Uptake and Outcomes of Peritoneal Dialysis among Aboriginal and Torres Strait Islander People: Analysis of Registry Data.

Introduction: Peritoneal dialysis (PD) enables people to use kidney replacement therapy (KRT) outside of healthcare-dependent settings, a strong priority of Aboriginal and Torres Strait Islander people. Methods: We undertook an observational study analyzing registry data to describe access to PD and its outcome as the first KRT among Aboriginal and Torres Strait Islander people between January 1, 2004 and December 31 2020. Results: Out of 4604 Aboriginal and Torres Strait Islander people, reflecting 10.4% of all Australians commencing KRT, PD was the first KRT modality among 665 (14.4%). PD utilization was 17.2% in 2004 to 2009 and 12.7% in 2016 to 2020 (P = 0.002); 1105 episodes of peritonitis were observed in 413 individuals, median of 3 (interquartile range [IQR], 2-5) episodes/patient. The crude peritonitis rate was 0.53 (95% confidence interval [CI], 0.50-0.56) episodes/patient-years without any significant changes over time. The median time to first peritonitis was 1.1 years. A decrease in the peritonitis incidence rate ratio (IRR) was observed in 2016 to 2020 (IRR, 0.63 [95% CI, 0.52-0.77], P < 0.001) compared to earlier eras (2010-2015: IRR, 0.90 [95% CI, 0.76-1.07], P = 0.23; Ref: 2004-2009). The cure rates decreased from 80.0% (n = 435) in 2004 to 2009, to 70.8% (n = 131) in 2016 to 2020 (P < 0.001). Conclusion: Aboriginal and Torres Strait Islander people who utilized PD as their first KRT during 2004 to 2020 recorded a higher peritonitis rate than the current benchmark of 0.4 episodes/patient-years. The cure rates have worsened recently, which should be a big concern. There is an exigent need to address these gaps in kidney care for Aboriginal and Torres Strait Islander people.

Experiences of Indigenous Patients Receiving Dialysis: Systematic Review of Qualitative Studies.

RATIONALE & OBJECTIVE: Indigenous People suffer a high burden of kidney disease. Those receiving maintenance dialysis have worse outcomes compared with similarly treated non-Indigenous patients. We characterized the experiences of Indigenous patients receiving dialysis in British-colonized countries to gain insights into which aspects of kidney care may benefit from improvement. STUDY DESIGN: A systematic review of published qualitative interview studies. SETTING & STUDY POPULATIONS: Indigenous Peoples aged 18 years and over, receiving hemodialysis or peritoneal dialysis in British-colonized countries. SELECTION CRITERIA FOR STUDIES: Search terms for Indigenous Peoples, dialysis, and qualitative research were entered into Medline, Embase, PsycINFO, and CINAHL and searched from inception to January 5, 2023. DATA EXTRACTION: Characteristics of each study were extracted into Microsoft Excel for quality assessment. ANALYTICAL APPROACH: Data were analyzed using thematic synthesis. RESULTS: The analysis included 28 studies involving 471 participants from Australia, New Zealand, Canada, and the United States. We identified four themes: centrality of family and culture (continuing dialysis for family, gaining autonomy through shared involvement, balancing primary responsibility to care for family); marginalization due to structural and social inequities (falling through gaps in primary care intensifying shock, discriminated against and judged by specialists, alienated and fearful of hospitals, overwhelmed by travel, financial and regimental burdens); vulnerability in accessing health care (need for culturally responsive care, lack of language interpreters, without agency in decision-making, comorbidities compounding complexity of self-management); and distress from separation from community (disenfranchisement and sorrow when away for dialysis, inability to perpetuate cultural continuity, seeking a kidney transplant). LIMITATIONS: We only included articles published in English. CONCLUSIONS: Indigenous patients receiving dialysis experience inequities in health care that compound existing accessibility issues caused by colonization. Improving the accessibility and cultural responsiveness of dialysis and kidney transplant services in collaboration with Indigenous stakeholders holds promise to enhance the experience of Indigenous patients receiving dialysis. PLAIN-LANGUAGE SUMMARY: Worldwide Indigenous populations suffer a high incidence of chronic disease leading to lower life expectancy, particularly for kidney disease, an insidious condition requiring long-term dialysis treatment. By listening to Indigenous dialysis patients' stories, we hoped to understand how to improve their experience. We gathered 28 qualitative research studies from four countries reporting Indigenous adults' experiences of dialysis. They described lacking awareness of kidney disease, poor access to health services, systemic racism, inadequate cultural safety, and being dislocated from family, community, and culture. These findings indicate that respectful collaboration with Indigenous Peoples to craft and implement policy changes holds promise to improve prevention, integrate culturally responsive health care practices, and provide better access to local dialysis services and opportunities for kidney transplants.

Exploring the Reported Strengths and Limitations of Aboriginal and Torres Strait Islander Health Research: A Narrative Review of Intervention Studies.

High quality intervention research is needed to inform evidence-based practice and policy for Aboriginal and Torres Strait Islander communities. We searched for studies published from 2008-2020 in the PubMed database. A narrative review of intervention literature was conducted, where we identified researcher reported strengths and limitations of their research practice. A total of 240 studies met inclusion criteria which were categorised as evaluations, trials, pilot interventions or implementation studies. Reported strengths included community engagement and partnerships; sample qualities; Aboriginal and Torres Strait Islander involvement in research; culturally appropriate and safe research practice; capacity building efforts; providing resources or reducing costs for services and communities; understanding local culture and context; and appropriate timelines for completion. Reported limitations included difficulties achieving the target sample size; inadequate time; insufficient funding and resources; limited capacity of health workers and services; and inadequate community involvement and communication issues. This review highlights that community consultation and leadership coupled with appropriate time and funding, enables Aboriginal and Torres Strait Islander health intervention research to be conducted. These factors can enable effective intervention research, and consequently can help improve health and wellbeing outcomes for Aboriginal and Torres Strait Islander people.

Acute Rejection, Overall Graft Loss, and Infection-related Deaths After Kidney Transplantation in Indigenous Australians.

Introduction: Aboriginal and Torres Strait Islander peoples (hereafter respectfully termed Indigenous Australians) experience a 3-fold increased risk of acute rejection after transplantation compared to non-Indigenous Australians. We investigated whether acute rejection explains the association between Indigenous status, infection-related deaths, and all-cause deaths after kidney transplantation, and whether acute rejection mediates the relationship between Indigenous status and overall graft loss. Methods: This cohort study included all recipients who received their first kidney transplant between 2005 and 2018 in Australia, using data from the Australia and New Zealand Dialysis and Transplant registry. Multivariable Cox regression models determined the associations between Indigenous status, graft loss, infection-related deaths, and all-cause deaths. Mediation analyses examined if acute rejection mediated these relationships. Primary outcome was infection-related death. Secondary outcomes included all-cause death and overall graft loss. Results: There were 9993 patients (n = 390 (3.9%) Indigenous Australians) who received a kidney transplant between 2005 and 2018, and they were followed-up with for 56,876 patient-years. A total of 1165 died (12%) (211 infection-related deaths) and 1957 (20%) lost their allografts. Compared with non-Indigenous recipients, the adjusted hazard ratio (HR) (95% confidence interval [CI]) for graft loss, infection-related deaths and all-cause deaths among Indigenous Australians were 2.27 (1.90-2.71), 3.01 (1.90-4.77) and 2.36 (1.89-2.94), respectively. The mediation analysis showed the association between Indigenous status and graft loss (but not infection-related death or all-cause death) was partially mediated by acute rejection (1.06 [1.03-1.09]), and the proportion of effects mediated by acute rejection was 0.10. Conclusion: Indigenous Australians experienced a higher risk of graft loss, a relationship mediated partially through acute rejection. The higher risk of infection-related death was independent of acute rejection.

Resetting the relationship: decolonizing peer review of First Nations' kidney health research.

Kerr et al. interpret the perspectives of First Nations People striving for kidney health within the United States, Canada, Aotearoa (New Zealand), and Australia. The urgency for First Nations Peoples' perspectives and leadership in kidney health care, research, quality reporting, and publishing was confirmed. Advancing this internationally is within scope of high-impact journals, such as Kidney International. Tracking Sovereignty is a proposed framework supporting First Nation Peoples' representation and leadership within journal submission and publication processes.

Rising Incidence of End-Stage Kidney Disease and Poorer Access to Kidney Transplant Among Australian Aboriginal and Torres Strait Islander Children and Young Adults.

INTRODUCTION: Details of the pediatric population with end-stage kidney disease (ESKD) in Australia and New Zealand have been published previously. There is, however, a paucity of studies exploring the trends in incidence, etiology, renal replacement therapy (RRT) modality, and transplant access among the Aboriginal and Torres Strait Islander children and young adults (ATCYAs) residing in Australia. METHODS: An observational study was undertaken and data on Australian patients who commenced RRT at ≤24 years of age between 1963 and 2017 were extracted from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). The incidence and prevalence rates were restricted from 1997 to 2017 because of the unavailability of Aboriginal- and Torres Strait Islander status-specific census data before 1997. RESULTS: A total of 3629 children and young adults received RRT during the observation period, including 178 (4.9%) who identified as ATCYAs and 3451 (95.1%) other children and young adults (OCYAs). Compared with OCYAs, incident rates have risen among ATCYAs since 2000, with the biggest rise for young adults 20 to 24 years of age. Fewer ATCYAs received a kidney transplant compared with OCYAs (56.2% vs. 89.3%, P < 0.001). Pre-emptive kidney transplants were less common in ATCYAs compared with OCYAs (3.4% vs. 16.8%, P < 0.001). Living related donor transplants were less common among ATCYAs than OCYAs (10.7% vs. 35.9%, P < 0.001). CONCLUSIONS: Our study shows rising incident rates and poorer access to kidney transplantation among ATCYAs in Australia. The reasons for this health care disparity and barriers to transplantation need to be explored further and must be addressed.

Effectiveness of Wellbeing Intervention for Chronic Kidney Disease (WICKD): results of a randomised controlled trial.

BACKGROUND: End stage kidney disease (ESKD) is associated with many losses, subsequently impacting mental wellbeing. Few studies have investigated the efficacy of psychosocial interventions for people with ESKD and none exist for Indigenous people, a population in which the ESKD burden is especially high. METHODS: This three-arm, waitlist, single-blind randomised controlled trial examined efficacy of the Stay Strong App in improving psychological distress (Kessler distress scale; K10), depressive symptoms (adapted Patient Health Questionnaire; PHQ-9), quality of life (EuroQoL; EQ. 5D) and dialysis adherence among Indigenous Australians undergoing haemodialysis in central and northern Australia (Alice Springs and Darwin), with follow up over two 3-month periods. Effects of immediate AIMhi Stay Strong App treatment were compared with those from a contact control app (The Hep B Story) and treatment as usual (TAU). Control conditions received the Stay Strong intervention after 3 months. RESULTS: Primary analyses of the full sample (N = 156) showed statistically significant decreases in K10 and PHQ-9 scores at 3 months for the Hep B Story but not for the Stay Strong app or TAU. Restricting the sample to those with moderate to severe symptoms of distress or depression (K10 > =25 or PHQ-9 > =10) showed significant decreases in K10 and PHQ-9 scores for both Stay Strong and Hep B Story. No significant differences were observed for the EQ-5D or dialysis attendance. CONCLUSIONS: Findings suggest that talking to people about their wellbeing and providing information relevant to kidney health using culturally adapted, locally relevant apps improve the wellbeing of people on dialysis. Further research is required to replicate these findings and identify active intervention components. TRIAL REGISTRATION: ACTRN12617000249358 ; 17/02/2017.

Oral health of aboriginal people with kidney disease living in Central Australia.

BACKGROUND: Associations between kidney disease and periodontal disease are not well documented among Aboriginal people of Australia. The purpose of this investigation was to report and compare demographic, oral health, anthropometric and systemic health status of Aboriginal Australians with kidney disease and to compare against relevant Aboriginal Australians and Australian population estimates. This provides much needed evidence to inform dental health service provision policies for Aboriginal Australians with kidney disease. METHODS: Sample frequencies and means were assessed in adults represented in six datasets including: (1) 102 Aboriginal Australians with kidney disease residing in Central Australia who participated in a detailed oral health assessment; (2) 312 Aboriginal participants of the Northern Territory's PerioCardio study; (3) weighted estimates from 4775 participants from Australia's National Survey of Adult Oral Health (NSAOH); (4) Australian 2016 Census (all Australians); (5) National Health Survey 2017-2018 (all Australians) and; (6) Australian Health Survey: Biomedical Results for Chronic Diseases, 2011-2012 (all Australians). Oral health status was described by periodontal disease and experience of dental caries (tooth decay). Statistically significant differences were determined via non-overlapping 95% confidence intervals. RESULTS: Aboriginal Australians with kidney disease were significantly older, less likely to have a tertiary qualification or be employed compared with both PerioCardio study counterparts and NSAOH participants. Severe periodontitis was found in 54.3% of Aboriginal Australians with kidney disease, almost 20 times the 2.8% reported in NSAOH. A higher proportion of Aboriginal Australians with kidney disease had teeth with untreated caries and fewer dental restorations when compared to NSAOH participants. The extent of periodontal attachment loss and periodontal pocketing among Aboriginal Australians with kidney disease (51.0%, 21.4% respectively) was several magnitudes greater than PerioCardio study (22.0%, 12.3% respectively) and NSAOH (5.4%, 1.3% respectively) estimates. CONCLUSIONS: Aboriginal Australians with kidney disease exhibited more indicators of poorer oral health than both the general Australian population and a general Aboriginal population from Australia's Northern Territory. It is imperative that management of oral health among Aboriginal Australians with kidney disease be included as part of their ongoing medical care.

Longitudinal whole-genome based comparison of carriage and infection associated Staphylococcus aureus in northern Australian dialysis clinics.

BACKGROUND: The study objective was to reveal reservoirs potentially leading to Staphylococcus aureus infections in haemodialysis clinic clients in the tropical north of the Australian Northern Territory (NT). This client population are primarily Aboriginal Australians who have a greater burden of ill health than other Australians. Reservoir identification will enhance infection control in this client group, including informing potential S. aureus decolonisation strategies. METHODS AND FINDINGS: The study participants were 83 clients of four haemodialysis clinics in the Darwin region of the NT, and 46 clinical staff and researchers who had contact with the clinic clients. The study design was longitudinal, encompassing swabbing of anatomical sites at two month intervals to yield carriage isolates, and also progressive collection of infection isolates. Swab sampling was performed for all participants, and infection isolates collected for dialysis clients only. Analysis was based on the comparison of 139 carriage isolates and 27 infection isolates using whole genome sequencing. Genome comparisons were based on of 20,651 genome-wide orthologous SNPs, presence/absence of the mecA and pvl genes, and inferred multilocus sequence type and clonal complex. Pairs of genomes meeting the definition of "not discriminated" were classed as defining potential transmission events. The primary outcome was instances of potential transmission between a carriage site other than a skin lesion and an infection site, in the same individual. Three such instances were identified. Two involved ST762 (CC1) PVL- MRSA, and one instance ST121 PVL+ MSSA. Three additional instances were identified where the carriage strains were derived from skin lesions. Also identified were six instances of potential transmission of a carriage strains between participants, including transmission of strains between dialysis clients and staff/researchers, and one potential transmission of a clinical strain between participants. There were frequent occurrences of longitudinal persistence of carriage strains in individual participants, and two examples of the same strain causing infection in the same participants at different times. Strains associated with infections and skin lesions were enriched for PVL and mecA in comparison to strains associated with long term carriage. CONCLUSIONS: This study indicated that strains differ with respect to propensity to stably colonise sites such as the nose, and cause skin infections. PVL+ strains were associated with infection and skin lesions and were almost absent from the carriage sites. PVL- MRSA (mainly CC1) strains were associated with infection and also with potential transmission events involving carriage sites, while PVL- MSSA were frequently observed to stably colonise individuals without causing infection, and to be rarely transmitted. Current clinical guidelines for dialysis patients suggest MRSA decolonisation. Implementation in this client group may impact infections by PVL- MRSA, but may have little effect on infection by PVL+ strains. In this study, the PVL+ strains were predominant causes of infection but rarely colonised typical carriage sites such as the nose, and in the case of ST121, were MSSA. The important reservoirs for infection by PVL+ strains appeared to be prior infections.