A Canadian Commentary on the NKF-ASN Task Force Recommendations on Reassessing the Inclusion of Race in Diagnosing Kidney Disease.

In 2021, a committee was commissioned by the Canadian Society of Nephrology to comment on the 2021 National Kidney Foundation-American Society of Nephrology Task Force recommendations on the use of race in glomerular filtration rate estimating equations. The committee met on numerous occasions and agreed on several recommendations. However, the committee did not achieve unanimity, with a minority group disagreeing with the scope of the commentary. As a result, this report presents the viewpoint of the majority members. We endorsed many of the recommendations from the National Kidney Foundation-American Society of Nephrology Task Force, most importantly that race should be removed from the estimated glomerular filtration rate creatinine-based equation. We recommend an immediate implementation of the new Chronic Kidney Disease Epidemiology Collaboration equation (2021), which does not discriminate among any group while maintaining precision. Additionally, we recommend that Canadian laboratories and provincial kidney organizations advocate for increased testing and access to cystatin C because the combination of cystatin C and creatinine in revised equations leads to more precise estimates. Finally, we recommend that future research studies evaluating the implementation of the new equations and changes to screening, diagnosis, and management across provincial health programs be prioritized in Canada.

Five Things to Know About Incremental Peritoneal Dialysis.

Incremental peritoneal dialysis (PD) offers patients newly starting dialysis less than the standard "full dose" of PD, reducing treatment burden and intrusiveness while minimizing symptoms of renal failure. Incremental PD is a cost-effective approach that has been associated with slower rates of decline in residual kidney function. This approach also produces less waste and in turn reduces environmental footprint compared to standard PD prescriptions. It also aligns with the International Society of Peritoneal Dialysis (ISPD) Practice Recommendations for high-quality, goal-oriented therapy. Awareness of incremental PD along with its advantages and limitations provides practitioners with the tools to provide more patient-centered dialysis prescriptions in appropriate populations.

La dialyse péritonéale (DP) incrémentale propose un traitement à une dose moindre que la « dose complète ¼ habituelle aux patients qui amorcent la dialyse; ce qui contribue à réduire le fardeau du traitement et à en limiter le caractère intrusif, tout en minimisant les symptômes de l'insuffisance rénale. La DP incrémentale est une approche qui présente un bon rapport coût/efficacité, en plus d'avoir été associée à un ralentissement du déclin de la fonction rénale résiduelle. Elle produit également moins de déchets que la DP standard, ce qui, par conséquent, réduit l'empreinte environnementale du traitement. Enfin, la DP incrémentale est conforme aux recommandations de pratique de l'International Society of Peritoneal Dialysis (ISPD) pour une thérapie de haute qualité axée sur les objectifs. La sensibilisation à la DP incrémentale, ainsi qu'à ses avantages et à ses limites, fournit aux praticiens les outils nécessaires pour prescrire une modalité de dialyse davantage centrée sur le patient dans les populations appropriées.

Continuous quality improvement in peritoneal dialysis: Your questions answered.

Peritoneal dialysis (PD) uptake around the globe has steadily increased over the last several decades as a viable alternative to haemodialysis. Continued success of this technique for patients is contingent on the application of continuous quality improvement (CQI) principles in PD practice which can improve patient outcomes and in turn lead to more successful PD programmes worldwide. In this installation of 'Your Questions Answered', we will outline an approach to quality improvement initiatives and examine the importance of CQI principles in PD practice. We will also highlight common pitfalls and provide strategies to identify potential targets for improvement within your PD programme.

Five Things to Know About Volume Overload in Peritoneal Dialysis.

Volume overload in peritoneal dialysis (PD) is common and associated with significant morbidity and mortality. If left untreated, it can result in premature technique failure in patients receiving PD. Practitioners should be aware of common causes and formulate a stepwise approach in the management of volume overload.

La surcharge volumique est fréquente chez les patients traités par dialyse péritonéale (DP) et elle est associée à davantage de morbidité et de mortalité. Une surcharge volumique non traitée peut entraîner une défaillance technique prématurée chez les patients sous dialyse péritonéale. Il est important que les praticiens connaissent les causes communes de la surcharge volumique et qu'une approche par étapes soit formulée pour sa prise en charge.

Peritoneal Dialysis Prescription and Adequacy in Clinical Practice: Core Curriculum 2023.

As the global prevalence of peritoneal dialysis (PD) continues to grow, practitioners must be equipped with prescribing strategies that focus on the needs and preferences of patients. PD is an effective form of kidney replacement therapy that offers numerous benefits to patients, including more flexibility in schedules compared with in-center hemodialysis (HD). Additional benefits of PD include salt and water removal without significant changes in patient hemodynamics. This continuous yet gentle removal of solutes and fluid is associated with better-preserved residual kidney function. Unfortunately, sometimes these advantages are overlooked at the expense of an emphasis on achieving small solute clearance targets. A more patient-centered approach emphasizes the importance of individualized treatment, particularly when considering incremental PD and other prescriptions that align with lifestyle preferences. In shifting the focus from small solute clearance targets to patient needs and clinical goals, PD remains an attractive, patient-centered form of kidney replacement therapy.

The Physician Leader: Teaching Leadership in Medicine.

An integral part of a physician's practice includes being a leader, especially as there is a strong need for skilled leaders to advocate and navigate patient-centered and organizational outcomes. Nephrologists undertake multiple leadership roles, but dedicated leadership training is lacking in medical and postgraduate education. Given the growing need for physician leaders, practitioners in nephrology and beyond must become better equipped in understanding the role of leadership skills in medical practice. Nephrology and the medical community as a whole should focus on intentional and dedicated leadership in medical education training to better groom physicians for leadership roles. In this paper, we define and discuss the components and styles of leadership. We further propose cognitive models that allow one to apply leadership theory in common practice.

Cardiovascular Effects of Home Dialysis Therapies: A Scientific Statement From the American Heart Association.

Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Currently, thrice-weekly in-center hemodialysis for 3 to 5 hours per session is the most common therapy worldwide for patients with treated kidney failure. Outcomes with thrice-weekly in-center hemodialysis are poor. Emerging evidence supports the overarching hypothesis that a more physiological approach to administering dialysis therapy, including in the home through home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and cardiovascular outcomes compared with thrice-weekly in-center hemodialysis. The Advancing American Kidney Health Initiative, which has a goal of increasing the use of home dialysis, is aligned with the American Heart Association's 2024 mission to champion a full and healthy life and health equity. We conclude that incorporation of interdisciplinary care models to increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.

Design and Development of a Digital Counseling Program for Chronic Kidney Disease.

Background: Self-management has shown to improve the quality of life in patients with chronic kidney disease (CKD). Readily accessible self-management tools are essential in promoting adherence to self-care behaviors. In recognizing that digital health facilitates efficient access to self-management programs, we developed a digital counseling program, ODYSSEE Kidney Health, to promote self-care behaviors while supporting health-related quality of life. Objective: To present the design and development of ODYSSEE Kidney Health for digital counseling for patients with CKD. Design: The study involved an iterative design process based on user-centered design principles to develop the digital counseling program, ODYSSEE Kidney Health. Setting: A sample of 10 to 15 participants were purposively sampled from nephrology clinics at the University Health Network, Toronto, Canada. Methods: Participants underwent 2 phases in the development process. In each phase, participants were presented with a component of the program, asked to perform goal-oriented tasks, and participate in the "think-aloud" process. Semi-structured interviews followed the first phase to identify feedback about the overall program. Thematic analysis of the interviews identified themes from the usability testing. Descriptive statistics were used to summarize patient demographic data. Results: We enrolled 11 participants (n = 7 males, n = 4 females, ages 30-82). The main themes generated anchored on (1) impact on nephrology care, (2) technical features, and (3) CKD content. Overall, participants reported positive satisfaction toward the navigation, layout, and content of the program. They cited the value of the program in their daily CKD care. Limitations: Study limitations included using a single center to recruit participants, most of the participants having prior technology use, and using one module as a representative of the entire digital platform. Conclusion: The acceptability of a digital counseling program for patients with CKD relies on taking the patients' perspective using a user-centered design process. It is vital in ensuring adoption and adherence to self-management interventions aimed at sustaining behavioral change.

Contexte: L'autogestion s'est avérée efficace pour améliorer la qualité de vie des patients atteints d'insuffisance rénale chronique (IRC). Des outils d'autogestion facilement accessibles sont essentiels pour favoriser l'adhésion aux comportements d'autogestion. Conscients que la santé numérique facilite l'accès efficace aux programmes d'autogestion, nous avons mis au point un programme de consultation numérique, ODYSSEE Kidney Health, afin de promouvoir les comportements d'autogestion tout en soutenant la qualité de vie liée à la santé. Objectif: Présenter la conception et le développement du programme de consultation numérique ODYSSEE Kidney Health, destiné aux patients atteints d'IRC. Conception: L'étude a impliqué un processus de conception itératif fondé sur des principes de conception axés sur l'utilisateur pour développer le programme de consultation numérique, ODYSSEE Kidney Health. Participants: Un échantillon de 10 à 15 participants choisis à dessein dans des cliniques de néphrologie du University Health Network de Toronto (Canada). Méthodologie: Les participants ont pris part à deux phases du processus de développement. À chaque phase, une composante du programme a été présentée aux participants et ceux-ci ont été invités à effectuer des tâches axées sur les objectifs et à participer à un processus de « réflexion à voix haute ¼. Des entretiens semi-structurés ont suivi la première phase pour fournir de la rétroaction sur le programme dans son ensemble. L'analyse thématique des entretiens a permis de dégager les thèmes des tests d'utilisabilité. Des statistiques descriptives ont servi à présenter les données démographiques des patients. Résultats: Nous avons inclus 11 participants (7 hommes, 4 femmes; de 30 à 82 ans). Les principaux thèmes générés sont ancrés sur: 1) l'impact sur les soins de néphrologie, 2) les caractéristiques techniques et 3) le contenu sur l'IRC. Dans l'ensemble, les participants étaient satisfaits de leur expérience de navigation, de la disposition des contenus et du contenu du programme. Ils ont mentionné la valeur du programme dans leurs soins quotidiens d'IRC. Limites: Un seul centre a été utilisé pour recruter des participants, la majorité des participants avait déjà utilisé la technologie et un seul module a été utilisé pour représenter l'ensemble de la plateforme numérique. Conclusion: L'acceptabilité d'un programme de consultation numérique destiné aux patients atteints d'IRC repose sur la prise en compte du point de vue des patients par le biais d'un processus de conception axé sur l'utilisateur. Ceci est essentiel pour garantir l'adoption et l'adhésion aux interventions d'autogestion visant à pérenniser les changements de comportement.

The need for individualizing teaching and assurance of knowledge transmission to patients training for home dialysis.

Patients have varied learning styles and this has implications for home haemodialysis (HHD). Assessment tools directed toward understanding these styles remains understudied. As a consequence, this may lead to substandard retention rates or adverse events in HHD programs. As part of a continuous quality improvement initiative we have aimed to improve our understanding of patient learning styles and consequently tailor home dialysis training to individuals. To objectively determine knowledge translation and comprehension, irrespective of learning styles, we have introduced an objective structured clinical examination (OSCE). This assessment tool allows for further refinement of educational priorities by highlighting both deficiencies and strengths. Thereafter, an exit OSCE ensures patients attain an acceptable standard to complete home haemodialysis independently. We hope this tool will help shape future training criteria for HHD programs and consequently reduce adverse event rates.

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

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

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

An Interprofessional Approach in Caring for a Patient on Maintenance Hemodialysis with COVID-19 in Toronto, Canada: An Educational Case Report.

RATIONALE: Hemodialysis patients are at significant risk from COVID-19 due to their frequent interaction with the health care system and medical comorbidities. We followed up the trajectory of the first COVID-19-positive maintenance hemodialysis patient at Sunnybrook Health Sciences Centre in Toronto. We present the lessons learned and changes in practices that occurred to prevent an outbreak in our center. PRESENTING CONCERNS OF THE PATIENT: The patient, a 66-year-old woman on in-center hemodialysis, initially presented with a 2-day history of a productive cough. She subsequently developed a fever, was placed on contact and droplet isolation, and admitted to hospital. DIAGNOSES: On March 13, 2020, the patient tested positive for COVID-19. Within the next 48 hours, she developed hypoxia and acute respiratory distress syndrome as a complication of her illness requiring an extended critical care stay. This extended critical care stay resulted in critical illness-associated secondary sclerosing cholangitis. INTERVENTIONS: An interprofessional team was established, performing rapid Plan-Do-Study-Act quality improvement cycles to improve screening practices and promote the safety of patients and staff in the hemodialysis unit. OUTCOMES: We present here the lessons learned, the changes to our screening protocols, and the clinical course of our first in-center hemodialysis patient with SARS-CoV-2. TEACHING POINTS: Regular review of the infection screening processes is paramount in preventing outbreaks of COVID-19, particularly in hemodialysis units. Hospital admission should be arranged if a patient exhibits any clinical signs of hemodynamic compromise or hypoxia. Early education for health care practitioners caring for patients with COVID-19 and refresher information regarding personal protective equipment helped promote the safety of staff and prevent health care-associated outbreaks.

The need for outpatient back-up for home hemodialysis patients: Implications for resource utilization.

INTRODUCTION: The provision of sufficient support contributes to home hemodialysis (HHD) technique survival. The need for back-up treatment in incident and prevalent patients on HHD has not been well described previously, and is important from both technique survival and resource allocation. We aimed to quantify the amount of back-up treatment given to patients in our HHD unit, and hypothesized that the provision of back-up HD facilitated technique survival. METHODS: This was a retrospective, single-center cohort study quantifying the provision of back-up HD between January and December 2018. Electronic and paper medical records were accessed for data collection. FINDINGS: One hundred and nineteen patients dialyzed independently at home during the study period (96 patient years of HHD). Seventy-eight (66%) patients required a total of 292 back-up HD sessions in the HHD unit, representing an average of three back-up HD runs per patient year of HHD. Fifty-three percent of back-up HD runs were required for vascular access related issues. The most common clinical issue requiring assessment and back-up HD was extracellular fluid volume management. An equal proportion (95%) of those that utilized back-up HD and those that did not utilize back-up HD maintained a positive disposition (transplant or ongoing HHD) in relation to technique survival in the short term. CONCLUSIONS: From a resource viewpoint, this program of approximately 100 HHD patients required the availability of one to two staffed HD stations each weekday for back-up HD. The provision of back-up HD was not a harbinger of HHD discontinuation.

Home Dialysis Among Elderly Patients: Outcomes and Future Directions.

Elderly patients who receive home dialysis (peritoneal dialysis or home hemodialysis) may have reduced survival compared to younger patients. Therefore, it is important to ascertain the goals of home dialysis in the elderly rather than simply fixate on standard metrics such as technique survival. As Canada's population continues to age, the prevalence of end-stage kidney disease among the elderly population is increasing. Patients with multiple comorbidities are now surviving long enough to be started on dialysis. Although home dialysis has been associated with better survival and improved quality of life, its impact on the frail and elderly populations require further elucidation. Home dialysis patients can either independently perform tasks or have support in the home to safely conduct dialysis. Moreover, patients burdened with frailty and multiple comorbidities who lack support in the home may not be able to perform home dialysis safely. Innovative strategies to improve accessibility to home-based therapies need further exploration. In addition, the concept of goal-directed dialysis promotes more individualized treatment. Future continuous quality improvement initiatives must examine if goal-directed dialysis leads to better quality of life outcomes in the elderly.

La survie des patients âgés recevant des traitements de dialyse à domicile (dialyse péritonéale ou dialyse à domicile) pourrait être réduite comparativement à celle des patients plus jeunes. Par conséquent, il est essentiel d'évaluer les objectifs de la dialyse à domicile chez les patients âgés plutôt que de simplement se fier à des paramètres standards tels que la survie d'un point de vue technique. Avec le vieillissement de la population canadienne, on note une augmentation de la prévalence de l'insuffisance rénale terminale chez les populations âgées. Des patients présentant de multiples comorbidités survivent désormais suffisamment longtemps pour être traités par dialyse. Bien que la dialyse à domicile soit associée à de meilleures chances de survie et à un rehaussement de la qualité de vie, ses conséquences sur les populations fragilisées et plus âgées doivent être éclairées. Les patients dialysés à domicile peuvent pratiquer la dialyse de façon autonome ou bénéficier de soutien pour procéder en toute sécurité. En outre, les patients fragilisés souffrant de multiples comorbidités et manquant de soutien à domicile pourraient ne pas être en mesure de procéder à la dialyse de façon sécuritaire. Des stratégies innovantes pour améliorer l'accessibilité à des traitements à domicile méritent d'être explorées. De plus, le concept de dialyse ciblée favorise un traitement plus individualisé. Les futures initiatives d'amélioration continue de la qualité doivent s'attarder à déterminer si la dialyse ciblée mène à une meilleure qualité de vie chez les patients âgés.

Incremental peritoneal dialysis: New ideas about an old approach.

Coping with the transition from end-stage kidney disease to dialysis can be challenging for patients and their care partners. Introducing incident dialysis patients to incremental forms of dialysis is associated with better quality of life and reduced cost. Incremental hemodialysis (HD) has generated significant interest over the last decade with treatments that focus on clinical criteria rather than prespecified Kt/Vurea targets. Incremental peritoneal dialysis (PD) has traditionally focused on the sum of residual renal and peritoneal clearances to achieve a specific Kt/Vurea value. Gradual increases in the PD dose were prescribed as the residual kidney function declined. Adopting a new approach to incremental PD similar to what has been done for incremental HD would obviate the need for Kt/Vurea and focus exclusively on clinical criteria. New incremental PD may be considered less disruptive to incident dialysis patients, and may be more likely to be accepted as treatment. It will also reduce our obsession with small solute kinetics and enhance encounters with patients by focusing instead on the holisitc clinical assessment.