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
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
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
- Gogna NK, Nossor V, Walker AC. Epidemic of acute poststreptococcal
glomerulonephritis in Aboriginal communities. Med J
Aust 1983; 1: 64-66.
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.
Carapetis JR, Currie BJ. Preventing rheumatic heart disease in
Australia. Med J Aust 1998; 168: 428-429.
Currie BJ, Carapetis JR. Skin infections and infestations in
Aboriginal communities in northern Australia.
Australas J Dermatol 2000; 41: 139-143.
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.
Baldwin DS. Poststreptococcal glomerulonephritis. A
progressive disease? Am J Med 1977; 62: 1-11.
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>
Spencer JL, Silva DT, Snelling P, Hoy WE. An epidemic of renal
failure among Australian Aboriginals. Med J Aust
1998; 168: 537-541.
Rodriguez-Iturbe B. Epidemic poststreptococcal
glomerulonephritis. Kidney Int 1984; 25: 129-136.
Chadban SJ, Atkins RC. Post-infectious glomerulonephritis. In:
Brady HR, Wilcox CS. Therapy in nephrology and hypertension.
Philadelphia: WB Saunders, 1998: 115-124.
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.
Eades SJ. Reconciliation, social equity and Indigenous health
[editorial]. Med J Aust 2000; 172: 468-469.