1. Dialysis outcomes in Australia & New Zealand
Stephen McDonald
ANZDATA Registry

2. Dialysis outcomes What is collected by ANZDATA: What is not collected:
ANZSN ASM 2002
Dialysis outcomes
What is collected by ANZDATA:
Mortality
Process indicators
Urea clearance
Haemoglobin
What is not collected:
Indicators of health & functional state
Mental health
Physical health
Surrogate markers of cardiovascular disease (LVH)

3. Acceptance of New Patients by Age
ANZSN ASM 2002
Acceptance of New Patients by Age
Australia
New Zealand
New RRT rates by age group

4. Survival on dialysis – 15-64 yrs
ANZSN ASM 2002
Survival on dialysis – yrs
Kaplan-Meier survival estimates, by year
Survival 5 10 15 20
0.00
0.25
0.50
0.75
1.00
1965-
1970-
1975-
1980-
1985-
1990-
1995-
2000-
Are mortality rates changing over time
Are dialysis practices changing?
Trends towards increasing URR, higher flow rates
Not longer hours
?membrane flux
Time (years)
Survival on dialysis, years old, at onset of RRT, censored at transplantation

5. Survival, 65-74 years ANZSN ASM 2002
Kaplan-Meier survival estimates, by year
1.00
0.75
Survival
0.50
1990-
1985-
1995-
0.25
1975-
1980-
1970-
0.00 5 10
Years
Survival on dialysis, years old, at onset of RRT

6. Proportion of CAD by age
ANZSN ASM 2002
Proportion of CAD by age .8 .6
Proportion with CAD .4 .2
15-
25-
35-
45-
55-
65-
75-
85-
Age (years)
Proportion of new dialysis patient with definite or suspected coronary artery disease (CAD),

7. ANZSN ASM 2002
Methods
All patients who began RRT in Australia or NZ since 1 October 1991
Commencement of collection of co-morbid data
Periods of transplant function excluded
Censored at death
Cox regression
Time dependent covariates for dialysis modality
Co-morbidities ascertained at RRT start

8. Outcomes by age ANZSN ASM 2002
1.00
15-
0.75
25-
35-
0.50
45-
55-
0.25
65-
85-
0.00
75- 1 3 5 7 9
Years
Kaplan Meier survival curves by age group for patients treated with dialysis who began RRT treatment in Australia or New Zealand 1 Jan Dec Periods of transplant function excluded.

9. Comorbid factors and outcome
ANZSN ASM 2002
Comorbid factors and outcome
2.5 2
1.5
Hazard ratio 1 .5
DM1
DM2
Aust Ab
Maori / PI
CAD
Cerebrovasc
High BP
Late referral
Lung
Male
PVD PD
Hazard ratios for mortality on dialysis, dialysis only, 1991-present, adjusted for age and gender

10. Effect of BMI on outcome
ANZSN ASM 2002
Effect of BMI on outcome 2
1.5
Hazard ratio 1
<20
35-
BMI (kg/m2)
Hazard ratios for mortality by BMI at entry, dialysis only, 1991-present, adjusted for age and gender and other comorbidities.

11. Predicted median survival
ANZSN ASM 2002
Predicted median survival
25 centile
50 centile
75 centile 15
Survival (years) 10 5 45 55 65 75 85
Age at RRT start
Median [IQR] survival by age. Age modelled as fractional polynomial, adjusted to 0 comorbidities & non-indigenous male

12. Interactions with time
ANZSN ASM 2002
Interactions with time
Hazard ratio (death)
Time period post RRT start
0-90 day
3-12 months
1-2 year
2-5 years
5+ years .5 1
1.5 2
2.5
Hazard ratios for late referral for mortality on dialysis, 1991-present, adjusted for age and gender and other co-morbidities

13. Interactions with time - 2
ANZSN ASM 2002
Interactions with time - 2
2.5 2
Hazard ratio (death)
1.5 1
0-90 day
3-12 months
1-2 year
2-5 years
5+ years
Time period post RRT start
Hazard ratios for coronary artery for mortality on dialysis, 1991-present, adjusted for age and gender and other comorbidities

14. Interactions of CAD with age
ANZSN ASM 2002
Interactions of CAD with age 5
Hazard ratio 2 1
25-
35-
45-
55-
65-
75-
85-
Age (years)
Hazard ratios for mortality of coronary artery disease by age category, adjusted for gender, dialysis patients

15. Indigenous outcomes Survival ANZSN ASM 2002 Years Years
1.00
1.00
Non-indigenous
0.75
0.75
Non-indigenous
Pacific Islander
0.50
Pacific Islander
0.50
Maori
Survival
0.25
0.25
Aboriginal
Aboriginal
Maori
0.00
0.00 5 10 5 10
Years
Years
Survival of new ESRD patients, , crude (left) and adjusted to age 40 (right), censored at transplantation. PI includes TSI

16. Centre effect What is the aim? What is a centre?
ANZSN ASM 2002
Centre effect
What is the aim?
making comparisons?
meeting a standard?
What is a centre?
How do you handle transfers?
What do you adjust for
? Role of dialysis dose
? Access

17. Crude death rates ANZSN ASM 2002
Rate (per 100) 10 20 30 40
Death rates of patients treated with dialysis, , by hospital of initial treatment, for centres with >20 deaths over the period.

18. Centre effect - 2 ANZSN ASM 200250
Rate estimate (per 100 per year) 20 10 5 1
Death rates of patients treated with dialysis, , by hospital of initial treatment, for all centres, sorted by number of new patients over that perio.

19. ANZSN ASM 2002
Dialysis mortality
Dialysis mortality is strongly related to variables which are known at time of RRT start
The influence of these varies over time
Age is strongly and progressively related to outcome
Adverse prognosis of indigenous groups
Remains after adjustment for comorbidities

20. Areas of further investigation
ANZSN ASM 2002
Areas of further investigation
This work provides the basis for developing and validating a predictive set of equations
How to incorporate factors such as dialysis dose and Hb into analyses
Vary with time
Cause or effect?
Centre effect
Planned for presentation at D & T 2003

21. ANZSN ASM 2002
Acknowledgements
The ANZDATA Registry is a collaborative effort of the Australian / New Zealand renal community, and could not exist without the dedicated support of the renal units and the individuals therein.

22. And still older… ANZSN ASM 2002
Survival
Years 1 3 5
0.00
0.25
0.50
0.75
1.00
1980-
1985-
1990-
1995-
2000-
Kaplan-Meier survival estimates, by year
Survival on dialysis, 75+ years old, at onset

23. Indigenous ESRD incidence
ANZSN ASM 2002
Indigenous ESRD incidence
New ESRD patient (Australia) by racial origin
For 2000, age standardised incidence rate ratio=7.8 [ ]

24. Interactions with time – 3
ANZSN ASM 2002
Interactions with time – 3
Hazard ratio (death)
Time period post RRT start
0-90 day
3-12 months
1-2 year
2-5 year
5+ years .5 1
1.5 2
Hazard ratios for type 2 diabetes for mortality on dialysis, 1991-present, adjusted for age and gender and other comorbidities

25. Interactions of CAD with age - 2
ANZSN ASM 2002
Interactions of CAD with age - 2 5 2
Hazard ratio 1 .5
25-
35-
45-
55-
65-
75-
85-
Age (years)
Hazard ratios for coronary artery disease by age category, adjusted for gender, all other co-morbidities and indigenous status