Canadian Association of Paediatric Nephrologists COVID-19 Rapid Response: Home and In-Center Dialysis Guidance.

PURPOSE OF THE PROGRAM: This article provides guidance on optimizing the management of pediatric patients with end-stage kidney disease (ESKD) who will be or are being treated with any form of home or in-center dialysis during the COVID-19 pandemic. The goals are to provide the best possible care for pediatric patients with ESKD during the pandemic and ensure the health care team's safety. SOURCES OF INFORMATION: The core of these rapid guidelines is derived from the Canadian Society of Nephrology (CSN) consensus recommendations for adult patients recently published in the Canadian Journal of Kidney Health and Disease (CJKHD). We also consulted specific documents from other national and international agencies focused on pediatric kidney health. Additional information was obtained by formal review of the published academic literature relevant to pediatric home or in-center hemodialysis. METHODS: The Leadership of the Canadian Association of Paediatric Nephrologists (CAPN), which is affiliated with the CSN, solicited a team of clinicians and researchers with expertise in pediatric home and in-center dialysis. The goal was to adapt the guidelines recently adopted for Canadian adult dialysis patients for pediatric-specific settings. These included specific COVID-19-related themes that apply to dialysis in a Canadian environment, as determined by a group of senior renal leaders. Expert clinicians and nurses with deep expertise in pediatric home and in-center dialysis reviewed the revised pediatric guidelines. KEY FINDINGS: We identified 7 broad areas of home dialysis practice management that may be affected by the COVID-19 pandemic: (1) peritoneal dialysis catheter placement, (2) home dialysis training, (3) home dialysis management, (4) personal protective equipment, (5) product delivery, (6) minimizing direct health care providers and patient contact, and (7) caregivers support in the community. In addition, we identified 8 broad areas of in-center dialysis practice management that may be affected by the COVID-19 pandemic: (1) identification of patients with COVID-19, (2) hemodialysis of patients with confirmed COVID-19, (3) hemodialysis of patients not yet known to have COVID-19, (4) management of visitors to the dialysis unit, (5) handling COVID-19 testing of patients and staff, (6) safe practices during resuscitation procedures in a pandemic, (7) routine hemodialysis care, and (8) hemodialysis care under fixed dialysis resources. We make specific suggestions and recommendations for each of these areas. LIMITATIONS: At the time when we started this work, we knew that evidence on the topic of pediatric dialysis and COVID-19 would be severely limited, and our resources were also limited. We did not, therefore, do formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. Thus, this article's advice and recommendations are primarily expert opinions and subject to the biases associated with this level of evidence. To expedite the publication of this work, we created a parallel review process that may not be as robust as standard arms' length peer-review processes. IMPLICATIONS: We intend these recommendations to help provide the best care possible for pediatric patients prescribed in-center or home dialysis during the COVID-19 pandemic, a time of altered priorities and reduced resources.

Podocyte Infolding Glomerulopathy, First Case Report From North America.

RATIONALE: Podocyte infolding glomerulopathy (PIG) is a newly described condition with only 37 cases reported worldwide. Due to its rarity, the pathogenesis and evolution of this disease is unclear. This case report contributes to our collective knowledge about the clinical and histological progression of this disease. PRESENTING CONCERNS OF THE PATIENT: Over the course of a year, a 52-year-old Malaysian woman with no known prior medical history developed progressively worsening edema and other findings consistent with nephrotic syndrome. DIAGNOSIS: Unlike most patients with PIG, this patient did not have any autoimmune disease. She was Hepatitis B core antibody positive with a Hepatitis B surface antibody >1000, suggesting prior Hepatitis B infection with immunity. A renal biopsy was performed which was consistent with PIG. A second renal biopsy was done 2 years later which again showed characteristic findings of PIG with worsened podocyte effacement but no interval change in chronicity. INTERVENTIONS: The patient was treated with blood pressure control and renin-angiotensin-aldosterone system (RAAS) blockade with irbesartan and spironolactone. She was also treated with prednisone at 1 mg/kg for 2 months followed by a taper for a total of 7 months of prednisone treatment. OUTCOMES: The patient had a partial response to a course of prednisone. However, since stopping steroids, her proteinuria and renal function has been gradually worsening. TEACHING POINTS: PIG is mostly found in patients of East Asian descent. It presents as proteinuria and is often associated with autoimmune disease but can be idiopathic. It is characterized on renal biopsy by infolding or protrusion of podocyte cytoplasm into glomerular basement membrane, as well as intramembranous cytoplasmic microspherules or microtubules. Atypical membranous nephropathy should be ruled out prior to diagnosis. Unlike membranous nephropathy, PIG usually responds at least partially to steroid monotherapy. To our knowledge, this is the first reported case of PIG from North America. Furthermore, it is the first case of PIG with repeat biopsy showing interval worsening of PIG rather than either resolution of PIG or transformation of PIG to a different diagnosis.

FONDEMENT: La glomérulonéphrite due à l'involution des podocytes (GIP) est une affection nouvellement décrite; seuls 37 cas ont été signalés jusqu'à présent dans le monde. La pathogenèse et l'évolution de cette maladie rare sont donc encore nébuleuses. Ce rapport de cas ajoute au savoir collectif sur sa progression clinique et histologique. PRÉSENTATION DU CAS: Une Malaisienne de 52 ans sans antécédents médicaux connus qui, sur une période d'un an, a développé un œdème s'étant aggravé progressivement et présenté d'autres résultats concordant avec un syndrome néphrotique. DIAGNOSTIC: Contrairement à la plupart des patients ayant reçu un diagnostic de GIP, cette patiente ne présentait aucune maladie auto-immune concomitante. Un résultat positif pour les anticorps anti-HBc et un compte supérieur à 1 000 pour les anticorps de surface contre l'hépatite B suggéraient une infection antérieure par l'hépatite B avec immunité. Une biopsie rénale avait montré un résultat compatible avec une GIP. Une deuxième biopsie rénale effectuée deux ans plus tard a également montré des résultats caractéristiques d'une GIP et une aggravation de l'épanchement des podocytes, mais aucun changement d'intervalle en terme de chronicité. INTERVENTIONS: La patiente a été traitée par maîtrise de la tension artérielle et blocage du SRAA avec irbésartan et spironolactone. Elle a également reçu une dose de 1 mg/kg de prednisone pendant deux mois, qui a par la suite été progressivement réduite. Le traitement à la prednisone s'est étalé sur un total de sept mois. RÉSULTATS: La patiente a répondu partiellement au traitement à la prednisone. Mais depuis l'arrêt des stéroïdes, une aggravation de la protéinurie et une altération de la fonction rénale progressives ont été observées. ENSEIGNEMENTS TIRÉS: La GIP affecte principalement des patients originaires de l'Asie de l'Est. Cette maladie se présente sous la forme d'une protéinurie et elle est souvent associée à une maladie auto-immune, bien qu'elle puisse aussi être idiopathique. À la biopsie rénale, la GIP se caractérise par un repli ou une protrusion du cytoplasme des podocytes dans la membrane basale glomérulaire, de même que par des microsphérules ou des microtubules cytoplasmiques intramembranaires. Une néphropathie membranaire atypique doit être exclue avant de poser le diagnostic. Contrairement à la néphropathie membranaire, la GIP répond généralement, au moins partiellement, aux stéroïdes en monothérapie. À notre connaissance, il s'agit du premier cas signalé de GIP en Amérique du Nord. Il s'agit en outre du premier cas de GIP avec biopsie répétée montrant une aggravation de la maladie pendant l'intervalle plutôt qu'une résolution ou une transformation de la maladie en un diagnostic différent.

Maintaining the Uptake of Peritoneal Dialysis During the COVID-19 Pandemic: A Research Letter.

BACKGROUND: Due to inherent challenges in maintaining physical distancing in hemodialysis units, the Canadian Society of Nephrology has recommended peritoneal dialysis as the preferred modality for patients requiring maintenance dialysis during the coronavirus disease 19 (COVID-19) pandemic. However, pursuing peritoneal dialysis is not without risk due to the requirement for in-person contact during catheter insertion and training, and there is a paucity of data regarding the experience of peritoneal dialysis during the early phases of the pandemic. OBJECTIVE: To examine the incidence and outcomes of peritoneal dialysis between March 17 and June 01, 2020 compared to the same time period in preceding years. DESIGN: Retrospective observational study. SETTING: British Columbia, Canada. After the pandemic was declared on March 17, 2020, patients continued to be trained in peritoneal dialysis. In an effort to limit time spent in hospital, patients were preferentially trained in continuous ambulatory peritoneal dialysis, training times were truncated for some patients, and peritoneal dialysis catheters were inserted by a physician at the bedside whenever feasible. PATIENTS: All patients aged >18 years who started chronic maintenance dialysis during the period March 17 to June 01 in the years 2018 to 2020 inclusive. The time period was extended to include the years 2010 to 2020 inclusive to evaluate longer term trends in dialysis incidence. MEASUREMENTS: A provincial clinical information system was used to capture the date of commencing dialysis, dialysis modality, and complications including peritonitis. Overall uptake of peritoneal dialysis included new starts and transitions to peritoneal dialysis from in-center hemodialysis during the observation period. METHODS: The incidence of dialysis during the specified time period, overall and by modality, was calculated per million population using census figures for the population at risk. Patients were followed for a minimum of 30 days from the start of peritoneal dialysis to capture episodes of peritonitis and COVID-19. RESULTS: A total of 211 patients started maintenance dialysis between March 17 and June 01, 2020. The incidence dialysis rate (41.3 per million population) was lower than that expected based on the 10-year trend from 2010 to 2019 inclusive (expected rate 45.7 per million population, 95% confidence interval 41.7 to 50.1). A total of 93 patients started peritoneal dialysis, including 32 patients who transitioned from in-center hemodialysis, contributing to a higher overall uptake of peritoneal dialysis compared to preceding years. The incidence rate for peritoneal dialysis of 18.2 per million population was higher than that expected (16.3 per million population, 95% confidence interval 14.0 to 19.0). Half of patients (48%) underwent a bedside peritoneal dialysis catheter insertion by a physician. During 30 days of follow-up, 2 (2.2%) patients experienced peritonitis and no patients were diagnosed with COVID-19. LIMITATIONS: Results are short term and generalizable only to regions with similarly low community rates of transmission of severe acute respiratory syndrome coronavirus 2. CONCLUSIONS: These preliminary findings indicate that peritoneal dialysis can be safely started and perhaps expanded as a means of mitigating the anticipated surge in in-center hemodialysis during the COVID-19 pandemic. Important contributors to the uptake of peritoneal dialysis in British Columbia were bedside catheter insertions and expediting transitions from in-center hemodialysis to peritoneal dialysis.

Quantifying Missed Opportunities for Recruitment to Home Dialysis Therapies.

BACKGROUND: Despite the recognized benefits of home therapies for patients and the health care system, most individuals with kidney failure in Canada continue to be initiated on in-center hemodialysis. To optimize recruitment to home therapies, there is a need for programs to better understand the extent to which potential candidates are not successfully initiated on these therapies. OBJECTIVE: We aimed to quantify missed opportunities to recruit patients to home therapies and explore where in the modality selection process this occurs. DESIGN: Retrospective observational study. SETTING: British Columbia, Canada. PATIENTS: All patients aged >18 years who started chronic dialysis in British Columbia between January 01, 2015, and December 31, 2017. The sample was further restricted to include patients who received at least 3 months of predialysis care. All patients were followed for a minimum of 12 months from the start of dialysis to capture any transition to home therapies. METHODS: Cases were defined as a "missed opportunity" if a patient had chosen a home therapy, or remained undecided about their preferred modality, and ultimately received in-center hemodialysis as their destination therapy. These cases were assessed for: (1) documentation of a contraindication to home therapies; and (2) the type of dialysis education received. Differences in characteristics among patients classified as an appropriate outcome or a missed opportunity were examined using Wilcoxon rank-sum test or χ2 test, as appropriate. RESULTS: Of the 1845 patients who started chronic dialysis during the study period, 635 (34%) were initiated on a home therapy. A total of 320 (17.3%) missed opportunities were identified, with 165 (8.9%) having initially chosen a home therapy and 155 (8.4%) being undecided about their preferred modality. Compared with patients who chose and initiated or transitioned to a home therapy, those identified as a missed opportunity tended to be older with a higher prevalence of cardiovascular disease. A contraindication to both peritoneal dialysis and home hemodialysis was documented in 8 "missed opportunity" patients. General modality orientation was provided to most (71%) patients who had initially chosen a home therapy but who ultimately received in-center hemodialysis. These patients received less home therapy-specific education compared with patients who chose and subsequently started a home therapy (20% vs 35%, P < .001). LIMITATIONS: Contraindications to home therapies were potentially under-ascertained, and the nature of contraindications was not systematically captured. CONCLUSIONS: Even within a mature home therapy program, we discovered a substantial number of missed opportunities to recruit patients to home therapies. Better characterization of modality contraindications and enhanced education that is specific to home therapies may be of benefit. Mapping the recruitment pathway in this way can define the magnitude of missed opportunities and identify areas that could be optimized. This is to be encouraged, as even small incremental improvements in the uptake of home therapies could lead to better patient outcomes and contribute to significant cost savings for the health care system. TRIAL REGISTRATION: Not applicable as this was a qualitative study.

CONTEXTE: Les avantages de la dialyse à domicile pour les patients et le système de santé sont reconnus. Pourtant, la majorité des personnes atteintes d'insuffisance rénale au Canada continue de recevoir des traitements d'hémodialyse en centre. Pour recruter davantage de patients sur les thérapies à domicile, il est nécessaire d'instaurer des programmes qui permettent d'établir dans quelle mesure les candidats potentiels n'y sont pas initiés avec succès. OBJECTIF: Nous souhaitions quantifier les occasions manquées de recruter des patients pour les modalités à domicile et déterminer où ces occasions manquées se produisent dans le processus de sélection de la modalité. CONCEPTION: Étude de cohorte rétrospective. CADRE: Colombie-Britannique (Canada). SUJETS: Tous les adultes ayant amorcé des traitements de dialyse chronique en Colombie-Britannique entre le 1er janvier 2015 et le 31 décembre 2017. L'échantillon a été davantage restreint pour inclure les patients ayant reçu au moins trois mois de soins prédialyse. Le suivi s'est étalé sur un minimum de douze mois à compter de l'amorce de la dialyse afin de capter toute transition vers une modalité à domicile. MÉTHODOLOGIE: Les cas ont été définis comme une « occasion manquée ¼ si la personne avait d'emblée choisi une modalité à domicile ou si elle était demeurée indécise quant à sa modalité préférée et avait finalement reçu des traitements d'hémodialyse en centre de façon permanente. Les occasions manquées ont été examinées pour: i) une contre-indication aux thérapies à domicile et; ii) le type de formation reçue pour la dialyse. L'évaluation des différences dans les caractéristiques des patients, selon que leur cas était classé comme un résultat favorable ou une occasion manquée, a été effectuée à l'aide du test de Wilcoxon ou du test du Chi-carré. RÉSULTATS: Des 1 845 patients ayant débuté des traitements de dialyse chronique au cours de la période étudiée, 635 (34 %) avaient amorcé la dialyse à domicile. En tout, 320 cas (17,3 %) ont été classés comme « occasions manquées ¼, soit 165 patients (8,9 %) ayant d'emblée choisi une thérapie à domicile et 155 (8,4 %) indécis quant à leur modalité préférée. Comparativement aux patients qui avaient choisi et amorcé un traitement à domicile ou qui avaient fait une transition (hémodialyse en centre vers une modalité à domicile), les patients classés « occasion manquée ¼ tendaient à être plus âgés avec une prévalence plus élevée de maladies cardiovasculaires. Une contre-indication à la fois à la dialyse péritonéale et à l'hémodialyse à domicile était documentée pour huit patients classés « occasion manquée ¼. Une orientation générale sur la modalité avait été fournie à la majorité des patients (71 %) qui avaient initialement choisi une thérapie à domicile, mais qui avaient finalement reçu une hémodialyse en centre. Ces patients avaient reçu moins d'information spécifique aux modalités pratiquées à domicile que les patients qui avaient d'emblée choisi et poursuivi leurs traitements à domicile (20 % contre 35 %, p < 0,001). LIMITES: Les contre-indications aux modalités à domicile pourraient avoir été sous-évaluées et leur nature n'était pas systématiquement prise en compte. CONCLUSION: Un nombre significatif d'occasions manquées de recruter des patients pour les modalités de dialyse à domicile a été observé, bien que le programme étudié soit solidement établi. Une meilleure caractérisation des contre-indications à ces modalités et davantage de formation spécifique à ces thérapies pourraient s'avérer bénéfiques. De plus, une cartographie du processus de recrutement pourrait contribuer à mieux définir l'ampleur des occasions manquées et à cerner les domaines susceptibles d'être optimisés. Cette démarche est à encourager, car toute amélioration progressive dans l'adoption des thérapies à domicile, aussi infime soit-elle, est susceptible d'améliorer les résultats des patients et de générer des économies importantes pour le système de santé. ENREGISTREMENT DE L'ESSAI: Sans objet, il s'agit d'une étude qualitative.

Balancing the Needs of Acute and Maintenance Dialysis Patients during the COVID-19 Pandemic: A Proposed Ethical Framework for Dialysis Allocation.

The COVID-19 pandemic continues to strain health care systems and drive shortages in medical supplies and equipment around the world. Resource allocation in times of scarcity requires transparent, ethical frameworks to optimize decision making and reduce health care worker and patient distress. The complexity of allocating dialysis resources for both patients receiving acute and maintenance dialysis has not previously been addressed. Using a rapid, collaborative, and iterative process, BC Renal, a provincial network in Canada, engaged patients, doctors, ethicists, administrators, and nurses to develop a framework for addressing system capacity, communication challenges, and allocation decisions. The guiding ethical principles that underpin this framework are (1) maximizing benefits, (2) treating people fairly, (3) prioritizing the worst-off individuals, and (4) procedural justice. Algorithms to support resource allocation and triage of patients were tested using simulations, and the final framework was reviewed and endorsed by members of the provincial nephrology community. The unique aspects of this allocation framework are the consideration of two diverse patient groups who require dialysis (acute and maintenance), and the application of two allocation criteria (urgency and prognosis) to each group in a sequential matrix. We acknowledge the context of the Canadian health care system, and a universal payer in which this framework was developed. The intention is to promote fair decision making and to maintain an equitable reallocation of limited resources for a complex problem during a pandemic.

Perceptions of Multidisciplinary Renal Team Members toward Home Dialysis Therapies.

Background: Patients with ESKD are encouraged to pursue home dialysis therapy with the aims of improving quality of life, increasing patient autonomy, and reducing cost to health care systems. In a multidisciplinary team setting, patients interact with nephrologists, nurses, and allied health staff, all of whom may influence a patient's modality choice. Our objective was to evaluate the perceptions of all renal team members toward home dialysis therapies. Methods: We performed a cross-sectional survey of multidisciplinary renal team members across five renal programs in British Columbia, Canada. The survey contained questions regarding primary work area, modality preference, patient and system factors that may influence modality candidacy, perceived knowledge of home therapies, and need for further education. Results: A total of 334 respondents (22 nephrologists, 172 hemodialysis nurses, 49 home nurses, 20 predialysis nurses, and 71 allied health staff) were included (48% response rate). All respondents felt that home dialysis was beneficial for patients who work or study, improved patients' quality of life, and provided cost savings to the system. Compared with in-center hemodialysis nurses, home therapies nurses were between five and nine times more likely to favor a home therapy for patients of older age, lower socioeconomic status, lower educational level, higher burden of comorbidities, and those lacking social supports. Nephrologists and patients were felt to have the most influence on modality choice, whereas dialysis nurses were seen as having the least effect on modality choice. Most respondents felt the need for further education in home therapies. Conclusions: The majority of multidisciplinary team members, including allied health staff, acknowledged the benefits of home therapies. There were significant discrepancies among team members regarding patient-/system-level factors that may affect the candidacy of home therapies. Structured, focused, and repeated education sessions for all renal team members may help to address misperceptions around factors that influence modality candidacy.

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

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

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

Canadian Society of Nephrology COVID-19 Rapid Response Team Home Dialysis Recommendations.

PURPOSE OF PROGRAM: This paper will provide guidance on how to best manage patients with end-stage kidney disease who will be or are being treated with home dialysis during the COVID-19 pandemic. SOURCES OF INFORMATION: Program-specific documents, pre-existing, and related to COVID-19; documents from national and international kidney agencies; national and international webinars, including webinars that we hosted for input and feedback; with additional information from formal and informal review of published academic literature. METHODS: Members of the Canadian Society of Nephrology (CSN) Board of Directors solicited a team of clinicians and administrators with expertise in home dialysis. Specific COVID-19-related themes in home dialysis were determined by the Canadian senior renal leaders community of practice, a group compromising medical and administrative leaders of provincial and health authority renal programs. We then developed consensus-based recommendations virtually by the CSN work-group with input from ethicists with nephrology training. The recommendations were further reviewed by community nephrologists and over a CSN-sponsored webinar, attended by 225 kidney health care professionals, for further peer input. The final consensus recommendations also incorporated review by the editors at the Canadian Journal of Kidney Health and Disease (CJKHD). KEY FINDINGS: We identified 7 broad areas of home dialysis practice management that may be affected by the COVID-19 pandemic: (1) peritoneal dialysis catheter placement, (2) home dialysis training, (3) home dialysis management, (4) personal protective equipment, (5) product delivery, (6) minimizing direct health care provider and patient contact, and (7) assisted peritoneal dialysis in the community. We make specific suggestions and recommendations for each of these areas. LIMITATIONS: This suggestions and recommendations in this paper are expert opinion, and subject to the biases associated with this level of evidence. To expedite the publication of this work, a parallel review process was created that may not be as robust as standard arms' length peer-review processes. IMPLICATIONS: These recommendations are intended to provide the best care possible during a time of altered priorities and reduced resources.

Predictors of Care Gaps in Home Dialysis: The Home Dialysis Virtual Ward Study.

BACKGROUND: Home dialysis patients may be at an increased risk of adverse events after transitional states. The home dialysis virtual ward (HDVW) trial was conducted in Canadian dialysis centers and aimed to evaluate potential care gaps and patient satisfaction during the HDVW. METHODS: The HDVW was a multicenter single-arm trial including peritoneal dialysis and home hemodialysis patients after 4 different events (hospital discharge, medical procedure, antibiotics, completion of training). Telephone-led interviews using a standardized assessment tool were performed over a 2-week period to assess a patient's care and adjust treatment as required. Upon completion, patients were surveyed to evaluate their perceived impact on domains of care using a rating scale; 1 not satisfied to 10 completely satisfied. RESULTS: The HDVW trial included 193 patients with a median number of potential care gaps/interventions of 1 (0-2) per patient. Patients admitted to the HDVW after hospital discharge were at a higher risk of potential gaps in care (OR 2.16, 95% CI 1.29-3.62), while longer dialysis vintage was -associated with a lower number of gaps/interventions (OR 0.97 per year, 95% CI 0.95-0.98). A total of 105/193 (54%) patients completed satisfaction surveys. Patients were highly satisfied with the HDVW (median rating scale score 8, IQR 2) and felt it had a positive impact (rating scale score ≥7) on their overall health, understanding of treatment and access to a nephrologist. CONCLUSION: The HDVW was effective at identifying several potential care gaps, and patients were satisfied across several domains of care. This intervention may be valuable in supporting home dialysis patients during care transitions.

Buttonhole versus Stepladder Cannulation for Home Hemodialysis: A Multicenter, Randomized, Pilot Trial.

BACKGROUND AND OBJECTIVES: Canadian home hemodialysis guidelines highlight the potential differences in complications associated with arteriovenous fistula (AVF) cannulation technique as a research priority. Our primary objective was to determine the feasibility of randomizing patients with ESKD training for home hemodialysis to buttonhole versus stepladder cannulation of the AVF. Secondary objectives included training time, pain with needling, complications, and cost by cannulation technique. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: All patients training for home hemodialysis at seven Canadian hospitals were assessed for eligibility, and demographic information and access type was collected on everyone. Patients who consented to participate were randomized to buttonhole or stepladder cannulation technique. Time to train for home hemodialysis, pain scores on cannulation, and complications over 12 months was recorded. For eligible but not randomized patients, reasons for not participating in the trial were documented. RESULTS: Patient recruitment was November 2013 to November 2015. During this time, 158 patients began training for home hemodialysis, and 108 were ineligible for the trial. Diabetes mellitus as a cause of ESKD (31% versus 12%) and central venous catheter use (74% versus 6%) were more common in ineligible patients. Of the 50 eligible patients, 14 patients from four out of seven sites consented to participate in the study (28%). The most common reason for declining to participate was a strong preference for a particular cannulation technique (33%). Patients randomized to buttonhole versus stepladder cannulation required a shorter time to complete home hemodialysis training. We did not observe a reduction in cannulation pain or complications with the buttonhole method. Data linkages for a formal cost analysis were not conducted. CONCLUSIONS: We were unable to demonstrate the feasibility of conducting a randomized, controlled trial of buttonhole versus stepladder cannulation in Canada with a sufficient number of patients on home hemodialysis to be able to draw meaningful conclusions.

Technique Failure in a Multicenter Canadian Home Hemodialysis Cohort.

RATIONALE & OBJECTIVE: Increasing uptake of home hemodialysis (HD) has led to interest in characteristics that predict discontinuation of home HD therapy for reasons other than death or transplantation. Recent reports of practice pattern variability led to the hypothesis that there are patient- and center-specific factors that influence these discontinuations. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Incident home HD patients at 7 centers in Canada between 2000 and 2010. PREDICTOR: Treatment center, case-mix, and process-of-care variables. OUTCOMES: Technique failure (defined as discontinuation of home HD therapy for any reason other than training failure, death, or transplantation) and mortality. ANALYTICAL APPROACH: Regression modeling of technique failure using Cox proportional hazard models adjusting for treatment center and modifiable and nonmodifiable patient-level variables, censored for death and transplantation. RESULTS: The cohort consisted of 579 patients. Mean age was 49.9±14.1 years, 74% were of European ancestry, median dialysis vintage was 1.9 (IQR, 0.6-5.2) years, and 68% used an arteriovenous access. Mean duration of dialysis was 31.2±12.6 hours per week. Unadjusted 1- and 2-year technique survival and overall survival were 90% and 83% and 94% and 87%, respectively. Treating center was a strong predictor of technique failure and mortality, with HRs ranging from 0.37 to 5.11 for technique failure (1 of 6 centers with P<0.05 relative to the reference) and 0.17 to 8.73 for mortality (3 of 6 centers with P<0.05 relative to the reference). With baseline adjustment for center, only older age and more than 3 treatments per week remained significant predictors of technique failure, while no individual-level variables remained as significant predictors of survival. LIMITATIONS: Limited statistical power. CONCLUSIONS: Home HD treating centers may influence technique failure and patient mortality independent of case-mix. The relationship between processes of care and patient outcomes requires further investigation.

Type B lactic acidosis from fluorouracil in fluorouracil, oxaliplatin and leucovorin treatment for carcinoma of the colon in a hemodialysis patient.

Type B lactic acidosis complicating malignancies is rare. Increased lactate production from abnormal metabolism of tumor tissue and extensive liver metastases impairing clearance are usual causes. Fluorouracil, commonly used as adjuvant cancer chemotherapy, is not well recognized among drugs that can lead to lactic acidosis. We report a hemodialysis patient, tumor free after surgery for colon carcinoma, developing acute severe lactic acidosis and encephalopathy. Pharmacogenetic studies failed to show common variants predisposing to the more typical patterns of fluorouracil toxicity. Routine monitoring of hemodialysis patients after fluorouracil is the only practical way to detect this potentially lethal complication.

Prevalence-Based Targets Underestimate Home Dialysis Program Activity and Requirements for Growth.

BACKGROUND: Many renal programs have targets to increase home dialysis prevalence. Data from a large Canadian home dialysis program were analyzed to determine if home dialysis prevalence accurately reflects program activity and whether prevalence-based assessments adequately reflect the work required for program growth. METHODS: Data from home dialysis programs in British Columbia, Canada, were analyzed from 2005 to 2015. Prevalence data were compared to dialysis activity data including intakes and exits to describe program turnover. Using current attrition rates, recruitment rates needed to increase home dialysis prevalence proportions were identified. RESULTS: We analyzed 7,746 patient-years of peritoneal dialysis (PD) and 1,362 patient-years of home hemodialysis (HHD). The proportion of patients on home dialysis increased by 3.34% over the ten years examined, while the number of prevalent home dialysis patients increased 2.65% per year and the number of patients receiving home dialysis at any time in the year increased 4.04% per year. For every 1 patient net home dialysis growth, 13.6 new patients were recruited. Patient turnover included higher rates of transplantation in home dialysis than facility-based HD. Overall, the proportion dialyzing at home increased from 29.3 to 32.6%. CONCLUSIONS: There is high patient turnover in home dialysis such that program prevalence is an incomplete marker of total program activity. This turnover includes high rates of transplantation, which is a desirable interaction that affects home dialysis prevalence. The shortcomings of this commonly used metric are important for renal programs to consider, and better understanding of the activities that support home dialysis and the complex trajectories that home dialysis patients follow is needed.

Evaluation of a 12-Month Pilot of Long-Term and Temporary Assisted Peritoneal Dialysis.

♦ BACKGROUND: Peritoneal dialysis (PD) is challenging for patients with functional limitations, and assisted PD can support these patients, but previous reports of assisted PD have not examined the role of temporary assisted PD and had difficulty identifying adequate comparator cohorts. ♦ METHODS: Peritoneal Dialysis Assist (PDA), a 12-month pilot of long-term and temporary assisted PD was completed in multiple PD centers in British Columbia, Canada. Continuous cycler PD (CCPD) patients were identified for PDA by standardized criteria, and service could be long-term or temporary/respite. The PDA program provided daily assistance with cycler dismantle and setup, but patients remained responsible for cycler connections and treatment decisions. Outcomes were compared against both the general CCPD population and patients who met PDA criteria but were not enrolled (PDA-eligible). ♦ RESULTS: Fifty-three PDA patients had an 88% 1-year death- and transplant-censored technique survival that was similar to the general CCPD cohort (84%) and PDA-eligible cohort (86%). The PDA cohort had lower peritonitis rates (0.18 episodes/patient-year vs 0.22 and 0.36, respectively), but higher hospitalization (55% vs 34% and 35%, respectively). Long-term PDA cost approximately CDN$15,000/year in addition to existing dialysis costs. A total of 8/11 respite PDA patients (73%) returned to self-care PD after a median PDA use of 29 days, which costs $1,250/patient. ♦ CONCLUSIONS: Peritoneal Dialysis Assist provides effective support to functionally-limited CCPD patients and yields acceptable clinical outcomes. The program costs less than transfer to HD or long-term care, which represents cost minimization for failing self-care PD patients. Respite PDA provides effective temporary support; most patients returned to self-care PD and service was cost-effective compared with alternatives of hospitalization or transfer to HD.

Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use.

Mineral and bone disorder is a common complication of end-stage renal disease. Notably, hyperphosphatemia likely promotes calcification of the myocardium, valves, and arteries. Hyperphosphatemia is associated with higher risk for cardiovascular mortality and morbidity along a gradient beginning at 5.0mg/dL. Among contemporary hemodialysis (HD) patients, mean serum phosphorus level is 5.2mg/dL, although 25% of patients have serum phosphorus levels of 5.5 to 6.9mg/dL; and 13%, >7.0mg/dL. Treatment of hyperphosphatemia is burdensome. Dialysis patients consume a mean of 19 pills per day, half of which are phosphate binders. Medicare Part D expenditures on binders for dialysis patients approached $700 million in 2013. Phosphorus removal with thrice-weekly HD (4 hours per session) is ∼3,000mg/wk. However, clearance is unlikely to counterbalance dietary intake, which varies around a mean of 7,000mg/wk. Dietary restriction and phosphate binders are important interventions, but each has limitations. Dietary control is complicated by limited access to healthy food choices and unclear labeling. Meanwhile, adherence to phosphate binders is poor, especially in younger patients and those with high pill burden. Multiple randomized clinical trials show that intensive HD reduces serum phosphorus levels. In the Frequent Hemodialysis Network (FHN) trial, short daily and nocturnal schedules reduced serum phosphorus levels by 0.6 and 1.6mg/dL, respectively, relative to 3 sessions per week. A similar effect of nocturnal HD was observed in an earlier trial. In the daily arm of the FHN trial, intensive HD significantly lowered estimated phosphate binder dose per day, whereas in the nocturnal arm, intensive HD led to binder discontinuation in 75% of patients. However, intensive HD appears to have no meaningful effects on serum calcium and parathyroid hormone concentrations. In conclusion, intensive HD, especially nocturnal HD, lowers serum phosphorus levels and decreases the need for phosphate binders.

Intensive Hemodialysis and Health-Related Quality of Life.

Diminished health-related quality of life (HRQoL) is common in dialysis patients and associated with increased risks for morbidity and mortality. Patients may present limitations in both physical and mental HRQoL. Poor physical HRQoL may be defined by limited physical function, role limitations due to physical health, dissatisfaction with physical ability, and impaired mobility. Sleep disorders such as obstructive sleep apnea, restless legs, and fatigue are typical manifestations of poor physical HRQoL in dialysis patients. Poor mental HRQoL may be defined by depressive thinking, lack of positive affect, anxiety, and feelings of social isolation. The prevalence of depression is high in dialysis patients. Intensive hemodialysis (HD) can positively address HRQoL. In 3 randomized clinical trials, relative to conventional HD, intensive HD increased physical and mental component summary scores from the 36-Item Short-Form Health Survey (SF-36), although individual treatment effects of daily nocturnal HD were not statistically significant. In another large prospective study, initiation of short daily HD therapy was followed after 12 months by improvements in all SF-36 domains, sleep quality, and restless legs symptoms. In a small study of nocturnal HD, apnea and hypopnea episodes per hour decreased by almost 70% after conversion from conventional HD. Intensive HD is also associated with a large reduction in postdialysis recovery time. In contrast, 2 randomized clinical trials failed to demonstrate statistically significant effects of intensive HD on the Beck Depression Inventory score despite a significant decrease in Beck Depression Inventory score in the prospective study of short daily HD. Furthermore, intensive HD may not improve objective physical performance and can increase burden on caregivers in the home setting. In conclusion, intensive HD potentially can address both physical and mental aspects of poor HRQoL relative to conventional HD. However, more studies are needed to understand the effects of intensive HD, including specific schedules, on HRQoL.

Intensive Hemodialysis and Potential Risks With Increasing Treatment.

Although intensive hemodialysis (HD) can address important clinical problems, increasing treatment also introduces risks. In this review, we assess risks pertaining to 6 domains: vascular access complications, infection, mortality, loss of residual kidney function, solute balance, and patient and care partner burden. In the Frequent Hemodialysis Network (FHN) trials, short daily and nocturnal schedules increased the incidence of access complications, although the incidence of access loss was not statistically higher. Observational studies indicate that infection-related hospitalization is an ongoing challenge with short daily HD. Excess risk may be catalyzed by poor infection control practices in the home setting in which intensive HD is typically delivered, but with fixed probability of bacterial contamination per cannulation, greater treatment frequency necessarily increases the risk for infectious complications. Buttonhole cannulation may increase the risk for metastatic infections. However, intensive HD in the home setting is associated with lower risk for infection than peritoneal dialysis. Data regarding mortality are equivocal. With extended follow-up of individuals in the FHN trials, short daily HD was associated with lower risk relative to the usual schedule, whereas nocturnal HD was associated with higher risk. In many, but not all, observational studies, short daily HD has been associated with lower risk than both in-center HD and peritoneal dialysis; however, observational studies are subject to unmeasured confounding. Intensive HD can accelerate the loss of residual kidney function in new dialysis patients with substantial urine output and can deplete solutes (eg, phosphorus) to the extent that supplementation is necessary. Finally, intensive HD may increase burden on patients and caregivers, possibly leading to technique failure. Some of these problems might be addressed with careful monitoring, so that relevant interventions (eg, antibiotics, retraining, and respite care) can be delivered. Ultimately, intensive HD is not a panacea for end-stage renal disease. Potential benefits and risks of treatment should be jointly considered.

Rationale for a home dialysis virtual ward: design and implementation.

BACKGROUND: Home-based renal replacement therapy (RRT) [peritoneal dialysis (PD) and home hemodialysis (HHD)] offers independent quality of life and clinical advantages compared to conventional in-center hemodialysis. However, follow-up may be less complete for home dialysis patients following a change in care settings such as post hospitalization. We aim to implement a Home Dialysis Virtual Ward (HDVW) strategy, which is targeted to minimize gaps of care. METHODS/DESIGN: The HDVW Pilot Study will enroll consecutive PD and HHD patients who fulfilled any one of our inclusion criteria: 1. following discharge from hospital, 2. after interventional procedure(s), 3. prescription of anti-microbial agents, or 4. following completion of home dialysis training. Clinician-led telephone interviews are performed weekly for 2 weeks until VW discharge. Case-mix (modified Charlson Comorbidity Index), symptoms (the modified Edmonton Symptom Assessment Scale) and patient satisfaction are assessed serially. The number of VW interventions relating to eight pre-specified domains will be measured. Adverse events such as re-hospitalization and health-services utilization will be ascertained through telephone follow-up after discharge from the VW at 2, 4, 12 weeks. The VW re-hospitalization rate will be compared with a contemporary cohort (matched for age, gender, renal replacement therapy and co-morbidities). Our protocol has been approved by research ethics board (UHN: 12-5397-AE). Written informed consent for participation in the study will be obtained from participants. DISCUSSION: This report serves as a blueprint for the design and implementation of a novel health service delivery model for home dialysis patients. The major goal of the HDVW initiative is to provide appropriate and effective supports to medically complex patients in a targeted window of vulnerability. TRIAL REGISTRATION: (NCT01912001).

Programmatic variation in home hemodialysis in Canada: results from a nationwide survey of practice patterns.

BACKGROUND: Over 40% of patients with end stage renal disease in the United States were treated with home hemodialysis (HHD) in the early 1970's. However, this number declined rapidly over the ensuing decades so that the overwhelming majority of patients were treated in-centre 3 times per week on a 3-4 hour schedule. Poor outcomes for patients treated in this fashion led to a renewed interest in home hemodialysis, with more intensive dialysis schedules including short daily (SDHD) and nocturnal (NHD). The relative infancy of these treatment schedules means that there is a paucity of data on 'how to do it'. OBJECTIVE: We undertook a systematic survey of home hemodialysis programs in Canada to describe current practice patterns. DESIGN: Development and deployment of a qualitative survey instrument. SETTING: Community and academic HHD programs in Canada. PARTICIPANTS: Physicians, nurses and technologists. MEASUREMENTS: Programmatic approaches to patient selection, delivery of dialysis, human resources available, and follow up. METHODS: We developed the survey instrument in three phases. A focus group of Canadian nephrologists with expertise in NHD or SDHD discussed the scope the study and wrote questions on 11 domains. Three nephrologists familiar with all aspects of HHD delivery reviewed this for content validity, followed by further feedback from the whole group. Multidisciplinary teams at three sites pretested the survey and further suggestions were incorporated. In July 2010 we distributed the survey electronically to all renal programs known to offer HHD according to the Canadian Organ Replacement Registry. We compiled the survey results using qualitative and quantitative methods, as appropriate. RESULTS: Of the academic and community programs that were invited to participate, 80% and 63%, respectively, completed the survey. We observed wide variation in programmatic approaches to patient recruitment, human resources, equipment, water, vascular access, patient training, dialysis prescription, home requirements, patient follow up, medications, and the approach to non-adherent patients. LIMITATIONS: Cross-sectional survey, unable to link variation to outcomes. Competition for patients between HHD and home peritoneal dialysis means that case mix for HHD may also vary between centres. CONCLUSIONS: There is wide variation between programs in all domains of HHD delivery in Canada. We plan further study of the extent to which differences in approach are related to outcomes.

PROBLÉMATIQUE: Au début des années 70, plus de 40% des patients en insuffisance rénale terminale aux États-Unis étaient traités par hémodialyse à domicile (HDD). Cette proportion a décliné rapidement au cours des décennies suivantes, de sorte que le mode de suppléance pour la majorité des patients est maintenant l'hémodialyse 3 fois par semaine à raison de 3 à 4 heures par séance. Les mauvais résultats obtenus avec cette méthode ont renouvelé l'intérêt pour l'HDD, notamment pour les dialyses intensives incluant la dialyse quotidienne courte (DQC) et l'hémodialyse nocturne (HDN). Étant donné leur nouveauté, il y a peu de données sur les façons de faire avec ces modes de suppléance. OBJECTIF: Afin de décrire les pratiques actuelles, nous avons réalisé un questionnaire systématique auprès des programmes d'HDD au Canada. DESIGN: Développement et déploiement d'un outil qualitatif. CADRE: Programmes d'HDD académiques et communautaires au Canada. PARTICIPANTS: Médecins, infirmières et technologues. VARIABLES MESURÉES: Approches pour la sélection des patients, le mode de suppléance, les ressources humaines disponibles et le mode de suivi pour chaque programme. MÉTHODOLOGIE: Nous avons développé un outil en trois phases. Un groupe de discussion composé de néphrologues canadiens ayant une expertise en DQC ou HDN ont échangé sur le contenu de l'étude et ont rédigé des questions sur 11 domaines. Trois néphrologues familiers avec tous les aspects de l'HDD ont révisé la validité des questions, puis ont demandé un nouvel avis à tout le groupe de discussion. Des équipes multidisciplinaires provenant de trois sites ont ensuite évalué le questionnaire et ont apporté des suggestions. En juillet 2010, le questionnaire a été distribué électroniquement à tous les programmes qui offrent l'HDD d'après le Registre canadien des insuffisances et des transplantations d'organes. Les résultats ont été compilés au moyen de méthodes qualitatives ou quantitatives, le cas échéant. RÉSULTATS: 80% des centres académiques et 63% des centres communautaires invités ont répondu au questionnaire. Nous avons observé des variations importantes entre les programmes quant au recrutement des patients, aux ressources humaines, à l'équipement, à l'eau, aux accès vasculaires, à l'entraînement des patients, à la prescription de dialyse, aux exigences du domicile, au suivi des patients, à la médication et à l'approche face aux patients non-adhérents. LIMITATIONS: Étude transversale, incapacité d'associer les variations aux issues cliniques. La compétition entre l'HDD et la dialyse péritonéale pour le recrutement des patients entraîne peut-être une variabilité entre les centres dans la composition des groupes de patients en HDD. CONCLUSIONS: Il y a de grandes variations entre les programmes dans tous les domaines concernant l'HDD au Canada. Nous planifions d'étudier dans le futur jusqu'à quel point ces différences sont reliées aux issues cliniques.