Kara L. FrejukOksana HarasemiwPaul KomendaBarry LavalleeLorraine McLeodCaroline ChartrandMichelle Di NellaThomas W. FergusonHeather MartinBrandy Wicklow and Allison B. Dart. Canadian Medical Association Journal. First published September 13, 2021.

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Background: The First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis project was a point-of-care screening program in rural and remote First Nations communities in Manitoba that aimed to identify and treat hypertension, diabetes and chronic kidney disease. The program identified chronic disease in 20% of children screened. We aimed to characterize clinical screening practices before and after intervention in children aged 10–17 years old and compare outcomes with those who did not receive the intervention.

Methods: This observational, prospective cohort study started with community engagement and followed the principles of ownership, control, access and possession (OCAP). We linked participant data to administrative data at the Manitoba Centre for Health Policy to assess rates of primary care and nephrology visits, disease-modifying medication prescriptions and laboratory testing (i.e., glycosylated hemoglobin [HbA1c], estimated glomerural filtration rate [eGFR] and urine albumin- or protein-to-creatinine ratio). We analyzed the differences in proportions in the 18 months before and after the intervention. We also conducted a 1:2 propensity score matching analysis to compare outcomes of children who were screened with those who were not.

Results: We included 324 of 353 children from the screening program (43.8% male; median age 12.3 yr) in this study. After the intervention, laboratory testing increased by 5.8% (95% confidence interval [CI] 1.1% to 10.1%) for HbA1c, by 9.9% (95% CI 4.2% to 15.5%) for eGFR and by 6.2% (95% CI 2.3% to 10.0%) for the urine albumin- or protein-to-creatinine ratio. We observed significant improvements in laboratory testing in screened patients in the group who were part of the program, compared with matched controls.

Interpretation: Chronic disease surveillance and care increased significantly in children after the implementation of a point-of-care screening program in rural and remote First Nation communities. Interventions such as active surveillance programs have the potential to improve the chronic disease care being provided to First Nations children.

Substantial health disparities exist between Indigenous and non-Indigenous people in Canada. The prevalence of diabetes and chronic kidney disease (CKD) among Indigenous people in Canada is 20% and 25.5%, respectively, which is two-to fivefold higher than the general population. Indigenous peoples are also at higher risk of progression to kidney failure as adults and in childhood. Risk factors for CKD, such as diabetes, hypertension and obesity, manifest earlier in life and contribute to higher lifetime risk of complications. These risk factors are more prominent in Indigenous communities given the systemic inequalities that affect them.

This burden of chronic disease may be mitigated by efforts to increase access to preventive care and implementation of programs to increase early diagnosis, education and treatment. Biomarkers for CKD in Indigenous youth are not entirely persistent in the early stages of disease. Early diabetes and CKD are often asymptomatic, and the opportunity to intervene is more impactful early in the disease course. One strategy to increase the likelihood of timely intervention is screening. The Diabetes Canada guidelines suggest screening for diabetes biennially for Indigenous children. Although Indigenous children are at higher risk of CKD, irrespective of diabetes status, guidelines do not currently exist for routine CKD screening in children.

Around the world, screening for CKD in children is a controversial issue, given the uncertainty of its effectiveness. In Canada, screening for CKD in the general pediatric population is not currently recommended. However, this approach does not consider screening in high-risk populations with reduced access to primary care resources. Manitoba has the highest rates of CKD in Canada, with a prevalence of 1704 per million population, compared with the overall rate of 1372 per million population in Canada. The Indigenous population is over-represented, with progression to kidney failure 8 years sooner than non-Indigenous people. The rates of CKD among Indigenous peoples in Canada are in keeping with populations around the world in which CKD screening is recommended and has been successful. Our group has also shown the cost-effectiveness of CKD screening in Indigenous adults.

The First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED): Screen, Triage, and Treat program sought to understand the burden of kidney disease risk factors in Indigenous people 10 years of age and older, and implement an initial screening and treatment program among 13 rural and remote First Nations communities. This point-of-care screening intervention project identified high rates of early risk factors for kidney disease in this population, and made referrals for follow-up to either primary care (low-risk individuals) or specialty care (intermediate- or high-risk individuals), depending on screening findings. In this study, we sought to determine clinical screening rates before and after the FINISHED intervention, and the impact of the program on chronic disease surveillance and treatment among those aged younger than 18 years.