Hotspots of kidney failure: Analysing Australian metropolitan dialysis demand for service planning

OBJECTIVE

To locate incident hotspots of dialysis demand in Australian capital cities and measure association with prevalent dialysis demand and socioeconomic disadvantage.

METHODS

A retrospective cohort study used Australia and New Zealand Dialysis and Transplant Registry data on people commencing dialysis for kidney failure (KF) resident in an Australian capital city, 1 January 2001 - 31 December 2021. Age-sex-standardised dialysis incidence was estimated by Statistical Area Level 3 (SA3) and dialysis prevalence by SA2.

RESULTS

A total of 32,391 people commencing dialysis were referenced to SA3s within city metropolitan areas based on residential postcode. Incident hotspots were located in Western Sydney. The highest average annual change of standardised incidence was 8.3 per million people (false discovery rate-corrected 95% CI 1.0,15.7) in Mount Druitt, reflecting a 263% increase in absolute demand from 2001-3 to 2019-21. Incident dialysis for diabetic kidney disease contributed substantially to total growth. Incident hotspots were co-located with areas where prevalent dialysis demand was associated with socioeconomic deprivation.

CONCLUSIONS

Novel spatial analyses of geo-referenced registry data located hotspots of kidney failure and associated socio-demographic and comorbid states.

IMPLICATIONS FOR PUBLIC HEALTH

These analyses advance current abilities to plan dialysis capacity at a local level. Hotspots can be targeted for prevention and slowing the progression of kidney disease.

Socioeconomic Position and Health Among Children and Adolescents With CKD Across the Life-Course

Children and adolescents in families of lower socioeconomic position (SEP) experience an inequitable burden of reduced access to healthcare and poorer health. For children living with chronic kidney disease (CKD), disadvantaged SEP may exacerbate their considerable disease burden. Across the life-course, CKD may also compromise the SEP of families and young people, leading to accumulating health and socioeconomic disadvantage. This narrative review summarizes the current evidence on relationships of SEP with kidney care and health among children and adolescents with CKD from a life-course approach, including impacts of family SEP on kidney care and health, and bidirectional impacts of CKD on SEP. It highlights relevant conceptual models from social epidemiology, current evidence, clinical and policy implications, and provides directions for future research. Reflecting the balance of available evidence, we focus primarily on high-income countries (HICs), with an overview of key issues in low- and middle-income countries (LMICs). Overall, a growing body of evidence indicates sobering socioeconomic inequities in health and kidney care among children and adolescents with CKD, and adverse socioeconomic impacts of CKD. Dedicated efforts to tackle inequities are critical to ensuring that all young people with CKD have the opportunity to live long and flourishing lives. To prevent accumulating disadvantage, the global nephrology community must advocate for local government action on upstream social determinants of health; and adopt a life-course approach to kidney care that proactively identifies and addresses unmet social needs, targets intervening factors between SEP and health, and minimizes adverse socioeconomic outcomes across financial, educational and vocational domains.

Recommendations for culturally safe clinical kidney care for First Nations Australians: a guideline summary

INTRODUCTION

First Nations Australians display remarkable strength and resilience despite the intergenerational impacts of ongoing colonisation. The continuing disadvantage is evident in the higher incidence, prevalence, morbidity and mortality of chronic kidney disease (CKD) among First Nations Australians. Nationwide community consultation (Kidney Health Australia, Yarning Kidneys, and Lowitja Institute, Catching Some Air) identified priority issues for guideline development. These guidelines uniquely prioritised the knowledge of the community, alongside relevant evidence using an adapted GRADE Evidence to Decision framework to develop specific recommendations for the management of CKD among First Nations Australians.

MAIN RECOMMENDATIONS

These guidelines explicitly state that health systems have to measure, monitor and evaluate institutional racism and link it to cultural safety training, as well as increase community and family involvement in clinical care and equitable transport and accommodation. The guidelines recommend earlier CKD screening criteria (age ≥ 18 years) and referral to specialists services with earlier criteria of kidney function (eg, estimated glomerular filtration rate [eGFR], ≤ 45 mL/min/1.73 m2 , and a sustained decrease in eGFR, > 10 mL/min/1.73 m2 per year) compared with the general population.

CHANGES IN MANAGEMENT AS RESULT OF THE GUIDELINES

Our recommendations prioritise health care service delivery changes to address institutional racism and ensure meaningful cultural safety training. Earlier detection of CKD and referral to nephrologists for First Nations Australians has been recommended to ensure timely implementation to preserve kidney function given the excess burden of disease. Finally, the importance of community with the recognition of involvement in all aspects and stages of treatment together with increased access to care on Country, particularly in rural and remote locations, including dialysis services.

Artificial intelligence-enabled decision support in nephrology

Kidney pathophysiology is often complex, nonlinear and heterogeneous, which limits the utility of hypothetical-deductive reasoning and linear, statistical approaches to diagnosis and treatment. Emerging evidence suggests that artificial intelligence (AI)-enabled decision support systems - which use algorithms based on learned examples - may have an important role in nephrology. Contemporary AI applications can accurately predict the onset of acute kidney injury before notable biochemical changes occur; can identify modifiable risk factors for chronic kidney disease onset and progression; can match or exceed human accuracy in recognizing renal tumours on imaging studies; and may augment prognostication and decision-making following renal transplantation. Future AI applications have the potential to make real-time, continuous recommendations for discrete actions and yield the greatest probability of achieving optimal kidney health outcomes. Realizing the clinical integration of AI applications will require cooperative, multidisciplinary commitment to ensure algorithm fairness, overcome barriers to clinical implementation, and build an AI-competent workforce. AI-enabled decision support should preserve the pre-eminence of wisdom and augment rather than replace human decision-making. By anchoring intuition with objective predictions and classifications, this approach should favour clinician intuition when it is honed by experience.

Psychosocial factors in patients with kidney failure and role for social worker: A secondary data audit

BACKGROUND

People with kidney failure face a multitude of psychosocial stressors that affect disease trajectory and health outcomes.

OBJECTIVES

To investigate psychosocial factors affecting people with kidney failure before or at start of kidney replacement therapy (KRT) and kidney supportive and palliative care (KSPC) phases of illness and to explore role of social worker during the illness trajectory.

METHODS

We conducted a secondary data audit of patients either before or at start of KRT (Phase 1) and at the KSPC (Phase 2) of illness and had psychosocial assessments between March 2012 and March 2020 in an Australian setting.

RESULTS

Seventy-nine individuals, aged 70 ± 12 years, had at least two psychosocial assessments, one in each of the two phases of illness. The median time between social worker evaluations in Phase 1 and Phase 2 was 522 (116-943) days. Adjustment to illness and treatment (90%) was the most prevalent psychosocial issue identified in Phase 1, which declined to 39% in Phase 2. Need for aged care assistance (7.6%-63%; p < 0.001) and carer support (7.6%-42%; p < 0.001) increased significantly from Phase 1 to Phase 2. There was a significant increase in psychosocial interventions by the social worker in Phase 2, including supportive counselling (53%-73%; p < 0.05), provision of education and information (43%-65%; p < 0.01), and referrals (28%-62%; p < 0.01).

CONCLUSION

Adults nearing or at the start of KRT experience immense psychosocial burden and adaptive demands that recognisably change during the course of illness. The positive role played by the nephrology social worker warrants further investigation.

Dialysis-network variability in home dialysis use not explained by patient characteristics: a national registry-based cohort study in France

Background

Although associated with better quality of life and potential economic advantages, home dialysis use varies greatly internationally and appears to be underused in many countries. This study aimed to estimate the dialysis-network variability in home dialysis use and identify factors associated with 1) the uptake in home dialysis, 2) the proportion of time spent on home dialysis and 3) home dialysis survival (patient and technique).

Methods

All adults ≥ 18 years old who had dialysis treatment during 2017-2019 in mainland France were included. Mixed-effects regression models were built to explore factors including patient or residence characteristics and dialysis network associated with variation in home dialysis use.

Results

During 2017-2019, 7 728/78 757 (9.8%) patients underwent dialysis at least once at home for a total of 120 594/ 1 508 000 (8%) months. The heterogeneity at the dialysis-network level and to a lesser extent the regional level regarding home dialysis uptake or total time spent was marginally explained by patient characteristics or residence and dialysis-network factors. Between-network heterogeneity was less for patient and technique survival. These results were similar when the analysis was restricted to home peritoneal dialysis or home hemodialysis.

Conclusions

Variability between networks in the use of home dialysis was not fully explained by non-modifiable patient and residence characteristics. Our results suggest that to increase home dialysis use in France, one should focus on home dialysis uptake rather than survival. Financial incentives and a quality improvement program should be implemented at the dialysis-network level to increase home dialysis use.

Impact of National Economy and Policies on End-Stage Kidney Care in South Asia and Southeast Asia

Background

The association between economic status and kidney disease is incompletely explored even in countries with higher economy (HE); the situation is complex in lower economies (LE) of South Asia and Southeast Asia (SA and SEA).

Methods

Fifteen countries of SA and SEA categorized as HE and LE, represented by the representatives of the national nephrology societies, participated in this questionnaire and interview-based assessment of the impact of economic status on renal care.

Results

Average incidence and prevalence of end-stage kidney disease (ESKD) per million population (pmp) are 1.8 times and 3.3 times higher in HE. Hemodialysis is the main renal replacement therapy (RRT) (HE-68%, LE-63%). Funding of dialysis in HE is mainly by state (65%) or insurance bodies (30%); out of pocket expenses (OOPE) are high in LE (41%). Highest cost for hemodialysis is in Brunei and Singapore, and lowest in Myanmar and Nepal. Median number of dialysis machines/1000 ESKD population is 110 in HE and 53 in LE. Average number of machines/dialysis units in HE is 2.7 times higher than LE. The HE countries have 9 times more dialysis centers pmp (median HE-17, LE-02) and 16 times more nephrologist density (median HE-14.8 ppm, LE-0.94 ppm). Dialysis sessions >2/week is frequently followed in HE (84%) and <2/week in LE (64%). "On-demand" hemodialysis (<2 sessions/week) is prevalent in LE. Hemodialysis dropout rates at one year are lower in HE (12.3%; LE 53.4%), death being the major cause (HE-93.6%; LE-43.8%); renal transplants constitute 4% (Brunei) to 39% (Hong Kong) of the RRT in HE. ESKD burden is expected to increase >10% in all the HE countries except Taiwan, 10%-20% in the majority of LE countries.

Conclusion

Economic disparity in SA and SEA is reflected by poor dialysis infrastructure and penetration, inadequate manpower, higher OOPE, higher dialysis dropout rates, and lesser renal transplantations in LE countries. Utility of RRT can be improved by state funding and better insurance coverage.

Area Deprivation and Risk of Death and CKD Progression: Long-Term Cohort Study in Patients under Unrestricted Nephrology Care

BACKGROUND

Area deprivation index (ADI) associates with prognosis in non-dialysis CKD. However, no study has evaluated this association in CKD patients under unrestricted nephrology care.

METHODS

We performed a long-term prospective study to assess the role of deprivation in CKD progression and mortality in stage 1-4 CKD patients under regular nephrology care, living in Naples (Italy). We used ADI calculated at census block levels, standardized to mean values of whole population in Naples, and linked to patients by georeference method. After 12 months of "goal-oriented" nephrology treatment, we compared the risk of death or composite renal outcomes (end-stage kidney disease or doubling of serum creatinine) in the tertiles of standardized ADI. Estimated glomerular filtration rate (eGFR) decline was evaluated by mixed effects model for repeated eGFR measurements.

RESULTS

We enrolled 715 consecutive patients (age: 64 ± 15 years; 59.1% males; eGFR: 49 ± 22 mL/min/1.73 m2). Most (75.2%) were at the lowest national ADI quintile. At referral, demographic, clinical, and therapeutic features were similar across ADI tertiles; after 12 months, treatment intensification allowed better control of hypertension, proteinuria, hypercholesterolaemia, and anaemia with no difference across ADI tertiles. During the subsequent long-term follow-up (10.5 years [interquartile range 8.2-12.6]), 166 renal events and 249 deaths were registered. ADI independently associated with all-cause death (p for trend = 0.020) and non-cardiovascular (CV) mortality (p for trend = 0.045), while CV mortality did not differ (p for trend = 0.252). Risk of composite renal outcomes was similar across ADI tertiles (p for trend = 0.467). The same held true for eGFR decline (p for trend = 0.675).

CONCLUSIONS

In CKD patients under regular nephrology care, ADI is not associated with CKD progression, while it is associated with all-cause death due to an excess of non-CV mortality.

Prevention of peritoneal dialysis-related peritonitis by regular patient retraining via technique inspection or oral education: a randomized controlled trial

BACKGROUND

There has been little research on strategies for prevention of peritoneal dialysis (PD)-related peritonitis. We explored whether regular retraining on bag exchanges (via two methods: technique inspection and oral education) every other month could help reduce the risk of peritonitis in PD patients through a randomized controlled trial (RCT).

METHOD

This is an RCT conducted at Peking University First Hospital. A total of 150 incident patients receiving PD at our centre were included between December 2010 and June 2016 and followed up until June 2018. Patients were randomly assigned 1:1:1 to receive retraining on bag exchange via technique inspection, oral education or usual care. The primary outcome was time to the first peritonitis episode. Secondary outcomes were time to organism-specific peritonitis, transfer to haemodialysis and all-cause death.

RESULTS

Patients in the technique inspection group, oral education group and usual care group (n = 50 for each group) were followed up for 47.5 ± 22.9 months. Time to first peritonitis was comparable between the groups. The technique inspection group showed a lower risk of first non-enteric peritonitis than the usual care group, while the oral education group did not show a significant benefit. The incidence of first non-enteric peritonitis in the usual care group (0.07/patient-year) was significantly higher than that in the technique inspection group (0.02/patient-year; P < 0.01) but was comparable with that in the oral education group (0.06/patient-year). Transfer to haemodialysis and all-cause mortality were not significantly different between the groups.

CONCLUSIONS

Neither technique inspection nor oral education significantly altered the risk of all-cause peritonitis compared with usual care, despite technique inspection showing a trend towards reducing the risk of non-enteric PD-related peritonitis.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01621997).

Chronic kidney disease and socio-economic status: a cross sectional study

Objective: This cross-sectional study investigated the relationship between individual-level markers of disadvantage, renal function and cardio-metabolic risk within an Indigenous population characterised by a heavy burden of chronic kidney disease and disadvantage.Design: Using data from 20 Indigenous communities across Australia, an aggregate socio-economic status (SES) score was created from individual-level socio-economic variables reported by participants. Logistic regression was used to assess the association of individual-level socio-economic variables and the SES score with kidney function (an estimated glomerular function rate (eGFR) cut-point of <60 ml/min/1.73 m²) as well as clinical indicators of cardio-metabolic risk.Results: The combination of lower education and unemployment was associated with poorer kidney function and higher cardio-metabolic risk factors. Regression models adjusted for age and gender showed that an eGFR < 60 ml/min/1.73 m² was associated with a low socio-economic score (lowest vs. highest 3.24 [95% CI 1.43-6.97]), remote living (remote vs. highly to moderately accessible 3.24 [95% CI 1.28-8.23]), renting (renting vs. owning/being purchased 5.76[95% CI 1.91-17.33]), unemployment (unemployed vs employed 2.85 [95% CI 1.31-6.19]) and receiving welfare (welfare vs. salary 2.49 [95% CI 1.42-4.37]). A higher aggregate socio-economic score was inversely associated with an eGFR < 60 ml/min/1.73 m² (0.75 [95% CI 063-0.89]).Conclusion: This study extends upon our understanding of associations between area-level markers of disadvantage and burden of end stage kidney disease amongst Indigenous populations to a detailed analysis of a range of well-characterised individual-level factors such as overall low socio-economic status, remote living, renting, unemployment and welfare. With the increasing burden of end-stage kidney disease amongst Indigenous people, the underlying socio-economic conditions and social and cultural determinants of health need to be understood at an individual as well as community-level, to develop, implement, target and sustain interventions.

Socioeconomic Status and Kidney Transplant Outcomes in a Universal Healthcare System: A Population-based Cohort Study

BACKGROUND

Conflicting evidence exists regarding the relationship between socioeconomic status (SES) and outcomes after kidney transplantation.

METHODS

We conducted a population-based cohort study in a publicly funded healthcare system using linked administrative healthcare databases from Ontario, Canada to assess the relationship between SES and total graft failure (ie, return to chronic dialysis, preemptive retransplantation, or death) in individuals who received their first kidney transplant between 2004 and 2014. Secondary outcomes included death-censored graft failure, death with a functioning graft, all-cause mortality, and all-cause hospitalization (post hoc outcome).

RESULTS

Four thousand four hundred-fourteen kidney transplant recipients were included (median age, 53 years; 36.5% female), and the median (25th, 75th percentile) follow-up was 4.3 (2.1-7.1) years. In an unadjusted Cox proportional hazards model, each CAD $10000 increase in neighborhood median income was associated with an 8% decline in the rate of total graft failure (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.87-0.97). After adjusting for recipient, donor, and transplant characteristics, SES was not significantly associated with total or death-censored graft failure. However, each CAD $10000 increase in neighborhood median income remained associated with a decline in the rate of death with a functioning graft (adjusted (a)HR, 0.91; 95% CI, 0.83-0.98), all-cause mortality (aHR, 0.92; 95% CI, 0.86-0.99), and all-cause hospitalization (aHR, 0.95; 95% CI, 0.92-0.98).

CONCLUSIONS

In conclusion, in a universal healthcare system, SES may not adversely influence graft health, but SES gradients may negatively impact other kidney transplant outcomes and could be used to identify patients at increased risk of death or hospitalization.

Socioeconomic status and dialysis quality of care

AIM

Lower socioeconomic status (SES) has been associated with increased dialysis mortality. This study aimed to determine if the quality of care (QOC) delivered to dialysis patients varied by SES.

METHODS

All non-Indigenous adults commencing haemodialysis (HD) or peritoneal dialysis (PD) registered with the Australia and New Zealand Dialysis and Transplant Registry between 2002 and 2012 were included. Each patient's location at dialysis start was classified into SES quartiles of advantaged to disadvantaged. Guidelines were used to determine attainment of adequate QOC at 6-<18 months and 18-<30 months after dialysis start, using logistic regression models. QOC measures included pre-dialysis phosphate, calcium, haemoglobin, transferrin saturation and ferritin. HD-related parameters included single pool Kt/V and percentage with functioning arteriovenous fistula/graft. PD-related parameters included weekly Kt/V and percentage transferring to HD.

RESULTS

Of 19 486 commencing dialysis, the median age was 65 years (interquartile range 53-74), 62.2% were male and 85.1% were Caucasian. At 6-<18 months after dialysis start, there were no significant differences by SES in attainment of biochemical targets, PD or HD adequacy. The disadvantaged quartile was less likely to achieve haemoglobin targets (odds ratio 0.88, 0.80-0.96, P = 0.01) or have a functioning arteriovenous fistula or graft (odds ratio 0.79, 0.68-0.92, P = 0.003) compared with the most advantaged group. Vascular access differences persisted at 18-<30 months.

CONCLUSION

Other than vascular access, area-level SES has minimal impact on QOC attainment among non-Indigenous dialysis patients in Australia. Increased mortality in lower SES groups may be due to pre-dialysis factors and other variables such as health-related behaviours, lifestyle and literacy.

Cost of dialysis therapies in rural and remote Australia - a micro-costing analysis

BACKGROUND

Maintenance dialysis is a costly and resource intense activity. In Australia, inadequate health infrastructure and poor access to technically skilled staff can limit service provision in remote areas where many Aboriginal dialysis patients live. With most studies based on urban service provision, there is little evidence to guide service development. However permanent relocation to an urban area for treatment can have significant social and financial impacts that are poorly quantified. This study is part of a broader project to quantify the costs and benefits of dialysis service models in urban and remote locations in Australia's Northern Territory (NT).

METHODS

We undertook a micro-costing analysis of dialysis service delivery costs in urban, rural and remote areas in the NT from the payer perspective. Recurrent maintenance costs (salaries, consumables, facility management and transportation) as well as capital costs were included. Missing and centralised costs were standardised; results were inflated to 2017 values and reported in Australian dollars.

RESULTS

There was little difference between the average annual cost for urban and rural services with respective median costs of $85,919 versus $84,629. However remote service costs were higher ($120,172 - $124,492), driven by higher staff costs. The inclusion of capital costs did not add substantially to annual costs. Annual home haemodialysis costs ($42,927) were similar to other jurisdictions despite the significant differences in program delivery and payment of expenses not traditionally borne by governments. Annual peritoneal dialysis costs ($58,489) were both higher than home and in-centre haemodialysis by recent national dialysis cost studies.

CONCLUSION

The cost drivers for staffed services were staffing models and patient attendance rates. Staff salaries and transport costs were significantly higher in remote models of care. Opportunities to reduce expenditure exist by encouraging community supported services and employing local staff. Despite the delivery challenges of home haemodialysis including high patient attrition, the program still provides a cost benefit compared to urban staffed services. The next component of this study will examine patient health service utilisation and costs by model of care to provide a more comprehensive analysis of the overall cost of providing services in each location.

Recruitment and participant baseline characteristics in the dialysis outcomes in those aged 65 years or older study

BACKGROUND

Despite an increasing number of older people commencing dialysis the impact of dialysis on their quality of life and survival, remains unclear. The Dialysis Outcomes in those aged over 65 years or older study is an accelerated prospective cohort longitudinal design study, designed to obtain sufficient health related quality of life data, linked to clinical data, to inform clinicians' and patients' decision-making with respect to end stage kidney disease (ESKD), outcomes, and options for management in New Zealand (NZ).

METHODS

The study has an accelerated prospective cohort longitudinal design, comprised of cross-sectional and longitudinal components. We report the baseline data on the 225 participants enrolled in the study. Dialysis duration was grouped in tertiles from less than one year (incident patients), 1-3 years and greater than 3 years. Health related quality of life data was obtained from self-reported questionnaires including KDQoL-36, EQ-5D-3 L, FACIT, WHODAS II, and the Personal Well-being Score.

RESULTS

The median age of the cohort was 71 years and two thirds were male. Three quarters of the participants were on dialysis at the baseline, with 42% of those on home dialysis (haemodialysis or peritoneal dialysis). Māori and Pacific people were over represented (20% Māori and 24% Pacific) in the sample, when compared to the general NZ population of the same age group (where 5% are Māori and 2% are Pacific). At baseline, there were no differences observed in sociodemographic, quality of life or health characteristics between the dialysis groups either by modality or duration of dialysis.

CONCLUSIONS

We report the baseline characteristics of participants enrolled prospectively into a longitudinal cohort observational study examining health related quality of life factors with clinical characteristics on dialysis outcomes in a group of New Zealanders aged 65 years or older who are either on dialysis or have been educated about dialysis (BMC Nephrol 14:175, 2013). Subsequent publications are planned, analysing the prospective longitudinal data to identify key factors that determine both outcome and quality of life for individuals of this age group.

TRIAL REGISTRATION

ACTRN12611000024943 .

Indigenous patient experiences of returning to country: a qualitative evaluation on the Country Health SA Dialysis bus

BACKGROUND

Rates of End-Stage Kidney Disease among Aboriginal and Torres Strait Islander (Indigenous) Australians in remote areas are disproportionately high; however, haemodialysis is not currently offered in most remote areas. People must therefore leave their 'Country' (with its traditions and supports) and relocate to metropolitan or regional centres, disrupting their kinship and the cultural ties that are important for their wellbeing. The South Australian Mobile Dialysis Truck is a service which visits remote communities for one to two week periods; allowing patients to have dialysis on 'Country', reuniting them with their friends and family, and providing a chance to take part in cultural activities. The aims of the study were to qualitatively evaluate the South Australian Mobile Dialysis Truck program, its impact on the health and wellbeing of Indigenous dialysis patients, and the facilitators and barriers to using the service.

METHODS

Face to face semi-structured interviews were conducted with 15 Indigenous dialysis patients and 10 nurses who had attended trips across nine dialysis units. Realist evaluation methodology and thematic analysis established patient and nursing experiences with the Mobile Dialysis Truck.

RESULTS

The consequences of leaving Country included grief and loss. Barriers to trip attendance included lower trip frequencies, ineffective trip advertisement, lack of appropriate or unavailable accommodation for staff and patients and poor patient health. Benefits of the service included the ability to fulfil cultural commitments, minimisation of medical retrievals from patients missing dialysis to return to remote areas, improved trust and relationships between patients and staff, and improved patient quality of life. The bus also provided a valuable cultural learning opportunity for staff. Facilitators to successful trips included support staff, clinical back-up and a co-ordinator role.

CONCLUSIONS

The Mobile Dialysis Truck was found to improve the social and emotional wellbeing of Indigenous patients who have had to relocate for dialysis, and build positive relationships and trust between metropolitan nurses and remote patients. The trust fostered improved engagement with associated health services. It also provided valuable cultural learning opportunities for nursing staff. This format of health service may improve cultural competencies with nursing staff who provide regular care for Indigenous patients.

Geographic Variations in the Risk of Emergency First Dialysis for Patients with End Stage Renal Disease in the Bretagne Region, France

Emergency first dialysis start considerably increases the risk of morbidity and mortality. Our objective was to identify the geographic variations of emergency first dialysis risk in patients with end-stage renal disease in the Bretagne region, France. The spatial scan statistic approach was used to determine the clusters of municipalities with significantly higher or lower risk of emergency first dialysis. Patient data extracted from the REIN registry (sociodemographic, clinical, and biological characteristics) and indicators constructed at the municipality level, were compared between clusters. This analysis identified a cluster of municipalities in western Bretagne with a significantly higher risk (RR = 1.80, p = 0.044) and one cluster in the eastern part of the region with a significantly lower risk (RR = 0.59, p < 0.01) of emergency first dialysis. The degree of urbanization (the proportion of rural municipalities: 76% versus 66%, p < 0.001) and socio-demographic characteristics (the unemployment rate: 11% versus 8%, p < 0.001, the percentage of managers in the labor force was lower: 9% versus 13% p < 0.001) of the municipalities located in the higher-risk cluster compared with the lower-risk cluster. Our analysis indicates that the patients' clinical status cannot explain the geographic variations of emergency first dialysis incidence in Bretagne. Conversely, where patients live seems to play an important role.

Low socio-economic status adversely effects dialysis survival in Australia

AIM

Low socio-economic status (SES) is associated with increased incidence of end-stage kidney disease and in the USA, poorer dialysis survival. All Australians have access to a universal healthcare system.

METHODS

The study included all non-indigenous adult Australians registered with the Australia and New Zealand Dialysis and Transplant Registry who commenced dialysis between 2003 and 2013. SES at dialysis start was classified into quartiles of advantaged through to disadvantaged using Australian Bureau of Statistics socio-economic indexes for areas. The primary outcome was survival assessed using a competing risk regression model with renal transplantation as a competing risk. There was a significant interaction between age and SES, and hence, age-stratified survival analyses were performed.

RESULTS

A total 20 810 commenced dialysis during the study period. Mortality for the most advantaged quartile was 102.4/1000 person-years (95% confidence interval (CI) 98.0-106.9) compared with 110.7/1000 person-years (95% CI 105.8-115.7) in the disadvantaged quartile. In adjusted analysis, dialysis survival, compared with quartile 1 (advantaged), was inferior in quartile 3 (sub-hazard ratio 1.10, 95% CI 1.03-1.17) and the disadvantaged quartile (sub-hazard ratio 1.09, 85% CI 1.02-1.16) and was significantly modified by age. This disparity in survival outcome between the different SES quartiles was only observed in younger patients but was attenuated in the older ones following an age-stratified analysis.

CONCLUSIONS

In Australia, low SES has an adverse effect on dialysis patient survival despite universal healthcare. This effect is mainly among younger patients where SES may have a greater proportional impact than co-morbidities.

Impact of CKD on Household Income

Introduction

The impact of chronic kidney disease (CKD) on income is unclear. We sought to determine whether CKD severity, serious adverse events, and CKD progression affected household income.

Methods

Analyses were undertaken in a prospective cohort of adults with moderate-to-severe CKD in the Study of Heart and Renal Protection (SHARP), with household income information available at baseline screening and study end. Logistic regressions, adjusted for sociodemographic characteristics, smoking, and prior diseases at baseline, estimated associations during the 5-year follow-up, among (i) baseline CKD severity, (ii) incident nonfatal serious adverse events (vascular or cancer), and (iii) CKD treatment modality (predialysis, dialysis, or transplanted) at study end and the outcome “fall into relative poverty.” This was defined as household income <50% of country median income.

Results

A total of 2914 SHARP participants from 14 countries were included in the main analysis. Of these, 933 (32%) were in relative poverty at screening; of the remaining 1981, 436 (22%) fell into relative poverty by study end. Compared with participants with stage 3 CKD at baseline, the odds of falling into poverty were 51% higher for those with stage 4 (odds ratio [OR]: 1.51; 95% confidence interval [CI]: 1.09–2.10), 66% higher for those with stage 5 (OR: 1.66; 95% CI: 1.11–2.47), and 78% higher for those on dialysis at baseline (OR: 1.78, 95% CI: 1.22–2.60). Participants with kidney transplant at study end had approximately half the risk of those on dialysis or those with CKD stages 3 to 5.

Conclusion

More advanced CKD is associated with increased odds of falling into poverty. Kidney transplantation may have a role in reducing this risk.

Social disparities in the prevalence of diabetes in Australia and in the development of end stage renal disease due to diabetes for Aboriginal and Torres Strait Islanders in Australia and Maori and Pacific Islanders in New Zealand

BACKGROUND

Disparities in health status occur between people with differing socioeconomic status and disadvantaged groups usually have the highest risk exposure and the worst health outcome. We sought to examine the social disparities in the population prevalence of diabetes and in the development of treated end stage renal disease due to type 1 diabetes which has not previously been studied in Australia and New Zealand in isolation from type 2 diabetes.

METHODS

This observational study examined the population prevalence of diabetes in a sample of the Australian population (7,434,492) using data from the National Diabetes Services Scheme and of treated end stage renal disease due to diabetes using data from the Australian and New Zealand Dialysis and Transplant Registry. The data were then correlated with the Australian Bureau of Statistics Socioeconomic Indexes for Areas for an examination of socioeconomic disparities.

RESULTS

There is a social gradient in the prevalence of diabetes in Australia with disease incidence decreasing incrementally with increasing affluence (Spearman's rho = .765 p < 0.001). There is a higher risk of developing end stage renal disease due to type 1 diabetes for males with low socioeconomic status (RR 1.20; CI 1.002-1.459) in comparison to females with low socioeconomic status. In Australia and New Zealand Aboriginal and Torres Strait Islanders, Maori and Pacific Islanders appear to have a low risk of end stage renal disease due to type 1 diabetes but continue to carry a vastly disproportionate burden of end stage renal disease due to type 2 diabetes (RR 6.57 CI 6.04-7.14 & 6.48 CI 6.02-6.97 respectively p < 0.001) in comparison to other Australian and New Zealanders.

CONCLUSION

Whilst low socioeconomic status is associated with a higher prevalence of diabetes the inverse social gradient seen in this study has not previously been reported. The social disparity seen in relation to treated end stage renal disease due to type 2 diabetes for Aboriginal and Torres Strait Islanders, Maori and Pacific Islanders has changed very little in the past 20 years. Addressing the increasing incidence of diabetes in Australia requires consideration of the underlying social determinants of health.

Gender differences in the dialysis treatment of Indigenous and non-Indigenous Australians

OBJECTIVE

Access to dialysis treatment and the types of treatments employed in Australia differs by Indigenous status. We examined whether dialysis treatment utilisation in Indigenous and non-Indigenous Australians also differs by gender.

METHODS

Using registry data we evaluated 21,832 incident patients (aged ≥18 years) commencing dialysis, 2001-2013. Incidence rates were calculated and multivariate regression modelling used to examine differences in dialysis treatment (modality, location and vascular access creation) by race and gender.

RESULTS

Dialysis incidence was consistently higher in Indigenous women compared to all other groups. Compared to Indigenous women, both non-Indigenous women and men were more likely to receive peritoneal dialysis as their initial treatment (non-Indigenous women RR=1.91, 95%CI 1.55-2.35; non-Indigenous men RR=1.73, 1.40-2.14) and were more likely to commence initial treatment at home (non-Indigenous women RR=2.07, 1.66-2.59; non-Indigenous men RR=1.95, 1.56-2.45). All groups were significantly more likely than Indigenous women to receive their final treatment at home.

CONCLUSIONS

Contemporary dialysis treatment in Australia continues to benefit the dominant non-Indigenous population over the Indigenous population, with non-Indigenous men being particularly advantaged. Implications for Public Health: Treatment guidelines that incorporate a recognition of gender-based preferences and dialysis treatment options specific to Indigenous Australians may assist in addressing this disparity.

The economic considerations of patients and caregivers in choice of dialysis modality

Introduction Broader adoption of home dialysis could lead to considerable cost savings for health services. Globally, however, uptake remains low. The aim of this study was to describe patient and caregiver perspectives of the economic considerations that influence dialysis modality choice, and elicit policy-relevant recommendations. Methods Semistructured interviews with predialysis or dialysis patients and their caregivers, at three hospitals in New Zealand. Interview transcripts were analyzed thematically. Findings 43 patients and 9 caregivers (total n = 52) participated. The three themes related to economic considerations were: (i) productivity losses associated with changes in employment; (ii) the need for personal subsidization of home dialysis expenses; and (iii) the role of socio-economic disadvantage as a barrier to home dialysis. Patients weighed the flexibility of home dialysis which allowed them to remain employed, against time required for training and out-of-pocket costs. Patients saw the lack of reimbursement of home dialysis costs as unjust and suggested that reimbursement would incentivize home dialysis uptake. Social disadvantage was a barrier to home dialysis as patients' housing was often unsuitable; they could not afford the additional treatment costs. Home hemodialysis was considered to have the highest out-of-pocket costs and was sometimes avoided for this reason. Discussion Our data suggests that economic considerations underpin the choices patients make about dialysis treatments, however these are rarely reported. To promote home dialysis, strategies to improve employment retention and housing, and to minimize out-of-pocket costs, need to be addressed directly by healthcare providers and payers.

A comparison of self-reported quality of life for an Australian haemodialysis and haemodiafiltration cohort

AIMS

Haemodiafiltration (HDF) has been widely studied for evidence of superior outcomes in comparison with conventional haemodialysis (HD), and there is increasing interest in determining if HDF confers any benefit in relation to quality of life. Studies have been conducted with randomized incident patients; however, little is known regarding HDF and quality of life for prevalent patients. This study examined and compared self-reported quality of life at two time points, 12 months apart in a cohort of satellite HD and HDF patients, using a disease specific questionnaire to determine if HDF conferred an advantage.

METHODS

A longitudinal study with a linear mixed-effect model measuring quality of life in a cohort of 171 patients (HD, n = 85, HDF, n = 86) in seven South Australian satellite dialysis centres.

RESULTS

Factors associated with significant reduction across the Kidney Disease Quality Of Life™ domains measured were younger age (- 20 to - 29) and comorbid diabetes (- 4.8 to - 11.1). HDF was not associated with moderation of this reduction at either time point (P > 0.05). Baseline physical functioning was reported as very low (median 33.9) and further reduced at time point two. In addition, dialysing for more than 12 h per week in a satellite dialysis unit was associated with reduced quality of life in relation to the burden of kidney disease (- 13.69).

CONCLUSION

This study has demonstrated that younger age and comorbid diabetes were responsible for a statistically significant reduction in quality of life, and HDF did not confer any advantage.

Australia and New Zealand Dialysis and Transplant Registry

The ANZDATA Registry includes all patients treated with renal replacement therapy (RRT) throughout Australia and New Zealand. Funding is predominantly from government sources, together with the non-government organization Kidney Health Australia. Registry operations are overseen by an Executive committee, and a Steering Committee with wide representation. Data is collected from renal units throughout Australia and New Zealand on a regular basis, and forwarded to the Registry. Areas covered include demographic details, primary renal disease, type of renal replacement therapy, process measures, and a variety of outcomes. From this data collection a number of themes of work are produced. These include production of Registry reports with an extensive range of national and regional data, a suite of quality assurance reports, key process indicator (KPI) reports, and data sets for a variety of audit and research purposes. The various types of information from the ANZDATA Registry are used in a wide variety of areas, including health services planning, safety and quality programs, and clinical research projects.

Low income, community poverty and risk of end stage renal disease

BACKGROUND

The risk of end stage renal disease (ESRD) is increased among individuals with low income and in low income communities. However, few studies have examined the relation of both individual and community socioeconomic status (SES) with incident ESRD.

METHODS

Among 23,314 U.S. adults in the population-based Reasons for Geographic and Racial Differences in Stroke study, we assessed participant differences across geospatially-linked categories of county poverty [outlier poverty, extremely high poverty, very high poverty, high poverty, neither (reference), high affluence and outlier affluence]. Multivariable Cox proportional hazards models were used to examine associations of annual household income and geospatially-linked county poverty measures with incident ESRD, while accounting for death as a competing event using the Fine and Gray method.

RESULTS

There were 158 ESRD cases during follow-up. Incident ESRD rates were 178.8 per 100,000 person-years (105 py) in high poverty outlier counties and were 76.3 /105 py in affluent outlier counties, p trend=0.06. In unadjusted competing risk models, persons residing in high poverty outlier counties had higher incidence of ESRD (which was not statistically significant) when compared to those persons residing in counties with neither high poverty nor affluence [hazard ratio (HR) 1.54, 95% Confidence Interval (CI) 0.75-3.20]. This association was markedly attenuated following adjustment for socio-demographic factors (age, sex, race, education, and income); HR 0.96, 95% CI 0.46-2.00. However, in the same adjusted model, income was independently associated with risk of ESRD [HR 3.75, 95% CI 1.62-8.64, comparing the <$20,000 income group to the >$75,000 group]. There were no statistically significant associations of county measures of poverty with incident ESRD, and no evidence of effect modification.

CONCLUSIONS

In contrast to annual family income, geospatially-linked measures of county poverty have little relation with risk of ESRD. Efforts to mitigate socioeconomic disparities in kidney disease may be best appropriated at the individual level.

Spatial distribution of end-stage renal disease (ESRD) and social inequalities in mixed urban and rural areas: a study in the Bretagne administrative region of France

Background

Several studies have investigated the implication of biological and environmental factors on geographic variations of end-stage renal disease (ESRD) incidence at large area scales, but none of them assessed the implication of neighbourhood characteristics (healthcare supply, socio-economic level and urbanization degree) on spatial repartition of ESRD. We evaluated the spatial implications of adjustment for neighbourhood characteristics on the spatial distribution of ESRD incidence at the smallest geographic unit in France.

Methods

All adult patients living in Bretagne and beginning renal replacement therapy during the 2004–09 period were included. Their residential address was geocoded at the census block level. Each census block was characterized by socio-economic deprivation index, healthcare supply and rural/urban typology. Using a spatial scan statistic, we examined whether there were significant clusters of high risk of ESRD incidence.

Results

The ESRD incidence was non-randomly spatially distributed, with a cluster of high risk in the western Bretagne region (relative risk, RR = 1.28, P-value = 0.0003). Adjustment for sex, age and neighbourhood characteristics induced cluster shifts. After these adjustments, a significant cluster (P = 0.013) persisted.

Conclusions

Our spatial analysis of ESRD incidence at a fine scale, across a mixed rural/urban area, indicated that, beyond age and sex, neighbourhood characteristics explained a great part of spatial distribution of ESRD incidence. However, to better understand spatial variation of ESRD incidence, it would be necessary to research and adjust for other determinants of ESRD.

Kidney disease in Aboriginal Australians: a perspective from the Northern Territory

This article outlines the increasing awareness, service development and research in renal disease in Aboriginal people in Australia's Northern Territory, among whom the rates of renal replacement therapy (RRT) are among the highest in the world. Kidney failure and RRT dominate the intellectual landscape and consume the most professional energy, but the underlying kidney disease has recently swung into view, with increasing awareness of its connection to other chronic diseases and to health profiles and trajectories more broadly. Albuminuria is the marker of the underlying kidney disease and the best treatment target, and glomerulomegaly and focal glomerulosclerosis are the defining histologic features. Risk factors in its multideterminant genesis reflect nutritional and developmental disadvantage and inflammatory/infectious milieu, while the major putative genetic determinants still elude detection. A culture shift of "chronic disease prevention" has been catalyzed in part by the human pain, logistic problems and great costs associated with RRT. Nowadays chronic disease management is the central focus of indigenous primary care, with defined protocols for integrated testing and management of chronic diseases and with government reimbursed service items and free medicines for people in remote areas. Blood pressure, cardiovascular risk and chronic kidney disease (CKD) are all mitigated by good treatment, which centres on renin-angiotensin system blockade and good metabolic control. RRT incidence rates appear to be stabilizing in remote Aboriginal people, and chronic disease deaths rates are falling. However, the profound levels of disadvantage in many remote settings remain appalling, and there is still much to be done, mostly beyond the direct reach of health services.

Mapping end-stage renal disease (ESRD): spatial variations on small area level in northern France, and association with deprivation

BACKGROUND

Strong geographic variations in the incidence of end-stage renal disease (ESRD) are observed in developed countries. The reasons for these variations are unknown. They may reflect regional inequalities in the population's sociodemographic characteristics, related diseases, or medical practice patterns. In France, at the district level, the highest incidence rates have been found in the Nord-Pas-de-Calais region. This area, with a high population density and homogeneous healthcare provision, represents a geographic situation which is quite suitable for the study, over small areas, of spatial disparities in the incidence of ESRD, together with their correlation with a deprivation index and other risk factors.

METHODS

The Renal Epidemiology and Information Network is a national registry, which lists all ESRD patients in France. All cases included in the Nord-Pas-de-Calais registry between 2005 and 2011 were extracted. Adjusted and smoothed standardized incidence ratio (SIR) was calculated for each of the 170 cantons, thanks to a hierarchical Bayesian model. The correlation between ESRD incidence and deprivation was assessed using the quintiles of Townsend index. Relative risk (RR) and credible intervals (CI) were estimated for each quintile.

RESULTS

Significant spatial disparities in ESRD incidence were found within the Nord-Pas-de-Calais region. The sex- and age-adjusted, smoothed SIRs varied from 0.66 to 1.64. Although no correlation is found with diabetic or vascular nephropathy, the smoothed SIRs are correlated with the Townsend index (RR: 1.18, 95% CI [1.00-1.34] for Q2; 1.28, 95% CI [1.11-1.47] for Q3; 1.30, 95% CI [1.14-1.51] for Q4; 1.44, 95% CI [1.32-1.74] for Q5).

CONCLUSION

For the first time at this aggregation level in France, this study reveals significant geographic differences in ESRD incidence. Unlike the time of renal replacement care, deprivation is certainly a determinant in this phenomenon. This association is probably independent of the patients' financial ability to gain access to healthcare.

Socioeconomic differences in the uptake of home dialysis

BACKGROUND AND OBJECTIVES

Home dialysis creates fewer lifestyle disruptions while providing similar or better outcomes than in-center hemodialysis. Socioeconomically advantaged patients are more likely to commence home dialysis (peritoneal dialysis and home hemodialysis) in many developed countries. This study investigated associations between socioeconomic status and uptake of home dialysis in Australia, a country with universal access to health care and comparatively high rates of home dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study analyzed 23,281 non-Indigenous adult patients who commenced chronic RRT in Australia from 2000 to 2011 according to the Australia and New Zealand Dialysis and Transplant Registry in a retrospective cohort study. This study investigated the proportion of patients who were ever likely to use home dialysis using nonmixture cure models and followed patients until the end of 2011 (median follow-up time=3.0 years, interquartile range=1.3-5.5 years). The main predictor was area socioeconomic status from postcodes grouped into quartiles using standard indices.

RESULTS

Patients from the most advantaged quartile of areas were less likely to commence peritoneal dialysis (odds ratio, 0.63; 95% confidence interval, 0.58 to 0.69) and more likely to use in-center hemodialysis than patients from the most disadvantaged areas (odds ratio, 1.19; 95% confidence interval, 1.10 to 1.30). Socioeconomic status was not associated with uptake of home hemodialysis. Rural areas were more disadvantaged and had higher rates of peritoneal dialysis, and privately funded hospitals rarely used home dialysis. Patients from the most advantaged quartile of areas were more likely to use private hospitals than patients from the most disadvantaged quartile (odds ratio, 5.9; 95% confidence interval, 4.6 to 7.5).

CONCLUSION

The lower incidence of peritoneal dialysis among patients from advantaged areas seems to be multifactorial. Identifying and addressing barriers to home dialysis in Australia could improve patient quality of life and reduce costs.

Socio-Economic Status and Peritonitis in Australian Non-Indigenous Peritoneal Dialysis Patients

♦

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.

Racial disparities in paediatric kidney transplantation

BACKGROUND

Transplantation is the preferred treatment for children with end-stage kidney disease (ESKD). Pre-emptive transplants, those from live donors and with few human leukocyte antigen (HLA) mismatches provide the best outcomes. Studies into disparities in paediatric transplantation to date have not adequately disentangled different transplant types.

METHODS

We studied a retrospective cohort of 823 patients aged <18 years who started renal replacement therapy (RRT) in Australia 1990-2011, using the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA). The primary outcomes were time to first kidney transplant and kidney donor type (deceased or living), analysed using competing risk regression.

RESULTS

Caucasian patients were most likely to receive any transplant, due largely to disparities in live donor transplantation. No Indigenous patients received a pre-emptive transplant. Indigenous patients were least likely to receive a transplant from a live donor (sub-hazard ratio 0.41, 95 % confidence interval 0.20-0.82, compared to Caucasians). Caucasian recipients had fewer HLA mismatches, were less sensitised and were more likely to have kidney diseases that could be diagnosed early or progress slowly.

CONCLUSIONS

Caucasian paediatric patients are more likely to receive optimum treatment--a transplant from a living donor and fewer HLA mismatches. Further work is required to identify and address barriers to live donor transplantation among minority racial groups.

Predictors of sun-related behaviors among young women: comparisons between outdoor tanners, fake tanners, and tan avoiders

OBJECTIVE

Skin cancer incidence continues to rise as a tanned appearance remains desirable, particularly among young women. Fake tanning provides a tanned appearance without exposure to ultraviolet radiation. In order to advance our understanding of the factors that contribute to long-term behavior change, this study explores determinants associated with different types of tanning.

PARTICIPANTS

The sample included 162 female students from the University of Adelaide, Australia, aged 18-26 years. Data were collected in July 2010.

METHODS

The current study measured differences in skin type, skin cancer knowledge, unrealistic optimism, appearance motivation, and sun-protective and sun exposure behaviors amongst outdoor tanners, fake tanners, and tan avoiders through an online survey.

RESULTS

Differences were observed for skin type, skin cancer knowledge, unrealistic optimism, sun protection, and sun exposure.

CONCLUSIONS

A "one-size-fits-all" approach to skin cancer prevention may not be appropriate; type of tanning behavior may need to be considered in health promotion work.

Transplantation rates for living- but not deceased-donor kidneys vary with socioeconomic status in Australia

Socioeconomic disadvantage has been linked to reduced access to kidney transplantation. To understand and address potential barriers to transplantation, we used the Australia and New Zealand Dialysis and Transplant Registry and examined primary kidney-only transplantation among adult non-Indigenous patients who commenced chronic renal replacement therapy in Australia during 2000-2010. Socioeconomic status was derived from residential postcodes using standard indices. Among the 21,190 patients who commenced renal replacement therapy, 4105 received a kidney transplant (2058 from living donors (660 preemptive) or 2047 from deceased donors) by the end of 2010. Compared with the most socioeconomic disadvantaged quartile, patients from the most advantaged quartile were more likely to receive a preemptive transplant (relative rate 1.93), and more likely to receive a living-donor kidney (adjusted subhazard ratio 1.34) after commencing dialysis. Socioeconomic status was not associated with deceased-donor transplantation. Thus, the association between socioeconomic status and living- but not deceased-donor transplantation suggests that potential donors (rather than recipients) from disadvantaged areas may face barriers to donation. Although the deceased-donor organ allocation process appears essentially equitable, it differs between Australian states.