Assessing Discharge Communication and Follow-up of Acute Kidney Injury in British Columbia: A Retrospective Chart Review.

Background and objective: Acute kidney injury (AKI) affects up to 20% of hospitalizations and is associated with chronic kidney disease, cardiovascular disease, increased mortality, and increased health care costs. Proper documentation of AKI in discharge summaries is critical for optimal monitoring and treatment of these patients once discharged. Currently, there is limited literature evaluating the quality of discharge communication after AKI. This study aimed to evaluate the accuracy and quality of documentation of episodes of AKI at a tertiary care center in British Columbia, Canada. Methods design setting patients and measurements: This was a retrospective chart review study of adult patients who experienced AKI during hospital admission between January 1, 2018, and December 31, 2018. Laboratory data were used to identify all admissions to the cardiac and general medicine ward complicated by AKI defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. A random sample of 300 AKI admissions stratified by AKI severity (eg, stages 1, 2, and 3) were identified for chart review. Patients were excluded if they required ongoing renal replacement therapy after admission, had a history of kidney transplant, died during their admission, or did not have a discharge summary available. Discharge summaries were reviewed for documentation of the following: presence of AKI, severity of AKI, AKI status at discharge, practitioner and laboratory follow-up plans, and medication changes. Results: A total of 1076 patients with 1237 AKI admissions were identified. Of the 300 patients selected for discharge summary review, 38 met exclusion criteria. In addition, AKI was documented in 140 (53%) discharge summaries and was more likely to be documented in more severe AKI: stage 1, 38%; stage 2, 51%; and stage 3, 75%. Of those with their AKI documented, 94 (67%) documented AKI severity, and 116 (83%) mentioned the AKI status or trajectory at the time of discharge. A total of 239 (91%) of discharge summaries mentioned a follow-up plan with a practitioner, but only 23 (10%) had documented follow-up with nephrology. Patients with their AKI documented were more likely to have nephrology follow-up than those without AKI documented (17% vs 1%). Regarding laboratory investigations, 92 (35%) of the summaries had documented recommendations. In summaries that included medications typically held during AKI, only about half made specific reference to those medications being held, adjusted, or documented a post-discharge plan for that medication. For those with nonsteroidal anti-inflammatory drugs (NSAIDs) listing, 64% of discharge summaries mentioned holding, and 9% mentioned a discharge plan. For those with angiotensin converting enzyme inhibitor (ACEi)/angiotensin II receptor blocker (ARB) listing, 38% mentioned holding these medications, and 46% mentioned a discharge plan. In summaries with diuretics listed, 35% mentioned holding, and 51% included a discharge plan. Conclusions and limitations: We found suboptimal quality and completeness of discharge reporting in patients hospitalized with AKI. This may contribute to inadequate follow-up and post-hospitalization care for this patient population. Strategies are required for increasing the presence and quality of AKI reporting in discharge summaries. Limitations include our definition of AKI based on lab criteria, which may have missed some of the injuries that met the criteria based on urine output. Another limitation is that our definition of AKI based on the highest and lowest creatinine during admission may have led to some overclassification. In addition, without outpatient laboratories, it is possible that we have not captured the true baseline creatinine in some patients.

Contexte et objectif: L'insuffisance rénale aiguë (IRA) complique jusqu'à 20 % des hospitalisations; elle est associée à l'insuffisance rénale chronique, aux maladies cardiovasculaires, à une mortalité accrue et à une augmentation des coûts de santé. La documentation appropriée de l'IRA dans les résumés de départ est essentielle pour optimiser la surveillance et le traitement des patients après leur sortie de l'hôpital. Il existe peu de littérature évaluant la qualité de la documentation de l'IRA dans les résumés de départ. Cette étude visait à évaluer l'exactitude et la qualité de la documentation des épisodes d'IRA dans un center de soins tertiaires de la Colombie-Britannique (Canada). Méthodologie conception et cadre de l'étude sujets et mesures: Il s'agit d'une étude rétrospective des dossiers de patients adultes ayant présenté une IRA au cours de leur admission à l'hôpital entre le 1er janvier 2018 et le 31 décembre 2018. Les données de laboratoire ont été utilisées pour répertorier toutes les admissions compliquées par une IRA (définie par les critères KDIGO) dans les services de cardiologie et de médecine générale. Un échantillon aléatoire de 300 admissions avec IRA stratifiée selon sa gravité (p. ex., stade, 1, 2 et 3) a été constitué pour l'examen des dossiers. Ont été exclus les patients qui avaient eu besoin d'une thérapie de suppléance rénale continue après leur admission, ceux qui avaient des antécédents de transplantation rénale, ceux qui étaient décédés pendant leur admission et ceux pour qui aucun résumé de départ n'était disponible. Les résumés de départ ont été examinés à la recherche d'une mention des éléments suivants : présence d'une IRA, gravité de l'IRA, statut de l'IRA à la sortie, plans de suivi pour les tests de laboratoire et suivi avec un praticien, changements dans la médication. Résultats: En tout, 1 076 patients avec un total de 1 237 admissions avec IRA ont été identifiés. Parmi les 300 patients sélectionnés pour l'examen du résumé de départ, 38 répondaient aux critères d'exclusion. L'IRA avait été documentée dans 140 (53 %) des cas et plus elle était grave, plus elle était susceptible d'être documentée (stade 1 = 38 %; stade 2 = 51 %; stade 3 = 75 %). Parmi ceux où l'IRA était documentée, 94 (67 %) mentionnaient sa gravité et 116 (83 %) mentionnaient son statut ou sa trajectoire à la sortie du patient. Un plan de suivi avec le praticien était mentionné dans 239 (91 %) des résumés de départ, mais seuls 23 (10 %) mentionnaient un suivi en néphrologie. Les patients dont l'IRA était documentée étaient plus susceptibles de faire l'objet d'un suivi en néphrologie que ceux sans mention de l'IRA (17 % contre 1 %). En ce qui concerne les plans de suivi de laboratoire, 92 (35 %) des résumés contenaient des recommandations. Dans les résumés qui mentionnaient des médicaments normalement maintenus pendant un épisode d'IRA, seule la moitié environ faisait spécifiquement référence à ces médicaments comme ayant été cessés, ajustés ou documentés dans un plan post-sortie. Dans les résumés de départ qui listaient des AINS, 64 % mentionnaient qu'ils avaient été cessés temporairement et 9 % comprenaient un plan au congé de l'hôpital. Dans les résumés de départ qui listaient des IECA/ARA, 38 % mentionnaient que ces médicaments avaient été cessés temporairement et 46 % comprenaient un plan au congé de l'hôpital. Dans les résumés qui listaient des diurétiques, 35 % mentionnaient qu'ils avaient été cessés temporairement et 51 % comprenaient un plan au congé de l'hôpital. Limites et conclusion: Nous avons constaté que la qualité et l'exhaustivité des résumés de départ étaient sous-optimales chez les patients hospitalisés ayant vécu un épisode d'IRA. Cette situation peut contribuer à l'inadéquation du suivi et des soins post-hospitalization pour cette population de patients. Des stratégies sont nécessaires pour accroître la documentation d'un épisode d'IRA dans les résumés de départ et augmenter la qualité de sa communication. Les résultats de cette étude sont notamment limités par notre définition de l'IRA fondée sur des critères de laboratoire qui pourraient avoir manqué des patients répondant aux critères fondés sur la production d'urine. Notre définition de l'IRA fondée sur le taux de créatinine le plus élevée et le plus faible pendant l'admission pourrait également avoir conduit à un surdiagnostic. En outre, sans les résultats de laboratoires externes, il est possible que nous n'ayons pas saisi la mesure initiale réelle de la créatinine chez certains patients.

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

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

Regional Variation in Hemoglobin Distribution Among Individuals With CKD: the ISN International Network of CKD Cohorts.

Introduction: Despite recognized geographic and sex-based differences in hemoglobin in the general population, these factors are typically ignored in patients with chronic kidney disease (CKD) in whom a single therapeutic range for hemoglobin is recommended. We sought to compare the distribution of hemoglobin across international nondialysis CKD populations and evaluate predictors of hemoglobin. Methods: In this cross-sectional study, hemoglobin distribution was evaluated in each cohort overall and stratified by sex and estimated glomerular filtration rate (eGFR). Relationships between candidate predictors and hemoglobin were assessed from linear regression models in each cohort. Estimates were subsequently pooled in a random effects model. Results: A total of 58,613 participants from 21 adult cohorts (median eGFR range of 17-49 ml/min) and 3 pediatric cohorts (median eGFR range of 26-45 ml/min) were included with broad geographic representation. Hemoglobin values varied substantially among the cohorts, overall and within eGFR categories, with particularly low mean hemoglobin observed in women from Asian and African cohorts. Across the eGFR range, women had a lower hemoglobin compared to men, even at an eGFR of 15 ml/min (mean difference 5.3 g/l, 95% confidence interval [CI] 3.7-6.9). Lower eGFR, female sex, older age, lower body mass index, and diabetic kidney disease were all independent predictors of a lower hemoglobin value; however, this only explained a minority of variance (R2 7%-44% across cohorts). Conclusion: There are substantial regional differences in hemoglobin distribution among individuals with CKD, and the majority of variance is unexplained by demographics, eGFR, or comorbidities. These findings call for a renewed interest in improving our understanding of hemoglobin determinants in specific CKD populations.

Safety and Effectiveness of Rivaroxaban Versus Warfarin Across GFR Levels in Atrial Fibrillation: A Population-Based Study in Australia and Canada.

Rationale & Objective: The benefit-risk profile of rivaroxaban versus warfarin for atrial fibrillation (AF) in patients with chronic kidney disease is uncertain. We compared rivaroxaban with warfarin across the range of kidney function in adults with AF. Study Design: Multicenter retrospective cohort. Setting & Participants: Adults with AF and a measure of estimated glomerular filtration rate (eGFR); using administrative data from 5 jurisdictions across Australia and Canada (2011-2018). Kidney function was categorized as eGFR ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2. Patients receiving dialysis and kidney transplant recipients were excluded. Exposures: New dispensation of either rivaroxaban or warfarin. Outcomes: Composite (1) effectiveness outcome (all-cause death, ischemic stroke, or transient ischemic attack) and (2) major bleeding events (intracranial, gastrointestinal, or other) at 1 year. Analytical Approach: Cox proportional hazards models accounting for propensity score matching were performed independently in each jurisdiction and then pooled using random-effects meta-analysis. Results: 55,568 patients (27,784 rivaroxaban-warfarin user matched pairs; mean age 74 years, 46% female, 33.5% with eGFR <60 mL/min/1.73 m2) experienced a total of 4,733 (8.5%) effectiveness and 1,144 (2.0%) bleeding events. Compared to warfarin, rivaroxaban was associated with greater or similar effectiveness across a broad range of kidney function (pooled HRs of 0.72 [95% CI, 0.66-0.78], 0.78 [95% CI, 0.58-1.06], 0.70 [95% CI, 0.57-0.87], and 0.78 [95% CI, 0.62-0.99]) for eGFR ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2, respectively). Rivaroxaban was also associated with similar risk of major bleeding across all eGFR categories (pooled HRs of 0.75 [95% CI, 0.56-1.00], 1.01 [95% CI, 0.79-1.30], 0.87 [95% CI, 0.66-1.15], and 0.63 [95% CI, 0.37-1.09], respectively). Limitations: Unmeasured treatment selection bias and residual confounding. Conclusions: In adults with AF, rivaroxaban compared with warfarin was associated with lower or similar risk of all-cause death, ischemic stroke and transient ischemic attack and similar risk of bleeding across a broad range of kidney function. Plain-Language Summary: This real-world study involved a large cohort of 55,568 adults with atrial fibrillation from 5 jurisdictions across Australia and Canada. It showed that the favorable safety (bleeding) and effectiveness (stroke or death) profile of rivaroxaban compared with warfarin was consistent across different levels of kidney function. This study adds important safety data on the use of rivaroxaban in patients with reduced kidney function, including those with estimated glomerular filtration rate <30 mL/min/1.73 m2 in whom the risks and benefits of rivaroxaban use is most uncertain. Overall, the study supports the use of rivaroxaban as a safe and effective alternative to warfarin for atrial fibrillation across differing levels of kidney function.

COVID-19 Vaccine Effectiveness Among Patients With Maintenance Dialysis; Observations From Population Level Cohort Studies in 2 Large Canadian Provinces.

Background: It was unknown if the effectiveness of COVID-19 vaccines could vary between regions. Objective: To explore key differences in COVID-19 pandemics in British Columbia (BC) and Ontario (ON) and to investigate if the vaccine effectiveness (VE) among maintenance dialysis population could vary between these 2 provinces. Study Design: Retrospective cohort. Setting and Patients: This retrospective cohort study included patients from population-level registry in BC who were on maintenance dialysis from December 14, 2020, to December 31, 2021. The COVID-19 VE among BC patients were compared to the previously published VE among similar patient population in ON. Two-sample t-test for unpaired data were used to investigate if the VE estimates from BC and ON were statistically significantly different. Exposure: Exposure to COVID-19 vaccines (BNT162b2, ChAdOx1nCoV-19, mRNA-1273) was modeled in a time-dependent fashion. Outcome: Reverse transcription polymerase chain reaction (RT-PCR) confirmed COVID-19 infection and related severe outcome defined by hospitalization or death. Analytical Approach: Time-dependent Cox regression analysis. Results: This study using BC data included 4284 patients. Median age was 70 years and 61% was male. Median follow-up time was 382 days. 164 patients developed COVID-19 infection. The ON study by Oliver et al included 13 759 patients with a mean age of 68 years. 61% of the study sample was male. Median follow-up time for patients in the ON study was 102 days. A total of 663 patients developed COVID-19 infection. During the overlapped study periods, BC had 1 pandemic wave compared to 2 in Ontario with substantially higher infection rates. Vaccination timing and roll out among the study population were substantially different. Median time between first and second dose was 77 days (interquartile range [IQR] 66-91) in BC compared to 39 days (IQR = 28-56) in Ontario. Distribution of COVID-19 variants during the study period appeared to be similar. In BC, compared to pre-vaccination person-time, risk of developing COVID-19 infection was 64% (aHR [95% CI] 0.36 [0.21, 0.63]), 80% (0.20 [0.12, 0.35]) and 87% (0.13 [0.06, 0.29]) less when exposed to 1 dose, 2 doses, and 3 doses, respectively. In contrast, risk reduction among Ontario patients was 41% (0.59 [0.46, 0.76]) and 69% (0.31 [0.22, 0.42]) for 1 dose and 2 doses, respectively (patients did not receive the third dose by study end date of June 30, 2021). VE against COVID-19 infection in BC and ON was not statistically significantly different, the P values for exposure to 1 dose and 2 doses comparisons were 0.103 and 0.163, respectively. Similarly, in BC, risk of developing COVID-19-related hospitalization or death were 54% (0.46 [0.24, 0.90]), 75% (0.25 [0.13, 0.48]) and 86% (0.14 [0.06, 0.34]) less for 1 dose, 2 doses, and 3 doses, respectively. Interestingly, exposure to second dose appeared to provide better protection against severe outcomes in Ontario versus BC, risk reduction was 83% (aHR = 0.17, 95% CI [0.10, 0.30]) and 75% (aHR = 0.25, 95% CI [0.13, 0.48]), respectively. However, the adjusted hazard ratios were not statistically significantly different between BC and ON, the P values were 0.676 and 0.369 for exposure to 1 dose and 2 doses, respectively. Limitations: Infection rate, variant distribution, and vaccination strategies were compared using publicly available data. VE estimates were compared from 2 independent cohort studies from 2 provinces without patient-level data sharing. Conclusions: Health Canada approved COVID-19 vaccines were highly effective among patients with maintenance dialysis from BC and ON. Although there appeared to be between province differences in pandemic waves and vaccination strategies, the VE against COVID-19 infection as well as related severe outcome appeared to be not statistically significantly different. A nationally representative VE could be estimated using pooled data from multiple regions.

Contexte: On ignore si l'efficacité des vaccins contre la COVID-19 varie d'une région à l'autre. Objectif: Examiner les principales différences entre les infections à la COVID-19 en Colombie-Britannique (C.-B.) et en Ontario et déterminer si l'efficacité des vaccins (EV) varie entre ces deux provinces dans la population des personnes sous dialyze d'entretien. Type d'étude: Étude de cohorte rétrospective. Sujets et cadre de l'étude: Cette étude de cohorte rétrospective porte sur des patients issus du registre de la population de Britanno-Colombiens sous dialyze d'entretien entre le 14 décembre 2020 et le 31 décembre 2021. L'EV contre la COVID-19 chez les patients de la C.-B. a été comparée à l'EV précédemment publiée pour une population de patients similaires en Ontario. Un test t à deux échantillons de données non appariées a été utilisé pour déterminer si les estimations de l'EV en C.-B. et en Ontario étaient statistiquement différentes. Exposition: L'exposition aux vaccins contre la COVID-19 (BNT162b2, ChAdOx1nCoV-19, mRNA-1273) a été modélisée en fonction du temps. Résultats: La RT-PCR a confirmé l'infection à la COVID-19 et les résultats graves liés à la maladie ont été définis par une hospitalization ou le décès. Approche analytique: Analyze par régression Cox dépendante du temps. Résultats: L'étude en cours utilisant les données de la C.-B. incluait 4 284 patients. L'âge médian était de 70 ans et 61 % étaient des hommes. Le temps médian de suivi était de 382 jours. De ces patients, 164 avaient contracté la COVID-19. L'étude de l'Ontario (Oliver et coll.) porte sur 13 759 patients (61 % d'hommes) dont la moyenne d'âge était de 68 ans. Le temps médian de suivi pour les patients de l'étude ontarienne était de 102 jours. Un total de 663 patients avait contracté la COVID-19. Au cours des périodes d'étude qui se sont chevauchées, la Colombie-Britannique a connu une vague pandémique, contre deux en Ontario, avec des taux d'infection beaucoup plus élevés. Le calendrier et le déploiement de la vaccination parmi la population étudiée étaient sensiblement différents. Le temps médian entre la première et la deuxième dose de vaccin était de 77 jours en C.-B. (ÉIQ: 66-91) et de 39 jours en Ontario (ÉIQ: 28-56). La répartition des différents variants du virus de la COVID-19 au cours de la période d'étude semble similaire. En C.-B., comparativement au temps-personne avant la vaccination, le risque de contracter la COVID-19 était réduit de 64 % (risque relatif corrigé [IC 95 %]: 0,36 [0,21-0,63]) après une dose, de 80 % (RRc: 0,20 (0,12-0,35)) après deux doses et de 87 % (RRc: 0,13 (0,06-0,29)) après 3 doses. En Ontario, la réduction de ce même risque était de 41 % (RRc: 0,59 (0,46-0,76)) après une dose et de 69 % (RRc: 0,31 (0,22-0,42)) après deux doses (les patients n'avaient pas reçu de troisième dose le 30 juin 2021, la date de fin de l'étude). L'EV contre une infection à la COVID-19 n'était pas statistiquement différente entre les deux provinces, avec des valeurs p pour les comparaisons d'exposition respectivement de 0,103 et de 0,163 pour la 1re et 2e dose. De même, en Colombie-Britannique, le risque d'être hospitalisé ou de décéder en raison d'une infection à la COVID-19 était réduit de 54 % (RRc: 0,46 (0,24-0,90)) après une dose, de 75 % (RRc: 0,25 (0,13-0,48)) après deux doses et de 86 % (RRc: 0,14 [0,06-0,34] après trois doses. Il est intéressant de noter que la deuxième dose semblait offrir une meilleure protection contre les complications graves aux patients de l'Ontario par rapport à ceux de la C.-B., avec une réduction du risque de 83 % [RRc: 0,17 (0,10-0,30)] et de 75 % [RRc: 0,25 (0,13-0,48)], respectivement. Les valeurs du risque relatif corrigé n'étaient cependant pas statistiquement différentes, leurs valeurs p s'établissant à 0,676 après la 1re dose et à 0,369 après la 2e. Limites: Le taux d'infection, la distribution des variants et les stratégies de vaccination ont été comparés à partir des données disponibles au public. Les estimations de l'EV ont été comparées à partir de deux études de cohortes indépendantes dans deux provinces, sans partage de données au niveau des patients. Conclusion: Les vaccins contre la COVID-19 approuvés par Santé Canada ont été très efficaces chez les patients sous dialyze d'entretien en Colombie-Britannique et en Ontario. Bien qu'il y ait des différences entre les provinces en ce qui concerne les vagues de pandémie et les stratégies de vaccination, l'efficacité des vaccins contre une infection à la COVID-19 et ses complications graves ne semble pas significativement différente. Une estimation représentative à l'échelle nationale de l'efficacité des vaccins pourrait être calculée à partir de données regroupées provenant de plusieurs régions.

Long-term effect of COVID-19 infection on kidney function among COVID-19 patients followed in post-COVID-19 recovery clinics in British Columbia, Canada.

BACKGROUND: We investigated the effect of Post-Acute COVID Syndrome or "long-COVID" on kidney function among patients followed in post-COVID recovery clinics (PCRC) in British Columbia, Canada. METHODS: Long-COVID patients referred to PCRC between July 2020 to April 2022, aged ≥18 years who had an estimated glomerular filtration rate (eGFR) value recorded at 3 months from the coronavirus disease 2019 (COVID-19) diagnosis (index) date were included. Those requiring renal replacement therapy prior to index date were excluded. Primary outcome was change in eGFR and urine albumin-creatinine ratio (UACR) after COVID-19 infection. The proportion of patients in each of the six eGFR categories (<30, 30-44, 45-59, 60-89, 90-120 and >120 mL/min/1.73 m2) and three UACR categories (<3, 3-30 and >30 mg/mmol) in all of the study time points were calculated. Linear mixed model was used to investigate change in eGFR over time. RESULTS: The study sample included 2212 long-COVID patients. Median age was 56 years, 51% were male. Half (∼47%-50%) of the study sample had normal eGFR (≥90 mL/min/1.73 m2) from COVID-19 diagnosis to 12 months post-COVID and <5% of patients had an eGFR <30 mL/min/1.73 m2. There was an estimated 2.96 mL/min/1.73 m2 decrease in eGFR within 1 year after COVID-19 infection that was equivalent to 3.39% reduction from the baseline. Decline in eGFR was highest in patients hospitalized for COVID-19 (6.72%) followed by diabetic patients (6.15%). More than 40% of patients were at risk of CKD. CONCLUSIONS: People with long-COVID experienced a substantial decline in eGFR within 1 year from the infection date. The prevalence of proteinuria appeared to be high. Close monitoring of kidney function is prudent among patients with persistent COVID-19 symptoms.

Kidney function and the comparative effectiveness and safety of direct oral anticoagulants vs. warfarin in adults with atrial fibrillation: a multicenter observational study.

AIMS: The aim of this study was to determine the comparative effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in adults with atrial fibrillation (AF) by level of kidney function. METHODS AND RESULTS: We pooled findings from five retrospective cohorts (2011-18) across Australia and Canada of adults with; a new dispensation for a DOAC or warfarin, an AF diagnosis, and a measure of baseline estimated glomerular filtration rate (eGFR). The outcomes of interest, within 1 year from the cohort entry date, were: (1) the composite of all-cause death, first hospitalization for ischaemic stroke, or transient ischaemic attack (effectiveness), and (2) first hospitalization for major bleeding defined as an intracranial, upper or lower gastrointestinal, or other bleeding (safety). Cox models were used to examine the association of a DOAC vs. warfarin with outcomes, after 1:1 matching via a propensity score. Kidney function was categorized as eGFR ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2. A total of 74 542 patients were included in the matched analysis. DOAC initiation was associated with greater or similar effectiveness compared with warfarin initiation across all eGFR categories [pooled HRs (95% CIs) for eGFR categories: 0.74(0.69-0.79), 0.76(0.54-1.07), 0.68(0.61-0.75) and 0.86(0.76-0.98)], respectively. DOAC initiation was associated with lower or similar risk of major bleeding than warfarin initiation [pooled HRs (95% CIs): 0.75(0.65-0.86), 0.81(0.65-1.01), 0.82(0.66-1.02), and 0.71(0.52-0.99), respectively). Associations between DOAC initiation, compared with warfarin initiation, and study outcomes were not modified by eGFR category. CONCLUSION: DOAC use, compared with warfarin use, was associated with a lower or similar risk of all-cause death, ischaemic stroke, and transient ischaemic attack and also a lower or similar risk of major bleeding across all levels of kidney function.

Prescription Pattern of Cation Exchange Resins and Their Efficacy in Treating Chronic Hyperkalemia Among Patients With Chronic Kidney Diseases: Findings From a Population-Based Analysis in British Columbia, Canada.

Background: Little was known about how chronic hyperkalemia (cHK) in patients with chronic kidney disease (CKD) is managed in British Columbia, Canada. Objective: To investigate the trend in sodium polystyrene sulfonate (SPS) and calcium polystyrene sulfonate (CPS) utilization and their efficacy in treating cHK in CKD patients from British Columbia, Canada. Study Design: Retrospective cohort. Setting & Patients: CKD patients aged ≥18 years, followed in Kidney Care Clinic (KCC), who had at least 2 potassium values ≥5.0 mmol/L separated by no more than 91 days during the period of June 1, 2015, to July 31, 2021, were included. Index date was the first date of the 2 potassium values ≥5.0 mmol/L. Patients who received SPS or CPS within 90 days before index date were excluded. Patients who were on dialysis or received kidney transplantation on or before index date were also excluded. Exposure: Continuous exposure to SPS and CPS. Outcome: SPS/CPS prescription utilization trend was described by the proportion of patients ever treated with SPS/CPS, median time in days between cHK diagnosis and initiating treatment with SPS/CPS, total and median number of SPS/CPS prescriptions dispensed. Change in mean serum potassium concentration before and after a 90-day continuous treatment with SPS/CPS was estimated. Analytical Approach: Descriptive. Results: This study included 10 495 patients with cHK (median age 74 years, 60% were male). Median follow-up time was 625 days. Only 2864 (27%) patients were dispensed at least 1 prescription of either SPS or CPS. A total 7300 prescriptions were dispensed; median prescriptions dispensed per patients were 2 (interquartile range [IQR]: 1-3). Median time from index date to the first prescription dispensing date was 154 days (IQR: 36-455). Continuous 90-day treatment with SPS/CPS decreased the mean serum potassium concentration by 0.60 mmol/L, from 5.58 to 4.98 mmol/L. Limitations: Descriptive observational study without control group. Conclusions: In British Columbia, only 1 in 4 CKD patients with cHK were dispensed with SPS/CPS, mostly with higher degrees of hyperkalemia. These medications appeared to be moderately effective in reducing the serum potassium concentration. Future research is necessary to evaluate the comparative effectiveness of newer generation medications.

Contexte: On savait peu de choses sur la façon dont l'hyperkaliémie chronique (HKc) est prise en charge chez les patients atteints d'insuffisance rénale chronique (IRC) de la Colombie-Britannique (C.-B.), au Canada. Objectif: Étudier les tendances d'utilisation du sulfonate de polystyrène sodique (SPS) et du sulfonate de polystyrène calcique (SPC), ainsi que l'efficacité de ces agents dans le traitement de l'HKc chez les patients britanno-colombiens atteints d'IRC. Type d'étude: étude de cohorte rétrospective. Sujets et cadre de l'étude: Ont été inclus des adultes atteints d'IRC suivis en clinique de soins rénaux qui avaient au moins 2 valeurs de potassium ≥ 5,0 mmol/L mesurées à moins de 91 jours d'intervalle entre le 1er juin 2015 et le 31 juillet 2021. La date de la première des deux valeurs de potassium ≥ 5,0 mmol/L constitue la date indice. Les patients qui avaient reçu du SPS ou du SPC dans les 90 jours précédant la date indice ont été exclus. Les patients sous dialyse ou ayant reçu une greffe rénale avant ou à la date indice ont également été exclus. Exposition: Exposition continue au SPS et au SPC. Résultats: La tendance d'utilisation de SPS/SPC a été décrite par la proportion de patients ayant déjà été traités par SPS/SPC, par le temps médian en jours entre le diagnostic d'hyperkaliémie chronique et le début du traitement par SPS/SPC, et par le nombre total et médian de prescriptions de SPS/SPC délivrées. La variation de la concentration moyenne de potassium sérique avant et après un traitement continu de 90 jours avec SPS/SPC a été estimée. Approche analytique: Descriptive. Résultats: L'étude porte sur 10 495 patients atteints d'hyperkaliémie chronique (60 % d'hommes; âge médian: 74 ans). Le temps médian de suivi était de 625 jours. Seulement 2 864 (27 %) patients avaient reçu au moins une prescription de SPS ou de SPC. Au total, 7 300 ordonnances ont été délivrées; la moyenne d'ordonnances délivrées par patient était de 2 (IIQ: 1, 3). Le délai médian entre la date indice et la date de la première ordonnance était de 154 jours (IIQ: 36, 455). Un traitement continu de 90 jours avec SPS/SPC a abaissé la concentration moyenne de potassium sérique de 0,60 mmol/L, la faisant passer de 5,58 à 4,98 mmol/L. Limites: Étude observationnelle descriptive sans groupe témoin. Conclusion: En C.-B., seul un patient sur quatre atteint d'IRC avec HKc avait reçu une prescription de SPS/SPC, la plupart présentaient des degrés plus élevés d'hyperkaliémie. Ces médicaments se sont avérés modérément efficaces pour réduire la concentration sérique en potassium. Des recherches supplémentaires sont nécessaires pour évaluer l'efficacité comparative des médicaments de nouvelle génération.

Temporal Trends in Hemoglobin, Use of Erythropoiesis Stimulating Agents, and Major Clinical Outcomes in Incident Dialysis Patients in Canada.

INTRODUCTION: Several jurisdictions have adopted a more conservative approach to anemia in patients receiving dialysis amid safety concerns from target hemoglobin studies. It is largely unknown if this has contributed to a change in clinical outcomes. METHODS: A national registry was used to identify 35,945 adult patients who initiated and were maintained on dialysis for ≥90 days in Canada from January 2007 to December 2015. Outcomes were ascertained until March 2017 via linkage with hospital discharge diagnoses. Cox proportional hazards models were used to investigate the association between the era of dialysis initiation and the primary composite outcome (acute myocardial infarction [AMI], stroke, or mortality). RESULTS: The mean hemoglobin at dialysis initiation decreased from 102.9 g/l in 2007 to 95.5 g/l in 2015, corresponding with a higher prevalence of hemoglobin <80 g/l (8% to 17%) and a reduction in erythropoiesis stimulating agent (ESA) use (49% to 44%). After multivariable adjustment, Era 3 (2013-2015) was associated with an 8% relative risk reduction in the primary outcome compared with Era 1 (2007-2009) (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.88-0.96), a 10% relative reduction in mortality (HR 0.90, 95% CI 0.85-0.94) but no significant change in AMI or stroke. In a model without era, neither hemoglobin nor ESA use was an independent predictor of outcome. CONCLUSION: There have been modest declines in average hemoglobin values and ESA use among incident dialysis patients in Canada with no change in major cardiovascular outcomes. Patient survival has improved over time, likely for reasons other than anemia management.

Latent Tuberculosis Therapy Outcomes in Dialysis Patients: A Retrospective Cohort.

RATIONALE & OBJECTIVES: Maintenance dialysis patients are at an increased risk for active tuberculosis (TB). In 2012, British Columbia, Canada, began systematically screening maintenance dialysis patients for latent TB infection (LTBI) and treating people with evidence of LTBI when appropriate. We examined LTBI treatment outcomes and compared treatment outcomes before and after rollout of the systematic screening program. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: The study comprised 365 people in British Columbia, Canada, initiating at least 90 days of dialysis from January 1, 2001, to May 31, 2017, and starting LTBI therapy: 290 (79.5%) people in the recent cohort and 75 (20.5%) in the historical cohort. People starting LTBI therapy from January 1, 2012, onward were classified as the recent cohort, whereas people starting LTBI therapy before January 1, 2012, were classified as the historical cohort. EXPOSURE: Systematic LTBI screening and therapy. OUTCOMES: Proportion of people who experience grade 3 to 5 adverse events (AEs) or any grade rash and end-of-treatment outcomes. ANALYTICAL APPROACH: Outcomes were reported using descriptive statistics. 2-sample test of proportions using χ2 distribution was used to test for statistical significance between the recent and historical cohorts. RESULTS: 298 (81.6%) people successfully completed LTBI therapy. The proportion of people experiencing a grade 3 to 4 AE or any grade rash was 21.1%. Most AEs were related to gastrointestinal events, general malaise, or pruritus that resulted in regimen changes. 2 (0.5%) people were hospitalized for AEs related to LTBI therapy. No significant difference was found between the recent and historical cohorts in all outcomes of interest. No grade 5 AEs (deaths) were attributed to LTBI therapy. LIMITATIONS: Retrospective data and generalizability outside low-TB-burden settings. CONCLUSIONS: Our findings suggest that a high proportion of people receiving maintenance dialysis can complete LTBI therapy. The rate of grade 3 to 4 AEs was high and associated with frequent medication changes during therapy. LTBI therapy in maintenance dialysis may be safe but requires close monitoring.

Advancing Palliative Care in Patients With CKD: From Ideas to Practice.

A palliative approach to care focuses on what matters most to patients with life-limiting illness, including chronic kidney disease (CKD). Despite recent publication of related clinical practice guidelines in nephrology, there is limited information about how to practically implement these recommendations. In this Perspective, we describe our experience integrating a palliative approach within routine care of patients with CKD glomerular filtration rate categories 4 and 5 (G4-G5) across a provincial kidney care network during the past 15 years. The effort was led by a multidisciplinary group, tasked with building capacity and developing tools and resources for practical integration within a provincial network structure. We used an evidence-based framework that includes recommendations for 4 pillars of palliative care to guide our work: (1) patient identification, (2) advance care planning, (3) symptom assessment and management, and (4) caring of the dying patient and bereavement. Activities within each pillar have been iteratively implemented across all kidney care programs using existing committees and organizational structures. Key quality indicators were used to guide strategic planning and improvement. We supported culture change through the use of multiple strategies simultaneously. Altogether, we established and integrated palliative care activities into routine CKD G4-G5 care across the continuum from nondialysis to dialysis populations.

Systematic Evaluation of a Provincial Initiative to Improve Transition to Home Dialysis Therapies.

BACKGROUND: The transition from choosing to initiating home dialysis therapies (HDTs) is not clearly standardized for patients and staff, causing increased anxiety and suboptimal self-management for chronic kidney disease (CKD) patients. At BC Renal, a "Transition to HDTs" guidebook (the Guide) was designed, outlining a step-wise approach to transitioning to HDTs for patients, to help address some of these concerns. OBJECTIVE: We used the Logic Model evaluation framework to assess the value of the Guide to improve patient and staff experience with transitioning to HDTs. DESIGN: This is a prospective cohort quality improvement study. SETTING: This study took place at home dialysis programs in British Columbia, Canada, with 2 pilot sites and 2 control sites. PATIENTS: Patients above age 18 who attended kidney care clinics and identified HDT as their renal replacement treatment of choice were included in this study. MEASUREMENTS: Patient demographics were obtained from British Columbia Renal Patient Records and Outcomes Management Information System, with differences analyzed using Mann-Whitney U test and chi-square test where applicable. Patient surveys were based on Likert rating scales, analyzed using Cochran-Armitage trend test. All tests were 2-sided, with P < .05 considered significant. METHODS: The study enrolled patients from December 2018 to April 2019 at 2 pilot and 2 control sites. Patients were followed up for 8 months. The intervention strategies included (1) training of front-line staff to use the Guide and (2) dissemination of the guide to patients. Evaluation tools measuring data at baseline and at the 8-month point included (1) qualitative and quantitative patient surveys, (2) qualitative staff surveys, (3) structured feedback session with renal care staff, and (4) transition rate and time between choosing and starting a HDT. RESULTS: In total, 108 patients were enrolled: 43 patients at pilot sites and 65 in control sites. Twenty-three of 65 in control vs 18 of 43 in pilot transitioned to a HDT by 8-month follow-up. Transition time was 80 vs 89 days in pilot vs control group, but it was not statistically different (P = .37). The proportion of patients that transitioned to a HDT was 42% vs 35% in pilot vs control group (P = .497). Patients' anxiety, illness knowledge, and activation of resources were not significantly different between patients who successfully transitioned at control and pilot sites. During interviews, patients confirmed that the Guide was effective and helped retain knowledge. The staff felt that the intervention did not increase their workload and that the Guide was a good communication tool, but was used inconsistently. LIMITATIONS: We had a small sample size and limited number of patients enrolled who chose home hemodialysis, with none in the control group. The results are therefore more applicable to peritoneal dialysis. CONCLUSIONS: The Logic Model was useful to evaluate our multi-intervention strategy. While there were no statistically significant differences in transition time, rate, and patient anxiety with or without the Guide, qualitative opinions from patients indicate that the Guide was a useful supplement. In addition, feedback from renal care staff suggested that the Guide served as a framework for communicating the transition process with patients, and was perceived as a useful tool. Future work is required to standardize the Guide's utilization. TRIAL REGISTRATION: As this is a quality improvement evaluation study, trial registration is not applicable.

CONTEXTE: L'absence de normalisation, tant pour les patients que pour les soignants, dans la procédure de transition entre le choix de la dialyse à domicile (DD) comme thérapie de remplacement rénal et l'initiation du traitement engendre de l'anxiété et se traduit par une autogestion sous-optimale de la maladie chez les patients atteints d'IRC. Un guide de « transition vers la DD ¼ (le Guide) a été élaboré par le BC Renal. Ce document destiné aux patients décrit une approche de transition par étapes et répond à certaines préoccupations. OBJECTIF: Le cadre d'évaluation du modèle logique a été utilisé pour mesurer la capacité du Guide à améliorer l'expérience des patients et du personnel soignant lors de la transition vers la DD. TYPE D'ÉTUDE: Une étude de cohorte prospective mesurant la qualité de l'amélioration. CADRE: L'étude s'est tenue dans le cadre du programme de DD de la Colombie-Britannique (Canada), sur deux sites pilotes et deux sites contrôles. SUJETS: Les patients adultes qui fréquentaient les cliniques de santé rénale sélectionnées et qui avaient choisi la DD comme thérapie de remplacement rénal ont été inclus. MESURES: Les caractéristiques démographiques des patients ont été obtenues à partir de la base de données PROMIS (Renal Patient Records and Outcomes Management Information System) de la Colombie-Britannique. Selon le cas, les tests U de Mann-Whitney ou de chi-deux ont servi à analyser les différences. Les enquêtes menées auprès des patients étaient basées sur les échelles de notation de Likert et ont été analysées à l'aide du test de tendance Cochran-Armitage. Tous les tests étaient bilatéraux et un résultat de p inférieur à 0,05 a été considéré comme significatif. MÉTHODOLOGIE: L'étude a inclus des patients entre décembre 2018 et avril 2019 dans deux sites pilotes et deux sites contrôles, et le suivi s'est étalé sur huit mois. Les stratégies d'intervention visaient la formation du personnel de première ligne à l'utilisation du Guide et la diffusion de celui-ci aux patients. L'expérience des participants a été évaluée à l'inclusion et après huit mois de suivi à l'aide des outils suivants: (1) enquêtes qualificatives et quantitatives auprès des patients, (2) enquêtes qualitatives auprès des soignants, (3) séances de rétroaction structurées avec les soignants, (4) taux de transition et temps écoulé entre le choix de la DD comme modalité et l'initiation de la procédure. RÉSULTATS: L'étude porte sur un total de 108 patients (43 en site pilote et 65 en site contrôle). Au cours des huit mois de suivi, 23 patients des sites contrôles et 18 patients des sites pilotes ont fait la transition vers la DD. Le temps écoulé entre la décision et l'initiation de la DD s'établissait à 80 et 89 jours (pilotes vs contrôles), une différence qui n'a pas été considérée significative (P = 0,37). La proportion de patients qui sont passés à la DD était de 42 % et de 35 % (pilotes vs contrôles [P = 0,497]). Le niveau d'anxiété du patient, les connaissances à l'égard de la maladie et l'activation des ressources n'ont pas été jugés significativement différents entre les patients qui avaient réussi la transition, indépendamment du site. Au cours des entretiens, les patients ont confirmé que le Guide était efficace et qu'il aidait à retenir les connaissances. Les soignants ont quant à eux mentionné que les interventions n'augmentent pas leur charge de travail et que le Guide est un bon outil de communication, mais qu'il est utilisé de manière inconstante. LIMITES: L'échantillon de patients est faible; peu de sujets avaient choisi l'hémodialyse comme modalité, dont aucun dans le groupe contrôle. Nos résultats s'appliquent donc davantage à la dialyse péritonéale. CONCLUSION: Le modèle logique s'est avéré utile pour évaluer notre stratégie à interventions multiples. Bien que nous n'ayons pu observer de différences significatives dans le taux de transition, le temps requis pour procéder et le niveau d'anxiété du patient (avec ou sans le Guide), les avis qualitatifs des patients suggèrent que le Guide est un complément utile. La rétroaction du personnel soignant indique qu'il sert de cadre pour discuter du processus de transition avec les patients, et qu'il est perçu comme un outil utile. D'autres études sont requises pour normaliser l'utilisation du Guide. ENREGISTREMENT DE L'ESSAI: Il s'agit d'une étude mesurant la qualité de l'amélioration de l'expérience, l'enregistrement n'est donc pas requis.

Effectiveness of Latent TB Screening and Treatment in People Initiating Dialysis in British Columbia, Canada.

BACKGROUND: People undergoing chronic dialysis are at an increased risk of active tuberculosis (TB). In 2012, the Canadian province of British Columbia began systematically screening people initiating dialysis for latent TB using interferon-gamma release assay (IGRA), and treating when appropriate. OBJECTIVE: The objective of this study was to compare active TB rate in people who initiated dialysis and were screened using an IGRA compared with those not screened during the same period. DESIGN: Retrospective cohort study. SETTING: British Columbia (BC), a Canadian province of 5.0 million people with an active TB incidence of 5.1 per 100 000 population. PARTICIPANTS: All people in BC who initiated at least 90 days of dialysis between January 2012 and May 2017 were included in the study. People were excluded if they were <18 years of age or had a prior history of active TB diagnosis or treatment for latent TB. METHODS: A retrospective cohort was created of British Columbians who initiated dialysis between 2012 and 2017. Individuals were stratified into a screened and nonscreened group. Multivariable Cox regression was used to determine the association between latent TB screening and the development of active TB. The primary outcome was incident active TB, either microbiologically confirmed or clinically diagnosed. RESULTS: Of the 3190 people included in the study, 1790 (56.1%) were screened, of which 152 (8.5%) initiated latent TB treatment postscreening. During follow-up, incident active TB was diagnosed in 6 (0.3%) of the 1790 people screened, compared with 11 (0.8%) of the 1400 people who received no screening. In multivariable analysis, latent TB screening and treatment was associated with a significant reduction in the rate of active TB (adjusted hazard ratio = 0.3, 95% confidence interval = 0.1-0.8; P < .01). LIMITATIONS: This was an observational retrospective study and the potential for unmeasured confounding should be carefully assessed. CONCLUSIONS: These findings suggest that systematically screening and treating people initiating dialysis can significantly decrease the rate of active TB in this high-risk population. Given the importance of screening high-risk groups, the results from this analysis could inform scale-up of TB screening in dialysis programs in other low incidence regions. Trial registration is not applicable as this was a retrospective cohort analysis and not a randomized trial.

CONTEXTE: Les patients sous dialyse chronique sont plus susceptibles de développer une tuberculose (TB) active. En 2012, la Colombie-Britannique (province canadienne) a entrepris de dépister systématiquement la TB latente chez les patients qui amorcent un traitement de dialyse. Le dépistage s'effectue à l'aide du test sanguin de libération d'interféron gamma (test IGRA­Interferon Gamma Release Assay) et les patients sont traités lorsque nécessaire. OBJECTIF: L'objectif de l'étude était de comparer le taux de TB active chez les patients dépistés par le test IGRA à celui des individus non testés au cours de la même période. TYPE D'ÉTUDE: Étude de cohorte rétrospective. CADRE: L'étude s'est tenue en Colombie-Britannique, une province canadienne de cinq millions d'habitants dont l'incidence de TB active est de 5,1 cas pour 100 000 habitants. PARTICIPANTS: Ont été inclus tous les Britanno-Colombiens ayant amorcé une dialyse de plus de 90 jours entre janvier 2012 et mai 2017. Les mineurs et les individus avec des antécédents de TB active ou ayant déjà été traités pour une TB latente ont été exclus. MÉTHODOLOGIE: Une étude de cohorte rétrospective a été menée auprès des Britanno-Colombiens ayant amorcé une dialyse entre 2012 et 2017. Les individus ont été divisés en deux groupes: un groupe dépisté et un groupe non dépisté. Une régression de Cox à variables multiples a servi à établir l'association entre une TB latente et le développement d'une TB active. Le principal résultat d'intérêt était une TB active confirmée par analyse microbiologique ou diagnostiquée cliniquement. RÉSULTATS: Des 3 190 individus retenus pour l'étude, 1 790 (56,1 %) ont été testés et de ceux-ci, 152 (8,5 %) ont été traités pour une TB latente après l'examen. Pendant le suivi, parmi les 1 790 individus dépistés, 6 patients (0,3 %) ont reçu un diagnostic de TB active comparativement à onze (0,8 %) parmi les 1400 qui n'avaient pas été examinés. Dans l'analyse multivariée, le traitement et le dépistage de la TB latente ont été associés à une réduction significative du taux de TB active (aHR 0,3; IC 95%: 0,1 à 0,8; p <0,01). LIMITES: Il s'agit d'une étude observationnelle rétrospective et le risque de confusion devrait être rigoureusement évalué. CONCLUSION: Ces résultats suggèrent que le taux de TB active chez les patients dialysés pourrait être réduit significativement par le dépistage et le traitement systématique des individus qui entreprennent un traitement de dialyse. Vu l'importance du dépistage des populations à haut risque, les résultats de cette étude sont susceptibles d'éclairer l'augmentation du dépistage de la TB au sein des programmes de dialyse dans d'autres régions de faible incidence.

Predicting kidney failure risk after acute kidney injury among people receiving nephrology clinic care.

BACKGROUND: Outcomes after acute kidney injury (AKI) are well described, but not for those already under nephrology clinic care. This is where discussions about kidney failure risk are commonplace. We evaluated whether the established kidney failure risk equation (KFRE) should account for previous AKI episodes when used in this setting. METHODS: This observational cohort study included 7491 people referred for nephrology clinic care in British Columbia in 2003-09 followed to 2016. Predictors were previous Kidney Disease: Improving Global Outcomes-based AKI, age, sex, proteinuria, estimated glomerular filtration rate (eGFR) and renal diagnosis. Outcomes were 5-year kidney failure and death. We developed cause-specific Cox models (AKI versus no AKI) for kidney failure and death, stratified by eGFR (

Population-based analysis of the effect of a comprehensive, systematic change in an emergency medical services resource allocation plan on 24-hour mortality.

BACKGROUND: Resource allocation planning for emergency medical services (EMS) systems determines appropriate resources including what paramedic qualification and how rapidly to respond to patients for optimal outcomes. The British Columbia Emergency Health Services implemented a revised response plan in 2013. METHODS: A pre- and post-methodology was used to evaluate the effect of the resource allocation plan revision on 24-hour mortality. All adult cases with evaluable outcome data (obtained through linked provincial health administrative data) were analyzed. Multivariable logistic regression was used to adjust for variations in other significant associated factors. Interrupted time series analysis was used to estimate immediate changes in level or trend of outcome after the start of the revised resource allocation plan implementation, while simultaneously controlling for pre-existing trends. RESULTS: The derived cohort comprised 562,546 cases (April 2012-March 2015). When adjusted for age, sex, urban/metro region, season, day, hour, and dispatch determinant, the probability of dying within 24 hours of an EMS call was 7% lower in the post-resource allocation plan-revision cohort (OR = 0.936; 95% CI: 0.886-0.989; p = 0.018). A subgroup analysis of immediately life-threatening cases demonstrated similar effect (OR = 0.890; 95% CI: 0.808-0.981; p = 0.019). Using time series analysis, the descending changes in overall 24-hour mortality trend and the 24-hour mortality trend in immediately life-threatening cases, were both statistically significant (p < 0.001). CONCLUSION: Comprehensive, evidence-informed reconstruction of a provincial EMS resource allocation plan is feasible. Despite change in crew level response and resource allocation, there was significant decrease in 24-hour mortality in this pan-provincial population-based cohort.

Glomerular Filtration Rate-Specific Cutoffs Can Refine the Prognostic Value of Circulating Cardiac Biomarkers in Advanced Chronic Kidney Disease.

BACKGROUND: Using standard cutoffs derived from healthy adults, high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are frequently elevated in patients with reduced glomerular filtration rate (GFR), with unclear implications. We sought to compare GFR-specific cutoffs of each biomarker with standard cutoffs for discrimination of cardiovascular risk in asymptomatic patients with chronic kidney disease. METHODS: We investigated a prospective cohort of 1956 participants with median GFR of 27 mL/min/1.73 m2. Cox proportional hazards models were used to examine the association between each biomarker and first adjudicated cardiovascular event (unstable angina, myocardial infarction, heart failure, stroke, cardiovascular death). We used an outcome-based approach to identify optimal risk-based cutoffs for each biomarker within GFR strata (< 20, 20-29, 30-44 mL/min/1.73 m2). We evaluated the added prognostic value of each biomarker to a multivariable base model, comparing GFR-specific with standard cutoffs. RESULTS: Hs-cTnT and NT-proBNP were elevated in 76% and 82% of participants, respectively. A total of 401 events were recorded during 6772 person-years at risk. Both biomarkers were independent predictors of cardiovascular events. Optimal cutoffs for each biomarker were higher than standard thresholds, being highest at GFR values < 20 mL/min/1.73 m2. Addition of hs-cTnT to the base model using GFR-specific cutoffs significantly improved reclassification for events (52%) and nonevents (21%). Similar findings were observed for NT-proBNP. In contrast, use of standard cutoffs failed to reclassify patients who had no event as lower risk. CONCLUSIONS: Among asymptomatic patients with advanced chronic kidney disease, optimal cutoffs for hs-cTnT and NT-proBNP differed according to GFR level and outperformed standard cutoffs for discrimination of cardiovascular risk.

Validation of Self-Reported Race in a Canadian Provincial Renal Administrative Database.

BACKGROUND: Administrative data are commonly used to study clinical outcomes in renal disease. Race is an important determinant of renal health delivery and outcomes in Canada but is not validated in most administrative data, and the correlation with census-based definitions of race is unknown. OBJECTIVES: Validation of self-reported race (SRR) in a Canadian provincial renal administrative database (Patient Records and Outcome Management Information System [PROMIS]) and comparison with the Canadian census categories of race. DESIGN: Prospective patient survey study to validate SRR in PROMIS. SETTING: British Columbia, Canada. PATIENTS: Adult patients registered in PROMIS. MEASUREMENTS: Survey SRR was used as gold standard to validate SRR in PROMIS. Self-reported race in PROMIS was compared with census race categories. METHODS: This is a cross-sectional telephone survey of a random sample of all adults in PROMIS conducted between February 2016 and November 2016. Responders selected a race category from PROMIS and from the Canadian census. Sensitivity (Sn) and specificity (Sp) were calculated with 95% confidence intervals (CIs). RESULTS: A total of 21 039 patients met inclusion criteria, 1677 were selected for the survey and 637 participated (38% response rate). There were no differences between the PROMIS, sampled, and responder populations. PROMIS SRR had an accuracy of 95.3% (95% CI: 94.2%-97.0%) when validated against the survey SRR with Sn and Sp ≥90% in all race groups except in Aboriginals (Sn 87.5%). The positive and negative predictive values were ≥95%, except in very low and high-prevalence groups, respectively. The Canadian census had an accuracy of 95.7% (95% CI: 94.4%-97.6%) when validated against PROMIS SRR with Sn and Sp ≥90%. The results did not differ in subgroups based on age, sex, birth outside Canada, or renal group (glomerulonephritis, chronic kidney disease, hemodialysis, peritoneal dialysis, transplant recipients, or live donors). LIMITATIONS: Analysis of minority groups and lower prevalence groups is limited by sample size. Results may not be generalizable to other administrative databases. CONCLUSIONS: We have shown high accuracy of PROMIS SRR that validates its use in the secondary analysis of administrative data for research. There is high correlation between PROMIS and census race categories which allows linkage with other data sources that use census-based definitions of race.

CONTEXTE: Les données administratives sont fréquemment utilisées pour étudier les issues cliniques en néphrologie. L'origine ethnique (OE) du patient est un déterminant important de la prestation de soins et des résultats en santé rénale au Canada, mais n'est pas validée dans la plupart des données administratives et la corrélation avec les définitions d'ethnies fondées sur le recensement demeure inconnue. OBJECTIFS: L'étude visait à valider l'origine ethnique autodéclarée (OEAD) dans une base de données administrative provinciale relative à la santé rénale (PROMIS), et à la comparer à l'origine ethnique inscrite au recensement canadien. TYPE D'ÉTUDE: Une étude prospective menée sous forme de sondage auprès de patients pour valider l'OEAD dans PROMIS. CADRE: Colombie-Britannique, Canada. SUJETS: Des patients adultes inscrits dans PROMIS. MESURES: L'OE mentionnée dans le sondage a servi d'étalon-or pour valider l'OEAD dans PROMIS, et cette dernière a été comparée à l'OE rapportée par le recensement. MÉTHODOLOGIE: Une enquête transversale conduite par téléphone entre février et novembre 2016 auprès d'un échantillon aléatoire d'adultes inscrits dans PROMIS. Les répondants devaient choisir une OE dans PROMIS et dans les catégories du recensement canadien. La sensibilité (Sn) et la spécificité (Sp) ont été calculées avec un intervalle de confiance à 95 % (IC 95 %). RÉSULTATS: Des 21 039 patients qui satisfaisaient les critères d'inclusion, 1 677 ont été sélectionnés pour le sondage et 637 ont participé (taux de réponse: 38 %). Aucune différence n'a été observée entre les populations de PROMIS, de l'échantillon et de répondants. L'OEAD dans PROMIS était exacte dans 95,3 % des cas (IC 95 %: 94,2-97,0 %), lorsque validée contre l'OEAD dans le sondage, avec une Sn et une Sp d'au moins 90 % pour tous les groupes ethniques, à l'exception des Autochtones (Sn: 87,5 %). Les valeurs prédictives positive et négative étaient d'au moins 95 %, sauf dans les groupes à très faible et à forte prévalence, respectivement. Le recensement canadien a montré une précision de 95,7 % (IC 95 %: 94,4-97,6 %) lorsque validé contre l'OEAD dans PROMIS avec une Sn et une Sp d'au moins 90 %. Les résultats n'ont pas varié dans les sous-groupes selon l'âge, le sexe, la naissance hors Canada ou le groupe de néphrologie (glomérulonéphrite, insuffisance rénale chronique, hémodialyse, dialyse péritonéale, receveurs d'une greffe ou donneurs vivants). LIMITES: L'analyse des groupes minoritaires et des groupes à faible prévalence est limitée par la taille de l'échantillon. Les résultats pourraient ne pas être généralisables à d'autres bases de données administratives. CONCLUSION: Nous avons montré la grande précision de l'OEAD dans PROMIS, ce qui valide son utilisation pour l'analyse secondaire de données administratives à des fins de recherche. Une forte corrélation existe entre les définitions de l'OE dans PROMIS et le recensement, ce qui permet d'établir des liens avec d'autres sources de données qui utilisent les mêmes définitions que le recensement.

A propensity score matched analysis shows no adverse effect of early steroid withdrawal in non-diabetic kidney transplant recipients with and without glomerulonephritis.

Recurrent glomerulonephritis (GN) is a common cause of graft loss after kidney transplantation. Steroids are critical to GN management before transplantation, but it is unclear if early steroid withdrawal after transplantation increases the risk of graft loss in patients with GN. Here USRDS data were used to examine the association of early steroid withdrawal with death censored graft loss and all cause graft loss in GN and non-GN adult, non-diabetic, non-sensitized first kidney-only transplant recipients from 1998-2012. A 2-stage propensity score-based matching algorithm was used to match early steroid withdrawal to steroid-maintained patients in the GN and non-GN groups. Multivariate Cox models using a robust variance estimator to account for matched pairs were used to examine the association of early steroid withdrawal with death censored or all cause graft loss in patients with (6388 patients each in early steroid withdrawal and steroid groups) or without GN (6590 each in early steroid withdrawal and steroid groups). Early steroid withdrawal was not associated with an increased risk of death censored or all cause graft loss in patients with or without GN. These findings were consistent across GN types and after accounting for transplant center. Thus, our findings support consideration of early steroid withdrawal in patients with GN at high risk of the adverse consequences of prolonged steroid exposure.