Starting treatment: Ethnicity The incidence of requiring renal replacement therapy remained substantially higher among Māori and Pacific patients than among non-Pacific patients. This disparity in entering end-stage kidney disease remains persistent for Māori and is worsening for Pacific patients over time (Figure 5). This difference in incidence based on ethnicity is likely to be partly explained by different demographic and clinical characteristics, although the role of ethnicity in development of end-stage kidney disease is incompletely understood. The incidence of renal replacement therapy has been stable (69-74 pmp) among non-Māori, non-Pacific patients, whereas the incidence is 266 pmp among Māori patients (3.7-fold higher) and 443 pmp among Pacific patients (6.2-fold higher). In 2013, the ratios were 4.5 among Māori and 5.5 among Pacific patients (Figure 5). There is considerable disparity in the opportunity to commence treatment with a kidney transplant (pre-emptive transplantation) based on ethnicity. Of the 24 patients who received a kidney transplant, none in 2014 identified as Māori and 1 (0.8%) identified as Pacific ethnicity (Figure 6).
Modality 2667 adult patients were treated with dialysis (633 pmp) and 1589 (377 pmp) were treated with transplantation at end of calendar year 2014. 11 children and adolescents were treated with dialysis and 39 were treated with kidney transplantation at end of calendar year 2014. Most DHBs treat more patients with dialysis than transplantation, with the exception of Starship, Capital and Coast, Canterbury, and Southern DHBs (Figure 9). Most patients treated with dialysis in NZ received facility-based haemodialysis within a hospital centre or satellite unit (Figure 10). The proportion of dialysis patients receiving facility haemodialysis treatment continued to increase year on year from 27.6% in 2005 to 31.6% in 2014 (Figure 10). This continues to be due to an increase in the number of patients treated with dialysis, rising from 298 in 2005 (29.7% of all dialysis patients) to 491 in 2014 (34.9% of all dialysis patients). The proportion of dialysis patients treated with satellite dialysis has remained relatively unchanged (16.1% of dialysis patients in 2005 to 15.9% of patients in 2014). The number and proportion of dialysis patients treated with peritoneal dialysis (either automated or continuous ambulatory) has fallen from 38.2% of dialysis patients in 2005 to 30.4% in 2014. There has been a steady year on year increase in patients on automated peritoneal dialysis (from 185 (9.8%) in 2005 to 377 (14.0%) in 2014), while the number and proportion of patients on CAPD has fallen steadily (28.3% in 2005 to 16.4% in 2014). The proportion of patients treated with home haemodialysis has shown a small steady increase in the last decade from 298 to 491 patients between 2005 and 2014 (15.8% to 18.2%). The number of home haemodialysis patients as a proportion of all haemodialysis has remained between 25-28% over the previous decade. The overall proportion of dialysis patients treated with any home-based dialysis is decreasing (from 54.0% in 2005 to 48.6% in 2014).
5 Vascular access for haemodialysis Prevalent vascular access In 2014, 80.6% of prevalent haemodialysis patients were dialyzing with permanent vascular access (either an arteriovenous fistula or (Figure 13). This is above the national standard of 70%. Starship, Counties Manukau, Hawkes Bay, Mid Central, and Taranaki DHBs did not meet the national prevalent vascular access standard. The marked variation in use of arteriovenous grafts persisted in 2014, with the proportion of patients having dialysis through an AV graft was 0% at Starship, Hawkes Bay and Canterbury, and 13.3% and 11.4% at Waikato and Southern. Central venous catheter use remains high with a national average of 23.1%. These were predominantly tunnelled central venous catheters for all DHBs. The central venous catheter rate ranged from 10.0% at Southern to 39.3% at Taranaki. Data were missing for 2.5% of patients.
Incident vascular access (all patients starting dialysis) The national incidence of permanent vascular access at commencement of dialysis remained highly variable across treating DHBs (Figure 14). The proportion of all patients starting haemodialysis with permanent access (either a fistula or graft) ranged between 17.7% at Hawkes Bay and 50.0% at Capital Coast and Southern. Only Capital Coast and Southern achieved the national standard of 50% of patients commencing haemodialysis with permanent vascular access. As in previous years, very few DHBs achieved the national standard of permanent vascular access, indicating the need to review practices throughout the country.
Peritoneal dialysis peritonitis rates Rates of PD peritonitis are decreasing over time. Patients experience an episode of peritonitis for every 28.5 months of treatment. This compared with every 20.8 months in 2010 (Figure 18). All centres achieved the standard of one episode of PD peritonitis for every 18 months of treatment. There were no episodes of PD peritonitis reported at Mid Central (Figure 19). Wide variation in PD peritonitis rates at some treating DHBs make interpretation of trends difficult.
9 Late specialist assessment In this report, a late specialist assessment is defined as a first nephrology specialist assessment occurring within 90 days of commencing renal replacement therapy. Late specialist assessment may necessitate starting dialysis rather than receiving a kidney transplant as first treatment. Overall, 14.1% of patients started dialysis within 90 days of their first specialist assessment (compared with 14.8% in 2013) (Figure 26). The late assessment rate was generally <20% at all DHBs, ranging from 4.9% at Canterbury to 21.5% at Counties Manukau. The late assessment rate is likely to be multifactorial related to demography, clinical comorbidity and DHB primary and secondary care referral patterns. At Starship, 37.5% of children started dialysis within 90 days of first specialist assessment, although numbers were very small, and observed previously. There appeared to be no discernible trend in late assessment rate according to ethnicity (Table 2). Table 2 Late specialist assessment rate 2014, by ethnicity Non-Māori, non-Pacific (%) Māori (%) Pacific (%) 2010 15 19 16 2011 22 18 26 2012 15 17 17 2013 11 15 22 2014 14 8 21 10 Transplantation Information in this report supplements the yearly report from the National Renal Transplant Service (NRTS) (established in 2014). Transplantation rates include kidney transplants from living donors and deceased donors. A small number of New Zealanders receive a kidney transplant together with another transplanted organ. There were 72 living donor kidney transplants in 2014 and 62 deceased donor kidney transplants. Two patients received a combined kidney and liver transplant and 2 patients received a combined kidney and pancreas transplant. Overall, kidney transplantation rates (PMP) remain relatively unchanged (Figure 27), although the number increased in 2014. Transplantation rates remained markedly variable by DHB including the proportion of living to deceased donor transplantation. Rates of transplantation appear to be falling at Hawkes Bay and increasing (particularly living donation) at Counties Manukau (Figure 28).
When transplantation rates are calculated as relative to the number of treated dialysis patients, the transplantation rates remained highly variable (Figure 29). In 2014, the transplantation rate per 100 dialysis patients ranged from 0.3 at Hawkes Bay to 9.0 at Capital Coast. The national average was 5 per 100 dialysis patients. The wide variation in transplantation rates between referring DHBs is observed year on year and likely to be related to complex practice and characteristics. Kidney transplant exchange program In 2014, there were two kidney exchange chains completed, providing 2 kidney transplants each. ABO incompatible transplantation In 2014, there were 5 ABO incompatible kidney transplants performed at Auckland and 2 at Canterbury (Table 3). Table 3 Summary of ABO blood group incompatible kidney transplantation Transplant DHB Referring DHB Number Auckland Waitemata 2 Auckland Counties Manukau 1 Auckland Capital Coast 1 Auckland Taranaki 1 Canterbury Canterbury 2