ETHNICITY

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ETHNICITY RENAL DISEASE John Feehally
2
AN EPIDEMIC OF KIDNEY DISEASE IN ETHNIC MINORITY
POPULATIONS
3
ESRD End stage renal disease
4
ESRD End stage renal disease
RRT Renal replacement therapy
5
ESRD End stage renal disease
RRT Renal replacement therapy
Dialysis
Renal transplant
6
CKD Chronic kidney disease
ESRD End stage renal disease
RRT Renal replacement therapy
Dialysis
Renal transplant
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CKD Chronic kidney disease Stages 1 - 5
ESRD End stage renal disease
RRT Renal replacement therapy
Dialysis
Renal transplant
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CKD Chronic kidney disease
Usually slowly progressive
ESRD End stage renal disease
RRT Renal replacement therapy
Dialysis
Renal transplant
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Factors predicting progression of
CKD Proteinuria Hypertension
CKD Chronic kidney disease
Usually slowly progressive
ESRD End stage renal disease
RRT Renal replacement therapy
Dialysis
Renal transplant
10
CKD Chronic kidney disease
ESRD End stage renal disease
RRT Renal replacement therapy
People with ESRD have high mortality even with
successful RRT
Dialysis
Renal transplant
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CARDIOVASCULAR RISK AND EARLY CHRONIC KIDNEY
DISEASE
Cardiovascular risk is HUGE Proteinuria is a
very strong predictor of CV death Cardiovascular
risk is bigger than diabetes Many - especially
older people - will die long before they reach
ESRD
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AN EPIDEMIC OF CKD IN ETHNIC MINORITY POPULATIONS
Epidemiology Possible pathogenetic
mechanisms Interventions which may be
effective The public health implications
13
AN EPIDEMIC OF CKD IN ETHNIC MINORITY POPULATIONS
Epidemiology Possible pathogenetic
mechanisms Interventions which may be
effective The public health implications
14
LEICESTER 1980
ESRD End stage renal disease
RRT Renal replacement therapy
Dialysis
Renal transplant
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1991 CENSUS
Leicestershire 867,000 8.4 Indo-Asian Leices
ter city 270,000 22 Indo-Asian primary
school children 32
Gujarati-speaking Hindus 60 Muslims 20 Pun
jabi-speaking Sikhs 17
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2001 CENSUS 50 of people living within the
Leicester city boundary are of South Asian
origin
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PREVALENCE OF TYPE 2 DIABETES LEICESTER IN
THE 1990S
25 of the South Asian population age gt 65
years have Type 2 diabetes
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RACIAL SUSCEPTIBILITY TO TYPE 2 DIABETES
South Asians Pacific Islanders Australian
Aborigines African Caribbeans Hispanics Native
Americans
20
PREDICTED INCREASES IN PREVALENCE OF DIABETES
1995
2025
King Diabetes Care 1998211414
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DISEASE SUSCEPTIBILITY IN SOUTH ASIANS
South Asians compared to White Europeans Leicester
1980-1995
Increased risk Coronary heart disease Type
2 diabetes Renal disease
Decreased risk Peripheral vascular
disease
Feehally et al. QJM 1993 86263
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SUSCEPTIBILITY TO TYPE 2 DIABETIC NEPHROPATHY
Is the increase in type 2 diabetic nephropathy
proportionate to the increase in type 2
diabetes?
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ESRD IN LEICESTER 1979- 1988
Relative risk of an South Asian diabetic
developing ESRD 13.6 CI 6.1 to 30.6
Burden AC et al. 1992
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LEICESTER Relative risk of an South Asian
diabetic developing ESRD 13.6 CI 6.1 to 30.6
PIMA INDIANS Age 45-64 years Risk of developing
ESRD is 14 times U.S. Whites
25
ESRD IN LEICESTER 1979- 1988
Relative risk of an South Asian diabetic
developing ESRD 13.6 CI 6.1 to 30.6
Relative risk of a non-diabetic South Asian
developing ESRD 3.6 CI 2.6-4.4
Burden AC et al. 1992
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INCREASED RISK OF ESRD IN ETHNIC MINORITIES
At least a 3 fold increased risk of ESRD is now
confirmed in South Asians and African
Caribbeans - UK Blacks and other ethnic
minorities - USRDS
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ESRD IN BLACK AMERICANS
Adjusted risk odds ratio for Blacks cf Whites
All causes 4.4 3.5-6.0 Hypertensive renal
disease 6.0 3.9-9.0 Type 1 diabetes 6.0
3.8-9.3 Type 2 diabetes 12.2 6.9-21.7
Tell - Ethnicity Health 1996121
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ESRD IN SOUTH ASIANS WEST LONDON LEICESTER
1982-1988

Hammersmith Leicester

SOUTH ASIANS Total population 8 9.3
ESRD Population 26 21
Lightstone L et al QJM 1995 88191
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DEMAND FOR RENAL REPLACEMENT THERAPY
Acceptance rate Demand ?
Is there equity of access ?
30
ESRD IN ETHNIC MINORITIES IN THE UK
6000 patients in 27 units with gt 85 ethnicity
data
UK Renal Registry 2002
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DEMAND FOR RENAL REPLACEMENT THERAPY
Thames Region 1992 White
South Asian African Caribbean Accep
tance rate per 106/yr M F M F M
F 16-34 yrs 32 28 69 48 124 70 35-65-yrs
133 84 419 333 430 292 gt 65 yrs 247 87 1288 4
54 1154 795 Total gt 16 yrs 109 63 290 192 286
181
Roderick 1994, 1996

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DEMAND FOR RENAL REPLACEMENT THERAPY
Thames Region 1992 White
South Asian African Caribbean Accep
tance rate per 106/yr M F M F M
F 16-34 yrs 32 28 69 48 124 70 35-65-yrs
133 84 419 333 430 292 gt 65 yrs 247 87 1288 4
54 1154 795 Total gt 16 yrs 109 63 290 192 286
181
Roderick 1994, 1996

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DEMAND FOR RENAL REPLACEMENT THERAPY
Thames Region 1992 White
South Asian African Caribbean Accep
tance rate per 106/yr M F M F M
F 16-34 yrs 32 28 69 48 124 70 35-65-yrs
133 84 419 333 430 292 gt 65 yrs 247 87 1288 4
54 1154 795 Total gt 16 yrs 109 63 290 192 286
181
Roderick 1994, 1996

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INCIDENCE OF KIDNEY DISEASE IN SOUTH ASIANS IN
SOUTH ASIA
There are no population based studies of the
requirement for RRT or of non-dialysed CKD
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Susceptibility to kidney disease or Increased
risk of progression ?
37
PROGRESSION OF CHRONIC KIDNEY DISEASE
Birth cohort analysis NHANES III
USRDS Prevalence of Stage 3 CKD Blacks
Whites
Risk of ESRD in CKD 3 identified in 1991
Blacks gt Whites RR 4.8 2.9-8.4
Hsu C-Y et al. JASN 2003 142902
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PROGRESSION OF CHRONIC KIDNEY DISEASE
Birth cohort analysis NHANES III
USRDS Prevalence of Stage 3 CKD Blacks
Whites
Risk of ESRD in CKD 3 identified in 1991
Blacks gt Whites RR 4.8 2.9-8.4
Hispanics - increased risk of progression CKD
to ESRD
Hsu C-Y et al. JASN 2003 142902 Peralta CA et
al.JASN 2006 17 2892
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CAUSES OF ESRD IN SOUTH ASIANS WEST LONDON
LEICESTER 1982-1988
Significant increases in Diabetic
nephropathy Biopsy-proven glomerulonephritis Ref
lux nephropathy

Lightstone QJM 1995 88191
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CAUSES OF ESRD IN SOUTH ASIANS WEST LONDON
LEICESTER 1979-1988
Small smooth kidneys CKD of uncertain cause
? Interstitial nephritis

Lightstone QJM 1995 88191
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CAUSES OF ESRD IN SOUTH ASIANS WEST LONDON
LEICESTER 1979-1988
Small smooth kidneys Chronic renal
impairment Low grade proteinuria Bland urine
sediment Low grade hypertension Shrunken
symmetrical kidneys on imaging

Lightstone QJM 1995 88191
42
CAUSES OF ESRD IN SOUTH ASIANS WEST LONDON
LEICESTER 1979-1988
Small smooth kidneys Chronic renal
impairment Low grade proteinuria Bland urine
sediment Low grade hypertension Shrunken
symmetrical kidneys on imaging

Is tuberculosis a causative agent ?
Lightstone QJM 1995 88191
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HYPERTENSION IN AFRICAN-CARIBBEANS
30 of African-Americans are hypertensive 8
have untreated BP gt 180/110 1 of Whites
Similar prevalence among Blacks
in USA Caribbean Latin America UK Urban Africa
6 in rural Africa
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RENAL BIOPSY FINDINGS IN SOUTH ASIANS
St. Marys Hospital, London
Relative risk South Asian/White 95
CI Hypertension-ischaemia 3.2
1.5-7.8 Diabetic nephropathy 4.0
2.0-7.9 Lupus nephritis 4.7
1.8-12.4 Focal segmental glomerulosclerosis 6.
6 2.7-16.4 Idiopathic interstitial
nephritis 7.2 2.7-18.9 Non-specific advanced
chronic renal disease 7.7 2.0-20.9
Ball et al - Q J Med 200194187
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INCIDENT ESRD IN USA BY PRIMARY DIAGNOSIS AND RACE
USRDS 2001 Annual Report
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RACIAL VARIATIONS IN LUPUS NEPHRITIS
More common and more severe in US Blacks
Hispanics Asians UK South Asians African
Caribbeans
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RENAL DISEASE IN SOUTH ASIANS
Childhood steroid sensitive nephrotic syndrome

LEICESTER Whites 1.3 per 100,000 per year
plt
0.0002 South Asians 9.4 per 100,000 per year
Feehally Arch Dis Child 1985 60 1018
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RENAL DISEASE IN SOUTH ASIANS
Childhood steroid sensitive nephrotic syndrome

LEICESTER Whites 1.3 per 100,000 per year
plt
0.0002 South Asians 9.4 per 100,000 per year
Independent of religion or birth place Similar
findings in Birmingham Bradford
Feehally Arch Dis Child 1985 60 1018
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Susceptibility to kidney disease and Increased
risk of progression ?
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RISK OF PROGRESSION IN DIABETIC NEPHROPATHY
Earle NDT 200116286
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SCREENING FOR CHRONIC KIDNEY DISEASE IN PRIMARY
CARE
LOLIPOP Study 6,188 South Asians, 3,232
Whites Age adjusted risk of Stage 3 4
CKD South Asians Whites
Lightstone L unpublished
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Can we learn from indigenous high risk racial
populations ?
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PIMA INDIANS

• A small native American tribe in Arizona
• Very high risk of type 2 diabetes
• No diabetes before World War II
• ESRD due only to diabetic nephropathy
• Incident ESRD gt 700 pmp per year

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ZUNI INDIANS

• 10,000 people in New Mexico
• 20 have proteinuria
• Almost all Zuni have a relative with ESRD
• ESRD gt 700 pmp per year
• ESRD is due to
• diabetic nephropathy 50
• mesangial proliferative GN including IgAN

Zuni Kidney Project
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RENAL DISEASE IN AUSTRALIAN ABORIGINES
Tiwi Islanders - Northern Territory Among the
least healthy people in the world Standardised
mortality ratio x 4 cf Whites Incidence of ESRD
up to 2700 per million per year 6 fold
increase in cardiovascular death Type 2 diabetes
Obesity
Hoy 2000 NDT151293
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ABORIGINAL AUSTRALIANS PROTEINURIA AND
MORTALITY
Hoy W et al KI 2003 63 Suppl 83 S6
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MORTALITY AND PROTEINURIA IN AUSTRALIAN ABORIGINES
Hoy 2000 NDT151293
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ABORIGINAL AUSTRALIANSSOCIO-ECONOMIC
DISADVANTAGE AND ESRD
Cass A et al Ethnicity Disease 2002 12 373
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INCREASED RISK OF ESRD IN ETHNIC MINORITIES

RACE
DEPRIVATION
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INCREASED RISK OF ESRD IN ETHNIC MINORITIES

RACE
DEPRIVATION
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RACIAL SUSCEPTIBILITY TO TYPE 2 DIABETES AND CKD
South Asians Pacific Islanders Australian
Aborigines African Caribbeans Hispanics Native
Americans
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RACIAL SUSCEPTIBILITY TO TYPE 2 DIABETES AND CKD
South Asians Pacific Islanders Australian
Aborigines African Caribbeans Hispanics Native
Americans
Why are White Caucasians protected from ESRD ?
64
INCREASED RISK OF ESRD IN ETHNIC MINORITIES
Recognise the enormous social, cultural, and
perhaps biological heterogeneity within the
broad ethnic groupings we use
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AN EPIDEMIC OF CKD IN ETHNIC MINORITY POPULATIONS
Epidemiology Possible pathogenetic
mechanisms Interventions which may be
effective The public health implications
66
SUSCEPTIBILITY TO RENAL DISEASE OR TO
PROGRESSION OF RENAL DISEASE ?
Genetic ?
Environment ?

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SUSCEPTIBILITY TO RENAL DISEASE - OR TO
PROGRESSION OF RENAL DISEASE ?
Environment ?
Genetic ?
Fetal environment?

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SUSCEPTIBILITY TO RENAL DISEASE
Thrifty genotype ?

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SUSCEPTIBILITY TO RENAL DISEASE
Thrifty genotype ?

Thrifty phenotype ?
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SUSCEPTIBILITY TO RENAL DISEASE - OR TO
PROGRESSION OF RENAL DISEASE ?
Environment ?
Genetic ?
Fetal environment?

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GENETIC SUSCEPTIBILITY TO RENAL DISEASE


Risk of other renal disease
Risk of type 2 diabetes
Risk of Hypertension
RISK FACTORS
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GENETIC SUSCEPTIBILITY TO RENAL DISEASE


Risk of other renal disease
Risk of type 2 diabetes
Risk of Hypertension
RISK FACTORS
Risk of progression
End stage renal disease
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GENETIC SUSCEPTIBILITY TO RENAL DISEASE IN
ETHNIC MINORITY POPULATIONS
PIMA INDIANS Strong family effect but.. Genom
e wide scanning has identified three possible
susceptibility loci One of these on chromosome 7
has genes of interest aldose reductase, TGFß, NOS

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GENETIC SUSCEPTIBILITY TO RENAL DISEASE IN
ETHNIC MINORITY POPULATIONS

• No genes yet identified which cause -
• susceptibility to renal disease
• increased risk of progression to renal failure
• ? Renin angiotensin system

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GENETIC SUSCEPTIBILITY TO RENAL DISEASE IN
ETHNIC MINORITY POPULATIONS

• No genes yet identified which cause -
• susceptibility to renal disease
• increased risk of progression to renal failure

DNA collections from relevant population groups
are urgently needed
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GENETIC SUSCEPTIBILITY TO RENAL DISEASE IN
ETHNIC MINORITY POPULATIONS
Broad population susceptibilities to renal
disease
Autosomal recessive disorders in populations
with increased consanguinity make a small
contribution to the burden of adult kidney disease

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SUSCEPTIBILITY TO RENAL DISEASE OR TO
PROGRESSION OF RENAL DISEASE ?
Genetic ?
Environment ?

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SUSCEPTIBILITY TO RENAL DISEASE OR TO
PROGRESSION OF RENAL DISEASE ?
Genetic ?
Environment ?
Is it the result of change? .or is it the rate
of change ?

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SUSCEPTIBILITY TO RENAL DISEASE
Environment ?
Genetic ?
Fetal environment?

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THE BARKER HYPOTHESIS
In utero programming contributes to adult
disease

• Low birth weight and/or catch up
• are associated with increased risk of -
• type 2 diabetes
• insulin resistance
• coronary heart disease
• hypertension

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Barker Low birth weight Type 2 Diabetes
Fetal programming
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THE BARKER HYPOTHESIS
In utero programming contributes to adult
disease
Mechanism ? Is there deprivation of metabolic
fuels needed for nephrogenesis ?

• Difficult to dissociate..
• intrauterine programming
• from
• subsequent adverse environmental factors

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THE BARKER HYPOTHESIS
In utero programming contributes to adult
disease

• Evidence for renal disease ?
• the kidney is susceptible to fetal malnutrition
  
• because 60 of nephrons are formed
• in the 3rd trimester
• kidney size is disproportionately reduced
• in small-for gestational babies Konje 1996

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Brenner, Chertow, Mackenzie Low birth weight
Reduced nephron number Hypertension
Barker Low birth weight Type 2 Diabetes
Fetal programming
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NEPHRON NUMBER AND ESSENTIAL HYPERTENSION
Nephron number reduced in White
Europeans White Americans but not in
Blacks Australian Aboriginals
Hughson Kidney Int 2003 63 2113
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GLOMERULAR NUMBER AND BIRTH WEIGHT
Autopsy study
Hughson Kidney Int 2003 63 2113
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GLOMERULAR NUMBER AND GLOMERULAR VOLUME
Autopsy study
Hughson Kidney Int 2003 63 2113
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GLOMERULAR NUMBER AND VOLUME AND BIRTH WEIGHT
In individuals without renal disease
.. Ethnicity did not significantly modify the
relationship between glomerular characteristics
and birth weight
Hughson Kidney Int 2003 63 2113
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BIRTHWEIGHT AND PROTEINURIA IN AUSTRALIAN
ABORIGINES
25 of Aborigines have birthweight lt 2500gm
Hoy 2000 NDT151293
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ABORIGINAL AUSTRALIANSAMPLIFYING RISK FACTORS
FOR PROTEINURIA
Hoy W et al Nephrology 2001 6 19-24
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PIMA INDIANS PROTEINURIA BIRTH WEIGHT
Nelson RG et al. Am J Epidem 1998 148 650
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Low birth weight IUGR
Kidney size
Nephron number
Glomerular size
Glomerulosclerosis
ESRD
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Low birth weight IUGR
Type 2 diabetes
Hypertension
Proteinuria
Progressive renal disease
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AN EPIDEMIC OF CKD IN ETHNIC MINORITY POPULATIONS
Epidemiology Possible pathogenetic
mechanisms Interventions which may be
effective The public health implications
95
Screening early detection
Opportunities for intervention
Progressive CKD
ESRD
RRT Renal replacement therapy
Dialysis
Renal transplant
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RENAL TRANSPLANT GRAFT SURVIVAL Leicester
1983-1996
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RENAL TRANSPLANTATION IN SOUTH ASIANS
Leicester 1983-1996 - first cadaveric grafts 80
South Asian 420 White recipients
meanSEM South Asian White p Time on
waiting list 361.2 14 0.7 lt
0.01 months HLA-DR mismatches 0.680.07 0.60.
03 0.28
Butterworth, 1999
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UK Transplant 2004
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UK Transplant 2004
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UK Transplant 2004
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UK Transplant 2004
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IMPROVING RENAL TRANSPLANTATION IN
AFRICAN-AMERICANS
Single centre 10 year experience Baltimore, USA

• Education about live donation
• Laporoscopic donor nephrectomy
• Use of HCV donors for HCV recipients

1 and 5 year patient graft survival Blacks
Whites Cadaveric waiting time 1.5 times in
Blacks cf Whites
Foster C et al. Ann Surg 2002 236 794
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RENAL TRANSPLANTATION IN ETHNIC MINORITIES
Those who are never listed must not be
forgotten Those who are never offered a kidney
must not be forgotten The low rate of
cadaveric organ donation in ethnic minorities
must be addressed A vigorous and pre-emptive
live donor transplant programme is needed

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Screening early detection
Opportunities for intervention
Progressive CKD
ESRD
RRT Renal replacement therapy
Dialysis
Renal transplant
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CHRONIC KIDNEY DISEASE
Modifying progression by. Control of blood
pressure Reduction in proteinuria
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CHRONIC KIDNEY DISEASE
Progression is speeded up by.
Blood pressure
Proteinuria
Improving these really makes a difference
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CHRONIC KIDNEY DISEASE
Progression is speeded up by.
Blood pressure
Proteinuria
Improving these really makes a difference
ACE inhibitors
108
ARE INTERVENTIONS TO DELAY PROGRESSION EFFECTIVE
IN ETHNIC MINORITIES ?
? legitimate to extrapolate from the
intervention trials mostly conducted in White
Caucasians No known unique risk factors for CKD
in ethnic minorities Risk factor control is
universally poor
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CHRONIC KIDNEY DISEASE
Controlling risk factors for progression effective
in all racial groups

• RENAAL Study
• Post hoc analysis
• Losartan
• reduces microalbuminuria
• reduces ESRD risk
• in all ethnic groups
• De Zeuuw et al. KI 2006 69 1675

AASK Study ACE inhibitors more effective than
CaCB in reducing ESRD In Black Americans
110
INTERVENTION FOR RENAL DISEASE IN AUSTRALIAN
ABORIGINES

• Tiwi Island - treatment programme started 1995
  
• Entry criteria BP gt 140/90
• Diabetes with microalbuminuria
• Overt proteinuria

Community-based health education ACE inhibitor
Hoy 2000 NDT151293
111
INTERVENTION FOR RENAL DISEASE IN AUSTRALIAN
ABORIGINES

• Community-based health education and ACE
  inhibitor
• controlled BP
• reduced proteinuria
• reduced incidence of ESRD

There was measurable benefit within 3 years
Hoy 2000 NDT151293
112
INTERVENTION FOR RENAL DISEASE IN AUSTRALIAN
ABORIGINES
Hoy W et al. KI 2003 63 Suppl 83 S66
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INTERVENTION FOR RENAL DISEASE IN AUSTRALIAN
ABORIGINES
Northern Territory Lack of sustained healthcare
investment has led to loss of the gains which
were made
Hoy personal communication
114
AN EPIDEMIC OF CKD IN ETHNIC MINORITY POPULATIONS
Epidemiology Possible pathogenetic
mechanisms Interventions which may be
effective The public health implications
115
PREVALENCE OF RENAL DISEASE IN ETHNIC MINORITY
POPULATIONS
Major implications for health policy
The UK Government now recognises the
impact of ethnicity on requirements for renal
care National Service Framework for Renal
Services
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PREVALENCE OF RENAL DISEASE IN ETHNIC MINORITY
POPULATIONS
Major implications for health policy
Improvement in overall public health should
reduce CKD in ethnic minorities
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PREVALENCE OF RENAL DISEASE IN ETHNIC MINORITY
POPULATIONS
Major implications for health policy
Improvement in social deprivation may
decrease ESRD independent of ethnicity
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PREVALENCE OF RENAL DISEASE IN ETHNIC MINORITY
POPULATIONS
Major implications for health policy
In very deprived populations health
improvement may paradoxically increase CKD
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PREVALENCE OF RENAL DISEASE IN ETHNIC MINORITY
POPULATIONS
Major implications for health policy
Fall in perinatal mortality will increase
survival of low birthweight babies Adults will
survive longer to get CKD
120
PREVALENCE OF RENAL DISEASE IN ETHNIC MINORITY
POPULATIONS
Major implications for health policy
Early intervention may not reduce RRT
requirement if cardiovascular risk is reduced
more than renal risk
121
PREVALENCE OF RENAL DISEASE IN ETHNIC MINORITY
POPULATIONS
Major implications for health policy
Increased resources now for Renal
replacement therapy
122
PREVALENCE OF RENAL DISEASE IN ETHNIC MINORITY
POPULATIONS
Major implications for health policy
Increased resources now for Renal replacement
therapy And this demand will increase rapidly
over the next few years
123
PREVALENCE OF RENAL DISEASE IN ETHNIC MINORITY
POPULATIONS
Major implications for health policy
Treating renal failure properly is
expensive Treating renal failure properly in a
multiethnic multicultural setting is even more
expensive
124
PREVALENCE OF RENAL DISEASE IN ETHNIC POPULATIONS
Major implications for health policy
Increased resources now for Screening ??
125
SCREENING FOR CHRONIC KIDNEY DISEASE IN PRIMARY
CARE
LOLIPOP Study
Target those with diabetes hypertension cardi
ovascular disease
Identify 80 of Stage 3-4 CKD In all ethnic
groups
Lightstone L unpublished
126
PARTNERSHIPS WITHIN THE HEALTH COMMUNITY
COMMUNITY Awareness Education
PRIMARY CARE Awareness Education
127
Screening early detection
Opportunities for intervention
Progressive CKD
ESRD
RRT Renal replacement therapy
Dialysis
Renal transplant
128
Screening early detection
Opportunities for intervention
Progressive CKD
These interventions must be rigorously tested
ESRD
RRT Renal replacement therapy
Dialysis
Renal transplant
129
PREVALENCE OF RENAL DISEASE IN ETHNIC MINORITY
POPULATIONS
Major implications for health policy
Research is needed into fundamental
disease mechanisms
130
AN EPIDEMIC OF KIDNEY DISEASE IN ETHNIC MINORITY
POPULATIONS
131
AN EPIDEMIC OF CKD IN ETHNIC MINORITY POPULATIONS
Epidemiology Possible pathogenetic
mechanisms Interventions which may be
effective The public health implications
132
(No Transcript)
133
PREVALENCE OF RENAL DISEASE IN ETHNIC POPULATIONS
Major implications for health policy
Increased resources now for Screening Early
intervention
but we must test our interventions
134
PREVALENCE OF RENAL DISEASE IN ETHNIC POPULATIONS
Major implications for health policy
Increased resources now for Community
awareness and education Changing practice in
primary care
135
PREVALENCE OF RENAL DISEASE IN ETHNIC POPULATIONS
Major implications for health policy
Increased resources now for Community
awareness and education Changing practice in
primary care
but we must test our interventions
136
The Leicester ABLE Project University
Hospitals of Leicester NHS Trust And East
Leicester Primary Care Trust
137
Leicester ABLE RENAL Project
138
We know what to do
139
We know what to do Intervene early Control
of diabetes Control of blood pressure

140
We know what to do We are not certain how
to do it
141
PARTNERSHIPS
COMMUNITY Awareness Education
142
People at high risk Leicester South Asian
people Diabetes High blood pressure Other
family members with kidney disease
143
Leicester ABLE RENAL Project
RENAL REducing Nephropathy in South Asians in
Leicester
Awareness and community education programme
for renal disease in an at-risk ethnic
population in Leicester
144
Leicester ABLE RENAL Project

• Recognise the breadth of our South Asian
  community
• The study should be
• relevant to all
• generalisable beyond Leicester

145
PARTNERSHIPS
COMMUNITY Awareness Education
ABLE RENAL PROJECT We are going to find out what
works
PRIMARY CARE Awareness Education
146
Leicester ABLE RENAL Project
East Leicester Primary Care Trust South Asian
population 50 gt70 people with diabetes are
South Asian
147
Leicester ABLE RENAL Project
Neerja Jain Dr Azhar Farooqi
148
Leicester ABLE RENAL Project
Dr Azhar Farooqi General practitioner Expert in
education and awareness Project Dil coronary
heart disease
149
Leicester ABLE RENAL Project PARTNERSHIPS

Primary care
Secondary care
Kidney Research UK

150
Leicester ABLE RENAL Project PARTNERSHIPS
Kidney Research UK

Primary care
Secondary care
Public and patients Involved in steering
group Peer educators

151
Leicester ABLE RENAL Project
Study 1 - Patients and general public
152
Leicester ABLE RENAL Project
Study 1 - Patients and general public
Establishing baseline awareness using focus groups
153
Leicester ABLE RENAL Project
Study 1 - Patients and general public
Establishing baseline awareness using focus groups
Focus groups take account of Age Gender Langua
ge Religion etc
154
Leicester ABLE RENAL Project
Study 1 - Patients and general public
Establishing baseline awareness using focus
groups Awareness media campaign Educational
programme peer educators
155
Leicester ABLE RENAL Project
Study 1 - Patients and general public
Establishing baseline awareness using focus
groups Awareness media campaign Educational
programme Awareness assessment repeated
156
Leicester ABLE RENAL Project
Study 2 - Health professionals
157
Leicester ABLE RENAL Project
Study 2 - Health professionals
Audit of current practice in general practices in
East Leicester
158
Leicester ABLE RENAL Project
Study 2 - Health professionals
Audit of current practice in general practices
in East Leicester Educational programme aimed at
current best practice provided in test but not
control practices
159
Leicester ABLE RENAL Project
Study 2 - Health professionals
Audit of current practice in general practices
in East Leicester Educational programme aimed at
current best practice provided in test but not
control practices Re-audit
160
Leicester ABLE RENAL Project
Study 2 - Health professionals

• This project is happening at a time of rapid
  change
• NSFs for Diabetes Renal Services
• DH funded Learning Set on CKD

161
COMMUNITY Awareness Education
PRIMARY CARE Awareness Education
162
COMMUNITY Awareness Education
ABLE RENAL PROJECT We are going to find out what
works
PRIMARY CARE Awareness Education
163
The NHS must invest resources in awareness
education
164
The NHS must invest resources In awareness
education But how can it invest effectively
?
165
The NHS must invest resources In awareness
education But how can it invest effectively
? We will help provide the evidence
166
RACIAL INFLUENCES IN END-STAGE RENAL DISEASE
Who has an increased risk ? Why are some
populations susceptible ? How big is the problem
? What are the public health implications
? Should we screen ?
167
A FRAMEWORK FOR A PUBLIC HEALTH APPROACH TO CKD
PREVENTION
Ramirez S et al. KI 2003 Suppl 83 S61