Cardiovascular Disease in Dialysis Patients

Cardiovascular disease (CVD) is highly prevalent in the dialysis population, affecting up to 60% of cohorts. Cardiovascular mortality rates are reported to be ~14 per 100 patient-years, which are 10- to 20-fold greater than those of age- and gender-matched controls. CVD is the primary cause of death in up to 40% of dialysis patients in Australia, New Zealand and the United States. Dialysis patients endure a greater burden of both traditional risk factors for CVD and risk factors related to loss of kidney function that may account for the higher CVD morbidity and mortality. Many cardiology guidelines include chronic kidney disease (CKD) and end-stage kidney disease (ESKD) as coronary heart disease (CHD) risk equivalents. It is therefore important for clinicians to both recognise and optimise the cardiovascular health of patients receiving maintenance dialysis. This chapter will focus on risk factor modification, screening and prevention of CVD in dialysis patients

Nephrology training in Australia and New Zealand: a survey of outcomes and adequacy

Advanced training programmes in nephrology should provide broad exposure to all aspects of nephrology. In Australia and New Zealand (ANZ), the Advanced Training Committee in Nephrology oversees training, and recent increases in trainee numbers have led to concern about dilution of experience.To investigate early career paths of nephrologists in ANZ and determine the adequacy of training by comparing self-determined competency and skill relevance among recently graduated nephrologists.In 2015, the Advanced Training Committee in Nephrology administered an online survey during the annual subscription for members of the Australian and New Zealand Society of Nephrology. Nephrologists who were awarded Fellowship after 2002 were invited to participate.The survey was completed by 113 Fellows with 8 respondents excluded (response rate 44.1%). Initial post-Fellowship work included full-time public hospital appointments (34.3%) or undertaking full-time higher research degrees (41.9%). The majority reported securing their desired employment. Respondents indicated adequate training in most clinical skills; however, responses of 'well trained' in home haemodialysis (41.8%), conservative care (42.9%), automated peritoneal dialysis (38.8%), and assessment of kidney transplant recipients (48%) and living kidney donors (34.7%) were less adequate. Although considered highly relevant to current practice, responses of 'well trained' were low for management and research skills, including complaint management (16.3%), private practice management (2%), health system knowledge (14.3%) and regulations (6.1%), ethics approval (23.5%), research funding (11.2%) and quality assurance (26.5%).Nephrology training in ANZ generally meets clinical needs and most secure their desired employment. Training in management and research are areas for improvement

A coaching program to improve dietary intake of patients with CKD: ENTICE-CKD

The dietary self-management of CKD is challenging. Telehealth interventions may provide an effective delivery method to facilitate sustained dietary change.This pilot, randomized, controlled trial evaluated secondary and exploratory outcomes after a dietitian-led telehealth coaching intervention to improve diet quality in people with stage 3-4 CKD. The intervention group received phone calls every 2 weeks for 3 months (with concurrent, tailored text messages for 3 months), followed by 3 months of tailored text messages without telephone coaching, to encourage a diet consistent with CKD guidelines. The control group received usual care for 3 months, followed by nontailored, educational text messages for 3 months.Eighty participants (64% male), aged 62±12 years, were randomized to the intervention or control group. Telehealth coaching was safe, with no adverse events or changes to serum biochemistry at any time point. At 3 months, the telehealth intervention, compared with the control, had no detectable effect on overall diet quality on the Alternative Health Eating Index (3.2 points, 95% confidence interval, -1.3 to 7.7), nor at 6 months (0.5 points, 95% confidence interval, -4.6 to 5.5). There was no change in clinic BP at any time point in any group. There were significant improvements in several exploratory diet and clinical outcomes, including core food group consumption, vegetable servings, fiber intake, and body weight.Telehealth coaching was safe, but appeared to have no effect on the Alternative Healthy Eating Index or clinic BP. There were clinically significant changes in several exploratory diet and clinical outcomes, which require further investigation.Evaluation of Individualized Telehealth Intensive Coaching to Promote Healthy Eating and Lifestyle in CKD (ENTICE-CKD), ACTRN12616001212448

Outcomes of cinacalcet withdrawal in Australian dialysis patients

Background: Secondary hyperparathyroidism (SHPT) in chronic kidney disease is associated with cardiovascular and bone pathology. Measures to achieve parathyroid hormone (PTH) target values and control biochemical abnormalities associated with SHPT require complex therapies, and severe SHPT often requires parathyroidectomy or the calcimimetic cinacalcet. In Australia, cinacalcet was publicly funded for dialysis patients from 2009 to 2015 when funding was withdrawn following publication of the EVOLVE study, which resulted in most patients on cinacalcet ceasing therapy. We examined the clinical and biochemical outcomes associated with this change at Australian renal centres. Methods: We conducted a retrospective study of dialysis patients who ceased cinacalcet after August 2015 in 11 Australian units. Clinical outcomes and changes in biochemical parameters were assessed over a 24‐ and 12‐month period respectively from cessation of cinacalcet. Results: 228 patients were included (17.7% of all dialysis patients from the units). Patients were aged 63±15 years with 182 patients on haemodialysis and 46 on peritoneal dialysis. Over 24 months following cessation of cinacalcet, we observed 26 parathyroidectomies, 3 episodes of calciphylaxis, 8 fractures and 50 deaths. Seven patients recommenced cinacalcet, meeting criteria under a special access scheme. Biochemical changes from baseline to 12 months after cessation included increased levels of serum PTH from 54 (IQR 27‐90) pmol/L to 85 (IQR 41‐139) pmol/L (

Should nephrologists consider vascular calcification screening?

Vascular calcification (VC) has been widely discussed over the last few decades and is associated with significant morbidity and mortality among patients with chronic kidney disease. Importantly, these patients have premature and rapidly progressive calcification when compared with the general population. VC is an active and complex process that is closely regulated by a growing list of inducers and inhibitors. VC can be detected using several non-invasive modalities including plain radiography, echocardiogram and computed tomography scans. However, the usefulness of these imaging measurements to capture treatment effects may be limited. Routine screening and monitoring for progression of VC remains highly debatable

Low socio-economic status adversely effects dialysis survival in Australia

Aim: Low socio-economic status (SES) is associated with increased incidence of end-stage kidney disease and in the USA, poorer dialysis survival. All Australians have access to a universal healthcare system. Methods: The study included all non-indigenous adult Australians registered with the Australia and New Zealand Dialysis and Transplant Registry who commenced dialysis between 2003 and 2013. SES at dialysis start was classified into quartiles of advantaged through to disadvantaged using Australian Bureau of Statistics socio-economic indexes for areas. The primary outcome was survival assessed using a competing risk regression model with renal transplantation as a competing risk. There was a significant interaction between age and SES, and hence, age-stratified survival analyses were performed. Results: A total 20 810 commenced dialysis during the study period. Mortality for the most advantaged quartile was 102.4/1000 person–years (95% confidence interval (CI) 98.0–106.9) compared with 110.7/1000 person–years (95% CI 105.8–115.7) in the disadvantaged quartile. In adjusted analysis, dialysis survival, compared with quartile 1 (advantaged), was inferior in quartile 3 (sub-hazard ratio 1.10, 95% CI 1.03–1.17) and the disadvantaged quartile (sub-hazard ratio 1.09, 85% CI 1.02–1.16) and was significantly modified by age. This disparity in survival outcome between the different SES quartiles was only observed in younger patients but was attenuated in the older ones following an age-stratified analysis. Conclusions: In Australia, low SES has an adverse effect on dialysis patient survival despite universal healthcare. This effect is mainly among younger patients where SES may have a greater proportional impact than co-morbidities

Impact of pay for performance on access at first dialysis in Queensland

Aim: Commencement of haemodialysis with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) is associated with improved survival compared with commencement with a central venous catheter. In 2011–2012, Queensland Health made incentive payments to renal units for early referred patients who commenced peritoneal dialysis (PD), or haemodialysis with an AVF/AVG. The aim of this study was to determine if pay for performance improved clinical care. Methods: All patients who commenced dialysis in Australia between 2009 and 2014 and were registered with the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) were included. A multivariable regression model was used to compare rates of commencing dialysis with a PD catheter or permanent AVF/AVG during the pay-for-performance period (2011–2012) with periods prior (2009–2010) and after (2013–2014). Results: A total of 10 858 early referred patients commenced dialysis during the study period, including 2058 in Queensland. In Queensland, PD as first modality increased with time (P < 0.001) but there was no change in AVF/AVG rate at first haemodialysis (P = 0.5). In a multivariate model using the pay-for-performance period as reference, the odds ratio for commencement with PD or haemodialysis with an AVF/AVG in Queensland was 1.02 (95% CI 0.81–1.29) in 2009–2010 and 1.28 (95% CI 1.01–1.61) in 2013–2014. There was no change for the rest of Australia (0.97 95% CI 0.87–1.09 in 2009–2010 and 1.00 95% CI 0.90–1.11 in 2013–14). Conclusion: Pay for performance did not improve rates of commencement of dialysis with PD or an AVF/AVG during the payment period. A lag effect on clinical care may explain the improvement in later years

An update on bone imaging and markers in chronic kidney disease

Introduction: Bone disorders in chronic kidney disease ( CKD) are associated with heightened risks of fractures, vascular calcification, poor quality of life and mortality compared to the general population. However, diagnosis and management of these disorders in CKD are complex and appreciably limited by current diagnostic modalities

Socioeconomic status and dialysis quality of care

Aim: Lower socioeconomic status (SES) has been associated with increased dialysis mortality. This study aimed to determine if the quality of care (QOC) delivered to dialysis patients varied by SES. Methods: All non-Indigenous adults commencing haemodialysis (HD) or peritoneal dialysis (PD) registered with the Australia and New Zealand Dialysis and Transplant Registry between 2002 and 2012 were included. Each patient's location at dialysis start was classified into SES quartiles of advantaged to disadvantaged. Guidelines were used to determine attainment of adequate QOC at 6