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Background: The outcomes of patients with focal segmental glomerulosclerosis (FSGS) on kidney replacement therapy (KRT) have not been well described. This study evaluated the outcomes of patients with kidney failure due to FSGS on KRT including dialysis and kidney transplantation. Method and materials: All adult patients with kidney failure who commenced KRT in Australia and New Zealand from 15th of May 1963 to 31st of December 2018 were retrospectively extracted from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Outcomes of patients with FSGS were compared to those with other causes of kidney failure (non-FSGS). Results: 85,052 patients commenced KRT during the study period, of whom 2991 (3.5%) were patients with FSGS. Compared to patients with non-FSGS, patients with FSGS experienced similar mortality on dialysis (adjusted hazard ratio [aHR] 0.98, 95% CI 0.90–1.06, p = 0.55) and following kidney transplantation (aHR 0.92, 95% CI 0.73–1.15, p = 0.47). The risk of first kidney allograft loss was higher in patients with FSGS (aHR 1.20, 95% CI 1.04–1.37, p = 0.01). However, when death was analysed as a competing risk, the survival in both groups was similar (sub-hazard ratio [SHR] 1.09, 95% CI 0.94–1.28, p = 0.26). Patients with FSGS had a longer waiting time for kidney transplantation (aHR 0.92, 95% CI 0.86–0.98, p = 0.02) and experienced an increased risk of disease recurrence in the allograft (aHR 1.73, 95% CI 1.35–2.21, p<0.001). Compared to patients with other forms of glomerular disease, patients with FSGS experienced similar dialysis and transplant patient survival and death-censored rate of kidney transplantation and allograft loss but higher rates of primary kidney disease recurrence. Conclusion: FSGS was associated with similar dialysis and transplant patient survival and death-censored first allograft loss compared to non-FSGS and other forms of glomerular disease. [ABSTRACT FROM AUTHOR]

Chronic kidney disease is common in patients with atrial fibrillation (AF) and is associated with heightened risks of stroke/systemic embolisation and bleeding. In this review we outline the evidence for AF stroke prevention in kidney disease, identify current knowledge gaps, and give recommendations for anticoagulation at various stages of chronic kidney disease. Overall, anticoagulation is underused. Warfarin use becomes increasingly difficult with advancing kidney disease, with difficulty maintaining international normalised ratio (INR) in therapeutic range, increased risk of intracranial and fatal bleeding compared to non-vitamin K oral anticoagulants (NOACs), and high rates of discontinuation. Similarly, the direct thrombin inhibitor dabigatran is not recommended as it is predominantly renally excreted with consequent increased plasma levels and bleeding risk with advanced kidney disease. The Factor Xa inhibitors apixaban and rivaroxaban have less renal excretion (25-35%), modest increases in plasma levels with advancing kidney disease, and are the preferred first line choice for anticoagulation in moderate kidney disease based on strong evidence from randomised clinical trials (RCTs). In severe kidney disease there is a paucity of RCT data, but extrapolation of the pharmacokinetic and RCT data for moderate kidney disease, and observational studies, support the considered use of dose-adjusted Factor Xa inhibitors unless the bleeding risk is prohibitive. In Australia, apixaban is approved for creatinine clearance down to 25 mL/min, and rivaroxaban down to 15 mL/min. For end-stage kidney disease warfarin is the only agent approved, but we recommend against anticoagulation (except in selected cases) due to high bleeding risk, multiple co-morbidities, and questionable benefit. [ABSTRACT FROM AUTHOR]

Background A number of peritoneal dialysis (PD) systems are available but there have been few studies comparing them. The aim of this study was to examine technique failure and patient survival between different PD company systems. Methods The study included all patients who commenced PD between 1995 and 2014 in Australia and New Zealand. Groups were compared according to the initial PD company system that they received. The primary outcome was a composite of PD technique failure and death. Results A total of 16 575 patients commenced PD using systems manufactured by Baxter [ n  = 13 438 (81%)], Fresenius Medical Care [ n  = 2848 (17%)] or Gambro [ n  = 289 (2%)]. Of these, 11 870 (72%) developed technique failure, including 5421 (33%) who died. The median time to technique failure or death for all patients was 625 [interquartile range (IQR) 318–1114] days: 629.5 (IQR 321–1121) days with Baxter, 620.5 (IQR 311–1069) days with Fresenius Medical Care and 538 (IQR 272–1001) days with Gambro systems (P = 0.023). There was a statistically significant increase in technique failure or mortality rates in patients on Gambro {adjusted incidence rate ratio [IRR] 1.46 [95% confidence interval (CI) 1.33–1.62]} and Fresenius [adjusted IRR 1.10 (95% CI 1.01–1.19)] systems compared with Baxter systems. No difference in patient survival was observed between the three PD systems. Conclusions PD systems manufactured by different companies may be associated with important differences in PD technique survival. This needs to be confirmed with adequately powered, prospective randomized controlled clinical trials. [ABSTRACT FROM AUTHOR]

Background: Fibrillary glomerulonephritis (FGN) and immunotactoid glomerulopathy (IG) are uncommon and characterised by non-amyloid fibrillary glomerular deposits. The aim of this study was to investigate characteristics and outcomes of patients undergoing renal replacement therapy (RRT) for end-stage kidney disease (ESKD) secondary to FGN and IG.Methods: All ESKD patients who commenced RRT in Australia and New Zealand 1 January 1990 to 31 December 2010 were included. Outcomes were assessed by Kaplan-Meier, multivariate logistic-regression analysis and multivariable Cox proportional-hazards survival analysis.Results: Of 45,216 individuals with ESKD, 55 (0.12%) had FGN and 11 (0.02%) had IG. The median survival of FGN patients on dialysis (5.63 years, 95% CI 3.31-7.96) was not significantly different from patients with other ESKD causes (median 4.01 years, 95% CI 4.34-4.47; log-rank 1.32, p = 0.25), but was significantly longer than that of IG patients (median 2.93 years, 95% CI 0.00-6.17; log-rank 4.8, p = 0.03). Thirteen (24%) FGN patients received 13 renal-allografts, 4 (36%) IG patients received 4 renal-allografts and 11,528 (26%) other ESKD patients received 12,278 renal-allografts. FGN patients experienced comparable outcomes to other ESKD patients for both 10-year patient survival (100 vs. 84%, p = 0.93) and renal-allograft survival (67 vs. 76%, p = 0.06). For IG, the median follow-up was 3.66 years with 75% patient survival and 100% renal-allograft survival. One (8%) FGN patient and 1 (25%) IG patient experienced recurrent FGN and IG respectively in their allograft.Conclusion: Patients with FGN have comparable dialysis and renal transplant outcomes to patients with other causes of ESKD. IG patients have inferior survival on dialysis, although renal transplant outcomes are acceptable. Disease recurrence in renal-allografts was low for both FGN and IG. [ABSTRACT FROM AUTHOR]

Background There are few reports regarding the long-term renal replacement therapy (RRT) outcomes of amyloidosis. Methods In this retrospective, multi-centre, multi-country registry analysis, all patients with and without amyloidosis who commenced RRT for end-stage renal failure (ESRF) in Australia and New Zealand between 1963 and 2010 were included. Results Of 58 422 patients who underwent RRT during the study period, 490 (0.8%) had ESRF secondary to amyloidosis. The median survival of amyloidosis patients on dialysis (2.09 years, 95% CI 1.85–2.32 years) was significantly inferior to that of patients with other causes of ESRF (4.45 years, 95% CI 4.39–4.51 years) (log-rank score 242, P < 0.001). The survival of amyloidosis patients receiving peritoneal dialysis (1.9 years, 95% CI 1.58–2.22) was comparable with those receiving haemodialysis (2.17 years, 95% CI 1.89–2.45) (P = 0.18). Fifty-three (13.8%) amyloidosis patients died of amyloidosis complications. Forty-six patients underwent renal transplantation with first graft survival rates of 45% at 5 years and 26% at 10 years. Nine (16.4%) patients experienced amyloidosis recurrence in their allografts, which led to graft failure in six patients. ESRF patients with amyloidosis experienced inferior median first renal allograft survival (4.55 years, 95% CI 1.96–7.15 versus 10.7 years, 95% CI 10.5–11.0, P = 0.001) and transplant patient survival (6.03 years, 95% CI 2.71–9.36 versus 16.8 years, 95% CI 16.4–17.1, P < 0.001) compared with patients with other causes of ESRF. Respective 10-year patient survival rates were 37 and 69%. Conclusions Amyloidosis was associated with poor patient survival following dialysis and/or renal transplantation, poor renal allograft survival and a significant incidence of disease recurrence in the allograft. An appreciable proportion of amyloid ESRF patients died of amyloidosis-related complications. [ABSTRACT FROM AUTHOR]

Background. The role of seasonal variation in peritoneal dialysis (PD)-related peritonitis has been limited to a few small single-centre studies. Methods. Using all 6610 Australian patients receiving PD between 1 October 2003 and 31 December 2008, we evaluated the influence of seasons on peritonitis rates (Poisson regression) and outcomes (multivariable logistic regression). Results. The overall rate of peritonitis was 0.59 episodes per patient-year of treatment. Using winter as the reference season, the peritonitis incidence rate ratios (95% confidence interval) for summer, autumn and spring were 1.02 (0.95–1.09), 1.01 (0.94–1.08) and 0.99 (0.92–1.06), respectively. Significant seasonal variations were observed in the rates of peritonitis caused by coagulase-negative Staphylococci (spring and summer peaks), corynebacteria (winter peak) and Gram-negative organisms (summer and autumn peaks). There were trends to seasonal variations in fungal peritonitis (summer and autumn peaks) and pseudomonas peritonitis (summer peak). No significant seasonal variations were observed for other organisms. Peritonitis outcomes did not significantly vary according to season. Conclusions. Seasonal variation has no appreciable influence on overall PD peritonitis rates or clinical outcomes. Nevertheless, significant seasonal variations were observed in the rates of peritonitis due to specific microorganisms, which may allow institutions to more precisely target infection control strategies prior to higher risk seasons. [ABSTRACT FROM AUTHOR]

Chronic kidney disease is a major public health problem globally. Despite this, there are fewer high-quality, high-impact clinical trials in nephrology than other internal medicine specialties, which has led to large gaps in evidence. To address this deficiency, the Australasian Kidney Trials Network, a Collaborative Research Group, was formed in 2005. Since then, the Network has provided infrastructure and expertise to conduct patient-focused high-quality, investigator-initiated clinical trials in nephrology. The Network has not only been successful in engaging the nephrology community in Australia and New Zealand but also in forming collaborations with leading researchers from other countries. This article describes the establishment, development, and functions of the Network. The article also discusses the current and future funding strategies to ensure uninterrupted conduct of much needed clinical trials in nephrology to improve the outcomes of patients affected by kidney diseases with cost-effective interventions. [ABSTRACT FROM AUTHOR]

There are few reports regarding outcomes of anti-glomerular basement membrane (GBM) disease in patients who underwent renal replacement therapy. To help define this we studied all patients with anti-GBM disease who started renal replacement therapy for end-stage renal disease (ESRD) in Australia and New Zealand (ANZDATA Registry) between 1963 and 2010 encompassing 449 individuals (0.8 percent of all ESRD patients). The median survival on dialysis was 5.93 years with death predicted by older age and a history of pulmonary hemorrhage. Thirteen patients recovered renal function, although 10 subsequently experienced renal death after a median period of 1.05 years. Of the 224 patients who received their first renal allograft, the 10-year median patient and renal allograft survival rates were 86% and 63%, respectively. Six patients experienced anti-GBM disease recurrence in their allograft, which led to graft failure in two. Using multivariable Cox regression analysis, patients with anti-GBM disease had comparable survival on dialysis or following renal transplantation (hazard ratios of 0.86 and 1.03, respectively) compared to those with ESRD due to other causes. Also, renal allograft survival (hazard ratio of 1.03) was not altered compared to other diseases requiring a renal transplant. Thus, anti-GBM disease was an uncommon cause of ESRD, and not associated with altered risks of dialysis, transplant or first renal allograft survival. Death on dialysis was predicted by older age and a history of pulmonary hemorrhage. [ABSTRACT FROM AUTHOR]

Aim: To describe and compare de novo arteriovenous fistula (AVF) failure rates between Australia and New Zealand (ANZ), and Malaysia., Background: AVFs are preferred for haemodialysis access but are limited by high rates of early failure., Methods: A post hoc analysis of 353 participants from ANZ and Malaysia included in the FAVOURED randomised-controlled trial undergoing de novo AVF surgery was performed. Composite AVF failure (thrombosis, abandonment, cannulation failure) and its individual components were compared between ANZ ( n  = 209) and Malaysian ( n  = 144) participants using logistic regression adjusted for patient- and potentially modifiable clinical factors., Results: Participants' mean age was 55 ± 14.3 years and 64% were male. Compared with ANZ participants, Malaysian participants were younger with lower body mass index, higher prevalence of diabetes mellitus and lower prevalence of cardiovascular disease. AVF failure was less frequent in the Malaysian cohort (38% vs 54%; adjusted odds ratio (OR) 0.53, 95% confidence interval (CI) 0.31-0.93). This difference was driven by lower odds of cannulation failure (29% vs 47%, OR 0.45, 95% CI 0.25-0.80), while the odds of AVF thrombosis (17% vs 20%, OR 1.24, 95% CI 0.62-2.48) and abandonment (25% vs 23%, OR 1.17, 95% CI 0.62-2.16) were similar., Conclusions: The risk of AVF failure was significantly lower in Malaysia compared to ANZ and driven by a lower risk of cannulation failure. Differences in practice patterns, including patient selection, surgical techniques, anaesthesia or cannulation techniques may account for regional outcome differences and warrant further investigation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) is an international, prospective study following persons treated by peritoneal dialysis (PD) to identify modifiable practices associated with improvements in PD technique and person survival. The aim of this study was to assess the representativeness of the Australian cohort included in PDOPPS compared to the complete Australian PD population, as reported to the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry., Methods: Adults with at least one PD treatment reported to ANZDATA Registry during the census period of PDOPPS Phase I (November 2014 to April 2018) were compared to the Australian PDOPPS cohort. The primary outcomes were the representativeness of centres and persons. Secondary outcomes explored the association of person characteristics with consent to study participation., Results: After data linkage, 511 PDOPPS participants were compared to 5616 Australians treated with PD. Within centres eligible for PDOPPS, selected centres were similar to other Australian centres. The PDOPPS participants' cohort tended to include older persons, more males, a higher proportion of Caucasians and more persons with higher socioeconomic advantage compared to the Australian PD population. Differences in distribution across sex and ethnicities between the PDOPPS cohort and the overall PD population were in part due to the selection and consent processes, during which females and non-Caucasians were more likely to not consent to PDOPPS participation., Conclusion: Sampling methods used in PDOPPS allowed for good national representativeness of the included centres. However, representativeness of the unweighted PDOPPS sample was suboptimal in regard to some participant characteristics.

Objective: Higher serum phosphate is associated with increased adverse outcomes including cardiovascular disease. Abnormalities of bone and mineral metabolism in chronic kidney disease (CKD), including higher serum phosphate, are important risk factors for increased cardiovascular disease. Associations between dietary phosphate intake and biochemical and cardiovascular parameters in non-dialysis CKD patients, however, have not been adequately studied. This study aimed to explore associations between phosphate intake and biomarkers of bone and mineral metabolism and intermediate cardiovascular markers in adults with stage 3-4 CKD., Design and Methods: One hundred thirty-two participants enrolled in the IMpact of Phosphate Reduction On Vascular End-points in Chronic Kidney Disease trial were invited to participate in this sub-study. At baseline, dietary phosphate intake and its source (animal, plant, or a mixture of animal and plant) were determined using a 7-day self-administered diet food record, and measurements were made of serum and urinary phosphate, serum calcium, parathyroid hormone, fibroblast growth factor-23, and the intermediate cardiovascular markers pulse wave velocity (PWV) and abdominal aortic calcification. The relationships between dietary phosphate intake and these bone metabolism and cardiovascular markers were explored using Pearson's correlation and linear regression. The effect of source of phosphate intake was analyzed using compositional data analysis., Results: Ninety participants (age 64 ± 12 years, 68% male, estimated glomerular filtration rate 26.6 ± 7.6 mL/min/1.73 m 2 , daily phosphate intake 1,544 ± 347 mg) completed the study. Correlations among dietary phosphate intake and biochemical measures, PWV, and abdominal aortic calcification ranged from r = -0.13 to r = +0.13. Linear regression showed no association between dietary phosphate measurements and biochemical or cardiovascular parameters. Source of phosphate intake was associated with PWV (P = .01), but not with other biomarkers of bone and mineral metabolism. Higher PWV values were associated with higher intake of plant-based relative to animal-based phosphate (1.058 [1.020-1.098], P = .003)., Conclusion: Levels of total dietary phosphate intake measured by dietary food record show no statistically significant relationship with biochemical markers of bone and mineral metabolism or intermediate cardiovascular markers. Higher PWV levels associated with higher intake of plant-based relative to animal-based phosphate intake were an unexpected finding and further research is needed in this area., (Copyright © 2021 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Dietary phosphate modification is a common therapy to treat hyperphosphatemia in individuals with chronic kidney disease (CKD). However, current dietary intake and common food sources of phosphate typically consumed by individuals with CKD are not well characterized. This study examined a cohort of CKD patients to determine total dietary intake and common food sources of phosphate, including phosphate additives., Design and Methods: Participants with CKD stages 3b and 4 recruited to a substudy of the "IMPROVE-CKD (IMpact of Phosphate Reduction On Vascular End-points in Chronic Kidney Disease) Study" completed a 7-day self-administered diet record at baseline. Diet histories were analyzed and daily phosphate intakes determined using FoodWorks V.9 (Xyris). The proportion of phosphate contributed by each food group was determined using the AUSNUT 2011-2013 Food Classification System. Ingredient lists of packaged food items consumed were reviewed to determine frequency of phosphate-based additives., Results: Ninety participants (mean eGFR 26.5 mL/min/1.73 m 2 ) completed this substudy. Mean phosphate intake of participants was 1544 ± 347 mg/day, with 96% of individuals exceeding the recommended daily intake of phosphate (1000 mg/day). The highest sources of dietary phosphate were milk-based products (25%) and meat and poultry products/dishes (25%). Phosphate-based food additives were identified in 39% (n = 331/845) of packaged foods consumed by participants., Conclusion: Dietary phosphate intakes of Australians with CKD are high and come from a variety of sources. Managing dietary phosphate intake requires a patient-centered, tailored approach with an emphasis on maintaining nutritional adequacy and awareness of phosphate additives., (Copyright © 2020 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The outcomes of culture-negative peritonitis in peritoneal dialysis (PD) patients have been reported to be superior to those of culture-positive peritonitis. The current study aimed to examine whether this observation also applied to different subtypes of culture-positive peritonitis., Methods: This multicentre registry study included all episodes of peritonitis in adult PD patients in Australia between 2004 and 2014. The primary outcome was medical cure. Secondary outcomes were catheter removal, hemodialysis transfer, relapsing/recurrent peritonitis and peritonitis-related death. These outcomes were analyzed using mixed effects logistic regression., Results: Overall, 11,122 episodes of peritonitis occurring in 5367 patients were included. A total of 1760 (16%) episodes were culture-negative, of which 77% were medically cured. Compared with culture-negative peritonitis, the odds of medical cure were lower in peritonitis caused by Staphylococcus aureus (adjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.52-0.73), Pseudomonas species (OR 0.20, 95% CI 0.16-0.26), other gram-negative organisms (OR 0.48, 95% CI 0.41-0.56), polymicrobial organisms (OR 0.30, 95% CI 0.25-0.35), fungi (OR 0.02, 95% CI 0.01-0.03), and other organisms (OR 0.61, 95% CI 0.49-0.76), while the odds were similar in other (non-staphylococcal) gram-positive organisms (OR 1.11, 95% CI 0.97-1.28). Similar results were observed for catheter removal and hemodialysis transfer. Compared with culture-negative peritonitis, peritonitis-related mortality was significantly higher in culture-positive peritonitis except that due to other gram-positive organisms. There was no difference in the odds of relapsing/recurrent peritonitis between culture-negative and culture-positive peritonitis., Conclusion: Culture-negative peritonitis had superior outcomes compared to culture-positive peritonitis except for non-staphylococcal gram-positive peritonitis.

Background: Concern regarding technique failure is a major barrier to increased uptake of peritoneal dialysis (PD), and the first year of therapy is a particularly vulnerable time., Study Design: A cohort study using competing-risk regression analyses to identify the key risk factors and risk periods for early transfer to hemodialysis therapy or death in incident PD patients., Setting & Participants: All adult patients who initiated PD therapy in Australia and New Zealand in 2000 through 2014., Predictors: Patient demographics and comorbid conditions, duration of prior renal replacement therapy, timing of referral, PD modality, dialysis era, and center size., Outcomes: Technique failure within the first year, defined as transfer to hemodialysis therapy for more than 30 days or death., Results: Of 16,748 patients included in the study, 4,389 developed early technique failure. Factors associated with increased risk included age older than 70 years, diabetes or vascular disease, prior renal replacement therapy, late referral to a nephrology service, or management in a smaller center. Asian or other race and use of continuous ambulatory PD were associated with reduced risk, as was initiation of PD therapy in 2010 through 2014. Although the risk for technique failure due to death or infection was constant during the first year, mechanical and other causes accounted for a greater number of cases within the initial 9 months of treatment., Limitations: Potential for residual confounding due to limited data for residual kidney function, dialysis prescription, and socioeconomic factors., Conclusions: Several modifiable and nonmodifiable factors are associated with early technique failure in PD. Targeted interventions should be considered in high-risk patients to avoid the consequences of an unplanned transfer to hemodialysis therapy or death., (Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.)

Background: Acinetobacter is a rare but important cause of peritonitis in peritoneal dialysis (PD) patients. As the complication has not been comprehensively evaluated previously, the present study examined the outcomes of Acinetobacter peritonitis in a large, national cohort of PD patients., Methods: The study included all episodes of peritonitis in Australia from January 2004 to December 2014 using Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) data. The primary outcome was peritonitis cure and secondary outcomes were catheter removal, hemodialysis transfer, recurrent/relapsing peritonitis, peritonitis-related hospitalization, and death. Outcomes were compared using multivariable logistic regression., Results: Overall, 5,367 patients experienced 11,122 episodes of peritonitis across 51 centers in Australia. Of these, 228 (4.2%) patients experienced 253 (2.3%) episodes of Acinetobacter peritonitis (176 episodes were due to Acinetobacter alone and 77 involved co-infection with other organisms). Of the 176 solitary Acinetobacter episodes, 131(74%) achieved cure with antibiotics alone. Compared with Acinetobacter , significantly lower odds of peritonitis cure were observed for Pseudomonas (adjusted odds ratio [AOR] 0.24, 95% confidence interval [CI]: 0.16 - 0.36), other gram-negative organisms (AOR 0.54, 95% CI 0.37 - 0.77), fungi (AOR 0.02, 95% CI 0.01 - 0.03), and polymicrobial organisms (AOR 0.36, 95% CI 0.25 - 0.51), whilst similar odds of cure were observed for Staphylococcus (AOR 0.73, 95% CI 0.50 - 1.06), other gram-positive organisms (AOR 1.32,95% CI 0.93 - 1.89), culture-negative (AOR 1.19, 95% CI 0.82 -1.71), and other organisms (AOR 0.72, 95% CI 0.49 - 1.07). The odds of catheter removal and hemodialysis transfer were higher with Pseudomonas , other gram-negative, fungal, and polymicrobial peritonitis than with Acinetobacter peritonitis. The odds of death were also higher with Pseudomonas and fungal peritonitis than with Acinetobacter peritonitis. Treatment of Acinetobacter peritonitis with gentamicin, ciprofloxacin, or ceftazidime achieved comparable outcomes., Conclusions: Outcomes of Acinetobacter peritonitis were favorable compared with most other forms of organism-specific peritonitis. Commonly used antibiotics covering gram-negative bacteria achieved comparable outcomes in Acinetobacter peritonitis., (Copyright © 2018 International Society for Peritoneal Dialysis.)

Background: Peritonitis is a common cause of technique failure in peritoneal dialysis (PD). Dialysis center-level characteristics may influence PD peritonitis outcomes independent of patient-level characteristics., Study Design: Retrospective cohort study., Setting & Participants: Using Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) data, all incident Australian PD patients who had peritonitis from 2004 through 2014 were included., Predictors: Patient- (including demographic data, causal organisms, and comorbid conditions) and center- (including center size, proportion of patients treated with PD, and summary measures related to type, cause, and outcome of peritonitis episodes) level predictors., Outcomes & Measurement: The primary outcome was cure of peritonitis with antibiotics. Secondary outcomes were peritonitis-related catheter removal, hemodialysis therapy transfer, peritonitis relapse/recurrence, hospitalization, and mortality. Outcomes were analyzed using multilevel mixed logistic regression., Results: The study included 9,100 episodes of peritonitis among 4,428 patients across 51 centers. Cure with antibiotics was achieved in 6,285 (69%) peritonitis episodes and varied between 38% and 86% across centers. Centers with higher proportions of dialysis patients treated with PD (>29%) had significantly higher odds of peritonitis cure (adjusted OR, 1.21; 95% CI, 1.04-1.40) and lower odds of catheter removal (OR, 0.78; 95% CI, 0.62-0.97), hemodialysis therapy transfer (OR, 0.78; 95% CI, 0.62-0.97), and peritonitis relapse/recurrence (OR, 0.68; 95% CI, 0.48-0.98). Centers with higher proportions of peritonitis episodes receiving empirical antibiotics covering both Gram-positive and Gram-negative organisms had higher odds of cure with antibiotics (OR, 1.22; 95% CI, 1.06-1.42). Patient-level characteristics associated with higher odds of cure were younger age and less virulent causative organisms (coagulase-negative staphylococci, streptococci, and culture negative). The variation in odds of cure across centers was 9% higher after adjustment for patient-level characteristics, but 66% lower after adjustment for center-level characteristics., Limitations: Retrospective study design using registry data., Conclusions: These results suggest that center effects contribute substantially to the appreciable variation in PD peritonitis outcomes that exist across PD centers within Australia., (Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.)

Background: Obesity is increasingly prevalent worldwide, and a greater number of patients initiate renal replacement therapy with a high body mass index (BMI). This study aimed to evaluate the association between BMI and organism-specific peritonitis., Methods: All adult patients who initiated peritoneal dialysis (PD) in Australia between January 2004 and December 2013 were included. Data were accessed through the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. The co-primary outcomes of this study were time to first organism-specific peritonitis episode, specifically gram-positive, gram-negative, culture-negative, and fungal. Secondary outcomes were individual rates of organism-specific peritonitis for the same 4 microbiological categories., Results: There were 7,381 peritonitis episodes among the 8,343 incident PD patients evaluated. After multivariable adjustment, obese patients (BMI 30 - 34.9 kg/m 2 ) had an increased risk of fungal peritonitis (adjusted hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.18 - 2.42), very obese patients (BMI ≥ 35 kg/m 2 ) had a significantly higher risk of gram-positive peritonitis (HR 1.15, 95% CI 1.02 - 1.30), while both obese and very obese patients experienced significantly higher risks of gram-negative peritonitis (HR 1.29, 95% CI 1.11 - 1.50 and HR 1.30, 95% CI 1.08 - 1.57, respectively) compared with patients with normal BMI (20 - 24.9 kg/m 2 ). Obesity and severe obesity were independently associated with increased incidence rate ratios of all forms of organism-specific peritonitis with a non-significant trend for severe obesity and gram-negative peritonitis association., Conclusion: Among Australian patients, obesity and severe obesity are associated with significantly increased rates of gram-positive, gram-negative, fungal, and culture-negative peritonitis., (Copyright © 2018 International Society for Peritoneal Dialysis.)

Background: Few studies have examined the relationship between socio-economic position (SEP) and peritoneal dialysis (PD) outcomes, particularly at a country level. The aim of this study was to investigate the relationships between SEP, technique failure, and mortality in PD patients undertaking treatment in Australia., Methods: The study included all Australian non-indigenous incident PD patients between January 1, 1997, and December 31, 2014, using Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data. The SEP was assessed by quartiles of postcode-based Australian Socio-Economic Indexes for Areas (SEIFA), including Index of Relative Socio-economic Advantage and Disadvantage (IRSAD - primary index), Index of Relative Socio-economic Disadvantage (IRSD), Index of Economic Resources (IER), and Index of Education and Occupation (IEO). Technique and patient survival were evaluated by multivariable Cox proportional hazards survival analyses., Results: The study included 9,766 patients (mean age 60.6 ± 15 years, 57% male, 38% diabetic). Using multivariable Cox regression, no significant association was observed between quartiles of IRSAD and technique failure (30-day definition p = 0.65, 180-day definition p = 0.68). Similar results were obtained using competing risks regression. However, higher SEP, defined by quartiles of IRSAD, was associated with better patient survival (Quartile 1 reference; Quartile 2 adjusted hazards ratio [HR] 0.96, 95% confidence interval [CI] 0.86 - 1.06; Quartile 3 HR 0.87, 95% CI 0.77 - 0.99; Quartile 4 HR 0.86, 95% CI 0.76 - 0.97). Similar results were found when IRSD was analyzed, but results were no longer statistically significant for IER and IEO., Conclusions: In Australia, where there is universal free healthcare, SEP was not associated with PD technique failure in non-indigenous PD patients. Higher SEP was generally associated with improved patient survival., (Copyright © 2017 International Society for Peritoneal Dialysis.)

Background and Objectives: Emerging evidence from recently published observational studies and an individual patient data meta-analysis shows that mammalian target of rapamycin inhibitor use in kidney transplantation is associated with increased mortality. Therefore, all-cause mortality and allograft loss were compared between use and nonuse of mammalian target of rapamycin inhibitors in patients from Australia and New Zealand, where mammalian target of rapamycin inhibitor use has been greater because of heightened skin cancer risk., Design, Setting, Participants, & Measurements: Our longitudinal cohort study included 9353 adult patients who underwent 9558 kidney transplants between January 1, 1996 and December 31, 2012 and had allograft survival ≥1 year. Risk factors for all-cause death and all-cause and death-censored allograft loss were analyzed by multivariable Cox regression using mammalian target of rapamycin inhibitor as a time-varying covariate. Additional analyses evaluated mammalian target of rapamycin inhibitor use at fixed time points of baseline and 1 year., Results: Patients using mammalian target of rapamycin inhibitors were more likely to be white and have a history of pretransplant cancer. Over a median follow-up of 7 years, 1416 (15%) patients died, and 2268 (24%) allografts were lost. There was a higher risk of all-cause mortality with time-varying mammalian target of rapamycin inhibitor use (hazard ratio, 1.47; 95% confidence interval, 1.23 to 1.76) as well as in the fixed time model analyses comparing mammalian target of rapamycin inhibitor use at baseline (hazard ratio, 1.54; 95% confidence interval, 1.22 to 1.93) and 1 year (hazard ratio, 1.63; 95% confidence interval, 1.32 to 2.01). Time-varying mammalian target of rapamycin inhibitor use was associated with higher risk of death because of malignancy (hazard ratio, 1.37; 95% confidence interval, 1.09 to 1.71). There were no statistically significant differences in the risk of all-cause (hazard ratio, 0.98; 95% confidence interval, 0.85 to 1.12) and death-censored (hazard ratio, 0.85; 95% confidence interval, 0.69 to 1.03) allograft loss between the mammalian target of rapamycin inhibitor use and nonuse groups in the time-varying model as well as the fixed time models., Conclusions: Mammalian target of rapamycin inhibitor use was associated with a higher risk of all-cause mortality but not allograft loss., (Copyright © 2016 by the American Society of Nephrology.)

Background: Clinical outcomes of patients with end-stage kidney disease (ESKD) receiving renal replacement therapy (RRT) secondary to IgA nephropathy (IgAN) have not been well described., Aim: To investigate the characteristics, treatments and outcomes of ESKD because of kidney-limited IgAN and Henoch-Schönlein purpura nephritis (HSPN) in the Australian and New Zealand RRT populations., Methods: All ESKD patients who commenced RRT in Australia and New Zealand between 1971 and 2012 were included. Dialysis and transplant outcomes were evaluated in both a contemporary cohort (1998-2012) and the entire cohort (1971-2012)., Results: Of 63 297 ESKD patients, 3721 had kidney-limited IgAN, and 131 had HSPN. For the contemporary cohort of IgAN patients on dialysis (n = 2194), 10-year patient survival was 65%. Of 1368 contemporary IgAN patients who received their first renal allograft, 10-year patient, overall renal allograft and death-censored renal allograft survival were 93%, 82% and 88%, respectively. Using multivariable Cox regression analysis, patients with IgAN had favourable dialysis patient survival (adjusted hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.57-0.69), overall renal allograft survival (HR 0.67, 95% CI 0.57-0.79) and renal transplant patient survival (HR 0.58, 95% CI 0.45-0.74) compared with ESKD controls. Similar results were found in the entire cohort and when using competing-risks models. Compared with kidney-limited IgAN patients, those with HSPN had worse dialysis patient survival (HR 1.94, 95% CI 1.02-3.69), overall renal allograft survival (HR 3.40, 95% CI 1.00-11.55) and renal transplant patient survival (HR 3.50, 95% CI 1.03-11.92)., Conclusion: IgAN ESKD was associated with better dialysis and renal transplant outcomes compared with other forms of ESKD. The survival outcomes of ESKD patients with HSPN were worse than kidney-limited IgAN., (© 2015 Asian Pacific Society of Nephrology.)

Unlabelled: ♦, Background: Previous studies have reported significant variation in peritonitis rates across dialysis centers. Limited evidence is available to explain this variability. The aim of this study was to assess center-level predictors of peritonitis and their relationship with peritonitis rate variations. ♦, Methods: All incident peritoneal dialysis (PD) patients treated in Australia between October 2003 and December 2013 were included. Data were accessed through the Australia and New Zealand Dialysis and Transplant Registry. The primary outcome was peritonitis rate, evaluated in a mixed effects negative binomial regression model. Peritonitis-free survival was assessed as a secondary outcome in a Cox proportional hazards model. ♦, Results: Overall, 8,711 incident PD patients from 51 dialysis centers were included in the study. Center-level predictors of lower peritonitis rates included smaller center size, high proportion of PD, low peritoneal equilibration test use at PD start, and low proportion of hospitalization for peritonitis. In contrast, a low proportion of automated PD exposure, high icodextrin exposure and low or high use of antifungal prophylaxis at the time of peritonitis were associated with a higher peritonitis rate. Similar results were obtained for peritonitis-free survival. Overall, accounting for center-level characteristics appreciably decreased peritonitis variability among dialysis centers (p = 0.02). ♦, Conclusion: This study identified specific center-level characteristics associated with the variation in peritonitis risk. Whether these factors are directly related to peritonitis risk or surrogate markers for other center characteristics is uncertain and should be validated in further studies., (Copyright © 2016 International Society for Peritoneal Dialysis.)

Unlabelled: ♦, Background: The aim of the present study was to investigate the relationship between socio-economic status (SES) and peritoneal dialysis (PD)-related peritonitis. ♦, Methods: Associations between area SES and peritonitis risk and outcomes were examined in all non-indigenous patients who received PD in Australia between 1 October 2003 and 31 December 2010 (peritonitis outcomes). SES was assessed by deciles of postcode-based Australian Socio-Economic Indexes for Areas (SEIFA), including Index of Relative Socio-economic Disadvantage (IRSD), Index of Relative Socio-economic Advantage and Disadvantage (IRSAD), Index of Economic Resources (IER) and Index of Education and Occupation (IEO). ♦, Results: 7,417 patients were included in the present study. Mixed-effects Poisson regression demonstrated that incident rate ratios for peritonitis were generally lower in the higher SEIFA-based deciles compared with the reference (decile 1), although the reductions were only statistically significant in some deciles (IRSAD deciles 2 and 4 - 9; IRSD deciles 4 - 6; IER deciles 4 and 6; IEO deciles 3 and 6). Mixed-effects logistic regression showed that lower probabilities of hospitalization were predicted by relatively higher SES, and lower probabilities of peritonitis-associated death were predicted by less SES disadvantage status and greater access to economic resources. No association was observed between SES and the risks of peritonitis cure, catheter removal and permanent hemodialysis (HD) transfer. ♦, Conclusions: In Australia, where there is universal free healthcare, higher SES was associated with lower risks of peritonitis-associated hospitalization and death, and a lower risk of peritonitis in some categories., (Copyright © 2015 International Society for Peritoneal Dialysis.)

Objectives: To study the body mass index (BMI) trajectory in patients with incident end-stage kidney disease and its association with all-cause mortality., Methods: This longitudinal cohort study included 17022 adult patients commencing hemodialysis [HD] (n = 10860) or peritoneal dialysis [PD] (n = 6162) between 2001 and 2008 and had ≥6-month follow-up and ≥2 weight measurements, using the Australia and New Zealand Dialysis and Transplant Registry data. The association of time-varying BMI with all-cause mortality was explored using multivariate Cox regression models., Results: The median follow-up was 2.3 years. There was a non-linear change in the mean BMI (kg/m2) over time, with an initial decrease from 27.6 (95% confidence interval [CI]: 27.5, 27.7) to 26.7 (95% CI: 26.6, 26.9) at 3-month, followed by increments to 27.1 (95% CI: 27, 27.2) at 1-year and 27.2 (95% CI: 26.8, 27.1) at 3-year, and a gradual decrease subsequently. The BMI trajectory was significantly lower in HD patients who died than those who survived, although this pattern was not observed in PD patients. Compared to the reference time-varying BMI category of 25.1-28 kg/m2, the mortality risks of both HD and PD patients were greater in all categories of time-varying BMI <25 kg/m2. The mortality risks were significantly lower in all categories of time-varying BMI >28.1 kg/m2 among HD patients, but only in the category 28.1-31 kg/m2 among PD patients., Conclusions: BMI changed over time in a non-linear fashion in incident dialysis patients. Time-varying measures of BMI were significantly associated with mortality risk in both HD and PD patients.

Background: There is a paucity of evidence to guide the best strategy for prevention of peritoneal-dialysis-related infections. Antibacterial honey has shown promise as a novel, cheap, effective, topical prophylactic agent without inducing microbial resistance. We therefore assessed whether daily application of honey at the exit site would increase the time to peritoneal-dialysis-related infections compared with standard exit-site care plus intranasal mupirocin prophylaxis for nasal carriers of Staphylococcus aureus., Methods: In this open-label trial undertaken in 26 centres in Australia and New Zealand, participants undergoing peritoneal dialysis were randomly assigned in a 1:1 ratio with an adaptive allocation algorithm to daily topical exit-site application of antibacterial honey plus standard exit-site care or intranasal mupirocin prophylaxis (only in carriers of nasal S aureus) plus standard exit-site care (control group). The primary endpoint was time to first infection related to peritoneal dialysis (exit-site infection, tunnel infection, or peritonitis). The trial is registered with the Australian New Zealand Clinical Trials Registry, number 12607000537459., Findings: Of 371 participants, 186 were assigned to the honey group and 185 to the control group. The median peritoneal-dialysis-related infection-free survival times were not significantly different in the honey (16·0 months [IQR not estimable]) and control groups (17·7 months [not estimable]; unadjusted hazard ratio 1·12, 95% CI 0·83-1·51; p=0·47). In the subgroup analyses, honey increased the risks of both the primary endpoint (1·85, 1·05-3·24; p=0·03) and peritonitis (2·25, 1·16-4·36) in participants with diabetes. The incidences of serious adverse events (298 vs 327, respectively; p=0·1) and deaths (14 vs 18, respectively; p=0·9) were not significantly different in the honey and control groups. 11 (6%) participants in the honey group had local skin reactions., Interpretation: The findings of this trial show that honey cannot be recommended routinely for the prevention of peritoneal-dialysis-related infections., Funding: Baxter Healthcare, Queensland Government, Comvita, and Gambro., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background and Objectives: The effect of biocompatible peritoneal dialysis (PD) solutions on PD-related peritonitis is unclear. This study sought to evaluate the relationship between use of biocompatible solutions and the probability of occurrence or clinical outcomes of peritonitis., Design, Setting, Participants, & Measurements: The study included all incident Australian patients receiving PD between January 1, 2007, and December 31, 2010, using Australia and New Zealand Dialysis and Transplant Registry data. All multicompartment PD solutions of neutral pH were categorized as biocompatible solutions. The independent predictors of peritonitis and the use of biocompatible solutions were determined by multivariable, multilevel mixed-effects Poisson and logistic regression analysis, respectively. Sensitivity analyses, including propensity score matching, were performed., Results: Use of biocompatible solutions gradually declined (from 7.5% in 2007 to 4.2% in 2010), with preferential use among smaller units and among younger patients without diabetes mellitus. Treatment with biocompatible solution was associated with significantly greater overall rate of peritonitis (0.67 versus 0.47 episode per patient-year; incidence rate ratio, 1.49; 95% confidence interval [CI], 1.19 to 1.89) and with shorter time to first peritonitis (hazard ratio [HR], 1.48; 95% CI, 1.17 to 1.87), a finding replicated in propensity score-matched cohorts (HR, 1.36; 95% CI, 1.09 to 1.71)., Conclusions: In an observational registry study, use of biocompatible PD solutions was associated with higher overall peritonitis rates and shorter time to first peritonitis. Further randomized studies adequately powered for a primary peritonitis outcome are warranted.

Background and Objectives: This study aimed to evaluate dialysis and transplant outcomes of patients with ESRD secondary to ANCA-associated vasculitis (AAV)., Design, Setting, Participants, & Measurements: All ESRD patients who commenced renal replacement therapy in Australia and New Zealand between 1996 and 2010 were included. Outcomes were assessed by Kaplan-Meier, multivariable Cox regression, and competing-risks regression survival analyses., Results: Of 36,884 ESRD patients, 228 had microscopic polyangiitis (MPA) and 221 had granulomatosis with polyangiitis (GPA). Using competing-risks regression, compared with other causes of ESRD, MPA patients (hazard ratio [HR], 0.89; 95% confidence interval [95% CI], 0.73-1.08; P=0.24) and GPA patients (HR, 0.94; 95% CI, 0.74-1.19; P=0.62) experienced comparable survival on dialysis. Forty-six MPA patients (21%) and 47 GPA (20%) patients received 98 renal allografts. Respective 10-year first graft survival rates in MPA, GPA, and non-AAV patients were 50%, 62%, 70%, whereas patient survival rates were 68%, 85% and 83%, respectively. Compared with non-AAV patients, MPA transplant recipients had higher risks of graft failure (HR, 1.87; 95% CI, 1.07-3.25; P=0.03) and death (HR, 1.94; 95% CI, 1.02-3.69; P=0.04), whereas GPA transplant recipients experienced comparable renal allograft survival (HR, 0.91; 95% CI, 0.43-1.93; P=0.81) and patient survival (HR, 0.58; 95% CI, 0.23-2.27; P=0.58). AAV recurrence was observed in two renal allografts (2%)., Conclusions: Compared with ESRD patients without AAV, those with GPA have comparable renal replacement therapy outcomes, whereas MPA patients have comparable dialysis survival but poorer renal transplant allograft and patient survival rates.

Background: There has been little study to date of daily variation in cardiac death in dialysis patients and whether such variation differs according to dialysis modality and session frequency., Study Design: Observational cohort study using ANZDATA (Australia and New Zealand Dialysis and Transplant) Registry data., Setting & Participants: All adult patients with end-stage kidney failure treated by dialysis in Australia and New Zealand who died between 1999 and 2008., Predictors: Timing of death (day of week), dialysis modality, hemodialysis (HD) session frequency, and demographic, clinical, and facility variables., Outcomes & Measurements: Cardiac and noncardiac mortality., Results: 14,636 adult dialysis patients died during the study period (HD, n = 10,338; peritoneal dialysis [PD], n = 4,298). Cardiac death accounted for 40% of deaths and was significantly more likely to occur on Mondays in in-center HD patients receiving 3 or fewer dialysis sessions per week (n = 9,503; adjusted OR, 1.26; 95% CI, 1.14-1.40; P < 0.001 compared with the mean odds of cardiac death for all days of the week). This daily variation in cardiac death was not seen in PD patients, in-center HD patients receiving more than 3 sessions per week (n = 251), or home HD patients (n = 573). Subgroup analyses showed that deaths related to hyperkalemia and myocardial infarction also were associated with daily variation in risk in HD patients. This pattern was not seen for vascular, infective, malignant, dialysis therapy withdrawal, or other deaths., Limitations: Limited covariate adjustment. Residual confounding and coding bias could not be excluded. Possible type 2 statistical error due to limited sample size of home HD and enhanced-frequency HD cohorts., Conclusions: Daily variation in the pattern of cardiac deaths was observed in HD patients receiving 3 or fewer dialysis sessions per week, but not in PD, home HD, and HD patients receiving more than 3 sessions per week., (Crown Copyright © 2012. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to investigate the characteristics and outcomes of patients receiving renal replacement therapy for end-stage kidney disease (ESKD) secondary to haemolytic uraemic syndrome (HUS)., Methods: The study included all patients with ESKD who commenced renal replacement therapy in Australia and New Zealand between 15/5/1963 and 31/12/2010, using data from the ANZDATA Registry. HUS ESKD patients were compared with matched controls with an alternative primary renal disease using propensity scores based on age, gender and treatment era., Results: Of the 58422 patients included in the study, 241 (0.4%) had ESKD secondary to HUS. HUS ESKD was independently associated with younger age, female gender and European race. Compared with matched controls, HUS ESKD was not associated with mortality on renal replacement therapy (adjusted hazard ratio [HR] 1.14, 95% CI 0.87-1.50, p = 0.34) or dialysis (HR 1.34, 95% CI 0.93-1.93, p = 0.12), but did independently predict recovery of renal function (HR 54.01, 95% CI 1.45-11.1, p = 0.008). 130 (54%) HUS patients received 166 renal allografts. Overall renal allograft survival rates were significantly lower for patients with HUS ESKD at 1 year (73% vs 91%), 5 years (62% vs 85%) and 10 years (49% vs 73%). HUS ESKD was an independent predictor of renal allograft failure (HR 2.59, 95% CI 1.70-3.95, p < 0.001). Sixteen (12%) HUS patients experienced failure of 22 renal allografts due to recurrent HUS. HUS ESKD was not independently associated with the risk of death following renal transplantation (HR 0.92, 95% CI 0.35-2.44, p = 0.87)., Conclusions: HUS is an uncommon cause of ESKD, which is associated with comparable patient survival on dialysis, an increased probability of renal function recovery, comparable patient survival post-renal transplant and a heightened risk of renal transplant graft failure compared with matched ESKD controls.

Objective: Management of peritoneal dialysis (PD)-associated peritonitis requires timely intervention by experienced staff, which may not be uniformly available throughout the week. The aim of the present study was to examine the effects of weekend compared with weekday presentation on peritonitis outcomes., Methods: The study, which used data from the Australia and New Zealand Dialysis and Transplant Registry, included all Australian patients receiving PD between 1 October 2003 and 31 December 2008. The independent predictors of weekend presentation and subsequent peritonitis outcomes were assessed by multivariate logistic regression., Results: Peritonitis presentation rates were significantly lower on Saturdays [0.46 episodes per year; 95% confidence interval (CI): 0.42 to 0.49 episodes per year] and on Sundays (0.43 episodes per year; 95% CI: 0.40 to 0.47 episodes per year) than all other weekdays; they peaked on Mondays (0.76 episodes per year; 95% CI: 0.72 to 0.81 episodes per year). Weekend presentation with a first episode of peritonitis was independently associated with lower body mass index and residence less than 100 km away from the nearest PD unit. Patients presenting with peritonitis on the weekend were significantly more likely to be hospitalized [adjusted odds ratio (OR): 2.32; 95% CI: 1.85 to 2.90], although microbial profiles and empiric antimicrobial treatments were comparable between the weekend and weekday groups. Antimicrobial cure rates were also comparable (79% vs 79%, p = 0.9), with the exception of cure rates for culture-negative peritonitis, which were lower on the weekend (80% vs 88%, p = 0.047). Antifungal prophylaxis was less likely to be co-prescribed for first peritonitis episodes presenting on weekdays (OR: 0.68; 95% CI: 0.05 to 0.89)., Conclusions: Patients on PD are less likely to present with peritonitis on the weekend. Nevertheless, the microbiology, treatment, and outcomes of weekend and weekday PD peritonitis presentations are remarkably similar. Exceptions include the associations of weekend presentation with a higher hospitalization rate and a lower cure rate in culture-negative infection.

Peritonitis is a major complication of peritoneal dialysis, but the relationship between peritonitis and mortality among these patients is not well understood. In this case-crossover study, we included the 1316 patients who received peritoneal dialysis in Australia and New Zealand from May 2004 through December 2009 and either died on peritoneal dialysis or within 30 days of transfer to hemodialysis. Each patient served as his or her own control. The mean age was 70 years, and the mean time receiving peritoneal dialysis was 3 years. In total, there were 1446 reported episodes of peritonitis with 27% of patients having ≥ 2 episodes. Compared with the rest of the year, there were significantly increased odds of peritonitis during the 120 days before death, although the magnitude of this association was much greater during the 30 days before death. Compared with a 30-day window 6 months before death, the odds for peritonitis was six-fold higher during the 30 days immediately before death (odds ratio, 6.2; 95% confidence interval, 4.4-8.7). In conclusion, peritonitis significantly associates with mortality in peritoneal dialysis patients. The increased odds extend up to 120 days after an episode of peritonitis but the magnitude is greater during the initial 30 days.

Background: The aim of the study was to determine whether distance between residence and peritoneal dialysis (PD) unit influenced peritonitis occurrence, microbiology, treatment and outcomes., Methods: The study included all patients receiving PD between 1/10/2003 and 31/12/2008, using ANZDATA Registry data., Results: 365 (6%) patients lived ≥100 km from their nearest PD unit (distant group), while 6183 (94%) lived <100 km (local group). Median time to first peritonitis in distant patients (1.34 years, 95% CI 1.07-1.61) was significantly shorter than in local patients (1.68 years, 95% CI 1.59-1.77, p = 0.001), whilst overall peritonitis rates were higher in distant patients (incidence rate ratio 1.32, 95% CI 1.20-1.46). Living ≥100 km away from a PD unit was independently associated with a higher risk of S. aureus peritonitis (adjusted odds ratio [OR] 1.64, 95% CI 1.09-2.47). Distant patients with first peritonitis episodes were less likely to be hospitalised (64% vs 73%, p = 0.008) and receive antifungal prophylaxis (4% vs 10%, p = 0.01), but more likely to receive vancomycin-based antibiotic regimens (52% vs 42%, p < 0.001). Using multivariable logistic regression analysis of peritonitis outcomes, distant patients were more likely to be cured with antibiotics alone (OR 1.55, 95% CI 1.03-2.24). All other outcomes were comparable between the two groups., Conclusions: Living ≥100 km away from a PD unit was associated with increased risk of S. aureus peritonitis, modified approaches to peritonitis treatment and peritonitis outcomes that were comparable to, or better than patients living closer to a PD unit. Staphylococcal decolonisation should receive particular consideration in remote living patients.

Background: Determinants and outcomes of peritoneal dialysis (PD)-associated peritonitis occurring within 4 weeks of completion of therapy of a prior episode caused by the same (relapse) or different organism (recurrence) recently have been characterized. However, determinants and outcomes of peritonitis occurring more than 4 weeks after treatment of a prior episode caused by the same (repeated) or different organism (nonrepeated) are poorly understood., Study Design: Observational cohort study using Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) data., Setting & Participants: All Australian PD patients between October 1, 2003, and December 31, 2007, with first episodes of repeated or nonrepeated peritonitis., Predictors: Repeated versus nonrepeated peritonitis, according to International Society of PD (ISPD) criteria., Outcomes & Measurements: Relapse, hospitalization, catheter removal, hemodialysis transfer, and death., Results: After a peritonitis episode, the probability that a subsequent episode represented repeated rather than nonrepeated peritonitis was highest in the second month (41%), then progressively decreased to a stable level of 14% from 6 months onward. When first episodes of repeated (n = 245) or nonrepeated peritonitis (n = 824) were analyzed, repeated peritonitis was predicted independently by a shorter elapsed time from the prior episode (adjusted OR per day elapsed, 0.91; 95% CI, 0.88-0.94). Staphylococcus aureus and coagulase-negative staphylococcus were isolated more frequently in repeated peritonitis, whereas Gram-negative, streptococcal, and fungal organisms were recovered more frequently in nonrepeated peritonitis. Using multivariate logistic regression, repeated peritonitis was associated independently with higher relapse (OR, 5.41; 95% CI, 3.72-7.89) and lower hospitalization rates (OR, 0.63; 95% CI, 0.46-0.85), but catheter removal, hemodialysis transfer, and death rates similar to nonrepeated peritonitis., Limitations: Limited covariate adjustment. Residual confounding and coding bias could not be excluded., Conclusions: Repeated and nonrepeated peritonitis episodes are caused by different spectra of micro-organisms and have different outcomes. Study findings suggest that the ISPD definition for repeated peritonitis should be limited to 6 months., (Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Hepatitis C virus (HCV) infection is associated with increased mortality and morbidity in end-stage renal failure (ESRF) patients. Despite a lower incidence and risk of transmission of HCV infection with peritoneal dialysis (PD), the optimal dialysis modality for HCV-infected ESRF patients is not known. The aim of this study was to evaluate the impact of dialysis modality on the survival of HCV-infected ESRF patients., Design, Setting, Participants, & Measurements: The study included all adult incident ESRF patients in Australia and New Zealand who commenced dialysis between January 1, 1994, and December 31, 2008, and were HCV antibody-positive at the time of dialysis commencement. Time to all-cause mortality was compared between hemodialysis (HD) and PD according to modality assignment at day 90, using Cox proportional hazards model analysis., Results: A total of 424 HCV-infected ESRF patients commenced dialysis during the study period and survived for at least 90 days (PD n = 134; HD n = 290). Mortality rates were comparable between PD and HD in the first year (10.7 versus 13.8 deaths per 100 patient-years, respectively; adjusted hazard ratio [HR] 0.65, 95% CI 0.34 to 1.26) and thereafter (20 versus 15.9 deaths per 100 patient-years, respectively; HR 1.27, 95% CI 0.86 to 1.88)., Conclusions: The survival of HCV-infected ESRF patients is comparable between PD and HD.

Background: The causes, predictors, treatment, and outcomes of relapsed and recurrent peritoneal dialysis (PD)-associated peritonitis are poorly understood., Study Design: Observational cohort study using Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data., Setting & Participants: All Australian PD patients between October 1, 2003, and December 31, 2007, with first episodes of peritonitis., Predictors: Demographic, clinical, and facility variables and type of peritonitis; relapse (same organism or culture-negative episode occurring within 4 weeks of completion of therapy of a prior episode or 5 weeks if vancomycin used); recurrence (different organism occurring within 4 weeks of completion of therapy of a prior episode or 5 weeks if vancomycin used); control (first peritonitis episode without relapse or recurrence)., Outcomes & Measurements: Hospitalization, catheter removal, hemodialysis therapy transfer, death., Results: Of 6,024 PD patients studied, first episodes of relapsed, recurrent, and control peritonitis occurred in 356, 165, and 2,021 patients, respectively. Coagulase-negative staphylococci and Staphylococcus aureus accounted for 48% of relapsing peritonitis (adjusted OR, 1.26 [95% CI, 0.94-1.70] and 1.54 [95% CI, 1.08-2.19], respectively), but were much less likely to be isolated in recurrent peritonitis. Recurrent peritonitis was associated more frequently with fungi (13%; OR, 2.16; 95% CI, 1.12-4.17). The empirical antimicrobial approaches to relapsing and recurrent peritonitis were similar and their subsequent clinical outcomes were comparable. Compared with uncomplicated peritonitis, relapsed and recurrent peritonitis were associated with higher rates of catheter removal (22% vs 30% vs 37%, respectively; P < 0.001) and permanent hemodialysis therapy transfer (20% vs 25% vs 32%; P < 0.001), but similar rates of hospitalization (73% vs 70% vs 70%) and death (2.8% vs 2.0% vs 1.2%)., Limitations: Limited covariate adjustment. Residual confounding and coding bias could not be excluded., Conclusions: Relapsed and recurrent peritonitis are caused by different spectra of micro-organisms, but are not readily clinically distinguishable at presentation. Empirical treatment with broad-spectrum antibiotics and subsequent adjustment according to antimicrobial susceptibilities results in similar clinical outcomes, albeit with appreciably higher rates of catheter removal and hemodialysis therapy transfer than for uncomplicated peritonitis., (Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.)

Background: Automated peritoneal dialysis (APD) is widely recommended for the management of high transporters by the International Society of Peritoneal Dialysis (ISPD), although there have been no adequate studies to date comparing the outcomes of APD and continuous ambulatory peritoneal dialysis (CAPD) in this high risk group., Methods: The relative impact of APD versus CAPD on patient and technique survival rates was examined by both intention-to-treat (PD modality at Day 90) and 'as-treated' time-varying Cox proportional hazards model analyses in all patients who started PD in Australia or New Zealand between 1 April 1999 and 31 March 2004 and who had baseline peritoneal equilibration tests confirming the presence of high peritoneal transport status., Results: During the study period, 4128 patients commenced PD. Of these, 628 patients were high transporters on PD at Day 90 (486 on APD and 142 on CAPD). Compared to high transporters treated with CAPD, APD-treated high transporters were more likely to be younger and Caucasian, and less likely to be diabetic. On multivariate intention-to-treat analysis, APD treatment was associated with superior survival [adjusted hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.35-0.87] and comparable death-censored technique survival (HR 0.88, 95% CI 0.64-1.21). Superior survival of high transporters treated with APD versus CAPD was also confirmed in supplemental as-treated analysis (HR 0.72, 95% CI 0.54-0.96), matched case-control analysis (HR 0.60, 95% CI 0.36-0.96) and subgroup analysis of high transporters treated entirely with APD versus those treated entirely with CAPD (HR 0.29, 95% CI 0.14-0.60). There were no statistically significant differences in patient survival or death-censored technique survival between APD and CAPD for any other transport group, except for low transporters, who experienced a higher mortality rate on APD compared with CAPD (HR 2.19, 95% CI 1.02-4.70)., Conclusions: APD treatment is associated with a significant survival advantage in high transporters compared with CAPD. However, APD treatment is associated with inferior survival in low transporters.

Background: There is limited information about the outcomes of patients commencing peritoneal dialysis (PD) after failed kidney transplantation. The aim of the present study was to compare patient survival, death-censored technique survival and peritonitis-free survival between patients initiating PD after failed renal allografts and those after failed native kidneys., Methods: The study included all patients from the ANZDATA Registry who started PD between April 1, 1991 and March 31, 2004. Times to death, death-censored technique failure and first peritonitis episode were examined by multivariate Cox proportional hazards models. For all outcomes, conditional risk set models were utilized for the multiple failure data, and analyses were stratified by failure order. Standard errors were calculated by using robust variance estimation for the cluster-correlated data., Results: In total, 13,947 episodes of PD were recorded in 23,579 person-years. Of these, 309 PD episodes were started after allograft failure. Compared with PD patients who had never undergone kidney transplantation, those with failed renal allografts were more likely to be younger, Caucasian, New Zealand residents and life-long non-smokers with lower body mass index (BMI), poorer initial renal function and a longer period from commencement of the first renal replacement therapy to PD. On multivariate analysis, PD patients with failed kidney transplants had comparable patient mortality [weighted hazards ratio (HR) 1.09, 95% confidence interval (CI) 0.81-1.45, P = 0.582], death-censored technique failure (adjusted HR 0.91, 95% CI 0.75-1.10, P = 0.315) and peritonitis-free survival (adjusted HR 0.92, 95% CI 0.72-1.16, P = 0.444) with those PD patients who had failed native kidneys. Similar findings were observed in a subset of patients (n = 5496) for whom peritoneal transport status was known and included in the models as a covariate., Conclusion: Patients commencing PD after renal allograft failure experienced outcomes comparable with those with failed native kidneys. PD appears to be a viable option for patients with failed kidney allografts.