Publications

AbstractBackground: The prevalence and impact of early-stage chronic kidney disease (CKD) on pregnancy is poorly defined. We aimed to identify women with suspected early CKD pre-conception and assess the impact on maternofoetal outcomes.Methods: We linked statewide perinatal datasets to pathology, renal registry and administrative datasets between 2005-23. We included women ≥18 years with one or more maternal serum creatinine measure within 5 years pre-conception or <30 days post-conception and examined maternofetal outcomes.Results: From 96 721 pregnancies (56 587 women), we included 42 212 pregnancies (33 116 women). Of those included, 644 had proteinuria or diagnosed kidney disease [and an estimated glomerular filtration rate (eGFR) >90 mL/min/1.73 m2], 2838 with an eGFR 60-90 mL/min/1.73 m2, and 30 with an eGFR 15-60 mL/min/1.73 m2. Only 6% of women with an eGFR <90 mL/min/1.73 m2 had formal quantitative measurement of albuminuria or proteinuria pre-conception. On multivariable analysis, women with suspected early CKD had an increased risk of gestation hypertension [odds ratio (OR) 1.21; confidence interval (CI) 1.04, 1.41] preeclampsia (OR 1.26; CI 1.03, 1.52), low birth weight (OR 1.15; CI 1.02, 1.31) and preterm delivery (OR 1.27; CI 1.03, 1.56) compared with those with normal kidney function.Conclusion: We identified that 1 in 10 pregnancies had an eGFR <90 mL/min/1.73 m2, proteinuria or diagnosed kidney disease, warranting further research focussing on pre-conception kidney function assessments. While these women were at an increased risk of some maternofetal outcomes, the absolute risk remains small.

BackgroundAcute kidney injury is a common complication of cardiac surgery and may lead to kidney failure. In a large sample sourced from national registries, we estimated the risk of kidney failure up to nine years following cardiac surgery and the associations with acute kidney injury, comorbidities and preoperative estimated glomerular filtration rate.MethodsData were linked probabilistically between population-based registries to identify adults with kidney failure (commencement of long-term kidney replacement therapy) following cardiac surgery. Risk of kidney failure accounting for the competing risk of death was estimated from 30 days following surgery using Fine-Gray models. Surgeries from 2010 to 2018 were included (n = 90 605) with follow-up until the end of 2018.ResultsA total of 465 adults (0.51%) developed kidney failure during follow-up and the cumulative incidence at five years was 0.65% (95% CI 0.59, 0.73). The risk of kidney failure increased with decreasing estimated glomerular filtration rate. The rate of any acute kidney injury was 26.2% and all stages were associated with kidney failure. For Stage 3 acute kidney injury compared with none, the adjusted subdistribution hazard ratio of kidney failure exceeded 4.4 at all intervals following surgery.ConclusionAcute kidney injury presented an enduring risk of kidney failure following cardiac surgery, independent of baseline estimated glomerular filtration rate. People comorbid with diabetes also experienced a high adjusted risk of kidney failure. All patients could benefit from perioperative management optimized to prevent acute kidney injury and regular postoperative nephrology follow-up for more than a year to mitigate the burden of kidney disease on the health system.

Background: Peritoneal dialysis (PD)-related infections are associated with an increased risk of mortality and impaired quality of life. The evidence for education interventions that lower rates of PD infection and improve patient outcomes is uncertain, which limits PD uptake despite its many advantages. The Targeted Education ApproaCH to Improve Peritoneal Dialysis Outcomes (TEACH-PD) is a registry-based, multi-center, cluster-randomized, controlled trial evaluating whether a standardized PD training curriculum for nurses and patients reduces the risk of PD-related infections.Methods: The demographic and clinical characteristics of the TEACH-PD participants were compared with patients who commenced PD during the recruitment period (July 2019 to September 2023) in Australia and New Zealand (ANZ) drawn from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry and who were not enrolled in TEACH-PD. The cluster and individual characteristics were compared between the trial and the registry population using descriptive statistics and standardized differences. The characteristics of centers and participants were also compared between the two contributing countries.Results: In total, 5,987 eligible patients commenced PD, with 1,462 subsequently enrolled from 42 eligible clusters into TEACH-PD. Overall, the demographic and clinical characteristics of TEACH-PD participants and ANZ patients not enrolled in TEACH-PD were similar. The participant characteristics differed between countries for ethnicity, body mass index, kidney function at dialysis commencement, and cause of kidney failure.Conclusions: TEACH-PD participants had similar demographic and clinical characteristics as non-trial patients commencing PD in ANZ. These results indicate that the findings from the TEACH-PD trial on completion may be broadly generalizable to dialysis care across ANZ.

Children of transplanted mothers are at increased risk of adverse birth outcomes, but childhood health outcomes are undefined. Using linked data from the Australia and New Zealand Dialysis and Transplant Registry, perinatal and hospital datasets, admissions were compared between children of transplanted mothers and mothers not exposed to kidney replacement therapy. From 2 067 661 babies, 137 children of transplanted mothers (137 birth admissions) were identified; 93 had 444 subsequent admissions, with a median follow-up of 2.3 years (interquartile range, 0.8-5.1). Subsequent admissions involved longer stays (>5 days: 7% versus 4%; P < .001) but similar admission frequencies (40% having 1 admission, 20% 2, 15% 3, 5% 4, and 20% ≥5; P = .31). Except for perinatal-originated conditions (3.7-fold higher admissions; 95% confidence interval, 2.1-6.5), other disease domains were similar between groups. Admission rates were comparable for preterm children, and children of mothers with hypertensive disorders of pregnancy, regardless of transplantation status. At birth, children of transplanted mothers required more ventilation (23% versus 5%, P < .001), medications (66% versus 31%, P < .001), and venous catheterization (19% versus 5%, P < .001). Medication use remained higher in subsequent admissions (19.7% versus 6.8%, P < .001). Hospital utilization data do not signal major additional health concerns beyond the perinatal period, providing reassuring evidence.

Glomerular diseases are rare with limited epidemiological and long-term outcome data. This study used linked health records to identify patients with glomerular disease and then track their long-term outcomes in Australia. Our findings show that glomerular disease affects about 89 in every 100,000 people, with 12 new cases per 100,000 people each year. Over an average period of 6 years, we found that those with glomerular disease had a 31 times higher risk of kidney failure and 2–4 times higher risk of death, heart disease, blood clots, and severe infections, compared to people without these conditions. These risks were similar whether the disease was newly diagnosed or had been present for some time. People with glomerular disease were hospitalised more often and for longer periods of time than those who did not have the condition. The poor outcomes of patients with glomerular diseases highlight the need for improved monitoring and treatment, with linked health data offering insights into the epidemiology and clinical outcomes of these rare kidney diseases.

Artificial intelligence (AI) promises significant advancements in nephrology. While current use of AI in clinical nephrology practice is limited, there is scope for application in transplant allocation, remote dialysis monitoring, and CKD management.Yet, despite its potential, the use of AI in nephrology raises important ethical issues. Challenges include concerns about trustworthiness and reliability of AI systems, accountability for inaccurate results, injustice from the perpetuation or exacerbation of individual and systemic biases and inequities, and risks to patient privacy arising from the need for AI to access to sensitive health data.In addition, there are unresolved questions about the application of current disclosure and informed consent practices for patients when AI is used in their care and about the environmental and sustainability effect of this energy-hungry technology in an already resource intensive specialty. This article explores these ethical challenges and gives recommendations for addressing them, both at an individual clinician and health care system level.

Purpose: Evidence suggests that patient navigators (PNs) can improve patient engagement, emotional wellbeing and clinical outcomes. This study explored how PNs influence the care experiences of Aboriginal and Torres Strait Islander peoples living with kidney failure, from the perspectives of patients and health service staff.Methods: Qualitative data were collected through kidney journey mapping and yarning interviews across four kidney health services employing PNs in the Northern Territory and South Australia. Data were thematically analysed to understand patient care experiences with and without PN support.Main findings: Patients reported challenges around inadequate communication, difficulty accessing appropriate services and support, poor cultural safety, and the emotional toll of treatment. Support included family and patient networks, positive relationships with health staff, and holistic models of care. PNs played a supportive role by sharing their kidney journey experiences, providing cultural connection, peer support and bridging systemic gaps.Principle conclusions: PNs strengthened patient care experiences by addressing service gaps, improving cultural support and sharing from lived experience. Embedding PNs into standard kidney care is a critical step toward achieving culturally safe, equitable and responsive health systems.

Background: The proportion of dialysis patients performing PD in Australia is decreasing over time.1 Understanding the trends in population, the rates and causes of peritonitis and haemodialysis (HD) transfer over time is critical towards understanding this trend.Methods Study Design: Registry-based cohort study using Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data. Inclusion criteria: All Australian patients starting PD older than 18 years, starting PD within 90 days of KRT entry from 1 January 2013 through 31 December 2022.Analysis: Peritonitis rates were analysed using Poisson regression, while time to first peritonitis and HD transfer were assessed using Cox Proportional Hazards and competing-risks regression models.Results: The demographic profile of PD patients has remained relatively stable. Peritonitis rates declined from 0.40 to 0.33 infections per patient-year between 2013 and 2022. Over time, peritonitis-associated HD transfer reduced, HR 0.96 [95% CI: 0.93-0.98], p < .001. Despite this, there was a deterioration in overall HD transfer, HR 1.03 [95% CI: 1.02-1.04] per year, p < .001 and worse adjusted non-infective HD transfer HR 1.02 [95% CI: 1.01-1.04] per year, p = .006.Conclusion: PD utilisation in Australia has declined over the past decade, despite improvements in peritonitis rates and peritonitis-associated HD transfer. The demographic profile of PD patients has remained relatively stable, suggesting systemic rather than patient-level factors are driving these trends. The apparent disconnect between infection control improvements and overall HD transfer highlights the growing importance of non-infective contributors such as access, psychosocial factors, and clinical support.

Background: Children living with chronic kidney disease (CKD) often experience significant psychological challenges, including emotional and behavioural difficulties linked to both the condition and its treatment. This study aimed to characterise the emotional, behavioural and adaptive functioning of children with CKD and to explore its relationship with CKD stage.Methods: Participants aged 6-18 years with any stage of CKD were recruited, and the Behaviour Assessment System for Children (BASC-2) was used to assess emotional, behavioural and adaptive functioning. Multivariable logistic regression was used to assess the association of CKD stage with emotional and behavioural outcomes.Results: The study included 53 participants, with a mean age of 12 years (s.d. 2.5). Among them, 27 (51%) were in CKD stages 1-5, 3 (6%) were receiving dialysis, and 22 (42%) had undergone kidney transplantation. In parent-report scales, an increased proportion of children with CKD were at risk for specific emotional difficulties (somatisation (n = 25, 47%), withdrawal (18, 33%), depression (17, 32%) and reduced adaptive skills (social skills and activities of daily living (17, 32%)) compared to general population norms. Children receiving kidney replacement therapy (KRT) were at an increased risk of adaptive skill deficits (OR 5.7, 95% CI 1.07-30.5) when compared to children with CKD stages 1-5, but there were uncertain differences between these groups for internalising (OR 1.1, 0.3-2.6) and externalising problems (OR 5.0, 0.85-29.5) and behavioural symptoms (OR 2.0, 0.4-9.4).Conclusions: Children with CKD are at increased risk of emotional difficulties (withdrawal, depression) and reduced social skills and activities of daily living compared to population norms. Adaptive skill deficits were more prevalent among children with KRT compared to children with CKD stages 1-5.

ObjectivesWhether patients with kidney failure who undergo cardiac surgery have a survival advantage with previous kidney transplantation is unclear. This study evaluated long-term outcomes after cardiac surgery for kidney transplant recipients and patients dependent on dialysis using national registries.MethodsProbabilistic data linkage was undertaken between registries for the period 2010-2019. Time-to-event analyses were used to estimate the risk after cardiac surgery of (1) survival for kidney-replacement therapy recipients (n = 1250), and (2) graft survival for kidney transplant recipients (n = 225). Using cardiac surgery as a time-varying covariate, kidney graft survival was compared among the national contemporary kidney transplant population (n = 7934).ResultsFive-year survival probabilities after cardiac surgery for patients with kidney transplants and receiving dialysis were 70% (95% confidence interval [CI], 61%-76%) and 49% (95% CI, 45%-53%), respectively. The benefit for kidney transplantation persisted in a multivariable Cox regression model (reference: facility hemodialysis; adjusted hazard ratio [HR], 0.53; 95% CI, 0.37-0.74; P < .001). Five-year kidney graft survival probability after cardiac surgery was 60% (95% CI, 52%-68%) and was lower with stage 3 acute kidney injury (reference: none; adjusted HR, 2.61; 95% CI, 1.32-5.16; P = .006). Among the national contemporary kidney transplant recipient population, cardiac surgery was associated with an increased risk of graft loss (adjusted HR, 1.70; 95% CI, 1.07-2.74; P = .026).ConclusionsAmong adults with kidney failure undergoing cardiac surgery, kidney transplant recipients experienced a long-term survival advantage compared with patients dependent on dialysis. Transplant recipients undergoing cardiac surgery had greater risk of graft loss than the national contemporary kidney transplant population.

Background: Lack of data regarding pregnancy post-kidney transplantation challenges clinicians who are faced with complex, high-risk cases. Aiming at tackling knowledge gaps and limited cross-cultural data on pregnancy in kidney transplant recipients (KTRs), we compared the methodologies and pregnancy outcomes of three registries based in three continents.Methods: Data were gathered from reports and publications of the Pregnancy After Renal Transplantation OUTcomes registry (PARTOUT, Netherlands), the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), and the Transplant Pregnancy Registry International (TPRI, United States of America and international). We targeted the similarities and differences among the registries to understand methodological variations.Results: The registries utilized distinct approaches regarding data collection which influence data interpretation. PARTOUT conducted a retrospective analysis of all Dutch pregnant KTRs between 1971 and 2017. ANZDATA includes annual surveys on all KTR parenthood events since 1968. TPRI offers international coverage and includes pregnant KTRs voluntarily registered since 1991. Despite methodological differences, preeclampsia, preterm birth and low birth weight were common pregnancy complications, and outcomes were mostly comparable among the registries.Conclusions: Despite differences in case capture, the three registries reported similar pregnancy and newborn outcomes, confirming that pregnancy in KTRs can be successful with careful monitoring across varying populations. Identifying the strengths and weaknesses of each registry can contribute to improved methodologies for global data collection and lower missing data rates. Although managing large databases may be challenging, aligning data across countries could lead to meaningful data pooling, while identifying drivers of outcomes across subpopulations.

IntroductionTherapy alerts during automated peritoneal dialysis (APD) can cause significant disruptions to patients' sleep and quality of life and may portend poorer outcomes. Understanding the relationship between alert frequency during this early period and longer-term PD outcomes is important.MethodsFollowing the probabilistic linkage of Vantive's Sharesource database to the Australian and New Zealand Dialysis and Transplant (ANZDATA) Registry, we examined the relationship between alert frequency in the first 30 days of APD and PD discontinuation. We included adult patients in Australia and New Zealand who commenced APD with the Vantive Homechoice Claria cycler over 2019-2023 and continued for at least 30 days. The average alerts per treatment in the first 30 days were divided into quartiles and time to PD discontinuation (inclusive of HD transfer and death), HD transfer only, and infective and non-infective HD transfer were modelled as outcomes.ResultsThe cohort was 1880 patients, 65% male, and median age at PD commencement of 58 years. Overall PD continuation at 1,2, and 3 years was 78%, 56% and 41%, with HD transfer rates at 14%, 23% and 27%. Higher rates of HD transfer in the first 12 months were seen in the groups with a higher average alert number. Within 12 months, there was a progressive risk of non-infective HD transfer with increasing 30-day alert quartile.ConclusionAlert burden in the first 30 days is a risk factor for HD transfer in the first 12 months, and resolving underlying issues early may help to improve PD continuation.