The Association Between Serum Vancomycin Level and Clinical Outcome in Patients With Peritoneal Dialysis Associated Peritonitis.

Introduction: Intraperitoneal (IP) vancomycin is often first-line empiric therapy and then maintenance therapy for peritoneal dialysis (PD) peritonitis. However, how vancomycin serum levels correlate with clinical outcomes remains unclear. Methods: We conducted a retrospective single-center adult cohort study of 98 patients with PD peritonitis treated with IP vancomycin between January 2016 and May 2022. The association between nadir vancomycin level and cure was evaluated in a logistic regression model, first unadjusted and then adjusted for age, sex, weight, glomerular filtration rate (GFR), and total number of days on PD. Vancomycin was assessed both as a continuous exposure (per 1 mg/l increase) and as a categorical exposure (<15 mg/l vs. ≥15 mg/l). A receiver operating characteristic curve (ROC) was created to explore nadir vancomycin level thresholds in an attempt to identify an optimal target level during treatment. Results: Of the patients, 81% achieved cure, and patients with nadir vancomycin level ≥15 mg/l were 7.5 times more likely to experience cure compared to those with a nadir level <15 mg/l (odds ratio [OR] 7.58, 95% confidence interval [CI] 1.71-33.57, P = 0.008). Weight, GFR, days on PD, sex, and age were not independently associated with outcome. The vancomycin level with the greatest discriminatory capacity for cure on the ROC analysis was 14.4 mg/l. Conclusion: Increasing IP vancomycin serum levels are associated with increased odds of cure; and maintaining vancomycin serum levels above 14-15 mg/l throughout the course of PD peritonitis treatment is likely to improve clinical outcomes.

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.

An International Survey of Peritoneal Dialysis Exercise Practices and Perceptions.

Introduction: Low activity levels and poor physical function are associated with technique failure and mortality in people receiving peritoneal dialysis (PD). Adequate levels of physical function are required to maintain independence for people choosing this predominantly home-based therapy. The objective of this study was to identify the exercise-related perceptions and practices of PD clinicians globally. Methods: We conducted a cross-sectional survey of PD clinicians from English-, Thai-, Spanish-, and Portuguese-speaking PD-prevalent countries exploring clinicians' perceptions and practices of swimming, activity following PD catheter insertion, lifting, and falls prevention. This study was convened by the International Society of Peritoneal Dialysis and Global Renal Exercise Network between July and December 2021. Results: Of 100 of the highest PD-prevalent countries, 85 responded and were represented in the findings. A total of 1125 PD clinicians (448 nephrologists, 558 nephrology nurses, 59 dietitians, and 56 others) responded from 61% high-income, 32% upper middle-income and 7% lower middle-income countries. The majority (n = 1054, 94%) agreed that structured exercise programs would be beneficial for people receiving PD. Most respondents believed people on PD could perform more exercise (n = 907, 81%) and that abdominal strengthening exercises could be safely performed (n = 661, 59%). Compared to clinicians in high-income countries, clinicians from lower middle-income status (odds ratio [OR], 5.57; 1.64 to 18.9) are more likely to promote participation in physical activity. Conclusion: Clinicians know the importance of physical activity in people receiving PD. Exercise counseling and structured exercise plans could be included in the standard care of people receiving PD to maintain independence.

A Diagnostic Dilemma "Cured" by Dialysis: An Educational Case Report.

Rationale: The differential diagnosis for a patient with high-anion-gap metabolic acidosis (HAGMA) is broad; lactic acidosis is an important entity to screen for and treat. An elevated serum lactate is often used as a marker of inadequate tissue perfusion in critically ill patients but can also be indicative of decreased lactate utilization or poor hepatic clearance. Investigating for the underlying cause such as diabetic ketoacidosis, malignancy, or culprit medications is essential to establish the diagnosis and treatment plan. Presenting concerns of the patient: A 60-year-old man with a history of substance use and end-stage kidney disease treated with hemodialysis presented to hospital with confusion, altered level of consciousness, and hypothermia. Initial laboratory investigations were significant for a severe HAGMA with elevated serum lactate and ß-hydroxybutyrate levels, but toxicology screen was negative, and there was no clear underlying precipitant. Urgent hemodialysis was arranged to mitigate his severe acidosis. Diagnoses: He had an initial single dialysis treatment for 4 hours, with posthemodialysis labs showing significant improvement in his acidosis, serum lactate level, and clinical status (cognition, hypothermia). Given this rapid resolution, a sample from his predialysis blood work was sent for analysis of plasma metformin and returned significantly elevated at 60 mcg/mL (therapeutic range 1-2 mcg/mL). Interventions and outcomes: On careful medication reconciliation in the dialysis unit, the patient stated he had never heard of the medication metformin, and there was no record of a filled prescription at his pharmacy. Given his living situation with shared accommodations, it was presumed that he had taken medications that were prescribed to a roommate. Several of his other medications including his antihypertensives were subsequently given after dialysis on dialysis days to improve adherence. Teaching points: Maintain a broad differential diagnosis for patients presenting with a clinical syndrome consistent with an acute toxicity even if no culprit medications are identifiable on history, especially in patients with a suggestive social history.Anion-gap metabolic acidosis (AGMA) is common in hospitalized patients but sometimes requires further history and/or confirmatory testing to elucidate the root cause underlying typical causes of AGMA such as lactic acidosis or ketoacidosis.The main treatment of metformin toxicity is resuscitation and supportive care; however, metformin's biochemical properties make it readily dialyzable via either diffusion or convection.The Extracorporeal Treatments In Poisoning group recommends hemodialysis for metformin toxicity when there is a serum lactate >20 mmol/L, a blood pH <7.0, a failure of standard therapy, end-organ damage (hepatic or renal insufficiency), or a decreased level of consciousness.

Justification: Le diagnostic différentiel d'un patient présentant une acidose métabolique à trou anionique élevé (AMTAE) est large. L'acidose lactique est une entité importante à dépister et à traiter. Un taux élevé de lactate sérique est fréquemment utilisé comme marqueur d'une perfusion tissulaire inadéquate chez les patients gravement malades, mais il peut également indiquer une utilization réduite du lactate ou une insuffisance hépatique. La recherche de la cause sous-jacente (acidocétose diabétique, malignité ou médicaments responsables) est essentielle pour établir le diagnostic et décider du plan de traitement. Présentation du cas: Un homme de 60 ans atteint d'insuffisance rénale terminale traitée par hémodialyse et ayant des antécédents de toxicomanie qui s'était présenté à l'hôpital confus, avec une altération de l'état de conscience et souffrant d'hypothermie. Les premières analyses de laboratoire ont révélé une grave acidose métabolique à trou anionique élevé et une concentration élevée de lactate sérique et de ß-hydroxybutyrate. Cependant, le bilan toxicologique était négatif et aucun facteur déclenchant sous-jacent clair n'avait été identifié. Une hémodialyse d'urgence a été organisée afin d'atténuer l'acidose. Diagnostic: Le patient a reçu un traitement initial de dialyze pendant quatre heures; les analyses de laboratoire post-hémodialyse ont montré une amélioration significative de l'acidose, du taux de lactate sérique et de l'état clinique (cognition, hypothermie). Vu cette résolution rapide, un échantillon de sang prédialyse a été envoyé pour analyze du taux de metformine plasmatique; cette analyze a révélé un taux significativement élevé de 60 µg/ml (plage thérapeutique: 1-2 µg/ml). Interventions et résultats: Au cours d'une vérification minutieuse de la médication du patient à l'unité de dialyze, ce dernier a déclaré n'avoir jamais entendu parler de metformine; il n'y avait par ailleurs aucune trace d'ordonnance remplie à sa pharmacie pour ce médicament. Étant donné son mode de vie en logements partagés, on a présumé que le patient avait pris des médicaments qui avaient été prescrits à un colocataire. Afin d'améliorer l'observance du traitement, plusieurs des autres médicaments du patient, notamment ses antihypertenseurs, ont par la suite été administrés les jours de dialyze, après la séance. Enseignements tirés: Maintenir un diagnostic différentiel large pour les patients présentant un syndrome clinique compatible avec une intoxication aiguë, et ce, même si aucun médicament responsable n'est identifiable à l'anamnèse, en particulier chez les patients qui ont des antécédents sociaux évocateurs.L'acidose métabolique à trou anionique (AMTA) est fréquente chez les patients hospitalisés, mais nécessite parfois une analyze plus approfondie des antécédents et/ou des tests de confirmations pour parvenir à déterminer la cause fondamentale sous-tendant les causes habituelles de l'AMTA comme l'acidose lactique ou l'acidocétose.Le principal traitement pour contrer la toxicité de la metformine est la réanimation et les traitements de soutien. Les propriétés biochimiques de la metformine la rendent cependant facilement dialysable par diffusion ou convection.Le groupe de travail EXTRIP (EXtracorporeal TReatments In Poisoning) recommande l'hémodialyse pour gérer la toxicité de la metformine en présence d'un taux de lactate sérique supérieur à 20 mmol/L, d'un pH sanguin inférieur à 7, d'un échec du traitement standard, de dommages aux organes cibles (insuffisance hépatique ou rénale) ou d'une altération de l'état de conscience.

Social determinants of health and the transition from advanced chronic kidney disease to kidney failure.

BACKGROUND: The transition from chronic kidney disease (CKD) to kidney failure is a vulnerable time for patients, with suboptimal transitions associated with increased morbidity and mortality. Whether social determinants of health are associated with suboptimal transitions is not well understood. METHODS: This retrospective cohort study included 1070 patients with advanced CKD who were referred to the Ottawa Hospital Multi-Care Kidney Clinic and developed kidney failure (dialysis or kidney transplantation) between 2010 and 2021. Social determinant information, including education level, employment status and marital status, was collected under routine clinic protocol. Outcomes surrounding suboptimal transition included inpatient (versus outpatient) dialysis starts, pre-emptive (versus delayed) access creation and pre-emptive kidney transplantation. We examined the association between social determinants of health and suboptimal transition outcomes using multivariable logistic regression. RESULTS: The mean age and estimated glomerular filtration rate were 63 years and 18 ml/min/1.73 m2, respectively. Not having a high school degree was associated with higher odds for an inpatient dialysis start compared with having a college degree {odds ratio [OR] 1.71 [95% confidence interval (CI) 1.09-2.69]}. Unemployment was associated with higher odds for an inpatient dialysis start [OR 1.85 (95% CI 1.18-2.92)], lower odds for pre-emptive access creation [OR 0.53 (95% CI 0.34-0.82)] and lower odds for pre-emptive kidney transplantation [OR 0.48 (95% CI 0.24-0.96)] compared with active employment. Being single was associated with higher odds for an inpatient dialysis start [OR 1.44 (95% CI 1.07-1.93)] and lower odds for pre-emptive access creation [OR 0.67 (95% CI 0.50-0.89)] compared with being married. CONCLUSIONS: Social determinants of health, including education, employment and marital status, are associated with suboptimal transitions from CKD to kidney failure.

Predictors of serum vancomycin levels in peritoneal dialysis-associated peritonitis.

BACKGROUND: Intraperitoneal (IP) vancomycin is often first-line empiric therapy for peritoneal dialysis (PD) peritonitis; however, whether dosing should be adjusted for patient-specific characteristics remains unclear. We sought to identify factors associated with the day 3 vancomycin serum level in patients receiving vancomycin for PD peritonitis. METHODS: Retrospective single-centre adult cohort of 58 patients with PD peritonitis treated with IP vancomycin between January 2016 and May 2022. Linear regression was used to examine the association between day 3 vancomycin level and candidate predictors including age, sex, weight, glomerular filtration rate (GFR), urea and creatinine clearance (total, residual, dialysate), PD modality, peritoneal solute transfer rate and initial vancomycin dose. Logistic regression was used to evaluate the likelihood of achieving a level (≥15 mg/L) associated with these predictor variables. RESULTS: A 2-g loading dose was given in 51 cases, and 38 patients (66%) had a therapeutic day 3 level. Each 5 mg/kg increase in initial vancomycin dose was associated with a 1.38 mg/L (95% confidence interval 0.52, 2.23) increase in day 3 level. Each 1 mL/min increase in GFR was associated with a 0.29 mg/L decrease (95% confidence interval 0.05, 0.52) in day 3 level. The likelihood of achieving a therapeutic level was approximately four times higher with an initial dose of ≥25 mg/kg compared to <25 mg/kg (odds ratio 3.75, 95% confidence interval 1.05, 13.46). CONCLUSIONS: Following an average 2-g vancomycin loading dose for suspected PD peritonitis, one-third of patients were subtherapeutic on day 3. GFR and weight-based dosing were independently associated with day 3 vancomycin level, and their consideration could improve the likelihood of achieving an early therapeutic level.

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.

2022 Canadian Cardiovascular Society Guideline for Use of GLP-1 Receptor Agonists and SGLT2 Inhibitors for Cardiorenal Risk Reduction in Adults.

This guideline synthesizes clinical trial data supporting the role of glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter 2 inhibitors (SGLT2i) for treatment of heart failure (HF), chronic kidney disease, and for optimizing prevention of cardiorenal morbidity and mortality in patients with type 2 diabetes. It is on the basis of a companion systematic review and meta-analysis guided by a focused set of population, intervention, control, and outcomes (PICO) questions that address priority cardiorenal end points. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system and a modified Delphi process were used. We encourage comprehensive assessment of cardiovascular (CV) patients with routine measurement of estimated glomerular filtration rate, urinary albumin-creatinine ratio, glycosylated hemoglobin (A1c), and documentation of left ventricular ejection fraction (LVEF) when evaluating symptoms of HF. For patients with HF, we recommend integration of SGLT2i with other guideline-directed pharmacotherapy for the reduction of hospitalization for HF when LVEF is > 40% and for the reduction of all-cause and CV mortality, hospitalization for HF, and renal protection when LVEF is ≤ 40%. In patients with albuminuric chronic kidney disease, we recommend integration of SGLT2i with other guideline-directed pharmacotherapy to reduce all-cause and CV mortality, nonfatal myocardial infarction, and hospitalization for HF. We provide recommendations and algorithms for the selection of glucagon-like peptide-1 receptor agonists and SGLT2i for patients with type 2 diabetes and either established atherosclerotic CV disease or risk factors for atherosclerotic CV disease to reduce all-cause and CV mortality, nonfatal stroke, and for the prevention of hospitalization for HF and decline in renal function. We offer practical advice for safe use of these diabetes-associated agents with profound cardiorenal benefits.

De-Prescribing Proton Pump Inhibitors in Patients With End Stage Kidney Disease: A Quality Improvement Project.

Background: Proton pump inhibitors (PPIs) are widely prescribed and may be associated with harm; hypomagnesemia and reduced effectiveness of calcium carbonate phosphate binders may be important in end-stage kidney disease (ESKD). Objectives: Our objectives included (1) discontinuing PPIs and H2 blockers and (2) assessing the impact on serum magnesium and markers of mineral metabolism. Design: Prospective cohort. Setting: Satellite hemodialysis unit of a tertiary care hospital. Patients: Incident and prevalent patients with ESKD treated with hemodialysis. Measurements: We assessed the impact of stopping PPI/H2 blockers in patients who did not have an absolute indication as per guidelines in the general population; serum magnesium, calcium, and phosphate were measured before and approximately 8 weeks later. Analysis of variance (ANOVA) test and Kruskal-Wallis was used to describe the population. Wilcoxon signed rank test for the paired change scores (from pre to post). Methods: The electronic medical record (EMR) was extensively searched for absolute indications for a PPI. Results were reviewed with the primary nephrology team before approaching patients about stopping the PPI. Basic demographic information and select medications were also collected. Results: Electronic medical records were reviewed for 179 patients, 74 had a PPI or H2 antagonist or both on their medication list (43%); 23 (31%) were assessed as appropriate. After primary team and patient review, 29 patients agreed to a trial of PPI withdrawal. Fourteen patients restarted their PPI, most for gastroesophageal reflux disease. Three patients had a GI bleed, 1 fatally. Serum calcium (P = .17) and the dose of phosphate binders (P = .075) did not change but serum phosphate increased (1.55 [0.29] to 1.85 [0.34] mmol/L; P = .0005). Serum magnesium also increased (1.01 [0.16] to 1.06 [0.14] mmol/L; P = .01). Limitations: Small patient numbers and observational nature of the study does not establish causation in this population at high risk to experience a gastrointestinal bleed. Conclusions: Our results suggest that PPI deprescribing as recommended in the general population may be associated with harm in patients with ESKD and requires further study. Trial Registration: Not registered.

Contexte: Les inhibiteurs de la pompe à protons (IPP) sont largement prescrits et peuvent être associés à une atteinte rénale; l'hypomagnésémie et la réduction de l'efficacité des chélateurs de phosphate à base de carbonate de calcium peuvent devenir significatifs chez les patients avec insuffisance rénale terminale (IRT). Objectifs: Nos objectifs comprenaient 1) l'arrêt des IPP et des antagonistes H2 et 2) l'évaluation des conséquences sur le taux de magnésium sérique et les marqueurs du métabolisme minéral. Conception: Étude de cohorte prospective. Cadre: L'unité d'hémodialyse satellite d'un hôpital de soins tertiaires. Sujets: Patients incidents et prévalents atteints d'IRT et traités par hémodialyse. Mesures: Nous avons évalué les conséquences de l'arrêt des IPP et antagonistes H2 chez les patients qui n'avaient pas d'indication absolue pour ces médicaments, conformément aux directives pour la population générale. Les taux sériques de magnésium, de calcium et de phosphate ont été mesurés avant l'arrêt et environ huit semaines plus tard. Les tests ANOVA et Kruskal-Wallis ont été utilisés pour décrire la population, et le test de rang de Wilcoxon pour les scores de changement appariés (de pré à post-intervention). Méthodologie: Les dossiers médicaux électroniques (DMÉ) ont été consultés rigoureusement à la recherche d'une indication absolue pour un IPP. Les résultats ont été revus avec l'équipe de néphrologie primaire avant d'approcher les patients quant à un arrêt des IPP. Les données démographiques initiales et les prescriptions pour certains médicaments ont également été recueillies. Résultats: Les DMÉ de 179 patients ont été consultés, révélant que 74 (43 %) d'entre eux prenaient soit un IPP, soit un antagoniste H2, soit les deux; chez 23 patients (31 %) la prescription était appropriée. Après évaluation par l'équipe médicale et discussion avec les patients, 29 patients ont accepté de cesser l'IPP. Quatorze patients ont recommencé les IPP, la plupart pour un reflux gastro-œsophagien. Trois patients ont souffert d'une hémorragie gastro-intestinale, dont une s'est avérée fatale. Le taux de calcium sérique (p=0,17) et la dose de chélateurs du phosphate (p=0,075) n'ont pas changé, mais le taux de phosphate sérique a augmenté (1,55 [0,29] à 1,85 [0,34] mmol/L; p=0,0005), tout comme le taux de magnésium sérique (1,01 [0,16] à 1,06 [0,14] mmol/L; p=0,01). Limites: Le faible échantillon de patients et la nature observationnelle de l'étude ne permettent pas d'établir un lien de causalité dans cette population présentant un risque élevé d'hémorragie gastro-intestinale. Conclusion: Nos résultats suggèrent que la déprescription des IPP recommandée dans la population générale pourrait être associée à un préjudice chez les patients atteints d'IRT. Des études plus approfondies sont nécessaires. Enregistrement de l'essai: Non enregistré.

Impact of Bioelectrical Impedance-Guided Fluid Management and Vitamin D Supplementation on Left Ventricular Mass in Patients Receiving Peritoneal Dialysis: A Randomized Controlled Trial.

RATIONALE & OBJECTIVE: Hypervolemia and vitamin D deficiency occur frequently in patients receiving peritoneal dialysis and may contribute to left ventricular (LV) hypertrophy. The effect of bioelectrical impedance analysis (BIA)-guided volume management or vitamin D supplementation on LV mass among those receiving peritoneal dialysis is uncertain. STUDY DESIGN: Two-by-two factorial randomized controlled trial. SETTING & PARTICIPANTS: Sixty-five patients receiving maintenance peritoneal dialysis. INTERVENTION: BIA-guided volume management versus usual care and oral cholecalciferol 50,000 U weekly for 8 weeks followed by 10,000 U weekly for 44 weeks or matching placebo. OUTCOME: Change in LV mass at 1 year measured by cardiac magnetic resonance imaging. RESULTS: Total body water decreased by 0.9 + 2.4 (SD) L in the BIA group compared with a 1.5 ± 3.4 L increase in the usual care group (adjusted between-group difference: -2.4 [95% CI, -4.1 to -0.68] L, P = 0.01). LV mass increased by 1.3 ± 14.3 g in the BIA group and decreased by 2.4 ± 37.7 g in the usual care group (between-group difference: +2.2 [95% CI, -13.9 to 18.3] g, P = 0.8). Serum 25-hydroxyvitamin D concentration increased by a mean of 17.2 ± 30.8 nmol/L in the cholecalciferol group and declined by 8.2 ± 24.3 nmol/L in the placebo group (between-group difference: 28.3 [95% CI, 17.2-39.4] nmol/L, P < 0.001). LV mass decreased by 3.0 ± 28.1 g in the cholecalciferol group and increased by 2.0 ± 31.2 g in the placebo group (between-group difference: -4.5 [95% CI, -20.4 to 11.5] g, P = 0.6). LIMITATIONS: Relatively small sample size with larger than expected variation in change in LV mass. CONCLUSIONS: BIA-guided volume management had a modest impact on volume status with no effect on the change in LV mass. Vitamin D supplementation increased serum vitamin D concentration but had no effect on LV mass. FUNDING: Unrestricted Baxter International extramural grant and the Kidney Foundation of Canada. TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT01045980.

Physical activity and exercise in peritoneal dialysis: International Society for Peritoneal Dialysis and the Global Renal Exercise Network practice recommendations.

Life participation requiring physical activity and physical function is a key patient-reported outcome for people receiving peritoneal dialysis (PD). Clinician guidance is required from multidisciplinary sources regarding exercise and activity advice to address the specific needs of this group. From August 2020 through to June 2021, the Global Renal Exercise Network and the International Society for Peritoneal Dialysis reviewed the published literature and international clinical experience to develop a set of clinical practice points. A set of questions relevant to physical activity and exercise were developed from the perspective of a person receiving PD and were the basis for the practice point development. The GRADE framework was used to evaluate the quality of evidence and to guide clinical practice points. The review of the literature found sparse quality evidence, and thus the clinical practice points are generally based on the expert consensus of people receiving PD, PD exercise expert clinicians and experienced PD exercise researchers. Clinical practice points address timing of exercise and activity (post-catheter insertion, peritoneal space empty or full), the uptake of specific activities (work, sex, swimming, core exercise), potential adverse outcomes related to activity and exercise (exit site care, perspiration, cardiovascular compromise, fatigue, intra-abdominal pressure), the effect of exercise and activity on conditions of interest (mental health, obesity, frailty, low fitness) and exercise nutrition.

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.

Complications and challenges of home hemodialysis: A historical review.

Home hemodialysis (HHD) has evolved as a preferred and safe kidney replacement modality over the past six decades. Despite advances in technological aspects of HHD, potential complications still pose a challenge to health care givers, patients, and their families. In this narrative review, we describe vascular access and cannulation, anticoagulation, nutritional, residual kidney function, psychosocial, technique failure, and machine/procedural-related complications. Addressing these problems is essential for favorable patient outcomes.

Multidisciplinary Team versus a "Phosphate-Counting" App for Serum Phosphate Control: A Randomized Controlled Trial.

Background: Hyperphosphatemia is almost universal in well-nourished patients with ESKD treated with dialysis due to an imbalance between dietary intake and phosphate removal via residual kidney function and dialysis. Although food phosphate content can vary dramatically between meals, the current standard is to prescribe a fixed dose of phosphate binder that may not match meal phosphate intake. The primary objective of our study was to determine if the use of an app that matches phosphate binder dose with food phosphate content would be associated with an improvement in serum phosphate and a reduction in calcium carbonate intake compared with the multidisciplinary renal team. Methods: Eighty patients with ESKD treated with peritoneal dialysis at a tertiary care hospital in Canada were randomized to the standard of care for serum phosphate management (multidisciplinary renal team) versus the OkKidney app. Serum phosphate was measured at baseline and then monthly for 3 months with adjustments to phosphate management as deemed necessary by the multidisciplinary team (control) or the phosphate binder multiplier in the OkKidney app (intervention) on the basis of the laboratory values. The primary analysis was an unpaired t test of the serum phosphate at study completion. Results: The participants were 56 (±14) years old, and 54% were men; the most common cause of ESKD was diabetes mellitus. The serum phosphate values were 1.96 (0.41) and 1.85 (0.44) mmol/L in the control and intervention groups, respectively, at the end of 3 months (P=0.30). The median elemental daily dose of calcium carbonate did not differ between the groups at study completion (587 mg [309-928] versus 799 mg [567-1183], P=0.29). Conclusions: The OkKidney app was associated with similar but not superior serum phosphate control to the standard of care, which included renal dietician support. Clinical Trial registry name and registration number: US National Library Medicine ClinicalTrials.gov, NCT01643486.

Use of the FRAIL Questionnaire in Patients With End-Stage Kidney Disease.

BACKGROUND: Frailty is a clinical phenotype of decreased physiologic reserve that is associated with increased morbidity and mortality. The most meaningful way to assess frailty in patients with end-stage kidney disease (ESKD) is unknown. OBJECTIVE: To assess the prevalence of frailty in ESKD patients using the easy-to-administer FRAIL scale and, to determine its association with mortality, transplantation, and hospitalization. DESIGN: A cohort study was used. SETTING: The Ottawa Hospital, Ottawa, Ontario, Canada, was the setting of this study. PATIENTS: All eligible adult ESKD patients treated with dialysis from August to November 2017 at The Ottawa Hospital were invited to participate. MEASUREMENTS: The FRAIL scale. METHODS: Eligible patients completed an exercise survey with FRAIL questions embedded within the instrument. Number of comorbid illnesses was determined from the electronic medical record and weight loss was calculated from target weight in the patients' dialysis prescription. Mortality, transplant status, and hospitalizations were ascertained from the electronic medical record 18 months later; differences by frailty status were evaluated using descriptive statistics. Kaplan-Meier and Cox regression models were used to examine the association between frailty and transplant. RESULTS: Of 476 ESKD patients screened, 261 participated; 101 receiving peritoneal dialysis, 135 intermittent hemodialysis, and 25 home hemodialysis. Thirty-nine, 145, and 77 were frail, pre-frail, and not frail, respectively. Employment status, ethnicity, and comorbid illnesses differed significantly by frailty status, but mortality did not. In univariate analysis, frail patients were less likely to be listed for (P = .05) and to receive a kidney transplant (P = .02). However, after adjusting for age and modality, frailty was not statistically associated with a decreased likelihood of transplant (Hazard Ratio: 0.15; confidence interval [CI], 0.02-1.15; P = .068). The results were similar when accounting for the competing risk of death (P = .060). Frail patients were more likely to be hospitalized (P = .01) and spend more time in the hospital (P = .04). LIMITATIONS: Single-center design with a relatively short follow-up and small sample size limiting the number of variables that could be assessed in analysis. We also excluded patients who were unable to communicate in English or French and those patients with physical limitations such as amputations, potentially affecting generalizability. CONCLUSIONS: Frail ESKD patients as identified by the FRAIL scale are less likely to receive a renal transplant; this association diminished statistically after adjusting for age and modality and when accounting for the competing risk of death. Frail patients were at increased risk of hospitalization. Further study with larger patient numbers and longer follow-up is needed to determine the usefulness of the FRAIL scale in predicting adverse outcomes. TRIAL REGISTRATION: Not required as this was an observational study.

CONTEXTE: La fragilité est un phénotype clinique d'une réduction de la réserve physiologique et est associée à une augmentation de la morbidité et de la mortalité. La meilleure façon d'évaluer la fragilité des patients atteints d'insuffisance rénale terminale (IRT) demeure toutefois inconnue. OBJECTIFS: Mesurer la prévalence de la fragilité chez les patients atteints d'IRT à l'aide de l'échelle FRAIL et examiner les liens entre la fragilité et la mortalité, la transplantation et le nombre d'hospitalisations. TYPE D'ÉTUDE: Étude de cohorte. CADRE: L'Hôpital d'Ottawa (Ontario) au Canada. SUJETS: Tous les adultes admissibles atteints d'IRT et traités par dialyze entre août et novembre 2017 à l'Hôpital d'Ottawa ont été invités à participer à l'étude. MESURES: L'échelle FRAIL mesurant la fragilité. MÉTHODOLOGIE: Les patients admissibles ont répondu à un sondage sur l'activité physique où des questions issues de l'échelle FRAIL avaient été intégrées. Le nombre de maladies concomitantes a été obtenu à partir du dossier médical électronique et la perte de poids a été calculée à partir du poids cible figurant dans la prescription de dialyze du patient. La mortalité, le statut de la transplantation et le nombre d'hospitalisations ont été déterminés à partir du dossier médical électronique 18 mois plus tard. La statistique descriptive a servi à évaluer les différences selon l'état de fragilité. Des modèles de régression de Kaplan Meier et de Cox ont été utilisés pour examiner l'association entre la fragilité et la transplantation. RÉSULTATS: Des 476 patients atteints d'IRT dépistés, 261 ont participé à l'étude (101 traités par dialyze péritonéale, 135 par hémodialyse intermittente et 25 en hémodialyse à domicile). Ces patients ont été jugés fragiles (n=39), préfragiles (n=145) ou non fragiles (n=77). La situation d'emploi, l'ethnicité et les maladies concomitantes différaient considérablement en fonction de l'état de fragilité, mais la mortalité s'est avérée similaire. L'analyze univariée a révélé que les patients jugés fragiles étaient moins susceptibles d'être inscrits sur la liste d'attente (p=0,05) et de recevoir une greffe rénale (p=0,02). Cependant, après correction selon l'âge et la modalité de dialyze, la fragilité n'a montré aucune corrélation statistiquement significative avec une diminution de la probabilité de subir une transplantation (RR : 0,15; IC à 95 %: 0,02-1,15; p=0,068). Les résultats étaient similaires en tenant compte du risque concurrent de décès (p=0,060). Enfin, les patients jugés fragiles étaient plus susceptibles d'être hospitalisés (p=0,01), et ce, pour de plus longs séjours (p=0,04). LIMITES: Le nombre de variables pouvant être évaluées dans l'analyze est limité par le fait qu'il s'agit d'une étude monocentrique avec un suivi relativement court et portant sur un faible échantillon de patients. L'exclusion des patients incapables de communiquer en anglais ou en français et des patients présentant des limitations physiques, notamment des amputations, pourrait affecter la généralisabilité des résultats. CONCLUSION: Les patients atteints d'IRT jugés fragiles par l'échelle FRAIL sont moins susceptibles de recevoir une greffe rénale. Une réduction statistiquement significative de cette association a été observée après une correction selon l'âge et la modalité de dialyze, et en tenant compte du risque concurrent de décès. Les patients fragiles présentent également un risque accru d'être hospitalisés. Une étude plus approfondie sur une plus grande cohorte de patients et avec un suivi à plus long terme est nécessaire pour déterminer l'utilité de l'échelle FRAIL pour prédire les issues défavorables. ENREGISTREMENT DE L'ESSAI: N'est pas requis, étude observationnelle.

Cannabis Use for Restless Legs Syndrome and Uremic Pruritus in in patients treated with maintenance dialysis: A Survey.

BACKGROUND: Restless legs syndrome (RLS) and uremic pruritus reduce the quality of life in patients with end-stage kidney disease (ESKD) and current treatments are often insufficient. There is an increasing interest in using cannabinoids for symptom management, and preliminary evidence suggests cannabinoids may help alleviate RLS and pruritus. OBJECTIVES: (1) To assess the frequency and severity of RLS and pruritus in our ESKD population with the current treatment options, (2) to estimate patient use of cannabinoids for these symptoms, and (3) to determine interest in participating in future trials to treat RLS and/or pruritus. DESIGN: Survey. PATIENTS: Adult prevalent patients with ESKD treated with dialysis at the Ottawa Hospital. MEASUREMENTS: International RLS Study Group Rating Scale and visual analogue scale for symptom severity of RLS and pruritus, respectively. METHODS: Eligible patients with ESKD treated at the Ottawa Hospital were invited to complete a survey to identify symptoms and severity of RLS and pruritus using validated scales, cannabis use for management, and interest in future trials. Basic demographic statistics to describe the study population and results were used. RESULTS: Sixty-nine percent (192 of 277) of eligible patients completed the surveys, 35 declined participation, and 50 surveys were not returned. Eighty-six (45%) and 129 patients (67%) reported symptoms of RLS and pruritus, respectively. Only 18 previously symptomatic patients were relieved with current treatment. Fifteen patients reported cannabis use for symptoms; 9 noted improvement. Most (>2 of 3) symptomatic patients were interested in participating in a future trial. LIMITATIONS: Single-center study in a tertiary-care hospital in Canada limiting generalizability. Quoted prevalence of symptoms is dependent on survey return. CONCLUSIONS: A large proportion of ESKD patients suffer from RLS and/or pruritus, most of which are not relieved by existing treatments. Few patients reported trying cannabis to decrease their symptoms despite legalization. This study confirms strong patient interest for future trials regarding cannabis for symptom relief. TRIAL REGISTRATION: Not applicable.

CONTEXTE: Le syndrome des jambes sans repos (SJSR) et le prurit urémique réduisent la qualité de vie des patients atteints d'insuffisance rénale terminale (IRT), et les traitements existants pour les soulager sont souvent insuffisants. Les cannabinoïdes suscitent un intérêt grandissant à cet effet et des données préliminaires suggèrent qu'ils pourraient atténuer le SJRS et le prurit. OBJECTIFS: 1) évaluer, dans une population de patients atteints d'IRT, la fréquence et la sévérité du SJRS et du prurit avec les options de traitement existantes; 2) estimer la consommation de cannabinoïdes pour soulager ces symptômes, et 3) sonder l'intérêt des patients à participer à des essais futurs sur les traitements du SJSR et du prurit. CONCEPTION: Sondage. SUJETS: Des adultes atteints d'IRT et dialysés à l'hôpital d'Ottawa. MESURES: L'échelle d'évaluation de l'International RLS Study Group et l'échelle visuelle analogique ont été utilisées pour mesurer respectivement la sévérité du SJSR et du prurit. MÉTHODOLOGIE: Les patients admissibles atteints d'IRT et dialysés à l'hôpital d'Ottawa ont été invités à répondre au sondage. Les répondants devaient identifier leurs symptômes de SJSR et de prurit et évaluer leur sévérité à l'aide d'échelles validées. Ils devaient également mentionner s'ils consommaient des cannabinoïdes pour soulager leurs symptômes et s'ils accepteraient de participer à de futurs essais sur le sujet. Des statistiques démographiques de base ont été employées pour décrire la population étudiée et les résultats. RÉSULTATS: Le sondage a été rempli par 192 des 277 patients admissibles (69 %); 35 patients ont refusé de participer et 50 sondages n'ont pas été retournés. Des symptômes de SJSR ont été rapportés par 86 répondants (45 %), et 129 patients (67 %) ont mentionné souffrir de prurit. Seuls 18 patients préalablement symptomatiques se sont dits soulagés par les traitements existants. La consommation de cannabis pour atténuer les symptômes a été rapportée par quinze patients, dont neuf voyaient une amélioration de leurs symptômes. Plus du 2/3 des patients symptomatiques accepteraient de participer à un essai futur. LIMITES: L'étude s'est tenue dans un seul center hospitalier de soins tertiaires canadien, ce qui limite la généralisabilité des résultats. La prévalence citée dépend du retour des sondages. CONCLUSION: Une grande proportion de patients atteints d'IRT souffre du SJSR et/ou de prurit urémique, la plupart d'entre eux n'étant pas soulagés par les traitements existants. Malgré la légalisation du cannabis, seuls quelques patients en consommaient pour atténuer leurs symptômes. Cette étude confirme le grand intérêt des patients envers de futurs essais examinant la consommation de cannabis pour soulager leurs symptômes. ENREGISTREMENT DE L'ESSAI: Sans objet.

Canadian Society of Nephrology Commentary on the Kidney Disease Improving Global Outcomes 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder.

PURPOSE OF REVIEW: (1) To provide commentary on the 2017 update to the Kidney Disease Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD); (2) to apply the evidence-based guideline update for implementation within the Canadian health care system; (3) to provide comment on the care of children with chronic kidney disease (CKD); and (4) to identify research priorities for Canadian patients. SOURCES OF INFORMATION: The KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD. METHODS: The commentary committee co-chairs selected potential members based on their knowledge of the Canadian kidney community, aiming for wide representation from relevant disciplines, academic and community centers, and different geographical regions. KEY FINDINGS: We agreed with many of the recommendations in the clinical practice guideline on the diagnosis, evaluation, prevention, and treatment of CKD-MBD. However, based on the uncommon occurrence of abnormalities in calcium and phosphate and the low likelihood of severe abnormalities in parathyroid hormone (PTH), we recommend against screening and monitoring levels of calcium, phosphate, PTH, and alkaline phosphatase in adults with CKD G3. We suggest and recommend monitoring these parameters in adults with CKD G4 and G5, respectively. In children, we agree that monitoring for CKD-MBD should begin in CKD G2, but we suggest measuring ionized calcium, rather than total calcium or calcium adjusted for albumin. With regard to vitamin D, we suggest against routine screening for vitamin D deficiency in adults with CKD G3-G5 and G1T-G5T and suggest following population health recommendations for adequate vitamin D intake. We recommend that the measurement and management of bone mineral density (BMD) be according to general population guidelines in CKD G3 and G3T, but we suggest against routine BMD testing in CKD G4-G5, CKD G4T-5T, and in children with CKD. Based on insufficient data, we also recommend against routine bone biopsy in clinical practice for adults with CKD or CKD-T, or in children with CKD, although we consider it an important research tool. LIMITATIONS: The committee relied on the evidence summaries produced by KDIGO. The CSN committee did not replicate or update the systematic reviews.

JUSTIFICATION: (1) Commenter les recommandations du KDIGO 2017 (Kidney Disease Improving Global Outcomes) sur les bonnes pratiques cliniques pour le diagnostic, l'évaluation et le traitement des troubles du métabolisme minéral osseux associés aux maladies rénales chroniques (TMO-MRC); (2) appliquer les lignes directrices actualisées et fondées sur les données probantes en vue de leur mise en œuvre dans le système de soins de santé canadien; (3) commenter les soins prodigués aux enfants atteints d'insuffisance rénale chronique (IRC) et (4) définir les priorités de recherche des patients Canadiens. SOURCES: Les recommandations du KDIGO 2017 (Kidney Disease Improving Global Outcomes) sur les bonnes pratiques cliniques pour le diagnostic, l'évaluation et le traitement des troubles du métabolisme minéral osseux associés aux maladies rénales chroniques (TMO-MRC). MÉTHODOLOGIE: Les coprésidents du comité ont sélectionné les membres potentiels sur la base de leur connaissance du secteur de la santé rénale au Canada, tout en visant une bonne représentation de toutes les disciplines concernées, des centres universitaires et communautaires et des différentes régions géographiques. PRINCIPAUX COMMENTAIRES: Nous approuvons un grand nombre des recommandations du KDIGO. Cependant, compte tenu de la rareté des anomalies du calcium et du phosphate et de la faible probabilité d'anomalies graves de la PTH (hormone parathyroïde), nous déconseillons le dépistage et la surveillance des taux de calcium, de phosphate, de PTH et de phosphatase alcaline chez les adultes atteints d'IRC de stade G3. Nous suggérons de mesurer ces paramètres chez les adultes de stade G4 et nous le recommandons pour les patients de stade G5. Chez les enfants, nous appuyons la recommandation de commencer la surveillance des TMO-MRC dès le stade G2, mais nous suggérons de mesurer le calcium ionisé plutôt que les taux de calcium total ou de calcium corrigé en fonction de l'albumine. En ce qui concerne la vitamine D, nous déconseillons le dépistage de routine des carences chez les adultes atteints d'IRC de stade G3 à G5 et G1T à G5T; nous suggérons plutôt de suivre les recommandations visant la population générale pour un apport adéquat en vitamine D. Nous recommandons que la mesure et la prise en charge de la densité minérale osseuse (DMO) se fassent en suivant les recommandations pour la population générale chez les adultes atteints d'IRC de stade G3 et G3T, mais nous déconseillons les tests de DMO de routine chez les adultes de stades G4-G5 et G4T-G5T, de même que chez les enfants atteints d'IRC. En raison de données insuffisantes, nous déconseillons également la pratique systématique d'une biopsie osseuse chez les adultes atteints d'IRC ou d'IRC-TMO, ainsi que chez les enfants atteints d'IRC, bien que nous la considérions comme un important outil de recherche. LIMITES: Le comité s'est appuyé sur le résumé des preuves rédigé par le KDIGO. Le comité de la SCN n'a pas reproduit ou mis à jour les revues systématiques.

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

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

The CSN COVID-19 Rapid Response Program.

The coronavirus disease (COVID-19) pandemic has created unprecedented challenges in caring for individuals living with kidney disease. In response to a growing call for up-to-date information and evidence-informed advice, the Canadian Society of Nephrology has established a COVID-19 Rapid Response Team that will leverage existing evidence and national expertise to inform kidney care practices in the COVID-19 era. Given limited published evidence and compressed timelines, formal clinical practice guidelines are not feasible, and we have adopted rapid review methods to instead provide interim guidance across identified priority areas. In this article, we describe the methodological approach that was applied in developing a first iteration of guidance documents addressing clinical and operational aspects of care for patients treated with in-center hemodialysis, home dialysis, those with advanced chronic kidney disease, those with glomerulonephritis, and those with acute kidney injury. We further describe strategies for maintaining ongoing engagement with the renal community to elicit emerging needs and perspectives as the situation unfolds.

The Risk of Stroke and Stroke Type in Patients With Atrial Fibrillation and Chronic Kidney Disease.

BACKGROUND: Atrial fibrillation (AF) and chronic kidney disease (CKD) are known to increase the risk of stroke. OBJECTIVES: We set out to examine the risk of stroke by kidney function and albuminuria in patients with and without AF. DESIGN: Retrospective cohort study. SETTINGS: Ontario, Canada. PARTICIPANTS: A total of 736 666 individuals (>40 years) from 2002 to 2015. MEASUREMENTS: New-onset AF, albumin-to-creatinine ratio (ACR), and an estimated glomerular filtration rate (eGFR). METHODS: A total of 39 120 matched patients were examined for the risk of ischemic, hemorrhagic, or any stroke event, accounting for the competing risk of all-cause mortality. Interaction terms for combinations of ACR/eGFR and the outcome of stroke with and without AF were examined. RESULTS: In a total of 4086 (5.2%) strokes (86% ischemic), the presence of AF was associated with a 2-fold higher risk for any stroke event and its subtypes of ischemic and hemorrhagic stroke. Across eGFR levels, the risk of stroke was 2-fold higher with the presence of AF except for low levels of eGFR (eGFR < 30 mL/min/1.73 m2, hazard ratio [HR]: 1.38, 95% confidence interval [CI]: 0.99-1.92). Similarly across ACR levels, the risk of stroke was 2-fold higher except for high levels of albuminuria (ACR > 30 mg/g, HR: 1.61, 95% CI: 1.31-1.99). The adjusted risk of stroke with AF differed by combinations of ACR and eGFR categories (interaction P value = .04) compared with those without AF. Both stroke types were more common in patients with AF, and ischemic stroke rates differed significantly by eGFR and ACR categories. LIMITATIONS: Medication information was not included. CONCLUSIONS: Patients with CKD and AF are at a high risk of total, ischemic, and hemorrhagic strokes; the risk is highest with lower eGFR and higher ACR and differs based on eGFR and the degree of ACR.

CONTEXTE: La fibrillation auriculaire (FA) et l'insuffisance rénale chronique (IRC) augmentent le risque d'accident vasculaire cérébral (AVC). OBJECTIF: Nous voulions analyser le risque d'AVC selon la fonction rénale et l'albuminurie chez des patients atteints d'IRC avec ou sans FA. TYPE D'ÉTUDE: Étude de cohorte rétrospective. CADRE: Ontario, Canada. SUJETS: Un total de 736 666 individus (>40 ans) entre 2002 et 2015. MESURES: Les nouveaux cas de FA, le rapport albumine/créatinine urinaire (RAC) et le débit de filtration glomérulaire estimé (DFGe). MÉTHODOLOGIE: Au total, 39 120 patients appariés ont été examinés pour le risque d'AVC ischémique, hémorragique ou autre, en tenant compte du risque concurrent de mortalité toutes causes confondues. Les effets d'interactions des combinaisons RAC/DFGe et de l'issue de l'AVC, avec ou sans FA, ont également été étudiés. RÉSULTATS: Pour un total de 4 086 AVC (5,2 %), dont 86 % d'AVC ischémiques, la présence de FA était associée à un risque deux fois plus élevé de survenue d'un AVC et d'un de ses sous-types (ischémique et hémorragique). Pour l'ensemble des niveaux de DFGe, le risque d'AVC se révélait deux fois plus élevé en présence de FA, sauf pour les faibles valeurs de DFGe (DFGe <30 mL/min/1,73 m2; RR: 1,38; IC 95 %: 0,99-1,92). De même, pour l'ensemble des niveaux de RAC, le risque d'AVC s'avérait deux fois plus élevé en présence de FA, à l'exception des patients présentant une albuminurie élevée (RAC >30 mg/g; RR: 1,61; IC 95 %: 1,31-1,99). Le risque ajusté d'AVC avec FA différait selon les catégories de combinaisons RAC/DFGe (valeur de p de l'interaction: 0,04) lorsque comparé aux cas sans FA. Les deux types d'AVC se sont avérés plus fréquents chez les patients atteints de FA, et les taux d'AVC ischémiques différaient significativement selon les catégories de DFGe et de RAC. LIMITES: Les renseignements sur la médication n'ont pas été inclus. CONCLUSION: Les patients atteints d'IRC et de FA sont plus susceptibles de subir un AVC ischémique, hémorragique ou total. Ce risque s'avère encore plus élevé en présence d'un faible DFGe et d'un RAC élevé, et diffère selon les valeurs de DFGe et de RAC.