Mental health and addiction service utilization among people living with chronic kidney disease.

BACKGROUND: Mental health problems, particularly anxiety and depression, are common in patients with chronic kidney disease (CKD), and negatively impact quality of life, treatment adherence, and mortality. However, the degree to which mental health and addictions services are utilized by those with CKD is unknown. We examined the history of mental health and addictions service use of individuals across levels of kidney function. METHODS: We performed a population-based cross-sectional study using linked healthcare databases from Ontario, Canada from 2009 to 2017. We abstracted the prevalence of individuals with mental health and addictions service use within the previous 3 years across levels of kidney function (eGFR$\ \ge $60, 45 to < 60, 30 to < 45, 15 to < 30, <15 mL/min per 1.73m2 and maintenance dialysis). We calculated prevalence ratios (PR) to compare prevalence across kidney function strata, while adjusting for age, sex, year of cohort entry, urban versus rural location, area-level marginalization, and Charlson comorbidity scores. RESULTS: Of 5 956 589 adults, 9% (n = 534 605) had an eGFR<60 mL/min per 1.73m2 or were receiving maintenance dialysis. Fewer individuals with eGFR < 60 had a history of any mental health and addictions service utilization (crude prevalence range 28% to 31%), compared to individuals with eGFR ≥ 60 (35%). Compared to eGFR ≥ 60, the lowest prevalence of individuals with any mental health and addictions service utilization was among those with eGFR 15 to < 30 (adjusted PR 0.86, 95% CI 0.85 to 0.88), eGFR < 15 (adjusted PR 0.81, 95% CI 0.76 to 0.86) and those receiving maintenance dialysis (adjusted PR 0.83, 95% CI 0.81 to 0.84). Less use of outpatient services accounted for differences in service utilization. CONCLUSIONS: Mental health and addictions service utilization is common but less so in individuals with advanced CKD in Ontario, Canada.

Vaccine Effectiveness Against SARS-CoV-2 Infection and Severe Outcomes in the Maintenance Dialysis Population in Ontario, Canada.

BACKGROUND: Vaccination studies in the hemodialysis population have demonstrated decreased antibody response compared with healthy controls, but vaccine effectiveness for preventing SARS-CoV-2 infection and severe disease is undetermined. METHODS: We conducted a retrospective cohort study in the province of Ontario, Canada, between December 21, 2020, and June 30, 2021. Receipt of vaccine, SARS-CoV-2 infection, and related severe outcomes (hospitalization or death) were determined from provincial health administrative data. Receipt of one and two doses of vaccine were modeled in a time-varying cause-specific Cox proportional hazards model, adjusting for baseline characteristics, background community infection rates, and censoring for non-COVID death, recovered kidney function, transfer out of province, solid organ transplant, and withdrawal from dialysis. RESULTS: Among 13,759 individuals receiving maintenance dialysis, 2403 (17%) were unvaccinated and 11,356 (83%) had received at least one dose by June 30, 2021. Vaccine types were BNT162b2 (n=8455, 74%) and mRNA-1273 (n=2901, 26%); median time between the first and second dose was 36 days (IQR 28-51). The adjusted hazard ratio (HR) for SARS-CoV-2 infection and severe outcomes for one dose compared with unvaccinated was 0.59 (95% CI, 0.46 to 0.76) and 0.54 (95% CI, 0.37 to 0.77), respectively, and for two doses compared with unvaccinated was 0.31 (95% CI, 0.22 to 0.42) and 0.17 (95% CI, 0.1 to 0.3), respectively. There were no significant differences in vaccine effectiveness among age groups, dialysis modality, or vaccine type. CONCLUSIONS: COVID-19 vaccination is effective in the dialysis population to prevent SARS-CoV-2 infection and severe outcomes, despite concerns about suboptimal antibody responses.

Higher-Dose Gabapentinoids and the Risk of Adverse Events in Older Adults With CKD: A Population-Based Cohort Study.

RATIONALE & OBJECTIVE: Gabapentinoids are opioid substitutes whose elimination by the kidneys is reduced as kidney function declines. To inform their safe prescribing in older adults with chronic kidney disease (CKD), we examined the 30-day risk of serious adverse events according to the prescribed starting dose. STUDY DESIGN: Population-based cohort study. SETTING & PARTICIPANTS: 74,084 older adults (64% women; median age, 79 [interquartile range, 73-85] years) with CKD (defined for this study as an estimated glomerular filtration rate <60 mL/min/1.73 m2 and excluding those receiving dialysis) and a newly prescribed gabapentinoid between 2008 and 2020 in Ontario, Canada. EXPOSURE: Higher-dose gabapentinoids (gabapentin >300 mg/d or pregabalin >75 mg/d) versus lower-dose gabapentinoids (gabapentin ≤300 mg/d or pregabalin ≤75 mg/d). OUTCOMES: The primary composite outcome was the 30-day risk of a hospital visit with encephalopathy, a fall, or a fracture or a hospitalization with respiratory depression. ANALYTICAL APPROACH: Comparison groups were balanced on indicators of baseline health using inverse probability of treatment weighting using propensity score analysis that generated a pseudosample for the reference group with a distribution of measured covariates similar to the exposed group. Weighted risk ratios were estimated using modified Poisson regression, and weighted risk differences were estimated using binomial regression. Prespecified subgroup analyses were conducted by estimated glomerular filtration rate category and type of gabapentinoid. RESULTS: Among 74,084 patients identified with CKD and a new prescription for gabapentin or pregabalin, 41% started at >300 or >75 mg/d, respectively. From this set of patients, a weighted study population with a size of 61,367 was generated. Patients who started at a higher dose had a higher 30-day risk of the primary outcome than patients who started at lower dose. Within the weighted population, the numbers of events for higher versus lower dose were 585 of 30,660 (1.9%) versus 462 of 30,707 (1.5%), respectively. The weighted risk ratio was 1.27 (95% CI, 1.13-1.42), and the weighted risk difference was 0.40% (95% CI, 0.21%-0.60%). In subgroup analyses, neither multiplicative nor additive interactions were statistically significant. LIMITATIONS: Residual confounding. CONCLUSIONS: In this population-based study, starting a gabapentinoid at a higher versus a lower dose was associated with a slightly higher risk of a hospital visit with encephalopathy, a fall, or a fracture or hospitalization with respiratory depression. If verified, these risks should be balanced against the benefits of using a higher-dose gabapentinoid.

Initiation Dose of Allopurinol and the Risk of Severe Cutaneous Reactions in Older Adults With CKD: A Population-Based Cohort Study.

RATIONALE & OBJECTIVE: Allopurinol should be started at lower doses in patients with chronic kidney disease (CKD) to avoid adverse effects. We examined the risk of severe cutaneous reactions in older adults with CKD who were newly prescribed allopurinol at varied doses. STUDY DESIGN: Population-based cohort study using linked health care databases. SETTING & PARTICIPANTS: Patients in Ontario, Canada (2008-2019) aged ≥66 years, with an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2, and who were new users of allopurinol. EXPOSURE: A new prescription for allopurinol >100 mg/d versus a dose ≤100 mg/d. OUTCOME: The primary outcome was a hospital visit with a severe cutaneous reaction within 180 days of starting allopurinol. Secondary outcomes included all-cause hospitalization and all-cause mortality. ANALYTICAL APPROACH: The exposure and referent groups were balanced on indicators of baseline health using inverse probability of treatment weighting on the propensity score. Weighted risk ratios (RR) were obtained using modified Poisson regression and weighted risk differences (RD) using binomial regression. RESULTS: Of 47,315 patients (median age, 76 years; median eGFR, 45 mL/min/1.73 m2), 55% started allopurinol at >100 mg/d. Starting allopurinol at >100 versus ≤100 mg/d was associated with an increased risk of a severe cutaneous reaction: number of events (weighted), 103 of 25,802 (0.40%) versus 46 of 25,816 (0.18%), respectively (weighted RR, 2.25 [95% CI, 1.50-3.37]; weighted RD, 0.22% [95% CI, 0.12%-0.32%]. Starting allopurinol at >100 versus ≤100 mg/d was associated with an increased risk of all-cause hospitalization but not with all-cause mortality. LIMITATIONS: This study was underpowered to detect risk differences in the association of allopurinol dose with outcomes across eGFR categories (ie, 45-59, 30-44, and <30 mL/min/1.73 m2). CONCLUSIONS: Older patients with CKD who started allopurinol at >100 mg/d versus ≤100 mg/d were twice as likely to visit a hospital with a severe cutaneous reaction in the next 180 days.

Differences in mRNA-1273 (Moderna) and BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 vaccine immunogenicity among patients undergoing dialysis.

BACKGROUND: Differences in immunogenicity between mRNA SARS-CoV-2 vaccines have not been well characterized in patients undergoing dialysis. We compared the serologic response in patients undergoing maintenance hemodialysis after vaccination against SARS-CoV-2 with BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna). METHODS: We conducted a prospective observational cohort study at 2 academic centres in Toronto, Canada, from Feb. 2, 2021, to July 20, 2021, which included 129 and 95 patients who received the BNT162b2 and mRNA-1273 SARS-CoV-2 vaccines, respectively. We measured SARS-CoV-2 immunoglobulin G antibodies to the spike protein (anti-spike), receptor binding domain (anti-RBD) and nucleocapsid protein (anti-NP) at 6-7 and 12 weeks after the second dose of vaccine and compared those levels with the median convalescent serum antibody levels from 211 controls who were previously infected with SARS-CoV-2. RESULTS: At 6-7 weeks after 2-dose vaccination, we found that 51 of 70 patients (73%) who received BNT162b2 and 83 of 87 (95%) who received mRNA-1273 attained convalescent levels of anti-spike antibody (p < 0.001). In those who received BNT162b2, 35 of 70 (50%) reached the convalescent level for anti-RBD compared with 69 of 87 (79%) who received mRNA-1273 (p < 0.001). At 12 weeks after the second dose, anti-spike and anti-RBD levels were significantly lower in patients who received BNT162b2 than in those who received mRNA-1273. For anti-spike, 70 of 122 patients (57.4%) who received BNT162b2 maintained the convalescent level versus 68 of 71 (96%) of those who received mRNA-1273 (p < 0.001). For anti-RBD, 47 of 122 patients (38.5%) who received BNT162b2 maintained the anti-RBD convalescent level versus 45 of 71 (63%) of those who received mRNA-1273 (p = 0.002). INTERPRETATION: In patients undergoing hemodialysis, mRNA-1273 elicited a stronger humoral response than BNT162b2. Given the rapid decline in immunogenicity at 12 weeks in patients who received BNT162b2, a third dose is recommended in patients undergoing dialysis as a primary series, similar to recommendations for other vulnerable populations.

COVID-19 in patients undergoing long-term dialysis in Ontario.

BACKGROUND: Patients undergoing long-term dialysis may be at higher risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and of associated disease and mortality. We aimed to describe the incidence, risk factors and outcomes for infection in these patients in Ontario, Canada. METHODS: We used linked data sets to compare disease characteristics and mortality between patients receiving long-term dialysis in Ontario who were diagnosed SARS-CoV-2 positive and those who did not acquire SARS-CoV-2 infection, between Mar. 12 and Aug. 20, 2020. We collected data on SARS-CoV-2 infection prospectively. We evaluated risk factors for infection and death using multivariable logistic regression analyses. RESULTS: During the study period, 187 (1.5%) of 12 501 patients undergoing dialysis were diagnosed with SARS-CoV-2 infection. Of those with SARS-CoV-2 infection, 117 (62.6%) were admitted to hospital and the case fatality rate was 28.3%. Significant predictors of infection included in-centre hemodialysis versus home dialysis (odds ratio [OR] 2.54, 95% confidence interval [CI] 1.59-4.05), living in a long-term care residence (OR 7.67, 95% CI 5.30-11.11), living in the Greater Toronto Area (OR 3.27, 95% CI 2.21-4.80), Black ethnicity (OR 3.05, 95% CI 1.95-4.77), Indian subcontinent ethnicity (OR 1.70, 95% CI 1.02-2.81), other non-White ethnicities (OR 2.03, 95% CI 1.38-2.97) and lower income quintiles (OR 1.82, 95% CI 1.15-2.89). INTERPRETATION: Patients undergoing long-term dialysis are at increased risk of SARS-CoV-2 infection and death from coronavirus disease 2019. Special attention should be paid to addressing risk factors for infection, and these patients should be prioritized for vaccination.

What do end-users want to know about managing the performance of healthcare delivery systems? Co-designing a context-specific and practice-relevant research agenda.

BACKGROUND: Despite increasing interest in joint research priority-setting, few studies engage end-user groups in setting research priorities at the intersection of the healthcare and management disciplines. With health systems increasingly establishing performance management programmes to account for and incentivize performance, it is important to conduct research that is actionable by the end-users involved with or impacted by these programmes. The aim of this study was to co-design a research agenda on healthcare performance management with and for end-users in a specific jurisdictional and policy context. METHODS: We undertook a rapid review of the literature on healthcare performance management (n = 115) and conducted end-user interviews (n = 156) that included a quantitative ranking exercise to prioritize five directions for future research. The quantitative rankings were analysed using four methods: mean, median, frequency ranked first or second, and frequency ranked fifth. The interview transcripts were coded inductively and analysed thematically to identify common patterns across participant responses. RESULTS: Seventy-three individual and group interviews were conducted with 156 end-users representing diverse end-user groups, including administrators, clinicians and patients, among others. End-user groups prioritized different research directions based on their experiences and information needs. Despite this variation, the research direction on motivating performance improvement had the highest overall mean ranking and was most often ranked first or second and least often ranked fifth. The research direction was modified based on end-user feedback to include an explicit behaviour change lens and stronger consideration for the influence of context. CONCLUSIONS: Joint research priority-setting resulted in a practice-driven research agenda capable of generating results to inform policy and management practice in healthcare as well as contribute to the literature. The results suggest that end-users are keen to open the "black box" of performance management to explore more nuanced questions beyond "does performance management work?" End-users want to know how, when and why performance management contributes to behaviour change (or fails to) among front-line care providers.

Baclofen has a risk of encephalopathy in older adults receiving dialysis.

At least 23 case reports link the muscle relaxant baclofen to encephalopathy in patients receiving dialysis. To explore this issue, we conducted a study to quantify the risk of encephalopathy from baclofen in patients receiving dialysis. Linked healthcare databases were used to conduct a population-based cohort study of older adults receiving maintenance dialysis in Ontario, Canada (1997-2018) to compare new users of baclofen to non-users. The primary outcome was the 30-day risk of hospitalization with encephalopathy, defined as a main diagnosis of delirium, disorientation, transient alteration of awareness, or transient cerebral ischemic attack. Inverse probability of treatment weighting on the propensity score was used to balance comparison groups on indicators of baseline health. Weighted risk ratios (RR) were obtained using modified Poisson regression and weighted risk differences (RD) using binomial regression. We studied 360 new baclofen users and 6109 non-users (2638 [41%] women; median age 75). The median baclofen dose was 20 mg/day. Hospitalization with encephalopathy occurred in 26 of 360 baclofen users (7.2%) and in under six of 6109 non-users (under 0.1%); weighted risk ratios, 78.3 (95% confidence interval 27.9 to 219.2); weighted risk differences, 7.1% (4.5% to 9.8%). The median time from baclofen dispensing to hospitalization with encephalopathy was three days. Among patients receiving dialysis, approximately one in 14 were hospitalized with encephalopathy shortly after starting baclofen. Thus, baclofen should be avoided in older adults receiving dialysis, and other muscle relaxants considered in its place. Hence, if baclofen must be used, a low dose should be prescribed, and older adults should be carefully monitored for signs of encephalopathy.

Complications From Tunneled Hemodialysis Catheters: A Canadian Observational Cohort Study.

RATIONALE & OBJECTIVE: Clinical practice guidelines discourage the use of central venous catheters (CVCs) for vascular access in dialysis. However, some patients have inadequate vessels for arteriovenous fistula creation or choose to use a dialysis catheter. The risks associated with CVC use and their relationship to patient age are poorly characterized. STUDY DESIGN: Observational retrospective cohort study. SETTING & PARTICIPANTS: Cohort of 1,041 patients older than 18 years from 5 Canadian dialysis programs who initiated outpatient maintenance hemodialysis therapy with a tunneled CVC between 2004 and 2012 and who had no creation of an arteriovenous fistula or arteriovenous graft. EXPOSURES: Age, sex, body size, initiating dialysis therapy in the hospital, and comorbid conditions. OUTCOMES: CVC-related procedures, hospitalization, and death. ANALYTICAL APPROACH: Complications were reported as a cumulative risk at 1 and 2 years. Cox proportional hazards regression for recurrent events was used to evaluate risk factors for study outcomes. RESULTS: At 1 year, risks for CVC-related bacteremia, malfunction, and central stenosis were 9%, 15%, and 2%, respectively. Risks for any CVC-related complication at 1 and 2 years were 30% and 38%, respectively. Death related to CVC complications occurred in 6 of 1,041 (0.5%) patients. Compared with patients younger than 60 years, patients aged 70 to 79 and those 80 years or older experienced lower rates of CVC complications: HRs of 0.67 (95% CI, 0.52-0.85; P = 0.001) and 0.69 (95% CI, 0.52-0.92; P = 0.01), respectively. LIMITATIONS: This Canadian dialysis population may not be representative of populations in other countries. CVC use was not compared with other types of hemodialysis vascular access. CONCLUSIONS: Approximately one-third of hemodialysis patients who used tunneled CVCs during 1 to 2 years experienced complications. Bacteremia occurred in ∼9% of patients at 1 year and were the most common cause of CVC-related hospitalizations. CVC-related death was infrequent. This information could be used to communicate the risk for CVC complications to patients treated with this type of hemodialysis vascular access.

Can economic incentives increase the use of home dialysis?

There are advantages to home dialysis for patients, and kidney care programs, but use remains low in most countries. Health-care policy-makers have many levers to increase use of home dialysis, one of them being economic incentives. These include how health-care funding is provided to kidney care programs and dialysis facilities; how physicians are remunerated for care of home dialysis patients; and financial incentives-or removal of disincentives-for home dialysis patients. This report is based on a comprehensive literature review summarizing the impact of economic incentives for home dialysis and a workshop that brought together an international group of policy-makers, health economists and home dialysis experts to discuss how economic incentives (or removal of economic disincentives) might be used to increase the use of home dialysis. The results of the literature review and the consensus of workshop participants were that financial incentives to dialysis facilities for home dialysis (for instance, through activity-based funding), particularly in for-profit systems, could lead to a small increase in use of home dialysis. The evidence was less clear on the impact of economic incentives for nephrologists, and participants felt this was less important than a nephrologist workforce in support of home dialysis. Workshop participants felt that patient-borne costs experienced by home dialysis patients were unjust and inequitable, though participants noted that there was no evidence that decreasing patient-borne costs would increase use of home dialysis, even among low-income patients. The use of financial incentives for home dialysis-whether directed at dialysis facilities, nephrologists or patients-is only one part of a high-performing system that seeks to increase use of home dialysis.

Association of Baclofen With Encephalopathy in Patients With Chronic Kidney Disease.

IMPORTANCE: At least 30 case reports have linked the muscle relaxant baclofen to encephalopathy in patients with chronic kidney disease (CKD). OBJECTIVE: To compare the 30-day risk of encephalopathy in patients with CKD and newly prescribed baclofen at greater than or equal to 20 mg per day vs less than 20 mg per day. The secondary objective was to compare the risk of encephalopathy in baclofen users vs nonusers. DESIGN, SETTING, AND PARTICIPANTS: Retrospective population-based cohort study in Ontario, Canada (2007-2018) using linked health care data. Participants comprised 15 942 older adults (aged 66 years or older) with CKD (defined as an estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2 but not receiving dialysis). The primary cohort was restricted to patients who were newly prescribed baclofen; participants in the secondary cohort were new users and nonusers. EXPOSURES: Prescription for oral baclofen greater than or equal to 20 mg per day vs less than 20 mg per day. MAIN OUTCOMES AND MEASURES: Hospital admission with encephalopathy, defined as a main diagnosis of delirium, disorientation, transient alteration of awareness, transient cerebral ischemic attack, or unspecified dementia within 30 days of starting baclofen. Inverse probability of treatment weighting on the propensity score was used to balance comparison groups on indicators of baseline health. Weighted risk ratios (RRs) were obtained using modified Poisson regression and weighted risk differences (RDs) using binomial regression. Prespecified subgroup analyses were conducted by eGFR category. RESULTS: The primary cohort comprised 15 942 patients with CKD (9699 [61%] women; median age, 77 years [interquartile range, 71-82]; 9707 [61%] patients started baclofen at ≥20 mg/d and 6235 [39%] at <20 mg/d). The primary outcome, hospitalization with encephalopathy, occurred in 108/9707 (1.11%) patients who started baclofen at greater than or equal to 20 mg per day and in 26/6235 (0.42%) who started baclofen at less than 20 mg per day; weighted RR, 3.54 (95% CI, 2.24 to 5.59); weighted RD, 0.80% (95% CI, 0.55% to 1.04%). In subgroup analysis, the absolute risk increased progressively at lower eGFR (weighted RD eGFR 45-59, 0.42% [95% CI, 0.19%-0.64%]; eGFR 30-44, 1.23% [95% CI, 0.62%-1.84%]; eGFR <30, 2.90% [95% CI, 1.30%-4.49%]; P for interaction, <.001]). In the secondary comparison with 284 263 nonusers, both groups of baclofen users had a higher risk of encephalopathy (<20 mg/d weighted RR, 5.90 [95% CI, 3.59 to 9.70] and ≥20 mg/d weighted RR, 19.8 [95% CI, 14.0 to 28.0]). CONCLUSIONS AND RELEVANCE: Among older patients with CKD who were newly prescribed baclofen, the 30-day incidence of encephalopathy was increased among those prescribed higher doses compared with lower doses. If verified, these risks should be balanced against the benefits of baclofen use.

Is the peritoneal dialysis biocompatibility hypothesis dead?

The peritoneal dialysis (PD) biocompatibility hypothesis is that conventional PD solutions with high levels of glucose degradation products (GDPs), glucose and lactate, and low pH cause morphological and functional damage to the peritoneal membrane and that this damage may be attenuated by biocompatible solutions. Functional findings from randomized trials have not supported this hypothesis, and now new data from a large European pediatric peritoneal biopsy study provide a morphologic correlate for this. The implications are discussed.

COVID-19 chez les patients ontariens sous dialyse à long terme.

CONTEXTE: Les patients sous dialyse à long terme pourraient avoir un risque accru d'infection par le coronavirus du syndrome respiratoire aigu sévère 2 (SRAS-CoV-2), et de maladie et de mortalité associées. Nous avons voulu décrire l'incidence, les facteurs de risque et les issues de l'infection chez ces patients en Ontario (Canada). MÉTHODES: Nous avons utilisé des ensembles de données reliées pour comparer les caractéristiques de la maladie et la mortalité chez les patients sous dialyse à long terme en Ontario qui ont testé positif pour le SRAS-CoV-2 et ceux qui n'ont pas développé d'infection, entre le 12 mars et le 20 août 2020. Nous avons recueilli des données sur l'infection par le SRAS-CoV-2 de manière prospective. Nous avons évalué les facteurs de risque d'infection et de mortalité par des analyses de régression logistique multivariées. RÉSULTATS: Pendant la période à l'étude, 187 patients dialysés sur 12 501 (1,5 %) ont reçu un diagnostic d'infection par le SRAS-CoV-2. Parmi eux, 117 (62,6 %) ont été hospitalisés, et le taux de mortalité était de 28,3 %. Les facteurs prédictifs significatifs associés à l'infection incluaient l'hémodialyse dans un centre plutôt que la dialyse à domicile (rapport de cotes [RC] 2,54; intervalle de confiance [IC] à 95 % 1,59­4,05), le fait de vivre dans un établissement de soins de longue durée (RC 7,67; IC à 95 % 5,30­11,11), le fait d'habiter la région du Grand Toronto (RC 3,27; IC à 95 % 2,21­4,80), les ethnicités Noire (RC 3,05; IC à 95 % 1,95­4,77), du sous-continent indien (RC 1,70; IC à 95 % 1,02­2,81) et autres non blanches (RC 2,03; IC à 95 % 1,38­2,97) et les quintiles de revenu inférieurs (RC 1,82; IC à 95 % 1,15­2,89). INTERPRÉTATION: Les patients sous dialyse à long terme sont exposés à un risque accru d'infection par le SRAS-CoV-2 et de mortalité due à la maladie à coronavirus 2019. Il faudra travailler à éliminer les facteurs de risque d'infection et vacciner ces patients en priorité.

A Patient-Centered Approach to Hemodialysis Vascular Access in the Era of Fistula First.

The primary vascular access options for the hemodialysis population are arteriovenous fistulas (AVF), arteriovenous grafts, and cuffed central venous catheters (CVC). AVFs are associated with the most favorable outcomes with respect to complications, interventions required to maintain functionality and patency, and overall cost. These population-based outcomes, in conjunction with the efforts of the Fistula First Breakthrough Initiative, have propelled the prevalence of AVFs in the US hemodialysis population. While this endeavor remains steadfast in assuring the continued dominance of this policy for AVF preference, it fails to take into account a subset of the dialysis population who will fail to see the benefits of an AVF. This subset of patients may include the elderly, those with poor vasculature anatomy, those with slowly progressive CKD who are more likely to die than progress to ESRD, and those with an overall poor long-term prognosis and shortened life expectancy. Thus, in an effort to avoid numerous unnecessary surgical and interventional procedures with minimal to no gains in clinical outcomes, an individualized patient approach must be adopted. The Centers for Medicare and Medicaid Services-instituted quality incentive program is designed to reward high AVF prevalence while also penalizing high CVC prevalence. The current model is devoid of case-based adjustment, thus penalties are disbursed to dialysis providers in accordance with a "one-size-fits-all" fistula only approach. The most suitable access for a patient remains the one that takes into account the characteristics unique to the individual patient with a primary focus on patient comfort, satisfaction, quality of life, and clinical outcomes.

Implementation of an agency to improve chronic kidney disease care in Ontario: lessons learned by the Ontario Renal Network.

In 2009, Ontario's Ministry of Health and Long-Term Care initiated the transfer of oversight and coordination of chronic kidney disease (CKD) care to the Ontario Renal Network (ORN) under the auspices of Cancer Care Ontario (CCO). The aim was to replicate the quality improvement and change management practices used for cancer control within CKD. Much of the ORN's first three years were dedicated to building the infrastructure necessary to bridge the gap between provincial policy and clinical practice. This article explores the accomplishments, challenges and lessons learned over that period. The results, which are applicable to the management of chronic diseases in Ontario, Canada, and internationally, confirm that sustainable change takes time and requires strong leadership, transparency, accountability and communication, supported by a solid foundation of data and evidence.

Timing of peritoneal dialysis initiation and mortality: analysis of the Canadian Organ Replacement Registry.

BACKGROUND: Several observational studies of hemodialysis patients show an association between early dialysis therapy initiation and increased mortality. Few studies have examined this association among peritoneal dialysis patients. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: A cohort of 8,047 incident peritoneal dialysis patients who started dialysis therapy in 2001-2009 and were treated in Canada. PREDICTOR: Estimated glomerular filtration rate (eGFR) at dialysis therapy initiation. Defined early, mid, and late starts as eGFR>10.5, 7.5-10.5, and <7.5mL/min/1.73m(2), respectively. OUTCOMES: Time to death. MEASUREMENTS: Proportional piecewise exponential survival models to compare mortality (overall and early) for the 3 predictor groups. RESULTS: Between 2001 and 2009, the proportion of patients starting peritoneal dialysis therapy as early starts increased from 29% (95% CI, 26%-32%) to 44% (95% CI, 41%-47%). Compared with the late-start group, the overall mortality rate was not higher for the early- (adjusted HR, 1.08; 95% CI, 0.96-1.23) or mid-start (adjusted HR, 0.96; 95% CI, 0.86-1.09) groups. However, when examined yearly, patients in the early-start group were significantly more likely to die within the first year of dialysis therapy compared with those in the late-start group (adjusted HR, 1.38; 95% CI, 1.10-1.73), but not in subsequent years. LIMITATIONS: Bias and residual confounding may have influenced the observed relationship between predictor and outcome. CONCLUSIONS: Patients are initiating peritoneal dialysis therapy at increasingly higher eGFRs. Contrary to most observational studies assessing hemodialysis, the early initiation of peritoneal dialysis therapy, at eGFR>10.5mL/min/1.73m(2), is not associated with increased mortality.