ASSOCIATION OF DIALYSIS ATTENDANCE WITH WAITLISTING OF NORTHERN TERRITORY (NT) BASED END STAGE KIDNEY DISEASE (ESKD) PATIENTS

N KHANAL1,2 , PD LAWTON3, A CASS3, SP MCDONALD1,2

1School of Medicine, University of Adelaide, Adelaide, South Australia; 2Australia & New Zealand Dialysis and Transplant Registry (ANZDATA), South Australian Health and Medical Research Institute (SAHMRI), Adelaide; 3Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory

Aim: To determine the relationship of dialysis attendance with wait-listing for kidney transplantation (KT) among NT based end stage kidney disease (ESKD) patients

Background: Substantial differences exist in the rates of wait-listing of Indigenous ESKD patients. Little is known about the association of dialysis attendance and wait-listing. When dialysis attendance is less than prescribed, it may affect nephrologists’ decision whether or not to refer patient for transplantation due to concerns about outcomes in the post-transplant period. We examined the relationship of facility haemodialysis (FHD) attendance with wait-listing in NT based ESKD patients.

Methods: We used NT hospital separations data, linked with waiting-list, demographic, comorbidity and transplant related information from the ANZDATA registry. Inclusion criteria: NT based ESKD patients who started renal replacement therapy between 28th June 2006 and 31st December 2011, were on FHD and wait-listed by 30th June 2012 censored for transplantation, death, renal recovery and lost to follow-up (n=295). Outcome measure: first active placement on waiting list. Predictors: attendance at FHD during the study period.

Results: Of 295 participants, 266 (90.2%) were Indigenous. Based on mean weekly FHD attendance, patients were divided in three groups: >2.75/week (n=106), 2.5 to 2.75/week (n=55) and <2.5/week (n=134). 21 patients (7.0%) were listed, of whom 15 (71.4%) received deceased donor transplants. Of 19 KT, there were 4 (21.04%) live donor transplants. Compared to >2.75 dialysis sessions/week, likelihood for listing was similar in those attending 2.5-2.75/week (HR 0.8 [95% CI 0.2-4.2]) and < 2.5/ week, (HR 1.7 [0.5-5.5]).

Conclusions: In the NT, rates of placement on the waiting list among those receiving FHD are low. FHD attendance was not associated with wait-listing, although the statistical power was limited.

COMPARISON OF FACT AND CAUSE OF DEATH BETWEEN ANZDATA AND THE NATIONAL DEATH INDEX

K DANSIE1,2, M SYPEK1, S MCDONALD1,2,3

1ANZDATA, Adelaide, South Australia; 2University of Adelaide, Adelaide, South Australia; 3Central Northern Adelaide Renal and Transplantation Service, South Australia

Aim: To compare the date and cause of death (CoD) recorded by ANZDATA with the National Death Index (NDI) and explore the differences when disagreement exists.

Background: ANZDATA uses a bespoke coding system for CoD. For researchers utilising ANZDATA it is important to understand the differences in CoD coding to the NDI and how this may affect comparisons with other reports.

Methods: Data linkage was performed between ANZDATA and NDI for all deaths in the period 1980-2013. CoD were classified at ICD chapter level. Overall and chapter specific agreement was assessed using the Kappa statistic.

Results: 28,583 patients were included in the cohort. 95.3% of ANZDATA reported deaths fell within +/- 3 days of the date of death reported by the NDI. Circulatory death was the most common CoD in both databases (ANZDATA 48.2%, NDI 32.3%).  Overall agreement at ICD chapter level of primary CoD was poor (35.9%, Kappa 0.22). Agreement was best for malignancy (kappa 0.71) followed by digestive (kappa 0.34) then circulatory (kappa 0.31) causes.

When there was disagreement on primary CoD these were most commonly coded as genitourinary (34.9%) and endocrine (25.0%) in NDI, and circulatory (38.9%) and withdrawal (24.0%) in ANZDATA. Where there was a ‘withdrawal from dialysis’ code listed as the CoD in ANZDATA, NDI CoD was most commonly coded as genitourinary (37%) or endocrine (21.1%).

Conclusions: There is poor agreement in primary CoD between ANZDATA and NDI, which is in part explained by the absence of diabetes and renal failure as CoD in ANZDATA and the absence of ‘withdrawal from dialysis’ in NDI. These differences should be appreciated when comparing reports that utilise these two data sources.

NEPHROLOGISTS’ PERSPECTIVES ON CANCER SCREENING IN PATIENTS WITH CHRONIC KIDNEY DISEASE

LJ JAMES1,2, G WONG1,2,3, JC CRAIG1,2, A TONG1,2

1 Sydney School of Public Health, University of Sydney, Sydney, NSW 2006; 2Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW 2145; 3Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW 2145.

Aim: To describe nephrologists’ perspectives on cancer screening and understand the factors impacting their practice.
Background:
Cancer is a leading cause of morbidity and mortality in patients with chronic kidney disease (CKD). However, cancer screening practices are highly variable among nephrologists, which may reflect uncertainties around the benefits and harms of screening in this setting, and the competing risk of death from other causes.

Methods: Semi-structured interviews were conducted with 21 nephrologists from 11 centres across Australia and New Zealand. Transcripts were analysed thematically.
Results:
Five themes were identified: empowering patients to make informed decisions (respecting patient preferences, communicating evidence-based recommendations, creating awareness of consequences, preparing patients for transplantation); justifiable risk taking (avoiding undue consequences in vulnerable populations, ensuring cost effectiveness, warranted by long term immunosuppression, assurance of reasonable survival gains); prioritising current or imminent complications; ambiguity of evidence in supporting decisions (absence of standardised recommendations, limited transferability of population-based data); and depending on a shared multidisciplinary approach (collaboration with primary health care, wary of inadequate dermatological services, generating targeted cancer preventative services).
Conclusion:
Nephrologists approach decisions about cancer screening in patients with CKD based on patient preferences, assessment of risk, justifiable survival gains, and current health priorities. Evidence-based guidelines and specialist clinics that address cancer screening may support shared decision making about cancer screening in CKD.

PROGRESSION OF KIDNEY DISEASE IN A COHORT OF CHRONIC KIDNEY DISEASE (CKD) PATIENTS

Z Wang1,2, J Zhang1,2, O Adegbija1,2,  R Abeysekera1,3, HG Healy1,3, KS Tan1,2,4, A Cameron1,2,3, WE Hoy1,2

1 NHMRC CKD.CRE and CKD.QLD, Brisbane, Queensland; 2UQCCR, University of Queensland (UQ), Brisbane, Queensland; 3Kidney Health Service (RBWH); Metro North Hospital and Health Service, Brisbane, Queensland; 4Renal Services (Logan), Metro South Hospital and Health Service, Brisbane, Queensland

Aim: To determine predictors associated with kidney disease progression.

Background: The CKD.QLD registry commenced incremental patient recruitment mid-2011 with CKD patients followed for disease progression and endpoints of death and/or initiation of renal replacement therapy (RRT).

Methods: In this observational longitudinal cohort study, subjects were patients with CKD, enrolled in the registry, and attending renal clinics in two major public hospitals in Queensland, Australia. Primary endpoints were the first of either an absolute 30% decline in eGFR (CKD-EPI) at 2 years, death or starting RRT. Proteinuria/albuminuria was defined by three categories using protein-to-creatinine ratio (PCR)/ albumin-to-creatinine ratio (ACR), or protein dipstick. Cox regression models were applied to test associations of significance.

Results: 1,052 patients of those with eGFR at consent<60 ml/min/1.73m2 were eligible (females 47.5%). Age at consent ranged 18 to 99 years, mean 68 (median 71) years. At two years, eGFR was reduced by>30% in 11% (n=106) of 937 patients who had that repeat measurement. 4.2% (n=49) and 6.3% (n=66) of 1,052 had died or commenced RRT respectively. A total of 221 (21%) reached the composite primary endpoint. Associations of independent significance (HR, 95%CI) were: age<70 years 1.4 (1.02-1.93), diabetic nephropathy (DN) 2.49 (1.19-5.22) and genetic renal disease (GRD) 3.35 (1.44-7.79), with glomerular nephritis (GN) a reference group, micro-proteinuria/albuminuria, 1.76 (1.03-3.0) ,and macro- proteinuria/albuminuria, 4.69 (2.9-7.59), with “normal” PCR or ACR or negative dipstick as the reference group.

Conclusions: The majority of patients with CKD did not progress by this definition. Of those who did, age<70 years, the presence of DN, GRD and proteinuria/albuminuria, both micro- and macro-, were powerful independent predictors of progression of kidney disease.

ASSOCIATION OF DIALYSIS ATTENDANCE WITH KIDNEY TRANSPLANT OUTCOMES IN NORTHERN TERRITORY (NT) BASED KIDNEY TRANSPLANT RECIPIENTS

N KHANAL1,2, PD LAWTON3, A CASS3, SP MCDONALD1,2

1School of Medicine, University of Adelaide, Adelaide, South Australia; 2Australia & New Zealand Dialysis and Transplant Registry (ANZDATA), South Australian Health and Medical Research Institute (SAHMRI), Adelaide;  3Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory

Aim: To determine the relationship of dialysis attendance with subsequent kidney transplant outcomes among NT transplant recipients

Background:  In assessment for potential kidney transplantation, surveys suggest nephrologists are concerned that missing dialysis may portend poor post-transplant outcomes. In fact, little is known about the association of dialysis attendance and outcomes of kidney transplantation. We examined the relationship of prior dialysis modality and facility haemodialysis (FHD) attendance with subsequent outcomes in NT kidney transplant recipients.

Methods: Data: NT hospital separations data, linked with demographic, comorbidity and transplant information from ANZDATA. Inclusion criteria: All NT based ESKD patients who started dialysis between 1st January 1995 and 31st December 2011 and received a kidney transplant by 30th June 2012 (n=113). Predictors: dialysis modality or attendance at FHD up to two years before transplantation. Outcome measure: all-cause graft survival post transplantation (including patient death).

Results: There were 67 patients receiving FHD subsequently transplanted, of whom 48 (71.6%) were Indigenous. Based on weekly FHD attendance, patients were divided in three groups: <2.5/week (n=10), 2.50 to 2.75/week (n=14) and >2.75/week (n=43). There were 48 outcome events. Compared to participants receiving self-care dialysis, n=46, hazard ratio (HR) for graft loss or patient death was 1.02 (95% CI, 0.61-1.69) in participants receiving FHD. Among FHD, compared to those attending >2.75 sessions/week, there was no significant trend observed for patients attending 2.50-2.75/week (HR 1.82 [95% CI 0.85-3.85]) or <2.5/week (HR 1.49 [95% CI 0.58-3.81]). With dialysis attendance (sessions per week) examined as a continuous variable, there was no significant trend of association, HR 0.62 (95% CI 0.15-2.60).

Conclusions: In the NT, facility haemodialysis attendance variation was not associated with post-transplant graft and patient survival.

ABSOLUTE RISK AND RISK FACTORS FOR STROKE MORTALITY IN PATIENTS WITH END STAGE KIDNEY DISEASE (ESKD): RETROSPECTIVE POPULATION-BASED COHORT USING DATA LINKAGE

NL DE LA MATA1, M ALFARO-RAMIREZ2, P MASSON3, RA SALMAN4, P KELLY1, AC WEBSTER1,5,6

1Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; 2School of Mathematics and Applied Statistics, University of Wollongong, Wollongong, NSW, Australia; 3Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK; 4Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland, UK; 5Centre for Renal and Transplant Research, Westmead Hospital, Westmead, NSW, Australia;  6Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, NSW, Australia.

Aim: To determine the absolute risk of stroke mortality, and associated risk factors, in the Australian and New Zealand ESKD population.

Background: People with ESKD have a higher risk of stroke than the general population.

Methods: Analysis included incident ESKD patients in Australia 1980-2013 and New Zealand 1988-2012, from ANZDATA. We ascertained primary cause of death from data linkage with national death registries and risk factors from ANZDATA. We used a competing risks regression model to identify risk factors and cumulative incidence of stroke and non-stroke mortality.

Results: A total of 58,241 ESKD patients were included in the analysis. There were 873 stroke deaths and 33,445 non-stroke deaths over 259,973 person-years (pys). Overall, the cumulative incidence of stroke death was 6.2% (95% CI: 5.5-6.9%) and non-stroke death was 22.5% (95% CI: 22.1-22.8%) at 2-year follow-up. A higher risk of stroke death was associated with older age (Subhazard ratio, SHR 1.70, 95% CI: 1.26-2.28, p<0.001), female sex (SHR 1.37, 95% CI: 1.16-1.61, p<0.001), prior stroke cerebrovascular disease (SHR 2.25, 95% CI: 1.87-2.72, p<0.001), diabetic CKD (SHR 1.27, 95% CI: 1.00-1.59, p=0.013), year of ESKD ≤1995 (SHR 1.52, 95% CI: 1.20-1.89, p value<0.001), normal BMI (SHR 1.72, 95% CI: 1.37-2.13, p<0.001), and no previous malignancy (SHR 1.61, 95% CI: 1.32-1.96, p<0.001).

Conclusions: The risk of stroke death in ESKD patients was higher with older age, cerebrovascular disease and diabetes. In the context of ESKD females and those with normal BMI, there was a greater risk of stroke mortality but not of non-stroke mortality.  Further research is warranted to determine whether targeted stroke interventions could benefit ESKD patients

SEX MATTERS: GENDER-RELATED DIFFERENCE IN RENAL REPLACEMENT THERAPY (RRT) INCIDENCE RATES

SP MCDONALD

ANZDATA Registry, Adelaide, South Australia 2Central Northern Adelaide Renal and Transplantation Service, Adelaide, South Australia, 3University of Adelaide, Adelaide, Australia

Aim: Examine changes in RRT incidence by gender

Background: The steady increase in RRT incidence and then stabilisation in recent years are well known. However, detailed changes in incidence with gender in Australia have not been examined or reported previously.

Methods: Using the ANZDATA Registry, rates of new renal replacement therapy were calculated for the period 1971-2015 by year, classified by gender, primary renal disease, and age at RRT start.

Results: For the period 1971-5 the Male:Female ratio (MFR) was 1.13 [95% CI 1.03-1.24]. Over time this has progressively increased to 1.65 [1.59-1.70] over the period 2011-5. These trends differed by age groups. Over 2011-5, MFR for 25-44 age group was 1.33 [1.21-1.46]; for >=75 year old group 2.77 [2.56-3.01]. Differences were also seen with primary renal disease: for diabetic nephropathy MFR was 1.92 [1.80-2.05] and glomerulonephritis 1.92 [1.76-2.10]. For polycystic disease, MFR was 1.48 [1.27-1.73].

Conclusions: There is a growing male excess among people starting RRT. This may reflect rates of disease prevalence, but the polycystic disease difference suggests differential dialysis uptake in addition.

PREVALENCE AND CORRELATES OF DEPRESSION IN ADULTS WITH CHRONIC KIDNEY DISEASE

CM MCKERCHER1, KA SANDERSON1,2, AJ VENN1, AL NEIL1, MD JOSE1,3,4

1Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania; 2School of Health Sciences, University of East Anglia, Norwich, UK; 3School of Medicine, University of Tasmania, Hobart, Tasmania; 3Royal Hobart Hospital, Hobart, Tasmania

Aim: To examine the prevalence and correlates of depressive symptoms in adults with advanced chronic kidney disease (CKD).

Background: Depression is independently associated with increased risk of mortality and poor health-related quality of life in dialysis patients, yet few studies have examined depression in adults with CKD prior to the initiation of renal replacement therapy.

Methods: 94 adults (29 women, 31%), aged ≥18 years (71.3±11.8 years) with CKD (eGFR <30 mls/min/1.73m2) and not receiving dialysis were recruited via treating physicians. Prevalence and severity of depressive symptoms was assessed using the 9-item Patient Health Questionnaire (PHQ-9). Cross-sectional associations between depressive symptoms and demographic, psychosocial, and clinical factors were examined using multivariable linear regression.

Results: Mean PHQ-9 score was 4.1±5.1, range 0-27. Prevalence of mild depression was 23% (PHQ-9 ≥5 & <10) and major depression was 12% (PHQ-9 ≥10). In partially adjusted models, lower age, increasing BMI, increasing number of symptoms of anxiety (Beck Anxiety Inventory, p<0.001), lower perceived social support (Multidimensional Scale of Perceived Social Support, p<0.05) and lower perceived physical health (SF-36 Physical Component Summary, p<0.05) were associated with increased severity of depressive symptoms. Anxiety, social support, and physical health remained significant in fully adjusted multivariable models. There was no association between kidney function (eGFR; mean 21.8±6.4 mls/min/1.73m2) and depressive symptoms.

Conclusions: Consistent with other chronic disease populations, the prevalence of major depression in this cohort was higher than the age-matched general population. Similarly, anxiety, social support and physical health appear to be important correlates of depressive symptoms in adults with pre-dialysis CKD. Prospective assessment of this cohort will allow us to examine the trajectory of depressive symptoms and their influence on health-related outcomes.

RESEARCH OUTPUTS REPORTING INDIGENOUS HEALTH OUTCOMES IN THE AUSTRALIA AND NEW ZEALAND DIALYSIS AND TRANSPLANT REGISTRY (ANZDATA): SYSTEMATIC REVIEW

SC PALMER1, SG PITAMA,2 V GRAY1, T KARA,3 JT HUGHES4,5

1 University of Otago Christchurch, Christchurch, Aotearoa/New Zealand; 2 Māori and Indigenous Health Institute, University of Otago Christchurch, Aotearoa/New Zealand; 3 Starship Hospital, Auckland District Health Board, Auckland, Aotearoa New Zealand; 4 Royal Darwin Hospital, Darwin, Northern Territories; 5 Menzies School of Health Research, Darwin, Northern Territories

Aim: To systematically document the research outputs related to Indigenous health outcomes arising from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA).

Background: Treatment patterns for dialysis and kidney transplantation and clinical outcomes differ by Indigeneity in Australia and Aotearoa/New Zealand.

Methods: Electronic databases were searched for peer-reviewed studies reporting analyses according to Indigeneity in ANZDATA between 1977 and 2017. We mapped the purpose of including Indigeneity within the study, research foci, and involvement of Indigenous stakeholders in study conduct.

Results: 257 eligible study reports were identified. 120 (47%) reported Indigeneity as a variable in statistical analyses, 53 (44%) reported the primary study outcome(s) according to Indigenous status, and 21 (18%) were principally designed to evaluate health outcomes among Indigenous peoples. Among the 21 studies designed to examine Indigenous health outcomes (published 1999-2017), 20 reported outcomes among Aboriginal and Torres Strait Islanders and 4 reported outcomes among Māori resident in Aotearoa/New Zealand. Six studies evaluated end-stage kidney disease, 7 evaluated dialysis, 4 evaluated dialysis and transplantation, and 4 evaluated transplantation. Eleven studies evaluated practice patterns and 15 reported clinical outcomes. Five studies (24%) were explicitly designed to explore disparities in dialysis or transplantation practices and/or outcomes. None of the studies reported involvement of Indigenous stakeholders in developing the research question, study design, or dissemination. Two studies reported practice patterns among younger Indigenous patients.

Conclusions: The evidence base for Indigenous health outcomes derived from ANZDATA is dominated by the use of Indigeneity as an analytical variable. Few studies based on the ANZDATA registry explore the causes of inequitable practice patterns and clinical outcomes experienced by Indigenous peoples with end-stage kidney disease.

IMPACT OF PRIVATE HEALTH INSURANCE ON DIALYSIS OUTCOMES – A COHORT STUDY

A SRIRAVINDRARAJAH1, SS KOTWAL2,3, S SEN1,4, S MCDONALD5,6, A CASS7, M GALLAGHER1,2,4

1Concord Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales; 2The George Institute for Global Health, Sydney, New South Wales; 3Prince of Wales Hospital, Sydney, New South Wales; 4Concord Repatriation General Hospital, Sydney, New South Wales; 5University of Adelaide, Adelaide, South Australia; 6Royal Adelaide Hospital, Adelaide, South Australia; 7Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory

Aim: To understand the impact of private health insurance upon dialysis modality in Australia.

Background: Re-imbursement systems have been associated with differences in treatment modalities for patients receiving renal replacement therapy (RRT).

Methods: All adult patients who commenced RRT in NSW between 2000-2010 were identified using the Australia and New Zealand Dialysis and Transplant Registry. Data were linked to the state hospitalisation dataset to obtain insurance status, health service use, and mortality. Dialysis modality in the first year after starting RRT, dialysis access type, health service utilisation and mortality were compared between privately insured (PI) and public patients using appropriate statistical techniques.

Results: PI patients were 38% (n=2152) of the 5737 patients in the study cohort. After adjustment for differences in baseline characteristics, PI patients were more likely to initiate RRT with in-centre haemodialysis (OR 1.22, 95% CI 1.01-1.46, P=0.03) and less likely to start with peritoneal dialysis (OR 0.81, 95% CI 0.67-0.98, P=0.03). At one-year after RRT initiation, PI patients were more likely to be receiving home haemodialysis (OR 1.38, 95% CI 1.01-1.88, P=0.04) or to have been transplanted (OR 1.71, 95% CI 1.22-2.40, P=0.002). PI patients were more likely to start haemodialysis with an arteriovenous fistula or graft (OR 1.91, 95% CI 1.50-2.43, P=<0.001), used 15% fewer bed days in the first year after RRT commencement (IRR 0.85, 95% CI 0.74-0.96, P=0.01) and had a lower mortality (HR 0.84, 95% CI 0.74-0.95, P=0.01).

Conclusions: Private health insurance in Australia is associated with higher use of home haemodialysis and transplantation at one year post RRT initiation. Sizeable differences in health service usage and outcomes in this group represent an equity challenge to renal services.

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