
We can reduce the protein in the urine.
Then we can improve the kidney function and reduce the rate of deterioration.
And then optimize blood pressure.
So again, low any frigidly lifestyle, diet advice, physical activity, lots of stuff.
And then there’s a few different agents that we like to prescribe.
To get blood pressure down some are renal protective like our aces and our arms.
We love ACE inhibitors and renal medicine.
Quite often we need 2-3 may more drugs to get good control on hypertension with people with CKD. If you’re at that stage.
I would suggest that involving the nephrologist and even the local physician team would be helpful, because if there can be other underlying issues that we need to address.
Again, that Bible has a little clinical tip that if you start these ACE inhibitors, the kidney function will drop slightly.
And there’s what to do if that happens, when when the threshold to see certain change agents, so lots of little pels of rhythm in that book and really, really helpful for.
Clinicians.
So if all that sounds very confusing and very overwhelming, we have a Kimberley Ring Service online service on full service rather and that’s the mobile phone number.
Feel free to pop that into your phone if you need.
It’s answered by Hayley, Emma or myself with three medical staff members of carers.
Hayley covers Broome Bridge down in the peninsula.
I cover Derby and surrounds in the Fitzroy Valley region. Emma is transplant.
Queries along with Nick Corset and the East Kimberley is shared by.
The share among the team.
It’s a Monday to Friday service 8 till 4:30, excluding public holidays and outside of those hours for emergencies, we advise to go to full Perth nephrology by switch.
Sorry, is that number for health professionals to call or for patients to call or professionals? Yeah.
So what we will be giving is so.
Uh as an example. So you, you’re sitting in a clinic and you’ve got someone with you notice that has potential CKD or hasn’t been like you’re not sure if they’ve been identified as someone with CKD.
You can call this number and say hey suspicion on your radar and we can quickly look at and say yeah or no, you’re not actually.
And then that can get the ball rolling for a film. Or hey, I’ve got this quandary of they’re on this, this and this, but I don’t know whether to add this or up titrate this one.
What do I do?
We can answer that question, or if they’re the late stages, hey, blood’s looking really dodgy and then we can liaise and be the link between mythology and yourself on the ground.
So we kind of we’re there as a sort of a helping.
That’s it’s clinician to clinician kind of thing.
So that’s a bit of a background on CKD and how the burden on our population is and what we like to do and our goals of care.
I hope that was relevant to you guys to a degree.
Any questions so far?
This is the halfway point, yeah.
Just a couple.
That that that’s to make sure things.
That is absolutely before us. I would like to be able to them and.
Do thank you.
So requires involved involvement involved.
Toxins that we expose ourselves to.
So, I mean, alcohol was obviously the big one, but that interaction of things like alcohol being smoking with a lot of people taking medications much more often, you know, people just popping pills at night and relax process, detoxifying that.
Just just the pressure that our kidneys and our nervous.
Yes, yes and no.
So there’s a few different things at play.
Alcohol actually doesn’t neglect negatively affect your kidney function.
It’s a bit of a misconception. It has indirect effects on your kidney, so it’s the liver function that is affected and then you got a renal syndrome sort of thing.
The byproduct of out toll is it dehydrates you.
It causes acute kidney injuries and we know repeated kidney injuries is what causes CKD.
So it’s not by the by the book. People think that, you know, because when I go to clinic patients go, they’re going to shame mode like, oh, I I don’t that much or I don’t drink at all.
And I’ve got CKD.
Everyone thinks I’m a boozehound because I’ve got CKD.
We have to explain.
It’s not actually.
It’s a it’s a whole other thing. Some of the things you’ve alluded to, you know, we can get ibuprofen off the shelf and we know that if you’re dehydrated and you’re popping ibuprofen left, right and center, that can cause an API or two kidney injury.
Our diet is particularly in remote and rural settings.
It’s highly processed, not much fresh fruit and veg. A lot of patients.
It’s so easy to get a cup of noodles for lunch and we know that there’s lots of.
Kid. Nasty than that, along with the carbohydrate load and then that affects diabetes. I mean, if we could eliminate, you know, excess sugar from our diets, all these people and in society in general, the whole country would be a whole lot healthier.
But we were addicted to it. We like sugar. That’s bad.
Yeah. Well, that’s we all have.
Good sweet tooth.
So it’s a combination of a few different things. You’ve got off that unfortunately for.
Original people.
They’re kind of on the back foot to begin with.
So we’ve now there’s more and more research.
That is what we know is epigenetics, that we know that these patients are born with less nephrons and less functioning kidneys, which is absolutely staggering.
And it’s through.
It’s through, you know, Mum and Dad have mild to moderate CFD and I inherit mild to moderate kidneys with poor function.
So it’s like an epigenetic thing. So you’re already on the back foot.
And we it’s still being worked out and still being researched, but.
We we think that’s why our initial population has such poor health outcomes at CKD because of this intergenerational passing down of genes with kidney functions that are not so great.
So you’re already on the back foot.
To come full circle.
Medications, if they’re the right ones prescribed, taking them is actually going to be beneficial for your kidneys. If they’re on the right stuff that we’ve added off very quickly.
But yeah, it’s the over counter stuff and mainly diet.
And that is when we are planning a really big, really big part of it.
You know how much Coca-Cola goes through these sort of shops in the remote Kimberley’s and stuff is out next.
Yeah, I hope that answered your question.
Sure. No, no thank you and.
Sort of.
From where we’re at, so the students have been up and doing a free pop up clinic at room circle and we’ve also been up in the RV as well.
And when we do an initiative comes out, we obviously examine’s blood pressure.
Yep, and what’sations like all of this, pairs with high and we’re always supposed to move. The other factor even like like we mentioned.
So at, at what point should we be considering this person needs to be removed or they are?
Because we obviously do the blood pressure check, but then when should we think, right?
We should maybe suggest this person goes to a GP to get that blood.
Egfr.
And it’s tricky, but essentially any of the risk factors from that initial screen, diabetics, people, overweight people who are over the age of 18 and indigenous because young people don’t have high blood pressure, that’s a bit of that’s unusual.
Any of the other ones that we read about smoking, vaping, history of API’s, family history of CKD, any of those risk factors which are well, I’m happy to go back too quickly.
Hey, what’s it?
There you go.
Anyone with any of those?
Big short answer is most people should just pop in and get a kidney check, but with their GP do that.
Yeah, yeah.
So we’re spreading the word and we’re getting. We’re trying to encourage people to do just the simple kidney check that we’ve described.
But if you were to refer them, you would say this person has risk factors for what we think you know has high blood pressure and risk factors for other chronic abilities such as CKD.
That would.
That would probably prompt your primary healthcare provider, your nurse, or your GP to do. Hopefully these tests you obviously know about it, and it can really prominent.
But these guys are going to graduate into this year and go wherever.
I’m just wondering if you’re going to have the same people that are just going up as yourself in the current sort of guidelines of all of this potentially.
This the resource that I was alluding to before is a kidney health Australia.
Not specifically for Kimberley, although we lean on it quite heavily, it’s for everyone.
So hopefully kidney health is sort of in their mind to a degree and this is a very easily free available resource.
I would hope that they would at least think about it somewhat because it is prevalent throughout Australia.
It’s it is rampant in Kimberley, but those stats at the start were nationwide statistics.
So hopefully it’s on.
Not sure it’s, but I hope that.
Any other questions before we move on to the dialysis stage, I mean that’s.
It’s pretty heavy for whatever clock it in the morning it is.
So sorry about that.
Would you rely much on questionnaires?
There’s a questionnaire.
I think it’s called SNAP 21 on those topics as well.
Would you rely much on providing questionnaires for potentially chasing that further?
So for chasing CKD as a screening tool, yes.
31 Yeah, there’s many ways to skin a cat.
I mean, everyone’s got a different way to do things ever so slightly.
I Don’ mind snap 21.
I don’t mind doing. We’ve got a we’re developing one. That pretty much plays off this kidney Australia handbook.
We’re developing one that’s very digestible and 21 is 21 question, isn’t it?
We don’t feel like she’s taking the exam.
Yeah. So we’ve kind of whittled it down to sort of three or four things.
Do you know about this?
Do you have this?
Yes. No, I don’t know.
Do you have this?
Yes. No, I don’t know.
That’s three or four things. The big hitting items and then we can go. Yeah, I reckon you’ve got a CKD.
That’s it.
LinkedIn and sorted out, but yeah, snap 21.
It’s a good one, but can feel like in if I took that to Luma for example, people feel like taking a test and they’ll probably go ask too many questions.
You know, like, so you gotta.
Really, you gotta dial into your clientele and who you’re sort of delivering this message to. You were talking about kidney disease with preserved tgfr and differences in what causes that.
Or is it more due to patient genetics?
A little bit so.
The Sophilitical merrier of disease.
The issue within the glomerulus itself and the protein bleaching out is the main issue.
You can have that preserved kidney function, but to CKD from the heavy protein in the urine, that’s a different phenomenon to diabetic or hypertensive nephropathy, which is the whole nephron as itself.
And that’s what we’re used to.
So there’s the whole nephron’s affected. Then the EGFR will drop down.
Or if you catch him later.
That is if.
That would be down if you catch him early. That’s usually when the preserved and that’s where a lot of them cases are missed so that people look at their UEC and go like Egypt, far greater than 90.
Job done Tippity Boo on your bike.
See you later. But when you get an ACR of about 30, that should be the point brought up.
Three, really. That’s that’s micro Ave.
But anyway, if you get an ACR that’s above 3 or 30, which is really bad.
That should be acted on, but a lot of people don’t know how to interpret ACR.
They get it and they go 30, I don’t know.
Is it bad that?
And that’s when we missed the boat. And people can keep going through their lives not knowing about their CK.
They’re not making changes and then all of a sudden, once they do get that drop in Egypt far below 60, oh, we’re stage 3. A lot of you know, like, now all of a sudden you’re you’re halfway down the chart and it’s you’re just finding out about it.
You know what I mean?
So that’s the thing I want you guys to take home is it’s just because egg far greater than 90.
There’s other things to look at.
It’s only 50% of the assessment.
So and and these changes would you would start seeing them in like the blog post from the the start of the disease progression or can they can be nice, can be early, it can be quite insidious. And then because there’s this phenomenon for hyperfiltration, so the kidney react.
To the CKD and tries to compensate for it, which bumps up the EGFR hides itself, but what it’s doing is by doing that, it’s wearing out its kidney function a lot quicker. So it does this sort of compensatory thing for a while.
And then all of a sudden it runs out of compensatory capacity and that just the decline goes down.
Is there any way to identify those people or you just wait until it’s just masked until it’s well? Like I said that that that graph there is how we work out the risk factor. So doing a blood pressure, doing a EGFR and doing a ACR that will put.
This graph into full perspective so.
You’ve got your UAC on the column here, which tells you which row you’re in.
And then the acrt which column you’re in pair that it’s blood pressure checks. Then you’ve got a risk stratification, so you can catch someone nice and early.
Cpad one you can go hang on.
So it’s similar to cardiovascular risk score, where you’re trying to manage the overall risk.
Sometimes identifying the disease and by the time you identify the patient, presents you symptomatic of CKD. It’s often too little, too late.
They’re way down the track and how often do you actually test them is like weekly.
Monthly ’cause, I said it has to be three months or more.
Yeah, with this is a. So if someone pops in with like an illness and you notice a drop in EGFR.
Then you would recheck them within a three month period, whether that’s next week, next fortnight, next month, as long as you get trend trends are your friends is basically what I say to people when you’re dealing with CKD, as long as you’ve got data to show that they.
Easy for their kidney function is on improve and then return to baseline. Job done.
Happy days that we’ve got out of the woods, but if you do that, repeat follow up and it stays low. That should pull the trigger on looking into. OK you might have CKD.
We need to do a bit more work here and work you up.
Yes. Are you seeing up here in Kimberley?
Because you know this, the population that with space speaking that mostly, you know, people who have diabetes are on the way like. But there’s also the other population that is sort of appears to be typical, be it healthy, does everything right.
We have proteins store that spoke to Dib room.
Everyone goes away.
Protein because I’m exercising.
And the mildly dehydrated living in Broome.
I see many people from from the I suppose physically active population.
Presenting or being identified. If you take supplements, I suppose in Perth.
Yeah, my, my, I’m an exercise physiologist and my concern is that so many my clients come to, oh, you’re taking all these protein supplements?
You don’t need them.
But what you’re doing and you know then, oh, I’m not drinking.
These bunch of stuff, you know, you need to be.
Oh no, I’m not doing that. Well, you probably need testing, but.
Are you seeing presentations?
Not, not really.
I mean the supplemental protein market, you’re quite right, is booming at the moment, but it’s like taking multivitamin if you’re eating a well balanced diet, you’re just making expensive urine. But in terms of overdosing on protein supplementation.
You have to be taking up a lot of it, like a lot, and proteinuria is not a matter of, like an overflow kind of phenomenon.
There’s actually damage to the kidney that’s letting proteins get leaked into the urine.
So if you don’t, it’s not going to come from the dehydration as well.
Oh yeah, so if you dehydrate yourself then you know you’re talking about like body builders and stuff.
I’m talking about it. So many people come to me and you know, they come to me and start lean.
Some resistance training.
They all are getting stronger.
I think it protein shock.
I need to go well, yeah.
Look at how much drinking you’re actually not drinking water part and you know in the long term because it’s different to being down South when.
You can drink.
So that that has the potential to turn into nastiness for your kidneys, for the simple fact that we know.
Like I said, dehydrating causes acute kidney injuries, repeated kidney injuries.
So yeah, there’s a potential for that to happen with five am. The initial part of your question was, have I seen that?
Rise of like, yeah, not really.
But there is potential risk.
Yeah.
All right. I might move to the dialysis section and try to keep it. Really that was a little bit more detailed than perhaps the next part.
Oh, and referring.
This is important part, so some of the things we refer to the nephrologist or indications, rapidly deteriorating HFR more than 50% of the three months our First Nation Australians.
Who benefits from the earlier referral?
Basically then, if I just take over the EGR, it’s below 45 with really bad protein urea sustained decrease in hfrs and taking lots of agents to manage their BP. I would suggest that refer to the nephrologist.
It doesn’t hurt even if they see him once and go. Nah, you’ve you’ve figured out what the cause is?
You’re doing all the right things discharging clinic. That is such a good outcome and worthwhile doing so when you get to the point where you’re referring patients.
Refer refer them early.
Took cares.
It’s a 2 for one.
Hey, how good is that?
So you refer to KRS the nephrologist and Kais.
And then we put them in streams.
They’ll either be in the primary care stream, which I will be a part of with Hayley and Emma and everyone, or the nephrology stream which the specialist will take over. And we’re kind of their hands on the ground.
So by referring to KA S you get a 2 for one thing.
So the e-mail address is on screen.
Taylorous admin@kmc.org dot U do not refer to central referral services because.
Broad Perth will reject them.
They want to keep them all in your house in the Kimberley.
Otherwise you end up with a patient from yakinora end up with a appointment in Godfrey St. in Godrich St. you know what I mean?
Like just logistically does not work.
So you want to keep them in the Kimberley, so referring to KRS will refer to nephrology at the same time, when we triage them, OK. And then we’ll keep an eye on them. They’re at least on our radar.
What do you need for referral?
Mmex, which we use has a template for their section, you’ll.
If I otherwise, if you’re not working with a place with MMX, just a generic template’s fine.
All the recent pathology investigations and up to date medication List A recent ultrasound, kidney uridised bladder.
Now that’s excluding obstructive and structural issues because that’s part of working out what the etiology of kidney disease is, right.
So if we know that there’s an obstructive issue, then the nephrolog to urology of starters.
But if it’s a structural issue, like a polycystic kidney disease, they don’t, they’s your answer.
No more. You know, we’ve got to.
We know the etiology.
We can fix that.
And also past medical examin history.
So that’s kind of a checklist if you’ve got those five things in your furo, we’re happy as Larry.
OK. So approaching renal replacement therapy. So the frequency of renal checks increases the stage late stages, so four and five blood pressures and weights are super helpful because at this point in time, usually their pathology is just out of whack. The little brackets with reference on the plat.
Is useless by the stage because kidney disease.
The the units and what we’re used to seeing as normal quote UN quote is very different to what the rest of the population’s like.
And essentially they, their pathology can look absolutely awful.
But because they’re compensated fine, though, they feel good.
So pathology is hard to rely on unless the etfi is like zero or two.
Then you go you need dialysis, so the pathology is less, less reliable because of the compensation and patients get used to feeling rubbish.
It’s more the symptoms that they’re feeling and their blood pressure and then why if you step on 10 kilos of weight within like.
Seeing them within the week.
Clinic for you, holy cow. You’re hanging on with all that fluid.
The time is now, so blood pressures and weights every time you see someone with CKD really, really important.
So often we go to review someone who can’t find it.
Don’t really worry about this person.
They need to start to ask us what was their last weight 02023.
Not so helpful.
When was their last blood pressure?
Six months ago. What’s that? Help.
So really good to get that really simple, easy, low hanging fruit in there.
Hopefully, by the time they’re four or five, they’ve discussed options of their renal replacement therapy and the floor options are satellite hemodialysis, which is where I step in as part of the random GP team.
Which is a bit of a funny name because usually the phone hemodialysis is attached to the clinic and lots of stuff.
Stuff. There’s pyritineodialysis, which you can do at home.
Lots of independence, but really strict criteria because the risk of getting infection with pancream and dying from it really high need a store. All your materials need to be pretty good dexterity with enhanced, fiddly with raying and with bad changes.
Good eyesights.
You can read the bag and have some form of health literacy.
So not everyone is a good candidate for PD, but we try and get them to keep them off machines.
And then there’s the conservative pathway.
Lots of patients when I say considered path, I think that we go you got CKD, you can die from it, OK?
See ya. Bye.
Not the case. We would still see them like any other patient. We would offer the medical support management.
We would weigh in, we would help with their symptoms, but the only difference is when they get to the point where things are getting dire, we have a goal in ceiling of care and we respect that.
There’s lots of elderly people in the back of the Fitzroy Valley who have no interest in moving.
Have lived there their whole life.
So I’m gonna get.
I’m gonna do this.
I know I’ll die from it.
I don’t care.
I wanna stay here and we respect that because satellite dialysis is hard work. You wouldn’t wish it on the worst day.
It’s really, really taxing mentally and physically, so we respect conservative pathway management if that’s what the patient wants. And it doesn’t mean we just passed them asunder and say good luck with your kidneys.
No, we we are still involved in that care.
I see a lot of conserved pathways when I go to clinics.
Things to consider. Obviously, if someone is going on to satellite dialysis, they’re going to be exchanging blood on a machine.
Risk of blood one virus is really high.
Think about hepatitis B vaccinations and their status immunizing them if they get into that point.
At least asking the question of their serology and things like that. If you see a young person who’s on dialysis and they’ve got really bad anemia and you’re only Ed because I used to be that person.
You. Oh, my God. They have even gotten 60 and it should.
Yeah, normal is above 100, so I’m 10, I’m 10.
Oh my God. The hemoglobin is half of what it should be.
Get him a unit of blood.
Pull back on that thought. If you’ve got a young person on dialysis because we might be working out for a transplant, you start putting them with units of blood.
You’re priming your immune system to reject a bra after so lots of people get a decision of transfusing their blood.
It’s not the end of the world, but we want to avoid it.
We’ve got lots of things we can do.
Otherwise iron we can do EPO.
There’s lots of things that we can do, and it’s probably chronic. The patient’s sitting there going.
Yeah, I feel a little bit tired a little bit.
Been there.
It’s been that way for ages.
You don’t need to fix it right here right now, even though the number is screaming at you on the screen.
So yeah, the usually a chronic issue if they if they’re having a blade and they, you know it’s in their boots, they need it.
They need it.
We don’t say, well, you don’t get the transmission, but just think about it in terms of is it a chronic issue?
Can we do other things?
Can we avoid that transfusion through immune priming?
Fisher’s OK, here we go.
We’re getting somewhere so.
Arteriovenous fistulas are joining in the artery and vein to make a big line of the vascular the vessel to plumbing to when we go to dialysis.
It’s three main types.
There’s the radio cafali, which is down the wrist.
There’s the bracer cathalic, which is around the elbow and the brachial basilic, which is up and tucked under the armpit.
So we work hand in hand with Vascular team for those three types, getting them to Tdap for we do mapping.
Ultrasound both of their upper limbs to find out which is the best, straightest, widest for vessels to work on.
And then they go in for an operation and have the two join together.
Takes about 6 to 8 weeks for it to mature.
So you can’t just have that operation stick a needle and dialise them.
It still takes time.
So there’s a lot of prep work with end stage CKD and that making sure the patient’s ready to start dialysis if dialysis is committed prior to the fistula being matured.
All placed they have acvc.
I’m not sure if that’s a good picture.
It’s a bit grainy, but essentially it’s a tunnel catheter that goes from their chest wall up through the superior vena cava into the right to the right atrium.
And you can see the tip of it just sitting there in the right atrium. Obviously not the best high risk for dislodgement high risk for infection, high risk in all ways, shapes and forms.
Can’t go swimming with it because you know he can get infection in it.
You got to keep it covered. If you have a shower.
So yes.
Very well. Last minute sort of crash landings will have a CBC basically.
Fistulas they look weird sometimes. Usually if they’ve been as I like to say, flogged out.
So that is from someone cannulating the same spot day after day, year after year.
It can look like an anatom Anaconda sitting on your arm.
People ask me, how do I examine a fistula?
Just look. Listen, feel.
Just keep it nice and simple. So look, if it’s a new one, look for the surgical scar.
I’ll tell you where it should be, and then you can focus your attention there, looking for signs of infection.
Retina swelling oozro cardinal signs that you’re aware of.
Does it look aneurysmal?
You can see the flash on the camera has made really good example of where the area of skin is shiny and thin.
That’s a risk of rupture.
That’s one we, and if it ruptures, there’s a litre a minute gone through there.
So people would exaggerate to death.
Very quickly, if they do prank, it’s a medical emergency and we take it very seriously. So looking at it, that’s what sort of things you’re looking at listening.
There should be a brewy now brewy’s are bad everywhere else in your body.
Shouldn’t shouldn’t brew though.
Or not. But because it’s an asthmosis of two vessels, there’s turbulent blood in there and it’s normal.
You should hear it so it kind of has. If you find a dialysis patient, put a dead step on their fistula, they don’t mind.
And you hear what?
They sound quite interesting in if you hear a high pitched whistle that could mean stenosis because it’s a narrowing of that vessel to be here whistling over the fistula.
Bad news if you hear nothing worse bad news because it means officialers all sudden clodded the failed and that’s their lifeline to dialysis. That is, you’re on a plane. You’re down to Perth.
You’re getting a new line straight away, so if you hear weird stuff, it’s probably normal. If you hear nothing, it’s bad.
And if you hear high pitched up, it’s bad.
And in field you should feel a thrill.
So when you put your hand over fistja should feel that turbulent blood mixing together.
It’s like a vibration.
It’s like a little buzzy be, you know, an Ed, the buzzy bead you do cannulas on.
Kids should feel like that is coming away again.
A lack of a thrill is bad if you don’t feel that could be plotted, could be failed, and if you feel aband impulse and a new one, like really strong bound impulse, it may mean it has not taken, hasn’t matured and.
So the turbulent blood flow is not because you’ve got like high concent low pressure, is that correct?
Yeah. So the high arterial pressure mixing with the low pressure venous blood mixing together and coming back from the circuit, yeah.
It goes to that same, but please no blood pressure cuffs or blood lead in on the side of the fistula.
It just reduces any risk. I mean push downs to shove, you can, but we prefer not to because you know, if you torn a coat above that, then all of a sudden you’ve got this more pressure.
On something like that, he says.
Oh my gosh, you know.
You may seem to ask us when do we do it?
Well, they may have all of these symptoms.
They have none of them.
It’s more of a syndrome, so they might be short of breath. They might have all the edema, they might havecetes loss of that diagnosisa, vomiting, fatigue, brain fog, confusion, all the way up to coma, pruritus.
So feeling itchy skin, muscle fatigue, cramping and headaches secondary to hypertension.
Basically, we start as when they’ve got refractory hyperkkulenia.
Selby and hypertension.
Deranged electrolytes. Severe acidosis.
Full download on urine. One of those things that is severe is enough to put a trigger.
We just keep an eye on all these things.
So logistics of commencing this is what usually makes people get really sad.
And it is sad because it’s quite harrowing for the patient so.
I come along so you need to start dialysis.
You know, OK.
It’s been a long time coming.
What I do well, you need now need to leave your home and community possibly for the first time ever.
Pats generally does not allow escorts when it comes to starting dialysis, so you’re going to have solo you land in Perth, you get plunked in a busy tertiary Ed. There’s all sorts of weird and wonderful things that will not look so wonderful.
Really high energy environment.
Quite scary if you’re not used to. You’re only used to a small clinic in a small remote community, then a tertiary Ed is a hefty place that’s really confronting.
If you crash land it you go and get a CVC.
You’ll commence dialysis under the watchful eye of the nephrology team.
They start with low pressures and low hours and build them up to a usual 4 hour plus session twice weekly.
Because that’s such a huge amount of stimuli, and to get your head around.
And it can be by having to patients. There’s two services we use country connect and country parts.
They coordinate supports assist with accommodation, linking with relevant services such as the Halos and Country Connect is particularly good for holistic, culturally appropriate cares when they’re in Perth, so linking them into there while you know in lieu of not having an escort or support person is the least.
We can do for our patients and we try and get them LinkedIn.
He generally spent three months in Perth under this observed dialysis for fine tuning. Sometimes Pats will allow you to have a sportperson at this stage, but you’re generally an outpatient by now, so you’re coming going to hospital, making your own way there by a bus or taxi if.
You’ve got money.
Or that’s where we get the country past. They can help give you a lift. That’s really helpful.
You sit there for three months in Perth, where it’s cold, miserable and raining, freezing. You probably don’t own too many winter clothes.
‘Cause, you’re from the east Kimberley.
Waiting for a seat to become available at one of the units. Now if they’re full and there’s no seats, we’re literally waiting for someone to die to take their spot because there’s no more chest, which is really sad if you have ongoing issues with your dialysis, the wait.
Time can be extended way beyond this.
There’s one lady that’s been down there for 18 months waiting to get herself sorted out to come back.
They’re still working on it.
Some patients will opt to discharge to larger dialysis units awaiting their preferred location.
So what I mean by that is.
I want to dialysis counter.
There’s no running counter to spawn Derby. OK, I’ll go to Derby for a bit and then I’m first on the list to go to come on over in the spots available.
So that’s a temporary thing, and these people are back in the region and they can be in on country somewhat.
Bitzroy Crossing takes a lot longer because there’s only four chairs out there.
However, an expansion has begun.
And there’s going to be 8 chairs out there, so we’re going to be able to get a lot more patients home, which is going to be great if you are compliant with your dialysis, you do the whole sessions.
The meditation you live a healthy lifestyle.
You don’t drink, don’t smoke.
You do the right thing.
You might be worked up for a transplant, but on average that takes a couple of years to work you up and make sure that you’re all the person to the raft.
That’s a whole lecture on self transplantation and I’d be happy to come back and talk about that.
So where can I dialysis in the Kimberley?
So where the four little kidney beans are, are there locations down the bottom?
Broome, where we are next one above it is Derby.
To the right Fitzroy and above that kind. No, I look after Derby Fitzroy Crossing and all the areas of CKD in between. Hayley does Broome and the peninsula and Biji and then Emma up here in the east.
So Broome, 10, chairs Derby, 13 chairs the biggest unit.
Fitzroy 4 chairs going to be 8 in the foreseeable future.
HS.
So types of hemodialysis, I started looking into this and it’s origins are from Greek words. I just thought of the guy from my big fat Greek.
For Thomas, one was a great the word.
Dioces meaning dissolution.
So Dia through Lucas loosening.
So although we say hemodialysis is a catch all, it’s actually hemodia filtration.
So put very, very simply, hemodialysis is just using osmotic and diffusion gradients.
One passes through high concentration, low concentration of exchange happens.
That’s dialysis.
That’s really, really oversimplified version that’s good for small molecules, but big molecules like phosphate, not so good for concentration gradients are hard.
Hemo Dye filtration is that same osmotic and diffusion gradient phenomena with oncotic or counter current pressure.
So we’re pushing the fluid through as well, which creates that oncotic drive for the bigger molecules.
In theory, it’s a better form of dialysis all about satellite units use HDF machines.
That’s essentially how it works, and this is a really, really really basic mind map of it.
So it says to the wall. So we’ve got it from the mains, so water comes in. It’s heteronized, so the circuit doesn’t slot, it goes into the dialyzer where it joins the other two circuits. So from the patient.
Their old blood comes through.
It’s pumped through the dialyser, which is the artificial kidney.
Thursday and comes back with your body.
Then we’ve got the dialer site, which has concentrations of different electrolytes that we can titrate and fine tune. It comes in and has counter current. So you’ve got the diffusion gradient from the concentration in the dial site as well as the push and the drive counter current. So.
You can see two hours and try to demonstrate the counter current.
That’s a really, really simple version of what a dialysis machine is doing.
They’re obviously a lot more technical than we can fine tune things, but essentially.
That’s what’s going on.
So what does dialysis remove?
Extra fluid nitrogenous waste creating new air, potassium phosphate medications.
All the good and bad stuff.
So we got to really be careful what we take out.
Fluid removal. This is how we think about it.
It’s probably a little bit technical, but bear with me.
So you’ve got the dialyser which is a set space, the vascular space which is in your blood flowing around. And then the extra vascular space and that’s what we hear about people having fluid on their lungs, in their tummy, in their feet, on their face.
We really want to get rid of the.
Extravascular spice stuff, but we can only get to it by vascular.
So brace yourself for the most primitive animation on how you’ll ever see.
So you check the patient on both dialysis. You get rid of their vascular space and you go, blood pressure’s improved and we got rid of a bit. And then your job done.
Not really, because then they refill from the extravascular space and top themselves straight back up.
So that’s why they come to dialysis.
We do the right thing. They get back to blood. Pressure’s still high again. Will they refill it?
So what we’re actually chipping away at is the third space. We’ve got to go via the two other spaces in a roundabout way.
If we take too much food at once, it can be trivial. Things like the patient cramps up, they feel uncomfortable, which is not good. We don’t like it, so we try to avoid it. But all the way up to hyperbelieve shock, hypertension, arrhythmia and sudden cardiac death. How?
Do we overcome that?
Well, we get them to come in for regular dialysis.
We do full sessions and we do a full restriction of one litre a day.
Up here, 1 litre a day is hectic, particularly when it’s really hot and humid.
Imagine how thirsty you are for being outside all day.
You smash a bottle of water.
That’s your fluid down for the day.
No more for you.
That’s it. You’re done.
So we end up in this big vicious circle, so you get big white hands, big volume shifts. We take more off on the machine.
They end up being hypertension hypertensive, so they get a bolus to bring them up otherwise.
They’re they’re flat and you know, not conscious.
And then if we take big volumes off the?
Debates the first mechanism, so it makes the patients literally more thirsty.
So survival mechanism, we’ve had this for millions and millions of years.
Your low volume of your blood, your thirsty refilling.
So we’re taking all the way.
The first mechanism is really the screaming. Their brain is going.
I’m so thirsty.
Get some water into me and then run around and we go big wave gains.
We take big fluids off 1st.
Bang Bang, bang, bang, bang, bang we go.
So it’s really hard.
Lots of Ed doctors and myself included when I worked in Ed go.
Well, why is the patient here for high potassium when dialysis will fix that?
Why don’t you just put on the shame?
And I used to do this too. Before I did this job.
But there’s a phenomenon called rebound hyperkalemia.
Essentially, they got really high potassium.
Take it off them in the machine.
Then they got really low potassium and then just like the fluid, all the potassium in their cells, bloods into their blood, and then they get a really high potassium again. And that’s what makes your cardiac membrane unstable and you get your arrhythmia to sudden cardiac death. So that.
Why when we send a patient the Ed is hyperkleven they go?
They’re doing it.
This is this graph of what I’m trying to demonstrate. Here is what we’re trying to avoid, and that sudden shift high, low, high makes the cardiac membrane really unstable.
And you can have toss or via and DT. Any arrhythmias?
That’s why.
So what’s the? What’s the window of that?
Depends on patients. So some patients are used operating at a six point somethings which is five for you and I they are normal for them.
Other patients are operator fours, so we gotta look at what each one is and if we’ve deemed that they’re high. But essentially we won’t dial that someone if they’re. If that’s over seven. That’s far too risky.
OK, we need to run, yeah.
Thank you.
So we mitigate this by doing gentle dialysis.
Repeat dialysis back-to-back and slowing things down. So we’re not denying dialysis. When Ed says that we are.
We’re mitigating the risk to making safeguards to patient and staff.
And when you when you get to Ed, you’ve got dialysis patient that comes in and their feel diverse. And yeah, I just go to dialysis.
I just take the tablets.
Why? Why? I just do this?
Because I was thinking to you about looking at a because you get to take. But remember, that’s 12 hours a week that they’re sitting there three times a week. You know, sitting there on a machine that’ll get the best of people the hardest of people would have trouble.
Doing that so you know, I don’t feel like today. I used to think to be like.
But now I see people. It’s really sad to see all these people sitting in machines for four or five hours.
So go easy on, you know, and when when they’re drinking too much fluid, remember that first mechanism is like, yeah, anyway, that’s it.
Those are the numbers that I want you to remember, and I think it’s 8:00 on the dot.
Olly legends.
Whoa. That was really interesting.
And I’m not even a doctor or study.
So thank you everybody that have tuned in, really appreciate your support and thank you Dave for doing that.
Were there any questions from?
Don’t know if that’s on.
We’ve lost all the Wi-Fi here, the Rural clinical school’s down South. I think hot spotting up my phone.
So that’s why I keep checking it, because I’ve been paranoid.
It’s going to drop, but this old presentation.
So yeah, thank you.
I’m going to cut it off now.
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