Skin Staining Following Intravenous Iron Extravasation in a Patient With Chronic Kidney Disease: A Case Report.

Rationale: Intravenous iron is commonly use in anemia related to chronic kidney disease. Skin staining due to iron extravasation is a rare adverse reaction that can leave a long-term staining of the skin. Presenting Concerns of the Patients: During iron derisomaltose infusion, patient reported iron extravasation. Five months after the incident, the skin stain related to the extravasation was still present. Diagnosis: A case of skin staining due to iron derisomaltose extravasation was diagnosed. Interventions/Outcomes: She was reviewed by dermatology and laser therapy was offered. Teaching Points: Patients and clinicians need to be aware of this complication, and protocol needs to be put in place to minimize extravasation and its complication.

Justification: L'administration de fer par voie intraveineuse est une procédure courante pour traiter l'anémie liée à l'IRC. La coloration cutanée due à l'extravasation du fer est un effet indésirable rare qui peut perdurer à long terme. Présentation du cas: Une patiente ayant signalé une extravasation du fer au cours d'une perfusion de dérisomaltose ferrique. Cinq mois après l'incident, la coloration de la peau liée à l'extravasation était toujours présente. Diagnostic: Un diagnostic de coloration cutanée due à une extravasation de dérisomaltose ferrique a été posé. Interventions/Résultats: La patiente a été revue en dermatologie et une thérapie au laser lui a été offerte. Enseignements tirés: Les patients et les cliniciens doivent être au fait de cette possible complication. Un protocole doit être mis en place pour minimiser l'extravasation et sa complication.

Development and Validation of Patient Education Tools for Deprescribing in Patients on Hemodialysis.

Background: Deprescribing is a patient-centered solution to reducing polypharmacy in patients on hemodialysis (HD). In a deprescribing pilot study, patients were hesitant to participate due to limited understanding of their own medications and their unfamiliarity with the concept of deprescribing. Therefore, patient education materials designed to address these knowledge gaps can overcome barriers to shared decision-making and reduce hesitancy regarding deprescribing. Objective: To develop and validate a medication-specific, patient education toolkit (bulletin and video) that will supplement an upcoming nationwide deprescribing program for patients on HD. Methods: Patient education tools were developed based on the content of previously validated deprescribing algorithms and literature searches for patients' preferences in education. A preliminary round of validation was completed by 5 clinicians to provide feedback on the accuracy and clarity of the education tools. Then, 3 validation rounds were completed by patients on HD across 3 sites in Vancouver, Winnipeg, and Toronto. Content and face validity were evaluated on a 4-point and 5-point Likert scale, respectively. The content validity index (CVI) score was calculated after each round, and revisions were made based on patient feedback. Results: A total of 105 patients participated in the validation. All 10 education tools achieved content and face validity after 3 rounds. The CVI score was 1.0 for most of the tools, with 0.95 being the lowest value. Face validity ranged from 72% to 100%, with majority scoring above 90%. Conclusion: Ten patient education tools on deprescribing were developed and validated by patients on HD. These validated, medication-specific education tools are the first of its kind for patients on HD and will be used in a nationwide implementation study alongside the validated deprescribing algorithms developed by our research group.

Contexte: La déprescription est une solution axée sur le patient pour réduire la polypharmacie chez les patients sous hémodialyse (HD). Dans une étude pilote sur la déprescription, les patients ont hésité à participer en raison de leur compréhension limitée de leurs propres médicaments et de leur manque de connaissance du concept de déprescription. Par conséquent, du matériel éducatif conçu pour combler ces lacunes dans les connaissances des patients pourrait surmonter les obstacles à la prise de décision partagée et réduire les hésitations à l'égard de la déprescription. Objectifs: Développer et valider une trousse d'information (bulletin et vidéo) pour les patients portant sur les médicaments. Cette trousse viendra compléter un futur programme national de déprescription pour les patients sous HD. Méthodologie: Des outils d'éducation pour les patients ont été développés à partir du contenu d'algorithmes de déprescription validés précédemment et de recherches documentaires sur les préférences des patients en matière d'éducation. Une ronde préliminaire de validation a été complétée par cinq cliniciens afin d'obtenir des commentaires sur l'exactitude et la clarté des outils d'éducation. Trois cycles de validation ont ensuite été réalisés par des patients sous HD dans trois sites: Vancouver, Winnipeg et Toronto. La validité du contenu et la validité apparente ont été évaluées à l'aide d'échelles de Likert à 4 et 5 points, respectivement. L'indice de validité du contenu (IVC) a été calculé après chaque ronde et des révisions ont été effectuées en fonction des commentaires des patients. Résultats: En tout, 105 patients ont participé à la validation. La validité du contenu et la validité apparente ont été atteintes pour les dix outils d'éducation après trois rondes auprès des patients. L'IVC s'établissait à 1,0 pour la plupart des outils évalués; 0,95 était la valeur d'indice la plus faible. La validité apparente variait entre 72% et 100%, la majorité des outils ayant obtenu un score supérieur à 90%. Conclusion: Dix outils d'éducation pour les patients portant sur la déprescription ont été développés et validés par des patients sous HD. Ces outils d'éducation validés portant spécifiquement sur les médicaments sont les premiers du genre conçus pour les patients sous HD. Ils seront utilisés dans le cadre d'une étude nationale de mise en œuvre, parallèlement aux algorithmes validés de déprescription qui ont été développés par notre groupe de recherche.

Multifaceted Intervention to Increase the Use of Home Dialysis: A Cluster Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Home dialysis therapies (peritoneal and home hemodialysis) are less expensive and provide similar outcomes to in-center hemodialysis, but they are underutilized in most health systems. Given this, we designed a multifaceted intervention to increase the use of home dialysis. In this study, our objective was to evaluate the effect of this intervention on home dialysis use in CKD clinics across Canada. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a cluster randomized controlled trial in 55 CKD clinic clusters in nine provinces in Canada between October 2014 and November 2015. Participants included all adult patients who initiated dialysis in the year following the intervention. We evaluated the implementation of a four-component intervention, which included phone surveys from a knowledge translation broker, a 1-year center-specific audit/feedback on home dialysis use, delivery of an educational package (including tools aimed at both providers and patients), and an academic detailing visit. The primary outcome was the proportion of patients using home dialysis at 180 days after dialysis initiation. RESULTS: A total of 55 clinics were randomized (27 in the intervention and 28 in the control), with 5312 patients initiating dialysis in the 1-year follow-up period. In the primary analysis, there was no difference in the use of home dialysis at 180 days in the intervention and control clusters (absolute risk difference, 4%; 95% confidence interval, -2% to 10%). Using a difference-in-difference comparison, the use of home dialysis at 180 days was similar before and after implementation of the intervention (difference of 0% in intervention clinics; 95% confidence interval, -2% to 3%; difference of 0.8% in control clinics; 95% confidence interval, -1% to 3%; P=0.84). CONCLUSIONS: A multifaceted intervention did not increase the use of home dialysis in adults initiating dialysis. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: A Cluster Randomized Trial to Assess the Impact of Patient and Provider Education on Use of Home Dialysis, NCT02202018.

Effects of a Knowledge-Translation Intervention on Early Dialysis Initiation: A Cluster Randomized Trial.

BACKGROUND: The Initiating Dialysis Early and Late (IDEAL) trial, published in 2009, found no clinically measurable benefit with respect to risk of mortality or early complications with early dialysis initiation versus deferred dialysis start. After these findings, guidelines recommended an intent-to-defer approach to dialysis initiation, with the goal of deferring it until clinical symptoms arise. METHODS: To evaluate a four-component knowledge translation intervention aimed at promoting an intent-to-defer strategy for dialysis initiation, we conducted a cluster randomized trial in Canada between October 2014 and November 2015. We randomized 55 clinics, 27 to the intervention group and 28 to the control group. The educational intervention, using knowledge-translation tools, included telephone surveys from a knowledge-translation broker, a 1-year center-specific audit with feedback, delivery of a guidelines package, and an academic detailing visit. Participants included adults who had at least 3 months of predialysis care and who started dialysis in the first year after the intervention. The primary efficacy outcome was the proportion of patients who initiated dialysis early (at eGFR >10.5 ml/min per 1.73 m2). The secondary outcome was the proportion of patients who initiated in the acute inpatient setting. RESULTS: The analysis included 3424 patients initiating dialysis in the 1-year follow-up period. Of these, 509 of 1592 (32.0%) in the intervention arm and 605 of 1832 (33.0%) in the control arm started dialysis early. There was no difference in the proportion of individuals initiating dialysis early or in the proportion of individuals initiating dialysis as an acute inpatient. CONCLUSIONS: A multifaceted knowledge translation intervention failed to reduce the proportion of early dialysis starts in patients with CKD followed in multidisciplinary clinics. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: ClinicalTrials.gov, NCT02183987. Available at: https://clinicaltrials.gov/ct2/show/NCT02183987.

Development and Validation of Nine Deprescribing Algorithms for Patients on Hemodialysis to Decrease Polypharmacy.

BACKGROUND: Polypharmacy is ubiquitous in patients on hemodialysis (HD), and increases risk of adverse events, medication interactions, nonadherence, and mortality. Appropriately applied deprescribing can potentially minimize polypharmacy risks. Existing guidelines are unsuitable for nephrology clinicians as they lack specific instructions on how to deprescribe and which safety parameters to monitor. OBJECTIVE: To develop and validate deprescribing algorithms for nine medication classes to decrease polypharmacy in patients on HD. DESIGN: Questionnaires and materials sent electronically. PARTICIPANTS: Nephrology practitioners across Canada (nephrologists, nurse practitioners, renal pharmacists). METHODS: A literature search was performed to develop the initial algorithms via Lynn's method for development of content-valid clinical tools. Content and face validity of the algorithms was evaluated over three interview rounds using Lynn's method for determining content validity. Canadian nephrology clinicians each evaluated three algorithms (15 clinicians per round, 45 clinicians in total) by rating each algorithm component on a four-point Likert scale for relevance; face validity was rated on a five-point scale. After each round, content validity index of each component was calculated and revisions made based on feedback. If content validity was not achieved after three rounds, additional rounds were completed until content validity was achieved. RESULTS: After three rounds of validation, six algorithms achieved content validity. After an additional round, the remaining three algorithms achieved content validity. The proportion of clinicians rating each face validity statement as "Agree" or "Strongly Agree" ranged from 84% to 95% (average of all five questions, across three rounds). LIMITATIONS: Algorithm development was guided by existing deprescribing protocols intended for the general population and the expert opinions of our study team, due to a lack of background literature on HD-specific deprescribing protocols. There is no universally accepted method for the validation of clinical decision-making tools. CONCLUSIONS: Nine medication-specific deprescribing algorithms for patients on HD were developed and validated by clinician review. Our algorithms are the first medication-specific, patient-centric deprescribing guidelines developed and validated for patients on HD.

CONTEXTE: La polypharmacie est très répandue chez les patients hémodialysés et augmente le risque d'événements indésirables, d'interactions médicamenteuses, d'inobservance au traitement et de mortalité. La déprescription, appliquée de façon appropriée, peut réduire les risques associés à la polypharmacie. Les directives de déprescription existantes ne conviennent cependant pas aux cliniciens en néphrologie puisqu'elles ne renferment aucune indication spécifique sur la manière de procéder ni sur les paramètres de sécurité à surveiller. OBJECTIF: Développer et valider des algorithmes de déprescription pour neuf classes de médicaments en vue de réduire la polypharmacie chez les patients hémodialysés. CONCEPTION: Des questionnaires et des documents envoyés par voie électronique. PARTICIPANTS: Des praticiens en néphrologies de partout au Canada (néphrologues, infirmières-praticiennes, pharmaciens spécialisés en néphrologie). MÉTHODOLOGIE: Une recherche bibliographique a été effectuée pour développer les algorithmes initiaux avec la méthode de Lynn pour le développement d'outils cliniques à contenu validé. Le contenu et la validité apparente des algorithmes ont été évalués au cours de trois cycles d'interviews par la méthode de Lynn pour déterminer la validité d'un contenu. Les praticiens interviewés (15 par cycle, pour un total de 45) ont chacun évalué trois algorithmes en classant la pertinence de leurs composants sur une échelle de Likert en quatre points, et en classant leur validité apparente sur une échelle en cinq points. Après chaque cycle, l'indice de validité du contenu a été calculé pour chaque composant et des correctifs ont été apportés en fonction de la rétroaction. Si la validité du contenu n'était pas atteinte après trois cycles, des cycles supplémentaires étaient effectués jusqu'à ce que celle-ci soit atteinte. RÉSULTATS: Six algorithmes ont atteint la validité après trois cycles de validation. Les trois algorithmes restants l'ont atteint après un cycle supplémentaire. La proportion de cliniciens ayant attribué la mention de validité apparente « d'accord ¼ ou « tout à fait d'accord ¼ se situait entre 84 et 95 % (moyenne des cinq questions, sur trois cycles). LIMITES: Le développement des algorithmes repose sur les protocoles de déprescription existants, destinés à la population générale, et sur l'avis des experts de notre équipe d'étude puisque la documentation portant sur des protocoles de déprescription spécifiques aux patients hémodialysés est insuffisante. Il n'existe aucune méthode universellement acceptée pour valider les outils de décision clinique. CONCLUSION: Neuf algorithmes de déprescription spécifiques aux patients hémodialysés ont été développés et validés par révision des cliniciens. Nos algorithmes sont les premiers guides de déprescription développés et validés spécifiquement pour les médicaments des patients hémodialysés. ENREGISTREMENT DE L'ESSAI: Sans objet ­ il s'agit d'une série de questionnaires.

Prescription Patterns in Dialysis Patients: Differences Between Hemodialysis and Peritoneal Dialysis Patients and Opportunities for Deprescription.

BACKGROUND: Patients treated with maintenance dialysis are at high risk of polypharmacy given their many comorbidities as well as complications from their disease state and treatment. The prescribing patterns and burden of polypharmacy in patients treated with maintenance dialysis, and specifically the difference between hemodialysis (HD) and peritoneal dialysis (PD) prescribing, are not well characterized. OBJECTIVES: The objectives of this study were to review the prescribing patterns for patients treated with maintenance dialysis, to compare prescribing pattern between HD and PD, and to identify opportunities for deprescription. DESIGN: This is a retrospective cohort study. SETTING: This study was conducted in all dialysis centers in British Columbia, Canada. PATIENTS: Patients who were receiving chronic dialysis (>120 days on the same dialysis modality) between June 3 and October 1, 2015, and registered in the British Columbia (BC) Renal Patient Records and Outcomes Management Information System. MEASUREMENTS: Patient demographics as well as both prescription and non-prescription medications were collected. Comparison of discrete and continuous variables was made by chi-square analysis and independent t test, respectively. All statistical tests were 2-sided, and a P value of <.05 was considered statistically significant. METHODS: Medications were classified by indication: (1) management of renal complications, (2) cardiovascular (CV) medications, (3) diabetes medications, or (4) management of symptoms, and then classified as to whether they were a "potentially inappropriate medication" (PIM) or not. Ethics approval was granted from the University of British Columbia Research and Ethics Board. RESULTS: In total, 3017 patients met inclusion criteria (2243 HD, 774 PD). The mean age was 66.2 ± 14.8 years. The HD group had more patients over 80 years old (22.1% vs 12.5%) and more patients with diabetes and CV disease. The mean number (standard deviation [SD]) of discrete prescribed medications was 17.71 (5.72) overall with more medications in the HD group versus the PD group. The mean number of medications increased with dialysis vintage in both groups. HD patients were on more medications for renal complications and management of symptoms than PD patients. Of the total number of medications prescribed, 5.02 (2.78) were classified as a PIM, with the number of PIMs higher in HD vs PD patients: 5.37 (2.83) versus 4.02 (2.37). LIMITATIONS: In BC, some of the medications are prescribed through standardized protocols and may not be comparable with other Canadian provinces. We report here prescribing patterns, not utilization patterns, as we are not able to ascertain actual consumption of prescribed medication. CONCLUSION: This study reviews and characterizes both the prescription and non-prescription medication prescribed to HD patients and PD patients in BC. Pill burden in both groups is high, as is the prescription of PIMs. Patients receiving maintenance HD receive more overall medications and more PIMs. These results highlight areas of opportunities for future systematic and patient-informed deprescription initiatives in both patient groups.

CONTEXTE: Les patients sous dialyse à long terme, en raison de leurs nombreuses comorbidités et des complications inhérentes à leur état de santé et à leur traitement, s'exposent à un plus grand risque de polypharmacie. On en sait toutefois peu sur le fardeau qu'elle représente pour ces patients et sur leurs profils de prescription, particulièrement sur les possibles différences entre les patients traités par hémodialyse ou par dialyse péritonéale. OBJECTIFS: Comparer les profils de prescription des patients traités par hémodialyse (HD) et par dialyse péritonéale (DP), et cerner les possibilités de déprescription. TYPE D'ÉTUDE: Étude de cohorte rétrospective. CADRE: Tous les centres de dialyse de la Colombie-Britannique (Canada). SUJETS: Les patients sous dialyse chronique (plus de 120 jours avec la même modalité) entre le 3 juin et le 1er octobre 2015, et inscrits dans la base de données Renal Patient Records and Outcomes Management Information System de Colombie-Britannique. MESURES: Les caractéristiques démographiques des patients et la liste des médicaments, prescrits ou non. Une analyse du chi-carré (variables discontinues) et un test t indépendant (variables continues) ont été employés pour comparer les différentes variables. Tous les tests statistiques étaient bilatéraux. Une valeur de P inférieure à 0,05 a été jugée significative. MÉTHODOLOGIE: Les médicaments ont été classés par indication : (1) traitement des complications rénales, (2) contre les maladies cardiovasculaires (3) contre le diabète et (4) traitement des symptômes. Ils ont ensuite été classés comme étant ou non un « médicament potentiellement inapproprié ¼ (MPI). L'approbation déontologique a été octroyée par le comité d'éthique de la recherche de l'Université de la Colombie-Britannique. RÉSULTATS: Un total de 3 017 patients, dont l'âge moyen était de 66,2 ± 14,8 ans, satisfaisaient les critères d'inclusion (2243 HD, 774 DP). Le groupe HD comportait davantage de patients âgés de plus de 80 ans (22,1 % contre 12,5 %) et de patients souffrant de diabète et de maladies cardiovasculaires. Le nombre moyen de prescriptions (écart-type) s'élevait à 17,71 (5,72) avec des nombres globaux plus élevés dans le groupe HD. Le nombre moyen de médicaments augmentait avec le temps passé en dialyse dans les deux groupes. Les patients HD prenaient davantage de médicaments pour traiter les symptômes et les complications rénales que les patients DP. Dans l'ensemble, une moyenne de 5,02 (2,78) médicaments ont été classés MPI, et leur nombre était plus élevé dans le groupe HD que dans le groupe DP (5,37 [2,83] contre 4,02 [2,37]). LIMITES: En C.-B., certains médicaments sont prescrits selon des protocoles standardisés, et ceci pourrait ne pas être comparable aux autres provinces canadiennes. L'article présente des profils de prescription et non des schémas de prise de médicaments, car nous ne pouvions vérifier la consommation réelle des médicaments prescrits. CONCLUSION: Cette étude examine et caractérise les médicaments sous ordonnance et en vente libre qui sont prescrits aux patients britanno-colombiens traités par HD et DP. La charge médicamenteuse est élevée dans les deux groupes, de même que le nombre d'ordonnances de MPI. Les patients traités par HD se voient prescrire davantage de médicaments et de MPI. Ces résultats montrent que des initiatives de déprescription systématiques et informées sont possibles pour ces deux groupes de patients.

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 (

Multidisciplinary Chronic Kidney Disease Clinic Practices: A Scoping Review.

BACKGROUND: Multidisciplinary chronic kidney disease (CKD) clinics improve patient outcomes but their optimal design is unclear. OBJECTIVE: To perform a scoping review to identify and describe current practices (structure, function) associated with multidisciplinary CKD clinics. DESIGN: Scoping review. SETTING: Databases included Medline, EMBASE, Cochrane, and CINAHL. PATIENTS: Patients followed in multidisciplinary CKD clinics globally. MEASUREMENTS: Multidisciplinary CKD clinic composition, entry criteria, follow-up, and outcomes. METHODS: We systematically searched the literature to identify randomized controlled trials, non-randomized interventional studies, or observational studies of multidisciplinary CKD clinics defined by an outpatient setting where two or more allied health members (with or without a nephrologist) provided longitudinal care to 50 or more adult or pediatric patients with CKD. Included studies were from 2002 to present. Searches were completed on August 10, 2018. Title, abstracts, and full texts were screened independently by two reviewers with disagreements resolved by a third. We abstracted data from included studies to summarize multidisciplinary CKD clinic team composition, entry criteria, follow-up, and processes. RESULTS: 40 studies (8 randomized controlled trials and 32 non-randomized interventional studies or observational studies) involving 23 230 individuals receiving multidisciplinary CKD care in 12 countries were included. Thirty-eight focused on adults (27 with CKD, 10 incident dialysis patients, one conservative therapy) while two studies focused on adolescents or children with CKD. The multidisciplinary team included a mean of 4.6 (SD 1.5) members consisting of a nephrologist, nurse, dietician, social worker, and pharmacist in 97.4%, 86.8%, 84.2%, 57.9%, and 42.1% of studies respectively. Entry criteria to multidisciplinary CKD clinics ranged from glomerular filtration rates of 20 to 70 mL/min/1.73m2 or CKD stages 1 to 5 without any proteinuria or risk equation-based criteria. Frequency of follow-up was variable by severity of kidney disease. Team member roles and standardized operating procedures were infrequently reported. LIMITATIONS: Unstandardized definition of multidisciplinary CKD care, studies limited to CKD defined by glomerular filtration rate, and lack of representation from countries other than Canada, Taiwan, the United States, and the United Kingdom. CONCLUSIONS: There is heterogeneity in multidisciplinary CKD team composition, entry criteria, follow-up, and processes with inadequate reporting of this complex intervention. Additional research is needed to determine the best model for multidisciplinary CKD clinics. TRIAL REGISTRATION: Not applicable.

CONTEXTE: Les cliniques multidisciplinaires d'insuffisance rénale chronique (cliniques d'IRC) permettent d'améliorer les issues des patients, mais le modèle optimal demeure inconnu. OBJECTIFS: Procéder à un examen exploratoire pour répertorier et décrire les pratiques actuelles (structure, fonction) des cliniques d'IRC. TYPE D'ÉTUDE: Revue exploratoire. SOURCES: Les bases de données Medline, EMBASE, Cochrane et CINAHL. SUJETS: Les patients suivis en cliniques d'IRC partout dans le monde. MESURES: La composition de la clinique, les critères d'admission, le suivi et les résultats. MÉTHODOLOGIE: Nous avons parcouru la littérature de façon systématique et répertorié les essais contrôlés à répartition aléatoire, les études interventionnelles non réparties aléatoirement ou les études observationnelles portant sur des cliniques d'IRC. Ces dernières étaient définies par un contexte de consultations externes où au moins deux fournisseurs de soins connexes (avec ou sans néphrologue) ont fourni des soins longitudinaux à au moins 50 patients, adultes ou enfants, atteints d'IRC. Les études incluses dataient de 2002 à aujourd'hui. La recherche s'est terminée le 10 août 2018. Deux réviseurs ont, de façon indépendante, passé en revue le titre, le résumé et l'article complet. Les désaccords ont été résolus par une tierce personne. La composition de l'équipe, les critères d'admission, le suivi et les processus de la clinique ont été déterminés à partir des données extraites des études retenues. RÉSULTATS: Ont été retenues 40 études (8 essais contrôlés à répartition aléatoire et 32 études interventionnelles non aléatoires ou études observationnelles) touchant 23 230 individus recevant des soins multidisciplinaires en IRC dans 12 pays différents. Trente-huit études portaient sur des adultes (patients atteints d'IRC [n=27], patients dialysés incidents [n=10] et patients ayant un traitement conservateur [n=1]). Les deux autres portaient sur des adolescents ou des enfants atteints d'IRC. L'équipe multidisciplinaire comptait en moyenne 4,6 (écart-type: 1,5) membres, dont un néphrologue, une infirmière, un diététiste, un travailleur social et un pharmacien (97,4 %, 86,8 %, 84,2 %, 57,9 % et 42,1 % des études, respectivement). Les critères d'admission à la clinique consistaient en un débit de filtration glomérulaire de 20 à 70 ml/min/1,73 m2, une IRC de stade 1 à 5 sans protéinurie ou des critères de risque fondés sur des équations. La fréquence des suivis variait selon la gravité de l'atteinte rénale. Les rôles des membres de l'équipe et les procédures opérationnelles standardisées étaient rarement discutés. LIMITES: Les résultats sont limités par une définition non standardisée de « soins multidisciplinaires en IRC ¼ et le manque de représentation de pays autres que le Canada, Taiwan, les États-Unis et le Royaume-Uni. De plus, les études retenues étaient limitées par une définition de l'IRC reposant sur le débit de filtration glomérulaire. CONCLUSION: On observe une hétérogénéité dans la composition des équipes multidisciplinaires des cliniques d'IRC. Les critères d'admission, le suivi et les procédures sont également divergents, et les rapports sur cette intervention complexe sont inadéquats. D'autres études sont nécessaires pour définir le meilleur modèle de clinique multidisciplinaire en IRC.

Association Between the Publication of the Initiating Dialysis Early and Late Trial and the Timing of Dialysis Initiation in Canada.

Importance: Published in 2010, the Initiating Dialysis Early and Late (IDEAL) randomized clinical trial, which randomized patients with an estimated glomerular filtration rate (GFR) between 10 and 15 mL/min/1.73 m2 to planned initiation of dialysis with an estimated GFR between 10 and 14 mL/min/1.73 m2 (early start) or an estimated GFR between 5 and 7 mL/min/1.73 m2 (late start), concluded that early initiation was not associated with improved survival or clinical outcomes. Objective: To assess the association between the IDEAL trial results and the proportion of early dialysis starts over time. Design, Setting, and Participants: This interrupted time series analysis used data from the Canadian Organ Replacement Register to study adult (≥18 years of age) patients with incident chronic dialysis between January 1, 2006, and December 31, 2015, in Canada, which has a universal health care system. Patients from the province of Quebec were excluded because its privacy laws preclude submission of deidentified data without first-person consent. The patients included in the study (n = 28 468) had at least 90 days of nephrologist care before starting dialysis and a recorded estimated GFR at dialysis initiation. Data analyses were performed from November 2016 to January 2019. Main Outcomes and Measures: The primary outcome was the proportion of early dialysis starts (estimated GFR >10.5 mL/min/1.73 m2), and the secondary outcomes included the proportions of acute inpatient dialysis starts, patients who started dialysis using a home modality, and patients receiving hemodialysis who started with an arteriovenous access. Measures included the trend prior to the IDEAL trial publication, the change in this trend after publication, and the immediate consequence of publication. Results: The final cohort comprised 28 468 patients, of whom 17 342 (60.9%) were male and the mean (SD) age was 64.8 (14.6) years. Before the IDEAL trial, a statistically significant increasing trend was observed in the monthly proportion of early dialysis starts (adjusted rate ratio, 1.002; 95% CI, 1.001-1.004; P = .004). After the IDEAL trial, an immediate decrease was observed in the proportion of early dialysis starts (rate ratio, 0.874; 95% CI, 0.818-0.933; P < .001), along with a statistically significant change in trend between the pretrial and posttrial periods (rate ratio, 0.994; 95% CI, 0.992-0.996; P < .001). No statistically significant differences were found in acute inpatient dialysis initiations, the proportion of patients receiving home dialysis as the initial modality, or the proportion of arteriovenous access creation at hemodialysis initiation after the IDEAL trial publication. Conclusions and Relevance: The publication of the IDEAL trial appeared to be associated with an immediate and meaningful change in the timing of dialysis initiation in Canada.

Rituximab induction therapy for de novo ANCA associated vasculitis in pregnancy: a case report.

BACKGROUND: The diagnosis of antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is rare in pregnancy but potentially life threatening. There are no randomized controlled trials to guide the management of AAV in pregnancy and fetal safety data remains limited. Rituximab administration, a treatment for AAV, has been reported in pregnant women with reassuring fetal outcomes in the oncology and rheumatology literature; however, no published reports describe its use in AAV. CASE PRESENTATION: We present a case of de novo myeloperoxidase positive (MPO) AAV diagnosed at 22 weeks gestation. Clinical presentation included elevated serum creatinine at 177 µmol/L, hematuria and nephrotic range proteinuria along with high-titre MPO. Diagnosis was confirmed by renal biopsy. Patient was treated with methylprednisolone IV followed by oral prednisone 70 mg daily and Rituximab 650 mg IV weekly for four weeks followed by azathioprine maintenance therapy and prednisone taper. Delivery occurred at 29 weeks gestation via cesarean section for maternal neurologic symptoms concerning for preeclampsia. Maternal and fetal CD + 19 cells were depleted at time of delivery with associated fetal lymphopenia in the absence of infection or other complications related to Rituximab use. The patient experienced a reduction in proteinuria and inflammatory markers following Rituximab therapy; however, serum creatinine increased to 375 µmol/L by 11 weeks post-partum. CONCLUSION: We report the first use, to our knowledge, of Rituximab with corticosteroids for induction therapy of AAV in pregnancy.

Randomized Controlled Trial for the Effect of Vitamin D Supplementation on Vascular Stiffness in CKD.

BACKGROUND AND OBJECTIVES: Vitamin D is implicated in vascular health in CKD. This study compared placebo, calcifediol, and calcitriol treatment with changes in vascular stiffness, BP, proteinuria, mineral metabolism parameters, C-reactive protein, and fibroblast growth factor 23 in patients with stable CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a double-blind, randomized controlled trial in out-patient CKD clinics in Vancouver, Canada, from February of 2011 to August of 2014, enrolling 119 patients with an eGFR of 15-45 ml/min per 1.73 m2. Change in pulse wave velocity (PWV) was measured after 6 months of treatment with a fixed dose of oral calcifediol (5000 IU 25-hydroxyvitamin D3), calcitriol (0.5 µg 1,25-dihydroxyvitamin D3), or placebo, thrice weekly. RESULTS: Eighty-seven participants were evaluated. Mean age was 66 years, 71% were men, 40% were diabetic, and mean baseline PWV was 11.5 m/s (SD=3.9 m/s). After 6 months, the PWV decreased in the calcifediol group (mean change, -1.1; 95% confidence interval [95% CI], -2.2 to 0.1 m/s), remained unchanged in the calcitriol group (mean change, 0.2; 95% CI, -0.9 to 1.4 m/s), and increased in the placebo group (mean change, 1.1; 95% CI, -0.1 to 2.2 m/s). The overall P value for between-arm changes was 0.03. Absolute PWV change was significantly different between groups (P=0.04): the combined vitamin D treatment group saw decreased PWV (mean change, -0.4; 95% CI, -1.2 to 0.4 m/s) whereas the placebo group saw increased PWV (mean change, +1.1; 95% CI, -0.1 to 2.2 m/s). The treatment group demonstrated significantly decreased serum parathyroid hormone (mean difference, -0.5; 95% CI, -0.7 to -0.3 ln[pg/ml]; P<0.001) and increased calcium (mean difference, 0.4; 95% CI, -0.1 to 0.7 mg/dl; P=0.02). In observational analysis, participants in the highest 25-hydroxyvitamin D tertile at trial end had significant decreases in PWV (mean change, -1.0; 95% CI, -2.0 to 0.0 m/s) compared with the middle and lowest tertiles (P<0.01). Side effects were minor and rare. CONCLUSIONS: Six months of supplemental vitamin D analogs at fixed doses may achieve a reduction of PWV in patients with advanced CKD. Because the treatment effect was attenuated when baseline PWV was included as a covariate, these findings should be replicated in larger populations and further studied.

Advanced age is not a barrier to creating a functional arteriovenous fistula: a retrospective study.

INTRODUCTION: Arteriovenous fistulas (AVFs) are the recommended form of vascular access for hemodialysis. However, controversy exists regarding whether AVFs are suitable for elderly patients. METHODS: Single-center retrospective review to investigate the impact of age on AVF outcomes. Five hundred and twenty-five patients with AVF creation were stratified based on age <65, 65-75, and >75 years. AVF outcomes including primary failure, AVF patency (primary, secondary, and functional), and AVF complications were studied for 3 years following AVF creation. RESULTS: The cohort was 63% male, 44% Caucasian, and 55% had diabetes or cardiovascular disease. 39% were aged <65 years, 33% 65-75 years, and 28% were aged >75 years. No differences in rates of primary failure, loss of primary patency, complications, or need for intervention were observed between age groups. There was a significant association of age with secondary patency and functional patency, with age >75 being an independent risk factor for shortened lifespan of the fistula. For patients aged >75 years, secondary patency at 3 years was 64% compared to 75%-78% for younger patients. Functional patency at 2 years was 69% for those aged >75 years compared to 78%-81% for younger patients. CONCLUSIONS: We found no difference in AVF maturation, primary patency, complications, or interventions in those over the age of 75 compared to younger counterparts. While secondary and functional patency rates were significantly lower in those aged >75 years, the magnitude of difference is likely not clinically relevant. Therefore, we recommend that advanced age alone should not preclude patients from AVF creation.

Perspectives on optimizing care of patients in multidisciplinary chronic kidney disease clinics.

PURPOSE OF REVIEW: To summarize a jointly held symposium by the Canadian Society of Nephrology (CSN), the Canadian Association of Nephrology Administrators (CANA), and the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) entitled "Perspectives on Optimizing Care of Patients in Multidisciplinary Chronic Kidney Disease (CKD) Clinics" that was held on April 24, 2015, in Montreal, Quebec. SOURCES OF INFORMATION: The panel consisted of a variety of members from across Canada including a multidisciplinary CKD clinic patient (Randall Russell), nephrology fellow (Dr. David Collister), geriatrician (Dr. Josee Verdon), and nephrologists (Dr. Monica Beaulieu, Dr. Adeera Levin). FINDINGS: The objectives of the symposium were (1) to gain an understanding of the goals of care for CKD patients, (2) to gain an appreciation of different perspectives regarding optimal care for patients with CKD, (3) to examine the components required for optimal care including education strategies, structures, and tools, and (4) to describe a framework and metrics for CKD care which respect patient and system needs. This article summarizes the key concepts discussed at the symposium from a patient and physician perspectives. Key messages include (1) understanding patient values and preferences is important as it provides a framework as to what to prioritize in multidisciplinary CKD clinic and provincial renal program models, (2) barriers to effective communication and education are common in the elderly, and adaptive strategies to limit their influence are critical to improve adherence and facilitate shared decision-making, (3) the use of standardized operating procedures (SOPs) improves efficiency and minimizes practice variability among health care practitioners, and (4) CKD scorecards with standardized system processes are useful in approaching variability as well as measuring and improving patient outcomes. LIMITATIONS: The perspectives provided may not be applicable across centers given the differences in patient populations including age, ethnicity, culture, language, socioeconomic status, education, and multidisciplinary CKD clinic structure and function. IMPLICATIONS: Knowledge transmission by collaborative interprovincial and interprofessional networks may play a role in facilitating optimal CKD care. Validation of system and clinic models that improve outcomes is needed prior to disseminating these best practices.

OBJECTIF DE LA REVUE: Cette revue se veut une récapitulation des thèmes abordés lors du colloque intitulé « Perspectives on Optimizing Care of Patients in Multidisciplinary Chronic Kidney Disease Clinics ¼. Ce colloque organisé conjointement par la Société Canadienne de Néphrologie, la Canadian Association of Nephrology Administrators (CANA) et la Canadian Kidney Knowledge Translation and Generation Network (CANN-NET), s'est tenu le 24 avril 2015 à Montréal, au Canada. SOURCES: Cette table ronde réunissait des membres provenant de partout au Canada. Les intervenants invités à discuter lors de ce colloque comptaient un patient fréquentant une clinique multidisciplinaire en suivi des maladies rénales chroniques (Randall Russell) un chercheur boursier en néphrologie (Dr David Collister), une gériatre (Dre Josée Verdon) et deux néphrologues (Dre Monica Beaulieu et Dre Adeera Levin). OBSERVATIONS: Ce colloque visait plusieurs objectifs. D'abord on voulait se faire une meilleure idée des objectifs fixés en matière de soins offerts aux patients souffrant d'IRC. On a ensuite tenté de faire le portrait des différents points de vue en matière de soins optimaux à prodiguer aux patients atteints d'IRC et se pencher sur les éléments requis pour y arriver, notamment les structures et outils nécessaires, et les méthodes pédagogiques à favoriser. Finalement, ce colloque visait à définir un cadre et des paramètres de soins en IRC qui respectent les besoins des patients et du système de santé. Le présent article résume les concepts-clés discutés lors de ce colloque du point de vue du médecin traitant, mais également de celui d'un patient atteint d'IRC. Les messages-clés abordés incluent les observations suivantes: 1) Il est important de tenir compte des valeurs et des préférences du patient dans l'établissement des priorités des cliniques multidisciplinaires et des modèles de programmes provinciaux en IRC. 2) On constate que les obstacles à une communication et à un enseignement efficaces sont fréquents chez les patients âgés. Ainsi les stratégies adaptatives limitant leur influence sont cruciales pour améliorer l'adhésion du patient au traitement et faciliter la prise de décision conjointe. 3) On observe que l'usage de procédures opérationnelles normalisées améliore l'efficacité et minimise la variabilité dans la pratique chez les professionnels de la santé. 4) Les fiches d'évaluation en IRC doublées d'une uniformisation des systèmes et des procédés, sont utiles pour aborder le traitement de la variabilité tout autant que pour mesurer et améliorer les résultats pour les patients. LIMITES DE L'ÉTUDE: Les points de vue exprimés peuvent ne pas s'appliquer dans tous les centres de soins compte tenu des différences appréciables parmi les patients souffrant d'IRC. Ces différences incluent notamment l'âge l'origine ethnique, les différences culturelles, la langue parlée, le statut socio-économique, le niveau de scolarité, de même que la structure et les fonctions de la clinique multidisciplinaire de suivi en IRC fréquentée par le patient. CONCLUSION: La transmission des connaissances par l'entremise d'un réseau interprovincial et interprofessionnel de collaboration pourrait contribuer à faciliter l'administration de soins optimaux en IRC. Une validation du système et des modèles cliniques permettant l'amélioration des résultats pour les patients est requise préalablement à la diffusion de ces pratiques exemplaires.

Knowledge Translation Interventions to Improve the Timing of Dialysis Initiation: Protocol for a Cluster Randomized Trial.

BACKGROUND: Early initiation of chronic dialysis (starting dialysis with higher vs lower kidney function) has risen rapidly in the past 2 decades in Canada and internationally, despite absence of established health benefits and higher costs. In 2014, a Canadian guideline on the timing of dialysis initiation, recommending an intent-to-defer approach, was published. OBJECTIVE: The objective of this study is to evaluate the efficacy and safety of a knowledge translation intervention to promote the intent-to-defer approach in clinical practice. DESIGN: This study is a multicenter, 2-arm parallel, cluster randomized trial. SETTING: The study involves 55 advanced chronic kidney disease clinics across Canada. PATIENTS: Patients older than 18 years who are managed by nephrologists for more than 3 months, and initiate dialysis in the follow-up period are included in the study. MEASUREMENTS: Outcomes will be measured at the patient-level and enumerated within a cluster. Data on characteristics of each dialysis start will be determined by linkages with the Canadian Organ Replacement Register. Primary outcomes include the proportion of patients who start dialysis early with an estimated glomerular filtration rate greater than 10.5 mL/min/1.73 m2 and start dialysis in hospital as inpatients or in an emergency room setting. Secondary outcomes include the rate of change in early dialysis starts; rates of hospitalizations, deaths, and cost of predialysis care (wherever available); quarterly proportion of new starts; and acceptability of the knowledge translation materials. METHODS: We randomized 55 multidisciplinary chronic disease clinics (clusters) in Canada to receive either an active knowledge translation intervention or no intervention for the uptake of the guideline on the timing of dialysis initiation. The active knowledge translation intervention consists of audit and feedback as well as patient- and provider-directed educational tools delivered at a comprehensive in-person medical detailing visit. Control clinics are only exposed to guideline release without active dissemination. We hypothesize that the clinics randomized to the intervention group will have a lower proportion of early dialysis starts. LIMITATIONS: Limitations include passive dissemination of the guideline through publication, and lead-time and survivor bias, which favors delayed dialysis initiation. CONCLUSIONS: If successful, this active knowledge translation intervention will reduce early dialysis starts, lead to health and economic benefits, and provide a successful framework for evaluating and disseminating future guidelines. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02183987.

MISE EN CONTEXTE: Malgré l'absence d'avantages probants pour la santé des patients et en dépit de coûts plus élevés liés à la dialyse, la décision d'amorcer un tel traitement au moment où la fonction rénale du patient est encore relativement élevée (dialyse hâtive) est en forte hausse depuis une vingtaine d'années au Canada et partout dans le monde. Toutefois, les lignes directrices canadiennes publiées en 2014 à ce sujet recommandent plutôt de retarder le démarrage de la dialyse. OBJECTIFS DE L'ÉTUDE: Cette étude a pour but d'évaluer l'efficacité et la sécurité d'une intervention au niveau de l'application des connaissances qui favoriserait le démarrage tardif de la dialyse chronique dans la pratique. CADRE ET TYPE D'ÉTUDE: Il s'agit d'un essai clinique randomisé en deux groupes parallèles avec échantillonnage par grappes (clusters). Cinquante-cinq cliniques multidisciplinaires traitant des patients en insuffisance rénale chronique et provenant de partout au Canada participent à l'étude. PATIENTS: L'étude porte sur des patients adultes suivis par un néphrologue depuis plus de trois mois et ayant démarré la dialyse au cours de la période de suivi. MESURES: Les données recueillies seront mesurées au niveau des patients et analysées par regroupement (clusters). Les paramètres de démarrage pour chaque début de dialyse seront établis par la consultation du registre canadien des insuffisances et des transplantations d'organes (RCITO). Les issues primaires sont i) la proportion de patients qui auront démarré la dialyse avec un débit de filtration glomérulaire estimé de plus de 10,5 mL/min/1,73 m2 (dialyse hâtive); ii) la proportion de patients pour lesquels l'amorce aura été faite au cours d'une hospitalisation ou lors d'une admission aux urgences. Les issues secondaires qui seront mesurées incluent : le taux de variation dans le moment du démarrage de la dialyse, le taux d'hospitalisations, le nombre de décès et les coûts associés aux soins prédialyse (lorsque l'évaluation est possible). On voudra également établir un rapport trimestriel des nouveaux cas de démarrages de dialyses, et savoir à quel point les éléments de transmission des connaissances seront acceptés dans la pratique. MÉTHODOLOGIE: Nous avons randomisé 55 cliniques multidisciplinaires en traitement de l'insuffisance rénale (clusters) au Canada à recevoir, ou non, une intervention de transmission des connaissances portant sur les lignes directrices Canadiennes du démarrage de la dialyse. L'intervention consiste en une visite médicale individuelle où l'information pertinente et des outils pédagogiques, tant pour le patient que pour le médecin traitant, sont distribués. Le suivi est assuré par rétroaction et par des vérifications ponctuelles (audits). Les groupes contrôles sont quant à eux mis au fait des nouvelles recommandations sans toutefois recevoir d'outils pédagogiques ni être soumis à la diffusion active de l'information. Nous émettons l'hypothèse que la proportion de dialyses hâtives diminuera au sein des cliniques ayant été randomisées dans le groupe où une intervention sera effectuée. LIMITES DE L'ÉTUDE: La première limite consiste en la possible diffusion passive des nouvelles lignes directrices uniquement par voie de publication. En outre, les biais liés à la survie et au délai d'exécution favorisent les démarrages tardifs de dialyse. CONCLUSION: Une intervention réussie au niveau de la transmission des connaissances contribuera à réduire le nombre d'amorces de dialyse hâtives. Dès lors, on peut penser que cela aura une incidence sur les coûts reliés à cette procédure et des avantages pour la santé des patients. Enfin, cette étude pourrait constituer un cadre favorable pour procéder à l'évaluation et à la diffusion de futures lignes directrices.

Risk factors associated with arteriovenous fistula failure after first radiologic intervention.

PURPOSE: Improving arteriovenous fistula (AVF) patency is an integral part of the care of hemodialysis patients, often requiring procedures such as percutaneous transluminal angioplasty (PTA). However, these interventions may fail to reduce AVF dysfunction and failure. The purpose of this study was to determine predictive factors for subsequent AVF failure post-PTA. METHODS: Data from 155 consecutive AVFs in 155 patients at a single institution who had undergone a first PTA and had at least 1 year of follow-up data were analyzed. Using survival analysis, we assessed primary and secondary patency, and identified predictive factors taking into account competing risks. RESULTS: Of the 155 patients, 52% required multiple subsequent PTAs; 32% of the AVFs were not in use prior to the first PTA. At first PTA, 83% had outflow vein stenosis (OVS), 26% had multiple stenoses and 43% of stenoses were longer than 2 cm. During follow-up, 1-, 2-, 3-year postintervention primary patency was 41%, 32%, 32% and secondary patency was 80%, 71% and 68%. AVFs with stenoses greater than 2 cm or OVS were at higher risk of requiring multiple PTAs (p = 0.04, 0.006). Factors associated with requiring a second PTA included stenosis greater than 2 cm (hazard ratio (HR) = 1.8, 95% confidence interval (CI) = 1.2-2.9), OVS (HR = 2.5, 95% CI = 1.1-5.4) and primary renal diagnosis of diabetes or renal vascular diseases (HR = 1.8, 95% CI = 1.1-2.9); after adjustments for competing risks, OVS and stenosis length remained associated with requiring subsequent PTAs. CONCLUSIONS: The location and size of the AVF stenosis at first PTA appear to be consistent factors associated with worse postintervention primary patency.

The need for improved uptake of the KDIGO glomerulonephritis guidelines into clinical practice in Canada: a survey of nephrologists.

BACKGROUND: The lack of glomerulonephritis (GN) guidelines has historically contributed to substantial variability in the treatment of GN. We hypothesize that there are barriers to GN guideline implementation leading to incomplete translation of the 2012 KDIGO GN guidelines into patient care, and that current practice patterns deviate from guideline recommendations. METHODS: Adult nephrologists in Canada (N = 390) were surveyed using a web-based tool. The survey of 40 questions captured physician demographics, self-reported GN case load, treatment approaches and barriers to guideline implementation. RESULTS: The response rate was 44%. Physicians report seeing six (IQR 4,10) new cases of idiopathic GN every 6 months. The majority treat ANCA GN according to guidelines, but 9-37% treat nephrotic focal segmental glomerulosclerosis or membranous nephropathy with non-recommended immunosuppression and 6-9% do not treat with any immunotherapy, whereas 26% treat subnephrotic disease with immunosuppression. The majority indicated that standardized care tools would improve patient care, but they were only available to 25-44%. Patient education tools and nursing support are unavailable to 87 and 67%, respectively; insurance coverage for immune therapies is poorly accessible to 84%, yet 86% feel this would improve care and 96% of physicians support comparing their practice with benchmarks from provincial GN registries. CONCLUSIONS: We show that 2 years after the publication of the KDIGO GN guidelines, 15-46% of Canadian nephrologists report treatment strategies not in keeping with guideline recommendations. We identify barriers to guideline implementation and widespread physician support for initiatives that address these barriers to improve patient care.

An overview of the British Columbia Glomerulonephritis network and registry: integrating knowledge generation and translation within a single framework.

BACKGROUND: Glomerulonephritis (GN) is a group of rare kidney diseases with a substantial health burden and high risk of progression to end-stage renal disease. Research in GN has been limited by poor availability of large comprehensive registries. Substantial variations in access to and administration of treatment and outcomes in GN have been described. Leveraging provincial resources and existing infrastructure, the British Columbia (BC) GN Network is an initiative which serves to combine research and clinical care objectives. The goal of the BC GN Network is to coordinate and improve health care, including robust data capture, on all patients with GN in BC, a Canadian province of over 4.6 million people. This provincial initiative will serve as a model for Canadian or other national and international endeavours. DESCRIPTION: The BC Provincial Renal Agency (BCPRA) is the provincial governmental agency responsible for health delivery for all kidney patients in BC. The BC GN Network has been created by the BCPRA to ensure high quality and equitable access to care for all patients with GN and is a platform for evidence based clinical care programs and associated health policy. All patients with biopsy-proven GN are registered at the time of kidney biopsy into the BCPRA provincial database of kidney disease patients, forming the BC GN Registry. Thereafter, all laboratory results and renal related outcomes are captured automatically. Histology data and core clinical variables are entered into the database. Additional linkages between the GN Registry and administrative databases ensure robust capture of medications, hospital admissions, health care utilization, comorbidities, cancer and cardiac outcomes, and vital statistics. CONCLUSIONS: The BC GN Network and Registry is a unique model in that it combines robust data capture, data linkages, and health care delivery and evaluation into one integrated system. This model utilizes existing health infrastructure to prospectively capture population level data on patients with GN, producing a rich dataset capable of real-time identification and evaluation of GN health policy initiatives, of supporting observational cohort studies and health services research in GN, and of facilitating patient recruitment into GN clinical trials.

The British Columbia Nephrologists' Access Study (BCNAS) - a prospective, health services interventional study to develop waiting time benchmarks and reduce wait times for out-patient nephrology consultations.

BACKGROUND: Early referral and management of high-risk chronic kidney disease may prevent or delay the need for dialysis. Automatic eGFR reporting has increased demand for out-patient nephrology consultations and in some cases, prolonged queues. In Canada, a national task force suggested the development of waiting time targets, which has not been done for nephrology. METHODS: We sought to describe waiting time for outpatient nephrology consultations in British Columbia (BC). Data collection occurred in 2 phases: 1) Baseline Description (Jan 18-28, 2010) and 2) Post Waiting Time Benchmark-Introduction (Jan 16-27, 2012). Waiting time was defined as the interval from receipt of referral letters to assessment. Using a modified Delphi process, Nephrologists and Family Physicians (FP) developed waiting time targets for commonly referred conditions through meetings and surveys. Rules were developed to weigh-in nephrologists', FPs', and patients' perspectives in order to generate waiting time benchmarks. Targets consider comorbidities, eGFR, BP and albuminuria. Referred conditions were assigned a priority score between 1-4. BC nephrologists were encouraged to centrally triage referrals to see the first available nephrologist. Waiting time benchmarks were simultaneously introduced to guide patient scheduling. A post-intervention waiting time evaluation was then repeated. RESULTS: In 2010 and 2012, 43/52 (83%) and 46/57 (81%) of BC nephrologists participated. Waiting time decreased from 98(IQR44,157) to 64(IQR21,120) days from 2010 to 2012 (p = <.001), despite no change in referral eGFR, demographics, nor number of office hrs/wk. Waiting time improved most for high priority patients. CONCLUSIONS: An integrated, Provincial initiative to measure wait times, develop waiting benchmarks, and engage physicians in active waiting time management associated with improved access to nephrologists in BC. Improvements in waiting time was most marked for the highest priority patients, which suggests that benchmarks had an influence on triaging behavior. Further research is needed to determine whether this effect is sustainable.

Responsiveness of FGF-23 and mineral metabolism to altered dietary phosphate intake in chronic kidney disease (CKD): results of a randomized trial.

BACKGROUND: High fibroblast growth factor-23 (FGF-23) levels are associated with adverse outcomes. We studied the responsiveness of FGF-23 and mineral metabolism to altered dietary phosphate intake in chronic kidney disease (CKD) and healthy control patients. METHODS: Thirty patients were enrolled: 18 normophosphatemic CKD subjects and 12 healthy controls. The study duration was 21 days with three 7-day dietary interventions; a high phosphate (HP, 2000 mg/day), low phosphate (750 mg/day) and low phosphate plus phosphate binder (aluminum hydroxide, 500 mg thrice daily with meals), with comparable macronutrient content, administered in random sequence. Baseline and weekly fasting morning measurements of FGF-23, serum phosphate (sPO(4)), 1,25-hydroxyvitamin D (1,25 D) and 24-h urinary calcium (uCa) and phosphate (uPO(4)) were collected. RESULTS: FGF-23 levels were higher in subjects versus controls (72 pg/mL versus 30 pg/mL) at baseline, while sPO(4) remained in the normal range throughout the study. The absolute changes of uPO(4) and uCa for CKD and controls vary according to diet. The absolute changes of FGF-23 and sPO(4) suggest that the effect of the diets might also depend on the CKD status (P-values interaction effect = 0.08 and 0.07, respectively); nonetheless, these changes are evident as a function of dietary interventions, irrespective of CKD status (P-values diet effect = 0.006 and <0.001, respectively). CONCLUSIONS: FGF-23 levels appear to be responsive to changes in diet in both CKD patients and controls. Further studies are required to determine whether lowering dietary phosphate and thus FGF-23 levels are of long-term benefit in CKD patients, irrespective of sPO(4) levels.

Optimizing AVF creation prior to dialysis start: the role of predialysis renal replacement therapy choices.

BACKGROUND: In British Columbia, multidisciplinary predialysis clinics encourage patients to consider independent modalities of renal replacement therapy (RRT) such as peritoneal dialysis (PD) 'first'. Despite up to 50% of patients choosing PD, PD incidence rates are ~30%. We explored the relationship between predialysis RRT choice and arteriovenous fistula (AVF) creation prior to hemodialysis (HD) start with particular focus on the group of patients who despite PD choice actually commence HD, and thus may contribute to 'suboptimal' HD starts without AVF creation. METHODS: We conducted a retrospective cohort study of all patients starting dialysis between 31 December, 2006 and 31 December 2008 in the province of British Columbia. Inclusion criteria were >3 months predialysis nephrology follow-up, at least one predialysis RRT education session and maintenance on dialysis for a minimum of 3 months (to ensure chronic dialysis). Patients with any prior history of RRT were excluded. RESULTS: There were 508 patients included in the study: 127 (25%) patients chose HD, 114 (22%) PD, 13 (3%) pre-emptive transplant, 5 (1%) conservative management and 249 (49%) had no documented modality decision. Of those who chose HD, 94% commenced HD. For those who chose PD, 64% commenced PD and 36% HD. In the undecided group, 68% started HD and 32% PD. For those patients who chose PD predialysis, the presence of cardiovascular disease [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.02-5.43] and lower serum albumin levels (OR 0.92, 95% CI 0.86-0.98) were associated with failure to commence PD. Predialysis AVF creation rates were 79% of those who chose and started HD, 39% of those who chose PD but started HD and 50% of those in the undecided group who commenced HD. CONCLUSIONS: AVF creation rates prior to HD start were lower in those patients with no documented dialysis modality choice and in those who failed to commence PD. Cardiovascular disease and lower serum albumin levels were associated with failure to start PD. Further work to ensure the efficacy of RRT modality choice pathway and to better predict those patients who will fail to commence PD is necessary, so that dialysis start can be 'optimized' with AVF creation in high-risk groups.