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The management of chronic kidney disease is complex. With disease management being the responsibility of parents in the paediatric renal clinic, the responsibility is gradually shifted to adolescents and young adults during the transition to adult care. This multi-perspective qualitative study aimed to explore the experiences of adolescents and young adults, their parents and health professionals to gain an insight into transitional care. Focussing on the transition process and transfer to adult care, 18 adolescents and young adults and eight mothers participated in individual semi-structured interviews. Additionally, three focus groups were conducted with 20 multidisciplinary health professionals. Data were transcribed verbatim and analysed thematically. Similar responses from adolescents and young adults and mothers included the reluctance to leave the paediatric health service. Mothers found the transition to adult care more challenging than the adolescents and young adults. While health professionals acknowledged that engaging adolescents and young adults in their own care was challenging, they believed parents had an important role in facilitating their child's independence. This study highlights that health professionals in both paediatric and adult health services need to work collaboratively. However, importantly, health professionals need to be mindful that parents require an equal amount of engagement as adolescents and young adults, if not more, to mitigate parental barriers in achieving a successful transfer.Copyright © The Author(s) 2021.

Aims: To review the Victorian increased viral risk donor (IVRD) program 22 months post-implementation. Background(s): IVRDs with at-risk behaviours for blood borne virus infection and negative nucleic acid testing (NAT) have a low absolute risk of window period infection but were historically under-utilised. A new system of allocation of these donors (defined by Public Health Service [PHS] 2013 criteria and open window periods) to pre-consented recipients was developed. Method(s): We retrospectively examined the characteristics of IVRDs (July 31 2018-May 31, 2020). Data for comparison with non-IVRDs was available for the first 7 months. Continuous data was expressed as median (IQR). Result(s): 40% of waitlisted recipients were pre-consented to accept IVRD kidneys. Thirty-two IVRDs (58 kidneys) were utilised, comprising 13.5% of all kidney donors. Only 9% of allocated IVRDs had neither kidney accepted. Injecting drug use (59%) was the commonest at-risk behaviour. NAT was performed 3 (2-4) days post-admission. 9 (28%) IVRDs had positive HCV Ab but negative NAT. 50% of recipients of these 9 IVRDs developed abnormal HCV serology, but no viraemia was detected in any IVRD recipients to date at 1 and 3 months post-transplantation. 3-month eGFR (CKD-EPI) was 65 (53-79) mL/min/1.73 m2. Compared with non-IVRDs, IVRDs were younger (37 (30-44) vs 51 (35-61) years; P < 0.01), with lower kidney donor profile index (KDPI) (26 (17-40) vs 59 (25-78); P < 0.001), and none had a KDPI >80% (0% vs 19%; P < 0.05). Waiting time was significantly shorter for blood group O IVRD vs non-IVRD recipients (26 (18-29) vs 38 (34-42) months; P = 0.001). Conclusion(s): IVRDs appear to offer better quality kidneys and may reduce waiting time with no transmission to date. Increasing the pre-consent rate may improve utilisation and benefit more waitlisted recipients.

UNLABELLED: Increased viral risk donors (IVRDs) with increased risk behaviors for blood-borne virus infection and negative nucleic acid testing have a low absolute risk of "window period" infection. Utilization and allocation of IVRD organs differ between jurisdictions. METHODS: We examined the characteristics and utilization of deceased donor IVRD kidneys and recipient outcomes within a 2-y period (July 31, 2018-July 31, 2020) postimplementation of a new opt-in allocation pathway for preconsented recipients in Victoria, Australia. RESULTS: Fifty-six kidneys from 31 IVRDs were utilized, comprising 13% of donors. Preconsent rate to accept IVRD kidneys increased to 41% of the waitlist in the 2 y postimplementation, and IVRDs having no kidneys utilized reduced to 0%. Compared with non-IVRD kidneys, kidney offer declines >10 per donor were less likely from IVRDs (3% vs 19%; P < 0.05). IVRDs were younger (median age 36 [IQR 30-44] vs 51 [35-60] y; P < 0.0001), with lower kidney donor profile index (25% [13-40%] vs 57% [29-75%]; P < 0.0001), and less hypertension (0% vs 22%; P < 0.01). Estimated glomerular filtration rate 3 mo post-transplant was superior (P < 0.01). Injecting drug use (61%) was the most common increased risk behavior. 29% of IVRDs were hepatitis C antibody positive but nucleic acid testing negative. No active infection was detected in any recipient post-transplant. CONCLUSIONS: The described opt-in system permits efficient allocation and utilization of kidneys from IVRDs, with superior quality and graft function. Education is crucial to facilitate informed consent and equity of access to this donor pool.

The optimum approach towards immunosuppression withdrawal following kidney transplant failure is unclear. Prolonged weaning may be associated with reduced sensitization, less graft nephrectomy and greater likelihood of retransplantation, but conversely increased risk of infection, malignancy and death. We conducted a single-centre retrospective analysis of patients experiencing graft failure between 2007 and 2017, comparing rates of sensitization, retransplantation, nephrectomy, infection, malignancy and death between patients who had immunosuppression weaned over <90 vs. 90-180 vs. >180 days. Patient survival after immunosuppression withdrawal over <90 vs. 90-180 vs. >180 days was 73.3%, 72.1% and 80.4%, respectively (P = 0.35), with no differences in cPRA (80.06 vs. 81.21 vs. 85.42, P = 0.66) or retransplantation rate [24/31 (77.4%) vs. 21/35 (60.0%) vs. 22/36 (61.1%), P = 0.13]. There was significantly less nephrectomy after late immunosuppression cessation [10/42 (23.8%) vs. 7/42 (16.7%) vs. 3/43 (7.0%), P = 0.01] but no differences in infections or malignancy. On competing risk regression (death as competing risk) controlling for cofactors including age, nephrectomy and rejection, prolonged immunosuppression did not predict likelihood of retransplantation (SHR 1.000, P = 0.88). Prolonged immunosuppression withdrawal does not reduce sensitization or improve retransplantation rates but is associated with less nephrectomy. Immunosuppression withdrawal should be tailored to individual circumstances after graft failure.

The Regolith X-ray Imaging Spectrometer (REXIS) is the student collaboration experiment proposed and built by an MIT-Harvard team, launched aboard NASA’s OSIRIS-REx asteroid sample return mission. REXIS complements the scientific investigations of other OSIRIS-REx instruments by determining the relative abundances of key elements present on the asteroid’s surface by measuring the X-ray fluorescence spectrum (stimulated by the natural solar X-ray flux) over the range of energies 0.5 to 7 keV. REXIS consists of two components: a main imaging spectrometer with a coded aperture mask and a separate solar X-ray monitor to account for the Sun’s variability. In addition to element abundance ratios (relative to Si) pinpointing the asteroid’s most likely meteorite association, REXIS also maps elemental abundance variability across the asteroid’s surface using the asteroid’s rotation as well as the spacecraft’s orbital motion. Image reconstruction at the highest resolution is facilitated by the coded aperture mask. Through this operation, REXIS will be the first application of X-ray coded aperture imaging to planetary surface mapping, making this student-built instrument a pathfinder toward future planetary exploration. To date, 60 students at the undergraduate and graduate levels have been involved with the REXIS project, with the hands-on experience translating to a dozen Master’s and Ph.D. theses and other student publications.

Introduction: Increased viral risk donors (IVRDs) with at-risk behaviours for blood borne virus infection and negative nucleic acid testing (NAT) have a low absolute risk of window period infection. A program allocating these kidneys to pre-consented recipients was recently implemented in the state of Victoria, Australia. We reviewed the performance after twelve months in operation. Material(s) and Method(s): We retrospectively examined the characteristics of IVRDs (defined by Public Health Service (PHS) 2013 criteria and open window periods) (31/07/2018-31/07/2019). Data for comparison with non-IVRDs was available for the first 7 months. Kidney function, serological and NAT results of recipients at 1 and 3 months post-transplantation were analysed. Continuous data was expressed as median (IQR). Results and Discussion: 33% of waitlisted patients were pre-consented at 12 months post-implementation, increasing from 24% at 7 months. Sixteen IVRDs (28 kidneys) were utilised, comprising 12.6% of all utilised kidney donors. Risk factors included people who inject drugs (57%), increased risk sexual behaviour (31%), imprisonment (6%) and multiple risk factors (6%). NAT was performed 3.0 (1.0-4.3) days after admission. Four IVRDs had abnormal serology results (3 HCV Ab positive, 1 HBcAb and HCV Ab positive) but negative NAT. All recipients but one of HCV Ab positive IVRDs seroconverted, but no viraemia was detected in recipients from all IVRDs to date. Adherence to post-transplant surveillance testing in recipients was 85%. eGFR (CKD-EPI) was 67 (54-77) and 68 (53-81) mL/min/1.73m2 at 1 and 3 months post-transplantation. Compared with non-IVRDs, IVRDs were significantly younger (36 (28-43) versus 53 (36-61) years; P<0.01). Kidney donor profile index (KDPI) was significantly lower (21 (10-39) versus 62 (27-77); P<0.01), more likely <=20 (50% versus 18%; P<0.05) and none had a KDPI >85 (0% versus 12%; P=0.35). Waiting time was significantly shorter for blood group O recipients

BACKGROUND: Secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD) leads to complex bone disease, affecting both trabecular and cortical bone, and increased fracture risk. Optimal assessment of bone in patients with CKD is yet to be determined. High-resolution magnetic resonance imaging (MRI) can provide three-dimensional assessment of bone microarchitecture, as well as determination of mechanical strength with finite element analysis (FEA). METHODS: We conducted a single-centre, cross-sectional study to determine bone microarchitecture with MRI in CKD patients with SHPT undergoing parathyroidectomy. Within two weeks of surgery, MRI was performed at the distal tibia and biochemical markers of SHPT (parathyroid hormone [PTH] and alkaline phosphatase [ALP]) were collected. Trabecular and cortical topological parameters as well as bone mechanical competence using FEA were assessed. Correlation of MRI findings of bone was made with biochemical markers. RESULTS: Twenty patients with CKD (15 male, 5 female) underwent MRI at the time of parathyroidectomy (16 on dialysis, 3 with functioning kidney transplant, one pre-dialysis with CKD stage 5). Median PTH at the time of surgery was 138.5 pmol/L [39.6-186.7 pmol/L]. MRI parameters in patients were consistent with trabecular deterioration, with erosion index (EI) 1.01 ± 0.3, and trabecular bone volume (BV/TV) 10.8 ± 2.9%, as well as poor trabecular network integrity with surface-to-curve ratio (S/C) 5.4 ± 2.3. There was also evidence of reduced cortical thickness, with CTh 2.698 ± 0.630 mm, and FEA demonstrated overall poor bone mechanical strength with mean elastic modulus of 2.07 ± 0.44. CONCLUSION: Patients with severe SHPT requiring parathyroidectomy have evidence of significant changes in bone microarchitecture with trabecular deterioration, low trabecular and cortical bone volume, and reduced mechanical competence of bone.

Blood group antigens are red blood cell (RBC) surface markers comprising specific carbohydrate moieties attached to the glycolipids and glycoproteins within the membrane. In addition to the major ABO blood group antigens, at least 35 minor blood group antigens have been defined to date. These antigens have immunogenic potential and may cause a transfusion reaction. There is evidence for renal expression of antigens from the Kidd, MNS, Duffy and Lewis groups and therefore the potential for antibodies directed against these antigens to cross-react in a transplanted kidney. In individuals lacking a specific RBC antigen, antibodies may develop after de novo exposure to that antigen, in addition to the potential presence of pre-existing innate antibodies. Relatively little attention has been paid to non-ABO system antibodies, with most reports in the literature focusing on transfusion reactions rather than on any putative role in allograft rejection. Here, we review each of these antigens in the context of renal transplantation and what limited evidence there is on how such immunological risk may be assessed and managed.

Choice of immunosuppression may modify the risk of cancer after kidney transplantation, however, long-term data are lacking. Using the Australian and New Zealand Dialysis and Transplant Registry, we compared the 9-year risk of incident cancer, non-melanoma skin cancer (NMSC), and death attributed to cancer among participants from Australia and New Zealand in four randomized-controlled trials which compared de novo or early switch to an everolimus-containing regimen with calcineurin-inhibitor-based triple therapy. An adjusted Cox-model with random effects was used to determine such risks. Two hundred seventy-nine patients (192 everolimus, 87 control) were followed for a median of 9 years (IQR 6.7, 11.2). Compared with control, everolimus use was not associated with a reduction in the risk of incident cancer, NMSC, or cancer-related death (unadjusted HR [95% CI] 0.86 [0.49-1.48], 0.58 [0.30-1.12], and 1.18 [0.32-4.38], respectively). Subgroup analyses showed a 56% reduction for NMSC in patients randomized to everolimus + reduced-dose calcineurin-inhibitor versus control (unadjusted HR 0.44 [0.21-0.92]), which remained significant after adjusting for age, gender and smoking (adjusted HR 0.45 [0.21-0.96]). Although de novo or early switch to everolimus did not alter the 9-year risk of incident cancer or cancer-related death, everolimus with reduced-dose calcineurin-inhibitor strategy may reduce the long-term risk of NMSC.Copyright © 2018 The American Society of Transplantation and the American Society of Transplant Surgeons

Introduction: Cancer after kidney transplantation (KT) is a significant cause of morbidity and mortality. Choice of immunosuppressive regimenmay modify the risk of cancer. Mammalian target of rapamycin inhibitors have been shown to have anti-oncogenic effects in both animal and human studies. A large individual patient data (IPD) meta-analysis showed that sirolimus was associated with a significant reduction in the risk of cancer, but at the cost of an increased risk of death. We aimed to determine the cumulative incidence of cancer in KTrecipients randomised to de novo or early switch to everolimus (EVL)maintenance immunosuppression versus controls on standard calcineurin inhibitor (CNI) based triple therapy. Material(s) and Method(s): We included all de novo or early EVL switch randomised controlled trials (RCTs) conducted in Australia and New Zealand KT recipients between 2001 - 2012 in the IPD meta-analysis (Fig 1). Participants were linked to the Australian and New Zealand Dialysis and Transplantation Registry (ANZDATA) to capture outcomes of incident cancer and all-cause mortality. We compared treatment allocation to EVL or control, with time to first cancer occurrence using Kaplan-Meier estimates. An adjusted Cox proportional hazards model with random effects using pooled individual patient data from all trials was used to determine the overall risks of cancer and death. Results and Discussion: The 279 Australian and New Zealand participants (EVL = 192, control = 87) were followed for a median of 9.0 yrs (IQR 6.8, 9.6). Four RCTs examined EVL immunosuppression using de Novo (n=141) or early (<4 mths) (n=138) strategies in addition to either reduced dose CNI or CNI-withdrawal. The control arm consisted of cyclosporine or tacrolimus with mycophenolic acid or azathioprine and steroid maintenance therapy. The cumulative incidence of any cancer was not significantly different between EVL and control (log-rank test p = 0.8) (Fig 2). 30 (15.6%) EVL patients develope

Choice of immunosuppression may modify the risk of cancer after kidney transplantation, however, long-term data are lacking. Using the Australian and New Zealand Dialysis and Transplant Registry, we compared the 9-year risk of incident cancer, non-melanoma skin cancer (NMSC), and death attributed to cancer among participants from Australia and New Zealand in four randomized-controlled trials which compared de novo or early switch to an everolimus-containing regimen with calcineurin-inhibitor-based triple therapy. An adjusted Cox-model with random effects was used to determine such risks. Two hundred seventy-nine patients (192 everolimus, 87 control) were followed for a median of 9 years (IQR 6.7, 11.2). Compared with control, everolimus use was not associated with a reduction in the risk of incident cancer, NMSC, or cancer-related death (unadjusted HR [95% CI] 0.86 [0.49-1.48], 0.58 [0.30-1.12], and 1.18 [0.32-4.38], respectively). Subgroup analyses showed a 56% reduction for NMSC in patients randomized to everolimus + reduced-dose calcineurin-inhibitor versus control (unadjusted HR 0.44 [0.21-0.92]), which remained significant after adjusting for age, gender and smoking (adjusted HR 0.45 [0.21-0.96]). Although de novo or early switch to everolimus did not alter the 9-year risk of incident cancer or cancer-related death, everolimus with reduced-dose calcineurin-inhibitor strategy may reduce the long-term risk of NMSC.

Bone disease in kidney transplant recipients (KTRs) is characterized by bone mineral density (BMD) loss but bone microarchitecture changes are poorly defined. In this prospective cohort study, we evaluated bone microarchitecture using non-invasive imaging modalities; high-resolution magnetic resonance imaging (MRI), peripheral quantitative computed tomography (pQCT), dual energy X-ray absorptiometry (DXA), and the trabecular bone score (TBS) following kidney transplantation. Eleven KTRs (48.3 ± 11.2 years) underwent MRI (tibia), pQCT (radius) and DXA at baseline and 12 months post-transplantation. Transiliac bone biopsies, performed at transplantation, showed 70% of patients with high/normal bone turnover. Compared with baseline, 12-month MRI showed deterioration in indices of trabecular network integrity-surface to curve ratio (S/C; -15%, P = 0.03) and erosion index (EI; +19%, P = 0.01). However, cortical area increased (+10.3%, P = 0.04), with a non-significant increase in cortical thickness (CtTh; +7.8%, P = 0.06). At 12 months, parathyroid hormone values (median 10.7 pmol/L) correlated with improved S/C (r = 0.75, P = 0.009) and EI (r = -0.71, P = 0.01) while osteocalcin correlated with CtTh (r = 0.72, P = 0.02) and area (r = 0.70, P = 0.02). TBS decreased from baseline (-5.1%, P = 0.01) with no significant changes in BMD or pQCT. These findings highlight a post-transplant deterioration in trabecular bone quality detected by MRI and TBS, independent of changes in BMD, underlining the potential utility of these modalities in evaluating bone microarchitecture in KTRs.

Introduction: Higher calcium dialysate is recommended for quotidian nocturnal hemodialysis (NHD) (>=6 nights/week) to maintain bone health. It is unclear what the optimal calcium dialysate concentration should be for alternate night NHD. We aimed to determine the effect of low calcium (LC) versus high calcium (HC) dialysate on cardiovascular and bone parameters in this population. Method(s): A randomized controlled trial where participants were randomized to LC (1.3 mmol/L, n = 24) or HC dialysate (1.6 or 1.75 mmol/L, n = 26). Primary outcome was change in mineral metabolism markers. Secondary outcomes included change in vascular calcification (VC) scores [CT abdominal aorta (AA) and superficial femoral arteries (SFA)), pulse wave velocity (PWV), bone mineral density (BMD) and left ventricular mass index (LVMI) over 12 months. Finding(s): In the LC group, pre-dialysis ionised calcium decreased -0.12 mmol/L (-0.18-0.06, P = 0.0001) and PTH increased 16 pmol/L (3.5-28.5, p = 0.01) from baseline to 12 months with no significant change in the HC group. In both groups, there was no progression of VC in AA or SFA and no change in PWV, LVMI or BMD. At 12 months, calcimimetics were prescribed in a higher percentage in the LC vs. HC groups (45.5% vs. 10.5%) with a lower proportion of the HC group being prescribed calcitriol (31.5% vs. 72%). Discussion(s): Although dialysate calcium prescription influenced biochemical parameters it was not associated with difference in progression of VC between HC and LC groups. An important finding was the potential impact of alternate night NHD in attenuating progression of VC and inducing stabilisation of LVMI and PWV.Copyright © 2016 International Society for Hemodialysis

INTRODUCTION: Higher calcium dialysate is recommended for quotidian nocturnal hemodialysis (NHD) (≥6 nights/week) to maintain bone health. It is unclear what the optimal calcium dialysate concentration should be for alternate night NHD. We aimed to determine the effect of low calcium (LC) versus high calcium (HC) dialysate on cardiovascular and bone parameters in this population. METHODS: A randomized controlled trial where participants were randomized to LC (1.3 mmol/L, n = 24) or HC dialysate (1.6 or 1.75 mmol/L, n = 26). Primary outcome was change in mineral metabolism markers. Secondary outcomes included change in vascular calcification (VC) scores [CT abdominal aorta (AA) and superficial femoral arteries (SFA)), pulse wave velocity (PWV), bone mineral density (BMD) and left ventricular mass index (LVMI) over 12 months. FINDINGS: In the LC group, pre-dialysis ionised calcium decreased -0.12 mmol/L (-0.18-0.06, P = 0.0001) and PTH increased 16 pmol/L (3.5-28.5, p = 0.01) from baseline to 12 months with no significant change in the HC group. In both groups, there was no progression of VC in AA or SFA and no change in PWV, LVMI or BMD. At 12 months, calcimimetics were prescribed in a higher percentage in the LC vs. HC groups (45.5% vs. 10.5%) with a lower proportion of the HC group being prescribed calcitriol (31.5% vs. 72%). DISCUSSION: Although dialysate calcium prescription influenced biochemical parameters it was not associated with difference in progression of VC between HC and LC groups. An important finding was the potential impact of alternate night NHD in attenuating progression of VC and inducing stabilisation of LVMI and PWV.

Aim: To validate high-resolution magnetic resonance imaging (HR-MRI) assessment of bone microstructure compared to histomorphometry and micro-CT of bone biopsies from renal transplant recipients. Background(s): Renal osteodystrophy (ROD) affects bone quantity and quality and is associated with increased fractures in chronic kidney disease. Screening for ROD is hindered by complex pathophysiology and inadequacy of current diagnostic methods. Bone biopsy is invasive and infrequently performed in routine practice. HR-MRI is a new imaging technique to assess trabecular and cortical microarchitecture. Method(s): Distal tibia HR-MRI scans (Siemens Trio, 3 T) and iliac crest bone biopsies were performed in 10 transplant recipients at transplantation. Structural parameters of biopsies were analysed by histomorphometry and 3D micro-CT. Structural measures included trabecular bone volume (TV/ BV), thickness (TbTh), number (TbN), separation (TbS), mean cortical thickness (CtTh) and porosity (Po.%). Bone mineral density (BMD) was measured by peripheral quantitative computed tomography (pQCT, radius) and dual energy x-ray absorptiometry (DXA, hip). Associations were determined by analysis with Spearman's rank correlation coefficients. Result(s): HR-MRI (tibia) and micro-CT (iliac crest) indices correlated positively for TbN and TbS (r = 0.52, p = 0.12 and 0.56, p = 0.09 respectively) and TV/BV, with no significant correlation for CtTh at these differing sites. HR-MRI (tibia) CtTh correlated to CtTh and BMD measured by pQCT (radius) (r = 0.65, p = 0.06 and 0.78, p = 0.008 respectively). Micro-CT (iliac) CtTh correlated to BMD by DXA (hip), and cortical porosity by micro-CT correlated negatively to BMD by DXA (r = -0.65, p = 0.04). Conclusion(s): Micro-CT histomorphometry correlates to tibial HR-MRI for important trabecular indices and to hip DXA for cortical indices. Non-invasive HR-MRI and DXA combined with biochemical turnover markers may provide rapid, accessible information t

Background: Recent evidence suggests that increased frequency and/or duration of dialysis are associated with improved outcomes. We aimed to describe the outcomes associated with patients starting extended-hours hemodialysis and assess for risk factors for these outcomes. Study Design: Case series. Setting & Participants: Patients were from 6 Australian centers offering extended-hours hemodialysis. Cases were patients who started treatment for 24 hours per week or longer at any time. Outcome(s): All-cause mortality, technique failure (withdrawal from extended-hours hemodialysis therapy), and access-related events. Measurements: Baseline patient characteristics (sex, primary cause of end-stage kidney disease, age, ethnicity, diabetes, and cannulation technique), presence of a vascular access-related event, and dialysis frequency. Result(s): 286 patients receiving extended-hours hemodialysis were identified, most of whom performed home (96%) or nocturnal (77%) hemodialysis. Most patients performed alternate-daily dialysis (52%). Patient survival rates using an intention-to-treat approach at 1, 3, and 5 years were 98%, 92%, and 83%, respectively. Of 24 deaths overall, cardiac death (n = 7) and sepsis (n = 5) were the leading causes. Technique survival rates at 1, 3, and 5 years were 90%, 77%, and 68%, respectively. Access event-free rates at the same times were 80%, 68%, and 61%, respectively. Access events significantly predicted death (HR, 2.85; 95% CI, 1.14-7.15) and technique failure (HR, 3.76; 95% CI, 1.93-7.35). Patients with glomerulonephritis had a reduced risk of technique failure (HR, 0.31; 95% CI, 0.14-0.69). Higher dialysis frequency was associated with elevated risk of developing an access event (HR per dialysis session, 1.56; 95% CI, 1.03-2.36). Limitation(s): Selection bias, lack of a comparator group. Conclusion(s): Extended-hours hemodialysis is associated with excellent survival rates and is an effective treatment option for a select group of patients

The latest Caring for Australians with Renal Impairment (CARI) guideline detailing renal transplant care, developed as a local modification of the Kidney Disease Improving Global Outcomes (KDIGO) guidelines. © 2011 Asian Pacific Society of Nephrology.

Background: Dialysis modality preferences of patients with chronic kidney disease (CKD) and family caregivers are important, yet rarely quantified. Study Design: Prospective, unlabeled, discrete-choice experiment with random-parameter logit analysis. Setting & Participants: Adults with stages 3-5 CKD and caregivers educated about dialysis treatment options from 8 Australian renal clinics. Predictors: Preferences for and trade-offs between the dialysis treatment attributes of life expectancy, number of hospital visits per week, ability to travel, hours per treatment, treatment time of day, subsidized transport service, and flexibility of treatment schedule. Outcomes & Measurements: Results presented as ORs for preferring home-based or in-center dialysis to conservative care. Results: 105 predialysis patients and 73 family caregivers completed the study. Median patient age was 63 years, and mean estimated glomerular filtration rate was 18.1 (range, 6-34) mL/min/1.73 m 2. Median caregiver age was 61 years. Home-based dialysis (either peritoneal or home hemodialysis) was chosen by patients in 65% of choice sets; in-center dialysis, in 35%; and conservative care, in 10%. For caregivers, this was 72%, 25%, and 3%, respectively. Both patients and caregivers preferred longer rather than shorter hours of dialysis (ORs of 2.02 [95% CI, 1.51-2.70] and 2.67 [95% CI, 1.85-3.85] for patients and caregivers, respectively), but were less likely to choose nocturnal than daytime dialysis (ORs of 0.07 [95% CI, 0.01-0.75] and 0.03 [95% CI, 0.01-0.20]). Patients were willing to forgo 23 (95% CI, 19-27) months of life expectancy with home-based dialysis to decrease their travel restrictions. For caregivers, this was 17 (95% CI, 16-18) patient-months. Limitations: Data were limited to stated preferences rather than actual choice of dialysis modality. Conclusions: Our study suggests that it is rare for caregivers to prefer conservative nondialytic care for family members with CKD. Home-bas

Background: For every patient with chronic kidney disease who undergoes renal-replacement therapy, there is one patient who undergoes conservative management of their disease. We aimed to determine the most important characteristics of dialysis and the trade-offs patients were willing to make in choosing dialysis instead of conservative care. Methods: We conducted a discrete choice experiment involving adults with stage 3-5 chronic kidney disease from eight renal clinics in Australia. We assessed the influence of treatment characteristics (life expectancy, number of visits to the hospital per week, ability to travel, time spent undergoing dialysis [i.e., time spent attached to a dialysis machine per treatment, measured in hours], time of day at which treatment occurred, availability of subsidized transport and flexibility of the treatment schedule) on patients' preferences for dialysis versus conservative care. Results: Of 151 patients invited to participate, 105 completed our survey. Patients were more likely to choose dialysis than conservative care if dialysis involved an increased average life expectancy (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.57-2.15), if they were able to dialyse during the day or evening rather than during the day only (OR 8.95, 95% CI 4.46-17.97), and if subsidized transport was available (OR 1.55, 95% CI 1.24-1.95). Patients were less likely to choose dialysis over conservative care if an increase in the number of visits to hospital was required (OR 0.70, 95% CI 0.56-0.88) and if there were more restrictions on their ability to travel (OR = 0.47, 95%CI 0.36-0.61). Patients were willing to forgo 7 months of life expectancy to reduce the number of required visits to hospital and 15 months of life expectancy to increase their ability to travel. Interpretation: Patients approaching endstage kidney disease are willing to trade considerable life expectancy to reduce the burden and restrictions imposed by dialysis. © 2012 Canadian Me

Aim: To determine the effect of low (LC) versus high (HC) dialysatecalcium (DC) on vascular calcification (VC) in alternate night nocturnal haemodialysis (ANNHD) patients. Background(s): Higher DC is traditionally used for nocturnal HD compared to conventional HD for improved bone health. VC is a risk factor for cardiovascular disease and mortality and is associated with higher exogenous calcium (Ca). The effect of DC on VC in ANNHD has not been studied. Method(s): ANNHD patients (N = 28) were randomized to receive LC (N = 14, 1.3 mmol/L) or HC (N = 14, 1.75 mmol/L) over 12 mths. Primary outcome was mineral metabolism markers at 0.6 wks, 3, 6, 9 and 12 mths. Secondary outcomes were DELTAVCscores (computed tomography, Hounsfield Units (HU)) at the abdominal aorta and superficial femoral arteries (SFA), and pulse wave velocity (PWV) at 12 mths. Analysis was intention-to-treat using mixed linear models. Result(s): Median age 54 yrs, 11% diabetic, 75% male, median 28 hrs/wk HD. 68% and 53% had aortic and SFA VC at baseline. There was a non-significant reduction in aortic and right SFA VC (-71.0 HU, p = 0.08 and -59.8 HU, p = 0.05 respectively), with no difference in left SFA VC at 12 months. No significant difference in aortic VC in the HC vs LC (-18.3 HU, p = 0.7) or in SFA VC or PWV was seen between DC groups. Ionized, pre and post-dialysis serum Ca fell significantly in the LC group (0.12 mmol/L, p < 0.001, 0.22, p = < 0.001 and 0.18, p = 0.003 respectively at 12 months vs baseline). Post dialysis serum Ca rose significantly in the HC group (0.23, p < 0.001). PTH rose progressively in the HC group (25.3 pmol/L at 12 months, p = 0.002). Conclusion(s): Despite significant falls in serum calcium with low DC, no difference in VC was seen in ANNHD patients after 12 months.

Aim: To assess variations in the degree of vascular calcification (VC) in the aorta and superficial femoral arteries (SFAs) at different sites in these vessels. Background(s): VC is a major contributor to increased cardiovascular disease in dialysis patients and an independent predictor of mortality. Computed tomography (CT) is gold standard for detection and VC in the abdominal aorta and SFAs is less well documented in anatomical distribution and severity compared to coronary calcification. Method(s): We report the distribution of VC in a cross-sectional study on 42 patients undertaking alternate night nocturnal haemodialysis (NHD, 28 hrs/ week) recruited for an RCT. NHD patients from Royal Melbourne Hospital (RMH) and Monash Medical Centre (MMC) underwent CT scans using different protocols: images through T11-L2 and upper thigh at RMH, and L2-L4 and lower thigh at MMC. Result(s): Patients at MMC (n = 28) and RMH (n = 14) had similar demographics with mean age 53 vs 45 yrs, 75 vs 64% male, both 14% diabetes, median 17 vs 25 mths on HD. Abdominal aortic VC was present in 68% MMC and 57% RMH patients, and mean number of aortic calcifications differed (4 vs 2.3). Median VC scores were 467 vs 62 Hounsfield units (HU) for MMC and RMH respectively, with significantly different measurements at different sites (T11-L2 vs L2-4, p = 0.02). Left and right SFA VC was seen in 46 and 54% MMC patients (median 152 and 0 HU) compared to 26 and 29% RMH (median 0 and 0 HU), with trend towards statistical significance between upper and lower thigh (p = 0.14 and 0.07, left and right SFAs). Conclusion(s): Arteries have different degrees of VC depending on the anatomical site measured. More aortic VC is seen infra-renal and more SFA VC is seen in the lower thigh which may determine CT protocols for VC studies.