Sunday, August 13, 2006

Kidney Disaster

The closer science looks, the more links it finds between lifestyle and long-term ailments, Julie Robotham writes in part two of a Herald series.

IN THE kidney dialysis unit at Royal Prince Alfred Hospital, patients get to watch TV free. Most public hospital patients pay a daily fee to activate the remote, but authorities have taken pity on those with kidney failure.

Hooked up to a machine that progressively filters their blood, five hours a day, three days a week, they get to see a lot of Oprah.

Magazines, knitting and a chat with those in the same predicament, and the entertainment options are just about exhausted. Only a quarter of patients remain in the paid workforce.

By any measure it is an unsatisfactory way to pass time, but dialysis is a reality for a growing number of Australians - for whom it is usually a late complication of a lifetime of imperfect health.

Ultimately, subsidising a few TV screens is a drop in the ocean. It costs between $50,000 and $100,000 to provide dialysis for a year, and most live three to four years after their illness has progressed this far.

"They have a lousy quality of life," says Associate Professor Steve Chadban, a transplant physician.

A healthy kidney filters water-soluble waste products. An unhealthy kidney leaves them in the bloodstream, dragging down the performance of just about every other organ.

Kidney disease, Chadban says, "affects mental functioning. People have inferior concentration. Physical stamina is reduced.

"We're hosing out the fires at this end. We need mass education at school to encourage people to have an active lifestyle and sensible eating habits."

About half of all cases of kidney disease occur in the wake of high blood pressure or diabetes, themselves often the direct consequences of excess weight and inactivity. Excessive weight can also damage the kidney directly, even in someone who is lucky enough to avoid diabetes, which is now the largest single cause of end-stage kidney disease. The kidneys are affected in about one-third of diabetics, but 90 per cent will die before their kidneys fail.

Even after this phenomenal rate of carnage, the ranks of Australians on dialysis are swelling by at least 6 per cent a year and swamping treatment services. Many are now so over-subscribed they no longer accept casual patients from elsewhere - adding the inability to travel to the indignities dialysis patients must endure.

Up to 2 million Australians have some kidney damage, of whom 40,000 have severe disease, including 12,000 - mostly in their 70s - who have reached "end stage", requiring dialysis or a transplant to stay alive. This is the sharp end of a mostly hidden epidemic.

But while few other diseases carry a comparable financial and personal cost for each victim, kidney failure is a microcosm of a rise in chronic illness attributable to poor diet, lack of exercise, excess weight and other features of a less than ideal lifestyle.

Clearly there is a paradox. We are living longer than ever. Children are rarely carried off by pneumonia or measles. Men no longer commonly drop dead from heart attacks in their 50s. By many measures we are healthier.

But there has been a trade-off. More of us are sustained through middle age and beyond on medications that keep us alive but sap our energy levels, blunt our libidos and mess with our heads. The exquisite boredom of the out-patient waiting room is a regular reality for an increasing number of people as medicine turns more to monitoring vital signs to head off the stroke or asthma attack before they happen.

Heart disease, arthritis, dementia, many cancers … the closer researchers look, the more links they find between daily lifestyle choices and the development of long-term health conditions, which threaten to ambush the health budget as the population ages.

Knee replacements last year outstripped hip replacements for the first time in Australia, as knee joints are more susceptible to overloading with extra weight. That is just one phenomenon in the changing demographics of arthritis, which is on the rise and affecting younger people, especially women.

Depending on the joint, the risk of arthritis may be doubled, trebled or even quadrupled in an obese person compared to one of normal weight, Access Economics found last year in a report commissioned by Arthritis Australia. "Twenty-four per cent of knee arthritis could be attributed to obesity," the report says. It also estimates that in 2004, 16 per cent of people were affected; their medical treatment cost $3 billion - 5 per cent of the health budget.

Factor in the indirect costs - carers, home modifications, special transport, lost taxes from those who can no longer work - and the bill climbs to $11 billion.

The cost of treating uncomplicated diabetes is $4000 per person per year, Professor Stephen Colagiuri from Prince of Wales Hospital told a state diabetes summit this year, rising to $10,000 for those whose disease has affected the eyes, heart or circulation. And conservatively, 1 million people have the disease, in which excess sugar in the blood combines with proteins in body tissues, attacking the heart, kidneys, eyes and blood vessel walls, leading to poor circulation and amputations - though only about half of the sufferers know they have it.

Being overweight, inactive or both can also increase the chance of developing a range of cancers.

John Hopper and Graham Giles from Cancer Council Victoria have tracked the effect of body weight on the occurrence of cancer and how patients fare after a diagnosis.

Their study of Victorian women found those who were obese were 50 per cent more likely to have a relapse of their disease and to die of any cause during five years of follow-up after a breast cancer diagnosis. There was no evidence doctors were under-dosing the obese women, and no evidence that their higher oestrogen levels contributed to their poorer prognosis.

The probability, the researchers concluded, was that the women's weight was linked to some other, as-yet unidentified, biological difference.

The same team found that the chance of developing myeloid leukaemia increased fivefold in overweight and obese people - or by one-third for every additional 10 centimetres they measured around the waist. And they confirmed a link between weight and bowel cancer.

The cancer council cautions people to try to limit weight gain to five kilograms or less throughout their adult life.

Fat chance! A wide-ranging national health study of Australian women published last year found the average young woman puts on five kilograms over seven years while she is in her 20s, typically before she has even started having babies. AusDiab 2, a large study of patterns of diabetes in the community, found women and men put on an average 14 kilograms between age 25 and 50.

As Australia's weight crisis worsens - pushed along by the ageing of the population - health authorities have a monster problem on their hands.

The system, with its grand old hospitals, its centres of excellence and its god-like specialists, was designed for a different era - in which otherwise healthy people would fall suddenly ill with a heart attack or infection, and either get better or swiftly die.

Administrators now need to realign that huge edifice to cater to a generation of people who may become moderately ill in midlife, and survive for decades.

At a conference on chronic disease last month, NSW Health officials outlined their strategy, adding arthritis, diabetes and dementia to a target list of illnesses for which an increasing proportion of care will be provided out in the community, and increasing from $15 million to $20 million annually the seed funding available to local areas to pilot new ways of working.

The good news, NSW Health's health system performance chief, Katherine McGrath, told the audience, was that 65,000 days of hospital care had been avoided for people with lung disease and heart disease. Extra heart monitoring machines and lung function measuring equipment had allowed better supervision of people with long-term illnesses in smaller clinics - preventing catastrophic relapses that would otherwise land them in emergency wards or in-patient beds.

Closer ties with occupational therapists, dietitians and psychologists and GPs meant more co-ordinated care and closer monitoring of symptoms.

But it was a speaker from the US, a few years ahead of Australia on the chronic illness curve, who captured the scale of the problem. "Thirty per cent of total health-care expenditure is attributable to 1 per cent of people," said Professor Paul Wallace, a medical director at health insurer Kaiser Permanente. "Over half the people in the [most expensive] 1 per cent have diabetes."


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