CHAPTER 12 END-STAGE KIDNEY DISEASE AMONG INDIGENOUS PEOPLES OF AUSTRALIA AND NEW ZEALAND. Stephen McDonald. Matthew Jose. Kylie Hurst INDIGENOUS 12-1

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1 ANZDATA Registry 213 Report INDIGENOUS END-STAGE KIDNEY DISEASE AMONG INDIGENOUS PEOPLES OF AUSTRALIA AND NEW ZEALAND CHAPTER 12 Stephen McDonald Matthew Jose Kylie Hurst 213 Annual Report - 36th Edition 12-1

2 INDIGENOUS ANZDATA Registry 213 Report INTRODUCTION In this chapter, rates of end-stage kidney disease among s of and are presented. For, these are Aboriginal and Torres Strait Islanders; for, analyses include and s. In all cases, indigenous origin is reported by the renal unit on the basis of self-description. and s resident in and Aboriginal and Torres Strait islanders resident in are not considered indigenous unless otherwise specified. For some tables, we have also included data on and s living in. While not indigenous to, these have been included as useful comparators with the NZ experience of this group. Figure 12.1 Mode of Treatment New Patients ATSI Total Total PD HD 1, , Graft PD HD 1, , Graft NEW PATIENTS Figures A total of 254 Aboriginal and Torres Strait Islander commenced dialysis in during 212. The majority (88%) were treated with haemodialysis as their initial RRT modality. No pre-emptive transplants were performed among Aboriginal ns in PD HD 1, , Graft PD HD 1, , Graft PD HD 1, , Graft The number of and starting dialysis increased in 212 (166 patients) and decreased (91 patients) respectively. 46 (28% of total) patients commenced on PD in 212 while the number of s starting with PD was 2%. 212 PD HD Graft Total 15,535 1,623 17,158 1,819 1, ,561 Figure 12.2 Percentage of New Patients - Commencing on Haemodialysis Figure 12.3 Percentage of New Patients - Commencing on Haemodialysis ATSI Non Non

3 ANZDATA Registry 213 Report INDIGENOUS INCIDENCE RATES Overall, the incidence rates (per million population) of indigenous peoples in and NZ are considerably higher than that for non-indigenous people. Direct comparisons are confounded by the different age distributions - the indigenous population for both countries is considerably younger than the non-indigenous population. Although rates fluctuate from year to year, in both countries the indigenous incidence rates have stabilised in recent years. The relative rate differs with age and also (for Aboriginal ns) with gender - this is illustrated in Figure Figure 12.4 Unadjusted incident RRT rate 5 Aboriginal & TSI, 4 and s, treated in Per million per year Per million per year Aboriginal and TSI s ANZDATA Note X and Y scales differ Figure 12.5 Relative incidence rate Aboriginal vs non Aboriginal, Among Aboriginal ns, there is a marked excess relative rate among those aged years. The relative rate is higher among females than males. Relative rate Age (years) Female Male Figure 12.6 Among and the excess rate is concentrated among older groups, and there is no gender difference. Relative rate Relative incidence rate Mäori & s vs non-mäori, Age (years) Mäori s The relative rates for male and female are similar at all ages for Mäori and s 12-3

4 INDIGENOUS ANZDATA Registry 213 Report There is also considerable variation between n jurisdictions in the Aboriginal/TSI RRT incident rates. The incidence rates for each State/Territory can be seen in Figure While rates for the very young (<15 years) and older (>65 years) groups are similar in each State/Territory, the rates for people years of age show a clear trend of progressively higher rates from NSW/Victoria to Queensland then South, Western and the Northern Territory. Data is shown for a three year period given the small numbers in some locations. Figure 12.7 Age-specific incidence rates of treated RRT among Aboriginal & TSI people, by state and age at RRT start per million per year years per million per year years per million per year years NT WA SA Qld Vic NSW NT WA SA Qld Vic NSW NT WA SA Qld Vic NSW per million per year years per million per year years per million per year years NT WA SA Qld Vic NSW NT WA SA Qld Vic NSW NT WA SA Qld Vic NSW Rate 95% CI ANZDATA and ABS data, The overall stabilisation of rates among Aboriginal ns is seen consistently across each age group. In some age groups (such as & years) there is a suggestion of a downwards trend. There are a number of factors which contribute to incident numbers of RRT (among both indigenous and non-indigenous people). It is not clear whether this stabilisation reflects the underlying rates of diabetes, rates of disease progression, referral patterns or other diseases. Figure 12.8 Per million per year note: Y axis scales differ Age-specific incident RRT rate Aboriginal & TSI, Rate 95% CI

5 ANZDATA Registry 213 Report INDIGENOUS Age specific trends for and s are shown in Figures 12.9 and Note that the Y axis scale varies. Figure 12.9 Per million per year Age-specific incident RRT rate, Rate 95% CI note: Y axis scales differ Figure 12.1 Per million per year Age-specific incident RRT rate s, Rate 95% CI note: Y axis scales differ 12-5

6 INDIGENOUS ANZDATA Registry 213 Report NEW TRANSPLANTS Figure New Transplants In both and New Zealand numbers of transplants to indigenous recipients were low. Over the period there was an increase in the number of transplants from deceased donors, which now have stabilised. Numbers from living donors remain extremely low. The table also contains transplants to and people resident in ; the number of these increased over 22-21, and has now stabilised. The number of transplants to and s recipients remains stable. In contrast to the situation in, there is a higher proportion of transplants from living donors Donor Source ATSI ATSI LD DD Total LD DD Total LD DD Total LD DD Total LD DD Total LD DD Total LD DD Total LD DD Total LD DD Total LD DD Total LD DD Total Figure Transplant Numbers. n figures include ATSI only. Number Deceased Live related Live unrelated transplants numbers ATSI in, and PP in 12-6

7 ANZDATA Registry 213 Report INDIGENOUS Cumulative incidence curves (utilising competing risk techniques to account for the effects of both components of graft failure) are shown for indigenous transplant outcomes in Figure It can be seen that for Aboriginal and TSI, there are higher rates of loss of graft function, and substantially higher rates of death with graft function compared with nonindigenous. Both of these differences are progressive over time. Lesser differences are seen for / PP. In particular, the excess death rate among /PP stabilises after the initial months. Figure Transplant outcomes Loss graft function Death with graft function Cumulative incidence s ATSI NZ non-indig Aust non-indig /PP ANZDATA, all grafts 1 Jan 21 to 31 Dec 212 DD1, cumulative incidence competing risks Information on donor source is shown in Figure There are substantially lower rates of living donation among indigenous groups in, with a lesser difference in. n figures include ATSI only. Figure Donor source, by indigenous status indigenous Aboriginal/TSI 16% 5% 7% 23% 61% 88% indigenous /Islander 21% 12% 31% 48% 23% 65% Deceased Live related Live unrelated ANZDATA, Donor source, grafts 1 Jan 21 to 31 Dec

8 INDIGENOUS ANZDATA Registry 213 Report TREATMENT OF PREVALENT PATIENTS The number of prevalent Aboriginal and Torres Strait Islander with treated end-stage kidney disease increased to 1618, continuing a gradual increase. The percentage of ATSI on home haemodialysis was 7% in 212 (this includes patients who perform independent self-care dialysis in community settings). The percentage of ATSI treated with peritoneal dialysis was steady in 212. The number of prevalent with treated end-stage kidney disease increased in 212, whilst remained the same. The percentage of (24%) treated with home haemodialysis remains similar to past years, whilst in this percentage (17%) has increased since 28. Figure Prevalent Patients (% Haemodialysis Patients on Home HD) Mode of Treatment Aboriginal/ TSI PD HD 6711 (13%) 997 (5%) 58 (14%) 169 (14%) 55 (32%) 463 (24%) 329 (13%) Func TX* PD HD 6981 (12%) 142 (7%) 69 (16%) 177 (16%) 65 (33%) 492 (26%) 38 (13%) Func TX* PD HD 727 (12%) 172 (7%) 78 (17%) 194 (15%) 628 (36%) 57 (26%) 421 (17%) Func TX* PD HD 7498 (12%) 1173 (6%) 79 (18%) 211 (18%) 649 (36%) 5 (26%) 449 (16%) Func TX* PD HD 7624 (12%) 128 (7%) 83 (13%) 232 (16%) 674 (38%) 533 (24%) 49 (17%) Func TX* * By Resident Country at 31st December 12-8

9 ANZDATA Registry 213 Report INDIGENOUS DIALYSIS MODALITY The distribution of dialysis modality is shown graphically in Figures below. Among indigenous ns, the principal differences are a substantially lower rate of home HD and APD. This figure also includes the experience for and s treated in at the end of 212; their experience is similar to non-indigenous groups. Similar data is shown for in Figure Again, rates of home treatments (home HD in particular) are lower among the indigenous groups. Figure indigenous Dialysis modality end 212, by indigenous origin Aboriginal/TSI 9% 13% 8% 47% 23% 6% 5% 6% 19% 64% islander 1% 13% 13% 12% 13% 8% 45% 21% 2% 46% APD Hospital HD Home HD CAPD Satellite HD Patients at end 212 dialysing and resident in Figure indigenous Dialysis modality end 212 NZ, by indigenous origin 23% 17% 17% 18% 9% 21% 19% 13% 29% 34% islander 14% 6% 12% 25% 43% APD Hospital HD Home HD CAPD Satellite HD Patients at end 212 dialysing and resident in 12-9

10 INDIGENOUS ANZDATA Registry 213 Report ESTIMATED GLOMERULAR FILTRATION RATE AT TREATMENT START In both and, there has been a gradual trend towards lower egfr at the time of dialysis start, over 211/12 among all groups. However, there is also a consistent difference (in both countries ) between indigenous and non-indigenous, with higher egfr values among the nonindigenous groups. Figure egfr at Dialysis Start Non - Aboriginal/TSI Median egfr (ml/min/1.73m Excluding pre-emptive transplants Figure egfr at Dialysis Start Non - Median egfr (ml/min/1.73m Excluding pre-emptive transplants 12-1

11 ANZDATA Registry 213 Report INDIGENOUS INCIDENCE AND PREVALENCE BY STATE/TERRITORY The next four pages show a variety of figures which summarise various key rates (incidence, prevalence, transplant rates) among indigenous people in and. In large part they show information from previous pages, in a series of differing formats. State Incidence The Northern Territory has the highest national incidence among indigenous people of treated end-stage kidney disease in at 743pmp, the next highest is in South (527 pmp). Dialysis by Resident State Treatment patterns for Aboriginal and Torres Strait Islander vary by State. The highest rates are in the Northern Territory, Western and South. Transplant by Referring State Rates of prevalent transplants vary substantially between States with highest rates in South and Western. These rates are per population, not per dialysis patient, and they reflect both background rates of kidney disease and transplant rates. Figure Incidence of New ATSI Patients 1,2 Per million ATSI population 1, QLD NSW/ACT VIC/TAS SA NT WA Figure Incidence of New Transplants ATSI Patients By referring State 2 Per million ATSI population QLD NSW/ACT VIC/TAS SA NT WA 12-11

12 INDIGENOUS ANZDATA Registry 213 Report Figure Figure Prevalence of Haemodialysis ATSI Patients Prevalence of Peritoneal Dialysis ATSI Patients 6, 7 Per million ATSI population 5, 4, 3, 2, 1, Per million ATSI population QLD NSW/ACTVIC/TAS SA NT WA QLD NSW/ACTVIC/TAS SA NT WA Figure Figure Functioning Transplants ATSI Patients 1, Deaths ATSI Patients 1,2 9 Per million ATSI population 1, Per million ATSI population QLD NSW/ACTVIC/TAS SA NT WA QLD NSW/ACTVIC/TAS SA NT WA 12-12

13 ANZDATA Registry 213 Report INDIGENOUS Figure Incidence of New Patients - and 4 Per Million Population Figure 12.3 Incidence of New Transplants - and 4 Per Million Population Figure Prevalence of Haemodialysis- and 1,5 Per Million Population 1,25 1,

14 INDIGENOUS ANZDATA Registry 213 Report Figure Prevalence of Peritoneal Dialysis- and 6 Per Million Population Figure Functioning Transplant - and 4 Per Million Population Figure Deaths - and 3 Per Million Population

15 ANZDATA Registry 213 Report INDIGENOUS GEOGRAPHICAL DISTRIBUTION Figure shows the number of incident ATSI (patients by postcode) The distribution of prevalent dialysis patients are summarized in Figure (by state) and by statistical subdivision (obtained by mapping postcodes to SSD). Note that some postcodes were distributed over more than one SSD Incident indigenous patients by postcode Incident numbers, by postcode, (5,1] (2,5] (1,2] (5,1] (2,5] (1,2] [,1] ANZDATA, indigenous patients only, based on postcode at first RRT Prevalent indigenous patients, 31 Dec 212 by state/territory Percent indigenous RRT patients, Dec (75,1] (5,75] (2,5] (1,2] (5,1] [,5] No data 12-15

16 INDIGENOUS ANZDATA Registry 213 Report Figure Prevalent indigenous dialysis patients 31 Dec 212 NSW Vic Qld SA WA NT Number of dialysis patients ANZDATA, based on postcode of residence reported at at end 212 mapped to SSD using ABS concordance files 12-16

17 ANZDATA Registry 213 Report INDIGENOUS LATE REFERRAL The percentage of Aboriginal and Torres Strait Islander referred late for treatment has been stable for the last 3 years, and is very similar to the non-indigenous rate. In % commenced haemodialysis using a catheter rather than permanent access (Figure 12.39); again this is a similar situation to the nonindigenous patients. The proportion of people referred late in 212 decreased to 17% from 18% in 211. For referred late, the proportion decreased to 16%. Most (6%) and (61%) commenced haemodialysis with a catheter (Figure 12.39). Figure Late Referral % Late Referral of (Total Number of Patients) ATSI 28 24% (251) 24% (21) 32% (41) 21% (2238) 31% (157) 22% (87) 17% (253) 29 22% (196) 32% (22) 37% (38) 2% (2175) 22% (177) 13% (13) 15% (34) 21 25% (26) 19% (26) 26% (42) 22% (256) 19% (155) 16% (19) 15% (251) 211 3% (256) 19% (21) 17% (46) 22% (2173) 18% (129) 26% (95) 22% (261) % (254) 34% (29) 26% (57) 21% (2194) 17% (167) 16% (92) 14% (254) VASCULAR ACCESS For all indigenous groups in and the vascular access rates (at first HD) are stable over recent years. For both indigenous and non-indigenous groups these rates are higher in NZ than. Figure Vascular Access Use at First ESKD Treatment Where this is Haemodialysis Vascular Access ATSI CVC 138 (58%) 9 (6%) 23 (64%) 178 (58%) 1 (7%) 6 (85%) 128 (71%) AVF/AVG CVC 11 (56%) 13 (52%) 25 (76%) 983 (54%) 99 (71%) 56 (64%) 138 (68%) AVF/AVG CVC 113 (59%) 1 (56%) 23 (64%) 13 (56%) 9 (74%) 65 (69%) 123 (66%) AVF/AVG CVC 135 (55%) 1 (45%) 26 (63%) 976 (52%) 68 (61%) 65 (74%) 135 (64%) AVF/AVG CVC 125 (51%) 15 (79%) 33 (69%) 928 (51%) 88 (6%) 55 (61%) 99 (57%) AVF/AVG

18 INDIGENOUS ANZDATA Registry 213 Report Figure 12.4 Incidence and Prevalence - Aboriginal And Torres Strait Islanders by Resident State (Number per million ATSI population in each state) Mode of Treatment QLD NSW/ACT VIC/TAS SA NT WA New Patients 56 (367) 33 (22) 4 (75) 19 (651) 76 (1146) 63 (857) 251 (466) Prevalent HD 243 (1593) 18 (662) 31 (578) 62 (2124) 335 (554) 218 (2965) 997 (1852) Prevalent PD 49 (321) 33 (22) 6 (112) 8 (274) 26 (392) 44 (598) 166 (38) Functioning 3 (197) 21 (129) 7 (13) 29 (994) 35 (528) 37 (53) 159 (295) Transplant 5 (33) 4 (25) 1 (19) 5 (171) 1 (15) 15 (24) 31 (58) Deaths 45 (295) 18 (11) 3 (56) 6 (26) 55 (83) 37 (53) 164 (35) New Patients 49 (313) 21 (126) 1 (182) 16 (537) 59 (875) 41 (548) 196 (356) Prevalent HD 248 (1585) 119 (715) 33 (61) 62 (282) 361 (5353) 219 (2925) 142 (1895) Prevalent PD 5 (32) 22 (132) 5 (91) 7 (235) 22 (326) 36 (481) 142 (258) Functioning 26 (166) 21 (126) 8 (146) 29 (974) 31 (46) 45 (61) 16 (291) Transplant 1 (6) 5 (3) 1 (18) 5 (168) 2 (3) 1 (134) 24 (44) Deaths 5 (32) 22 (132) 9 (164) 14 (47) 42 (623) 4 (534) 177 (322) New Patients 62 (386) 3 (177) 13 (232) 17 (56) 52 (758) 32 (42) 26 (367) Prevalent HD 253 (1576) 12 (77) 42 (748) 67 (225) 368 (5365) 222 (2913) 172 (199) Prevalent PD 49 (35) 29 (171) 5 (89) 2 (66) 29 (423) 28 (367) 142 (253) Functioning 3 (187) 26 (153) 1 (178) 33 (186) 32 (466) 46 (64) 177 (315) Transplant 4 (25) 6 (35) 2 (36) 5 (165) 2 (29) 9 (118) 28 (5) Deaths 55 (343) 18 (16) 1 (18) 9 (296) 42 (612) 38 (499) 163 (29) New Patients 63 (383) 36 (28) 13 (226) 16 (516) 67 (96) 61 (786) 256 (446) Prevalent HD 268 (1627) 141 (814) 5 (87) 77 (2483) 395 (5663) 242 (3118) 1173 (244) Prevalent PD 56 (34) 21 (121) 3 (52) 2 (65) 2 (287) 32 (412) 134 (234) Functioning 32 (194) 29 (167) 12 (29) 34 (197) 33 (473) 5 (644) 19 (331) Transplant 3 (18) 5 (29) 2 (35) 4 (129) 5 (72) 9 (116) 28 (49) Deaths 39 (237) 2 (115) 5 (87) 5 (161) 47 (674) 33 (425) 149 (26) New Patients 54 (32) 48 (271) 14 (238) 12 (379) 84 (1185) 42 (532) 254 (433) Prevalent HD 29 (1716) 162 (916) 53 (92) 77 (2433) 436 (6149) 262 (3316) 128 (2183) Prevalent PD 53 (314) 34 (192) 6 (12) 5 (158) 19 (268) 28 (354) 145 (247) Functioning 37 (219) 28 (158) 13 (221) 31 (98) 33 (465) 51 (645) 193 (329) Transplant 5 (3) 2 (11) 2 (34) 1 (32) 5 (71) 5 (63) 2 (34) Deaths 3 (178) 13 (73) 8 (136) 12 (379) 46 (649) 24 (34) 133 (227) 12-18

19 ANZDATA Registry 213 Report INDIGENOUS Figure Cause of Death 212 Modality Cause Aboriginal/ TSI Dialysis Cardiac 53 (43%) 4 (44%) (29%) 66 (53%) 33 (55%) 59 (34%) Dialysis Vascular 7 (6%) 1 (11%) 1 (6%) 96 (7%) 9 (7%) 4 (7%) 1 (6%) Dialysis Infec on 15 (12%) 1 (11%) 1 (6%) 12 (8%) 11 (9%) 6 (1%) 12 (7%) Dialysis Social 35 (28%) 1 (11%) 1 (6%) 499 (39%) 17 (14%) 8 (13%) 54 (31%) Dialysis Malignancy 2 (2%) 74 (6%) 6 (5%) 7 (4%) Dialysis Miscellaneous 11 (9%) 2 (22%) 2 (11%) 142 (11%) 15 (12%) 9 (15%) 31 (18%) 212 Dialysis Total Transplant Cardiac 2 (33%) 33 (21%) 2 (5%) 1 (5%) 6 (29%) Transplant Vascular 16 (1%) 1 (5%) 2 (1%) Transplant Infec on 2 (33%) 22 (14%) 1 (25%) 2 (1%) Transplant Social 16 (1%) 1 (5%) Transplant Malignancy 2 (33%) 1 (1%) 45 (29%) 1 (25%) 8 (38%) Transplant Miscellaneous 1 24 (15%) 2 (1%) Transplant Total

20 INDIGENOUS ANZDATA Registry 213 Report This page is intentionally blank 12-2

End Stage Kidney Disease Among Indigenous Peoples of Australia and New Zealand

Chapter 12 End Stage Kidney Disease Among Indigenous Peoples of and New Zealand 216 ANZDATA Registry 39th Annual Report Data to 31-Dec-215 Introduction In this chapter, rates of end-stage kidney disease