Burden of end-stage renal disease among indigenous peoples in Australia and New Zealand

Rates of end-stage renal disease (ESRD) among indigenous people in Australia and New Zealand are considerably higher than the non-indigenous population. This trend, apparent for several years, is described here using data from the Australia & New Zealand Dialysis and Transplant (ANZDATA) Registry. The average age at start of renal replacement therapy (RRT) is approximately 10 years less than non-indigenous people. Among those starting RRT, rates of "diabetic nephropathy" are higher among indigenous patients, reflecting higher rates of diabetes. The increased burden of illness extends to coronary artery disease and chronic lung disease, which are present at rates 1.5 to 2 times non-indigenous rates. Once dialysis treatment has commenced, indigenous people are less likely to be placed on the active cadaveric transplant waiting list, and less likely to receive a graft. Overall mortality outcomes are poorer for indigenous patients overall, and for each RRT modality. These outcomes are not simply due to increased frequency of co-morbid illness: for indigenous people receiving dialysis treatment the mortality rate adjusted for age and gender is around 11/2 times the non-indigenous rate. These data are consistent with studies showing increased rates of markers of early renal disease (in particular albuminuria) among both Australian and New Zealand indigenous groups, and reflect a broader health profile marked by high rates of diabetes, cardiovascular disease and chronic lung disease. Addressing these issues is a major challenge for health care providers in these regions.     

Trends in incidence of end-stage renal failure in Australia, 1972-1991

Age-specific and cumulative incidence rates were calculatedfor entry into Australian end-stage renal failure programmesfrom 1972 to 1991, as a result of all causes, or from analgesicnephropathy, glomerulonephritis, hypertension and vascular disease,or diabetes. Three different trends were demonstrated. A risingrecorded incidence of renal failure occurred throughout theperiod of observation in those aged 0–4 years (all causes)and in those aged 55 years and over (all categories, least inanalgesic nephropathy) principally attributable to a fallingfraction of patients not accepted for treatment. Falling incidencerates indicating a real reduction in the burden of disease wereseen for analgesic nephropathy (at least up to the age of 64years) and hypertension and vascular disease (only up to theage of 54 years). In young adults the unchanging incidence ofrenal failure due to all causes, glomerulonephritis and diabetesprobably reflect nearly complete acceptance rates into end-stagerenal failure programmes, and therefore approximate the trueburden of disease. In end-stage renal failure, age- specificor age-standardized cumulative rates are required to distinguishrising or falling incidence of disease from trends due to changingmedical practice.     

Trends in incidence of end-stage renal disease in Japan, 1983-2000: age-adjusted and age-specific rates by gender and cause.

BACKGROUND: Trends in age-adjusted or age-specific incidence rates of end-stage renal disease (ESRD) have never been examined in Japan, a major ESRD epidemic area. METHODS: A nationwide registry has provided the number of ESRD patients commencing maintenance renal replacement therapy for time period from 1983 to 2000. We computed gender- and age-specific incidence rates of ESRD over 2-year periods, in total or by cause. Age-adjusted incidence rates were calculated using the 1985 Model Population of Japan as the standard. RESULTS: Causes of ESRD in 1999-2000 were, in order of decreasing frequency, diabetic nephropathy, chronic glomerulonephritis, unknown causes, nephrosclerosis and polycystic kidney disease in men, and chronic glomerulonephritis, diabetic nephropathy, unknown causes, nephrosclerosis and polycystic kidney disease in women. The age-adjusted all-cause incidence of ESRD increased until 1995-1996, but has since levelled off in both genders. The age-adjusted rate for diabetic nephropathy has been rapidly increasing, while that for chronic glomerulonephritis has decreased since 1995-1996. The former rate exceeded the latter in 1997-1998 in men. All-cause ESRD has rapidly increased in the eighties age group, whereas the increase slowed down in younger age groups in the late 1990s. The rate for diabetic nephropathy has linearly risen in almost every age group in men, whereas it began to level off in women aged 40-59 years at about 1995. For chronic glomerulonephritis, the rate had already started to decline in the mid-1980s in those aged <45 years. The rate of nephrosclerosis has been increasing independently of age. CONCLUSIONS: The present study shows changes in the epidemiological features of the incidence of ESRD in Japan from 1983 to 2000.     

Interpreting incidence trends for treated end-stage renal disease: implications for evaluating disease control in Australia

BACKGROUND: Five sources of change modify trends in incidence of treated end-stage renal disease (ESRD): (i) demography; (ii) disease control, comprising prevention and treatment of progressive kidney disease; (iii) competing risks, which encompass dying from untreated uraemia or non-renal comorbidity; (iv) lead-time bias; and (v) classification bias. Thus, rising crude incidence of treated ESRD may conceal effective disease control when there has been demographic change, lessening competing risks, or the introduction of bias. METHODS: Age-specific incidences of treated ESRD in Australia were calculated from Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data by indigenous/non-indigenous status (all causes) and by primary renal disease (non-indigenous only) for two successive decades, 1982-1991 and 1992-2001. RESULTS: We postulate that less competing risks explained much of the increase in treated ESRD in the elderly and Indigenous Australians. The increase in glomerulonephritic ESRD in non-indigenous Australians could be ascribed mainly to immigration from non-European countries. There was no significant change in incidence of treated ESRD in Indigenous or non-indigenous persons aged less than 25 years, in non-indigenous persons aged 25-64 years for ESRD caused by hereditary polycystic disease or hypertension, or in type 1 diabetics aged over 55 years. End-stage renal disease from analgesic nephropathy had declined. The increase in treated ESRD caused by type 2 diabetic nephropathy appeared to be multifactorial. Lead-time/length bias and less competing risks may have concealed a small favourable trend in other primary renal diseases. CONCLUSION: Whether recent disease control measures have had an impact on incidence of treated ESRD is not yet certain, but seems more likely than implied by previous reports.     

The incidence of treated end-stage renal disease in New Zealand Maori and Pacific Island people and in Indigenous Australians.

BACKGROUND: Although Indigenous Australians, New Zealand Maori and Pacific Island people comprise an unduly high proportion of patients treated for end-stage renal disease (ESRD) in the two countries, no population-based age- and disease-specific rates have been published. METHODS: From data provided to the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), truncated age- and sex-standardized incidence rates were calculated for treated ESRD due to all causes and by primary renal disease, in four broad age groups of Maori, Pacific Island people and all 'other' New Zealanders and Indigenous and non-indigenous Australians, for the period 1992-2001. RESULTS: The incidence of ESRD did not differ in persons aged 0-14 years. In adults, Maori and Pacific Island people had similar rates of ESRD, a little more than half those of Indigenous Australians except in persons aged 65 years and over in whom the rates were nearly equal, but two to ten times the rates in 'other' New Zealanders and non-indigenous Australians. The excess of ESRD in Indigenous Australians was due principally to type II diabetic nephropathy and glomerulonephritis (all common types except lupus nephritis), but was seen also in respect of type I diabetic nephropathy, hypertensive renal disease and analgesic nephropathy, while the excess in Maori and Pacific Island people was confined to type II diabetic nephropathy, hypertensive renal disease and glomerulonephritis (especially lupus nephritis and type I mesangiocapillary glomerulonephritis, but not mesangial IgA disease). CONCLUSIONS: The incidence and pattern of treated ESRD differs quantitatively and qualitatively between Maori, Pacific Island people and other New Zealanders, and Indigenous and non-indigenous Australians.     

Trends in the incidence of renal replacement therapy for end-stage renal disease in Europe, 1990-1999.

BACKGROUND: The epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) varies considerably worldwide, but we have lacked reliable quantitative estimates of trends in the incidence by age, sex and cause in Europe over the last decade. METHODS: We analysed data from nine countries participating in the ERA-EDTA registry: Austria, Belgium, Denmark, Finland, Greece, The Netherlands, Norway, Spain and UK (Scotland). Adjusted incidence rates for age and sex were studied for 2 year periods between 1990 and 1999. Average annual changes (%) were estimated by Poisson regression. RESULTS: The adjusted incidence rate of RRT increased from 79.4 per million population (pmp) (range: 58.4-101.0) in 1990-1991 to 117.1 pmp (91.6-144.8) in 1998-1999, i.e. 4.8% (3.1-6.4%) each year. This increase did not flatten out at the end of the decade, except in The Netherlands, and was greater in men than women, 5.2 vs 4.0%/year. In most countries, the incidence rate remained stable for those younger than 45 years; it rose by 2.2%/year on average in the 45-64 year age group and by 7.0% among those 65-74 years; it tripled over the decade in those 75 years or older, and by 1998-1999 it ranged from 140.9 to 540.4 pmp between countries. The incidence of ESRD due to diabetes, hypertension and renal vascular disease nearly doubled over 10 years; in 1998-1999, it varied between countries from 10.2 to 39.3 pmp for diabetes, from 5.8 to 21.0 for hypertension, and from 1.0 to 15.5 for renal vascular disease. CONCLUSION: RRT incidence continues to rise but at various rates in the European countries studied, tending to widen the gap between them. This mainly results from enlarging differences in incidence in the elderly and, to a lesser extent, in that due to diabetes, hypertension and renal vascular disease.     

Regional variability in the incidence of end-stage renal disease: an epidemiological approach.

BACKGROUND: Regional variability in the incidence of end-stage renal disease (ESRD) in Austria is reported. Our aim was to investigate the reason for low rates in the state of Tyrol. METHODS: ESRD incidence data were obtained from the Austrian Dialysis and Transplantation Registry. Additional sources were two health interview surveys, the Hospital Discharge Registry, the Mortality Registry and the Drug Wholesale Registry. RESULTS: Between 1995 and 1999, 4811 new cases of ESRD were recorded; the state of Tyrol (T) had a mean annual, age-adjusted incidence of 97.9/1 000 000 population [95% confidence interval (CI) 86.9-109.1], a number significantly lower than that for the rest of Austria [(RA), 120.9 (95% CI 116.9-124.5); P < 0.001]. This was due mainly to a difference in the incidence of ESRD patients with type 2 diabetes mellitus [(DM-2) T = 12.2 (95% CI 8.2-16.2) vs RA = 28.9 (95% CI 27.2-30.6); P < 0.001]. When these patients were excluded, the difference in the overall ESRD incidence disappeared. When data from various registries were analysed for the prevalence of DM, a highly significant correlation was found between ESRD incidence and DM. CONCLUSION: We conclude that the variability in the ESRD incidence in Austria is explained mainly by regional differences in DM-2. Data from similar studies might be useful for predictions concerning resource allocation for ESRD programmes in the future.     

Report of renal failure treatment in Australia and New Zealand from the dialysis and transplant registry (ANZDATA)

Summary: The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) has recorded 15675 patients resident in Australia and 2909 patients in New Zealand who have been treated by dialysis and transplantation for end-stage renal failure. the majority of patients have a functioning transplant (51% Australia, 50% New Zealand). Cadaveric organs have been the mainstay of the transplant programme from 1963 to 1993 (91% Australia, 87% New Zealand). In recent years the early graft survival has dramatically improved; the 12 month graft survivals were 74 and 87% in Australia, and 68 and 78% in New Zealand in 1983 and 1992, respectively. A large majority of patients have dialysed at home (49% Australia, 84% New Zealand) or with low level assistance in facilities remote from tertiary level hospital renal units (21% Australia). While most patients use haemodialysis (64% Australia, 41% New Zealand), continuous ambulatory peritoneal dialysis is the predominant form of dialysis in the home (63% Australia, 70% New Zealand). the demographic analysis displays a slight predominance of males (55.5% Australia, 50.4% New Zealand), and a steadily increasing number of patients over 65 years old (31% Australia, 15% New Zealand), and of diabetics (16% Australia, 31% New Zealand). Aborigines, Maoris and Pacific Islanders have a strikingly higher rate of renal failure per million population than the Caucasoid/Europid population. Certain causes of renal failure such as excess analgesic ingestion and malignant hypertension have declined. Glomerulonephritis has been the most common cause of renal failure in Australia (33%), diabetic nephropathy the most common in New Zealand (31%).     

Trends in incidence of treated end-stage renal disease, overall and by primary renal disease, in persons aged 20-64 years in Europe, Canada and the Asia-Pacific region, 1998-2002

AIMS: To determine if rates of diabetic and non-diabetic end-stage renal disease (ESRD), which had been rising in young and middle-aged adults in all populations up to the mid-1990s, had started to decline, and if so, whether improvement had occurred in respect of each of the principal primary renal diseases causing ESRD. METHODS: Poisson regression of age- and sex-standardized incidence of ESRD for persons aged 20-64 years in 18 populations from Europe, Canada and the Asia-Pacific region, for 1998-2002. RESULTS: In persons from 12 European descent (Europid) populations combined, there was a small downward trend in all-cause ESRD (-1.7% per year, P = 0.001), with type 1 diabetic ESRD falling by 7.8% per year (P < 0.001), glomerulonephritic ESRD by 3.1% per year (P = 0.001), and 'all other non-diabetic' ESRD by 2.5% per year (P = 0.02). The reductions in ESRD attributed to hypertensive (-2.2% per year) and polycystic renal disease (-1.5% per year) and unknown diagnosis (-0.2% per year) were not statistically significant. On the other hand, the incidence of type 2 diabetic ESRD rose by 9.9% per year (P < 0.001) in the combined Europid population, although that of (principally type 2) diabetic ESRD remained unchanged in the pooled data from the four non-Europid populations. CONCLUSION: Recent preventive strategies, probably chiefly modern renoprotective treatment, appear to have been effective for tertiary prevention of ESRD caused by the proteinuric nephropathies other than type 2 diabetic nephropathy, for which the continuing increase in Europid populations represents a failure of prevention and/or a change in the nephropathic potential of type 2 diabetes.     

Geographic, ethnic, age-related and temporal variation in the incidence of end-stage renal disease in Europe, Canada and the Asia-Pacific region, 1998-2002.

BACKGROUND: Only unbiased estimates of end-stage renal disease (ESRD) incidence and trends are useful for disease control-identification of risk factors and measuring the effect of intervention. METHODS: Age- and sex-standardized incidences (with trends) were calculated for all-cause and diabetic/non-diabetic ESRD for persons aged 0-14, 15-29, 30-44 and 45-64 years in 13 populations identified geographically, and six populations identified by ethnicity. RESULTS: The incidence of ESRD varied most with age, ethnicity and prevalence of diabetes. All non-Europid populations had excess ESRD, chiefly due to rates of type 2 diabetic ESRD that were greater than accounted for by community prevalences of diabetes. Their rates of non-diabetic ESRD also were raised, with contributions from most common primary renal diseases except type 1 diabetic nephropathy and polycystic kidney disease. The ESRD rates generally were low, and more similar than different, in Europid populations, except for variable contributions from type 1 (high in Finland, Sweden, Denmark and Canada) and type 2 (high in Austria and Canada) diabetes. In Europid populations during 1998-2002, all-cause ESRD declined by 2% per year in persons aged 0-44 years, and all non-diabetic ESRD by a similar amount in persons aged 45-64 years, in whom diabetic ESRD had increased by 3% per year. CONCLUSIONS: Increased susceptibility to type 2 diabetes and to kidney disease progression characterizes excess ESRD in non-Europid peoples. The decline in all-cause ESRD in young persons, and non-diabetic ESRD in the middle-aged, probably reflects improving management of progressive renal disease.     

Associations between comorbidities, treatment choice and outcome in the elderly with end-stage renal disease.

BACKGROUND: New patients treated for end-stage renal disease are increasingly elderly: in France, 38% are 75 years or older. The best treatment choices for the elderly are still debated. METHODS: We studied case-mix factors associated with choice of initial dialysis modality and 2-year survival in the 3512 patients aged 75 years or older who started dialysis between 2002 and 2005 and were included in the French REIN registry. RESULTS: Overall, 18% began with peritoneal dialysis (PD), 50% with planned haemodialysis (planned HD) and 32% with unplanned HD, that is, HD that started on an emergency basis. At least one comorbid condition was reported for 85%, and three or more for 36%, but case-mix varied with age. PD was chosen significantly more often than planned HD for the oldest (> or =85) compared with the youngest (75-79) patients: odds ratio 2.1 (95% confidence interval, 1.5-2.8), in those with congestive heart failure: 1.8 (1.5-2.3) and severe behavioural disorder: 2.2 (1.3-3.5), but less often for obese patients: 0.5 (0.3-0.8) and smokers: 0.4 (0.2-0.9). Two-year survival rates were 58, 52 and 39% in patients aged 75-79, 80-84 and > or =85, respectively. Compared with planned HD, unplanned HD was associated with a risk of mortality 50% higher, and PD with a risk 30% higher, independent of patient case-mix. CONCLUSION: PD is a common treatment option in French elderly patients, but our study suggests the need for caution in the long-term use. The high frequency of unplanned HD would require further attention.     

The dilemmas of patient treatment for end-stage renal disease

In past years, physicians responsible for the treatment of chronic uremia have faced dilemmas that have been methodologic and economic while attempting to provide good patient care. These have been overcome, but in the course of time a larger one has developed. The current dilemma is one of high costs for end-stage renal disease (ESRD) management and the failure of current treatment programs to adequately rehabilitate the ESRD patient. In spite of widespread concern about this dilemma, few current data and even fewer projections exist about the eventual costs for their care. Existing data demonstrate several problems that are the basis of this dilemma: (1) the projections of incidence and prevalence of ESRD patients have been too low; (2) renal transplantation has failed to develop into a dominant (and least costly) form of ESRD therapy; (3) home dialysis programs have failed to offset the rapidly expanding in-center dialysis population; and (4) prevalence of and costs for chronic hemodialysis have increased far beyond expected levels. Using current data for the US population as to the incidence and overall mortality rate of ESRD patients, it is apparent that the dialysis population is only 39% of the way toward a steady state-corresponding to only the 4th year of a calculated 25-year growth curve. Although the current costs for maintenance of ESRD patients exceeds $1.3 billion, based upon such projections with the current distribution of patient treatment modalities, the overall annual cost will be in excess of $3.3 billion before a steady state is achieved. Improvement in mortality rates or increases in the incidence of patients will increase the steady state prevalence and the overall costs. Renal transplantation, unless kidney survival rate is increased so that it approximates patient survival, is unlikely to offset the rapidly increasing costs. New technology that would reduce the costs for center-based chronic hemodialysis has not been identified. Emphasis upon home dialysis modalities as a method of increasing patient rehabilitation and reducing costs appears to be a short-term necessity. Increased research and development in prevention of ESRD and in achieving better transplant kidney survival appear to be extremely important as long-term goals.     

Incidence of end-stage renal disease in overseas-born, compared with Australian-born, non-indigenous Australians

BACKGROUND: Barriers to immigration from non-European sources were relaxed in the 1970s. As a result, more Australians are now of Middle Eastern, Asian or Pacific Islander origin, rather than British or European. Currently, overseas-born persons comprise one-third of non-indigenous Australians with end-stage renal disease (ESRD). METHODS: Using data recorded by the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, age-standardized incidence rates were calculated for ESRD due to all causes and to certain primary renal diseases for all non-indigenous Australians who were aged over 15 years when first treated for ESRD between 1993 and 2001. Truncated age-standardized incidence rates were calculated for ESRD due to glomerulonephritis by type. RESULTS: Immigrants from the British Isles and 'rest of Europe' had less, and those from the Pacific Island nations, East/South-East Asia, Indian subcontinent, Middle East and Southern Europe more ESRD from all causes than the Australian-born. Two diseases accounted for most of the excess: Type 2 diabetic nephropathy and glomerulonephritis (the latter not significant for the Indian-born). There was a small excess (not always significant) of hypertensive/arteriopathic renal disease in Asian- and Middle Eastern-born persons. The East/South-East Asian-born had the highest rates of ESRD due to mesangial immunoglobulin A (IgA) disease and lupus nephritis, and the Middle Eastern-born the highest rates from focal sclerosing glomerulonephritis. CONCLUSION: For Australians born in the Pacific Island nations, Asia, the Middle East or Southern Europe, excess prevalence of, and/or susceptibility to, diseases that cause ESRD has more than offset any 'healthy migrant' effect.     

Frequency,etiology and treatment of childhood end-stage kidney disease in Australia and New Zealand

To describe the trends in end-stage kidney disease (ESKD) in children in Australia and New Zealand over time and across different ages, we analyzed data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA). A total of 1,485 children aged less than 18 years received renal replacement therapy (RRT) during the period from 1963 to 2006, of which children 55.6% were male. The incidence of ESKD increased over the first two decades but has been stable at 8 per million since the mid-1980s. The prevalence of ESKD continues to increase in all age groups, especially among older children, and is currently 50 per million in those aged less than 18 years. The cause of ESKD over the entire cohort was one-third each for glomerulonephritis (32.5%), structural anomalies (hypoplasia/dysplasia, posterior urethral valves or reflux nephropathy, 35.8%), and cystic disease or other conditions (31.7%). Proportionately, glomerulonephritis is becoming less common. Overall, 50% of children were commenced on peritoneal dialysis as the initial RRT modality, 30% were started on hemodialysis, and 20% underwent transplantation pre-emptively. The proportion of children receiving transplants has not increased over time.     

Effect of anaemia on mortality, cardiovascular hospitalizations and end-stage renal disease among patients with chronic kidney disease

Objective:   To determine whether an independent association exists between anaemia and chronic kidney disease (CKD) outcomes in a quasi-incidence cohort when patients' most recent laboratory values are considered.
Methods:   We conducted a dynamic, retrospective cohort study among patients with incident CKD in a large health maintenance organization administrative data set. CKD was defined by two estimated glomerular filtration rates (eGFR). We measured the absolute rates for all-cause mortality, cardiovascular hospitalizations and end-stage renal disease.
Results:   Our completed cases Cox regression model followed 5885 patients with both CKD and haemoglobin measures. For patients with the most severe anaemia (haemoglobin <10.5 g/dL), we estimated an increased rate of mortality (hazard ratio (HR) = 5.27, CI 4.37–6.35), cardiovascular hospitalizations (HR = 2.18, CI 1.76–2.70) and end-stage renal disease (HR = 5.46, CI 3.38–8.82) when compared with patients who were not anaemic; the HR reflect time-varying haemoglobins and eGFR.
Conclusion:   Anaemia is a predictor of excess mortality, excess cardiovascular hospitalizations and excess end-stage renal disease even when the progression of CKD is considered by controlling for time-varying eGFR values.     

Cardiovascular calcification in end-stage renal disease.

Cardiovascular diseases are common in patients with end-stage renal disease (ESRD) and cardiovascular morbidity and mortality among dialysis patients are substantially higher than in the general population. The reasons for this high incidence are multiple. They include traditional factors such as hypertension, diabetes, dyslipidaemia, sodium overload, and elevated homocysteine levels as well as disturbances of mineral metabolism, specifically abnormalities in phosphorus and calcium homeostasis. This review will describe the specific cardiovascular complications related to calcifications in ESRD, the implications of the abnormalities of mineral metabolism in its pathogenesis and the current imaging techniques available for the detection of cardiovascular calcifications. Excess of calcium load contributes to the development of cardiac calcifications; therefore, alternative strategies to diminish exogenous calcium load should be considered in patients with ESRD.     

Cardiovascular complications in pediatric end-stage renal disease

Mortality from end-stage renal disease (ESRD) is often due to cardiac causes. Although cardiovascular complications of ESRD have long been recognized, only recently has the presence of traditional cardiovascular risk factors been associated with late cardiovascular complications. This review presents a history of cardiac involvement in ESRD, the pathophysiology of accelerated atherosclerosis and left ventricular hypertrophy, and a summary of the literature on cardiovascular risk assessment in children. Techniques for non-invasive assessment of cardiac end-organ injury are also discussed. Recommendations for monitoring of risk factors and treatment in the pediatric ESRD population are presented.     

Increases in renal replacement therapy in Australia and New Zealand: understanding trends in diabetic nephropathy

Aim: The incidence of end‐stage kidney disease (ESKD) has been increasing worldwide, with increasing numbers of older people, people with diabetic nephropathy and indigenous people. We investigated the incidence of renal replacement therapy (RRT) in Australia and New Zealand (NZ) to better understand the causes of these effects. Methods: Data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA)registry and relevant population data were used to investigate the incidence of RRT in five demographic groups: Indigenous and non‐indigenous Australians, Māori, Pacific Islanders and other New Zealanders, as well as differences between genders and age groups. Results: The numbers of patients commencing RRT each year increased by 321% between 1990 and 2009. This increase was largely driven by increases in patients with diabetic nephropathy. In 2009 35% of new patients had ESKD resulting from diabetic nephropathy 92% of which were type 2. Indigenous Australians, and Māori and Pacific people of NZ have elevated risks of commencing RRT due to diabetic nephropathy, although the risks compared with non‐indigenous Australians have decreased over time. A small element of lead time bias also contributed to this increase. Males are more likely to commence RRT due to diabetes than females, except among Australian Aborigines, where females are more at risk. There is a marked increase in older, more comorbid patients. Conclusions: Patterns of incident renal replacement therapy strongly reflect the prevalence of diabetes within these groups. In addition, other factors such as reduced risk of dying before reaching ESKD, and increased acceptance of older and sicker patients are also contributing to increases in incidence of RRT.     

The renal epidemiology and information network (REIN): a new registry for end-stage renal disease in France.

The French Renal Epidemiology and Information Network (REIN) registry began in 2002 to provide a tool for public health decision support, evaluation and research related to renal replacement therapies (RRT) for end-stage renal disease (ESRD). It relies on a network of nephrologists, epidemiologists, patients and public health representatives, coordinated regionally and nationally. Continuous registration covers all dialysis and transplanted patients. In 2003, 2070 patients started RRT, 7854 were on dialysis and 7294 lived with a functioning graft in seven regions (with a population of 16.5 million people). The overall crude annual incidence rate of RRT for ESRD was 123 per million population (p.m.p.) with significant differences in age-adjusted rates across regions, from 84 [95% confidence interval (CI): 74-94] to 155 [138-172] p.m.p. The principal causes of ESRD were hypertension (21%) and diabetic (20%) nephropathies. Initial treatment for ESRD was peritoneal dialysis for 15% of patients and a pre-emptive graft for 3%. The one-year survival rate was 81% [79-83] in the cohort of 2002-2003 incident patients. As of December 31, 2003, the overall crude prevalence was 898 [884-913] p.m.p, with 5% of patients receiving peritoneal dialysis, 47% on haemodialysis and 48% with a functioning graft. The experience in these seven regions over these two years clearly shows the feasibility of the REIN registry, which is progressively expanding to cover the entire country.