Association of an Acute Kidney Injury Follow-up Clinic With Patient Outcomes and Care Processes: A Cohort Study.

RATIONALE & OBJECTIVE: To determine whether attendance at an acute kidney injury (AKI) follow-up clinic is associated with reduced major adverse kidney events. STUDY DESIGN: Propensity-matched cohort study. SETTING & PARTICIPANTS: Patients hospitalized with AKI in Ontario, Canada, from February 1, 2013, through September 30, 2017, at a single clinical center, who were not receiving dialysis when discharged. EXPOSURE: Standardized assessment by a nephrologist. OUTCOMES: Time to a major adverse kidney event, defined as death, initiation of maintenance dialysis, or incident/progressive chronic kidney disease. ANALYTICAL APPROACH: Propensity scores were used to match each patient who attended an AKI follow-up clinic to 4 patients who received standard care. Cox proportional hazards models were fit to assess the association between the care within an AKI follow-up clinic and outcomes. To avoid immortal time bias, we randomly assigned index dates to the comparator group. RESULTS: We matched 164 patients from the AKI follow-up clinic to 656 patients who received standard care. During a mean follow-up of 2.2±1.3 (SD) years, care in the AKI follow-up clinic was not associated with a reduction in major adverse kidney events relative to standard care (22.1 vs 24.7 events per 100 patient-years; HR, 0.91 [95% CI, 0.75-1.11]). The AKI follow-up clinic was associated with a lower risk of all-cause mortality (HR, 0.71 [95% CI, 0.55-0.91]). Patients aged at least 66 years who attended the AKI follow-up clinic were more likely to receive ß-blockers (HR, 1.34 [95% CI, 1.02-1.77]) and statins (HR, 1.35 [95% CI, 1.05-1.74]), but not angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (HR, 1.21 [95% CI, 0.94-1.56]). LIMITATIONS: Single-center study and residual confounding. CONCLUSIONS: Specialized postdischarge follow-up for AKI survivors was not associated with a lower risk of major adverse kidney events but was associated with a lower risk of death and increased prescriptions for some cardioprotective medications.

Impact of Bioelectrical Impedance-Guided Fluid Management and Vitamin D Supplementation on Left Ventricular Mass in Patients Receiving Peritoneal Dialysis: A Randomized Controlled Trial.

RATIONALE & OBJECTIVE: Hypervolemia and vitamin D deficiency occur frequently in patients receiving peritoneal dialysis and may contribute to left ventricular (LV) hypertrophy. The effect of bioelectrical impedance analysis (BIA)-guided volume management or vitamin D supplementation on LV mass among those receiving peritoneal dialysis is uncertain. STUDY DESIGN: Two-by-two factorial randomized controlled trial. SETTING & PARTICIPANTS: Sixty-five patients receiving maintenance peritoneal dialysis. INTERVENTION: BIA-guided volume management versus usual care and oral cholecalciferol 50,000 U weekly for 8 weeks followed by 10,000 U weekly for 44 weeks or matching placebo. OUTCOME: Change in LV mass at 1 year measured by cardiac magnetic resonance imaging. RESULTS: Total body water decreased by 0.9 + 2.4 (SD) L in the BIA group compared with a 1.5 ± 3.4 L increase in the usual care group (adjusted between-group difference: -2.4 [95% CI, -4.1 to -0.68] L, P = 0.01). LV mass increased by 1.3 ± 14.3 g in the BIA group and decreased by 2.4 ± 37.7 g in the usual care group (between-group difference: +2.2 [95% CI, -13.9 to 18.3] g, P = 0.8). Serum 25-hydroxyvitamin D concentration increased by a mean of 17.2 ± 30.8 nmol/L in the cholecalciferol group and declined by 8.2 ± 24.3 nmol/L in the placebo group (between-group difference: 28.3 [95% CI, 17.2-39.4] nmol/L, P < 0.001). LV mass decreased by 3.0 ± 28.1 g in the cholecalciferol group and increased by 2.0 ± 31.2 g in the placebo group (between-group difference: -4.5 [95% CI, -20.4 to 11.5] g, P = 0.6). LIMITATIONS: Relatively small sample size with larger than expected variation in change in LV mass. CONCLUSIONS: BIA-guided volume management had a modest impact on volume status with no effect on the change in LV mass. Vitamin D supplementation increased serum vitamin D concentration but had no effect on LV mass. FUNDING: Unrestricted Baxter International extramural grant and the Kidney Foundation of Canada. TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT01045980.

Medications Used Routinely in Primary Care to be Dose-Adjusted or Avoided in People With Chronic Kidney Disease: Results of a Modified Delphi Study.

Background: Chronic kidney disease (CKD) affects up to 18% of those over the age of 65 years. Potentially inappropriate medication prescribing in people with CKD is common. Objectives: Develop a pragmatic list of medications used in primary care that required dose adjustment or avoidance in people with CKD, using a modified Delphi panel approach, followed by a consensus workshop. Methods: We conducted a comprehensive literature search to identify potential medications. A group of 17 experts participated in a 3-round modified Delphi panel to identify medications for inclusion. A subsequent consensus workshop of 8 experts reviewed this list to prioritize medications for the development of point-of-care knowledge translation materials for primary care. Results: After a comprehensive literature review, 59 medications were included for consideration by the Delphi panel, with a further 10 medications added after the initial round. On completion of the 3 Delphi rounds, 66 unique medications remained, 63 requiring dose adjustment and 16 medications requiring avoidance in one or more estimated glomerular filtration rate categories. The consensus workshop prioritized this list further to 24 medications that must be dose-adjusted or avoided, including baclofen, metformin, and digoxin, as well as the newer SGLT2 inhibitor agents. Conclusion and Relevance: We have developed a concise list of 24 medications commonly used in primary care that should be dose-adjusted or avoided in people with CKD to reduce harm. This list incorporates new and frequently prescribed medications and will inform an updated, easy to access source for primary care providers.

Identifying Needs for Self-management Interventions for Adults With CKD and Their Caregivers: A Qualitative Study.

RATIONALE & OBJECTIVE: Fostering the ability of patients to self-manage their chronic kidney disease (CKD), with support from caregivers and providers, may slow disease progression and improve health outcomes. However, little is known about such patients' needs for self-management interventions. We aimed to identify and describe the needs of adults with CKD and informal caregivers for CKD self-management support. STUDY DESIGN: Descriptive qualitative study using semi-structured interviews and focus groups. SETTING & PARTICIPANTS: 6 focus groups (37 participants) and 11 telephone interviews with adults with CKD (stages 1-5, not on renal replacement therapy) and informal caregivers from across Canada. ANALYTIC APPROACH: Thematic analysis. RESULTS: 3 major themes were identified: (1) empowerment through knowledge (awareness and understanding of CKD, diet challenges, medication and alternative treatments, attuning to the body, financial implications, mental and physical health consequences, travel and transportation restrictions, and maintaining work and education), (2) activation through information sharing (access, meaningful and relevant, timing, and amount), and (3) tangible supports for the health journey (family, community, and professionals). LIMITATIONS: Participants were primarily white, educated, married, and English speaking, which limits generalizability. CONCLUSIONS: There are opportunities to enhance CKD self-management support by addressing knowledge pertinent to living well with CKD and priority areas for sharing information and providing tangible support. Future efforts may consider the development of innovative CKD self-management support interventions based on the diverse patient and caregiver needs identified in this study.

Changes in Kidney Function Do Not Differ between Healthy Adults Consuming Higher- Compared with Lower- or Normal-Protein Diets: A Systematic Review and Meta-Analysis.

Background: Higher-protein (HP) diets are advocated for several reasons, including mitigation of sarcopenia, but their effects on kidney function are unclear. Objective: This meta-analysis was conducted to determine the effect of HP intakes on kidney function in healthy adults. Methods: We conducted a systematic review and meta-analysis of trials comparing HP (≥1.5 g/kg body weight or ≥20% energy intake or ≥100 g protein/d) with normal- or lower-protein (NLP; ≥5% less energy intake from protein/d compared with HP group) intakes on kidney function. Medline and EMBASE databases were searched. Randomized controlled trials comparing the effects of HP with NLP (>4 d duration) intakes on glomerular filtration rate (GFR) in adults without kidney disease were included. Results: A total of 2144 abstracts were reviewed, with 40 articles selected for full-text review; 28 of these were analyzed and included data from 1358 participants. Data were analyzed using random-effects meta-analysis (RevMan 5; The Cochrane Collaboration), meta-regression (STATA; StataCorp), and dose-response analysis (Prism; GraphPad). Analyses were conducted using postintervention (post) GFR and the change in GFR from preintervention to post. The post-only comparison showed a trivial effect for GFR to be higher after HP intakes [standardized mean difference (SMD): 0.19; 95% CI: 0.07, 0.31; P = 0.002]. The change in GFR did not differ between interventions (SMD: 0.11; 95% CI: -0.05, 0.27; P = 0.16). There was a linear relation between protein intake and GFR in the post-only comparison (r = 0.332, P = 0.03), but not between protein intake and the change in GFR (r = 0.184, P = 0.33). The main limitation of the current analysis is the unclear risk of selection bias of the included trials. Conclusions: Postintervention GFR comparisons indicate that HP diets result in higher GFRs; however, when changes in GFR were compared, dietary protein had no effect. Our analysis indicates that HP intakes do not adversely influence kidney function on GFR in healthy adults.

Primary care provider perceptions of enablers and barriers to following guideline-recommended laboratory tests to confirm chronic kidney disease: a qualitative descriptive study.

BACKGROUND: Patients should receive follow-up serum creatinine tests after an initial abnormal result to diagnose chronic kidney disease. However, half of the time this fails to occur in primary care. We interviewed primary care providers to better understand their perceptions of enablers and barriers to following this guideline-recommended care. METHODS: We performed a qualitative descriptive study guided by the Theoretical Domains Framework (TDF), a framework for behavioural change. We used purposeful sampling to recruit primary care providers (physicians and nurse practitioners) based on provider and practice characteristics (rural, solo versus team practice, etc.) from Ontario, Canada. We completed one-on-one interviews with providers using a semi-structured and open-ended interview guide based on the 14 TDF domains. We alternated between data collection and analysis, where we used directed content analysis to identify frequent, important, and conflicting enablers and barriers. RESULTS: We completed 13 interviews with nine primary care physicians and four nurse practitioners. Nine themes related to the TDF emerged from the data: 1) environmental context and resources, 2) knowledge, 3) memory, attention, and decision processes, 4) beliefs about consequences, 5) goals, 6) social or professional role, 7) behavioural regulation, 8) skills, and 9) optimism. Within these themes, we identified 16 enablers and five barriers. Some enablers included, providers' knowledge on appropriate testing, their motivation to order these tests, and their use of tools and resources to help order follow-up serum creatinine tests. However, providers perceived some barriers including that ordering confirmatory laboratory tests for chronic kidney disease was not always a priority in regards to other care they wish to provide. Providers also noted that a perceived barrier is patients not going to the laboratory to complete the test. CONCLUSIONS: We identified novel enablers and barriers to primary care providers completing guideline recommended repeat testing for the diagnosis of chronic kidney disease. Similar research is needed to understand the views of patients. These research findings can be used to inform strategies to improve the quality of care.

Gremlin promotes peritoneal membrane injury in an experimental mouse model and is associated with increased solute transport in peritoneal dialysis patients.

The peritoneal membrane becomes damaged in patients on peritoneal dialysis (PD). Gremlin 1 (GREM1) inhibits bone morphogenic proteins (BMPs) and plays a role in kidney development and fibrosis. We evaluated the role of gremlin in peritoneal fibrosis and angiogenesis. In a cohort of 32 stable PD patients, GREM1 concentration in the peritoneal effluent correlated with measures of peritoneal membrane damage. AdGrem1, an adenovirus to overexpress gremlin in the mouse peritoneum, induced submesothelial thickening, fibrosis, and angiogenesis in C57BL/6 mice, which was associated with decreased expression of BMP4 and BMP7. There was evidence of mesothelial cell transition to a mesenchymal phenotype with increased α smooth muscle actin expression and suppression of E-cadherin. Some of the GREM1 effects may be reversed with recombinant BMP7 or a pan-specific transforming growth factor ß (TGF-ß) antibody. Neovascularization was not inhibited with a TGF-ß antibody, suggesting a TGF-ß-independent angiogenic mechanism. Swiss/Jackson Laboratory (SJL) mice, which are resistant to TGF-ß-induced peritoneal fibrosis, responded in a similar fashion to AdGrem1 as did C57BL/6 mice with fibrosis, angiogenesis, and mesothelial-to-mesenchymal transition. GREM1 was associated with up-regulated TGF-ß expression in both SJL and C57BL/6 mice, but SJL mice demonstrated a defective TGF-ß-induced GREM1 expression. In summary, GREM1 induces fibrosis and angiogenesis in mouse peritoneum and is associated with increased solute transport in these PD patients.

Estimated GFR reporting influences recommendations for dialysis initiation.

Automated reporting of estimated GFR (eGFR) with serum creatinine measurement is now common. We surveyed nephrologists in four countries to determine whether eGFR reporting influences nephrologists' recommendations for dialysis initiation. Respondents were randomly allocated to receive a survey of four clinical vignettes that included either serum creatinine concentration only or serum creatinine and the corresponding eGFR. For each scenario, the respondent was asked to rank his or her likelihood of recommending dialysis initiation on a modified 8-point Likert scale, ranging from 1 ("definitely not") to 8 ("definitely would"). Analysis of the 822 eligible responses received showed that the predicted likelihood of recommending dialysis increased by 0.55 points when eGFR was reported (95% confidence interval, 0.33 to 0.76), and this effect was larger for eGFRs >5 ml/min per 1.73 m(2) (P<0.001). Subgroup analyses suggested that physicians who had been in practice ≥13 years were more affected by eGFR reporting (P=0.03). These results indicate that eGFR reporting modestly increases the likelihood that dialysis is recommended, and physicians should be aware of this effect when assessing patients with severe CKD.

Impact of the 2021 CKD-EPI eGFR Equation on Kidney Care Referral Criteria in Ontario, Canada: A Population-based Cross-sectional Study.

Background: In some jurisdictions, individuals become eligible or recommended for referral for different types of kidney care using criteria based on their estimated glomerular filtration rate (eGFR). Historically, GFR was estimated with an equation developed in 2009, which included a Black race term. An updated, race-free equation was developed in 2021. It is unclear how adoption of the 2021 equation will influence the number of individuals meeting referral criteria to receive different types of kidney care. Objective: To develop population-based estimates on how the number of individuals meeting the eGFR-based referral criteria to receive three different types of kidney care (nephrologist consultation, care in a multi-care specialty clinic, kidney transplant evaluation) changes when the 2021 versus 2009 equation is used to calculate eGFR. Design: Population-based, cross-sectional study. Setting: Ontario, Canada's most populous province with 14.2 million residents as of 2021. Less than 5% of Ontario's residents self-identify as being of Black race. Patients: Adults with at least one outpatient serum creatinine measurement in the 2 years prior to December 31, 2021. Measurements: Referral criteria to 3 different types of kidney care: nephrologist consultation, multi-care specialty clinic, and evaluation for a kidney transplant. The eGFR thresholds used to define referral eligibility or recommendation for these kidney health services were based on guidelines from Ontario's provincial renal agency. Methods: The number of individuals meeting referral criteria for the 3 different healthcare services was compared between the 2009 and 2021 equations, restricted to individuals not yet receiving that level of care. As individual-level race data were not available, estimates were repeated, randomly assigning a Black race status to 1%, 5%, and 10% of the population. Results: We had an outpatient serum creatinine measurement available for 1 048 110 adults. Using the 2009 equation, 37 345 individuals met the criteria to be referred to a nephrologist, 10 019 met the criteria to receive care in a multi-care specialty clinic, and 10 178 met the criteria to be referred for kidney transplant evaluation. Corresponding numbers with the 2021 equation (and the percent relative to the 2009 equation) were 26 645 (71.3%), 9009 (89.9%), and 8615 (84.6%) individuals, respectively. These numbers were largely unchanged when Black race was assumed in up to 10% of the population. Limitations: Referral criteria based solely on urine albumin-to-creatinine ratio were not assessed. Self-reported race data were unavailable. Conclusions: For healthcare planning, in regions where a minority of the population is Black, a substantial number of individuals may no longer meet referral criteria for different types of kidney healthcare following adoption of the new 2021 eGFR equation.

Contexte: Dans certaines régions, les individus sont dirigés vers différents types de soins rénaux, ou y deviennent admissibles, selon des critères fondés sur le débit de filtration glomérulaire estimé (DFGe). Historiquement, le DFG était estimé avec une équation développée en 2009 comportant un terme qui tenait compte du fait d'être une personne de race noire. Une nouvelle équation sans mention de la race a été développée en 2021. Il est difficile de savoir comment l'adoption de l'équation de 2021 influencera le nombre de personnes qui répondront aux critères pour recevoir divers types de soins rénaux. Objectifs: Établir des estimations populationnelles de la variation du nombre de personnes qui répondent aux critères d'orientation fondés sur le DFGe pour recevoir trois différents types de soins rénaux (consultation avec un néphrologue, soins dans une clinique multidisciplinaire spécialisée, évaluation pour une transplantation rénale) selon que le DFGe est calculé avec l'équation de 2021 ou de 2009. Conception: Étude populationnelle transversale rétrospective. Cadre: L'Ontario, la province la plus peuplée du Canada avec 14,2 millions d'habitants en 2021. Moins de 5 % des résidents de l'Ontario s'identifient comme étant de race noire. Sujets: Des adultes avec au moins une mesure de la créatinine sérique en ambulatoire au cours des deux ans précédant le 31 décembre 2021. Mesures: Les critères d'orientation vers trois différents types de soins rénaux : consultation avec un néphrologue, soins en clinique multidisciplinaire spécialisée et évaluation pour une transplantation rénale. Les seuils de DFGe utilisés pour définir l'admissibilité à ­ ou l'orientation vers ­ ces services de santé rénale étaient fondés sur les lignes directrices de l'agence provinciale de soins rénaux de l'Ontario. Méthodologie: On a comparé les nombres d'individus répondant aux critères d'orientation pour les trois différents services de santé, calculés avec les équations de 2009 et de 2021, en se limitant aux personnes qui ne recevaient pas encore de tels soins. Les données individuelles sur la race n'étant pas disponibles, les estimations ont été répétées en attribuant aléatoirement un statut de race noire à 1 %, à 5 % et à 10 % de la population étudiée. Résultats: Une mesure de la créatinine sérique en ambulatoire était disponible pour un total de 1 048 110 adultes. Avec l'équation de 2009, 37 345 personnes répondaient aux critères pour être dirigées vers un néphrologue, 10 019 répondaient aux critères pour recevoir des soins dans une clinique multidisciplinaire spécialisée et 10 178 répondaient aux critères pour être évaluées pour une transplantation rénale. Avec l'équation de 2021, ces mêmes nombres de personnes (pourcentage par rapport à l'équation de 2009) étaient respectivement 26 645 (71,3 %), 9 009 (89,9 %) et 8 615 (84,6 %). Des chiffres qui sont demeurés majoritairement inchangés même en assumant une proportion de jusqu'à 10 % de personnes de race noire dans la population. Limites: Les critères d'orientation fondés uniquement sur le rapport albumine/créatinine urinaire n'ont pas été évalués. Les données autodéclarées sur la race n'étaient pas disponibles. Conclusion: Pour la planification des soins de santé, dans les régions où une minorité de la population est noire, un nombre important de personnes pourraient ne plus répondre aux critères d'orientation vers différents types de soins rénaux après l'adoption de l'équation de 2021 pour le calcul du DFGe.

The Association Between Intradialytic Symptom Clusters and Recovery Time in Patients Undergoing Maintenance Hemodialysis: An Exploratory Analysis.

Background: Individuals receiving hemodialysis often experience concurrent symptoms during treatment and frequently report feeling unwell after dialysis. The degree to which intradialytic symptoms are related, and which specific symptoms may impair health-related quality of life (HRQoL) is uncertain. Objectives: To explore intradialytic symptoms clusters, and the relationship between intradialytic symptom clusters with dialysis treatment recovery time and HRQoL. Design/setting: We conducted a post hoc analysis of a prospective cohort study of 118 prevalent patients receiving hemodialysis in two centers in Calgary, Alberta and Hamilton, Ontario, Canada. Participants: Adults receiving hemodialysis treatment for at least 3 months, not scheduled for a modality change within 6 weeks of study commencement, who could provide informed consent and were able to complete English questionnaires independently or with assistance. Methods: Participants self-reported the presence (1 = none to 5 = very much) of 10 symptoms during each dialysis treatment, the time it took to recover from each treatment, and weekly Kidney Disease Quality of Life 36-Item-Short Form (KDQoL-36) assessments. Principal component analysis identified clusters of intradialytic symptoms. Mixed-effects, ordinal and linear regression examined the association between symptom clusters and recovery time (categorized as 0, >0 to 2, >2 to 6, or >6 hours), and the physical component and mental component scores (PCS and MCS) of the KDQoL-36. Results: One hundred sixteen participants completed 901 intradialytic symptom questionnaires. The most common symptom was lack of energy (56% of treatments). Two intradialytic symptom clusters explained 39% of the total variance of available symptom data. The first cluster included bone or joint pain, muscle cramps, muscle soreness, feeling nervous, and lack of energy. The second cluster included nausea/vomiting, diarrhea and chest pain, and headache. The first cluster (median score: -0.56, 25th to 75th percentile: -1.18 to 0.55) was independently associated with longer recovery time (odds ratio [OR] 1.62 per unit difference in score, 95% confidence interval [CI]: 1.23-2.12) and decreased PCS (-0.72 per unit difference in score, 95% CI: -1.29 to -0.15) and MCS scores (-0.82 per unit difference in score, 95% CI: -1.48 to -0.16), whereas the second cluster was not (OR 1.24, 95% CI: 0.97-1.58; PCS 0.19, 95% CI -0.46 to 0.83; MCS -0.72, 95% CI: -1.50 to 0.06). Limitations: This was an exploratory analysis of a small data set from 2 centers. Further work is needed to externally validate these findings to confirm intradialytic symptom clusters and the generalizability of our findings. Conclusions: Intradialytic symptoms are correlated. The presence of select intradialytic symptoms may prolong the time it takes for a patient to recover from a dialysis treatment and impair HRQoL.

Contexte: Il arrive fréquemment que les personnes qui reçoivent des traitements d'hémodialyse éprouvent des symptômes concomitants pendant la dialyze et signalent un malaise après le traitement. On en sait toutefois peu sur le degré de corrélation de ce malaise avec les symptômes intradialytiques et sur les symptômes précis qui peuvent altérer la qualité de vie liée à la santé (QVLS). Objectifs: Explorer différents groupes de symptômes intradialytiques et la relation de ceux-ci avec le temps de récupération post-dialyze et la QVLS. Cadre et conception de l'étude: Nous avons procédé à une analyze post-hoc d'une étude de cohorte prospective portant sur 118 patients prévalents recevant une hémodialyse dans deux centers, soit à Calgary (Alberta) et à Hamilton (Ontario) au Canada. Sujets: Des adultes qui recevaient des traitements d'hémodialyse depuis au moins trois mois ­ sans changement de modalité prévu dans les six semaines suivant le début de l'étude ­ qui pouvaient donner leur consentement éclairé et qui étaient en mesure de remplir des questionnaires en anglais de façon autonome ou avec de l'aide. Méthodologie: Pour chaque traitement de dialyze, les participants devaient autoévaluer le degré de présence (de 1 [non présent] à 5 [très présent]) de dix symptômes et le temps nécessaire pour récupérer de chaque traitement, puis remplir des évaluations hebdomadaires à l'aide du questionnaire KDQoL-36. Une analyze des composantes principales a permis de définir des groupes de symptômes intradialytiques. Une régression à effets mixtes, ordinale et linéaire, a servi à examiner l'association entre les groupes de symptômes et le temps de récupération (0 heure; de 0 à 2 heures; de 2 à 6 hures; plus de 6 heures), et les scores des composantes physiques et psychologiques du KDQoL-36. Résultats: Cent seize patients ont rempli un total de 901 questionnaires sur les symptômes intradialytiques. Le symptôme le plus fréquemment déclaré était le manque d'énergie (56 % des traitements). Deux groupes de symptômes intradialytiques ont expliqué 39 % de la variance totale des données disponibles sur les symptômes. Le premier groupe comprenait des douleurs osseuses ou articulaires, des crampes musculaires, des douleurs musculaires, une sensation de nervosité et un manque d'énergie. Le deuxième groupe comprenait des nausées/vomissements, de la diarrhée, des douleurs thoraciques et des maux de tête. Le premier groupe (score médian : ­0,56; du 25e au 75e percentile : ­1, 18 à 0,55) a été indépendamment associé à un temps de récupération plus long (rapport de cotes : 1,62 par unité de différence de score; IC 95 % : 1,23 à 2,12) et à une diminution des scores des composantes physiques (RC : ­0,72; IC 95 % : ­1, 29 à ­0,15) et des scores des composantes psychologiques (RC : ­0,82; IC 95 % : ­1, 48 à ­0,16). Le deuxième groupe n'a pas été associé avec le temps de récupération (RC : 1,24; IC 95 % : 0,97 à 1,58) ni avec le score des composantes physiques (RC : 0,19; IC 95 % : ­0,46 à 0,83) et les scores des composantes psychologiques (RC : ­0,72; IC 95 % : ­1, 50 à 0,06). Limites: Il s'agissait d'une analyze exploratoire d'un petit ensemble de données provenant de deux centers. D'autres études externes sont nécessaires pour valider ces résultats et, ainsi, confirmer nos groupes de symptômes intradialytiques et la généralisabilité de nos résultats. Conclusion: Les symptômes intradialytiques sont corrélés. La présence de certains symptômes intradialytiques peut prolonger le temps de récupération post-dialyze et altérer la qualité de vie des patients.

Patient Care Gaps Prior to Maintenance Dialysis Initiation: A Population-Based Retrospective Study.

Background: Guidelines in Ontario, Canada, recommend timely referral for multidisciplinary kidney care to facilitate planned dialysis initiation. Many patients do not receive recommended multidisciplinary kidney care prior to dialysis. Objective: To better understand why this gap in pre-dialysis care exists, we conducted a study to describe the pathways by which patients initiate maintenance dialysis. Design: A retrospective cohort study. Setting: Population-based, using health care administrative databases from Ontario, Canada. Patients: Adults initiating maintenance dialysis from April 2016 to March 2019. Measurements and methods: Patients were grouped based on whether they received recommended multidisciplinary kidney care prior to dialysis initiation (at least 1 year of care with at least 2 visits). For those who did not receive recommended care, we grouped patients as having no identified care gap or into the following groups: (1) lack of timely chronic kidney disease (CKD) screening, (2) late nephrology referral (<1 year), or (3) late or no referral for multidisciplinary kidney care among patients followed by a nephrologist for at least 1 year. Results: A total of 9216 patients were included with a mean (standard deviation) age of 66 (15) years, and 61.5% were male. Of the total, 896 (9.7%) patients died, 7671 (83.2%) remained on dialysis at 90 days, and 649 (7.0%) had stopped dialysis due to kidney function recovery within 90 days. Of the 9216 patients, 5434 (59%) had not received recommended multidisciplinary kidney care. Among those without recommended care, there were 2251 (41.4%) patients with no identified care gaps, 1351 (24.9%) patients with a lack of timely CKD screening, 359 (6.6%) patients with late nephrology referral, and 1473 (27.1%) patients with late or no referral for multidisciplinary kidney care. Limitations: We could not determine if patients were referred but declined multidisciplinary kidney care. Conclusions: More than half of patients had not received recommended multidisciplinary kidney care. Many patients experienced an acute decline in kidney function, which may not be preventable, but in others, there were missed opportunities for CKD screening or early referral to nephrology, or at the level of nephrology practice for early referral for multidisciplinary care. This work could be used to inform policies aimed at improving increased uptake of multidisciplinary kidney care prior to dialysis.

Contexte: Les lignes directrices de l'Ontario (Canada) recommandent que les patients soient dirigés en temps opportun vers une prise en charge multidisciplinaire de la maladie rénale afin de faciliter l'initiation planifiée de la dialyze. Cette recommandation n'est toutefois pas appliquée pour de nombreux patients. Objectif: Afin de mieux comprendre ce qui explique cette lacune dans les soins de prédialyse, nous avons menu une étude visant à décrire le parcours des patients jusqu'à l'initiation de la dialyse chronique. Conception: Étude de cohorte rétrospective. Cadre: Étude populationnelle réalisée à partir des bases de données administratives de santé de l'Ontario (Canada). Sujets: Adultes ayant amorcé une dialyse d'entretien entre avril 2016 et mars 2019. Méthodologie et mesures: Les patients ont été groupés selon qu'ils avaient ou non reçu des soins multidisciplinaires recommandés avant l'initiation de la dialyse (au moins un an de soins incluant au moins deux visites). Les patients qui n'avaient pas reçu les soins recommandés ont été groupés soit comme ne présentant aucune lacune de soins identifiée, soit dans l'un des groupes suivants: i) absence de dépistage de l'IRC en temps opportun; ii) référence tardive en néphrologie (<1 an); iii) patients suivis depuis au moins un an par un néphrologue et non référés vers des soins multidisciplinaires ou référés tardivement. Résultats: En tout, 9 216 patients (61,5 % d'hommes) âgés en moyenne de 66 ans (écart-type: 15 ans) ont été inclus. De cette cohorte, 896 (9,7 %) patients sont décédés, 7 671 (83,2 %) étaient toujours sous dialyse après 90 jours et 649 (7,0 %) avaient cessé la dialyse dans les 90 jours en raison de la récupération de la fonction rénale. Le nombre total de patients n'ayant pas reçu les soins multidisciplinaires recommandés s'élevait à 5 434 (59 %). De ce nombre, 2 251 patients (41,4 %) ont été classés sans lacune de soins identifiée, 1 351 patients (24,9 %) n'avaient pas bénéficié d'un dépistage précoce de l'IRC, 359 patients (6,6 %) avaient été référés tardivement en néphrologie, et 1 473 patients (27,1 %) n'avaient pas été référés en soins multidisciplinaires ou l'avaient été tardivement. Limites: Nous n'avons pas été en mesure de déterminer si certains patients référés vers des soins multidisciplinaires avaient refusé ces soins. Conclusion: Plus de la moitié des patients n'ont pas reçu les soins multidisciplinaires recommandés avant la dialyse. De nombreux patients ont vécu une baisse rapide de leur fonction rénale, qui n'aurait possiblement pas pu être évitée, mais dans d'autres cas, des occasions de dépistage précoce de l'IRC ou de référence précoce en néphrologie ont été manquées. Au niveau de la pratique en néphrologie, là encore, des occasions de référence précoce vers des soins multidisciplinaires ont pu être manquées. Ces travaux pourraient éclairer les politiques visant à améliorer la prise en charge multidisciplinaire de la maladie rénale avant la dialyse.

An eHealth self-management intervention for adults with chronic kidney disease, My Kidneys My Health: a mixed-methods study.

BACKGROUND: There is limited research of electronic tools for self-management for patients with chronic kidney disease (CKD). We sought to evaluate participant engagement, perceived self-efficacy and website usage in a preliminary evaluation of My Kidneys My Health, a patient-facing eHealth tool in Canada. METHODS: We conducted an explanatory sequential mixed-methods study of adults with CKD who were not on kidney replacement therapy and who had access to My Kidneys My Health for 8 weeks. Outcomes included acceptance (measured by the Technology Acceptance Model), self-efficacy (measured by the Chronic Disease Self-Efficacy Scale [CDSES]) and website usage patterns (captured using Google Analytics). We analyzed participant interviews using qualitative content analysis. RESULTS: Twenty-nine participants with CKD completed baseline questionnaires, of whom 22 completed end-of-study questionnaires; data saturation was achieved with 15 telephone interviews. Acceptance was high, with more than 70% of participants agreeing or strongly agreeing that the website was easy to use and useful. Of the 22 who completed end-of-study questionnaires, 18 (82%) indicated they would recommend its use to others and 16 (73%) stated they would use the website in the future. Average scores for website satisfaction and look and feel were 7.7 (standard deviation [SD] 2.0) and 8.2 (SD 2.0) out of 10, respectively. The CDSES indicated that participants gained an increase in CKD information. Interviewed participants reported that the website offered valuable information and interactive tools for patients with early or newly diagnosed CKD, or for those experiencing changes in health status. Popular website pages and interactive features included Food and Diet, What is CKD, My Question List and the Depression Screener. INTERPRETATION: Participants indicated that the My Kidneys My Health website provided accessible content and tools that may improve self-efficacy and support in CKD self-management. Further evaluation of the website's effectiveness in supporting self-management among a larger, more heterogenous population is warranted.

The WISHED Randomized Controlled Trial: Impact of an Interactive Health Communication Application on Home Dialysis Use in People With Chronic Kidney Disease.

BACKGROUND: While home dialysis therapies are more cost effective and may offer improved health-related quality of life, uptake compared to in-center hemodialysis remains low. OBJECTIVE: To test whether a web-based interactive health communication application (IHCA) compared to usual care would increase home dialysis use. DESIGN: Randomized control trial. SETTING: Patients were recruited from 3 multidisciplinary kidney clinics across Ontario, Canada (Hamilton, Kingston, London). PATIENTS: We included adults with advanced chronic kidney disease (CKD) followed in multidisciplinary kidney clinics. Patients who had not completed dialysis modality education, who did not have access to a home computer or the internet, who had significant hearing or vision impairment, who could not read/write/speak English, who had a medical contraindication for home dialysis, or who had selected conservative kidney care were excluded. MEASUREMENTS: The primary outcome was any use of home dialysis (peritoneal dialysis or home hemodialysis) within 90 days of dialysis initiation. Secondary outcomes were social support, decision conflict and dialysis knowledge measured at baseline, 6 months and 1 year. METHODS: Eligible patients were randomized to either usual care or the IHCA in addition to usual care in a 1:1 ratio. As part of usual care, all patients received education about dialysis modalities and kidney transplantation delivered by clinic nurses according to local practices. Randomization was performed using a computer-generated sequence in randomly permuted block sizes, stratified by site, and allocation occurred using sequentially numbered sealed, opaque envelopes. Participants, care providers, and outcome assessors were not blinded to the intervention. All analyses were performed blinded using an intention to treat approach. We estimated the effect of the ICHA on the odds of the primary outcome using unadjusted logistic regression models. Linear mixed models for repeated measures over time were used to analyze the impact of the IHCA on the secondary outcomes of interest. RESULTS: We randomized 140 (usual care, n = 71; IHCA, n = 69) out of a planned 264 patients (mean [SD] age 61 [14.5] years, 65% men). Among patients randomized to the IHCA group that completed 6-month and 1-year follow-up visits, 56.8% and 71.4%, respectively, had not accessed the IHCA website within the past month. There were 23 (32.4%) and 26 (37.7%) patients in the usual care and IHCA groups who received a home dialysis therapy within 90 days of dialysis initiation (odds ratio, OR = 1.3, 95% CI = [0.6-2.5], P = .5). Among the 78 patients who initiated dialysis (n = 38 usual care, n = 40 IHCA), 60.5% and 65% in the usual care and IHCA groups received a home therapy within 90 days of dialysis initiation (OR = 1.2, 95% CI = [0.5-3.0], P = .7). Secondary outcomes did not differ by intervention group over time. LIMITATIONS: The trial was underpowered due to poor recruitment and use of the IHCA was low. CONCLUSIONS: We did not find evidence of a difference in home dialysis uptake with IHCA use, but our analyses were notably underpowered. The incorporation of greater patient engagement, qualitative research and design research, and pilot implementation may help future evaluations of strategies to improve home dialysis uptake. TRIAL REGISTRATION: ClinicalTrials.gov #NCT01403454, registration date: Jul 21, 2011.

CONTEXTE: La dialyse à domicile est une modalité plus économique qui améliore la qualité de vie liée à la santé des patients. Malgré cela, son adoption demeure faible par rapport à l'hémodialyse en centre hospitalier. OBJECTIF: Vérifier si l'utilization d'une application interactive de communication en santé (AICS) accessible en ligne augmente l'adoption de la dialyse à domicile comparativement aux soins habituels. TYPE D'ÉTUDE: Essai contrôlé à répartition aléatoire. CADRE: Les patients ont été recrutés dans trois cliniques multidisciplinaires de néphrologie en Ontario, au Canada (Hamilton, Kingston, London). SUJETS: Nous avons inclus des adultes atteints d'insuffisance rénale chronique (IRC) de stade avancé suivis en clinique multidisciplinaire de néphrologie. Ont été exclus les patients n'ayant pas terminé la formation sur les modalités de dialyse, n'ayant pas accès à un ordinateur ou à Internet à domicile, ayant une déficience auditive ou visuelle importante, ne sachant pas lire, écrire ou parler en anglais, présentant une contre-indication médicale à la dialyse à domicile ou ayant choisi un traitement conservateur. MESURES: Le principal résultat était utilisation de la dialyse à domicile (dialyse péritonéale ou hémodialyse) dans les 90 jours suivant l'amorce du traitement. Les critères d'évaluation secondaires étaient le soutien social, les conflits décisionnels et les connaissances en matière de dialyse mesurés à l'inclusion, après six mois et après un an. MÉTHODOLOGIE: Les patients admissibles ont été répartis aléatoirement dans un rapport 1:1 pour recevoir les soins habituels ou l'AICS en plus des soins habituels. Dans le cadre des soins habituels, tous les patients ont reçu une formation sur les modalités de dialyse et la transplantation rénale donnée par le personnel infirmier de la clinique, conformément aux pratiques locales. La répartition aléatoire a été effectuée à l'aide d'une séquence générée par ordinateur dans des blocs de taille permutée au hasard, stratifiés par site. L'attribution s'est faite par enveloppes scellées et opaques, numérotées de façon séquentielle. L'intervention ne s'est pas faite à l'insu des participants, des fournisseurs de soins et des évaluateurs. Toutes les analyses ont été effectuées en aveugle avec une approche en intention de traiter. Nous avons estimé l'effet de l'AICS sur les probabilités du résultat principal en utilisant des modèles de régression logistique non corrigés. Des modèles mixtes linéaires pour des mesures répétées dans le temps ont été employés pour analyser l'impact de l'AICS sur les critères secondaires d'intérêt. RÉSULTATS: Des 264 patients prévus au départ (âge moyen [ÉT]: 61 [14,5] ans; 65 % d'hommes), 140 ont été répartis aléatoirement (71 en soins habituels; 69 avec l'AICS). Dans le groupe AICS, 56,8 % des patients ayant eu une visite de suivi après six mois et 71,4 % après un an n'avaient pas accédé au site Web de l'AICS au cours du mois précédent. Le nombre de patients ayant adopté la dialyse à domicile dans les 90 jours s'élevait à 23 (32,4 %) dans le groupe des soins habituels et à 26 (37,7 %) dans le groupe AICS (risque relatif [RR]: 1,3; IC 95 %: 0,6-2,5; p=0,5). Des 78 patients ayant amorcé des traitements de dialyse (38 en soins habituels; 40 avec l'AICS), la proportion de patients ayant reçu la dialyse à domicile dans les 90 suivants s'élevait à 60,5 % dans le groupe des soins habituels et à 65 % dans le groupe AICS (RR: 1,2; IC 95 %: 0,5-3,0; p=0,7). Les critères d'évaluation secondaires n'ont pas différé au fil du temps selon le groupe d'intervention. LIMITES: L'essai manque de robustesse en raison du faible recrutement et de la faible utilisation de l'AICS. CONCLUSION: Nous n'avons trouvé aucune preuve supportant une plus grande adoption de la dialyse à domicile avec l'AICS, mais nos analyses manquaient nettement de robustesse. Éventuellement, une plus grande participation des patients, une recherche qualificative et une recherche conceptuelle et une mise en œuvre pilote pourraient faciliter l'évaluation des stratégies visant à augmenter l'adoption de la dialyse à domicile.

A Web-Based Self-Management Support Prototype for Adults With Chronic Kidney Disease (My Kidneys My Health): Co-Design and Usability Testing.

BACKGROUND: Supporting patients to self-manage their chronic kidney disease (CKD) has been identified as a research priority by patients with CKD and those who care for them. Self-management has been shown to slow CKD progression and improve the quality of life of individuals living with the disease. Previous work has identified a need for a person-centered, theory-informed, web-based tool for CKD self-management that can be individualized to a patient's unique situation, priorities, and preferences. We addressed this gap using an integrated knowledge translation method and patient engagement principles. OBJECTIVE: The aim of this study is to conduct systematic co-design and usability testing of a web-based self-management prototype for adults with CKD (nondialysis and nontransplant) and their caregivers to enhance self-management support. METHODS: A multistep, iterative system development cycle was used to co-design and test the My Kidneys My Health prototype. The 3-step process included creating website features and content using 2 sequential focus groups with patients with CKD and caregivers, heuristic testing using the 10 heuristic principles by Nielsen, and usability testing through in-person 60-minute interviews with patients with CKD and their caregivers. Patients with CKD, caregivers, clinicians, researchers, software developers, graphic designers, and policy makers were involved in all steps of this study. RESULTS: In step 1, 18 participants (14 patients and 4 caregivers) attended one of the 2 sequential focus groups. The participants provided specific suggestions for simplifying navigation as well as suggestions to incorporate video, text, audio, interactive components, and visuals to convey information. A total of 5 reviewers completed the heuristic analysis (step 2), identifying items mainly related to navigation and functionality. Furthermore, 5 participants completed usability testing (step 3) and provided feedback on video production, navigation, features and functionality, and branding. Participants reported visiting the website repeatedly for the following features: personalized food tool, my health care provider question list, symptom guidance based on CKD severity, and medication advice. Usability was high, with a mean system usability score of 90 out of 100. CONCLUSIONS: The My Kidneys My Health prototype is a systematically developed, multifaceted, web-based CKD self-management support tool guided by the theory and preferences of patients with CKD and their caregivers. The website is user friendly and provides features that improve user experience by tailoring the content and resources to their needs. A feasibility study will provide insights into the acceptability of and engagement with the prototype and identify preliminary patient-reported outcomes (eg, self-efficacy) as well as potential factors related to implementation. This work is relevant given the shift to virtual care during the current pandemic times and provides patients with support when in-person care is restricted.

Impact of haemoglobin and erythropoietin dose changes on mortality: a secondary analysis of results from a randomized anaemia management trial.

BACKGROUND: Anaemia is a common complication of chronic kidney disease. A number of studies have identified an adverse association between haemoglobin (Hgb) variability and mortality. To date, no study has evaluated the impact of Hgb variability on mortality in the setting of a uniform Hgb target and erythropoiesis-stimulating agents (ESA) dosing strategy. METHODS: One hundred and fifty-four haemodialysis (HD) patients from a previous randomized anaemia management study were followed up for up to 6 years. The impact of Hgb variability and ESA dosing parameters on subsequent mortality risk were evaluated. RESULTS: More rapid rises in Hgb (Hgb deflect(pos)) and ESA dose increases were independently associated with mortality in multivariate analysis, whereas more rapid Hgb declines (Hgb deflect(neg)) and ESA dose decreases were not. Each gram per litre per week increase in Hgb deflect(pos) was associated with an adjusted hazard ratio (HR) of 1.23 (1.03-1.48), while for every 1000-unit increase in ESA dose, the adjusted HR was 1.12 (1.01-1.24). Factors associated with positive Hgb deflections included frequency and magnitude of ESA dose changes, baseline Hgb, patient weight and presence of an HD catheter. CONCLUSIONS: Rapid Hgb rises and greater average Eprex dose increases were independently associated with a higher mortality risk in HD patients after adjustment for baseline Hgb and Eprex dose. A randomized controlled trial evaluating different ESA dosing strategies in response to individual patient ESA responsiveness is needed.

Perceived and Objective Kidney Disease Knowledge in Patients With Advanced CKD Followed in a Multidisciplinary CKD Clinic.

BACKGROUND: One of the key components of multidisciplinary CKD clinics is education; however, kidney disease knowledge among patients followed in these clinics is not routinely measured. OBJECTIVE: The aim of this study was to determine objective and perceived kidney disease knowledge and patient characteristics associated with knowledge among patients followed in a multi-care kidney clinic. DESIGN: This is a cross-sectional survey study. SETTING: This study was conducted in a multi-care kidney clinic in Ontario, Canada. PATIENTS: Patients who did not speak English, who were unable to read due to significant vision impairment, or who had a known history of dementia or significant cognitive impairment were excluded. MEASUREMENTS: Perceived kidney disease knowledge was evaluated using a previously validated 9-item survey (PiKS). Each question on the perceived knowledge survey had 4 possible responses, ranging from "I don't know anything" (1) to "I know a lot" (4). Objective kidney disease knowledge was evaluated using a previously validated survey (KiKS). METHODS: The association between patient characteristics and perceived and objective kidney disease knowledge was determined using linear regression. RESULTS: A total of 125 patients were included, 57% were male, the mean (SD) age and eGFR were 66 (13) years and 16 (5.9) mL/min/1.73 m2, respectively. The median (IQR) objective and perceived knowledge survey scores were 19 out of 27 (16, 21) and 2.9 out of 4 (2.4, 3.2), respectively. Only 25% of patients answered correctly that CKD can be associated with no symptoms, and 64% of patients identified correctly that the kidneys make urine. More than 60% of patients perceived themselves to know nothing or only a little about medications that help or hurt the kidney. Older age was independently associated with lower perceived and objective knowledge, but sex, income, and educational attainment were not. LIMITATIONS: This is a single-center study. Cognitive impairment was based on the treating team's informal assessment or prior documentation in the chart; formal cognitive testing was not performed as part of this study. CONCLUSIONS: Despite resource-intensive care, CKD knowledge of patients followed in a multidisciplinary clinic was found to be modest. Whether enhanced educational strategies can improve knowledge and whether increasing knowledge improves patient outcomes warrants further study.

CONTEXTE: L'éducation sur les maladies rénales est une des raisons d'être des cliniques multidisciplinaires d'IRC, mais les connaissances des patients suivis dans ces cliniques ne sont pas mesurées de façon systématique. OBJECTIF: Évaluer les connaissances objectives et perçues sur l'insuffisance rénale des patients suivis dans une clinique multidisciplinaire de maladies rénales et déterminer les caractéristiques des patients associées à ces connaissances. TYPE D'ÉTUDE: Étude transversale menée sous forme de questionnaire. CADRE: Une clinique multidisciplinaire de suivi des maladies rénales en Ontario (Canada). SUJETS: Les patients ne parlant pas anglais, ne pouvant lire en raison d'un important trouble de la vision ou ayant des antécédents de démence ou d'un important déficit cognitif ont été exclus. MESURES: Les connaissances perçues quant à l'insuffisance rénale ont été évaluées à l'aide d'un questionnaire préalablement validé composé de neuf questions (PiKS). Chaque question sur la connaissance perçue disposait de quatre choix de réponse allant de « Je n'y connais rien (1) ¼ à « J'en connais beaucoup (4) ¼. Les connaissances objectives ont été évaluées à l'aide d'un questionnaire préalablement validé (KiKS). MÉTHODOLOGIE: L'association entre les caractéristiques du patient et les connaissances objectives et perçues a été établie par régression linéaire. RÉSULTATS: Au total, 125 patients ont été inclus. L'échantillon était composé à 57 % d'hommes dont l'âge médian (SD) était de 66 (13) ans et dont le DFGe médian (SD) s'établissait à 16 (5,9) mL/min/1,73 m2. Les scores médians (EIQ) obtenus aux tests de connaissances objectives et perçues étaient respectivement de 19 sur 27 (16-21) et de 2,9 sur 4 (2,4-3,2). Seuls 25 % des patients ont répondu correctement que l'IRC peut se manifester en absence de symptômes, et 64 % des patients savaient que les reins produisent l'urine. Plus de 60 % des patients avaient l'impression de ne rien connaître ou d'en savoir très peu sur les médicaments qui aident ou qui nuisent aux reins. De faibles connaissances objectives et perçues ont été indépendamment associées à un âge plus avancé; ce qui n'a pas été le cas pour le sexe, le revenu et le niveau de scolarité. LIMITES: L'étude a été menée dans un seul centre. Le déficit cognitif a été établi sur la base de l'évaluation informelle de l'équipe soignante ou de la documentation antérieure figurant au dossier. Aucun test cognitif formel n'a été effectué dans le cadre de cette étude. CONCLUSION: Malgré les multiples ressources disponibles, les connaissances sur l'IRC des patients suivis dans une clinique multidisciplinaire se sont avérées modestes. Une étude plus approfondie est requise pour déterminer si de meilleures stratégies d'éducation peuvent améliorer les connaissances des patients, et si l'accroissement de ces connaissances est susceptible d'améliorer les issues cliniques chez les patients.

Potentially inappropriate prescribing in older adults with advanced chronic kidney disease.

BACKGROUND: Older adults with chronic kidney disease (CKD) are at heightened risk for polypharmacy. We examined potentially inappropriate prescribing in this population and whether introducing pharmacists into the ambulatory kidney care model was associated with improved prescribing practices. METHODS: Retrospective cohort study using linked administrative databases. We included patients with an eGFR ≤30 mL/min/1.73 m2 ≥66 years of age followed in multidisciplinary kidney clinics in Ontario, Canada (n = 25,016 from 28 centres). The primary outcome was the absence of a statin prescription or the receipt of a potentially inappropriate prescription defined by the American Geriatric Society Beers Criteria® and a modified Delphi panel that identified key drugs of concern in CKD. We calculated the crude cumulative incidence and incidence rate for the primary outcome and used change-point regression to determine if a change occurred following pharmacist introduction. RESULTS: There were 6,007 (24%) and 16,497 patients (66%) not prescribed a statin and with ≥1 potentially inappropriate prescription, respectively. The rate of potentially inappropriate prescribing was 125.6 per 100 person-years and was higher in more recent years. The change-point regression analysis included 2,275 patients from two centres. No immediate change was detected at pharmacist introduction, but potentially inappropriate prescribing was increasing pre-pharmacist introduction, and this rising trend was reversed post-pharmacist introduction. The incidence of potentially inappropriate prescribing still remained high post-pharmacist introduction. CONCLUSIONS: Potentially inappropriate prescribing practices were common. Incorporating pharmacists into the kidney care model may improve prescribing practices. The role of pharmacists in the ambulatory kidney care team warrants further investigation in a randomized controlled trial.

Interhospital Transfer and Outcomes in Patients with AKI: A Population-Based Cohort Study.

Background: Patients with AKI may require interhospital transfer to receive RRT. Interhospital transfer may lead to delays in therapy, resulting in poor patient outcomes. There is minimal data comparing outcomes among patients undergoing transfer for RRT versus those who receive RRT at the hospital to which they first present. Methods: We conducted a population-based cohort study of all adult patients (≥19 years) who received acute dialysis within 14 days of admission to an acute-care hospital between April 1, 2004 and March 31, 2015. The transferred group included all patients who presented to a hospital without a dialysis program and underwent interhospital transfer (with the start of dialysis ≤3 days of transfer and within 14 days of initial admission). All other patients were considered nontransferred. The primary outcome was time to 90-day all-cause mortality, adjusting for demographics, comorbidities, and measures of acute illness severity. We also assessed chronic dialysis dependence as a secondary outcome, using the Fine and Gray proportional hazards model to account for the competing risks of death. In a secondary post hoc analysis, we assessed these outcomes in a propensity score-matched cohort, matching on age, sex, and prior CKD status. Results: We identified 27,270 individuals initiating acute RRT within 14 days of a hospital admission, of whom 2113 underwent interhospital transfer. Interhospital transfer was associated with lower rate of mortality (adjusted hazard ratio [aHR], 0.90; 95% CI, 0.84 to 0.97). Chronic dialysis dependence was not significantly different between groups (aHR, 0.98; 95% CI, 0.91 to 1.06). In the propensity score-matched analysis, interhospital transfer remained associated with a lower risk of death (HR, 0.88; 95% CI, 0.80 to 0.96). Conclusions: Interhospital transfer for receipt of RRT does not confer higher mortality or worse kidney outcomes.

Kidney Function and Potassium Monitoring After Initiation of Renin-Angiotensin-Aldosterone System Blockade Therapy and Outcomes in 2 North American Populations.

BACKGROUND: Clinical practice guidelines recommend routine kidney function and serum potassium testing within 30 days of initiating ACE (angiotensin-converting enzyme) inhibitor or angiotensin II receptor blocker therapy. However, evidence is lacking about whether follow-up testing reduces therapy-related adverse outcomes. METHODS AND RESULTS: We conducted 2 population-based retrospective cohort studies in Kaiser Permanente Northern California and Ontario, Canada. Patients with outpatient serum creatinine and potassium tests in the 30 days after starting ACE inhibitor or angiotensin II receptor blocker therapy were matched 1:1 to patients without follow-up tests. We evaluated the association of follow-up testing with 30-day all-cause mortality and hospitalization with acute kidney injury or hyperkalemia using Cox regression. We also developed and externally validated a risk score to identify patients at risk of having abnormally high serum creatinine and potassium values in follow-up. We identified 75 251 matched pairs initiating ACE inhibitor or angiotensin II receptor blocker therapy between January 1, 2007, and December 31, 2017, in Kaiser Permanente Northern California. Follow-up testing was not significantly associated with 30-day all-cause mortality in Kaiser Permanente Northern California (hazard ratio, 0.75 [95% CI, 0.54-1.06]) and was associated with higher mortality in 84 905 matched pairs in Ontario (hazard ratio, 1.32 [95% CI, 1.07-1.62]). In Kaiser Permanente Northern California, follow-up testing was significantly associated with higher rates of hospitalization with acute kidney injury (hazard ratio, 1.66 [95% CI, 1.10-2.22]) and hyperkalemia (hazard ratio, 3.36 [95% CI, 1.08-10.41]), as was observed in Ontario. The risk score for abnormal potassium provided good discrimination (area under the curve [AUC], 0.75) and excellent calibration of predicted risks, while the risk score for abnormal serum creatinine provided moderate discrimination (AUC, 0.62) but excellent calibration. CONCLUSIONS: Routine laboratory monitoring after ACE inhibitor or angiotensin II receptor blocker initiation was not associated with a lower risk of 30-day mortality. We identified patient subgroups in which targeted testing may be effective in identifying therapy-related changes in serum potassium or kidney function.

Association between markers of inflammation, fibrosis and hypervolemia in peritoneal dialysis patients.

BACKGROUND/AIM: Volume expansion in peritoneal dialysis (PD) patients is associated with left ventricular hypertrophy. The link between inflammation and hypervolemia has not been extensively studied. The aim of this study was to determine if an association exists between hypervolemia and markers of inflammation in PD patients. METHODS: In this cross-sectional study of 22 prevalent PD patients, volume was determined by bioelectrical impedance analysis. Serum and peritoneal effluent interleukin-6 (IL-6) and peritoneal transforming growth factor (TGF)-beta(1) were measured. A fast peritoneal equilibration test determined peritoneal transport status. RESULTS: Bioimpedance-derived measures of hypervolemia correlated with peritoneal effluent IL-6 and TGF-beta(1). Peritoneal IL-6 was also associated with high peritoneal transport status. CONCLUSIONS: Markers of inflammation and fibrosis (peritoneal IL-6 and TGF-beta(1)) are associated with markers of hypervolemia.