Factors contributing to a coronavirus disease 2019 (COVID-19) outbreak on a mixed medical-surgical unit in a Canadian acute-care hospital.

Objective: To identify preventable factors that contribute to the cross transmission of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) to patients in healthcare facilities. Design: A case-control study was conducted among inpatients on a coronavirus disease 2019 (COVID-19) outbreak unit. Setting: This study was conducted in a medical-surgical unit of a tertiary-care hospital in Nova Scotia in May 2021. Patients: Patients hospitalized on the unit for at least 12 hours and healthcare workers (HCW) working on the unit within 2 weeks of outbreak declaration were included. Methods: Risk factors for SARS-CoV-2 infection were analyzed using simple and multiple logistic regression. Whole-genome sequencing (WGS) was performed to identify SARS-CoV-2 strain relatedness. Network analysis was used to describe patient accommodation. Results: SARS-CoV-2 infections were identified in 21 patients (29.6%) and 11 HCWs (6.6%). WGS data revealed 4 distinct clades of related sequences. Several factors likely contributed to the outbreak, including failure to identify SARS-CoV-2, a largely incomplete or unvaccinated population, and patient wandering behaviors. The most significant risk factor for SARS-CoV-2 infection was room sharing with an infectious patient, which was the only factor that remained statistically significant following multivariate analysis (odds ratio [OR], 9.2l; 95% confidence interval [CI], 2.04-41.67; P = .004). Conclusions: This outbreak likely resulted from admission of 2 patients with COVID-19, with subsequent transmissions to 17 patients and 11 staff. WGS and bioinformatics analyses were critical to identifying previously unrecognized nosocomial transmissions of SARS-CoV-2. This study supports strategies to reduce nosocomial transmissions of SARS-CoV-2, such as single-patient rooms, promotion of COVID-19 vaccination, and infection prevention and control measures including management of wandering behaviors.

Pre-transplant maintenance dialysis duration and outcomes after kidney transplantation: A multicenter population-based cohort study.

The association between pre-transplant dialysis duration and post-transplant outcomes may vary by the population and endpoints studied. We conducted a population-based cohort study using linked healthcare databases from Ontario, Canada including kidney transplant recipients (n = 4461) from 2004 to 2014. Our primary outcome was total graft failure (i.e., death, return to dialysis, or pre-emptive re-transplant). Secondary outcomes included death-censored graft failure, death with graft function, mortality, hospitalization for cardiovascular events, hospitalization for infection, and hospital readmission. We presented results by pre-transplant dialysis duration (pre-emptive transplant, and .01-1.43, 1.44-2.64, 2.65-4.25, 4.26-6.45, and 6.46-36.5 years, for quintiles 1-5). After adjusting for clinical characteristics, pre-emptive transplantation was associated with a lower rate of total graft failure (adjusted hazard ratio [aHR] .68, 95% CI: .46, .99), while quintile 4 was associated with a higher rate (aHR 1.31, 95% CI: 1.01, 1.71), when compared to quintile 1. There was no significant relationship between dialysis duration and death-censored graft failure, cardiovascular events, or hospital readmission. For death with graft function and mortality, quintiles 3-5 had a significantly higher aHR compared to quintile 1, while for infection, quintiles 2-5 had a higher aHR. Longer time on dialysis was associated with an increased rate of several adverse post-transplant outcomes.

Risk Factors and Outcomes of Early Hospital Readmission in Canadian Kidney Transplant Recipients: A Population-Based Multi-Center Cohort Study.

BACKGROUND: Early hospital readmissions (EHRs) occur commonly in kidney transplant recipients. Conflicting evidence exists regarding risk factors and outcomes of EHRs. OBJECTIVE: To determine risk factors and outcomes associated with EHRs (ie, hospitalization within 30 days of discharge from transplant hospitalization) in kidney transplant recipients. DESIGN: Population-based cohort study using linked, administrative health care databases. SETTING: Ontario, Canada. PATIENTS: We included 5437 kidney transplant recipients from 2002 to 2015. MEASUREMENTS: Risk factors and outcomes associated with EHRs. We assessed donor, recipient, and transplant risk factors. We also assessed the following outcomes: total graft failure, death-censored graft failure, death with a functioning graft, mortality, and late hospital readmission. METHODS: We used multivariable logistic regression to examine the association of each risk factor and the odds of EHR. To examine the relationship between EHR status (yes vs no [reference]) and the outcomes associated with EHR (eg, total graft failure), we used a multivariable Cox proportional hazards model. RESULTS: In all, 1128 kidney transplant recipients (20.7%) experienced an EHR. We found the following risk factors were associated with an increased risk of EHR: older recipient age, lower income quintile, several comorbidities, longer hospitalization for initial kidney transplant, and older donor age. After adjusting for clinical characteristics, compared to recipients without an EHR, recipients with an EHR had an increased risk of total graft failure (adjusted hazard ratio [aHR]: 1.46, 95% CI: 1.29, 1.65), death-censored graft failure (aHR: 1.62, 95% CI: 1.36, 1.94), death with graft function (aHR: 1.34, 95% CI: 1.13, 1.59), mortality (aHR: 1.41, 95% CI: 1.22, 1.63), and late hospital readmission in the first 0.5 years of follow-up (eg, 0 to <0.25 years: aHR: 2.11, 95% CI: 1.85, 2.40). LIMITATIONS: We were not able to identify which readmissions could have been preventable and there is a potential for residual confounding. CONCLUSIONS: Results can be used to identify kidney transplant recipients at risk of EHR and emphasize the need for interventions to reduce the risk of EHRs. TRIAL REGISTRATION: This is not applicable as this is a population-based cohort study and not a clinical trial.

CONTEXTE: Les réadmissions précoces à l'hôpital (RPH) sont fréquentes chez les receveurs d'une greffe rénale. Les données sur les facteurs de risque d'une RPH et sur les résultats qui y sont associés restent toutefois contradictoires. OBJECTIF: Définir les facteurs de risque et les effets associés à une RPH (soit une hospitalization dans les 30 jours suivant la sortie de l'hôpital après la transplantation) chez les receveurs de greffe rénale. TYPE D'ÉTUDE: Étude de cohorte représentative d'une population, réalisée à partir des bases de données administratives en santé. CADRE: Ontario, Canada. SUJETS: Ont été inclus 5 437 adultes receveurs d'une greffe rénale entre 2002 et 2015. MESURES: Les facteurs de risque et les résultats associés à une RPH. Nous avons évalué les facteurs de risque du donneur, du receveur et de la transplantation. Nous avons également évalué les résultats suivants : l'échec du greffon, l'échec du greffon censuré par le décès, le décès avec un greffon fonctionnel, la mortalité et les réadmissions tardives. MÉTHODOLOGIE: Nous avons utilisé la régression logistique multivariée pour examiner l'association de chaque facteur de risque et les probabilités de RPH. Un modèle multivarié des risques proportionnels de Cox a par ailleurs servi à examiner la relation entre le statut des RPH (oui vs non [référence]) et les résultats associés à celles-ci (p. ex., l'échec de la greffe). RÉSULTATS: Dans la cohorte étudiée, 1 128 receveurs d'une greffe rénale (20,7 %) ont été réadmis précocement à l'hôpital. Les facteurs de risque suivants ont été associés à un risque accru de RPH : âge plus avancé du receveur, provenance d'un quartier au quintile de revenu inférieur, présence de plusieurs comorbidités, hospitalization initiale plus longue pour la transplantation rénale et âge plus avancé du donneur. Après ajustement pour les caractéristiques cliniques, par rapport aux receveurs de greffe qui n'avaient pas été réadmis précocement, les patients avec une RPH présentaient un risque accru d'échec du greffon (risque relatif corrigé [RRc] : 1,46; IC 95 % : 1,29-1,65), d'échec du greffon censuré par le décès (RRc: 1,62; IC 95 % : 1,36-1,94), de décès avec un greffon fonctionnel (RRc: 1,34; IC 95 % : 1,13-1,59), de mortalité (RRc: 1,41; IC 95 % : 1,22-1,63) et de réadmission tardive au cours des premiers six mois de suivi (p. ex., entre 0 et moins de 0,25 an de suivi, le RRc était de 2,11; [IC 95 % : 1,85-2,40]). LIMITES: Nous n'avons pas été en mesure d'identifier les réadmissions qui auraient pu être prévenues et il existe un risque de facteurs de confusion résiduels. CONCLUSION: Ces résultats peuvent être employés pour identifier les receveurs d'une greffe rénale susceptibles d'être réadmis rapidement à l'hôpital. Ces résultats soulignent en outre la nécessité d'interventions pour réduire le risque de RPH. ENREGISTREMENT DE L'ESSAI: Sans objet puisqu'il s'agit d'une étude de cohorte basée sur la population et non d'un essai clinique.

Comparison of All-Cause Mortality Between Canadian Kidney Transplant Recipients and Patients With Cancer: A Population-Based Cohort Study.

BACKGROUND: Understanding rates of mortality in kidney transplant recipients relative to other common diseases can enhance our understanding of the mortality burden in kidney transplant recipients. OBJECTIVE: To compare the survival probability in Canadian female and male kidney transplant recipients with patients with common cancers (female: breast, colorectal, lung, or pancreas; male: prostate, colorectal, lung, or pancreas) in a contemporary population. DESIGN: Population-based cohort study using linked administrative health care databases. SETTING: Ontario, Canada. PATIENTS: A total of 6888 incident kidney transplant recipients (median age was 50 and 51 years in females and males, respectively) and a total of 532 452 incident patients with cancer (median age range 60 to 72 years across cancer types) from 1997 to 2015. MEASUREMENTS: All-cause mortality. METHODS: The survival of study participants was described using the Kaplan-Meier product limit estimator. The rate of survival was compared between kidney transplant recipients and patients with cancer using extended Cox regression with a Heaviside function. RESULTS: Kidney transplant recipients had a higher survival probability compared with all cancer types. For example, male kidney transplant recipients had a 5-year survival probability of 89.6% (95% confidence interval [CI]: 88.6%-90.5%) compared with 83.3% (95% CI: 83.1%-83.5%) in patients with prostate cancer, and 14.0% (95% CI: 13.7%-14.3%), 56.1% (95% CI: 55.7%-56.5%), and 9.1% (95% CI: 8.5%-9.7%) in patients with lung, colorectal, and pancreas cancer, respectively. After presenting survival probabilities by age at cohort entry and after adjusting for clinical characteristics, similar results were found with a few exceptions. Unlike the unadjusted analysis, in the adjusted analysis males with prostate cancer had a significantly higher survival compared with kidney transplant recipients and females with breast cancer had higher survival compared with kidney transplant recipients at 2+ years of follow-up. In a subpopulation of the cohort who had information available on cancer stage (ie, stages 1-4), we generally found similar results to our primary analysis with kidney transplant recipients having a higher survival probability compared with each cancer stage. However, female kidney transplant recipients had a lower survival probability compared with females with stage 1 breast cancer, whereas male kidney transplant recipients had a lower survival probability compared with males with stage 1 to 3 prostate cancer. LIMITATIONS: External generalizability, residual confounding, and cancer stage could only be provided for a subpopulation. CONCLUSION: Mortality in kidney transplant recipients is lower than in patients with several cancer types. These results improve our understanding of the mortality burden in this population and reaffirm kidney transplantation as a good treatment option for end-stage kidney disease but also highlight the continuing need to improve posttransplant survival. TRIAL REGISTRATION: This is not applicable as this is a population-based cohort study and not a clinical trial.

CONTEXTE: La comparaison du taux de mortalité des receveurs d'une greffe rénale par rapport à celui des patients atteints d'autres maladies courantes pourrait améliorer notre compréhension du fardeau que cela représente chez les transplantés rénaux. OBJECTIFS: Comparer la probabilité de survie des transplantés rénaux canadiens, femmes et hommes, à celle de patients atteints de cancers fréquents (femmes : sein, colorectal poumons ou pancréas; hommes : prostate, colorectal, poumons ou pancréas) dans une population contemporaine. TYPE D'ÉTUDE: Étude de cohorte représentative d'une population réalisée à partir des données administratives en santé. CADRE: Ontario, Canada. SUJETS: L'étude porte sur 6 888 transplantés du rein incidents (âge médian : 50 ans [femmes] et 51 ans [hommes]) et un total de 532 452 patients atteints d'un cancer (âge médian : 60 à 72 ans pour tous les types de cancers) répertoriés entre 1997 et 2015. MESURES: Mortalité toutes causes confondues. MÉTHODOLOGIE: La survie des patients a été décrite à l'aide de l'estimateur produit-limite de Kaplan-Meier. Une régression étendue de Cox avec une distribution de Heaviside a servi à comparer les taux survie des transplantés rénaux et des patients atteints d'un cancer. RÉSULTATS: La probabilité de survie des transplantés Renaud s'est avérée plus élevée que celle observée pour tous les types de cancer. À titre d'exemple, la probabilité de survie des hommes transplantés était de 89,6 % (IC à 95 % : 88,6-56,9 %) après 5 ans alors qu'elle s'établissait à 83,3 % (IC 95 % : 83,1-83,5 %) chez les patients atteints d'un cancer de la prostate et à 14,0 % (IC à 95 % : 13,7-14,3 %), 56,1 % (IC 95 % : 55,7-56,5 %) et 9,1 % (IC 95 % : 8,5-9,7 %) chez les patients atteints respectivement d'un cancer du poumon, colorectal et du pancréas. Des résultats similaires, à quelques exceptions près, ont été observés après une présentation des probabilités de survie selon l'âge à l'inclusion dans la cohorte et après correction en fonction des caractéristiques cliniques. Dans l'analyse corrigée, contrairement à l'analyse non corrigée, la probabilité de survie des hommes atteints d'un cancer de la prostate et celle des femmes atteintes d'un cancer du sein étaient significativement plus élevées que celle des receveurs d'une greffe rénale après plus de deux ans de suivi. Une sous-population issue de la cohorte de patients disposant d'informations sur le stade du cancer (stades 1 à 4) a montré des résultats généralement similaires à ceux de notre analyse primaire; les transplantés rénaux montrant une probabilité de survie plus élevée comparativement à chaque stade de cancer. Cependant, les receveuses d'une greffe rénale présentaient une probabilité de survie plus faible que les femmes atteintes d'un cancer du sein de stade 1; un résultat similaire a été observé chez les receveurs d'un rein comparativement aux hommes atteints d'un cancer de la prostate de stade 1 à 3. LIMITES: Généralisabilité externe; facteurs de confusion résiduels; stade du cancer connu pour une sous-population uniquement. CONCLUSION: Le taux de mortalité chez les receveurs d'un greffe rénale est inférieur à celui des patients atteints de plusieurs types de cancer. Ces résultats permettent de mieux comprendre le fardeau que représente la mortalité dans cette population et de réaffirmer la transplantation rénale comme option de traitement valide pour l'insuffisance rénale terminale. Ces résultats rappellent également qu'il demeure indispensable d'améliorer les taux de survie post-transplantation. ENREGISTREMENT DE L'ESSAI: Sans objet. Il s'agit d'une étude de cohorte basée sur une population et non d'un essai clinique.

A Propensity Score-weighted Comparison of Outcomes Between Living and Standard Criteria Deceased Donor Kidney Transplant Recipients.

BACKGROUND: Consider a theoretical situation in which 2 patients with similar baseline characteristics receive a kidney transplant on the same day: 1 from a standard criteria deceased donor, the other from a living donor. Which kidney transplant will last longer? METHODS: We conducted a population-based cohort study using linked administrative healthcare databases from Ontario, Canada, from January 1, 2005, to March 31, 2014, to evaluate several posttransplant outcomes in individuals who received a kidney transplant from a standard criteria deceased donor (n = 1523) or from a living donor (n = 1373). We used PS weighting using overlap weights, a novel weighting method that emphasizes the population of recipients with the most overlap in baseline characteristics. RESULTS: Compared with recipients of a living donor, the rate of all-cause graft failure was not statistically higher for recipients of a standard criteria deceased donor (hazard ratio, 1.1; 95% confidence interval [CI], 0.8-1.6). Recipients of a standard criteria deceased donor, compared with recipients of a living donor had a higher rate of delayed graft function (23.6% versus 18.7%; odds ratio, 1.3; 95% CI, 1.0-1.6) and a longer length of stay for the kidney transplant surgery (mean difference, 1.7 d; 95% CI, 0.5-3.0). CONCLUSIONS: After accounting for many important donor and recipient factors, we failed to observe a large difference in the risk of all-cause graft failure for recipients of a standard criteria deceased versus living donor. Some estimates were imprecise, which meant we could not rule out the presence of smaller clinically important effects.

Alpha-Blocker Use and the Risk of Hypotension and Hypotension-Related Clinical Events in Women of Advanced Age.

Alpha-blockers (ABs) are commonly prescribed as part of a multidrug regimen in the management of hypertension. We set out to assess the risk of hypotension and related adverse events with AB use compared with other blood pressure (BP) lowering drugs using a population-based, retrospective cohort study of women (≥66 years) between 1995 and 2015 in Ontario, Canada. Cox proportional hazards examined the association of AB use and hypotension and related events (syncope, fall, and fracture) compared with other BP lowering drugs matched via a high dimensional propensity score. The primary outcome was a composite of hospitalizations for hypotension and related events (syncope, fractures, and falls) within 1 year. From 734 907 eligible women, 14 106 were dispensed an AB (mean age, 75.7; standard deviation 6.9 years, median follow-up 1 year) and matched to 14 106 dispensed other BP lowering agents. The crude incidence rate of hypotension and related events was 95.7 (95% CI [confidence interval], 90.4-101.1, events 1214 [8.6%]) with AB and 79.8 (95% CI, 74.9-84.7 per 1000 person-years, events 1025 [7.3%]) with other BP lowering medications (incident rate ratio, 1.20; 95% CI, 1.10-1.30). The risk was higher for hypotension (hazard ratio, 1.71; 95% CI, 1.33-2.20) and syncope (hazard ratio, 1.44; 95% CI, 1.18-1.75) with no difference in falls, fractures, adverse cardiac events, or all-cause mortality. Treatment of hypertension in women with ABs is associated with a higher risk of hypotension and hypotension-related events compared with other BP lowering agents. Our findings suggest that ABs should be used with caution, even as add on therapy for hypertension.

Mortality in Incident Maintenance Dialysis Patients Versus Incident Solid Organ Cancer Patients: A Population-Based Cohort.

RATIONALE & OBJECTIVE: The mortality rate is high among dialysis patients, but how this compares with other diseases such as cancer is poorly understood. We compared the survival of maintenance dialysis patients with that for patients with common cancers to enhance the understanding of the burden of end-stage kidney disease. STUDY DESIGN: Population-based cohort study. SETTING & PARTICIPANTS: 33,500 incident maintenance dialysis patients in Ontario, Canada, and 532,452 incident patients with cancer (women: breast, colorectal, lung, or pancreas; men: prostate, colorectal, lung, or pancreas) from 1997 to 2015 using administrative health care databases. EXPOSURE: Incident kidney failure treated with maintenance dialysis versus incident diagnoses of cancer. OUTCOME: All-cause mortality. ANALYTICAL APPROACH: Kaplan-Meier product limit estimator was used to describe the survival of subgroups of study participants. Extended Cox regression with a Heaviside function was used to compare survival between patients with incident kidney failure treated with maintenance dialysis and individual diagnoses of various incident cancers. RESULTS: In men, dialysis had worse unadjusted 5-year survival (50.8%; 95% CI, 50.1%-51.6%) compared with prostate (83.3%; 95% CI, 83.1%-83.5%) and colorectal (56.1%; 95% CI, 55.7%-56.5%) cancer, but better survival than lung (14.0%; 95% CI, 13.7%-14.3%) and pancreas (9.1%; 95% CI, 8.5%-9.7%) cancer. In women, dialysis had worse unadjusted 5-year survival (49.8%; 95% CI, 48.9%-50.7%) compared with breast (82.1%; 95% CI, 81.9%-82.4%) and colorectal (56.8%; 95% CI, 56.3%-57.2%) cancer, but better survival than lung (19.7%; 95% CI, 19.4%-20.1%) and pancreas (9.4%; 95% CI, 8.9%-10.0%) cancer. After adjusting for clinical characteristics, similar results were found except when examining men and women with lung and pancreas cancer, for which dialysis patients had a higher rate of death 4 or more years after diagnosis. Women and men 70 years and older with incident kidney failure treated with maintenance dialysis had unadjusted 10-year survival probabilities that were comparable to pancreas and lung cancer. LIMITATIONS: Cancer stage could be obtained for only a subpopulation. CONCLUSIONS: Survival in incident dialysis patients was lower than in patients with several different solid-organ cancers. These results highlight the need to develop interventions to improve survival on dialysis therapy and can be used to aid advance care planning for elderly patients beginning treatment with maintenance dialysis.

Socioeconomic Status and Kidney Transplant Outcomes in a Universal Healthcare System: A Population-based Cohort Study.

BACKGROUND: Conflicting evidence exists regarding the relationship between socioeconomic status (SES) and outcomes after kidney transplantation. METHODS: We conducted a population-based cohort study in a publicly funded healthcare system using linked administrative healthcare databases from Ontario, Canada to assess the relationship between SES and total graft failure (ie, return to chronic dialysis, preemptive retransplantation, or death) in individuals who received their first kidney transplant between 2004 and 2014. Secondary outcomes included death-censored graft failure, death with a functioning graft, all-cause mortality, and all-cause hospitalization (post hoc outcome). RESULTS: Four thousand four hundred-fourteen kidney transplant recipients were included (median age, 53 years; 36.5% female), and the median (25th, 75th percentile) follow-up was 4.3 (2.1-7.1) years. In an unadjusted Cox proportional hazards model, each CAD $10000 increase in neighborhood median income was associated with an 8% decline in the rate of total graft failure (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.87-0.97). After adjusting for recipient, donor, and transplant characteristics, SES was not significantly associated with total or death-censored graft failure. However, each CAD $10000 increase in neighborhood median income remained associated with a decline in the rate of death with a functioning graft (adjusted (a)HR, 0.91; 95% CI, 0.83-0.98), all-cause mortality (aHR, 0.92; 95% CI, 0.86-0.99), and all-cause hospitalization (aHR, 0.95; 95% CI, 0.92-0.98). CONCLUSIONS: In conclusion, in a universal healthcare system, SES may not adversely influence graft health, but SES gradients may negatively impact other kidney transplant outcomes and could be used to identify patients at increased risk of death or hospitalization.

The Association of Kidney Function and Albuminuria With the Risk and Outcomes of Syncope: A Population-Based Cohort Study.

BACKGROUND: The risks and subsequent outcomes of syncope among seniors with chronic kidney disease (CKD) are unclear. METHODS: We conducted a population-based retrospective cohort study of 272,146 patients ≥ 66 years old, in Ontario, Canada, from April 1, 2006, to March 31, 2016. Using administrative health care databases, we examined the association of estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (ACR) with incident syncope and the association of incident syncope with the composite outcome of myocardial infarction, stroke, and death by levels of eGFR/ACR, using adjusted Cox proportional hazards models. RESULTS: A total of 15,074 incident syncopal events occurred during the study period. The adjusted risk for syncope was higher with a lower eGFR and higher ACR in a stepwise manner (eGFR 60 to < 90: HR 1.17 [1.09-1.26] vs eGFR < 30: HR 1.67 (1.50-1.87) with eGFR ≥ 90 referent; ACR > 30: HR 1.15 [1.07-1.24] with ACR < 3 referent). Among the 12,710 patients with a first syncope event and 1 year of follow-up, the adjusted risk for the composite outcome was higher with a lower eGFR and higher ACR in a stepwise manner (eGFR 60 to < 90: HR 1.05 [0.90-1.22] vs eGFR < 30: HR 1.62 [1.34-1.96] with eGFR ≥ 90 referent; ACR > 30: HR 1.77 [1.60-1.96], ACR < 3 referent). CONCLUSIONS: A lower eGFR and higher ACR are associated with a higher risk of a hospital encounter for syncope and of related complications among persons of advanced age.

Predicting 3-Year Survival in Patients Receiving Maintenance Dialysis: An External Validation of iChoose Kidney in Ontario, Canada.

BACKGROUND: Many patients with end-stage kidney disease (ESKD) do not appreciate how their survival may differ if treated with a kidney transplant compared with dialysis. A risk calculator (iChoose Kidney) developed and validated in the United States provides individualized mortality estimates for different treatment options (dialysis vs living or deceased donor kidney transplantation). The calculator can be used with patients and families to help patients make more educated treatment decisions. OBJECTIVE: To validate the iChoose Kidney risk calculator in Ontario, Canada. DESIGN: External validation study. SETTING: We used several linked administrative health care databases from Ontario, Canada. PATIENTS: We included 22 520 maintenance dialysis patients and 4505 kidney transplant recipients. Patients entered the cohort between 2004 and 2014. MEASUREMENTS: Three-year all-cause mortality. METHODS: We assessed model discrimination using the C-statistic. We assessed model calibration by comparing the observed versus predicted mortality risk and by using smoothed calibration plots. We used multivariable logistic regression modeling to recalibrate model intercepts using a correction factor, when appropriate. RESULTS: In our final version of the iChoose Kidney model, we included the following variables: age (18-80 years), sex (male, female), race (white, black, other), time on dialysis (<6 months, 6-12 months, >12 months), and patient comorbidities (hypertension, diabetes, and/or cardiovascular disease). Over the 3-year follow-up period, 33.3% of dialysis patients and 6.2% of kidney transplant recipients died. The discriminatory ability was moderate (C-statistic for dialysis: 0.70, 95% confidence interval [CI]: 0.69-0.70, and C-statistic for transplant: 0.72, 95% CI: 0.69-0.75). The 3-year observed and predicted mortality estimates were comparable and even more so after we recalibrated the intercepts in 2 of our models (dialysis and deceased donor kidney transplantation). As done in the United States, we developed a Canadian Web site and an iOS application called Dialysis vs. Kidney Transplant- Estimated Survival in Ontario. LIMITATIONS: Missing data in our databases precluded the inclusion of all variables that were in the original iChoose Kidney (ie, patient ethnicity and low albumin). We were unable to perform all preplanned analyses due to the limited sample size. CONCLUSIONS: The original iChoose Kidney risk calculator was able to adequately predict mortality in this Canadian (Ontario) cohort of ESKD patients. After minor modifications, the predictive accuracy improved. The Dialysis vs. Kidney Transplant- Estimated Survival in Ontario risk calculator may be a valuable resource to help ESKD patients make an informed decision on pursuing kidney transplantation.

CONTEXTE: Plusieurs patients atteints d'insuffisance rénale terminale (IRT) ignorent à quel point leurs chances de survie varient selon qu'ils sont traités par dialyse ou par une greffe rénale. Un modèle de prévision des risques (l'outil de calcul iChoose Kidney), développé et validé aux États-Unis, fournit une estimation personnalisée des chances de survie selon les différentes modalités de traitement (dialyse ou greffe d'un rein provenant d'un donneur vivant ou décédé). L'outil de calcul peut être employé par les patients et leurs familles pour les aider à prendre une décision plus éclairée au sujet du traitement. OBJECTIF DE L'ÉTUDE: Valider l'outil de calcul iChoose Kidney dans une cohorte de patients de l'Ontario, au Canada. TYPE D'ÉTUDE: Une étude de validité externe. CADRE DE L'ÉTUDE: Plusieurs bases de données couplées du système de santé ontarien (Canada). PATIENTS: Un total de 22 520 patients dialysés et de 4 505 receveurs d'une greffe de rein ont été inclus entre 2004 et 2014. MESURES: La mortalité toutes causes sur une période de trois (3) ans. MÉTHODOLOGIE: Nous avons évalué le pouvoir discriminant du modèle à l'aide de la statistique C. L'étalonnage du modèle a été établi en comparant les risques de mortalité observé et prédit, et à l'aide de courbes d'étalonnage lissées. Des modèles de régression logistique multivariés ont été employés pour réétalonner les valeurs à l'origine en utilisant au besoin un facteur de correction. RÉSULTATS: Notre version définitive du modèle de prévision inclut les variables suivantes : l'âge du patient (18 à 80 ans), son genre, sa race (blanc, noir, autre), son expérience en dialyse (moins de 6 mois, entre 6 et 12 mois, plus de 12 mois) et ses comorbidités (hypertension, diabète et maladies cardiovasculaires). Au cours des trois ans de suivi, 33,3 % des patients dialysés et 6,2 % des receveurs d'une greffe sont décédés. Le pouvoir discriminant s'est avéré modéré avec une valeur de statistique C de 0,70 (IC 95 % : 0,69-0,70) pour la dialyse et de 0,72 (IC 95 % : 0,69-0,75) pour les greffes. Les taux de mortalité observé et estimé au cours des trois ans étaient comparables, et davantage après le réétalonnage des valeurs à l'origine dans deux de nos modèles (dialyse et receveur d'un rein d'un donneur décédé). Comme aux États-Unis, nous avons développé un site Web et une application iOS canadiens nommés Dialysis vs. Kidney Transplant-Estimated Survival in Ontario. LIMITES: Des informations manquantes dans les bases de données consultées nous ont empêchés de tenir compte de toutes les variables incluses dans le modèle iChoose Kidney original, notamment l'origine ethnique du patient et les valeurs d'albuminurie. De plus, la taille restreinte de l'échantillon ne nous a pas permis de procéder à toutes les analyses prévues. CONCLUSION: La version originale du modèle de prévision des risques iChoose Kidney a prédit adéquatement le risque de mortalité dans une cohorte de patients ontariens atteints d'IRT. La précision du pouvoir prédictif du modèle s'est améliorée à la suite d'ajustements mineurs. L'outil Dialysis vs. Kidney Transplant-Estimated Survival in Ontario pourrait ainsi devenir une ressource précieuse pour les patients ontariens atteints d'IRT, pour les aider à prendre une décision éclairée dans leur choix d'une modalité de traitement.

Trends in Early Hospital Readmission After Kidney Transplantation, 2002 to 2014: A Population-Based Multicenter Cohort Study.

BACKGROUND: Early hospital readmission (EHR) is associated with morbidity, mortality, and significant healthcare costs. However, trends over time in EHR events in kidney transplant recipients have not been examined. We conducted a population-based cohort study using linked healthcare databases from Ontario, Canada, to determine whether the EHR incidence has changed from 2002 to 2014 in kidney transplant recipients. METHODS: We defined EHR as an unplanned admission for any reason to an acute care hospital within 30 days of being discharged from the hospital for transplantation; admissions for elective procedures were excluded. RESULTS: We included 5437 kidney transplant recipients. More recently transplanted recipients (2011 to 2014 vs 2002 to 2004) were older and more likely to have coronary artery disease. A total of 1128 (20.7%) kidney transplant recipients experienced an EHR. There was no trend in EHR across eras with a 30-day cumulative incidence of 23.0%, 21.4%, 18.4%, and 21.0% (P for trend =0.197) for the years 2002 to 2004, 2005 to 2007, 2008 to 2010, and 2011 to 2014, respectively. In the multivariable Cox proportional hazards model, we found no association between era of transplant and EHR. When examining variation in EHR across the 6 adult transplant centers, we found the 30-day cumulative incidence varied significantly from 15.5% to 27.1% (P < 0.001). CONCLUSIONS: One in 5 kidney transplant recipients will experience an EHR; however, an increase in EHR over time has not been observed despite increasing recipient age and comorbidities.

Incident Atrial Fibrillation and the Risk of Congestive Heart Failure, Myocardial Infarction, End-Stage Kidney Disease, and Mortality Among Patients With a Decreased Estimated GFR.

BACKGROUND: The association of atrial fibrillation (AF), estimated glomerular filtration rate (eGFR), and adverse events remains unknown. STUDY DESIGN: Population-based retrospective cohort study from Ontario, Canada. SETTING & PARTICIPANTS: 1,422,978 adult residents with eGFRs < 90mL/min/1.73m2 from April 1, 2006, through March 31, 2015. FACTOR: A diagnosis of AF at hospitalization. OUTCOMES: Congestive heart failure (CHF), myocardial infarction (MI), end-stage kidney disease, all-cause mortality. RESULTS: All adverse events were more frequent in individuals with AF (93,414 propensity score matched) compared to no AF, and this difference was more pronounced within the first 6 months of the index date (CHF: 3.04% [AF] vs 0.28% [no AF], subdistribution HR [sHR] of 11.57 [95% CI, 10.26-13.05]; MI: 0.97% [AF] vs 0.21% [no AF], sHR of 4.76 [95% CI, 4.17-5.43]; end-stage kidney disease: 0.16% [AF] vs 0.03% [no AF], sHR of 5.84 [95% CI, 3.82-8.93]; and all-cause mortality: 6.11% [AF] vs 2.50% [no AF], HR of 2.62 [95% CI, 2.50-2.76]) than in the period more than 6 months after the index date (CHF: 6.87% [AF] vs 2.87% [no AF], sHR of 2.64 [95% CI, 2.55-2.74]; MI: 2.21% [AF] vs 1.81% [no AF], sHR of 1.24 [95% CI, 1.18-1.30]; end-stage kidney disease: 0.52% [AF] vs 0.32% [no AF], sHR of 1.75 [95% CI, 1.57-1.95]; and all-cause mortality: 15.55% [AF] vs 15.10% [no AF], HR of 1.07 [95% CI, 1.04-1.10]). The results accounted for the competing risk for mortality. eGFR level modified the effect of AF on CHF (P for interaction < 0.05). LIMITATIONS: Observational study design does not permit determination of causality; only a single outpatient eGFR measure was used; medication data were not included. CONCLUSIONS: Incident AF is associated with a high risk for adverse outcomes in patients with eGFRs < 90mL/min/1.73m2. Because the risk is exceedingly high within the first 6 months after AF diagnosis, therapeutic interventions and monitoring may improve outcomes.

Risk of Venous Thromboembolism in Patients by Albuminuria and Estimated GFR.

BACKGROUND: The risk for venous thromboembolism (VTE) is elevated with albuminuria or a low estimated glomerular filtration rate (eGFR). However, the VTE risk due to the combined effects of eGFR and albuminuria are unknown. STUDY DESIGN: Population-based cohort study. SETTINGS & PARTICIPANTS: 694,956 adults in Ontario, Canada, from 2002 to 2012. FACTORS: eGFR and albumin-creatinine ratio (ACR). OUTCOME: VTE. RESULTS: 15,180 (2.2%) VTE events occurred during the study period. Both albuminuria and eGFR were independently associated with VTE. The association of albuminuria and VTE differed by level of eGFR (P for ACR × eGFR interaction < 0.001). After considering the competing risk for death, there was a 61% higher rate of VTE in patients with normal eGFRs (eGFRs>90mL/min/1.73m2) and heavy albuminuria (ACR>300mg/g) compared with those with normal eGFRs and no albuminuria (subdistribution HR, 1.61; 95% CI, 1.38-1.89). Among those with reduced kidney function (eGFR, 15-29mL/min/1.73m2), the risk for VTE was only minimally increased, irrespective of albuminuria (subdistribution HRs of 1.23 [95% CI, 1-1.5] and 1.09 [95% CI, 0.82-1.45] for ACR<30 and >300mg/g, respectively). LIMITATIONS: Only single determinations of ACR and eGFR were used. Diagnostic/International Classification of Diseases codes were used to define VTE. CONCLUSIONS: Albuminuria increases the risk for VTE markedly in patients with normal eGFRs compared with those with lower eGFRs.

Evaluation of a Hockey Deceased Organ Donation Awareness Campaign: A Population-Based Cohort Study.

BACKGROUND: The Kidney Foundation of Canada developed a pilot campaign to educate persons attending junior hockey league games in London, Ontario, Canada, on deceased organ donation. OBJECTIVE: To evaluate the impact of a hockey campaign on the number of new organ and tissue donor registrants. DESIGN: Population-based retrospective cohort study. SETTING: Residents of London, Ontario. PATIENTS: We included 255 476 individuals eligible to register for organ donation with a London, Ontario postal code. MEASUREMENTS: We compared the number of new deceased organ donor registrants in London, Ontario, during the campaign period (March 12 to April 16, 2015) with 3 different time periods (December 30, 2014 to February 3, 2015; February 4 to March 11, 2015; April 17 to May 22, 2015). We also compared registration rates in London with 2 Ontario cities (Kitchener-Waterloo and Hamilton) matching in a 1:1 ratio on age, sex, and income quintile. METHODS: To compare registrations across time periods, we used binomial regression with an identity link function and generalized estimating equations with an independence correlation structure. We used modified Poisson regression to compare registration rates between cities. RESULTS: During the campaign period, there were slightly more registrations (1218 registered of 252 832 unregistered individuals [0.48%]) compared with an earlier time period (risk difference: 0.09%; 95% confidence interval [CI]: 0.05%-0.12%). However, there was no significant difference compared with 2 time periods immediately before and after the campaign. London had slightly more registrations during the campaign period compared with the matched city of Hamilton (1180 registered of 236 582 unregistered individuals [0.50%] vs 490 registered of 236 582 unregistered individuals [0.21%]; risk ratio: 2.41; 95% CI: 2.17-2.68). The registration rate in London did not significantly differ from Kitchener-Waterloo. LIMITATIONS: Unable to conclude whether the minor increase in deceased organ donor registration was the result of the campaign or other factors (e.g., simultaneous organ registration events, seasonality). CONCLUSIONS: Overall, a minor increase in deceased organ donor registration was observed during the hockey organ donation awareness campaign; however, the specific impact of the campaign on organ donor registration could not be determined.

CONTEXTE: La Fondation canadienne du rein a développé une campagne pilote pour sensibiliser les gens qui assistent à des matchs de hockey junior à London en Ontario (Canada) sur le don d'organes post-mortem. OBJECTIF DE L'ÉTUDE: Évaluer l'impact qu'une campagne de sensibilisation auprès des gens assistant à des parties de hockey pouvait avoir sur le nombre de nouvelles inscriptions à la liste des donneurs d'organes et de tissus. TYPE D'ÉTUDE: Il s'agit d'une étude rétrospective de cohorte menée au sein de la population. CADRE DE L'ÉTUDE: L'étude a été réalisée auprès de résidents de London en Ontario. PARTICIPANTS: Nous avons inclus un total de 255 476 individus ayant un code postal inscrit à London en Ontario et qui étaient admissibles à faire un don d'organe. MESURES: Nous avons répertorié le nombre de nouvelles inscriptions à la liste de donneurs d'organes à London en Ontario au cours de la période de la campagne, soit du 12 mars au 16 avril 2015. Nous avons comparé ce résultat aux nombres de nouvelles inscriptions obtenus lors de trois autres périodes, soit du 30 décembre 2014 au 3 février 2015; du 4 février au 11 mars 2015 et du 17 avril au 22 mai 2015. De plus, nous avons comparé le taux de nouvelles inscriptions de London à celui de deux autres villes de l'Ontario, soit Kitchener-Waterloo et Hamilton. La comparaison a été établie selon un ratio de 1:1 où les participants étaient appariés sur la base de leur âge, de leur sexe et de leur revenu. MÉTHODOLOGIE: Pour comparer le nombre de nouvelles inscriptions entre les périodes choisies, nous avons utilisé un modèle de régression binomiale comportant une fonction de lien d'identité, de même que des équations d'estimation généralisées avec structure de corrélation de l'indépendance. Une version modifiée du modèle de régression de Poisson a été utilisée pour comparer les taux d'inscription entre les villes. RÉSULTATS: Au cours de la campagne de sensibilisation, nous avons observé une faible hausse des inscriptions (1 218 nouvelles inscriptions [0,48%]) par rapport à une période antérieure (différence de risque: 0,09%; IC 95%: 0,05% - 0,12%). Cependant, aucune différence significative n'a été observée par rapport aux périodes immédiatement avant et après la campagne de sensibilisation. Un nombre légèrement plus élevé d'inscriptions a eu lieu dans la ville de London pour la période étudiée par rapport à la ville de Hamilton (1 180 inscrits et 236 582 non-inscrits [0,50%] contre 490 inscrits et 236 582 non-inscrits [0,21%]; risque relatif = 2,41; IC 95% = 2,17-2,68). Aucune différence significative n'a été observée entre le taux d'inscription à London et celui de Kitchener-Waterloo. LIMITES DE L'ÉTUDE: Il a été impossible de déterminer si la campagne de sensibilisation a contribué à la légère augmentation du nombre d'inscriptions à la liste de donneurs d'organes post-mortem ou si celle-ci résulte d'autres facteurs (p. ex. événements spontanés d'inscriptions à la liste des donneurs, caractère saisonnier). CONCLUSIONS: Dans l'ensemble, une légère augmentation du nombre d'inscriptions à la liste des donneurs d'organes post-mortem a été observée au cours de la campagne de sensibilisation menée pendant les parties de hockey. Toutefois, il a été impossible d'établir si la campagne de sensibilisation a eu un effet réel sur le nombre d'inscriptions.

Association of Proteinuria and Incident Atrial Fibrillation in Patients With Intact and Reduced Kidney Function.

BACKGROUND: Early evidence suggests proteinuria is independently associated with incident atrial fibrillation (AF). We sought to investigate whether the association of proteinuria with incident AF is altered by kidney function. METHODS AND RESULTS: Retrospective cohort study using administrative healthcare databases in Ontario, Canada (2002-2015). A total of 736 666 patients aged ≥40 years not receiving dialysis and with no previous history of AF were included. Proteinuria was defined using the urine albumin-to-creatinine ratio (ACR) and kidney function by the estimated glomerular filtration rate (eGFR). The primary outcome was time to AF. Cox proportional models were used to determine the hazard ratio for AF censored for death, dialysis, kidney transplant, or end of follow-up. Fine and Grey models were used to determine the subdistribution hazard ratio for AF, with death as a competing event. Median follow-up was 6 years and 44 809 patients developed AF. In adjusted models, ACR and eGFR were associated with AF (P<0.0001). The association of proteinuria with AF differed based on kidney function (ACR × eGFR interaction, P<0.0001). Overt proteinuria (ACR, 120 mg/mmol) was associated with greater AF risk in patients with intact (eGFR, 120) versus reduced (eGFR, 30) kidney function (adjusted hazard ratios, 4.5 [95% CI, 4.0-5.1] and 2.6 [95% CI, 2.4-2.8], respectively; referent ACR 0 and eGFR 120). Results were similar in competing risk analyses. CONCLUSIONS: Proteinuria increases the risk of incident AF markedly in patients with intact kidney function compared with those with decreased kidney function. Screening and preventative strategies should consider proteinuria as an independent risk factor for AF.

Increasing the Rate of Living Donor Kidney Transplantation in Ontario: Donor- and Recipient-Identified Barriers and Solutions.

PURPOSE OF REVIEW: To hear from living kidney donors and recipients about what they perceive are the barriers to living donor kidney transplantation, and how patients can develop and lead innovative solutions to increase the rate and enhance the experiences of living donor kidney transplantation in Ontario. SOURCES OF INFORMATION: A one-day patient-led workshop on March 10th, 2016 in Toronto, Ontario. METHODS: Participants who were previously engaged in priority-setting exercises were invited to the meeting by patient lead, Sue McKenzie. This included primarily past kidney donors, kidney transplant recipients, as well as researchers, and representatives from renal and transplant health care organizations across Ontario. KEY FINDINGS: Four main barriers were identified: lack of education for patients and families, lack of public awareness about living donor kidney transplantation, financial costs incurred by donors, and health care system-level inefficiencies. Several novel solutions were proposed, including the development of a peer network to support and educate patients and families with kidney failure to pursue living donor kidney transplantation; consistent reimbursement policies to cover donors' out-of-pocket expenses; and partnering with the paramedical and insurance industry to improve the efficiency of the donor and recipient evaluation process. LIMITATIONS: While there was a diversity of experience in the room from both donors and recipients, it does not provide a complete picture of the living kidney donation process for all Ontario donors and recipients. The discussion was provincially focused, and as such, some of the solutions suggested may already be in practice or unfeasible in other provinces. IMPLICATIONS: The creation of a patient-led provincial council was suggested as an important next step to advance the development and implementation of solutions to overcome patient-identified barriers to living donor kidney transplantation.

OBJECTIFS DE LA REVUE: Obtenir l'avis des donneurs de rein et des receveurs d'une greffe ontariens sur ce qu'ils considèrent comme des obstacles aux transplantations rénales provenant d'un donneur vivant, et sur la manière dont les patients pourraient élaborer et mener à bien des solutions innovantes pour accroître le nombre de greffes et améliorer l'expérience d'un donneur vivant à la suite d'une transplantation rénale. SOURCES: Les données ont été recueillies lors d'un atelier d'une journée dirigé par les patients, qui s'est tenu le 10 mars 2016 à Toronto (Ontario). MÉTHODOLOGIE: Les participants, qui s'étaient préalablement livrés à des exercices visant à définir des priorités, ont été invités à prendre part à l'atelier présidé par Sue McKenzie, une patiente. Le groupe de participants était constitué en premier lieu de donneurs de reins et de receveurs d'une greffe, mais également de chercheurs et de représentants de divers organismes en soins de santé rénale et en transplantation de partout en Ontario. PRINCIPALES CONCLUSIONS: Quatre principaux obstacles ont été identifiés : le manque d'information destinée aux patients et à leurs familles, le manque de sensibilisation auprès du public relativement aux donneurs vivants, les frais financiers encourus par les donneurs et, de façon globale, les inefficacités en matière de soins dans le système de santé. Plusieurs solutions ont été proposées lors de l'atelier, notamment l'élaboration d'un réseau de pairs visant à supporter les patients souffrant d'insuffisance rénale ainsi que leur famille et à les informer au sujet de la transplantation avec un donneur vivant. On a également proposé l'adoption de politiques de remboursement pour couvrir les frais encourus par les donneurs et l'établissement de partenariats entre le paramédical et les compagnies d'assurances afin d'améliorer l'efficacité du processus d'évaluation donneur-receveur. LIMITES: Malgré la diversité des expériences vécues par les donneurs et les receveurs présents dans la salle, l'ensemble des réponses ne fournit pas un portrait complet du processus de don de rein vivant qui soit représentatif de tous les donneurs et receveurs de l'Ontario. La discussion portait sur des obstacles et des solutions spécifiques à la situation en Ontario. Par conséquent, il est possible que certaines des solutions apportées soient déjà en pratique ou au contraire, s'avèrent impossibles dans d'autres provinces. CONCLUSIONS: La création d'un conseil provincial, mené par un patient ou une patiente, a été proposée comme étant la prochaine étape cruciale pour faire progresser la conception et la mise en œuvre de solutions concrètes permettant de surmonter les obstacles à la transplantation rénale avec donneur vivant qu'ont identifiés les patients.

The association of anticoagulation, ischemic stroke, and hemorrhage in elderly adults with chronic kidney disease and atrial fibrillation.

The utility of anticoagulants for ischemic stroke prophylaxis in elderly patients with chronic kidney disease (CKD) and atrial fibrillation remains uncertain. In this population-based retrospective cohort study, we determined the association of anticoagulant use with ischemic stroke or hemorrhage in elderly patients (66 years and older) with advanced chronic kidney disease (eGFR under 45 ml/min/1.73m2) and atrial fibrillation. We followed 6,544 patients with CKD and new onset atrial fibrillation, of whom 1,475 filled a prescription for an anticoagulant. We used propensity-score matched Cox proportional hazards and competing risk models to determine the time to first event of ischemic stroke, hemorrhage or mortality. After matching to examine exposure to anticoagulants, 1,417 matched pairs were identified. The crude rate of ischemic stroke and hemorrhage were 41.3 and 61.3 with anticoagulants and 34.4 and 34.3 without anticoagulants per 100 person-years, respectively. The hazard ratios of ischemic stroke, hemorrhage, and mortality for receipt of an anticoagulation prescription were 1.10 (95% confidence interval, 0.78-1.56), 1.42 (1.04-1.93), and 0.74 (0.62-0.88) as compared to non-receipt of anticoagulation. After accounting for the competing risk of death, the hazard ratios for ischemic stroke and hemorrhage were 1.12 (0.90-1.39) and 1.60 (1.31-1.97), respectively. The findings were consistent in a sensitivity analysis accounting for time varying anticoagulant exposure. Thus, in older patients with CKD and atrial fibrillation, receipt of an anticoagulant was not associated with a lower risk of ischemic stroke, but a higher risk of hemorrhage and a lower risk of mortality.