Review of the kidney health of Indigenous peoples

What is known about kidney health for Indigenous people?

Kidney health problems are more common for Indigenous people than for non-Indigenous people [1]. For example, end-stage renal disease (ESRD) (when kidneys stop working completely) has become more recognised in recent years. Rates of ESRD are highest in northern Australian communities [2].

Some reasons for the high number of kidney health problems in many Indigenous communities include:

• living in places where sanitation is not good,
• too much use of alcohol and tobacco,
• not enough fresh, healthy food (eating too much fatty and take-away foods), and
• a combination of other health problems that make kidneys unhealthy (such as diabetes (see diabetes section), infections and high blood pressure (see background information)

Fixing and managing kidney health problems requires good medical treatments, but public health measures are needed too.

Kidney health problems

The term 'chronic kidney disease' (CKD) includes the following sicknesses:

• diabetic nephropathy (a complication of diabetes where high sugar levels in the blood damage nerves and affect the function of the kidneys) [3]
• hypertensive renal disease (kidney problems caused by high blood pressure) [3]
• glomerular disease (when damage to the glomeruli interferes with the filtering of wastes out of the body, and red blood cells and protein leak into the urine) [3]
• chronic renal failure (a gradual and progressive loss of the ability of the kidneys to get rid of wastes) [3]
• ESRD (the complete or near complete failure of the kidneys to function to get rid of wastes) [1]

'Kidney failure' and 'renal failure' (ESRD) are the most serious kidney health problems, involving temporary or permanent loss of kidney function. This may happen fast (over a period of days or weeks) or slowly over years [4].

Indigenous people with ESRD and those who are on dialysis or have had a kidney transplant are registered with the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) [1]. The registry uses information from hospital records and other sources to document:

• how many people have kidney health problems
• how often people have kidney health problems
• things that can go wrong with the kidneys
• how many people die from kidney problems or kidney-related problems

Information from ANZDATA is used to support health care planning and research collaboration, and also for reports of individual hospital activity and outcomes of treatment.

What is end-stage renal disease (ESRD)?

Chronic renal failure is the slow loss of kidney function that gradually gets worse over several years until the kidneys stop working for good [5]. This is also known as end-stage renal disease (ESRD).

How common is ESRD for Indigenous people?

ESRD among Indigenous people is a big problem. The rates of ESRD are much higher for Indigenous people than for non-Indigenous people across most of the country - particularly in remote areas (where rates are up to thirty times higher) [1], [6].

Data from ANZDATA show that between 2001 and 2004;

• 704 Indigenous people were newly reported with ESRD, and
• the overall rate of 779 per 1,000,000 population for Indigenous people was more than nine times the rate of 86 per 1,000,000 for non-Indigenous people (Figure 1) [Derived from [7].

Figure 1. Rates of ESRD, by Indigenous status and State/Territory, Australia, 2001-2004

Source: Derived from [7] and ABS low series population projections
Notes

1. Rates per 1,000,000 population have been standardised using the Australian population at 31 December 2002 as the reference
2. Rate ratio is the Indigenous rate divided by the non-Indigenous rate
3. Figures for Australia include Tasmania and the ACT

[Details of new cases of ESRD are provided to the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). The figures presented in Table 1 have been derived from data provided by ANZDATA. The HealthInfoNet is most grateful for the provision of these data, and for technical advice provided by ANZDATA.]

At what age do Indigenous people report having ESRD?

New cases of ESRD for Indigenous people are reported at much younger ages than for non-Indigenous people (Figure 2) [Derived from [7].

• For 2001-2004, almost six out of ten of Indigenous people newly registered with the ANZDATA were aged less than 55 years, compared with only one out of three of non-Indigenous people newly registered.
• Apart from the age group 0-14 years, rates were higher for Indigenous people across all ages compared with non-Indigenous people.

Figure 2 Age-specific rates of ESRD, by Indigenous status and State/Territory, Australia, 2001-2004

Source: Derived from [7] and ABS low series population projections
Notes
1 Rates per 1,000,000 population
2 Rate ratio is the Indigenous rate divided by the non-Indigenous rate
3 Figures for Australia include Tasmania and the ACT
[Details of new cases of ESRD are provided to the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). The figures presented in Table 1 have been derived from data provided by ANZDATA. The HealthInfoNet is most grateful for the provision of these data, and for technical advice provided by ANZDATA.]

How many Indigenous people die from ESRD?

For the period 1999-2003, death rates from chronic kidney disease (CKD) were up to 10 times higher for Indigenous people than for non-Indigenous people [1]. Death rates were especially high after the age of 25 years for both Indigenous males and females compared with non-Indigenous people.

Chronic renal failure was reported as accounting for;

• 3% of Indigenous male deaths
• 5% of Indigenous female deaths

Indigenous patients often present with more than one serious illness that could lead to death (such as diabetes, hypertension (abnormally raised blood pressure), infections and poor nutrition) [8]. Only one cause can be recorded as the underlying cause of death, but it is useful to describe the extent to which other conditions have been reported at the time of death [1]. For example, deaths from diabetes, where renal failure was reported as an associated cause of death among Indigenous people, occurred at almost twice the rate for Indigenous males and females than for non-Indigenous people [1].

Why do Indigenous people have high levels of ESRD?

High rates of ESRD among Indigenous people are due to many risk factors, including:

• increasing age
• low birthweight and infant malnutrition
• adult weight gain (being overweight)
• signs of syndrome X (increasing blood pressure, insulin, blood glucose and lipid levels)
• skin infections
• post-streptococcal glomerulonephritis
• repeated pregnancies
• family history of renal disease [1] [9] [10]

The following factors are related to poverty, unemployment, homelessness and fractured kinships since the time of colonisation:

• overcrowded and substandard housing
• poor nutrition
• reduced activity levels
• high levels of tobacco and alcohol consumption
• community and cultural disruptions [11] [12].

The health conditions associated with renal disease include:

• cerebrovascular disease
• lung disease
• peripheral vascular disease
• coronary artery disease
• diabetes [1] (In 2003, diabetes was the main cause of ESRD for more than 55% of Indigenous patients on dialysis compared with 18% of non-Indigenous patients on dialysis [13])

How is ESRD treated and how can it be prevented among Indigenous people?

Medical intervention is necessary to avoid death from ESRD. Current treatment options include;

• kidney transplantation (the replacement of a diseased kidney with a healthy one, from a donor person who has died or from a living family member - usually the best option in terms of both health outcome and cost effectiveness) [14] and
• dialysis - a medical procedure that uses a machine to remove waste and toxins from the blood and helps serve the functions normally performed by the kidneys [15].

In 2004, Indigenous people represented around one in 40 people of the national population, but they accounted for around one in 10 of all people commencing renal replacement therapy (RRT) each year [7]. (RRT is a term used to cover the range of life-supporting treatments for renal failure (that is, transplantation and dialysis [15]). Rates of RRT for ESRD have increased over the past 20 years for Indigenous people, but they are still only about one-third as likely as non-Indigenous people to receive a kidney transplant [16]. In 2003, of all registered Indigenous ESRD patients:

• around six in seven were reliant on dialysis (compared with around one-half of non-Indigenous people) and
• one in seven had received a kidney transplant (compared with almost one-half of non-Indigenous people) [1].
• of the 1,431 patients aged less than 65 years who were on the waiting list for a kidney transplant in Australia at 31 December 2004, nine out of ten were Indigenous patients, with the percentages of Indigenous people in each state being: NT - 81%; WA - 21%; Qld - 9%; NSW, the ACT and SA - all 4%; and Vic - 1%) [7].

Opportunities for transplantation within the Indigenous population are limited by a number of factors:

• Indigenous people are less likely to be placed on the active transplant waiting list and less likely to move from the waiting list to transplantation [1], [17] [18]
• for Indigenous people who do receive a transplant, the success rate remains about two-thirds that for non-Indigenous people
• problems with service delivery, infections or poor compliance
• miscommunication between Indigenous patients and health professionals
• a lack of compatible donors
• access issues ( hundreds, and in cases thousands, of kilometres of travel are needed to access services located within the major urban centres of Perth, Adelaide, Melbourne, Sydney, Newcastle and Brisbane) [6], [9], [14].

What are the options for dialysis treatment?

Haemodialysis (dialysis of the blood to remove toxic wastes from the bloodstream) [15], is the most common form of treatment for Indigenous people with ESRD [1].

Self-care dialysis in remote communities

Delivering self-care dialysis services close to, or in, the home helps with treatment. It means Indigenous people can remain in their own communities, with their own family and social supports, and the costs of re-housing and supporting relocated dialysis patients are avoided [19]. Problems with self-care dialysis in the home include:

• keeping suitable dialysis partners/carers due to their requirements for attendance at cultural duties
• suitable housing
• changing living situations
• communication problems (such as language barriers) [20].

Remote-area dialysis is 25% more expensive than metropolitan self-care dialysis, but, when one takes account of re-location expenses, the overall cost is around one-half of that involving relocation of patients to the city [14].

Relocation to dialysis facilities in major centres

When self-care dialysis is not available or not practicable, remote-area patients are relocated to dialysis units, mainly in major cities. More than three-quarters of all Indigenous people commencing RRT in remote areas during 1999-2001 had to relocate to access treatment [21]. Relocation from remote communities can lead to problems for both the individuals and the health-care system [14] [22]. A major issue is the alienation and isolation felt by patients.

Why do some Indigenous people withdraw from ESRD treatment?

ESRD treatment rates for Indigenous people are high, but rates of withdrawal (dropping out) from treatment are also high. Early withdrawal from treatment causes death for many Indigenous patients [9]. Reasons for withdrawal include:

• difficulties with chronic (long-term) disability
• loss of social support
• complex treatment regimen
• isolation and alienation (being away from homelands) that happens with relocation [9].

Withdrawal from treatment causes many deaths, but even those Indigenous people who continue treatment have relatively low survival rates - the survival rates for Indigenous ESRD patients are lower than those for non-Indigenous patients [9].

What are preventive measures?

Primary prevention efforts call for:

• sustained improvements in infrastructure (underlying base) of living and environmental conditions, education, and health services
• putting in place effective and well resourced primary health care programs
• primary health care measures to improve diet, control blood pressure and infections, maintain healthy adult weight, and to increase birth weight.

Secondary and tertiary measures, such as screening and pharmacological (medicine and drug) interventions, also promise to reduce the risk of serious renal disease by slowing disease development [9], [11] [14] [23]. Things that have worked well in programs aimed at reducing kidney health problems include:

• maximum involvement of local workers
• a community-based rather than clinic-based focus
• a collaborative approach involving participants in their own testing
• providing clear information not just instructions
• setting goals that are personal and meaningful for those with the kidney health problem [24].

What is glomerulonephritis?

The kidneys filter blood through small groups of blood vessels, known as a glomerulus [4]. There are about 1 million glomeruli in each kidney. Glomerulonephritis is a sickness that causes damage to the glomerulus [25] [26]. Damaged glomeruli let protein and red blood cells leak into the urine, and may stop waste from being properly filtered out of the body [4]. The lack of filtering can lead to fluid build-up in the body causing swelling in parts of the body (for example, face, hands, ankles and feet). A serious form of glomerulonephritis is acute post-streptococcal glomerulonephritis (APSGN) (an inflammation of the glomeruli following an infection, such as one in the throat).

How common is acute post-streptococcal glomerulonephritis among Indigenous people?

APSGN is a potentially serious health problem that happens two to three weeks after skin or throat infection [27] [28]. APSGN is uncommon in the wider Australian population, but outbreaks of APSGN in remote Indigenous communities in northern Australia have been reported since the 1960s [29]. Outbreaks continue to occur every 5-7 years across the Top End [27] and are most likely to affect Indigenous children living in these areas [30].

What causes (high levels of) APSGN in northern Australia ?

Factors contributing to (high rates of) APSGN for Indigenous people include:

• humid weather conditions in tropical northern Australia
• scabies and skin sores [30].

The main factors contributing to the spread of the disease include:

• poor, overcrowded housing
• limited access to medical care
• poor personal hygiene (keeping clean) and inadequate environmental cleanliness [28] [31].

How many Indigenous people die from APSGN?

APSGN has been described as a mild sickness that usually ends with complete recovery within days or weeks [29] [32] [33]. However, APSGN is also associated with problems leading to hospitalisation (for example; severe hypertension - abnormally raised blood pressure - acute renal failure, fluid overload) and has occasionally caused death. The contribution of APSGN to end-stage renal disease (ESRD) in later life is unknown, but it is likely that a history of APSGN in childhood is a powerful risk factor for renal failure later [34] [35] [36].

How is APSGN treated and how can it be prevented among Indigenous people?

There is no simple treatment, but APSGN is a preventable disease [36]. No vaccine is yet available, so preventing streptococcal infection remains the most important part of prevention [37] [38]. Prevention requires:

• control of scabies and skin sores
• improved housing and social conditions
• hygiene (cleanliness) education to reduce the spread of streptococcal infections
• screening to identify cases
• use of penicillin to stop the spread of disease [28] [35] [36].

What is a urinary tract infection (UTI)?

A urinary tract infection (UTI) is an infection or sickness in the upper or lower part of the urinary tract [4]. Having a UTI is not always a serious problem, but it can lead to kidney damage and can cause more serious renal problems, including end-stage renal disease (ESRD) [25].

Some people with a UTI do not show signs of having it. The signs for lower UTI are:

• frequent urination
• painful urination
• tenderness in the lower pelvic area [25].

The signs for an upper UTI infection are:

• fever
• back or loin pain
• chills [25] [26].

How common are UTIs among Indigenous people?

A hospital-based study in Darwin found that Indigenous men and women had higher rates overall of UTI than their non-Indigenous counterparts, but rates are greater among non-Indigenous people after the age of 60 years [39].

Except for children in their first year of life, UTIs were more common among Indigenous females than males, with consistently high rates of infection until around 60 years of age [39]. Indigenous males were at greatest risk during infancy.

Unfortunately, easily treatable UTIs often remain undetected (particularly in Indigenous children), which increases the individual's risk of developing more serious renal disease [40].

What causes a UTI?

Usually, a UTI is caused by bacteria (tiny germs that can be killed with antibiotic medicine). Bacteria can enter the urethra and travel to the bladder, but they usually get flushed out with urine without causing an infection. Sometimes, however, the bacteria multiply and cause an infection.

Inadequate living conditions and poor environmental standards contribute to the high levels of UTI observed in some Indigenous communities [40]. As stated above, females are more likely than males to develop UTIs. Other risk factors include age and sexual activity [39].

How are UTIs treated and how can they be prevented among Indigenous people?

Lower UTI is easily treated, generally by a single dose or short course of antibiotics. Upper UTI usually requires hospitalisation and administration of antibiotics into the vein (intravenously). Antibiotics may also be administered to prevent recurrent infection [25] [41]. Improvements in screening and follow-up of infections among Indigenous people is needed to reduce the rate of UTI [40] [42].

What is urolithiasis?

We have now described sicknesses that affect the renal system and sicknesses that affect the urinary tract, but there is also a sickness that affects both areas: urolithiasis. The term urolithiasis refers to the formation of one or more pebble-like objects (commonly referred to as calculi or renal stones) in the renal or urinary tract [25] [41].

Symptoms for urolithiasis are:

• poor growth [43]
• fever [44] [45]
• abdominal pain [44] [46] [47]
• difficult or painful urination [45] [46].

Urolithiasis can cause blockages that give rise to severe illness or renal damage, but this is not common [43] [47].

How common is urolithiasis among Indigenous people?

More attention has been given to the problem of urolithiasis among Indigenous people than problems from urinary tract infections (UTIs). The literature reports that urolithiasis is common among some Indigenous children [43] [44] [45] [46] [47] [48], but seldom occurs among Indigenous adults [45] . This contrasts with the pattern of urolithiasis reported among non-Indigenous people and other populations of the developed world, where the incidence is much higher among adults than children [43] [45].

National or regional statistics for urolithiasis do not exist, but a number of studies confirm high rates among Indigenous children from the arid inland areas of Australia [43] [45] [47] [48].

A review of patient records collected between 1972 and 1986 in WA show that the number of Indigenous children presenting with urolithiasis was more than double that of non-Indigenous children [43]. Other research conducted in the 1980s documented urolithiasis among Indigenous children living in central Australia and in the dry inland regions of WA [43] [45] [46] .

What causes urolithiasis among Indigenous people?

Indigenous children with urolithiasis tend to come from desert regions of Australia, are more likely to be male, and are typically younger than 3 years of age [43] [44] [45] [46] [47].

Risk factors for urolithiasis in Indigenous children include:

• dehydration (not drinking enough water)
• diarrhoea
• recurrent infectious disease [43] [44] [45] [46] [47] [48]
• hot, dry environmental conditions [43] [46]
• poor water quality [48].

How is urolithiasis treated and how can it be prevented among Indigenous people?

The treatment of urolithiasis has traditionally involved surgical procedures to remove stones [43] [44] [47]. This means extended hospitalisation and separation from family, and is costly [43] [47]. Fortunately, long-term antibiotic therapy and urinary alkalinisation (neutralising acid) has become the more common treatment in recent years because this is safe and effective [44] [48].

For prevention of urolithiasis, attention must be directed to:

• housing
• water
• waste disposal systems [47].

To sum up: improvements in environmental conditions, such as the provision of adequate drinking water are essential to reduce the incidence of urolithiasis [48].

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