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Dialysis outcomes in Australia & New Zealand

Dialysis outcomes in Australia & New Zealand. Stephen McDonald ANZDATA Registry. Dialysis outcomes. What is collected by ANZDATA : Mortality Process indicators Urea clearance Haemoglobin What is not collected : Indicators of health & functional state Mental health Physical health

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Dialysis outcomes in Australia & New Zealand

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  1. Dialysis outcomes in Australia & New Zealand Stephen McDonald ANZDATA Registry

  2. ANZSN ASM 2002 Dialysis outcomes • What is collected by ANZDATA: • Mortality • Process indicators • Urea clearance • Haemoglobin • What is not collected: • Indicators of health & functional state • Mental health • Physical health • Surrogate markers of cardiovascular disease (LVH)

  3. ANZSN ASM 2002 Acceptance of New Patients by Age Australia New Zealand New RRT rates by age group 1990-2001

  4. Kaplan-Meier survival estimates, by year 1.00 2000- 0.75 Survival 0.50 1995- 1965- 1970- 0.25 1990- 1980- 1985- 1975- 0.00 0 5 10 15 20 ANZSN ASM 2002 Survival on dialysis – 15-64 yrs Time (years) Survival on dialysis, 15-64 years old, at onset of RRT, censored at transplantation

  5. ANZSN ASM 2002 Survival, 65-74 years Kaplan-Meier survival estimates, by year 1.00 0.75 Survival 0.50 1990- 1985- 1995- 0.25 1975- 1980- 1970- 0.00 0 5 10 Years Survival on dialysis, 65-74 years old, at onset of RRT

  6. ANZSN ASM 2002 Proportion of CAD by age .8 .6 Proportion with CAD .4 .2 0 15- 25- 35- 45- 55- 65- 75- 85- Age (years) Proportion of new dialysis patient with definite or suspected coronary artery disease (CAD), 1995-2001

  7. ANZSN ASM 2002 Methods • All patients who began RRT in Australia or NZ since 1 October 1991 • Commencement of collection of co-morbid data • Periods of transplant function excluded • Censored at death • Cox regression • Time dependent covariates for dialysis modality • Co-morbidities ascertained at RRT start

  8. ANZSN ASM 2002 Outcomes by age 1.00 15- 0.75 25- 35- 0.50 45- 55- 0.25 65- 85- 75- 0.00 1 3 5 7 9 Years Kaplan Meier survival curves by age group for patients treated with dialysis who began RRT treatment in Australia or New Zealand 1 Jan 1991 - 31 Dec 2000. Periods of transplant function excluded.

  9. ANZSN ASM 2002 Comorbid factors and outcome 2.5 2 1.5 Hazard ratio 1 .5 CAD DM1 DM2 Aust Ab Maori / PI Cerebrovasc High BP Late referral Lung Male PVD PD Hazard ratios for mortality on dialysis, dialysis only, 1991-present, adjusted for age and gender

  10. ANZSN ASM 2002 Effect of BMI on outcome 2 1.5 Hazard ratio 1 <20 20-24.9 25-29.9 30-34.9 35- BMI (kg/m2) Hazard ratios for mortality by BMI at entry, dialysis only, 1991-present, adjusted for age and gender and other comorbidities.

  11. ANZSN ASM 2002 Predicted median survival 25 centile 50 centile 75 centile 15 10 Survival (years) 5 0 45 55 65 75 85 Age at RRT start Median [IQR] survival by age. Age modelled as fractional polynomial, adjusted to 0 comorbidities & non-indigenous male

  12. 2.5 2 1.5 Hazard ratio (death) 1 .5 0-90 day 3-12 months 1-2 year 2-5 years 5+ years Time period post RRT start ANZSN ASM 2002 Interactions with time Hazard ratios for late referral for mortality on dialysis, 1991-present, adjusted for age and gender and other co-morbidities

  13. ANZSN ASM 2002 Interactions with time - 2 2.5 2 Hazard ratio (death) 1.5 1 0-90 day 3-12 months 1-2 year 2-5 years 5+ years Time period post RRT start Hazard ratios for coronary artery for mortality on dialysis, 1991-present, adjusted for age and gender and other comorbidities

  14. ANZSN ASM 2002 Interactions of CAD with age 5 Hazard ratio 2 1 25- 35- 45- 55- 65- 75- 85- Age (years) Hazard ratios for mortality of coronary artery disease by age category, adjusted for gender, dialysis patients

  15. ANZSN ASM 2002 Indigenous outcomes 1.00 1.00 Non-indigenous 0.75 0.75 Non-indigenous Pacific Islander 0.50 0.50 Pacific Islander Maori Survival 0.25 0.25 Aboriginal Aboriginal Maori 0.00 0.00 0 5 10 0 5 10 Years Years Survival of new ESRD patients, 1991-2001, crude (left) and adjusted to age 40 (right), censored at transplantation. PI includes TSI

  16. ANZSN ASM 2002 Centre effect • What is the aim? • making comparisons? • meeting a standard? • What is a centre? • How do you handle transfers? • What do you adjust for • ? Role of dialysis dose • ? Access

  17. 40 30 Rate (per 100) 20 10 0 ANZSN ASM 2002 Crude death rates Death rates of patients treated with dialysis, 1991-2001, by hospital of initial treatment, for centres with >20 deaths over the period.

  18. ANZSN ASM 2002 Centre effect - 2 50 Rate estimate (per 100 per year) 20 10 5 1 Death rates of patients treated with dialysis, 1991-2001, by hospital of initial treatment, for all centres, sorted by number of new patients over that perio.

  19. ANZSN ASM 2002 Dialysis mortality • Dialysis mortality is strongly related to variables which are known at time of RRT start • The influence of these varies over time • Age is strongly and progressively related to outcome • Adverse prognosis of indigenous groups • Remains after adjustment for comorbidities

  20. ANZSN ASM 2002 Areas of further investigation • This work provides the basis for developing and validating a predictive set of equations • How to incorporate factors such as dialysis dose and Hb into analyses • Vary with time • Cause or effect? • Centre effect • Planned for presentation at D & T 2003

  21. ANZSN ASM 2002 Acknowledgements • The ANZDATA Registry is a collaborative effort of the Australian / New Zealand renal community, and could not exist without the dedicated support of the renal units and the individuals therein.

  22. Kaplan-Meier survival estimates, by year 1.00 0.75 2000- Survival 1990- 0.50 1995- 1980- 0.25 1985- 0.00 1 3 5 Years ANZSN ASM 2002 And still older… Survival on dialysis, 75+ years old, at onset

  23. ANZSN ASM 2002 Indigenous ESRD incidence New ESRD patient (Australia) by racial origin 1990-2000. For 2000, age standardised incidence rate ratio=7.8 [6.6-9.2]

  24. 2 1.5 Hazard ratio (death) 1 .5 0-90 day 3-12 months 1-2 year 2-5 year 5+ years Time period post RRT start ANZSN ASM 2002 Interactions with time – 3 Hazard ratios for type 2 diabetes for mortality on dialysis, 1991-present, adjusted for age and gender and other comorbidities

  25. ANZSN ASM 2002 Interactions of CAD with age - 2 5 2 Hazard ratio 1 .5 25- 35- 45- 55- 65- 75- 85- Age (years) Hazard ratios for coronary artery disease by age category, adjusted for gender, all other co-morbidities and indigenous status

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