Call to address lupus severity in Indigenous Australians

Lupus

By Mardi Chapman

9 Jul 2024

The distinctive phenotype of systemic lupus erythematosus (SLE) in Aboriginal and Torres Strait Island peoples is associated with high rates of lupus nephritis, increased rates of progression to end-stage kidney disease and renal replacement therapy, and higher mortality than other Australians with SLE.

According to a Review article published in Lancet Rheumatology [link here], the higher disease severity and mortality is “probably due to a complex interplay of socioeconomic, environmental, and genetic risk factors.”

They include exposure to group A streptococcal and human T-lymphotropic virus type 1 infections, geographic remoteness, social and cultural barriers to accessing care, language and communication challenges, mistrust in the health-care system, genetic factors and comorbidities.

The Review said low nephron numbers at birth in Indigenous Australians was thought to be a consequence of increased rates of intrauterine growth restriction and low birthweight – a disadvantage which plays out over the lifespan.

“Lower nephron number at birth is hypothesised to contribute to the increased rates of progression to chronic kidney disease and end-stage kidney disease in Aboriginal and Torres Islander patients with lupus nephritis, with less functional reserve in the face of renal insults across the life course,” it said.

“Low nephron number at birth provides an example of the way in which social health inequalities can influence the risk of disease within and across populations.”

The authors, rheumatologists from around the country, said the estimated prevalence of SLE in Indigenous Australians was about two to four times that of other Australians.

Lupus nephritis is about 10 times more common and mortality up to six times higher than in the general Australian population with SLE.

They noted other severe and organ-threatening lupus manifestations including neurological and haematological manifestations, antiphospholipid syndrome, pneumonitis, and pulmonary arterial hypertension, were also more common in Indigenous than non-Indigenous people.

On the flip side, less severe manifestations such as acute cutaneous lupus and photosensitivity were less likely to occur in Aboriginal and Torres Strait Islander peoples.

The authors said suggested strategies for closing the health gap for Indigenous Australians with SLE were based on little direct evidence and more from evidence related to other conditions.

They include:

  • better management of comorbidities, particularly atherosclerotic disease and cardiovascular risk factors, as well as non-SLE related chronic kidney disease
  • improved delivery of specialist care to communities e.g. visiting rheumatology services
  • improved shared care between general practitioners in rural and remote communities and SLE specialists
  • telehealth rheumatology
  • improved allied health support to communities
  • expanded point of care pathology for routine blood tests
  • increased capacity of Aboriginal Community Controlled Health Services, including nurses and Aboriginal Health Practitioners
  • improved patient and community awareness about SLE to improve early diagnosis
  • education and resources in local languages
  • increased Aboriginal and Torres Strait Islander representation in the health workforce,
  • improved cultural knowledge and sensitivity in health care
  • identification of the molecular profile of SLE in Aboriginal and Torres Strait Islander peoples.

“Working together with Aboriginal and Torres Strait Islander peoples to identify priorities for future research and strategies to address barriers to optimal health care is imperative to help achieve better outcomes for Aboriginal and Torres Strait Islander peoples with SLE,” they concluded.

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