Mortality outcomes for Maori requiring renal replacement therapy during critical illness: a single unit audit in Aotearoa New Zealand.

BACKGROUND: Maori in New Zealand (NZ) are disproportionately affected by chronic kidney disease (CKD) and experience lower life expectancy on community dialysis compared with non-Maori. We previously identified a higher renal replacement therapy (RRT) requirement for Maori in our intensive care unit (ICU), the tertiary referral centre for NZ's Te Manawa Taki region. AIM: To describe mortality outcomes by ethnicity in the population requiring RRT in our ICU. METHODS: Retrospective audit of the Australia and NZ Intensive Care Society database for adult admissions to our general ICU from Te Manawa Taki between 2014 and 2018. Patients were stratified by non-RRT requirement (non-RRT), RRT-requiring acute kidney injury (AKI-RRT) and RRT-requiring end-stage renal disease (ESRD). RESULTS: Relative to the population of Te Manawa Taki, Maori were over-represented across all strata, especially ESRD (61.8%), followed by AKI-RRT (35.0%) and non-RRT (32.4%) (P < 0.001). There was no excess mortality by ethnicity in any stratum. Crude in-ICU mortality was similar by ethnicity among AKI-RRT (30.8% among Maori, vs 31.5%; P = 1.000) and ESRD (16.4% among Maori, vs 20.6%; P = 0.826). This trend remained at 1 year. Adjusted for clinically selected variables, neither AKI-RRT nor ESRD mortality was predicted by Maori ethnicity, both in-ICU and at 1 year. Irrespective of ethnicity, AKI-RRT patients had highest in-ICU mortality (31.2%; P < 0.001), while ESRD had highest 1-year mortality (46.1%; P < 0.001). CONCLUSION: Increased RRT requirement among Maori in our ICU is due to higher representation among ESRD. We did not demonstrate excess mortality by ethnicity in any stratum. AKI-RRT had higher in-ICU mortality than ESRD, but this reversed at 1 year.

Maori Health Outcomes in Intensive Care Following Cardiac Surgery in Aotearoa New Zealand.

BACKGROUND: Maori, the indigenous peoples of Aotearoa New Zealand (NZ) experience disproportionately worse outcomes in cardiovascular health compared to non-Maori. Waikato Hospital provides tertiary cardiothoracic services to the Midland region of NZ, and has instituted an official policy to eliminate ethnic inequity in health. We aimed to audit the outcomes of our cardiothoracic intensive care unit (ICU) against this standard. METHOD: We analysed data from the prospectively-entered Australia and NZ Intensive Care Society database for all planned cardiothoracic ICU admissions from 2014 to 2018 at Waikato Hospital for patients aged 15-years and older (n=2,736). Outcomes measured were in-ICU, in-hospital, and 1-year mortality. RESULTS: Maori were under-represented in this cohort (17.9%) compared to the general Midland population. Maori patients were younger (median 60 vs 68-years old, p<0.001), were more commonly female (34.8% vs 23.6%, p<0.001), domiciled in more deprived areas (2018 NZ Index of Deprivation of 9 vs 6, p<0.001), and more likely to have rheumatic heart disease (35.6% vs 16.6%, p<0.001). More non-Maori required coronary vessel only surgery (57.4% vs 45.2%), whilst more Maori required valvular only surgery (41.1% vs 31.2%) (p<0.001 overall). Baseline Acute Physiology and Chronic Health Evaluation (APACHE) III risk of death score was higher for Maori (1.53% vs 0.89%, p<0.001), as was the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (2.04% vs 1.55%, p<0.001). Unadjusted mortality was higher for Maori in-ICU (3.1% vs 1.3%, p=0.005) and at 1-year (7.1% vs 3.8%, p=0.002). Adjusted in-ICU mortality, however, was predicted by combined coronary-valvular surgery (adjusted odds ratio, AOR 25.5 [95% confidence interval (CI) 3.30-348.46], p=0.005), Australia and New Zealand Risk of Death (ANZROD) score (AOR 1.11 [CI 1.05-1.19] p<0.001), and renal replacement therapy requirement (AOR 154.56 [CI 30.86-1,107.17] p<0.001), but not by Maori ethnicity (AOR 0.27 [CI 0.03-1.43] p=0.156). CONCLUSION: Our audit has identified significant inequity for Maori at our cardiothoracic ICU. Maori are sicker on presentation for planned cardiac surgery, as evidenced by higher admission severity scores, and experience higher unadjusted mortality up to 1-year compared to non-Maori. Maori also appear under-represented despite a greater burden of cardiovascular disease in the community. Further study is required to identify if upstream risk factors, including failure of early detection and referral for disease, contribute to these findings.

Relationships Between Early Nutrition and Blood Glucose Concentrations in Very Preterm Infants.

OBJECTIVES: The aim of the study was to determine whether changes to early nutrition are associated with levels of glycemia in very preterm infants. METHODS: A retrospective, observational study of infants <1500 g or <30 weeks' gestation admitted to Neonatal Intensive Care, National Women's Hospital, New Zealand, before (Old Protocol) and after (New Protocol) a change in nutritional protocol. Nutritional intakes were calculated and averaged by day for postnatal days 1 to 7 (week 1) and 1 to 28 (month 1). Relationships between glycemia measures, macronutrient intakes, and achievement of 10% enteral feeds (≥10% total intake) were explored using logistic regression. RESULTS: Old Protocol (n = 190) and New Protocol (n = 267) groups had similar baseline characteristics. In week 1, New Protocol infants received more protein, less fat, and carbohydrate, had lower mean blood glucose concentrations (BGCs) (mean ±â€ŠSD 4.9 ±â€Š1.2 vs 5.6 ±â€Š1.4 mmoll/L, P < 0.0001), less hyperglycemia (BGC > 8.5 mmol/L, 71 [27%] vs 80 [42%], P = 0.0005), but similar hypoglycemia (BGC < 2.6). In month 1, New Protocol infants also had less hyperglycemia (105 [39%] vs 96 [51%], P = 0.02) and lower mean BGC (5.0 ±â€Š1.1 vs 5.5 ±â€Š1.1 mmol/L, P < 0.0001), but insulin usage was similar. After adjustment for birth weight z score and gestational age, hyperglycemia was significantly associated with week 1 intakes (g ·â€Škg ·â€Šday) of protein (odds ratio [95% confidence intervals] 0.47 [0.23-0.79], P = 0.004), fat (0.54 [0.40-0.74], P < 0.0001), and carbohydrate (1.25 [1.09-1.44], P < 0.0001). These relationships were similar for month 1. Each additional day to achieve 10% enteral feeds was associated with increased odds of hypoglycemia (1.09 [1.00-1.18], P = 0.04) and hyperglycemia (1.16 [1.06-1.28], P = 0.002). CONCLUSIONS: In very preterm infants, macronutrient balance and small, early enteral feeds may assist glycemic control.

Pure red cell aplasia associated with recombinant erythropoietin: a case report and brief review of the literature.

Pure red cell aplasia (PRCA) is a rare adverse effect of recombinant erythropoietin (rEPO). Affected patients rapidly become transfusion-dependent, with many requiring immunosuppressive therapy for remission. We report a confirmed case in an elderly female, possibly the first of its kind in New Zealand, who was started on rEPO for anaemia of chronic kidney disease. We also briefly review current literature on rEPO-associated PRCA.