Impact of Prior Abdominal Procedures on Peritoneal Dialysis Catheter Outcomes: Findings From the North American Peritoneal Dialysis Catheter Registry.

RATIONALE & OBJECTIVE: A history of prior abdominal procedures may influence the likelihood of referral for peritoneal dialysis (PD) catheter insertion. To guide clinical decision making in this population, this study examined the association between prior abdominal procedures and outcomes in patients undergoing PD catheter insertion. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Adults undergoing their first PD catheter insertion between November 1, 2011, and November 1, 2020, at 11 institutions in Canada and the United States participating in the International Society for Peritoneal Dialysis North American Catheter Registry. EXPOSURE: Prior abdominal procedure(s) defined as any procedure that enters the peritoneal cavity. OUTCOMES: The primary outcome was time to the first of (1) abandonment of the PD catheter or (2) interruption/termination of PD. Secondary outcomes were rates of emergency room visits, hospitalizations, and procedures. ANALYTICAL APPROACH: Cumulative incidence curves were used to describe the risk over time, and an adjusted Cox proportional hazards model was used to estimate the association between the exposure and primary outcome. Models for count data were used to estimate the associations between the exposure and secondary outcomes. RESULTS: Of 855 patients who met the inclusion criteria, 31% had a history of a prior abdominal procedure and 20% experienced at least 1 PD catheter-related complication that led to the primary outcome. Prior abdominal procedures were not associated with an increased risk of the primary outcome (adjusted HR, 1.12; 95% CI, 0.68-1.84). Upper-abdominal procedures were associated with a higher adjusted hazard of the primary outcome, but there was no dose-response relationship concerning the number of procedures. There was no association between prior abdominal procedures and other secondary outcomes. LIMITATIONS: Observational study and cohort limited to a sample of patients believed to be potential candidates for PD catheter insertion. CONCLUSION: A history of prior abdominal procedure(s) does not appear to influence catheter outcomes following PD catheter insertion. Such a history should not be a contraindication to PD. PLAIN-LANGUAGE SUMMARY: Peritoneal dialysis (PD) is a life-saving therapy for individuals with kidney failure that can be done at home. PD requires the placement of a tube, or catheter, into the abdomen to allow the exchange of dialysis fluid during treatment. There is concern that individuals who have undergone prior abdominal procedures and are referred for a catheter might have scarring that could affect catheter function. In some institutions, they might not even be offered PD therapy as an option. In this study, we found that a history of prior abdominal procedures did not increase the risk of PD catheter complications and should not dissuade patients from choosing PD or providers from recommending it.

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

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

Outcomes of the First and Second Hemodialysis Fistula: A Cohort Study.

RATIONALE & OBJECTIVE: Fistulas are the preferred form of hemodialysis access; however, many fistulas fail to mature into usable accesses after creation. Data for outcomes after placement of a second fistula are limited. STUDY DESIGN: Cohort study. SETTING & PARTICIPANTS: People who initiated hemodialysis therapy in any of 5 Canadian dialysis programs (2004-2012) and had at least 1 hemodialysis fistula placed. PREDICTOR: Second versus initial fistula; receipt of 2 versus 1 fistula; second versus first fistula in recipients of 2 fistulas. OUTCOMES: Catheter-free fistula use during 1 year following initiation of hemodialysis therapy or following fistula creation, if created after hemodialysis therapy start; proportion of time with catheter-free use; time to catheter free use; time of functional patency. ANALYTICAL APPROACH: Logistic regression; fractional regression. RESULTS: Among the 1,091 study participants (mean age, 64±15 [SD] years; 63% men; 59% with diabetes), 901 received 1 and 190 received 2 fistulas. 38% of second fistulas versus 46% of first fistulas were used catheter free at least once. Average percentages of time that second and initial fistulas were used catheter free were 34% and 42%, respectively (OR, 0.72; 95% CI, 0.54-0.94). Compared with people who received 1 fistula, those who received 2 fistulas were less likely to achieve catheter-free use (26% vs 56%) and remain catheter free (23% vs 49% of time; OR, 0.30, 95% CI, 0.24-0.39). Among people who received 2 fistulas, the proportion of time that the second fistula was used catheter free was 11% higher with each 10% greater proportion of time that the first fistula was used catheter free (95% CI, 1%-22%). Model discrimination was modest (C index, 0.69). LIMITATIONS: Unknown criteria for patient selection for 1 or 2 fistulas; unknown reasons for prolonged catheter use. CONCLUSIONS: Outcomes of a second fistula may be inferior to outcomes of the initial fistula. First and second fistula outcomes are weakly correlated and difficult to predict based on clinical characteristics.

Proton Pump Inhibitors Use in Kidney Transplant Recipients: A Population-Based Study.

Background: Kidney transplant recipients are commonly prescribed proton-pump inhibitors (PPIs), but due to concern for polypharmacy, chronic use should be limited. Objective: The objective was to describe PPI use in kidney transplant recipients beyond their first year of transplant to better inform and support deprescribing initiatives. Design: We conducted a retrospective, population-based cohort study using linked health care databases. Setting: This study was conducted in Alberta, Canada. Patients: We included all prevalent adult, kidney-only transplant recipients between April 2008 and December 2017 who received their transplant between May 2002 and December 2017. Measurements: The primary outcome was ongoing or new PPI use and patterns of use, including frequency and duration of therapy, and assessment of indication for PPI use. Methods: We ascertained baseline characteristics, covariate information, and outcome data from the Alberta Kidney Disease Network (AKDN). We compared recipients with evidence of a PPI prescription in the 3 months prior to study entry to those with a histamine-2-receptor antagonist (H2Ra) fill and those with neither. Results: We identified 1823 kidney transplant recipients, of whom 868 (48%) were on a PPI, 215 (12%) were on an H2Ra, and 740 (41%) were on neither at baseline. Over a median follow-up of 5.4 years (interquartile range [IQR] = 2.6-9.3), there were almost 45 000 unique PPI prescriptions dispensed, the majority (80%) of which were filled by initial PPI users. Recipients who were on a PPI at baseline would spend 91% (IQR = 70-98) of their graft survival time on a PPI in follow-up, and nephrologists were the main prescribers. We identified an indication for ongoing PPI use in 54% of recipients with the most common indication being concurrent antiplatelet use (26%). Limitations: Our kidney transplant recipients have access to universal health care coverage which may limit generalizability. We identified common gastrointestinal indications for PPI use but did not include rare conditions due to concerns about the validity of diagnostic codes. In addition, symptoms suggestive of reflux may not be well coded as the focus of follow-up visits is more likely to focus on kidney transplant. Conclusions: Many kidney transplant recipients are prescribed a PPI at, or beyond, the 1-year post-transplant date and are likely to stay on a PPI in follow-up. Almost half of the recipients in our study did not have an identifiable indication for ongoing PPI use. Nephrologists frequently prescribe PPIs to kidney transplant recipients and should be involved in deprescribing initiatives to reduce polypharmacy.

Contexte: On prescrit couramment des inhibiteurs de la pompe à protons (IPP) aux receveurs d'une greffe rénale; une pratique qui devrait cependant être limitée en raison de préoccupations liées à la polypharmacie. Objectif: Décrire l'utilisation des IPP chez les receveurs d'une greffe rénale au-delà de la première année post-greffe, afin de mieux informer et de soutenir les initiatives de déprescription. Type d'étude: Étude de cohorte populationnelle rétrospective réalisée à partir des bases de données couplées du système de santé. Cadre: Alberta, Canada. Sujets: Nous avons recueilli les données d'avril 2008 à décembre 2017 de tous les adultes qui avaient reçu un rein seulement entre mai 2002 et décembre 2017. Mesures: Le principal critère de jugement était la prise continue ­ ou une nouvelle ordonnance ­ d'IPP et les modalités d'utilisation, notamment la fréquence et la durée du traitement, ainsi que l'indication pour la prescription d'IPP. Méthodologie: Nous avons vérifié les caractéristiques initiales, les informations covariées et les données sur les résultats colligées dans l'Alberta Kidney Disease Network (AKDN). Nous avons comparé des receveurs présentant des preuves d'une prescription d'IPP au cours des trois mois précédant l'entrée dans l'étude à des patients avec une ordonnance d'antagonistes des récepteurs de l'histamine-2 (aRH2), ainsi qu'à des patients n'ayant aucune de ces prescriptions. Résultats: Nous avons identifié 1 823 receveurs d'une greffe rénale; 868 (48 %) recevaient un IPP, 215 (12 %) recevaient un aRH2 et 740 (41 %) ne recevaient aucun traitement à l'inclusion. Au cours d'un suivi médian de 5,4 ans (intervalle interquartile [IIQ]: 2,6-9,3), près de 45 000 ordonnances uniques d'IPP ont été délivrées, dont la majorité (80 %) avait été remplie par des utilisateurs initiaux d'IPP. Les receveurs qui prenaient des IPP à l'inclusion avaient passé 91 % (IIQ: 70-98) de leur temps de survie du greffon à prendre un IPP durant la période de suivi, et ces médicaments avaient été majoritairement prescrits par des néphrologues. Une indication justifiant l'utilisation continue d'un IPP était présente chez 54 % des receveurs; la plus courante étant l'utilisation concomitante d'un agent antiplaquettaire (26 %). Limites: Les receveurs inclus dans notre étude ont accès à une couverture médicale universelle, ce qui peut limiter la généralisabilité des résultats. Nous avons repéré des indications gastro-intestinales courantes pour l'utilisation d'IPP, mais nous n'avons pas inclus les affections rares en raison de préoccupations concernant la validité des codes diagnostiques. Aussi, les symptômes évocateurs d'un reflux pourraient ne pas être bien codés, car les visites de suivi sont plus susceptibles de porter sur la transplantation rénale. Conclusion: De nombreux receveurs d'une greffe rénale se voient encore prescrire un IPP dans l'année suivant la transplantation, ou au-delà, et sont susceptibles de continuer d'en prendre pendant le suivi. Près de la moitié des receveurs de notre étude n'avaient pas d'indication clairement identifiable de prendre un IPP en continu. Les néphrologues prescrivent fréquemment des IPP aux receveurs d'une greffe rénale et devraient être impliqués dans les initiatives de déprescription visant à réduire la polypharmacie.

Risk Factors for Developing Low Estimated Glomerular Filtration Rate and Albuminuria in Living Kidney Donors.

Rationale & Objective: Chronic kidney disease is associated with significant morbidity and mortality in the general population, but little is known about the incidence and risk factors associated with developing low estimated glomerular filtration rate (eGFR) and moderate-severe albuminuria in living kidney donors following nephrectomy. Study Design: Retrospective, population-based cohort study. Setting & Participants: Kidney donors in Alberta, Canada. Exposure: Donor nephrectomy between May 2001 and December 2017. Outcome: Two eGFR measurements <45 mL/min/1.73 m2 or 2 measurements of moderate or severe albuminuria from 1-year postdonation onwards that were at least 90 days apart. Analytical Approach: Associations between potential risk factors and the primary outcome were assessed using Cox proportional hazard regression analyses. Results: Over a median follow-up period of 8.6 years (IQR, 4.7-12.6 years), 47 of 590 donors (8.0%) developed sustained low eGFR or moderate-severe albuminuria with an incidence rate of 9.2 per 1,000 person-years (95% confidence interval, 6.6-11.8). The median time for development of this outcome beyond the first year after nephrectomy was 2.9 years (IQR, 1.4-8.0 years). Within the first 4 years of follow-up, a 5 mL/min/1.73 m2 lower predonation eGFR increased the hazard of developing postdonation low eGFR or moderate-severe albuminuria by 26% (adjusted HR, 1.26; 95% CI, 1.10-1.44). Furthermore, donors were at higher risk of developing low eGFR or albuminuria if they had evidence of predonation hypertension (adjusted HR, 2.52; 95% CI, 1.28-4.96) or postdonation diabetes (adjusted HR, 4.72; 95% CI, 1.54-14.50). Limitations: We lacked data on certain donor characteristics that may affect long-term kidney function, such as race, smoking history, and transplant-related characteristics. Conclusions: A proportion of kidney donors at an incidence rate of 9.2 per 1,000 person-years will develop low eGFR or albuminuria after donation. Donors with lower predonation eGFR, predonation hypertension, and postdonation diabetes are at increased risk of developing this outcome.

The purpose of this study was to understand the risk of developing kidney disease in living kidney donors after donation. We followed 590 donors in Alberta, Canada for almost 9 years. Approximately 8% of donors developed reduced kidney function (low estimated glomerular filtration rate) or increased protein in the urine (albuminuria). Donors with lower kidney function before donation, hypertension before donation, or diabetes after donation had a higher likelihood of experiencing these kidney outcomes. This research provides important insights to patients and health care providers to better support the long-term kidney health of living kidney donors.

The impact of the Starting dialysis on Time, At home on the Right Therapy (START) project on the use of peritoneal dialysis.

BACKGROUND: Peritoneal dialysis (PD) is actively promoted, but increasing PD utilisation is difficult. The objective of this study was to determine if the Starting dialysis on Time, At Home, on the Right Therapy (START) project was associated with an increase in the proportion of dialysis patients receiving PD within 6 months of starting therapy. METHODS: Consecutive patients over age 18, with end-stage kidney failure, who started dialysis between 1 April 2015 and 31 March 2018 in the province of Alberta, Canada. Programmes were provided with high-quality data about the individual steps in the process of care that drive PD utilisation that were used to identify problem areas, design and implement interventions to address them, and then evaluate whether those interventions had impact. The primary outcome was the proportion of patients receiving PD within 6 months of starting dialysis. Secondary outcomes included hospitalisation, death or probability of transfer to haemodialysis (HD). Interrupted time series methodology was used to evaluate the impact of the quality improvement initiative on the primary and secondary outcomes. RESULTS: A total of 1962 patients started dialysis during the study period. Twenty-seven per cent of incident patients received PD at baseline, and there was a 5.4% (95% confidence interval: 1.5-9.2) increase in the use of PD in the province immediately after implementation. There were no changes in the rates of hospitalisation, death or probability of transfer to HD after the introduction of START. CONCLUSIONS: The approach used in the START project was associated with an increase in the use of PD in a setting with high baseline utilisation.

The Association of Intra-Abdominal Adhesions with Peritoneal Dialysis Catheter-Related Complications.

BACKGROUND: This study investigated the association of intra-abdominal adhesions with the risk of peritoneal dialysis (PD) catheter complications. METHODS: Individuals undergoing laparoscopic PD catheter insertion were prospectively enrolled from eight centers in Canada and the United States. Patients were grouped based on the presence of adhesions observed during catheter insertion. The primary outcome was the composite of PD never starting, termination of PD, or the need for an invasive procedure caused by flow restriction or abdominal pain. RESULTS: Seven hundred and fifty-eight individuals were enrolled, of whom 201 (27%) had adhesions during laparoscopic PD catheter insertion. The risk of the primary outcome occurred in 35 (17%) in the adhesion group compared with 58 (10%) in the no adhesion group (adjusted HR, 1.64; 95% confidence interval [CI], 1.05 to 2.55) within 6 months of insertion. Lower abdominal or pelvic adhesions had an adjusted HR of 1.80 (95% CI, 1.09 to 2.98) compared with the no adhesion group. Invasive procedures were required in 26 (13%) and 47 (8%) of the adhesion and no adhesion groups, respectively (unadjusted HR, 1.60: 95% CI, 1.04 to 2.47) within 6 months of insertion. The adjusted odds ratio for adhesions for women was 1.65 (95% CI, 1.12 to 2.41), for body mass index per 5 kg/m 2 was 1.16 (95% CI, 1.003 to 1.34), and for prior abdominal surgery was 8.34 (95% CI, 5.5 to 12.34). Common abnormalities found during invasive procedures included PD catheter tip migration, occlusion of the lumen with fibrin, omental wrapping, adherence to the bowel, and the development of new adhesions. CONCLUSIONS: People with intra-abdominal adhesions undergoing PD catheter insertion were at higher risk for abdominal pain or flow restriction preventing PD from starting, PD termination, or requiring an invasive procedure. However, most patients, with or without adhesions, did not experience complications, and most complications did not lead to the termination of PD therapy.

Follow-up Care of Critically Ill Patients With Acute Kidney Injury: A Cohort Study.

Rationale & Objective: To evaluate follow-up care of critically ill patients with acute kidney injury (AKI). Study Design: Retrospective cohort study. Setting & Participants: Patients admitted to the intensive care unit (ICU) with AKI in Alberta, Canada from 2005 to 2018, who survived to discharge without kidney replacement therapy or estimated glomerular filtration rate <15 mL/min/1.73 m2. Exposure: AKI (defined as ≥50% or ≥0.3 mg/dL serum creatinine increase). Outcomes: The primary outcome was the cumulative incidence of an outpatient serum creatinine and urine protein measurement at 3 months postdischarge. Secondary outcomes included an outpatient serum creatinine or urine protein measurement or a nephrologist visit at 3 months postdischarge. Analytical Approach: Patients were followed from hospital discharge until the first of each outcome of interest, death, emigration from the province, kidney replacement therapy (maintenance dialysis or kidney transplantation), or end of study period (March 2019). We used non-parametric methods (Aalen-Johansen) to estimate the cumulative incidence functions of outcomes accounting for competing events (death and kidney replacement therapy). Results: There were 29,732 critically ill adult patients with AKI. The median age was 68 years (IQR, 57-77), 39% were female, and the median baseline estimated glomerular filtration rate was 72 mL/min/1.73 m2 (IQR, 53-90). The cumulative incidence of having an outpatient creatinine and urine protein measurement at 3 months postdischarge was 25% (95% CI, 25-26). At 3 months postdischarge, 64% (95% CI, 64-65) had an outpatient creatinine measurement, 28% (95% CI, 27-28) had a urine protein measurement, and 5% (95% CI, 4-5) had a nephrologist visit. Limitations: We lacked granular data, such as urine output. Conclusions: Many critically ill patients with AKI do not receive the recommended follow-up care. Our findings highlight a gap in the transition of care for survivors of critical illness and AKI.

Progression of Kidney Disease in Kidney Transplant Recipients With a Failing Graft: A Matched Cohort Study.

Background: Few studies have assessed outcomes in transplant recipients with failing grafts as most studies have focused on outcomes after graft loss. Objective: To determine whether renal function declines faster in kidney transplant recipients with a failing graft than in people with chronic kidney disease of their native kidneys. Design: Retrospective cohort study. Setting: Alberta, Canada (2002-2019). Patients: We identified kidney transplant recipients with a failing graft (2 estimated glomerular filtration rate [eGFR] measurements 15-30 mL/min/1.73 m2 ≥90 days apart). Measurements: We compared the change in eGFR over time (eGFR with 95% confidence limits, LCLeGFRUCL) and the competing risks of kidney failure and death (cause-specific hazard ratios [HRs], LCLHRUCL). Methods: Recipients (n = 575) were compared with propensity-score-matched, nontransplant controls (n = 575) with a similar degree of kidney dysfunction. Results: The median potential follow-up time was 7.8 years (interquartile range, 3.6-12.1). The hazards for kidney failure (HR1.101.331.60) and death (HR1.211.592.07) were significantly higher for recipients, while the eGFR decline over time was similar (recipients vs controls: -2.60-2.27-1.94 vs -2.52-2.21-1.90 mL/min/1.73 m2 per year). The rate of eGFR decline was associated with kidney failure but not death. Limitations: This was a retrospective, observational study, and there is a risk of bias due to residual confounding. Conclusions: Although eGFR declines at a similar rate in transplant recipients as in nontransplant controls, recipients have a higher risk of kidney failure and death. Studies are needed to identify preventive measures to improve outcomes in transplant recipients with a failing graft.

Contexte: Peu d'études ont évalué les résultats chez les patients transplantés dont le greffon est défaillant; la majorité des études s'étant plutôt concentrées sur les résultats après la perte du greffon. Objectif: Vérifier si la fonction rénale décline plus rapidement chez les patients transplantés dont le greffon est défaillant que chez les personnes souffrant d'une insuffisance chronique sur reins natifs. Conception: Étude de cohorte rétrospective. Cadre: Alberta, Canada (2002 à 2019). Sujets: Nous avons identifié des patients transplantés dont le greffon est défaillant (défini par deux mesures du débit de filtration glomérulaire estimé [DFGe] de 15-30 ml/min/1,73 m2 à au moins 90 jours d'intervalle). Mesures: Nous avons comparé l'évolution du DFGe dans le temps (DFGe avec intervalles de confiance [IC] à 95 % inférieur et supérieur: ICIDFGeICS) et les rapports de risque d'insuffisance rénale et de décès (intervalles de rapport de risque (RR) lié à la cause: ICIRRICS). Méthodologie: Les transplantés dont le greffon est défaillant (n=575) ont été comparés à des témoins non transplantés (n=575) appariés selon le score de propension et présentant un niveau similaire de dysfonctionnement rénal. Résultats: Le temps médian de suivi potentiel était de 7,8 ans (ÉIQ: 3,6 à 12,1). Les risques d'insuffisance rénale (RR: 1,101,331,60) et de décès (RR: 1,211,592,07) étaient significativement plus élevés chez les transplantés dont le greffon est défaillant, mais le déclin du DFGe au fil du temps était similaire dans les deux groupes (receveurs: -2,60-2,27-1,94 ml/min/1,73 m2 par an; témoins: -2,52-2,21-1,90 ml/min/1,73 m2 par an). Le taux de déclin du DFGe a été associé à une insuffisance rénale terminale, mais pas au décès. Limites: Il s'agit d'une étude observationnelle rétrospective et il existe un risque de biais dû à des facteurs de confusion résiduels. Conclusion: Bien que le DFGe décline à un rythme similaire chez les transplantés dont le greffon est défaillant et les témoins non transplantés, le risque d'insuffisance rénale terminale et de décès est plus élevé pour les transplantés. D'autres études sont nécessaires pour identifier les mesures préventives qui pourraient améliorer les résultats des patients transplantés dont le greffon est défaillant.

Development and External Validation of a Machine Learning Model for Progression of CKD.

Introduction: Prediction of disease progression at all stages of chronic kidney disease (CKD) may help improve patient outcomes. As such, we aimed to develop and externally validate a random forest model to predict progression of CKD using demographics and laboratory data. Methods: The model was developed in a population-based cohort from Manitoba, Canada, between April 1, 2006, and December 31, 2016, with external validation in Alberta, Canada. A total of 77,196 individuals with an estimated glomerular filtration rate (eGFR) > 10 ml/min per 1.73 m2 and a urine albumin-to-creatinine ratio (ACR) available were included from Manitoba and 107,097 from Alberta. We considered >80 laboratory features, including analytes from complete blood cell counts, chemistry panels, liver enzymes, urine analysis, and quantification of urine albumin and protein. The primary outcome in our study was a 40% decline in eGFR or kidney failure. We assessed model discrimination using the area under the receiver operating characteristic curve (AUC) and calibration using plots of observed and predicted risks. Results: The final model achieved an AUC of 0.88 (95% CI 0.87-0.89) at 2 years and 0.84 (0.83-0.85) at 5 years in internal testing. Discrimination and calibration were preserved in the external validation data set with AUC scores of 0.87 (0.86-0.88) at 2 years and 0.84 (0.84-0.86) at 5 years. The top 30% of individuals predicted as high risk and intermediate risk represent 87% of CKD progression events in 2 years and 77% of progression events in 5 years. Conclusion: A machine learning model that leverages routinely collected laboratory data can predict eGFR decline or kidney failure with accuracy.

The availability of support and peritoneal dialysis survival: A cohort study.

BACKGROUND: Providing support is important to maintain a patient on peritoneal dialysis (PD), though its impact on outcomes has not been investigated thoroughly. We examined the association between having support and risk of a transfer to hemodialysis. METHODS: In this retrospective observational cohort study, we used data captured in the Dialysis Measurement Analysis and Reporting system about patients who started PD in Alberta, Canada, between 1 January 2013 and 30 September 2018. Support was defined as the availability of a support person in the home who was able, willing and available to provide support for PD in the patient's residence. The outcome of interest was a transfer to hemodialysis for at least 90 days. We estimated the cumulative incidence of a transfer over time accounting for competing risks and hazard ratios to summarise the association between support and a transfer. We split follow-up time as hazard ratios varied over time. RESULTS: Six hundred and eighty-three incident PD patients, median age 58 years (IQR: 47-68) and 35% female, were followed for a median of 15 months. The cumulative incidence of a transfer to hemodialysis at 24 months was 26%. Having support was associated with a reduced risk of a transfer between 3 and 12 months after the start of dialysis (HR3-12mo: 0.44; 95% CI: 0.25-0.78), but not earlier (hazard ratio (HR)<3mo: 0.96; 95% confidence interval (CI): 0.55-1.69) or later (HR>12mo: 1.19; 95% CI: 0.65-2.17). CONCLUSIONS: A transfer to hemodialysis is common. Having a support person at home is associated with a short-term protective effect after the initiation of PD.

Four steps to standardize reporting of peritoneal dialysis technique failure: A proposed approach.

BACKGROUND: Technique failure is an important outcome measure in research and quality improvement in peritoneal dialysis (PD) programs, but there is a lack of consistency in how it is reported. METHODS: We used data collected about incident dialysis patients from 10 Canadian dialysis programs between 1 January 2004 and 31 December 2018. We identified four main steps that are required when calculating the risk of technique failure. We changed one variable at a time, and then all steps, simultaneously, to determine the impact on the observed risk of technique failure at 24 months. RESULTS: A total of 1448 patients received PD. Selecting different cohorts of PD patients changed the observed risk of technique failure at 24 months by 2%. More than one-third of patients who switched to hemodialysis returned to PD-90% returned within 180 days. The use of different time windows of observation for a return to PD resulted in risks of technique failure that differed by 16%. The way in which exit events were handled during the time window impacted the risk of technique failure by 4% and choice of statistical method changed results by 4%. Overall, the observed risk of technique failure at 24 months differed by 20%, simply by applying different approaches to the same data set. CONCLUSIONS: The approach to reporting technique failure has an important impact on the observed results. We present a robust and transparent methodology to track technique failure over time and to compare performance between programs.

Effect of diagnostic score reporting following a structured clinical assessment of dental hygiene student performance.

Background: Diagnostic score reporting is one method of providing feedback to all students following a structured clinical assessment but its effect on learning has not been studied. The objective of this study was to assess the impact of this feedback on student reflection and performance following a dental hygiene assessment. Methods: In 2016, dental hygiene students at the University of Alberta participated in a mock structured clinical assessment during which they were randomly assigned to receive a diagnostic score report (intervention group) or an overall percentage grade of performance (control group). The students later reflected upon their performance and took their regularly scheduled structured clinical assessment. Reflections underwent content analysis by diagnostic domains (eliciting essential information, effective communication, client-centred care, and interpreting findings). Results were analysed for group differences. Results: Students performed best on eliciting essential information (92%) and poorest on interpreting findings (42%). The intervention group was more likely to view interpreting findings as a weakness, p = 0.007, while the control group was more likely to view eliciting essential information as a weakness, p = 0.04. No differences were found on the actual assessment scores, p > 0.05. Discussion: Students who received diagnostic score reporting appeared to reflect more accurately upon their weaknesses. However, this knowledge did not translate into improved performance. Modifications and enhancements to the report may be necessary before an effect on performance will be seen. Conclusion: Diagnostic score reporting is a promising feedback method that may aid student reflection. More research is needed to determine if these reports can improve performance.

Contexte: Le suivi de la notation des diagnostics est une des méthodes utilisées pour fournir de la rétroaction aux étudiants à la suite d'une évaluation clinique structurée, mais ses effets sur l'apprentissage n'ont pas été étudiés. La présente étude visait à évaluer l'effet de cette rétroaction sur la réflexion et la performance des étudiants à la suite d'une évaluation en hygiène dentaire. Méthodologie: Les étudiants en hygiène dentaire de l'Université de l'Alberta ont participé à une évaluation clinique structurée fictive pendant laquelle ils étaient désignés de façon aléatoire pour recevoir un suivi de la notation des diagnostics (groupe d'intervention) ou une note globale en pourcentage de leur performance (groupe témoin). Les étudiants ont plus tard réfléchi à leur performance et ont fait leur évaluation clinique structurée déjà à l'horaire. Une analyse de contenu a été effectuée sur les réflexions selon les domaines de diagnostics (obtention de renseignements essentiels, communication efficace, prestation de soins axés sur le client et interprétation des constatations). Les résultats ont été analysés pour déterminer les différences entre les groupes. Résultats: Les étudiants ont le mieux réussi sur l'obtention d'information essentielle (92 %) et ont le moins bien réussi sur l'interprétation des constatations (42 %). Le groupe d'intervention était plus susceptible de réfléchir à l'interprétation des constatations en tant que faiblesse, p = 0,007, alors que le groupe témoin était plus susceptible de réfléchir à l'obtention de l'information essentielle en tant que faiblesse, p = 0,04. Aucune différence n'a été trouvée sur les notations actuelles de l'évaluation, p > 0,05. Discussion: Les étudiants qui ont reçu un suivi de la notation des diagnostics semblaient réfléchir plus précisément sur leurs faiblesses. Cependant, cette connaissance ne s'est pas traduite par une performance améliorée. Des modifications et des améliorations du suivi peuvent être nécessaires avant qu'un effet sur la performance soit constaté. Conclusions: Le suivi de la notation des diagnostics présente une méthode de rétroaction prometteuse qui pourrait aider à la réflexion des étudiants. D'autres recherches sont nécessaires pour déterminer si ces rapports peuvent améliorer la performance.

Development of diagnostic score reporting for a dental hygiene structured clinical assessment.

Background: Structured clinical assessments capture key information about performance that is rarely shared with the student as feedback. The purpose of this review is to describe a general framework for applying diagnostic score reporting within the context of a structured clinical assessment and to demonstrate that framework within dental hygiene. Methods: The framework was developed using current research in the areas of structured clinical assessments, test development, feedback in higher education, and diagnostic score reporting. An assessment blueprint establishes valid diagnostic domains by linking clinical competencies and test items to the domains (e.g., knowledge or skills) the assessment intends to measure. Domain scores can be given to students as reports that identify strengths and weaknesses and provide information on how to improve. Results: The framework for diagnostic score reporting was applied to a dental hygiene structured clinical assessment at the University of Alberta in 2016. Canadian dental hygiene entry-to-practice competencies guided the assessment blueprinting process, and a modified Delphi technique was used to validate the blueprint. The final report identified 4 competency-based skills relevant to the examination: effective communication, client-centred care, eliciting essential information, and interpreting findings. Students received reports on their performance within each domain. Discussion: Diagnostic score reporting has the potential to solve many of the issues faced by administrators, such as item confidentiality and the time-consuming nature of providing individual feedback. Conclusion: Diagnostic score reporting offers a promising framework for providing valid and timely feedback to all students following a structured clinical assessment.

Contexte: Les évaluations cliniques structurées saisissent des renseignements clés sur la performance qui est rarement partagée avec les étudiants à titre de rétroaction. L'objectif de la présente étude est de définir une structure générale pour établir le suivi de la notation des diagnostics dans le cadre d'une évaluation clinique structurée et pour mettre en évidence ce cadre au sein de l'hygiène dentaire. Méthodologie: Le cadre a été créé à l'aide de la recherche actuelle dans les domaines d'évaluations cliniques structurées, d'élaboration de tests, de la rétroaction en éducation supérieure, et du suivi de la notation des diagnostics. Un plan d'évaluation détermine les domaines diagnostiques valides en liant les compétences cliniques et les éléments de tests aux domaines (p. ex., les connaissances ou les habiletés) que l'évaluation prévoit de mesurer. La notation des domaines peut être donnée aux étudiants sous forme de rapports qui précisent les forces et les faiblesses, et fournissent de l'information sur la façon de s'améliorer. Résultats: Le cadre de suivi de la notation des diagnostics a été appliqué à une évaluation clinique structurée en hygiène dentaire de l'Université de l'Alberta en 2016. Les compétences canadiennes d'entrée en pratique en hygiène dentaire ont guidé le processus de planification de l'évaluation et une technique modifiée de Delphi a été utilisée pour valider le plan. Le rapport final a ciblé quatre habiletés fondées sur des compétences, pertinentes à l'examen : communication efficace, soins axés sur le client, obtention des renseignements essentiels, et interprétation des constatations. Les étudiants ont reçu des rapports sur leur performance dans chaque domaine. Discussion: Le suivi de la notation des diagnostics a le potentiel de résoudre plusieurs des enjeux auxquels sont confrontés les administrateurs, comme la confidentialité des éléments et le temps demandé pour la rétroaction individuelle. Conclusion: Le suivi de la notation des diagnostics offre un cadre prometteur pour fournir une rétroaction valide et rapide à tous les étudiants à la suite d'une évaluation clinique structurée.

Association Between Attempted Arteriovenous Fistula Creation and Mortality in People Starting Hemodialysis via a Catheter: A Multicenter, Retrospective Cohort Study.

BACKGROUND: In North America, most people start hemodialysis via a central venous catheter ("catheter"). These patients are counseled to undergo arteriovenous fistula ("fistula") creation within weeks of starting hemodialysis because fistulas are associated with improved survival. OBJECTIVES: To determine whether attempting to create a fistula in patients who start hemodialysis via a catheter is associated with improved mortality. We also sought to determine whether differences in baseline patient characteristics, vascular procedures for access-related complications, or days in hospital may confound or mediate the relationship between attempted fistula creation and mortality. DESIGN: Multicenter, retrospective cohort study. SETTING: Six dialysis programs located in Ontario, Alberta, and Manitoba. PATIENTS: Patients aged ≥18 years who initiated hemodialysis via a catheter between January 1, 2004, and May 31, 2012, who had not had a previous attempt at fistula creation. We excluded those who had a life expectancy less than 1 year, who transitioned to peritoneal dialysis within 6 months of starting dialysis, and people who started hemodialysis via a graft. MEASUREMENTS: Attempted fistula creation, all-cause mortality, patient characteristics and comorbidities, vascular procedures for access-related complications, and days spent in hospital. METHODS: We used survival methods, including marginal structural models, to account for immortal time bias and time-varying confounding. RESULTS: In total, 1832 patients initiated hemodialysis via a catheter during the study period and met inclusion criteria. Of these patients, 565 (31%) underwent an attempt at fistula creation following hemodialysis start. As compared to those who did not receive a fistula attempt, these people were younger, had fewer comorbidities, and were more likely to have started dialysis as an outpatient and to have received pre-dialysis care. In a marginal structural model controlling for baseline characteristics and comorbidities, attempted fistula creation was associated with a significantly lower mortality (hazard ratio [HR] = 0.53; 95% confidence interval [CI] = 0.43-0.66). This effect did not appear to be confounded or mediated by differences in the number of days spent in hospital or vascular procedures for access-related complications. It also remained similar in analyses restricted to patients who survived at least 6 months (HR = 0.60; 95% CI = 0.47-0.77) and to patients who started hemodialysis as an outpatient (HR = 0.48; 95% CI = 0.33-0.68). LIMITATIONS: There is likely residual confounding and treatment selection bias. CONCLUSIONS: In this multicenter cohort study, attempting fistula creation in people who started hemodialysis via a catheter was associated with significantly reduced mortality. This reduction in mortality could not be explained by differences in patient characteristics or comorbidities, days spent in hospital, or vascular procedures for access-related complications. Residual confounding or selection bias may explain the observed benefits of fistulas for hemodialysis access. TRIAL REGISTRATION: Not applicable (cohort study).

CONTEXTE: En Amérique du Nord, la plupart des patients amorcent l'hémodialyse avec un cathéter veineux central (cathéter). Dans les semaines qui suivent le début de la dialyse, on conseille à ces patients la création d'une fistule artérioveineuse (fistule), cette dernière étant associée à un taux de survie accru. OBJECTIF: Vérifier si la tentative de créer une fistule est associée à un accroissement de la survie chez les patients ayant amorcé l'hémodialyse avec un cathéter. Nous souhaitions aussi évaluer si les différences dans les caractéristiques initiales des patients, les interventions vasculaires pour gérer les complications liées à l'accès ou la durée du séjour pouvaient aggraver ou médier la relation entre la mortalité et le fait de tenter la création d'une fistule. TYPE D'ÉTUDE: Étude de cohorte rétrospective menée dans plusieurs centres. CADRE: Six programmes de dialyse situés en Ontario, en Alberta et au Manitoba. SUJETS: Les patients adultes ayant amorcé l'hémodialyse avec un cathéter entre le 1er janvier 2004 et le 31 mai 2012, et n'ayant pas antérieurement tenté la création d'une fistule. Ont été exclus les patients ayant une espérance de vie inférieure à un an, ceux qui étaient passés à la dialyse péritonéale dans les six mois suivant le début de la dialyse, et ceux qui avaient commencé l'hémodialyse par un greffon artérioveineux. MESURES: La tentative de création d'une fistule, la mortalité toutes causes confondues, les caractéristiques initiales et comorbidités des patients, les interventions vasculaires pour gérer les complications liées à l'accès et le nombre jours passés à l'hôpital. MÉTHODOLOGIE: Nous avons utilisé des méthodes de survie, notamment des modèles structurels marginaux, pour tenir compte du biais d'immortalité et des facteurs confusionnels variables dans le temps. RÉSULTATS: Au cours de la période étudiée, 1 832 patients avaient amorcé une hémodialyse avec un cathéter et répondaient aux critères d'inclusion. Parmi eux, 565 (31 %) avaient tenté la création d'une fistule après le début de l'hémodialyse. Ces patients étaient plus jeunes, présentaient moins de comorbidités et étaient plus susceptibles d'avoir amorcé la dialyse en clinique externe et d'avoir reçu des soins de prédialyse que les patients qui n'avaient pas tenté la création d'une fistule. Dans un modèle structurel marginal contrôlant les caractéristiques initiales et les comorbidités, la tentative de création d'une fistule a été associée à un taux de mortalité significativement inférieur [risque relatif (RR) : 0,53; intervalle de confiance (IC) à 95 % : 0,43-0,66]. Cet effet n'a pas semblé aggravé ou médié par des différences dans la durée du séjour à l'hôpital ou par les interventions vasculaires pour gérer les complications liées à l'accès. Cela est également demeuré similaire dans les analyses, mais uniquement chez les patients ayant survécu au moins 6 mois (RR : 0,60; IC 95 % : 0,47-0,77) et chez les patients ayant commencé l'hémodialyse en clinique externe (RR : 0,48; IC 95 % : 0,33-0,68). LIMITES: Probabilité de facteurs de confusion résiduels et de biais relatifs au choix du traitement. CONCLUSION: Dans cette étude de cohorte multicentrique, la création d'une fistule chez des patients ayant commencé l'hémodialyse avec un cathéter a été associée à une réduction significative de la mortalité. Cette réduction de la mortalité n'a cependant pas pu être expliquée par des différences dans les caractéristiques ou les comorbidités des patients, par la durée du séjour à l'hôpital ou par les interventions vasculaires pratiquées pour gérer les complications liées à l'accès. Un biais de sélection ou des facteurs de confusion résiduels pourraient expliquer les bienfaits observés par la création d'une fistule pour l'accès à l'hémodialyse.

Starting Dialysis on Time, At Home on the Right Therapy (START): Description of an Intervention to Increase the Safe and Effective Use of Peritoneal Dialysis.

BACKGROUND: Most of the patients with end-stage kidney failure are treated with dialysis. Jurisdictions around the world are actively promoting peritoneal dialysis (PD) because it is equivalent to hemodialysis in terms of clinical outcomes, but is less costly. Unfortunately, PD penetration remains low. OBJECTIVES: The Starting dialysis on Time, At Home, on the Right Therapy (START) Project had 2 overarching goals: (1) to provide information that would help programs increase the safe and effective use of PD, and (2) to reduce inappropriate, early initiation of dialysis in patients with kidney failure. In this article, we focus on the first objective and describe the rationale for START and the methods employed. DESIGN: The START Project was a comprehensive, province-wide quality improvement intervention. SETTING: The START project was implemented in both Alberta Kidney Care (AKC)-South and AKC-North, including all 7 renal programs in the province. PATIENTS: The project included all patients who commenced maintenance dialysis between October 1, 2015, and March 31, 2018, in Alberta, Canada who met our inclusion criteria. MEASUREMENTS: We reported baseline characteristics of incident dialysis patients overall, and by site. Our key performance indicator was the proportion of patients who received PD for any period of time within 180 days of the first dialysis treatment. Reports also included detailed metrics pertaining to the 6 steps in the process of modality selection and we had the capacity to provide more granular data on an as-needed basis. To understand loss of PD patients, we reported the numbers of incident patients who recovered kidney function, experienced technique failure, received a transplant, were lost to follow-up, transferred to another program, or died. METHODS: START provided dialysis programs with a conceptual framework for understanding the drivers of PD utilization. High-quality, detailed data were collected using a tool that was custom-built for this purpose, and were mapped to steps in the process of care that drove the outcomes of interest. This allowed sites to identify gaps in care, develop action plans, and implement local interventions to address them. The process was supported by an Innovation Learning Collaborative consisting of 3 learning sessions that brought frontline staff together from across the province to share strategies and learnings. Ongoing data collection allowed teams to determine whether their interventions were effective at each subsequent learning session, and to revisit their interventions if required (the "Plan-Do-Study-Act Cycle"). RESULTS: Future work will report on the impact of the START project on incident PD utilization at a provincial and regional level. LIMITATIONS: The time required to design and implement interventions in practice, as well as the need for multiple PDSA (Plan-Do-Study-Act) cycles to see results, meant that the true potential may not be realized during a relatively short intervention period. Change required buy-in and support from local and provincial leadership and frontline staff. In the absence of accountability for local performance, we relied on the goodwill of participating programs to use the information and resources provided to effect change. Finally, the burden of documentation and data collection for frontline staff was high at baseline. We anticipated that adding supplemental data collection would be difficult. CONCLUSIONS: The START project was a comprehensive, province-wide initiative to maximize the safe and effective use of PD in Alberta, Canada. It standardized the management of incident dialysis patients, leveraged high-quality data to facilitate the reporting of metrics mapped to steps in the process of care that drove incident PD utilization, and helped programs to identify gaps in care and target them for improvement. Future work will report on the impact of the program on incident utilization at the provincial and regional level.

CONTEXTE: La majorité des patients atteints d'insuffisance rénale terminale (IRT) sont traités par dialyze. On s'efforce, partout dans le monde, de promouvoir la dialyze péritonéale (DP) parce qu'elle donne des résultats cliniques équivalents à ceux de l'hémodialyse, mais à moindres coûts. Malheureusement, l'adhésion à la DP demeure faible. OBJECTIFS: Le projet START (The Starting dialysis on Time, At Home, on the Right Therapy) avait deux objectifs principaux : (1) fournir de l'information qui aiderait les programs à accroître l'utilization sûre et efficace de la DP, et (2) réduire l'initiation précoce et inappropriée de la dialyze chez les patients atteints d'insuffisance rénale. Dans cet article, nous nous concentrons sur le premier objectif et nous décrivons la raison d'être de START et les méthodes employées. TYPE D'ÉTUDE: Le projet START était une intervention globale d'amélioration de la qualité à l'échelle provinciale. CADRE: Le projet START a été mis en œuvre au sein de l'Alberta Kidney Care (AKC) ­ South et de l'AKC-North, qui incluent les 7 programs rénaux de la province. SUJETS: Le projet a inclus tous les patients répondant aux critères d'inclusion qui avaient amorcé des traitements de dialyze d'entretien entre le 1er octobre 2015 et le 31 mars 2018 en Alberta (Canada). MESURES: Nous avons rapporté les caractéristiques de base des patients dialysés incidents de façon globale et par site. Notre principal indicateur de performance était la proportion de patients qui ont reçu la DP pendant une période quelconque au cours des 180 jours suivant le premier traitement de dialyze. Les rapports comprenaient également des mesures détaillées concernant les 6 étapes du processus de sélection de la modalité et nous étions en mesure de fournir des données plus précises au besoin. Pour mieux définir la perte de patients sur DP, nous avons rapporté le nombre de patients incidents ayant récupéré une fonction rénale, ayant vécu une défaillance technique, ayant reçu une greffe, ayant été perdus de vue, ayant été transférés à un autre program ou étant décédés. MÉTHODOLOGIE: START a fourni aux programs de dialyze un cadre conceptuel pour comprendre les facteurs d'utilization de la DP. Des données détaillées et de grande qualité ont été recueillies à l'aide d'un outil conçu spécifiquement à cette fin, et ont été mises en correspondance avec les étapes du processus de soins ayant conduit aux résultats d'intérêt. Ainsi, les sites ont pu déceler les lacunes dans les soins, élaborer des plans d'action et mettre en œuvre des interventions locales pour combler ces lacunes. Le processus a été appuyé par une collaboration d'apprentissage innovante constituée de trois séances d'apprentissage qui ont réuni le personnel de première ligne de toute la province afin que ceux-ci partagent leurs stratégies et apprentissages. La collecte continue de données a permis aux équipes de déterminer si leurs interventions étaient efficaces et de revoir leurs interventions si nécessaire (le cycle PDSA: Plan-Do-Study-Act) lors de chaque séance d'apprentissage ultérieure. RÉSULTATS: Les travaux futurs feront état de l'impact du projet START sur l'utilization de la DP à l'échelle provinciale et régionale. LIMITES: Le véritable potentiel du projet pourrait ne pas se révéler lors d'une période d'intervention relativement courte en raison du temps requis pour concevoir les interventions et les mettre en œuvre dans la pratique, et parce que le processus nécessite de procéder à plusieurs cycles PDSA avant de produire des résultats. Le changement exige l'adhésion et le soutien des directions locales et provinciales et du personnel de première ligne. En l'absence de responsabilisation à l'égard des réalisations locales, nous nous sommes appuyés sur la bonne volonté des programs participants à utiliser l'information et les ressources fournies pour faire le changement. Aussi, en début de processus, le fardeau de documenter et de collecter les données s'est avéré lourd pour le personnel de première ligne. Nous avions prévu qu'il serait difficile d'ajouter une collecte de données supplémentaire. CONCLUSION: Le projet START était une initiative globale à l'échelle provinciale qui visait à maximiser l'utilization sécuritaire et efficace de la DP en Alberta, au Canada. Le projet a normalisé la gestion des patients dialysés incidents, a exploité des données de haute qualité pour faciliter la déclaration des indicateurs correspondant aux étapes du processus de soins menant à l'utilization de la DP, et a aidé les programs à déceler les lacunes de soins et à les améliorer. Les travaux futurs feront état de l'impact du program sur l'utilization incidente au niveau régional et provincial.

Sex differences in the vascular access of hemodialysis patients: a cohort study.

BACKGROUND: We describe differences for probability of receiving a fistula attempt, achieving fistula use, remaining catheter-free and the rate of access-related procedures as a function of sex. METHODS: Prospectively collected vascular access data on incident dialysis patients from five Canadian programs using the Dialysis Measurement Analysis and Reporting System to determine differences in fistula-related outcomes between women and men. The probability of receiving a fistula attempt and the probability of fistula use were determined using binary logistic regression. Catheter and fistula procedure rates were described using Poisson regression. We studied time to fistula attempt and time to fistula use, accounting for competing risks. RESULTS: We included 1446 (61%) men and 929 (39%) women. Men had a lower body mass index (P < 0.001) and were more likely to have coronary artery disease (P < 0.001) and peripheral vascular disease (p < 0.001). A total of 688 (48%) men and 403 (43%) women received a fistula attempt. Women were less likely to receive a fistula attempt by 6 months {odds ratio [OR] 0.64 [95% confidence interval (CI) 0.52-0.79]} and to achieve catheter-free use of their fistula by 1 year [OR 0.38 (95% CI 0.27-0.53)]. At an average of 2.30 access procedures per person-year, there is no difference between women and men [incidence rate ratio (IRR) 0.97 (95% CI 0.87-1.07)]. Restricting to those with a fistula attempt, women received more procedures [IRR 1.16 (95% CI 1.04-1.30)] attributed to increased catheter procedures [IRR 1.50 (95% CI 1.27-1.78)]. There was no difference in fistula procedures [IRR women versus men 0.96 (95% CI 0.85-1.07)]. CONCLUSION: Compared with men, fewer women undergo a fistula attempt. This disparity increases after adjusting for comorbidities. Women have the same number of fistula procedures as men but are less likely to successfully use their fistula.

Quantifying the risk of insertion-related peritoneal dialysis catheter complications following laparoscopic placement: Results from the North American PD Catheter Registry.

BACKGROUND: Peritoneal dialysis (PD) is a more cost-effective therapy to treat kidney failure than in-center hemodialysis, but successful therapy requires a functioning PD catheter that causes minimal complications. In 2015, the North American Chapter of the International Society for Peritoneal Dialysis established the North American PD Catheter Registry to improve practices and patient outcomes following PD catheter insertion. AIMS: The objective of this study is to propose a methodology for defining insertion-related complications that lead to significant adverse events and report the risk of these complications among patients undergoing laparoscopic PD catheter insertion. METHODS: Patients undergoing laparoscopic PD catheter insertion were enrolled at 14 participating centers in Canada and the United States and followed using a Web-based registry. Insertion-related complications were defined as flow restriction, exit-site leak, or abdominal pain at any point during follow-up. We also included infections or bleeding within 30 days of insertion, and any immediate postoperative complications. Adverse events were categorized as PD never starting or termination of PD therapy, delay in the start of PD therapy or interruption of PD therapy, an emergency department visit or hospitalization, or need for invasive procedures. Cause-specific cumulative incidence functions were used to estimate risk. RESULTS: Five hundred patients underwent laparoscopic PD catheter insertion between 10 November 2015 and 24 July 2018. The cumulative risk of insertion-related complications 6 months from the date of insertion that led to an adverse event was 24%. The risk of flow restriction, exit-site leak, and pain at 6 months was 10.2%, 5.7%, and 5.3%, respectively. PD was never started or terminated in 6.4% of patients due to an insertion-related complication. Leaks and flow restrictions were most likely to delay or interrupt PD therapy. Flow restrictions were the primary cause of invasive procedures. Fifty percent of the complications occurred before the start of PD therapy. CONCLUSIONS: Insertion-related complications leading to significant adverse events following laparoscopic placement of PD catheters are common. Many complications occur before the start of PD. Insertion-related complications are an important area of focus for future research and quality improvement efforts.

The Influence of Age on the Likelihood of Catheter-Free Fistula Use in Hemodialysis Patients.

BACKGROUND: Clinical practice guidelines recommend arteriovenous fistulas as the preferred form of vascular access for hemodialysis. However, some studies have suggested that older age is associated with poorer fistula outcomes. OBJECTIVE: We assessed the impact of age on the outcomes of fistula creation and access-related procedures. DESIGN: This was a prospective cohort study using data collected as part of the Dialysis Measurement Analysis and Reporting (DMAR) system. SETTING: Participating Canadian dialysis programs, including Southern Alberta Renal Program, Manitoba Renal Program, Sunnybrook Health Sciences Centre (Toronto, Ontario), London Health Sciences Centre (London, Ontario), and The Ottawa Hospital (Ottawa, Ontario). PATIENTS: Incident hemodialysis patients aged 18 years and older who started dialysis between January 1, 2004, and May 31, 2012. MEASUREMENTS: The primary outcome was the proportion of all first fistula attempts that resulted in catheter-free fistula use, defined as independent use of a fistula for hemodialysis (ie, no catheter in place). Secondary outcomes included the time to catheter-free fistula use among patients with a fistula creation attempt, total number of days of catheter-free fistula use, and the proportion of a patient's hemodialysis career spent with an independently functioning fistula (ie, catheter-free fistula use). METHODS: We compared patient characteristics by age group, using t tests or Wilcoxon rank sum tests, and chi-square or Fisher exact tests, as appropriate. Logistic and fractional logistic regression were used to estimate the odds of achieving catheter-free fistula use by age group and the proportion of dialysis time spent catheter-free, respectively. RESULTS: A total of 1091 patients met our inclusion criteria (567 age ≥ 65; 524 age < 65). Only 57% of first fistula attempts resulted in catheter-free fistula use irrespective of age (adjusted odds ratio [OR]≥65vs<65: 1.01; P = .93). The median time from hemodialysis start to catheter-free use of the first fistula did not differ by age when grouped into fistulas attempted pre- and post-dialysis initiation. The adjusted rates of access-related procedures were comparable (incidence rate ratio [IRR]≥65vs<65: 0.95; P = .32). The median percentage of follow-up time spent catheter-free was similar and low in patients who attempted fistulas (<65 years: 19% vs ≥65 years: 21%; P = .85). LIMITATIONS: The relatively short follow-up time may have underestimated the benefits of fistula creation and the observational study design precludes inferences about causality. CONCLUSIONS: In our study, older patients who underwent a fistula attempt were just as likely as younger patients to achieve catheter-free fistula use, within a similar time frame, and while requiring a similar number of access procedures. However, the minority of dialysis time was spent catheter-free.

CONTEXTE: Les lignes directrices cliniques recommandent de privilégier la fistule artérioveineuse comme accès vasculaire pour l'hémodialyse. Certaines études suggèrent toutefois que les résultats seraient moins bons chez les patients âgés. OBJECTIF: Nous avons examiné l'effet de l'âge du patient sur l'issue de la création d'une fistule et sur les procédures liées à l'accès. TYPE D'ÉTUDE: Il s'agit d'une étude de cohorte prospective utilisant les données colligées par le système DMAR (Dialysis Measurement Analysis and Reporting). CADRE: Les programmes de dialyse canadiens participants, soit le Southern Alberta Renal Program, le Manitoba Renal Program, le Sunnybrook Health Sciences Centre (Toronto, Ontario), le London Health Sciences Centre (London, Ontario), et l'hôpital d'Ottawa (Ottawa, Ontario). SUJETS: Les patients adultes incidents ayant amorcé une hémodialyse entre le 1er janvier 2004 et le 31 mai 2012. MESURES: La principale mesure était la proportion de premières fistules créées ayant mené à une utilisation sans cathéter, soit à un usage indépendant pour l'hémodialyse. Les mesures secondaires incluaient le temps écoulé jusqu'à l'utilisation d'une fistule sans cathéter pour les patients ayant subi une première tentative, le nombre total de jours d'utilisation d'une fistule sans cathéter, et la proportion du temps de dialyse passé avec une fistule indépendante fonctionnelle (sans cathéter). MÉTHODOLOGIE: Nous avons comparé les caractéristiques des patients par groupe d'âge à l'aide de tests t ou de tests de somme des rangs de Wilcoxon, et de tests chi-deux ou de tests exacts de probabilité de Fisher, selon le cas. Une régression logistique et une régression logistique fractionnée ont été employées pour estimer respectivement, selon le groupe d'âge, les chances d'utiliser une fistule sans cathéter et la proportion du temps de dialyse passé sans cathéter. RÉSULTATS: Au total, 1 091 patients satisfaisaient nos critères d'inclusion (n=567 [≥65 ans]; n=524 [<65 ans]). Seulement 57 % des premières tentatives de création d'une fistule ont mené à une utilisation sans cathéter, indépendamment de l'âge (rapport de cote corrigé [RC]≥65contre<65: 1,01; p=0,93). Le temps médian jusqu'à l'utilisation sans cathéter de la première fistule créée n'a pas varié en fonction de l'âge lorsque les patients ont été groupés selon que la fistule avait été créée avant ou après l'amorce de la dialyse. Les taux corrigés de procédures liées à l'accès vasculaire étaient similaires (rapport des taux d'incidence [RTI]≥65contre<65 0,95; p=0,32); tout comme le pourcentage médian de temps de dialyse passé sans cathéter qui s'est avéré faible pour tous les patients (19 % [<65 ans] contre 21 % [≥65 ans]; p=0,85). LIMITES: La période de suivi relativement courte pourrait avoir sous-estimé les avantages de créer une fistule, et la nature observationnelle de l'étude ne permet pas de tirer de conclusions sur la causalité. CONCLUSION: Selon notre étude, les patients âgés avaient autant de chance que les plus jeunes d'utiliser la fistule sans cathéter, et ce, dans un délai semblable et avec sensiblement le même nombre de procédures liées à l'accès vasculaire. Néanmoins, la proportion du temps de dialyse passé sans cathéter était faible.

Timing of Fistula Creation and the Probability of Catheter-Free Use: A Cohort Study.

BACKGROUND: Fistula creation is recommended to avoid the use of central venous catheters for hemodialysis. The extent to which timing of fistula creation minimizes catheter use is unclear. OBJECTIVE: To compare patient outcomes of 2 fistula creation strategies: fistula attempt prior to the initiation of dialysis ("predialysis") or fistula attempt after starting dialysis ("postinitiation"). DESIGN: Cohort study. SETTING: Five Canadian dialysis programs. PATIENTS: Patients who started hemodialysis between 2004 and 2012, who underwent fistula creation, and were tracked in the Dialysis Measurement Analysis and Reporting (DMAR) system. MEASUREMENTS: Catheter-free fistula use within 1 year of hemodialysis start, probability of catheter-free fistula use during follow-up, and rates of access-related procedures. METHODS: Retrospective data analysis: logistic regression; negative binomial regression. RESULTS: Five hundred and eight patients had fistula attempts predialysis and 583 postinitiation. At 1 year, 80% of those with predialysis attempts achieved catheter-free use compared to 45% with post-initiation attempts (adjusted odds ratio [OR]preVSpost = 4.67; 95% confidence interval [CI] = 3.28-6.66). The average of all patient follow-up time spent catheter-free was 63% and 28%, respectively (probability of use per unit time, ORpreVSpost = 2.90; 95% CI = 2.18-3.85). This finding was attenuated when accounting for maturation time and when restricting the analysis to those who achieved catheter-free use. Predialysis fistula attempts were associated with lower procedure rates after dialysis initiation-1.61 procedures per person-year compared with 2.55-but had 0.65 more procedures per person prior to starting dialysis. LIMITATIONS: Observational design, unknown indication for predialysis and postinitiation fistula creation, and unknown reasons for prolonged catheter use. CONCLUSIONS: Predialysis fistula attempts were associated with a higher probability of catheter-free use and remaining catheter-free over time, and also resulted in fewer procedures compared with postinitiation attempts, which could be due to timing of attempt or patient factors. Catheter use and procedures were still common for all patients, regardless of the timing of fistula creation.

CONTEXTE: La création d'une fistule est recommandée pour l'hémodialyse afin d'éviter l'utilisation de cathéters veineux centraux. On ignore toutefois à quel point le moment choisi pour la créer minimise l'utilisation d'un cathéter. OBJECTIF: Comparer les résultats des patients selon que la fistule est créée avant (pré-dialyse) ou après (post-initiation) l'initiation de la dialyse. TYPE D'ÉTUDE: Étude de cohorte. CADRE: Cinq centres canadiens de dialyse. SUJETS: Des patients repérés dans le système DMAR (Dialysis Measurement Analysis and Reporting) ayant amorcé un traitement d'hémodialyse et subi une tentative de création de fistule entre 2004 et 2012. MESURES: L'utilisation d'une fistule sans cathéter dans l'année suivant le début de l'hémodialyse, la probabilité d'utiliser une fistule sans cathéter au cours de la période de suivi, et les taux de procédures liées à l'accès vasculaire. MÉTHODOLOGIE: Analyse rétrospective des données, régression logistique et régression binomiale négative. RÉSULTATS: Cinq cent huit patients ont eu une création de fistule pré-dialyse et 583 patients ont eu une création de fistule après l'initiation de la dialyse. Après un an, 80 % des patients avec une fistule pré-dialyse l'utilisaient sans cathéter contre 45 % des patients avec une fistule post-initiation (rapport de cotes corrigé [RC] préVSpost: 4,67; IC 95 %: 3,28 ­ 6,66). Les patients ont respectivement passé 63 % et 28 % (probabilité d'utilisation par unité de temps, RCpréVSpost: 2,90; IC 95 %: 2,18 ­ 3,85) de leur temps de suivi sans cathéter. Ce résultat s'est atténué en tenant compte du temps de maturation de la fistule et en limitant l'analyse aux patients ayant utilisé la fistule sans cathéter. La création d'une fistule pré-dialyse a été associée à de plus faibles taux de procédures après l'initiation de la dialyse (1,61 procédure par année-personne contre 2,55), mais avait demandé 0,65 procédure de plus par personne avant le début de la dialyse. LIMITES: Étude observationnelle; manque d'information sur les motifs justifiant la création d'une fistule avant ou après le début de la dialyse et sur les raisons de l'utilisation prolongée d'un cathéter. CONCLUSION: La création d'une fistule pré-dialyse a été associée à une plus grande probabilité d'éviter l'utilisation d'un cathéter et que cela se poursuive dans le temps. Elle s'est également traduite par un taux réduit de procédures comparativement aux tentatives post-initiation, ce qui pourrait être lié au moment de la tentative de création de fistule ou à des facteurs propres aux patients. L'utilisation d'un cathéter et les procédures liées à l'accès vasculaire sont toutefois demeurées fréquentes pour tous les patients, peu importe le moment où la fistule avait été créée.