The Effect of Age on Performance of the Kidney Failure Risk Equation in Advanced CKD.

INTRODUCTION: The Kidney Failure Risk Equation (KFRE) is a clinical tool widely used to predict progression from chronic kidney disease (CKD) to kidney failure. This study aimed to evaluate the effect of age on KFRE performance in advanced CKD. METHODS: We conducted a retrospective cohort study among 1701 consecutive patients referred to an advanced CKD clinic in Ottawa, Canada, between 2010 and 2018. Patients were categorized by age as follows: <60, 60 to 69, 70 to 79, and ≥80 years. Calibration plots compared the predicted (through the KFRE) and observed incidence of kidney failure. Concordance statistic (C-statistic) evaluated discrimination. Cumulative incidence of kidney failure was compared between models that accounted for the competing risk of death and those that did not. RESULTS: We found that the KFRE overestimated the risk of kidney failure among the oldest subset of patients (≥80 years) with absolute and relative differences of 7.6% and 22.8%, respectively, over 2 years (P = 0.047), and 24.7% and 40.4%, respectively, over 5 years (P < 0.001). The degree of overestimation in the elderly was most pronounced among those with the highest predicted risks for kidney failure. KFRE discrimination was acceptable (C-statistic 0.70-0.79) across all age categories. The cumulative incidence of kidney failure was overestimated in models that did not account for the competing risk of death, and this overestimation was more pronounced with older age. CONCLUSION: The KFRE overestimates kidney failure risk among elderly patients with advanced CKD. This overestimation relates to the increasing competing risk of death with older age, particularly over longer time horizons.

Comparison of Clinical Outcomes and Safety Associated With Chlorthalidone vs Hydrochlorothiazide in Older Adults With Varying Levels of Kidney Function.

Importance: Thiazide diuretics are commonly prescribed for the treatment of hypertension, a disease highly prevalent among older individuals and in those with chronic kidney disease. How specific thiazide diuretics compare in regard to safety and clinical outcomes in these populations remains unknown. Objective: To compare safety and clinical outcomes associated with chlorthalidone or hydrochlorothiazide use among older adults with varying levels of kidney function. Design, Setting, and Participants: This population-based retrospective cohort study was conducted in Ontario, Canada, from 2007 to 2015. Participants included adults aged 66 years or older who initiated chlorthalidone or hydrochlorothiazide during this period. Data were analyzed from December 2019 through September 2020. Exposures: New chlorthalidone users were matched 1:4 with new hydrochlorothiazide users by a high-dimensional propensity score. Time-to-event models accounting for competing risks examined the associations between chlorthalidone vs hydrochlorothiazide use and the outcomes of interest overall and within estimated glomerular filtration rate (eGFR) categories (≥60, 45-59, and <45 mL/min/1.73 m2). Main Outcomes and Measures: The outcomes of interest were adverse kidney events (ie, eGFR decline ≥30%, dialysis, or kidney transplantation), cardiovascular events (composite of myocardial infarction, coronary revascularization, heart failure, or atrial fibrillation), all-cause mortality, and electrolyte anomalies (ie, sodium or potassium levels outside reference ranges). Results: After propensity score matching, the study cohort included 12 722 adults (mean [SD] age, 74 [7] years; 7063 [56%] women; 5659 [44%] men; mean [SD] eGFR, 69 [19] mL/min/1.73 m2), including 2936 who received chlorthalidone and 9786 who received hydrochlorothiazide. Chlorthalidone use was associated with a higher risk of eGFR decline of 30% or greater (hazard ratio [HR], 1.24 [95% CI, 1.13-1.36]) and cardiovascular events (HR, 1.12 [95% CI, 1.04-1.22]) across all eGFR categories compared with hydrochlorothiazide use. Chlorthalidone use was also associated with a higher risk of hypokalemia compared with hydrochlorothiazide use, which was more pronounced among those with higher eGFR (eGFR ≥60 mL/min/1.73 m2: HR, 1.86 [95% CI, 1.67-2.08]; eGFR 45-59 mL/min/1.73 m2: HR, 1.57 [95% CI, 1.25-1.96]; eGFR <45 mL/min/1.73 m2: HR, 1.10 [95% CI, 0.84-1.45]; P for interaction = .001). No significant differences were observed between chlorthalidone and hydrochlorothiazide for dialysis or kidney transplantation (HR, 1.44 [95% CI, 0.88-2.36]), all-cause mortality (HR, 1.10 [95% CI, 0.93-1.29]), hyperkalemia (HR, 1.05 [95% CI, 0.79-1.39]), or hyponatremia (HR, 1.14 [95% CI, CI 0.98-1.32]). Conclusions and Relevance: This cohort study found that among older adults, chlorthalidone use was associated with a higher risk of eGFR decline, cardiovascular events, and hypokalemia compared with hydrochlorothiazide use. The excess risk of hypokalemia with chlorthalidone was attenuated in participants with reduced kidney function. Placed in context with prior observational studies comparing the safety and clinical outcomes associated with thiazide diuretics, these results suggest that there is no evidence to prefer chlorthalidone over hydrochlorothiazide.

Kidney, Cardiac, and Safety Outcomes Associated With α-Blockers in Patients With CKD: A Population-Based Cohort Study.

RATIONALE & OBJECTIVES: Alpha-blockers (ABs) are commonly prescribed for control of resistant or refractory hypertension in patients with and without chronic kidney disease (CKD). The association between AB use and kidney, cardiac, mortality, and safety-related outcomes in CKD remains unknown. STUDY DESIGN: Population-based retrospective cohort study. SETTINGS & PARTICIPANTS: Ontario (Canada) residents 66 years and older treated for hypertension in 2007 to 2015 without a prior prescription for an AB. EXPOSURES: New use of an AB versus new use of a non-AB blood pressure (BP)-lowering medication. OUTCOMES: 30% or greater estimated glomerular filtration rate (eGFR) decline; dialysis initiation or kidney transplantation (kidney replacement therapy); composite of acute myocardial infarction, coronary revascularization, congestive heart failure, or atrial fibrillation; safety (hypotension, syncope, falls, and fractures) events; and mortality. ANALYTICAL APPROACH: New users of ABs (doxazosin, terazosin, and prazosin) were matched to new users of non-ABs by a high dimensional propensity score. Cox proportional hazards and Fine and Gray models were used to examine the association of AB use with kidney, cardiac, mortality, and safety outcomes. Interactions by eGFR categories (≥90, 60-89, 30-59, and<30mL/min/1.73m2) were explored. RESULTS: Among 381,120 eligible individuals, 16,088 were dispensed ABs and matched 1:1 to non-AB users. AB use was associated with higher risk for≥30% eGFR decline (HR, 1.14; 95% CI, 1.08-1.21) and need for kidney replacement therapy (HR, 1.28; 95% CI, 1.13-1.44). eGFR level did not modify these associations, P interaction=0.3and 0.3, respectively. Conversely, AB use was associated with lower risk for cardiac events, which was also consistent across eGFR categories (HR, 0.92; 95% CI, 0.89-0.95; P interaction=0.1). AB use was also associated with lower mortality risk, but only among those with eGFR<60mL/min/1.73m2 (P interaction<0.001): HRs were 0.85 (95% CI, 0.78-0.93) and 0.71 (95% CI, 0.64-0.80) for eGFR of 30 to 59 and<30mL/min/1.73m2, respectively. LIMITATIONS: Observational design, BP measurement data unavailable. CONCLUSIONS: AB use in CKD is associated with higher risk for kidney disease progression but lower risk for cardiac events and mortality compared with alternative BP-lowering medications.

Hypertension Canada's 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children.

Hypertension Canada's 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.

Inter-arm difference in blood pressure in patients referred to tertiary hypertension center: Prevalence, risk factors, and relevance to physicians.

The prevalence of inter-arm BP difference is high in hypertension and is associated with adverse cardiovascular outcomes. We performed a retrospective chart review of prevalent patients in the Ottawa Hospital Hypertension Center to assess for prevalence, risk factors, and whether finding of inter-arm BP difference >10 mmHg leads to investigations of the aorta and aortic arch. Inter-arm BP difference among 493 patients was present in 16.2% (95% confidence interval [CI]13.3-19.9%), and it was associated with presence of peripheral arterial disease. Physicians did not investigate ascending aorta and aortic arch for causes of the clinically significant inter-arm BP difference.

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

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

End-Stage Kidney Disease in Patients With Autosomal Dominant Polycystic Kidney Disease: A 12-Year Study Based on the Canadian Organ Replacement Registry.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease, with afflicted patients often progressing to end-stage kidney disease (ESKD) requiring renal replacement therapy (RRT). As the timelines to ESKD are predictable over decades, it follows that ADPKD patients should be optimized regarding kidney transplantation, home dialysis therapies, and vascular access. OBJECTIVES: To examine the association of kidney transplantation, dialysis modalities, and vascular access in ADPKD patients compared with a matched, non-ADPKD cohort. SETTING: Canadian patients from 2001-2012 excluding Quebec. PATIENTS: All adult incident ESKD patients who received dialysis or a kidney transplant. MEASUREMENTS: ADPKD as defined by the treating physician. METHODS: ADPKD and non-ADPKD patients were propensity score (PS) matched (1:4) using demographics, comorbidities, and lab values. Conditional logistic regression and Cox proportional hazards models were used to examine associations with kidney transplantation (preemptive or any), dialysis modality (peritoneal, short daily, home, or in-center hemodialysis [HD]), vascular access (arteriovenous fistula [AVF], permanent or temporary central venous catheter [CVC]), and dialysis survival. RESULTS: We matched 2120 ADPKD (99.9%) with 8283 non-ADPKD with no significant imbalances between the groups. ADPKD was significantly associated with preemptive kidney transplantation (odds ratio [OR] = 7.13, 95% confidence interval [CI] = 5.74-8.87), any kidney transplant (OR = 2.37, 95% CI = 2.14-2.63), and initial therapy of nocturnal daily HD (OR = 2.74, 95% CI = 1.38-5.44), whereas in-center intermittent HD was significantly less likely in the ADPKD population (OR = 0.59, 95% CI = 0.54-0.65). There was no difference in peritoneal dialysis (PD) as initial RRT but lower use of any PD among the ADPKD group (OR = 0.85, 95% CI = 0.77-0.95). ADPKD patients were significantly more likely to have an AVF (OR = 3.25, 95% CI = 2.79-3.79) and less likely to have either a permanent (OR 0.68, 95% CI 0.59-0.78) or temporary (OR = 0.49, 95% CI = 0.41-0.59) CVC as compared with the non-ADPKD cohort. Survival on either in-center HD or PD was better for ADPKD patients (HD: hazard ratio [HR] 0.48, 95% CI 0.44-0.53; PD: HR 0.73, 95% CI 0.60-0.88). LIMITATIONS: Conservative care patients were not captured; despite PS matching, the possibility of residual confounding remains. CONCLUSIONS: ADPKD patients were more likely to receive a kidney transplant, use home HD, dialyze with an AVF, and have better survival relative to non-ADPKD patients. Conversely, they were less likely to receive PD either as initial therapy or anytime during ESKD. This may be attributed to higher transplantation or clinical decision-making processes susceptible to education and intervention.

CONTEXTE: La maladie polykystique rénale autosomique dominante chez l'adulte (MPRAD) est la maladie rénale héréditaire la plus fréquente. Les patients qui en sont atteints développent souvent une insuffisance rénale terminale (IRT) et nécessitent une thérapie de remplacement rénal (TRR). Étant donné que l'évolution vers l'IRT est prévisible sur plusieurs décennies, on devrait préparer la voie vers la greffe rénale, la dialyse à domicile et l'accès vasculaire pour les patients atteints de la MPRAD. OBJECTIFS: L'étude visait à comparer l'association avec la greffe rénale, les modalités de dialyse et l'accès vasculaire entre les patients atteints et non atteints. CADRE DE L'ÉTUDE: L'étude s'est tenue entre 2001 et 2012 auprès de patients canadiens hors Québec. PATIENTS: Ont été inclus dans l'étude tous les patients adultes nouvellement atteints d'IRT qui ont reçu de la dialyse ou une greffe rénale. MESURES: La maladie polykystique autosomique dominante des reins, telle que diagnostiquée par le médecin traitant. MÉTHODOLOGIE: On a effectué l'appariement par scores de propension des patients MPRAD avec les sujets non-MPRAD (ratio 1:4) selon leur profil démographique, leurs comorbidités et leurs résultats de laboratoire. Avec des modèles conditionnels de régression logistique et de risques proportionnels de Cox, on a déterminé l'association avec la greffe rénale (préventive et tous types confondus), la modalité de dialyse (péritonéale, quotidienne courte, à domicile ou en centre), l'accès vasculaire (fistule artérioveineuse [FAV], cathéter veineux central [CVC] temporaire ou permanent) et de la survie du patient dialysé. RÉSULTATS: Nous avons jumelé 2 120 patients MPRAD (99,9 %) à 8 283 patients non-MPRAD. Les deux groupes ne présentaient aucun déséquilibre notable. La MPRAD a été associée de façon significative à la greffe rénale préemptive (RC : 7,13; IC 95 % : 5,74-8,87), à tout type de greffe rénale (RC : 2,37; IC 95 % : 2,14-2,63) et à une thérapie initiale par hémodialyse quotidienne nocturne (RC : 2,74; IC 95 % : 1,38-5,44); alors que l'hémodialyse intermittente en centre s'est avérée beaucoup moins probable chez les patients MPRAD (RC : 0,59; IC 95 % : 0,54-0,65). Aucune différence n'a été observée en ce qui concerne le recours à la dialyse péritonéale (DP) comme TRR initiale, mais l'utilisation de la DP chez les patients du groupe MPRAD était inférieure (RC : 0,85; IC 95 % : 0,77-0,95). Pour ce qui est de l'accès vasculaire, les patients MPRAD étaient significativement plus susceptibles d'avoir recours à une FAV (RC : 3,25; IC 95 % : 2,79-3,79) et moins enclins à choisir le CVC permanent (RC : 0,68; IC 95 % : 0,59-0,78) ou temporaire (RC : 0,49; IC 95 % : 0,41-0,59) que le groupe témoin. Les perspectives de survie des patients, que ce soit avec l'hémodialyse (HD) en centre ou avec la DP, étaient meilleures pour le groupe MPRAD (RR : 0,48; IC 95 % : 0,44-0,53 pour l'HD; RR : 0,73; IC 95 % : 0,60-0,88 pour la DP). LIMITES DE L'ÉTUDE: Les patients suivis pour des soins conservateurs n'ont pas été pris en compte; et bien que nous ayons jumelé les sujets par scores de propension, un facteur confusionnel résiduel pourrait subsister. CONCLUSION: Les patients atteints de la MPRAD sont plus susceptibles de recourir à une greffe rénale, à l'hémodialyse à domicile et à un accès vasculaire par FAV; ils ont aussi de meilleures chances de survie que les patients non-MPRAD. Inversement, ils étaient moins susceptibles d'être traités par dialyse péritonéale, tant comme traitement initial qu'à n'importe quel autre moment en IRT. Ceci pourrait être attribuable au plus grand nombre de greffes ou à des processus décisionnels cliniques davantage portés vers la formation et l'intervention.

Thiazide diuretic-caused hyponatremia in the elderly hypertensive: will a bottle of Nepro a day keep hyponatremia and the doctor away? Study protocol for a proof-of-concept feasibility trial.

BACKGROUND: Hypertension is the most common modifiable risk factor for cardiovascular disease, with an increasing prevalence with age, but with easily available medications to control it. Adverse effects of these medications do limit their use, in particular hyponatremia due to thiazide and thiazide-like diuretics. This is more common in the elderly patients due to a combination of inadequate protein intake and impaired urinary dilution capability, made worse by additional thiazide use. Limiting free water intake and increasing protein intake are often not successful resulting in thiazide avoidance. Daily protein supplement is a potential option in this clinical scenario. We describe the protocol for a feasibility study to explore this option. METHODS: This is a single-arm, prospective, open-label proof-of-concept trial, including elderly patients with thiazide diuretic-induced hyponatremia. Forty patients will be enrolled and receive a bottle of a protein supplement daily, providing 120 mmol of solutes and permitting an extra 163 mL free water loss, for 4 weeks. The main outcome measures will be (1) feasibility for enrollment, (2) safety of the intervention, and (3) potential efficacy of the intervention in improving hyponatremia. Secondary outcome measures will include changes in urine osmolality, body weight, and urea measurements. DISCUSSION: Thiazide diuretic-induced hyponatremia is an important adverse effect, with significant clinical impact, such as delirium and falls, and limits the use of these potent antihypertensive agents. There are little data on the effect or safety of protein supplementation and also on whether a trial of this is feasible. The results of this proof-of-concept feasibility trial will help plan and execute a larger definitive trial to test protein supplementation as an effective strategy in this condition. TRIAL REGISTRATION: The trial is registered with Clinical trials, registration identifier: NCT02614807.

Thus Far and No Further: Should Diastolic Hypotension Limit Intensive Blood Pressure Lowering?

OPINION STATEMENT: Intensive blood pressure lowering to systolic blood pressure thresholds of less than 120 mmHg is making a slow comeback with the publication of trials supporting its benefit, especially in lowering stroke and congestive heart failure. At the same time, there is an increasing awareness of the prevalence and risk of diastolic hypotension, especially at levels of less than 60 mmHg, with support for the existence of a J-curve coming from post hoc analyses of trials and epidemiological data from large cohort studies. Hence, intensive lowering of systolic blood pressure should be done cautiously in those patients who have pre-existing coronary artery disease, and a diastolic blood pressure between 60 and 70 mmHg. Among those with diastolic blood pressure already below 60 mmHg, but whose systolic blood pressure is not at target, we recommend shared decision-making with an explicit discussion of the risks and benefits, and taking patient preferences into account. Further research with biomarkers and risk models exploring heterogeneity of outcomes might allow for more precise targeting of intensive blood pressure lowering in individuals most likely to benefit, with avoiding those most likely to harm.

Are Automated Blood Pressure Monitors Comparable to Ambulatory Blood Pressure Monitors? A Systematic Review and Meta-analysis.

Ambulatory blood pressure (BP) monitoring (ABPM) provides an accurate assessment of BP and cardiovascular risk. BpTRU (BpTRU Medical Devices Ltd, Coquitlam, British Columbia, Canada) and other automated oscillometric BP monitors (AOBPs) have been proposed to replace ABPM. A systematic review was carried out to determine the accuracy of AOBP measurement, compared with ABPM. A literature search was performed using MedLine, EMBASE and CINAHL databases until Oct 28, 2016. We selected all studies that included intraindividual comparisons between AOBP monitoring and ABPM. Study selection, demographic characteristics, and BP values including details of BP measurement techniques were abstracted in duplicate. Quantitative synthesis was performed to report the weighted mean difference between systolic and diastolic BP measured using the 2 methods. From the 859 nonduplicate citations from the search, 19 full-text articles were selected for the systematic review. The median sample size was 226 (range, 17-654). In the pooled analysis, the weighted mean difference between the 2 methods for systolic BP was -1.52 mm Hg (95% confidence interval [CI], -3.29 to 0.25 mm Hg; P = 0.09) and for diastolic BP was 0.33 mm Hg (95% CI, -0.97 to 1.64; P = 0.62). The study-level difference in means for systolic BP ranged from -9.7 to 9 mm Hg with significant heterogeneity (Cochran Q = 270; I2 = 93.3; P < 0.001) and for diastolic BP ranged from -4 to 6 mm Hg with significant heterogeneity (Cochran Q = 382; I2 = 95.3; P < 0.001). Because of the significant heterogeneity we believe that use of the AOBP should not replace awake ambulatory BP (ABPM) as the reference standard.

Does pragmatically structured outpatient dietary counselling reduce sodium intake in hypertensive patients? Study protocol for a randomized controlled trial.

BACKGROUND: Hypertension is highly prevalent among adults, and is the most important modifiable risk factor for cardiovascular events, in particular stroke. Decreasing sodium intake has the potential to prevent or delay the development of hypertension and improve blood pressure control, independently of blood pressure lowering drugs, among hypertensive patients. Despite guidelines recommending a low sodium diet, especially for hypertensive individuals, sodium intake remains higher than recommended. A recent systematic review indicated that the efficacious counselling methods described in published trials are not suitable for hypertension management by primary care providers in Canada in the present form. The primary reason for the lack of feasibility is that interventions for sodium restriction in these trials was not limited to counselling, but included provision of food, prepared meals, or intensive inpatient training sessions. METHODS/DESIGN: This is a parallel, randomized, controlled, open-label trial with blinded endpoints. Inclusion criteria are adult patients with hypertension with high dietary sodium intake (defined as ≥ 100 mmol/day). The control arm will receive usual care, and the intervention arm will receive usual care and an additional structured counselling session by a registered dietitian, with four follow-up telephone support sessions over four weeks. The two primary outcomes are change in sodium intake from baseline, as measured by a change in 24-hour urinary sodium measurements at four weeks and one year. Secondary outcomes include change in blood pressure (as measured by 24-hour ambulatory monitoring), change in 24-hour urinary potassium, and change in body weight at the same time points. DISCUSSION: Though decreasing sodium intake has been reported to be efficacious in lowering blood pressure, there exists a gap in the evidence for an effective intervention that could be easily translated into clinical practice. If successful, our intervention would be suitable for outpatient programs such as hypertension clinics or interprofessional family practices (family health teams). A negative, or partially negative (positive effect at four weeks with attrition by 12 months) trial outcome also has significant implications for healthcare delivery and use of resources. TRIAL REGISTRATION: The trial was registered with Clinicaltrials.gov (identifier: NCT02283697) on 2 November 2014.

Use of a national continuing medical education meeting to provide simulation-based training in temporary hemodialysis catheter insertion skills: a pre-test post-test study.

BACKGROUND: Simulation-based-mastery-learning (SBML) is an effective method to train nephrology fellows to competently insert temporary, non-tunneled hemodialysis catheters (NTHCs). Previous studies of SBML for NTHC-insertion have been conducted at a local level. OBJECTIVES: Determine if SBML for NTHC-insertion can be effective when provided at a national continuing medical education (CME) meeting. Describe the correlation of demographic factors, prior experience with NTHC-insertion and procedural self-confidence with simulated performance of the procedure. DESIGN: Pre-test - post-test study. SETTING: 2014 Canadian Society of Nephrology annual meeting. PARTICIPANTS: Nephrology fellows, internal medicine residents and medical students. MEASUREMENTS: Participants were surveyed regarding demographics, prior NTHC-insertion experience, procedural self-confidence and attitudes regarding the training they received. NTHC-insertion skills were assessed using a 28-item checklist. METHODS: Participants underwent a pre-test of their NTHC-insertion skills at the internal jugular site using a realistic patient simulator and ultrasound machine. Participants then had a training session that included a didactic presentation and 2 hours of deliberate practice using the simulator. On the following day, trainees completed a post-test of their NTHC-insertion skills. All participants were required to meet or exceed a minimum passing score (MPS) previously set at 79%. Trainees who did not reach the MPS were required to perform more deliberate practice until the MPS was achieved. RESULTS: Twenty-two individuals participated in SBML training. None met or exceeded the MPS at baseline with a median checklist score of 20 (IQR, 7.25 to 21). Seventeen of 22 participants (77%) completed post-testing and improved their scores to a median of 27 (IQR, 26 to 28; p < 0.001). All met or exceeded the MPS on their first attempt. There were no significant correlations between demographics, prior experience or procedural self-confidence with pre-test performance. LIMITATIONS: Small sample-size and self-selection of participants. Costs could limit the long-term feasibility of providing this type of training at a CME conference. CONCLUSIONS: Despite most participants reporting having previously inserted NTHCs in clinical practice, none met the MPS at baseline; this suggests their prior training may have been inadequate.

CONTEXTE: L'apprentissage assuré par la simulation est une méthode efficace pour former les résidents en néphrologie à insérer un cathéter d'hémodialyse non tunnellisé. Des études précédentes sur l'apprentissage assuré par la simulation pour l'insertion de cathéters non tunnellisés ont été effectuées à l'échelon local. OBJECTIFS: Déterminer si l'apprentissage assuré par la simulation pour l'insertion de cathéters non tunnellisés peut être efficace lorsque les possibilités sont offertes lors d'une conférence nationale de formation médicale continue (FMC). Décrire la corrélation entre les facteurs démographiques, les expériences antérieures d'insertion de cathéters non tunnellisés, de même que l'assurance personnelle en matière de simulation de la procédure. Évaluer la perception des apprenants face à l'apprentissage assuré par la simulation dans le cadre d'une conférence nationale de FMC. TYPE D'ÉTUDE: Prétest/post-test. CONTEXTE: Réunion annuelle 2014 de la Société canadienne de néphrologie. PARTICIPANTS: Les résidents en néphrologie et en médecine interne et les étudiants en médecine. MESURES: On a effectué un sondage auprès des participants au sujet des caractéristiques démographiques, de leurs expériences antérieures d'insertion de cathéters non tunnellisés, de leur assurance personnelle et leur attitude par rapport à la formation reçue. Les compétences en matière d'insertion de cathéters non tunnellisés ont été évaluées selon une liste de contrôle en 28 points. MÉTHODES: Les participants ont subi un prétest de leurs compétences en matière d'insertion de cathéters non tunnellisés dans la veine jugulaire interne, à l'aide d'un simulateur de patient et d'une machine à échographie. Les participants ont ensuite suivi une séance de formation qui comprenait une présentation didactique et deux heures d'exercices sur le simulateur. Le jour suivant, ils ont subi un post-test de leurs compétences. Tous les participants devaient atteindre ou dépasser la note minimale de passage précédemment fixée à 79%. Ceux qui n'ont pas atteint cette note ont dû effectuer des exercices supplémentaires jusqu'à l'atteindre. RÉSULTATS: Vingt-deux personnes ont participé à la formation sur l'insertion de cathéters d'hémodialyse non tunnellisés. Aucun d'entre eux n'a atteint ou dépassé la note minimale de passage en premier lieu, pour une médiane de 20 (ÉI = écart interquartile, entre 7,25 et 21). Dix-sept des 22 participants (77%) ont terminé le post-test en améliorant leur note, pour une médiane de 27 (ÉI, entre 26 et 28; p < 0,0001). Tous ont atteint ou excédé la note de passage lors de leur premier essai. Il n'existe aucune corrélation significative entre les facteurs démographiques, l'expérience antérieure et l'assurance personnelle, d'une part, et les résultats du prétest, d'autre part. Les participants ont confirmé l'apport de la formation, et qu'elle devrait être intégrée à la formation postdoctorale en néphrologie. LIMITES DE L'ÉTUDE: Échantillonnage restreint et autosélection des participants. Le rapport coût-efficacité n'a pas été évalué. Les coûts pourraient limiter la faisabilité à long terme de la prestation de ce type de formation au cours de conférences de FMC. CONCLUSIONS: Bien que plusieurs participants aient rapporté posséder de l'expérience antérieure dans l'insertion de cathéters non tunnellisés en pratique clinique, aucun d'entre eux n'a atteint la note minimale de passage en premier lieu; ceci suggère que leur formation antérieure ait été inadéquate. Il est possible d'offrir des possibilités d'apprentissage assuré par la simulation pour l'insertion de cathéters d'hémodialyse non tunnellisés qui soit efficace dans le contexte d'une conférence nationale de formation médicale continue.

BpTRUth: do automated blood pressure monitors outperform mercury?

Manual measurement of blood pressure (BP) in the office (MOBP) is inferior in accuracy when compared with ambulatory BP measurements (ABPM) since it misses white coat and masked effects on BP. BpTRU, an automated office BP device (AOBP), has been reported to reduce white coat effect. We performed a retrospective review of the diagnostic accuracy of MOBP (taken by a trained nurse in clinical hypertension) and AOBP using the Bland-Altman method in hypertensive patients referred to a Renal Hypertension Clinic. In 329 hypertensive patients, the 95% limits of agreement between systolic AOBP and ABPM were -31 mm Hg to 33 mm Hg and for MOBP and ABPM were -27.8 mm Hg to 37.4 mm Hg. The bias between systolic MOBP and systolic ABPM was 4.9 mm Hg (95% confidence interval, 3.0-6.6 mm Hg) whereas the bias between the systolic AOBP and the systolic ABPM was -3.2 (95% confidence interval, -1.3 to -5.0). AOBP did not improve treatment relevant classification errors compared with MOBP (28% vs. 23%; P = .052). Our data support findings by others showing that AOBP improves, but does not eliminate, white coat effect. The increased detection of white coat effect appears related to systematic downward bias by BpTRU. As a result, detection of masked effect is undermined by BpTRU.

Temporary hemodialysis catheter placement by nephrology fellows: implications for nephrology training.

The insertion of temporary hemodialysis catheters is considered to be a core competency of nephrology fellowship training. Little is known about the adequacy of training for this procedure and the extent to which evidence-based techniques to reduce complications have been adopted. We conducted a web-based survey of Canadian nephrology trainees regarding the insertion of temporary hemodialysis catheters. Responses were received from 45 of 68 (66%) eligible trainees. The median number of temporary hemodialysis catheters inserted during the prior 6 months of training was 5 (IQR, 2-11), with 9 (20%) trainees reporting they had inserted none. More than one-third of respondents indicated that they were not adequately trained to competently insert temporary hemodialysis catheters at both the femoral and internal jugular sites. These findings are relevant to a discussion of the current adequacy of procedural skills training during nephrology fellowship. With respect to temporary hemodialysis catheter placement, there is an opportunity for increased use of simulation-based teaching by training programs. Certain infection control techniques and use of real-time ultrasound should be more widely adopted. Consideration should be given to the establishment of minimum procedural training requirements at the level of both individual training programs and nationwide certification authorities.

Assessment of vancomycin use in chronic haemodialysis patients: room for improvement.

BACKGROUND: Vancomycin is frequently prescribed for the management of infections in haemodialysis patients. We evaluated the appropriateness of vancomycin use in our chronic haemodialysis population. METHODS: Charts of all chronic haemodialysis patients who received vancomycin between 1 March 2003 and 1 March 2004 were retrospectively reviewed. Indication was assessed according to the modified Hospital Infection Control Practices Advisory Committee guidelines for vancomycin prescription. The prescribed dosing regimens were evaluated. RESULTS: A total of 163 courses of vancomycin in 105 patients were assessed. Of all courses, 88% were considered to be initially appropriate, but this decreased to 63% once culture and sensitivity results were available. Use of vancomycin for the management of beta-lactam-sensitive organisms accounted for the majority of inappropriate use. The most common vancomycin-dosing regimen prescribed was 500 mg intravenously at each haemodialysis session (51%); however, considerable variability was observed. CONCLUSIONS: Although the initial indication for vancomycin use was generally appropriate, inappropriate continuation of this antibiotic, failure to obtain proper cultures to guide therapy and potentially subtherapeutic dosing regimens were some of the challenges identified. Centres providing chronic haemodialysis should take steps to optimize vancomycin prescription to improve clinical outcomes and reduce the risk of antimicrobial resistance.