Kidney health
Reviews
Information about the kidney health of Indigenous peoples is reviewed here.
-
Reviews
- »Review of the kidney health of Indigenous peoples
- Other reviews
- Background info
Review of the kidney health of Indigenous peoples
Disorders of the urinary tract
Unlike the severe diseases of the renal system, disorders of the urinary tract (specifically disorders of the bladder, ureters and urethra) generally present as clinically mild cases. However, they have the potential to cause considerable morbidity, and may, on occasion, lead to severe renal disease, including ESRD [3]. The potentially serious consequences associated with urinary tract disorders, coupled with their prevalence (particularly among women) highlights the public health significance of these conditions.
The health effects of diseases of the urinary tract upon Indigenous people have received comparatively little attention in recent years, with limited documentation of the prevalence of disorders of the bladder, ureters and urethra. Available data suggest, however, that the pattern of urinary tract infection (UTI) exhibited among Indigenous people tends to differ from that observed among non-Indigenous people [60].
Urinary tract infections
Epidemiological and anecdotal evidence from the 1980s indicates that UTIs are particularly common among Indigenous people [60, 62]. Unfortunately, easily treated UTIs often remain undetected, particularly in Indigenous children, and increase the individual’s risk of developing more serious renal disease [62].
UTI may be present despite few physical symptoms, but lower urinary tract infection is typically associated with frequent, painful urination, and tenderness in the lower pelvic area [3]. Upper urinary tract infection is associated with a range of clinical features, most commonly: fever, back or loin pain; and chills and rigors [3, 44]. Single episodes of UTI rarely have serious consequences, but recurrent or persistent infections may promote kidney damage when coupled with conditions such as diabetes [3].
Risk factors and aetiology of urinary tract infections
UTIs are generally bacterial in origin, but Mycobacterium tuberculosis, fungi, parasites and adenoviruses may also cause infection. Inadequate living conditions and poor environmental standards contribute to the high levels of UTI observed in some Indigenous communities [62]. Females are more likely than males to contract UTIs, and other risk factors include age and sexual activity [60].
Incidence
The most common types of procedures recorded for Indigenous people in 2003-04 were procedures on the urinary system [1]. A majority (32%) of these procedures were for haemodialysis (a procedure which artificially performs the work of the kidneys in patients with ESRD).
A hospital-based study in Darwin found that Indigenous men and women had higher rates overall of UTI than their non-Indigenous counterparts, but age-specific rates are greater among non-Indigenous people after the age of 60 years [60]. With the exception of children in their first year of life, UTIs occurred far more frequently among Indigenous females, with consistently high rates of infection until around 60 years of age. Indigenous males, on the other hand, were at greatest risk during infancy.
Half a decade later, a study investigating the association between pre-term birth and genitourinary tract infections in Indigenous women during pregnancy found that almost 30% of the Indigenous women sampled had a urinary tract infection during pregnancy, and 11% had an infection at the time of delivery [63].
Treatment and prevention of UTIs
Lower urinary tract infection is easily treated, generally by a single dose or short course of antibiotics. Upper urinary tract infection usually requires hospitalisation and administration of intravenous antibiotics. Antibiotics may also be administered to prevent recurrent infection [3, 44]. Despite the simplicity of prophylaxis and cure, evidence suggests that screening, treatment and follow-up of infections among Indigenous people is often inadequate, and must be improved [62, 63]. Like other conditions of the kidney and urinary tract, rates of UTI among Indigenous people will undoubtedly be reduced when socioeconomic conditions and overall health status improve.
Other disorders of the kidney and urinary tract
A number of conditions may affect both the renal system and the urinary tract, among them urolithiasis. The term urolithiasis refers to the formation of one or more pebble-like masses (commonly referred to as calculi or stones) in the renal or urinary tract [3, 44]. Urolithiasis is not a common public health problem within affluent populations in developed countries, but its prevalence and unusual presentation among some Indigenous children justifies its coverage here [64].
Urolithiasis among Indigenous people
In contrast to UTI, considerably more attention has been devoted to the problem of urolithiasis among Indigenous people. Apart from one early report, the literature consistently reports that urolithiasis is unusually common among some Indigenous children [64-69], but seldom presents among Indigenous adults [69, 70]. 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 [64, 69].
Risk factors and aetiology of urolithiasis among Indigenous children
The high rates of urolithiasis observed among some Indigenous children have been attributed to dietary factors, dehydration, endemic diarrhoea, recurrent infectious disease [64-69], hot, dry environmental conditions [64, 65] and poor water quality [68]. These risk factors are intimately related to the familiar socioeconomic risk factors that underlie the high burden of disease suffered by Indigenous people generally.
The varied risk factors point to the multifactorial aetiology of urolithiasis among Indigenous children. Until recently, a favoured hypothesis regarding the development of childhood renal stones focused on the role of cereal-based diets in the formation of urate and oxalate stones [64, 67]. However, recent research has challenged this hypothesis, emphasising instead the importance of diarrhoea and dehydration in the development of urolithiasis [68]. The deleterious effect of endemic diarrhoea on hydration, and the contributory role in the formation of stones, is compounded by hot, dry environmental conditions and often unpalatable drinking water [64, 65, 68].
Patient demographics and clinical features
Indigenous children with urolithiasis tend to come from desert regions of Australia, are more likely to be male, and are frequently less than 3 years of age [64-67, 69]. They commonly present with, or have a history of, failure to thrive, UTI, and/or recurrent infectious disease (particularly diarrhoea) [64-67, 69].
The stones found in Indigenous children are rarely associated with anatomical or metabolic disorders and are commonly located in the upper urinary tract [64, 65, 67, 69]. They are composed primarily of uric acid, urate and oxalate [64-67], similar to the ‘endemic’ stones typically found in paediatric populations from developing regions of the world where the disorder is prevalent [64].
The formation of calculi in non-Indigenous children is uncommon [64, 66]. When urolithiasis does occur, it presents at a later age (usually mid to late childhood) and is generally attributable to a malformation of the urinary tract or a metabolic disorder [64, 66].
Incidence
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 – notifications appear to be rising in response to increased awareness and improved diagnostic techniques [64-66, 68, 69].
A comprehensive review of patient records collected between 1972 and 1986 from the major paediatric referral hospital in WA reported that the number of Indigenous children presenting with urolithiasis was more than double that of non-Indigenous children [64]. A review of patients with urinary tract calculi admitted to the Urology Unit of the Adelaide Children’s Hospital between 1978 and 1987 estimated that 0.34% of Indigenous children under 10 years of age (based on 1981 census figures) suffered from the disease [66].
Other research conducted in the 1980s documented endemic urolithiasis among Indigenous children living in central Australia and in the dry inland regions of WA [64, 65, 69-71]. A more recent study has described rates of urolithiasis in children from a western desert Aboriginal community in central Australia as ‘alarmingly high’ [68]. In this study, calculi occurred most frequently in the 0-2 years age group, with almost one in 10 children in this age group presenting with the disorder each year. This figure differs markedly from the rates reported in developed nations that range from one in 1,000 to one in 9,000 paediatric hospital admissions.
Morbidity
Reviews of hospital records reveal that Indigenous children with urolithiasis suffer considerable morbidity, which typically involves abdominal pain and difficult or painful urination [65-67, 69]. It is commonly chronic in nature and associated with poor growth [64], fever [67, 69], abdominal pain [65-67] and difficult or painful urination [65, 69]. It is not unusual for renal function to be compromised, and urinary tract obstruction may give rise to severe acute illness, but this is not common [64, 66]. Despite the incomplete state of follow-up data, evidence suggests that the combination of obstruction and infection may culminate in renal damage [64].
Management
The management of paediatric urolithiasis has traditionally involved a variety of major surgical procedures to remove stones [64, 66, 67]. The significant morbidity suffered by many Indigenous children with urolithiasis is therefore often compounded by the need for extended hospitalisation and separation from family, and is accompanied by high economic costs [64, 66]. Fortunately, the use of long-term antibiotic therapy and urinary alkalinisation as a means of treatment appears to have become more common in recent years, and the safe and effective use of alkaline therapy among many Indigenous children has been reported [67, 68].
Prevention and control of urolithiasis
An understanding of the anatomical, physiological and dietary factors that underlie the development of urolithiasis in Indigenous children is likely to yield information that will contribute to the management of the condition, but the aetiological importance of hazardous living and environmental conditions should not be overlooked [68]. Attention must be directed to the long-term public health implications and the need for preventive measures [66]. Housing, water and waste disposal systems are inadequate in many Indigenous communities and increase the risk of urolithiasis. Improvements in environmental conditions, specifically the provision of adequate drinking water and the eradication of poor living conditions, are therefore essential to reduce the incidence of renal stones [68].
Summary
Disorders of the kidney and renal tract pose a significant, and frequently serious, public health threat for many Indigenous Australians [68]. ESRD underlies much of the renal morbidity and mortality seen in Indigenous communities and currently dominates health care and research priorities. However, recurring epidemics of APSGN in northern Australia, the suspected high prevalence of UTIs, the unusual epidemiology of urolithiasis, and the potential contribution of each of these conditions to more serious renal disease, highlight the importance of these other kidney and renal tract conditions for Indigenous people. Continuing high rates of ESRD, the negative social consequences that accompany treatment, and the high cost of tertiary level medical care all illustrate the immediate need for a comprehensive health care approach that addresses both the medical and socioeconomic dimensions of this major problem.
A range of biopsychosocial issues underlie the generally poor health status of many Indigenous people. Poverty, poor living conditions, limited access to medical care, and inadequate environmental sanitation contribute to high rates of renal-urologic disorders in many Indigenous communities. The prevention, management and control of kidney and renal tract disorders will depend not only on effective, acceptable medical and surgical treatment, but, importantly, on preventive action to address the poor socioeconomic conditions that underlie these conditions. Without adequate forward planning that considers service needs, service availability, and workforce projections, however, there will not be adequate resources to provide minimum standards of care for the growing number of Indigenous people dependant on dialysis [12]. A comprehensive approach that addresses both the medical and socioeconomic dimensions of these health conditions is an immediate priority.
References
1. Australian Bureau
of Statistics, Australian Institute of Health and Welfare
(2005) The health and welfare of Australia's Aboriginal
and Torres Strait Islander peoples 2005. (ABS catalogue
no. 4704.0) Canberra: Australian Institute of Health and Welfare
and the Australian Bureau of Statistics
View
report
2. Hoy W, Kelly A, Jacups S, McKendry K, Baker P, et al. (1999) Stemming the tide: reducing cardiovascular disease and renal failure in Australian Aborigines. Australian And New Zealand Journal of Medicine;29(3):480-483
View
abstract
3. Kumar PJ, Clark ML (1994) Clinical
medicine: a text book for medical students and doctors.
London: Bailliere Tindall
4. National Kidney and Urologic Diseases
Information Clearinghouse (2002) Your kidneys and how
they work. Retrieved 4 October 2006 from http://kidney.niddk.nih.gov/kudiseases/pubs/yourkidneys/index.htm
5. Cass A, Cunningham J, Snelling
P, Wang Z, Hoy W (2004) Exploring the pathways leading from
disadvantage to end-stage renal disease for Indigenous Australians.
Social Science and Medicine;58(4):767-785
6. Cass A, Cunningham J, Wang Z, Hoy
W (2001) Regional variation in the incidence of end-stage
renal disease in Indigenous Australians. Medical Journal
of Australia;175:24-27
View
paper
7. Australia and New Zealand Dialysis
and Transplant Registry (2005) The 28th annual report:
data to 2004. Adelaide: Australia and New Zealand Dialysis
and Transplant Registry
View
report
8. Spencer JL, Silva DT, Snelling
P, Hoy WE (1998) An epidemic of renal failure among Australian
Aboriginals. Medical Journal of Australia;168(11):537-541
View
paper
9. Hoy WE, Mathews JD, Pugsley DJ
(1995) Treatment of Australian Aboriginals with end-stage
renal disease in the top end of the Northern Territory: 1978-93.
Nephrology;1:307-313
10. Thomas MAB (1998) Kidney disease
in Australian Aboriginals: time for decisive action [editorial].
Medical Journal of Australia;168(11):532-533
View
paper
11. Stewart JH, McCredie MR, Williams
SM, McDonald SP (2004) Interpreting incidence trends for treated
end-stage renal disease: implications for evaluating disease
control in Australia. Nephrology;9(4):238-246
12. Kidney Health Australia (2006)
National chronic kidney disease strategy, draft January
2006. Melbourne:: Kidney Health Australia
View
report
13. Hoy W (1996) Renal disease in
Australian Aboriginals: community health programs are critical
to containing the renal disease epidemic. Medical Journal
of Australia;165:126-127
14. Cass A, Gillen AG, Horvath JS
(1999) End-stage renal disease in Aboriginals in New South
Wales: a very different picture to the Northern Territory.
Medical Journal of Australia;171(8):407-410
View
paper
15. Menzies School of Health Research
(1999) 1998-1999 Annual Report. Darwin: Menzies School
of Health Research
View
download information
16. Hoy W, Vanbuynder P, Mathews J, Pugsley D, Wang Z (2001) Renal disease and the environment: lessons from Aboriginal Australia. Nephrology;6:19-24
View
abstract
17. Excell L, McDonald S, eds. (2004)
ANZDATA Registry Report 2004. Adelaide: Australia
and New Zealand Dialysis and Transplant Registry
View
report
18. Hoy W (1998) Renal disease as
a metaphor: towards a more integrated view of Aboriginal health.
Clinical & Experimental Pharmacology & Physiology;
25(12):1038-1042
19. Hoy WE, Mathews JD, McCredie
DA, Pugsley DJ, Hayhurst BG, et al. (1998) The multidimensional
nature of renal disease: rates and associations of albuminuria
in an Australian Aboriginal community. Kidney International;54(4):1296-1304
View
abstract
20. Hoy WE, Mathews JD (nd) The
multidimensional nature of renal disease: findings in a high
risk Australian Aboriginal community [unpublished].1-16
21. Phillips CB, Patel MS, Weeramanthri
TS (1995) High mortality from renal disease and infection
in Aboriginal central Australians with diabetes. Australian
Journal of Public Health;19(5):482-486
22. Hoy W, Vanbuynder P, Mathews
JD, You J, Baker P, et al. (1999) Renal disease in Australian
Aborigines. Paper presented at the RACP meeting May 1999,
Perth, Western Australia
23. Walker W, Hoy W, McCreadie D,
Hayhurst B, Mathews JD (1997) The Barker hypothesis and
chronic renal disease: supportive data. Paper presented
at the Nutrition unplugged: back to basics. 16th Dietitians
Association of Australia [DAA] National Conference 14-17 May
1997 14-17 May, Hobart
24. Barker DJP, ed. (1994) Mothers,
babies and disease in later life. London: BMJ Publishing
Group
25. Hoy WE, Rees M, Kile E, Mathews
JD, McCredie DA, et al. (1998) Low birthweight and renal disease
in Australian Aborigines. [research letters]. Lancet;352(9143):1826-1827
26. Hoy WE, Rees M, Kile E, Mathews
JD, Wang Z (1999) A new dimension to the Barker hypothesis:
low birthweight and susceptibility to renal disease. Kidney
International;56(3):1072-1077
View
abstract
27. Devitt J, McMasters T (1996)
Living on medicine. Social and cultural dimensions of
end stage renal disease among Aboriginal people of Central
Australia. Paper presented at the Central Australian
Aboriginal Congress Alice Springs
28. McDonald S (2004) Indigenous
transplant outcomes in Australia: what the ANZDATA Registry
tells us. Nephrology;9(Supplement 4):s138-s143
29. Cass A, Cunningham C, Snelling
P, Wang Z, Hoy W (2003) Renal transplantation for Indigenous
Australians: identifying the barriers to equitable access.
Ethnicity and Health;8(2):111-119
30. McDonald SP, Russ GR (2003)
Current incidence, treatment patterns and outcome of end-stage
renal disease among Indigenous groups in Australia and New
Zealand. Nephrology;8(1):42-48
31. Villarra A, Warr K (2004) Home
haemodialysis in remote Australia. Nephrology;9(Supplement
4):s134-s137
32. Australian Bureau of Statistics,
Australian Institute of Health and Welfare (2001) The
health and welfare of Australia's Aboriginal and Torres Strait
Islander peoples 2001. (ABS catalogue no. 4704.0) Canberra:
A joint program of the Australian Bureau of Statistics and
the Australian Institute of Health and Welfare
33. Standing Committee on Aboriginal
and Torres Strait Islander Health, Statistical Information
Management Committee (2006) National summary of the 2003
and 2004 jurisdictional reports against the Aboriginal and
Torres Strait Islander health performance indicators.
(AIHW category no. IHW 16) Canberra: Australian Institute
of Health and Welfare
View
report
34. Kimberley Aboriginal Medical
Services Council (2000) The Kimberley Renal Health Centre:
information circular. February 2000. Retrieved 14 March
from http://www.hcn.net.au/kamsc/renal.htm
35. Feutrill J, Thomas L, Lazberger
J, al e (1996) Determinants of CAPD peritonitis rates in Aboriginal
and non-Aboriginal patients. Kidney International;50:1411
36. Devitt J, McMasters A (1998)
Living on medicine. A cultural study of end-stage renal
disease among Aboriginal people. Alice Springs: IAD Press
View
abstract
37. Cass A, Lowell A, Christie M,
Snelling PL, Flack M, et al. (2002) Sharing the true stories:
improving communication between Aboriginal patients and healthcare
workers. Medical Journal of Australia;176(10):466-470
View
paper
38. Couzos S, Murray R (2003) Aboriginal
primary health care: an evidence-based approach. 2nd
ed. South Melbourne: Oxford University Press
39. Menzies School of Health Research
(2000) Menzies School of Health Research 1999-2000 Annual
Report. Darwin: Menzies School of Health Research
View
download information
40. Hoy WE, Baker PR, Kelly AM,
Wang Z (2000) Reducing premature death and renal failure in
Australian Aboriginals: a community-based cardiovascular and
renal protective program. Medical Journal of Australia;172:473-478
View
paper
41. Moore L, Lloyd MS, Pugsley DJ,
Seymour AE (1996) Renal disease in the Australian Aboriginal
population: a pathological study. Nephrology;2:315-21
42. Hoy W (1996) Renal disease in
Australian Aboriginals: community health programs are critical
to containing the renal disease epidemic [editorial]. Medical
Journal of Australia;165:126-127
43. The George Institute for International
Health (2006) Renal. Retrieved 8 November 2006 from
http://www.thegeorgeinstitute.org/research/renal/renal_home.cfm
44. Isselbacher KJ, Adams RD, Braunwald
E, Petersdorf RG, Wilson JD (1980) Harrison's principles
of internal medicine. 9th ed. New York: McGraw-Hill Book
Company
45. Carapetis JR, Currie BJ, Kaplan E (1999) Epidemiology and prevention of Group A Streptococcal infections: acute respiratory tract infections, skin infections, and their sequelae at the close of the twentieth century.
Clinical Infectious Diseases;28:205-210
View
paper
46. Binns P, Markey P, Krause V
(2005) An outbreak of acute post-streptococcal glomerulonephritis
in a remote Aboriginal community in 2005. The Northern
Territory Communicable Diseases Bulletin;12(2):12-15
47. Centre for Disease Control (1997)
Guidelines for the control of acute post-streptococcal glomerulonephritis.
The Northern Territory Communicable Diseases Bulletin;4(2):5-6
48. Streeton C, Hanna J, Messer
R, Merianos A (1995) An epidemic of acute post-streptococcal
glomerulonephritis among Aboriginal children. Journal
of Paediatric Child Health;31:245-248
49. Gogna NK, Nossar V, Walker AC
(1983) Epidemic of acute poststreptococcal glomerulonephritis
in Aboriginal communities. Medical Journal of Australia;1(January
22):64-66
50. Gardiner DL, Sriprakash KS (1996)
Molecular epidemiology of impetiginous group A streptococcal
infections in Aboriginal communities of northern Australia.
Journal of Clinical Microbiology;34(6):1448-1452
View
abstract
51. White AV, Hoy WE, McCredie DA
(2001) Childhood post-streptococcal glomerulonephritis as
a risk factor for chronic renal disease in later life. Medical
Journal of Australia;174:492-496
View
paper
52. Atkins RC (2001) How bright
is their future? Post-streptococcal glomerulonephritis in
Indigenous communities in Australia [editorial]. Medical
Journal of Australia;174:489-490
View
paper
53. Nimmo G, Tinniswood R, Nuttall
N, Baker G, McDonald B (1992) Group A streptococcal infection
in an Aboriginal community. Medical Journal of Australia;157:521-522
54. Johnston F, Carapetis J, Patel MS, Wallace T, Spillane P (1999) Evaluating the use of penicillin to control outbreaks of acute poststreptococcal glomerulonephritis.
Pediatric Infectious Disease Journal;18(4):327-332
View
abstract
55. Goodfellow AM, Hoy WE, Sriprakash
KS, Daly MJ, Reeve MP, et al. (1999) Proteinuria is associated
with persistence of antibody to streptococcal M protein in
Aboriginal Australians. Epidemiology and Infection;122(1):67-75
View
abstract
56. Streeton C (1995) A review of
the epidemiology of acute poststreptococcal glomerulonephritis
and acute rheumatic fever in far North Queensland. In: Streeton
C, ed. Master of Applied Epidemiology bound volume.
Canberra: National Centre for Epidemiology and Population
Health, Australian National University:211-218
57. Streeton C, Hanna J (1995) Acute
poststreptococcal glomerulonephritis and acute rheumatic fever
in far North Queensland, 1994. Communicable Diseases Intelligence;19(6):137-140
58. Carapetis J (1995) An outbreak
of acute poststreptococcal glomerulonephritis in an Aboriginal
community. Communicable Diseases Intelligence;19(6):140-142
59. Devanesen D, Bernard E, Stokes
ML, Daby J, Withnall K, et al. (1987) Lessons from an outbreak
of glomerulonephritis in an Aboriginal community. Annual
Report Menzies School of Health Research:86-89
60. Assumpcao C (1988) Some urinary
tract disease in Australian Aboriginal inpatients in 1980.
Australian and New Zealand Journal of Medicine;18:17-20
61. Van Buynder PG, Gaggin JA, Martin
D, pugsley D, Mathews JD (1992) Streptococcal infection and
renal disease markers in Australian Aboriginal children. Medical
Journal of Australia;156(Apr 20):537-540
62. Williams R, Allam B (1992) Aboriginal
renal disease awareness. Aboriginal and Islander Health
Worker Journal;16(1):4-5
63. Schultz R, Read AW, Straton
AY, Stanley FJ, Morich P (1991) Genitourinary tract infections
in pregnancy and low birth weight: case-control study in Australian
Aboriginal women. British Medical Journal;303:1369-1373
64. Jones TW, Henderson TR (1989)
Urinary calculi in children in Western Australia: 1972-86.
Australian Paediatric Journal;25:93-95
65. Adsett DB (1982) Urinary calculi
in children of the Kimberley region of Western Australia.
Australian Paediatric Journal;18:283-5
66. Cassey JG, Ahmed S (1989) Urinary
tract calculi in Aboriginal children. Aust. Paediatr.
J.;25:363 - 365
67. Thambi Dorai C, Dewan P, Boucaut
H, Ehrlich J (1994) Urolithiasis in Australian Aboriginal
children. Australian and New Zealand Journal of Surgery;64(2):99-101
68. Williams W, Nicholas J, Nungurrayi
P, Napurrula C (1996) Paediatric urolithiasis in a remote
Australian Aboriginal community. Journal of Paediatric
Child Health;32(4):344-346
69. Wisniewski ZS, Brockis JG, Ryan
GD (1981) Urinary bladder stones in Aboriginal children. Australian
and New Zealand Journal of Surgery;51(3):292-295
70. Farago C (1987) Overinvestigation
of Aboriginal children with urinary tract infection? [letter].
Medical Journal of Australia;147(10):521
71. Harris L, Griffin P, Lucas J
(1985) Urinary tract calculi in Aboriginal children [abstract].
Aust. Paediatr. J.;21:207
Endnotes
1 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.
2 Rates of dialysis are the outcome of some individuals accessing services many times for example an individual reliant on treatment may undergo dialysis 2 or 3 times a week.
This web site contains PDF documents that require the most current version of Adobe Reader to view. To download click on the icon below.
