Palliative clinical trials in advanced chronic liver disease: Challenges and opportunities.

Patients with advanced chronic liver disease have a complex symptom burden and many are not candidates for curative therapy. Despite this, provision of palliative interventions remains woefully inadequate, with an insufficient evidence base being a contributory factor. Designing and conducting palliative interventional trials in advanced chronic liver disease remains challenging for a multitude of reasons. In this manuscript we review past and ongoing palliative interventional trials. We identify barriers and facilitators and offer guidance on addressing these challenges. We hope that this will reduce the inequity in palliative care provision in advanced chronic liver disease.

Metabolic acidosis is undertreated and underdiagnosed: a retrospective cohort study.

BACKGROUND: Guidelines recommend treatment of metabolic acidosis (MA) in patients with chronic kidney disease (CKD), but the diagnosis and treatment rates in real-world settings are unknown. We investigated the frequency of MA treatment and diagnosis in patients with CKD. METHODS: In this retrospective cohort study, we examined administrative health data from two US databases [Optum's de-identified Integrated Claims + Clinical Electronic Health Record Database (US EMR cohort; 1 January 2007 to 30 June 2019) and Symphony Health Solutions IDV® (US claims cohort; 1 May 2016 to 30 April 2019)] and population-level databases from Manitoba, Canada (1 April 2006 to 31 March 2018). Patients who met laboratory criteria indicative of CKD and chronic MA were included: two consecutive estimated glomerular filtration results <60 mL/min/1.73 m2 and two serum bicarbonate results 12 to <22 mEq/L over 28-365 days. Outcomes included treatment of MA (defined as a prescription for oral sodium bicarbonate) and a diagnosis of MA (defined using administrative records). Outcomes were assessed over a 3-year period (1 year pre-index, 2 years post-index). RESULTS: A total of 96 184 patients were included: US EMR, 6179; Manitoba, 3223; US Claims, 86 782. Sodium bicarbonate treatment was prescribed for 17.6%, 8.7% and 15.3% of patients, and a diagnosis was found for 44.7%, 20.9% and 20.9% of patients, for the US EMR, Manitoba and US Claims cohorts, respectively. CONCLUSIONS: This analysis of 96 184 patients with laboratory-confirmed MA from three independent cohorts of patients with CKD and MA highlights an important diagnosis and treatment gap for this disease-modifying complication.

Hyperkalemia-Related Discontinuation of Renin-Angiotensin-Aldosterone System Inhibitors and Clinical Outcomes in CKD: A Population-Based Cohort Study.

RATIONALE & OBJECTIVE: Renin-angiotensin-aldosterone system (RAAS) inhibitors are evidence-based therapies that slow the progression of chronic kidney disease (CKD) but can cause hyperkalemia. We aimed to evaluate the association of discontinuing RAAS inhibitors after an episode of hyperkalemia and clinical outcomes in patients with CKD. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Adults in Manitoba (7,200) and Ontario (n = 71,290), Canada, with an episode of de novo RAAS inhibitor-related hyperkalemia (serum potassium ≥ 5.5 mmol/L) and CKD. EXPOSURE: RAAS inhibitor prescription. OUTCOME: The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular (CV) mortality, fatal and nonfatal CV events, dialysis initiation, and a negative control outcome (cataract surgery). ANALYTICAL APPROACH: Cox proportional hazards models examined the association of RAAS inhibitor continuation (vs discontinuation) and outcomes using intention to treat approach. Sensitivity analyses included time-dependent, dose-dependent, and propensity-matched analyses. RESULTS: The mean potassium and mean estimated glomerular filtration rate were 5.8 mEq/L and 41 mL/min/1.73 m2, respectively, in Manitoba; and 5.7 mEq/L and 41 mL/min/1.73 m2, respectively, in Ontario. RAAS inhibitor discontinuation was associated with a higher risk of all-cause mortality (Manitoba: HR, 1.32 [95% CI, 1.22-1.41]; Ontario: HR, 1.47 [95% CI, 1.41-1.52]) and CV mortality (Manitoba: HR, 1.28 [95% CI, 1.13-1.44]; and Ontario: HR, 1.32 [95% CI, 1.25-1.39]). RAAS inhibitor discontinuation was associated with an increased risk of dialysis initiation in both cohorts (Manitoba: HR, 1.65 [95% CI, 1.41-1.85]; Ontario: HR, 1.11 [95% CI, 1.08-1.16]). LIMITATIONS: Retrospective study and residual confounding. CONCLUSIONS: RAAS inhibitor discontinuation is associated with higher mortality and CV events compared with continuation among patients with hyperkalemia and CKD. Strategies to maintain RAAS inhibitor treatment after an episode of hyperkalemia may improve clinical outcomes in the CKD population.

Effects of a Knowledge-Translation Intervention on Early Dialysis Initiation: A Cluster Randomized Trial.

BACKGROUND: The Initiating Dialysis Early and Late (IDEAL) trial, published in 2009, found no clinically measurable benefit with respect to risk of mortality or early complications with early dialysis initiation versus deferred dialysis start. After these findings, guidelines recommended an intent-to-defer approach to dialysis initiation, with the goal of deferring it until clinical symptoms arise. METHODS: To evaluate a four-component knowledge translation intervention aimed at promoting an intent-to-defer strategy for dialysis initiation, we conducted a cluster randomized trial in Canada between October 2014 and November 2015. We randomized 55 clinics, 27 to the intervention group and 28 to the control group. The educational intervention, using knowledge-translation tools, included telephone surveys from a knowledge-translation broker, a 1-year center-specific audit with feedback, delivery of a guidelines package, and an academic detailing visit. Participants included adults who had at least 3 months of predialysis care and who started dialysis in the first year after the intervention. The primary efficacy outcome was the proportion of patients who initiated dialysis early (at eGFR >10.5 ml/min per 1.73 m2). The secondary outcome was the proportion of patients who initiated in the acute inpatient setting. RESULTS: The analysis included 3424 patients initiating dialysis in the 1-year follow-up period. Of these, 509 of 1592 (32.0%) in the intervention arm and 605 of 1832 (33.0%) in the control arm started dialysis early. There was no difference in the proportion of individuals initiating dialysis early or in the proportion of individuals initiating dialysis as an acute inpatient. CONCLUSIONS: A multifaceted knowledge translation intervention failed to reduce the proportion of early dialysis starts in patients with CKD followed in multidisciplinary clinics. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: ClinicalTrials.gov, NCT02183987. Available at: https://clinicaltrials.gov/ct2/show/NCT02183987.

Opioids and the Risk of Motor Vehicle Collision: A Systematic Review.

Background: Opioid analgesics are among the most commonly prescribed medications, but questions remain regarding their impact on the day-to-day functioning of patients including driving. We set out to perform a systematic review on the risk of motor vehicle collision (MVC) associated with prescription opioid exposure. Method: We searched Medline, PubMed, EMBASE, Scopus, and TRID from January 1990 to August 31, 2021 for primary studies assessing prescribed opioid use and MVCs. Results: We identified 14 observational studies that met inclusion criteria. Among those, 8 studies found an increased risk of MVC among those participants who had a concomitant opioid prescription at the time of the MVC and 3 found no significant increase of culpability of fatal MVC. The 3 studies that evaluated the presence of a dose-response relationship between the dose of opioids taken and the effects on MVC risk reported the existence of a dose-response relationship. Due to the heterogeneity of the different studies, a quantitative meta-analysis to sum evidence was deemed unfeasible. Our review supports increasing evidence on the association between motor vehicle collisions and prescribed opioids. This research would guide policies regarding driving legislation worldwide. Conclusion: Our review indicates that opioid prescriptions are likely associated with an increased risk of MVCs. Further studies are warranted to strengthen this finding, and investigate additional factors such as individual opioid medications, opioid doses and dose adjustments, and opioid tolerance for their effect on MVC risk.

Association of Physical Activity and Poor Health Outcomes in Patients With Advanced CKD.

RATIONALE & OBJECTIVE: Chronic kidney disease (CKD) is associated with declining physical function and activity. In the general population, lower physical activity is associated with poorer quality of life and greater all-cause mortality. The aim of this study was to assess if lower physical activity levels are associated with adverse health outcomes in patients with advanced CKD. STUDY DESIGN: A multicenter prospective cohort study. SETTING & PARTICIPANTS: 579 adult patients with CKD glomerular filtration rate categories 4 and 5 (G4-G5) treated at 4 Canadian multidisciplinary kidney health clinics between 2012 and 2018. EXPOSURE: Patient-reported measures of physical activity using the Physical Activity Scale for the Elderly (PASE) questionnaire and subsequently stratified PASE scores into tertiles. OUTCOME: All-cause mortality, progression to kidney failure, and future falls. ANALYTICAL APPROACH: Outcomes were analyzed using time-dependent proportional hazards models and logistic regression models. RESULTS: In 1,193 days of follow-up observation, 118 patients died, 204 progressed to dialysis, and 129 reported a fall. When compared with low physical activity, higher levels of physical activity were associated with a 52% lower all-cause mortality (adjusted HR, 0.48; 95% CI, 0.27-0.85) in models adjusted for age, sex, and comorbidity. No associations were detected between higher levels of physical activity and either slower progression to kidney failure or a lower rate of future falls. LIMITATIONS: Physical activity and falls were self-reported. Our population was of limited racial/ethnic diversity, which may affect generalizability. Findings were observational and do not indicate whether interventions targeting physical activity may affect adverse health outcomes. CONCLUSIONS: Higher levels of physical activity were associated with about 50% lower all-cause mortality in the advanced CKD population. These findings are consistent with a potential benefit from maintained physical activity as patients approach kidney failure.

Impact of point-of-care screening for hypertension, diabetes and progression of chronic kidney disease in rural Manitoba Indigenous communities.

BACKGROUND: In 2013-2015, we conducted point-of-care screening for hypertension, diabetes and chronic kidney disease in rural and remote Indigenous communities in Manitoba, Canada. In this study, we aimed to determine whether optimal follow-up care was provided, defined as proportion of individuals with appropriate kidney disease laboratory testing, medication prescriptions and physician visits. METHODS: We linked screening data from participants to provincial administrative data sets to evaluate whether frequencies of laboratory testing, prescriptions of disease-modifying medications, and primary care and nephrology visits differed in the 18 months before and after screening. We also conducted a propensity score matching analysis to compare outcomes between screened and unscreened adults. RESULTS: Of 1353 adults who received the screening intervention and who had complete administrative data available, 44% were at risk of kidney failure at screening. Among these individuals, frequencies of comprehensive laboratory testing (estimated glomerular filtration rate and urine albumin to creatinine ratio) improved by 17.0% (95% confidence interval [CI] 11.5 to 22.5), anti-hyperglycemic medications improved by 4.4% (95% CI 1.0 to 7.8), and nephrology visits for participants meeting referral criteria improved by 5.9% (95% CI 3.4 to 8.5). We observed significant improvements in laboratory testing, antihyperglycemic medications and nephrology visits in the screened group compared with the 1:1 matched comparison group. INTERPRETATION: Point-of-care screening programs in rural and remote Indigenous communities are adaptable methods for increasing awareness, monitoring risk and treating chronic diseases. Interventions such as the development of a national screening program could improve chronic disease care in high-risk populations.

Impact of a screen, triage and treat program for identifying chronic disease risk in Indigenous children.

BACKGROUND: The First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis project was a point-of-care screening program in rural and remote First Nations communities in Manitoba that aimed to identify and treat hypertension, diabetes and chronic kidney disease. The program identified chronic disease in 20% of children screened. We aimed to characterize clinical screening practices before and after intervention in children aged 10-17 years old and compare outcomes with those who did not receive the intervention. METHODS: This observational, prospective cohort study started with community engagement and followed the principles of ownership, control, access and possession (OCAP). We linked participant data to administrative data at the Manitoba Centre for Health Policy to assess rates of primary care and nephrology visits, disease-modifying medication prescriptions and laboratory testing (i.e., glycosylated hemoglobin [HbA1c], estimated glomerural filtration rate [eGFR] and urine albumin- or protein-to-creatinine ratio). We analyzed the differences in proportions in the 18 months before and after the intervention. We also conducted a 1:2 propensity score matching analysis to compare outcomes of children who were screened with those who were not. RESULTS: We included 324 of 353 children from the screening program (43.8% male; median age 12.3 yr) in this study. After the intervention, laboratory testing increased by 5.8% (95% confidence interval [CI] 1.1% to 10.1%) for HbA1c, by 9.9% (95% CI 4.2% to 15.5%) for eGFR and by 6.2% (95% CI 2.3% to 10.0%) for the urine albumin- or protein-to-creatinine ratio. We observed significant improvements in laboratory testing in screened patients in the group who were part of the program, compared with matched controls. INTERPRETATION: Chronic disease surveillance and care increased significantly in children after the implementation of a point-of-care screening program in rural and remote First Nation communities. Interventions such as active surveillance programs have the potential to improve the chronic disease care being provided to First Nations children.

Screening for chronic kidney disease: moving toward more sustainable health care.

PURPOSE OF REVIEW: Chronic kidney disease (CKD) is a pervasive and growing health concern that has a significant impact on mortality and morbidity, putting stress on global healthcare systems. CKD affects ∼14% of general populations and ∼36% of high-risk populations and is projected to rise in the coming decade due to increasing rates of diabetes and hypertension. RECENT FINDINGS: Screen, triage, and treat programs aim to detect early stage disease with the intention of promoting medical and lifestyle interventions in line with a patient's level of risk that may slow disease progression and reduce morbidity and mortality. Early detection facilitates appropriate risk stratification and coordination of care among patients, primary care and nephrology ensuring resources are utilized appropriately. SUMMARY: By using readily available laboratory measures, screening for CKD in high-risk populations is cost effective and beneficial to both individuals and healthcare systems. Program models such as Kidney Early Evaluation Program and First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis have proven the efficacy of screening initiatives in these groups, but improvements are required to maximize the benefits of early CKD detection.

Acute Kidney Injury Events in Patients With Type 2 Diabetes Using SGLT2 Inhibitors Versus Other Glucose-Lowering Drugs: A Retrospective Cohort Study.

RATIONALE & OBJECTIVE: Sodium/glucose cotransporter 2 (SGLT2) inhibitors slow the progression of chronic kidney disease and prevent heart failure events. However, SGLT2 inhibitors may increase the risk for acute kidney injury (AKI). Our objective was to assess whether SGLT2 inhibitor use, compared with all other glucose-lowering drugs (oGLDs), is associated with increased rates of AKI. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Adults in Manitoba, Canada, with type 2 diabetes mellitus followed up from June 2014 until March 2017. EXPOSURES: Initial SGLT2 inhibitor or oGLD use ascertained through a province-wide outpatient prescription database. OUTCOME: The primary outcome was incident AKI, identified either by an increase in serum creatinine level and/or hospital discharge codes for AKI while taking glucose-lowering drugs (on-treatment approach). ANALYTICAL APPROACH: A propensity score analysis was used to assemble groups of incident users of SGLT2 inhibitors and a 1:1 matched set of oGLD users. The rate of AKI was compared across matched groups using cause-specific hazards models. Sensitivity analyses considered exposure to be constant throughout follow-up after initiation of the drug treatment (intention-to-treat approach) or incorporated recurrent exposures (new user design). RESULTS: Comparing 4,778 incident users of SGLT2 inhibitors with 4,778 incident users of oGLDs, there were no differences observed in the primary outcome (HR, 0.64; 95% CI, 0.40-1.03; P = 0.06) using an on-treatment approach. In neither set of sensitivity analyses were SGLT2 inhibitors associated with increased risk for AKI. LIMITATIONS: Drug choice may have been related to AKI risk, laboratory data were obtained from clinical care, and changes in adverse event reporting may have followed the US Food and Drug Administration warning. There were insufficient data to compare individual SGLT2 inhibitors. CONCLUSIONS: Compared with oGLDs, SGLT2 inhibitors were not observed to be associated with increased risk for AKI in a clinical population-based cohort.

Peripheral Artery Disease: Its Adverse Consequences With and Without CKD.

RATIONALE & OBJECTIVES: Chronic kidney disease (CKD) is a potent risk factor for macrovascular disease and death. Peripheral artery disease (PAD) is more common in patients with CKD and is associated with lower-limb complications and mortality. We sought to compare the prevalence of PAD in and outside the setting of kidney disease and examine how PAD affects the risk for adverse health outcomes, specifically lower-limb complications, cardiovascular events, and survival. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 453,573 adult residents of Manitoba with at least 1 serum creatinine measurement between 2007 and 2014. EXPOSURE: PAD defined by hospital discharge diagnosis codes and medical claims. OUTCOMES: All-cause mortality, cardiovascular events, and lower-limb complications, including foot ulcers and nontraumatic amputations. ANALYTICAL APPROACH: Survival analysis using Cox proportional hazards models. RESULTS: The prevalence of PAD in our study population was 4.5%, and patients with PAD were older, were more likely to be male, and had a higher burden of comorbid conditions, including diabetes and CKD. PAD was associated with higher risks for all-cause mortality, cardiovascular events, and lower-limb complications in patients with estimated glomerular filtration rate (eGFR) ≥ 60mL/min/1.73m2, those with CKD GFR categories 3 to 5 (G3-G5), and those treated by dialysis (CKD G5D). Although HRs for PAD were lower in the CKD population, event rates were higher as compared with those with eGFR≥60mL/min/1.73m2. In particular, compared with patients with eGFR≥60mL/min/1.73m2 and without PAD, patients with CKD G5D had 10- and 12-fold higher risks for lower-limb complications, respectively (adjusted HRs of 10.36 [95% CI, 8.83-12.16] and 12.02 [95% CI, 9.58-15.08] for those without and with PAD, respectively), and an event rate of 75/1,000 patient-years. LIMITATIONS: Potential undercounting of PAD and complications using administrative codes and the limited ability to examine quality-of-care indicators for PAD. CONCLUSIONS: PAD is more common in patients with CKD G3-G5 and G5D compared with those with eGFR≥60mL/min/1.73m2 and frequently leads to lower-limb complications. Medical interventions and care pathways specifically designed to slow or prevent the development of lower-limb complications in this population are urgently needed.

Evaluation of administrative case definitions for chronic kidney disease in children.

INTRODUCTION: Administrative data is increasingly used for chronic disease surveillance; however, its validity to define cases of chronic kidney disease (CKD) in children is unknown. We sought to evaluate the performance of case definitions for CKD in children. METHODS: We utilized population-based administrative data from the Manitoba Center for Health Policy to evaluate the validity of algorithms based on a combination of hospital claims, outpatient physician visits, and pharmaceutical use over 1-3 years in children <18 years of age. Algorithms were compared with a laboratory-based definition (estimated glomerular filtration rate < 90 ml/min/1.73 m2 and/or presence of proteinuria). RESULTS: All algorithms evaluated had very low sensitivity (0.20-0.39) and moderate positive predictive value (0.52-0.68). Algorithms had excellent specificity (0.98-0.99) and negative predictive value (0.96-0.97). Receiver operating characteristic (ROC) curves indicate fair accuracy (0.60-0.68). Sensitivity improved with increasing years of data. One or more physician claims and one or more prescriptions over 3 years had the highest sensitivity and ROC. CONCLUSIONS: The sensitivity of administrative data algorithms for CKD is unacceptably low for a screening test. Specificity is excellent; therefore, children without CKD are correctly identified. Alternate data sources are required for population-based surveillance of this important chronic disease.

The Fracture Risk Assessment Tool (FRAX®) predicts fracture risk in patients with chronic kidney disease.

The Fracture Risk Assessment Tool (FRAX®) was developed to predict fracture risk in the general population, but its applicability to patients with chronic kidney disease (CKD) is unknown. Using the Manitoba Bone Mineral Density (BMD) Database, we identified adults not receiving dialysis with available serum creatinine measurements and bone densitometry within 1 year. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Incident major osteoporotic fractures and hip fractures were ascertained from population-based health care databases. The performance of FRAX, derived without and with BMD, was studied in relation to CKD stage. Among 10,099 subjects (mean age 64 ± 13 years, 13.0% male), 2,154 had eGFR 30-60 mL/min/1.73 m2 (CKD stage 3) and 590 had eGFR <30 mL/min/1.73 m2 (CKD stages 4-5). During a 5-year observation period, 772 individuals experienced a major osteoporotic fracture and 226 had a hip fracture. FRAX predicted risk for major osteoporotic fracture and hip fracture in all eGFR strata. For every standard deviation increase in FRAX score derived with BMD, the hazard ratio (HR) for hip fracture was 4.54 (95% confidence interval [CI] 3.57-5.77) in individuals with eGFR ≥ 60 mL/min/1.73m2, 4.52 (95% CI 3.15-6.49) in individuals with eGFR 30-60 mL/min/1.73m2, and 3.10 (95% CI 1.80-5.33) in individuals with eGFR <30 mL/min/1.73m2. The relationship between FRAX and major osteoporotic fracture was stronger in those with CKD compared to those with preserved eGFR. These findings support the use of FRAX to risk stratify patients with non-dialysis CKD for major osteoporotic fractures and hip fractures.

Heart failure in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.

The incidence and prevalence of heart failure (HF) and chronic kidney disease (CKD) are increasing, and as such a better understanding of the interface between both conditions is imperative for developing optimal strategies for their detection, prevention, diagnosis, and management. To this end, Kidney Disease: Improving Global Outcomes (KDIGO) convened an international, multidisciplinary Controversies Conference titled Heart Failure in CKD. Breakout group discussions included (i) HF with preserved ejection fraction (HFpEF) and nondialysis CKD, (ii) HF with reduced ejection fraction (HFrEF) and nondialysis CKD, (iii) HFpEF and dialysis-dependent CKD, (iv) HFrEF and dialysis-dependent CKD, and (v) HF in kidney transplant patients. The questions that formed the basis of discussions are available on the KDIGO website http://kdigo.org/conferences/heart-failure-in-ckd/, and the deliberations from the conference are summarized here.

Technique Failure in a Multicenter Canadian Home Hemodialysis Cohort.

RATIONALE & OBJECTIVE: Increasing uptake of home hemodialysis (HD) has led to interest in characteristics that predict discontinuation of home HD therapy for reasons other than death or transplantation. Recent reports of practice pattern variability led to the hypothesis that there are patient- and center-specific factors that influence these discontinuations. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Incident home HD patients at 7 centers in Canada between 2000 and 2010. PREDICTOR: Treatment center, case-mix, and process-of-care variables. OUTCOMES: Technique failure (defined as discontinuation of home HD therapy for any reason other than training failure, death, or transplantation) and mortality. ANALYTICAL APPROACH: Regression modeling of technique failure using Cox proportional hazard models adjusting for treatment center and modifiable and nonmodifiable patient-level variables, censored for death and transplantation. RESULTS: The cohort consisted of 579 patients. Mean age was 49.9±14.1 years, 74% were of European ancestry, median dialysis vintage was 1.9 (IQR, 0.6-5.2) years, and 68% used an arteriovenous access. Mean duration of dialysis was 31.2±12.6 hours per week. Unadjusted 1- and 2-year technique survival and overall survival were 90% and 83% and 94% and 87%, respectively. Treating center was a strong predictor of technique failure and mortality, with HRs ranging from 0.37 to 5.11 for technique failure (1 of 6 centers with P<0.05 relative to the reference) and 0.17 to 8.73 for mortality (3 of 6 centers with P<0.05 relative to the reference). With baseline adjustment for center, only older age and more than 3 treatments per week remained significant predictors of technique failure, while no individual-level variables remained as significant predictors of survival. LIMITATIONS: Limited statistical power. CONCLUSIONS: Home HD treating centers may influence technique failure and patient mortality independent of case-mix. The relationship between processes of care and patient outcomes requires further investigation.

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.

CKD and Sedentary Time: Results From the Canadian Health Measures Survey.

RATIONALE & OBJECTIVE: Sedentary behavior and low physical activity are associated with incident diabetes, cardiovascular disease, and early mortality. Previous studies have examined associations between chronic kidney disease (CKD) and physical activity, but little is known about the role of sedentary time. STUDY DESIGN: Cross-sectional national survey. SETTING & PARTICIPANTS: A nationally representative sample of adults (n=8,444) participating in the Canadian Health Measures Survey's (CHMS) activity monitoring component (2007-2013). PREDICTOR: Estimated glomerular filtration rate (eGFR). OUTCOMES: Sedentary time (total sedentary minutes/total wear time) measured using triaxial accelerometry. ANALYTICAL APPROACH: Multivariable ordinal logistic regression for quartiles of sedentary time and linear regression for sedentary time measured on a continuous scale were performed in the entire study population and in the subgroup with CKD. RESULTS: Mean proportion of sedentary time ranged from 58% (least sedentary quartile: Q1) to 81% (most sedentary quartile: Q4). Lower eGFR, older age, lower serum albumin level, higher blood pressure, cardiovascular disease, diabetes, and higher body mass index were independently associated with a higher proportion of sedentary time. Patients with eGFRs < 45mL/min/1.73m2 had more than 4-fold higher likelihood of being sedentary (OR, 4.2; 95% CI, 2.5-7.3). Within the CKD subgroup, greater sedentary time was associated with diabetes (OR, 2.68; 95% CI, 1.56-4.59) and arthritis (OR, 2.32; 95% CI, 1.43-3.77) in adjusted analysis. LIMITATIONS: Cross-sectional design precluded evaluation of longitudinal outcomes and establishment of the causal nature of observed associations. Small sample of individuals with advanced CKD. CONCLUSIONS: In this cross-sectional survey, reduced eGFR was strongly and independently associated with greater sedentary time. This risk was further heightened by the presence of diabetes and arthritis. Studies to determine causes for sedentary behavior and assess the feasibility and value of interventions to reduce sedentary time in CKD are needed.

Prevalence, socio-demographic characteristics, and comorbid health conditions in pre-dialysis chronic kidney disease: results from the Manitoba chronic kidney disease cohort.

BACKGROUND: Chronic Kidney Disease (CKD) is common and its prevalence has increased steadily over several decades. Monitoring of rates and severity of CKD across populations is critical for policy development and resource planning. Administrative health data alone has insufficient sensitivity for this purpose, therefore utilizing population level laboratory data and novel methodology is required for population-based surveillance. The aims of this study include a) develop the Manitoba CKD Cohort, b) estimate CKD prevalence, c) identify individuals at high risk of progression to kidney failure and d) determine rates of comorbid health conditions. METHODS: Administrative health and laboratory data from April 1996 to March 2012 were linked from the data repository at the Manitoba Centre for Health Policy. Prevalence was estimated using three methods: a) all CKD cases in administrative and laboratory databases; b) all CKD cases captured only through the laboratory data; c) and the capture-recapture method. Patients were stratified by risk by estimated Glomerular Filtration Rate (eGFR) and albuminuria based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. For comorbid health conditions, the counts were modelled using a Generalized Linear Model (GLM). RESULTS: The Manitoba CKD Cohort consisted of 55,876 people with CKD. Of these, 18,342 were identified using administrative health data, 27,393 with laboratory data, and 10,141 people were identified in both databases. The CKD prevalence was 5.6% using the standard definition, 10.6% using only people captured by the laboratory data and 10.6% using the capture-recapture method. Of the identified cases, 46% were at high risk of progression to end-stage kidney disease (ESKD), 41% were at low risk and 13% were not classified, due to unavailable laboratory data. High risk cases had a higher burden of comorbid conditions. CONCLUSION: This study reports a novel methodology for population based CKD surveillance utilizing a combination of administrative health and laboratory data. High rates of CKD at risk of progression to ESKD have been identified with this approach. Given the high rates of comorbidity and associated healthcare costs, these data can be used to develop a targeted and comprehensive public health surveillance strategy that encompass a range of interrelated chronic diseases.

Screening for kidney disease in Indigenous Canadian children: The FINISHED screen, triage and treat program.

BACKGROUND: Indigenous populations are disproportionately affected by kidney failure at younger ages than other ethnic groups in Canada. As symptoms do not occur until disease is advanced, early kidney disease risk is often unrecognized. OBJECTIVES: We sought to evaluate the yield of community-based screening for early risk factors for kidney disease in youth from rural Indigenous communities in Canada. METHODS: The FINISHED project screened 11 rural First Nations communities in Manitoba, Canada after community and school engagement. The results for the 10- to 17-year olds are reported here. Body mass index (BMI), blood pressure, estimated glomerular filtration rate (eGFR), hemoglobin A1c's (HbA1c) and urine albumin-to-creatinine ratios (ACR) were assessed. All children were triaged and referred to either primary or tertiary care, depending on risk. RESULTS: A total of 353 were screened (estimated 22.4% of population). The median age was 12 years (IQR 10 to 13), 55% were female and 55% were overweight or obese. Overall, 21.8% of children had at least one abnormality. Hypertension was identified in 5.4% and 11.9% had prehypertension. None of the children had an eGFR < 60 ml/min/1.73 m2 however 10.5% had an ACR > 3 mg/mmol and 6.2% had an eGFR < 90 ml/min/1.73 m2 suggestive of early kidney disease. Diabetes was identified in 1.4%, and 1.4% had HbA1c's between 6.1% and 6.49%. CONCLUSIONS: Risk factors for chronic kidney disease are highly prevalent in rural Indigenous children. More research is required to confirm the persistence of these findings, and to evaluate the efficacy of screening children to prevent or delay progression to kidney failure.