End-stage renal disease in aboriginals in New South Wales: a very different picture to the Northern Territory

Aboriginal to non-Aboriginal differentials in 2-year outcomes following non-fatal first-ever acute MI persist after adjustment for comorbidity

BACKGROUND

We investigated the relationship between Aboriginality and 2-year cardiovascular disease outcomes in non-fatal first-ever myocardial infarction during 2000-04, with progressive adjustment of covariates, including comorbidities.

DESIGN

Historical cohort study.

METHODS

Person-linked hospital and mortality records were used to identify 28-day survivors of first-ever myocardial infarction in Western Australia during 2000-04 with 15-year lookback. The outcome measures were: (1) cardiovascular disease death; (2) recurrent admission for myocardial infarction; and (3) the composite of (1) and (2).

RESULTS

Compared with non-Aboriginal patients, Aboriginals were younger and more likely to live remotely. The proportions having 5-year histories of diabetes and chronic kidney disease were double and triple those of non-Aboriginals. When adjusting for demographic variables alone, the Aboriginal to non-Aboriginal hazard ratios for cardiovascular death or recurrent myocardial infarction were 3.6 (95% CI 2.5-5.3) in men and 4.5 (95% CI 2.8-7.3) in women. After adjustment for comorbidities, including diabetes, chronic kidney disease and heart failure, the hazard ratios decreased 36% and 47% to 2.3 (1.6-3.0) and 2.4 (1.5-4.0) in males and females, respectively.

CONCLUSIONS

The high prevalence of comorbidities in Aboriginal people, including diabetes, kidney disease, heart failure, and other risk factors contribute substantially to the disparity in post-myocardial infarction outcomes in Aboriginal people, reinforcing the importance of both primary prevention and comprehensive management of chronic conditions in this population. Aboriginality remains a significant independent risk factor for disease recurrence or mortality, even after adjusting for comorbidity, suggesting the need for society-level interventions addressing social disadvantage.

Pseudomonas peritonitis in Australia: predictors, treatment, and outcomes in 191 cases

BACKGROUND AND OBJECTIVES

Pseudomonas peritonitis is a serious complication of peritoneal dialysis. To date, there as been no comprehensive, multicenter study of this condition.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The predictors, treatment, and clinical outcomes of Pseudomonas peritonitis were examined by binary logistic regression and multilevel, multivariate Poisson regression in all Australian PD patients in 66 centers between 2003 and 2006.

RESULTS

A total of 191 episodes of Pseudomonas peritonitis (5.3% of all peritonitis episodes) occurred in 171 individuals. Its occurrence was independently predicted by Maori/Pacific Islander race, Aboriginal/Torres Strait Islander race, and absence of baseline peritoneal equilibration test data. Compared with other organisms, Pseudomonas peritonitis was associated with greater frequencies of hospitalization (96 versus 79%; P = 0.006), catheter removal (44 versus 20%; P < 0.001), and permanent hemodialysis transfer (35 versus 17%; P < 0.001) but comparable death rates (3 versus 2%; P = 0.4). Initial empiric antibiotic choice did not influence outcomes, but subsequent use of dual anti-pseudomonal therapy was associated with a lower risk for permanent hemodialysis transfer (10 versus 38%, respectively; P = 0.03). Catheter removal was associated with a lower risk for death than treatment with antibiotics alone (0 versus 6%; P < 0.05).

CONCLUSIONS

Pseudomonas peritonitis is associated with high rates of catheter removal and permanent hemodialysis transfer. Prompt catheter removal and use of two anti-pseudomonal antibiotics are associated with better outcomes.

Antecedents of renal disease in Aborigines

Rates of end-stage renal disease in the Aboriginal community have been increasing over the past two decades, particularly in the northern and more remote areas of Australia, and especially in disadvantaged communities. Proteinuria predicts the rate of loss of renal function and is common in young adults and virtually universal in those over 50 years old. Cumulative independent risk factors include low birthweight, recurrent skin infections, adult obesity, diabetes or its precursors, smoking, excessive alcohol intake and a family history of renal disease. A plausible theory is that intrauterine malnutrition permanently reduces total nephron numbers, which are then overworked in adulthood by the metabolic stresses of obesity (from excess alcohol and poor diet), blood pressure and infections, while starved of blood supply through smoking. Although renal disease is often only detected when already established, there are great rewards for active medical intervention. Control of blood pressure (preferentially using angiotensin-converting enzyme (ACE) inhibitors and angiotensin-II receptor blockers (AIIRB) in combination) can often stop or even reverse kidney damage, despite ongoing poor diabetic control. Adequately funded kidney health programmes with active Aboriginal Health Worker involvement are enormously cost-effective: tight blood pressure control at least halves the rate of disease progression, and every year of dialysis deferred for one patient could fund the appointment of two more health workers. Addressing the underlying social causes for this epidemic is critical.

Deprivation and dialysis: pathways to kidney failure in Australian Aborigines

Rates of end-stage renal disease among Australian Aboriginal people have been increasing over the past 2 decades, particularly in the northern and more remote areas of Australia, and especially in disadvantaged communities. Proteinuria predicts the rate of loss of kidney function; it is common in young adults and virtually universal in those over 50 years of age. Cumulative independent risk factors include low birth weight, recurrent skin infections, adult obesity, diabetes or its precursors, smoking, excessive alcohol intake, and a family history of renal disease. A plausible theory is that intrauterine malnutrition permanently reduces total nephron numbers, which are then overworked in adulthood by the metabolic stresses of obesity (from excess alcohol and poor diet), by higher blood pressures, and by infections, while starved of blood supply because of smoking. Although kidney disease is often only detected when already well established, active medical intervention offers great rewards. Control of blood pressure (preferentially using angiotensin-converting enzyme (ACE) inhibitors and angiotensin-II receptor blockers (AIIRBs) in combination) can often stop or even reverse kidney damage, even if ongoing diabetes control is poor. Adequately funded kidney health programs with active Aboriginal health worker involvement are enormously cost-effective: tight blood pressure control at least halves the rate of disease progression, and every year of dialysis deferred for 1 patient could fund the appointment of 2 health workers. Addressing the underlying social causes for this epidemic is critical.

Childhood post-streptococcal glomerulonephritis as a risk factor for chronic renal disease in later life

OBJECTIVE

To test the hypothesis that post-streptococcal glomerulonephritis (PSGN) in childhood is a risk factor for chronic renal disease in later life.

DESIGN

Retrospective cohort study.

SETTING

A remote Aboriginal community in the "Top End" of the Northern Territory that experienced two epidemics of PSGN in 1980 and 1987, respectively.

PARTICIPANTS

472 people who were aged 2-15 years during either epidemic. They were categorised by clinical features recorded during the epidemics as having clinically defined PSGN (63), "abnormal urine" (haematuria or proteinuria; 86) or controls (323).

OUTCOME MEASURES

Urinary albumin to creatinine ratio (ACR), haematuria (by dipstick urinalysis), blood pressure, serum creatinine level, and calculated glomerular filtration rate (GFR) during community screening in 1992-1998.

RESULTS

Overt albuminuria (ACR > 34 mg/mmol) was present at follow-up in 13% of the PSGN group, 8% of the abnormal urine group, and 4% of the control group. The odds ratio (OR) for overt albuminuria in those with a history of PSGN compared with the control group, adjusted for age and sex, was 6.1 (95% CI, 2.2-16.9). Haematuria (>trace) was present in 21% of the PSGN group compared with 7% of the control group (adjusted OR, 3.7; 95% CI, 1.8-8.0). There were no significant differences between the groups in blood pressure, serum creatinine level or calculated GFR.

CONCLUSION

In this population, a history of PSGN in childhood is a risk factor for albuminuria and haematuria in later life.