Non-surgical interventions to control bleeding from arteriovenous fistulas and grafts inside and outside the hemodialysis unit: a scoping review.

Background: Prolonged bleeding from arteriovenous fistulas (AVF) and arteriovenous grafts (AVG) associates with worse outcomes; Within the hemodialysis unit these outcomes include anemia and quality of life disruptions, and outside the hemodialysis unit includes fatal hemorrhage. However, various guidelines for AVF/AVG bleeding management inside and outside the hemodialysis unit lack consensus. Methods: A scoping review was conducted of four databases, from inception to 17 February 2024. The study population was hemodialysis patients experiencing bleeding from AVF or AVG. Studies that assessed non-operative management were included. Results: Sixteen studies met inclusion criteria. Most (14/16) addressed post-cannulation bleeding from AVF/AVG within the dialysis unit. Compared with standard dressings, hemostatic dressings (chitosan-, cellulose- or thrombin-based) decreased post-cannulation bleeding time at arterial and venous site 35.7%-84.0% (P < .05) and 38.5%-78.7% (P < .05), respectively. Use of chitosan-based dressings decreased percentage of patients bleeding 4-min post-cannulation by 16.3%-39.2%. One pilot observational study demonstrated no access thromboses or infections with short-term use of a compression device within the hemodialysis unit. However, the role of compression devices and tourniquets within the dialysis unit remains unclear, despite widespread use. Long-term AVF/AVG survival was not reported in any study. Limited research confirms that devices are effective in prevention of catastrophic out-of-hospital bleeding. It remains uncertain if device availability enhances patient confidence in managing out-of-hospital bleeding. This may impact patient choices around dialysis modality, access and transplant, but this remains uncertain. Conclusions: In hemodialysis patents with bleeding from AVF/AVG, several alternative dressings or devices decrease post-cannulation bleeding time within the hemodialysis unit. Existing research has not established criteria on when it might be appropriate to use specialized dressings. There is very limited research on methods to control bleeding from AVF/AVG outside the hemodialysis unit. More data are required before evidence-based guidelines can be made. Recommendations for future research are provided.

Protection against Incidences of Serious Cardiovascular Events Study with daily fish oil supplementation in dialysis patients (PISCES): protocol for a randomised controlled trial.

INTRODUCTION: Patients with kidney failure with replacement therapy (KFRT) suffer premature cardiovascular (CV) mortality and events with few proven pharmacological interventions. Omega-3 polyunsaturated essential fatty acids (n-3 PUFAs) are associated with a reduced risk of CV events and death in non-dialysis patients and in patients with established CV disease but n-3 PUFAs have not been evaluated in the high risk KFRT patient population. METHODS AND ANALYSIS: This multicentre randomised, placebo controlled, parallel pragmatic clinical trial tests the hypothesis that oral supplementation with n-3 PUFA, when added to usual care, leads to a reduction in the rate of serious CV events in haemodialysis patients when compared with usual care plus matching placebo. A target sample size of 1100 KFRT patients will be recruited from 26 dialysis units in Canada and Australia and randomised to n-3 PUFA or matched placebo in a 1:1 ratio with an expected intervention period of at least 3.5 years. The primary outcome to be analysed and compared between intervention groups is the rate of all, not just the first, serious CV events which include sudden and non-sudden cardiac death, fatal and non-fatal myocardial infarction, stroke, and peripheral vascular disease events. ETHICS AND DISSEMINATION: This study has been approved by all institutional ethics review boards involved in the study. Participants could only be enrolled following informed written consent. Results will be published in peer-reviewed journals and presented at scientific and clinical conferences. TRIAL REGISTRATION NUMBER: ISRCTN00691795.

A Simple Exercise Program for Patients With End-Stage Kidney Disease to Improve Strength and Quality of Life: Clinical Research Protocol.

Background: Most patients with end-stage kidney disease (ESKD) appreciate the importance of exercise and would like to increase their physical activity; however, they report a few key barriers, including (1) lack of physician advice to do so, (2) lack of safe and convenient programs (ie, appropriate for home or neighborhood), and (3) cost. Importantly, patients indicated in a previous survey that they would prefer an exercise program that improves muscle strength and symptoms, and are less interested in cardiovascular disease prevention. Objective: To test the feasibility of a simple, prescribed exercise program using Nordic walking poles in patients with ESKD treated with dialysis. Design: Randomized multicenter pilot trial of an exercise intervention that includes Nordic walking poles, personalized physician exercise prescriptions, pedometers, and access to exercise videos, compared with standard of care, in patients being treated with maintenance dialysis. Setting: Multicenter tertiary care centers in Canada. Patients: Ambulatory adult patients with ESKD treated with peritoneal dialysis or hemodialysis (HD) for at least 6 months at participating sites are potentially eligible. Inclusion criteria include ability to use Nordic walking poles (either de novo or in place of mobility aid) and to provide informed consent in English or in French. Exclusion criteria include (1) any absolute contraindication to exercise, (2) baseline step count >8000 steps/day, (3) planned living donor kidney transplant, and (4) participation in another interventional trial that may affect the results of this study. Methods: This is a randomized multicenter pilot trial of an exercise intervention that consists of a prescription to exercise using Nordic walking poles, a pedometer to track activity, and access to exercise videos, with the comparator of standard of care (dialysis unit staff encouragement to exercise) in patients being treated with maintenance dialysis. Randomization is concealed and uses a 1:1 ratio for group assignment. Our specific aims are to determine the feasibility of patient recruitment, adherence to the exercise program (verified by step counts), and efficacy of the intervention on patient-important outcomes that were assessed as a priority by patients in a prior survey-specifically strength, fatigue, and sleep. We record days spent in hospital and loss of independent living to inform sample size calculations for a definitive trial of exercise in patient with ESKD treated with dialysis. Adverse events are closely monitored. Outcomes: Primary: Our recruitment goal is 90 to 150 patients over 27 months; adherence success will be defined if >75% of randomized patients, excluding those who are transplanted or deceased, achieve >80% of their prescribed steps at 6 and 12 months. Secondary Efficacy Outcomes: (1) strength-hand grip strength and 5 times sit to stand, (2) energy-Short Form (SF)-36 vitality subscale, and (3) sleep-Pittsburg Sleep Quality Index will be assessed at baseline, 6, and 12 months. Results: Trial recruitment started before the COVID-19 pandemic and the pandemic led to many interruptions and delays. Online exercise Web sites and a tailored video were added to the protocol to encourage activity when participants were unable or reluctant to walk in public places. Limitations: This trial was designed to include ambulatory patients with ESKD and does not address the burden of disease in patients with very restricted mobility. Trial Registration: NCT03787589.

Contexte: La plupart des patients atteints d'insuffisance rénale terminale (IRT) comprennent l'importance de l'exercice physique et souhaitent augmenter leur niveau d'activité. Ils signalent toutefois quelques obstacles, notamment 1) le manque de conseils médicaux pour le faire; 2) le manque de programmes sécuritaires et faciles (c.-à-d. pouvant être suivis à la maison ou dans le quartier); et 3) les coûts. Il convient de noter que les patients avaient indiqué dans une enquête précédente préférer un programme d'exercices améliorant la force musculaire et les symptômes liés à la maladie, et être moins intéressés par la prévention des maladies cardiovasculaires. Objectif: Dans une population de patients atteints d'IRT traités par dialyse, tester la faisabilité d'un programme prescrit et simple à suivre d'exercices impliquant l'utilisation de bâtons de marche nordique. Conception: Essai pilote randomisé multicentrique mené chez des patients traités par dialyse d'entretien. L'essai compare les soins habituels à une intervention comprenant des exercices avec bâtons de marche nordique, un programme personnalisé prescrit par un médecin, un podomètre et l'accès à des vidéos d'exercices. Cadre: Plusieurs centres de soins tertiaires au Canada. Sujets: Tous les patients adultes ambulatoires atteints d'IRT traités par dialyse péritonéale ou hémodialyse depuis au moins 6 mois dans les sites participants sont potentiellement admissibles. Pour être inclus, les patients doivent pouvoir utiliser des bâtons de marche nordique (de novo ou en remplacement de l'aide à la mobilité) et fournir un consentement éclairé en anglais ou en français. Les critères d'exclusion sont : 1) toute contre-indication absolue à l'exercice; 2) le fait de marcher déjà au moins 8 000 pas/jour; 3) avoir une transplantation rénale d'un donneur vivant prévue; 4) la participation à un autre essai interventionnel susceptible d'affecter les résultats de la présente étude. Méthodologie: Il s'agit d'un essai pilote randomisé multicentrique examinant une intervention en matière d'activité physique. L'intervention consiste en une prescription d'activité physique à l'aide de bâtons de marche nordique, elle donne accès à un podomètre pour suivre l'activité, ainsi qu'à des vidéos d'exercices; le comparateur est la norme de soins (encouragement par le personnel de l'unité de dialyse à pratiquer une activité physique) pour les patients traités par dialyse d'entretien. La randomisation est masquée et utilise un ratio de 1:1 pour l'affectation aux groupes. Nous examinons la faisabilité du recrutement des patients, l'observance du programme d'exercices (vérifiée par le nombre de pas) et l'efficacité de l'intervention sur les résultats de santé ayant été jugés comme importants et prioritaires par les patients dans une enquête précédente ­ plus précisément la force, la fatigue et le sommeil. Nous enregistrons le nombre de jours passés à l'hôpital et la perte de vie autonome afin d'éclairer les calculs de la taille de l'échantillon d'un essai définitif qui portera sur l'activité physique en contexte d'HD. Les événements indésirables sont étroitement surveillés. Mesures: Primaires : nous souhaitons recruter 90 à 150 patients sur une période de 27 mois; l'observance sera jugée comme un succès si plus de 75 % des patients randomisés (excluant les patients transplantés ou décédés) atteignent plus de 80 % de leur prescription de nombres de pas/jour après 6 et 12 mois. Paramètres secondaires d'efficacité : 1) Force ­ mesure de la force de préhension et 5 fois l'exercice de se lever d'une position assise; 2) Énergie ­ sous-échelle du test de vitalité SF-36; et 3) Sommeil ­ mesure de l'Indice de la qualité du sommeil Pittsburg à l'inclusion et après 6 mois et 12 mois. Résultats: Le recrutement s'est amorcé avant la pandémie de COVID-19, puis celle-ci a entraîné de nombreuses interruptions et retards. Des sites d'exercices en ligne et une vidéo personnalisée ont été ajoutés au protocole afin d'encourager les patients à continuer de faire de l'activité physique lorsqu'ils ne pouvaient pas marcher dans des lieux publics ou étaient réticents à le faire. Limites: Cet essai a été conçu pour inclure des patients ambulatoires atteints d'IRT, il ne traite pas du fardeau de la maladie chez les patients à mobilité très restreinte.

North American Weight Management Programs for People Living With Chronic Kidney Disease: An Environmental Scan.

Background: The availability and accessibility of patient-centered weight management programs is critical to mitigate the increasing prevalence of obesity in people living with chronic kidney disease (CKD). Little is known about the availability of contemporary programs that can safely and effectively support individuals living with obesity and CKD across North America. Objective: We sought to identify weight management programs specific to those with CKD and explore their safety, affordability, and adaptability to this patient population. We also identified the barriers and facilitators of identified programming including their accessibility to real-world patients (eg, cost, access, support, and time). Design: Environmental scan of weight management programs. Setting: North America. Patient: People living with CKD. Methods: We identified weight management programs and associated barriers and facilitators, via an Internet-based search of commercial, community-based, and medically supervised weight management programming. We also conducted a gray literature search and contacted weight management experts and program facilitators to explore strategies as well as their barriers and facilitators. Results: We identified 40 weight management programs available to people living with CKD across North America. Programs were commercial (n = 7), community-based (n = 9), and medically supervised (Canada n = 13, U.S n = 8) in origin. Three programs were specifically tailored to CKD (n = 3). In addition to formal programs, we also identified online nutritional resources and guidelines for weight loss in CKD (n = 8), and additional strategies (self-management tools, group orientated programs, moderate energy restrictions in conjunction with exercise and Orlistat) for weight loss from the gray literature (n = 3). Most common barriers were difficulty accessing some of the suggested nutritious food options due to the high cost, lack of support from family, friends and health practitioners, the time commitment required to participate, and the exclusion from weight management programs due to unique dietary needs for the CKD population. Most common facilitators were programs that were patient-centered, evidence-based, and offered both group and individual formats. Limitations: Although our search criteria were broad, it is possible that we did not capture all weight management programs available across North America. Conclusions: This environmental scan has generated a resource list of existing safe and effective programs for or adaptable to people with CKD. This information will inform future efforts to develop and deliver CKD-specific weight management programs to patients living with comorbid disease. Engaging people living with CKD to understand the acceptability of these programs, is an important focus for future research.

Contexte: Pour atténuer la prévalence croissante de l'obésité chez les personnes atteintes d'insuffisance rénale chronique (IRC), il est essentiel de rendre disponibles et accessibles des programs de gestion du poids destinés à ces patients. On en sait peu sur la disponibilité de programs contemporains permettant de soutenir efficacement et en toute sécurité les personnes souffrant d'obésité et d'IRC en Amérique du Nord. Objectifs: Nous souhaitions identifier les programmes de gestion du poids destinés aux personnes atteintes d'IRC et explorer leur sûreté, leur accessibilité et leur capacité d'adaptation à cette population de patients. Nous avons également répertorié les obstacles et les éléments facilitateurs des programmes identifiés, notamment leur accessibilité aux patients du monde réel (p. ex., coût, accès, soutien, temps). Conception: Analyse environnementale des programmes de gestion du poids. Cadre: Amérique du Nord. Sujets: Personnes atteintes d'IRC. Méthodologie: Nous avons identifié les programmes de gestion du poids, ainsi que les obstacles et éléments facilitateurs associés, par le biais d'une recherche des programmes de gestion du poids commerciaux, communautaires et médicalement supervisés sur Internet. Nous avons également recherché dans la littérature grise et communiqué avec des experts en gestion du poids et des intervenants de programmes pour explorer les autres stratégies, leurs obstacles et éléments facilitateurs. Résultats: Nous avons identifié 40 programmes de gestion du poids offerts aux personnes atteintes d'IRC dans toute l'Amérique du Nord; des programmes commerciaux (n = 7), communautaires (n = 9) et médicalement supervisés (Canada: n = 13; États-Unis: n = 8). Trois programmes étaient spécifiquement adaptés à l'IRC (n = 3). En plus des programmes officiels, des lignes directrices et des ressources nutritionnelles pour la perte de poids en contexte d'IRC ont été trouvées en ligne (n = 8), et d'autres stratégies (n = 3) pour la perte de poids (outils d'autogestion, programmes axés sur des groupes, restrictions énergétiques modérées jumelées à l'exercice et Orlistat) ont été trouvées dans la littérature grise. Les obstacles les plus courants étaient la difficulté d'accès à certaines des options alimentaires suggérées en raison de leur coût élevé; le manque de soutien de la famille, des proches et des professionnels de la santé; le temps nécessaire pour participer aux programmes; et l'exclusion des programmes en raison des restrictions alimentaires particulières des patients atteints d'IRC. Les éléments facilitateurs les courants étaient le fait que ces programmes étaient axés sur le patient, qu'ils étaient fondés sur des données probantes et qu'ils offraient des formats individuels et de groupe. Limites: Bien que nos critères de recherche étaient larges, il est possible que nous n'ayons pas saisi tous les programmes de gestion du poids disponibles en Amérique du Nord. Conclusion: Cette analyse environnementale a permis de dresser une liste des programmes sûrs et efficaces destinés ou pouvant être adaptés aux personnes atteintes d'IRC. Ces informations serviront de base aux efforts futurs visant à élaborer et à proposer des programmes de gestion du poids propres aux patients atteints d'IRC et d'une comorbidité. La participation des personnes atteintes d"IRC à la compréhension de l"acceptabilité de ces programmes est un axe de recherche important pour le futur. Mots clés: insuffisance rénale chronique; insuffisance rénale terminale; gestion de l"obésité; gestion du poids; nutrition.

Glucagon-like peptide 1 receptor agonists in end-staged kidney disease and kidney transplantation: A narrative review.

AIMS: Glucagon-like peptide 1 receptor agonists (GLP-1RA) improve glycemic control and promote weight loss in type 2 diabetes (DM2) and obesity. We identified studies describing the metabolic benefits of GLP-1RA in end-staged kidney disease (ESKD) and kidney transplantation. DATA SYNTHESIS: We searched for randomized controlled trials (RCTs) and observational studies that investigated the metabolic benefits of GLP-1RA in ESKD and kidney transplantation. We summarized the effect of GLP-1RA on measures of obesity and glycemic control, examined adverse events, and explored adherence with therapy. In small RCTs of patients with DM2 on dialysis, liraglutide for up to 12 weeks lowered HbA1c by 0.8%, reduced time in hyperglycemia by ∼2%, lowered blood glucose by 2 mmol/L and reduced weight by 1-2 kg, compared with placebo. In prospective studies inclusive of ESKD, 12 months of semaglutide reduced HbA1c by 0.8%, and contributed to weight losses of 8 kg. In retrospective cohort studies in DM2 and kidney transplantation, 12 months of GLP-1RA lowered HbA1c by 2%, and fasting glucose by ∼3 mmol/L compared with non-use, and in some reports, weight losses of up to 4 kg were described. Gastrointestinal (GI) side effects were most commonly reported, with hypoglycemia described with GLP-1RA in hemodialysis, particularly in those using insulin. CONCLUSIONS: GLP-1RA are growing in popularity in those with DM2 and obesity. In small RCTs and observational cohort studies modest glycemic and weight benefits have been described in ESKD and transplantation, but GI side effects may limit adherence. Larger and longer term studies of GLP-1RA remain important.

Management of Type 2 Diabetic Kidney Disease in 2022: A Narrative Review for Specialists and Primary Care.

Purpose of review: Kidney disease is present in almost half of Canadian patients with type 2 diabetes (T2D), and it is also the most common first cardiorenal manifestation of T2D. Despite clear guidelines for testing, opportunities are being missed to identify kidney diseases, and many Canadians are therefore not receiving the best available treatments. This has become even more important given recent clinical trials demonstrating improvements in both kidney and cardiovascular (CV) endpoints with sodium-glucose cotransporter 2 (SGLT2) inhibitors and a nonsteroidal mineralocorticoid receptor antagonist, finerenone. The goal of this document is to provide a narrative review of the current evidence for the treatment of diabetic kidney disease (DKD) that supports this new standard of care and to provide practice points. Sources of information: An expert panel of Canadian clinicians was assembled, including 9 nephrologists, an endocrinologist, and a primary care practitioner. The information the authors used for this review consisted of published clinical trials and guidelines, selected by the authors based on their assessment of their relevance to the questions being answered. Methods: Panelists met virtually to discuss potential questions to be answered in the review and agreed on 10 key questions. Two panel members volunteered as co-leads to write the summaries and practice points for each of the identified questions. Summaries and practice points were distributed to the entire author list by email. Through 2 rounds of online voting, a second virtual meeting, and subsequent email correspondence, the authors reached consensus on the contents of the review, including all the practice points. Key findings: It is critical that DKD be identified as early as possible in the course of the disease to optimally prevent disease progression and associated complications. Patients with diabetes should be routinely screened for DKD with assessments of both urinary albumin and kidney function. Treatment decisions should be individualized based on the risks and benefits, patients' needs and preferences, medication access and cost, and the degree of glucose lowering needed. Patients with DKD should be treated to achieve targets for A1C and blood pressure. Renin-angiotensin-aldosterone system blockade and treatment with SGLT2 inhibitors are also key components of the standard of care to reduce the risk of kidney and CV events for these patients. Finerenone should also be considered to further reduce the risk of CV events and chronic kidney disease progression. Education of patients with diabetes prescribed SGLT2 inhibitors and/or finerenone is an important component of treatment. Limitations: No formal guideline process was used. The practice points are not graded and are not intended to be viewed as having the weight of a clinical practice guideline or formal consensus statement. However, most practice points are well aligned with current clinical practice guidelines.

Justification: L'insuffisance rénale est présente chez près de la moitié des patients canadiens atteints de diabète de type 2 (DT2). Il s'agit également de la première manifestation cardiorénale la plus fréquente du DT2. Bien qu'il existe des lignes directrices claires pour son dépistage, des occasions de diagnostiquer l'insuffisance rénale sont manquées, ce qui fait en sorte que de nombreux Canadiens ne reçoivent pas les meilleurs traitements disponibles. Cette préoccupation a pris de l'importance puisque de récents essais cliniques ont démontré des améliorations dans les paramètres rénaux et cardiovasculaires (CV) avec la prise de finérénone, un antagoniste non stéroïdien des récepteurs minéralocorticoïdes (nsMRA), et d'inhibiteurs du cotransporteur de glucose de sodium 2 (SGLT2). L'objectif de cet article est de fournir une revue narrative des données probantes actuelles appuyant cette nouvelle norme de soins pour le traitement de l'insuffisance rénale diabétique (IRD), ainsi que des points de pratique. Sources de l'information: Un groupe d'experts composé de cliniciens canadiens, dont neuf néphrologues, un endocrinologue et un prestataire de soins primaires, a été formé. Les auteurs de cette revue ont utilisé des lignes directrices et des essais cliniques publiés comme sources; ceux-ci ont été choisis sur la base d'une évaluation de leur pertinence pour les questions auxquelles ils avaient répondu. Méthodologie: Les panélistes se sont réunis virtuellement pour discuter de potentielles questions à répondre dans le cadre de cette revue, et se sont entendus sur dix questions clés. Deux membres du panel se sont portés volontaires pour être co-responsables et rédiger les résumés et les points de pratique pour chacune des questions identifiées. Ces derniers ont été distribués par courriel à l'ensemble des auteurs. Après deux tours de vote en ligne, une deuxième réunion virtuelle et la correspondance électronique qui a suivi, les auteurs sont parvenus à un consensus sur le contenu de la revue narrative, y compris sur tous les points de pratique. Principaux résultats: Il est essentiel que l'IRD soit diagnostiquée le plus tôt possible afin de prévenir de façon optimale la progression de la maladie et les complications qui y sont associées. On devrait procéder au dépistage systématique de l'IRD chez les patients diabétiques par l'évaluation de l'albumine urinaire ET de la fonction rénale. Les décisions relatives au traitement devraient être individualisées en fonction des risques et des avantages pour le patient, de ses besoins et préférences, de l'accès aux médicaments et des coûts, ainsi que du degré nécessaire de réduction de la glycémie. Les patients atteints d'IRD devraient être traités pour atteindre les cibles d'A1c et de pression artérielle. Le blocage du SRAA et le traitement avec des inhibiteurs du SGLT2 sont également des composantes clés de la norme de soins visant à réduire le risque d'événements rénaux et CV pour ces patients. La finérénone devrait également être envisagée pour réduire encore davantage les risques d'événements CV et de progression vers l'IRC. L'éducation des patients diabétiques auxquels on prescrit des inhibiteurs du SGLT2 et/ou de la finérénone est un élément important du traitement. Limites: Aucun processus officiel de directives n'a été utilisé. Les points de pratique ne sont pas notés et ne sont pas destinés à être considérés comme ayant le poids d'une directive de pratique clinique ou d'une déclaration de consensus officielle. Cependant, la plupart des points de pratique sont bien alignés avec les lignes directrices actuelles de pratique clinique.

A New Perspective to Longstanding Challenges with Outpatient Hyperkalemia: A Narrative Review.

Purpose of Review: Outpatient hyperkalemia is a common problem with potentially deadly consequences. Potassium level thresholds to treat outpatient hyperkalemia are unstandardized and variable, leaving health care providers to rely on their own clinical judgment. This narrative review highlights the challenges of outpatient hyperkalemia management and includes recommendations for future studies that may standardize treatment, improve patient outcomes, and optimize health care utilization. Sources of Information: PubMed, Google Scholar, and the reference lists of identified articles were used to include English, peer-reviewed studies and guidelines for this review. Methods: This narrative review examines outpatient hyperkalemia from both a laboratory and clinical perspective. In addition to peer-reviewed literature, guidelines and expert consensus statements were included to highlight the inconsistencies and paucity of evidence that health care providers rely on to make clinical decisions. Key Findings: There are multiple reasons why outpatient hyperkalemia management is both challenging and sub-optimal. Clinicians must discern if the potassium level result is accurate and, if so, does the result warrant referral to the emergency department. Factitious hyperkalemia, or falsely elevated potassium level results due to analytical errors, occurs frequently, but there are no ways to identify it other than for hemolyzed samples. Additionally, guidelines and expert panels are inconsistent on the thresholds for treatment and the management of hyperkalemia. Finally, there are inconsistencies between laboratories as to when and how providers are notified of results, and the suggested thresholds for urgent management. A study that integrates the expertise of clinical biochemists and clinicians is needed to inform evidence-based guidelines for the management of outpatient hyperkalemia. Limitations: This was a comprehensive review of what is known and what still needs to be understood for the management of outpatient hyperkalemia. A formal tool to assess the quality of the included studies was not used and selection bias may have occurred.

Raison de la revue: L'hyperkaliémie ambulatoire est fréquente et peut avoir des conséquences mortelles. Les seuils de potassium justifiant le traitement de l'hyperkaliémie ambulatoire varient et ne sont pas normalisés; les professionnels de la santé doivent par conséquent s'en remettre à leur propre jugement clinique. Cette revue narrative met en évidence les défis liés à la prise en charge de l'hyperkaliémie ambulatoire et comprend des recommandations pour de futures études pour standardiser le traitement, améliorer les résultats des patients et optimiser l'utilisation des soins de santé. Sources d'information: PubMed, Google Scholar et les listes de références des articles répertoriés ont été utilisés pour inclure les études évaluées par les pairs et les lignes directrices rédigées en anglais. Méthodologie: Cette revue narrative examine la prise en charge de l'hyperkaliémie ambulatoire du point de vue clinique et paraclinique. En plus des articles évalués par les pairs, on a inclus des lignes directrices et des déclarations de consensus d'experts afin de mettre en évidence les incohérences et la rareté des données probantes sur lesquelles s'appuient les prestataires de soins de santé pour prendre des décisions cliniques. Principaux resultants: Plusieurs raisons peuvent expliquer pourquoi la prise en charge de l'hyperkaliémie ambulatoire est à la fois difficile et sous-optimale. Les cliniciens doivent juger eux-mêmes si le résultat du potassium est exact et, dans l'affirmative, déterminer s'il justifie l'aiguillage du patient vers les urgences. L'hyperkaliémie factice, soit des taux de potassium faussement élevés en raison d'erreurs analytiques, est fréquente, mais il n'existe aucun moyen de l'établir à l'exception des échantillons hémolysés. Aussi, les lignes directrices et les groupes d'experts ne s'entendent pas sur les seuils de traitement et de prise en charge de l'hyperkaliémie. Enfin, on observe des incohérences entre les laboratoires quant au moment et à la façon dont les prestataires sont informés des résultats, de même qu'en ce qui concerne les seuils suggérés pour une prise en charge urgente. Une étude intégrant l'expertise des biochimistes cliniques et des cliniciens est nécessaire pour éclairer des lignes directrices fondées sur des données probantes pour la prise en charge de l'hyperkaliémie ambulatoire. Limites: Il s'agit d'un examen complet de ce que l'on connaît et de ce qui doit encore être compris au sujet de la prise en charge de l'hyperkaliémie ambulatoire. Des biais de sélection pourraient s'être introduits puisqu'aucun outil formel n'a été utilisé pour évaluer les études incluses.

Cardiac implications of upper-arm arteriovenous fistulas: A case series.

BACKGROUND: Cardiovascular disease is a major cause of morbidity and mortality in patients with end-stage kidney disease. Arterio-venous fistulas (AVF), the gold standard for hemodialysis vascular access, are known to alter cardiac morphology and circulatory hemodynamics. We present a prospective case series of patients after creation of an AVF, explore the timeline for changes in their cardiac morphology, and detail considerations for clinicians. METHODS: Patients were recruited in 2010 at multiple centers immediately prior to the creation of an upper-arm AVF and the initiation of hemodialysis. Cardiovascular magnetic resonance images were taken at intake before the creation of the AVF, 6-month follow-up, and 12-month follow-up. Image segmentation was used to measure left ventricular volume and mass, left atrial volume, and ejection fraction. RESULTS: Eight patients met eligibility criteria. All eight patients had a net increase in left ventricular mass over enrollment, with a mean increase of 9.16 g (+2.96 to +42.66 g). Five participants had a net decrease in ejection fraction, with a mean change in ejection fraction of -5.4% (-21% to +5%). Upon visual inspection the patients with the largest ejection fraction decrease had noticeably hypertrophic and dilated ventricles. Left atrial volume change was varied, decreasing in five participants, while increasing in three participants. Changes in morphology were present at 6-month follow-up, even in patients who did not maintain AVF patency for the entirety of the 6-month period. CONCLUSION: All patients included in this prospective case series had increases in left ventricular mass, with variability in the effects on the ejection fraction and left atrial volume. As left ventricular mass is an independent predictor of morbidity and mortality, further research to determine appropriate vascular access management in both end-stage kidney disease and kidney transplant populations is warranted.

Inhibit progression of coronary artery calcification with vitamin K in hemodialysis patients (the iPACK-HD study): a randomized, placebo-controlled multi-center, pilot trial.

BACKGROUND: Vitamin K activates matrix Gla protein (MGP), a key inhibitor of vascular calcification. There is a high prevalence of sub-clinical vitamin K deficiency in patients with end-stage kidney disease. METHODS: A parallel randomized placebo-controlled pilot trial was designed to determine whether 10 mg of phylloquinone thrice weekly versus placebo modifies coronary artery calcification progression over 12 months in patients requiring hemodialysis with a coronary artery calcium score (CAC) ≥30 Agatston Units (ClinicalTrials.gov identifier NCT01528800). The primary outcome was feasibility (recruitment rate, compliance with study medication, study completion and adherence overall to study protocol). CAC score was used to assess calcification at baseline and 12 months. Secondary objectives were to explore the impact of phylloquinone on vitamin K-related biomarkers (phylloquinone, dephospho-uncarboxylated MGP and the Gla-osteocalcin to Glu-osteocalcin ratio) and events of clinical interest. RESULTS: A total of 86 patients with a CAC score ≥30 Agatston Units were randomized to either 10 mg of phylloquinone or a matching placebo three times per week. In all, 69 participants (80%) completed the trial. Recruitment rate (4.4 participants/month) and medication compliance (96%) met pre-defined feasibility criteria of ≥4.17 and ≥90%, respectively. Patients randomized to phylloquinone for 12 months had significantly reduced levels of dephospho-uncarboxylated MGP (86% reduction) and increased levels of phylloquinone and Gla-osteocalcin to Glu-osteocalcin ratio compared with placebo. There was no difference in the absolute or relative progression of coronary artery calcification between groups. CONCLUSION: We demonstrated that phylloquinone treatment improves vitamin K status and that a fully powered randomized trial may be feasible.

Improving Timeliness in Surgical Discharge Summary Distribution: A Quality Improvement Initiative.

Objective: To implement a quality improvement initiative to achieve an institutional targeted discharge summary distribution metric of 50% within 48 hours of patient discharge from hospital within an academic tertiary care otolaryngology-head and neck surgery department. Methods: A pre- and postintervention study was conducted. Process mapping was performed. Interventions included education and engagement, implementation of auto-authentication (distribution immediately following transcription without review by the most responsible physician), and audit and feedback. The percentage of discharge summaries dictated with the auto-authentication code was evaluated. Process measures were collected for 12 months pre- and postimplementation. Balancing measures included workload and revisions to auto-authenticated notes. Analysis included summary statistics, statistical process control charting, and unpaired t tests. Results: The mean ± SD percentage of discharge summaries distributed within 48 hours increased from 19% ± 6.4% preintervention to 54% ± 20% postintervention (P < .0001). Seventy-four percent of discharge summaries were dictated via the auto-authentication code. The target metric was met in 71% of discharges with the auto-authentication codes as compared with 26% with non-auto-authentication. The interventions did not result in any change to perceived workload, and the incidence of auto-authentication revisions was <1%. The results were sustained with an increase of 72% the following quarter. For fiscal year 2021-2022, performance remained sustained with an 85% completion rate. Discussion: Our surgical department exceeded and sustained the targeted metric for timely discharge summary distribution using a quality improvement approach. Implications for Practice: Timely distribution of discharge summaries optimizes patients' transitions of care and can be achieved through stakeholder education and engagement, auto-authentication, and audit with feedback.

Recognition of Obesity and Perceptions of Weight Loss Management in Patients With Chronic Kidney Disease: A Retrospective Cross-Sectional Study.

Background: Obesity is, directly and indirectly, linked to the progression of chronic kidney disease (CKD). However, nephrologists' recognition of obesity and willingness to address and manage obesity are unknown. Objectives: The aim of this article is to investigate if obesity is recognized and documented in the clinical encounter and to examine nephrologists' perceptions of obesity and comfort with weight loss management. Design: We conducted a 2-part study. Part I used a retrospective chart review and part II used an anonymous online survey of practicing nephrologists (n = 14) in our center. Setting: The study took place in the Multi-care Kidney Clinic (MCKC) at London Health Sciences Centre in London, Ontario, Canada. Patients: In part I, we conducted a retrospective chart review of 10 random patients with advanced CKD and obesity (body mass index [BMI] > 30 kg/m2) from each of the nephrologists between January and December 2019. Methods: In part I, charts were assessed for documentation of obesity and/or a treatment plan (lifestyle counseling, pharmacologic intervention, and specialist referral). In part II, a survey completed by the nephrologists explored their current experience and perceptions of obesity and comfort with weight loss management. Responses were ranked on a 5-point Likert scale. Results: In all, 140 patient charts were reviewed. The median age was 69 (interquartile range [IQR] = 60-77) years, estimated glomerular filtration rate (eGFR) was 17 (IQR = 12-20) ml/min/1.73 m2, weight was 99 (IQR = 90-116) kg, and BMI was 36 (IQR = 33-40) kg/m2. Obesity with a BMI was documented in 36 (26%) charts, and only 2 (1%) documented a weight loss plan, which only included non-pharmacologic strategies. There were 13 survey responses (93% response rate). All nephrologists agreed that obesity negatively affects the health of patients with CKD. Twelve (92%) reported discussing obesity with patients, but none felt that they had time to treat it. All reported discussions of obesity would evoke a negative patient response, while 5 (38%) thought patients actually want to discuss obesity. Regarding treatment, 8 (62%) nephrologists felt comfortable with non-pharmacologic treatment, but only 1 respondent was comfortable with pharmacologic treatments. Twelve (92%) nephrologists thought patients should be referred to a specialist. Limitations: There was limited generalizability as this was a single center study. The BMI may reflect hypervolemia rather than body mass. Conclusion: In our study, nephrologists rarely document and manage obesity in patients with advanced CKD, despite their perception of treatment benefits. Improved outcomes of obesity management for patients with CKD will require increased knowledge and clinical tools to efficiently address obesity with patients.

Contexte: L'obésité est directement et indirectement liée à la progression de l'insuffisance rénale chronique (IRC). La reconnaissance de l'obésité par les néphrologues et leur volonté de la prendre en charge demeurent toutefois mal connues. Objectifs: Vérifier si l'obésité est reconnue et documentée lors de la rencontre clinique. Examiner les perceptions des néphrologues quant à l'obésité et leur confort face à la gestion du poids. Conception: Notre étude était constituée de deux parties. La première consistait en un examen rétrospectif des dossiers et la deuxième en un sondage anonyme mené en ligne auprès des néphrologues praticiens (n = 14) de notre centre. Cadre: La clinique multidisciplinaire en santé rénale (CMSR) du London Health Sciences Centre de London, en Ontario (Canada). Sujets: Dans la première partie, nous avons examiné rétrospectivement les dossiers de dix patients aléatoires atteints d'IRC de stade avancé et jugés obèses (IMC > 30 kg/m2) pour chacun des néphrologues participants entre janvier et décembre 2019. Méthodologie: Dans la première partie, les dossiers ont été examinés à la recherche d'une mention de l'obésité et/ou d'un plan de traitement (conseils sur le mode de vie, intervention pharmacologique, aiguillage vers un spécialiste). Dans la deuxième partie, un sondage réalisé auprès des néphrologues a exploré leur expérience et leurs perceptions actuelles sur l'obésité et leur confort quant à la gestion de la perte de poids. Les réponses ont été classées sur une échelle Likert de 5 points. Résultats: En tout, 140 dossiers patients ont été examinés. L'âge médian s'établissait à 69 ans (ÉIQ: 60-77), le DFGe médian à 17 ml/min/1,73 m2 (ÉIQ: 12-20), le poids médian à 99 kg (ÉIQ: 90-116) et l'IMC médian à 36 kg/m2 (ÉIQ: 33-40). L'obésité avec IMC était documentée dans 36 dossiers (26%) et seulement deux dossiers (1%) comportaient un plan de perte de poids, lequel ne comprenait que des stratégies non pharmacologiques. Treize néphrologues ont répondu au sondage (taux de réponse: 93%). Tous ont convenu que l'obésité affecte négativement la santé des patients atteints d'IRC; douze (92%) ont mentionné discuter d'obésité avec leurs patients, mais aucun ne pensait avoir le temps de la traiter. Tous les répondants ont indiqué que les discussions abordant l'obésité recevaient un accueil négatif de la part du patient; seuls 5 néphrologues (38%) étaient d'avis que les patients sont réellement ouverts à discuter d'obésité. Quant à son traitement, huit néphrologues (62%) se sont dits à l'aise avec un traitement non pharmacologique; un seul répondant était à l'aise avec les traitements pharmacologiques. Selon douze répondants (92%), les patients devraient être dirigés vers un spécialiste. Limites: Étude dans un seul centre, ce qui limite la généralisabilité. L'IMC pourrait refléter une hypervolémie plutôt que la masse corporelle. Conclusion: Dans notre étude, les néphrologues ont rarement documenté et pris en charge l'obésité de leurs patients atteints d'IRC de stade avancé, et ce, bien qu'ils croient aux avantages de son traitement. Pour améliorer la prise en charge de l'obésité chez les patients atteints d'IRC, il faudra améliorer les connaissances et les outils cliniques permettant de la traiter efficacement chez ces patients.

Kidney Function in Factory Workers Exposed to Heat Stress: A 2-Year Follow-up Study.

OBJECTIVES: The aims of the study are to re-evaluate kidney function in workers exposed and not exposed to heat stress after 2 years and to compare kidney function cross-shift using creatinine and cystatin C. METHODS: Participants were workers from a metallurgical industry. The clinical and biochemical markers of hydration and kidney function were evaluated before and after a single shift in work. RESULTS: We included 14 workers (6 in the heat group and 8 in the control group). The serum creatinine levels did not change during the follow-up period. Cross-shift, creatinine-based eGFR (estimated glomerular filtration rate) decreased, and cystatin C-based eGFR was maintained in the heat and control groups. CONCLUSIONS: Workers exposed to heat stress maintained their kidney function after a 2-year follow-up. Cystatin C is a better kidney function marker than creatinine for cross-shift assessments in this setting.

Community engagement in kidney research: Guatemalan experience.

BACKGROUND: Community engagement is essential for effective research when addressing issues important to both the community and researchers. Despite its effectiveness, there is limited published evidence concerning the evaluation of community engagement in research projects, especially in the area of nephrology. METHODS: We developed a community engagement program in Guatemala to address the role of hydration in chronic kidney disease of unknown origin, using five key engagement principles: 1. Local relevance and determinants of health. 2. Acknowledgment of the community. 3. Dissemination of findings and knowledge gained to all partners. 4. Usage of community partners' input. 5. Involvement of a cyclical and iterative process in the pursuit of goals. The effectiveness of community engagement was measured by a structured questionnaire on a 5-point likert scale. This measure determined how well and how often the research team adhered to the five engagement principles. We assessed internal consistency for each set of the engagement items through Omega coefficient. RESULTS: Sixty-two community leaders completed the questionnaire. Seventy-five percent were female, with a mean age of 37 years. All 5 engagement principles scored highly on the 5-point likert scale. Every item set corresponding to an engagement principles evaluation had a Omega coefficient > 0.80, indicating a firm internal consistency for all question groups on both qualitative and quantitative scales. CONCLUSION: Engagement of the community in the kidney research provides sustainability of the efforts and facilitates the achievements of the goals. Community leaders and researchers became a team and develop a relationship in which commitment and empowerment facilitated the participation in all aspects of the research process. This initiative could be a useful tool for researchers, especially in low-middle income countries, to start research in a community, achieve objectives in a viable form, and open opportunities to further studies.

A Quantitative and Qualitative Study on Patient and Physician Perceptions of Nephrology Telephone Consultation During COVID-19.

BACKGROUND: COVID-19 required rapid adoption of virtual modalities to provide care for patients with a chronic disease. Care was initially provided by telephone, which has not been evaluated for its effectiveness by patients and providers. This study reports patients' and nephrologists' perceptions and preferences surrounding telephone consultation in a chronic kidney disease (CKD) clinic. OBJECTIVE: To evaluate patient and physician perspectives on the key advantages and disadvantages of telephone consultations in a nephrology out-patient clinic setting. DESIGN: Cross-sectional observational survey study. SETTING: General nephrology clinic and a multidisciplinary kidney care clinic in London, Ontario, Canada. PARTICIPANTS: Patients with CKD who were fluent in English and participated in at least one telephone consultation with a nephrologist during the COVID-19 pandemic. METHODS AND MEASUREMENTS: Nephrologists' and participants' input facilitated the development of both patient and nephrologist surveys. Participants provided self-reported measures in 5 domains of satisfaction: user experience, technical quality, perceived effectiveness on well-being, perceived usefulness, and effect on interaction. Nephrologists provided self-reported measures within 6 categories: general experience, time management, medication changes, quality of care, job satisfaction, and challenges/strengths. Descriptive statistics were used to present data. Content analysis was performed on 2 open-ended responses. RESULTS: Of the 372 participants recruited, 235 participated in the survey (63% response). In all, 79% of the participants were ≥65 years old and 91% were white. Telephone consultation was a comfortable experience for 68%, and 73% felt it to be a safer alternative during the pandemic. Although 65% perceived no changes to health care access, most reported spending less time and fewer resources on transit and parking. Disadvantages to telephone consultation included a lack of physical examination and reduced patient-physician rapport. Eleven of 14 nephrologists were surveyed, with most reporting confidence in the use of telephone consultation. Physician barriers to telephone consultation included challenges with communications and lack of technology to support telephone clinics. LIMITATIONS: Our survey included a majority of older, white participants, which may not be generalizable to other participants particularly those of other ages and ethnicity. CONCLUSION: Although both patients and nephrologists adapted to telephone consultations, there remain opportunities to further explore populations and situations that would be better facilitated with an in-person visit. Future research in virtual care will require measurement of health care outcomes and economics. TRIAL REGISTRATION: Not applicable as this was a survey.

PATENCY-2 trial of vonapanitase to promote radiocephalic fistula use for hemodialysis and secondary patency.

OBJECTIVE: Arteriovenous fistulas created for hemodialysis often fail to become usable and are frequently abandoned. This prospective trial evaluated the efficacy of vonapanitase, a recombinant human elastase, in increasing radiocephalic fistula use for hemodialysis and secondary patency. METHODS: PATENCY-2 was a randomized, double-blind, placebo-controlled trial in patients on or approaching the need for hemodialysis undergoing radiocephalic arteriovenous fistula creation. Of 696 screened, 613 were randomized, and 603 were treated (vonapanitase n = 405, placebo n = 208). The study drug solution was applied topically to the artery and vein for 10 min immediately after fistula creation. The primary endpoints were fistula use for hemodialysis and secondary patency (fistula survival without abandonment). Other efficacy endpoints included unassisted fistula use for hemodialysis, primary unassisted patency, fistula maturation and unassisted maturation by ultrasound criteria, and fistula procedure rates. RESULTS: The proportions of patients with fistula use for hemodialysis was similar between groups, 70% vonapanitase and 65% placebo, (p = 0.33). The Kaplan-Meier estimates of 12-month secondary patency were 78% (95% confidence interval [CI], 73-82) for vonapanitase and 76% (95% CI, 70-82) for placebo (p = 0.93). The proportions with unassisted fistula use for hemodialysis were 46% vonapanitase and 37% placebo (p = 0.054). The Kaplan-Meier estimates of 12-month primary unassisted patency were 50% (95% CI, 44-55) for vonapanitase and 43% (95% CI, 35-50) for placebo (p = 0.18). There were no differences in the proportion of patients with fistula maturation or in fistula procedure rates. Adverse events were similar between groups. Vonapanitase was not immunogenic. CONCLUSIONS: Vonapanitase treatment did not achieve clinical or statistical significance to meaningfully improve radiocephalic fistula surgical outcomes. Outcome in the placebo group were better than in historical controls. Vonapanitase was well-tolerated and safe. TRIAL REGISTRATION: clinicaltrials.gov: NCT02414841 (https://clinicaltrials.gov/ct2/show/NCT02414841).

Can Additional Water a Day Keep the Cysts Away, in Patients with Polycystic Kidney Disease?

Can Additional Water a Day Keep the Cysts Away, in Patients with Polycystic Kidney Disease? If a patient with autosomal dominant polycystic kidney disease could drink enough water to suppress arginine vasopressin release, would cyst growth be attenuated, thereby reducing the decline in kidney function over time? Louise M. Moist, M.D. discusses this randomized controlled trial.

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.