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How bright is their future?

Robert C Atkins
Med J Aust 2001; 174 (10): 489-490.
Published online: 21 May 2001

Editorial

How bright is their future?

Post-streptococcal glomerulonephritis in Indigenous communities in Australia

Streptococcal skin infection may have a major role in the epidemic of chronic renal disease among Indigenous Australians.

MJA 2001; 174: 489-490

  In 1836, Richard Bright, from Guy's Hospital, London, described the clinical entity of acute glomerulonephritis, later known as Bright's disease. However, it was not until 1907 that streptococci were suggested as a cause of acute glomerulonephritis. At that time, post-streptococcal glomerulonephritis (PSGN) was rife throughout the world, as it remains today in some developing countries. With increasing living standards, Australia has a very low overall incidence of streptococcal infection, but, in contrast, our Indigenous communities have one of the highest incidences in the world, and corresponding high incidences of PSGN and rheumatic heart disease.1-4

In this issue of the Journal, White and colleagues highlight anew the problem of the health of our Indigenous communities and provide some ominous insight into the long-term sequelae of PSGN.5

It has been contentious whether PSGN is a relatively benign disease, as traditionally thought, or whether, as suggested 25 years ago, it may lead to progressive renal disease and eventually end-stage renal failure.6 The reported study of albuminuria and haematuria — the harbingers of progressive renal disease — in a remote Aboriginal community suggests that the latter is correct. The study found that people with a history of PSGN in childhood had a risk of overt albuminuria more than six times that in the control group. In fact, the data show that a quarter of cases of overt albuminuria in this population may be attributable to PSGN in childhood. This is alarming, particularly as the Aboriginal population has an incidence of end-stage renal failure 10 times greater than that of the non-Aboriginal population of Australia.1,7,8 It is even more distressing when we realise that streptococcal disease should theoretically be preventable.

Proteinuria is increasingly recognised as the best overall indicator of progressive renal disease, whatever the cause. It would thus be very important to follow the study population, preferably over many more years, to determine whether renal damage does indeed progress and lead to end-stage renal failure. Other aspects of epidemic and endemic post-streptococcal infection could also be explored. It has been suggested that, because of the high rate of nephritis in families, a familial trait may be involved, increasing susceptibility to the disease.9 This may have some relevance to the PSGN epidemics in this population.

There is no simple treatment for PSGN, and preventing streptococcal infection remains the most important control strategy.10 Penicillin is beneficial in preventing spread of infection during epidemics.2 No vaccine is as yet available. As concluded by White and colleagues, prevention of streptococcal infection through improved economic and living conditions, and particularly control of skin infections, is possible and should reduce the incidence of renal involvement.

However, the real tragedy highlighted by this study is that, despite the passage of up to 20 years since these children were infected with streptococci, nothing much has changed to lower the rates of infection among Aboriginal children. Indeed, a very recent report demonstrated that skin infections still occur in up to 70% of Aboriginal children, with the major pathogens being group A streptococci.4

It is imperative that such important results are heeded. Not until fundamental changes take place in the social, economic and living conditions of our Indigenous communities will this streptococcal disease be eliminated, as it has been in all other areas of Australia.

We have a bipartisan Federal Government committed to improving the health of Indigenous Australians and an office for Aboriginal and Torres Strait Islander Health in the Commonwealth Department of Health and Aged Care, which is providing a comprehensive funding strategy for Indigenous health issues. The head of the Northern Territory Peak Aboriginal Health Organisation, Pat Andersen, is on record as describing the Primary Health Care Access Programme, now under way, as the most exciting event in Aboriginal affairs since the 1967 referendum. Furthermore, recent studies have shown that Aboriginal people can participate enthusiastically and effectively in chronic disease management, with improvement in their renal disease.11

Thus, the challenge at this time of reconciliation is to restore social equity and health to Indigenous Australians.12 It is to be hoped that this will eliminate post-streptococcal disease in Aboriginal communities. The future should be bright.

Robert C Atkins
Professor of Medicine and Director of Nephrology
Monash Medical Centre, Melbourne, VIC

  1. Gogna NK, Nossor V, Walker AC. Epidemic of acute poststreptococcal glomerulonephritis in Aboriginal communities. Med J Aust 1983; 1: 64-66.
  2. Streeton CL, Hanna JN, Messer RD, Merianos A. An epidemic of acute post-streptococcal glomerulonephritis among aboriginal children. J Paediatr Child Health 1995; 31: 245-248.
  3. Carapetis JR, Currie BJ. Preventing rheumatic heart disease in Australia. Med J Aust 1998; 168: 428-429.
  4. Currie BJ, Carapetis JR. Skin infections and infestations in Aboriginal communities in northern Australia. Australas J Dermatol 2000; 41: 139-143.
  5. White AV, Hoy WE, McCredie DA. Childhood poststreptococcal glomerulonephritis as a risk factor for chronic renal disease in later life. Med J Aust 2001; 174: 492-496.
  6. Baldwin DS. Poststreptococcal glomerulonephritis. A progressive disease? Am J Med 1977; 62: 1-11.
  7. Briganti E, McNeil J, Atkins RC, editors. The epidemiology of diseases of the kidney and urinary tract: an Australian perspective. Adelaide: Australian Kidney Foundation Report, 1999. Available at <www.med.monash.edu.au/Epidemiology/general_info/publications.html>
  8. Spencer JL, Silva DT, Snelling P, Hoy WE. An epidemic of renal failure among Australian Aboriginals. Med J Aust 1998; 168: 537-541.
  9. Rodriguez-Iturbe B. Epidemic poststreptococcal glomerulonephritis. Kidney Int 1984; 25: 129-136.
  10. Chadban SJ, Atkins RC. Post-infectious glomerulonephritis. In: Brady HR, Wilcox CS. Therapy in nephrology and hypertension. Philadelphia: WB Saunders, 1998: 115-124.
  11. Hoy WE, Baker PR, Kelly AM, Wang Z. Reducing premature death and renal failure in Australian Aboriginals. A community-based cardiovascular and renal protective program. Med J Aust 2000; 172: 473-478.
  12. Eades SJ. Reconciliation, social equity and Indigenous health [editorial]. Med J Aust 2000; 172: 468-469.


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