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.