In Australia, >1.7 million adults older than the age of 18 years have indicators of CKD, such as reduced estimated glomerular filtration rate (eGFR) or proteinuria. This equates to 1 in 10 Australian adults, with even higher incidence among indigenous Australians (Aboriginal and Torres Strait Islanders) of 1 in 5 ¹¹ who make up approximately 3.8% of the total Australian population (estimated to be 983,700 people as of June 2021). In contrast to the nonindigenous population where the CKD burden appears to be predominantly situated in major cities, the highest CKD burden in the indigenous population is found in remote and very remote areas (remote 34% vs. nonremote 13%). ^, Along with remoteness, major factors contributing to these higher rates include socioeconomic deprivation, poor access to health care, and the long-term impacts of colonization and racism. With the growth in CKD burden, the number of patients with end-stage kidney failure (ESKF) has doubled in Australia over the past decade and is currently >28,000 patients. ^, This growth is not surprising and is an inevitable consequence of background increase in both behavioral (e.g., inactive/insufficiently active: 56%; smoking on daily basis: 16%) and biomedical (e.g., overweight or obese: 63%; high blood pressure: 32% [including 22% with uncontrolled high blood pressure]) risk factors for CKD in the Australian general population. Diabetes mellitus is the fastest growing chronic disease, and diabetic nephropathy has become the most common cause of ESKF in Australia (37%) as a result. ^, Inherently, the burden of CKD relates to not only the health care requirements of patients who progress to ESKF but also broader public health through its close association with CVD, which affects 22% of Australian adults. CKD was estimated to cause 1.1% of the total burden of disease and injury in Australia in 2022 with nearly 73% of this burden attributed to years of life lost due to premature death. The rate of burden was 7.8 times higher in indigenous Australians compared with nonindigenous Australians. Patients with CKD incur 85% higher health care costs and 50% higher government subsidies than individuals without CKD. In 2021 Kidney Health Australia estimated the annual cost of CKD to be A$9.9 billion, which includes expenditure on health services, the impact on productivity, and individual costs. ^, The overall cost per person living with CKD in 2021 was A$41,795 rising to >A$182,000 for those with kidney failure.

According to the Australia and NZ Dialysis and Transplant (ANZDATA) Registry, there were 3281 new KRT patients in Australia in 2021 ( Fig. 79.2 ), with an overall incidence rate of 127 per million population (pmp). Although this rate has remained stable for several years, the number of prevalent patients has continued to climb with 28,542 (1109 pmp) patients receiving KRT at the end of 2021.

Number of new patients commencing kidney replacement therapy from the 1960s to 2020 in Australia and New Zealand.

From ANZDATA Registry. 45th report. Chapter 1 : Incidence of kidney failure with replacement therapy. Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia. < http://www.anzdata.org.au >; 2022.

The mean ages of female and male patients commencing KRT were 58.7 years and 61.2 years, respectively. The most common cause of ESKF among incident KRT patients in Australia is diabetes mellitus (37%), followed by glomerulonephritis (17%), hypertension (12%), polycystic kidney disease (6%), reflux nephropathy (2%), and others. In 2021, more than half (53%) of ESKF patients received dialysis, which comprised facility (hospital or satellite) hemodialysis (75%), peritoneal dialysis (PD; 17%), and home hemodialysis (8%). Patient survival on hemodialysis has remained relatively unchanged over the past few years. The ongoing costs of caring for a patient with ESKF on dialysis are significant and greatest for in-center hemodialysis (A$76,881/person per year), followed by satellite hemodialysis (A$63,505), PD (A$51,640), and home hemodialysis (A$47,775).

Aboriginal and Torres Strait Islander Australians experience higher rates of kidney failure at all ages older than the age of 15 years ( Fig. 79.3 ), with greater disparities among indigenous women. There are marked differences in treatment modalities for Aboriginal/Torres Strait Islanders with the majority treated with faculty-based hemodialysis (74%) with few accessing home dialysis (either hemodialysis or PD) ( Fig. 79.4 ). Unfortunately, this has significant impacts on the social and cultural values important to Aborigines and Torres Strait Islanders because these individuals, by dialyzing in facility units often at great distances from their homes, are removed from their people and country with major negative impacts on their mental health and well-being.

Dialysis Modality Australia 2021.

From ANZDATA Registry. 45th report. Chapter 2 : Prevalence of kidney failure with replacement therapy. Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia. < http://www.anzdata.org.au >; 2022.

Patient survival on hemodialysis at kidney replacement therapy start.

Australia 2010–2020, censored for transplant and transfer to PD.

From ANZDATA Registry. 45th report. Chapter 4 : Haemodialysis. Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia. < http://www.anzdata.org.au >; 2022.

With the growth in the prevalent ESKF population, facility hemodialysis capacity has been saturated and attention has been drawn to enhancing the capacity of home dialysis, particularly PD, which makes up 70% of all home dialysis patients in Australia. Although patient survival on PD is comparable with hemodialysis (1 year 94% [95% confidence interval {CI}: 93%–95%], 3 years 75% [95% CI: 73%–76%], 5 years 55% (95% CI: 52%–56%)], this is significantly modified by the age of the patients with 5 year survival rates of 85% (95% CI: 81–88) for those <40 years compared to 50% (95% CI: 48–52) for those aged 65 to 74 years. Further uptake of PD has been hampered by relatively limited time on PD (3 years 37% [95% CI: 35%–39%]). Time on PD (previously referred to as technique survival) has improved slowly over the years but remains relatively low and is driven by infection (19%; e.g., peritonitis) inadequate dialysis (18%; e.g., inadequate fluid ultrafiltration and solute clearance) and mechanical issues (12%). Despite improvement in existing PD guidelines, along with the development of key performance indicators to meet evidence-based practice, and reinforcement of PD training, which has led to a significant improvement in PD peritonitis rates, there remains a large (sevenfold) variation in peritonitis rates among PD units and up to twofold variation between states. Although some of these differences relate to patient-level risk factors (e.g., living distantly from PD unit and indigenous ), the majority of the risk has been shown to be associated with modifiable center-level characteristics (e.g., center size, proportion of PD, and peritoneal equilibration test use at PD start). ^,

In 2021, 857 (33 pmp) transplants were performed in Australia, 202 of which were live-donor kidney transplants. The reduced numbers reflect the impact of the COVID pandemic as pre-COVID transplant numbers were as high as 1149 per annum (2018), which was the highest number ever performed (40 pmp, which is still only about 30% of the rate of incident ESKF patients [127 pmp]). ^,

The number of renal transplants has consistently increased (2004: 650 patients; 2018: 1149 patients), largely from an increase in the rate of deceased-donor renal transplantation in the context of a national reform program “Donate Life” led by the Australian Organ and Tissue Donation and Transplant Authority (AOTDTA) to increase organ donation rate ( www.donatelife.gov.au ). With the growing burden of CKD and patients with ESKF requiring KRT, there has been a focus on increasing transplant rates as it confers benefits at both patient (e.g., improved survival) and government levels (e.g., cost-effective treatment, estimated cost in the first year A$65,375 [deceased-donor renal transplant] to A$70,553 [live-donor renal transplant], with ongoing cost from the years thereafter of A$10,749/year]). An increased rate of kidney transplantation has translated into a growth in the prevalence of patients with functioning grafts to 13,349 patients (519 pmp) in 2021 compared with 6981 patients (341 pmp) in 2005. Unfortunately, Aboriginal/Torres Strait Islanders are markedly underrepresented, making up only 3% of the prevalent transplant recipients in 2021. Similar within-country disparities in transplant rates involving ethnic minorities have been reported previously in Canada and the United States. There have been specific initiatives commenced to try to address these inequalities of access with the setting up of the National Indigenous Kidney Transplantation Taskforce: changing systems to achieve equitable access to kidney transplantation. A number of culturally specific recommendations, along with developing an Aboriginal and Torres Strait Islander kidney health workforce and building effective change-enabling structures to improve the delivery of culturally safe care, have been published. ^,

For first-time recipients of kidney transplants in Australia, the 1-year graft survival rate was excellent, especially for living-donor kidney transplantation recipients (99% vs. 96% in deceased-donor recipients). The 5-year survival rates for primary transplants during 2015–2021 are 92% and 83%, respectively. Although the long-term outcomes (i.e., >10-year graft survival) have also improved gradually, the trend has been less evident compared with short-term outcomes. ^,

According to the ANZDATA Registry, the most common cause of graft loss during the years 2012–2021 was death with a functioning graft ( n = 2447, 47.7%), followed by chronic allograft nephropathy ( n = 1320, 25.7%). The most common cause of death was cancer ( n = 353, 26%), followed by CVD ( n = 308, accounting for 23% of deaths). Relative cancer mortality is higher than the general population (standardized mortality rate [SMR] 2.9, 95% CI: 2.7–3.1) with nonmelanoma skin cancer (SMR 50.9, 95% CI: 43.5–59.6) and lymphoma (SMR 42.2, 95% CI: 35.3–50.5) the highest in transplant recipients. Although the patient survival rates are superior after transplant compared with remaining on dialysis, the risk of death remains significantly greater than in the general population by up to 10-fold.

The exact number and characteristics of patients who choose not to dialyze when they reach ESKF is unknown. The Patient Information about Options for Treatment (PIVOT) study observed that 14% of incident stage V CKD patients chose a no-dialysis pathway, but this is likely to be an underestimate of true disease burden because it did not account for patients who were never referred to nephrology services in the first instance. It has been suggested that for every patient who dies while receiving KRT, there is another patient who has died without accessing KRT. ^,

Acute kidney injury (AKI) has a broad range of causes. It is commonly diagnosed in general hospitalized patients in developed countries such as Australia (e.g., critically ill patients admitted to intensive care units in the context of sepsis). Another cause of AKI relatively unique to Australia includes snakebites caused by hemotoxic or myotoxic snakes, such as brown snakes, which account for more than half of all hospitalized snakebites in Australia. There have been reports of thrombotic microangiopathy-like presentations after brown snakebites with resultant severe AKI requiring temporary treatment with hemodialysis and plasma exchange.

In Australia, hospitalizations due to AKI have more than doubled between 2000–2001 and 2012–2013 (from 8050 to 18,010), representing an increase of 6%/year. More recent studies using a laboratory-based algorithm detected AKI in 12.4% of all hospitalizations in 16.4% of patients admitted to 4 metropolitan hospitals in Sydney Australia, over a 5-year period, whereas hospital coding for AKI significantly underreported AKI incidence. Even though the deaths due to AKI have remained relatively similar over the past decade (an average of 4670 deaths/year between 2000 and 2012), the average length of stay in AKI hospitalizations was about twice as long as the average length of stay for hospitalizations overall (11.4 days vs. 5.6 days). People living in remote areas, in socioeconomically disadvantaged areas, and with Aboriginal and Torres Strait Islander status were associated with higher rates of hospitalizations and mortality due to AKI. ^, There was a high rate of infections as the primary cause of AKI with the age groups skewed to a much younger age group than the national average. Again, there was significant underreporting of AKI on the discharge summaries.

The burden of kidney disease (AKI, CKD, and ESKF) in indigenous Australians is disproportionately greater compared with that in nonindigenous Australians (see Fig. 79.3 ) ^, and affects these patients at an earlier age. For instance, of all the patients who commenced KRT for treatment of ESKF in Australia between the years 2010 and 2021, 59% of indigenous patients were younger than 55 years old, compared with 31% of nonindigenous patients. Although the most common cause of ESKF in Australia is diabetic nephropathy for both groups, the proportion of indigenous patients with diabetic nephropathy is more than double that of nonindigenous patients (69% vs. 35%). Differences in the causes of CKD and AKI across these two groups are more challenging to describe in detail because data are not as readily available due to a lack of established CKD and AKI registries (the ANZDATA only includes ESKF patients who received dialysis or kidney transplantation). The reasons for ethnic inequality in the burden of kidney disease among indigenous Australians have been attributed to higher levels of socioeconomic disadvantage ^{, ,} residence in “remote” and “very remote” areas of Australia and a high burden of chronic diseases, such as diabetes mellitus, which is an important cause of kidney disease. ^, Many other contributory factors include poorer nutrition, higher tobacco use, alcohol consumption, and lower levels of education attainment, employment, social support, and housing, as well as the impact of colonization and racism. ^{, ,} Moreover, there is a greater proportion of indigenous patients who reside in remote and very remote areas of Australia, where access to and use of health services are more challenging.

In recognition of a significant deficit in health outcomes of indigenous patients in Australia, on December 20, 2007, the Council of Australian Governments agreed to work with indigenous communities to achieve the target of “closing the gap” on indigenous disadvantage. The Closing the Gap campaign aims to address gaps in not only the areas of health but also education and employment. One of the three main health goals includes targeting main components of the life expectancy gap and chronic diseases, such as CKD and diabetes mellitus. Some of the listed targets to improve outcomes in this area include attainment of blood pressure targets in patients with type 2 diabetes mellitus and stabilization of all-cause incidence of ESKF within 5–10 years. In order to help support access to appropriate medications, indigenous patients with chronic diseases or at risk of developing chronic diseases, such as CKD, are eligible to access the Closing the Gap Pharmaceutical Benefits Scheme copayment measure to help access most prescription medications at a lower price or free of charge, depending on eligibility criteria ( http://www.humanservices.gov.au/ ). Following implementation of the scheme, improvements in health care access and a declining trend in indigenous mortality rates from chronic diseases have been observed. However, significant discrepancies between Aboriginal and Torres Strait Island people and the general population remain. These include much higher rates of hospitalization for care involving dialysis (age-standardized rate at ⁴⁵³ per ¹⁰⁰⁰ compared with per ¹⁰⁰⁰ ), with dialysis responsible for % of all hospitalizations for indigenous Australians. The rate of burden due to CKD for indigenous Australians was eight times that for nonindigenous Australians. Although age-standardized death rates for kidney disease among indigenous Australians had declined, the gap between indigenous and nonindigenous Australians has not changed significantly.

Also, as discussed earlier, there are considerable inequities for Aboriginal and Torres Strait Island people accessing transplantation. To address this, numerous specific initiatives commenced to try to address these inequalities of access. For example, the National Indigenous Kidney Transplantation Taskforce ^, was established to change systems to achieve equitable access to kidney transplantation. A myriad of culturally specific recommendations, along with developing an Aboriginal and Torres Strait Islander kidney health workforce and building effective change-enabling structures to improve the delivery of culturally safe care, have been published. ^,

One of the main predictors of poor patient outcomes in those with ESKF has included late referral, defined as less than 3 months between referral and KRT commencement. Although there are cases for which prevention or early recognition may not be possible, most CKD cases should have been able to be recognized in primary care and reviewed by a nephrologist before imminently requiring KRT. In appreciation of the importance of early recognition of CKD, several initiatives have been developed and evolved over the years in Australia. These have focused on empowering health care providers to recognize risk factors for CKD to trigger screening, optimally manage risk factors to retard progression of disease, and know when a specialist referral is indicated. These include the “Kidney Health Check” through Kidney Health Australia and the Primary Care Education Advisory Committee for Kidney Health Australia to increase awareness, as well as implementation of best practice detection and management of CKD ( www.kcat.org.au ). Other strategies to improve quality of care delivery in primary care settings include development of customized software programs to integrate with primary care electronic health care records. This allows real-time promotion of detection and management of CKD according to best practice recommendations (eMAP:CKD) and provision of decision support tools for health care providers (Health Tracker, George Institute).

Although clear guidelines exist on indications for referral to a nephrologist in Australia (e.g., eGFR <30 mL/min/1.73 m ² ), some remote living patients are unable to be reviewed easily by nephrologists. In areas where telehealth facilities are available, nephrologists from the nearest renal units have managed selected patients with CKD via telehealth with local nursing support and coordination.

Information on patients with ESKF receiving KRT is well described through the ANZDATA Registry, which collects a wide range of statistics relating to the outcomes of treatment of those with ESKF from all renal units in Australia and NZ ( www.anzdata.org.au ). Data relating to CKD are also collected through the Australian Institute of Health and Welfare (AIHW) ( www.aihw.gov.au ) and Australian Health Survey from the Australian Bureau of Statistics ( http://www.abs.gov.au/australianhealthsurvey ). To further enhance understanding of disease and outcomes, several newer registries have been developed over the past decade, including statewide collaborative multidisciplinary research and practice programs in various states across Australia, such as CKD.QLD (Chronic Kidney Disease in Queensland, https://cre-ckd.centre.uq.edu.au/CKD.QLD ), the Registry of Kidney Diseases (Victoria), and for specific disease groups, such as for glomerulonephritis (QLD. GN Registry).

The NZ health care system is predominantly publicly funded by taxes. Twenty District Health Boards (DHBs) have recently been amalgamated into a single health authority—Te Whatu Ora, with the proposed aim to improve health equity across the nation. Te Whatu Ora regional entities are responsible for funding health care services to their catchment population within a geographic region, providing acute care services, and promoting the health of the population. All public hospital and specialist outpatient services within the public system are free, while attendance in primary care incurs some payment, based on income. KRT (dialysis or kidney transplantation) is provided nearly entirely within the public health care system. Renal specialists provide dialysis and transplantation care through hospital-based remuneration and are not incentivized to provide specific dialysis treatment modalities. Citizens or permanent residents of NZ and dependencies (Niue, the Cook Islands, and Tokelau) receive treatment for ESKF within the tax-funded public health system in New Zealand. Auckland, the largest city in New Zealand, has an estimated population of 1.6 million and is also home to the largest population of Pacific people (approximately 240,000) of any city in the world.

In Aotearoa/New Zealand, the true proportion of the population who have CKD is unknown, as census or systematic observational data have not been reported. The prevalence of CKD, defined as an eGFR <60 mL/min/1.73 m ² or the presence of albuminuria >3 mg/mol (A2-3), has been estimated in the Otago Southland region (a population of just under 400,000) at 11.8% consistent with prevalence rates in a comparable Australian population. Increasing age, female sex, ethnic groups (Māori and Pacific people), social deprivation, and diabetes mellitus were associated with a higher risk of CKD. CKD was more prevalent in Māori (odds ratio 1.56, CI 1.45–1.69) and Pacific people (odds ratio 2.62, CI 2.28–3.01) even after adjustment for confounding factors including the presence of diabetes mellitus when compared with the NZ European population. These data emphasize the importance of nondiabetic kidney disease in Māori and Pacific people despite diabetic nephropathy being the most common cause of ESKF in these groups. Previous studies have demonstrated higher rates of glomerular and hypertensive kidney disease in Māori and Pacific people. ^,

More recently, data from the two largest primary health care providers in South Auckland with 25,132 registered patients, of whom 37.5% were NZ European, 29.7% Samoan, 12.2% Māori, and the rest either other Pacific Island groups or Asian, demonstrated an overall prevalence of CKD of 13.0% ( Table 79.1 ). However, the prevalence of CKD in the Samoan cohort was 17.8%, Māori 10.4%, and NZ European 7.1%, with the other Pacific Island groups having a prevalence between 15.7% and 21.8% for CKD. However, only 47.5% of this population had actually been tested for CKD despite the known increased risk of CKD within Māori and Pacific communities. The prevalence of CKD among those actually tested, using the KDIGO criteria for CKD, rose to 36.3% for Samoans, with similar high percentages for other Pacific Island groups and Māori at 24.1%, and NZ European at 15.6% (see Table 79.1 ). The true prevalence probably lies between these two sets of values. It is important to note that individuals registered by primary health care providers represents nearly the entire population. To access primary health care in New Zealand, an individual needs to be registered with a primary health care provider.

Approximately 700 NZ patients (including 28 children and adolescents) commenced KRT and 187 patients received a kidney transplant in 2021 while 472 patients are actively on the waiting list for kidney transplantation. The incidence of new patients starting KRT in NZ was 137 pmp in 2021; although the incidence has largely plateaued in the past 2 years, it reflects an ongoing increase over time with currently 5452 patients (1054 pmp) receiving KRT consisting of 2297 individuals with a transplant and 3155 on dialysis. There is considerable regional variation in the incidence of treated ESKF across the country with higher rates in Northern regions, excluding higher-income areas of Auckland.

Diabetes is the most frequent cause of treated ESKF in Aotearoa/New Zealand, with 54% of patients treated with dialysis and 22% of kidney transplant recipients having a diagnosis of diabetes. Risk factors for CKD frequently coexist including socioeconomic deprivation, obesity, dyslipidemia, and hypertension. ^,

The annual health expenditure in Aotearoa/NZ has risen on average 5.1% compared with annual population growth of 1.3% between 1990 and 2010. The total health expenditure was NZ$30 billion in 2022, and in 2022 it accounted for 11.2% of real GDP, like many peer nations in the Organization for Economic Co-operation and Development. ^, The estimated health costs attributable to CKD in NZ have been estimated, comparing a cohort commencing dialysis in 2014/2015 with a cohort receiving a kidney transplant in 2014/2015. The first year of dialysis was associated with total patient costs of NZ$150,878 of which the majority was dialysis costs. Projected costs over the life expectancy of each cohort estimated that dialysis will cost >NZ$1 million compared with NZ$0.5 million for a transplant recipient. In addition, the value of improved quality of life from transplantation could be up to NZ$0.5 million. In addition, loss of productivity for those on dialysis was estimated to be NZ$47,026 per person per year. ^, Recent studies have estimated the direct costs of diabetes in NZ to account for NZ$2.1 billion (0.67% of NZ GDP) with the bulk of the costs being direct public health system costs, but economic costs to the individuals and their families are also substantial (approximately half of the estimated total costs). The provision of dialysis is estimated to cost 1% of New Zealand’s health expenditure.

The incidence of treated ESKF in NZ is not equitable, with an incidence of 88 pmp for New Zealand European patients, compared with incidences of 209 pmp for Māori and 398 pmp for Pacific patients, giving a 3.5-fold difference in the incidence of treated ESKF ( Fig. 79.5 ). ^, These rates continue to increase, especially for Pacific people ( Fig. 79.6 ). There is considerable regional variation in the incidence of treated ESKF across the country with higher rates in Northern regions, excluding higher-income areas of Auckland. Notably, the age of onset for diabetes diagnosis is 10 years younger among non-European ethnicities in NZ, in parallel with the premature onset of treated ESKF at younger age groups for Māori and Pacific patients.

Incidence of kidney replacement therapy by ethnicity—Aotearoa, New Zealand 2017–2020.

From ANZDATA Registry. 45th report. Chapter 9 . Kidney failure in Aotearoa New Zealand. Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia. < http://www.anzdata.org.au >; 2022.

Incidence of kidney replacement therapy—Aotearoa, New Zealand.

From ANZDATA Registry. 45th report. Chapter 9 . Kidney failure in Aotearoa New Zealand. Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia. < http://www.anzdata.org.au >; 2022.

The prevalence of individuals treated for ESKF in NZ varies over threefold by ethnicity, with a prevalence of 767 pmp for NZ European patients, 1453 pmp for Māori, and 2656 pmp for Pacific patients. The most common cause of treated ESKF for incident patients in NZ varied due to ethnicity with diabetic kidney disease accounting for 66% in Māori, 63% in Pacific, and 28% in NZ European; glomerulonephritis accounting for 13% in Māori, 12% in Pacific, and 25% in NZ European; hypertension accounted for 13% in NZ European, 5% in Māori, and 4% in Pacific; and polycystic kidney disease accounted for 8% in NZ European and only 1% in Māori and Pacific. Overall, the incidence rates for Māori and Pacific are markedly higher than those for NZ Europeans with the inequity likely confounded and underestimated by the younger age at presentation for Māori and Pacific people.

There is marked inequity in kidney transplantation rates in NZ based on ethnicity. Despite an age-standardized risk of ESKF for Māori and Pacific patients, approximately 2 to 10 times that for NZ European patients, the rate of kidney transplantation is markedly lower.

In 2021, 37 Māori patients received a kidney transplant (42 pmp) while 26 Pacific patients received a kidney transplant (64 pmp), compared with 120 NZ Europeans (32 pmp). This compares with dialysis incidences of 216 pmp and 272 pmp for those populations, respectively. In addition, recent increases in preemptive kidney transplantation appear to be favoring NZ European patients, whereas Māori and Pacific are less likely to receive a preemptive transplant when compared with NZ Europeans. This phenomenon of increased disparity in transplantation rates during periods of improved access through better service delivery have been similarly observed in Australia, Canada, and the United States. In addition, there is considerable variation between NZ renal centers in the rate of transplantation, varying between 9 pmp and 46 pmp, which in part reflects geographic isolation.

Māori patients with CKD have experienced marginalization within the NZ health care system due to a number of factors including inequities in the provision of early detection and preventive care, rurality, delayed referral to specialist care, the impact of systemic racism and colonialization, and a lack of awareness by clinicians of important cultural aspects related to health and the involvement of family (whanau) in decision making. In addition, there is often a multigenerational fear of dialysis, which needs to be overcome by the early involvement of whanau and peers in identifying CKD and aligning decision making with patient priorities. ^, In recognition of these inequalities, members of Caring for Australians and New Zealanders with kidney impairment (CARI) developed clinical practice guidelines for management of CKD for Māori in Aotearoa NZ. They highlight the need for cultural safety; the need to address social determinants of risk factors for kidney health, such as justice, housing, education, and poverty; the provision of whanau-based care (family) within an indigenous health framework including building knowledge about CKD and health issues that contribute to it using whanau-focused and culturally safe strategies.

The incidence of treated ESKF in NZ is similar to that of neighboring Australia (127 pmp in 2021). The incidence of dialysis varies markedly by nephrology center catchment area with the highest rate for Counties Manukau (including South Auckland; 611 pmp) and Waikato (496 pmp) and lowest for Southern (45 pmp) and Canterbury (78 pmp) regions, with differences between regions related in part to ethnicity and socioeconomic opportunity.

Overall, 3155 people were treated with dialysis in NZ in 2021, accounting for a prevalence of 610 pmp. Together with kidney transplantation (444 pmp), the overall prevalence of KRT for Aotearoa/NZ in 2021 was 1054 pmp, which is nearly identical to neighboring Australia (947 pmp) and comparable with the average of the nation-states of the European Union (1090 pmp).

Older age groups have the highest incidence of KRT with the highest incidence among people in the 65- to 74-year-old age group. However, for Māori and Pacific people, the highest incidence is in the 45- to 54-year-old age group, which in turn has a far greater impact on both the individual and their whanau (family) because they are often the key income earners or have the major role in family care. Of the 28 children and young adults (0 to 25 years old) commencing KRT in 2021, 2 received a preemptive transplant, 8 commenced PD, and 18 commenced hemodialysis. The proportion of adults older than 85 years of age starting dialysis remains low. ^,

Overall, most prevalent patients with treated ESKF in NZ are treated with dialysis (61.2%; Fig. 79.7 ). NZ has the highest global rate of home-based dialysis therapy (38% of those on dialysis). In 2021, 12.0% of patients treated with dialysis in NZ did home hemodialysis, 26% did PD (CAPD or APD), and 62% received faculty (hospital or satellite) hemodialysis. There is marked regional variation in home hemodialysis uptake, ranging from 12% of all dialysis patients treated at the Capital and Coast District region to 58% at the Southern region. Regional variation is likely related to the different clinical approachs to the provision of home dialysis (two centers, Canterbury and Southern), maintain an extensive home dialysis program, remoteness, comorbidity, and socioeconomic factors. Home-based hemodialysis among children is rare.

Prevalence of dialysis and transplantation in Aotearoa New Zealand.

From ANZDATA Registry. 45th report. Chapter 9 . Kidney failure in Aotearoa New Zealand. Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia. < http://www.anzdata.org.au >; 2022.

In NZ, hemodialysis is accessed in three principal settings: facility (hospital or satellite), community house, or home. Community house hemodialysis involves patients performing their hemodialysis independently without direct nursing or medical supervision in an unstaffed nonmedical community homelike setting and is used in two DHB regions (Counties Manukau and Hawke’s Bay), serving approximately 650,000 people. In a 10-year analysis between 2000 and 2010, 113 patients commenced dialysis in a community house setting.

Median patient survival on hemodialysis in NZ varies with modality, age, and ethnicity. The median survival for those aged 25 to 44 years is 8 years, 45 to 64 years is 5.5 years, 65 to 74 years is 3.7 years, 75 to 84 years is 2.8 years, and 85+ years is 2.2 years. There is a 52% lower risk of mortality with home dialysis during the first 3 years of dialysis and beyond, although this difference may not be present for Pacific patients. ^, The median survival for PD in NZ is 3.92 years (95% CI: 2.11–6.34), although it varies substantially by age, comorbidity, and time. ^{, ,}

The costs of dialysis are not publicly available. Estimations of dialysis and transplant treatment costs are available from the Auckland Regional Renal Report in 2002–2004. In that report, annual costs (including routine dialysis treatments, hospitalizations, physician assessment not related to dialysis, and transportation) were estimated at US$44,053 for hospital hemodialysis, US$32,995 for satellite hemodialysis, US$25,078 for continuous APD, and US$23,003 for home hemodialysis. Costs of APD are not available.

Three centers perform kidney transplantation in NZ: Auckland, Wellington, and Christchurch. Simultaneous kidney and pancreas transplants are performed in Auckland, as are combined solid organ transplants. In 2021, there were 187 kidney transplants performed in NZ, of which 87 were from live donors. This represents a rate of 36 pmp. Of the recipients, Māori made up just 20% despite the much higher proportion of Māori with ESKF. ^, The number of transplant operations each year has continued to increase over the past 5 years and is likely to be related to quality improvement initiatives arising from government funding over the previous decade. Other contributing factors include the NZ kidney exchange program and ABO-incompatible kidney transplantation. Of note, transplant rates in NZ were not dramatically affected by the COVID-19 pandemic. Currently, there are ²²⁹⁷ people with a functioning graft in NZ. ^,

As is observed in Australia, the most frequent cause of graft loss is death with a functioning transplant (442 patients during 2012–2021; 51.6%), followed by chronic allograft nephropathy (193 patients; 22.5%). The most common causes of death for transplant recipients are cancer (29.8% of all deaths), with nonmelanoma skin cancer and lymphoma the major two malignancies, and CVD (25.5% of all deaths). ^,

Few systematic data exist for the incidence and outcomes related to AKI in Aotearoa/NZ in adults. Limited data suggest that the crude hospital mortality for patients admitted to intensive care with AKI (42.7%) is substantially higher than for those patients without AKI (13.4%), although in the decade through 2006, mortality decreased among patients with AKI.

For children, the annual incidence of AKI between 2001 and 2006 was 4.0 per 100,000 children younger than 15 years of age, most commonly associated with cardiac surgery (58%), hemolytic uremic syndrome (17%), and sepsis (13%). Survival of AKI to hospital discharge for children was 89%, with evidence of ongoing kidney impairment in 40%. Māori and Pacific children are treated for AKI more often in part related to the high rates of rheumatic heart disease and poststreptococcal glomerulonephritis in both Māori and Pacific children compared with NZ European children.

CKD and AKI are managed collaboratively across the health sector in primary, secondary, and tertiary care. At present, hospital-based dialysis services are provided by 11 secondary or tertiary-level hospitals to their own regions. CKD is most identified within primary care settings, and referral is made to nephrology services for virtual or in-person consultation.

Expenditure on ESKF care is about 1% of total health expenditure. ESKF treatment is nearly entirely funded through the publicly funded health system. All inpatient and outpatient secondary-level health care services including hospital-based care are free to patients, as are pharmaceuticals prescribed within secondary services. Primary care services are subsidized, although patients may be required to pay for services above any subsidy they receive. Similarly, prescriptions in the primary care setting accrue direct costs to the patient.

Regional centers based around a tertiary hospital provider are provided a budget, weighted according to the services they provide and the demographic and socioeconomic characteristics of their population. Budgetary constraints occur, such that centers are incentivized to manage funds within their allocation including dialysis and transplantation care. This has led to inequities in accessing timely and appropriate kidney care, especially as it related to those who live rurally, which includes a significant number of Māori. ^, In particular, there is little in the way of subsidies for travel to a regional center, which further adds to the inequities of accessing care, especially for Māori who frequently cannot afford the costs of travel or the loss of income associated with having to spend considerable time accessing health care from remote settings. Qualitative research has documented the considerable social disruption arising from dialysis treatment in NZ because of living remotely from dialysis and transplantation care. This has also contributed to inequities in the delivery of health care, especially implementation of kidney disease management.

Late assessment by a specialist nephrologist (within 3 months of requiring KRT) is associated with poorer clinical outcomes and reduces the likelihood of preemptive transplantation. In NZ, approximately 10% of patients experience late assessment, although this proportion is decreasing, with rates for Māori (12%) and Pacific people (9%) compared with NZ European (10%).

There have been some nationwide programs in NZ to guide primary and secondary care practitioners in assessment and referral of patients with CKD. These include the Best Practice Advocacy Centre (bpac ^nz ) detailed review of CKD management for general practitioners (GPs ( https://bpac.org.nz/2022/ckd.aspx ), along with Health Pathways, which are principally designed to support primary care clinicians to manage patients in the community and guide referral practices for specialist assessment ( www.healthpathwayscommunity.org ). Decision aids for patients and clinicians making choices about treatment for ESKF have been developed by Kidney Health NZ, an established patient advocacy group.

A randomized clinical trial of community-based visits by nurse-led health care assistants for medication adherence and algorithm-guided blood pressure care in Māori and Pacific patients led to greater use of medications, lower blood pressure, and reductions in proteinuria, suggesting an effective model of primary care for CKD. Unfortunately, when funding finished for this project, the benefits were quickly lost. Challenges to wider adoption of newer primary care practices to prevent ESKF include limited resourcing for nursing, availability of secondary care services to upskill primary care clinicians, and adequate protocols to integrate medical management across primary and secondary care. A recent systematic review of studies examining the effectiveness of chronic disease management programs of indigenous people in Australia, NZ, and Canada demonstrated that effective and acceptable programs were those that were integrated in existing health services, were nurse led, provided intensive follow-up, had governance structures supporting local leadership, included robust clinical systems for communication, and involved indigenous health workers as central to practice.

NZ has a National Health Index that assigns a unique number to each person in NZ who receives health care. This includes information on name, address, date and place of birth, gender, resident and citizen status, ethnicity, and (if appropriate) date of death. The National Health Index number can be linked to other national and international health information repositories. An important aspect of health information used to drive health care improvement is the accurate recording of ethnicity data, especially for Māori and identifying health inequalities. Specific protocols for the collection, recording, and output of ethnicity data are described for the Health and Disability Sector, with a specific focus to improve health outcomes and reduce health inequity. Key requirements include 1. ethnicity as self-identification, 2. ethnicity is context specific and can change, 3. more than one ethnicity can be recorded, and 4. a standardized approach increases the accuracy of ethnicity data for decision making. It is likely, due to increasing availability of large data sets, routine capture of diagnostic codes, and the National Health Index, that additional census data for kidney diseases will become available in the future.

As well as a strong focus on addressing the health inequities that Māori face, there is also heightened awareness of the similar health issues faced by Pacific people living in NZ, as well as in Pacific Islanders. The next sections highlight the impact of kidney disease in the Pacific Islands.