Correspondence

Indigenous Australians and Living Kidney Donation

N Engl J Med 2009; 361:1513-1516October 8, 2009

Article

To the Editor:

Indigenous Australians comprise 2.5% of the total population of Australia, but like other minority groups worldwide, rates of chronic kidney disease are higher among this indigenous group than among the general population. Transplantation remains the preferred form of renal-replacement therapy, and the use of living donors maximizes transplantation rates with a generally minimal long-term effect on donors.1 However, the consequences of the use of this strategy in indigenous Australians are unclear, given the likelihood of a family or community history of chronic kidney disease in potential donors.

We performed a retrospective analysis of all living kidney donors from the Northern Territory of Australia since 1985. A total of 50 people (22 of whom were self-reported to be indigenous) were accepted as kidney donors and were evaluated according to standard pretransplantation protocols at the same transplantation center, irrespective of their race or ethnic group. Donors were assessed by a transplantation nephrologist, and each donor was found to have normal kidney function (a calculated glomerular filtration rate [GFR] of >90 ml per minute per 1.73 m² of body-surface area), a normal intravenous pyelogram and renal angiogram, normal blood pressure (<140/80 mm Hg), a normal oral glucose-tolerance test, a normal electrocardiogram, and no proteinuria.

Sixteen of 22 indigenous donors (73%) had medical follow-up over a median period of 16.1 years. At the last follow-up of these carefully selected donors, two (12%) had died, three (19%) required renal-replacement therapy, and the majority had hypertension, diabetes, established proteinuria, and an estimated GFR of less than 60 ml per minute (Table 1Table 1Characteristics of Living Kidney Donors and the General Population among Indigenous and Nonindigenous Australians from the Northern Territory.). Of 16 nonindigenous donors, only 6 (38%) had an estimated GFR of less than 60 ml per minute; none had other clinically significant coexisting conditions.

Clearly, “standardized assessment” has failed these indigenous donors. Hoy et al.2 best described the natural history of kidney disease in indigenous Australian communities. The confirmed rates of proteinuria and end-stage kidney disease in our study were significantly worse among indigenous donors than among the general population, and the estimated GFR at the last follow-up provides support for this concern (although estimated GFR validation studies involving indigenous Australians have not yet been completed).

Our present study also raises the questions of whether donors with any family history of kidney disease should be accepted and of whether more extensive testing before donation would avert these adverse outcomes. A kidney biopsy performed before donation may be of benefit, since low nephron endowment and glomerulomegaly have been described,5 but this procedure increases donor risk. The heterogeneity of indigenous peoples within and outside Australia limits the ability to generalize these observations; donor outcomes in other minority groups have not, to our knowledge, been reported. Until comprehensive, prospective outcome data on kidney donors from different minority groups are available, the extrapolation of modest long-term risk to all donors may do a disservice to the integrity of the living-donor kidney program.

Natasha M. Rogers, M.D.
Queen Elizabeth Hospital, Adelaide, SA, Australia

Paul D. Lawton, M.D.
Royal Darwin Hospital, Darwin, NT, Australia

Matthew D. Jose, M.D., Ph.D.
Menzies Research Institute, Hobart, TAS, Australia

Supported by a CellCept Australia Research Grant from Roche Australia.

Dr. Rogers reports receiving grant support from Roche; and Dr. Jose, receiving consulting fees from Novartis and grant support from Roche.

No other potential conflict of interest relevant to this letter was reported.

5 References

1. 1

   Ibrahim HN, Foley R, Tan L, et al. Long-term consequences of kidney donation. N Engl J Med 2009;360:459-469
   Full Text | Web of Science | Medline

2. 2

   Hoy WE, Wang Z, VanBuynder P, Baker PR, Mcdonald SM, Mathews JD. The natural history of renal disease in Australian Aborigines. 2. Albuminuria predicts natural death and renal failure. Kidney Int 2001;60:249-256
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   Hoy WE, Kondalsamy-Chennakesavan S, Wang Z, et al. Quantifying the excess risk for proteinuria, hypertension and diabetes in Australian Aborigines: comparison of profiles in three remote communities in the Northern Territory with those in the AusDiab study. Aust N Z J Public Health 2007;31:177-183
   CrossRef | Web of Science | Medline

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   Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez A. The burden of disease and injury in Australia 2003. Canberra: Australian Institute of Health and Welfare, 2003. (Accessed September 17, 2009, at http://www.aihw.gov.au/publications/index.cfm/title/10317.)
   

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   Hoy WE, Hughson MD, Singh GR, Douglas-Denton R, Bertram JF. Reduced nephron number and glomerulomegaly in Australian Aborigines: a group at high risk for renal disease and hypertension. Kidney Int 2006;70:104-110
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Citing Articles (2)

Citing Articles

1. 1

   Christos Chatzikyrkou, Jan Menne, Wilfried Gwinner, Bernhard M. Schmidt, Frank Lehner, Cornelia Blume, Anke Schwarz, Hermann Haller, Mario Schiffer. (2011) Pathogenesis and management of hypertension after kidney transplantation. Journal of Hypertension 29:12, 2283-2294
   CrossRef

2. 2

   Leroy J. Storsley, Ann Young, David N. Rush, Peter W. Nickerson, Julie Ho, Vuthana Suon, Martin Karpinski. (2010) Long-Term Medical Outcomes Among Aboriginal Living Kidney Donors. Transplantation 90:4, 401-406
   CrossRef