Combination therapy with kidney protective therapies: optimizing the benefits?

PURPOSE OF REVIEW: Recent advances in the treatment of chronic kidney disease (CKD) have led to the development of several new agents that are kidney protective, particularly in people with diabetes. These agents include sodium/glucose cotransporter-2 inhibitors (SGLT-2 inhibitors), mineralocorticoid receptor antagonists (MRAs), and glucagon-like peptide-1 receptor agonists (GLP-1RAs). This review summarizes the available data regarding the effects of using these therapies in combination. RECENT FINDINGS: There is convincing evidence that SGLT-2 inhibitors and MRAs individually improve kidney function and reduce the risk of cardiovascular events in people with CKD, especially diabetic CKD. There is some evidence that GLP-1RAs may be beneficial, but further studies are needed.The available data support an additive kidney and cardiovascular benefit using combination therapy with SGLT-2 inhibitors and MRAs, and possibly with SGLT2 inhibitors and GLP-1RAs, but more long-term data are needed. The currently available data suggest that combining these agents would likely be beneficial and may be an appropriate long-term strategy. SUMMARY: Several new agents are useful in slowing the progress of CKD. Further research to identify which combinations of agents work best together and which combinations are most effective for people with different characteristics, in order to personalize treatment and improve outcomes for people with CKD, should be a priority.

Tunneled Hemodialysis Catheter Tip Design and Risk of Catheter Dysfunction: An Australian Nationwide Cohort Study.

RATIONALE & OBJECTIVE: Hemodialysis catheter dysfunction is an important problem for patients with kidney failure. The optimal design of the tunneled catheter tip is unknown. This study evaluated the association of catheter tip design with the duration of catheter function. STUDY DESIGN: Observational cohort study using data from the nationwide REDUCCTION trial. SETTING & PARTICIPANTS: 4,722 adults who each received hemodialysis via 1 or more tunneled central venous catheters in 37 Australian nephrology services from December 2016 to March 2020. EXPOSURE: Design of tunneled hemodialysis catheter tip, classified as symmetrical, step, or split. OUTCOME: Time to catheter dysfunction requiring removal due to inadequate dialysis blood flow assessed by the treating clinician. ANALYTICAL APPROACH: Mixed, 3-level accelerated failure time model, assuming a log-normal survival distribution. Secular trends, the intervention, and baseline differences in service, patient, and catheter factors were included in the adjusted model. In a sensitivity analysis, survival times and proportional hazards were compared among participants' first tunneled catheters. RESULTS: Among the study group, 355 of 3,871 (9.2%), 262 of 1,888 (13.9%), and 38 of 455 (8.4%) tunneled catheters with symmetrical, step, and split tip designs, respectively, required removal due to dysfunction. Step tip catheters required removal for dysfunction at a rate 53% faster than symmetrical tip catheters (adjusted time ratio, 0.47 [95% CI, 0.33-0.67) and 76% faster than split tip catheters (adjusted time ratio, 0.24 [95% CI, 0.11-0.51) in the adjusted accelerated failure time models. Only symmetrical tip catheters had performance superior to step tip catheters in unadjusted and sensitivity analyses. Split tip catheters were infrequently used and had risks of dysfunction similar to symmetrical tip catheters. The cumulative incidence of other complications requiring catheter removal, routine removal, and death before removal were similar across the 3 tip designs. LIMITATIONS: Tip design was not randomized. CONCLUSIONS: Symmetrical and split tip catheters had a lower risk of catheter dysfunction requiring removal than step tip catheters. FUNDING: Grants from government (Queensland Health, Safer Care Victoria, Medical Research Future Fund, National Health and Medical Research Council, Australia), academic (Monash University), and not-for-profit (ANZDATA Registry, Kidney Health Australia) sources. TRIAL REGISTRATION: Registered at ANZCTR with study number ACTRN12616000830493. PLAIN-LANGUAGE SUMMARY: Central venous catheters are widely used to facilitate vascular access for life-sustaining hemodialysis treatments but often fail due to blood clots or other mechanical problems that impede blood flow. A range of adaptations to the design of tunneled hemodialysis catheters have been developed, but it is unclear which designs have the greatest longevity. We analyzed data from an Australian nationwide cohort of patients who received hemodialysis via a tunneled catheter and found that catheters with a step tip design failed more quickly than those with a symmetrical tip. Split tip catheters performed well but were infrequently used and require further study. Use of symmetrical rather than step tip hemodialysis catheters may reduce mechanical failures and unnecessary procedures for patients.

Machine learning for prediction of chronic kidney disease progression: Validation of the Klinrisk model in the CANVAS Program and CREDENCE trial.

AIM: To validate the Klinrisk machine learning model for prediction of chronic kidney disease (CKD) progression in patients with type 2 diabetes in the pooled CANVAS/CREDENCE trials. MATERIALS AND METHODS: We externally validated the Klinrisk model for prediction of CKD progression, defined as 40% or higher decline in estimated glomerular filtration rate (eGFR) or kidney failure. Model performance was assessed for prediction up to 3 years with the area under the receiver operating characteristic curve (AUC), Brier scores and calibration plots of observed and predicted risks. We compared performance of the model with standard of care using eGFR (G1-G4) and urine albumin-creatinine ratio (A1-A3) Kidney Disease Improving Global Outcomes (KDIGO) heatmap categories. RESULTS: The Klinrisk model achieved an AUC of 0.81 (95% confidence interval [CI] 0.78-0.83) at 1 year, and 0.88 (95% CI 0.86-0.89) at 3 years. The Brier scores were 0.020 (0.018-0.022) and 0.056 (0.052-0.059) at 1 and 3 years, respectively. Compared with the KDIGO heatmap, the Klinrisk model had improved performance at every interval (P < .01). CONCLUSIONS: The Klinrisk machine learning model, using routinely collected laboratory data, was highly accurate in its prediction of CKD progression in the CANVAS/CREDENCE trials. Integration of the model in electronic medical records or laboratory information systems can facilitate risk-based care.

Multifaceted Quality Improvement Interventions to Prevent Hemodialysis Catheter-Related Bloodstream Infections: A Systematic Review.

RATIONALE & OBJECTIVE: Central venous catheters (CVCs) are widely used for hemodialysis but are prone to burdensome and costly bloodstream infections. We determined whether multifaceted quality improvement interventions in hemodialysis units can prevent hemodialysis catheter-related bloodstream infections (HDCRBSI). STUDY DESIGN: Systematic review. SETTING & STUDY POPULATIONS: PubMed, EMBASE, and CENTRAL were searched from inception to April 23, 2022, to identify randomized trials, time-series analyses, and before-after studies that examined the effect of multifaceted quality improvement interventions on the incidence of HDCRBSI or access-related bloodstream infections (ARBSI) among people receiving hemodialysis outside of the intensive care unit (ICU). DATA EXTRACTION: Two people independently extracted data and assessed the risk of bias and quality of evidence using validated tools. ANALYTICAL APPROACH: Intervention effects, validity, and characteristics of studies with the same design were compared. Differences between study designs were described. RESULTS: We included 21 studies from 8,824 identified by our search. Among 15 studies that measured HDCRBSI, 2 methodologically heterogenous cluster randomized trials reported discordant intervention effects, 2 interrupted time-series analyses reported favorable interventions with discordant patterns of effect, and 11 before-after studies reported favorable interventions with a very high risk of bias. Among 6 studies that only measured ARBSI, 1 time-series analysis and 1 before-after study did not find a favorable intervention effect, and 4 before-after studies reported a favorable effect with a very high risk of bias. The overall quality of evidence was low for HDCRBSI and very low for ARBSI. LIMITATIONS: Nine definitions of HDCRBSI were used. Ten studies included hospital-based and satellite facilities but did not report separate intervention effects for each type of facility. CONCLUSIONS: Multifaceted quality improvement interventions may prevent HDCRBSI outside the ICU. However, evidence supporting them is of low quality, and further carefully conducted studies are warranted. REGISTRATION: Registered at PROSPERO with registration number CRD42021252290. PLAIN-LANGUAGE SUMMARY: People with kidney failure rely on central venous catheters to facilitate life-sustaining hemodialysis treatments. Unfortunately, hemodialysis catheters are a common source of problematic bloodstream infections. Quality improvement programs have effectively prevented catheter-related infections in intensive care units, but it is unclear whether they can be adapted to patients using hemodialysis catheters in the community. In a systematic review that included 21 studies, we found that most quality improvement programs were reported to be successful. However, the findings were mixed among higher-quality studies, and overall the quality of evidence was low. Ongoing quality improvement programs should be complemented by more high-quality research.

Electronic alerts and a care bundle for acute kidney injury-an Australian cohort study.

BACKGROUND: Early recognition of hospital-acquired acute kidney injury (AKI) may improve patient management and outcomes. METHODS: This multicentre study was conducted at three hospitals (H1-intervention; H2 and H3-controls) served by a single laboratory. The intervention bundle [an interruptive automated alerts (aAlerts) showing AKI stage and baseline creatinine in the eMR, a management guide and junior medical staff education] was implemented only at H1. Outcome variables included length-of-stay (LOS), all-cause in-hospital mortality and management quality. RESULTS: Over 6 months, 639 patients developed AKI (265 at H1 and 374 at controls), with 94.7% in general wards; 537 (84%) patients developed Stage 1, 58 (9%) Stage 2 and 43 (7%) Stage 3 AKI. Median LOS was 9 days (IQR 4-17) and was not different between intervention and controls. However, patients with AKI stage 1 had shorter LOS at H1 [median 8 versus 10 days (P = 0.021)]. Serum creatinine had risen prior to admission in most patients. Documentation of AKI was better in H1 (94.8% versus 83.4%; P = 0.001), with higher rates of nephrology consultation (25% versus 19%; P = 0.04) and cessation of nephrotoxins (25.3 versus 18.8%; P = 0.045). There was no difference in mortality between H1 versus controls (11.7% versus 13.0%; P = 0.71). CONCLUSIONS: Most hospitalized patients developed Stage 1 AKI and developed AKI in the community and remained outside the intensive care unit (ICU). The AKI eAlert bundle reduced LOS in most patients with AKI and increased AKI documentation, nephrology consultation rate and cessation of nephrotoxic medications.

Medication use and hospital-acquired acute kidney injury: an electronic health record-based study.

BACKGROUND AND AIMS: Medications remain an important contributor to the development of acute kidney injury (AKI). This study aimed to examine associations between (i) administration of medications known to reduce glomerular filtration rate (GFR), that is, GFR modifiers and subsequent hospital-acquired AKI; and (ii) potentially medication-related AKI and patient adverse outcomes. METHODS: A retrospective cohort study utilising electronic health record data of patients admitted to a tertiary hospital in Australia in 2015. Timing of medication administration was compared with timing of AKI development. AKI cases were identified using an algorithm based on serum creatinine level changes. Multilevel regression models were applied with adjustment for relevant demographic and clinical factors. RESULTS: Among 11 503 admissions, AKI was identified in 955 patients (8.3%) and 637 (66.7% of 955) were preceded by administration of a GFR modifier. Patients without prior AKI were 17% more likely to develop AKI after administration of these medications (adjusted odds ratio 1.17, 95% confidence interval (CI) 1.003-1.37). Older age and comorbidity with diabetes, acute myocardial infarction, peripheral vascular disease, liver cirrhosis and multiple myeloma were also significant predictors. Patients with potentially medication-related AKI were 11.69 times more likely to die in hospital (95% CI 7.84-17.43) and stayed 3.49 times longer in hospital (95% CI 3.26-3.73), compared with those without AKI. CONCLUSIONS: Administration of medications contributing to the reduction of GFR is associated with an increased risk of hospital-acquired AKI and worse patient outcomes. Caution is required when prescribing these medications to patients at risk of developing AKI, and monitoring patients for deterioration is needed if administered.

Retrospective study on the epidemiology of antineutrophil cytoplasmic autoantibodies-associated vasculitis in two Australian health districts.

BACKGROUND: Antineutrophil cytoplasmic autoantibodies (ANCA)-associated vasculitis (AAV) is more prevalent in rural Australia compared with metropolitan areas, suggesting a role of environment in disease pathogenesis. However, the prevalence of environmental risk factors in Australian AAV patients has not been described. AIMS: To compare the incidence of AAV between two health districts (Illawarra Shoalhaven Local Health District (ISLHD), a mixed rural/metropolitan region, and South Eastern Sydney Local Health District (SESLHD), a metropolitan region) in Australia and its relationship to environmental exposures. METHODS: Cases of AAV from 2002 to 2017 were retrospectively identified from ISLHD and SESLHD using electronic medical records. Eligible participants were invited to complete a standardised questionnaire examining their exposure to silica, solvents, metal, dust, farming, gardening and sunlight. RESULTS: One hundred and fifty-six cases of AAV were identified from 2002 to 2017. A higher cumulative incidence of AAV was observed in the ISLHD (184.2 (95% confidence interval (CI) 143.6-232.7) per million) compared with SESLHD (102.6 (95% CI 82.1-126.8) per million). Over 50% of the cohort had high levels of silica and solvents exposure, based on self-reported questionnaires. There was no significant relationship between region and exposure to silica (P = 0.96), solvents (P = 0.44), metal (P = 0.33), dust (P = 0.25), farming (P = 0.90), gardening (P = 0.93) or sunlight (P = 0.55). CONCLUSIONS: We found a higher incidence of AAV in ISLHD compared with SESLHD with high levels of exposure to silica and solvents in both regions based on self-reported questionnaires. Prospective systematic collection of data, such as a registry of AAV, is warranted to further explore the relationship between environmental exposures and AAV.

Variability in estimated glomerular filtration rate and the risk of major clinical outcomes in diabetes: Post hoc analysis from the ADVANCE trial.

There are limited data on whether estimated glomerular filtration rate (eGFR) variability modifies the risk of future clinical outcomes in type 2 diabetes (T2D). We assessed the association between 20-month eGFR variability and the risk of major clinical outcomes in T2D among 8241 participants in the ADVANCE trial. Variability in eGFR (coefficient of variation [CVeGFR ]) was calculated from three serum creatinine measurements over 20 months. Participants were classified into three groups by thirds of CVeGFR : low (≤6.4; reference), moderate (>6.4 to ≤12.1) and high (>12.1). The primary outcome was the composite of major macrovascular events, new or worsening nephropathy and all-cause mortality. Cox regression models were used to estimate hazard ratios (HRs). Over a median follow-up of 2.9 years following the 20-month period, 932 (11.3%) primary outcomes were recorded. Compared with low variability, greater 20-month eGFR variability was independently associated with higher risk of the primary outcome (HR for moderate and high variability: 1.07, 95% CI: 0.91-1.27 and 1.22, 95% CI: 1.03-1.45, respectively) with evidence of a positive linear trend (p = .015). These data indicate that eGFR variability predict changes in the risk of major clinical outcomes in T2D.

The kinetic estimated glomerular filtration rate ratio predicts acute kidney injury.

AIM: Kinetic estimated Glomerular Filtration Rate (KeGFR) approximates GFR under non-steady-state conditions. We investigated whether the ratio of KeGFR difference to baseline eGFR could predict acute kidney injury (AKI) earlier than a creatinine-based algorithm that triggered an AKI electronic Alert (eAlert). METHODS: This retrospective, single-centre, proof-of-concept cohort study assessed all patients diagnosed with AKI by an automated serum creatinine-based eAlert. The kinetic eGFR, the kinetic eGFR difference from baseline and the ratio of difference to baseline was calculated in subjects with at least two serum creatinine (sCr) measurements within 72 h of AKI. RESULTS: Patients in the AKI cohort (n = 140) had a significant decline in KeGFR ratio (AKI: 17% IQR 7% to 29%, Non-AKI: 0 IQR -12% to 9%; P-value <.0001). A decrease of the ratio greater than 10% predicted AKI with a sensitivity of 66%, a specificity of 77%, a positive predictive value of 63%, and negative predictive value of 80%. The median lead time between KeGFR ratio decrease and AKI was 24 h (IQR: 19-27 h). CONCLUSIONS: KeGFR ratio is a cheap, simple method that predicted AKI 24 h before laboratory detection. KeGFR may facilitate triaging patients to increased monitoring or intervention.

Under-detection of acute kidney injury in hospitalised patients: a retrospective, multi-site, longitudinal study.

BACKGROUND: Acute kidney injury (AKI) is a rapid deterioration of renal function, often caused by a variety of co-existing morbidities complicating its recognition and treatment, leading to short- and long-term adverse clinical outcomes. There are limited data on the incidence of AKI in Australia using the Kidney Disease Improving Global Outcomes creatinine-based consensus definition. AIM: To determine the incidence and estimate the extent of under-reporting of AKI in four hospitals in the South-Eastern Sydney/Illawarra regions of New South Wales, Australia. METHOD: A laboratory algorithm based on the Kidney Disease Improving Global Outcomes creatinine-based definition for AKI was applied retrospectively to laboratory data for adult patients admitted to the study hospitals between 2009 and 2013 to identify those with AKI. The results were compared with the incidence of AKI based on diagnostic codes for AKI reported for the same period. RESULTS: AKI was detected in 12.4% of all hospitalisations (46 101/370 969) and 16.4% of patients (31 448/192 133) across the 5-year study period using the laboratory algorithm. Of these, 72.1% were AKI Stage 1 (33 246/46101). AKI was coded in only 15.9% of hospitalisations with AKI Stage 1 (5294/33 246), 38.5% of hospitalisations with Stage 2 (2381/6185), and 46.8% with Stage 3 (3120/6670). Yearly incidence of laboratory-identified AKI trended downward between 2009 and 2013, while annual incidence determined by coding trended upward. CONCLUSION: Although coding trends suggested a continuous increase in clinician awareness of AKI across the study period, AKI in hospitalised patients remained significantly under-reported.

Impact of supplemental private health insurance on dialysis and outcomes.

BACKGROUND: The influence of health insurance systems on the treatment of end-stage kidney disease (ESKD) patients ispoorly understood. AIM: We investigated how supplemental private health insurance (PHI) coverage impacted ESKD treatment modalitiesand patient outcomes. The influence of health insurance systems on the treatment of end-stage kidney disease (ESKD) patients is poorly understood. We investigated how supplemental private health insurance (PHI) coverage impacted ESKD treatment modalities and patient outcomes. METHODS: All adult patients commencing ESKD treatment in New South Wales, Australia from 2000 to 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, allowing the comparisons of mortality, ESKD treatment modality and health service utilisation between privately insured and public patients. RESULTS: The cohort of 5737 patients included 38% (n = 2152) with PHI. At 1 year after ESKD treatment initiation, PHI patients had lower mortality (hazard ratio 0.84, 95% confidence interval (CI) 0.74-0.95, P = 0.01), were more likely to be receiving home haemodialysis (HD) (odds ratio (OR) 1.38, 95% CI 1.01-1.89, P = 0.04), to have been transplanted (OR 1.75, 95% CI 1.25-2.46, P = 0.001) and used fewer hospital days (incidence rate ratio 0.85, 95% CI 0.74-0.96, P = 0.01). After adjustment, PHI patients were more likely to initiate ESKD treatment with facility-based HD (OR 1.22, 95% CI 1.01-1.46, P = 0.03) but were less likely to be started on peritoneal dialysis (OR 0.81, 95% CI 0.67-0.98, P = 0.03). CONCLUSION: Our findings suggest that supplemental PHI in Australia is associated with lower-risk ESKD treatment attributes and improved health outcomes. A greater understanding of the treatment pathways that deliver these outcomes may inform treatment for the broader ESKD treatment population.

Hospitalized fracture rates amongst patients with chronic kidney disease in Australia using data linkage.

BACKGROUND: Renal osteodystrophy leading to fractures in chronic kidney disease (CKD) is associated with significant hospitalization, morbidity, mortality and health care costs. There is a paucity of data on fractures in the CKD population in Australia. AIM: To describe the trends and impact of hospitalized fractures in an Australian population of non-dialysis CKD patients. METHODS: Retrospective observational data derived using data linkage. Fracture rates, trends in hospital admissions, comorbidity burden and mortality were analysed in a non-dialysis CKD population between 2000 and 2010 in the Australian state of New South Wales. Hospitalized patients with CKD and fractures were compared with CKD patients without fracture. RESULTS: A total of 149 839 hospitalized patients with CKD were included, of whom 9898 (6.6%) experienced one or more fractures. Patients with fracture were older, more likely to be female with a higher comorbidity burden than those without. Hospital admissions involving fracture were longer than non-fracture admissions (14.3 vs 5.9 days, P < .0001) and patients were less likely to be discharged home (28.3% vs 80.9%, P < .0001). The 12-month mortality rate was high at 41%. CONCLUSION: Australian non-dialysis CKD patients with hospitalized fractures were older, had a greater burden of disease, and have similar rates of fracture and associated mortality compared to international CKD cohorts. Implications of fracture requiring hospitalization are considerable, with longer admissions, greater healthcare costs, lower likelihood of discharge home and significant mortality. As fracture prevention in the CKD population evolves, treatment algorithms should account for those at greatest risk.

Current practice in dialysis central venous catheter management: Multi-disciplinary renal team perspectives.

AIM: To explore the current practices related to the insertion, management and removal of dialysis central venous catheters (CVCs) used in patients with chronic kidney disease requiring haemodialysis. METHODS: This qualitative descriptive study involved semi-structured interviews with surgeons, interventional radiologists, renal physicians, dialysis nurses, renal access nurses and renal researchers involved in the care of patients with chronic kidney disease requiring haemodialysis. Data were collected from staff at eight hospitals in six states and territories of Australia. Thirty-eight face-to-face interviews were conducted. A modified five-step qualitative content analysis approach was used to analyse the data. RESULTS: Improved visualization technology and its use by interventional radiologists has steered insertions to specialist teams in specialist locations. This is thought to have decreased risk and improved patient outcomes. Nurses were identified as the professional group responsible for maintaining catheter access integrity, preventing access failure and reducing access-related complications. While best practice was considered important, justifications for variations in practice related to local patient and environment challenges were identified. CONCLUSION: The interdisciplinary team is central in the insertion, maintenance, removal and education of patients regarding dialysis CVCs. Clinicians temper research-based decision-making about central dialysis access catheter management with knowledge of individual, environmental and patient factors. Strategies to ensure guidelines are appropriately translated for use in a wide variety of settings are necessary for patient safety.

Incidence of Ischaemic Heart Disease in Men and Women With End-Stage Kidney Disease: A Cohort Study.

BACKGROUND: The incidence of ischaemic heart disease (IHD) has fallen consistently in the general population; attributed to effective primary prevention strategies. Differences in incidence have been demonstrated by sex. Whether this fall in incidence and sex differences is mirrored in people with end-stage kidney disease (ESKD) is unclear. We aimed to establish the relative risk of IHD events in the ESKD population. METHODS: We performed a retrospective cohort study from 2000 to 2010 in people with ESKD in New South Wales. We performed data linkage of the Australia and New Zealand Dialysis and Transplant Registry and state wide hospital admission and death registry data and compared this to general population data. The primary outcome was the incidence rate, incidence rate ratio (IRR), and time-trend for any IHD event. We calculated these using indirect standardisation by IHD event. RESULTS: 10,766 participants, contributed 44,149 years of observation time. Incidence rates were substantially higher than the general population for all IHD events (any IHD event: IRR 1.8, 95% confidence interval [CI] 1.7-1.9 for men, IRR 3.4, 95% CI 3.1-3.6 for women). Excess risk was higher in younger people (age 30-49 IRR 4.8, 95% CI 4.2-5.4), and in women with a three-fold increase risk overall and nearly a 10-fold increase in risk in young women (female age 30-49 years: IRR 9.8 95% CI 7.7-12.3), results were similar for angina and acute myocardial infarction. Ischaemic heart disease rates showed some decline for men over time, (ratio of IRR 0.93, 95% CI 0.90-0.95) but were stable for women (ratio of IRR 0.97, 95% CI 0.94-1.01). CONCLUSIONS: People with ESKD have substantially higher rates of IHD than the general population, especially women, in whom no improvement appears evident over the past 10 years.

Dialysis catheter management practices in Australia and New Zealand.

AIM: Dialysis catheter-associated infections (CAI) are a serious and costly burden on patients and the health-care system. Many approaches to minimizing catheter use and infection prophylaxis are available and the practice patterns in Australia and New Zealand are not known. We aimed to describe dialysis catheter management practices in dialysis units in Australia and New Zealand. METHODS: Online survey comprising 52 questions, completed by representatives from dialysis units from both countries. RESULTS: Of 64 contacted units, 48 (75%) responded (Australia 43, New Zealand 5), representing 79% of the dialysis population in both countries. Nephrologists (including trainees) inserted non-tunnelled catheters at 60% and tunnelled catheters at 31% of units. Prophylactic antibiotics were given with catheter insertion at 21% of units. Heparin was the most common locking solution for both non-tunnelled (77%) and tunnelled catheters (69%), with antimicrobial locks being predominant only in New Zealand (80%). Eight different combinations of exit site dressing were in use, with an antibiotic patch being most common (35%). All units in New Zealand and 84% of those in Australia undertook CAI surveillance. However, only 51% of those units were able to provide a figure for their most recent rate of catheter-associated bacteraemia per 1000 catheter days. CONCLUSION: There is wide variation in current dialysis catheter management practice and CAI surveillance is suboptimal. Increased attention to the scope and quality of CAI surveillance is warranted and further evidence to guide infection prevention is required.

Methodological challenges to collecting clinical and economic outcome data: Lessons from the pilot dialysis outcomes India study.

AIM: Contemporary data on clinical and economic outcomes and quality of care amongst dialysis patients in India are not available. This pilot prospective study aimed to evaluate the feasibility of data collection and follow up within routine dialysis practice to inform setting up a dialysis registry. METHODS: An electronic instrument was developed to collect information on clinical and socio-demographic characteristics, outcome and out-of-pocket expenditure on incident patients commencing haemodialysis (HD) at two centres. Dialysis unit staff were trained in collecting and entering information on an electronic case record form. Patients were followed up at 1, 3, 6, 9 and 12 months to ascertain outcomes and treatment related costs. RESULTS: A total of 119 patients (37 females, age 47.5 ± 17.2 years) were enrolled. After 1 year, 38 (32%) patients were continuing on HD; 35 (29%) had died, 30 (25%) underwent a kidney transplant, and 16 (13%) had stopped dialysis. We noted a high prevalence of catastrophic health expenditure. Data collection was facilitated by appointing a designated staff member who received an incentive. Collection of financial information, clinical course for patients transferring out of the primary unit and the cause of death, when it occurred out of hospital was challenging. CONCLUSION: Prospective data collection of incident dialysis patients was feasible but is resource-intensive. High out-of-pocket costs force some patients to stop dialysis and can generate a sense of despair. Poor patient experiences and suspicion over the use of such data adversely affects collection of important clinical and health economic data.

Effects of health service geographic accessibility in patients with treated end stage kidney disease: Cohort study 2000-2010.

AIM: Patients in rural areas experience poor access to health services. There are limited data on patterns of health service utilization in rural patients treated with renal replacement therapy (RRT). METHODS: All prevalent patients over the age of 18 and resident in New South Wales who were receiving RRT on 01/07/2000 and incident patients who started RRT between 01/07/2000 up until 31/07/2010 were included in the study. The Accessibility Remoteness Index of Australia was used to measure rurality and to categorize participant postcode of residence at the time of their first use of a New South Wales healthcare facility after the start of RRT. We assessed (1) rates of hospitalization, (2) rates of inter-hospital transfer (IHT), (3) length of hospital stay (LOS) and (4) survival. Day-only and dialysis admissions were excluded. Negative binomial regression was used to calculate incidence rate ratios (IRR) for hospitalizations, IHT and LOS. Cox proportional hazards was used to calculate hazard ratios (HR) for survival. RESULTS: Of the 10 505 patients included in the analysis, 1527 (15%) were rural residents while 8978 (85%) resided in urban areas. Median follow up time from start of RRT/study to end of study/death was 4.2 years (IQR 2.0 to 8.2). After allowing for differences in baseline characteristics, rural residence increased the rates of hospitalization by 8% (IRR 1.08: 95% CI 1.01-1.15; P = 0.02), rates of IHT by 176% (IRR 2.76: 95% CI 2.44-3.13; P < 0.001) and the hazard of death by 14% (HR 1.14 95% CI: 1.05-1.24; P = 0.003) LOS was similar (Median 4.0; P = 0.07). CONCLUSIONS: Rural residents receiving RRT have higher hospitalization rates, markedly higher rates of IHT and higher long-term mortality compared with their urban counterparts.

Worldwide access to treatment for end-stage kidney disease: a systematic review.

BACKGROUND: End-stage kidney disease is a leading cause of morbidity and mortality worldwide. Prevalence of the disease and worldwide use of renal replacement therapy (RRT) are expected to rise sharply in the next decade. We aimed to quantify estimates of this burden. METHODS: We systematically searched Medline for observational studies and renal registries, and contacted national experts to obtain RRT prevalence data. We used Poisson regression to estimate the prevalence of RRT for countries without reported data. We estimated the gap between needed and actual RRT, and projected needs to 2030. FINDINGS: In 2010, 2·618 million people received RRT worldwide. We estimated the number of patients needing RRT to be between 4·902 million (95% CI 4·438-5·431 million) in our conservative model and 9·701 million (8·544-11·021 million) in our high-estimate model, suggesting that at least 2·284 million people might have died prematurely because RRT could not be accessed. We noted the largest treatment gaps in low-income countries, particularly Asia (1·907 million people needing but not receiving RRT; conservative model) and Africa (432,000 people; conservative model). Worldwide use of RRT is projected to more than double to 5·439 million (3·899-7·640 million) people by 2030, with the most growth in Asia (0·968 million to a projected 2·162 million [1·571-3·014 million]). INTERPRETATION: The large number of people receiving RRT and the substantial number without access to it show the need to both develop low-cost treatments and implement effective population-based prevention strategies. FUNDING: Australian National Health and Medical Research Council.

Risk Factors for Stroke in People with End-Stage Kidney Disease: A Cohort Study.

BACKGROUND: It is unclear how traditional cardiovascular risk factors and different treatment modalities for end-stage kidney disease (ESKD) affect stroke risk in people with ESKD. We aimed to identify the risk factors for stroke (ischemic and hemorrhagic) in people with ESKD. METHODS: We conducted a retrospective cohort study using data linkage between the Australian and New Zealand Dialysis and Transplant Registry, clinical and administrative datasets. Using Cox proportional hazards models, we estimated the magnitudes of risk of hospitalization with different subtypes of strokes associated with traditional cardiovascular risk factors and ESKD treatment modalities (hemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation). Results were expressed as hazard ratios (HRs) with 95% CIs. RESULTS: A total of 10,745 people received treatment for ESKD in New South Wales, Australia, between 2000 and 2010. We observed 640 hospitalizations for stroke in 49,497 person-years of follow-up (129.4 per 10,000 person years). Some risk factors were consistent with those found in the general population, including smoking and a history of previous stroke. Other risk factors were novel for people with ESKD. Women were 85% more likely to have an intracerebral hemorrhage (HR 1.85, 95% CI 1.22-2.79) and 30% more likely to have an ischemic stroke (HR 1.30, 95% CI 1.01-1.66) than men. Compared to people on HD, people with kidney transplants had a 65% lower risk of intracerebral hemorrhage (HR 0.35, 95% CI 0.18-0.69) but a similar risk of ischemic stroke (HR 0.97, 95% CI 0.64-1.49). People on PD had a 36% higher risk of ischemic stroke (HR 1.36, 95% CI 1.05-1.76) but a similar risk of intracerebral hemorrhage compared to people on HD (HR 0.69, 95% CI 0.43-1.11). CONCLUSIONS: These findings could be used to establish reliable estimates of the risk of stroke in people with ESKD and identify those who are most likely to benefit from preventive treatments.