CHAPTER 5. Haemodialysis. Kevan Polkinghorne Hannah Dent Aarti Gulyani Kylie Hurst Stephen McDonald

Transcription

1 CHAPTER Haemodialysis Kevan Polkinghorne Hannah Dent Aarti Gulyani Kylie Hurst Stephen McDonald

2 STOCK AND FLOW AUSTRALIA The annual stock and flow of HD patients during the period - is shown in Figures.,. and.. There were 8,7 patients receiving HD treatment at st December, an increase of %; of these 9% were hospital based, 9% were in satellite centres and % at home, the same as in 9. A total of,98 patients received HD for the first time during the year, a decrease of % from 9, after a decrease of % from 8. The proportion of all HD patients in each age group is shown in Figure.7. There were,84 people 7 years receiving haemodialysis, including 9 people 8 years, a rise of % from 9, following a % rise for the previous year. There were 48 transplant operations, an % increase from 9 (49 operations), representing % of all HD patients dialysing and % of those patients < years. There were 4 patients aged years transplanted. There were,8 deaths in. For more detail regarding age and mode of HD in each State see Appendix II at the Website ( Figure. Stock and Flow of Haemodialysis Patients Patients new to HD 49 8 First Dialysis Treatment Previous Dialysis (PD) Failed Transplant Transplanted Deaths 8 Never Transplanted Previous Transplant Transfer to Peritoneal Dialysis Patients Dialysing (HD) at December Patients Dialysing (HD) at Home at December NEW ZEALAND The annual stock and flow of HD patients during the period - is shown in Figures.,.4 and.. There were,4 patients receiving treatment at st December, a continuation of the trend from 8-9. Hospital based HD (4%), satellite HD (9%) and home HD (%) have all remained the same for the past three years. is continued on page -. % of all Home Dialysis (HD and PD) Patients % % % % % Patients new to HD First Dialysis Treatment 7 Previous Dialysis (PD) Failed Transplant 8 7 Transplanted 9 47 Deaths 8 77 Never Transplanted 7 8 Previous Transplant 7 Transfer to Peritoneal Dialysis Patients Dialysing (HD) at December Patients Dialysing (HD) at Home at December % of all Home Dialysis (HD and PD) Patients % % % % 4% -

3 Figure Stock and Flow of Haemodialysis Patients - 87 Patients New Patients Transplants Perm. Transfer Deaths No. Dialysing Figure. Stock and Flow of Haemodialysis Patients - Number (%) Age Groups New Patients * -4 years (%) 9 (%) (%) 9 (%) (%) -4 years 4 (%) 4 (%) 4 (%) 4 (%) 4 (%) -4 years 77 (4%) 94 (%) (%) 89 (4%) 7 (4%) -44 years 8 (%) 87 (9%) 7 (8%) 7 (9%) (8%) 4-4 years 9 (4%) (%) 4 (%) (%) 8 (%) -4 years 44 (%) 47 (%) 447 (%) 44 (%) 4 (%) -74 years (%) 48 (4%) 4 (%) (%) 47 (4%) 7-84 years 4 (%) 4 (%) 4 (%) 4 (%) 97 (%) >=8 years 4 (%) 44 (%) 7 (%) 9 (%) 8 (4%) Total (%) (%) 49 (%) (%) 8 (%) Patients Dialysing -4 years 7 (%) (%) (%) 9 (%) (%) -4 years 94 (%) 98 (%) 88 (%) 9 (%) 98 (%) -4 years (4%) (4%) 9 (4%) 9 (4%) 8 (%) -44 years 97 (%) 77 (%) 9 (9%) 9 (8%) 84 (8%) 4-4 years 4 (%) (%) 74 (%) 4 (%) (%) -4 years 8 (%) 8 (%) 7 (%) 77 (%) 84 (%) -74 years 7 (4%) 84 (4%) 894 (4%) 8 (4%) (4%) 7-84 years 49 (%) (%) 8 (%) 7 (%) 84 (%) >=8 years 8 (%) (%) 7 (%) (4%) 9 (%) Total 7 (%) 79 (%) 79 (%) 8 (%) 87 (%) Primary Renal Disease * Glomerulonephritis 4 (%) 48 (4%) 4 (%) 4 (%) 47 (%) Analgesic Nephropathy 48 (%) 4 (%) 4 (%) 9 (%) 8 (%) Hypertension 7 (%) (%) (%) 8 (4%) 78 (4%) Polycystic Disease 4 (%) 7 (%) (%) (%) (7%) Reflux Nephropathy (%) (%) 9 (%) (%) 4 (%) Diabetic Nephropathy 8 (%) 4 (%) 74 (%) 8 (%) 7 (%) Miscellaneous (%) 7 (%) (%) (%) 4 (%) Uncertain (%) (7%) 7 (7%) 4 (7%) (%) Total (%) (%) 49 (%) (%) 8 (%) * New patients receiving first haemodialysis treatment -

4 Figure Stock and Flow of Haemodialysis Patients - 4 Patients New Patients Transplants Perm. Transfer Deaths No. Dialysing Figure. Stock and Flow of Haemodialysis Patients - Number (%) Age Groups New Patients * -4 years (%) (%) (%) (%) (%) -4 years (4%) (%) (%) (%) (%) -4 years (7%) 7 (4%) (4%) 4 (%) (%) -44 years (8%) 4 (%) 4 (9%) 4 (%) 9 (%) 4-4 years 9 (%) (7%) 84 (%) 89 (%) 9 (%) -4 years 9 (4%) (%) 7 (%) (4%) 8 (8%) -74 years 94 (%) 88 (%) 89 (%) 9 (%) 8 (%) 7-84 years 4 (%) 9 (%) (8%) (%) 8 (%) >=8 years 4 (%) 4 (%) (%) (%) (%) Total 47 (%) 8 (%) 94 (%) 49 (%) 9 (%) Patients Dialysing -4 years (%) (%) (%) (%) 4 (%) -4 years (%) 9 (%) 8 (%) 4 (%) 4 (%) -4 years 88 (7%) 8 (%) 7 (%) 9 (%) 89 (%) -44 years (%) (%) 49 (%) (%) 4 (%) 4-4 years 47 (%) (%) 7 (%) 9 (%) 8 (%) -4 years 47 (8%) 4 (7%) 7 (8%) 4 (7%) 47 (8%) -74 years 9 (%) 97 (%) 9 (%) (%) (%) 7-84 years 87 (7%) 8 (8%) (9%) 47 (%) (%) >=8 years 9 (%) (%) (%) (%) 4 (%) Total (%) (%) 4 (%) 48 (%) 4 (%) Primary Renal Disease * Glomerulonephritis 9 (%) 89 (%) 7 (8%) 9 (%) 88 (%) Analgesic Nephropathy (%) (%) (%) (%) Hypertension 9 (%) 4 (%) (8%) 44 (%) 8 (%) Polycystic Disease (%) (4%) 4 (4%) 8 (4%) (%) Reflux Nephropathy 7 (%) 8 (%) 9 (%) (%) (%) Diabetic Nephropathy 84 (4%) (4%) 4 (%) (49%) (%) Miscellaneous (8%) 47 (%) 4 (%) 4 (%) (9%) Uncertain 9 (7%) (%) (4%) 4 (%) (%) Total 47 (%) 8 (%) 94 (%) 49 (%) 9 (%) * New patients receiving first haemodialysis treatment -4

5 Figure. Age (%) of New Haemodialysis Patients Figure.7 Age (%) of Current Haemodialysis Patients -Dec- Number of Patients = 8 4 Number of Patients = >= >=8 NEW ZEALAND (continued from page -) There were 9 patients who received HD for the first time, a small decrease in number from 9. Eighty three percent were having their initial dialysis treatment, % were previously dialysing with peritoneal dialysis and % were failed transplants. The modal age group for new HD patients was -4 years (8%), 7% were < years and % years (Figures. and.8). The age distribution of the prevalent HD population was similar (Figure.). There were 47 HD patients who received transplants in ( in 9). Four patients years were transplanted. There were deaths in the same as number as 9. For more details see Appendix III at the Website ( Figure.8 Figure.9 Age (%) of New Haemodialysis Patients Age (%) of Current Haemodialysis Patients -Dec- Number of Patients = 9 8 Number of Patients = >= >=8 -

6 AUSTRALIA Blood flow rates in showed a similar picture in and continued to slowly rise.the proportion receiving a prescribed blood flow rate of mls/ minute or higher was 8% in the same as in 9 with 78% in 8. Only 4% (4 patients) were prescribed < mls/minute. Blood flow rates are lower in patients dialysing using central venous catheters than in those using AVFs or AVGs (Figure.). NEW ZEALAND In December, 8% of patients were prescribed mls/minute or higher. There were 7% using < mls/minute, many of these were receiving long hour HD. Figure. Aust NZ Country Figure. Blood Flow Rates (mls/minute) - No. Pts * < -49 Mls/Minute >4 December 84.%.% 4.% 7.9%.%.7% December 9 8.%.% 4.% 7.%.8% 4% December % 4.4%.% 4.8% %.9% December 7 79.% 4.% 8.4%.%.%.9% December 7.4% 4.%.%.%.% 4.4% December 4.%.%.4% 49.%.7%.% December 9 48.%.4% 4.9% 4.9%.%.% December 8 4.4% 7.%.7% 4.% 7.%.9% December 7.%.% 8.8% 4.% %.% December.4%.9%.% 44.8%.%.% Blood Flow Rate by Type of Access December Blood Flow Rate AVF AVG CVC * AVF AVG CVC < (.%) - 7 (.%) (.%) (.%) (.%) (.%) (.%) 7 (.7%) 7 (.%) (.%) (.%) (.%) (.9%) 98 (.%) 9 (7.7%) 4 (.8%) (49.4%) (7.4%) 47 (.%) 79 (8.%) 8 (.7%) 48 (.%) (8.%) (.7%) (.4%) (8.7%) 8 (.%) (.8%) 7 (%) >=4 89 (4.4%) (.7%) 4 (.%) (.8%) - (.%) Total (%) 747 (%) (%) (%) 78 (%) 4 (%) * Number of patients having C.V.V. HD not included Figure. Figure. Distribution of Blood Flow Rates Prevalent Haemodialysis Distribution of Blood Flow Rates Prevalent Haemodialysis, 8 4,, 4,, >=4 At Dec (848) 9 (88) 8 (78) >=4 At Dec (4) 9 (47) 8 (7) -

7 Figure.4 Duration and Number of Sessions Per Week December Sessions Per week Hours of Each Treatment <4 4 4>4-4. >4.- >-. >. Total <= 4 (4.4%) 4 (4.8%) 8 (.%) 8 (8.4%) 8 (.8%) (.%) 7749 (%) >-< 4 (7.8%) 88 (.%) (9.4%) (.4%) 9 (.7%) 4 (4.4%) 4 (%) >= 7 (4.8%) (.%) (.%) 9 (.8%) (.%) 9 (.%) (%) Total 4 (.4%) (9.8%) (%) (7.4%) 48 (.8%) 47 (.%) 8444 (%) <= (.%) (7.7%) 7 (.%) 448 (.%) (.%) 7 (.%) (%) >-< 8 (.%) (%) (.7%) 4 (%) (.7%) (.%) (%) >= 4 (%) 8 (8.%) (7.%) (.7%) - (.%) 8 (%) Total 44 (.9%) (%) 84 (8.%) (%) 4 (.%) 7 (7%) (%) Figure. 8 4 Haemodialysis Frequency (per Week) December Dec 8 Dec 9 Dec Dec 8 Dec 9 Dec >-< FREQUENT AND LONG (Figures.4 -.) The proportions of those dialysing > times per week in has plateaued with no change from 7. In the proportion dialysing more than three times per week continues to increase. The proportions dialysing 4. hours per session has plateaued as has the total hours per week. As a result, the proportions dialysing more than the standard hours per week has now stabilised in but not. In, 4% and 4% of HD patients were dialysing. hours per week in and respectively.figures.-. show these from several prospectives. Figure. Haemodialysis Session Length (Hours) December 8 - Figure.7 Haemodialysis Duration (Hours per Week) December Dec 8 Dec 9 Dec Dec 8 Dec 9 Dec >. >-. >4.- > < Dec 8 Dec 9 Dec Dec 8 Dec 9 Dec < -7

8 Figure.8 age of Patients Dialysing Five or More Days per Week.... Mar 4 Dec Dec 7 Dec 9 Mar 4 Dec Dec 7 Dec 9 Dec 4 Dec Dec 8 Dec Dec 4 Dec Dec 8 Dec Survey Period Figure. age of Patients - Dialysing Days per Week Dialysing 4. Hours per Session or Longer 4 Mar 4 Dec Dec 7 Dec 9 Mar 4 Dec Dec 7 Dec 9 Dec 4 Dec Dec 8 Dec Dec 4 Dec Dec 8 Dec Survey Period Figure. age of Patients Dialysing > Hours per Week 4 Mar 4 Dec Dec 7 Dec 9 Mar 4 Dec Dec 7 Dec 9 Dec 4 Dec Dec 8 Dec Dec 4 Dec Dec 8 Dec Survey Period -8

9 Dialysis frequency and session length vary among the n States. Patients in Queensland, Victoria and South are more likely to dialyse more frequently, while patients in New South Wales/ACT and the Northern Territory tend to dialyse longer per session on average (Figures. -.). Figure. Haemodialysis age Sessions per Week By n State and Country Qld NSW/ACT Vic Tas SA NT WA New Zealand Dec- 49 (.%) (.9%) 48 (.%) (.%) 8 (.4%) (.%) (.9%) 8 (.8%) Dec-9 4 (.%) 7 (%) 9 (.8%) (.4%) (.%) - (.%) 8 (.9%) Dec-8 (.4%) (.9%) 4 (.%) (.%) 8 (.7%) (.%) (.%) 4 (.%) Dec-7 7 (4.%) (%) (.%) (.8%) 9 (.9%) - 4 (%) 7 (.%) Figure. Haemodialysis age 4. Hours Per Session Three Sessions per Week By n State and Country Qld NSW/ACT Vic Tas SA NT WA New Zealand Dec- 89 (.8%) 8 (.9%) 744 (.7%) 77 (.8%) 7 (4.4%) 9 (7.9%) 8 (.%) 8 (.%) Dec-9 79 (49.9%) 77 (4.%) (.%) 7 (.%) (%) 4 (79.%) (4.8%) 748 (%) Dec-8 7 (49.4%) 7 (.%) 4 (%) (4.%) (.8%) 7 (7.7%) 77 (.%) (48.7%) Dec-7 78 (49.7%) (%) (.%) 4 (%) (.%) 78 (8.%) 8 (.%) 74 (.%) Figure. Haemodialysis age > Hours per Week By n State and Country Qld NSW/ACT Vic Tas SA NT WA New Zealand Dec- 978 (.%) 4 (7.9%) 94 (4.%) 89 (.7%) (9.%) 8 (77.4%) (%) 984 (4.%) Dec-9 94 (.%) 9 (7.%) 87 (4.%) 87 (.%) (.%) 4 (8.%) 7 (.8%) 9 (.%) Dec-8 88 (.%) (74.4%) 87 (4.%) 9 (4.8%) (.7%) 8 (78.7%) (8.%) 78 (8.4%) Dec-7 84 (.%) 87 (74.%) 84 (4.%) (4.7%) (.%) 8 (84.7%) (.%) 8 (.%) -9

10 OUTCOME AMONG PATIENTS In, there has been little change in haemodialysis patient survival over time, after adjusting for age, diabetes status, sex, race and comorbidities. In, recent cohorts have slightly better survival. In both countries, diabetes status and age have marked effects on haemodialysis patient survival. (Figures.4 -.4). Note: For all tables and graphs the times indicated are from the 9th day and not the first treatment. Figure.4 Haemodialysis at 9 Days Patient Survival Censored for Transplant 99 - % [9% Confidence Interval] No. of Patients Survival months year years years [9, 94] 87 [8, 88] [4, 7] 48 [47, ] [9, 94] 8 [8, 87] [4, 7] 47 [4, 48] -7 9 [9, 9] 8 [8, 87] [, ] 47 [4, 49] [9, 9] 87 [8, 88] [9, 9] 87 [84, 89] [8, ] 4 [7, 4] [9, 9] 88 [8, 9] [, 8] 44 [4, 48] [9, 9] 89 [8, 9] [, 8] 44 [9, 48] [9, 9] 9 [87, 9] - - Figure. Figure. Patient Survival - Haemodialysis at 9 Days 99 - Censored for Transplant - Patient Survival - Haemodialysis at 9 Days 99 - Censored for Transplant -.. Patient Survival (9) -4 (44) -7 () 8- (7) 4 Years Patient Survival (7) -4 (84) -7 (947) 8- (7) 4 Years -

11 Figures.7-.8 These figures show survival curves for patients treated with haemodialysis at day 9, adjusted to a median age of. years for and 7. years for ; non-diabetic primary renal disease; caucasoid race; female gender and no comorbid conditions (lung disease, coronary artery disease, peripheral vascular disease or cerebrovascular disease). Note: x axis scale refers to time after day 9. PRD = Primary renal disease. Figure.-. show survival stratified by age at the start of treatment. Figure.7. Patient Survival - Haemodialysis at 9 Days 99 - Censored for Transplant - Adjusted for Age,Diabetic PRD and Gender Patient Survival (9) -4 (44) -7 () 8- (7) 4 Years Figure.8. Patient Survival - Haemodialysis at 9 Days 99 - Censored for Transplant - Adjusted for Age,Diabetic PRD and Gender Patient Survival (7) -4 (84) -7 (947) 8- (7) 4 Years -

12 Figure.9 Haemodialysis at 9 Days Patient Survival - Diabetic / Non Diabetic Censored for Transplant 99 - % [9% Confidence Interval] No. of Patients Survival months year years years Non Diabetic (n=,89) 9 9 [9, 9] 8 [8, 87] 7 [, 8] [49, ] Diabetic (n=4,8) 8 9 [9, 94] 87 [8, 87] [, 4] 4 [4, 44] Non Diabetic (n=,4) 4 9 [9, 94] 88 [8, 89] 7 [, 9] 48 [4, ] Diabetic (n=,7) 4 9 [94, 9] 89 [87, 9] [, ] 9 [, 4] Figure.. Patient Survival - Haemodialysis at 9 Days 99 - Censored for Transplant - Patient Survival.7... Non-diabetic (9) Diabetic (8) 4 Years Figure.. Patient Survival - Haemodialysis at 9 Days 99 - Censored for Transplant - Patient Survival.7... Non-diabetic (4) Diabetic (4) 4 Years -

13 Figure. Haemodialysis at 9 Days Patient Survival - By Age Group Censored for Transplant 99 - % [9% Confidence Interval] Age Groups No. of Patients Survival months year years years -9 years 4 98 [97, 99] 9 [9, 97] 87 [8, 89] 8 [77, 8] 4-9 years 84 9 [9, 9] 9 [9, 9] 77 [7, 78] [, ] -74 years 8 9 [9, 9] 8 [84, 8] [, ] 4 [4, 4] >=7 years [8, 88] 77 [7, 79] 4 [44, 48] [, ] -9 years [98, ] 9 [94, 98] 8 [78, 87] 7 [, 77] 4-9 years 49 9 [94, 9] 9 [89, 9] 7 [7, 7] [48, ] -74 years 7 9 [9, 94] 8 [84, 88] 7 [4, ] [, 7] >=7 years 84 [79, 87] 7 [, 7] [7, 9] 7 [, ] Figure.. Patient Survival - Haemodialysis at 9 Days 99 - Censored for Transplant - Patient Survival.7... Age <4 (4) 4-9 (84) -74 (8) >=7 (99) 4 Years Figure.4. Patient Survival - Haemodialysis at 9 Days 99 - Censored for Transplant - Patient Survival.7... Age <4 (484) 4-9 (49) -74 (7) >=7 () 4 Years -

14 MEMBRANE TYPE AND SURFACE AREAS AUSTRALIA Figures Usage of low flux polysulfone dialysers was % in, (% in December 9, % in 8 and 7%in 7). While the use of high flux polysulphone continues to decrease (% in 9, % in 9,.% in 8, 7% in both 7 and, 9% in and 9% in 4. High flux Polysulphone-Helixone increased to 7% in December from % in 9, 49% in 8, 9% in 7 and 4% in. High flux Polyamix increased to % this year from 9% last year and % in 8. There were 9% of patients receiving dialysis with high flux dialysers in (88% in 9, 8% in 8, 7% in 7 and 4% in ). NEW ZEALAND Figures. and.9. Low flux polysulphone decreased to % in December, from % and 4% in December 9 and 8 respectively. There were 7% (4 patients) reported as receiving dialysis with high flux dialysers in December, an increase from % (9patients) in 9 and %(7 patients) in 8. Figure. Dialyser Membrane Type Haemodialyser Membrane Types Flux Square Metres < >.9 Total CELLULOSE ACETATE LOW... CELLULOSE TRIACETATE HIGH DIACETATE LOW.. 4. POLYAMIX HIGH POLYAMIX LOW POLYETHERSULFONE HIGH.. 9 POLYNEPHRON HIGH POLYSULPHONE HIGH.. 8 POLYSULPHONE LOW POLYSULPHONE-HELIXONE HIGH Total POLYAMIX HIGH POLYAMIX LOW POLYSULPHONE HIGH.... POLYSULPHONE LOW POLYSULPHONE-HELIXONE HIGH Total Figure. Number of Patients at end of by HD Modality NT NSW/ACT Vic Qld SA WA Tas NZ Total Haemodiafiltration , Haemodialysis - Hollow 4,9,8, ,7 9, Haemofiltration 9 4 Total 4,99,97,7 8,,7 Figure.7 Figure.8 Haemodialysis Surface Area Haemodialysis Surface Area,, 9 (8) (848) (49) (9) , <= <=

15 ANAEMIA In, mean haemoglobin and erythropoietic agent use has stabilised. Haemodialysis patients had a higher erythropoietic agent usage despite a similar mean haemoglobin compared to peritoneal dialysis patients (Figures.9 -.4). In, mean haemoglobin has stabilised at 4 g/l. The increase in erythropoietic agent usage seen over - has reached a plateau. Figure.9 Mean Haemoglobin Among Dialysis Patients By Survey Period Mean Hb(g/L) Mar 4 Dec Dec 7 Dec 9 Mar 4 Dec Dec 7 Dec 9 Dec 4 Dec Dec 8 Dec Dec 4 Dec Dec 8 Dec Survey Period PD HD Figure.4 Use of Erythropoietic Agents By Survey Period Mar 4 Dec Dec 7 Dec 9 Mar 4 Dec Dec 7 Dec 9 Dec 4 Dec Dec 8 Dec Dec 4 Dec Dec 8 Dec Survey Period PD HD -

16 HAEMOGLOBIN In, haemoglobin is < g/l in 8% and >4g/L in 4% of haemodialysis patients, which is the same as the previous two years. In, the corresponding percentages are 4% and 4% respectively. Figure.4 shows the proportion of patients with proven or likely cardiovascular disease reported as a comorbidity to the Registry, achieving the clinical target of haemoglobin g/l. Figure.4 Haemoglobin - Haemodialysis December 8- Hb(g/L) < Dec 8 Dec 9 Dec Dec 8 Dec 9 Dec Figure.4 Haemoglobin - Haemodialysis By Coronary Artery Disease Status - December 8- Haemoglobin - Haemodialysis By Coronary Artery Disease Status - December 8- Hb(g/L) < - > Hb(g/L) < - > Dec 8 Dec 9 Dec Dec 8 Dec 9 Dec No CAD CAD Dec 8 Dec 9 Dec Dec 8 Dec 9 Dec No CAD CAD -

17 HAEMOGLOBIN BY TREATING CENTRE Figures.4-.4 These figures show the median haemoglobin (with inter-quartile range) for individual centres, arranged from lowest to highest. Also shown are the proportion of patients in each centre with a haemoglobin of - g/l. In, median haemoglobin for each centre ranged from to g/l for haemodialysis patients and in 7-8 g/l. The proportion of patients in with a haemoglobin of - g/l in each centre ranged from % to 8% for haemodialysis patients and for 8% to %. Figure.4 Figure.44 Haemoglobin in Haemodialysis Patients Haemoglobin in Haemodialysis Patients December December 4 4 Median Hb (g/l) Median Hb (g/l) 9 Excludes hospitals with < patients 9 Excludes hospitals with < patients Figure.4 Figure.4 % Haemodialysis Patients with Hb - g/l % Haemodialysis Patients with Hb - g/l December December Excludes hospitals with < patients Excludes hospitals with < patients

18 FERRITIN AND TRANSFERRIN SATURATION Figures In and the proportions of haemodialysis patients with ferritin < mcg/l and those with ferritin mcg/l have been relatively stable. In both distributions of transferrin saturation have been unchanged for the past three years, while in the proportion with a transferrin saturation < has reduced. Figure.47 Ferritin - Haemodialysis December 8- g/l < Dec 8 Dec 9 Dec Dec 8 Dec 9 Dec 4 4 Figure.48 Transferrin Saturation - Haemodialysis December 8- T/Sat(%) < Dec 8 Dec 9 Dec Dec 8 Dec 9 Dec -8

19 FERRITIN BY TREATING CENTRE Figures These figures show the proportions of patients in each centre with ferritin of - mcg/l and transferrin saturation of >% respectively, as recommended by the CARI guidelines. In, the proportions of patients with ferritin within this range in each centre varied widely between -8% for haemodialysis patients. Similarly large variations between centres were seen for transferrin saturation, between -%. Again, this large variation probably reflects differences in practices, protocols and patient case-mix among centres. In, the corresponding figures for ferritin were between 7-4% for haemodialysis patients and the corresponding figures for transferrin saturation were between 48-8%. In both countries, significant proportions of patients did not have ferritin and transferrin saturation within the recommended ranges, even in the best performing centres. Figure % Haemodialysis Patients with Ferritin - g/l December Excludes hospitals with < patients 4 4 Figure % Haemodialysis Patients with Ferritin - g/l December Excludes hospitals with < patients Figure. Figure. % Haemodialysis Patients with TSat >% % Haemodialysis Patients with TSat >% December December Excludes hospitals with < patients Excludes hospitals with < patients

20 SERUM CALCIUM Figure. In both and the proportions of patients with proportions with serum calcium.4 mmol/l has continued to decrease, while those with <. mmol/l have decreased in, but remained fairly stable in. Figure. Serum Calcium - Haemodialysis December 8- Calcium (mmol/l) < Dec 8 Dec 9 Dec Dec 8 Dec 9 Dec SERUM CALCIUM BY TREATING CENTRE Figures.4 and. show the proportions of patients at each centre with serum calcium. -.4 mmol/l, as recommended by the CARI guidelines. Note: however, that the values in the guidelines were for corrected total calcium, while those in this report are for uncorrected total calcium. In, the proportions ranged widely between -% for haemodialysis patients, while in the corresponding proportions were 4-8%. Figure % Haemodialysis Patients with Calcium.-.4 mmol/l December Excludes hospitals with < patients 4 4 Figure % Haemodialysis Patients with Calcium.-.4 mmol/l December Excludes hospitals with < patients

21 SERUM PHOSPHATE Figure. In, the control of serum phosphate has stabilised after a period of steady improvements. In, the proportion with serum phosphate >.8 mmol/l has largely remained stable. Figure. Serum Phosphate - Haemodialysis December 8- Phosphate (mmol/l) < Dec 8 Dec 9 Dec Dec 8 Dec 9 Dec SERUM PHOSPHATE BY TREATING CENTRE Figures show the proportions of patients at each centre with serum phosphate.8-. mmol/l, as recommended by the CARI guidelines. In, the proportions ranged widely between -9% for haemodialysis patients and in, the corresponding proportions were 9-%. Figure.7 Figure % Haemodialysis Patients with Phosphate.8-. mmol/l December Excludes hospitals with < patients % Haemodialysis Patients with Phosphate.8-. mmol/l December Excludes hospitals with < patients

22 CALCIUM-PHOSPHATE PRODUCT Figure.9 In both and, calcium-phosphate product has continued to improve, among haemodialysis patients, with smaller proportions of patients with a product. mmol /l. Overall, the proportion of people with high calcium-phosphate product was substantially higher in than. Figure.9 Calcium Phosphate Product - Haemodialysis December 8- Ca X PO4 (mmol /L ) < Dec 8 Dec 9 Dec Dec 8 Dec 9 Dec CALCIUM-PHOSPHATE PRODUCT BY TREATING CENTRE Figures. -. show the proportions of patients at each centre with calcium-phosphate product <4. mmol /L, as recommended by the CARI guidelines. In, the proportions ranged widely between 4-% for haemodialysis patients while in, the corresponding proportions were 4-%. Figure. Figure % Haemodialysis Patients with Ca X PO 4 < 4. mmol /L December Excludes hospitals with < patients % Haemodialysis Patients with Ca X PO 4 < 4. mmol /L December Excludes hospitals with < patients

23 UREA REDUCTION RATIO Figures. and.4 Distributions of URR values have been fairly stable over the past three years. About 8% and % of patients on haemodialysis three times a week have URR <% in and respectively. URR is highest in patients dialysing with an AV graft and lowest in those using catheters Figure..Of those with URR < %, 8% in and % in had CVC access. Figure. Figure. URR (%) Dec 8 Dec 9 Dec Dec 8 Dec 9 Dec Urea Reduction Ratio HD Three Sessions per Week < HD Three Sessions per Week - December URR (%) 8 Urea Reduction Ratio Related to Type of Access < AVF AVG CVC AVF AVG CVC 7 7 Figure.4 Urea Reduction Ratio - Prevalent Patients Three Sessions per Week - December Hours per Session Urea Reduction Ratio % < >= Total <4 hours (8.%) 4 (8.9%) 9 4 hours 4 (8.%) 7 (9.7%) 9 >4- hours (7.4%) (9.%) 7 > hours 7 (.7%) 4 (88.%) Total 88 (8.4%) 44 (9.%) 7 <4 hours (4.%) 9 (.%) 4 hours 49 (.%) (7.7%) 4 >4- hours 78 (8.%) 4 (7.8%) > hours (.%) (84.%) 7 Total 44 (9.%) 8 (7.8%) 79 -

24 UREA REDUCTION RATIO BY TREATING CENTRE Figures. and. show the median URR in each hospital and Figures.7 and.8 show the proportions of haemodialysis patients dialysing three times per week in each hospital with URR > 7%, the target recommended by the CARI guidelines. Median URR values in the respective countries did not vary greatly: 4-8% in and 7-7% in. However, the proportions with URR >7% in each unit varied widely, from -9% in and 9-8% in. Figure. Figure. Median URR in Haemodialysis Patients (Three Sessions per Week) Median URR in Haemodialysis Patients (Three Sessions per Week) December December Median URR(%) Median URR(%) Excludes hospitals with < patients Excludes hospitals with < patients Figure % Haemodialysis Patients with URR>7% (Three Sessions per Week) December Excludes hospitals with < patients 4 4 Figure % Haemodialysis Patients with URR>7% (Three Sessions per Week) December Excludes hospitals with < patients 4 7-4

25 VASCULAR ACCESS AT FIRST TREATMENT Figures.9 to.78 The proportion of patients starting haemodialysis with an AVF has continued to rise in both and although the majority of patients still commence with a catheter. In, tunnelled catheters were more common than non-tunnelled, but the reverse was true in. Diabetic, female, young (age <years) patients and patients who were first seen by nephrologists < months before starting haemodialysis ( late referrals ) were less likely to start with an AVF or AVG. In both n and indigenous peoples had similar or increased rates of AVF or AVG at the commencement of dialysis. ANZDATA does not collect HD without permanent access information about indication for catheter usage, hence the reason less than half of non-late referred patients commence is not known. Figure.9 Vascular Access - Initial RRT Haemodialysis at Initial Modality AVF AVG Tunnel Catheter Non-Tunnel Catheter Figure.7 Vascular Access - Initial RRT By Age Group AVF AVG Tunnel Catheter Non-Tunnel Catheter < < Figure.7 Vascular Access - Initial RRT By Diabetic Status - AVF AVG Tunnel Catheter Non-Tunnel Catheter Figure.7 Vascular Access - Initial RRT By Diabetic Status - AVF AVG Tunnel Catheter Non-Tunnel Catheter Non Diabetic Diabetic Non Diabetic Diabetic -

26 VASCULAR ACCESS AT FIRST TREATMENT Figure.7 Vascular Access - Initial RRT By Gender - AVF AVG Tunnel Catheter Non-Tunnel Catheter Figure.74 Vascular Access - Initial RRT By Gender - AVF AVG Tunnel Catheter Non-Tunnel Catheter Female Male Female Male Figure.7 Vascular Access - Initial RRT By Referral Time - AVF AVG Tunnel Catheter Non-Tunnel Catheter Figure.7 Vascular Access - Initial RRT By Referral Time - AVF AVG Tunnel Catheter Non-Tunnel Catheter Early Late Early 7 Late 7 7 Figure.77 Vascular Access - Initial RRT By Racial Origin - AVF AVG Tunnel Catheter Non-Tunnel Catheter Figure.78 Vascular Access - Initial RRT By BMI - AVF AVG Tunnel Catheter Non-Tunnel Catheter Caucasian ATSI Asian Caucasian Maori Pacific People Underweight Normal Overweight Obese Morbidly Obese Underweight Normal Overweight Obese Morbidly Obese -

27 VASCULAR ACCESS AT FIRST TREATMENT Figure.79 Vascular Access at First Treatment Haemodialysis as Initial Modality -Jan-7 to -Dec AVF or AVG CVC AVF or AVG CVC AVF or AVG CVC AVF or AVG CVC QLD 49 (4%) (9%) (%) 49 (4%) (4%) (9%) 8 (4%) (9%) NSW/ACT 8 (%) 7 (%) 87 (%) 74 (7%) 77 (%) (4%) 8 (%) (4%) Vic (47%) 7 (%) 8 (47%) 9 (%) (%) (%) 7 (4%) 4 (%) Tas 4 (4%) (9%) (%) (%) (4%) (7%) (%) (9%) SA (8%) 48 (4%) 7 (4%) (4%) 89 (%) 7 (9%) 4 (4%) 79 (9%) NT (%) 44 (9%) 9 (49%) 4 (%) 7 (4%) (4%) (4%) 9 (4%) WA (%) (7%) 7 (4%) (%) (9%) (%) (%) (9%) 78 (%) (7%) 7 (%) 47 (77%) (%) 49 (9%) 8 (%) 4 (7%) Figures.8 and.8 show the proportion of patients of each hospital starting haemodialysis with AVF/AVG, arranged from the lowest to the highest. In, this ranged widely from -7%. The corresponding range in was -4%. This wide variation probably reflects differences in practices, protocols, resources and patient case-mix among centres. However, the patient case-mix is unlikely to explain all of this variation. Figure.8 Figure.8 % New HD Patients Staring with AVF/AVG Jan - Dec % New HD Patients Staring with AVF/AVG Jan - Dec Excludes hospitals with < patients Excludes hospitals with < patients

28 PREVALENT ACCESS Figures In both and, the proportions of patients dialysing with an AV graft are declining, while those dialysing with an AV fistulas are stable. The proportions dialysing with catheters have also stabilised. Female patients in both countries, young (age < years) in or old (age 7 years) patients in were less likely to be dialysing with an AVF or AVG. Figure.8 Prevalent Haemodialysis Access AVF AVG Tunnel Catheter Non-Tunnel Catheter Dec 7 Dec 8 Dec 9 Dec Dec 7 Dec 8 Dec 9 Dec Figure.8 Prevalent Haemodialysis Access By Age Group - December AVF AVG Tunnel Catheter Non-Tunnel Catheter < <

29 PREVALENT ACCESS Figure.84 Prevalent Haemodialysis Access By Diabetic Status - Figure.8 Prevalent Haemodialysis Access By Diabetic Status - AVF AVG Tunnel Catheter Non-Tunnel Catheter AVF AVG Tunnel Catheter Non-Tunnel Catheter Dec 7 Dec 8 Dec 9 Dec Dec 7 Dec 8 Dec 9 Dec Non Diabetic Diabetic Dec 7 Dec 8 Dec 9 Dec Dec 7 Dec 8 Dec 9 Dec Non Diabetic Diabetic Figure.8 Prevalent Haemodialysis Access By Gender - Figure.87 Prevalent Haemodialysis Access By Gender - AVF AVG Tunnel Catheter Non-Tunnel Catheter AVF AVG Tunnel Catheter Non-Tunnel Catheter Dec 7 Dec 8 Dec 9 Dec Dec 7 Dec 8 Dec 9 Dec Female Male Dec 7 Dec 8 Dec 9 Dec Dec 7 Dec 8 Dec 9 Dec Female Male Figure.88 Prevalent Haemodialysis Access By BMI - AVF AVG Tunnel Catheter Non-Tunnel Catheter Underweight Normal Overweight Obese Morbidly Obese Underweight Normal Overweight Obese Morbidly Obese -9

30 PREVALENT ACCESS Figures In indigenous people were more likely to dialyse with an AVF. In New Zealand, Maori and Pacific people were more likely to dialyse with an AVF. Patients on home haemodialysis have the highest rate of AVF use in both and. Figure.89 Prevalent Haemodialysis Access By Racial Origin - December AVF AVG Tunnel Catheter Non-Tunnel Catheter Caucasian ATSI Asian Caucasian Maori Pacific People Figure.9 Prevalent Haemodialysis Access By Facility - December AVF AVG Tunnel Catheter Non-Tunnel Catheter Hosp HD Sat HD Home HD Hosp HD Sat HD Home HD -

31 PREVALENT ACCESS Figures show the proportion of haemodialysis patients at each hospital dialysing with an AVF/AVG on st December,, arranged from the lowest to the highest. In, the proportions varied widely from 8-%. The corresponding range in was 7-9%. The error bars displayed show the 9% confidence intervals. Figure.9 Prevalent Vascular Access at -Dec- Dec 7 Dec 8 Dec 9 Dec AVF or AVG CVC AVF or AVG CVC AVF or AVG CVC AVF or AVG CVC QLD (89%) 48 (%) 8 (87%) (%) 7 (88%) (%) 4 (88%) (%) NSW/ACT 4 (84%) 94 (%) 7 (84%) 4 (%) 4 (8%) 448 (7%) 8 (8%) 4 (%) Vic 79 (89%) (%) 87 (9%) (%) 89 (89%) 7 (%) 4 (89%) (%) Tas (88%) (%) (8%) 4 (8%) 8 (8%) (%) 8 (88%) 8 (%) SA 4 (9%) 47 (%) 4 (88%) (%) 48 (9%) (%) (89%) (%) NT 97 (89%) 8 (%) 8 (9%) 4 (9%) (9%) 7 (4%) 7 (9%) (8%) WA 4 (77%) 4 (%) (7%) (7%) 9 (7%) 8 (4%) 4 (78%) 78 (%) 99 (7%) 4 (%) 98 (7%) (7%) (7%) 7 (%) (78%) 4 (%) Figure.9 Figure.9 % Prevalent HD Patients Dialysing with AVF/AVG December % Prevalent HD Patients Dialysing with AVF/AVG December Excludes hospitals with < patients Excludes hospitals with < patients

32 OBESITY IN INCIDENT PATIENTS Figures show the proportions of incident haemodialysis patients with obesity and morbid obesity. In both and obesity rates have been increasing over the last ten years. The proportion of morbidly obese patients starting haemodialysis has doubled from to in both countries. As might be expected, patients with diabetes are more likely to be obese or morbidly obese compared to those without diabetes (Figures.99 -.). Obesity for these analysis is defined as a BMI>kg/m². Morbid obesity is defined as kg/m² Figure.94 age Obese 4 Obesity in Incident Haemodialysis Patients By Year Figure.9 Obesity in Incident Haemodialysis Patients By State and Country age Obese 4 4 QLD NSW ACT VIC TAS SA NT WA AUS NZ Figure.9 age Morbidly Obese Morbid Obesity in Incident Haemodialysis Patients By Year

33 Figure.97 Morbid Obesity in Incident Haemodialysis Patients By State and Country - 8 age Morbidly Obese QLD NSW ACT VIC TAS SA NT WA AUS NZ Figure.98 age Obese 4 Obesity in Incident Haemodialysis Patients By Diabetes Non-Diabetic Diabetes Co-morbid Diabetic nephropathy Non-Diabetic Diabetes Co-morbid Diabetic nephropathy Figure.99 age Morbidly Obese 4 Morbid Obesity in Incident Haemodialysis Patients By Diabetes - 9 Non-Diabetic Diabetes Co-morbid Diabetic nephropathy 8 Non-Diabetic Diabetes Co-morbid Diabetic nephropathy -

34 OBESITY IN PREVALENT PATIENTS Figures. -. show the proportion of prevalent haemodialysis patients with obesity and morbid obesity. In both and prevalent obesity rates have been increasing over the last ten years. The proportion of morbidly obese patients treated with haemodialysis has nearly doubled from to in both countries. Patients with diabetes are more like to be obese or morbidly obese compared to those without diabetes (Figures. and.). Figure. age Obese 4 Obesity in Prevalent Haemodialysis Patients By Year Figure. age Morbidly Obese Morbid Obesity in Prevalent Haemodialysis Patients By Year

35 Figure. Obesity in Prevalent Haemodialysis Patients By State and Country - 49 age Obese QLD NSW ACT VIC TAS SA NT WA AUS NZ Figure. Morbid Obesity in Prevalent Haemodialysis Patients By State and Country - age Morbidly Obese QLD NSW ACT VIC TAS SA NT WA AUS NZ Figure.4 Figure. age Obese 4 8 Non-Diabetic Obesity in Prevalent Haemodialysis Patients By Diabetes - 9 Diabetes Co-morbid 4 Diabetic nephropathy Non-Diabetic Diabetes Co-morbid 8 Diabetic nephropathy age Morbidly Obese Morbid Obesity in Prevalent Haemodialysis Patients By Diabetes - 7 Non-Diabetic Diabetes Co-morbid 7 8 Diabetic nephropathy Non-Diabetic Diabetes Co-morbid Diabetic nephropathy -

36 Home Haemodialysis The proportion of all prevalent dialysis patients who were using home HD in each State was 4% for New South Wales, % the ACT, % Queensland, 8% Victoria, 7% the Northern Territory, % Tasmania, % Western and % for South. These proportions were lower among older people (Figure.). The distribution of numbers of patients receiving home haemodialysis by state is shown in Figure.. As can be appreciated, numbers are greatest in New South Wales and in, with substantial numbers also in Victoria and Queensland. Figure.7 shows the trend over recent years. In particular, can be appreciated that in the States with fewer patients (Northern Territory, South, Western and Tasmania) there are clear trends towards growth. Figure. Home HD numbers by state 489 at end 4 4 Number NT NSW/ACT Vic Qld SA WA Tas NZ Figure.7 Home HD numbers at end year Number NT NSW/ACT Vic Qld SA WA Tas 4 NZ Year -

37 The distribution of prevalent home dialysis patients by age group is shown in Figure.8. Figure.8 Home HD numbers by age group by state at end 8 4 NT NSW/ACT Vic Qld SA WA Tas NZ Figure. Proportion (%) of Prevalent Patients aged years Treated with Home Haemodialysis - State Queensland.%.% 4.% 4% 4.% New South Wales 4.9%.4%.%.4%.% n Capital Territory 4.%.8% 4.4%.7%.% Victoria.%.9%.%.4%.4% Tasmania %.%.7%.4%.% South % Northern Territory.% % %.%.9% Western.%.9%.%.8%.%.4%.8%.8%.9%.% 8.% 8.% 8.% 8.% -7

38 The trend is for different age groups are illustrated for and in the Figure. and.. The Y axes for individual grafts vary the absolute numbers in the age groups to 4 years are substantially greater than among older patients. Figure. Home HD numbers at end year - by age group Number Year Figure. Home HD numbers at end year NZ - by age group Number Year -8

39 Technique failure The following figures explore the concept of technique failure as applied to home haemodialysis. Each treatment episode can end in a variety of ways. Changes to another dialysis modality (either institutional haemodialysis or peritoneal dialysis) are considered a failure, as is death. Follow-up is censored at transplantation, or Dec. Figure. Technique failure. Home haemodialysis Years Censored at transplantation Figure. Technique failure Home haemodialysis Years Age at RRT start < Censored at transplantation and NZ combined -9

40 When death of patient is counted as a censoring event (rather than failure ), the differences between the age groups become less apparent (Figure.4). It can be seen that (among those alive and not transplanted) over 7% of home haemodialysis patients continue in this therapy after years. However, as time passes there is a progressive difference which emerges with higher technique failure rates among the older patients. Figure.4 Death censored technique failure Home HD Years Years Age at RRT start < Age at RRT start < Censored at transplantation and death ANZDATA Registry Definitions in use CARI guidelines Quotidian HD Long Hour HD Caring for Australasians with Renal Impairment guidelines > sessions/week and/or >. hours/session. hours per HD session High Flux Dialyser AVF AVG CVC Obese BMI Morbid Obe\sity BMI Ultrafiltration coefficient (kuf) > ml/hr/mmhg as specified by the manufacturer) Native vein arteriovenous fistula Synthetic arteriovenous bridge graft Central venous HD catheter (Includes both tunnelled and non-tunnelled unless otherwise stated) -4

41 -4