Integrating the patient voice: patient-centred and equitable clinical risk prediction for kidney health and disease.

PURPOSE OF REVIEW: Personalized approaches to care are increasingly common in clinical nephrology. Although risk prediction models are developed to estimate the risk of kidney-disease related outcomes, they infrequently consider the priorities of patients they are designed to help. RECENT FINDINGS: This review discusses certain steps in risk prediction tool development where patients and their priorities can be incorporated. Considering principles of equity throughout the process has been the focus of recent literature. SUMMARY: Applying a person-centred lens has implications for several aspects of risk prediction research. Incorporating the patient voice may involve partnering with patients as researchers to identify the target outcome for the tool and/or determine priorities for outcomes related to the kidney disease domain of interest. Assessing the list of candidate predictors for associations with inequity is important to ensure the tool will not widen disparity for marginalized groups. Estimating model performance using person-centred measures such as model calibration may be used to compare models and select a tool more useful to inform individual treatment decisions. Finally, there is potential to include patients and families in determining other elements of the prediction framework and implementing the tool once development is complete.

The effect of goal-directed fluid therapy on delayed graft function in kidney transplant recipients: A systematic review and meta-analysis.

Delayed graft function (DGF) is a common post-operative complication with potential long-term sequelae for many kidney transplant recipients, and hemodynamic factors and fluid status play a role. Fixed perioperative fluid infusions are the standard of care, but more recent evidence in the non-transplant population has suggested benefit with goal-directed fluid strategies based on hemodynamic targets. We searched MEDLINE, EMBASE, Cochrane Controlled Trials Registry and Google Scholar through December 2022 for randomized controlled trials comparing risk of DGF between goal-directed and conventional fluid therapy in adults receiving a living or deceased donor kidney transplant. Effect estimates were reported with odds ratios (OR) and pooled using random effects meta-analysis. We identified 4 studies (205 participants) that met the inclusion criteria. The use of goal-directed fluid therapy had no significant effect on DGF (OR 1.37 95% CI, 0.34-5.6; p = 0.52; I2 = 0.11). Subgroup analysis examining effects among deceased and living kidney donation did not reveal significant differences in the effects of fluid strategy on DGF between subgroups. Overall, the strength of the evidence for goal-directed versus conventional fluid therapy to reduce DGF was of low certainty. Our findings highlight the need for larger trials to determine the effect of goal-directed fluid therapy on this patient-centered outcome.

Processes of Care After Hospital Discharge for Survivors of Acute Kidney Injury: A Population-Based Cohort Study.

RATIONALE & OBJECTIVE: Survivors of acute kidney injury (AKI) are at high risk of adverse outcomes. Monitoring of kidney function, screening for proteinuria, use of statins and renin-angiotensin-aldosterone system (RAAS) inhibitors, and nephrology follow-up among survivors have not been fully characterized. We examined these processes of care after discharge in survivors of hospitalized AKI. STUDY DESIGN: Population-based retrospective cohort study. SETTING & PARTICIPANTS: Adults in Alberta, Canada, admitted to the hospital between 2009 and 2017, then followed from their discharge date until 2019 for a median follow-up of 2.7 years. EXPOSURE: Hospital-acquired AKI diagnostically conforming to Kidney Disease: Improving Global Outcomes (KDIGO) serum creatinine criteria for stage 2 or stage 3 disease, or the need for acute dialysis. OUTCOME: Outcomes after hospital discharge included the proportion of participants who had evaluation of kidney function, were seen by a specialist or general practitioner, and received postdischarge prescriptions for recommended medications for chronic kidney disease (CKD). ANALYTICAL APPROACH: Cumulative incidence curves to characterize the proportion of participants who received each process of care outcome within the first 90 days and subsequent 1-year follow-up period after hospital discharge. To avoid risks associated with multiple hypothesis testing, differences were not statistically compared across groups. RESULTS: The cohort (n=23,921) included 50.2% men (n=12,015) with a median age of 68.1 [IQR, 56.9-78.8] years. Within 90 days after discharge, 21.2% and 8.6% of patients with and without pre-existing CKD, respectively, were seen by a nephrologist; 60.1% of AKI survivors had at least 1 serum creatinine measured, but only 25.5% had an assessment for albuminuria within 90 days after discharge; 52.7% of AKI survivors with pre-existing CKD, and 51.6% with de novo CKD were prescribed a RAAS inhibitor within 4-15 months after discharge. LIMITATIONS: Retrospective data were collected as part of routine clinical care. CONCLUSIONS: The proportion of patients receiving optimal care after an episode of AKI in Alberta was low and may represent a target for improving long-term outcomes for this population. PLAIN-LANGUAGE SUMMARY: A study in Alberta, Canada, examined the care received by patients with acute kidney disease (AKI) during hospitalization and after discharge between 2007 and 2019. The results showed that a low proportion of patients with moderate to severe AKI were seen by a kidney specialist during hospitalization or within 90 days after discharge. Fewer than 25% of AKI patients had their kidney function monitored with both blood and urine tests within 90 days of discharge. Additionally, about half of AKI survivors with chronic kidney disease (CKD) were prescribed guideline recommended medications for CKD within 15 months after discharge. There is potential to improve health care delivery to these patients both in hospital and after hospital discharge.

Implementing a Formalized Risk-Based Approach to Determine Candidacy for Multidisciplinary CKD Care: A Descriptive Cohort Study.

Background: The kidney failure risk equation (KFRE) can be used to predict progression to end-stage kidney disease in a clinical setting. Objective: Evaluate implementation of a formalized risk-based approach in nephrologists' outpatient clinics and multidisciplinary chronic kidney disease (CKD) clinics to determine candidacy for multidisciplinary care, and the impact of CKD care selection on clinical outcomes. Design: Population-based descriptive cohort study. Setting: Alberta Kidney Care South. Patients: Adults attending or considered for a multidisciplinary CKD clinic between April 1, 2017, and March 31, 2019. Measurements: Exposure-The course of CKD care assigned by the nephrologist: management at multidisciplinary CKD clinic; management by a nephrologist or primary care physician. Primary Outcome-CKD progression, defined as commencement of kidney replacement therapy (KRT). Secondary Outcomes-Death, emergency department visits, and hospitalizations. Methods: We linked operational data from the clinics (available until March 31, 2019) with administrative health and laboratory data (available until March 31, 2020). Comparisons among patient groups, courses of care, and clinical settings with negative binomial regression count models and calculated unadjusted and fully adjusted incidence rate ratios. For the all-cause death outcome, we used Cox survival models to calculate unadjusted and fully adjusted hazard ratios. Results: Of the 1748 patients for whom a KFRE was completed, 1347 (77%) remained in or were admitted to a multidisciplinary CKD clinic, 310 (18%) were managed by a nephrologist only, and 91 (5%) were referred back for management by their primary care physician. There was a much higher kidney failure risk among patients who remained at or were admitted to a multidisciplinary CKD clinic (median 2-year risk of 34.7% compared with 3.6% and 0.8% who remained with a nephrologist or primary care physician, respectively). None of the people managed by their primary care physician alone commenced KRT, while only 2 (0.6%) managed by a nephrologist without multidisciplinary CKD care commenced KRT. The rates of emergency department visits, hospitalizations, and death were lower in those assigned to management outside the multidisciplinary CKD clinics when compared with those managed in the multidisciplinary care setting. Limitations: The follow-up period may not have been long enough to determine outcomes, and potentially limited generalizability given variability of care in multidisciplinary clinics. Conclusions: Our findings indicate that a portion of patients can be directed to less resource-intensive care without a higher risk of adverse events. Trial registration: Not applicable.

Contexte: L'équation KFRE (Kidney Failure Risk Equation) peut être utilisée en environnement clinique pour prédire le risque d'évolution vers l'insuffisance rénale terminale (IRT). Objectif: Évaluer la mise en œuvre d'une approche structurée fondée sur le risque dans les cliniques multidisciplinaires d'insuffisance rénale chronique (IRC) et les cliniques ambulatoires des néphrologues afin de déterminer l'aptitude des patients à recevoir des soins multidisciplinaires et de mesurer l'incidence des soins d'IRC reçus sur les résultats cliniques. Conception: Étude de cohorte populationnelle descriptive. Cadre: Alberta Kidney Care South. Sujets: Adultes fréquentant ou envisageant de fréquenter une clinique multidisciplinaire d'IRC entre le 1er avril 2017 et le 31 mars 2019. Mesures: Exposition­le parcours de soins d'IRC attribué par le néphrologue ­ prise en charge en clinique multidisciplinaire d'IRC; prise en charge par un néphrologue ou un médecin de premier recours. Principaux résultats­progression de l'IRC, définie comme l'amorce d'une thérapie de remplacement rénal (TRR). Résultats secondaires­décès, visites aux urgences et hospitalisations. Méthodologie: Nous avons couplé les données opérationnelles des cliniques (disponibles jusqu'au 31 mars 2019) aux données administratives de santé et aux données de laboratoire (disponibles jusqu'au 31 mars 2020). Des modèles de régression binomiale négative et des rapports des taux d'incidence non corrigés et entièrement corrigés ont servi aux comparaisons entre les groupes de patients, les parcours de soins et les environnements cliniques. Les risques relatifs non corrigés et entièrement corrigés de décès toutes causes confondues ont été calculés à l'aide de modèles de survie de Cox. Résultats: Des 1 748 patients avec une KFRE calculée, 1 347 (77 %) sont restés ou ont été admis dans une clinique multidisciplinaire d'IRC, 310 (18 %) ont été pris en charge par un néphrologue seulement et 91 (5 %) ont été orientés pour une prise en charge par leur médecin de premier recours. Le risque d'insuffisance rénale terminale était beaucoup plus élevé chez les patients restés ou admis dans une clinique multidisciplinaire d'IRC (risque médian à 2 ans : 34,7 %) que chez ceux pris en charge par un néphrologue (3,6 %) et par un médecin de premier recours (0,8 %). Aucun patient pris en charge par un médecin de premier recours n'avait amorcé une TRR; 2 personnes (0,6 %) prises en charge par un néphrologue sans soins multidisciplinaires d'IRC avaient amorcé une TRR. Les taux de visites aux urgences, d'hospitalisations et de décès étaient plus faibles chez les patients pris en charge à l'extérieur des cliniques multidisciplinaires d'IRC comparativement à ceux pris en charge dans ces cliniques. Limites: La période de suivi n'était peut-être pas été assez longue pour déterminer les résultats. La variabilité des soins dans les cliniques multidisciplinaires pourrait également limiter la généralisation des résultats. Conclusion: Nos résultats suggèrent qu'une partie des patients pourrait être dirigée vers des soins nécessitant moins de ressources sans hausser le risque d'événements indésirables.

Identification and Prioritization of Canadian Society of Nephrology Clinical Practice Guideline Topics With Multidisciplinary Stakeholders and People Living With Kidney Disease: A Clinical Research Protocol.

Background: Despite efforts to provide evidence-based care for people living with kidney disease, health care provider goals and priorities are often misaligned with those of individuals with lived experience of disease. Coupled with competing interests of time, resources, and an abundance of suitable guideline topics, identifying and prioritizing areas of focus for the Canadian nephrology community with a patient-oriented perspective is necessary and important. Similar priority-setting exercises have been undertaken to establish research priorities for kidney disease and to standardize outcomes for kidney disease research and clinical care; however, research priorities are distinct from priorities for guideline development. Inclusion of people living with health conditions in the selection and prioritization of guideline topics is suggested by patient engagement frameworks, though the process to operationalizing this is variable. We propose that the Canadian Society of Nephrology Clinical Practice Guideline Committee (CSN CPGC) takes the opportunity at this juncture to incorporate evidence-based prioritization exercises with involvement of people living with kidney disease and their caregivers to inform future guideline activities. In this protocol, we describe our planned research methods to address this. Objective: To establish consensus-based guideline topic priorities for the CSN CPGC using a modified Delphi survey with involvement of multidisciplinary stakeholders, including people living with kidney disease and their caregivers. Study design: Protocol for a Modified Delphi Survey. Setting: Pilot-tested surveys will be distributed via email and conducted using the online platform SurveyMonkey, in both French and English. Participants: We will establish a group of multidisciplinary clinical and research stakeholders (both within and outside CSN membership) from Canada, in addition to people living with kidney disease and/or their caregivers. Methods: A comprehensive literature search will be conducted to generate an initial list of guideline topics, which will be organized into three main categories: (1) International nephrology-focused guidelines that may require Canadian commentary, (2) Non-nephrology specific guidelines from Canada that may require CSN commentary, and (3) Novel topics for guideline development. Participants will engage in a multi-round Modified Delphi Survey to prioritize a set of "important guideline topics." Measures: Consensus will be reached for an item based on both median score on the Likert-type scale (≥ 7) and the percentage agreement (≥ 75%); the Delphi process will be complete when consensus is reached on each item. Guideline topics will then be given a priority score calculated from the total Likert ratings across participants, adjusted for the number of participants. Limitations: Potential limitations include participant response rates and compliance to survey completion. Conclusions: We propose to incorporate evidence-based prioritization exercises with the engagement of people living with kidney disease and their caregivers to establish consensus-based guideline topics and inform future guidelines activities of the CSN CPGC.

Contexte: Malgré les efforts déployés pour fournir aux personnes atteintes de néphropathies des soins fondés sur les données probantes, il s'avère que les objectifs et priorités des prestataires de soins de santé sont souvent mal alignés avec ceux des personnes qui ont une expérience concrète de la maladie. Compte tenu des intérêts concurrents en matière de temps et de ressources, et de l'abondance de sujets pertinents pour l'élaboration de lignes directrices, il est nécessaire et important d'identifier et de hiérarchiser les domaines prioritaires pour la communauté néphrologique canadienne dans une perspective orientée vers le patient. Des exercices semblables pour la définition des priorités ont été entrepris afin d'établir les priorités de la recherche sur les maladies rénales et normaliser les soins cliniques et les résultats de la recherche sur les maladies rénales. Or, les priorités de la recherche diffèrent des priorités pour l'élaboration des lignes directrices. Bien que les façons de procéder varient, les cadres d'engagement des patients suggèrent que des personnes vivant avec des problèmes de santé soient incluses dans la sélection et la hiérarchisation des sujets des lignes directrices. À cet égard, nous proposons que le Comité sur les lignes directrices de pratique clinique de la Société canadienne de néphrologie (CSN CPGC ­ Canadian Society of Nephrology Clinical Practice Guideline Committee) profite de l'occasion pour intégrer des exercices d'établissement des priorités fondés sur des données probantes et impliquer des personnes vivant avec une néphropathie et des soignants afin de guider les futures activités d'élaboration de lignes directrices. Dans ce protocole, nous décrivons la méthodologie de recherche que nous suivrons pour y remédier. Objectif: Établir des priorités consensuelles en matière de sujets de lignes directrices pour le CSN CPGC à l'aide d'une enquête Delphi modifiée et avec la participation d'intervenants multidisciplinaires, notamment des personnes vivant avec une néphropathie et leurs soignants. Conception: Protocole pour une enquête Delphi modifiée. Cadre: Des sondages pilotes, en anglais et en français, seront distribués par courriel et réalisés à l'aide de la plateforme en ligne SurveyMonkey. Participants: Nous créerons un groupe d'intervenants multidisciplinaires canadiens œuvrant en clinique et en recherche (à la fois des membres et des non membres de la SCN) auquel s'ajouteront des personnes atteintes d'une néphropathie et/ou leurs soignants. Méthodologie: Une recherche exhaustive sera effectuée dans la littérature afin de constituer une première liste de sujets de lignes directrices, laquelle sera divisée en trois catégories principales: (1) lignes directrices internationales axées sur la néphrologie et pouvant nécessiter des commentaires canadiens, (2) lignes directrices canadiennes non spécifiquement liées à la néphrologie et pouvant nécessiter des commentaires de la SCN, (3) nouveaux sujets pour l'élaboration de lignes directrices. Les participants s'engageront dans une enquête Delphi modifiée à plusieurs tours afin de hiérarchiser un ensemble de « sujets importants pour l'élaboration de lignes directrices ¼. Mesures: Un consensus sera atteint pour un énoncé s'il atteint à la fois un score médian (≥7) sur l'échelle de Likert et le pourcentage d'accord établi (≥ 75 %); le processus Delphi sera terminé lorsque le consensus sera atteint pour chaque énoncé. Les sujets pour l'élaboration de lignes directrices recevront ensuite une cote de priorité calculée à partir du total des scores des participants sur l'échelle Likert et ajustée en fonction du nombre de participants. Limites: L'étude pourrait être limitée par le taux de réponse des participants et leur engagement à compléter toutes les étapes de l'enquête. Conclusion: Nous proposons d'intégrer des exercices de définition des priorités fondés sur des données probantes et impliquant la participation de personnes vivant avec une néphropathie et de leurs soignants afin de déterminer des sujets consensuels pour l'élaboration de lignes directrices et de guider les futures activités du CSN CPGC en lien avec ce processus.

Follow-up Care of Critically Ill Patients With Acute Kidney Injury: A Cohort Study.

Rationale & Objective: To evaluate follow-up care of critically ill patients with acute kidney injury (AKI). Study Design: Retrospective cohort study. Setting & Participants: Patients admitted to the intensive care unit (ICU) with AKI in Alberta, Canada from 2005 to 2018, who survived to discharge without kidney replacement therapy or estimated glomerular filtration rate <15 mL/min/1.73 m2. Exposure: AKI (defined as ≥50% or ≥0.3 mg/dL serum creatinine increase). Outcomes: The primary outcome was the cumulative incidence of an outpatient serum creatinine and urine protein measurement at 3 months postdischarge. Secondary outcomes included an outpatient serum creatinine or urine protein measurement or a nephrologist visit at 3 months postdischarge. Analytical Approach: Patients were followed from hospital discharge until the first of each outcome of interest, death, emigration from the province, kidney replacement therapy (maintenance dialysis or kidney transplantation), or end of study period (March 2019). We used non-parametric methods (Aalen-Johansen) to estimate the cumulative incidence functions of outcomes accounting for competing events (death and kidney replacement therapy). Results: There were 29,732 critically ill adult patients with AKI. The median age was 68 years (IQR, 57-77), 39% were female, and the median baseline estimated glomerular filtration rate was 72 mL/min/1.73 m2 (IQR, 53-90). The cumulative incidence of having an outpatient creatinine and urine protein measurement at 3 months postdischarge was 25% (95% CI, 25-26). At 3 months postdischarge, 64% (95% CI, 64-65) had an outpatient creatinine measurement, 28% (95% CI, 27-28) had a urine protein measurement, and 5% (95% CI, 4-5) had a nephrologist visit. Limitations: We lacked granular data, such as urine output. Conclusions: Many critically ill patients with AKI do not receive the recommended follow-up care. Our findings highlight a gap in the transition of care for survivors of critical illness and AKI.

Measuring albuminuria or proteinuria: does one answer fit all?

Measurement of proteinuria is critical for diagnosing and monitoring kidney disease. A variety of measures are available to clinicians and can identify all urinary proteins (proteinuria) or urine albumin alone (albuminuria). Proteinuria and albuminuria can be measured in either a random urine sample or a timed urine collection (often over 24 hours). Although an international guideline advocates the use of the urinary albumin-to-creatinine ratio for most purposes, this measure is not universally available worldwide and historically has been more costly than alternatives. In addition, there may be important differences in accuracy between the albumin-to-creatinine ratio and others based on magnitude of albuminuria, sex, and certain clinical contexts. In this mini review, we review recommendations from international guidelines and discuss specific contexts where the optimal measure of proteinuria is unclear and, in some situations, controversial. We discuss the evidence supporting current recommendations for choice of measure, including the clinical settings of glomerulonephritis, transplantation, and pregnancy. We also discuss how patient sex and cost may impact this decision.

Reduction in Thrombolytic Usage in Hemodialysis Patients Following a Quality Assurance Review: A Research Letter.

Background: Catheter malfunction in hemodialysis (HD) is increasingly managed with recombinant tissue plasminogen activator (rt-PA, alteplase), though evidence of improved catheter function is lacking. Objective: To evaluate the effect of a standardized rt-PA administration protocol on rt-PA usage, catheter function, and adverse events. Design: Observational quality improvement study. Setting: Single, urban, community HD unit in Calgary, Alberta. Patients: Patients treated with maintenance in-center HD through central venous catheter. Outcomes: Incidence of rt-PA usage, catheter interventions, hospitalizations, and measures of dialysis efficacy. Methods: The rt-PA protocol was designed following a consultative and iterative design period with dialysis shareholders, which included focusing on standard objective criteria before use and targeting use to the problematic lumen. Protocol implementation occurred over a 6-month period in 2021. Patient and dialysis data were collected through our regional dialysis electronic health record. Results: Implementation of the rt-PA protocol resulted in decreased rt-PA use (standardized per 100 dialysis sessions) compared to the preprotocol period (incidence rate ratio [IRR] of 0.57, 95% confidence interval [CI]: [0.34, 0.94]). Line procedures were also less frequent (IRR = 0.42, 95% CI: [0.18, 0.89]). Hospitalization rates and measures of dialysis efficacy were similar in both periods. Limitations: Small sample size with single dialysis center and short duration of follow-up. Conclusions: Implementation of a multidisciplinary designed rt-PA administration protocol decreased incident rt-PA usage.

Contexte: L'activateur tissulaire du plasminogène recombinant (rt-PA, alteplase) est de plus en plus utilisé pour la prise en charge du dysfonctionnement du cathéter en hémodialyse, bien qu'on manque de preuves sur l'amélioration de la fonction du cathéter. Objectif: Évaluer l'effet d'un protocole normalisé d'administration de rt-PA sur l'utilization de rt-PA, la fonction du cathéter et les événements indésirables. Type d'étude: Étude observationnelle d'amélioration de la qualité. Cadre: L'unité d'hémodialyse communautaire d'un center urbain de Calgary (Alberta). Sujets: Patients traités en center par hémodialyse d'entretien avec cathéter veineux central. Résultats: Mesure de l'efficacité de la dialyze et incidence de l'utilization du rt-PA, des interventions par cathéter et des hospitalisations. Méthodologie: Le protocole rt-PA a été élaboré après une période de consultation et d'itération auprès des intervenants en dialyze qui consistait à mettre l'accent sur les critères objectifs normalisés avant son utilization et à cibler son utilization dans la lumière problématique du cathéter. La mise en œuvre du protocole s'est déroulée sur une période de 6 mois en 2021. Les données sur les patients et les séances de dialyze ont été recueillies par le biais du dossier médical électronique régional pour la dialyze. Résultats: La mise en œuvre du protocole rt-PA a entraîné une diminution de l'utilization de rt-PA (normalisée pour 100 séances de dialyze) par rapport à la période pré-protocole (rapport du taux d'incidence [RTI] de 0,57; intervalle de confiance à 95% [IC 95 %] de 0.34 à 0.94). Les interventions au niveau des cathéters ont également été moins fréquentes (RTI: 0.42; IC 95 %: 0.18-0.89). Les taux d'hospitalization et les mesures de l'efficacité de la dialyze étaient semblables pour les deux périodes. Limites: Étude menée dans un seul center de dialyze, sur un échantillon de petite taille, avec un suivi de courte durée. Conclusion: La mise en œuvre d'un protocole d'administration de rt-PA conçu de façon multidisciplinaire a diminué l'incidence de l'utilization de rt-PA.

Low-value preoperative cardiac testing before low-risk surgical procedures: a population-based cohort study.

BACKGROUND: Choosing Wisely Canada (CWC) recommends avoiding noninvasive advanced cardiac testing (e.g., exercise stress testing [EST], echocardiography and myocardial perfusion imaging [MPI]) for preoperative assessment in patients scheduled to undergo low-risk noncardiac surgery. In this study, we assessed the temporal trends in testing, overlapping with the introduction of the CWC recommendations in 2014, and patient and provider factors associated with low-value testing. METHODS: In this population-based retrospective cohort study, we used linked health administrative data in Alberta, Canada, to identify adult patients who underwent elective noncardiac surgery between Apr. 1, 2011, and Mar. 31, 2019, who had preoperative noninvasive advanced cardiac tests (EST, echocardiography or MPI) within 6 months before surgery. We included electrocardiography as an exploratory outcome. We excluded patients at high risk using the Revised Cardiac Risk Index (score ≥ 1 considered to indicate high risk), and modelled patient and temporal factors associated with the number of tests. RESULTS: We identified 1 045 896 elective noncardiac operations performed in 798 599 patients and 25 599 advanced preoperative cardiac tests; 2.1% of operations were preceded by advanced cardiac testing. The incidence of testing increased over the study period, and, by 2018/19, patients were 1.3 times (95% confidence interval 1.2-1.4) more likely to receive a preoperative advanced test compared to 2011/12. Urban patients were more likely to receive a preoperative advanced cardiac test than their rural counterparts. Electrocardiography was the most common preoperative cardiac test, preceding 182 128 procedures (17.4%). INTERPRETATION: Preoperative advanced cardiac testing was infrequent in adult Albertans who underwent low-risk elective noncardiac operations. Despite CWC recommendations, the use of some tests appears to be increasing, and there was substantial variation across geographic areas.

Prediction of major postoperative events after non-cardiac surgery for people with kidney failure: derivation and internal validation of risk models.

BACKGROUND: People with kidney failure often require surgery and experience worse postoperative outcomes compared to the general population, but existing risk prediction tools have excluded those with kidney failure during development or exhibit poor performance. Our objective was to derive, internally validate, and estimate the clinical utility of risk prediction models for people with kidney failure undergoing non-cardiac surgery. DESIGN, SETTING, PARTICIPANTS, AND MEASURES: This study involved derivation and internal validation of prognostic risk prediction models using a retrospective, population-based cohort. We identified adults from Alberta, Canada with pre-existing kidney failure (estimated glomerular filtration rate [eGFR] < 15 mL/min/1.73m2 or receipt of maintenance dialysis) undergoing non-cardiac surgery between 2005-2019. Three nested prognostic risk prediction models were assembled using clinical and logistical rationale. Model 1 included age, sex, dialysis modality, surgery type and setting. Model 2 added comorbidities, and Model 3 added preoperative hemoglobin and albumin. Death or major cardiac events (acute myocardial infarction or nonfatal ventricular arrhythmia) within 30 days after surgery were modelled using logistic regression models. RESULTS: The development cohort included 38,541 surgeries, with 1,204 outcomes (after 3.1% of surgeries); 61% were performed in males, the median age was 64 years (interquartile range [IQR]: 53, 73), and 61% were receiving hemodialysis at the time of surgery. All three internally validated models performed well, with c-statistics ranging from 0.783 (95% Confidence Interval [CI]: 0.770, 0.797) for Model 1 to 0.818 (95%CI: 0.803, 0.826) for Model 3. Calibration slopes and intercepts were excellent for all models, though Models 2 and 3 demonstrated improvement in net reclassification. Decision curve analysis estimated that use of any model to guide perioperative interventions such as cardiac monitoring would result in potential net benefit over default strategies. CONCLUSIONS: We developed and internally validated three novel models to predict major clinical events for people with kidney failure having surgery. Models including comorbidities and laboratory variables showed improved accuracy of risk stratification and provided the greatest potential net benefit for guiding perioperative decisions. Once externally validated, these models may inform perioperative shared decision making and risk-guided strategies for this population.

Small for date preterm infants and risk of higher blood pressure in later life: A systematic review and meta-analysis.

BACKGROUND: Historical reports suggest that infants born small for gestational age (SGA) are at increased risk for high blood pressure (BP) at older ages after adjustment for later age body size. Such adjustment may be inappropriate since adiposity is a known cause of cardiovascular and metabolic disease. OBJECTIVES: To assess the association between SGA births and later BP among preterm births, considering potential background confounders and over-adjustment for later body size. METHODS: A database search of studies up to October 2022 included MEDLINE, EMBASE and CINAHL. Studies were included if they reported BP (systolic [SBP] or diastolic [DBP]) (outcomes) for participants born preterm with SGA (exposure) or non-SGA births. All screening, extraction steps, and risk of bias (using the Risk of Bias In Non-randomised Studies of Interventions [ROBINS-I] tool) were conducted in duplicate by two reviewers. Data were pooled in meta-analysis using random-effects models. We explored potential sources of heterogeneity. RESULTS: We found no meaningful difference in later BP between preterm infants with and without SGA status at birth. Meta-analysis of 25 studies showed that preterm SGA, compared to preterm non-SGA, was not associated with higher BP at age 2 and older with mean differences for SBP 0.01 mmHg (95% CI -0.10, 0.12, I2  = 59.8%, n = 20,462) and DBP 0.01 mm Hg (95% CI -0.10, 0.12), 22 studies, (I2  = 53.0%, n = 20,182). Adjustment for current weight did not alter the results, which could be due to the lack of differences in later weight status in most of the included studies. The included studies were rated to be at risk of bias due to potential residual confounding, with a low risk of bias in other domains. CONCLUSIONS: Evidence indicates that preterm infants born SGA are not at increased risk of developing higher BP as children or as adults as compared to non-SGA preterm infants.

Implementation of a Perioperative Glycemic Management Quality Improvement Pathway in Gynecologic Oncology Patients: A Single-cohort Interrupted Time-series Analysis.

OBJECTIVE: We evaluated implementation and clinical outcomes of a perioperative glycemic management pathway in gynecologic oncology. METHODS: Interrupted time-series analysis was used to compare process, balancing and outcome measures and clinical outcomes from 18 months preimplementation to 18 months postimplementation. RESULTS: Compared with in the preimplementation period, the proportion of patients who underwent preoperative screening with glycated hemoglobin in the postimplementation period increased by 11.3% (95% confidence interval [CI], 5.0% to 17.7%; p=0.001). The proportion of patients with diabetes who had at least 1 blood glucose measurement after surgery increased by 15.3% (95% CI, -3.2% to 33.8%; p=0.10). There was no change in the proportion of patients who had any hyperglycemia or moderate or severe hyperglycemia. The median length of stay decreased by 0.42 days (95% CI, -0.91 to 0.07 days; p=0.09). There were major quality gaps in perioperative glycemic management that did not clearly improve after implementation of a multidisciplinary care pathway. CONCLUSION: Optimal strategies for improvement of perioperative glycemic management are not yet known.

Risk Scores for Clinical Risk Stratification of Emergency Department Patients With Chest Pain but No Acute Myocardial Infarction: A Systematic Review.

BACKGROUND: Chest pain is a common cause for emergency department (ED) presentations. After myocardial infarction (MI) has been ruled out by means of electrocardiography and troponin testing, decisions around anatomic or functional testing may be informed by clinical risk scores. We conducted a systematic review to synthesize evidence of the prognostic performance of chest pain risk scores among ED patients who have had MI ruled out by means of a high-sensitivity troponin assay. METHODS: We queried multiple databases from inception to May 17, 2022. We included studies that quantified risk of 30-day major adverse cardiac events (MACE), at different cutoffs of clinical risk scores, among adult patients who had MI ruled out by means of a high-sensitivity troponin assay. Prognostic performance of each score was synthesized and described, but meta-analysis was not possible. RESULTS: Six studies met inclusion criteria. Short-term MACE risk among patients who had MI ruled out by means of high-sensitivity cardiac troponin assays was very low. The HEART score, with a cutoff of 3 or less, predicted a very low risk of MACE among the greatest proportion of patients. Other scores had lower sensitivity or classified fewer patients as low risk. CONCLUSIONS: The HEART score with a cutoff value of 3 or less accurately identified the greatest number of patients at low risk of 30-day MACE. However, MACE risk among patients who have MI ruled out by means of high-sensitivity troponin testing is sufficiently low that clinical risk stratification or noninvasive testing may be of little additional value in identifying patients with coronary disease.

Strategies for intraoperative glucose management: a scoping review.

PURPOSE: Perioperative hyperglycemia is associated with adverse outcomes for patients with and without diabetes. Guidelines and published protocols for intraoperative glycemic management have substantial variation in their recommendations. We sought to characterize the current evidence-guiding intraoperative glycemic management in a scoping review. SOURCES: Our search strategy included MEDLINE (Ovid and EBSCO), PubMed, PubMed Central, EMBASE, CINAHL, Cochrane Library, SciVerse Scopus, and Web of Science and a gray literature search of Google, Google Scholar, hand searching of the reference lists of included articles, OAISter, institutional protocols, and ClinicalTrails.gov. PRINCIPAL FINDINGS: We identified 41 articles that met our inclusion criteria, 24 of which were original research studies. Outcomes and exposures were defined heterogeneously across studies, which limited comparison and synthesis. Investigators often created arbitrary and differing categories of glucose values rather than analyzing glucose as a continuous variable, which limited our ability to combine results from different studies. In addition, the study populations and surgery types also varied considerably, with few studies performed during day surgeries and specific surgical disciplines. Study populations often included more than one type of surgery, indication, and urgency that were expected to have varying physiologic and inflammatory responses. Combining low- and high-risk patients in the same study population may obscure the harms or benefits of intraoperative glycemic management for high-risk procedures or patients. CONCLUSION: Future studies examining intraoperative glycemic management should carefully consider the study population, surgical characteristics, and pre- and postoperative management of hyperglycemia.

RéSUMé: OBJECTIF: L'hyperglycémie périopératoire est associée à des effets indésirables chez les patients diabétiques et non diabétiques. Les lignes directrices et les protocoles publiés pour la prise en charge glycémique peropératoire présentent des variations substantielles dans leurs recommandations. Nous avons cherché à caractériser les données probantes actuelles guidant la prise en charge glycémique peropératoire dans une étude de portée. SOURCES: Notre stratégie de recherche a inclus les bases de données MEDLINE (Ovid et EBSCO), PubMed, PubMed Central, EMBASE, CINAHL, Cochrane Library, SciVerse Scopus et Web of Science, ainsi qu'une recherche documentaire grise sur Google, Google Scholar, la recherche manuelle des listes de référence des articles inclus, OAISter, les protocoles institutionnels et ClinicalTrials.gov. CONSTATATIONS PRINCIPALES: Nous avons identifié 41 articles qui répondaient à nos critères d'inclusion, dont 24 étaient des études de recherche originales. Les critères d'évaluation et les expositions étaient définis de manière hétérogène d'une étude à l'autre, ce qui a limité la comparaison et la synthèse. Les chercheurs ont souvent créé des catégories arbitraires et différentes de valeurs glycémiques plutôt que d'analyser la glycémie comme une variable continue, ce qui a limité notre capacité à combiner les résultats de différentes études. En outre, les populations étudiées et les types de chirurgie variaient également considérablement, avec peu d'études réalisées lors de chirurgies ambulatoires et dans certaines disciplines chirurgicales spécifiques. Les populations étudiées comprenaient souvent plus d'un type de chirurgie, d'indication et d'urgence, pour lesquelles des réponses physiologiques et inflammatoires variables étaient attendues. La combinaison de patients à faible et à haut risque dans la même population d'étude a pu masquer les inconvénients ou les avantages d'une prise en charge glycémique peropératoire pour les interventions ou les patients à haut risque. CONCLUSION: Les études futures portant sur la prise en charge glycémique peropératoire devraient examiner attentivement la population étudiée, les caractéristiques chirurgicales et la prise en charge pré- et postopératoire de l'hyperglycémie.

Association of Kidney Function With Major Postoperative Events After Noncardiac Ambulatory Surgeries: A Population-Based Cohort Study.

OBJECTIVE: The aim of this study was to estimate the association between estimated glomerular filtration rate (eGFR) and acute myocardial infarction (AMI) or death after ambulatory noncardiac surgery. SUMMARY BACKGROUND DATA: People with chronic kidney disease (CKD) commonly undergo surgical procedures. Although most are performed in an ambulatory setting, the risk of major perioperative outcomes after ambulatory surgery for people with CKD is unknown. METHODS: In this retrospective population-based cohort study using administrative health data from Alberta, Canada, we included adults with measured preoperative kidney function undergoing ambulatory noncardiac surgery between April 1, 2005 and February 28, 2017. Participants were categorized into 6 eGFR categories (in mL/min/1.73m 2 )of ≥60 (G1-2), 45 to 59 (G3a), 30 to 44 (G3b), 15 to 29 (G4), <15 not receiving dialysis (G5ND), and those receiving chronic dialysis (G5D). The odds of AMI or death within 30 days of surgery were estimated using multivariable generalized estimating equation models. RESULTS: We identified 543,160 procedures in 323,521 people with a median age of 66 years (IQR 56-76); 52% were female. Overall, 2338 people (0.7%) died or had an AMI within 30 days of surgery. Compared with the G1-2 category, the adjusted odds ratio of death or AMI increased from 1.1 (95% confidence interval: 1.0-1.3) for G3a to 3.1 (2.6-3.6) for G5D. Emergency Department and Urgent Care Center visits within 30 days were frequent (17%), though similar across eGFR categories. CONCLUSIONS: Ambulatory surgery was associated with a low risk of major postoperative events. This risk was higher for people with CKD, which may inform their perioperative shared decision-making and management.

Perioperative management for people with kidney failure receiving dialysis: A scoping review.

BACKGROUND: People with kidney failure receiving dialysis (CKD-G5D) are more likely to undergo surgery and experience poorer postoperative outcomes than those without kidney failure. In this scoping review, we aimed to systematically identify and summarize perioperative strategies, protocols, pathways, and interventions that have been studied or implemented for people with CKD-G5D. METHODS: We searched MEDLINE, EMBASE, CINAHL Plus, Cochrane Database of Systematic Reviews, and Cochrane Controlled Trials registry (inception to February 2020), in addition to an extensive grey literature search, for sources that reported on a perioperative strategy to guide management for people with CKD-G5D. We summarized the overall study characteristics and perioperative management strategies and identified evidence gaps based on surgery type and perioperative domain. Publication trends over time were assessed, stratified by surgery type and study design. RESULTS: We included 183 studies; the most common study design was a randomized controlled trial (27%), with 67% of publications focused on either kidney transplantation or dialysis vascular access. Transplant-related studies often focused on fluid and volume management strategies and risk stratification, whereas dialysis vascular access studies focused most often on imaging. The number of publications increased over time, across all surgery types, though driven by non-randomized study designs. CONCLUSIONS: Despite many current gaps in perioperative research for patients with CKD-G5D, evidence generation supporting perioperative management is increasing, with recent growth driven primarily by non-randomized studies. Our review may inform organization of evidence-based strategies into perioperative care pathways where evidence is available while also highlighting gaps that future perioperative research can address.

Sex differences in COVID-19 symptoms and outcomes in people with kidney failure treated with dialysis: a prospective cohort study.

BACKGROUND: People with kidney failure treated with dialysis are at increased risk of SARS-CoV-2 infection, and severe COVID-19 outcomes such as hospitalization and death. Though there are well-defined sex differences in outcomes for the general population with COVID-19, we do not know whether this translates into kidney failure populations. We aimed to estimate the differences in COVID-19 symptoms and clinical outcomes between males and females treated with maintenance dialysis. METHODS: In this prospective observational cohort study, we included adults treated with maintenance dialysis in Southern Alberta, Canada that tested positive for COVID-19 between March 2020 and February 2022. We examined the association between sex (dichotomized as male and female) with COVID-19 symptoms including fever, cough, malaise, shortness of breath, muscle joints/aches, nausea and/or vomiting, loss of appetite, diarrhea, headache, sore throat, and loss of smell/taste using chi-square or Fisher's exact tests. Secondary outcomes included 30-day hospitalization, ICU admission, and death. RESULTS: Of 1,329 cohort participants, 246 (18.5%) tested positive for SARS-CoV-2 and were included in our study, including 95 females (39%). Of 207 participants with symptoms assessed, females had less frequent fever (p = 0.003), and more nausea or vomiting (p = 0.003) compared to males, after correction for multiple testing. Males exhibited no symptoms 25% of the time, compared with 10% of females (p = 0.01, not significant when corrected for multiple testing). We did not identify statistically significant differences in clinical outcomes between the sexes, though vaccinated patients had lower odds of hospitalization. CONCLUSIONS: Sex differences in COVID-19 symptoms were identified in a cohort of patients treated with maintenance dialysis, which may inform sex-specific screening strategies in dialysis units. Further work is necessary to examine mechanisms for identified sex differences.

Using the Revised Cardiac Risk Index to Predict Major Postoperative Events for People With Kidney Failure: An External Validation and Update.

Background: People with kidney failure have high risk of postoperative morbidity and mortality. Although the revised cardiac risk index (RCRI) is used to estimate the risk of major postoperative events, it has not been validated in this population. We aimed to externally validate the RCRI and determine whether updating the model improved predictions for people with kidney failure. Methods: We derived a retrospective, population-based cohort of adults with kidney failure (maintenance dialysis or sustained estimated glomerular filtration rate < 15 mL/min per 1.73 m2) who had surgery in Alberta, Canada between 2005 and 2019. We categorized participants based on RCRI variables and assigned risk estimates of death or major cardiac events, and then estimated predictive performance. We re-estimated the coefficients for each RCRI variable and internally validated the updated model. Net benefit was estimated with decision curve analysis. Results: After 38,541 surgeries, 1204 events (3.1%) occurred. The estimated C-statistic for the original RCRI was 0.64 (95% confidence interval: 0.62, 0.65). Examination of calibration revealed significant risk overestimation. In the re-estimated RCRI model, discrimination was marginally different (C-statistic 0.67 [95% confidence interval: 0.66, 0.69]), though calibration was improved. No net benefit was observed when the data were examined with decision curve analysis, whereas the original RCRI was associated with harm. Conclusions: The RCRI performed poorly in a Canadian kidney failure cohort and significantly overestimated risk, suggesting that RCRI use in similar kidney failure populations should be limited. A re-estimated kidney failure-specific RCRI may be promising but needs external validation. Novel perioperative models for this population are urgently needed.

Contexte: Les personnes atteintes d'insuffisance rénale présentent un risque élevé de mortalité et de morbidité postopératoires. L'indice de risque cardiaque révisé (IRCR) est utilisé pour estimer le risque d'événements postopératoires majeurs, mais il n'a pas été validé au sein de cette po-pulation. Nous avons cherché à réaliser une validation externe de l'IRCR et à déterminer si une modification du modèle pourrait permettre une meilleure valeur prédictive pour les patients atteints d'insuffisance rénale. Méthodologie: Nous avons étudié rétrospectivement une cohorte populationnelle d'adultes atteints d'insuffisance rénale (sous dialyse d'entretien ou avec un débit de filtration glomérulaire estimé < 15 ml/min/1,73 m2, de façon soutenue) ayant subi une intervention chirurgicale en Alberta (Canada) entre 2005 et 2019. Les participants ont été classifiés selon les variables de l'IRCR, et une estimation du risque de décès ou d'événement cardiovasculaire majeur leur a été attribuée; la performance prédictive a ensuite été évaluée. Nous avons réestimé les coefficients pour chacune des variables de l'IRCR et nous avons validé de manière interne le modèle modifié. Le bénéfice net a été estimé avec une analyse de la courbe décisionnelle. Résultats: Après 38 541 interventions chirurgicales, des événements cardiovasculaires sont survenus dans 1 204 cas (3,1 %). La statistique C estimée obtenue avec l'IRCR initial était de 0,64 (intervalle de confiance [IC] à 95 %, de 0,62 à 0,65). Un examen de la calibration de l'indice a révélé une surestimation significative du risque. Avec le modèle d'IRCR modifié, la discrimination présentait une légère différence (statistique C de 0,67 [IC à 95 %, de 0,66 à 0,69]), bien que la calibration ait été améliorée. Pour l'indice modifié, aucun bénéfice net n'a été observé lors de l'examen des données par une analyse décisionnelle, alors qu'un préjudice était associé à l'IRCR initial. Conclusions: L'IRCR s'est révélé peu concluant dans une cohorte populationnelle de patients canadiens atteints d'insuffisance rénale et il a significativement surestimé les risques pour ces patients, ce qui suggère que l'utilisation de l'IRCR dans des populations similaires atteintes d'insuffisance rénale devrait être limitée. Un IRCR réestimé, propre à la population des patients atteints d'insuffisance rénale, pourrait être prometteur, mais requiert une validation externe. De nouveaux modèles périopératoires sont indispensables pour cette population.