Implications of Implementing the 2021 CKD-EPI Equation Without Race on Managing Patients With Kidney Disease in British Columbia, Canada.

Introduction: We investigated the implications of implementing race-free Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2021 equation among real-world patients with chronic kidney disease (CKD) from British Columbia (BC), Canada. Methods: This study included nondialysis-dependent patients with CKD aged ≥19 years who were registered in the Patient Records and Outcome Management Information System (PROMIS) as of March 31, 2016 (index date) with ≥1 serum creatinine measurement within 1 year before the index date. Patients with a history of kidney transplantation before the index date were excluded. CKD-EPI 2021 versus 2009 equation was the exposure variable. Difference in mean estimated glomerular filtration rate (eGFR) and number (%) of patients reclassified to a different eGFR category were estimated. We used Fine and Gray subdistribution hazard model to investigate the association between change in eGFR category and progression to kidney failure (incident maintenance dialysis or kidney transplantation) within 2 years. Results: A total of 11,604 patients (median age 73 years, 52% male) were included. Compared to the 2009 equation, eGFR from 2021 equation was on average 2.7 ml/min per 1.73 m2 higher. Variation was higher among males. Overall, ∼17% of the study sample were reclassified to a category with higher eGFR by 2021 equation (switchers). The highest proportion (28%) of patients were reclassified from G5 to G4. The risk of progressing to kidney failure was 22% less among switchers compared to nonswitchers; adjusted subdistribution hazard ratio (HR) (95% confidence interval [CI]) is 0.78 (0.65, 0.94). Conclusion: CKD-EPI 2021 equation appeared to provide higher eGFR compared to 2009 equation. This higher eGFR values appeared to be concordant with subsequent real-world CKD progression outcomes. Higher eGFR from the 2021 equation may have substantial clinical implications in both diagnosis as well as long-term care of patients with CKD.

Applications of SGLT2 inhibitors beyond glycaemic control.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors were initially developed for their glucose-lowering effects and have shown a modest glycaemic benefit in people with type 2 diabetes mellitus (T2DM). In the past decade, a series of large, robust clinical trials of these therapies have demonstrated striking beneficial effects for various care goals, transforming the chronic disease therapeutic landscape. Cardiovascular safety studies in people with T2DM demonstrated that SGLT2 inhibitors reduce cardiovascular death and hospitalization for heart failure. Subsequent trials in participants with heart failure with reduced or preserved left ventricular ejection fraction demonstrated that SGLT2 inhibitors have beneficial effects on heart failure outcomes. In dedicated kidney outcome studies, SGLT2 inhibitors reduced the incidence of kidney failure among participants with or without diabetes. Post hoc analyses have suggested a range of other benefits of these drugs in conditions as diverse as metabolic dysfunction-associated steatotic liver disease, kidney stone prevention and anaemia. SGLT2 inhibitors have a generally favourable adverse effect profile, although patient selection and medication counselling remain important. Concerted efforts are needed to better integrate these agents into routine care and support long-term medication adherence to close the gap between clinical trial outcomes and those achieved in the real world.

Kidney Failure Risk Equation in vascular access planning: a population-based study supporting value in decision making.

Background: The Kidney Failure Risk Equation (KFRE) can play a better role in vascular access (VA) planning in patients with chronic kidney disease (CKD) requiring hemodialysis (HD). We described the VA creation and utilization pattern under existing estimated glomerular filtration rate (eGFR)-based referral, and investigated the utility of KFRE score as an adjunct variable in VA planning. Methods: Patients with CKD aged ≥18 years with eGFR <20 mL/min/1.73 m2 who chose HD as dialysis modality from January 2010 to August 2020 were included from a population-based database in British Columbia, Canada. Modality selection date was the index date. Exposures were categorized as (i) current eGFR-based referral, (ii) eGFR-based referral plus KRFE 2-year risk score on index date (KFRE-2) >40% and (iii) eGFR-based referral plus KFRE-2 ≤40%. We estimated the proportion of patients who started HD on arteriovenous fistula/graft (AVF/G) within 2 years, indicating timely pre-emptive creation, and the proportion of patients in whom AVF/G was created but did not start HD within 2 years, indicating too-early creation. Results: Study included 2581 patients, median age 71 years, 60% male. Overall, 1562(61%) started HD and 276 (11%) experienced death before HD initiation within 2 years. Compared with current referral, the proportion of patients who started HD on AVF/G was significantly higher when KFRE-2 was considered in addition to current referral (49% vs 58%, P-value <.001). Adjunct KFRE-2 significantly reduced too-early creation (31% vs 18%, P-value <.001). Conclusions: KFRE in addition to existing eGFR-based referral for VA creation has the potential to improve VA resource utilization by ensuring more patients start HD on AVF/G and may minimize too-early/unnecessary creation. Prospective research is necessary to validate these findings.

Identifying Barriers and Facilitators for Increasing Uptake of Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors in British Columbia, Canada, using the Consolidated Framework for Implementation Research.

Background: Care gaps remain in modern health care despite the availability of robust, evidence-based medications. Although sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated profound benefits in improving both cardiovascular and kidney outcomes in patients, the uptake of these medications remain suboptimal, and the causes have not been systematically explored. Objective: The purpose of this study was to use the Consolidated Framework for Implementation Research (CFIR) to describe the barriers and facilitators faced by clinicians in British Columbia, Canada, when prescribing an SGLT2 inhibitor. To achieve this, we conducted semistructured interviews using the CFIR with practicing family physicians, nephrologists, endocrinologists, and cardiologists in British Columbia. Design: Semistructured interviews. Setting: British Columbia, Canada. Participants: Actively practicing family physicians, nephrologists, endocrinologists, and cardiologists in British Columbia. Methods: Twenty-one clinicians were interviewed using questions derived from the CFIR. The audio recordings were transcribed verbatim, and each transcription was individually analyzed in duplicate using thematic analysis. The analysis focused on identifying barriers and facilitators to using SGLT2 inhibitors in clinical practice and coded using the CFIR constructs. Once the transcriptions were coded, overarching themes were created. Results: Five overarching themes were identified to the barriers and facilitators to using SGLT2 inhibitors: current perceptions and beliefs, clinician factors, patient factors, medication factors, and health care system factors. The current perceptions and beliefs were that SGLT2 inhibitors are efficacious and have distinct advantages over other agents but are underutilized in British Columbia. Clinician factors included varying levels of knowledge of and comfort in prescribing SGLT2 inhibitors, and patient factors included intolerable adverse events and additional pill burden, but many were enthusiastic about potential benefits. Multiple SGLT2 inhibitor related adverse events like mycotic infections and euglycemic diabetic ketoacidosis and the difficulty in obtaining reimbursement for these medications were also identified as a barrier to prescribing these medications. Facilitators for the use of SGLT2 inhibitors included consensus among colleagues, influential leaders, and peers in support of their use, and endorsement by national guidelines. Limitations: The experience from the clinicians regarding costs and the reimbursement process is limited to British Columbia as each province has its own procedures. There may be responder bias as clinicians were approached through purposive sampling. Conclusion: This study highlights different themes to the barriers and facilitators of using SGLT2 inhibitors in British Columbia. The identification of these barriers provides a specific target for improvement, and the facilitators can be leveraged for the increased use of SGLT2 inhibitors. Efforts to address and optimize these barriers and facilitators in a systematic approach may lead to an increase in the use of these efficacious medications.

Contexte: Des lacunes subsistent dans les soins de santé modernes, malgré l'existence de médicaments éprouvés et fondés sur des données probantes. Les inhibiteurs du cotransporteur de sodium-glucose de type 2 (SGLT2) ont démontré d'importants effets dans l'amélioration des résultats cardiovasculaires et rénaux des patients, mais l'utilization de ces médicaments demeure sous-optimale et les raisons qui expliquent cette situation n'ont pas été systématiquement explorées. Objectif: Utiliser le Consolidated Framework for Implementation Research (CFIR) pour décrire les obstacles et les éléments facilitateurs rencontrés par les cliniciens de la Colombie-Britannique (Canada) lorsqu'ils prescrivent un inhibiteur du SGLT2. Pour ce faire, nous avons mené des entretiens semi-structurés au moyen du CFIR auprès de médecins de famille, de néphrologues, de cardiologues et d'endocrinologues exerçant en Colombie-Britannique. Conception: Entretiens semi-structurés. Cadre: Colombie-Britannique (Canada). Participants: Médecins de famille, cardiologues, endocrinologues et néphrologues exerçant en Colombie-Britannique. Méthodologie: Les questions dérivées du CFIR ont été posées à vingt-et-un cliniciens. Les enregistrements audio ont été transcrits verbatim et chaque transcription a été analysée individuellement en double en utilisant l'analyze thématique. L'analyze s'est concentrée sur l'identification des obstacles et des facilitateurs à l'utilization des inhibiteurs du SGLT2 dans la pratique clinique et sur le codage selon les concepts du CFIR. Une fois les transcriptions codées, des thèmes généraux ont été créés. Résultats: Cinq thèmes généraux ont été identifiés pour les obstacles et les facilitateurs à l'utilization des inhibiteurs du SGLT2: les perceptions et les croyances actuelles, les facteurs liés aux cliniciens, les facteurs liés aux patients, les facteurs liés aux médicaments et les facteurs liés au système de santé. Les perceptions et croyances actuelles étaient que les inhibiteurs du SGLT2 sont efficaces, qu'ils présentent des avantages distincts des autres agents, mais qu'ils sont sous-utilisés en Colombie-Britannique. Les facteurs liés aux cliniciens incluaient des niveaux variables de connaissance et de confort vis-à-vis la prescription d'inhibiteurs du SGLT2. Les facteurs liés aux patients incluaient les événements indésirables intolérables et la charge médicamenteuse supplémentaire, mais plusieurs répondants voyaient positivement les bienfaits potentiels. Les nombreux événements indésirables liés aux inhibiteurs du SGLT2, notamment les infections mycosiques et l'acidocétose diabétique euglycémique, et la difficulté à obtenir le remboursement de ces médicaments ont également été cités comme raisons limitant la prescription de ces médicaments. Le consensus parmi les collègues, les leaders influents et les pairs en faveur des inhibiteurs du SGLT2 et l'inclusion de ces médicaments dans les lignes directrices nationales figuraient parmi les facilitateurs. Limites: Les expériences rapportées par les cliniciens en ce qui concerne les coûts et le processus de remboursement se limitent à la Colombie-Britannique, car chaque province a ses propres procédures. L'étude comporte un possible biais de réponse puisque les cliniciens ont été approchés par échantillonnage dirigé. Conclusion: Cette étude met en évidence différents thèmes concernant les obstacles et les facilitateurs à l'utilization des inhibiteurs du SGLT2 en Colombie-Britannique. L'identification de ces obstacles fournit une cible précise pour l'amélioration, alors que les facilitateurs peuvent être mis à profit pour accroître l'utilization des inhibiteurs de SGLT2. Les efforts déployés pour aborder et optimiser ces obstacles et ces facilitateurs dans le cadre d'une approche systématique pourraient mener à une augmentation de l'utilization de ces médicaments efficaces.

Kidney and Cardiovascular Effects of Canagliflozin According to Age and Sex: A Post Hoc Analysis of the CREDENCE Randomized Clinical Trial.

RATIONALE & OBJECTIVE: It is unclear whether the effect of canagliflozin on adverse kidney and cardiovascular events in those with diabetic kidney disease varies by age and sex. We assessed the effects of canagliflozin among age group categories and between sexes in the Canagliflozin and Renal Endpoints in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) study. STUDY DESIGN: Secondary analysis of a randomized controlled trial. SETTING & PARTICIPANTS: Participants in the CREDENCE trial. INTERVENTION: Participants were randomly assigned to receive canagliflozin 100mg/d or placebo. OUTCOMES: Primary composite outcome of kidney failure, doubling of serum creatinine concentration, or death due to kidney or cardiovascular disease. Prespecified secondary and safety outcomes were also analyzed. Outcomes were evaluated by age at baseline (<60, 60-69, and≥70 years) and sex in the intention-to-treat population using Cox regression models. RESULTS: The mean age of the cohort was 63.0±9.2 years, and 34% were female. Older age and female sex were independently associated with a lower risk of the composite of adverse kidney outcomes. There was no evidence that the effect of canagliflozin on the primary outcome (a composite of kidney failure, a doubling of serum creatinine concentration, or death from kidney or cardiovascular causes) differed between age groups (HRs, 0.67 [95% CI, 0.52-0.87], 0.63 [0.48-0.82], and 0.89 [0.61-1.29] for ages<60, 60-69, and≥70 years, respectively; P=0.3for interaction) or sexes (HRs, 0.71 [95% CI, 0.54-0.95] and 0.69 [0.56-0.84] in women and men, respectively; P=0.8for interaction). No differences in safety outcomes by age group or sex were observed. LIMITATIONS: This was a post hoc analysis with multiple comparisons. CONCLUSIONS: Canagliflozin consistently reduced the relative risk of kidney events in people with diabetic kidney disease in both sexes and across age subgroups. As a result of greater background risk, the absolute reduction in adverse kidney outcomes was greater in younger participants. FUNDING: This post hoc analysis of the CREDENCE trial was not funded. The CREDENCE study was sponsored by Janssen Research and Development and was conducted collaboratively by the sponsor, an academic-led steering committee, and an academic research organization, George Clinical. TRIAL REGISTRATION: The original CREDENCE trial was registered at ClinicalTrials.gov with study number NCT02065791.

Findings of Sodium-Glucose Cotransporter-2 Inhibitor Kidney Outcome Trials Applied to a Canadian Chronic Kidney Disease Population: A Retrospective Cohort Study.

Background: The canagliflozin and renal endpoints in diabetes with established nephropathy clinical evaluation (CREDENCE) and dapagliflozin and prevention of adverse outcomes in chronic kidney disease (DAPA-CKD) trials have demonstrated significant kidney benefits with sodium-glucose cotransporter-2 (SGLT2) inhibitors. SGLT2 inhibitors are now standard of care for patients with diabetic kidney disease and have also been shown to be effective in those with albuminuric CKD with or without diabetes. Objective: We sought to determine how many patients in nephrology care in British Columbia, Canada, would have been eligible for those trials, to compare rates of outcomes, and to estimate cost avoidance arising from widespread use of SGLT2 inhibitors in this cohort. Study design: Retrospective cohort study. Setting: British Columbia, Canada. Participants: CKD patients followed in the Kidney Care Clinics in British Columbia. Measurements: We compared the outcomes of kidney failure, sustained estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2, dialysis, transplant, death from any cause, and doubling of serum creatinine. We also compared the composite outcome of kidney failure and doubling of serum creatinine. Methods: The cohort was derived using a provincial database by combining the inclusion criteria of CREDENCE and DAPA-CKD trials. We included adult patients aged ≥18 years, urine albumin to creatinine ratio (UACR) ≥20 mg/mmol, and eGFR between 25 and 90 mL/min/1.73 m2, between April 1, 2014 and March 31, 2017. The primary outcome was compared with the outcomes experienced in the placebo arms of CREDENCE and DAPA-CKD. The composite outcome stratified by eGFR categories were compared in the British Columbia cohort and the CREDENCE trial. Cost avoidance was estimated based on the number needed to treat to prevent one instance of kidney failure. Results: A total of 17.5% (3138/17 963) of patients were eligible, resulting in a cohort with a mean age of 69.7 years and 38% women. The eGFR slope of the British Columbia cohort was -4.21 ± 0.47 mL/min. The mean eGFR was 37.0 mL/min/1.73 m2, median UACR was 55.3 mg/mmol, and use of renin-angiotensin-aldosterone system inhibitors was 56.6%. The British Columbia cohort experienced nearly double the outcomes of kidney failure, death from any cause, and doubling of serum creatinine than the placebo arms of CREDENCE and DAPA-CKD. When stratified by eGFR, the British Columbia cohort and the CREDENCE placebo arm had similar event rates for those with an eGFR <45 mL/min but there were still higher rates of outcome in the greater than 45 mL/min eGFR groups in the British Columbia cohort. Treating the British Columbia cohort with canagliflozin could lead to net cost avoidance of $2.31 million over 2.6 years. Limitations: The database only captures those referred to the Kidney Care Clinics by nephrologists, which may lead to selection bias of higher risk patients in the British Columbia cohort. The cost avoidance analysis was a limited high-level analysis. Conclusions: The British Columbia cohort represents a high-risk group in whom implementation of the use of SGLT2 inhibitors may well improve outcomes and reduce health care system costs.

Contexte: Les essais cliniques CREDENCE et DAPA-CKD ont démontré que les inhibiteurs du cotransporteur sodium-glucose-2 (SGLT2) présentent des avantages significatifs pour les reins. Les inhibiteurs du SGLT2 sont désormais la norme en matière de soins pour les patients atteints de néphropathie diabétique et se sont également avérés efficaces chez les patients atteints d'une insuffisance rénale chronique (IRC) albuminurique avec ou sans diabète. Objectifs: Déterminer le nombre de patients suivis en néphrologie en Colombie-Britannique (Canada) qui auraient été admissibles à ces essais, afin de comparer les résultats et estimer les coûts pouvant être évités par une utilisation généralisée des inhibiteurs du SGLT2 dans cette cohorte. Type d'étude: Étude de cohorte rétrospective. Cadre: Colombie-Britannique (Canada). Sujets: Les patients atteints d'IRC suivis dans les cliniques de prévention rénale (Kidney Care Clinics) en Colombie-Britannique. Mesures: Nous avons comparé les résultats de l'insuffisance rénale terminale (baisse soutenue du taux de filtration glomérulaire estimé [DFGe] à moins de 15 ml/min/1,73 m2, dialyse, transplantation), les décès de toutes causes confondues et le doublement de la concentration de créatinine sérique. Nous avons également comparé le critère composite de l'insuffisance rénale terminale et du doublement de la concentration de créatinine sérique. Méthodologie: La cohorte a été dérivée d'une base de données provinciale en combinant les critères d'inclusion des essais CREDENCE et DAPA-CKD. Ont été inclus les patients adultes répertoriés entre le 1er avril 2014 et le 31 mars 2017 avec un rapport albumine/créatinine urinaire (RACu) ≥ 20 mg/mmol et un DFGe entre 25 et 90 ml/min/1,73 m2. Le critère de jugement principal a été comparé aux résultats observés dans les groupes placebos des essais CREDENCE et DAPA-CKD. Le critère composite, stratifié selon les catégories de DFGe, a été comparé dans la cohorte de la Colombie-Britannique et l'essai CREDENCE. Les coûts évités ont été estimés en fonction du nombre de traitements nécessaires pour prévenir un cas d'insuffisance rénale terminale. Résultats: Des 17 963 patients répertoriés, 3 138 (17,5 %) auraient été admissibles (38 % de femmes; âge moyen: 69,7 ans). La pente du DFGe pour la cohorte de la Colombie-Britannique était de −4,21 ± 0,47 ml/min. Dans cette même cohorte, le DFGe moyen s'établissait à 37,0 ml/min/1,73 m2, le RACu moyen à 55,3 mg/mmol et le taux d'utilisation des inhibiteurs du système rénine-angiotensine-aldostérone à 56,6 %. La cohorte de la Colombie-Britannique a connu près de deux fois plus d'événements liés à l'insuffisance rénale terminale, de décès de toutes causes confondues et de doublement de la concentration de créatinine sérique que les groupes placebos des essais CREDENCE et DAPA-CKD. Après la stratification selon le DFGe, la cohorte de la Colombie-Britannique et le groupe placebo de l'essai CREDENCE ont montré des taux d'événements similaires pour les patients présentant un DFGe < 45 ml/min, mais la cohorte de la Colombie-Britannique a montré des taux plus élevés d'événements dans les groupes avec un DFGe supérieur à 45 ml/min. Le traitement de la cohorte de la Colombie-Britannique par la canagliflozine pourrait permettre d'éviter un coût net de 2,31 M$ canadiens sur 2,6 ans. Limites: La base de données ne contient que les patients orientés par des néphrologues vers les cliniques de prévention rénale (Kidney Care Clinics), ce qui peut entraîner un biais favorisant la sélection des patients à risque élevé dans la cohorte de la Colombie-Britannique. L'analyse des coûts évités était une analyse de haut niveau limitée. Conclusion: La cohorte de la Colombie-Britannique représente un groupe de patients à haut risque chez qui l'utilisation des inhibiteurs du SGLT2 pourrait améliorer les résultats en matière d'insuffisance rénale et permettre de réduire les coûts pour le système de santé.

Digital health technologies to support medication adherence in chronic kidney disease.

Non-adherence to medications is a critical challenge in the management of people with chronic kidney disease (CKD). This review explores the complexities of adherence in this population, the unique barriers and enablers of good adherence behaviours, and the role of emerging digital health technologies in bridging the gap between evidence-based treatment plans and the real-world standard of care. We present the current evidence supporting the use of digital health interventions among CKD populations, identifying the key research questions that remain unanswered, and providing practical strategies for clinicians to support medication adherence in a digital age.

Sex, Gender, and Cardiovascular Disease in Chronic Kidney Disease.

This review on sex, gender, and cardiovascular diseases in chronic kidney disease attempts to summarize what we know and what we do not know about the effects of sex and gender on cardiovascular disease in chronic kidney disease. We discuss and define the terminology of sex and gender, and the underlying physiology for differences observed. We explore how sex and gender affect specific cardiovascular diseases such as coronary artery disease, congestive heart failure, arrhythmias, cardiovascular mortality, and pre-eclampsia. We conclude with a review of recent randomized controlled trials and highlight the pharmacokinetic and pharmacodynamic differences in both sexes.

Digital health and artificial intelligence in kidney research: a report from the 2020 Kidney Disease Clinical Trialists (KDCT) meeting.

The exponential growth in digital technology coupled with the global coronavirus disease 2019 pandemic is driving a profound change in the delivery of medical care and research conduct. The growing availability of electronic monitoring, electronic health records, smartphones and other devices and access to ever greater computational power provides not only new opportunities, but also new challenges. Artificial intelligence (AI) exemplifies the potential of this digital revolution, which also includes other tools such as mobile health (mHealth) services and wearables. Despite digital technology becoming commonplace, its use in medicine and medical research is still in its infancy, with many clinicians and researchers having limited experience with such tools in their usual practice. This article, derived from the 'Digital Health and Artificial Intelligence' session of the Kidney Disease Clinical Trialists virtual workshop held in September 2020, aims to illustrate the breadth of applications to which digital tools and AI can be applied in clinical medicine and research. It highlights several innovative projects incorporating digital technology that range from streamlining medical care of those with acute kidney injury to the use of AI to navigate the vast genomic and proteomic data gathered in kidney disease. Important considerations relating to any new digital health project are presented, with a view to encouraging the further evolution and refinement of these new tools in a manner that fosters collaboration and the generation of robust evidence.

Evidence-Based Decision Making 4: Clinical Practice Guidelines.

Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioners and patient to reach appropriate health-care decisions. The synthesis and translation of a large amount of evidence into practice recommendations should ultimately reduce the use of unnecessary or harmful interventions, help patients to achieve maximum benefit, and minimize risk, all at an acceptable cost.In the past, CPGs were developed based on expert opinion, and using consensus methodology either formally or informally. Over the last 30 years, the evolution of increasingly transparent and robust methodology has led to more "evidence-based" recommendations. Clinical practice guidelines should be developed within the principles of bias minimization, systematic evidence retrieval and review, and a focus on patient relevant outcomes. Multiple nationally based and international groups now have published specific guidance for the development, dissemination, and evaluation of CPG.This chapter describes the key principles of CPG development, including the importance of updating, disseminating, and evaluating the impact of CPG , and attempts to differentiate CPG intended for populations of patients from "evidence-based decision making" for individual patients, recognizing that the fundamental principles are the same.

A Provincial Survey of the Contemporary Management of Autosomal Dominant Polycystic Kidney Disease.

BACKGROUND: Recent years have witnessed an encouraging expansion of knowledge and management tools in the care of patients with autosomal dominant polycystic kidney disease (ADPKD), including measurement of total kidney volume as a biomarker of disease progression, stringent blood pressure targets to slow cyst growth, and targeted treatments such as tolvaptan. OBJECTIVES: We sought to evaluate clinicians' familiarity with, and usage of, novel evidence-based management tools for ADPKD. DESIGN: On-line survey. SETTING: British Columbia, Canada. PARTICIPANTS: Nephrologists in academic and community practice (excluding clinicians who practice exclusively in transplantation). MEASUREMENTS: Participants answered multiple-choice questions in 6 domains: sources of information, self-identified needs for optimal care delivery, prognostication, imaging tests, blood pressure targets, and use of tolvaptan. METHODS: An online survey was developed and disseminated via email to 65 nephrologists engaged in current clinical practice in British Columbia. RESULTS: A total of 29 nephrologists (45%) completed the questionnaire. The most popular source of information was the primary literature (83% of respondents). While 86% of respondents reported assessing the risk of disease progression before the onset of kidney function decline, most were using traditional metrics such as blood pressure and proteinuria rather than validated prediction tools such as the Mayo Classification. Although 90% of respondents obtained additional imaging after diagnosis in some or all of their ADPKD patients, only 1 in 5 reported being confident in their ability to interpret kidney size. The recommended blood pressure (BP) target of <110/75 mmHg was sought by 17% of respondents. All respondents reported being familiar with the literature regarding tolvaptan; however, only half were confident in their ability to identify suitable patients for treatment. The top 3 needs identified by clinicians were better access to medications (69%), clear management protocols (66%), and easier access to imaging tests (59%). LIMITATIONS: Funding mechanisms for tolvaptan can vary; therefore, clinicians' experience with the drug may not be generalizable. Although the response rate was acceptable, the survey is nonetheless subject to responder bias. CONCLUSION: This survey indicates that there is substantial variability in the usage of, and familiarity with, evidence-based ADPKD management tools among contemporary nephrologists, contributing to incomplete translation of evidence into clinical practice. Providing greater access to tolvaptan or imaging tests is unlikely to improve patient care without enhancing knowledge translation and education. TRIAL REGISTRATION: Not applicable as this was a survey.

CONTEXTE: On a assisté au cours des dernières années à un élargissement prometteur des connaissances et des outils de gestion dans le domaine des soins prodigués aux patients atteints de maladie polykystique rénale autosomale dominante (MPRAD). On pense notamment à la mesure du volume rénal total comme biomarqueur de l'évolution de la maladie, à des cibles strictes en matière de pression artérielle visant à ralentir la croissance des kystes et à des traitements ciblés comme le tolvaptan. OBJECTIFS: Nous souhaitions évaluer la connaissance des cliniciens à l'égard de ces nouveaux outils fondés sur des données probantes et mesurer leur usage en contexte de MPRAD. TYPE D'ÉTUDE: Sondage en ligne. CADRE: Colombie-Britannique, Canada. PARTICIPANTS: Les néphrologues pratiquant en milieu hospitalier universitaire et communautaire (à l'exception des médecins pratiquant exclusivement en transplantation). MESURES: Les participants ont répondu à un questionnaire à choix multiples touchant six domaines précis: les sources d'information, les besoins autodéclarés pour une prestation de soins optimaux, le pronostic, les tests d'imagerie, les cibles de pression artérielle et l'utilization du tolvaptan. MÉTHODOLOGIE: Un sondage en ligne a été élaboré et distribué par courriel à 65 néphrologues pratiquant actuellement en Colombie-Britannique. RÉSULTATS: En tout, 29 néphrologues (45 %) ont répondu au questionnaire. La principale source d'information était la littérature (83 % des répondants). Bien que 86 % des répondants mentionnaient évaluer le risque de progression de la maladie avant les premières manifestations d'un déclin de la fonction rénale, la plupart recouraient à des indicateurs traditionnels comme la pression artérielle et la protéinurie plutôt qu'à des outils validés comme la classification de la clinique Mayo. Et bien que 90 % des répondants aient pu faire des tests d'imagerie supplémentaires après le diagnostic, chez certains ou chez tous leurs patients atteints de MPRAD, seul un médecin sur cinq s'est déclaré confiant en sa capacité d'interpréter la taille du rein. La cible recommandée de pression artérielle, soit moins de 110/75 mmHg, était recherchée par seulement 17 % des répondants. Tous les médecins ont mentionné être familiers avec la littérature portant sur le tolvaptan, mais la moitié des répondants doutaient de leur capacité à bien cerner les patients pour qui ce traitement est adéquat. Les cliniciens ont nommé trois principaux besoins: un meilleur accès aux médicaments (69 %), des protocoles de prise en charge clairs (66 %) et un accès plus facile aux tests d'imagerie (59 %). LIMITES: Les mécanismes de financement du tolvaptan sont variables et ainsi, l'expérience des cliniciens avec ce médicament pourrait ne pas être généralisable. Bien que le taux de réponse ait été jugé acceptable, le sondage demeure sujet à des biais de la part des répondants. CONCLUSION: Ce sondage indique qu'il existe une variabilité substantielle dans l'usage et la connaissance des outils de gestion de la MPRAD fondés sur les données probantes parmi les néphrologues. Cette situation contribue à l'application incomplète des résultats dans la pratique clinique. Offrir un accès accru au tolvaptan ou aux tests d'imagerie est peu susceptible d'améliorer les soins si l'application des connaissances et l'éducation ne sont pas améliorées. ENREGISTREMENT DE L'ESSAI: Sans objet puisqu'il s'agit d'une étude sous forme de sondage.

CT of Kidney Volume in Autosomal Dominant Polycystic Kidney Disease: Accuracy, Reproducibility, and Radiation Dose.

Background Total kidney volume (TKV) assessment is valuable in autosomal dominant polycystic kidney disease (ADPKD) but the reference standard method of MRI planimetry requires access to MRI and time-consuming interpretation. Purpose To determine whether accurate TKV measurements comparable to the resource-intensive reference standard of MRI planimetry can be obtained by using alternate methods including dose-reducing CT protocols and time-saving measurement equations. Materials and Methods In this prospective study conducted September 2016 to June 2017, adult participants with ADPKD underwent one MRI and two CT examinations. Low-dose (LD) and ultra-low-dose (ULD) CT examinations were performed with radiation doses 1.4 and 2.6 times lower, respectively, than the authors' institution's standard abdomen and pelvis CT. ULD CT examinations were reconstructed via model-based iterative reconstruction. Three TKV measurement equations were applied to all image sets, and MRI manual planimetry was the reference standard. Spearman correlation with the reference standard, simple linear regression, and root mean square error (RMSE) calculation analyzed accuracy of these methods; intraclass correlation coefficient examined reproducibility. Results Thirty participants (mean age, 41 years; age range, 24-67 years) had a mean TKV of 1368.9 mL ± 1146.13 (standard deviation). The ULD and LD CT protocols had median dose-length product of 58.8 and 115.5 mGy ∙ cm, respectively (P = .01), and CT dose index of 1.2 and 3.9 mGy, respectively (P < .001). All imaging modalities and measurement equations had excellent correlation with the reference standard (r2 > 0.98). RMSE ranged from 80.5 to 157.3 mL (5.9%-11.5% of mean TKV). Intraclass correlation coefficients were greater than 0.98 for all methods. Mean measurement times for the ellipsoid method ranged from 4.6 to 5.2 minutes compared with a mean of 27.7 minutes (range, 14-60 minutes) for manual planimetry. Conclusion Accurate and reproducible total kidney volume measurements comparable to the reference standard of MRI planimetry can be obtained by using a dose-minimizing ultra-low-dose CT protocol and volume measurement based on discrete linear measurements. © RSNA, 2019 Online supplemental material is available for this article.

Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses.

STUDY OBJECTIVE: Corticosteroids (steroids) are often used to mitigate symptoms and prevent subsequent reactions in emergency department (ED) patients with allergic reactions, despite a lack of evidence to support their use. We sought to determine the association of steroid administration with improved clinical outcomes. METHODS: Adult allergy-related encounters to 2 urban EDs during a 5-year period were identified and classified as "anaphylaxis" or "allergic reaction." Regional and provincial databases identified subsequent ED visits or deaths within a 7-day period. The primary outcome was allergy-related ED revisits in the steroid- and nonsteroid-exposed groups, adjusting for potential confounders with a propensity score analysis; secondary outcomes included the number of clinically important biphasic reactions and deaths. RESULTS: Two thousand seven hundred one encounters (473 anaphylactic) were included; 48% were treated with steroids. Allergy-related ED revisits occurred in 5.8% and 6.7% of patients treated with and without steroids, respectively (adjusted odds ratio [OR] 0.91; 95% confidence interval [CI] 0.64 to 1.28), with a number needed to treat (NNT) to benefit of 176 (95% CI NNT to benefit 39 to ∞ to NNT to harm 65). The adjusted OR in the anaphylaxis subgroup was 1.12 (95% CI 0.41 to 3.27). In the allergic reaction group, the adjusted OR was 0.91 (95% CI 0.63 to 1.31), with an NNT to benefit of 173 (95% CI NNT to benefit 38 to ∞ to NNT to harm 58). In the steroid and nonsteroid groups, there were 4 and 1 clinically important biphasic reactions, respectively. There were no deaths. CONCLUSION: Among ED patients with allergic reactions or anaphylaxis, corticosteroid use was not associated with decreased relapses to additional care within 7 days.

Incidence of clinically important biphasic reactions in emergency department patients with allergic reactions or anaphylaxis.

STUDY OBJECTIVE: Allergic reactions are common presentations to the emergency department (ED). An unknown proportion of patients will develop biphasic reactions, and patients are often monitored for prolonged periods to manage potential reactions. We seek to determine the incidence of clinically important biphasic reactions. METHODS: Consecutive adult patients presenting to 2 urban EDs with allergic reactions during a 5-year period were identified. Encounters were dichotomized as "anaphylaxis" or "allergic reaction" with an explicit algorithm. A comprehensive chart review was conducted on each index and all subsequent visits to detail patient presentations, comorbidities, ED management, and predefined clinically important biphasic reactions. Regional and provincial databases were linked to identify subsequent ED visits and deaths within a 7-day period. The primary outcome was the proportion of patients with a clinically important biphasic reaction, and the secondary outcome was mortality. RESULTS: Of 428,634 ED visits, 2,819 (0.66%) encounters were reviewed (496 anaphylactic and 2,323 allergic reactions). Overall, 185 patients had at least 1 subsequent visit for allergic symptoms. Five clinically important biphasic reactions were identified (0.18%; 95% confidence interval [CI] 0.07% to 0.44%), with 2 occurring during the ED visit and 3 postdischarge. There were no fatalities (95% CI 0% to 0.17%). In the anaphylaxis and allergic reaction groups, clinically important biphasic reactions occurred in 2 patients (0.40%; 95% CI 0.07% to 1.6%) and 3 patients (0.13%; 95% CI 0.03% to 0.41%), respectively. CONCLUSION: Among ED patients with allergic reactions or anaphylaxis, clinically important biphasic reactions and fatalities are rare. Our data suggest that prolonged routine monitoring of patients whose symptoms have resolved is likely unnecessary for patient safety.