Long-term clinical outcomes of bariatric surgery in adults with severe obesity: A population-based retrospective cohort study.

BACKGROUND: Bariatric surgery leads to sustained weight loss in a majority of recipients, and also reduces fasting insulin levels and markers of inflammation. We described the long-term associations between bariatric surgery and clinical outcomes including 30 morbidities. METHODS: We did a retrospective population-based cohort study of 304,157 adults with severe obesity, living in Alberta, Canada; 6,212 of whom had bariatric surgery. We modelled adjusted time to mortality, hospitalization, surgery and the adjusted incidence/prevalence of 30 new or ongoing morbidities after 5 years of follow-up. RESULTS: Over a median follow-up of 4.4 years (range 1 day-22.0 years), bariatric surgery was associated with increased risk of hospitalization (HR 1.46, 95% CI 1.41,1.51) and additional surgery (HR 1.42, 95% CI 1.32,1.52) but with a decreased risk of mortality (HR 0.76, 95% CI 0.64,0.91). After 5 years (median of 9.9 years), bariatric surgery was associated with a lower risk of severe chronic kidney disease (HR 0.45, 95% CI 0.27,0.75), coronary disease (HR 0.49, 95% CI 0.33,0.72), diabetes (HR 0.51, 95% CI 0.47,0.56), inflammatory bowel disease (HR 0.55, 95% CI 0.37,0.83), hypertension (HR 0.70, 95% CI 0.66,0.75), chronic pulmonary disease (HR 0.75, 95% CI 0.66,0.86), asthma (HR 0.79, 95% 0.65,0.96), cancer (HR 0.79, 95% CI 0.65,0.96), and chronic heart failure (HR 0.79, 95% CI 0.64,0.96). In contrast, after 5 years, bariatric surgery was associated with an increased risk of peptic ulcer (HR 1.99, 95% CI 1.32,3.01), alcohol misuse (HR 1.55, 95% CI 1.25,1.94), frailty (HR 1.28, 95% 1.11,1.46), severe constipation (HR 1.26, 95% CI 1.07,1.49), sleep disturbance (HR 1.21, 95% CI 1.08,1.35), depression (HR 1.18, 95% CI 1.10,1.27), and chronic pain (HR 1.12, 95% CI 1.04,1.20). INTERPRETATION: Bariatric surgery was associated with lower risks of death and certain morbidities. However, bariatric surgery was also associated with increased risk of hospitalization and additional surgery, as well as certain other morbidities. Since values and preferences for these various benefits and harms may differ between individuals, this suggests that comprehensive counselling should be offered to patients considering bariatric surgery.

Association of Glomerular Filtration Rate Decline With Clinical Outcomes in a Population With Type 2 Diabetes.

Background: While historical rate of decline in kidney function is informally used by clinicians to estimate risk of future adverse clinical outcomes especially kidney failure, in people with type 2 diabetes the epidemiology and independent association of historical eGFR slope on risk is not well described. Objective: Determine the association of eGFR slope and risk of clinically important outcomes. Design Setting and Patients: Observational population-based cohort with type 2 diabetes in Alberta. Measurement and Methods: An Alberta population-based cohort with type 2 diabetes was assembled, characterized, and observed over 1 year (2018) for clinical outcomes of ESKD, first myocardial infarction, first stroke, heart failure, and disease-specific and all-cause hospitalization and mortality. Kidney function was defined using KDIGO criteria using the most recent eGFR and albuminuria measured in the preceding 18 months; annual eGFR slope utilized measurements in the 3 years prior and was parameterized using three methods (percentiles, and linear term with and without missingness indicator). Demographics, laboratory results, medications, and comorbid conditions using validated definitions were described. In addition to descriptive analysis, odds ratios from fully adjusted logistic models regressing outcomes on eGFR slope are reported; the marginal risk of clinical outcomes was also determined. Results: Among 336 376 participants with type 2 diabetes, the median annual eGFR slope was -0.41 mL/min/1.73 m2 (IQR -1.67, 0.62). In fully adjusted models, eGFR slope was independently associated with many adverse clinical outcomes; among those with ≤10th percentile of slope (median -4.71 mL/min/1.73 m2) the OR of kidney failure was 2.22 (95% CI 1.75, 2.82), new stroke 1.23 (1.08, 1.40), heart failure 1.42 (1.27, 1.59), MI 0.98 (0.77, 1.23) all-cause hospitalization 1.31 (1.26, 1.36) and all-cause mortality 1.56 (1.44, 1.68). For every -1 mL/min/1.73 m2 in eGFR slope, the OR of outcomes ranged from 1.01 (0.98, 1.05 for new MI) to 1.09 (1.08, 1.10 for all-cause mortality); findings were significant for 10 of the 13 outcomes considered. Limitations: Causality cannot be established with this study design. Conclusions: These findings support consideration of the rate of eGFR decline in risk stratification and may inform clinicians and policymakers to optimize treatment and inform health care system planning.

Contexte: Bien que les antécédents de déclin de la fonction rénale soient utilisés de manière informelle par les cliniciens pour estimer le risque d'issues cliniques défavorables ­ particulièrement l'insuffisance rénale terminale (IRT) ­ chez les diabétiques de type 2, l'épidémiologie de la pente du DFGe et son association indépendante sur ce risque demeurent mal décrites. Objectif: Examiner l'association entre la pente du DFGe et le risque de résultats d'importance clinique. Sujets et conception de l'étude: Étude de cohorte observationnelle basée sur une population d'Albertains atteints de diabète de type 2. Méthodologie et mesures: Nous avons constitué, caractérisé et observé une cohorte d'Albertains atteints de diabète de type 2 sur une période d'un an (2018) pour les résultats cliniques suivants: IRT, premier infarctus du myocarde (IM), premier AVC, insuffisance cardiaque, ainsi que les hospitalisations et la mortalité liées à la maladie et à toutes causes confondues. La fonction rénale a été définie selon les critères KDIGO à partir des plus récentes valeurs de DFGe et d'albuminurie mesurées dans les 18 mois précédents. La pente annuelle du DFGe a été calculée à partir des mesures effectuées au cours des trois années précédentes et paramétrée selon trois méthodes (percentiles, termes linéaires avec et sans indications de données manquantes). Les données démographiques, les résultats de laboratoire, les médicaments et les comorbidités ont été décrits selon les définitions validées. En plus de l'analyze descriptive, des rapports de cotes (RC) pour les résultats liés au déclin du DFGe ont été établis à l'aide de modèles de régression logistique entièrement ajustés; le risque marginal des résultats cliniques d'intérêt a également été déterminé. Résultats: Parmi les 336 376 diabétiques de type 2 participants, la pente annuelle médiane du DFGe s'établissait à −0,41 ml/min/1,73 m2 (ÉIQ: −1,67 à 0,62). Dans les modèles ajustés, la pente du DFGe a été associée de façon indépendante à plusieurs issues cliniques défavorables. Parmi ceux qui présentaient une pente du DFGe ≤10e percentile (médiane: −4,71 ml/min/1,73 m2), le RC était de 2,22 (IC 95 %: 1,75 à 2,82) pour l'insuffisance rénale; de 1,23 (1,08 à 1,40) pour les nouveaux AVC; de 1,42 (1,27 à 1,59) pour l'insuffisance cardiaque; de 0,98 (0,77 à 1,23) pour les nouveaux IM; de 1,31 (1,26 à 1,36) pour les hospitalisations toutes causes confondues et de 1,56 (1,44 à 1,68) pour la mortalité toutes causes confondues. Pour chaque tranche de - 1 ml/min/1,73 m2 de la pente du DFGe, le RC des résultats cliniques variait de 1,01 (0,98 à 1,05) pour les nouveaux IM à 1,09 (1,08 à 1,10) pour la mortalité toutes causes confondues; les résultats étaient significatifs pour 10 des 13 résultats examinés. Limites: La causalité ne peut pas être établie avec ce plan d'étude. Conclusion: Ces résultats plaident en faveur de la prise en compte du taux de déclin du DFGe dans la stratification du risque. Ils peuvent également aider les cliniciens et les décideurs à optimiser le traitement et à planifier les systèmes de soins de santé.

Associations of Estradiol With Mortality and Health Outcomes in Patients Undergoing Hemodialysis: A Prospective Cohort Study.

Background: Both lower and higher estradiol (E2) levels have been associated with increased mortality among women with kidney failure. However, robust data are still lacking. Objective: We investigated the interaction of diabetes and age on linear and nonlinear associations between E2 levels, adverse outcomes, and health-related quality of life (HRQOL) in Canadian women undergoing hemodialysis (HD). Design: Population-based cohort study; data from Canadian Kidney Disease Cohort Study (CKDCS). Setting & patients: A total of 427 women undergoing HD enrolled in the CKDCS. Measurements: Baseline E2 (in pmol/L) and E2 tertiles (<38 pmol/L, 38-95 pmol/L, >95 pmol/L). Methods: Cox-proportional hazards used for all-cause and cardiovascular disease (CVD) mortality. Fine-Gray models used for incident CVD. Mixed models used for Health Utilities Index Mark 3 (HUI3), Kidney Disease Quality of Life Physical Component Scores (KDQOL12-PCS), and Mental Component Scores (KDQOL12-MCS). Results: Over a median follow-up of 3.6 (interquartile range [IQR]: 1.6-7.5) years, 250 (58.6%) participants died; 74 deaths (29.6%) were CV-related. Among 234 participants without prior CV events, 80 (34.2%) had an incident CVD event. There were no significant linear associations between E2 and all-cause mortality, CVD mortality, and incident CVD. However, E2 showed a significant concave association with all-cause mortality, but not with CVD mortality and incident CVD. Among patients aged ≥63 years, higher E2 levels were associated with lower HUI3 scores, mean difference (MD) = -0.062 per 1 - SD pmol/L, 95% confidence interval (CI) = -0.112 to -0.012, but the opposite was observed in younger patients (<63 years) in whom higher E2 levels were associated with higher HUI3 scores (MD = 0.032 per 1 - SD pmol/L, 95% CI = 0.008-0.055), Pinteraction = .045. No associations were observed among E2, KDQOL12-PCS (MD = -0.15 per 1 - SD pmol/L, 95% CI = -1.15 to 0.86), and KDQOL12-MCS (MD = -0.63 per 1 - SD pmol/L, 95% CI = -1.82 to 0.57). Limitations: Unmeasured confounding and small sample size. Conclusions: The association between E2 and all-cause mortality may be nonlinear, while no association was observed for CVD mortality, incident CVD, KDQOL12-PCS, and KDQOL12-MCS. Furthermore, the association between serum E2 and HUI3 was modified by age: Higher levels were associated with higher utility among women aged <63 years and the converse observed among older women.

Contexte: Les taux faibles comme les taux élevés d'estradiol (E2) ont été associés à une mortalité accrue chez les femmes souffrant d'insuffisance rénale. Les données fiables à ce sujet font cependant encore défaut. Objectif: Nous avons étudié l'incidence du diabète et de l'âge sur les associations linéaires et non linéaires entre les niveaux d'E2, les issues défavorables et la qualité de vie liée à la santé (QVLS) chez les Canadiennes suivant des traitements d'hémodialyse (HD). Conception: Étude de cohorte en population réalisée à partir des données de la Canadian Kidney Disease Cohort Study (CKDCS). Sujets et cadre de l'étude: 427 femmes sous HD inscrites à la CKDCS. Mesures: Le taux d'E2 initial (pmol/L) et les taux d'E2 tertiles (<38 pmol/L; 38-95 pmol/L; >95 pmol/L). Méthodologie: Des modèles à risques proportionnels de Cox ont été utilisés pour mesurer la mortalité toutes causes confondues et la mortalité liée aux maladies cardiovasculaires (MCV). Des modèles Fine-Gray ont été utilisés pour mesurer les MCV incidentes; et des modèles mixtes ont été utilisés pour calculer l'indice Health Utilities Index Mark 3 (HUI3) et les scores des composantes physique (KDQOL12-PCS [Physical Component Score]) et mentale (KDQOL12-MCS [Mental Component Score])) du questionnaire sur la qualité de vie (KDQOL). Résultats: Au cours d'un suivi médian de 3,6 ans (intervalle interquartile [IIQ]: 1,6 à 7,5 ans), 250 participantes (58,6 %) sont décédées; 74 décès (29,6 %) étaient liés à un événement CV. Parmi les 234 participantes sans événements cardiovasculaires antérieurs, 80 (34,2 %) ont vécu un événement incident de MCV. Aucune association linéaire significative n'a été observée entre le taux d'E2 et la mortalité toutes causes confondues, la mortalité par MCV ou les MCV incidentes. Le taux d'E2 a cependant montré une association concave significative avec la mortalité toutes causes confondues, mais pas avec la mortalité par MCV ni avec les MCV incidentes. Chez les patientes âgées de 63 ans et plus, des taux élevés d'E2 ont été associés à des scores HUI3 plus faibles (différence moyenne [DM] = -0,062 par 1-SD pmol/L; intervalle de confiance à 95 % [IC95]: -0,112 à 0,012); alors qu'on a observé le contraire chez les patientes plus jeunes (< 63 ans), où des taux élevés d'E2 étaient plutôt associés à des scores plus élevés d'HUI3 (DM = 0,032 par 1-SD pmol/L; IC95: 0,008 à 0,055; p=0,045). Aucune association n'a été observée entre le taux d'E2, le KDQOL12-PCS (DM = -0,15 par 1-SD pmol/L; IC 95: -1,15 à 0,86) et le KDQOL12-MCS (DM = -0,63 par 1-SD pmol/L; IC95: -1,82 à 0,57). Limites: Facteurs de confusion non mesurés; échantillon de petite taille. Conclusion: Il pourrait exister une association non linéaire entre le taux d'E2 et la mortalité toutes causes confondues. Aucune association n'a toutefois été observée entre le taux d'E2 et la mortalité par MCV, les MCV incidentes, le KDQOL12-PCS et le KDQOL12-MCS. En outre, l'association entre le taux sérique d'E2 et l'HUI3 a été modifiée par l'âge: des taux plus élevés d'E2 ont été associés à un indice de santé plus élevé (HUI) chez les femmes âgées de moins de 63 ans, alors que l'inverse a été observé chez les femmes plus âgées.

Multidisciplinary Support To Access living donor Kidney Transplant (MuST AKT): A Clinical Research Protocol for a Pilot Randomized Controlled Trial to Increase Living Kidney Donation.

Background: Living donor kidney transplantation (LDKT) is the optimal treatment for eligible patients with kidney failure, although it is underutilized. Contextually tailored patient- and family-centered interventions may be effective to increase LDKT. Objective: We outline a protocol to test the feasibility of the Multidisciplinary Support To Access living donor Kidney Transplant (MuST AKT) intervention designed to increase LDKT. Design: Non-blinded single-center pilot randomized controlled trial with a qualitative interview component. Setting: Academic transplant referral center in Northern Alberta Region with a population of more than 2 million in its catchment area. Patients: English-speaking patients of the age range 18 to 75 years who are referred for kidney transplantation are eligible to participate. Measurements: Feasibility will be assessed by indicators of recruitment, retention, and completion rates, treatment fidelity, adherence to intervention, engagement in intervention, and acceptability. Methods: Participants will be randomly assigned 1:1 to either standard care (control) or the experimental group who receive standard care plus the MuST AKT intervention, a person-centered program designed to assist and enable the kidney transplant candidate to achieve what is required to receive an LDKT. The intervention consists of an introductory session and 4 intervention sessions delivered in-person or virtually. Limitations: Inferences cannot be drawn regarding the efficacy/effectiveness of the MuST AKT intervention. This study is non-blinded. Conclusions: This pilot study is the first step in our broader initiative to increase LDKT in our health care jurisdiction. The results of this study will be used to inform the development of a future definitive randomized controlled trial. Trial registration number: NCT04666545.

Contexte: Bien qu'elle soit encore sous-utilisée, la transplantation d'un rein provenant d'un donneur vivant (TRDV) constitue le traitement optimal pour les patients atteints d'insuffisance rénale qui sont admissibles. Des interventions personnalisées, axées sur le patient et la famille, pourraient s'avérer efficaces pour favoriser la TRDV. Objectif: Nous décrivons un protocole examinant la faisabilité de l'intervention MuST AKT (Multidisciplinary Support To Access living donor Kidney Transplant), laquelle vise l'augmentation des TRDV. Conception: Essai clinique pilote unicentrique, sans insu, comportant une composante d'entretiens qualitatifs. Cadre: Un center universitaire pour les transplantations du Nord de l'Alberta, situé dans une zone de référence comptant plus de deux millions de personnes. Sujets: Seront admissibles tous les patients anglophones âgés de 18 à 75 ans aiguillés pour une transplantation rénale. Mesures: La faisabilité sera évaluée par des indicateurs du taux de recrutement, de rétention et d'achèvement, de même que par la fidélité au traitement, l'adhésion à l'intervention, l'engagement dans l'intervention et l'acceptabilité. Méthodologie: Les sujets seront répartis aléatoirement 1:1 dans le groupe témoin, qui recevra les soins habituels, ou dans le groupe expérimental, qui recevra les soins habituels et l'intervention MuST AKT. Ce program axé sur le patient est conçu pour aider les candidats à une greffe rénale à réaliser les étapes nécessaires pour recevoir une TRDV. L'intervention est constituée d'une séance d'introduction et de quatre séances d'intervention réalisées en personne ou virtuellement. Limites: Nous ne serons pas en mesure de tirer des conclusions quant à l'efficacité de l'intervention MuST AKT. Cette étude n'est pas menée en aveugle. Conclusion: Cette étude pilote constitue la première étape d'une initiative plus vaste qui vise à accroître la TRDV dans notre région sanitaire. Les résultats de cette étude seront utilisés pour guider l'élaboration d'un futur essai clinique définitif.

Association Between Arterial Stiffness and Measures of Autonomic Dysfunction in People With Chronic Kidney Disease.

Background: Autonomic nervous system (ANS) dysfunction and vascular stiffness increase cardiovascular risk in people with chronic kidney disease (CKD). Chronic elevations in sympathetic activity can lead to increased arterial stiffness; however, the relationship between these variables is unknown in CKD. Objective: To explore the association between measures of autonomic function and arterial stiffness in patients with moderate-to-severe CKD. Methods: This study was a prespecified secondary analysis of a randomized controlled trial. This included the following measures: 24-hour ambulatory blood pressure (BP), carotid-femoral and carotid-radial pulse wave velocity (PWV), and postexercise heart rate recovery (HRR). We used mixed effect linear regression models with Bayesian information criteria (BIC) to assess the contribution of ANS measurements. Results: Forty-four patients were included in the analysis. Mean carotid-femoral and carotid-radial PWV were 7.12 m/s (95% CI 6.13, 8.12) and 8.51 m/s (7.90, 9.11), respectively. Mean systolic dipping, calculated as percentage change in mean systolic readings from day to night, was 10.0% (95% CI 7.79, 12.18). Systolic dipping was independently associated with carotid-radial PWV, MD -0.09 m/s (95% CI -0.15, -0.02) and had the lowest BIC. Conclusions: Systolic dipping was associated with carotid-radial PWV in people with moderate-to-severe CKD; however, there was no association with carotid-femoral PWV. Systolic dipping may be a feasible surrogate of ANS function, as the association with carotid-radial PWV was consistent with the minimal clinically important difference (MCID). Future studies are needed to define the relationship between ANS function, arterial stiffness, and CV events over time in people with CKD.

Contexte: Le dysfonctionnement du système nerveux autonome (SNA) et la rigidité artérielle augmentent le risque d'événements cardiovasculaires chez les personnes atteintes d'insuffisance rénale chronique (IRC). Les élévations chroniques de l'activité sympathique peuvent accroître la rigidité artérielle, mais on ne connaît pas le lien entre ces variables en contexte d'IRC. Objectif: Explorer l'association entre les mesures de la fonction autonome et la rigidité artérielle chez les patients atteints d'IRC modérée ou grave. Méthodologie: Cette étude était l'analyze secondaire prédéfinie d'un essai contrôlé randomisé. Mesures incluses: le suivi de la pression artérielle (PA) ambulatoire sur 24 heures, la vitesse de l'onde de pouls (VOP) carotido-fémorale et carotido-radiale, et la récupération de la fréquence cardiaque (HRR­Heart Rate Recovery) après l'effort. Nous avons eu recours à des modèles de régression linéaire à effets mixtes avec critères d'information bayésiens (BIC ­ Bayesian Information Criteria) pour évaluer la contribution des mesures du SNA. Résultats: Quarante-quatre patients sont inclus dans l'analyze. La valeur moyenne des VOP carotido-fémorale et carotido-radiale était respectivement de 7,12 m/s (IC 95 %: 6,13 à 8,12) et de 8,51 m/s (IC 95 %: 7,90 à 9,11). La chute systolique moyenne, calculée en pourcentage de variation entre les valeurs systoliques moyennes du jour et de la nuit, était de 10,0 % (IC 95 %: 7,79 à 12,18). La chute systolique a été indépendamment associée à la VOP carotido-radiale, avec un écart moyen de -0,09 m/s (IC 95 %: -0,15 à -0,02) et a présenté les plus faibles BIC. Conclusion: La chute systolique a été associée à la VOP carotido-radiale chez les personnes atteintes d'IRC modérée ou grave, mais aucune association n'a été observée avec la VOP carotido-fémorale. La chute systolique pourrait être un substitut de la fonction du SNA, car l'association avec la VOP carotido-radiale était cohérente avec la différence minimale cliniquement importante (DMCI). D'autres études sont nécessaires pour mieux définir la relation entre la fonction du SNA, la rigidité artérielle et les événements cardiovasculaires au fil du temps chez les personnes atteintes d'IRC.

Degree of Albuminuria is Associated With Increased Risk of Fragility Fractures Independent of Estimated GFR.

Introduction: Fragility fractures are common in persons with chronic kidney disease (CKD); however, the association between fragility fractures and albuminuria is not well-studied. The primary objective of this study is to determine the association of albuminuria with incident risk of fragility fractures. The secondary objective is to examine the risk of fragility fracture by estimated glomerular filtration rate (eGFR) and Kidney Disease Improving Global Outcomes (KDIGO) risk categories. Methods: Community dwelling adults residing in Alberta, Canada who had at least 1 creatinine and albuminuria measurement between April 1, 2008 and March 31, 2019 participated in the study (N = 2.72 million). Incident fragility fractures were identified using Canadian Chronic Disease Surveillance Systems Osteoporosis Working Group algorithms. Albuminuria was categorized as none/mild (albumin-to-creatinine ratio [ACR] <30 mg/g, protein-to-creatinine ratio [PCR] <150 mg/g, trace/negative dipstick); moderate (ACR 30-300 mg/g, PCR 150-500 mg/g, 1+ dipstick) or severe (ACR >300 mg/g, PCR >500 mg/g, ≥2+ dipstick). Multivariable analysis controlled for 42 variables. Results: Patients with severe albuminuria had an increased risk of hip fracture (odds ratio [OR] = 1.37; 95% confidence interval [CI] 1.28, 1.47]), vertebral fracture (OR = 1.31; 95% CI 1.21, 1.41) and any-type fracture (OR = 1.22; 95% CI 1.17, 1.28) compared with patients with none/mild albuminuria. Patients in the most severe KDIGO risk category had an increased risk of hip fracture (OR = 1.22; 95% CI 1.16, 1.29), vertebral fracture (OR = 1.18; 95% CI 1.09, 1.26) and any type of fracture (OR = 1.25; 95% CI 1.21, 1.30). Conclusion: This study demonstrates the important role of albuminuria as a risk factor for fragility fractures in CKD and may help inform risk stratification and prevention strategies in this high-risk population category.

Kidney function monitoring and trajectories in patients with atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) and chronic kidney disease (CKD) frequently co-exist. The frequency of kidney monitoring and range of kidney function in patients with AF in clinical practice are uncertain. METHODS: All adult Albertans with AF between 2008 and 2017 were identified using ICD-9 and -10 codes 427.3 and I48. Kidney Disease Improving Global Outcomes (KDIGO) risk categories were defined using eGFR by the Chronic Kidney Disease Epidemiology Collaborative equation and albuminuria results within 6 months of eGFR measurement. eGFR trajectories were compared from baseline to maximum value within the following year. RESULTS: Among 105,946 patients with AF, 16.0% were KDIGO category G1 (eGFR ≥ 90), 49.0% G2 (60-89.9), 19.8% G3a (45-59.9), 11.4% G3b (30-44.9), and G4 3.8% (15-29.9). Albuminuria was normal/mild 83.4%, moderate 11.7%, and severe 4.9%. Kidney monitoring was more common among people with lower eGFR and worse albuminuria, from approximately twice annually for G1-2/A1-2 to 8 times annually in stage G4A3. Approximately 60-80% of patients received guideline-recommended monitoring, consistent across KDIGO stages. With lower baseline eGFR, annual change in eGFR decreased while the relative proportion of patients who worsened compared to improved increased: for baseline eGFR 60-89.9, 16.7% worsened vs 6.7% improved, but for eGFR 30-44.9, 8.8% worsened but only 1.0% improved. CONCLUSION: The frequency of kidney function monitoring in patients with AF increased with worsening KDIGO risk category and adhered to KDIGO guidelines in approximately three quarters of patients. A minority of patients had moderate to severe eGFR impairment, of whom most remained stable over 1 year.

Frailty and Clinical Outcomes in Patients Treated With Hemodialysis: A Prospective Cohort Study.

Rationale and Objective: Frailty is common among people with kidney failure treated with hemodialysis (HD). The objective was to describe how frailty evolves over time in people treated by HD, how improvements in frailty and frailty markers are associate with clinical outcomes, and the characteristics that are associated with improvement in frailty. Study Design: Prospective cohort study. Setting and Participants: Adults initiating thrice weekly in-center HD in Canada. Exposure: We classified frailty using a 5-point score (3 or more indicates frailty) based on physical inactivity, slowness or weakness, poor endurance or exhaustion, and malnutrition. We categorized the frailty trajectory as never present, improving, deteriorating, and always present. Outcomes: All-cause death, hospitalizations, and placement into long-term care. Analytical Approach: We examined the association between time-varying frailty measures and these outcomes using Cox and negative binomial models, after adjustment for potential confounders. Results: 985 participants were included and followed up for a median of 33 months; 507 (51%) died, 761 (77%) experienced ≥1 hospitalization and 115 (12%) entered long-term care. Overall, 760 (77%) reported frailty during follow-up. Three-quarters (78%) of those with frailty at baseline remained frail throughout the follow-up, 46% without baseline frailty became frail, and 23% with baseline frailty became nonfrail. Higher frailty scores were associated with an increased risk of mortality (fully adjusted HR, 1.58 per unit; 95% CI, 1.39-1.80) and an increased rate of hospitalization (RR, 1.16 per unit; 95% CI, 1.09-1.23). Compared with those who were frail throughout the follow-up, participants with frailty at baseline but improving during follow-up showed a lower mortality (HR, 0.59; 95% CI, 0.42-0.81), and a lower rate of hospitalization (RR, 0.70; 95% CI, 0.56-0.87). Limitations: There was missing data on frailty at baseline and during follow-up. Conclusions: Frailty was associated with a higher risk of poor outcomes compared with those without frailty, and participants whose status improved from frail to nonfrail showed better clinical outcomes than those who remained frail. These findings emphasize the importance of identifying and implementing effective treatments for frailty in patients receiving maintenance HD.

Associations between hearing loss and clinical outcomes: population-based cohort study.

Background: Hearing loss (HL) is a leading cause of disability worldwide, but its clinical consequences and population burden have been incompletely studied. Methods: We did a retrospective population-based cohort study of 4,724,646 adults residing in Alberta between April 1, 2004 and March 31, 2019, of whom 152,766 (3.2%) had HL identified using administrative health data. We used administrative data to identify comorbidity and clinical outcomes, including death, myocardial infarction, stroke/transient ischemic attack, depression, dementia, placement in long-term care (LTC), hospitalization, emergency visits, pressure ulcers, adverse drug events and falls. We used Weibull survival models (binary outcomes) and negative binomial models (rate outcomes) to compare the likelihood of outcomes in those with vs without HL. We calculated population-attributable fractions to estimate the number of binary outcomes associated with HL. Findings: The age-sex-standardized prevalence of all 31 comorbidities at baseline was higher among participants with HL than those without. Over median follow-up of 14.4 y and after adjustment for potential confounders at baseline, participants with HL had higher rates of days in hospital (rate ratio 1.65, 95% CI 1.39, 1.97), falls (RR 1.72, 95% CI 1.59, 1.86), adverse drug events (RR 1.40, 95% CI 1.35, 1.45), and emergency visits (RR 1.21, 95% CI 1.14, 1.28) compared to those without, and higher adjusted hazards of death, myocardial infarction, stroke/transient ischemic attack, depression, heart failure, dementia, pressure ulcers and LTC placement. The estimated number of people with HL who required new LTC placement annually in Canada was 15,631, of which 1023 were attributable to HL. Corresponding estimates for new dementia among people with HL were 14,959 and 4350, and for stroke/TIA the estimates were 11,582 and 2242. Interpretation: HL is common, is often accompanied by substantial comorbidity, and is associated with significant increases in risk for a broad range of adverse clinical outcomes, some of which are potentially preventable. This high population health burden suggests that increased and coordinated investment is needed to improve the care of people with HL. Funding: Canadian Institutes of Health Research; David Freeze chair in health services research.

Associations between body mass index and all-cause mortality: A systematic review and meta-analysis.

Fasting insulin and c-reactive protein confound the association between mortality and body mass index. An increase in fat mass may mediate the associations between hyperinsulinemia, hyperinflammation, and mortality. The objective of this study was to describe the "average" associations between body mass index and the risk of mortality and to explore how adjusting for fasting insulin and markers of inflammation might modify the association of BMI with mortality. MEDLINE and EMBASE were searched for studies published in 2020. Studies with adult participants where BMI and vital status was assessed were included. BMI was required to be categorized into groups or parametrized as non-first order polynomials or splines. All-cause mortality was regressed against mean BMI squared within seven broad clinical populations. Study was modeled as a random intercept. ß coefficients and 95% confidence intervals are reported along with estimates of mortality risk by BMIs of 20, 30, and 40 kg/m2 . Bubble plots with regression lines are drawn, showing the associations between mortality and BMI. Splines results were summarized. There were 154 included studies with 6,685,979 participants. Only five (3.2%) studies adjusted for a marker of inflammation, and no studies adjusted for fasting insulin. There were significant associations between higher BMIs and lower mortality risk in cardiovascular (unadjusted ß -0.829 [95% CI -1.313, -0.345] and adjusted ß -0.746 [95% CI -1.471, -0.021]), Covid-19 (unadjusted ß -0.333 [95% CI -0.650, -0.015]), critically ill (adjusted ß -0.550 [95% CI -1.091, -0.010]), and surgical (unadjusted ß -0.415 [95% CI -0.824, -0.006]) populations. The associations for general, cancer, and non-communicable disease populations were not significant. Heterogeneity was very large (I2 ≥ 97%). The role of obesity as a driver of excess mortality should be critically re-examined, in parallel with increased efforts to determine the harms of hyperinsulinemia and chronic inflammation.

Associations of body mass index, fasting insulin, and inflammation with mortality: a prospective cohort study.

BACKGROUND/OBJECTIVES: Obesity is often considered to increase the risk for premature mortality. Higher fasting insulin and c-reactive protein are associated with higher body mass index (BMI) and all-cause mortality, so may confound the association between obesity and mortality. Our objective was to determine the independent associations between BMI, fasting insulin, c-reactive protein, and all-cause mortality in a general population sample. METHODS: This prospective cohort study included non-institutionalized US adults (≥20 years) from the National Health and Nutrition Examination Surveys 1999-2000 to 2013-2014. The main exposures of interest were BMI, fasting insulin, c-reactive protein. Mortality data were obtained through linking participants to the National Death Index (ending December 31, 2015). RESULTS: There were 12,563 participants with a median age of 45 years (range 20-85) and 47.9% were male. The median BMI was 27 kg/m2 (IQR 24-32), median fasting insulin was 54 pmol/L (IQR 35-87), and median c-reactive protein was 1.9 mg/L (IQR 0.8-4.4). In a Cox model adjusted for age, biological sex, cigarette smoking, and ten chronic conditions, higher BMI parameterized with quadratic and linear terms was not associated with mortality. When fasting insulin and the natural logarithm of c-reactive protein were included in the model, an inverse association between BMI and mortality was present (compared to the referent category of 5th percentile: 1st percentile, HR 1.10, 95% CI 1.06-1.13; 99th percentile, HR 0.48, 95% CI 0.34-0.69). In contrast, higher levels of fasting insulin and c-reactive protein were associated with an increased risk of mortality (for fasting insulin: 1st percentile, HR 0.98, 95% CI 0.97-0.99; 99th percentile, HR 1.83, 95% CI 1.48-2.26; for c-reactive protein, 1st percentile, HR 0.87, 95% CI 0.84-0.90; 99th percentile, HR 2.77, 95% CI 2.12-3.62). CONCLUSIONS: Higher fasting insulin and higher c-reactive protein confound the association between BMI and the risk of all-cause mortality. The increase in mortality that has been attributed to higher BMI is more likely due to hyperinsulinemia and inflammation rather than obesity.

Age, multimorbidity and dementia with health care costs in older people in Alberta: a population-based retrospective cohort study.

BACKGROUND: The growing burden associated with population aging, dementia and multimorbidity poses potential challenges for the sustainability of health systems worldwide. We sought to examine how the intersection among age, dementia and greater multimorbidity is associated with health care costs. METHODS: We did a retrospective population-based cohort study in Alberta, Canada, with adults aged 65 years and older between April 2003 and March 2017. We identified 31 morbidities using algorithms (30 algorithms were validated), which were applied to administrative health data, and assessed costs associated with hospital admission, provider billing, ambulatory care, medications and long-term care (LTC). Actual costs were used for provider billing and medications; estimated costs for inpatient and ambulatory patients were based on the Canadian Institute for Health Information's resource intensive weights and Alberta's cost of a standard hospital stay. Costs for LTC were based on an estimated average daily cost. RESULTS: There were 827 947 people in the cohort. Dementia was associated with higher mean annual total costs and individual mean component costs for almost all age categories and number of comorbidities categories (differences in total costs ranged from $27 598 to $54 171). Similarly, increasing number of morbidities was associated with higher mean total costs and component costs (differences in total costs ranged from $4597 to $10 655 per morbidity). Increasing age was associated with higher total costs for people with and without dementia, driven by increasing LTC costs (differences in LTC costs ranged from $115 to $9304 per age category). However, there were no consistent trends between age and non-LTC costs among people with dementia. When costs attributable to LTC were excluded, older age tended to be associated with lower costs among people with dementia (differences in non-LTC costs ranged from -$857 to -$7365 per age category). INTERPRETATION: Multimorbidity, older age and dementia were all associated with increased use of LTC and thus health care costs, but some costs among people with dementia decreased at older ages. These findings illustrate the complexity of projecting the economic consequences of the aging population, which must account for the interplay between multimorbidity and dementia.

Incident Cardiovascular Disease Among Adults With Cancer: A Population-Based Cohort Study.

Background: Patients with cancer and cancer survivors are at increased risk for incident heart failure, but there are conflicting data on the long-term risk for other cardiovascular events and how such risk may vary by cancer site. Objectives: The aim of this study was to determine the impact of a new cancer diagnosis on the risk for fatal and nonfatal cardiovascular events. Methods: Using administrative health care databases, a population-based retrospective cohort study was conducted among 4,519,243 adults residing in Alberta, Canada, from April 2007 to December 2018. Participants with new cancer diagnoses during the study period were compared with those without cancer with respect to risk for subsequent cardiovascular events (cardiovascular mortality, myocardial infarction, stroke, heart failure, and pulmonary embolism) using time-to-event survival models after adjusting for sociodemographic data and comorbidities. Results: A total of 224,016 participants with new cancer diagnoses were identified, as well as 73,360 cardiovascular deaths and 470,481 nonfatal cardiovascular events during a median follow-up period of 11.8 years. After adjustment, participants with cancer had HRs of 1.33 (95% CI: 1.29-1.37) for cardiovascular mortality, 1.01 (95% CI: 0.97-1.05) for myocardial infarction, 1.44 (95% CI: 1.41-1.47) for stroke, 1.62 (95% CI: 1.59-1.65) for heart failure, and 3.43 (95% CI: 3.37-3.50) for pulmonary embolism, compared with participants without cancer. Cardiovascular risk was highest for patients with genitourinary, gastrointestinal, thoracic, nervous system and hematologic malignancies. Conclusions: A new cancer diagnosis is independently associated with a significantly increased risk for cardiovascular death and nonfatal morbidity regardless of cancer site. These findings highlight the need for a collaborative approach to health care for patients with cancer and cancer survivors.

Physical Activity in Renal Disease and the Effect on Hypertension: A Randomized Controlled Trial.

INTRODUCTION: Exercise is an effective strategy for blood pressure (BP) reduction in the general population, but its efficacy for the management of hypertension in chronic kidney disease (CKD) is not known. We evaluated the difference in 24-h ambulatory systolic BP (SBP) with exercise training in people with moderate to severe CKD. METHODS: Participants with an estimated glomerular filtration rate (eGFR) of 15-44 mL/min per 1.73 m2 and SBP >120 mm Hg were randomized to receive thrice-weekly moderate-intensity aerobic-based exercise over 24 weeks, or usual care. Phase 1 included supervised in-center and home-based sessions for 8 weeks. Phase 2 was 16 weeks of home-based sessions. BP, arterial stiffness, cardiorespiratory fitness, and markers of cardiovascular (CV) risk were analyzed using mixed linear regression. RESULTS: We randomized 44 people; 36% were female, the median age was 69 years, 55% had diabetes, and the median eGFR was 28 mL/min per 1.73 m2. Compared with usual care, there was no significant change in 24-ambulatory SBP at 8 weeks (2.96 mm Hg; 95% confidence interval (CI): -2.56, 8.49) or 24 weeks. Peak oxygen uptake improved by 1.9 mL/kg/min in the exercise group (95% CI: 0.03, 3.79) at 8 weeks with a trend toward higher body mass index 1.84 kg/m2 (95% CI: -0.10, 3.78) and fat free mass, but this was not sustained at 24 weeks. Markers of CV risk were unchanged. CONCLUSIONS: Despite an improvement in peak aerobic capacity and body composition, we did not detect a change in 24-h ambulatory SBP in people with moderate-to-severe CKD.

Update on Existing Care Models for Chronic Kidney Disease in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: Approximately 78% of chronic kidney disease (CKD) cases reside in low- and middle-income countries (LMICs). However, little is known about the care models for CKD in LMICs. OBJECTIVE: Our objective was to update a prior systematic review on CKD care models in LMICs and summarize information on multidisciplinary care and management of CKD complications. DESIGN: We searched MEDLINE, EMBASE, and Global Health databases in September 2020, for papers published between January 1, 2017, and September 14, 2020. We used a combination of search terms, which were different iterations of CKD, care models, and LMICs. The World Bank definition (2019) was used to identify LMICs. SETTING: Our review included studies published in LMICs across 4 continents: Africa, Asia, North America (Mexico), and Europe (Ukraine). The study settings included tertiary hospitals (n = 6), multidisciplinary clinics (n = 1), primary health centers (n = 2), referral centers (n = 2), district hospitals (n = 1), teaching hospitals (n = 1), regional hospital (n = 1), and an urban medical center (n = 1). PATIENTS: Eighteen studies met inclusion criteria, and encompassed 4679 patients, of which 4665 were adults. Only 9 studies reported mean eGFR which ranged from 7 to 45.90 ml/min/1.73 m2. MEASUREMENTS: We retrieved the following details about CKD care: funding, urban or rural location, types of health care staff, and type of care provided, as defined by Kidney Disease Improving Global Outcomes (KDIGO) guidelines for CKD care. METHODS: We included studies which met the following criteria: (1) population was largely adults, defined as age 18 years and older; (2) most of the study population had CKD, and not end-stage kidney disease (ESKD); (3) population resided in an LMIC as defined by the World Bank; (4) manuscript described in some detail a clinical care model for CKD; (5) manuscript was in either English or French. Animal studies, case reports, comments, and editorials were excluded. RESULTS: Eighteen studies (24 care models with 4665 patients) met inclusion criteria. Out of 24 care models, 20 involved interdisciplinary health care teams. Twenty models incorporated international guidelines for CKD management. However, conservative kidney management (management of kidney failure without dialysis or renal transplant) was in a minority of models (11 of 24). Although there were similarities between all the clinical care models, there was variation in services provided and in funding arrangement; the latter ranged from comprehensive government funding (eg, Sri Lanka, Thailand), to out-of-pocket payments (eg, Benin, Togo). LIMITATIONS: These include (1) lack of detail on CKD care in many of the studies, (2) small number of included studies, (3) using a different definition of care model from the original Stanifer et al paper, and (4) using the KDIGO Guidelines as the standard for defining a CKD care model. CONCLUSIONS: Most of the CKD models of care include the key elements of CKD care. However, access to such care depends on the funding mechanism available. In addition, few models included conservative kidney management, which should be a priority for future investment. TRIAL REGISTRATION: Not applicable.

CONTEXTE: Environ 78 % des patients atteints d'insuffisance rénale chronique (IRC) habitent un pays à revenu faible ou intermédiaire (PRFI). On en sait toutefois peu sur les modèles de prise en charge pour l'IRC dans les PRFI. OBJECTIFS: Nous souhaitions faire la mise à jour d'une revue systématique antérieure qui portait sur les modèles de prise en charge pour l'IRC dans les PRFI. Nous voulions également synthétiser l'information concernant les soins multidisciplinaires en IRC et la prise en charge des complications. CONCEPTION DE L'ÉTUDE: En septembre 2020, les bases de données MEDLINE, EMBASE et Global Health ont été consultées à la recherche d'articles publiés entre le 1er janvier 2017 et le 14 septembre 2020. Nous avons utilisé une combinaison de termes de recherche, incluant différentes itérations d'IRC, de modèles de prise en charge et de PRFI. La définition de la Banque mondiale (2019) a été utilisée pour identifier les PRFI. CADRE: Nous avons inclus des études publiées dans des PRFI de quatre continents : Afrique, Asie, Amérique du Nord (Mexique) et Europe (Ukraine). Les études avaient été réalisées dans des hôpitaux tertiaires (N = 6), une clinique multidisciplinaire, des centres de soins primaires (N = 2), des centres d'aiguillage (N = 2), un hôpital communautaire, un hôpital universitaire, un hôpital régional et un centre médical urbain. SUJETS: Les 18 études répondant aux critères d'inclusion portaient sur un total de 4 679 patients, dont 4 665 adultes. Neuf études seulement rapportaient un DFGe moyen, lequel s'étendait de 7 à 45,90 ml/min/1,73 m2. MESURES: Les informations suivantes sur les soins en IRC ont été extraites : financement, établissement urbain ou rural, catégories de personnel soignant et type de soins fournis, définis par les recommandations de KDIGO (Kidney Disease Improving Global Outcomes) pour la prise en charge d'IRC. MÉTHODOLOGIE: Nous avons inclus les études qui répondaient aux critères suivants : (1) la population étudiée était principalement constituée d'adultes (18 ans et plus); (2) la majorité de la population étudiée était atteinte d'IRC et non d'insuffisance rénale terminale (IRT); (3) la population étudiée habitait un PRFI selon la définition de la Banque mondiale; (4) le manuscrit décrivait avec suffisamment de détails un modèle de soins cliniques pour l'IRC; (5) le manuscrit était rédigé en anglais ou en français. Les études sur les animaux, les rapports de cas, les commentaires et les éditoriaux ont été exclus. RÉSULTATS: 18 études (24 modèles de soins, 4 665 patients) répondaient aux critères d'inclusion. Sur 24 modèles de soins, 20 avaient impliqué des équipes de soins interdisciplinaires. Les recommandations internationales pour la prise en charge de l'IRC avaient été intégrées à 20 modèles de soins. La prise en charge conservatrice de l'IRC (sans dialyse ni greffe rénale) n'était cependant rapportée que dans une minorité de modèles (11/24). Bien que nous ayons noté des similitudes entre tous les modèles de soins cliniques, des variations ont été observées dans les services fournis et dans les modalités de financement; ces dernières allant du financement public complet (p. ex. : Sri Lanka, Thaïlande) aux versements directs par les patients (p. ex. : Bénin, Togo). LIMITES: Les limites comprennent notamment: (1) le manque de détails sur les soins en IRC dans plusieurs études; (2) le faible nombre d'études incluses; (3) l'utilisation d'un modèle de soins dont la définition différait de l'originale présentée par Stanifer et coll.; et (4) l'utilisation des recommandations de KDIGO comme norme pour définir un modèle de soins pour l'IRC. CONCLUSION: La plupart des modèles de soins intégraient les éléments clés des soins recommandés pour l'IRC. L'accès à ces soins dépendait toutefois du mécanisme de financement en place. Cependant, peu de modèles intégraient la prise en charge conservatrice de l'IRC, laquelle devrait être une priorité pour de futurs investissements.

Wearable Fitness Trackers to Predict Clinical Deterioration in Maintenance Hemodialysis: A Prospective Cohort Feasibility Study.

RATIONALE & OBJECTIVE: People receiving hemodialysis often require urgent care or hospitalizations. It is possible that reductions in a patient's level of physical activity may serve as an "early warning" of clinical deterioration, allowing timely clinical intervention. We explored whether step count could serve as a trigger for deterioration. STUDY DESIGN: Prospective observational cohort feasibility study. SETTING & PARTICIPANTS: We recruited consenting adult participants from outpatient dialysis clinics in Calgary, AB, between June 28, 2019, and October 10, 2019. EXPOSURE AND OUTCOMES: Participants wore a wristband fitness tracker for 4 weeks. Activity data from the trackers were imported weekly into the study database. Demographic, clinical management, functional impairment, and frailty were assessed at baseline. Clinical events (urgent care and emergency department visits and hospitalizations) were monitored during the observation period. ANALYTICAL APPROACH: Box and whisker plots and line plots were used to describe each participant's daily steps. Adjusted rate ratios (and 95 % confidence intervals) were calculated to assess the associations between the number of steps taken each day and potential predictors. RESULTS: Data from 46 patients were included; their median age was 64 years (range, 22 to 85), and 63 % were men. The median number of steps taken per day was 3,133 (range, 248-13,753). Fourteen events among 11 patients were reported. Within patients, step count varied considerably; it was not possible to identify a patient-specific normal range for daily step count. There was no association between step count and the occurrence of clinical events, although the number of events was very small. LIMITATIONS: The number of participants was relatively small, and there were too few events to model to examine whether step count could predict clinical deterioration. CONCLUSIONS: Within-patient variation in daily step count was too high to generate a normal range for patients. However, patient-specific norms over a longer period (3- or 7-day periods) appear potentially worthy of future study in a larger sample and/or over a longer follow-up.

Voicing Individual Concerns for Engagement in Hemodialysis (VOICE-HD): A Mixed Method, Randomized Pilot Trial of Digital Health in Dialysis Care Delivery.

BACKGROUND: People receiving in-center hemodialysis (HD) have prioritized the need for more individualized health information and better communication with nephrologists. The most common setting for patient-nephrologist interactions is during the HD treatment, which is a time pressured setting that lacks privacy. OBJECTIVE: To facilitate effective communication in the hemodialysis (HD) unit, we evaluated the usability of a web application (web app) from both the patient and physician perspective. The main aim of the web app was to support patients in prioritizing their dialysis concerns outside of the clinical HD encounter. DESIGN: Mixed method, parallel arm, multi-site, pilot randomized controlled trial. SETTING: Two outpatient Canadian HD centers. PARTICIPANTS: Adult patients receiving in-center HD and their attending nephrologists. METHODS: Patients were randomized to either a web application or an active control (paper form) for logging concerns to be addressed at weekly encounters with the nephrologist over 8 weeks. Topics included: HD treatment, symptoms, modality, and medications. The primary outcome was usability, defined as effectiveness (engagement with the tool, frequency of submitted concerns, whether the concern was satisfactorily addressed) and satisfaction with the tool using a priori thresholds and explored in interviews with patients and nephrologists. RESULTS: 77 patients (30 women, median age 61, interquartile range [53,67], median 2 years [1,4] on dialysis) and 19 nephrologists (4 women, median age 46 [36,65]) were enrolled. Patient use of a digital device at baseline was low (20%). Engagement with the tool was 70% (web app) and 100% (paper) with a lower proportion of patients in the web app group submitting at least one concern over 8 weeks compared to the paper form group: 56.7% vs 87.9%. Weekly concerns were satisfactorily addressed in both groups and ≥70% of patients would continue to use the tools. For patients, both tools promoted preparation and participation in the encounter; however, only the web app facilitated greater privacy in relaying concerns. For most nephrologists, the tools were disruptive to their workflow and were perceived as unnecessary given existing processes and familiarity with patients. For future versions of the app, patients suggested more features to facilitate self-management and nephrologists suggested integration with health databases and multidisciplinary teams. LIMITATIONS: Tertiary setting may limit generalizability. CONCLUSIONS: Both tools promoted fundamental components of self-management; however, patients in the paper form group submitted concerns more often and this tool was easier to remember to use. Although modifications would likely enhance web app usability, successful future adoption is limited by physician acceptance.Trial registration ClinicalTrials.gov NCT03605875.

CONTEXTE: Les personnes qui reçoivent l'hémodialyse (HD) en center hospitalier jugent nécessaire d'obtenir des informations de santé plus individualisées et d'avoir une meilleure communication avec les néphrologues. Les interactions entre les patients et les néphrologues ont plus souvent lieu pendant l'hémodialyse, mais ce contexte manque d'intimité et les parties sont souvent pressées par le temps. OBJECTIFS: Pour aider à établir une communication plus efficace dans l'unité d'hémodialyse (HD), nous avons évalué la convivialité d'une application Web du point de vue du patient et du médecin. Cette application Web devait aider les patients à faire part de leurs préoccupations liées à la dialyze en dehors des séances d'HD. TYPE D'ÉTUDE: Essai multicentrique randomisé contrôlé avec groupes parallèles, réalisé par méthodes mixtes. CADRE: Deux centers d'hémodialyse canadiens en consultation externe. SUJETS: Des adultes recevant des traitements d'HD en center hospitalier et leurs néphrologues traitants. MÉTHODOLOGIE: Les patients ont été répartis aléatoirement pour utiliser l'application Web ou un témoin actif (formulaire papier) pour consigner, sur une période de huit semaines, les préoccupations à aborder lors des rencontres hebdomadaires avec leur néphrologue. Les sujets abordés concernaient le traitement d'HD, les symptômes, la modalité et les médicaments. Le principal critère d'évaluation était la facilité d'utilization, définie par l'efficacité (engagement avec l'outil, fréquence des soumissions, si le problème a été traité de façon satisfaisante). La satisfaction à l'égard de l'outil a été évaluée avec des seuils préétablis et explorée lors d'entrevues avec les patients et les néphrologues. RÉSULTATS: Ont été inclus 77 patients (30 femmes) sous dialyze depuis 2 ans (durée médiane; intervalle interquartile [1,4]) et dont l'âge médian s'établissait à 61 ans [53-67]. Ont aussi été inclus 19 néphrologues (4 femmes; âge médian : 46 ans [36-65]). Au début de l'étude, l'utilization d'un dispositif numérique par les patients était faible (20 %). L'engagement avec l'outil était de 70 % (application Web) et de 100 % (formulaire). Les patients du groupe « application Web ¼ sont moins nombreux à avoir soumis au moins une préoccupation au cours des huit semaines comparativement au groupe utilisant les formulaires papier (56,7 % c. 87,9 %). Les préoccupations hebdomadaires ont été abordées de façon satisfaisante dans les deux groupes et plus de 70 % des patients continueraient d'utiliser ces outils. Pour les patients, les deux outils ont favorisé la préparation et la participation à la rencontre, mais seule l'application Web a permis d'accroître la confidentialité dans la transmission des préoccupations. La plupart des néphrologues ont trouvé que ces outils perturbaient leur flux de travail et les ont perçus comme inutiles puisqu'ils jugent qu'un processus et une familiarité avec les patients existent déjà. Les patients ont suggéré que les futures versions de l'application aient plus de caractéristiques pour faciliter l'autogestion; les néphrologues ont quant à eux suggéré qu'elle soit intégrée aux bases de données sur la santé et aux équipes multidisciplinaires. LIMITES: Étude menée dans des centers de soins tertiaires, ceci pourrait limiter la généralisabilité des résultats. CONCLUSION: Les deux outils ont facilité des composantes fondamentales de l'autogestion. Cependant, les patients qui utilisaient des formulaires papier ont plus souvent fait part de leurs préoccupations. Il s'est également avéré qu'on pensait davantage à utiliser cet outil que l'application. Bien que des modifications puissent accroître la convivialité de l'application Web, son adoption demeure limitée par l'acceptation des médecins.

Current status of health systems financing and oversight for end-stage kidney disease care: a cross-sectional global survey.

OBJECTIVES: The Global Kidney Health Atlas (GKHA) is a multinational, cross-sectional survey designed to assess the current capacity for kidney care across all world regions. The 2017 GKHA involved 125 countries and identified significant gaps in oversight, funding and infrastructure to support care for patients with kidney disease, especially in lower-middle-income countries. Here, we report results from the survey for the second iteration of the GKHA conducted in 2018, which included specific questions about health financing and oversight of end-stage kidney disease (ESKD) care worldwide. SETTING: A cross-sectional global survey. PARTICIPANTS: Key stakeholders from 182 countries were invited to participate. Of those, stakeholders from 160 countries participated and were included. PRIMARY OUTCOMES: Primary outcomes included cost of kidney replacement therapy (KRT), funding for dialysis and transplantation, funding for conservative kidney management, extent of universal health coverage, out-of-pocket costs for KRT, within-country variability in ESKD care delivery and oversight systems for ESKD care. Outcomes were determined from a combination of desk research and input from key stakeholders in participating countries. RESULTS: 160 countries (covering 98% of the world's population) responded to the survey. Economic factors were identified as the top barrier to optimal ESKD care in 99 countries (64%). Full public funding for KRT was more common than for conservative kidney management (43% vs 28%). Among countries that provided at least some public coverage for KRT, 75% covered all citizens. Within-country variation in ESKD care delivery was reported in 40% of countries. Oversight of ESKD care was present in all high-income countries but was absent in 13% of low-income, 3% of lower-middle-income, and 10% of upper-middle-income countries. CONCLUSION: Significant gaps and variability exist in the public funding and oversight of ESKD care in many countries, particularly for those in low-income and lower-middle-income countries.

Effectiveness and Utilization of Cardiac Rehabilitation Among People With CKD.

INTRODUCTION: Cardiac rehabilitation (CR) is a proven therapy for reducing cardiovascular death and hospitalization. Whether CR participation is associated with improved outcomes in patients with chronic kidney disease (CKD) is unknown. METHODS: We obtained data on all adult patients in Calgary, Alberta, Canada with angiographically proven coronary artery disease from 1996 to 2016 referred to CR from The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and TotalCardiology Rehabilitation. An estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 or kidney replacement therapy defined CKD. Predictors of CR use were estimated with multinomial logistic regression. The association between starting versus not starting and completion versus noncompletion of CR and clinical outcomes were estimated using multivariable Cox proportional hazards models. RESULTS: Of 23,215 patients referred to CR, 12,084 were eligible for inclusion. Participants with CKD (N = 1322) were older, had more comorbidity, lower exercise capacity on graded treadmill testing, and took longer to be referred and to start CR than those without CKD. CKD predicted not starting CR: odds ratio 0.73 (95% confidence interval [CI] 0.64-0.83). Over a median 1 year follow-up, there were 146 deaths, 40 (0.3%) from CKD and 106 (1.0%) not from CKD. Similar to those without CKD, the risk of death was lower in CR completers (hazard ratio [HR] 0.24 [95% CI 0.06-0.91) and starters (HR 0.56 [95% CI 0.29- 1.10]) with CKD. CONCLUSION: CR participation was associated with comparable benefits in people with moderate CKD as those without who survived to CR. Lower rates of CR attendance in this high-risk population suggest that strategies to increase CR utilization are needed.