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Aim: We aimed to describe the incidence of new onset vascular disease and vascular death in Australian children receiving renal replacement therapy (RRT). We also aimed to evaluate whether demographic or childhood clinical factors predict these endpoints, and whether vascular disease predicts mortality. Background(s): Cardiovascular death is a leading cause of mortality in paediatric end stage kidney disease (ESKD). There is however relatively little known about clinically relevant vascular disease in this population. Method(s): Data on Australian patients who commenced RRT at <18 years of age from 1991-2017 were extracted from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). The association of variables with outcomes were evaluated using Fine and Gray competing risk models. Result(s): A cohort of 1268 patients were followed up for a median of 10.31 years. Vascular disease was reported in 5.4%, and vascular death in 4.1%. The cumulative incidence of any vascular event, i.e. disease or death, at 10 and 20 years was 5.5% and 12.8% respectively. Vascular events were predicted by non-Caucasian (especially Indigenous) ethnicity. For the 804 patients who were followed-up after 18 years of age, vascular disease was predicted by longer childhood dialysis duration and vascular mortality by lack of transplantation during childhood. Whilst vascular disease was only reported for 15.4% of patients who had a vascular death, it was predictive of mortality. Conclusion(s): Cumulative incidence of vascular events is significant after commencing RRT during childhood. Vascular events are associated with ethnicity, longer childhood dialysis duration and lack of transplantation during childhood.

Aim: To understand antibody mediated rejection (AMR) surveillance and management among paediatric nephrologists. Background(s): Little high-quality evidence exists to guide AMR management in kidney transplantation. A recent consensus statement from The Transplantation Society provides recommendations based on expert opinion. In paediatrics there may be challenges that lead physicians to vary practice from such recommendations. Method(s): Members of the Australian and New Zealand Paediatric Nephrology Association (ANZPNA) were emailed an electronic survey in June 2020. Scenarios were presented of non-ABOI, non-pre-sensitized patients with AMR. Result(s): Of 34 ANZPNA nephrologists, 11 responded with 80% survey completion rate. Whilst the majority (66%) do not perform protocol biopsies, the majority do undertake routine DSA surveillance (66%), mostly at yearly intervals, starting at 6 months post-transplant. AT1R antibody testing is performed by 90%, most commonly in DSA negative AMR or with past early graft thrombosis. For a 10-week indication biopsy demonstrating PTC1 and linear C4d, 81% used a combination of methylprednisolone, IVIG and plasma exchange before DSA status was known. There was some variation dependent on presence of vascular access, concomitant T-cell rejection and degree of creatinine rise. There were 3 respondents who added rituximab with a subsequent finding of a Class 1 or 2 DSA with MFI 2200. IVIG prescription was highly variable. Plasma exchange with IVIG was used by 66% in late DSA+ AMR at 18 months. Where chronic active AMR at 6 years is associated with 25% IFTA and an eGFR drop to 30, plasma exchange with IVIG was used by 44% and IVIG/Rituximab combination by 44%. Conclusion(s): Considerable variation exists in paediatric AMR management. Physicians are more aggressive in chronic active AMR management than published recommendations.

Aim: We aimed to describe the incidence of new onset vascular disease and vascular death in Australian children receiving renal replacement therapy (RRT). We also aimed to evaluate whether demographic or childhood clinical factors predict these endpoints, and whether vascular disease predicts mortality. Background(s): Cardiovascular death is a leading cause of mortality in paediatric end stage kidney disease (ESKD). There is however relatively little known about clinically relevant vascular disease in this population. Method(s): Data on Australian patients who commenced RRT at <18 years of age from 1991-2017 were extracted from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). The association of variables with outcomes were evaluated using Fine and Gray competing risk models. Result(s): A cohort of 1268 patients were followed up for a median of 10.31 years. Vascular disease was reported in 5.4%, and vascular death in 4.1%. The cumulative incidence of any vascular event, i.e. disease or death, at 10 and 20 years was 5.5% and 12.8% respectively. Vascular events were predicted by non-Caucasian (especially Indigenous) ethnicity. For the 804 patients who were followed-up after 18 years of age, vascular disease was predicted by longer childhood dialysis duration and vascular mortality by lack of transplantation during childhood. Whilst vascular disease was only reported for 15.4% of patients who had a vascular death, it was predictive of mortality. Conclusion(s): Cumulative incidence of vascular events is significant after commencing RRT during childhood. Vascular events are associated with ethnicity, longer childhood dialysis duration and lack of transplantation during childhood.

Aim: To understand antibody mediated rejection (AMR) surveillance and management among paediatric nephrologists. Background(s): Little high-quality evidence exists to guide AMR management in kidney transplantation. A recent consensus statement from The Transplantation Society provides recommendations based on expert opinion. In paediatrics there may be challenges that lead physicians to vary practice from such recommendations. Method(s): Members of the Australian and New Zealand Paediatric Nephrology Association (ANZPNA) were emailed an electronic survey in June 2020. Scenarios were presented of non-ABOI, non-pre-sensitized patients with AMR. Result(s): Of 34 ANZPNA nephrologists, 11 responded with 80% survey completion rate. Whilst the majority (66%) do not perform protocol biopsies, the majority do undertake routine DSA surveillance (66%), mostly at yearly intervals, starting at 6 months post-transplant. AT1R antibody testing is performed by 90%, most commonly in DSA negative AMR or with past early graft thrombosis. For a 10-week indication biopsy demonstrating PTC1 and linear C4d, 81% used a combination of methylprednisolone, IVIG and plasma exchange before DSA status was known. There was some variation dependent on presence of vascular access, concomitant T-cell rejection and degree of creatinine rise. There were 3 respondents who added rituximab with a subsequent finding of a Class 1 or 2 DSA with MFI 2200. IVIG prescription was highly variable. Plasma exchange with IVIG was used by 66% in late DSA+ AMR at 18 months. Where chronic active AMR at 6 years is associated with 25% IFTA and an eGFR drop to 30, plasma exchange with IVIG was used by 44% and IVIG/Rituximab combination by 44%. Conclusion(s): Considerable variation exists in paediatric AMR management. Physicians are more aggressive in chronic active AMR management than published recommendations.

Aim: To evaluate the association between evidence based targets of haemoglobin (Hb), phosphate and calcium in young (age <25yrs) dialysis patients with demographic and clinical variables, and explore the impact of these categories on time to transplant and survival on dialysis. Background(s): Hb and phosphate are associated with mortality on dialysis in adult patients. Whether these relationships hold in young patients with less comorbidities is unclear. Off-target indices may also be associated with transplantation delay given postulated links to nonadherence. Method(s): All incident young Australian dialysis patients (N=789) within ANZDATA from 2003 to 2015 were assessed. First reported uncorrected calcium, haemoglobin (Hb) and phosphate at 3-15 months were categorized according to evidence based targets. Multivariate Cox models with age stratification were developed to examine associations between categories with time to transplant and mortality. Result(s): Low calcium and phosphate were significantly more common in those with diabetic kidney disease (42.9%, 30.8% respectively) compared with glomerulonephritis (14.66%, 15%). High phosphate was associated with older age, and high calcium with younger age. Hb>120 was more common in regional/remote (25.2% versus 19% cities) or low socioeconomic postcodes (27.3% lowest SES, 13.9% highest SES). Time to transplant did not associate with Hb, phosphate or calcium categories in the multivariate analysis. Mortality was significantly associated with Hb>120 for those starting dialysis at 20-25 years (HR 4.1 95%CI 1.64-10.1). Low calcium was associated with mortality for the 15-20 year age group (HR 12.4 95%CI 1.7-91). Conclusion(s): Age, remoteness, SES, race, and ESKD cause were associated with off-target calcium, phosphate and Hb. These indices did not associate with time to transplant, however high Hb was associated with increased mortality on dialysis.

Aim: To evaluate the association between evidence based targets of haemoglobin (Hb), phosphate and calcium in young (age <25yrs) dialysis patients with demographic and clinical variables, and explore the impact of these categories on time to transplant and survival on dialysis. Background(s): Hb and phosphate are associated with mortality on dialysis in adult patients. Whether these relationships hold in young patients with less comorbidities is unclear. Off-target indices may also be associated with transplantation delay given postulated links to nonadherence. Method(s): All incident young Australian dialysis patients (N=789) within ANZDATA from 2003 to 2015 were assessed. First reported uncorrected calcium, haemoglobin (Hb) and phosphate at 3-15 months were categorized according to evidence based targets. Multivariate Cox models with age stratification were developed to examine associations between categories with time to transplant and mortality. Result(s): Low calcium and phosphate were significantly more common in those with diabetic kidney disease (42.9%, 30.8% respectively) compared with glomerulonephritis (14.66%, 15%). High phosphate was associated with older age, and high calcium with younger age. Hb>120 was more common in regional/remote (25.2% versus 19% cities) or low socioeconomic postcodes (27.3% lowest SES, 13.9% highest SES). Time to transplant did not associate with Hb, phosphate or calcium categories in the multivariate analysis. Mortality was significantly associated with Hb>120 for those starting dialysis at 20-25 years (HR 4.1 95%CI 1.64-10.1). Low calcium was associated with mortality for the 15-20 year age group (HR 12.4 95%CI 1.7-91). Conclusion(s): Age, remoteness, SES, race, and ESKD cause were associated with off-target calcium, phosphate and Hb. These indices did not associate with time to transplant, however high Hb was associated with increased mortality on dialysis.