Abstract
Background: In Aotearoa/New Zealand, Maori, as the indigenous people, experience chronic kidney disease at three times the rate of non-Maori, non-Pacific New Zealanders. Maori commence dialysis treatment for end-stage kidney disease at three times the rate of New Zealand European adults. To examine for evidence of inequity in dialysis-related incidence, treatment practices, and survival according to indigeneity in Aotearoa/New Zealand, utilising a Kaupapa Maori approach.
Methods: We conducted a retrospective cohort study involving adults who commenced treatment for end-stage kidney disease in Aotearoa/New Zealand between 2002 and 2011. We extracted data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) linked to the New Zealand National Health Index (NHI). Propensity score methods were used to assemble a cohort of 1039 Maori patients matched 1: 1 on clinical and socio-demographic characteristics with a cohort of 1026 non-Maori patients. We compared incidence of end-stage kidney disease and treatment practices. Differences in the risks of all-cause mortality during treatment between propensity-matched cohorts were estimated using Cox proportional hazards and generalised linear models.
Results: Non-Maori patients were older, more frequently lived in urban areas (83% versus 67% [standardised difference 0.38]) and bore less socioeconomic deprivation (36% living in highest decile areas versus 14% [0.53]). Fewer non-Maori patients had diabetes (35% versus 69%, [-0.72]) as a cause of kidney failure. Non-Maori patients were more frequently treated with peritoneal dialysis (34% versus 29% [0.11]), received a pre-emptive kidney transplant (4% vs 1% [0.19]), and were referred to specialist care < 3 months before treatment (25% vs 19% [0.15]) than Maori patients. Fewer non-Maori started dialysis with a non-tunnelled dialysis vascular catheter (43% versus 47% [-0.08]). The indigenous-age standardised incidence rate ratio for non-Maori commencing renal replacement therapy in 2011 was 0.50 (95% CI, 0. 40-0.61) compared with Maori. Propensity score matching generated cohorts with similar characteristics, although non-Maori less frequently started dialysis with a non-tunnelled venous catheter (30% versus 47% [-0.35]) or lived remotely (3% versus 14% [-0.50]). In matched cohorts, non-Maori experienced lower all-cause mortality at 5 yr. after commencement of treatment (risk ratio 0.78, 95% CI 0.72-0.84). New Zealand European patients experienced lower mortality than Maori patients in indigenous age-standardised analyses (age-standardised mortality rate ratio 0.58, 95% CI 0.51-0.67).
Conclusions: Non-Maori patients are treated with temporary dialysis vascular access less often than Maori, and experience longer life expectancy with dialysis, even when socioeconomic, demographic, and geographical factors are equivalent. Based on these disparities, health services should monitor and address inequitable treatment practices and outcomes in end-stage kidney disease care.