Caring for Kidneys in the Antipodes: How Australia and New Zealand Have Addressed the Challenge of End-Stage Renal Failure

Geopolitical and Social Background 

Australia and New Zealand are independent nations, each with proudly autonomous political systems, mutually friendly, strong competitors with each other in many fields while genuinely cooperative in many others, and sharing important historical and social traits that create similar patterns of thought, but often subject to different geopolitical and economic constraints. They lie geographically in Oceania (Fig 1).

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Figure 1. Australasia subregion of Oceania, showing Australia and New Zealand. Australasia is often commonly referred to as the antipodes, a term that refers to places on the earth's surface that are diametrically opposite to each other. It is often used to denote Australia and New Zealand because of their situation as places on the opposite side of the globe to Europe. Adapted and reproduced from The World Factbook of the US Central Intelligence Agency.1

Australia is the only continent occupied by a single nation. Its land surface area of 2,941,283 square miles makes it the sixth largest country in the world (after China, Canada, Russia, the United States, and Brazil), but its population of only 21 million people makes it one of the most sparsely populated. Furthermore, some 85% of its inhabitants live in a dozen or so urban cities situated around its coastline. Its national capital, Canberra, is its only major inland city. Hence, it is one of the world's most urbanized nations despite relatively few people living in regional and rural areas that produce much of its vast mineral and agricultural wealth. Its climate ranges from tropical in the north to alpine in the south, surrounding a forbiddingly arid interior. The educational standards of its locally born inhabitants (mostly of Northern European ancestry) rank among the highest 5% in the world; although many of the political and economic refugees from Asia, the Middle East, and South America whom it has recently accepted as immigrants lack fluency in the English language and sometimes have lower literacy standards in their own languages, thereby reducing their ability to cope with illness. About 1% of Australia's population (although the figure is debated) are descendents of the country's pre-European aboriginal inhabitants; the significance of their social and health issues, including and especially in renal disease, far outweighs their numerical importance.

New Zealand has important geographical and social differences from Australia. It consists of 2 larger and several smaller islands with an area of only 105,755 square miles, occupied by just more than 4 million people. It therefore is about the same size as the American state of Colorado or just a little larger than the United Kingdom, but with a population of only about 7% as many as the latter. It also is highly urbanized, although its half-dozen largest cities are smaller than Australian ones, with populations ranging from about 100,000 to 1 million people. Its educational standards are even higher than Australia's, but its economy is somewhat weaker. Some 10% of its people are of native Maori ancestry, often educationally and economically reasonably successful, whereas another 10% are immigrants (especially from Polynesia), often with lower educational standards. The health problems of the Maori and other Polynesian peoples pose important challenges because of their propensity to develop metabolic diseases with renal impairment as a prominent feature.

Major hospitals in both Australia and New Zealand are publicly funded, as are their universal health insurance systems, although many people also purchase private insurance to ensure personalized attention from specialists and access to private hospitals in which standards of accommodation (although not clinical care) are often higher. The 2 countries' administrative arrangements differ significantly from each other, and neither is identical to any other country's system. General practitioners nevertheless underpin the system in each by initially assessing all patients and referring those who need complex care to specialists. Most nephrologists have attachments to public hospitals, which dominate arrangements for treating renal failure, although a few centers (many of them owned by international dialysis machine manufacturers) treat privately insured patients. Government systems in both countries heavily subsidize the costs of prescription medications, including those needed by patients with renal failure. Governments also fund the purchase of dialysis machines and consumables for home and public hospital use. Most of the nursing and paramedical staff members involved in renal care are salaried employees of government instrumentalities. Many nephrologists also are salaried employees of government hospitals, with some having rights of private practice; others are university-employed academics with conjoint hospital appointments; and yet others, especially in Australia, are self-employed practitioners with remunerated access to public hospitals. This system has changed little during the past 60 years.

Government boards in New Zealand and in each of Australia's 8 states and territories independently register physicians to practice and (when necessary) police their activities. Specialist accreditation requires completion of training approved by the Royal Australasian College of Physicians, the Royal Australasian College of Surgeons, and similar colleges for other disciplines. This usually takes about 5 years after the first medical degree and residency. Many subspecialties, especially nephrology and transplant surgery, traditionally have encouraged trainees also to work overseas before returning to take permanent local positions, although recent European regulations now limit this opportunity. Possession of higher research-based academic degrees, all achievable locally, is necessary for appointment to practice in many teaching hospitals.

Australasia (the term encompasses Australia with New Zealand) for many years had only 4 medical schools, all government owned. These were at the Universities of Sydney (founded 1850), Melbourne (1853), Otago (in Dunedin, New Zealand, 1869), and Adelaide (1874). They all encouraged medical research, but the opening of many additional medical schools associated with new universities founded after 1960 in the era that closely corresponded to the development of facilities for the treatment of patients with renal failure stimulated a proliferation of healthy competitive activity in the field by clinicians who held salaried or honorary academic positions.

An important unwritten, but long-standing, aspect of national policy in both countries has been a commitment to equality of opportunity for every resident. Both have long championed individual freedom and representative (“democratic”) government exercised through a Westminster-style parliamentary system (with parliaments in Australia not only for the federal government, but also for each state and territory) with checks and balances that culminate in the monarch (who for historical reasons is the same person for both countries and for each state in Australia, but who acts independently upon the advice of each government). An important consequence of this attitude for the development of renal failure services has been a desire to provide every citizen with whatever medical care is necessary and that society can somehow afford. This attitude has encouraged effective delivery of services at the same time that the relatively small population base and previous economic vicissitudes of both countries have inhibited innovation.

The Development of Dialysis 

In 1947, Willem Kolff2 published his book New Ways of Treating Uraemia, which showed for the first time that hemodialysis can be efficacious for the treatment of patients with renal failure. The Medical Journal of Australia promptly published a detailed and favorable review of this book3 and commented further on the subject on several subsequent occasions in the 1950s.4, 5, 6, 7 Kolff and others internationally were using dialysis at the time for the treatment of patients with acute renal failure, a situation that John Dique,8 a pathologist at the Royal Brisbane Hospital, emulated in 1955 when he constructed an artificial kidney machine locally and used it to treat a woman with postpartum acute renal failure. He treated many more patients with acute renal failure during the next 4 years.9, 10

Keith Kirkland, a urologist, imported an Alwall hemodialysis machine in 1957 to treat patients who had acute renal failure at Sydney Hospital. He immediately saw the potential benefits of the procedure and proposed that each large Australian city establish a renal unit with dialysis facilities.11 Physicians working at the Kanematsu Medical Research Institute at Sydney Hospital, led by Malcolm Whyte and David Edwards, soon afterward established dialysis as a standard treatment for patients with acute renal failure.12, 13, 14 In 1958, Vernon Marshall at the Alfred Hospital, and, shortly thereafter, John Niall at St Vincent's Hospital started dialysis in Melbourne, whereas others in Adelaide and at Prince Henry Hospital in Sydney all started similar treatments between 1961 and 1962.15, 16, 17, 18, 19 Surgeons in Australia started inserting the external vascular access shunts that Belding Scribner and his colleagues in Seattle had described in 1960 as soon as these became commercially available.20 These initially facilitated dialysis in Australia for patients with acute renal failure, although they immediately also opened the way for the successful treatment of long-term dialysis patients, especially after the introduction of arteriovenous fistulas in 1967. Peritoneal dialysis received less local attention than hemodialysis despite the influential publications of Boen21 and Maxwell et al22 in 1959. However, the mid-1960s saw the introduction in Australia of single-use peritoneal dialysis catheters by Bill Gurr23 at the Alfred Hospital in Melbourne, Trevor Wood24 at Royal Hobart Hospital, and John Stewart and F.C. Neale25 at Sydney Hospital.

Developments in New Zealand followed a pattern similar to those in Australia, although at later dates. J. Verney Cable26 introduced hemodialysis for acute renal failure at the Wellington Hospital in 1960, whereas Derek North and his collaborators at the Auckland Hospital started providing peritoneal dialysis in 1961.27 They followed this with hemodialysis in 1967.28 A patient with chronic renal failure who purchased his own dialysis machine was responsible for the introduction of hemodialysis in Christchurch in 1969.29

Later developments in dialysis tended to follow similar paths in both countries. The major hospitals in each of the Australian states and territories and in New Zealand all have the status of university teaching hospitals. Each of these in general acquired the capacity to perform both hemodialysis and peritoneal dialysis, mostly during the 1970s and 1980s. Some also developed home dialysis training facilities, most established or developed associations with satellite dialysis units, and all created their own transplantation programs or developed links with programs run by other institutions. Dialysis centers initially were all situated in state capital cities in Australia and the larger cities of New Zealand, although as time passed, renal physicians working in various regional centers developed comprehensive services in the hospitals that they attended. A progressive increase in patient numbers subsequently led to the development by the directors of many of the parent centers of satellite hemodialysis units, usually in smaller suburban and rural hospitals, but sometimes freestanding. The vast majority of these centers were originally and remain in public ownership under the control of state and territory governments, although commercial companies have set up a few facilities that cater to privately insured patients and overseas visitors. The number of parent units in 2007 ranged from 18 in each of New South Wales and Queensland to 1 in the Australian Capital Territory, whereas New Zealand had 10. The number of satellite units ranged from 64 in Victoria to 1 in Tasmania, whereas New Zealand had 9.

The Development of Transplantation 

The initial approaches to dialysis therapy largely focused on the treatment of patients who had acute renal failure, but they prepared the way for the management of long-term dialysis patients in whom local interest was developing because of the possibility of introducing renal transplantation. The unsuccessful early attempts at transplantation in Europe and the United States (reviewed by Papalois et al30) had failed to impress Australasian surgeons, but the report in 1955 by Hume et al31 of their experiences in Boston encouraged Richard Lovell and Maurice Ewing at Royal Melbourne Hospital to attempt a nonimmunosuppressed grafting procedure in 1956.32 This failed. The proposal by Roy Calne of an immunosuppressive regimen based upon the combination of corticosteroids and azathioprine followed by the first successful transplantations in the United States in 1962 using that protocol led Ewing's group at the Royal Melbourne Hospital to undertake a further series of operations starting in August 1963 using cadaveric donors.33 Their first 4 recipients died after a brief postoperative course, with the result that it was not until April 1965 that they had a successful outcome. A group at Queen Elizabeth Hospital in Adelaide led by James Lawrence and Peter Knight, who started performing transplantations in February 1965, performed the first successful grafting in Australia, in their case from a living donor.34, 35 A team led by Campbell Maclaurin and Derek North in Auckland undertook a successful transplantation in New Zealand between identical twins in May 1965.36 They, together with Peter Doak, went on to establish a cadaveric program during the following year.37 A group at Prince Henry Hospital in Sydney, led by David Jeremy and Gerald Murnaghan, also started performing transplantations from both living and cadaveric donors in August 1965.

Teams at several other Australasian hospitals started renal transplantation programs during the next few years, as listed in Table 1. Some amalgamations of various programs later occurred, but 2 distinct patterns of organization emerged; 1 of centralized transplantation for all patients who were waiting within a given state and the other of diversified transplantation. The former system has prevailed in Queensland, where all operations occur at Princess Alexandra Hospital, and in South Australia, where all adult operations occur at Queen Elizabeth Hospital. The latter has prevailed in New South Wales, Victoria, and Western Australia, where several units compete for patients. The Australian Capital Territory, the Northern Territory, and, nowadays, Tasmania send their patients to larger centers for their surgery.

Table 1. Dates of the Start of Kidney Transplantation at Australian and New Zealand Hospitals

	Year	Hospital	Country or State	References
	1963	Royal Children's Hospital	Victoria
	1956, 1963, 1965	Royal Melbourne Hospital	Victoria	32, 33
	1965	Queen Elizabeth Hospital	South Australia	34, 35
	1965	Auckland Hospital	New Zealand	36, 37
	1965	Prince Henry/Prince of Wales Hospital	New South Wales
	1967	Alfred Hospital	Victoria
	1967	Royal Perth Hospital	Western Australia	38
	1967	Sydney Hospital	New South Wales	39, 40, 41
	1967	Royal Prince Alfred Hospital	New South Wales	39, 40, 41
	1967	St Vincent's Hospital	Victoria
	1968	Royal Hobart Hospital	Tasmania
	1969	Wellington Hospital	New Zealand	42
	1969	St Vincent's Hospital	New South Wales
	1969	Princess Alexandra Hospital	Queensland	43
	1972	Monash Medical Centre	Victoria
	1969	Christchurch Hospital	New Zealand	44
	1973	Dunedin Hospital	New Zealand
	1974	Austin Hospital	Victoria
	1974	Waikato Hospital Hamilton	New Zealand
	1975	Fairfield Hospital	Victoria
	1976	Concord Hospital	New South Wales
	1977	Mater Hospital	New South Wales
	1979	Princess Margaret Hospital	Western Australia
	1979	Sir Charles Gairdner Hospital	Western Australia
	1979	Sydney Children's Hospital	New South Wales
	1980	Royal Newcastle/John Hunter Hospital	New South Wales
	1981	Women's and Children's Hospital	South Australia
	1983	Royal North Shore Hospital	New South Wales
	1984	Monash Medical Centre (Pediatric)	Victoria
	1986	Westmead Hospital	New South Wales
	1993	St George Hospital	New South Wales
	1995	Westmead Children's Hospital	New South Wales
	1997	Flinders Medical Centre	South Australia
	1998	Hollywood Hospital	Western Australia
	2000	St John of God Hospital	Western Australia

Centralized tissue-typing laboratories developed in the capital cities of each Australian state and New Zealand at an early stage of the development of their transplant programs. All units undertaking transplantation traditionally have relied heavily on HLA typing to foster good results. An early feature of transplantation in the 2 countries was consequent recognition that large donor pools would also enhance results. A consequence of this was the development in 1970 of a national exchange program between all transplantation units in both Australia and New Zealand that has continued to operate, albeit with occasional modifications to its rules, until the present time.45 A related consequence of this was an early interest in the development of novel formulae for the composition of organ-preservation fluids.46

Some Subsequent Trends in the Renal Failure Program 

Certain distinctive trends have emerged over the years as the renal failure program has developed in Australia and New Zealand. The development of an Australian transplant registry in 1965 and a dialysis registry in 1971, with their subsequent amalgamation to create the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) in 1976, has provided a wealth of valuable information concerning both modalities of treatment, underpinned by the confidence that they have succeeded in capturing virtually every patient receiving long-term dialysis or having a renal transplant in the 2 countries. Comparison of information from consecutive reports enables one to examine trends in types of patients and their treatments.47, 48

The number of people receiving regular dialysis treatment in Australia has increased from 1,092 (77 per million population [pmp]) in 1978 to 9,182 (446 pmp) in 2007. The corresponding figures for New Zealand showed an increase from 171 (55 pmp) in 1978 to 1,971 (476 pmp) in 2007. The number of people living in Australia with a functioning renal transplant increased from 2,215 (156 pmp) in 1978 to 6,845 (332 pmp) in 2007. The corresponding figures for New Zealand were 347 (111 pmp), increasing to 1,253 (303 pmp). This meant that the total number of people in the 2 countries receiving renal replacement treatment increased from 3,825 to 19,251.

The incidence of new patients starting treatment for end-stage renal disease increased from about 30 pmp to about 116 pmp in both countries during the same period. Mean age when starting treatment increased from 40 to 60.7 years in Australia and correspondingly in New Zealand, but at a slightly lower level.

Approximately a third of all new patients in both countries had glomerulonephritis as their primary renal disease in 1977, with diabetes accounting for only 5% in Australia against 18% in New Zealand. However, the pattern had changed by 2007, with glomerulonephritis decreasing to 23% in Australia and 21% in New Zealand, whereas diabetes had increased to 32% and 42%, respectively. Conversely, analgesic nephropathy decreased from 22% to 2% in Australia, whereas it had never contributed significantly in New Zealand. Cardiovascular diseases have always been the most common cause of death of both dialysis patients and transplant recipients in both countries.

Australia and New Zealand have always had a relatively high proportion of their dialysis patients undertaking self-administered treatment at home, either on artificial kidney machines or by peritoneal dialysis. The absolute numbers of patients undertaking home hemodialysis have continued to increase during the years, although the proportion of the entire end-stage renal failure population receiving this form of therapy has progressively decreased. In 1977, a total of 51% of Australian dialysis patients and 47.5% of New Zealand patients were undertaking home hemodialysis, whereas the figures decreased to 12.2% and 26.4% by 2006. Peritoneal dialysis increased markedly in popularity in the late 1970s and early 1980s soon after continuous ambulatory treatment became available, but gradually decreased thereafter as increasing numbers of satellite centers became available.

Both Australia and New Zealand sourced most kidneys that they used as they started their transplantation programs from deceased donors. However, a gradual change developed later as increasing numbers of living people, principally related, although occasionally altruistic-unrelated, offered to donate, often stimulated by the length of the cadaveric waiting lists. The initial focus on donation from deceased individuals stimulated an early and continuing interest in the ethical, philosophical, and legal implications of dialysis and transplantation, an interest that was inevitably encouraged by the rich heritage of general philosophical enquiry that existed in both countries. The importance of such considerations then reflected into the background organizational and administrative arrangements that prevailed in ways that enhanced the entire undertaking.

Organizational and Administrative Background 

The development and maintenance of a program as complex as that involved with the management of patients with end-stage renal failure at a national level inevitably requires the existence of an interacting network of institutions and secondary organizations to create a milieu in which clinicians and hospitals can work effectively. Australia and New Zealand have been singularly fortunate in this regard because both their governments and structural elements in their nongovernmental civil societies have been persistently and uniformly supportive.

Transplantation in particular requires a conducive legal framework in which to flourish. Without it, clinicians find themselves repeatedly at risk of infringing laws in ways that threaten severe penalties. Events that had a profound effect on creating a benign atmosphere in this regard in Australasia were first a forum held by The Australian Postgraduate Foundation in Medicine in 1968, and second, the reference of the issue of human tissue transplantation by the Attorney-General of Australia to the Australian Law Reform Commission in 1976. The former resulted in a detailed local analysis of various philosophical, moral, psychological, social, and legal issues surrounding the subject, including a profoundly influential dissertation by the internationally renowned jurist, Zelman Cowan (who, as Sir Zelman, later became Governor General of Australia).49, 50, 51 Similar discussions occurred in New Zealand.52, 53 The Law Reform Commission's Report was tabled in the Australian Parliament on September 21, 1977, and provided a template for the parliaments of the various Australian states and territories to enact reasonably uniform legislation to sanction existing ad hoc practices, legitimize the concept of brain death, and permit future cautious liberalization of the use of tissues from deceased donors.54, 55, 56 The thrust of each of these events was to replicate the most advanced thinking on the subject in other countries and enable the local jurisdictions to remain competitive in advancing beside other first-world countries in the area of transplantation.

The National Health and Medical Research Council in Australia is a federal organization that has a key role in advising government on medical issues. It established a committee in 1968 to report on rationalization of facilities for organ transplantation and dialysis. This report also had a profound effect on future local developments in the field. It recommended that governments (state and federal) take steps to prevent the development of renal failure, establish organ transplantation and renal units, encourage the integration and collaboration between hospitals for such purposes, accept a staffing model that it proposed for such units, establish training programs for staff members, establish tissue-typing laboratories, select patients on only medical grounds for treatment, support transplant donor procurement programs, and support research. The report provided a considerable boost to the field locally, although it attracted some criticism in that it was dominated by protransplantation thinking. It thus recommended that “In general, recurrent haemodialysis should be restricted to patients awaiting transplantation,” and it opined that only “A small number of patients unsuitable for transplantation require recurrent haemodialysis as a definitive form of treatment.”57 The report, despite its lack of balance on this aspect, nevertheless had a strong positive influence on the development of facilities nationally, especially because another role of the Council was and remains to provide substantial governmental funding for selected areas of medical research.

Another organization that has strongly supported medical research in Australia, as has its counterpart in New Zealand, has been Kidney Health Australia (initially known as The Australian Kidney Foundation). It was established in 1968, modeled upon similar organizations in the United States and Britain. It has systematically raised money during the years to support research into many aspects of renal disease and their treatment, as well as exercising an advocacy role on behalf of patients and a supportive organizational role for beneficial moves in the field. The 3 most important of these have been the development of the ANZDATA, the holding of biennial dialysis and transplantation workshops for the promotion and integration of treatment methods throughout Australia and New Zealand, and the development in conjunction with the Cochrane Foundation of the Caring for Australians with Renal Insufficiency (CARI) practice guidelines. Each of these, as in so many other aspects of the local renal failure initiatives, can be argued merely to reflect best practice developments internationally. However, that hardly detracts from their importance because without them, the field would inevitably have stagnated locally, whereas their existence has ensured a broad application to all Australians and New Zealanders of innovations soon after they have gained international acceptance.

Many of the activities of the Kidney Foundations in the 2 countries have occurred in conjunction with the Australian and New Zealand Society of Nephrology (originally The Australasian Society of Nephrology). This organization, founded in 1965, has regularly held an annual scientific meeting that rotates between various cities in the 2 countries, established committees to deal with issues of importance to the field, promoted research, and fostered (in conjunction with The Royal Australasian College of Physicians) the training of young nephrologists. It had an important role, in conjunction with the Asian Pacific Society of Nephrology (to which many Australasian nephrologists also belong) in the foundation of the journal Nephrology in 1995. The Transplantation Society of Australia and New Zealand, founded in 1982, also has had a crucial role in promoting research and administrative issues through its annual scientific meeting and committees. The Renal Society of Australasia (formerly The Dialysis Society of Australasia), founded in 1972, has similarly provided a forum especially for nurses, technicians, and allied health professionals with interests in the field of chronic renal failure. Australians and New Zealanders also have participated actively in various international organizations of relevance, especially the International Society of Nephrology and the Transplantation Society. Two past presidents of the former, Professors Priscilla Kincaid Smith and Robert Atkins, have come from Australia, whereas it held its annual congress in Sydney in 1997. Two presidents of the latter, Sir Peter Morris and Professor Jeremy Chapman, have also come from Australia, whereas it held its annual congresses in Sydney in 1988 and 2008.

A most satisfying outcome of the comprehensive background support available in Australia and New Zealand in the field of chronic renal disease has been the wealth of research activity that individual clinicians, scientists, hospitals, and tertiary institutions have undertaken over the years. Fashions have changed progressively in the aspects that have attracted workers, but they have produced a continuing flow of publications in both local and international journals. Current areas of particular note include the promotion of home and nocturnal dialysis, as well as the effective provision of treatment to disadvantaged aboriginal and Maori populations on the one hand and the subjects of chronic allograft nephropathy and xenotransplantation on the other. One might nevertheless argue that despite this continuing wealth of activity, no single paradigm-shifting research has ever emanated from either Australia or New Zealand in the field of chronic renal disease. However, a counterargument to this would be that the solidity of the research undertaken and the achievement of comprehensive egalitarian treatment programs for the entire populations of the 2 countries in the face of major geographic, economic, and social impediments have of themselves represented a worthy outcome.