The need for individualizing teaching and assurance of knowledge transmission to patients training for home dialysis.

Patients have varied learning styles and this has implications for home haemodialysis (HHD). Assessment tools directed toward understanding these styles remains understudied. As a consequence, this may lead to substandard retention rates or adverse events in HHD programs. As part of a continuous quality improvement initiative we have aimed to improve our understanding of patient learning styles and consequently tailor home dialysis training to individuals. To objectively determine knowledge translation and comprehension, irrespective of learning styles, we have introduced an objective structured clinical examination (OSCE). This assessment tool allows for further refinement of educational priorities by highlighting both deficiencies and strengths. Thereafter, an exit OSCE ensures patients attain an acceptable standard to complete home haemodialysis independently. We hope this tool will help shape future training criteria for HHD programs and consequently reduce adverse event rates.

International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in North America and the Caribbean.

The International Society of Nephrology established the Global Kidney Health Atlas project to define the global capacity for kidney replacement therapy and conservative kidney care, and this second iteration was to describe the availability, accessibility, quality, and affordability of kidney failure (KF) care worldwide. This report presents results for the International Society of Nephrology North America and the Caribbean region. Relative to other regions, the North America and Caribbean region had better infrastructure and funding for health care and more health care workers relative to the population. Various essential medicines were also more available and accessible. There was substantial variation in the prevalence of treated KF in the region, ranging from 137.4 per million population (pmp) in Jamaica to 2196 pmp in the United States. A mix of public and private funding systems cover costs for nondialysis chronic kidney disease care in 60% of countries and for dialysis in 70% of countries. Although the median number of nephrologists is 18.1 (interquartile range, 15.3-29.5) pmp, which is approximately twice the global median of 9.9 (interquartile range, 1.2-22.7) pmp, some countries reported shortages of other health care workers. Dialysis was available in all countries, but peritoneal dialysis was underutilized and unavailable in Barbados, Cayman Islands, and Turks and Caicos. Kidney transplantation was primarily available in Canada and the United States. Economic factors were the major barriers to optimal KF care in the Caribbean countries, and few countries in the region have chronic kidney disease-specific national health care policies. To address regional gaps in KF care delivery, efforts should be directed toward augmenting the workforce, improving the monitoring and reporting of kidney replacement therapy indicators, and implementing noncommunicable disease and chronic kidney disease-specific policies in all countries.

Workforce capacity for the care of patients with kidney failure across world countries and regions.

INTRODUCTION: An effective workforce is essential for optimal care of all forms of chronic diseases. The objective of this study was to assess workforce capacity for kidney failure (KF) care across world countries and regions. METHODS: Data were collected from published online sources and a survey was administered online to key stakeholders. All country-level data were analysed by International Society of Nephrology region and World Bank income classification. RESULTS: The general healthcare workforce varies by income level: high-income countries have more healthcare workers per 10 000 population (physicians: 30.3; nursing personnel: 79.2; pharmacists: 7.2; surgeons: 3.5) than low-income countries (physicians: 0.9; nursing personnel: 5.0; pharmacists: 0.1; surgeons: 0.03). A total of 160 countries responded to survey questions pertaining to the workforce for the management of patients with KF. The physicians primarily responsible for providing care to patients with KF are nephrologists in 92% of countries. Global nephrologist density is 10.0 per million population (pmp) and nephrology trainee density is 1.4 pmp. High-income countries reported the highest densities of nephrologists and nephrology trainees (23.2 pmp and 3.8 pmp, respectively), whereas low-income countries reported the lowest densities (0.2 pmp and 0.1 pmp, respectively). Low-income countries were most likely to report shortages of all types of healthcare providers, including nephrologists, surgeons, radiologists and nurses. CONCLUSIONS: Results from this global survey demonstrate critical shortages in workforce capacity to care for patients with KF across world countries and regions. National and international policies will be required to build a workforce capacity that can effectively address the growing burden of KF and deliver optimal care.

Long-Term Impact of Bariatric Surgery on Renal Outcomes at a Community-Based Publicly Funded Bariatric Program: The Regina Bariatric Study.

BACKGROUND: Obesity is recognized as an independent risk factor for chronic kidney disease through multiple direct and indirect biological pathways. Bariatric surgery is a proven, effective method for sustained weight loss. However, there is a relative paucity of data on the impact of bariatric surgery on renal outcomes. OBJECTIVE: The primary objective was to evaluate the change in urine albumin/creatinine ratio (ACR) in patients undergoing bariatric surgery, at 12 months after the procedure. Secondary objectives were to determine the changes in ACR at (6 and 24 months), estimated glomerular filtration rate (eGFR; 6, 12, and 24 months), and hemoglobin A1c (HbA1c); 12 and 24 months) after the procedure. DESIGN: This observational retrospective cohort study included consecutive obese patients who underwent bariatric surgery. SETTING: Provincial Bariatric Surgery Clinic at the Regina General Hospital, Saskatchewan. PATIENTS: This study includes 471 consecutive obese adult patients who underwent bariatric surgery between 2008 and 2015. MEASUREMENTS: We studied the impact of bariatric surgery on body mass index (BMI), renal outcomes (urine ACR and eGFR) and metabolic outcomes (fasting glucose, total cholesterol, low-density lipoprotein, triglycerides, and HbA1c) in 471 patients. METHODS: Patients were followed for 2 years postsurgery in the bariatric clinic. Mixed linear models that accounted for the repeated nature of the data were used to access changes in outcomes over time. RESULTS: Patients were predominantly female (81%) with a mean age (±SD) of 46 ± 10 years. Most patients (87%) had a BMI > 40 kg/m2 and 81% of the patients underwent Roux-en-Y gastric bypass. The mean BMI decreased from 47.7 ± 7.8 kg/m2 at baseline to 37.1 ± 7.9 kg/m2 at 6 months and 34.8 ± 8.8 kg/m2 at 12 months. In a subcohort of patients with microalbuminuria, ACR showed an improvement from a median [interquartile] value of 5.1 [3.7-7.5] mg/mmol at baseline to 2.3 [1.2-3.6] mg/mmol at 6 months (P = .007), to 1.4 [0.9-3.7] mg/mmol at 2-year follow-up (P < .001). Similarly, eGFR increased in patients with microalbuminuria from 109 ± 10 mL/min/1.73 m2 at baseline to 120 ± 36 mL/min/1.73 m2 at 2-year follow-up (P = .013). There were statistically significant reductions in triglycerides, fasting glucose, and HbA1c. LIMITATIONS: This was a retrospective chart review, with the lack of a control group. Patients with eGFR less than 60 mL/min/1.73 m2 were not considered for surgery, and we had to measure renal outcomes predominantly on the presence of proteinuria. CONCLUSIONS: Our results suggest bariatric surgery significantly decreased weight and consequently improved renal and metabolic outcomes (eGFR, ACR, fasting glucose, cholesterol, and triglycerides) in patients with elevated BMI.

CONTEXTE: L'obésité est reconnue comme un facteur de risque indépendant d'insuffisance rénale chronique (IRC) via de multiples voies biologiques directes et indirectes. La chirurgie bariatrique est une méthode efficace et éprouvée pour perdre du poids de façon durable. Or, il existe peu de données mesurant l'impact de cette intervention sur les issues rénales. OBJECTIFS: L'objectif principal était de mesurer la variation du rapport albumine/créatinine (RAC) urinaire chez des patients subissant une chirurgie bariatrique, 12 mois après l'intervention. On souhaitait aussi mesurer le RAC (6 mois et 24 mois), le débit de filtration glomérulaire estimé (DFGe) (6, 12 et 24 mois) et le taux d'hémoglobine glyquée (HbA1c) (12 et 24 mois) à intervalles réguliers après l'intervention. TYPE D'ÉTUDE: Étude de cohorte rétrospective observationnelle portant sur des patients obèses ayant subi une chirurgie bariatrique. CADRE: La clinique provinciale de chirurgie bariatrique du Regina General Hospital (Saskatchewan). SUJETS: Un total de 471 patients consécutifs ayant subi une chirurgie bariatrique entre 2008 et 2015. MESURES: Nous avons étudié l'impact de la chirurgie bariatrique sur l'indice de masse corporelle (IMC), les issues rénales (RAC, DFGe) et les résultats métaboliques (glycémie à jeun, cholestérol total) de 471 patients. MÉTHODOLOGIE: Les patients ont été suivis dans une clinique bariatrique jusqu'à deux ans après l'intervention. Des modèles mixtes linéaires tenant compte de la nature répétitive des données ont été employés pour évaluer les variations dans les résultats au fil du temps. RÉSULTATS: La cohorte était majoritairement féminine (81%) et l'âge moyen (±SD) se situait à 46 ± 10 ans. La majorité des sujets (87%) présentait un IMC supérieur à 40 kg/m2 et 81% des patients avaient subi une dérivation gastrique de type Roux-en-Y. L'IMC moyen est passé de 47,7 ± 7,8 kg/m2 (initial) à 37,1 ± 7,9 kg/m2 après 6 mois, et à 34,8 ± 8,8 kg/m2 après 12 mois. Dans une sous-cohorte de patients atteints de microalbuminurie, le RAC est passé d'une valeur médiane (EIQ) initiale de 5,1 [3,7-7,5] mg/mmol à 2,3 [1,2-3,6] mg/mmol après 6 mois (P = 0,007), et à 1,4 [0,9-3,7] mg/mmol après deux ans de suivi (P < 0,001). Parallèlement, dans cette même sous-cohorte, le DFGe est passé de 109 ± 10 mL/min/1,73 m2 (initial) à 120 ± 36 mL/min/1,73 m2 après deux ans de suivi (P = 0,013). Des réductions statistiquement significatives ont également été observées pour les triglycérides, la glycémie à jeun et l'HbA1c. LIMITES: Il s'agit d'une analyze de dossiers rétrospective sans groupe contrôle. Les patients avec un DFGe inférieur à 60 mL/min/1,73 m2 n'ont pas été pris en compte pour l'intervention et nous avons dû mesurer les issues rénales principalement en fonction de la présence d'une protéinurie. CONCLUSION: Nos résultats suggèrent que la chirurgie bariatrique entraîne une perte significative de poids et, conséquemment, une amélioration des issues rénales et métaboliques (DFGe, RAC, glycémie à jeun, taux de cholestérol et de triglycérides) chez les patients présentant un IMC élevé.

Renal tubular acidosis as the initial presentation of Sjögren's syndrome.

We present a 44-year-old female with an initial presentation with distal renal tubular acidosis (RTA) after she presented with hypokalaemia and normal anion gap acidosis. Three years following the diagnosis, she presented with progressive renal impairment. In the absence of any clinical, biochemical and radiological clues, she underwent a renal biopsy which showed severe tubulitis secondary to lymphocytic infiltration. Serological investigations subsequently revealed positive anti-nuclear, anti-Sjögren's syndrome related antigen A (SS-A), and anti-Sjögren's syndrome related antigen B (SS-B) antibodies, supporting the diagnosis of Sjögren's syndrome. This case is unique in that distal RTA was the presenting clinical manifestation of Sjögren's syndrome. We hope that a consideration for Sjögren's syndrome is made in patients with seemingly idiopathic RTA.

Simultaneous Clinical Presentation of Renal Cell Carcinoma and Immunoglobulin Light Chain Amyloidosis.

A 77-year-old female was admitted to the hospital for an evaluation of congestive heart failure. She gave a history of progressive peripheral edema over eight to 10 months, extending up to the knees bilaterally. Admitting creatinine was 148 mmol/L, serum albumin was 15g/L, and urine protein on quantification was 9.09 g/day. Her immunoglobulin G (IgG) level was 18.4g/L and serum-free kappa level was 92.3 mg/L. The immunofixation of urine revealed monoclonal IgG kappa (1.97 g/d). Her kidney biopsy subsequently confirmed the diagnosis of immunoglobulin light chain (AL) amyloidosis. During the course of investigations, it was incidentally noted that she had a mass on her right kidney, which on biopsy was identified as renal cell carcinoma (RCC). This case deals with the rare situation of AL amyloidosis existing with a solid organ carcinoma and the therapeutic dilemma of treating two unrelated conditions involving the kidneys.

Valacyclovir-associated neurotoxicity treated with intensification of peritoneal dialysis.

We report a 57-year-old woman with end-stage renal disease (ESRD) on maintenance peritoneal dialysis (PD), who presented to the emergency room (ER) by ambulance with complaints of confusion and altered sensorium for 48 hours. She had been reviewed in a walk-in clinic 72 hours earlier and had been prescribed the standard 1000 mg three times per day of valacyclovir for an acute attack of shingles instead of 500 mg once a day on ESRD. In the ER, she received further 500 mg of intravenous acyclovir as herpes encephalitis was clinically suspected. CT of the brain and lumbar puncture were non-contributory to the diagnosis. Valacyclovir and acyclovir were discontinued when the diagnosis of valacyclovir-associated neurotoxicity became clinically evident. As the patient's Glasgow Coma Scale declined, we intensified her PD regimen from one to six exchanges per day and 24 hours later there was a significant neurological improvement.

Drainless Abdominoplasty Using Barbed Progressive Tension Sutures.

We describe our current technique of drainless abdominoplasty using barbed progressive tension sutures. The perioperative management and detailed steps of procedure are outlined, including indications for concomitantly performing liposuction and repair of diastasis of the rectus abdominis muscles. This approach reliably improves abdominal contour, minimizes complications, and is straightforward to learn and perform.