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BACKGROUND: Approximately one-third of rapid response teams (RRT) involve end-of-life care (EOLC) issues. Intensive care unit (ICU) registrar experience in such calls is underinvestigated. AIMS: To evaluate the proportion of RRT calls triaged as relating to EOLC issues, issues around communication regarding prognostication, registrar self-reported moral distress and associations between RRT EOLC classification and patient outcomes. METHODS: Prospective observational study of RRT calls in a tertiary referrals hospital between December 2016 and January 2017 using a standardised case report form and data from an electronic RRT database. RESULTS: There were 401 RRT calls in the study period, and data were available for 270 (67%) calls, of which 72%, 10% and 18% were triaged as 'obviously not EOLC call', 'obvious EOLC call' and 'uncertain EOLC call' respectively. Most discussions regarding prognostication occurred between registrars, and more than half (55%) were with a covering doctor. Consensus on prognostication was achieved in 93% cases. Registrars reported distress in 19% of calls that obviously related to EOLC and 22% of calls that were uncertain, compared with <1% of calls that were obviously not relating to EOLC. Inhospital mortality was 6%, 67% and 39% for obviously not EOLC, obvious EOLC and uncertain EOLC calls respectively. CONCLUSIONS: EOLC issues occur commonly in RRT calls and are often associated with moral distress to ICU registrars. Although consensus on prognostication is usually achieved, conversations often involve covering doctors. These issues impact on the ICU registrar experience of RRT calls and require further exploration.

The Global Kidney Health Atlas (GKHA) is a multinational, cross-sectional survey designed to assess the current capacity for kidney care across all world regions. The 2017 GKHA involved 125 countries and identified significant gaps in oversight, funding and infrastructure to support care for patients with kidney disease, especially in lower-middle-income countries. Here, we report results from the survey for the second iteration of the GKHA conducted in 2018, which included specific questions about health financing and oversight of end-stage kidney disease (ESKD) care worldwide. A cross-sectional global survey. Key stakeholders from 182 countries were invited to participate. Of those, stakeholders from 160 countries participated and were included. Primary outcomes included cost of kidney replacement therapy (KRT), funding for dialysis and transplantation, funding for conservative kidney management, extent of universal health coverage, out-of-pocket costs for KRT, within-country variability in ESKD care delivery and oversight systems for ESKD care. Outcomes were determined from a combination of desk research and input from key stakeholders in participating countries. 160 countries (covering 98% of the world's population) responded to the survey. Economic factors were identified as the top barrier to optimal ESKD care in 99 countries (64%). Full public funding for KRT was more common than for conservative kidney management (43% vs 28%). Among countries that provided at least some public coverage for KRT, 75% covered all citizens. Within-country variation in ESKD care delivery was reported in 40% of countries. Oversight of ESKD care was present in all high-income countries but was absent in 13% of low-income, 3% of lower-middle-income, and 10% of upper-middle-income countries. Significant gaps and variability exist in the public funding and oversight of ESKD care in many countries, particularly for those in low-income and lower-middle-income countries.Copyright © Autho

OBJECTIVES: The Global Kidney Health Atlas (GKHA) is a multinational, cross-sectional survey designed to assess the current capacity for kidney care across all world regions. The 2017 GKHA involved 125 countries and identified significant gaps in oversight, funding and infrastructure to support care for patients with kidney disease, especially in lower-middle-income countries. Here, we report results from the survey for the second iteration of the GKHA conducted in 2018, which included specific questions about health financing and oversight of end-stage kidney disease (ESKD) care worldwide. SETTING: A cross-sectional global survey. PARTICIPANTS: Key stakeholders from 182 countries were invited to participate. Of those, stakeholders from 160 countries participated and were included. PRIMARY OUTCOMES: Primary outcomes included cost of kidney replacement therapy (KRT), funding for dialysis and transplantation, funding for conservative kidney management, extent of universal health coverage, out-of-pocket costs for KRT, within-country variability in ESKD care delivery and oversight systems for ESKD care. Outcomes were determined from a combination of desk research and input from key stakeholders in participating countries. RESULTS: 160 countries (covering 98% of the world's population) responded to the survey. Economic factors were identified as the top barrier to optimal ESKD care in 99 countries (64%). Full public funding for KRT was more common than for conservative kidney management (43% vs 28%). Among countries that provided at least some public coverage for KRT, 75% covered all citizens. Within-country variation in ESKD care delivery was reported in 40% of countries. Oversight of ESKD care was present in all high-income countries but was absent in 13% of low-income, 3% of lower-middle-income, and 10% of upper-middle-income countries. CONCLUSION: Significant gaps and variability exist in the public funding and oversight of ESKD care in many countries, particularly f

Zinc inhibits replication of the SARS-CoV virus. We aimed to evaluate the safety, feasibility, and biological effect of administering high-dose intravenous zinc (HDIVZn) to patients with COVID-19. We performed a Phase IIa double-blind, randomized controlled trial to compare HDIVZn to placebo in hospitalized patients with COVID-19. We administered trial treatment per day for a maximum of 7 days until either death or hospital discharge. We measured zinc concentration at baseline and during treatment and observed patients for any significant side effects. For eligible patients, we randomized and administered treatment to 33 adult participants to either HDIVZn (n = 15) or placebo (n = 18). We observed no serious adverse events throughout the study for a total of 94 HDIVZn administrations. However, three participants in the HDIVZn group reported infusion site irritation. Mean serum zinc on Day 1 in the placebo, and the HDIVZn group was 6.9 ± 1.1 and 7.7 ± 1.6 µmol/l, respectively, consistent with zinc deficiency. HDIVZn, but not placebo, increased serum zinc levels above the deficiency cutoff of 10.7 µmol/l (p < .001) on Day 6. Our study did not reach its target enrollment because stringent public health measures markedly reduced patient hospitalizations. Hospitalized COVID-19 patients demonstrated zinc deficiency. This can be corrected with HDIVZn. Such treatment appears safe, feasible, and only associated with minimal peripheral infusion site irritation. This pilot study justifies further investigation of this treatment in COVID-19 patients.

Over the last 40 years, acute renal replacement therapy (RRT) in the intensive care units (ICUs) of high-income countries has transitioned from the predominant use of intermittent hemodialysis (and the much less common use of peritoneal dialysis) to the almost exclusive use of continuous renal replacement therapy (CRRT). Accordingly, CRRT has become the most common form of vital organ support delivered to critically ill patients. A series of clinical and technical advances has enabled the transformation of basic CRRT machines into highly sophisticated and customized devices. Recent work has focused on using evidence from clinical trials to enhance the application of CRRT with regard to timing of initiation, choice of modality, dose, and anticoagulation. However, many questions remain unanswered. Uncertainty surrounding volume control and the utility of strategies to minimize circulatory stress are key areas for future development. Advances in membrane technology, combination with other extracorporeal therapies, and personalization of CRRT delivery may provide additional benefit to certain subgroups. Development of quality metrics and use of data analytics to audit and benchmark could provide important insight into practice, while biofeedback and automated CRRT prescription could increase safety. In this review, we summarize the evolution of CRRT and highlight several future areas for development.

Introduction: The association between acute kidney injury (AKI) and an increased risk of early morbidity and mortality is well established. However, the impact of AKI on long-term outcomes is less clear. Objective(s): To determine the long-term risk of death, chronic kidney disease (CKD), and end stage kidney disease (ESKD) in critically ill patients with AKI. Method(s): A literature search was performed through EMBASE, MEDLINE, and grey literature sources to identify cohort studies reporting an association between AKI and at least one of the outcomes of interest. All studies published between 2004 and 2017 involving critically ill adults were considered eligible if they defined AKI according to consensus definitions (RIFLE, AKIN, or KDIGO), included a non-AKI control group, and followed patients for at least 1 year. Exclusion criteria included solid organ transplant recipients and patients with AKI "syndromes". Risk of bias was assessed by the Newcastle- Ottawa Scale and random effects meta-analysis was used to compare the risk estimates between studies. Result(s): The search retrieved 3435 citations, of which 57 underwent full-text review. Eighteen studies comprising 92,218 patients met the inclusion criteria. The most common sources of bias were poor representativeness of patient cohorts, and insufficient follow up. Across the 10 studies examining mortality, AKI was associated with a significantly increased risk of death (HR 1.71, 95% CI 1.43-2.04), which progressively increased with AKI stage, although heterogeneity was high (I2 84.5%). There was also an association between AKI and ESKD (HR 5.18, 95% CI 3.14-8.53) and a non-significant increased risk of CKD (HR 5.72, 95% CI 0.62-52.67). Conclusion(s): Despite high heterogeneity between studies, AKI was associated with inferior long-term survival and an increased risk of adverse renal outcomes. Strategies to identify patients at greatest risk are required, to ensure appropriate long-term care is coordinated for t

Objective To determine the global capacity (availability, accessibility, quality, and affordability) to deliver kidney replacement therapy (dialysis and transplantation) and conservative kidney management. Design International cross sectional survey. Setting International Society of Nephrology (ISN) survey of 182 countries from July to September 2018. Participants Key stakeholders identified by ISN's national and regional leaders. Main outcome measures Markers of national capacity to deliver core components of kidney replacement therapy and conservative kidney management. Results Responses were received from 160 (87.9%) of 182 countries, comprising 97.8% (7338.5 million of 7501.3 million) of the world's population. A wide variation was found in capacity and structures for kidney replacement therapy and conservative kidney management-namely, funding mechanisms, health workforce, service delivery, and available technologies. Information on the prevalence of treated end stage kidney disease was available in 91 (42%) of 218 countries worldwide. Estimates varied more than 800-fold from 4 to 3392 per million population. Rwanda was the only low income country to report data on the prevalence of treated disease; 5 (<10%) of 53 African countries reported these data. Of 159 countries, 102 (64%) provided public funding for kidney replacement therapy. Sixty eight (43%) of 159 countries charged no fees at the point of care delivery and 34 (21%) made some charge. Haemodialysis was reported as available in 156 (100%) of 156 countries, peritoneal dialysis in 119 (76%) of 156 countries, and kidney transplantation in 114 (74%) of 155 countries. Dialysis and kidney transplantation were available to more than 50% of patients in only 108 (70%) and 45 (29%) of 154 countries that offered these services, respectively. Conservative kidney management was available in 124 (81%) of 154 countries. Worldwide, the median number of nephrologists was 9.96 per million population, which varied with i

Aim: Percutaneous renal biopsy is often essential for providing reliable diagnostic and prognostic information for people with suspected kidney disease, however the procedure can lead to complications and concerns among patients. This study aims to identify and integrate patient priorities and perspectives into the Kidney Health Australia - Caring for Australasians with Renal Impairment clinical practice guidelines for renal biopsy, to ensure patient-relevance. Method(s): We convened a workshop, consisting of three simultaneous focus groups and a plenary session, with 10 patients who had undergone a renal biopsy and seven caregivers. Topics and outcomes prioritized by patients and their caregivers were compared to those identified by the guideline working group, which was comprised of seven nephrologists. Transcripts and flipcharts were analyzed thematically to identify the reasons for participants' choices. Result(s): In total, 34 topics/outcomes were identified, 14 of which were common to the list of 28 previously identified by the guideline working group. Most of the new topics identified by patients/caregivers were related to communication and education, psychosocial support, and self-management. We identified five themes underpinning the reasons for topic and outcome selection: alleviating anxiety and unnecessary distress, minimizing discomfort and disruption, supporting family and caregivers, enabling self-management, and protecting their kidney. A new topic on patient care and education was added to the guideline as a result. Conclusion(s): Patient and caregiver involvement in developing guidelines on renal biopsy ensured that their concerns and needs for education, psychosocial support, and self-management were explicitly addressed; enabling a patient-centred approach to renal biopsies.Copyright © 2018 Asian Pacific Society of Nephrology

Aims: This study aims to identify and integrate patient priorities and perspectives into the Kidney Health Australia - Caring for Australasians with Renal Impairment clinical practice guidelines for renal biopsy, to ensure patientrelevance. Background(s): Percutaneous renal biopsy is often essential for providing reliable diagnostic and prognostic information for people with suspected kidney disease, however the procedure can lead to complications and concerns among patients. Method(s): We convened a workshop, consisting of three simultaneous focus groups and a plenary session, with ten patients who had undergone a renal biopsy and seven caregivers. Topics and outcomes prioritised by patients and their caregivers were compared to those identified by the guideline working group, which was comprised of seven nephrologists. Transcripts and flipcharts were analysed thematically to identify the reasons for participants' choices. Result(s): In total, 34 topics/outcomes were identified, 14 of which were common to the list of 28 previously identified by the guideline working group. Most of the new topics identified by patients/caregivers were related to communication and education, psychosocial support, and self-management. We identified five themes underpinning the reasons for topic and outcome selection: Alleviating anxiety and unnecessary distress, minimising discomfort and disruption, supporting family and caregivers, enabling self-management, and protecting their kidney. A new topic on patient care and education was added to the guideline as a result. Conclusion(s): Patient and caregiver involvement in developing guidelines on renal biopsy ensured that their concerns and needs for education, psychosocial support, and self-management were explicitly addressed; enabling a patient-centred approach to renal biopsies.

Introduction and Aims: Robust estimatesof the long-term outcomesof acute kidney injury are needed to inform clinical practice and guide optimal allocation of healthcare resources. This systematic review and meta-analysis aimed to quantify the association between acute kidney injury and chronic kidney disease, end stage kidney disease, and death, using consensus definitions of exposure. Method(s): Systematic searches were performed through EMBASE, MEDLINE, and grey literature sources to identify cohort studies reporting an association between acute kidney injury and at least one of the outcomes of interest. All studies in adults published after 2004, using standardised definitions for acute kidney injury (Risk, Injury, Failure, Loss, and End-stage kidney disease; Acute Kidney Injury Network; or Kidney Disease Improving Global Outcomes), which included a non-acute kidney injury control arm, and followed patients for at least 1 year were considered eligible. A modified Newcastle-Ottawa Scale was used to assess risk of bias, random effects meta-analysis was performed to estimate the pooled risk, and meta-regression was completed to identify potential sources of heterogeneity. Result(s): The search retrieved 3435 unique citations, of which 30 cohort studies (comprising 1,012,627 participants) were eligible for inclusion. The most frequent sources of bias related to inadequate follow up and variable adjustment for potential confounders. Compared to those without acute kidney injury, individuals with acute kidney injury were at significantly increased risk of chronic kidney disease (6 studies; 15,925 participants; hazard ratio [HR] 3.71, 95% CI 2.35-5.86; I2 93.1% p<0.001), end stage kidney disease (5 studies; 45,365 participants; HR 4.18, 95% CI 1.93-9.08; I2 88.8% p<0.001), and death (16 studies; 913,682 participants; HR 1.54, 95% CI 1.40-1.71; I2 85.6% p<0.001). The risk of death increased with greater acute kidney injury severity, and was highest in intensive care and

Introduction and Aims: It is unclear if haemodiafiltration (HDF) improves patient survival compared to standard haemodialysis (HD). Observational studies have tended to show benefit with HDF, while meta-analyses have not provided definitive proof of superiority. This study aimed to evaluate the association between HD modality and survival in the entire Australian and New Zealand incident HD patient population. Method(s): Using data from the ANZDATA Registry, this binational inception cohort study examined all patients who commenced HD in Australia and New Zealand between 2000 and 2014. The primary outcome was all-cause mortality, measured from first HD treatment, and the secondary outcome was cardiovascular mortality. Outcomes were examined using multivariable Cox and competing risk regression analyses. Patients were censored at permanent discontinuation of HD or at 31 December 2014. Analyses were stratified by country. Result(s): The study included 26,961 patients (4110 HDF, 22,851 standard HD) with a median follow-up of 5.57 (interquartile range 3.07-8.79) years. Patients who received HDF were more likely to be obese (p<0.001) or diabetic (p<0.001), and less likely to be white (p<0.001) or aged >70 years (p<0.001). There were no differences in pre-existing cardiovascular disease (p=0.3) or vascular access (p=0.2) between groups. Compared to standard HD, HDF was associated with a significantly lower risk of all-cause mortality (adjusted HR for Australia 0.63,95% CI 0.57-0.68; adjusted HR for New Zealand 0.74, 95% CI 0.70-0.79). In Australian patients, there was an association between HDF and reduced cardiovascular mortality (adjusted SHR 0.83,95% CI 0.69-0.99). Conclusion(s): Compared tostandard HD, HDF was associated with superior survival in Australian and New Zealand patients.

Introduction and Aims: Technique failure is a major complication of peritoneal dialysis (PD) treatment and is associated with significant risk to patients and health services. The first year has been recognised as a particularly vulnerable period, with studies estimating that just under one-half of patients who develop technique failure do so within this time. This study aimed to identify the key risk factors and risk periods for early transfer to haemodialysis or death in incident PD patients. Method(s): Using data from the ANZDATA Registry, this study included all adult patients who commenced PD in Australia and New Zealand between 2000 and 2014. Competing risk regression models were used to analyse the primary outcome, which was technique failure within the first year (kidney transplantation was the competing risk), as well as the secondary outcomes, which examined each cause of technique failure (kidney transplantation and other causes of technique failure were the competing risks). Patients were censored at the time of kidney transplantation, recovery of renal function, loss to follow up, or at 365.25 days after commencement of PD. Result(s): Of 16,748 patients who commenced PD during the study period, 4,389 patients reached the primary outcome. Factors associated with increased risk included age >70 years, diabetes or vascular disease, prior renal replacement therapy, late referral to a nephrology service, or management in a smaller centre. Asian or other race and use of continuous ambulatory PD were associated with reduced risk, as was commencement of PD between 2010 and 2014. Although the risk of technique failure due to death or infection was constant over the first year, mechanical and other causes accounted for a greater number of cases within the initial 9 months of treatment. [Figure Presented] Conclusion(s): Several modifiable and non-modifiable factors are associated with early technique failure. Variation in the principal cause of early technique fai

Aim: To evaluate graft and patient outcomes following kidney transplantation in end stage kidney disease (ESKD) secondary to hyperoxaluria using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Background(s): Hyperoxaluria has presented a challenge for transplant physicians given the risk of disease recurrence in the graft. There has been no analysis of transplant and patient outcomes using the ANZDATA registry. Method(s): This cohort study compared the outcomes of all patients with ESKD secondary to hyperoxaluria who received a kidney transplant in Australia and New Zealand between 1965 and 2015 to propensity score matched controls with ESKD secondary to reflux nephropathy. The primary outcome measure was graft survival. Secondary outcomes included estimated glomerular filtration rate (eGFR), acute rejection and patient survival. Result(s): Nineteen kidney transplants were performed in 16 patients with hyperoxaluria between September 1965 and December 2015. Median graft survival was 1.8 years (IQR 0.4-10.6) in hyperoxaluria recipients compared to 6.8 years (IQR 2.7-13.0) in reflux nephropathy controls. Compared to reflux nephropathy, hyperoxaluria was not associated with an increased risk of graft failure (SHR 2.43, 95% CI 0.94-6.22, p=0.07). The most common cause of graft failure in the hyperoxaluria cohort was recurrent disease in contrast to chronic allograft nephropathy for reflux nephropathy recipients. Hyperoxaluria was associated with a higher post-transplant serum creatinine, but not with an increased risk of acute rejection or death. Conclusion(s): Compared to reflux nephropathy, ESKD secondary to hyperoxaluria was not associated with inferior graft survival, patient survival, or acute rejection risk. However, post-transplant serum creatinine was higher and there was a shorter time to graft failure.

The spectrum of renal disease in patients with diabetes encompasses both diabetic kidney disease (including albuminuric and non-albuminuric phenotypes) and non-diabetic kidney disease. Diabetic kidney disease can manifest as varying degrees of renal insufficiency and albuminuria, with heterogeneity in histology reported on renal biopsy. For patients with diabetes and proteinuria, the finding of non-diabetic kidney disease alone or superimposed on the changes of diabetic nephropathy is increasingly reported. It is important to identify non-diabetic kidney disease as some forms are treatable, sometimes leading to remission. Clinical indications for a heightened suspicion of non-diabetic kidney disease and hence consideration for renal biopsy in patients with diabetes and nephropathy include absence of diabetic retinopathy, short duration of diabetes, atypical chronology, presence of haematuria or other systemic disease, and the nephrotic syndrome.