Abstract
BackgroundIn Aotearoa/New Zealand, Māori, as the indigenous people, experience chronic kidney disease at three times the rate of non-Māori, non-Pacific New Zealanders. Māori commence dialysis treatment for end-stage kidney disease at three times the rate of New Zealand European adults. To examine for evidence of inequity in dialysis-related incidence, treatment practices, and survival according to indigeneity in Aotearoa/New Zealand, utilising a Kaupapa Māori approach.MethodsWe conducted a retrospective cohort study involving adults who commenced treatment for end-stage kidney disease in Aotearoa/New Zealand between 2002 and 2011. We extracted data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) linked to the New Zealand National Health Index (NHI). Propensity score methods were used to assemble a cohort of 1039 Māori patients matched 1:1 on clinical and socio-demographic characteristics with a cohort of 1026 non-Māori patients. We compared incidence of end-stage kidney disease and treatment practices. Differences in the risks of all-cause mortality during treatment between propensity-matched cohorts were estimated using Cox proportional hazards and generalised linear models.ResultsNon-Māori patients were older, more frequently lived in urban areas (83% versus 67% [standardised difference 0.38]) and bore less socioeconomic deprivation (36% living in highest decile areas versus 14% [0.53]). Fewer non-Māori patients had diabetes (35% versus 69%, [− 0.72]) as a cause of kidney failure. Non-Māori patients were more frequently treated with peritoneal dialysis (34% versus 29% [0.11]), received a pre-emptive kidney transplant (4% vs 1% [0.19]), and were referred to specialist care < 3 months before treatment (25% vs 19% [0.15]) than Māori patients. Fewer non-Māori started dialysis with a non-tunnelled dialysis vascular catheter (43% versus 47% [− 0.08]). The indigenous-age standardised incidence rate ratio for non-Māori commencing renal replacement therapy in 2011 was 0.50 (95% CI, 0.40–0.61) compared with Māori.Propensity score matching generated cohorts with similar characteristics, although non-Māori less frequently started dialysis with a non-tunnelled venous catheter (30% versus 47% [− 0.35]) or lived remotely (3% versus 14% [− 0.50]). In matched cohorts, non-Māori experienced lower all-cause mortality at 5 yr. after commencement of treatment (risk ratio 0.78, 95% CI 0.72–0.84). New Zealand European patients experienced lower mortality than Māori patients in indigenous age-standardised analyses (age-standardised mortality rate ratio 0.58, 95% CI 0.51–0.67).ConclusionsNon-Māori patients are treated with temporary dialysis vascular access less often than Māori, and experience longer life expectancy with dialysis, even when socioeconomic, demographic, and geographical factors are equivalent. Based on these disparities, health services should monitor and address inequitable treatment practices and outcomes in end-stage kidney disease care.
Highlights
In Aotearoa/New Zealand, Māori, as the indigenous people, experience chronic kidney disease at three times the rate of non-Māori, non-Pacific New Zealanders
An accepted explanation for inequitable outcomes is that increased rates of kidney disease for indigenous peoples are attributable to higher rates of poverty, diabetes, hypertension, and cardiovascular disease [5, 6]
We aligned the study methodology with the United Nation Declaration on the Rights of indigenous peoples, and included Māori as patients who self-identified as Māori and who were resident in Aotearoa/New Zealand [17]
Summary
In Aotearoa/New Zealand, Māori, as the indigenous people, experience chronic kidney disease at three times the rate of non-Māori, non-Pacific New Zealanders. Māori commence dialysis treatment for end-stage kidney disease at three times the rate of New Zealand European adults. To examine for evidence of inequity in dialysis-related incidence, treatment practices, and survival according to indigeneity in Aotearoa/New Zealand, utilising a Kaupapa Māori approach. Chronic kidney disease disproportionally impacts indigenous peoples [1,2,3]. Inequitable health outcomes for indigenous peoples related to kidney disease and other long-term conditions have not been adequately explained by existing epidemiological approaches. An accepted explanation for inequitable outcomes is that increased rates of kidney disease for indigenous peoples are attributable to higher rates of poverty, diabetes, hypertension, and cardiovascular disease [5, 6]. It is essential that research methodologies are employed to inform understanding of inequity in the setting of chronic disease [8]
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