Medication Deprescribing in Patients Receiving Hemodialysis: A Prospective Controlled Quality Improvement Study.

Rationale & Objective: Patients treated with dialysis are commonly prescribed multiple medications (polypharmacy), including some potentially inappropriate medications (PIMs). PIMs are associated with an increased risk of medication harm (eg, falls, fractures, hospitalization). Deprescribing is a solution that proposes to stop, reduce, or switch medications to a safer alternative. Although deprescribing pairs well with routine medication reviews, it can be complex and time-consuming. Whether clinical decision support improves the process and increases deprescribing for patients treated with dialysis is unknown. This study aimed to test the efficacy of the clinical decision support software MedSafer at increasing deprescribing for patients treated with dialysis. Study Design: Prospective controlled quality improvement study with a contemporaneous control. Setting & Participants: Patients prescribed ≥5 medications in 2 outpatient dialysis units in Montréal, Canada. Exposures: Patient health data from the electronic medical record were input into the MedSafer web-based portal to generate reports listing candidate PIMs for deprescribing. At the time of a planned biannual medication review (usual care), treating nephrologists in the intervention unit additionally received deprescribing reports, and patients received EMPOWER brochures containing safety information on PIMs they were prescribed. In the control unit, patients received usual care alone. Analytical Approach: The proportion of patients with ≥1 PIMs deprescribed was compared between the intervention and control units following a planned medication review to determine the effect of using MedSafer. The absolute risk difference with 95% CI and number needed to treat were calculated. Outcomes: The primary outcome was the proportion of patients with one or more PIMs deprescribed. Secondary outcomes include the reduction in the mean number of prescribed drugs and PIMs from baseline. Results: In total, 195 patients were included (127, control unit; 68, intervention unit); the mean age was 64.8 ± 15.9 (SD), and 36.9% were women. The proportion of patients with ≥1 PIMs deprescribed in the control unit was 3.1% (4/127) vs 39.7% (27/68) in the intervention unit (absolute risk difference, 36.6%; 95% CI, 24.5%-48.6%; P < 0.0001; number needed to treat = 3). Limitations: This was a single-center nonrandomized study with a type 1 error risk. Deprescribing durability was not assessed, and the study was not powered to reduce adverse drug events. Conclusions: Deprescribing clinical decision support and patient EMPOWER brochures provided during medication reviews could be an effective and scalable intervention to address PIMs in the dialysis population. A confirmatory randomized controlled trial is needed.

Patients treated with dialysis are commonly prescribed multiple medications, some of which are potentially inappropriate medications (PIMs). PIMs can increase a patient's pill burden and are associated with an increased risk of harm (some examples include falls, fractures, and hospitalization). Deprescribing is a proposed solution that aims to highlight medications that can be stopped, reduced, or switched to a safer option, under supervision of a health care provider. We aimed to determine if a quality improvement intervention in the dialysis unit could increase deprescribing compared to usual care. The study took place in 2 outpatient hemodialysis units where usual care involves nurses and nephrologists performing medication reviews twice a year. The intervention was a deprescribing report that was generated with the help of a software tool called MedSafer, along with brochures for patients with information on PIMs they were taking. In the intervention unit, we increased the number of patients who had a medication safely deprescribed by 36.6% more than on the control unit. Although the study was small, a future larger study in dialysis patients might show that a computer software such as MedSafer can prevent harmful complications from taking too many medications.

The Burden of Home Dialysis: An Overlooked Challenge.

Home dialysis offers several clinical and quality-of-life benefits for patients with kidney failure. However, it is important to recognize that home dialysis may place an increased burden on patients and their care partners. Sources of burden may include concerns about the ability to adequately and safely perform dialysis at home, physical symptoms, impairment of life participation, psychosocial challenges, and care partner burnout. Overlooking or failing to address these issues may lead to adverse events that negatively affect health and quality of life and reduce longevity of home dialysis. This study will explore aspects of home dialysis associated with burden, emphasize the need for increased awareness of potential challenges, and elaborate on strategies to overcome sources of burden. Future research should actively involve patients and care partners to better understand their motivation, experiences, and needs to better inform support strategies.

Outcomes of Integrated Home Dialysis Care: Results From the Canadian Organ Replacement Register.

RATIONALE & OBJECTIVE: The integrated home dialysis model proposes the initiation of kidney replacement therapy (KRT) with peritoneal dialysis (PD) and a timely transition to home hemodialysis (HHD) after PD ends. We compared the outcomes of patients transitioning from PD to HHD with those initiating KRT with HHD. STUDY DESIGN: Observational analysis of the Canadian Organ Replacement Register (CORR). SETTINGS & PARTICIPANTS: All patients who initiated PD or HHD within the first 90 days of KRT between 2005 and 2018. EXPOSURE: Patients transitioning from PD to HHD (PD+HHD group) versus patients initiating KRT with HHD (HHD group). OUTCOME: (1) A composite of all-cause mortality and modality transfer (to in-center hemodialysis or PD for 90 days) and (2) all hospitalizations (considered as recurrent events). ANALYTICAL APPROACH: A propensity score analysis for which PD+HHD patients were matched 1:1 to (1) incident HHD patients ("incident-match" analysis) or (2) HHD patients with a KRT vintage at least equivalent to the vintage of PD+HHD patients at the transition time ("vintage-matched" analysis). Cause-specific hazards models (composite outcome) and shared frailty models (hospitalization) were used to compare groups. RESULTS: Among 63,327 individuals in the CORR, 163 PD+HHD patients (median of 1.9 years in PD) and 711 HHD patients were identified. In the incident-match analysis, compared to the HHD patients, the PD+HHD group had a similar risk of the composite outcome (HR, 0.88 [95% CI, 0.58-1.32]) and hospitalizations (HR, 1.04 [95% CI, 0.76-1.41]). In the vintage-match analysis, PD+HHD patients had a lower hazard for the composite outcome (HR, 0.61 [95% CI, 0.40-0.94]) but a similar hospitalization risk (HR, 0.85 [95% CI, 0.59-1.24]). LIMITATIONS: Risk of survivor bias in the PD+HHD cohort and residual confounding. CONCLUSIONS: Controlling for KRT vintage, the patients transitioning from PD to HHD had better clinical outcomes than the incident HHD patients. These data support the use of integrated home dialysis for patients initiating home-based KRT. PLAIN-LANGUAGE SUMMARY: The integrated home dialysis model proposes the initiation of dialysis with peritoneal dialysis (PD) and subsequent transition to home hemodialysis (HHD) once PD is no longer feasible. It allows patients to benefit from initial lifestyle advantages of PD and to continue home-based treatments after its termination. However, some patients may prefer to initiate dialysis with HHD from the outset. In this study, we compared the long-term clinical outcomes of both approaches using a large Canadian dialysis register. We found that both options led to a similar risk of hospitalization. In contrast, the PD-to-HHD model led to improved survival when controlling for the duration of kidney failure.

Volume Status Assessment by Lung Ultrasound in End-Stage Kidney Disease: A Systematic Review.

Purpose of review: Lung ultrasound is a noninvasive bedside technique that can accurately assess pulmonary congestion by evaluating extravascular lung water. This technique is expanding and is easily available. Our primary outcome was to compare the efficacy of volume status assessment by lung ultrasound with clinical evaluation, echocardiography, bioimpedance, or biomarkers. The secondary outcomes were all-cause mortality and cardiovascular events. Sources of information: We conducted a MEDLINE literature search for observational and randomized studies with lung ultrasound in patients on maintenance dialysis. Methods: From a total of 2363 articles, we included 28 studies (25 observational and 3 randomized). The correlation coefficients were pooled for each variable of interest using the generic inverse variance method with a random effects model. Among the clinical parameters, New York Heart Association Functional Classification of Heart Failure status and lung auscultation showed the highest correlation with the number of B-lines on ultrasound, with a pooled r correlation coefficient of .57 and .36, respectively. Among echocardiographic parameters, left ventricular ejection fraction and inferior vena cava index had the strongest correlation with the number of B-lines, with a pooled r coefficient of .35 and .31, respectively. Three randomized studies compared a lung ultrasound-guided approach with standard of care on hard clinical endpoints. Although patients in the lung ultrasound group achieved better decongestion and blood pressure control, there was no difference between the 2 management strategies with respect to death from any cause or major adverse cardiovascular events. Key findings: Lung ultrasound may be considered for the identification of patients with subclinical volume overload. Trials did not show differences in clinically important outcomes. The number of studies was small and many were of suboptimal quality. Limitations: The included studies were heterogeneous and of relatively limited quality.

Motif de la revue: L'échographie pulmonaire est une technique non-invasive réalisée au chevet du patient qui permet d'évaluer avec précision la congestion pulmonaire en mesurant l'eau pulmonaire extravasculaire. Cette technique facilement accessible est de plus en plus utilisée. Notre principal critère de jugement était de comparer l'efficacité de l'évaluation de la volémie par échographie pulmonaire avec l'évaluation clinique, l'échocardiographie, la bio-impédance ou les biomarqueurs. Les critères d'évaluation secondaires étaient la mortalité toutes causes confondues et les événements cardiovasculaires. Sources: Nous avons recherché sur MEDLINE les études observationnelles et les essais randomisés où une échographie pulmonaire avait été réalisée chez des patients sous dialyse d'entretien. Méthodologie: Sur un total de 2 363 articles, nous avons retenu 28 études (25 observationnelles et 3 randomisées). Les coefficients de corrélation ont été regroupés pour chaque variable d'intérêt en utilisant la méthode générique de variance inverse avec un modèle à effets aléatoires. Les paramètres cliniques qui avaient montré les corrélations les plus élevées avec le nombre de lignes B à l'échographie étaient le statut de l'insuffisance cardiaque selon la classification de la New York Heart Association et l'auscultation pulmonaire, avec des coefficients de corrélation r regroupés respectifs de 0,57 et de 0,36. Les paramètres de l'échocardiographie qui avaient montré les plus fortes corrélations avec le nombre de lignes B étaient la fraction d'éjection du ventricule gauche et l'indice de la veine cave inférieure, avec des coefficients r regroupés respectifs de 0,35 et de 0,31. Trois essais randomisés avaient comparé une approche guidée par échographie pulmonaire aux normes de soins selon des critères cliniques stricts. Bien que les patients du groupe avec échographie pulmonaire aient montré une décongestion plus efficace et un meilleur contrôle de la pression artérielle, aucune différence n'a été observée entre les deux stratégies de prise en charge en ce qui concerne les décès de toutes causes confondues ou les événements cardiovasculaires indésirables majeurs. Principales observations: L'échographie pulmonaire pourrait être envisagée pour identifier les patients qui présentent une surcharge volumique subclinique. Les essais inclus n'ont pas montré de différences dans les résultats cliniquement pertinents. Le nombre d'études incluses était faible et plusieurs étaient de qualité sous-optimale. Limites: Les études incluses étaient hétérogènes et de qualité relativement limitée.

Home hemodialysis technique survival: insights and challenges.

Home hemodialysis (HHD) offers several clinical, quality of life and cost-saving benefits for patients with end-stage kidney disease. While uptake of this modality has increased in recent years, its prevalence remains low and high rates of discontinuation remain a challenge. This comprehensive narrative review aims to better understand what is currently known about technique survival in HHD patients, elucidate the clinical factors that contribute to attrition and expand on possible strategies to prevent discontinuation. With increasing efforts to encourage home modalities, it is imperative to better understand technique survival and find strategies to help maintain patients on the home therapy of their choosing. It is crucial to better target high-risk patients, examine ideal training practices and identify practices that are potentially modifiable to improve technique survival.

Electronic Decision Support for Deprescribing in Patients on Hemodialysis: Clinical Research Protocol for a Prospective, Controlled, Quality Improvement Study.

Background: Patients on dialysis are commonly prescribed multiple medications (polypharmacy), many of which are potentially inappropriate medications (PIMs). Potentially inappropriate medications are associated with an increased risk of falls, fractures, and hospitalization. MedSafer is an electronic tool that generates individualized, prioritized reports with deprescribing opportunities by cross-referencing patient health data and medications with guidelines for deprescribing. Objectives: Our primary aim was to increase deprescribing, as compared with usual care (medication reconciliation or MedRec), for outpatients receiving maintenance hemodialysis, through the provision of MedSafer deprescribing opportunity reports to the treating team and patient empowerment deprescribing brochures provided directly to the patients themselves. Design: This controlled, prospective, quality improvement study with a contemporary control builds on existing policy at the outpatient hemodialysis centers where biannual MedRecs are performed by the treating nephrologist and nursing team. Setting: The study takes place on 2 of the 3 outpatient hemodialysis units of the McGill University Health Centre in Montreal, Quebec, Canada. The intervention unit is the Lachine Hospital, and the control unit is the Montreal General Hospital. Patients: A closed cohort of outpatient hemodialysis patients visit one of the hemodialysis centers multiple times per week for their hemodialysis treatment. The initial cohort of the intervention unit includes 85 patients, whereas the control unit has 153 patients. Patients who are transplanted, hospitalized during their scheduled MedRec, or die before or during the MedRec will be excluded from the study. Measurements: We will compare rates of deprescribing between the control and intervention units following a single MedRec. On the intervention unit, MedRecs will be paired with MedSafer reports (the intervention), and on the control unit, MedRecs will take place without MedSafer reports (usual care). On the intervention unit, patients will also receive deprescribing patient empowerment brochures for select medication classes (gabapentinoids, proton-pump inhibitors, sedative hypnotics and opioids for chronic non-cancer pain). Physicians on the intervention unit will be interviewed post-MedRec to determine implementation barriers and facilitators. Methods: The primary outcome will be the proportion of patients with 1 or more PIMs deprescribed on the intervention unit, as compared with the control unit, following a biannual MedRec. This study will build on existing policies aimed at optimizing medication therapy in patients undergoing maintenance hemodialysis. The electronic deprescribing decision support tool, MedSafer, will be tested in a dialysis setting, where nephrologists are regularly in contact with patients. MedRecs are an interdisciplinary clinical activity performed biannually on the hemodialysis units (in the Spring and Fall), and within 1 week following discharge from any hospitalization. This study will take place in the Fall of 2022. Semi-structured interviews will be conducted among physicians on the intervention unit to determine barriers and facilitators to implementation of the MedSafer-supplemented MedRec process and analyzed according to grounded theory in qualitative research. Limitations: Deprescribing can be limited due to nephrologists' time constraints, cognitive impairment of the hemodialyzed patient stemming from their illness and complex medication regimens, and lack of sufficient patient resources to learn about the medications they are taking and their potential harms. Conclusions: Electronic decision support can facilitate deprescribing for the clinical team by providing a nudge reminder, decreasing the time it takes to review and effectuate guideline recommendations, and by lowering the barrier of when and how to taper. Guidelines for deprescribing in the dialysis population have recently been published and incorporated into the MedSafer software. To our knowledge, this will be the first study to examine the efficacy of pairing these guidelines with MedRecs by leveraging electronic decision support in the outpatient dialysis population. Trial registration: This study was registered on Clinicaltrials.gov (NCT05585268) on October 2, 2022, prior to the enrolment of the first participant on October 3, 2022. The registration number is pending at the time of protocol submission.

Contexte: Les patients sous dialyse se voient souvent prescrire de nombreux médicaments (polypharmacie), dont plusieurs médicaments potentiellement inappropriés (MPI). Les MPI sont associés à un risque accru de chutes, de fractures et d'hospitalisations. MedSécure est un outil électronique qui génère des rapports individualisés et classés par ordre de priorité indiquant les possibilités de déprescription. L'outil fonctionne en croisant les données sur la santé des patients et les médicaments sous ordonnance avec des lignes directrices pour la déprescription. Objectifs de l'étude: L'objectif principal est de favoriser la déprescription par rapport aux soins habituels (Medication Reconciliation [MedRecs] ou bilan comparatif des médicaments) chez les patients ambulatoires recevant une hémodialyse d'entretien, en fournissant des rapports MedSécure de déprescription à l'équipe soignante et des brochures encourageant la déprescription aux patients. Conception: Cette étude prospective et contrôlée (témoin contemporain) d'amélioration de la qualité s'appuie sur la politique existante dans les centers d'hémodialyse ambulatoires où un bilan des médicaments (MedRecs) est effectué deux fois par année par le néphrologue traitant et l'équipe de soins infirmiers. Cadre: L'étude a lieu dans deux des trois unités d'hémodialyse ambulatoire du Center universitaire de santé McGill à Montréal (Québec, Canada). L'unité d'intervention est l'Hôpital de Lachine et l'unité témoin est l'Hôpital général de Montréal. Sujets: Une cohorte fermée de patients ambulatoires sous hémodialyse qui visitent plusieurs fois par semaine un center d'hémodialyse pour leurs traitements. La cohorte initiale de l'unité d'intervention compte 85 patients, tandis que l'unité témoin compte 132 patients. Seront exclus les patients qui recevront une greffe, qui seront hospitalisés pendant leur MedRecs ou qui décèderont avant ou pendant le MedRecs. Mesures: Nous comparerons les taux de déprescription entre les unités témoin et d'intervention après un seul MedRecs. Dans l'unité d'intervention, le MedRecs sera associé aux rapports MedSécure (l'intervention); dans l'unité témoin, le MedRecs aura lieu sans rapports MedSécure (soins habituels). Au sein de l'unité d'intervention, les patients recevront également des brochures encourageant la déprescription pour certaines classes de médicaments (gabapentinoïdes, inhibiteurs de la pompe à protons, hypnotiques sédatifs et opioïdes pour les douleurs chroniques non cancéreuses). Les médecins de l'unité d'intervention seront interviewés après le MedRec pour déterminer les obstacles et les facilitateurs à la mise en œuvre. Méthodologie: Le principal critère d'évaluation sera la proportion de patients dans l'unité d'intervention chez qui au moins un MPI sera déprescrit après un MedRec semestriel, par rapport à l'unité témoin. L'étude s'appuiera sur les politiques existantes visant à optimiser la médication chez les patients suivant des traitements d'hémodialyse d'entretien. L'outil électronique d'aide à la décision de déprescription MedSécure sera testé en contexte de dialyse, où les néphrologues sont régulièrement en contact avec les patients. Les MedRecs sont une activité clinique interdisciplinaire effectuée semestriellement sur les unités d'hémodialyse (au printemps et à l'automne) et dans la semaine suivant un congé de l'hôpital. Cette étude aura lieu à l'automne 2022. Des entretiens semi-structurés seront menés avec les médecins de l'unité d'intervention afin d'établir les obstacles et les facilitateurs à la mise en œuvre du processus MedRec complété par MedSécure, puis analysés selon une théorie fondée sur la recherche qualitative. Limites: La déprescription peut être limitée par des contraintes de temps des néphrologues, des troubles cognitifs résultant des maladies et des régimes médicamenteux complexes des patients sous hémodialyse ou par un manque de ressources pour éduquer les patients sur les médicaments qu'ils prennent et leurs méfaits potentiels. Conclusion: Un outil électronique d'aide à la décision peut faciliter le processus de déprescription pour l'équipe clinique en fournissant un rappel, en réduisant le temps nécessaire à l'examen et à l'application des recommandations, et en limitant les obstacles liés au moment et à la façon de réduire le nombre de médicaments. Des lignes directrices sur la déprescription dans la population des patients sous dialyse ont récemment été publiées et incorporées au logiciel MedSécure. À notre connaissance, il s'agit de la première étude à examiner l'efficacité du couplage des lignes directrices avec le MedRecs en tirant parti de l'outil électronique d'aide à la décision en contexte d'hémodialyse ambulatoire.

Psychotropic Drugs and Adverse Kidney Effects: A Systematic Review of the Past Decade of Research.

BACKGROUND AND OBJECTIVE: Psychotropic drugs are a heterogenous group of treatments prescribed for many psychiatric disorders, often for long periods. Their effects on the kidney and its functioning are complex and a source of significant research and debate. This article aims to review recent evidence of the acute and chronic kidney adverse events of diverse psychotropes. METHODS: A systematic search of randomized controlled trials and large observational studies (n ≥ 100) reporting the effects of psychotropic drugs on the kidney was conducted. The MEDLINE, PsycInfo, and EMBASE databases from 2011 to 2021, inclusive, were broadly searched with few restrictions and no prespecified outcomes. Two or more independent reviewers assessed and summarized all eligible studies, including risks of bias and levels of evidence. RESULTS: In all, 1999 abstracts were screened for eligibility and 47 articles were included, which examined lithium (33), antiepileptics (10), antipsychotics (13), and antidepressants (9). No studies examining kidney adverse effects of other psychotropes, such as benzodiazepines, met inclusion criteria. Study populations were adult (8), geriatric (9), and mixed (30). Lithium was almost unanimously associated with (1) chronic kidney disease and (2) nephrogenic diabetes insipidus in methodologically diverse studies. The most supported risk factors for declining kidney functioning with lithium were advanced age, duration of lithium treatment, acute lithium toxicity, female sex, medications with known renal interactions, diabetes mellitus/hyperglycemia, and overall medical comorbidity. Supratherapeutic lithium concentrations are both the causes and consequences of acute kidney injury. Once significant chronic kidney disease has developed, four studies found that replacing lithium with other mood stabilizers does not slow progression, and the evolution to end-stage kidney disease is rare overall with modern practices. Compared to lithium, fewer studies examined antipsychotics and antiepileptics but found relatively less direct kidney harms. Antidepressants were not associated with acute or chronic kidney harms. CONCLUSIONS: Despite the heterogeneity of findings, owing to varying methodologies and research challenges, recent studies strongly suggest that lithium is associated with an increased risk of chronic kidney disease and nephrogenic diabetes insipidus, especially in older adults and long-term lithium users. Clinicians should balance the harms of lithium against its established benefits, and ensure adequate monitoring and management of comorbidities in all patients. Weaker evidence suggests that antiepileptics such as valproate and antipsychotics result in comparatively less harm to the kidney than lithium, but warrant monitoring because of multiple direct and indirect mechanisms for potential kidney adverse events. Antidepressants do not have clear kidney adverse effects and appear safe (though potentially less effective) in the setting of kidney disease. Other classes of psychotropic drugs have received little research interest. Further research is warranted, particularly into specific antiepileptics and antipsychotics, and careful attention should be paid to mitigating important sources of bias such as confounding by indication.

Low-dose trimethoprim-sulfamethoxazole for the treatment of Pneumocystis jirovecii pneumonia (LOW-TMP): protocol for a phase III randomised, placebo-controlled, dose-comparison trial.

INTRODUCTION: Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection of immunocompromised hosts with significant morbidity and mortality. The current standard of care, trimethoprim-sulfamethoxazole (TMP-SMX) at a dose of 15-20 mg/kg/day, is associated with serious adverse drug events (ADE) in 20%-60% of patients. ADEs include hypersensitivity reactions, drug-induced liver injury, cytopenias and renal failure, all of which can be treatment limiting. In a recent meta-analysis of observational studies, reduced dose TMP-SMX for the treatment of PJP was associated with fewer ADEs, without increased mortality. METHODS AND ANALYSIS: A phase III randomised, placebo-controlled, trial to directly compare the efficacy and safety of low-dose TMP-SMX (10 mg/kg/day of TMP) with the standard of care (15 mg/kg/day of TMP) among patients with PJP, for a composite primary outcome of change of treatment, new mechanical ventilation, or death. The trial will be undertaken at 16 Canadian hospitals. Data will be analysed as intention to treat. Primary and secondary outcomes will be compared using logistic regression adjusting for stratification and presented with 95% CI. ETHICS AND DISSEMINATION: This study has been conditionally approved by the McGill University Health Centre; Ethics approval will be obtained from all participating centres. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT04851015.

Targeted Cancer Therapies Causing Elevations in Serum Creatinine Through Tubular Secretion Inhibition: A Case Report and Review of the Literature.

Rationale: Targeted cancer therapies have revolutionized the field of oncology by selecting for specific molecular pathways, thus improving overall clinical prognosis. However, many of these targeted treatments have been reported to have adverse kidney effects, including acute kidney injury, interstitial nephritis, and glomerular disease. Furthermore, some of these targeted therapies have also been found to cause an asymptomatic rise in serum creatinine levels through inhibition of active tubular secretion. Presenting concerns: A 79-year-old woman was being followed for stage 4 A2 chronic kidney disease secondary to type 2 diabetes and longstanding hypertension. She was diagnosed with invasive mammary carcinoma and was initiated on letrozole, an aromatase inhibitor, and palbociclib, a selective cyclin-dependent kinase inhibitor, was subsequently added. Prior to the initiation of her treatments, her baseline estimated glomerular filtration rate (eGFR) fluctuated between 25 and 28 mL/min/1.73 m2 over the previous year. After initiating palbociclib, her serum creatinine progressively increased, despite having well-controlled blood pressure and diabetes. In addition, there was no history of pre-renal events nor any sonographic evidence of obstruction. Within 7 months, her eGFR based on serum creatinine had decreased down to 12 mL/min/1.73 m2. Interventions: Given that there were no clinical or other biochemical changes suggestive of worsening renal function, a serum cystatin C was measured using an immunoturbidimetric assay, which was 1.71 mg/L and correlated with an eGFR of 33 mL/min/1.73 m2 based on the chronic kidney disease epidemiology collaboration (CKD-EPI) cystatin C equation (2012). This value was consistent with her previous baseline. Based on these findings, the significant decrease in eGFR measured by serum creatinine was attributed to the inhibitory effects of palbociclib on tubular creatinine secretion, rather than representing true kidney damage. Thus, a kidney biopsy was not performed in this context. Outcomes: Seven months later, a repeat serum cystatin C was repeated to assess for any worsening of the patient's kidney function and revealed an eGFR of 35 mL/min/1.73 m2 based on the CKD-EPI cystatin C equation (2012), thus revealing stable kidney function and reinforcing the inhibitory effects of palbociclib on tubular creatinine secretion through its direct effects on kidney transporters. Teaching points: This case report and literature review acknowledges the importance of using alternative methods of assessing kidney function when patients are undergoing targeted cancer therapies known to affect tubular creatinine secretion, which include cyclin-dependent kinase 4/6 inhibitors, poly(adenosine diphosphate-ribose) polymerase inhibitors, tyrosine kinase inhibitors, and mesenchymal-epithelial transition inhibitors. The use of non-creatinine-based markers of glomerular filtration rate (GFR), such as cystatin C and nuclear renal scans, will allow for more accurate estimation of kidney function in the appropriate setting, thus avoiding invasive diagnostic tests and unnecessary adjustments of treatment plans. However, certain targeted cancer therapies have also been proven to cause true kidney injury; therefore, physicians must still maintain a high degree of suspicion and consider invasive investigations and/or cessation or reduction of treatments when alternative measurements of kidney function do not suggest an underestimation of GFR via serum creatinine.

Contexte: Les thérapies ciblées contre le cancer ont révolutionné le domaine de l'oncologie en sélectionnant des voies moléculaires spécifiques, ce qui améliore le pronostic clinique global. Il a toutefois été rapporté que plusieurs de ces traitements ciblés entraînent des effets indésirables sur les reins, notamment l'insuffisance rénale aiguë, la néphrite interstitielle et la glomérulonéphrite. Qui plus est, certains de ces traitements provoquent aussi une augmentation asymptomatique des taux de créatinine sérique en inhibant la sécrétion tubulaire active. Présentation du cas: Une femme de 79 ans était suivie pour une insuffisance rénale chronique de stade 4 A2 secondaire à un diabète de type 2 et à une hypertension de longue date. La patiente été diagnostiquée avec un carcinome mammaire invasif et a reçu du létrozole, un inhibiteur de l'aromatase. Un traitement au palbociclib, un inhibiteur sélectif de la kinase dépendante de la cycline, a été ajouté par la suite. Avant le début du traitement, le DFGe initial de la patiente avait fluctué de 25 à 28 ml/min/1,73 m2 lors de l'année précédente. Après avoir commencé le palbociclib, son taux de créatinine sérique a augmenté progressivement, malgré une pression artérielle et un diabète bien contrôlés. La patiente n'avait aucun antécédent d'événements pré-rénaux ni de preuves échographiques d'obstruction. En sept mois, son DFGe basé sur la créatinine sérique était passé à 12 ml/min/1,73 m2. Intervention: En absence de changements cliniques ou biochimiques suggérant une aggravation de la fonction rénale, la cystatine C sérique a été mesurée par dosage immunoturbidimétrique. Son taux (1,71 mg/L) correspondait à un DFGe de 33 ml/min/1,73 m2 obtenu par l'équation CKD-EPI (2012) pour la cystatine C; une valeur comparable à sa référence précédente. À la lumière de ces résultats, la chute significative du DFGe mesurée par la créatinine sérique a été attribuée aux effets inhibiteurs du palbociclib sur la sécrétion tubulaire de créatinine, plutôt qu'à une véritable atteinte rénale. C'est pourquoi une biopsie rénale n'a pas été effectuée. Résultats: Après sept mois, la mesure de la cystatine C sérique a été répétée pour évaluer une potentielle aggravation de la fonction rénale. Cette nouvelle mesure a révélé un DFGe de 35 ml/min/1,73 m2 obtenu avec l'équation CKD-EPI (2012) de la cystatine C, ce qui indique une fonction rénale stable et renforce le diagnostic retenu d'un effet inhibiteur du palbociclib sur la sécrétion tubulaire de créatinine dû à ses effets directs sur les transporteurs rénaux. Enseignements tirés: Ce rapport de cas et la revue de la littérature soulignent l'importance d'utiliser d'autres méthodes d'évaluation de la fonction rénale lorsque les patients suivent des traitements ciblés contre le cancer connus pour affecter la sécrétion tubulaire de créatinine, notamment les inhibiteurs de la kinase dépendante de la cycline (CDK4/6), les inhibiteurs de la polymérase poly-adénosine diphosphate ribose (PARP), les inhibiteurs de la tyrosine kinase (TK) et les inhibiteurs de la transition mésenchymateuse-épithéliale (TEM). L'utilisation de marqueurs du DFG autres que la créatinine, tels que la cystatine C et la scintigraphie rénale nucléaire, permettra une estimation plus précise de la fonction rénale dans le contexte approprié, évitant ainsi des tests diagnostiques invasifs et des ajustements inutiles des plans de traitement. On sait toutefois que certains traitements ciblés contre le cancer sont à l'origine de véritables lésions rénales. Par conséquent, les médecins doivent maintenir un haut degré de suspicion et envisager des examens invasifs et/ou l'arrêt ou la réduction des traitements lorsque d'autres mesures de la fonction rénale ne suggèrent pas une sous-estimation du DFG par la créatinine sérique.

Deprescribing Opportunities for Hospitalized Patients With End-Stage Kidney Disease on Hemodialysis: A Secondary Analysis of the MedSafer Cluster Randomized Controlled Trial.

Background: End-stage kidney disease patients on dialysis have a substantial risk of polypharmacy due their propensity for comorbidity and contact with the health care system. MedSafer is an electronic decision support tool that integrates patient comorbidity and medication lists to generate personalized deprescribing reports focused on identifying potentially inappropriate medications (PIMs). Objective: To conduct a secondary analysis of patients on regular hemodialysis included in the MedSafer randomized controlled trial to investigate the patterns of polypharmacy and evaluate the efficacy of the MedSafer deprescribing algorithms. Design: Secondary analysis of a cluster randomized clinical trial. Setting: Medical units in 11 acute care hospitals in Canada. Patients: The MedSafer trial enrolled 5698 participants with an expected prognosis of >3 months, age 65 years and older, and on 5 or more daily home medications; 140 participants were receiving chronic hemodialysis. Measurements: The primary outcome of the trial was 30-day adverse drug events (ADEs) post-hospital discharge, and a key secondary outcome was deprescribing. Methods: Control patients received usual care (medication reconciliation), whereas clinicians caring for intervention patients received a MedSafer report that highlighted individualized opportunities for deprescribing. Results: There were 70 patients in each of the control and intervention arms. The median number of home medications was 14 (compared with a median of 10 medications in the general trial population). The most frequent medications observed that were potentially inappropriate were proton pump inhibitors (potentially inappropriate in 55/76 users; 72.4%), diabetes medications in patients with a HBA1C <7.5% (36/65 users; 55.4%), docusate (27/27 users; 100%), gabapentinoids (27/36 users; 75%), and combination antiplatelet/anticoagulants (22/97 users; 22.7%). The proportion of PIMs deprescribed was higher during the intervention phase (28.8% vs 19.3%; absolute increase 9.4% [95% confidence interval 1.3%-17.6%]) compared with the control phase. There was no observed difference in ADEs at 30-day post-discharge between the control and the intervention groups. The most common ADE (n = 3) was gastrointestinal bleeding attributed to antiplatelet agents. Limitations: This was a post hoc exploratory analysis, the original trial did not stratify by hemodialysis status, and the small sample size precludes drawing any definitive conclusions. Conclusion: MedSafer facilitates deprescribing in hospitalized patients on hemodialysis. Larger-scale implementation of decision support software for deprescribing in dialysis and long-term follow-up are likely required to demonstrate an impact on ADEs.

Contexte: Le risque de polypharmacie est important chez les patients atteints d'insuffisance rénale terminale (IRT) sous dialyse en raison de leurs nombreuses comorbidités et de leurs contacts fréquents avec le système de santé. MedSafer est un outil électronique d'aide à la décision qui intègre les comorbidités et la liste de médicaments des patients pour générer des rapports de déprescription personnalisés, axés sur l'identification de médicaments potentiellement inappropriés (MPI). Objectifs: Procéder à une analyse secondaire des patients sous hémodialyse inclus dans l'essai contrôlé randomisé MedSafer dans le but d'examiner les profils de polypharmacie et d'évaluer l'efficacité des algorithmes de déprescription de MedSafer. Type d'étude: Analyse secondaire d'un essai clinique randomisé en grappes. Cadre: Les unités médicales de onze hôpitaux de soins aigus au Canada. Sujets: L'essai MedSafer a inclus 5698 patients de 65 ans et plus avec un pronostic attendu de plus de trois mois et prenant au moins cinq médicaments quotidiennement à domicile; 140 patients étaient traités par hémodialyse chronique. Mesures: Le principal critère d'évaluation de l'essai était la survenue d'événements indésirables attribuables aux médicaments (ÉIM) dans les 30 jours suivant le congé de l'hôpital. Un des principaux critères d'évaluation secondaires était la déprescription. Méthodologie: Les patients du groupe témoin recevaient les soins habituels (bilan comparatif des médicaments) alors qu'un rapport MedSafer soulignant les possibilités de déprescription individuelles était envoyé aux cliniciens qui prenaient en charge les patients du groupe d'intervention. Résultats: Chaque bras de l'essai (témoin et intervention) comptait 70 sujets. Le nombre médian de médicaments pris à domicile était de 14 (comparativement à 10 dans la population générale de l'essai). Les médicaments les plus souvent cités comme potentiellement inappropriés étaient les inhibiteurs de la pompe à protons (55/76 patients; 72,4%), les médicaments contre le diabète chez les patients avec un taux d'HbA1c inférieur à 7,5% (36/65 patients; 55,4%), le docusate (27/27 patients; 100%), les gabapentinoïdes (27/36 patients; 75%) et les antiplaquettaires/anticoagulants combinés (22/97 patients; 22,7%). La proportion de MPI déprescrits était plus élevée dans la phase d'intervention que dans la phase témoin (28,8% c. 19,3%; augmentation absolue de 9,4% [IC 95%: 1,3 à 17,6%]). Aucune différence n'a été observée entre les deux groupes en ce qui concerne les ÉIM dans les 30 jours suivant le congé de l'hôpital. Une hémorragie gastro-intestinale attribuable aux agents antiplaquettaires était l'événement indésirable le plus fréquent (n = 3). Limites: Il s'agit d'une analyse exploratoire a posteriori. L'essai initial n'a pas été stratifié selon le status en hémodialyse. La faible taille de l'échantillon ne permet pas de tirer des conclusions définitives. Conclusion: MedSafer facilite la déprescription chez les patients hospitalisés qui reçoivent des traitements d'hémodialyse. Pour démontrer un éventuel impact sur les événements indésirables attribuables aux médicaments, il apparaît nécessaire de faire un suivi à plus long terme et à plus grande échelle du logiciel d'aide à la décision de déprescription en contexte de dialyse.

Home versus In-Center Dialysis and Day of the Week Hospitalization: A Cohort Study.

Background: The dialysis treatment day after the 2-day interdialytic interval (Monday/Tuesday) is associated with a heightened risk of hospitalization for patients on in-center hemodialysis (ICHD). In this national cohort study, we sought to characterize hospitalizations by day of the week for patients receiving ICHD, home HD (HHD), and peritoneal dialysis (PD) and to identify whether there were differences in the probability of a Monday/Tuesday admission for each modality type. Methods: Patients on maintenance dialysis in Canada were analyzed from 2005 to 2014 using the Canadian Organ Replacement Register. Patients on hemodialysis were categorized as those receiving ICHD, HHD, frequent ICHD, or frequent HHD (the latter two included short daily and nocturnal HD). Hospitalizations were attributed to the previous treatment if they occurred within 30 days of a treatment change. Differences in the proportion of patients experiencing a Monday/Tuesday admission with all other days of the week were compared using a generalized linear model with binomial distribution and reported using adjusted odds ratios (OR) with 95% CIs. Results: Overall, 27,430 individuals experienced 111,748 hospitalization episodes. Rates per 1000 patient days were 3.76, 2.98, 2.71, 2.16, and 2.13 for each of frequent ICHD, ICHD, PD, HHD, and frequent HHD, respectively. Compared with those on ICHD, only patients receiving frequent HHD (OR, 0.89; 95% CI, 0.81 to 0.97) and PD (OR, 0.95; 95% CI, 0.93 to 0.97) had a lower odds of experiencing a Monday/Tuesday admission. The OR was lower when restricted to hospitalization episodes for cardiovascular reasons comparing frequent HHD with ICHD (OR, 0.68; 95% CI, 0.48 to 0.96). Conclusion: In this nationally representative cohort, we identified that the probability of a Monday/Tuesday admission was lower for frequent HHD and PD compared with ICHD, most notably for hospitalizations due to cardiovascular causes. Gaining a better understanding of the reasons behind this observation may help to develop future strategies to reduce overall and cause-specific hospitalization for patients receiving dialysis.

Long-term Effects of a Brief Mindfulness Intervention Versus a Health Enhancement Program for Treating Depression and Anxiety in Patients Undergoing Hemodialysis: A Randomized Controlled Trial.

Background: Depression and anxiety affect approximately 50% of patients with kidney failure receiving hemodialysis and are associated with decreased quality of life and increased risk of hospitalization and mortality. A Brief Mindfulness Intervention (BMI) may be promising in treating depressive and anxiety symptoms in this population, but the long-term sustainability of the intervention's effects is unknown. Objective: We previously conducted a randomized controlled trial (RCT; n = 55) comparing an 8-week BMI with an active control (Health Enhancement Program [HEP]) for patients receiving dialysis, with depression and/or anxiety. Here, we examine the 6-month follow-up data to determine the long-term sustainability of BMI versus HEP in reducing (1) depressive symptoms, (2) anxiety symptoms, and (3) the efficacy of BMI versus HEP in reducing the likelihood of hospitalization. Design: In this study, we analyzed 6-month follow-up data from an 8-week assessor-blinded parallel RCT, which evaluated the efficacy of a BMI against an active control, HEP, in patients receiving hemodialysis with symptoms of depression and/or anxiety. Setting: The study took place at hemodialysis centers in 4 tertiary-care hospitals in Montreal, Canada. Participants: Participants included adults aged ≥18 years who were receiving in-center hemodialysis 3 times per week and had symptoms of depression and/or anxiety as indicated by a score ≥6 on the Patient Health Questionnaire-9 (PHQ-9) and/or the General Anxiety Disorder-7 (GAD-7). Methods: Participants were randomized to the treatment arm (BMI) or the active control arm (HEP) and completed assessments at baseline, 8 weeks, and 6-month follow-up. Depression was assessed using the PHQ-9, and anxiety was assessed by the GAD-7. Hospitalization rates were assessed using medical chart information. Results: We observed significant decrease in depression scores over 6 months in both BMI and HEP groups, with no significant difference between groups. Anxiety scores significantly decreased over 6 months, but only in the BMI group. Brief Mindfulness Intervention and Health Enhancement Program were comparable in terms of hospitalization rates. Limitations: The limitations of our study include the modest sample size and lack of a third arm such as a waitlist control. Conclusions: Our results suggest that the beneficial effects of BMI and HEP for improving mood disorder symptoms in patients receiving dialysis persist at 6-month follow-up. Both interventions showed sustained effects for depressive symptoms, but BMI may be more useful in this population given its efficacy in reducing anxiety symptoms as well. Trial registration: Prior to recruitment, the trial had been registered (ClinicalTrials.gov Identifier: NCT03406845).

Contexte: La dépression et l'anxiété touchent environ 50% des patients atteints d'insuffisance rénale sous hémodialyse et sont associées à une diminution de la qualité de vie et à un risque accru d'hospitalisation et de mortalité. Une brève intervention basée sur la pleine conscience pourrait s'avérer prometteuse pour le traitement des symptômes liés à l'anxiété et à la dépression dans cette population. On ignore toutefois la viabilité à long terme des effets d'une telle intervention. Objectifs: Nous avons précédemment mené un essai contrôlé randomisé (n = 55) comparant une brève intervention de pleine conscience (IPC) de huit semaines à un témoin actif (Programme d'amélioration de la santé [PAmS]) chez les patients sous dialyse présentant des symptômes de dépression et/ou d'anxiété. Nous examinons ici les données après six mois de suivi pour déterminer la viabilité à long terme de l'IPC par rapport au PAmS sur la réduction (1) des symptômes dépressifs, (2) des symptômes d'anxiété, et (3) l'efficacité de l'IPC par rapport au PAmS à réduire la probabilité d'hospitalisation. Type d'étude: Un essai contrôlé randomisé, d'une durée de huit semaines, mené en parallèle et en aveugle pour l'évaluateur, lequel évaluait l'efficacité d'une IPC par rapport au témoin actif (PAmS) chez les patients sous hémodialyse présentant des symptômes de dépression et/ou d'anxiété. Cadre: L'étude a eu lieu dans les centres d'hémodialyse de quatre hôpitaux de soins tertiaires de Montréal (Canada). Participants: Des adultes qui recevaient des traitements d'hémodialyse en centre 3x/semaine et qui présentaient des symptômes de dépression et/ou d'anxiété tels que définis par un score ≥6 au questionnaire sur la santé des patients (PHQ-9) et/ou sur le trouble général d'anxiété-7 (GAD-7). Méthodologie: Les participants ont été répartis aléatoirement dans le groupe de traitement (IPC) ou le groupe témoin actif (PAmS) et ont répondu aux questionnaires au début de l'étude, après huit semaines et après six mois de suivi. La dépression a été évaluée à l'aide du PHQ-9 et l'anxiété par le GAD-7. Les taux d'hospitalisation ont été évalués à l'aide des dossiers médicaux. Résultats: Nous avons observé une diminution significative des scores de dépression sur six mois dans les groupes IPC et PAmS, sans différence significative entre les groupes. Seul le groupe IPC a montré une diminution significative des scores d'anxiété sur six mois. Les taux d'hospitalisation étaient comparables dans les deux groupes. Limites: Taille modeste de l'échantillon et absence d'un troisième bras tel un groupe témoin constitué de patients sur une liste d'attente. Conclusion: Nos résultats suggèrent que les effets bénéfiques de l'IPC et du PAmS sur les symptômes des troubles de l'humeur des patients sous dialyse persistent après six mois de suivi. Les deux interventions ont montré des effets durables sur les symptômes dépressifs, mais l'IPC pourrait s'avérer plus pertinente dans cette population puisqu'elle a également montré une efficacité à réduire les symptômes d'anxiété. Enregistrement de l'essai: L'essai avait été enregistré avant le recrutement (ClinicalTrials.gov Identificateur : NCT03406845).

Do Brief Mindfulness Interventions (BMI) and Health Enhancement Programs (HEP) Improve Sleep in Patients in Hemodialysis with Depression and Anxiety?

(1) Objective: to determine if a brief mindfulness intervention (BMI) and a health education program (HEP) could improve measures of insomnia in patients undergoing hemodialysis. (2) Methods: this was a planned secondary analysis of a randomized controlled trial of BMI vs. HEP for hemodialysis patients with depression and/or anxiety symptoms. The primary outcome for the analysis was the Athens Insomnia Scale (AIS). The secondary outcome was consolidation of daily inactivity (ConDI), an actigraphy measure that describes sleep continuity and is based on a sleep detection algorithm validated by polysomnography. We also explored whether changes in AIS and ConDI were associated with changes in depression, anxiety, and quality of life scores over 8-week follow-up. (3) Results: BMI and HEP groups did not differ significantly from one another. Exposure to BMI or HEP improved sleep quality (baseline AIS 9.9 (±5.0) vs. 8-week follow-up 6.4 (±3.9), (V = 155.5, p = 0.015)), but not ConDI. Improvements in AIS were associated with lower depression scores (Rho = 0.57, p = 0.01) and higher quality-of-life scores (Rho = 0.46, p = 0.04). (4) Conclusions: mindfulness and HEP may be helpful interventions to improve self-reported sleep quality in patients undergoing hemodialysis. Decreases in insomnia scores were associated with decreased depression symptoms and increased quality of life scores.

Brief Mindfulness Intervention vs. Health Enhancement Program for Patients Undergoing Dialysis: A Randomized Controlled Trial.

BACKGROUND: Between 20-50% of patients undergoing maintenance dialysis for end-stage kidney disease experience symptoms of depression and/or anxiety, associated with increased mortality, greater health care utilization, and decreased quality of life. It is unknown whether mindfulness-based interventions can improve depression and anxiety symptoms in patients receiving this treatment. METHODS: We conducted an 8-week multicenter randomized controlled trial comparing a brief mindfulness intervention (BMI) vs. an active control (Health Enhancement Program [HEP]) in 55 patients receiving dialysis with symptoms of depression and/or anxiety. The primary outcome was change in Patient Health Questionnaire-9 (PHQ-9) depression scores, with a primary analysis in participants with baseline PHQ-9 ≥ 10, and a secondary analysis including all participants. The secondary outcome was change in Generalized Anxiety Disorder-7 (GAD-7) anxiety scores with corresponding primary and secondary analyses. RESULTS: Both BMI and HEP reduced depressive symptoms, with no difference between trial arms (PHQ-9 change = -7.0 vs. -6.1, p = 0.62). BMI was more effective than HEP in reducing anxiety (GAD-7 change = -8.7 vs. -1.4, p = 0.01). Secondary analyses revealed no differences between arms. CONCLUSIONS: For patients undergoing dialysis, both BMI and HEP may be helpful interventions for depression symptoms, and BMI may be superior to HEP for anxiety symptoms. Mindfulness-based and other psychosocial interventions may be further evaluated in those undergoing dialysis as treatment options for symptoms of depression and anxiety.

Utility of Abdominal Imaging in Peritoneal Dialysis Patients Presenting With Peritonitis.

BACKGROUND: Peritonitis remains a major complication in peritoneal dialysis (PD). Abdominal imaging is often performed in the setting of peritonitis to evaluate for concomitant intra-abdominal processes. However, the usefulness of this procedure is unknown. OBJECTIVE: The aim of this study was to assess the prevalence of abdominal imaging performed in the setting of PD peritonitis and to evaluate clinical parameters associated with abnormal imaging results to identify clinical situations in which radiographic examinations are informative. DESIGN: This is a retrospective cohort study. SETTING: The study was conducted at the Toronto General Hospital, Ontario, Canada. PATIENTS: We studied 166 episodes of PD peritonitis in 114 patients between January 1, 2011, and June 30, 2016. MEASUREMENTS: Baseline demographics, characteristics of PD peritonitis, and characteristics of abdominal imaging performed. METHODS: The association between relevant clinical parameters and abnormal abdominal imaging was examined using a univariate and multivariate logistic regression model. RESULTS: Abdominal imaging (computed tomography [CT] scan or ultrasound) was performed in 68 cases (41%). Patients were more likely to undergo imaging if they required hospitalization, were admitted to the intensive care unit (ICU), had polymicrobial or fungal organisms causing peritonitis, had relapsing/recurrent/refractory peritonitis, had an indication for hemodialysis or PD catheter removal, or presented with hypotension, tachycardia, or an elevated serum lactate. Of the imaging performed, abnormalities were found in 32 cases (47%). The most common findings were bowel obstruction, intra-abdominal collection, and biliary abnormalities. In the univariate analysis, ICU admission (43.3% vs 14.3%, P < .01) and need for temporary or permanent hemodialysis (62.5% vs 30.6%, P < .01) were associated with imaging abnormalities. Importantly, the peritonitis organism was not associated with abnormal imaging results. In a multivariate analysis, ICU admission was the only significant clinical parameter associated with imaging abnormalities with an odds ratio (OR) of 4.4 (95% confidence interval [CI]: 1.1-17.4, P = .04). LIMITATIONS: Single-center study, small sample size, and lack of detailed information on the exact indications leading to abdominal imaging. CONCLUSIONS: Abdominal imaging is commonly performed in the setting of PD peritonitis. Abnormalities are not infrequent and are present in almost half of the cases, with need for ICU admission being the most significant clinical parameter associated with abnormal findings. Therefore, abdominal imaging should be performed in carefully selected patients with PD peritonitis, especially if there is evidence of hemodynamic instability. While the finding of fungal or polymicrobial peritonitis was a driver for abdominal imaging, the presence of these organisms did not predict radiologic abnormalities.

CONTEXTE: La péritonite demeure une des principales complications de la dialyse péritonéale (DP), et l'imagerie abdominale est couramment utilisée pour évaluer la présence de processus intra-abdominaux concomitants. OBJECTIFS: Établir la prévalence de l'imagerie abdominale dans les cas de péritonites liées à la DP et déterminer les paramètres cliniques associés à des résultats d'imagerie anormaux afin d'identifier les situations cliniques pour lesquelles les examens radiographiques sont informatifs. TYPE D'ÉTUDE: Étude de cohorte rétrospective. CADRE: L'hôpital général de Toronto (Ontario) au Canada. SUJETS: Nous avons examiné 166 épisodes de péritonites liées à la DP survenues chez 114 patients entre le 1er janvier 2011 et le 30 juin 2016. MESURES: Les données démographiques des patients, les caractéristiques de la péritonite et les caractéristiques de l'imagerie abdominale effectuée. MÉTHODOLOGIE: Le lien entre les paramètres cliniques pertinents et une imagerie abdominale anormale a été établi à l'aide de modèles de régression logistique univariée et multivariée. RÉSULTATS: Une imagerie abdominale (tomodensitométrie ou échographie) a été effectuée dans 68 cas (41 %). Les patients étaient plus susceptibles de subir un examen d'imagerie s'ils devaient être hospitalisés ou admis à l'unité des soins intensifs (USI), si la péritonite était causée par une infection fongique ou polymicrobienne, s'il s'agissait d'une péritonite récurrente/réfractaire ou d'une rechute, s'ils avaient une indication d'hémodialyse ou de retrait du cathéter de DP, ou s'ils présentaient de l'hypotension, de la tachycardie ou un taux élevé de lactate sérique. Une anomalie a été détectée dans 32 (47 %) des tests d'imagerie effectués; une occlusion abdominale, une collection intra-abdominale ou une anomalie biliaire étant les plus fréquemment observées. Dans l'analyse univariée, une admission aux USI (43,3 % vs 14,3 %; P < 0,01) et le besoin d'hémodialyse temporaire ou permanente (62,5 % vs 30,6 %; P < 0,01) ont été associés à des anomalies détectées lors de l'imagerie. La présence de microorganismes causant la péritonite n'a toutefois pas été associée à des résultats d'imagerie anormaux. Dans l'analyse multivariée, seule une admission aux USI a été significativement associée à un résultat d'imagerie anormal, avec un rapport de cotes de 4,4 (IC 95 %: 1,1-17,4; P = 0,04). LIMITES: Étude monocentrique, échantillon de faible taille et manque d'informations détaillées sur les indications pour l'imagerie abdominale. CONCLUSION: L'imagerie abdominale est couramment pratiquée en présence d'une péritonite liée à la dialyse péritonéale. Des anomalies sont observées dans près de la moitié des cas et l'admission aux soins intensifs constitue le paramètre clinique le plus significativement associé à un résultat d'imagerie anormal. Dès lors, l'imagerie abdominale devrait être envisagée pour certains patients soigneusement sélectionnés présentant une péritonite liée à la DP, particulièrement s'il y a instabilité hémodynamique. Enfin, bien qu'un diagnostic de péritonite fongique ou polymicrobienne soit un moteur d'imagerie abdominale, la présence de ces microorganismes ne s'est pas avérée prédictive d'anomalies radiologiques.

Ventricular ejection fraction over time in patients on intensive home hemodialysis: A retrospective cohort study.

INTRODUCTION: Intensive hemodialysis has been demonstrated to have several beneficial cardiovascular effects. There is a paucity of studies examining the effect of intensive home hemodialysis (IHHD) on left ventricular ejection fraction (LVEF). METHODS: We conducted a retrospective cohort study at the Toronto General Hospital including all IHHD patients between 1999 and 2017 with baseline and follow-up echocardiograms for at least a year. Patients were categorized according to LVEF at follow-up: patients with normal and patients with abnormal LVEF and/or a decline in LVEF. Normal LVEF was defined as ≥55% and a decline as ≥5% at follow-up compared to baseline Cox regression analyses were performed to ascertain the association between reduced LVEF and reaching the composite endpoint of death, cardiovascular hospitalization, and technique failure, respectively. Multivariate logistic analysis was used to investigate possible risk factors for changes in LVEF. FINDINGS: A total of 154 patients were included in the study. At baseline, 18.8% (29/154) of patients had reduced LVEF. After a mean follow-up of 3.9 years, overall mean LVEF did not change (59.3% [at follow-up] vs. 59.9% [baseline], P = 0.45). Seventeen out of the 130 patients with normal LVEF (13.1%) and nine out of the 24 with abnormal LVEF (37.9%) reached the composite endpoint of death, cardiovascular hospitalization, or technique failure. Reduced LVEF at baseline odds ratio ((OR) 13.26 [95% confidence interval (CI) 4.62-38.05]) as well as coronary heart disease (OR 7.82 [95% CI 1.92-31.82]) were associated with reduced ejection fraction at follow-up. When adjusted for age and diabetes, patients with abnormal LVEF were more likely to reach the composite endpoint hazard ratio ((HR) 3.85, 95% CI 1.70-8.71). We did not identify a risk factor associated with progression or worsening of LVEF. DISCUSSION: Preserved LVEF occurs in most patients on IHHD and is associated with better clinical outcomes. Further studies are needed to identify the mechanism affecting left ventricular function in patients undergoing intensive hemodialysis.

A comparison of technique survival in Canadian peritoneal dialysis and home hemodialysis patients.

BACKGROUND: High discontinuation rates remain a challenge for home hemodialysis (HHD) and peritoneal dialysis (PD). We compared technique failure risks among Canadian patients receiving HHD and PD. METHODS: Using the Canadian Organ Replacement Register, we studied adult patients who initiated HHD or PD within 1 year of beginning dialysis between 2000 and 2012, with follow-up until 31 December 2013. Technique failure was defined as a transfer to any alternative modality for a period of ≥60 days. Technique survival between HHD and PD was compared using a Fine and Gray competing risk model. We also examined the time dependence of technique survival, the association of patient characteristics with technique failure and causes of technique failure. RESULTS: Between 2000 and 2012, 15 314 patients were treated with a home dialysis modality within 1 year of dialysis initiation: 14 461 on PD and 853 on HHD. Crude technique failure rates were highest during the first year of therapy for both home modalities. During the entire period of follow-up, technique failure was lower with HHD compared with PD (adjusted hazard ratio = 0.79; 95% confidence interval 0.69-0.90). However, the relative technique failure risk was not proportional over time and the beneficial association with HHD was only apparent after the first year of dialysis. Comparisons also varied among subgroups and the superior technique survival associated with HHD relative to PD was less pronounced in more recent years and among older patients. Predictors of technique failure also differed between modalities. While obesity, smoking and small facility size were associated with higher technique failure in both PD and HHD, the association with age and gender differed. Furthermore, the majority of discontinuation occurred for medical reasons in PD (38%), while the majority of HHD patients experienced technique failure due to social reasons or inadequate resources (50%). CONCLUSIONS: In this Canadian study of home dialysis patients, HHD was associated with better technique survival compared with PD. However, patterns of technique failure differed significantly among these modalities. Strategies to improve patient retention across all home dialysis modalities are needed.

The Potential Burden of Home Dialysis on Patients and Caregivers: A Narrative Review.

PURPOSE OF REVIEW: Home dialysis modalities offer several benefits for patients with end-stage kidney disease when compared with facility-based thrice-weekly hemodialysis. To increase uptake of home dialysis, many centers are encouraging a "home-first" approach. However, it is important to appreciate that "one size may not fit all" and that dialysis modality selection is a complex decision that needs to be individualized. The purpose of this review was to explore aspects associated with home dialysis that may be associated with burden for patients and their caregivers and to discuss strategies to alleviate these concerns. SOURCES OF INFORMATION: Original research articles were identified from PubMed using search terms "peritoneal dialysis," "home hemodialysis," "home dialysis," "barriers," "quality of life" and "burden." METHODS: We performed a focused narrative review examining potential sources of burden with home dialysis therapies after conducting a critical appraisal of the literature and identifying the major recurring themes. KEY FINDINGS: Home dialysis is associated with burden for certain patients. Indeed, some patients may experience ongoing concerns regarding the risks of adverse events and of inadequately performing dialysis on their own. Psychosocial issues affecting quality of life may also arise and include fear of social isolation, sleep disturbances, perceived financial burden, anxiety, and fatigue. Patients who depend on a caregiver may worry about creating a stressful home environment for their close ones. Furthermore, the demands associated with being a caregiver may lead to psychosocial distress in the caregivers themselves. All these factors may lead to burnout and consequently, therapy discontinuation necessitating an unplanned transition to in-center hemodialysis leading to adverse outcomes. However, certain strategies may help alleviate burden especially if concerns are identified early on. LIMITATIONS: As we did not apply any formal tool to assess the quality of the studies included, selection bias may have occurred. Nonetheless, we have attempted to provide a comprehensive review on the topic using numerous diverse studies and extensive review of the literature. IMPLICATIONS: Future studies should focus on better identifying patient priorities and strategies to facilitate dialysis modality selection and improve quality of life.

JUSTIFICATION: Les modalités de dialyse à domicile présentent plusieurs avantages pour les patients atteints d'insuffisance rénale terminale comparativement à l'hémodialyse trois fois par semaine en centre. Pour accroître l'adhésion des patients à la dialyse à domicile, plusieurs centres privilégient une approche « à domicile d'abord ¼. Cette approche n'est toutefois pas universelle, et le choix de la modalité de dialyse est une décision complexe qui doit être personnalisée. Cette revue de la littérature avait pour but d'explorer les aspects de la dialyse à domicile susceptibles de représenter un fardeau pour les patients et leurs soignants, et de discuter de stratégies pour les atténuer. SOURCES: Les articles ont été répertoriés dans PUBMED à l'aide des termes de recherche peritoneal dialysis (dialyse péritonéale), home hemodialysis (hémodialyse à domicile), home dialysis (dialyse à domicile), barriers (entraves), quality of life (qualité de vie) et burden (fardeau). MÉTHODOLOGIE: Après avoir fait une évaluation critique de la documentation et dégagé les principaux termes récurrents, nous avons procédé à une revue narrative ciblée examinant les éléments susceptibles d'alourdir le fardeau lié à la dialyse à domicile. PRINCIPAUX RÉSULTATS: Certains patients perçoivent la dialyse à domicile comme un fardeau, certains sont préoccupés par les risques d'événements indésirables et s'inquiètent de ne pas être en mesure de la pratiquer adéquatement. Des enjeux psychosociaux affectant la qualité de vie, notamment la peur de l'isolement social, des troubles du sommeil, la perception d'un fardeau financier, l'anxiété et la fatigue pourraient survenir. De plus, les patients qui dépendent d'un soignant pourraient s'inquiéter de créer un environnement stressant pour leurs proches. Du côté des soignants, les exigences associées à leur rôle peuvent entraîner une détresse psychosociale. Tous ces facteurs sont susceptibles de conduire à l'épuisement et ultimement, à l'interruption du traitement, ce qui nécessite alors une transition non planifiée vers l'hémodialyse en centre et entraîne des issues indésirables. Néanmoins, certaines stratégies pourraient atténuer le fardeau perçu, en particulier si ces préoccupations sont décelées à un stade précoce. LIMITES: Les résultats pourraient comporter un biais de sélection puisque nous n'avons pas utilisé d'outils formels pour évaluer la qualité des études retenues. Nous avons néanmoins tenté de procéder à une revue exhaustive du sujet grâce à un examen approfondi de la documentation et à un échantillon de plusieurs études différentes. CONCLUSION: Les études à venir devraient se concentrer sur une meilleure définition des priorités des patients et des stratégies pour faciliter le choix de la modalité de dialyse et améliorer la qualité de vie.