Australia And New Zealand Dialysis And Transplant Research Articles

Risk-Factor Profile of an International Cohort of Living Kidney Donors: The ANZDATA Living Donor Registry 2004-2010

Background: Living donor kidney transplantation is the preferred treatment for end-stage kidney disease. Existing literature suggests that donation within the bounds of current guidelines is relatively safe. However, efforts to maximise access to transplantation may result in acceptance of donors who do not fit within current guidelines. Methods: Since 2004 the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry has maintained a registry of living kidney donors. We examined the donor risk profile of Australian and New Zealand kidney donors over 2004-2010 and compared this profile with the Australasian clinical practice guidelines for donor acceptance. Results: There were 2,408 transplant operations from living donors during 2004-2010. Fifty-nine involved the use of non-directed donor kidneys after surgical management of a pathological process and were excluded from further analysis. The remaining 2,349 donors were aged from 18 to 81 with a mean age of 48.5 years. 1356 donors (57.7%) were female, and the majority were Caucasian (2,051 donors, 87.3%). 46 donors (2.0%) had a measured GFR< 80mL/min and 32 (1.4%) had proteinuria >300mg/day. Cardiovascular risk factors were common - 323 (13.8%) were hypertensive; 978 (41.6%) were overweight (BMI 25-29.9 kg/m2) and a further 402 (17.1%) were obese (BMI≥30 kg/m2); 7 (0.3%) were diabetic while a further 46 (2.0%) had impaired glucose tolerance; and 187 (8.0%) were smokers at the time of donation. Only 980 donors (41.7%) had no reported cardiovascular risk factors. According to current Australasian guidelines 457 donors (19.5%) had at least one relative contraindication to donation and 283 (12.0%) had at least one absolute contraindication to donation. Conclusions: The majority of living kidney donors in Australia and New Zealand have at least one cardiovascular risk factor, and a substantial minority have a relative or absolute contraindication to donation according to current clinical practice guidelines. In the context of the known increase in cardiovascular risk associated with chronic kidney disease among the general community, these findings mandate tight follow-up of this cohort. Heightened awareness of donor risk may be appropriate.

Risk-Factor Profile of an International Cohort of Living Kidney Donors: The ANZDATA Living Donor Registry 2004-2010

Background: Living donor kidney transplantation is the preferred treatment for end-stage kidney disease. Existing literature suggests that donation within the bounds of current guidelines is relatively safe. However, efforts to maximise access to transplantation may result in acceptance of donors who do not fit within current guidelines. Methods: Since 2004 the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry has maintained a registry of living kidney donors. We examined the donor risk profile of Australian and New Zealand kidney donors over 2004-2010 and compared this profile with the Australasian clinical practice guidelines for donor acceptance. Results: There were 2,408 transplant operations from living donors during 2004-2010. Fifty-nine involved the use of non-directed donor kidneys after surgical management of a pathological process and were excluded from further analysis. The remaining 2,349 donors were aged from 18 to 81 with a mean age of 48.5 years. 1356 donors (57.7%) were female, and the majority were Caucasian (2,051 donors, 87.3%). 46 donors (2.0%) had a measured GFR< 80mL/min and 32 (1.4%) had proteinuria >300mg/day. Cardiovascular risk factors were common - 323 (13.8%) were hypertensive; 978 (41.6%) were overweight (BMI 25-29.9 kg/m2) and a further 402 (17.1%) were obese (BMI≥30 kg/m2); 7 (0.3%) were diabetic while a further 46 (2.0%) had impaired glucose tolerance; and 187 (8.0%) were smokers at the time of donation. Only 980 donors (41.7%) had no reported cardiovascular risk factors. According to current Australasian guidelines 457 donors (19.5%) had at least one relative contraindication to donation and 283 (12.0%) had at least one absolute contraindication to donation. Conclusions: The majority of living kidney donors in Australia and New Zealand have at least one cardiovascular risk factor, and a substantial minority have a relative or absolute contraindication to donation according to current clinical practice guidelines. In the context of the known increase in cardiovascular risk associated with chronic kidney disease among the general community, these findings mandate tight follow-up of this cohort. Heightened awareness of donor risk may be appropriate.

Socio-economic status and incidence of renal replacement therapy: a registry study of Australian patients

Socio-economic disadvantage has been linked to higher incidence of end-stage kidney disease in developed countries. Associations between socio-economic status (SES) and incidence of renal replacement therapy (RRT) have not been explored for different kidney diseases, genders or age groups in a country with universal access to healthcare. We investigated the incidence of non-indigenous patients commencing RRT in Australia in 2000-09, using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Patient postcodes were grouped into deciles using a standard SES index. We analysed incidence by five groups of kidney diseases, age groups, gender and geographic remoteness. Incidence of RRT decreased with increasing area advantage. Differences were most evident for the most disadvantaged areas [markedly increased burden; incident rate ratio (IRR) 1.27; 95% confidence interval (CI) 1.18-1.38] and most advantaged decile (decreased burden, IRR 0.76; 95% CI 0.72-0.81), compared with decile 5. Patients with diabetic nephropathy showed the greatest disparities: residents of the most disadvantaged decile were 2.38 (95% CI 2.09-2.71) times more at risk than the most advantaged decile. Congenital and genetic kidney diseases showed lesser gradients-the most disadvantaged decile was 1.28 times (95% CI 0.98-1.68) more at risk. SES was not associated with incidence for patients older than 69 years. These SES gradients existed, despite all Australians having access to healthcare. Diseases associated with lifestyle show the greatest gradients with SES.

Daily Variation in Death in Patients Treated by Long-term Dialysis: Comparison of In-Center Hemodialysis to Peritoneal and Home Hemodialysis

There has been little study to date of daily variation in cardiac death in dialysis patients and whether such variation differs according to dialysis modality and session frequency. Observational cohort study using ANZDATA (Australia and New Zealand Dialysis and Transplant) Registry data. All adult patients with end-stage kidney failure treated by dialysis in Australia and New Zealand who died between 1999 and 2008. Timing of death (day of week), dialysis modality, hemodialysis (HD) session frequency, and demographic, clinical, and facility variables. Cardiac and noncardiac mortality. 14,636 adult dialysis patients died during the study period (HD, n = 10,338; peritoneal dialysis [PD], n = 4,298). Cardiac death accounted for 40% of deaths and was significantly more likely to occur on Mondays in in-center HD patients receiving 3 or fewer dialysis sessions per week (n = 9,503; adjusted OR, 1.26; 95% CI, 1.14-1.40; P < 0.001 compared with the mean odds of cardiac death for all days of the week). This daily variation in cardiac death was not seen in PD patients, in-center HD patients receiving more than 3 sessions per week (n = 251), or home HD patients (n = 573). Subgroup analyses showed that deaths related to hyperkalemia and myocardial infarction also were associated with daily variation in risk in HD patients. This pattern was not seen for vascular, infective, malignant, dialysis therapy withdrawal, or other deaths. Limited covariate adjustment. Residual confounding and coding bias could not be excluded. Possible type 2 statistical error due to limited sample size of home HD and enhanced-frequency HD cohorts. Daily variation in the pattern of cardiac deaths was observed in HD patients receiving 3 or fewer dialysis sessions per week, but not in PD, home HD, and HD patients receiving more than 3 sessions per week.

Relapsing and Recurrent Peritoneal Dialysis–Associated Peritonitis: A Multicenter Registry Study

The causes, predictors, treatment, and outcomes of relapsed and recurrent peritoneal dialysis (PD)-associated peritonitis are poorly understood. Observational cohort study using Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data. All Australian PD patients between October 1, 2003, and December 31, 2007, with first episodes of peritonitis. Demographic, clinical, and facility variables and type of peritonitis; relapse (same organism or culture-negative episode occurring within 4 weeks of completion of therapy of a prior episode or 5 weeks if vancomycin used); recurrence (different organism occurring within 4 weeks of completion of therapy of a prior episode or 5 weeks if vancomycin used); control (first peritonitis episode without relapse or recurrence). Hospitalization, catheter removal, hemodialysis therapy transfer, death. Of 6,024 PD patients studied, first episodes of relapsed, recurrent, and control peritonitis occurred in 356, 165, and 2,021 patients, respectively. Coagulase-negative staphylococci and Staphylococcus aureus accounted for 48% of relapsing peritonitis (adjusted OR, 1.26 [95% CI, 0.94-1.70] and 1.54 [95% CI, 1.08-2.19], respectively), but were much less likely to be isolated in recurrent peritonitis. Recurrent peritonitis was associated more frequently with fungi (13%; OR, 2.16; 95% CI, 1.12-4.17). The empirical antimicrobial approaches to relapsing and recurrent peritonitis were similar and their subsequent clinical outcomes were comparable. Compared with uncomplicated peritonitis, relapsed and recurrent peritonitis were associated with higher rates of catheter removal (22% vs 30% vs 37%, respectively; P < 0.001) and permanent hemodialysis therapy transfer (20% vs 25% vs 32%; P < 0.001), but similar rates of hospitalization (73% vs 70% vs 70%) and death (2.8% vs 2.0% vs 1.2%). Limited covariate adjustment. Residual confounding and coding bias could not be excluded. Relapsed and recurrent peritonitis are caused by different spectra of micro-organisms, but are not readily clinically distinguishable at presentation. Empirical treatment with broad-spectrum antibiotics and subsequent adjustment according to antimicrobial susceptibilities results in similar clinical outcomes, albeit with appreciably higher rates of catheter removal and hemodialysis therapy transfer than for uncomplicated peritonitis.

Secular Trends in Cardiovascular Mortality Rates of Patients Receiving Dialysis Compared With the General Population

Cardiovascular mortality rates in the general population have decreased over time. We hypothesized that cardiovascular mortality rates in dialysis patients, which are higher than in the general population, have not decreased as much as those in the general population. Comparison of registry data with population data. Data for prevalent Australian patients for whom dialysis was the first renal replacement therapy were obtained from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry for 1992-2005. Data for a comparable Australian general population were obtained from the Australian Bureau of Statistics. Cardiovascular mortality rates per 100 person-years were calculated from ANZDATA Registry data, and age-specific relative risks were calculated relative to cardiovascular mortality rates in the general population. Included in this cohort were 34,741 dialysis patients with 93,112 person-years of follow-up and 7,267 cardiovascular deaths. Cardiovascular mortality rates decreased over time in the general population and in dialysis patients older than 55 years. In patients aged 55-64 years, cardiovascular mortality rates were 9.0 (95% CI, 7.8-10.3) per 100 person-years in 1992-1994 and 6.4 (95% CI, 5.5-7.3) in 2004-2005; corresponding relative risks were 32.4 (95% CI, 28.2-37.2) and 52.0 (95% CI, 45.2-59.9), respectively. The corresponding cardiovascular mortality rates for dialysis patients aged 65-74 years were 11.6 (95% CI, 10.4-13.0) and 8.3 (95% CI, 7.4-9.3); relative risks were 12.9 (95% CI, 11.6-14.5) and 20.8 (95% CI, 18.7-23.2). Using negative binomial regression, the relative risk associated with dialysis compared with the general population increased over time (P for interaction = 0.001). Causes of death used to define cardiovascular mortality were not coded using identical systems in the ANZDATA Registry and the Australian population. Despite decreasing cardiovascular mortality rates in some dialysis patients, the excess cardiovascular risk compared with the general population is increasing.

Remote indigenous peritoneal dialysis patients have higher risk of peritonitis, technique failure, all-cause and peritonitis-related mortality

The number of indigenous patients with end-stage kidney disease (ESKD) is increasing in Australia, reflecting a similar trend in other countries. Because many indigenous patients live in remote areas, peritoneal dialysis (PD) is often preferred. Compared to non-indigenous PD patients, indigenous patients have increased complication rates but the effect of residential locations on outcomes remains unclear. The aim of this study is to examine the association between race and PD outcomes stratified by location. Using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, all adult ESKD patients commencing PD in Australia between 1995 and 2008 were included. Patients were stratified as non-indigenous or indigenous race and were grouped according to their residential location, the latter stratified into metropolitan, regional and remote areas. Outcomes evaluated included peritonitis, technique failure, peritonitis-related and all-cause mortality. Regional and/or remote PD patients generally have a greater risk peritonitis-related complications and/or mortality compared to metropolitan patients. However, remote indigenous PD patients had the greatest risk of all PD-related complications, including all-cause and peritonitis-related mortality. This registry analysis demonstrates that non-metropolitan PD patients, especially remote indigenous patients, have higher complication rates, suggesting that environmental factors are important in determining PD outcomes.

Trends in adult post‐kidney transplant immunosuppressive use in Australia, 1991–2005

Kidney transplant outcomes have improved over the past 15 years, partly due to improvements in immunosuppression. We used data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry to examine trends in immunosuppressive use post transplant. All adult (recipient age 16+ years) kidney-only transplants performed in Australia from April 1991 to December 2005 were followed to graft loss or December 2005. Immunosuppressive use at induction, 1, 3 and 5 years post transplant were analysed by transplant cohort. Calcineurin-inhibitors (CNI) were used in most recipients for induction and maintenance immunosuppression, with increasing tacrolimus use. Induction cyclosporin dose increased since 2001 (from 5.8 to 7.9 mg/kg per day), but maintenance cyclosporin and tacrolimus dose decreased (from 3.8 to 3.0 mg/kg per day cyclosporin at 1 year post transplant). CNI-free induction increased since 2002 (from 1.4% to 8.4%), while CNI-free maintenance increased throughout the study period. Mycophenolates were the predominant antimetabolite used. Steroid-free maintenance decreased (from 22.7% to 8.7% at 1 year post transplant), as did median prednisolone doses (from 0.12 to 0.09 mg/kg per day at 1 year post transplant). Sirolimus or everolimus are increasingly used for CNI-sparing rather than as antimetabolites substitutes. OKT3 or antithymocyte globulin induction decreased, while anti-CD25 antibody usage increased from 9.5% to 57.1% since 2000. There is a trend to more potent induction immunosuppression with tacrolimus, mycophenolates and anti-CD-25 antibodies, but with CNI avoidance or minimization during maintenance phase. While steroid avoidance/cessation decreased, maintenance steroid dose has also decreased. Anti-CD25 antibodies are now used in >50% of recipients.

High membrane transport status on peritoneal dialysis is not associated with reduced survival following transfer to haemodialysis

High transporter status is associated with reduced survival of patients receiving peritoneal dialysis (PD). This may be due primarily to the development of complications related to the PD process, in which case the survival disadvantage may not persist following transfer to haemodialysis (HD). In this study, we aimed to assess the impact of peritoneal membrane transporter status on patient survival and the likelihood of return to PD following transfer from PD to HD. The Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry was searched to identify all patients between 1 April 1999 and 31 March 2004 who had received PD and subsequently transferred to HD, in whom an incident 4 h dialysate: plasma creatinine ratio was recorded. A Cox proportional hazards model was used to identify factors significantly associated with patient and technique survival after commencement of HD. A total of 918 patients were included in the analysis. On multivariate Cox regression analysis there was no difference in survival between transport groups relative to the reference group of low average transporters (adjusted hazard ratio (HR) 0.71, 95% CI 0.42-1.19, P = 0.19, HR 0.94, 95% CI 0.63-1.38, P = 0.73 and HR 0.24, 95% CI 0.06-1.01, P = 0.051 for high, high average and low transporter groups, respectively). Significant predictors of mortality were duration of PD more than 22 months (HR 2.32, 95% CI 1.24-4.33, P = 0.01), increasing age, late referral to a nephrologist and a history of diabetes mellitus. The likelihood of returning to PD was increased if initial PD technique failure was due to mechanical complications compared with all other causes of failure [HR 3.65 (95% CI 2.78-4.79) P < 0.001] and decreased with higher body mass index [HR 0.97 per kg/m(2) (95% CI 0.94-0.99), P = 0.01] and the 4 h dialysate: plasma creatinine ratio considered as a continuous variable [4 h D:P Cr; HR 0.32 per unit (95% CI 0.12-0.89), P = 0.03]. The survival disadvantage associated with high peritoneal membrane transport status during PD treatment does not persist following transfer to HD. Early transfer to HD may be beneficial in this patient group.

Predictors of Renal Recovery in Australian and New Zealand end-Stage Renal Failure Patients Treated with Peritoneal Dialysis

The aim of this study was to investigate the factors affecting recovery and durability of dialysis-independent renal function following commencement of peritoneal dialysis (PD). Retrospective, observational cohort study of the Australian and New Zealand PD patient population. Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. The study reviewed all patients in Australia and New Zealand who commenced PD for treatment of end-stage renal failure between 15 May 1963 and 31 December 2004. The primary outcomes examined were recovery of dialysis-independent renal function and time from PD commencement to recovery of renal function. A secondary outcome measure was time to renal death (patient death or recommencement of renal replacement therapy) following recovery of dialysis-independent renal function. 24663 patients commenced PD during the study period. Of these, 253 (1%) recovered dialysis-independent renal function. An increased likelihood of recovery was predicted by autoimmune renal disease, hemolytic-uremic syndrome, paraproteinemia, cortical necrosis, renovascular disease, and treatment in New Zealand. A reduced likelihood of recovery was associated with polycystic kidney disease and indigenous race. Analysis of a contemporary subset of 14743 patients in whom complete data were available for body mass index, smoking, and comorbidities yielded comparable results, except that increasing age was additionally associated with a decreased likelihood of recovery. Of the 253 patients who recovered renal function, 151 (60%) recommenced renal replacement therapy and 49 (19%) died within a median period of 226 days (interquartile range 110-581 days). The only significant predictors of continued renal survival after renal recovery were autoimmune renal disease and cortical necrosis. Recovery of renal function in patients treated with PD is rare and determined mainly by renal disease type and race. In the majority of cases, recovery is short term. The apparently high rate of early patient death or return to dialysis after recovery of renal function on PD raises questions about the appropriateness of discontinuing PD therapy under such circumstances.

Thyroid cancer in the renal transplant population: epidemiological study

The epidemiology of thyroid neoplasms in the renal transplant population has not been widely published. The present study compares the behaviour of thyroid cancer in the transplant cohort with that of the general population. It also documents the transplantation outcomes of patients with thyroid and non-thyroid cancers. All recipients of renal grafts are registered with the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Data were obtained from this institution and analysed using Microsoft Excel and Stata statistical software. Risk ratio, attributable risk, Mann-Whitney test, and the Kaplan-Meier survival probability were calculated. Between 1963 and 31 March 2002, 23 (0.22%) patients were diagnosed with thyroid cancer from a cohort of 10,689 renal transplant recipients. The median age in the renal-transplant thyroid cancer group was 48.2 years (range: 23-67 years), and there were 11 (48%) male patients, compared to 26% of thyroid cancer patients in the general population (P = 0.02). The median time to thyroid cancer diagnosis after transplantation was 68 months (range: 3-253 months) compared to 102 months (range: 3-363 months; P = 0.004) in non-thyroid cancers. Ten patients (43%) were found to have lymphatic metastasis, eight of whom presented at the time of primary diagnosis. The risk ratio (RR) was 5.2 (95% confidence interval: 2.0-16.6), with an attributable risk of 17.4 cases per 10,000. There were two cancer-related deaths resulting in a survival probability of 89% at 5, 10 and 15 years. There is a higher incidence of thyroid cancer and an altered sex distribution in the renal transplant population. A significant proportion presents with lymphatic metastasis requiring lymph node dissection and radioactive iodine treatment.

Factors influencing reported rates of treated end-stage renal disease

Rates of treated end-stage renal disease have risen relentlessly throughout the Western world over the past 30 years, with little indication of a slowing in the rate. This increase has a number of causes, such as important trends in disease prevalence, changing population structure, and changing treatment patterns. A number of biases also affect measured rates of renal replacement therapy. These biases include lead-time and length bias, as well as classification bias. A further important effect will be changes in competing risks, in particular, changing mortality from cardiovascular disease. We examine the effects of these factors by analyzing data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Rates of treated ESRD have risen steadily over the past 30 years, which appears to be the result of several factors. Rates among older people have increased particularly, as have rates among Australian and New Zealand indigenous peoples. Higher rates are also seen among some immigrant groups. Accentuating the effect of these changing rates are changes in the structure of the population and the tendency to commence treatment earlier. The increase in rates of ESRD treatment is often ascribed to an explosion of kidney disease. Although a major contribution comes from increasing disease prevalence, understanding the implications of this increase requires comprehension of a number of other factors.

Interpreting incidence trends for treated end-stage renal disease: implications for evaluating disease control in Australia.

Five sources of change modify trends in incidence of treated end-stage renal disease (ESRD): (i) demography; (ii) disease control, comprising prevention and treatment of progressive kidney disease; (iii) competing risks, which encompass dying from untreated uraemia or non-renal comorbidity; (iv) lead-time bias; and (v) classification bias. Thus, rising crude incidence of treated ESRD may conceal effective disease control when there has been demographic change, lessening competing risks, or the introduction of bias. Age-specific incidences of treated ESRD in Australia were calculated from Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data by indigenous/non-indigenous status (all causes) and by primary renal disease (non-indigenous only) for two successive decades, 1982-1991 and 1992-2001. We postulate that less competing risks explained much of the increase in treated ESRD in the elderly and Indigenous Australians. The increase in glomerulonephritic ESRD in non-indigenous Australians could be ascribed mainly to immigration from non-European countries. There was no significant change in incidence of treated ESRD in Indigenous or non-indigenous persons aged less than 25 years, in non-indigenous persons aged 25-64 years for ESRD caused by hereditary polycystic disease or hypertension, or in type 1 diabetics aged over 55 years. End-stage renal disease from analgesic nephropathy had declined. The increase in treated ESRD caused by type 2 diabetic nephropathy appeared to be multifactorial. Lead-time/length bias and less competing risks may have concealed a small favourable trend in other primary renal diseases. Whether recent disease control measures have had an impact on incidence of treated ESRD is not yet certain, but seems more likely than implied by previous reports.

Obesity is a Risk Factor for Peritonitis in the Australian and New Zealand Peritoneal Dialysis Patient Populations

The aim of the present investigation was to examine the association between body mass index (BMI) and peritonitis rates among incident peritoneal dialysis (PD) patients in a large cohort with long-term follow-up. Retrospective observational cohort study of the Australian and New Zealand PD patient population. Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. The study included all incident adult patients (n = 10 709) who received PD in Australia and New Zealand in the 12-year period between 1 April 1991 and 31 March 2003. Patients were classified as obese (BMI > or = 30 kg/m2), overweight (BMI 25.0 - 29.9 kg/m2), normal weight (20 - 24.9 kg/m2), or underweight (< 20 kg/m2). Time to first peritonitis and episodes of peritonitis per patient-year were recorded over the 12-year period. Higher BMI was associated with a shorter time to first peritonitis episode, independent of other risk factors [hazard ratio 1.08 for each 5-kg/m2 increase in BMI, 95% confidence interval (CI) 1.04 - 1.12, p < 0.001]. When peritonitis outcomes were analyzed as episodes of peritonitis per patient-year, these rates were significantly higher among patients with higher BMI: underweight 0.69 episodes/year (95% CI 0.66 - 0.73), normal weight 0.79 (95% CI 0.77 - 0.81), overweight 0.88 (95% CI 0.85 - 0.90), obese 1.06 (95% CI 1.02 - 1.09). Coronary artery disease and chronic lung disease were associated with both shorter time to first peritonitis and higher peritonitis rates, independently of these other factors. There was also a "vintage effect," with lower peritonitis rates seen among people who commenced dialysis in more recent years. Higher BMI at the commencement of renal replacement therapy is a significant risk factor for peritonitis. The mechanisms for this remain undefined.

Current incidence, treatment patterns and outcome of end-stage renal disease among indigenous groups in Australia and New Zealand.

The changes in rates of treated end-stage renal disease (ESRD) among indigenous populations have profound consequences for those individuals affected and for health-care providers. By using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, we examined the current incidence, treatment and outcomes of ESRD among indigenous groups in Australia and New Zealand. All patients who began renal replacement therapy (RRT) in Australia or New Zealand between October 1991 and September 2000 were included. Rates of ESRD, RRT modalities, renal transplantation and mortality were the outcomes examined. End-stage renal disease rates among indigenous groups in Australia and New Zealand exceeded non-indigenous rates up to eightfold. The median age of indigenous ESRD patients was younger (51 vs 60 years, P < 0.0001), and there was an excess of comorbidities, particularly diabetes. For Australian Aboriginal and Torres Strait Islanders, and New Zealand Maori patients, mortality rates across all modalities of RRT were 70% higher than non-indigenous rates. Indigenous people were less likely to receive a renal transplant prior to dialysis treatment, less likely to be accepted onto the cadaveric transplant waiting list, and less likely to receive a well-matched transplant. The poorer outcomes among Australian Aboriginal and Torres Strait Islanders, and New Zealand Maori patients did not appear to be explained by the different comorbid conditions or age. Whether the outcomes reflect unmeasured differences in disease burden or treatment differences is not known. Tackling this problem will involve a spectrum of people and approaches, from tertiary care providers and RRT to local staff and preventative programs.

Factors affecting haemodialysis‐access survival in a single centre retrospective cohort study

SUMMARY: A retrospective review was undertaken in the prevalent haemodialysis population of an Australian Tertiary Renal Unit of patients who started haemodialysis between April 1994 and September 2000. the study aimed to assess the factors affecting the choice of long‐term arteriovenous haemodialysis access, and the factors influencing access survival. Data were obtained from clinical charts and Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data. the minimum follow up was 3 months. There were 71 patients studied (66.2% male, 22.5% diabetic, mean age 56.9 years). Late referral (&lt;3 months) patients constituted 35.2%. Only 39% of patients were Australian born. Seventy‐one patients had a total of 96 new vascular access operations, and 57 revision operations. of the 71 first‐access procedures, 56 were native fistulae and nine were synthetic grafts. Only 31% of long‐term vascular access was in place 6 weeks or longer prior to the start of dialysis. of 25 subsequent (new) access placements, only eight were fistulae and 17 were grafts. Diabetes, peripheral vascular disease and coronary artery disease all significantly predisposed to the placement of synthetic grafts. First native fistulae had superior survival to subsequent native fistulae. Subsequent fistulae had a significant rate of early loss, but were then stable. Survival of native fistulae was always superior to synthetic grafts (P= 0.0072). First synthetic graft survival was similar to the survival of subsequent grafts. Although native fistulae are already favoured for first access, these results suggest that native fistulae should more often be considered for subsequent (secondary) access.