Global Dialysis Perspective: Australia

Abstract

Hemodialysis (HD) was first introduced to Australia in the late 1950s to support patients with AKI, with subsequent establishment of maintenance HD by 1962 (1). Since then, like many other developed countries, Australia has seen an exponential rise in the incidence and prevalence of dialysis-treated ESKD (2). Below we provide a snapshot of the current state of the delivery of dialysis in Australia. Treated ESKD in Australia An accurate record of the incidence, outcomes, and practice patterns of all patients treated with KRT in Australia has been available since the early days of dialysis through the establishment of the Australian and New Zealand Dialysis and Transplant (ANZDATA) registry (3). The core functions of the registry are funded by the Australian and New Zealand Governments and Kidney Health Australia, a nongovernment organization. This funding covers the costs of the registry infrastructure, personnel and production of registry reports. Data collection is not funded and provided to the registry with “in kind” support of all contributing renal units. Operations are overseen by an Executive Group and a Steering Committee, which reports to the funding bodies, and the Australia and New Zealand Society of Nephrology. Registry data is collected in real time for key events (such as dialysis initiation, kidney transplantation or death) and a more comprehensive cross-sectional survey is conducted yearly on December 31. Areas covered include demographic details, primary renal disease, type of KRT, process measures, and a variety of outcomes. For patients on dialysis, this includes type and location dialysis, dialysis prescription, dry weight, type of dialysis access, and basic biochemistry (hemoglobin, calcium, and phosphate). The registry does not routinely collect data on hospitalizations, although linkage to state-based hospitalizations data has been performed as part of separate research projects. As of December 31, 2018, there were 13,399 people with ESKD on dialysis treatment in Australia, a prevalence rate of 536 per million population (4), with center-based HD as the predominant therapy at 75% and home-based therapy at 25% (30% of which are on home HD and 70% of which are on home peritoneal dialysis [PD]). An overall summary of the demographics of the incident Australian dialysis population is given in Table 1. Like the majority of other countries, the most common cause of ESKD was diabetic nephropathy (38%), followed by GN (17%) and hypertension (12%), with these rates being relatively stable over the past 5 years (5). The unadjusted overall mortality rate for individuals on dialysis in Australia during 2017 was 14.4 per 100 patient-years (95% confidence interval, 13.7 to 15.1), with dialysis withdrawal and cardiovascular disease being the leading causes of death. Compared to their non‐Indigenous counterparts, Indigenous patients on dialysis have a 40% increased risk of death after adjusting for differences in comorbidity, a significant disparity in survival that has remained unchanged since 1995 (6). Table 1. - Demographics of incident patients receiving KRT in Australia (2017) (5) Characteristic N (%) Incident patients on KRT, n (pmp) 3056 (124) Age, yr 0–14 37 (1) 15–24 79 (3) 25–34 155 (5) 35–44 270 (9) 45–54 492 (16) 55–64 734 (24) 65–74 751 (25) 75–84 485 (16) ≥85 53 (2) Male 1899 (62) Primary renal disease Diabetic nephropathy 1159 (38) GN 523 (17) Hypertension 380 (12) Polycystic disease 203 (7) Reflux nephropathy 72 (2) Other 413 (14) Unknown/not reported 306 (10) Diabetic status Type 1 179 (6) Type 2 1357 (44) No 1467 (48) Not reported 53 (2) Smoking status Current 326 (11) Former 1085 (36) Never 1508 (49) Not reported 137 (4) Vascular disease Coronary artery disease 900 (29) Peripheral vascular disease 442 (14) Cerebrovascular disease 234 (8) Chronic lung disease 313 (10) pmp, rate per million population. The majority (90%) of HD is delivered as high-flux conventional, thrice weekly, in a dialysis facility (7). Treatment times are typically (for 92% of patients) between 4 and 5 hours (42%, 24%, and 28% for 4, 4.5, and 5 hours, respectively) with dialysis blood flows of 300–349 ml/min. The arteriovenous fistula is the predominant form of permanent vascular access with a prevalence of 80%, with catheters at 16% and arteriovenous graft at 4%. The incident arteriovenous fistula rate remains much lower at 40%, and has not changed substantially over the past 10 years. The proportion of patients on facility-based HD who are treated with hemodiafiltration is currently 33% and has been increasing markedly over the past 10 years. However, the use of hemodiafiltration varies considerably across different treating centers and states (from 6% to 54%) (7,8). The proportion of patients treated with home HD has declined in recent years and sits at 10%, although this varies by state from 4% to 13% (7). Patients treated with home HD generally have longer treatment times and/or more frequent weekly sessio