Narrative review
Urology Information science
Volume 211 - Issue 8

Impending challenges of the burden of end‐stage kidney disease in Australia

Authors:  Wai H Lim, David W Johnson, Stephen P McDonald, Carmel Hawley, Philip A Clayton, Matthew D Jose and Germaine Wong

Med J Aust 2019; 211 (8): 374-380.e3. || doi: 10.5694/mja2.50354
Published online: 21 October 2019

Despite the immense economic burden of the growing number of people with chronic and end-stage kidney disease, it is still not recognised as one of the five national priority areas in Australia

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Summary

  • Sex and age‐specific incidence rates of patients with treated end‐stage kidney disease (ESKD) in Australia are comparable to those in European countries, but substantially lower compared with those in the United States, Canada and many Asian countries.
  • The incidence rates of treated ESKD in Australia increase with advancing age; however, the incidence of ESKD is likely to be underestimated because a proportion of patients with ESKD (about 50%) remain untreated.
  • Late referral to nephrologists has reduced over the past decade, temporally associated with improved ESKD recognition. However, late referral still occurs in one in five Australians with ESKD.
  • One in two Australians with ESKD has diabetes, with up to 35% of cases directly attributed to diabetes.
  • Mortality rates for patients with ESKD remain substantially higher compared with the age‐matched general population, although there has been a significant improvement in survival over time.
  • Cardiovascular disease and cancer are the two most common causes of death in patients with ESKD.

The growing burden and costs related to the identification and treatment of chronic kidney disease (CKD) and end‐stage kidney disease (ESKD) will be one of the foremost global public health threats in the 21st century.1,2 However, country‐specific strategies and solutions that aim to counteract this challenge have been developed.3 Given the differences in population sizes, health care structures, medical workforce, and economic and social inequalities, individual countries will need to adapt and develop policy guidelines to respond to the growing burden of CKD and ESKD. It is therefore necessary to develop effective strategies that go beyond tackling the projected increasing burden and costs associated with the treatment of ESKD and that focus on preventing ESKD risk factors, such as diabetes and hypertension, and the comorbid conditions related to kidney disease, including cardiovascular disease (CVD), infections and cancers.4

This review describes the incidence, aetiology and survival disadvantage of patients with ESKD in Australia, using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry. It also highlights areas that can be addressed in improving future clinical and government health care policies for the delivery and organisation of care for patients with ESKD.

Data sources

Relevant data were extracted from the most recent (or otherwise stated) annual data reports from the ANZDATA registry,5,6 the United States Renal Data System (USRDS),7,8,9 the Canadian Organ Replacement Register (CORR),10 the United Kingdom Renal Registry11 and the Australian Bureau of Statistics.12,13,14 In addition, we conducted a comprehensive literature search in the online database MEDLINE to source relevant studies, without language restriction, using the search terms “kidney or renal disease” or “chronic kidney disease” or “end‐stage kidney disease”. We included articles published from 2000 to 2018.

Global sex‐ and age‐specific incidence of treated end‐stage kidney disease

Box 1 (A and B) compares the sex‐specific incidence rates of patients with treated ESKD commencing renal replacement therapy (RRT) in Australia and in selected countries worldwide where data were available (2016 data), expressed as incidence per million population (pmp).5,9 The incidence of treated ESKD was substantially higher in men compared with women across most countries. In Australia, there were 1791 male and 1032 female patients with incident treated ESKD in 2016, corresponding to 149 and 85 patients pmp, respectively,13 which compares with the incidence rates in males of 444 pmp in the United States, 252 pmp in Canada and 153 pmp in the United Kingdom, and with the incidence rates in females of 314 pmp, 149 pmp and 87 pmp, respectively.5,9

The comparison of the age‐specific incidence rates of patients with treated ESKD in Australia and other countries is shown in Box 2 (A, B and C) (2016 data).9 In the studied countries, the incidence rate of treated ESKD is substantially greater with advancing age, exceeding 1000 pmp in patients aged 65 years or more in the US, Malaysia, Singapore, Taiwan and Greece. It is noteworthy that the age‐ and sex‐specific rates of patients with incident ESKD across neighbouring Asia–Pacific regions are substantially higher, overtaking the incidences of ESKD in many high income countries. This variation may reflect differences in the susceptibility to and progression of CKD, as well as improved access to health care and/or RRT in those countries.15 Other potential reasons for the disparate incidence rates between countries may include:

  • the institution of effective early CKD detection and management programs in high income countries;
  • disproportionate increases in diabetes and obesity in many low and middle income countries;
  • disproportionate increases in the diagnosis of CKD of unknown aetiology in many low and middle income countries;16
  • and progressive shifts of many countries towards universal health coverage leading to improved access to RRT in a number of low and middle income countries.17,18,19

Nevertheless, substantial variations in country economies (ie, gross domestic product), availability of clinical registries, health care workforce, health care financing, and health care policies are likely to influence the coverage and comprehensiveness of the data capture and treatment of patients with ESKD, resulting in unreliable estimates of the true incidence of patients with ESKD undergoing RRT in some countries.20,21 Understanding the information that may explain these differences is critical for the global community, and it requires reliable and sustained data collection to adequately inform the global pattern of ESKD incidence and care.22,23

It must be emphasised that the incidence of ESKD is likely to be underestimated in Australia and there is a substantial proportion of people with ESKD who are untreated or have declined treatment. In a data‐linkage study, with data from the ANZDATA registry and the Australian Institute of Health and Welfare National Mortality Database, evaluating the burden of ESKD in Australia, 21 370 cases of incident ESKD were registered between 2003 and 2007, with similar numbers of documented treated (10 949) and untreated patients (10 421). There was an inverse relationship between age and uptake of treatment for ESKD, with more than 90% of people with ESKD aged 60 years or under having accepted treatment, compared with less than 30% for those aged more than 80 years.24 Similar rates have been observed in the US.25,26 Globally, it is estimated that between one‐half and three‐quarters of people with ESKD die without accessing RRT, with this figure being highest in places such as Africa (84–91%).27

Aetiology of end‐stage kidney disease in Australia

In Australia, ESKD attributed to diabetic nephropathy and glomerulonephritis accounted for 35% and 18% of patients commencing RRT in 2016, respectively,5 with similar proportions being observed in Canada (38% and 11%, respectively)10 and the UK (29% and 14%, respectively) (2016 data).11 In contrast, 75% of ESKD cases in the US were attributed to diabetic nephropathy (47%) and hypertension (28%), with 7% of ESKD cases attributed to glomerulonephritis (2016 data).7

In Australia, the proportion of ESKD attributed to diabetic nephropathy has steadily increased over the past 15 years, paralleling the increase in the proportion of patients with incident ESKD with prevalent diabetes at the initiation of RRT (Box 3).5 This growth in diabetes prevalence is of major concern and is likely to mirror the obesity epidemic in the community.31 The latest estimates are that two in three adults (or 11.2 million adults) in Australia are either overweight or obese,13 rapidly reaching the obesity epidemic crisis observed in the US.32 If the number of patients with obesity and diabetes continues to rise, it is likely that these comorbid conditions will drive the growing burden of ESKD in Australia and worldwide.33 Nevertheless, given a lack of details of the characteristics of patients with ESKD who have declined treatment for the disease, the true contribution of diabetes to the burden of ESKD is likely to be underestimated.

Choice of dialysis modality for end‐stage kidney disease in Australia

The choice of dialysis modality substantially differs between countries.34,35 Of 23 840 patients with prevalent treated ESKD in Australia in 2016, 47% had received a kidney transplant, 38% were maintained on satellite haemodialysis, 10% on peritoneal dialysis and 5% on home haemodialysis.36 However, there is substantial ethnic disparity in the choice of RRT, with Indigenous Australians with prevalent ESKD more likely to be maintained on satellite haemodialysis compared with non‐Indigenous Australians (75% v 35%).37 The proportions of Indigenous Australians with prevalent ESKD maintained on home haemodialysis, or on peritoneal dialysis, or who received a kidney transplant were 6%, 7% and 13%, respectively, compared with 12%, 10% and 50% for non‐Indigenous Australians with prevalent ESKD, respectively (2016 data).37

In contrast, peritoneal dialysis is the preferred dialysis modality in Hong Kong,38 whereas in the US (2016 data), 88%, 2% and 10% of patients receiving prevalent dialysis were maintained on satellite haemodialysis, home haemodialysis and peritoneal dialysis, respectively.7,36,39 The differences between countries in the choice of RRT are likely to be influenced by multiple factors, including patient (eg, cognitive ability, family support, health literacy), facility (eg, physician bias or experience, infrastructure support), health care system (eg, public v private models, financial incentives, clinician reimbursement) and industry factors (eg, costs, distribution or delivery systems).40,41,42

There is substantial variation in dialysis modality selection and outcomes between Australian centres. For example, peritoneal dialysis uptake by centres ranges between 0% and 78%,43 and the rates of peritoneal dialysis‐related complications, such as peritonitis and technique failure, vary more than sevenfold between these centres.44,45,46 Detailed analysis of these observations suggest that centre‐related characteristics are the major driver of these variations,44,45 suggesting that more work is required to address these wide variations in dialysis centres practices and outcomes.

Kidney transplantation for end‐stage kidney disease

The number of kidney transplants has grown by 70% in the past decade, with the total number of transplants increasing from 641 in 2006 to 1091 in 2016, paralleling the increase in organ donation rate (deceased organ donors increased from ten donors pmp in 2006 to 21 donors pmp in 2016).47,48 Similarly, the transplantation rate of all patients receiving dialysis has increased from 5.7 per 100 dialysis‐years in 2006 to 7.7 per 100 dialysis‐years in 2016.47,48 In 2017, there were 1109 kidney transplants performed in Australia and 11 687 prevalent kidney transplant recipients, and the transplantation rate of all patients undergoing dialysis remained stable at 7.5 per 100 dialysis‐years.49

Living kidney donation rates have declined over the past 5 years (24% of overall transplants in 2016), with similar trends observed in other countries including the UK and the US.8,50,51 The reasons for this decline remain unclear, but may be related to the financial impact on live donors.52 Even though the Supporting Living Organ Donors Program implemented by the Australian Government has mitigated some of the financial burden for living donors (http://www.health.gov.au/internet/main/publishing.nsf/Content/Leave-for-living-organ-donors), further research to identify other barriers is needed. Of 264 live‐donor transplants in 2016, 44% occurred pre‐emptively (ie, transplantation before initiation of dialysis), with 26% and 20% from spousal and parental donors, respectively.52 Despite the higher rates of ESKD in Indigenous Australians, the transplantation rate for this population is considerably lower compared with non‐Indigenous patients,53 with Indigenous patients contributing only 3% of total transplants in 2016. Likewise, only 3% of all active deceased donor wait‐listed patients were Indigenous.37,54 Less than 10% of Indigenous patients received kidneys from a live donor, compared with 25% in non‐Indigenous patients with ESKD.37,47,54

Late referrals

Late referral — defined in the ANZDATA registry as the initiation of dialysis within 90 days of referral to a renal service — is an important challenge to improving the health care of patients with ESKD. It has consistently been shown to be associated with a greater risk of premature mortality.55,56 This adverse association is likely related to the delayed introduction of specific treatment for kidney disease and related complications and delayed planning for dialysis access and consideration of kidney transplantation.57 The reasons for late referrals are diverse and unique to each country. However, they are likely to range from poor awareness until the patient is symptomatic, impaired access to health care, suboptimal screening of high risk patients (diabetes and hypertension), health care providers' lack of recognition that early referral may be required, and a multitude of other patient‐related factors, such as socio‐economic disadvantage, denial and underappreciation of the importance of follow‐up.58,59,60,61,62

The proportion of late referrals has declined in Australia over the past decade, reducing from 25% in 2005 to 18% in 2016,5,63 with similar proportions reported in other countries (UK, 16%; Canada, 27%) (2016 data).10,11 The proportion of late referrals in Australia in 2017 remained at 18%.6 In Australia, some of the strategies implemented to improve the recognition of CKD include:

  • the laboratory reporting of automatic estimated glomerular filtration rate (eGFR);
  • the Kidney Health Australia's promotion of kidney health checks (assessment of blood pressure, eGFR and albuminuria) in high risk patients; and
  • the Primary health care Education Advisory board for Kidney Health Australia's (PEAK) implementation of comprehensive, multipronged primary health care CKD education programs.

These strategies are likely to have resulted in the reduction in late referrals,64,65 particularly for older patients and Indigenous people with ESKD.66 Despite the 32% reduction in late referrals in the past decade, improved understanding of the barriers and attributes of late referrals coupled with innovative approaches, such as targeted CKD screening programs in high risk or specifically targeted population groups, are still required to further reduce the rate of late referrals.

Sex disparity

In Australia, the incidence rates of treated ESKD (36% and 38% of incident patients were women in 2016 and 2017, respectively)5,6 and the mortality attributed to CKD and dialysis‐related hospitalisations were up to two times higher in men than women, with similar rates observed in other countries.13,67,68 In addition, fewer women were wait‐listed for kidney transplantation or received kidney transplants, with women comprising only 38% of all patients who were listed in the deceased donor transplant waiting list or who had a functioning kidney transplant in Australia (2016 data).54 While some have attributed this disparity to a truly greater propensity of men with CKD to progress to ESKD, despite the fact that early stage CKD is more common in women, the precise reasons are uncertain. It is also possible that imprecise estimation of renal function in women and gender bias in the approach to ESKD care (including approach to and barriers precluding timely access to transplant wait‐listing and subsequent transplantation) are operative.67 Identifying potential modifiable factors is urgently needed to better understand and reduce this sex disparity in the management of women with ESKD.69,70,71

End‐stage kidney disease risk in Indigenous Australians

There is considerable variation in the incidence of ESKD and transplantation rate among Indigenous Australians. The relative rate of ESKD is up to 15 times higher in Indigenous Australians (incident rate 380 pmp) compared with non‐Indigenous Australians, with the disparity more pronounced in women and in Indigenous Australians aged between 35 and 65 years (2016 data).37 Indigenous Australians experience substantially higher rates of diabetes, and therefore the incidence of diabetic nephropathy as cause of ESKD is much higher in Indigenous compared with non‐Indigenous Australians (69% v 33%) (2012–2016 data).37 However, the proportion of Indigenous patients who had experienced late referral was similar to non‐Indigenous patients (15% and 17%, respectively, between 2013 and 2017 v 36% and 23%, respectively, between 2002 and 2006).6 These data are encouraging and suggest that the strategies aimed at assisting identification and timely access to renal services have been generally effective in this population.

Factors contributing to the reduced access of kidney transplantation for Indigenous Australians with ESKD are complex. They involve intertwining issues relating to delayed referral and access to undertaking essential kidney transplant work‐up investigations, access to tertiary transplantation units in the capital cities across Australia (eg, remote residential locations), and high rates of medical unsuitability for both Indigenous patients with ESKD and potential donors, thus resulting in low rates of live‐donor transplantation.53,72,73,74 Once deemed suitable for transplant wait‐listing, Indigenous patients have a longer waiting time and are more likely to receive poor immunologically matched kidneys, as donor kidneys are largely sourced from non‐Indigenous Australians.75

It is likely that a different model of care is needed to support access to transplantation and to improve outcomes after transplantation. This model of care may include the provision of culturally appropriate education regarding transplantation to patients and families, may establish a better support structure in remote areas (eg, to facilitate investigations, follow‐up and medication adherence), and may consider allocating more immunologically compatible donor kidneys to Indigenous patients.

Mortality rates of patients with treated end‐stage kidney disease

In the general population, decreased kidney function has been shown to be an independent risk factor for all‐cause mortality and CVD events.76,77,78 Similarly, ESKD is associated with a significant survival disadvantage compared with the general population. 79,80Box 4 shows the crude unadjusted mortality rates over the past decade for dialysis and transplant patients with ESKD compared with the age‐matched general population in Australia, with the magnitude of the survival disadvantage inversely related to age (2016 data).14,81 Compared with the general population, age‐specific mortality rates are lower in patients who have received kidney transplants compared with those on maintenance dialysis.

In keeping with the advances in improved screening guidelines and treatment for ESKD and related vascular risk factors, the mortality rates for both dialysis and transplant patients in Australia are progressively falling (P < 0.001 for trend for both dialysis and transplant patients), but remained inferior compared with the age‐matched general population. The mortality rates for prevalent dialysis and transplant patients were 14.5 (95% CI, 13.7–15.2) and 2.3 (95% CI, 1.0–2.7) per 100 patient‐years in 2005, and 13.8 (95% CI, 13.1–14.4) and 2.1 (95% CI, 1.8–2.4) per 100 patient‐years in 2016, respectively.81,82 The mortality rates for prevalent dialysis and transplant Indigenous patients were 11.1 (95% CI, 9.5–12.8) and 2.4 (95% CI, 0.9–5.3), respectively, compared with 14.3 (95% CI, 13.6–15.1) and 2.1 (95% CI, 1.9–2.4), respectively, in non‐Indigenous patients (2016 data).81 The mortality rates of Australian patients with treated ESKD in 2017 were similar, with rates of 14.4 (95% CI, 13.7–15.1) and 1.9 (95% CI, 1.7–2.2) per 100 patient‐years for prevalent dialysis and transplant patients, respectively.83

Cause‐specific mortality

CVD remains one of the predominant causes of mortality in patients with treated ESKD in Australia (Box 5) (2016 data). However, this has modestly reduced over time, with withdrawal from treatment being the most common cause of mortality in dialysis patients in 2016.81,82,84 In 2017, the three most common causes of death for dialysis patients were withdrawal (32% of overall deaths), CVD (30%) and infection (10%); whereas for kidney transplant recipients, the three most common causes were cancer (25%), CVD (23%) and infection (14%).83 A substantial proportion of CVD deaths are not directly related to complications of atherosclerotic CVD, but to an excess of sudden cardiac death.85,86,87 Even though patients with CKD and dialysis and transplant patients have an excess of traditional CVD risk factors, treatment strategies (such as statin therapy and erythropoietin) targeted against these risk factors have largely been ineffective or have only had a modest benefit.88,89,90,91,92,93,94,95 In addition, it is likely that novel CVD risk factors, such as inflammation and arterial stiffness, have equally important roles in the pathogenesis of CVD in patients with ESKD. Until there are effective treatment options for these risk factors,95,96,97,98 CVD will continue to be one of the dominant causes of mortality.

For patients with ESKD aged between 45 and 74 years and who received a kidney transplant, cancer has become the commonest cause of mortality (32% cancer v 21% CVD deaths [2016 data] and 25% cancer v 24% CVD deaths [2017 data]).81,83 Epidemiological studies have consistently shown that patients with ESKD are at a greater risk of certain cancers and cancer‐related deaths, particularly those cancers likely to have viral (eg, cervical cancer), immune (eg, melanoma) or uraemia‐related aetiologies (eg, renal cancers), compared with the age‐matched general population.99,100,101,102,103 Other than uraemia or immunosuppression‐induced alterations in the immune system, poor adherence to age‐specific cancer screening and the likelihood that cancers are more aggressive at presentation are some of the additional risk factors that contribute to a higher risk of cancer mortality in patients with ESKD.101,104,105 The current recommendations regarding the treatment of patients with ESKD are largely extrapolated from clinical trials and guidelines adapted from both the general population and patients with CKD, with a summary of these recommendations published by each country (eg, www.cari.org.au) and global consensus (https://kdigo.org/guidelines). As the treatment of patients with ESKD is likely to extend from primary health care clinicians across to specialists from all disciplines, clinicians have to be vigilant in ensuring that an optimal but individualised treatment plan is prepared for all patients with ESKD, including screening and treatment of vascular risk factors to targets and adherence to age‐specific screening guidelines.104,106

Gaps in health care delivery for patients with end‐stage kidney disease

Given the considerable economic impact of the projected growth in patients with ESKD, additional measures are required to improve the health outcomes of these patients. First, clinical education and preventive programs need to be augmented to promote CKD recognition and the close monitoring of progression in individuals at risk of CKD or with established CKD. Multiple strategies have already been implemented, such as the publication of CKD management guidelines for GPs;107 the creation of mobile apps that provide guidance to primary health care providers and patients (eg, https://itunes.apple.com/au/app/ckd-go!/id1047480612?mt=8); and the provision of automated web‐based clinical risk prediction tools for CKD.108,109 These strategies were designed to counteract lack of awareness and low detection rates of people with CKD among primary health care physicians.110 Nevertheless, it is likely that the awareness of these programs remains suboptimal. Second, there needs to be a concerted, nationwide effort to implement integrated chronic disease management strategies, including improved coordination and communication regarding patients with CKD between primary and specialist care physicians to ensure timely access to appropriate clinical investigations and treatment. Third, patient autonomy and appropriate support in the choice of RRT, particularly home dialysis treatments such as peritoneal dialysis and home haemodialysis, should be provided by all renal centres while ensuring timely access to transplantation. Fourth, a commitment needs to be made to establish CKD registries or data linkages to other health information systems in order to capture the rates of CKD and untreated ESKD, to complement the data collected in the ANZDATA registry, and to better inform future health care planning and resource allocation regarding the growing burden of CKD and ESKD in Australia.

Conclusion

Even though the health outcomes of people with CKD and ESKD have steadily improved over time, the projected growth in patients with incident and prevalent ESKD in Australia remains one of the major public health concerns. However, CKD is not recognised as one of the five national priority areas identified in Australia, which is of substantial concern, considering the immense economic burden related to the growing number of people with CKD and ESKD. Urgent actions are required to effectively counteract these CKD‐ and ESKD‐related challenges. These actions should include the identification of barriers for early referrals in people with kidney disease, the national integration of the available health reforms and strategies to help identify and manage people with kidney disease, the introduction of appropriate measures and models of care to ensure improved equity of access to RRT for all Australians, and the promotion of a greater research focus specifically targeted to improving health outcomes for people with CKD and ESKD.

Box 1 – Sex‐specific incidence rates of patients with treated end‐stage kidney disease (ESKD) requiring renal replacement therapy in the year 2016 (expressed as per million population [pmp]) by selected countries — men (A) and women (B)*5,9

*These rates do not account for differences in the population age structures of the represented countries.

Box 2 – Age‐specific incidence rates of patients with treated end‐stage kidney disease requiring renal replacement therapy in the year 2016 — expressed as per million population (pmp) — by selected countries: Australia v other major Western countries (A), Australia v other European countries (B), and Australia v Asia–Pacific countries (C)*

*Age strata of 20–44 years, 45–64 years, 65–74 years and ≥ 75 years are shown.5,9

Box 3 – Temporal trends of the primary causes of end‐stage kidney disease (ESKD) and comorbid conditions between 2000 and 2016*5,28,29,30

Incident treated ESKD patients

2000

2005

2010

2016

Total number of patients

1723

2210

2257

2823

Causes of ESKD

 

 

 

 

 Glomerulonephritis

30%

24%

22%

18%

 Diabetic nephropathy

22%

32%

35%

35%

 Polycystic disease

6%

7%

7%

6%

 Hypertension

14%

14%

14%

14%

 Reflux nephropathy

5%

3%

3%

2%

 Analgesic nephropathy

5%

3%

2%

< 1%

Comorbid conditions

 

 

 

 

 Diabetes (type 1 and type 2)

31%

42%

46%

49%

 Former/current smokers

49%

52%

53%

47%

 Coronary artery disease

28%

33%

35%

26%

 Peripheral vascular disease

18%

18%

18%

14%

 Cerebrovascular disease

10%

11%

11%

9%

* Data expressed as percentages of incident treated ESKD patients by year.

Box 4 – Crude unadjusted age‐specific mortality rates for patients with end‐stage kidney disease treated with dialysis or transplantation compared with the general population in 2005 (A), 2010 (B) and 2016 ([C] dialysis and [D] transplant, stratified by sex and treatment types)*

*Age strata of ≤ 25–34 years, 35–44 years, 45–54 years, 55–64 years, 65–74 years, 75–84 years and ≥ 85 years are shown.81,82,84

Box 5 – Bar graphs showing the proportion of deaths attributed to cardiovascular disease (CVD), infection, cancer, withdrawal from treatment and other causes, by treatment type — (A) dialysis and (B) transplant — in 2005, 2010 and 2016. Panels C, D and E show the proportion of deaths attributed to CVD, infection, cancer, withdrawal and other causes according to age groups and treatment types — (C) haemodialysis, (D) peritoneal dialysis, and (E) transplant patients (2016 data only)81,82,84

 

Authors

  • Wai H Lim1
  • David W Johnson2,3
  • Stephen P McDonald4,5
  • Carmel Hawley2,3
  • Philip A Clayton4
  • Matthew D Jose6,7
  • Germaine Wong8
  • 1. Sir Charles Gairdner Hospital, Perth, WA
  • 2. Princess Alexandra Hospital, Brisbane, QLD
  • 3. Centre for Health Services Research, University of Queensland, Brisbane, QLD
  • 4. South Australian Health and Medical Research Institute, ANZDATA Registry, Adelaide, SA
  • 5. University of Adelaide, Adelaide, SA
  • 6. University of Tasmania, Hobart, TAS
  • 7. Royal Hobart Hospital, Hobart, TAS
  • 8. Westmead Hospital, Sydney, NSW

Correspondence: wai.lim@health.wa.gov.au

Competing interests

No relevant disclosures.

Acknowledgements

We acknowledge the substantial contributions of the Australian and New Zealand nephrology community (physicians, surgeons, database managers, nurses, renal operators and patients), which provides information to, and maintains, the ANZDATA database. The data reported here have been supplied by the ANZDATA registry, the UK Renal Registry, USRDS and CORR. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of any organisation. Wai Lim is supported by a Clinical Research Fellowship from the Raine Medical Research Foundation (University of Western Australia and Department of Health Western Australia) and by a Don and Lorraine Jacquot Career Development Fellowship (Royal Australasian College of Physicians). David Johnson is supported by a National Health and Medical Research Council (NHMRC) Practitioner Fellowship. Germaine Wong is supported by an NHMRC Career Development Fellowship. The ANZDATA Registry is funded by the Australian Organ and Tissue Authority, the New Zealand Ministry of Health and Kidney Health Australia.

References

Provenance: Commissioned; externally peer reviewed.

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