Carmel M. Hawley

Description:Background: Patients with kidney failure receiving chronic kidney replacement therapy (KRT: dialysis or kidney transplantation) have increased risks of postoperative mortality and morbidity. This study assesses the outcomes of acute cholecystitis in patients on chronic KRT who undergo cholecystectomy compared to nonoperative management. Methods: This bi-national population cohort study evaluated all incident and prevalent patients receiving chronic KRT using linked data between Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry and jurisdictional hospital admission datasets between 2000 and 2015. Patients with a primary diagnosis of acute cholecystitis were identified using the International Classification of Diseases (ICD) and were divided into two groups: patients who underwent cholecystectomy and those who received nonoperative management. Comorbidity-adjusted Cox models were used to determine the associations of cholecystectomy with 30-day and 12-month mortality. Results: From the 46 779 patients on chronic KRT, there were 1520 patients with an initial emergency presentation of acute cholecystitis, of whom 87% received nonoperative management. Thirty-day mortality risk was no different between the two groups (5.4 vs. 5.1%, p = .83). Despite higher odds for nonfatal outcomes including composite cardiovascular complications (MI, CVA, cardiac arrest: OR 2.08, 95% CI (1.13-3.81)), ICU admission (OR 3.51, 95% CI (2.41-5.10)), and blood transfusions (OR 2.29, 95% CI (1.60-3.27)), surgery was associated with improved survival at 12 months compared with nonoperative management (HR 0.61, 95% CI (0.43-0.87)). Patients who received nonoperative management had a higher 30-day readmission rate (17.6 vs. 12.5%, p = .44). Conclusions: In patients with acute cholecystitis, compared with nonoperative management, surgery was associated with better survival at 12 months but higher rates of early morbidity.

Description:BackgroundPeritonitis is a serious complication associated with risks of death and transfer to haemodialysis for patients receiving peritoneal dialysis (PD). To mitigate such risks, it is important to identify potentially reversible risk factors, such as hypokalaemia.MethodPatients who started PD at the Princess Alexandra Hospital, Australia from 1st January 2013 to 31st December 2022 were included. Hypokalaemia, defined as serum potassium <3.5 mmol/L, was assessed at the time of PD initiation and evaluated as categories (<3.5 mmol/L, 3.5-4.5 mmol/L and >4.5 mmol/L) based on 6-month average after PD commencement. Time to first peritonitis was examined using multi-variable Cox survival analyses censored for transplantation, recovery of kidney function or loss to follow up. Competing risk regression was conducted as sensitivity analysis. Peritonitis rates were compared using Poisson regression analysis.ResultsIn total, 486 patients were included. 6-Month average serum potassium level was <3.5 mmol/L in 30 patients (6.2%), 3.5-4.5 mmol/L in 301 patients (62%) and >4.5 mmol/L in 155 patients (32%). During the study period, 192 patients experienced peritonitis with comparable proportions across all three groups (35%, 40% and 40%, respectively). Using multi-variable regression modelling, we found that time to first peritonitis was not significantly associated with hypokalaemia based on 6-month average (hazard ratio 1.14, 95% confidence interval [CI] 0.67-1.95) or baseline hypokalaemia (hazard ratio 0.73, 95% CI 0.34-1.54). Using the categories based on 6-month average serum potassium level, mean peritonitis rate was higher among patients in the <3.5 mmol/L group (0.79 episodes/patient-year) compared to those in the 3.5-4.5 mmol/L (0.61 episodes/patient-year) and >4.5 mmol/L (0.47 episodes/patient-year), whilst the difference was not significant (p = 0.14).ConclusionIn this study, no significant association was identified between hypokalaemia and risk of peritonitis, although estimates were imprecise.

Description:Objective: Our study aims to define the rates of mortality and nonfatal complications in patients with kidney failure undergoing elective endovascular aortic aneurysm repair (EVAR) for the management of infrarenal abdominal aortic aneurysm (AAA) in Australia and New Zealand. Methods: A retrospective bi-national data linkage between the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and state-based health-related datasets identified patients receiving chronic kidney replacement therapy (KRT) who underwent EVAR for AAA between 1 January 2000 and 31 December 2015. Linked data were interrogated to define patient demography, modality of KRT, date of death, and the occurrence of specific nonfatal complications. Patients were categorised by modality (haemodialysis (HD), peritoneal dialysis (PD), home haemodialysis (HHD), and kidney transplant (KT)), and logistic regression analysis was used to determine the rates of 30-day and twelve-month mortality, as well as nonfatal postoperative complications. Results: During the study period, 367 patients receiving KRT underwent 397 EVAR procedures for AAA. Of these, 216 (54%) were performed electively, and 181 (46%) were performed emergently. The rate of elective EVAR was 0.25 per 100 patient-years, with the majority of cases (51%) occurring in patients receiving HD. Overall, 30-day mortality following elective EVAR was 2.7% (95% CI 0.4-5.1), with HD patients being at greatest risk at 4.2% (95% CI 0.4-8.0). Postoperative infective complications were more common than cardiovascular complications. Twelve-month mortality following elective EVAR was 18.3% (95% CI 13.1-23.4) for the entire cohort, with HD and PD patients being at approximately equivalent risk. All adverse outcomes were observed with greater frequency following emergency EVAR compared with those undertaken electively. Conclusions: Patients on chronic KRT have high rates of morbidity and mortality following elective EVAR. This should be accounted for during shared decision making and when considering the relationship between risk and benefit in the management of AAA in this population.

Description:Limited consumer involvement in chronic kidney disease (CKD) research may reduce its relevance, impact, and transferability into practice and policy. We aimed to describe the current landscape of consumer (patients with CKD and caregivers) involvement in published CKD research. Electronic databases were searched to August 2023. Articles describing consumer involvement in CKD research were eligible. All text were imported into NVivo for line-by-line coding using descriptive synthesis of these domains: defining involvement, purpose of involvement, selection, stages of the research, resources, and evaluation. We included 106 articles that involved over 4500 consumers from 15 countries. Eighty-two articles (77%) defined consumer involvement, using 8 different terms. Forty-three articles (41%) addressed reasons for involving consumers in research. Consumers were predominantly identified through clinical or patient networks based on demographic or clinical characteristics. Those involved at higher levels (e.g., coresearcher/patient partner) often had medical or academic training. Consumers were rarely drivers or commissioners of research (n = 6, 6%) and were most likely to be involved as informants (n = 81, 76%) with limited decision-making power. Most articles described consumer involvement in priority setting (n = 48, 45%) and research design (n = 57, 53%) with less evidence of involvement in implementation (n = 28, 26%) and evaluation (n = 24, 22%). Barriers included limited resources (i.e., financial, logistical, or training) and the need for tailored solutions continue to exist. Consumer involvement resulted in increased recruitment and retention, richer data, and more useful outputs for end users. Consumers were mostly involved in discrete activities with limited decision-making power. Increasing financial, logistical, and training resources for consumers may support more meaningful involvement. Ongoing evaluation of processes or impacts of consumer involvement, including consistent reporting, is needed to strengthen evidence and practice in CKD research.

Description:Deceased donor kidney allocation relies on HLA compatibility at the antigen level, as optimal matching reduces the risk of acute rejection. Whether HLA allele-level mismatches improve, the prediction of acute rejection after transplantation remains unclear. Using data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) from 2017 to 2020, HLA antigenic and allelic mismatches between recipients and deceased donors were calculated with imputation of two-field allelic equivalents undertaken where required. The discordance between antigen and allele mismatches was calculated, and oblique random survival forest models were used to predict acute rejection. Predictive performance of antigen (HLA-A, -B, -DRB1 and -DQB1), allele (HLA-A, -B, -DRB1 and -DQB1) and extended allele (HLA-A, -B, -C, -DRB1, -DQA1 and -DQB1) models was examined using concordance index and integrated Brier scores, with variable importance calculated using permutation-based methods. Among 2644 recipients followed for a median of 1.7 years, 521 recipients (20%) experienced acute rejection. Discordant numbers of antigenic and allelic mismatches occurred in 8%, 9%, 24% and 17% of HLA-A, -B, -DRB1 and -DQB1 loci, respectively. Predictive performances were similar across all models, with concordance indices of 0.62-0.63 and integrated Brier scores of 0.09. HLA-DRB1 and -DQB1 mismatches were the strongest predictors of acute rejection across models. In patients matched at the HLA-DRB1 or -DQB1 antigen, those with allelic mismatches had similar incidences of rejection compared to those without. Allelic-level assessment of HLA compatibility did not improve the prediction of acute rejection and may disadvantage certain recipients by reclassifying them into higher mismatch categories in allocation algorithms without providing clear clinical benefit.