Peritoneal dialysis practice in Australia and New Zealand: a call to action

Peritoneal dialysis technique survival in Australia and New Zealand is lower than in other parts of the world. More than two-thirds of technique failures are related to infective complications (predominantly peritonitis) and 'social reasons'. Practice patterns vary widely and more than one-third of peritoneal dialysis units do not meet the International Society of Peritoneal Dialysis minimum accepted peritonitis rate. In many cases, poor peritonitis outcomes reflect significant deviations from international guidelines. In this paper we propose a series of practical recommendations to improve outcomes in peritoneal dialysis patients through appropriate patient selection, prophylaxis and treatment of infectious complications, investigation of social causes of technique failure and a greater focus on patient education and clinical governance.     

Dialysis treatment in Australia, 1982 to 1988

The incidence of new dialysis-dependent patients in Australia increased rapidly from 1982, due mainly to acceptance for treatment of more elderly patients. In 1988, 21% of patients beginning dialysis were 65 to 74 years old, and a further 26% were 55 to 64 years. Consequently, the prevalence of dialysis-dependent patients increased considerably during the same period, particularly in the age range 55 to 74 years. Diabetes-induced renal failure accounted for a constant low proportion of new patients, approximately 10%, which contrasted with the experience in some other countries. Hemodialysis (HD) was the more common method of treatment compared with continuous ambulatory peritoneal dialysis (CAPD) in 1988 (70% v 30%, respectively). Home dialysis treatment, HD or CAPD, supported 50% of all dialysis-dependent patients. Patient survival at 1, 2, and 5 years after initiating treatment was 89%, 78%, and 48%, respectively. Age and method of dialysis significantly influenced survival; the elderly and diabetic had a lower expectation of survival. The difference in survival of HD compared with CAPD increased with the duration of treatment, reaching 20% at 5 years (5-year survival, 59% HD; 39% CAPD). There was no evidence of increasing mortality among patients beginning treatment recently. Withdrawal from treatment represented 16% of deaths during 1988; 19% of the deaths were in the age group 65 to 74 years. The influence of the morbidity and mortality of dialysis on provision of such treatment for end-stage renal failure in the elderly population warrants an objective review of both the benefits to the individual and the availability of health care to the whole society.     

Peritoneal dialysis practice in Australia and New Zealand: A call to sustain the action

This paper updates a previous ‘Call to Action’ paper (Nephrology 2011; 16: 19–29) that reviewed key outcome data for Australian and New Zealand peritoneal dialysis patients and made recommendations to improve care. Since its publication, peritonitis rates have improved significantly, although they have plateaued more recently. Peritoneal dialysis patient and technique survival in Australian and New Zealand have also improved, with a reduction in the proportion of technique failures attributed to ‘social reasons’. Despite these improvements, technique survival rates overall remain lower than in many other parts of the world. This update includes additional practical recommendations based on published evidence and emerging initiatives to further improve outcomes.     

Supporting peritoneal dialysis in remote Australia

SUMMARY:   Peritoneal dialysis is usually considered a first-choice treatment for end-stage renal disease for patients living in remote areas. The advantages of peritoneal dialysis over haemodialysis are that peritoneal dialysis preserves the residual renal function for longer, provides patients with more independence and gives patients a greater opportunity to return home quickly. In Australia, Aboriginal people suffer end-stage renal failure at disproportionately higher rates than the general population. Given that many Aboriginal people live in remote communities a task of peritoneal dialysis units is to ensure the successful setting up and maintenance of peritoneal dialysis programmes in the outback. This paper examines how peritoneal dialysis units located in the city are able to deliver peritoneal dialysis to patients located often hundreds of kilometres and at times thousands of kilometres away in very remote communities. In preparing this paper interviews were conducted with renal and remote community-based health professionals in Western Australia and the Northern Territory, and with peritoneal dialysis patients in Western Australia. The success of remote peritoneal dialysis programmes relies on many elements, most importantly an integrated approach to care by all members of the peritoneal dialysis team. The peritoneal dialysis team included not just health professionals but also patients, their families, their communities and other support people such as those involved in the transport of peritoneal dialysis supplies to the outback. Careful communication, a willingness to participate, friendliness and delivering care and supplies with a smile are essential ingredients to a winning program. Without all of these ingredients dialysis in the bush may fail.     

A look at dialysis delivery in Australia

Australia, in a sense, has as many dialysis delivery systems as it has states, with the differences in delivery systems being far greater between those states than is the case, for example, in the U.S. However, if common trends are apparent across the nation in dialysis delivery, they include: an increasing tendency to move HD delivery out of major teaching hospital centres into the community a modest decrease in PD use as more HD becomes available an increased role for the private sector in terms of HD delivery, ranging from direct facility ownership to pay-per-treatment arrangements in public hospitals an awareness of a need to make particular provision for the Aboriginal population, given their high rate of ESRD, their geographical dispersion, and their socio-economic deprivation. It will be interesting to observe how these processes evolve in the years ahead and whether these initiatives lead to "catch up" in Australia's incidence of treated ESRD relative to that of other Western countries.     

Associations of dialysis modality and infectious mortality in incident dialysis patients in Australia and New Zealand

BACKGROUND: The aim of the present investigation is to compare rates, types, causes, and timing of infectious death in incident peritoneal dialysis (PD) and hemodialysis (HD) patients in Australia and New Zealand. STUDY DESIGN: Observational cohort study using the Australian and New Zealand Dialysis and Transplant Registry data. SETTING & PARTICIPANTS: The study included all patients starting dialysis therapy between April 1, 1995, and December 31, 2005. PREDICTOR: Dialysis modality. OUTCOMES & MEASUREMENTS: Rates of and time to infectious death were compared by using Poisson regression, Kaplan-Meier, and competing risks multivariate Cox proportional hazards model analyses. RESULTS: 21,935 patients started dialysis therapy (first treatment PD, n = 6,020; HD, n = 15,915) during the study period, and 1,163 patients (5.1%) died of infectious causes (PD, 529 patients; 7.6% versus HD, 634 patients; 4.2%). Incidence rates of infectious mortality in PD and HD patients were 2.8 and 1.7/100 patient-years, respectively (incidence rate ratio PD versus HD, 1.66; 95% confidence interval [CI], 1.47 to 1.86). After performing competing risks multivariate Cox analyses allowing for an interaction between time on study and modality because of identified nonproportionality of hazards, PD consistently was associated with increased hazard of death from infection compared with HD after 6 months of treatment (<6 months hazard ratio [HR], 1.08; 95% CI, 0.76 to 1.54; 6 months to 2 years HR, 1.31; 95% CI, 1.09 to 1.59; 2 to 6 years HR, 1.51; 95% CI, 1.26 to 1.80; >6 years HR, 2.76; 95% CI, 1.76 to 4.33). This increased risk of infectious death in PD patients was largely accounted for by an increased risk of death caused by bacterial or fungal peritonitis. LIMITATIONS: Patients were not randomly assigned to their initial dialysis modality. Residual confounding and coding bias could not be excluded. CONCLUSIONS: Dialysis modality selection significantly influences risks, types, causes, and timing of fatal infections experienced by patients with end-stage kidney disease in Australia and New Zealand.     

Neurosurgery in Victoria, Australia: training and practice compared with the United Kingdom

In the UK there are currently great changes taking place in both higher surgical training and consultant practice. Australia inherited the British system, many aspects of which it retains, but has moved to a US type training programme. Recent experience of British and Australian neurosurgical practice allows useful comparisons to be made with possible benefit to both. Neurosurgery in Australia is a more consultant based service than that in the UK, with 73 consultants for a population of 18 million. Consultants work primarily from their private rooms and consultant numbers in the public sector are misleading as few of them approach full time. Neurosurgical training is organized on a national basis with a finite training programme. This consists of a rotation of different jobs supplemented by consultant led lectures and tutorials. Training is regularly monitored, with a final exit examination. The disadvantages are the relative lack of operating whilst training, many neurosurgeons becoming accredited with the personal operating experience expected of a British registrar; and the working hours; most trainees work 1 in 1, which precludes any sort of normal family life. In summary, the relative strengths of the British and Australian systems are largely complementary, there being ample scope for each to learn from the other.     

Surgical practice to reduce dialysis access insufficiency

Background: Patients who are dependant on a percutaneous central venous catheter for dialysis have an excess morbidity and mortality compared with patients with an autologous arteriovenous fistula. Methods: In an effort to improve outcomes related to episodes of permanent access insufficiency, defined as a patient requiring a venous catheter for haemodialysis, a 12‐month prospective audit of surgery carried out to establish and maintain dialysis access was carried out at our institution. Results: Effective measures that reduced the period of time that patients required a venous catheter for dialysis included regular communication between dialysis staff, the surgical service and patients attending for treatment in the dialysis unit, liberal use of duplex ultrasound imaging, pursuing autologous access in the majority of patients, early intervention to correct failing vascular access before conduit thrombosis, using both traditional open surgical and endovascular solutions in establishing and maintaining vascular access, using peritoneal dialysis as a long‐term or temporary alternative to haemodialysis and, in cases of arteriovenous polytetrafluoroethylene graft occlusion, early thrombectomy and mandatory revision to provide a conduit immediately available for effective dialysis. Conclusion: Conducting an audit of surgical practice contributed to an improvement in outcomes for dialysis‐dependant patients. Establishing an arteriovenous fistula in a greater proportion of cases before initiating renal replacement therapy may further address the problem of dialysis access insufficiency.     

腹膜透析专职护士准入及管理实践

目的建立并实施腹膜透析专职护士准入管理模式,提高肾内科护士专科护理水平。方法设定腹膜透析专职护士准入基本条件,拟定准入培训考核内容,建立准入管理方法,构建腹膜透析专职护士准入管理模式。结果实施腹膜透析专职护士准入管理后,专职护士腹膜透析理论与操作考核成绩显著提升(P0.05,P0.01);腹膜透析操作抽检合格率从25.00~72.92%提高至50.00%~100.00%。结论实施腹膜透析专职护士准入管理可提高腹膜透析护理质量,确保护理安全,促进专科护理发展。     

Subjective global assessment of nutrition,dialysis quality,and the theory of the scientific method in Nephrology practice

In an era of evidence-based medicine and dialysis performance measures, there is strong motivation to find specific, objective, quantifiable, and reproducible parameters to characterize the clinical condition of chronic kidney disease patients and to present population-wide statistics that may describe quality of care in dialysis centers. Yet, in the last three decades, several studies demonstrated that while parameters including Kt/V urea, serum phosphorus, parathyroid hormone, serum cholesterol fulfill all these criteria, efforts to optimize these lab parameters failed to improve survival on dialysis. However, subjective assessments of nutrition including subjective global assessment and malnutrition–inflammation score, while not ideally suited for statistical analysis and not optimal from the point of view of scientific methodology due to their general, semi-quantifiable, subjective nature have, nevertheless, proved themselves as some of the strongest predictors of clinical outcomes in the dialysis population. Where does this paradox leave us? We propose that a deeper understanding of relevance of these variables in the dialysis population may improve appreciation of the clinical situation of individual patients and may result in a paradigm shift from dialysis adequacy to quality dialysis.