Leading leaps in genetic research from northern Australia

Townsville nephrologist Professor Andrew Mallett is internationally recognised for his work in identifying new approaches, understanding and treatments for genetic kidney disease.

The Bowen-raised James Cook University graduate returned to North Queensland in late 2020 as director of clinical research at Townsville Hospital and Health Service, becoming the first JCU Medicine graduate to be appointed professor of medicine.

Prof Mallett leads the KidGen Collaborative, a national clinical and research consortium championing novel diagnostic and research pathways for patients and families affected by inherited kidney disorders. His multidisciplinary renal genetics clinic model operates in 18 locations across Australia.

“Kidney health is a national quandary,” Prof Mallett says. “It's a massive need. At a national level today, there are something like 1.7 million Australians affected by kidney disease, and about a million of them don't even know it. Kidney disease disproportionately affects those in Northern Australia and in rural and remote areas. Wherever you practise, you're contributing to the greater good, but to do it here where there's clearly such need, I think is really important.”

Prof Mallett is one of a handful of nephrologists in the country who specialise in genetic forms of kidney disease. “When I was doing my renal advanced training in 2011 to 2013, there was no one in Australia in that subspecialty area,” he says.

After completing a Churchill Fellowship in the United Kingdom, France and North America, he focused his career on heritable forms of kidney disease. “It's an area in which there's a great clinical and research connection,” he says. “By understanding how changes in our genes may cause or relate to the development of kidney disease, we've got a really good chance of understanding how these diseases individually work, and that may lead to better treatments in the future.

“At the same time, there's a great personal connection to patients, because many are seeking a diagnosis. What is the cause of their kidney disease? What is the type of their kidney disease? Both when I was a renal advanced trainee and before that as a more junior physician trainee and medical student, most of the time we didn't have good answers. Everyone seemed so comfortable with that, and I really wasn't.

“A lot of my research is focused on the development and application of new genomic technologies to help patients in a clinical context to get those answers.  We now understand that at scale, and it's available in clinics right around the county.”

A key achievement has been the Medicare listing of genomic testing of patients with heritable forms of kidney disease as of July 1 this year. “It’s something that was aspirational and unthinkable five years ago,” he says. “It's been great to contribute in a research way to realising things like that at the same time as doing the research that underpins driving major clinical and policy change.”

Now a teacher of JCU medical students, Prof Mallett started at JCU in 2001 as a 17-year-old fresh from boarding school in Brisbane and a holiday job as an assistant nurse at Bowen Hospital.

“I worked as an AIN (Assistant in Nursing) at Bowen Hospital practically every weekend from before I got into medical school and then for the first five years I was at medical school,” Prof Mallett says.

The specialty of nephrology

A dialysis patient inspired his interest in nephrology as a fourth-year student on placement at Townsville’s Mater Hospital. “We did small case studies that were focused around the underlying physiology and pathophysiology of the organ system that was affected for a patient,” Prof Mallett says. “You got to know the person and, using your case-based learning framework, a lot more about the underlying conditions and disease. Through meeting this one gentleman who was on dialysis, I fell in love with renal physiology and pathophysiology and then renal medicine. It was always the thing I kept coming back to.”

Prof Mallett did sixth year in Mackay and stayed for his first two postgraduate years before completing physician training at the Royal Brisbane and Women’s Hospital (RBWH) and Princess Alexandra Hospital.

“Nephrologists look after people who have complex health conditions, and we look after them in a complete way, so we're comfortable with uncertainty,” he says. “We have to be good communicators with our patients because no one wakes up on a Monday morning and says, ‘I think I'll be diagnosed with and understand kidney disease this week.’

“It's so challenging for us to conceptualise it, let alone many of our patients who are experiencing it. It’s that overlap of having a very deep and meaningful long-term relationship with your patients and the underlying conditions themselves being complex, which brings out the problem solver in all of us.

“First Nations Australians are disproportionately affected by kidney disease and our understanding of that is continuing to unravel.”

“In this part of Australia, there's fantastic work particularly by people at places like the Menzies Institute in Darwin, who are doing amazing research in this space.

“Closing the gap in healthcare outcomes for First Nations people is also about trying to better understand how we can identify who may be at risk, may have the early stages of kidney disease and, more importantly, if they should develop more advanced stages of kidney disease, how can we best provide great care and treatment for those patients to not just a gold standard, but also give care that is culturally attuned, respectful, and ensures that they can live their lives to the fullest.

“That looks a bit different to what it does in other parts of Australia because here, it's a low-density environment and, unfortunately, major health conditions all too often in northern Queensland, particularly in remote areas, mean large amounts of travel or relocation.”

JCU and health equity

Prof Mallett, a 2021 Outstanding Alumni Award winner, is proud of the diversity of medical career outcomes his alma mater has produced in its 21-year life. “JCU gave a nicely well-rounded and socially accountable medical education,” he says. “The JCU program instilling the theme of health equity has been important. It also gives you a great understanding of the experience of clinicians who are located outside of tertiary hospitals and how it's so important that we all connect together in providing a continuum of care for individual patients. Everybody deserves great health care.”

Training in NQ

With Townsville University Hospital chosen as the site for Queensland’s second kidney transplant service, it’s a time of growth for the specialty in the north.

“Because it's an extension of basic physician training, the vast majority of renal physician advanced training can be done here in northern Queensland,” Prof Mallett says. “For renal advanced training, two of the three years can be done in northern Queensland, between Townsville and Cairns. There's a third year where one has to be in an acute transplant centre.  

"At the moment that means moving away, so going to Brisbane, Sydney, Melbourne, Perth or Adelaide, but in the next few years with the current proposal and work around the kidney transplant service being established in North Queensland, that may change.”

“It's an exciting time where those training pathways will become that little bit easier, particularly in specialty training. There is value in seeing different things done differently in different places, but it will be great to realise some form of a nephrology training network within the next five to 10 years here in northern Queensland.”

‘It helps you to have more’

Prof Mallett says virtual meetings have levelled the playing field for research collaboration. From Townsville, he’s able to co-lead a US-based initiative along with a paediatric nephrologist at Boston Children's Hospital and to lead a national consortium based in Melbourne whilst also having a wet-lab team based in Brisbane.

“When I transitioned from the RBWH to North Queensland, none of my research or research leadership activities changed,” he says.

“I think in a virtualised world, the ability to generate impact is actually much clearer than it's ever been before. It's focusing on the relevant community or group of patients or whatever it is that you specialise in or are passionate about. You don't have to be in the middle of Brisbane or Sydney to do that.”

Prof Mallett and his wife, Dr Cassandra Rawlings, also a renal physician and JCU medical graduate, enjoy the rewards of regional practice and the tropical lifestyle.

“Being physically located in northern Australia, particularly here in North Queensland, is amazing because the experience you get of living here is fantastic,” he says. “The communities are nothing if not very, very genuine. I think there's something that's wonderful about that. 

“Life is about professional fulfilment, personal fulfilment and a whole lot of other things, too. Having it all is impossible, but regional specialist practice helps you to have more.

“I think there are more opportunities in regional specialty practice to be closer to the things that are important to you in terms of the kinds of wrongs you want to right and the kinds of impacts you want to try to help generate.”

NQRTH connects medical students, intern and junior doctors with a network of opportunities and resources designed to create a supportive and clear path to specialist (including general practice) training, and beyond, in our regions. NQRTH connects students and junior doctors with research specialists and research opportunities. Our network works together to strengthen medical specialist training with the view to build a health workforce prepared to meet the health needs of our regional and rural communities in Cairns, Central West, Mackay, North West, Torres and Cape, and Townsville. NQRTH is facilitated by James Cook University, who partner with hospital and health services and training providers to create a connected career pathway beginning at the medical undergraduate level right through to fellowship.