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Background: Sarcopenia is associated with significant morbidity and mortality in patients with chronic kidney disease. The prevalence of sarcopenia in the dialysis population varies from 4% to 63%. However, the prevalence and risk factors of sarcopenia in the Australian dialysis population remain uncertain. Aim: To study the prevalence of sarcopenia in patients on maintenance dialysis by using the European Working Group on Sarcopenia in Older People (EWGSOP) diagnostic criteria of sarcopenia and to identify associated risk factors. Methods: We evaluated adult patients on maintenance haemodialysis and peritoneal dialysis in this single-centre cross-sectional study in Australia. Patient's clinical (age, gender, dialysis modality and diabetic status) and laboratory parameters (serum albumin, calcium, phosphate, 25-hydroxy-vitamin D and parathyroid hormone levels) were investigated. We employed bioimpedance spectroscopy, hand grip dynamometer and the timed up and go test (TUG) to evaluate muscle mass, strength and function, respectively. Results: We evaluated 39 dialysis patients with a median age of 69 years old. The prevalence of sarcopenia was 18%. Sarcopenia was associated with low serum albumin (p = 0.02) and low serum phosphate level (p = 0.04). Increasing age and female sex were potential risk factors for sarcopenia (p = 0.05 and 0.08, respectively). Low lean muscle mass, reduced hand grip strength and prolonged TUG were present in 23.1%, 41% and 40.5%, respectively, of the cohort. The hand grip test had good correlation with lean muscle evaluation and the TUG. Conclusions: Sarcopenia was prevalent in 18% of maintenance haemodialysis patients from an Australian single-centre cohort, with low serum albumin and phosphate as significant risk factors. more...

Background: High convection volume hemodiafiltration may improve survival compared to high-flux hemodialysis, however there is significant variation in its use. Clinician attitudes towards hemodiafiltration are poorly understood but may explain differences in practice patterns. Method(s): A 17-question online survey was administered from February 2017 to January 2018. Clinicians involved in the care of hemodialysis patients were invited to participate via the Australian and New Zealand Society of Nephrology. The survey addressed domains of clinician knowledge; hemodiafiltration prescription; perceived benefits, harms, and barriers to use; and indications and contraindications. Result(s): Eighty-two responses were received from clinicians affiliated with 49 of 81 hemodialysis units (60 unit response rate). Hemodiafiltration was prescribed by 87 of respondents, but generally to less than 25 of patients. The percentage of respondents prescribing hemodiafiltration to most of their patients was greater for those in privately funded (60) than publicly funded units (28). Only 26 of respondents considered the level of evidence supporting the superiority of hemodiafiltration over high-flux hemodialysis to be high. Its key benefits were perceived to be superior middle molecule clearance, hemodynamic stability, phosphate clearance, and amyloid prevention. Common indications included frequent intradialytic symptoms, intradialytic hypotension, and uremic polyneuropathy. Few respondents (14) agreed hemodiafiltration conveyed harm to patients, however 25 considered frequent circuit clotting to be a relative contraindication. Although most respondents (63) believed hemodiafiltration was more expensive than high-flux hemodialysis, this was not a barrier to its use. Three-quarters of respondents prescribed post-dilution hemodiafiltration, but only 55 targeted a convection volume greater than 20L. Conclusion(s): Most clinicians in Australia and New Zealand prescribe hemodiafiltration more...

Background: We described the use of haemodiafiltration (HDF) in Australia and New Zealand over time, and any patient or centre-related associations with use of HDF. Method(s): We included all incident patients commencing haemodialysis in Australia and New Zealand between 2000-2014. The primary outcome was commencement of HDF over time, which was evaluated using multivariable logistic regression stratified by country. Result(s): Of 27,433 patients starting haemodialysis, 3,339 (14.4) of 23,194 patients in Australia and 810 (19.1) of 4,239 in New Zealand received HDF. Uptake increased over time in both countries but was more rapid in New Zealand. In Australia, HDF use was more likely in males (OR 1.13, 95CI 1.03-1.24, p=0.009) with BMI>30 kg/m2(OR 1.46, 95CI 1.33-1.61), and less likely in older patients (reference <40 years; 40-54 years OR 0.85, 95 confidence interval [CI] 0.72-0.99; 55-69 years OR 0.79, 95 CI 0.67-0.91; >70 years OR 0.48, 95 CI 0.41-0.56) and those with chronic lung disease (OR 0.84, 95CI 0.76-0.94, p<0.001), cerebrovascular disease (OR 0.76, 95CI 0.67-0.85, p<0.001) or peripheral vascular disease (OR 0.77, 95CI 0.70-0.85, p<0.001). Larger centres (defined by number of new patients/year) were more likely to prescribe HDF: 36-147/year OR 26.75 (95CI 18.54-38.59); 17-35/year OR 7.51 (95CI 5.35-10.55); 7-16/year OR 3.00 (95CI 2.19-4.13; <6/year reference. HDF was used more in private dialysis clinics (public OR 0.13, 95CI 0.05-0.32). In New Zealand, where there is no private dialysis, HDF use was more likely in Maori and Pacific Islanders (OR 1.32, 95CI 1.05 -1.66) compared to Caucasians and less likely in males (OR 0.76, 95CI 0.62 -0.94, p=0.01). In both countries, centres with higher HD:PD patient ratios were significantly more likely to prescribe HDF. Centre differences explained 36 of variability in HDF uptake in Australia and 48 in New Zealand. Conclusion(s): HDF uptake has increased over time, and was associated with similar centre characteristics more...

Background: It is unclear if haemodiafiltration improves patient survival compared with standard haemodialysis. Observational studies have tended to show benefit with haemodiafiltration, while meta-analyses have not provided definitive proof of superiority. Method(s): Using data from the Australia and New Zealand Dialysis and Transplant Registry, this binational inception cohort study compared all adult patients who commenced haemodialysis in Australia and New Zealand between 2000 and 2014. The primary outcome was all-cause mortality. Cardiovascular mortality was the secondary outcome. Outcomes were measured from the first haemodialysis treatment and were examined using multivariable Cox regression analyses. Patients were censored at permanent discontinuation of haemodialysis or at 31 December 2014. Analyses were stratified by country. Result(s): The study included 26 961 patients (4110 haemodiafiltration, 22 851 standard haemodialysis; 22 774 Australia, 4187 New Zealand) with a median follow-up of 5.31 (interquartile range 2.87-8.36) years. Median age was 62 years, 61% were male, 71% were Caucasian. Compared with standard haemodialysis, haemodiafiltration was associated with a significantly lower risk of all-cause mortality [adjusted hazard ratio (HR) for Australia 0.79, 95% confidence interval (95% CI) 0.72-0.87; adjusted HR for New Zealand 0.88, 95% CI 0.78-1.00]. In Australian patients, there was also an association between haemodiafiltration and reduced cardiovascular mortality (adjusted HR 0.78, 95% CI 0.64-0.95). Conclusion(s): Haemodiafiltration was associated with superior survival across patient subgroups of age, sex and comorbidity.Copyright © The Author(s) 2018. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. more...

Background: The use of haemodiafiltration (HDF) for the management of patients with end-stage kidney failure is increasing worldwide. Factors associated with HDF use have not been studied and may vary in different countries and jurisdictions. The aim of this study was to document the pattern of increase and variability in uptake of HDF in Australia and New Zealand, and to describe patient- and centre-related factors associated with its use. Method(s): Using the Australian and New Zealand Dialysis and Transplant Registry, all incident patients commencing haemodialysis (HD) between 2000 and 2014 were included. The primary outcome was HDF commencement over time, which was evaluated using multivariable logistic regression stratified by country. Result(s): Of 27 433 patients starting HD, 3339 (14.4%) of 23 194 patients in Australia and 810 (19.1%) of 4239 in New Zealand received HDF. HDF uptake increased over time in both countries but was more rapid in New Zealand than Australia. In Australia, HDF use was more likely in males (odds ratio (OR) 1.13, 95% confidence interval (CI) = 1.03-1.24, P = 0.009) and less likely with older age (reference <40 years; 40-54 years OR = 0.85; 95% CI = 0.72-0.99; 55-69 years OR = 0.79; 95% CI = 0.67-0.91; >70 years OR = 0.48; 95% CI = 0.41-0.56); higher body mass index (body mass index (BMI) < 18.5 kg/m2 OR = 0.62; 95% CI = 0.46-0.84; 18.5-29.9 kg/m2 reference; >30 kg/m2 OR = 1.46; 95% CI = 1.33-1.61), chronic lung disease (OR = 0.84; 95% CI = 0.76-0.94; P < 0.001), cerebrovascular disease (OR = 0.76; 95% CI = 0.67-0.85; P < 0.001) and peripheral vascular disease (OR = 0.77; 95% CI = 0.70-0.85; P < 0.001). No association was identified with race. In New Zealand, HDF use was more likely in Maori and Pacific Islanders (OR = 1.32; 95% CI = 1.05-1.66) and Asians (OR = 1.75; 95% CI = 1.15-2.68) compared to Caucasians, and less likely in males (OR = 0.76; 95% CI = 0.62-0.94; P = 0.01). No association was identified with BMI or co-morbidities. I more...

Introduction Maintaining fluid intake sufficient to reduce arginine vasopressin (AVP) secretion has been hypothesised to slow kidney cyst growth in autosomal dominant polycystic kidney disease (ADPKD). However, evidence to support this as a clinical practice recommendation is of poor quality. The aim of the present study is to determine the long-term efficacy and safety of prescribed water intake to prevent the progression of height-adjusted total kidney volume (ht-TKV) in patients with chronic kidney disease (stages 1-3) due to ADPKD. Methods and analysis A multicentre, prospective, parallel-group, open-label, randomised controlled trial will be conducted. Patients with ADPKD (n=180; age ≤65 years, estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m 2) will be randomised (1:1) to either the control (standard treatment+usual fluid intake) or intervention (standard treatment+prescribed fluid intake) group. Participants in the intervention arm will be prescribed an individualised daily fluid intake to reduce urine osmolality to ≤270 mOsmol/kg, and supported with structured clinic and telephonic dietetic review, self-monitoring of urine-specific gravity, short message service text reminders and internet-based tools. All participants will have 6-monthly follow-up visits, and ht-TKV will be measured by MRI at 0, 18 and 36 months. The primary end point is the annual rate of change in ht-TKV as determined by serial renal MRI in control vs intervention groups, from baseline to 3 years. The secondary end points are differences between the two groups in systemic AVP activity, renal disease (eGFR, blood pressure, renal pain), patient adherence, acceptability and safety. Ethics and dissemination The trial was approved by the Human Research Ethics Committee, Western Sydney Local Health District. The results will inform clinicians, patients and policy-makers regarding the long-term safety, efficacy and feasibility of prescribed fluid intake as an approach to reduce kidn more...

Introduction and Aims: It is unclear if haemodiafiltration (HDF) improves patient survival compared to standard haemodialysis (HD). Observational studies have tended to show benefit with HDF, while meta-analyses have not provided definitive proof of superiority. This study aimed to evaluate the association between HD modality and survival in the entire Australian and New Zealand incident HD patient population. Method(s): Using data from the ANZDATA Registry, this binational inception cohort study examined all patients who commenced HD in Australia and New Zealand between 2000 and 2014. The primary outcome was all-cause mortality, measured from first HD treatment, and the secondary outcome was cardiovascular mortality. Outcomes were examined using multivariable Cox and competing risk regression analyses. Patients were censored at permanent discontinuation of HD or at 31 December 2014. Analyses were stratified by country. Result(s): The study included 26,961 patients (4110 HDF, 22,851 standard HD) with a median follow-up of 5.57 (interquartile range 3.07-8.79) years. Patients who received HDF were more likely to be obese (p<0.001) or diabetic (p<0.001), and less likely to be white (p<0.001) or aged >70 years (p<0.001). There were no differences in pre-existing cardiovascular disease (p=0.3) or vascular access (p=0.2) between groups. Compared to standard HD, HDF was associated with a significantly lower risk of all-cause mortality (adjusted HR for Australia 0.63,95% CI 0.57-0.68; adjusted HR for New Zealand 0.74, 95% CI 0.70-0.79). In Australian patients, there was an association between HDF and reduced cardiovascular mortality (adjusted SHR 0.83,95% CI 0.69-0.99). Conclusion(s): Compared tostandard HD, HDF was associated with superior survival in Australian and New Zealand patients. more...

Introduction and Aims: Technique failure is a major complication of peritoneal dialysis (PD) treatment and is associated with significant risk to patients and health services. The first year has been recognised as a particularly vulnerable period, with studies estimating that just under one-half of patients who develop technique failure do so within this time. This study aimed to identify the key risk factors and risk periods for early transfer to haemodialysis or death in incident PD patients. Method(s): Using data from the ANZDATA Registry, this study included all adult patients who commenced PD in Australia and New Zealand between 2000 and 2014. Competing risk regression models were used to analyse the primary outcome, which was technique failure within the first year (kidney transplantation was the competing risk), as well as the secondary outcomes, which examined each cause of technique failure (kidney transplantation and other causes of technique failure were the competing risks). Patients were censored at the time of kidney transplantation, recovery of renal function, loss to follow up, or at 365.25 days after commencement of PD. Result(s): Of 16,748 patients who commenced PD during the study period, 4,389 patients reached the primary outcome. Factors associated with increased risk included age >70 years, diabetes or vascular disease, prior renal replacement therapy, late referral to a nephrology service, or management in a smaller centre. Asian or other race and use of continuous ambulatory PD were associated with reduced risk, as was commencement of PD between 2010 and 2014. Although the risk of technique failure due to death or infection was constant over the first year, mechanical and other causes accounted for a greater number of cases within the initial 9 months of treatment. [Figure Presented] Conclusion(s): Several modifiable and non-modifiable factors are associated with early technique failure. Variation in the principal cause of early technique fai more...

Aim: To evaluate the association between haemodialysis (HD) modality and survival in the entire Australian and New Zealand incident HD patient population. Background(s): There is ongoing uncertainty regarding the comparative effects of haemodiafiltration (HDF) and standard HD on patient survival. Randomized trials have reported inconsistent results, while observational studies have tended to demonstrate benefit. Method(s): Using data from the ANZDATA Registry, this cohort study examined all patients who commenced HD in Australia and New Zealand between 2000 and 2014. The primary outcome was all-cause mortality, measured from first HD treatment, and the secondary outcome was cardiovascular mortality. Outcomes were examined using multivariable Cox regression and competing risk analyses. Patients were censored at permanent discontinuation of HD or at 31 December 2014. Analyses were stratified by country. Result(s): The study included 26,961 patients (4110 HDF, 22,851 standard HD) with a median follow-up of 5.57 (interquartile range 3.07-8.79) years. Patients who received HDF were more likely to be obese or diabetic, and less likely to be white or aged >=70 years. There was no difference in cardiovascular disease or vascular access between groups. Compared to standard HD, HDF was associated with a significantly lower risk of all-cause mortality (adjusted HR for Australia 0.60, 95% CI 0.55-0.66; adjusted HR for New Zealand 0.75, 95% CI 0.68-0.82). In Australian patients, there was an association between HDF and reduced cardiovascular mortality (adjusted SHR 0.83, 95% CI 0.69-0.99). Conclusion(s): Compared to standard HD, HDF was associated with superior survival in Australian and New Zealand patients. The benefit of HDF may have been heightened by longer treatment time and preferential use of permanent vascular access, both of which facilitate higher convection volumes. more...

Aim: To describe uptake of haemodiafiltration (HDF) in Australia and New Zealand over time and determine the factors associated with HDF use. Background(s): HDF is increasingly common in clinical practice, despite uncertain comparative effects of HDF versus standard high flux haemodialysis on patient outcomes. The factors associated with increased HDF utilization have not been described previously in Australia and New Zealand. Method(s): We included incident haemodialysis (HD) patients in Australia and New Zealand between 2000-2014, using ANZDATA. The primary outcome was HDF uptake over time. We evaluated factors potentially associated with HDF including social determinacies, country, centre, private versus public, , body mass index, ethnicity, comorbidities, dialysis access and dialysis small solute clearance prior to HDF commencement. Result(s): Of 27,432 starting HD, 3,339/23,193 (14.4%) patients in Australia and 810/4,239 (19.1%) in New Zealand received HDF. Uptake was quicker in New Zealand and increased over time in both countries. Younger patients <40years, with co-morbidity (lung, cerebrovascular or peripheral vascular disease), in larger hospitals (>30 new dialysis patients/year), were more likely to receive HDF (all P<0.001). There was no effect of race or sex, but in Australia greater BMI increased likelihood of receiving HDF, as did living in NSW, QLD, SA or Tasmania (all P<0.001). In addition, centre differences explained 34% of HDF uptake in Australia, and 65% in New Zealand. There was no difference for public versus private dialysis centres. Neither living remotely, nor lower socioeconomic status influenced modality. Conclusion(s): HDF uptake was quicker in New Zealand than in Australia, but still represents <20% of all HD. HDF use appears to be driven predominantly by centre effects, but in Australia state differences persist. more...

This paper updates a previous 'Call to Action' paper (Nephrology 2011; 16: 19-29) that reviewed key outcome data for Australian and New Zealand peritoneal dialysis patients and made recommendations to improve care. Since its publication, peritonitis rates have improved significantly, although they have plateaued more recently. Peritoneal dialysis patient and technique survival in Australian and New Zealand have also improved, with a reduction in the proportion of technique failures attributed to 'social reasons'. Despite these improvements, technique survival rates overall remain lower than in many other parts of the world. This update includes additional practical recommendations based on published evidence and emerging initiatives to further improve outcomes.Copyright © 2016 Asian Pacific Society of Nephrology more...