Experiences, Knowledge Gaps and Information Needs of Women in Australia with Transfusion Dependent Thalassaemia in Regard to Fertility and Pregnancy.

OBJECTIVES: Transfusion dependent ß-thalassaemia can have significant effects on fertility and is also associated with significant risks in pregnancy. However, little is known about the perspectives of women living with the condition with regards to reproductive issues. The aim of this study was to assess the experience, knowledge and information needs of Australian women living with transfusion dependent ß-thalassaemia in relation to fertility and pregnancy. METHODS: A cross sectional study using an online anonymous survey, self-administered through REDCap, addressing key issues related to the experience, knowledge and information needs of women with transfusion dependent ß-thalassaemia. Descriptive and inferential analysis was conducted using STATA. RESULTS: Sixty participants were included in the analysis. Two-thirds of sexually active, pre-menopausal women were using contraception. Just under half of the participants who were sexually active had children and half had required some form of assisted reproductive technology to achieve a pregnancy. Less than half identified the importance of contraception as part of ensuring optimised pre-pregnancy care, and less than half had accessed pre-pregnancy care. Although there was good understanding of the increased risk of infertility and pregnancy complications, the specific risks and causes of these risks were poorly understood. Around half of the participants indicated they wanted more information on these medical issues. CONCLUSIONS FOR PRACTICE: Our study demonstrated significant concerns and knowledge gaps in Australian women with transfusion dependent ß-thalassaemia with regards to disease-specific issues related to fertility and pregnancy, and a desire for related patient information.

Effect of chronic kidney disease on all-cause mortality in tuberculosis disease: an Australian cohort study.

BACKGROUND: While there has been a recent epidemiological and clinical focus on the interaction between diabetes and tuberculosis, the interaction between chronic kidney disease and tuberculosis has been less studied. In particular, little is known of the effect of eGFR levels well above that seen in end stage kidney disease on mortality. METHODS: We conducted a retrospective cohort study of 653 adults from a large Australian hospital network, using data from a state-wide registry of reported tuberculosis cases between 2010 and 2018, with ascertainment of diabetes status and renal function data from hospital medical records and laboratory data. Cox proportional hazards regression models were used to calculate hazard ratios for all-cause mortality associated with categories of chronic kidney disease in adults with tuberculosis disease. RESULTS: Total number of deaths was 25 (3.8%). Compared to tuberculosis cases with eGFR ≥ 60 ml/min, all-cause mortality was higher for those with chronic kidney disease from an eGFR level of 45 ml/min. The association was independent of sex, age and diabetes status with adjusted hazard ratio of 4.6 (95% CI: 1.5, 14.4) for eGFR 30-44 ml/min and 8.3 (95% CI: 2.9, 23.7) for eGFR < 30 ml/min. CONCLUSIONS: Our results suggest a notably increased risk of all-cause mortality even in those with more moderate degrees of renal impairment, in a low tuberculosis prevalence setting. The impact of these findings on a population basis are at least as significant as that found with diabetes and warrant further investigation in populations with higher tuberculosis prevalence.

Effects of empagliflozin treatment on cardiac function and structure in patients with type 2 diabetes: a cardiac magnetic resonance study.

BACKGROUND: The effects of empagliflozin on cardiac structure and function are not known. AIMS: To examine the changes in cardiac structure and function following the addition of empagliflozin in patients with type 2 (T2D) diabetes using cardiac magnetic resonance (CMR) imaging. METHODS: Twenty patients attending a specialist diabetes service recommended for treatment with empagliflozin, and 8 control patients with T2D on stable glucose lowering therapy were recruited for cardiac imaging. Participants underwent CMR scans at baseline and 6 months. Inclusion criteria were established T2D, age < 75 years, estimated glomerular filtration rate ≥45 mL/min/1.73 m2 . RESULTS: 17 of 20 in the empagliflozin group, and all of 8 in the control group completed the study. Empagliflozin therapy was associated with reduction in left ventricular end diastolic volume 155 mL (137 mL, 174 mL) at baseline to 145 mL (125 mL, 165 mL) at 6 months, P < 0.01, compared with the control group 153 mL (128 mL, 179 mL) at baseline and 158 mL (128 mL, 190 mL), not significant. There were no differences in measures of left ventricular mass, ejection fraction, heart rate or markers of cardiac fibrosis at baseline and 6 months in either group. CONCLUSIONS: This is the first CMR study to examine the effects of empagliflozin on cardiac function and structure, showing evidence of reduced end diastolic volume. This is likely to reflect change in plasma volume, and may explain the reduced cardiovascular death and heart failure seen in the EMPA-REG OUTCOME trial.

Long-Term Effectiveness of Continuous Subcutaneous Insulin Infusion in the Prevention of Hypoglycemia in Adults with Type 1 Diabetes.

Background: Reducing hyperglycemia while avoiding hypoglycemia is the key clinical goal in managing people with type 1 diabetes. Insulin delivery techniques and regimens are constantly evolving to achieve these goals. At present, use of multiple daily injections (MDI) is the standard of care, but there is increasing interest in continuous subcutaneous insulin infusion (CSII). There is a deficit of studies comparing long-term glycemic control and hypoglycemia outcomes between these therapeutic options. Methods: This was a single-center, retrospective cohort study of adults with type 1 diabetes. Data were derived from electronic medical records and included demographic and clinical factors. Participants had all undergone intensive diabetes education, followed by CSII or continued MDI. The primary outcome was difference in hypoglycemia, defined as the percentage of self-monitoring blood glucose levels less than 3.9 mmol/L. Up to 10 years of follow-up data were available, between 2000 and 2016. Results: There were 69 participants using CSII and 78 using MDI. Self-monitoring blood glucose data showed significantly less hypoglycemia with CSII by over 30%, occurring as early as the first year and sustained throughout the follow-up period (P < 0.001). This benefit of CSII on reducing hypoglycemia was independent of more frequent hypoglycemia and higher body weight at baseline, factors that were also independently associated with reduced hypoglycemia. Conclusions: In selected adults with type 1 diabetes, long-term CSII can provide long-term clinically relevant and sustained reductions in hypoglycemia, particularly in those with greater initial risk of hypoglycemia and higher body weight, and improved glycemic control compared with MDI.

Continuous Subcutaneous Insulin Infusion Can Be Used Effectively and Safely in Older Patients with Type 1 Diabetes: Long-Term Follow-up.

Use of continuous subcutaneous insulin infusion (CSII) in adults with type 1 diabetes has become increasingly popular in recent years, with recent studies examining the efficacy of CSII use in pregnancy and in type 2 diabetes. However, there is very limited information on the benefit of CSII in older patients with type 1 diabetes. Electronic medical records were retrospectively analyzed for patients with type 1 diabetes undertaking structured patient education and initiated on CSII or multiple daily injections (MDI) between 2000 and 2016. Outcomes examined related to changes in glycemic parameters and weight and utilization of healthcare resources. Data relating to 293 patients fulfilled the inclusion criteria, with up to 10 years of follow-up data available. For patients commencing CSII, glycemic and weight outcomes and utilization of healthcare resources were similar in older compared with younger patients. For older patients, use of CSII was associated with better glycemic outcomes at the cost of a small increase in healthcare resources compared with MDI. CSII can be used effectively and safely in the longer term in carefully selected older patients with type 1 diabetes, with similar outcomes as observed in younger patients using CSII, and potentially better glycemic outcomes than MDI in older patients.

Exercise and calcium combined results in a greater osteogenic effect than either factor alone: a blinded randomized placebo-controlled trial in boys.

UNLABELLED: We examined the combined effects of exercise and calcium on BMC accrual in pre- and early-pubertal boys. Exercise and calcium together resulted in a 2% greater increase in femur BMC than either factor alone and a 3% greater increase in BMC at the tibia-fibula compared with the placebo group. Increasing dietary calcium seems to be important for optimizing the osteogenic effects of exercise. INTRODUCTION: Understanding the relationship between exercise and calcium during growth is important given that the greatest benefits derived from these factors are achieved during the first two decades of life. We conducted a blinded randomized-controlled exercise-calcium intervention in pre- and early-pubertal boys to test the following hypotheses. (1) At the loaded sites (femur and tibia-fibula), exercise and calcium will produce greater skeletal benefits than either exercise or calcium alone. (2) At nonloaded sites (humerus and radius-ulna), there will be an effect of calcium supplementation. MATERIALS AND METHODS: Eighty-eight pre- and early-pubertal boys were randomly assigned to one of four study groups: moderate impact exercise with or without calcium (Ca) (Ex+Ca and Ex+placebo, respectively) or low impact exercise with or without Ca (No-Ex+Ca and No-Ex+Placebo, respectively). The intervention involved 20 minutes of either moderate- or low-impact exercise performed three times a week and/or the addition of Ca-fortified foods using milk minerals (392+/-29 mg/day) or nonfortified foods over 8.5 months. Analysis of covariance was used to determine the main and combined effects of exercise and calcium on BMC after adjusting for baseline BMC. RESULTS: At baseline, no differences were reported between the groups for height, weight, BMC, or bone length. The increase in femur BMC in the Ex+Ca group was approximately 2% greater than the increase in the Ex+placebo, No-Ex+Ca, or No-Ex+Placebo groups (all p<0.03). At the tibia-fibula, the increase in BMC in the Ex+Ca group was approximately 3% greater than the No-Ex+placebo group (p<0.02) and 2% greater than the Ex+Placebo and the No-Ex+Ca groups (not significant). No effect of any group was detected at the humerus, ulna-radius, or lumbar spine for BMC, height, bone area, or volume. CONCLUSIONS: In this group of normally active boys with adequate calcium intakes, additional exercise and calcium supplementation resulted in a 2-3% greater increase in BMC than controls at the loaded sites. These findings strengthen the evidence base for public health campaigns to address both exercise and dietary changes in children for optimizing the attainment of peak BMC.

Risk of renal allograft loss from recurrent glomerulonephritis.

BACKGROUND: Recurrent glomerulonephritis is a known cause of renal allograft loss; however, the incidence of this complication is poorly defined. We determined the incidence, timing, and relative importance of allograft loss due to the recurrence of glomerulonephritis. METHODS: A total of 1505 patients with biopsy-proved glomerulonephritis received a primary renal transplant in Australia from 1988 through 1997. Recurrence was confirmed by renal biopsy. The Kaplan-Meier method was used to estimate the 10-year incidence of allograft failure due to recurrent glomerulonephritis, and this incidence was compared with the incidence of acute rejection, chronic rejection, and death with a functioning allograft. Characteristics of the recipients and donors were examined as potential predictors of recurrence. RESULTS: Allograft loss due to the recurrence of glomerulonephritis occurred in 52 recipients, with a 10-year incidence of 8.4 percent (95 percent confidence interval, 5.9 to 12.0). The type of glomerulonephritis, the sex of the recipient, and the peak level of panel-reactive antibodies were independent predictors of the risk of recurrence. Recurrence was the third most frequent cause of allograft loss at 10 years, after chronic rejection and death with a functioning allograft. Despite the effect of recurrence, the overall 10-year incidence of allograft loss was similar among transplant recipients with biopsy-proved glomerulonephritis and among those with other causes of renal failure (45.4 percent [95 percent confidence interval, 40.9 to 50.2] vs. 45.8 percent [95 percent confidence interval, 42.3 to 49.3], P=0.09). CONCLUSIONS: Recurrence is an important cause of allograft loss for those with renal failure due to glomerulonephritis. No risk factors for recurrence were identified that warrant altering the approach to transplantation. However, accurate estimates of risk can now be provided to potential recipients of renal allografts.

Proteinuria reduction and progression to renal failure in patients with type 2 diabetes mellitus and overt nephropathy.

BACKGROUND: Little is known of the effects of blood pressure reduction by specific classes of antihypertensive drugs on the association between proteinuria reduction and progression of kidney insufficiency and development of end-stage kidney disease in patients with overt diabetic nephropathy in type 2 diabetes mellitus. METHODS: Associations between baseline proteinuria and proteinuria reduction by either irbesartan, amlodipine, or control for similar decrements in blood pressure and the cumulative incidence of renal end points were examined using the Kaplan-Meier method in patients enrolled in the Irbesartan Diabetic Nephropathy Trial. RESULTS: Risk for kidney failure doubled for each doubling of baseline proteinuria level (hazard ratio, 2.04; 95% confidence interval, 1.87 to 2.22; P < 0.001). For each halving of proteinuria level between baseline and 12 months with treatment, risk for kidney failure was reduced by more than half (hazard ratio, 0.44; 95% confidence interval, 0.40 to 0.49; P < 0.001). For the same proportional change in proteinuria, the reduction in risk for kidney failure was significantly greater for irbesartan compared with amlodipine ( P = 0.048), but not control ( P = 0.245). Proteinuria reduction in the first 12 months of therapy with irbesartan is associated with 36% of the total renoprotective effect observed. CONCLUSION: Baseline proteinuria is an important risk factor for kidney failure and provides a means to identify patients at greatest risk. Halving proteinuria halves the kidney risk. Proteinuria reduction using an angiotensin receptor-blocking agent, such as irbesartan, should be regarded as an important therapeutic goal in renoprotective strategies.

Laser in situ keratomileusis for refractive error after cataract surgery.

PURPOSE: To evaluate the safety and efficacy of laser in situ keratomileusis (LASIK) to correct refractive error following cataract surgery. SETTING: The Eye Institute, Sydney, Australia. METHODS: This retrospective study reviewed 23 eyes (19 patients; 10 female, 9 male) treated with LASIK for refractive error following cataract surgery. The Summit Apex Plus and Ladarvision excimer laser and the SKBM microkeratome were used. The mean age was 63.5 years (range 50 to 88 years). The mean length of follow-up was 8.4 months (range 1 to 12 months) and mean interval between cataract surgery and LASIK was 12 months (range 2.5 to 46 months). RESULTS: The mean preoperative spherical equivalent refraction (SEQ) for myopic eyes was -3.08 +/- 0.84 diopters (D) (range -4.75 to -2.00 D) and for hyperopic eyes was +1.82 +/- 1.03 D (range +0.75 to +3.00 D). The mean improvement following LASIK surgery was greater for myopic than hyperopic eyes (myopic, 2.54 +/- 1.03 D versus hyperopic, 1.73 +/- 0.62 D; P=.033). The percentage of patients within +/-0.5 D of intended refraction post-LASIK surgery was 83.3% for myopic eyes and 90.9% for hyperopic eyes and all eyes were within +/-1.0 D of intended (P<.001). The percentage of eyes with uncorrected visual acuity of 20/40 or better in the myopic group improved from none preoperatively to 91.7% postoperatively (P<.001) and in the hyperopic group improved from 27.3% preoperatively to 90.9% postoperatively (P=.008). No eyes lost 2 or more lines of best corrected visual acuity. CONCLUSION: Laser in situ keratomileusis appears to be effective in correcting refractive error following cataract surgery. Longer-term studies are required to determine refractive stability.

Health-related quality of life in Australian adults with renal insufficiency: a population-based study.

BACKGROUND: Health-related quality of life is increasingly recognized as an important outcome in clinical research and patient care. Although there are a large number of reports of quality of life in the setting of end-stage renal disease, the impact of lesser degrees of renal impairment in the general population has not been described. METHODS: Data relating to quality of life measured by the Medical Outcomes Study 36-Item Short Form (SF-36) was available for 10,525 participants (93.6%) of the Australian Diabetes, Obesity and Lifestyle Study, a randomly selected representative sample of the Australian population aged 25 years or older. Results are examined by category of renal function (Cockcroft-Gault estimated glomerular filtration rate: normal, > or =60 mL/min/1.73 m2; renal insufficiency, <60 mL/min/1.73 m2). RESULTS: Significant impairment in health-related quality of life was seen with renal insufficiency for all SF-36 scales except Vitality and Mental Health. Adjusting for the substantial comorbidity associated with renal insufficiency, scores for Physical Functioning, Role-Physical, General Health, Vitality, and Role-Emotional were significantly lower. Examination of age-specific effects on health-related quality of life showed that mental health was particularly impaired in the younger age group, and Physical Functioning, in the older age group with renal insufficiency. Patterns of impairment were similar in men and women. CONCLUSION: Results from this study indicate that the current emphasis on clinical interventions aimed at preserving renal function are likely to improve the negative impact of kidney disease on health-related quality of life; however, prospective studies are needed to confirm these findings.

Smoking is associated with renal impairment and proteinuria in the normal population: the AusDiab kidney study. Australian Diabetes, Obesity and Lifestyle Study.

BACKGROUND: Smoking has been associated with the prevalence, development, and progression of kidney disease. The effect of smoking on kidney function in the healthy population is unclear. We examined the relationship between smoking and indicators of kidney damage in a healthy population without impaired fasting glucose levels, impaired glucose tolerance, diabetes mellitus, or hypertension. METHODS: This is a randomly selected, population-based, cross-sectional study of 11,247 Australian adults. Smoking status was determined by questionnaire. Subjects were tested for indicators of kidney damage: renal impairment by Cockcroft-Gault-estimated glomerular filtration rate less than 60 mL/min/1.73 m2 and proteinuria by urine protein-creatinine ratio of 0.20 mg/mg or greater. RESULTS: After adjusting for potential confounding factors, smoking was significantly associated with renal impairment in men with an odds ratio of 3.59, but not in women. Smoking was significantly associated with proteinuria in subjects with high-normal systolic blood pressure, with odds ratios ranging from 3.64 at 131.5 mm Hg to 5.76 at 139.5 mm Hg, and in subjects with high-normal 2-hour glucose levels, with odds ratios ranging from 1.76 at 7.0 mmol/L to 10.84 at 7.7 mmol/L. Lifetime exposure, but not current level of smoking, correlated with lower estimated glomerular filtration rate and greater urine protein-creatinine ratio. CONCLUSION: Smoking is associated with renal impairment and proteinuria in a population without hypertension or abnormal glucose metabolism. A dose-response relationship was found between cumulative amount of smoking and indicators of kidney damage. In conjunction with other studies and plausible biological mechanisms, this study suggests that smoking may cause kidney damage, even in a healthy population.

Prevalence of albuminuria in Australia: the AusDiab Kidney Study.

BACKGROUND: Albuminuria is an important predictor of risk of progressive renal disease, cardiovascular disease, and mortality; however, the prevalence in the general population is not well defined. We determined estimates of the population prevalence and associations of microalbuminuria and macroalbuminuria in Australian adults; 11,247 Australians aged > or = 25 years living in 42 randomly selected population clusters were tested for albuminuria (spot urine albumin:creatinine (mg/mmol): normal < 3.4, microalbuminuria 3.4 to 34, macroalbuminuria > 34). METHODS: Prevalence of micro- and macroalbuminuria were assessed with age, sex, obesity, smoking, hypertension (> or = 140/90 mm Hg or known diagnosis on treatment), glucose metabolism status (WHO criteria according to fasting glucose and oral glucose tolerance test), ischemic heart and cerebrovascular disease, and low glomerular filtration rate (calculated glomerular filtration rate < 60 mL/min/1.73m2). RESULTS: Microalbuminuria and macroalbuminuria proteinuria were present in 6.0% and 0.6% of the population, respectively. The majority of subjects with microalbuminuria (64%) and macroalbuminuria (76%) had hypertension, and approximately half of those with albuminuria had abnormal glucose metabolism. Of all participants with microalbuminuria, 25.9% had normal blood pressure and glucose metabolism, and in this group, alternative associations of microalbuminuria included obesity (13.5%), smoking (20.7%), and low glomerular filtration rate (12.3%). CONCLUSION: Albuminuria is present in a small percentage of the general adult population, but is highly prevalent in subjects with hypertension and/or abnormal glucose metabolism. The majority of cases of microalbuminuria and macroalbuminuria in the general population are among those with hypertension.

Transferring patients for primary angioplasty in eastern Melbourne (the SHIPEM registry): are we meeting the guidelines?

OBJECTIVES: To compare clinical outcomes between patients with ST-elevation myocardial infarction (STEMI) presenting to a hospital with facilities for primary percutaneous coronary intervention (PCI) and patients transferred from a non-PCI-capable unit, and to determine the success rate of meeting clinical guidelines for management of STEMI. DESIGN, SETTING AND PARTICIPANTS: Prospective study of patients with STEMI who underwent PCI at Box Hill Hospital (BHH), Melbourne, between 1 July 2002 and 30 June 2008. We compared two patient groups: "BHH patients", who were admitted directly to BHH (a hospital with PCI capability), and "SHIPEM (Shipping Infarcts for Primary Angioplasty in Eastern Melbourne Registry) patients", who were transferred from other hospitals without PCI capability. MAIN OUTCOME MEASURES: Clinical outcomes; symptom-to-first-door time (time between symptom onset and arrival at first hospital); first-door-to-balloon time (time between arrival at the first hospital and inflation of the angioplasty balloon); compliance with Cardiac Society of Australia and New Zealand/National Heart Foundation of Australia (CSANZ/NHFA) guidelines for management of patients with STEMI. RESULTS: There were 598 patients in the BHH group and 189 in the SHIPEM group. The median first-door-to-balloon time was 89 minutes (interquartile range [IQR], 69-107 minutes) for BHH patients and 128 minutes (IQR, 104-157 minutes) for SHIPEM patients. These figures did not vary significantly over the 6 years of the registry. In the BHH group, 180 patients (30.1%) had a symptom-to-first-door time of < or = 60 minutes, with 32 (17.8%) receiving PCI in < or = 60 minutes. The corresponding figure for the SHIPEM group was 48 patients (25.4%), with 1 (2.1%) receiving PCI within 60 minutes. In the BHH group, 304 patients (50.8%) had a symptom-to-first-door time of 61-180 minutes, with 166 (54.6%) receiving PCI in < or = 90 minutes. In the SHIPEM group, 50 patients (26.5%) had a symptom-to-first-door time of > 180 minutes, with 21 (42.0%) receiving PCI in < or = 120 minutes. CONCLUSION: Our study demonstrates that transfer for PCI is feasible and safe in selected patients, with outcomes comparable to those of patients presenting to a PCI-capable unit. However, the CSANZ/NHFA targets, predicated by symptom-to-first-door time, are not being met and have not improved over time, which suggests that strategies to improve symptom-to-first-door, first-door-to-balloon and transfer times need to be addressed.

A randomized controlled trial of a standardized educational intervention for patients with cancer pain.

CONTEXT: Published literature has not defined the effectiveness of standardized educational tools that can be self-administered in the general oncology population with pain. OBJECTIVES: We sought to determine if an educational intervention consisting of a video and/or booklet for adults with cancer pain could improve knowledge and attitudes about cancer pain management, pain levels, pain interference, anxiety, quality of life, and analgesic use. METHODS: Eligible participants had advanced cancer, a pain score >/=2 of 10 in the last week, English proficiency, an estimated prognosis of more than one month, and were receiving outpatient cancer treatment at participating hospitals. Participants completed baseline assessments and then were randomly allocated to receive a booklet, a video, both, or neither, in addition to standard care. Outcome measures at two and four weeks included the Barriers Questionnaire (BQ), Brief Pain Inventory, Global Quality of Life Scale, and Hospital Anxiety and Depression Scale. Adequacy of analgesia and severity of pain were assessed with the Pain Management Index and a daily pain diary. RESULTS: One hundred fifty-eight participants were recruited from 21 sites over 42 months. Baseline mean barriers scores were lower than reported in previous Australian studies at 1.33 (standard deviation: 0.92). Mean average pain and worst pain scores improved significantly in patients receiving both the video and booklet by 1.17 (standard error [SE]: 0.51, P=0.02) and 1.12 (SE: 0.57, P=0.05), respectively, on a 0-10 scale. The addiction subscale of the BQ score was improved by 0.44 (SE: 0.19) for participants receiving any part of the intervention (P=0.03). CONCLUSION: Provision of a video and/or booklet for people with cancer pain was a feasible and effective adjunct to the management of cancer pain.

Prevalence and treatment of cardiovascular disease and traditional risk factors in Australian adults with renal insufficiency.

AIM: To evaluate the prevalence and treatment of cardiovascular disease and traditional cardiovascular disease risk factors in Australian adults with renal insufficiency. METHODS: The Australian Diabetes, Obesity and Lifestyle Study was a cross-sectional survey of Australian adults undertaken in 1999-2000. Participants were categorized based on the Cockcroft-Gault estimated glomerular filtration rate in terms of normal renal function (<60 mL/min per 1.73 m(2)) and renal insufficiency (<60 mL/min per 1.73 m(2)). Outcome measures were the prevalence of cardiovascular disease, estimated risk of cardiovascular disease (20% over 10 years) and traditional cardiovascular risk factors, and frequency of pharmacological treatment of traditional cardiovascular risk factors. RESULTS: Among adults with renal insufficiency, cardiovascular disease was present in 29.4 (95% CI: 25.1-33.6) per 100, with an additional 47.9 (95% CI: 44.9-50.9) per 100 having an estimated risk of cardiovascular disease (20% over 10 years). At least one cardiovascular risk factor was present in 90.1%. Hypertension and type 2 diabetes mellitus were three times more frequent, while hyperlipidaemia was nearly twice as frequent in those participants with renal insufficiency. Of those with renal insufficiency, 58.2% with hypertension were treated, with only 14.5% of this group being treated to current recommended target levels of blood pressure, while only 32.5% with hyperlipidaemia were treated, with 7.4% of this group being treated to target lipid levels. CONCLUSION: The present study demonstrates significant scope to reduce the high burden of cardiovascular risk factors in Australian adults with renal insufficiency in the general community, through treatment of traditional risk factors for cardiovascular disease.

Association between albuminuria and proteinuria in the general population: the AusDiab Study.

BACKGROUND: The relationship between urinary albumin and total protein excretion and the appropriateness of one test over the other are unclear due to the paucity of large epidemiological studies of albuminuria and proteinuria. In screening for renal and cardiovascular disease, whether to measure albuminuria, proteinuria or both, is currently an unanswered question. METHODS: Random urine samples from 10,596 (94.2%) participants of the Australian Diabetes, Obesity and Lifestyle Study were tested for albuminuria (urine albumin:creatinine > or =30 mg/g) and proteinuria (urine protein:creatinine > or =0.20 mg/mg). This study was a representative sample of the national non-institutionalized population drawn from 42 randomly selected urban and non-urban areas (census collector districts) across Australia. RESULTS: Among a representative cross-section of the Australian adult population, urine albumin excretion was strongly correlated with total protein excretion, particularly among the elderly, and those with diabetes mellitus, hypertension, obesity and renal impairment (P <0.001). Albuminuria performed well as a screening test for proteinuria: sensitivity 91.7% [95% confidence interval (CI) 87.7-94.5%], specificity 95.3% (95% CI 94.9-95.7%) and negative predictive value 99.8% (95% CI 99.7-99.9%). However, among those with proteinuria, 8% excreted albumin within the normal range. CONCLUSIONS: While albuminuria may be a suitable test for general population screening for renal and cardiovascular disease, it should not replace testing for proteinuria in those with known or suspected renal disease.

Macrophage migration inhibitory factor in systemic lupus erythematosus.

OBJECTIVE: To examine associations between serum macrophage migration inhibitory factor (MIF) and disease-related variables and corticosteroid use in patients with systemic lupus erythematosus (SLE). METHODS: Serum MIF concentration was measured by ELISA in 90 female patients with SLE and 279 healthy controls. Univariate and multivariate regression analyses were used to examine the associations between serum MIF concentration and disease-related indices of SLE and corticosteroid use. RESULTS: Serum MIF concentrations were positively associated with SLE disease damage (SLICC/ACR index), and indices of disease damage were greater in SLE patients with serum MIF concentrations above the normal median value. Serum MIF concentration was also observed to be significantly greater in patients with SLICC/ACR damage index (DI) scores >/= 3. Serum MIF was also positively associated with current corticosteroid dose. Significantly higher SLICC/ACR DI scores were observed in patients with values of serum MIF above the normal median, and this remained significant after adjusting for corticosteroid dose. Serum MIF concentration was also predictive of SLICC/ACR index after 3 years of followup, but this association was partly confounded by corticosteroid dose. Serum MIF was also negatively associated with serum creatinine concentration, independent of disease damage and corticosteroid dose. CONCLUSION: MIF is overexpressed in patients with SLE. While this can be partly explained by corticosteroid use, there is evidence of an association between MIF and lupus-related disease damage.

Graft loss following renal transplantation in Australia: is there a centre effect?

BACKGROUND: Assessment of centre variation in renal transplantation outcome provides an opportunity to examine differences in quality of care between centres. However, differences in outcome may represent differences in patient factors between centres and be biased by sampling variability and inadequate data ascertainment. METHODS: Differences in 12-month graft survival in 1986 primary renal transplant adult recipients from 16 centres in Australia between 1993 and 1998 were examined. Fifteen recipient and donor factors known prior to transplantation were examined to determine factors independently predictive of graft survival. Differences between centres in these factors were examined. Unadjusted and multivariable adjusted outcomes for each centre were compared to the average for all centres. Multivariable hierarchical modelling was employed to account for potential bias due to sampling variability. RESULTS: Factors predictive of reduced 12-month graft survival on multivariable analysis that were significantly different between centres were time on dialysis prior to transplantation, donor age, organ source, and number of human lymphocyte antigen mismatches. Unadjusted 12-month graft survival for all centres was 91.7% and ranged from 83.1 to 96.4%. Although two centres performed significantly lower than average, this poorer outcome was accounted for in one of these two centres after adjusting for factors shown to be independently predictive of outcome. However, multivariable hierarchical modelling failed to identify any centre as performing significantly different to average, with 12-month graft survival ranging from 89.2 to 92.2%. Outcome in patients excluded from the study due to inadequate data ascertainment was significantly worse than patients who were included. CONCLUSIONS: There was no evidence of centre variation after accounting for variation in risk factors predictive of poor outcome between centres, as well as potential bias due to sampling variability. Exclusion of patients due to inadequate data remains an important source of bias in estimating accurate outcomes. Appropriate analytical strategies and consideration of sources of bias are important for the valid identification of centres with poorer outcomes.

Prevalence of kidney damage in Australian adults: The AusDiab kidney study.

The incidence of ESRD is increasing dramatically. Progression to end-stage may be halted or slowed when kidney damage is detected at an early stage. Kidney damage is frequently asymptomatic but is indicated by the presence of proteinuria, hematuria, or reduced GFR. Population-based studies relating to the prevalence of kidney damage in the community are limited, particularly outside of the United States. Therefore, the prevalence of proteinuria, hematuria, and reduced GFR in the Australian adult population was determined using a cross-sectional study of 11,247 noninstitutionalized Australians aged 25 yr or over, randomly selected using a stratified, cluster method. Subjects were interviewed and tested for proteinuria-spot urine protein to creatinine ratio (abnormal: >/=0.20 mg/mg); hematuria-spot urine dipstick (abnormal: 1+ or greater) confirmed by urine microscopy (abnormal: >10,000 red blood cells per milliliter) or dipstick (abnormal: 1+ or greater) on midstream urine sample; and reduced GFR-Cockcroft-Gault estimated GFR (abnormal: <60 ml/min per 1.73 m(2)). The associations between age, gender, diabetes mellitus, and hypertension, and indicators of kidney damage were examined. Proteinuria was detected in 2.4% of cases (95% CI: 1.6%, 3.1%), hematuria in 4.6% (95% CI: 3.8%, 5.4%), and reduced GFR in 11.2% (95% CI: 8.6%, 13.8%). Approximately 16% had at least one indicator of kidney damage. Age, diabetes mellitus, and hypertension were independently associated with proteinuria; age, gender, and hypertension with hematuria; and age, gender, and hypertension with reduced GFR. Approximately 16% of the Australian adult population has either proteinuria, hematuria, and/or reduced GFR, indicating the presence of kidney damage. Identifying and targeting this section of the population may provide a means to reduce the burden of ESRD.