Hoy W E, Mathews J D, McCredie D A, Pugsley D J, Hayhurst B G, Rees M, Kile E, Walker K A, Wang Z
Menzies School of Health Research, Darwin, Northern Territory, Australia.
Kidney Int. 1998 Oct;54(4):1296-304. doi: 10.1046/j.1523-1755.1998.00099.x.
An epidemic of end-stage renal disease (ESRD) is accompanying the rising rates of hypertension, type 2 diabetes and cardiovascular disease among Aborigines in the Northern Territory of Australia. Incidence rates are now 21 times those of nonAboriginal Australians and are doubling every four years. We describe the rates and associations of renal disease in one remote community, which has a current ESRD incidence of 2700 per million, and cardiovascular mortality among the highest in Australia.
Between 1992 and 1995 a community-wide screening program was conducted, in which the urinary albumin/creatinine ratio (ACR) was used as the chief renal disease marker. More than 90% of the population ages five and older participated.
Albuminuria was evident in early childhood and increased dramatically with age; 26% of adults had microalbuminuria and 24% had overt albuminuria. All renal failure developed out of a background of overt albuminuria. ACR was significantly correlated with the presence of scabies at screening, with a history of poststreptococcal glomerulonephritis, which is epidemic and endemic in the community, with increasing body wt, blood pressure, glucose, insulin and lipid levels, and with evidence of heavy drinking. ACR was also significantly and inversely correlated with birth weight. As a result of its association with deteriorating hemodynamic and metabolic profiles, increasing ACR was also correlated with increasing cardiovascular risk score. Direct observations showed, and multivariate models predicted, progressive amplification of ACR when multiple risk factors were present simultaneously. Albuminuria also clustered in families.
Renal disease in this population is multifactorial, with risk factors related to whole-of-life nutrition, metabolic and hemodynamic profiles, infections, health behaviors, and possibly a family predisposition. Its relationship to low birth weight, and its associations with deteriorating metabolic and hemodynamic profiles, suggest that renal disease is, in part, a component of Syndrome X, which explains the simultaneous increase in metabolic, cardiovascular and renal disease in Aboriginal people. The family clustering might have both environmental and genetic causes, and is under further investigation. Most of the identified risk factors arise out of poverty, disadvantage and accelerated lifestyle change, and the current epidemic can be explained by the confluence of many risk factors in the last few decades. The introduction of effective and sustained programs to address social, economic and educational inequities in all Aboriginal communities, and of screening and renal- and cardiovascular-protective treatment programs for those already afflicted are matters of great urgency.
在澳大利亚北领地的原住民中，终末期肾病（ESRD）的流行伴随着高血压、2型糖尿病和心血管疾病发病率的上升。目前其发病率是澳大利亚非原住民的21倍，且每四年翻一番。我们描述了一个偏远社区的肾病发病率及相关因素，该社区目前的ESRD发病率为每百万人口2700例，心血管疾病死亡率在澳大利亚位居前列。
1992年至1995年开展了一项全社区筛查项目，其中尿白蛋白/肌酐比值（ACR）被用作主要的肾病标志物。五岁及以上的人群中超过90%参与了此次筛查。
蛋白尿在儿童早期就很明显，并随着年龄的增长而急剧增加；26%的成年人有微量白蛋白尿，24%有显性白蛋白尿。所有肾衰竭均由显性白蛋白尿发展而来。筛查时，ACR与疥疮的存在、社区中流行且 endemic（此处原文有误，疑为“地方性的”之意，可能是 endemic 的拼写错误）的链球菌感染后肾小球肾炎病史、体重增加、血压、血糖、胰岛素和血脂水平升高以及大量饮酒证据显著相关。ACR还与出生体重呈显著负相关。由于其与血流动力学和代谢状况恶化相关，ACR升高也与心血管疾病风险评分增加相关。直接观察显示，当多种危险因素同时存在时，多变量模型预测ACR会进行性升高。蛋白尿在家族中也有聚集现象。
该人群的肾病是多因素的，危险因素与终生营养、代谢和血流动力学状况、感染、健康行为以及可能的家族易感性有关。其与低出生体重的关系，以及与代谢和血流动力学状况恶化的关联，表明肾病部分是X综合征的一个组成部分，这解释了原住民中代谢、心血管和肾脏疾病同时增加的现象。家族聚集现象可能有环境和遗传原因，正在进一步调查中。大多数已确定的危险因素源于贫困、不利条件和加速的生活方式改变，当前的流行可以用过去几十年中多种危险因素的汇聚来解释。在所有原住民社区引入有效且持续的项目以解决社会、经济和教育不平等问题，以及为已患病者开展筛查和肾脏及心血管保护治疗项目迫在眉睫。
