PRE-STERNAL PERITONEAL DIALYSIS CATHETERS: 14-YEAR EXPERIENCE IN A SINGLE CENTRE

LW CHAN, E TAN, P SIZELAND

Midland Regional Renal Services, Hamilton, Waikato, New Zealand

Aim: To analyse local clinical outcomes of Swan-neck Pre-sternal Peritoneal Dialysis Catheters (PPDCs).

Background: The PPDC, with its parasternal exit-site, is designed to reduce catheter-associated complications and prolong survival, especially for obese patients. With increasing use of such catheters, analysing their outcomes becomes important.

Methods: Single-centre data was retrospectively collected for PPDCs inserted in Waikato Hospital from 2002-2015, using electronic and hardcopy records. Demographic data included age, gender, Body Mass Index (BMI), ethnicity, primary kidney disease (PKD) and indications for PPDC. Catheter outcomes that were analysed included technique survival (TS), catheter-related mechanical and infective complications. TS outcomes were censored for death, transplant or elective modality change.

Results: 100 PPDCs were inserted in 89 patients. Patient demographics: mean age (59.3±0.9years), male/female ratio (34%:66%), mean BMI (35.4±0.5kg/m2), ethnicity (Maori/European/Others, 79%/16%/5%) and PKD (diabetes/glomerulonephritis/others, 66%/16%/18%). The major indication for PPDC was obesity (95%). Outcomes: mean TS (20.9±1.6months), longest TS (78 months) and 1-year TS (81.3%). 18 catheters were removed within one year, due to: obstruction (8), peritoneal-pleural leak (2), abdominal leak (1), tunnel/exit site infections (4) and peritonitis (3). Staphylococcus aureus (67%) was the commonest organism causing exit-site/tunnel infection. The peritonitis rate was 0.48 episodes/year; Coagulase-negative Staphylococcus (38%) was the commonest organism. 13% patients died within year one. None were transplanted.

Conclusions: PPDC is a feasible access option. Our 1-year TS meets current ISPD recommendations. PPDC patients were pre-dominantly female, obese, Maori and diabetic. Mechanical complications accounted for most (61%) 1-year catheter removals.

Discussion: Obesity and diabetes may have predisposed to higher mechanical/infection risk and subsequent PPDC failure. Future studies could incorporate longer term observations and matched-control comparisons with patients on haemodialysis or/and conventional abdominal peritoneal dialysis.

EARLY MESOTHELIAL CELL RESPONSES TO STAPHYLOCOCCUS EPIDERMIDIS INFECTION

A McGUIRE1, A CHAKERA1, 2,

1 Translational Renal Research Group, Harry Perkins Institute of Medical Research, Perth, Western Australia; 2 Renal Unit, Sir Charles Gairdner Hospital, Perth, Western Australia

Aim: To define the early changes in mesothelial gene expression in response to infection with Staphylococcus epidermidis.

Background: Peritonitis is responsible for the majority of peritoneal dialysis treatment failures and significant morbidity and mortality. Gram positive microorganisms account for 60-70% of PD peritonitis cases, with Staphylococcus epidermidis the most commonly isolated pathogen. Mesothelial cells lining the abdominal cavity orchestrate the initial host responses to infection however the effects of infection on mesothelial cells are not well characterized.

Methods: We systematically investigated the early mesothelial cell responses to infection with clinical and reference isolates of S. epidermidis using primary mesothelial cells and the mesothelial cell line Met-5A. Confluent mesothelial cells were challenged with 107 colony forming units of S. epidermidis for 1 hour before RNA was isolated using the RNeasy Plus Mini kit. Initial analyses were performed using an unbiased whole genome microarray, followed by assessment of a targeted panel of genes known to be involved in the human antibacterial response. Findings were then validated using qPCR.

Results: We identified 38 differentially regulated genes (adj. p-value < 0.05) representing 35 canonical pathways after 1 hour exposure to S. epidermidis. Including a number of genes not previously described in mesothelial cell responses to infection. Marked heterogeneity was observed between different clinical isolates of S. epidermidis, and between Met-5A and primary mesothelial cells.

Conclusions: Multiple unique pathways are activated within 1 hour by reference strains and clinical isolates of S. epidermidis. Identifying key differences in these responses and how they vary over time between common clinical pathogens will enhance our understanding of mesothelial cell biology and may define novel therapeutic targets.

OBESITY IS NOT ASSOCIATED WITH INCREASED MORTALITY IN AUSTRALIA AND NEW ZEALAND PERITONEAL DIALYSIS PATIENTS

S MURTHY1, S ULLAH2, J BARBARA1,3, G PASSARIS1, S MCDONALD2,4,5, R JUNEJA1,3

1 Flinders Medical Centre, Adelaide, South Australia; 2ANZDATA Registry, Adelaide, South Australia; 3Flinders University, Adelaide, South Australia; 4Royal Adelaide Hospital, Adelaide, South Australia; 5The University of Adelaide, Adelaide, South Australia

Aim: This study aimed to investigate the association of body mass index (BMI) with peritoneal dialysis outcomes in Australia and New Zealand patients.

Background: The association of BMI with peritoneal dialysis outcomes remains uncertain. There have been numerous studies with varied associations.

Methods: ANZDATA registry data for 10,364 incident peritoneal dialysis patients between 1 April 2002 and 31 March 2014 were analysed. Patients were assigned to 4 BMI categories: Underweight (<18.5), Normal (18.5 – 24.9), Overweight (25 – 29.9) and obese (≥30). A multivariate Cox model and competing risk analysis were performed to predict technique and patient survival.

Results: Of the 10,364 patients, almost 27% (n=2,806) were obese. Obesity was associated with a risk of technique failure (HR, 1.24; 95% CI, 1.16 – 1.32; P<0.001) but not with increased mortality (HR, 1.04; 95% CI, 0.96 – 1.13; P= 0.31). The overall technique failure rate (per 1000 person-years) showed a declining trend (P<0.004). Underweight status was strongly associated with increased mortality (HR, 1.32; 95% CI, 1.10 – 1.58; P < 0.01). For cardiovascular events, both overweight and obesity were strongly associated with increased mortality (HRs, 1.24 and 1.47; 95% CI, 1.12 to 1.39 and 1.32 to 1.64; P <0.001 respectively). Standard Cox proportional hazards and competing risk models showed almost similar results for patient survival.

Conclusions: Underweight status is associated with increased mortality for peritoneal dialysis patients. Obesity is not associated with increased mortality but continues to be associated with a risk of technique failure. The data also suggests a declining trend over the study duration in technique failure. Underweight patients need careful evaluation before commencement on peritoneal dialysis.

RAPID FLOW CYTOMETRIC IDENTIFICATION AND ANALYSIS OF STAPHYLOCOCCUS SPP. FROM PERITONEAL DIALYSATE

K MULRONEY1, T INGLIS2, A CHAKERA1, 3,

1Translational Renal Research Group, Harry Perkins Institute of Medical Research, Perth, Western Australia; 2Department of Microbiology; PathWest Laboratory Medicine, Perth, Australia; 3Renal Unit, Sir Charles Gairdner Hospital, Perth, Western Australia

Aim: To assess the utility of an anti-Staphylococcal antibody for flow cytometry detection of Staphylococcal spp from peritoneal dialysate.

Background: Staphylococci are a common cause of peritonitis. Clinical outcomes for patients are directly impacted by the speed with which appropriate antimicrobial therapy can be administered. Current identification and antibiotic sensitivity testing for causative organisms leads to delays between 48 and 72 hours. We present a technique for identification of Staphylococci, to the genus level, within 3 hours of dialysate collection.

Methods: Bacterial control strains and dialysate from 10 cases of peritonitis were analysed. Suspensions were incubated with a monoclonal anti-Staphylococcus antibody, and exposed to a secondary antibody conjugated to AlexaFluor® 647. Samples were washed, then stained with 10µM SYTO® 9 and 2x Live/DEADTM Fixable Violet. Samples were acquired using an Attune NxT flow cytometer. Data were analysed with FlowJo.

Results: 75-95% of all events in samples of S. aureus and S. epidermidis were positive for the presence of the antibody, with an increase in antibody-specific mean fluorescence intensity between 1-2 orders of magnitude. In E. coli and K. pneumoniae samples, 5% – 7% of events had a fluorescence intensity above unstained cells. Approximately 90% of events for Strep. pneumoniae samples were positive. Of the 10 clinical isolates tested, all samples containing Staphylococcus spp. were positive and matched results from conventional culture and MALDI-Biotyper analysis.

Conclusions: Use of an antibody specific for Staphylococcus spp. in a flow cytometry assay provides a rapid measure of identifying and enumerating Staphylococcal cells from clinical samples, but currently provides a false positive for Streptococcus pneumoniae. Further development will be required to improve specificity, and target range, of the assay.

WHICH BLOOD PRESSURE MEASUREMENTS SHOULD DRIVE THERAPY IN A TRIAL OF INTENSIVE VERSUS USUAL TREATMENT OF HYPERTENSION IN HEMODIALYSIS PATIENTS ?

A HARFORD1, D MISKULIN2, J GASSMAN3, R SCHRADER4, S PAINE4, P ZAGER1,4

1University of New Mexico, Albuquerque, New Mexico, United States; 2Tufts Medical Center, Boston, Massachusetts, United States; 3Cleveland Clinic, Cleveland, Ohio, United States; 4Dialysis Clinic, Inc., Albuquerque, New Mexico, United States

Aim: Assess the feasibility of using standardized predialysis blood pressure (SDUBP), home blood pressure (HBPM) or ambulatory blood pressure (ABPM) to drive therapy in a randomized, controlled trial (RCT) of intensive versus usual control of hypertension in hemodialysis patients.

Background: Since there are no RCTs powered for hard outcomes the optimal blood pressure target remains unknown. Moreover, there is evidence suggesting that HBPM and ABPM are superior to SDUBP in predicting outcomes.

Methods: We conducted a pilot study, which randomized 126 participants to a SDUBP of 110-140 or 155-165 mmHg. We used SDUBP to drive therapy but also collected data on adherence with prescribed weekly HBPM and quarterly ABPM during the 1-year intervention.

Results: Adherence with obtaining ≥4 SDUBP per month was excellent in months 1 (97%), 3 (96%), 6 (90%), 9 (88%) and 12 (75%). Adherence with obtaining ≥1 HBPM in months 1 (82%), 3 (72%), 6 (73%), 9 (64%) and 12 (62%) was modest but poor with ≥4 HBPM (36%, 28%, 34%, and 22%) in months 1, 3, 6, 9 and 12, respectively.  We achieved sustained separation in both SDUBP and HBPM across study arms.  Adherence with ABPM was only 20% in quarters 1, 2, 3, but surprisingly 60% in quarter 4. 

Conclusions: Despite the putative advantages of HBPM and ABPM in predicting outcomes adherence with weekly HBPM and quarterly ABPM was poor. Adherence with ≥1 HBPM per month was good but this may not be frequent enough to safely drive therapy in a full-scale RCT. Use of HBPM or ABPM to drive therapy in a full-scale RCT will require great attention to ensure adequate adherence. Otherwise the trial should rely upon SDUBP.

IMPROVING THE SAFETY OF HAEMODIALYSIS BY OPTIMISING ANTICOAGULATION (ISHAN): A PILOT STUDY

T BATT1, R PRASAD1, L LINCZ2, R PATEL3, M SHASTRI3, N LIOUFAS4, AG SMITH1, MD JOSE 3,4

1Haematology Department, Royal Hobart Hospital, Tasmania;  2Hunter Haematology Research Group, Calvary Mater Newcastle Hospital, Waratah, NSW; 3Nephrology Department, Royal Hobart Hospital, Tasmania; 4School of Medicine, University of Tasmania.

Aims: To investigate anti-Xa levels, thrombin generation, enoxaparin fragments and clinical effectiveness of enoxaparin given for haemodialysis.

Background: Low molecular weight heparins (LMWH) are used during haemodialysis to prevent clotting of the dialysis circuit with dosing regimens based on weight or clinical effectiveness, without routine measurement of anticoagulation effect. Individual oligosaccharide fragments of LMWH may have specific biological activity.

Methods: Prospective observational repeated measures study using currently prescribed enoxaparin, measuring anti-Xa levels, thrombin generation and enoxaparin fragments. Bleeding and thrombosis outcomes were recorded. Anti-Xa >0.5U/ml was considered adequate.

Results: 16 subjects during 31 dialysis sessions (mean 276 minutes) completed the study. Enoxaparin dose varied widely (mean 49 mg, range 0.22 – 1.24 mg/kg). There were no serious bleeding events, nor significant difference in bleeding times between doses. No therapeutic bioaccumulation of enoxaparin was detected. A dose of 20 mg was inadequate to reach an anti-Xa level of >0.5 U/ml, and did not suppress thrombin generation to below 50%. Four sessions recorded clots in the dialyser, 3 of which were using 20mg. Doses of 40 and 60 mg did suppress thrombin generation at 2 hours, but only a dose of 80 mg maintained this for the duration of dialysis. Modelling of our data suggests anti-Xa levels of >0.53 U/ml suppresses thrombin generation to 15%. Enoxaparin fragment (dp8-dp16) levels were highly variable between patients but remained relatively stable over the study period. Dp6 was only detected in patients receiving ≥40mg and was quickly cleared after 4 h.

Conclusion: A dose of 80 mg of enoxaparin was required to achieve adequate anti-Xa levels throughout the dialysis session. Enoxaparin fragments are numerous and cleared at different rates.

CHANGE OF SUBJECTIVE GLOBAL ASSESSMENT (SGA) SCORE IS ASSOCIATED WITH A CHANGE IN SERUM ALBUMIN AND HAND GRIP STRENGTH

M CHAN1,2,3, S BAHCECI1, A WILSON4

1The St. George Hospital, Kogarah, NSW; 2University of New South Wales, Kensington, NSW;  3University of Wollongong, Wollongong, NSW; 4The Sutherland Hospital, Caringbah, NSW

Aim: To examine the relationship between the changes (D) of nutrition status scored by Subjective Global Assessment (SGA) and various nutritional parameters.

Background: SGA (7 point scale) is a validated nutrition assessment tool commonly used in the haemodialysis (HD) population and correlates with various clinical parameters to predict outcomes. However, the relationships between the changes (D) of these parameters over time as in routine nutrition monitoring have seldom been examined in the literature.

Methods: Retrospective analysis of routine nutritional assessment record were performed in a cohort of HD patients over a three month period. Data collected were demographics such as age and gender; nutritional parameters including dry body weight (BW), serum albumin (s-alb), haemoglobin (Hb), SGA and hand-grip strength (HGS) which is also a functional capacity measure. Changes (D) and percentage (%) of changes (D) from baseline were examined. Statistical analyses were performed using descriptive statistics and ANOVA.

Results: Ninety-two subjects were studied (male, 59.8%; age, 70.5±12.5 years; diabetic, 54.3%). Prevalence of malnutrition (SGA score B & C) was 34.8% at both month 0 and 3. 24 (26.1%) have improved SGA score (+1), 52 (56.5%) remained stable with no change in SGA score (0) and 16 (17.4%) have deteriorated SGA score (-1). The associated changes for SGA score +1, 0, -1 and D %BW were 0.6±1.3 vs. 0.2±2.5 vs. -1.1±2.5 (p=0.06); D %s-alb were 1.6±10.5 vs. 0±7.7 vs. -6.0±7.9 (p=0.02); D %Hb were -1.0±9.6 vs. 0.8±10.2 vs. -4.9±5.3 (p=0.3); D %HGS were 20.6±38.7 vs 3.3±18.4 vs. -11.2±38.7 (p<0.0001) respectively.

Conclusions: Change of SGA score is positively associated with the change of s-alb and HGS. HGS could be a useful tool for serial nutrition assessment.

FRUIT INTAKE AND CARDIOVASCULAR AND ALL-CAUSE MORTALITY IN ADULTS ON HEMODIALYSIS: THE DIET-HD MULTINATIONAL COHORT STUDY

V SAGLIMBENE1,2, G WONG1,3,4, N BONDONNO5, M RUOSPO2,6, SC PALMER7, K CAMPBELL8, V GARCIA LARSEN9, P NATALE2, A TEIXEIRA-PINTO1, L GARGANO2, AM MURGO2, DW JOHNSON8,10, M TONELLI11, R GELFMAN2, E CELIA2, T ECDER2, A BERNAT2, D DEL CASTILLO2, D TIMOFTE2, M TÖRÖK2, A BEDNAREK-SKUBLEWSKA2,12, J DUŁAWA2,13, P STROUMZA2, M HANSIS2, E FABRICIUS2, C WOLLHEIM2, J HEGBRANT2, JC CRAIG1,3, GFM STRIPPOLI1,2,14

1University of Sydney, Sydney, New South Wales; 2Diaverum Medical-Scientific Office, Lund, Sweden; 3Children’s Hospital at Westmead, Sydney, New South Wales; 4Westmead Hospital, Sydney, New South Wales; 5University of Western Australia, Perth, Western Australia; 6Amedeo Avogadro University of Eastern Piedmont, Novara, Italy; 7University of Otago Christchurch, Christchurch, New Zealand; 8University of Queensland at Princess Alexandra Hospital, Woolloongabba, Queensland; 9Johns Hopkins Bloomberg School of Public Health, Baltimore, US; 10University of Queensland, Woolloongabba, Queensland; 11University of Calgary, Calgary, Canada; 12Medical University of Lublin, Lublin, Poland; 13Medical University of Silesia, Katowice, Poland; 14University of Bari, Bari, Italy

Aim: To evaluate the association between fruit intake and mortality for adults treated with haemodialysis.

Background: High fruit intake is associated with reduced risk of cardiovascular disease in the general population. It is unclear whether this association occurs in patients on haemodialysis, in whom high fruit intake is generally discouraged due to risks associated with hyperkalaemia.

Methods: Using data from the DIET-HD study, a prospective, longitudinal study in 9757 adults treated with haemodialysis in Europe and South America, fruit intake (portions/day) was measured by the GA2LEN food frequency questionnaire. Adjusted Cox regression analyses clustered by country were conducted to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for cardiovascular and all-cause mortality.

Results: During a median follow up of 1.5 years (8108 person-years), there were 1214 deaths including 515 attributable to cardiovascular causes. There was no association between fruit intake (one portion (70 g) increase per day) and cardiovascular (HR 1.00, 95% CI 0.97-1.02) and all-cause mortality (0.99, 0.97-1.00). Apple consumption (≥ 1 apple per day versus none) was associated with lower risks of cardiovascular (0.67, 0.52-0.88) and all-cause (0.83, 0.69-0.98) mortality. Higher consumption (one fruit increase per day) of avocados (2.75, 1.28-5.91) and apricots (1.84, 1.26-2.69) was associated with increased cardiovascular mortality.

Conclusions: There was no overall association between fruit consumption and short-term all-cause and cardiovascular mortality for people treated with haemodialysis. Daily apple consumption may be associated with lower mortality in this clinical setting.

PREVALENCE AND PATTERNS OF COGNITIVE IMPAIRMENT IN ADULTS ON HAEMODIALYSIS: THE COGNITIVE-HD STUDY

A VAN ZWIETEN1,2, G WONG1,2.3, M RUOSPO4,5, SC PALMER6, MR BARULLI7, A IURILLO7, V SAGLIMBENE1,4, P NATALE4, L GARGANO4, M MURGO4, CT LOY1,8, R TORTELLI7, JC CRAIG1,2,9, DW JOHNSON10,11, M TONELLI12, J HEGBRANT4, C WOLLHEIM4, G LOGROSCINO7,13, GFM STRIPPOLI1,4,14 ON BEHALF OF THE COGNITIVE-HD STUDY INVESTIGATORS

1Sydney School of Public Health, University of Sydney, Sydney, New South Wales; 2Centre for Kidney Research, Children’s Hospital at Westmead, Westmead, New South Wales;3 Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales; 4Diaverum Medical-Scientific Office, Lund, Sweden; 5Division of Nephrology and Transplantation, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy; 6Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand; 7Neurodegenerative Diseases Unit, Department of Clinical Research in Neurology, University of Bari “A. Moro”, “Pia Fondazione Cardinale G. Panico”, Tricase, Lecce, Italy; 8Huntington Disease Service, Westmead Hospital, Westmead, New South Wales; 9Department of Nephrology, Children’s Hospital at Westmead, Westmead, New South Wales; 10Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland; 11Translational Research Institute, University of Queensland, Woolloongabba, Queensland; 12Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; 13Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari “A. Moro”, Bari, Italy; 14Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare, Bari, Italy.

Aim: To evaluate the prevalence and patterns of cognitive impairment in adults on haemodialysis, across five domains of learning and memory, complex attention, executive function, language, and perceptual-motor function.

Background: Existing evidence indicates that haemodialysis patients are at increased risk of cognitive impairment, yet the extent of impairment and patterns of co-occurrence across the spectrum of cognitive domains are understudied.

Methods: We recruited patients from a network of 20 dialysis centres in Italy, and conducted a cross-sectional assessment of their cognitive function (learning and memory, complex attention, executive function, language, and perceptual-motor function) using a neuropsychological battery of ten tests. We calculated test and domain z-scores relative to population norms, defining cognitive impairment as a z-score ≤ -1.5.

Results: Overall 676 of 958 patients in the network participated (70.6%), with a median age of 70.9 years (range 21.6–94.1) and 262 (38.8%) women. Proportions of participants with impairment on each domain were: perceptual-motor function 31.5% (n=150/476), language 41.2% (n=273/662), executive function 41.7% (n=281/674), learning and memory 42.2% (n=269/638) and complex attention 48.8% (n=329/674). Among the 474 participants with data for all domains, 28.9% (n=137) were not impaired on any domain, with 25.9% impaired on a single domain (n=123), 17.3% on two domains (n=82), 13.9% on three domains (n=66), 9.1% on four domains (n=43) and 4.9% (n=23) on all five domains.

Conclusions: Cognitive impairment is extremely common among older hemodialysis patients, across a diverse range of domains, and individual patients often experience multiple deficits. Cognitive function should be routinely considered in clinical care for this patient group, and future research should focus on identifying risk factors for cognitive decline, to facilitate the development of targeted interventions.

 

THE UPTAKE OF HAEMODIAFILTRATION IN AUSTRALIA AND NEW ZEALAND: AN ANZDATA REGISTRY STUDY

K MAC1, J HEDLEY2, PJ KELLY2,3, V LEE1,3, JWM AGAR3,4, CM HAWLEY3,5, DW JOHNSON3,5, EJ SEE3,6, KR POLKINGHORNE3,6, KS RABINDRANATH3,7, K SUD3,8 AC WEBSTER1,3

1 Department of Nephrology, Westmead Hospital, Westmead, NSW; 2Sydney School of Public Health, University of Sydney, Sydney, NSW; 3Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA;  4Department of Nephrology, University Hospital Geelong, Geelong, VIC; 5Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, QLD; 6Department of Nephrology, Monash Health, Clayton, VIC; 7Department of Nephrology, Waikato District Hospital, Hamilton, NZ; 8Department of Nephrology, Nepean Hospital, Kingswood, NSW

Aim: To describe uptake of haemodiafiltration (HDF) in Australia and New Zealand over time and determine the factors associated with HDF use.

Background: HDF is increasingly common in clinical practice, despite uncertain comparative effects of HDF versus standard high flux haemodialysis on patient outcomes. The factors associated with increased HDF utilization have not been described previously in Australia and New Zealand.

Methods: We included incident haemodialysis (HD) patients in Australia and New Zealand between 2000-2014, using ANZDATA. The primary outcome was HDF uptake over time. We evaluated factors potentially associated with HDF including social determinacies, country, centre, private versus public, , body mass index, ethnicity, comorbidities, dialysis access and dialysis small solute clearance prior to HDF commencement.

Results: Of 27,432 starting HD, 3,339/23,193 (14.4%) patients in Australia and 810/4,239 (19.1%) in New Zealand received HDF. Uptake was quicker in New Zealand and increased over time in both countries. Younger patients <40years, with co-morbidity (lung, cerebrovascular or peripheral vascular disease), in larger hospitals (>30 new dialysis patients/year), were more likely to receive HDF (all P<0.001). There was no effect of race or sex, but in Australia greater BMI increased likelihood of receiving HDF, as did living in NSW, QLD, SA or Tasmania (all P<0.001). In addition, centre differences explained 34% of HDF uptake in Australia, and 65% in New Zealand. There was no difference for public versus private dialysis centres. Neither living remotely, nor lower socioeconomic status influenced modality.

Conclusions: HDF uptake was quicker in New Zealand than in Australia, but still represents <20% of all HD. HDF use appears to be driven predominantly by centre effects, but in Australia state differences persist.

 

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