A Single-Center Retrospective Study on the Initiation of Peritoneal Dialysis in Patients With Cardiorenal Syndrome and Subsequent Hospitalizations.

BACKGROUND: Inotropic dependence and diuretic resistance in patients with cardiorenal syndrome (CRS) lead to frequent hospitalizations and are associated with high mortality. Starting peritoneal dialysis (PD) acutely (within 2 weeks of a heart failure hospitalization) offers effective volume removal without hemodynamic compromise in this population. There is little data on this approach in the North American literature. OBJECTIVE: To determine whether volume-overloaded patients with CRS on maximal doses of diuretic therapy had reduced hospitalization for heart failure following PD initiation. DESIGN: Retrospective cohort study. SETTING: Academic hospital network (University Health Network, Toronto, Ontario). PATIENTS: Patients with CRS receiving a bedside catheter and starting PD within 2 weeks of insertion at the University Health Network from January 1, 2013, to December 31, 2018. METHODS AND MEASUREMENTS: Data for heart failure-related hospitalizations and length of stay 6 months before and after PD initiation were collected. Patients who died, switched to hemodialysis, or were transferred to another facility within 6 months of starting PD were excluded from the analysis. RESULTS: We identified 31 patients with CRS who had a bedside PD catheter inserted. The average age of patients was 66.0 ± 13.0 years. There were 7 (22.6%) deaths and 4 (12.9%) transfers to other programs or hemodialysis within 6 months of catheter insertion. After exclusion, we analyzed hospitalization and length of stay data for 20 patients. The hospitalization rate 6 months before PD initiation was 6.9 admissions per 1000 patient-days. This decreased to 2.5 admissions per 1000 patient-days after PD initiation. In addition, there was also a significant reduction in the average length of stay per hospitalization (24.1-3.9 days; P = .001). LIMITATIONS: Our study did not assess the severity of heart failure symptoms using a standardized functional classification system. We did not assess quality of life and illness intrusiveness scores before and after starting dialysis, nor did we capture non-heart-failure-related hospitalizations or external admissions at other hospital sites. We limited eligibility to clinically stable patients with no prior major abdominal surgical history in a single Canadian PD program using bedside ultrasound approach for catheter insertions by experienced nephrologists and included a small number of patients. CONCLUSIONS: Volume-overloaded patients with CRS receiving maximal diuretic therapy have lower hospitalization rates and shorter stays after initiation of PD. The development of a bedside PD catheter insertion program and close collaboration between nephrology and cardiology services may facilitate acute start dialysis in this population.

CONTEXTE: La dépendance inotrope et la résistance aux diurétiques entraînent de fréquentes hospitalisations et sont associées à une mortalité élevée chez les patients atteints du syndrome cardio-rénal (SCR). Dans cette population, l'amorce de la dialyse péritonéale (DP) en temps opportun, soit dans les deux semaines suivant une hospitalisation pour insuffisance cardiaque, permet d'éliminer efficacement la surcharge liquidienne sans compromettre l'hémodynamie. On trouve toutefois peu de données sur cette approche dans la littérature nord-américaine. OBJECTIF: Déterminer si les patients atteints du SCR et présentant une surcharge volémique qui reçoivent une dose maximale de diurétiques sont hospitalisés moins souvent pour insuffisance cardiaque après l'amorce de la DP. TYPE D'ÉTUDE: Une étude de cohorte rétrospective. CADRE: Un réseau de centres hospitaliers universitaires (University Health Network) de Toronto (Ontario). SUJETS: Des patients atteints du SCR, hospitalisés au University Health Network entre le 1er janvier 2013 et le 31 décembre 2018, à qui on avait installé un cathéter de DP au chevet et qui avaient amorcé un traitement de dialyse dans les deux semaines suivant l'insertion. MÉTHODOLOGIE: On a recueilli les données sur les hospitalisations pour insuffisance cardiaque et la durée des séjours dans les six mois avant et après l'initiation de la PD. Les patients décédés, passés à l'hémodialyse ou ayant été transférés vers un autre centre dans les six mois suivant l'amorce de la PD ont été exclus de l'analyse. RÉSULTATS: Nous avons identifié 31 patients atteints du SCR, âgés en moyenne de 66,0 ±13,0 ans, à qui un cathéter de DP avait été installé au chevet. Dans les six mois suivant l'insertion du cathéter, sept patients (22,6 %) sont décédés et quatre (12,9 %) ont été transférés dans un autre centre ou sont passés à l'hémodialyse. À la suite de ces exclusions, l'analyse a porté sur les hospitalisations et les durées de séjour de 20 patients. Le taux d'hospitalisation dans les six mois précédant l'initiation de la DP s'établissait à 6,9 admissions par 1 000 jours-patient; un taux qui est passé à 2,5 admissions par 1 000 jours-patient une fois la DP amorcée. On a également observé une réduction significative de la durée moyenne du séjour, celle-ci étant passée de 24,1 à 3,9 jours (p=0,001). LIMITES: La gravité des symptômes de l'insuffisance cardiaque n'a pas été évaluée à l'aide d'un système de classification fonctionnel normalisé. Les scores de la qualité de vie et du caractère intrusif de la maladie n'ont pas été évalués avant et après l'amorce de la dialyse. Les données des hospitalisations non liées à l'insuffisance cardiaque et des admissions externes dans d'autres sites n'ont pas été colligées. L'admissibilité a été limitée aux patients cliniquement stables et sans antécédent de chirurgie abdominale majeure. Les participants provenaient d'un seul programme canadien de DP où la méthode d'insertion du cathéter utilise une approche par ultrasons pratiquée par un néphrologue expérimenté. Enfin, l'étude porte sur un faible échantillon de sujets. CONCLUSION: Les patients atteints du SCR et présentant une surcharge volémique qui reçoivent une dose maximale de diurétiques ont été moins souvent hospitalisés à la suite de l'amorce de la DP. Le développement d'un programme d'insertion du cathéter de DP au chevet du patient et une collaboration étroite entre les services de cardiologie et de néphrologie pourraient faciliter l'amorce rapide de la dialyse dans cette population.

Quantifying the risk of insertion-related peritoneal dialysis catheter complications following laparoscopic placement: Results from the North American PD Catheter Registry.

BACKGROUND: Peritoneal dialysis (PD) is a more cost-effective therapy to treat kidney failure than in-center hemodialysis, but successful therapy requires a functioning PD catheter that causes minimal complications. In 2015, the North American Chapter of the International Society for Peritoneal Dialysis established the North American PD Catheter Registry to improve practices and patient outcomes following PD catheter insertion. AIMS: The objective of this study is to propose a methodology for defining insertion-related complications that lead to significant adverse events and report the risk of these complications among patients undergoing laparoscopic PD catheter insertion. METHODS: Patients undergoing laparoscopic PD catheter insertion were enrolled at 14 participating centers in Canada and the United States and followed using a Web-based registry. Insertion-related complications were defined as flow restriction, exit-site leak, or abdominal pain at any point during follow-up. We also included infections or bleeding within 30 days of insertion, and any immediate postoperative complications. Adverse events were categorized as PD never starting or termination of PD therapy, delay in the start of PD therapy or interruption of PD therapy, an emergency department visit or hospitalization, or need for invasive procedures. Cause-specific cumulative incidence functions were used to estimate risk. RESULTS: Five hundred patients underwent laparoscopic PD catheter insertion between 10 November 2015 and 24 July 2018. The cumulative risk of insertion-related complications 6 months from the date of insertion that led to an adverse event was 24%. The risk of flow restriction, exit-site leak, and pain at 6 months was 10.2%, 5.7%, and 5.3%, respectively. PD was never started or terminated in 6.4% of patients due to an insertion-related complication. Leaks and flow restrictions were most likely to delay or interrupt PD therapy. Flow restrictions were the primary cause of invasive procedures. Fifty percent of the complications occurred before the start of PD therapy. CONCLUSIONS: Insertion-related complications leading to significant adverse events following laparoscopic placement of PD catheters are common. Many complications occur before the start of PD. Insertion-related complications are an important area of focus for future research and quality improvement efforts.

Quality improvement in pediatric nephrology-a practical guide.

Improving quality of care delivery is an important focus for all practicing physicians. Frontline clinicians are in a great position to identify clinical problems and find innovative solutions. The current review describes the method used for quality improvement based on the Model for Improvement, a structural framework to guide improvement work. At its basis are three fundamental questions: What are we trying to accomplish? How will I know that a change will lead to improvement? And what changes could we make that will result in improvement? This preparation phase aims to identify and understand the problem, choose an intervention, and determine reliable measures to gauge improvement. The intervention is then tested using PLAN-DO-STUDY-ACT (PDSA) cycles, an iterative approach to systematically improve processes and outcomes. PLAN focuses on defining the goal of the cycle and describing in details what will be done. DO concentrates on the concrete application of the plan. STUDY focuses on data analyses as ACT identifies lessons learned from the cycle and orientate the goals of the following PDSA cycle. Learning from each cycle, developing an interdisciplinary team and repeated interventions are core principles involved in implementing a sustainable quality improvement program. The Model for Improvement will be illustrated by a common quality problem in pediatric nephrology.

A Survey of Training for Temporary Hemodialysis Catheter Insertion During Nephrology Fellowship in Canada: An Update.

BACKGROUND: Controversy exists as to whether the insertion of temporary hemodialysis catheters (THDCs) should remain a mandatory requirement of nephrology fellowship training in Canada. A survey conducted by our group in 2012 showed that many nephrology trainees reported inadequate training to achieve procedural competence. OBJECTIVE: To determine the current practices and training of the insertion of THDCs in nephrology fellowship programs in Canada and how this has evolved since 2012. DESIGN: A survey study was designed comprising the following sections: demographics, details regarding the number and types of THDCs inserted within the past 6 months of fellowship training, adherence to sterile techniques, the use of ultrasound guidance during THDC insertion, training for THDC insertion received before and during nephrology fellowship, and self-perceived adequacy of training and competence in THDC insertion. SETTING: The survey was distributed by e-mail in May 2018 either directly or through Canadian nephrology training programs. PARTICIPANTS: Current trainees of Canadian adult nephrology training programs. MEASUREMENTS: Descriptive statistics were used to analyze the summarized data. The means and interquartile ranges (IQRs) were used to summarize the number of THDC insertions performed, and the categorical data, including data on training and self-perceived competency, were reported using frequencies and percentages. A chi-squared test was used to evaluate the relationship between those who received simulation-based training and self-perceived confidence in either internal jugular or femoral catheter insertion. METHODS: An online survey, available in both English and French, was distributed to all adult nephrology trainees in Canada in May 2018 either directly or through their respective programs. RESULTS: Completed surveys were received from 46 of 136 nephrology trainees across Canada (34%). Of those who responded, the median (IQR) number of combined femoral and/or internal jugular THDCs inserted in the past 6 months of fellowship training was 3 (1-6). Eight respondents (17%) indicated that they had not inserted a THDC in the past 6 months. However, only 7 of 42 respondents (17%) indicated that they did not feel competent or adequately trained to perform either femoral or internal jugular THDC insertion. LIMITATIONS: Limitations of the study include participation of trainees at different stages of their training. Many trainees indicated that it was not a requirement to keep a formal log of their procedures performed and likely had recall bias when reporting their procedure details. CONCLUSIONS: Nephrology fellows in Canada are performing fewer THDC insertions compared to 2012 but report higher levels of self-perceived competence and better training. This may be as a result of significantly more simulation-based training. Our data suggest that training to procedural mastery using simulation-based techniques may be a path to ensuring adequate training for THDC insertion despite fewer procedures being performed during training.

CONTEXTE: Une controverse existe à savoir si l'insertion de cathéters d'hémodialyse temporaires (CHT) devrait demeurer une exigence de la formation des néphrologues au Canada. Une enquête menée par notre groupe en 2012 montrait que plusieurs stagiaires en néphrologie jugeaient leur formation insuffisante pour l'acquisition de compétences techniques. OBJECTIFS: Faire état des pratiques et de la formation actuelles en matière d'insertion de CHT dans les programs canadiens de stages en néphrologie, et témoigner de l'évolution de la situation depuis 2012. CONCEPTION DE L'ÉTUDE: L'étude, sous forme de sondage, a été conçue en incluant les éléments suivants: les données démographiques, les détails quant au nombre et au type de cathéters insérés au cours des six derniers mois de la formation, l'observance des techniques d'asepsie, le recours à l'échoguidage pendant la procédure, la formation reçue sur l'insertion de CHT avant et pendant le stage en néphrologie, et l'auto-évaluation de l'adéquation de la formation et des compétences individuelles en insertion de CHT. TYPE D'ÉTUDE: Un sondage distribué en mai 2018 par courrier électronique, directement ou par l'entremise des programs de formation en néphrologie. SUJETS: Les stagiaires actuels des programs canadiens de formation en néphrologie adulte. MESURES: Des statistiques descriptives ont été utilisées pour analyzer les données agrégées. Les moyennes et les écarts interquartiles (EIQ) ont été employés pour résumer le nombre d'insertions de CHT. Les données catégorielles, y compris les données sur la qualité de la formation et la compétence perçue, ont été rapportées en fréquences et en pourcentages. Enfin, un test x2 a évalué le lien entre la compétence individuelle perçue quant à l'insertion d'un cathéter dans la jugulaire interne ou dans la veine fémorale et le fait d'avoir ou non reçu une formation par simulation. MÉTHODOLOGIE: En mai 2018, un sondage électronique, disponible en anglais et en français, a été distribué à tous les stagiaires canadiens en néphrologie adulte, directement ou par l'intermédiaire de leurs programs respectifs. RÉSULTATS: Des 136 stagiaires ayant reçu le sondage, 46 (34%) l'ont retourné dument rempli. Le nombre médian combiné de CHT insérés dans la veine fémorale et/ou la jugulaire interne au cours des 6 derniers mois de formation était de 3 (EIQ: 1 à 6). Huit répondants (17%) n'avaient pas pratiqué cette procédure au cours des six derniers mois. Néanmoins, seulement 7 répondants sur un total de 42 (17%) ont indiqué ne pas se sentir à l'aise ou suffisamment formés pour pratiquer l'insertion d'un CHT dans la veine fémorale ou dans la jugulaire interne. LIMITES: L'étude porte sur des stagiaires à différentes étapes de leur formation. Aussi, plusieurs stagiaires ont indiqué qu'on ne les obligeait pas à tenir un registre officiel des procédures effectuées, leur déclaration pourrait donc présenter un biais de rappel. CONCLUSION: Les stagiaires en néphrologie canadiens pratiquent moins d'insertions de CHT, mais signalent une meilleure formation et des niveaux plus élevés de compétence perçue qu'en 2012, un constat qui pourrait s'expliquer par une formation axée sur la simulation de meilleure qualité. Ces résultats suggèrent que l'apprentissage de procédures par des techniques axées sur la simulation pourrait constituer un moyen d'assurer une formation adéquate en insertion de CHT, et ce, malgré le nombre réduit de procédures exécutées pendant la formation.

Supporting the Establishment of New Home Dialysis Programs Through the Explore Home Dialysis Program.

INTRODUCTION: The globally increasing prevalence of chronic kidney disease has resulted in an ever-growing demand for renal replacement therapy. Although programs are present around the world, there is a paucity of immersive educational programs that train clinicians and administrators to develop new home dialysis programs. Explore Home Dialysis (EHD) is a program created to fill this gap. METHODS: We present the results of the evaluation of the EHD program. Our team interviewed 23 clinicians and administrators who participated in the EHD program. We also assessed country-specific needs and challenges associated with home dialysis. RESULTS: The 4 main findings include (i) the evaluation of the effectiveness of the EHD program; (ii) the need for an educational program to train individuals on how to deploy home dialysis programs; (iii) evidence that such an educational program is beneficial to participants and for the establishment of new home dialysis programs; and (iv) the identification of barriers to the development of home dialysis programs in countries represented in this study. The data show an increased demand, with strong patient and provider interest in establishing new programs, interest in accessing resources to train clinical and administrative staff in how to run a home dialysis program, and positive feedback about the EHD program in general. CONCLUSIONS: The data from this study were used in the next iteration of the EHD program, to inform clinicians about challenges in the deployment of new home dialysis programs, and to present educational resources that need to be developed in the future.

Assessing Student Attitudes Regarding Cost-Consciousness in Medical Education.

This article was migrated. The article was marked as recommended. Purpose: The purpose of this study was to compare attitudes regarding cost-consciousness between student populations at two medical schools in the United States and Canada. Method: We conducted a cross-sectional survey of students at Harvard Medical School and University of Toronto. We performed chi-square analyses comparing responses from the two institutions. Results: Response rates were 48% (n=162) and 45% (n=228) at Harvard and the University of Toronto, respectively. At both institutions, >96% of students agreed clinicians at all stages of training should be familiar with cost-conscious decision-making, 80% agreed physicians are responsible for discussing healthcare costs with patients, and over 80% felt they had too little education on the topic in medical school. Students differed in opinions about the extent to which patients should inquire about costs, with students at Harvard more likely to endorse this opinion compared with those from Toronto (51% vs 28%, respectively), and differed over whether cost-consciousness led to rationing of healthcare (Harvard 30% vs Toronto 51%). Fewer than 10% of all students expressed concerns that incorporating costs into care was unethical. Overall, 85% of students from both countries would like more formal teaching on this topic. Discussion: Students from both schools strongly endorsed a need to learn more about cost-conscious decision-making. Findings suggest students in both systems can benefit from learning similar core concepts related to high-value, cost-conscious care, and teaching in this topic can be customized to reflect specific differences in expectations and practices in the two healthcare systems.

Renal thrombotic microangiopathy and pulmonary arterial hypertension in a patient with late-onset cobalamin C deficiency.

Cobalamin C (cblC) deficiency is the most commonly inherited inborn error of vitamin B12 metabolism. It is characterized by multisystem involvement with severe neurological, hematological, renal and cardiopulmonary manifestations. Disease is most commonly diagnosed early in the first decade of life. We report a case of a 20-year-old woman who developed severe pulmonary arterial hypertension while under nephrologic follow-up for chronic kidney disease. She had initially presented at 14 years of age with visual disturbance and acute renal failure and been diagnosed with thrombotic thrombocytopenic purpura on the basis of kidney biopsy findings of thrombotic microangiopathy and compatible ADAMTS13 (a disentegrin and metalloproteinase with a thrombospondin type 1 motif member 13). When cblC deficiency was eventually diagnosed, remarkable improvement in cardiopulmonary function was evident upon initiation of treatment. This case highlights the importance of a timely diagnosis and initiation of treatment for cblC deficiency. Clinical diagnosis may be challenged by asynchronous organ symptom presentation and by misleading laboratory tests, in this case: an initial low ADAMTS13. A simple test of plasma homocysteine level should be encouraged in cases of thrombotic microangiopathy and/or pulmonary artery hypertension.

Self-cannulation of the vascular access in home hemodialysis: Overcoming patient-level barriers.

Patients with end-stage kidney disease who are considering home hemodialysis (HHD) face the challenge of learning to self-cannulate their arteriovenous access. Current practice discourages the use of tunneled central venous catheters, with recent indications that self-cannulating patients have superior outcomes. Patient-level barriers do not appear to preclude a successful HHD program and should not be viewed as insurmountable by healthcare staff or patients. The healthcare team must address patient fears while instructing the patient to perform self-cannulation safely. Identification and understanding of the barriers perceived by the patient will allow the patient and healthcare team work collaboratively, toward the goal of independence with self-cannulation both during initial training and follow-up care. The aim of this review was to provide a practical resource to aid in the identification and resolution of these patient-level barriers, with the overall goal of improving the patient experience and medical outcomes in home hemodialysis programs.

Does peritoneal dialysis have a role in urgent-start end-stage kidney disease?

Despite its many positive attributes, peritoneal dialysis remains underutilized, particularly in the United States. Urgent-start peritoneal dialysis (PD) has been proposed as a method of increasing PD prevalence. Urgent-start PD has been shown to be safe, feasible, and effective. However, urgent-start PD is also accompanied by several multidimensional challenges. This article is intended to equip the reader with a practical sense of whether an urgent-start PD program would be appropriate in his or her own clinical context and if appropriate, what factors would be necessary for such a program to flourish. As such, we summarize latent factors, which are necessary to consider before instituting an urgent-start PD. Then, using a series of clinical vignettes, highlight the component parts of a successful urgent-start PD program and the patient population who stand to benefit most from this strategy. The discussion is then balanced by presenting limitations to consider in the urgent-start PD approach.

Closing the Care Gap: A Primer on Quality Improvement for Heart Failure Clinicians.

Quality improvement (QI) initiatives have become an integral part of patient-centered care. In this primer, we outline 6 steps for initiating, implementing, and monitoring improvement in heart failure care. These steps include acknowledging that improvement is needed and setting a culture for improvement; forming a QI team; understanding the local problem; generating improvement strategies that will fit with the local problem; monitoring; testing; and refining improvements, analysis of data, and interpretation of run charts. This primer provides tools and resources for clinicians who want to learn how to perform QI specifically in the field of heart failure. We will illustrate the application of these steps using a hypothetical example for a congestive heart failure postdischarge clinic.

Ultrasound-Guided Cannulation of the Hemodialysis Arteriovenous Access.

Successful cannulation of the arteriovenous access for patients with end-stage kidney failure to allow catheter-free hemodialysis is associated with superior patient outcomes. With an increasing rate of arteriovenous access creation, coupled with increasing dialysis patient age, the "difficult-to-cannulate" access is becoming more commonplace. Ultrasound-guided cannulation aims to improve first-time successful cannulations and minimize cannulation-associated complications such as infiltration and hematoma formation, minimizing delays in access use and reducing catheter dependency. Ultrasound-guided cannulation has the potential to not only improve patient experience but also reduce morbidity associated with complications, dialysis catheter dependency, and subsequent healthcare costs. A smooth and complication-free dialysis initiation is also important for the longevity of technique survival and self-cannulation in home hemodialysis patients. Appropriate training of the ultrasound operator is required to ensure competent image acquisition with simultaneous needling. There are various approaches and considerations in choosing how to apply the ultrasound probe and needle the access, which are often governed by personal choice, training, and institutional patterns of practice more than a robust evidence base. Future research should focus on providing more clarity on the optimal method of utilizing ultrasound guidance in arteriovenous access cannulation, the precise indications for its use and, lastly, the benefits it confers compared to traditional blind cannulation.

Targeted Deprescribing in an Outpatient Hemodialysis Unit: A Quality Improvement Study to Decrease Polypharmacy.

BACKGROUND: Polypharmacy in hemodialysis patients can result in adverse patient outcomes. Deprescribing tools can reduce polypharmacy, yet no method exists for an outpatient hemodialysis population. DESIGN: Quality improvement study. SETTING & PARTICIPANTS: 240 patients in a tertiary-care outpatient hemodialysis unit. QUALITY IMPROVEMENT PLAN: We aimed to: (1) develop a deprescribing tool for target medications with poor evidence for efficacy and safety, (2) determine its effectiveness in decreasing polypharmacy, and (3) monitor patient safety and satisfaction. OUTCOMES: The primary outcome was the proportion of target medications completely deprescribed after 4 weeks. Secondary outcomes were the proportion of target medications completely deprescribed after 6 months, average number of medications per patient before and after deprescription, and proportion of successful deprescriptions for each target medication. MEASUREMENTS: Number of medications deprescribed at 4 weeks and 6 months. Patient safety and satisfaction were monitored using drug-specific monitoring parameters. RESULTS: A deprescribing tool for specific medications was developed and implemented in the hemodialysis unit. 5 medication classes were selected: quinine, diuretics, α1-blockers, proton pump inhibitors, and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins). All 240 patients in the unit were screened using the deprescribing tool. There were 171 of 240 (71%) patients prescribed at least 1 of the 5 target medications, and after applying the tool, 35 of 40 (88%) eligible patients had the medications deprescribed. There were 31 of 40 (78%) target medications completely deprescribed. 6 months after the study, only 5 of 31 (16%) medications discontinued were represcribed. At the end of the study, 57% of patients were taking fewer medications than at baseline. No adverse events were observed. LIMITATIONS: Single-center study that relied on patient self-reporting of medication use and adherence to our recommendations. CONCLUSIONS: Deprescribing tools can be applied successfully in an outpatient hemodialysis unit to reduce polypharmacy while maintaining patient safety and satisfaction.

Choosing Wisely: The Canadian Society of Nephrology's List of 5 Items Physicians and Patients Should Question.

PURPOSE OF REVIEW: The purpose of this review is to contribute to the Choosing Wisely Canada campaign and develop a list of 5 items for nephrology health care professionals and patients to re-evaluate based on evidence that they are overused or misused. SOURCES OF INFORMATION: A working group was formed from the Canadian Society of Nephrology (CSN) Clinical Practice Guidelines Committee. This working group sequentially used a multistage Delphi method, a survey of CSN members, a modified Delphi process, and a comprehensive literature review to determine 10 candidate items representing potentially ineffective care in nephrology. An in-person vote by CSN members at their Annual General Meeting was used to rank each item based on their relevance to and potential impact on patients with kidney disease to derive the final 5 items on the list. KEY MESSAGES: One hundred thirty-four of 609 (22%) CSN members responded to the survey, from which the CSN working group identified 10 candidate-misused items. Sixty-five CSN members voted on the ranking of these items. The top 5 recommendations selected for the final list were (1) do not initiate erythropoiesis-stimulating agents in patients with chronic kidney disease (CKD) with hemoglobin levels greater than or equal to 100 g/L without symptoms of anemia; (2) do not prescribe nonsteroidal anti-inflammatory drugs for individuals with hypertension or heart failure or CKD of all causes, including diabetes; (3) do not prescribe angiotensin-converting-enzyme inhibitors in combination with angiotensin II receptor blockers for the treatment of hypertension, diabetic nephropathy or heart failure; (4) do not initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their nephrology health care team; and (5) do not initiate dialysis in outpatients with CKD category G5-ND in the absence of clinical indications. LIMITATIONS: A low survey response rate of both community and academic nephrologists could contribute to sampling bias. However, the purpose of this report is to generate discussion, rather than study practice variation. IMPLICATIONS: These 5 evidence-based recommendations aim to improve outcomes and individualize care for patients with kidney disease, while reducing inefficiencies and preventing harm.

OBJECTIFS DE LA REVUE: Contribuer à la campagne nationale Choisir avec soin (Choosing Wisely Canada) et dresser une liste de cinq pratiques à être réévaluées par les professionnels de la santé et par les patients en néphrologie, parce que trop utilisées ou utilisées incorrectement. SOURCES: Un groupe de travail a été constitué au sein du comité de recommandations pour la pratique clinique de la Société canadienne de néphrologie (SCN). Ce groupe de travail a utilisé, de façon séquentielle, la méthode Delphi par paliers, un sondage mené auprès des membres de la SCN, une version modifiée de la méthode Delphi et une revue exhaustive de la littérature pour établir une liste de 10 pratiques candidates identifiant des soins potentiellement inefficaces en néphrologie. Les éléments retenus ont fait l'objet d'un vote auprès des membres de la SCN présents lors de l'assemblée générale annuelle. Ces derniers ont voté sur chacun des éléments pour permettre de les classer en fonction de leur pertinence et de l'impact potentiel qu'ils pouvaient avoir sur les patients atteints d'insuffisance rénale. Cinq éléments ont été retenus au terme de ce processus. RECOMMANDATIONS PRINCIPALES: Seuls 134 des 609 membres de la SCN (soit 22 %) ont répondu au sondage. Le groupe de travail de la SCN a identifié 10 pratiques candidates pour lesquelles 65 membres de la SCN ont voté en vue de procéder à un classement. Les 5 recommandations retenues dans la liste finale étaient (1) de ne pas entreprendre de traitement avec des agents stimulant l'érythropoïèse (ASE) chez les patients atteints d'insuffisance rénale chronique (IRC) dont le taux d'hémoglobine est supérieur ou égal à 100 g/L sans symptômes d'anémie ; (2) de ne pas prescrire de médicaments anti-inflammatoires non stéroïdiens (AINS) chez les individus souffrant d'hypertension, d'insuffisance cardiaque ou d'IRC peu importe la cause, y compris le diabète ; (3) de ne pas prescrire d'inhibiteurs de l'ECA (enzyme de conversion de l'angiotensine) en combinaison avec des antagonistes des récepteurs de l'angiotensine II (ARA II) pour le traitement de l'hypertension, de la néphropathie diabétique ou de l'insuffisance cardiaque ; (4) de ne pas amorcer d'hémodialyse chronique sans assurer un processus décisionnel partagé entre les patients, leurs familles, et leur équipe de soin de santé en néphrologie ; et (5) de ne pas amorcer l'hémodialyse chez les patients externes atteints d'IRC de catégorie G5-ND en l'absence d'indications cliniques. LIMITES: Le faible taux de réponse au sondage de la part des néphrologues de la communauté et du milieu universitaire a pu contribuer à introduire un biais attribuable à l'échantillonnage. Cependant, le but de ce rapport est de susciter la discussion, plutôt que d'étudier les variations dans la pratique. IMPLICATIONS: Ces cinq recommandations fondées sur des données probantes visent à améliorer les résultats des patients atteints d'insuffisance rénale et à individualiser les soins qui leur sont prodigués, tout en réduisant les lacunes et en prévenant les torts qui pourraient en découler.

Attitudes and Opinions of Canadian Nephrologists Toward Continuous Quality Improvement Options.

BACKGROUND AND OBJECTIVES: A shift to holding individual physicians accountable for patient outcomes, rather than facilities, is intuitively attractive to policy makers and to the public. We were interested in nephrologists' attitudes to, and awareness of, quality metrics and how nephrologists would view a potential switch from the current model of facility-based quality measurement and reporting to publically available reports at the individual physician level. DESIGN SETTING PARTICIPANTS AND MEASUREMENTS: The study was conducted using a web-based survey instrument (Online Appendix 1). The survey was initially pilot tested on a group of 8 nephrologists from across Canada. The survey was then finalized and e-mailed to 330 nephrologists through the Canadian Society of Nephrology (CSN) e-mail distribution list. The 127 respondents were 80% university based, and 33% were medical/dialysis directors. RESULTS: The response rate was 43%. Results demonstrate that 89% of Canadian nephrologists are engaged in efforts to improve the quality of patient care. A minority of those surveyed (29%) had training in quality improvement. They feel accountable for this and would welcome the inclusion of patient-centered metrics of care quality. Support for public reporting as an effective strategy on an individual nephrologist level was 30%. CONCLUSIONS: Support for public reporting of individual nephrologist performance was low. The care of nephrology patients will be best served by the continued development of a critical mass of physicians trained in patient safety and quality improvement, by focusing on patient-centered metrics of care delivery, and by validating that all proposed new methods are shown to improve patient care and outcomes.

CONTEXTE ET OBJECTIFS DE L'ÉTUDE: Une transition vers l'attribution de la responsabilité des résultats des patients au médecin traitant plutôt qu'à l'établissement de soins de santé est un concept attrayant pour les décideurs et le grand public. Notre objectif d'étude était bipartite: d'abord, nous voulions explorer la perception et la connaissance qu'ont les néphrologues des indicateurs de la qualité des soins; ensuite, nous souhaitions prendre connaissance de l'avis des néphrologues sur un éventuel changement de modèle, lequel évalue actuellement la qualité des soins de manière globale plutôt que pour chaque médecin et enfin, sur l'idée que de tels rapports individuels soient accessibles au public. CONCEPTION ET CADRE DE L'ÉTUDE PARTICIPANTS ET MÉTHODOLOGIE: L'étude a été réalisée à l'aide d'un sondage Web (voir l'annexe 1). Une version provisoire du sondage a d'abord été testée auprès de huit néphrologues de partout au Canada. La version définitive du sondage a été envoyée par courriel à 330 néphrologues figurant sur la liste d'envoi de la Société canadienne de néphrologie (SCN). Le taux de réponse global a été de 43%. Des 127 répondants, la grande majorité (80%) travaillait en milieu universitaire et 33% occupait un poste de directeur médical ou de directeur d'unité de dialyse. RÉSULTATS: Les résultats ont démontré que 89% des néphrologues canadiens s'efforcent déjà d'améliorer les soins prodigués aux patients, et qu'une minorité d'entre eux (29%) ont reçu une formation pertinente. De manière générale, ils se sentent responsables de la qualité des soins et sont réceptifs à l'idée d'inclure des critères d'évaluation plus axés sur les patients. Le taux d'approbation en regard de l'accès libre aux rapports individuels comme une stratégie efficace au plan individuel était de 30%. CONCLUSION: Un faible pourcentage des néphrologues s'est prononcé en faveur de la divulgation publique de rapport faisant état de leur performance individuelle. Les soins prodigués aux patients suivis en néphrologie seront perfectionnés en continuant d'augmenter le nombre de médecins formés en matière d'amélioration de la qualité des soins aux patients et de sécurité, en promouvant des indicateurs de qualité centrés sur les patients, et en vérifiant que toute nouvelle méthode proposée vise foncièrement à améliorer les soins ou les résultats des patients.

Renal Tubular Toxicity Associated With Rosuvastatin Therapy.

Preapproval clinical trials examining the safety and efficacy of rosuvastatin demonstrated an increased incidence of proteinuria, hematuria, rhabdomyolysis, and other acute kidney injury of unknown cause at high doses. The latter cases manifested with urine sediment findings and in some cases, renal histology, indicating renal tubular injury in the absence of rhabdomyolysis. Despite these provocative findings, there have been very few reports in the literature regarding non-rhabdomyolysis-mediated acute kidney injury associated with high-dose rosuvastatin since its widespread introduction more than a decade ago, suggesting that it is either a rare entity or systematically underdiagnosed and under-reported. We present a case of renal tubular toxicity attributable to the initiation of rosuvastatin treatment at a dose of 40mg in a patient with no prior evidence of kidney disease. Tubular toxicity should be considered in cases of unexplained kidney injury in the setting of exposure to a potent statin such as rosuvastatin, particularly at high dose. The limited evidence suggests a good kidney prognosis following withdrawal of the agent in these cases.

Achieving Procedural Competence during Nephrology Fellowship Training: Current Requirements and Educational Research.

Concerns have previously been raised as to whether training programs are ensuring that nephrology fellows achieve competence in the procedural skills required for independent practice. We sought to review the current requirements for procedural training as well as educational research pertaining to achieving competence in the core nephrology procedures of nontunneled (temporary) hemodialysis catheter insertion and percutaneous kidney biopsy. At this time, there is no universal approach to procedural training and assessment during nephrology fellowship. Nonetheless, simulation-based mastery learning programs have been shown to be effective in improving fellows' skills in nontunneled (temporary) hemodialysis catheter insertion and should be provided by all nephrology training programs. For percutaneous kidney biopsy, the development and evaluation of inexpensive simulators are a promising starting point for future study. Current practice with respect to procedural training during nephrology fellowship remains imperfect; however, the ongoing shift toward competency-based evaluation provides opportunities to refocus on improvement.

How to Diagnose Solutions to a Quality of Care Problem.

To change a particular quality of care outcome within a system, quality improvement initiatives must first understand the causes contributing to the outcome. After the causes of a particular outcome are known, changes can be made to address these causes and change the outcome. Using the example of home dialysis (home hemodialysis and peritoneal dialysis), this article within this Moving Points feature on quality improvement will provide health care professionals with the tools necessary to analyze the steps contributing to certain outcomes in health care quality and develop ideas that will ultimately lead to their resolution. The tools used to identify the main contributors to a quality of care outcome will be described, including cause and effect diagrams, Pareto analysis, and process mapping. We will also review common change concepts and brainstorming activities to identify effective change ideas. These methods will be applied to our home dialysis quality improvement project, providing a practical example that other kidney health care professionals can replicate at their local centers.

How to Measure and Interpret Quality Improvement Data.

This article will demonstrate how to conduct a quality improvement project using the change idea generated in "How To Use Quality Improvement Tools in Clinical Practice: How To Diagnose Solutions to a Quality of Care Problem" by Dr. Ziv Harel and colleagues in this Moving Points feature. This change idea involves the introduction of a nurse educator into a CKD clinic with a goal of increasing rates of patients performing dialysis independently at home (home hemodialysis or peritoneal dialysis). Using this example, we will illustrate a Plan-Do-Study-Act (PDSA) cycle in action and highlight the principles of rapid cycle change methodology. We will then discuss the selection of outcome, process, and balancing measures, and the practicalities of collecting these data in the clinic environment. We will also introduce the PDSA worksheet as a practical way to oversee the progress of a quality improvement project. Finally, we will demonstrate how run charts are used to visually illustrate improvement in real time, and how this information can be used to validate achievement, respond appropriately to challenges the project may encounter, and prove the significance of results. This article aims to provide readers with a clear and practical framework upon which to trial their own ideas for quality improvement in the clinical setting.