Tackling the Profound Impact of Chronic Kidney Disease on Indigenous Peoples

Dr. Paul Komenda MD, MHA, FRCPC, FASN

Over 12 percent of Canadians have chronic kidney disease (CKD)¹. When the CKD progresses to kidney failure, the majority of patients will undergo hemodialysis treatment in a facility three times per week, each session lasting about four hours, for the rest of their lives². Compounded with commuting time to and from treatment (especially for those living in rural and remote areas), this can result in a significant decrease in quality of life, inability to hold a job, and an added economic burden to the patient. Hemodialysis treatments cost healthcare payors over $60,000-80,000 per patient per year,3 and patients report very poor health-related quality of life and a mortality rate exceeding that of most cancers⁴.

The kidney care community advocates for more cost-effective treatment options, which offer a better quality of life and improved outcomes, although several obstacles hinder significant progress in improving kidney failure treatment. These barriers include challenging reimbursement frameworks, minimal technology innovation and an increasingly older and more frail patient population that may not be good candidates for these types of treatments⁵.

Comorbidities such as hypertension and diabetes are often the root causes of kidney disease, in addition to many autoimmune conditions. As with many chronic diseases, kidney disease affects poor and vulnerable populations more often and more severely⁶. However, when it comes to kidney disease and its complications, there seems to be no group that has been more alarmingly affected than Indigenous Canadians^7,8.

As a physician who practices clinical epidemiology and Western medicine in the Province of Manitoba, it has taken over a decade to begin to understand the profound impact kidney failure has on rural and remote Indigenous People. The root causes of colonialism, intergenerational trauma, residential schools, loss of language and connection to the land, play a far greater role than what many have viewed as a simple fix of improving diet, lifestyle habits and attitude toward healthcare “compliance.” Working with Indigenous patient partners, elders, and healthcare workers in partnership with communities has given me the privilege of learning more about the unique challenges in communities.

In Manitoba, over 15% of our population are First Nations. Many of our First Nations communities are located in the rural and remote parts of the province without road access, easy connections to major centers, or even high-speed internet on which much of our modern Western economy relies. Poverty and underemployment are directly linked to many of the health disparities we see on graphs and charts in offices in the cities.

Over ten years ago, our team partnered with the Diabetes Integration Project. This was a dedicated team of First Nations nurses, physicians and community members performing diabetes screening and care in a culturally safe way. Integrating our knowledge of kidney screening, epidemiology, risk prediction and easy access to kidney health specialty care into their proven community-based culturally competent care model, led to a recipe for success.

The finished project screened over 2,000 First Nations adults and children in rural and remote communities for diabetes, kidney disease and hypertension and connected people to care appropriate to their level of risk⁸. This program led to an urban screening program in Winnipeg delivered by primary care groups in First Nations and other vulnerable groups in higher-risk parts of the city. With time, this program gained national attention and Kidney Check was born as part of the CANSOLVE-CKD network, a consortium of Canadian researchers who received over $65 million in funding from the Canadian Institute for Health Research and a host of matching fund partners to execute kidney health research priorities in partnership with kidney disease patients in Canada⁹.

“As a patient partner in the CanSolve Network and a patient lead on the Kidney Check project, I believe that early detection of kidney disease is vital to our rural & remote communities. My disease was detected in routine testing by my primary care physician & I was referred to a nephrologist. From there, I was successfully treated with steroids & chemo meds. Without this early intervention, I was on my way to declining kidney function. At a time when kidney disease is so prevalent in our communities, we need to have a screening program to mitigate the risks of kidney disease. I am conscious of my good kidney health & strongly advocate for more kidney point-of-care testing in our communities. “ - Cathy Woods. Patient Partner, CAN-SOLVE CKD, Indigenous Peoples Engagement and Research Council

Kidney Check is now live in multiple Canadian provinces, providing a point-of-care screening and connection to care for Indigenous People¹⁰. Indigenous patients are an integral part of the project team, and communities continue to be at the center of all work that is done¹¹.

Now, more than ever, screening and treatment for early-stage kidney disease is vital to the sustainability of our healthcare system. In the last five years, we have far more potent treatments for early-stage kidney disease than we’ve ever had before, and if applied early, we can delay or prevent the need for dialysis in these vulnerable patients. This gives hope to people that a screening and treatment program is a far greater badge of honour for communities than the construction of an expensive dialysis facility that often costs rural and remote locations an excess of $200,000 per patient per year and yields an unacceptably poor quality of life and health outcomes.¹² Rural and remote access to dialysis services deserves attention, but it's crucial to prioritize both funding and implementation of screening and prevention programs equally.

Kidney Check and culturally safe point-of-care testing in communities have paved the way for other important initiatives like virtual screening, where requisitions and education are mailed directly to patients, similar to many cancer screening initiatives. Advances in big data analytics for large health systems and the science of risk prediction using advanced AI algorithms will permit the targeting of patients at high risk of progression that can be identified and treated earlier with these new therapeutics.

We have much work to do, but I am proud to be part of the work in Manitoba focusing on new screening and treatment paradigms in communities with an unmet need. This work will continue to support self-determined care within Indigenous communities, while also being applicable to all Canadians or those around the world with limited access to conventional primary care screening and treatment.

I am hopeful for the future and thankful for the opportunities to learn from our First Nations partners and communities.

References:

1. Arora P, Vasa P, Brenner D, Iglar K, McFarlane P, Morrison H, Badawi A. Prevalence estimates of chronic kidney disease in Canada: results of a nationally representative survey. CMAJ. 2013 Jun 11;185(9):E417-23. doi: 10.1503/cmaj.120833. Epub 2013 May 6. PMID: 23649413; PMCID: PMC3680588.
2. Blake, P. G. (2020). Global dialysis perspective: Canada. Kidney360, 1(2), 115.
3. Ferguson, T. W., Whitlock, R. H., Bamforth, R. J., Beaudry, A., Darcel, J., Di Nella, M., ... & Komenda, P. (2021). Cost-utility of dialysis in Canada: hemodialysis, peritoneal dialysis, and nondialysis treatment of kidney failure. Kidney medicine, 3(1), 20-30.
4. Naylor, K. L., Kim, S. J., McArthur, E., Garg, A. X., McCallum, M. K., & Knoll, G. A. (2019). Mortality in incident maintenance dialysis patients versus incident solid organ cancer patients: a population-based cohort. American Journal of Kidney Diseases, 73(6), 765-776.
5. Osterlund, K., Mendelssohn, D., Clase, C., Guyatt, G., & Nesrallah, G. (2014, March). Identification of facilitators and barriers to home dialysis selection by Canadian adults with ESRD. In Seminars in dialysis (Vol. 27, No. 2, pp. 160-172).
6. Hundemer, G. L., Ravani, P., Sood, M. M., Zimmerman, D., Molnar, A. O., Moorman, D., ... & Akbari, A. (2023). Social determinants of health and the transition from advanced chronic kidney disease to kidney failure. Nephrology Dialysis Transplantation, 38(7), 1682-1690.
7. Komenda, P., Lavallee, B., Ferguson, T. W., Tangri, N., Chartrand, C., McLeod, L., ... & Rigatto, C. (2016). The prevalence of CKD in rural Canadian Indigenous peoples: results from the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) screen, triage, and treat program. American Journal of Kidney Diseases, 68(4), 582-590.
8. Thomas, D. A., Huang, A., McCarron, M. C., Kappel, J. E., Holden, R. M., Yeates, K. E., & Richardson, B. R. (2018). A retrospective study of chronic kidney disease burden in Saskatchewan’s First Nations people. Canadian Journal of Kidney Health and Disease, 5, 2054358118799689.
9. Levin, A., Adams, E., Barrett, B. J., Beanlands, H., Burns, K. D., Chiu, H. H. L., ... & Manns, B. (2018). Canadians seeking solutions and innovations to overcome chronic kidney disease (Can-SOLVE CKD): form and function. Canadian journal of kidney health and disease, 5, 2054358117749530.
10. Curtis, S., Sokoro, A., Martin, H., McLeod, L., Chartrand, C., Lavallee, B., ... & Komenda, P. (2021). A comprehensive quality assurance platform in Canada for national point-of-care chronic kidney disease screening: the kidney check program. Kidney International Reports, 6(2), 513-517.
11. Woods, C., Settee, C., Beaucage, M., Robinson-Settee, H., Desjarlais, A., Adams, E., ... & Nahanee, D. (2023). Ensuring Indigenous co-leadership in health research: a Can-SOLVE CKD case example. International Journal for Equity in Health, 22(1), 234.
12. Ferguson, T. W., Zacharias, J., Walker, S. R., Collister, D., Rigatto, C., Tangri, N., & Komenda, P. (2015). An economic assessment model of rural and remote satellite hemodialysis units. PloS one, 10(8), e0135587.