Technique Failure in a Multicenter Canadian Home Hemodialysis Cohort.

RATIONALE & OBJECTIVE: Increasing uptake of home hemodialysis (HD) has led to interest in characteristics that predict discontinuation of home HD therapy for reasons other than death or transplantation. Recent reports of practice pattern variability led to the hypothesis that there are patient- and center-specific factors that influence these discontinuations. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Incident home HD patients at 7 centers in Canada between 2000 and 2010. PREDICTOR: Treatment center, case-mix, and process-of-care variables. OUTCOMES: Technique failure (defined as discontinuation of home HD therapy for any reason other than training failure, death, or transplantation) and mortality. ANALYTICAL APPROACH: Regression modeling of technique failure using Cox proportional hazard models adjusting for treatment center and modifiable and nonmodifiable patient-level variables, censored for death and transplantation. RESULTS: The cohort consisted of 579 patients. Mean age was 49.9±14.1 years, 74% were of European ancestry, median dialysis vintage was 1.9 (IQR, 0.6-5.2) years, and 68% used an arteriovenous access. Mean duration of dialysis was 31.2±12.6 hours per week. Unadjusted 1- and 2-year technique survival and overall survival were 90% and 83% and 94% and 87%, respectively. Treating center was a strong predictor of technique failure and mortality, with HRs ranging from 0.37 to 5.11 for technique failure (1 of 6 centers with P<0.05 relative to the reference) and 0.17 to 8.73 for mortality (3 of 6 centers with P<0.05 relative to the reference). With baseline adjustment for center, only older age and more than 3 treatments per week remained significant predictors of technique failure, while no individual-level variables remained as significant predictors of survival. LIMITATIONS: Limited statistical power. CONCLUSIONS: Home HD treating centers may influence technique failure and patient mortality independent of case-mix. The relationship between processes of care and patient outcomes requires further investigation.

Predictors of Care Gaps in Home Dialysis: The Home Dialysis Virtual Ward Study.

BACKGROUND: Home dialysis patients may be at an increased risk of adverse events after transitional states. The home dialysis virtual ward (HDVW) trial was conducted in Canadian dialysis centers and aimed to evaluate potential care gaps and patient satisfaction during the HDVW. METHODS: The HDVW was a multicenter single-arm trial including peritoneal dialysis and home hemodialysis patients after 4 different events (hospital discharge, medical procedure, antibiotics, completion of training). Telephone-led interviews using a standardized assessment tool were performed over a 2-week period to assess a patient's care and adjust treatment as required. Upon completion, patients were surveyed to evaluate their perceived impact on domains of care using a rating scale; 1 not satisfied to 10 completely satisfied. RESULTS: The HDVW trial included 193 patients with a median number of potential care gaps/interventions of 1 (0-2) per patient. Patients admitted to the HDVW after hospital discharge were at a higher risk of potential gaps in care (OR 2.16, 95% CI 1.29-3.62), while longer dialysis vintage was -associated with a lower number of gaps/interventions (OR 0.97 per year, 95% CI 0.95-0.98). A total of 105/193 (54%) patients completed satisfaction surveys. Patients were highly satisfied with the HDVW (median rating scale score 8, IQR 2) and felt it had a positive impact (rating scale score ≥7) on their overall health, understanding of treatment and access to a nephrologist. CONCLUSION: The HDVW was effective at identifying several potential care gaps, and patients were satisfied across several domains of care. This intervention may be valuable in supporting home dialysis patients during care transitions.

Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use.

Mineral and bone disorder is a common complication of end-stage renal disease. Notably, hyperphosphatemia likely promotes calcification of the myocardium, valves, and arteries. Hyperphosphatemia is associated with higher risk for cardiovascular mortality and morbidity along a gradient beginning at 5.0mg/dL. Among contemporary hemodialysis (HD) patients, mean serum phosphorus level is 5.2mg/dL, although 25% of patients have serum phosphorus levels of 5.5 to 6.9mg/dL; and 13%, >7.0mg/dL. Treatment of hyperphosphatemia is burdensome. Dialysis patients consume a mean of 19 pills per day, half of which are phosphate binders. Medicare Part D expenditures on binders for dialysis patients approached $700 million in 2013. Phosphorus removal with thrice-weekly HD (4 hours per session) is ∼3,000mg/wk. However, clearance is unlikely to counterbalance dietary intake, which varies around a mean of 7,000mg/wk. Dietary restriction and phosphate binders are important interventions, but each has limitations. Dietary control is complicated by limited access to healthy food choices and unclear labeling. Meanwhile, adherence to phosphate binders is poor, especially in younger patients and those with high pill burden. Multiple randomized clinical trials show that intensive HD reduces serum phosphorus levels. In the Frequent Hemodialysis Network (FHN) trial, short daily and nocturnal schedules reduced serum phosphorus levels by 0.6 and 1.6mg/dL, respectively, relative to 3 sessions per week. A similar effect of nocturnal HD was observed in an earlier trial. In the daily arm of the FHN trial, intensive HD significantly lowered estimated phosphate binder dose per day, whereas in the nocturnal arm, intensive HD led to binder discontinuation in 75% of patients. However, intensive HD appears to have no meaningful effects on serum calcium and parathyroid hormone concentrations. In conclusion, intensive HD, especially nocturnal HD, lowers serum phosphorus levels and decreases the need for phosphate binders.

Intensive Hemodialysis and Health-Related Quality of Life.

Diminished health-related quality of life (HRQoL) is common in dialysis patients and associated with increased risks for morbidity and mortality. Patients may present limitations in both physical and mental HRQoL. Poor physical HRQoL may be defined by limited physical function, role limitations due to physical health, dissatisfaction with physical ability, and impaired mobility. Sleep disorders such as obstructive sleep apnea, restless legs, and fatigue are typical manifestations of poor physical HRQoL in dialysis patients. Poor mental HRQoL may be defined by depressive thinking, lack of positive affect, anxiety, and feelings of social isolation. The prevalence of depression is high in dialysis patients. Intensive hemodialysis (HD) can positively address HRQoL. In 3 randomized clinical trials, relative to conventional HD, intensive HD increased physical and mental component summary scores from the 36-Item Short-Form Health Survey (SF-36), although individual treatment effects of daily nocturnal HD were not statistically significant. In another large prospective study, initiation of short daily HD therapy was followed after 12 months by improvements in all SF-36 domains, sleep quality, and restless legs symptoms. In a small study of nocturnal HD, apnea and hypopnea episodes per hour decreased by almost 70% after conversion from conventional HD. Intensive HD is also associated with a large reduction in postdialysis recovery time. In contrast, 2 randomized clinical trials failed to demonstrate statistically significant effects of intensive HD on the Beck Depression Inventory score despite a significant decrease in Beck Depression Inventory score in the prospective study of short daily HD. Furthermore, intensive HD may not improve objective physical performance and can increase burden on caregivers in the home setting. In conclusion, intensive HD potentially can address both physical and mental aspects of poor HRQoL relative to conventional HD. However, more studies are needed to understand the effects of intensive HD, including specific schedules, on HRQoL.

Intensive Hemodialysis and Potential Risks With Increasing Treatment.

Although intensive hemodialysis (HD) can address important clinical problems, increasing treatment also introduces risks. In this review, we assess risks pertaining to 6 domains: vascular access complications, infection, mortality, loss of residual kidney function, solute balance, and patient and care partner burden. In the Frequent Hemodialysis Network (FHN) trials, short daily and nocturnal schedules increased the incidence of access complications, although the incidence of access loss was not statistically higher. Observational studies indicate that infection-related hospitalization is an ongoing challenge with short daily HD. Excess risk may be catalyzed by poor infection control practices in the home setting in which intensive HD is typically delivered, but with fixed probability of bacterial contamination per cannulation, greater treatment frequency necessarily increases the risk for infectious complications. Buttonhole cannulation may increase the risk for metastatic infections. However, intensive HD in the home setting is associated with lower risk for infection than peritoneal dialysis. Data regarding mortality are equivocal. With extended follow-up of individuals in the FHN trials, short daily HD was associated with lower risk relative to the usual schedule, whereas nocturnal HD was associated with higher risk. In many, but not all, observational studies, short daily HD has been associated with lower risk than both in-center HD and peritoneal dialysis; however, observational studies are subject to unmeasured confounding. Intensive HD can accelerate the loss of residual kidney function in new dialysis patients with substantial urine output and can deplete solutes (eg, phosphorus) to the extent that supplementation is necessary. Finally, intensive HD may increase burden on patients and caregivers, possibly leading to technique failure. Some of these problems might be addressed with careful monitoring, so that relevant interventions (eg, antibiotics, retraining, and respite care) can be delivered. Ultimately, intensive HD is not a panacea for end-stage renal disease. Potential benefits and risks of treatment should be jointly considered.

Rationale for a home dialysis virtual ward: design and implementation.

BACKGROUND: Home-based renal replacement therapy (RRT) [peritoneal dialysis (PD) and home hemodialysis (HHD)] offers independent quality of life and clinical advantages compared to conventional in-center hemodialysis. However, follow-up may be less complete for home dialysis patients following a change in care settings such as post hospitalization. We aim to implement a Home Dialysis Virtual Ward (HDVW) strategy, which is targeted to minimize gaps of care. METHODS/DESIGN: The HDVW Pilot Study will enroll consecutive PD and HHD patients who fulfilled any one of our inclusion criteria: 1. following discharge from hospital, 2. after interventional procedure(s), 3. prescription of anti-microbial agents, or 4. following completion of home dialysis training. Clinician-led telephone interviews are performed weekly for 2 weeks until VW discharge. Case-mix (modified Charlson Comorbidity Index), symptoms (the modified Edmonton Symptom Assessment Scale) and patient satisfaction are assessed serially. The number of VW interventions relating to eight pre-specified domains will be measured. Adverse events such as re-hospitalization and health-services utilization will be ascertained through telephone follow-up after discharge from the VW at 2, 4, 12 weeks. The VW re-hospitalization rate will be compared with a contemporary cohort (matched for age, gender, renal replacement therapy and co-morbidities). Our protocol has been approved by research ethics board (UHN: 12-5397-AE). Written informed consent for participation in the study will be obtained from participants. DISCUSSION: This report serves as a blueprint for the design and implementation of a novel health service delivery model for home dialysis patients. The major goal of the HDVW initiative is to provide appropriate and effective supports to medically complex patients in a targeted window of vulnerability. TRIAL REGISTRATION: (NCT01912001).

Vascular access for intensive maintenance hemodialysis: a systematic review for a Canadian Society of Nephrology clinical practice guideline.

BACKGROUND: Practices in vascular access management with intensive hemodialysis may differ from those used in conventional hemodialysis. STUDY DESIGN: We conducted a systematic review to inform clinical practice guidelines for the provision of intensive hemodialysis. SETTING & POPULATION: Adult patients receiving maintenance (>3 months) intensive hemodialysis (frequent [≥5 hemodialysis treatments per week] and/or long [>5.5 hours per hemodialysis treatment]). SELECTION CRITERIA FOR STUDIES: We searched EMBASE and MEDLINE (1990-2011) for randomized and observational studies. We also searched conference proceedings (2007-2011). INTERVENTIONS: (1) Central venous catheter (CVC) versus arteriovenous (AV) access, (2) buttonhole versus rope-ladder cannulation, (3) topical antimicrobial cream versus none in buttonhole cannulation, and (4) closed connector devices among CVC users. OUTCOMES: Access-related infection, survival, hospitalization, patency, access survival, intervention rates, and quality of life. RESULTS: We included 23, 7, and 5 reports describing effectiveness by access type, buttonhole cannulation, and closed connector device, respectively. No study directly compared CVC with AV access. On average, bacteremia and local infection rates were higher with CVC compared with AV access. Access intervention rates were higher with more frequent hemodialysis, but access survival did not differ. Buttonhole cannulation was associated with bacteremia rates similar to those seen with CVCs in some series. Topical mupirocin seemed to attenuate this effect. No direct comparisons of closed connector devices versus standard luer-locking devices were found. Low rates of actual or averted (near misses) air embolism and bleeding were reported with closed connector devices. LIMITATIONS: Overall, evidence quality was very low. Limited direct comparisons addressing main review questions, small sample sizes, selective outcome reporting, publication bias, and residual confounding were major factors. CONCLUSIONS: This review highlights several differences in the management of vascular access in conventional and intensive hemodialysis populations. We identify a need for standardization of vascular access outcome reporting and a number of priorities for future research.

Canadian Society of Nephrology guidelines for the management of patients with ESRD treated with intensive hemodialysis.

Intensive (longer and more frequent) hemodialysis has emerged as an alternative to conventional hemodialysis for the treatment of patients with end-stage renal disease. However, given the differences in dialysis delivery and models of care associated with intensive dialysis, alternative approaches to patient management may be required. The purpose of this work was to develop a clinical practice guideline for the Canadian Society of Nephrology. We applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for guideline development and performed targeted systematic reviews and meta-analysis (when appropriate) to address prioritized clinical management questions. We included studies addressing the treatment of patients with end-stage renal disease with short daily (≥5 days per week, <3 hours per session), long (3-4 days per week, ≥5.5 hours per session), or long-frequent (≥5 days per week, ≥5.5 hours per session) hemodialysis. We included clinical trials and observational studies with or without a control arm (1990 and later). Based on a prioritization exercise, 6 interventions of interest included optimal vascular access type, buttonhole cannulation, antimicrobial prophylaxis for buttonhole cannulation, closed connector devices, and dialysate calcium and dialysate phosphate additives for patients receiving intensive hemodialysis. We developed 6 recommendations addressing the interventions of interest. Overall quality of the evidence was very low and all recommendations were conditional. We provide detailed commentaries to guide in shared decision making. The main limitation was the very low overall quality of evidence that precluded strong recommendations. Most included studies were small single-arm observational studies. Three randomized controlled trials were applicable, but provided only indirect evidence. Published information for patient values and preference was lacking. In conclusion, we provide 6 recommendations for the practice of intensive hemodialysis. However, due to very low-quality evidence, all recommendations were conditional. We therefore also highlight priorities for future research.

Dialysate calcium concentration and mineral metabolism in long and long-frequent hemodialysis: a systematic review and meta-analysis for a Canadian Society of Nephrology clinical practice guideline.

BACKGROUND: Patients treated with conventional hemodialysis (HD) develop disorders of mineral metabolism that are associated with increased morbidity and mortality. More frequent and longer HD has been associated with improvement in hyperphosphatemia that may improve outcomes. STUDY DESIGN: Systematic review and meta-analysis to inform the clinical practice guideline on intensive dialysis for the Canadian Society of Nephrology. SETTING & POPULATION: Adult patients receiving outpatient long (≥5.5 hours/session; 3-4 times per week) or long-frequent (≥5.5 hours/session, ≥5 sessions per week) HD. SELECTION CRITERIA FOR STUDIES: We included clinical trials, cohort studies, case series, case reports, and systematic reviews. INTERVENTIONS: Dialysate calcium concentration ≥1.5 mmol/L and/or phosphate additive. OUTCOMES: Fragility fracture, peripheral arterial and coronary artery disease, calcific uremic arteriolopathy, mortality, intradialytic hypotension, parathyroidectomy, extraosseous calcification, markers of mineral metabolism, diet liberalization, phosphate-binder use, and muscle mass. RESULTS: 21 studies were identified: 2 randomized controlled trials, 2 reanalyses of data from the randomized controlled trials, and 17 observational studies. Dialysate calcium concentration ≥1.5 mmol/L for patients treated with long and long-frequent HD prevents an increase in parathyroid hormone levels and a decline in bone mineral density without causing harm. Both long and long-frequent HD were associated with a reduction in serum phosphate level of 0.42-0.45 mmol/L and a reduction in phosphate-binder use. There was no direct evidence to support the use of a dialysate phosphate additive. LIMITATIONS: Almost all the available information is related to changes in laboratory values and surrogate outcomes. CONCLUSIONS: Dialysate calcium concentration ≥1.5 mmol/L for most patients treated with long and long-frequent dialysis prevents an increase in parathyroid hormone levels and decline in bone mineral density without increased risk of calcification. It seems prudent to add phosphate to the dialysate for patients with a low predialysis phosphate level or very low postdialysis phosphate level until more evidence becomes available.

Intensive hemodialysis associates with improved survival compared with conventional hemodialysis.

Patients undergoing conventional maintenance hemodialysis typically receive three sessions per week, each lasting 2.5-5.5 hours. Recently, the use of more intensive hemodialysis (>5.5 hours, three to seven times per week) has increased, but the effects of these regimens on survival are uncertain. We conducted a retrospective cohort study to examine whether intensive hemodialysis associates with better survival than conventional hemodialysis. We identified 420 patients in the International Quotidian Dialysis Registry who received intensive home hemodialysis in France, the United States, and Canada between January 2000 and August 2010. We matched 338 of these patients to 1388 patients in the Dialysis Outcomes and Practice Patterns Study who received in-center conventional hemodialysis during the same time period by country, ESRD duration, and propensity score. The intensive hemodialysis group received a mean (SD) 4.8 (1.1) sessions per week with a mean treatment time of 7.4 (0.87) hours per session; the conventional group received three sessions per week with a mean treatment time of 3.9 (0.32) hours per session. During 3008 patient-years of follow-up, 45 (13%) of 338 patients receiving intensive hemodialysis died compared with 293 (21%) of 1388 patients receiving conventional hemodialysis (6.1 versus 10.5 deaths per 100 person-years; hazard ratio, 0.55 [95% confidence interval, 0.34-0.87]). The strength and direction of the observed association between intensive hemodialysis and improved survival were consistent across all prespecified subgroups and sensitivity analyses. In conclusion, there is a strong association between intensive home hemodialysis and improved survival, but whether this relationship is causal remains unknown.

Optimizing AVF creation prior to dialysis start: the role of predialysis renal replacement therapy choices.

BACKGROUND: In British Columbia, multidisciplinary predialysis clinics encourage patients to consider independent modalities of renal replacement therapy (RRT) such as peritoneal dialysis (PD) 'first'. Despite up to 50% of patients choosing PD, PD incidence rates are ~30%. We explored the relationship between predialysis RRT choice and arteriovenous fistula (AVF) creation prior to hemodialysis (HD) start with particular focus on the group of patients who despite PD choice actually commence HD, and thus may contribute to 'suboptimal' HD starts without AVF creation. METHODS: We conducted a retrospective cohort study of all patients starting dialysis between 31 December, 2006 and 31 December 2008 in the province of British Columbia. Inclusion criteria were >3 months predialysis nephrology follow-up, at least one predialysis RRT education session and maintenance on dialysis for a minimum of 3 months (to ensure chronic dialysis). Patients with any prior history of RRT were excluded. RESULTS: There were 508 patients included in the study: 127 (25%) patients chose HD, 114 (22%) PD, 13 (3%) pre-emptive transplant, 5 (1%) conservative management and 249 (49%) had no documented modality decision. Of those who chose HD, 94% commenced HD. For those who chose PD, 64% commenced PD and 36% HD. In the undecided group, 68% started HD and 32% PD. For those patients who chose PD predialysis, the presence of cardiovascular disease [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.02-5.43] and lower serum albumin levels (OR 0.92, 95% CI 0.86-0.98) were associated with failure to commence PD. Predialysis AVF creation rates were 79% of those who chose and started HD, 39% of those who chose PD but started HD and 50% of those in the undecided group who commenced HD. CONCLUSIONS: AVF creation rates prior to HD start were lower in those patients with no documented dialysis modality choice and in those who failed to commence PD. Cardiovascular disease and lower serum albumin levels were associated with failure to start PD. Further work to ensure the efficacy of RRT modality choice pathway and to better predict those patients who will fail to commence PD is necessary, so that dialysis start can be 'optimized' with AVF creation in high-risk groups.

The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial.

Prior small studies have shown multiple benefits of frequent nocturnal hemodialysis compared to conventional three times per week treatments. To study this further, we randomized 87 patients to three times per week conventional hemodialysis or to nocturnal hemodialysis six times per week, all with single-use high-flux dialyzers. The 45 patients in the frequent nocturnal arm had a 1.82-fold higher mean weekly stdKt/V(urea), a 1.74-fold higher average number of treatments per week, and a 2.45-fold higher average weekly treatment time than the 42 patients in the conventional arm. We did not find a significant effect of nocturnal hemodialysis for either of the two coprimary outcomes (death or left ventricular mass (measured by MRI) with a hazard ratio of 0.68, or of death or RAND Physical Health Composite with a hazard ratio of 0.91). Possible explanations for the left ventricular mass result include limited sample size and patient characteristics. Secondary outcomes included cognitive performance, self-reported depression, laboratory markers of nutrition, mineral metabolism and anemia, blood pressure and rates of hospitalization, and vascular access interventions. Patients in the nocturnal arm had improved control of hyperphosphatemia and hypertension, but no significant benefit among the other main secondary outcomes. There was a trend for increased vascular access events in the nocturnal arm. Thus, we were unable to demonstrate a definitive benefit of more frequent nocturnal hemodialysis for either coprimary outcome.

Supporting patient choice: an intervention to promote independent dialysis therapies.

Independent dialysis therapies are as effective as in-center therapies but cost only about half as much. This project incorporated a patient focus group to better understand patient perceptions and possible barriers related to choosing independent dialysis therapies. Focus group findings included hardship related to loss of kidney function, the need for support from healthcare professionals, the need for educational materials and recruitment strategies focused on the benefits of independent dialysis, the need for peer support to encourage choice of independent dialysis modality, and support for technical issues. Themes identified by the focus group were used to create two new education tools and a nurse-delivered education program for patients with CKD. Future evaluation will determine whether these efforts lead to an increase in selection of independent dialysis therapies.

Perceptions of Multidisciplinary Renal Team Members toward Home Dialysis Therapies.

Background: Patients with ESKD are encouraged to pursue home dialysis therapy with the aims of improving quality of life, increasing patient autonomy, and reducing cost to health care systems. In a multidisciplinary team setting, patients interact with nephrologists, nurses, and allied health staff, all of whom may influence a patient's modality choice. Our objective was to evaluate the perceptions of all renal team members toward home dialysis therapies. Methods: We performed a cross-sectional survey of multidisciplinary renal team members across five renal programs in British Columbia, Canada. The survey contained questions regarding primary work area, modality preference, patient and system factors that may influence modality candidacy, perceived knowledge of home therapies, and need for further education. Results: A total of 334 respondents (22 nephrologists, 172 hemodialysis nurses, 49 home nurses, 20 predialysis nurses, and 71 allied health staff) were included (48% response rate). All respondents felt that home dialysis was beneficial for patients who work or study, improved patients' quality of life, and provided cost savings to the system. Compared with in-center hemodialysis nurses, home therapies nurses were between five and nine times more likely to favor a home therapy for patients of older age, lower socioeconomic status, lower educational level, higher burden of comorbidities, and those lacking social supports. Nephrologists and patients were felt to have the most influence on modality choice, whereas dialysis nurses were seen as having the least effect on modality choice. Most respondents felt the need for further education in home therapies. Conclusions: The majority of multidisciplinary team members, including allied health staff, acknowledged the benefits of home therapies. There were significant discrepancies among team members regarding patient-/system-level factors that may affect the candidacy of home therapies. Structured, focused, and repeated education sessions for all renal team members may help to address misperceptions around factors that influence modality candidacy.

Podocyte Infolding Glomerulopathy, First Case Report From North America.

RATIONALE: Podocyte infolding glomerulopathy (PIG) is a newly described condition with only 37 cases reported worldwide. Due to its rarity, the pathogenesis and evolution of this disease is unclear. This case report contributes to our collective knowledge about the clinical and histological progression of this disease. PRESENTING CONCERNS OF THE PATIENT: Over the course of a year, a 52-year-old Malaysian woman with no known prior medical history developed progressively worsening edema and other findings consistent with nephrotic syndrome. DIAGNOSIS: Unlike most patients with PIG, this patient did not have any autoimmune disease. She was Hepatitis B core antibody positive with a Hepatitis B surface antibody >1000, suggesting prior Hepatitis B infection with immunity. A renal biopsy was performed which was consistent with PIG. A second renal biopsy was done 2 years later which again showed characteristic findings of PIG with worsened podocyte effacement but no interval change in chronicity. INTERVENTIONS: The patient was treated with blood pressure control and renin-angiotensin-aldosterone system (RAAS) blockade with irbesartan and spironolactone. She was also treated with prednisone at 1 mg/kg for 2 months followed by a taper for a total of 7 months of prednisone treatment. OUTCOMES: The patient had a partial response to a course of prednisone. However, since stopping steroids, her proteinuria and renal function has been gradually worsening. TEACHING POINTS: PIG is mostly found in patients of East Asian descent. It presents as proteinuria and is often associated with autoimmune disease but can be idiopathic. It is characterized on renal biopsy by infolding or protrusion of podocyte cytoplasm into glomerular basement membrane, as well as intramembranous cytoplasmic microspherules or microtubules. Atypical membranous nephropathy should be ruled out prior to diagnosis. Unlike membranous nephropathy, PIG usually responds at least partially to steroid monotherapy. To our knowledge, this is the first reported case of PIG from North America. Furthermore, it is the first case of PIG with repeat biopsy showing interval worsening of PIG rather than either resolution of PIG or transformation of PIG to a different diagnosis.

FONDEMENT: La glomérulonéphrite due à l'involution des podocytes (GIP) est une affection nouvellement décrite; seuls 37 cas ont été signalés jusqu'à présent dans le monde. La pathogenèse et l'évolution de cette maladie rare sont donc encore nébuleuses. Ce rapport de cas ajoute au savoir collectif sur sa progression clinique et histologique. PRÉSENTATION DU CAS: Une Malaisienne de 52 ans sans antécédents médicaux connus qui, sur une période d'un an, a développé un œdème s'étant aggravé progressivement et présenté d'autres résultats concordant avec un syndrome néphrotique. DIAGNOSTIC: Contrairement à la plupart des patients ayant reçu un diagnostic de GIP, cette patiente ne présentait aucune maladie auto-immune concomitante. Un résultat positif pour les anticorps anti-HBc et un compte supérieur à 1 000 pour les anticorps de surface contre l'hépatite B suggéraient une infection antérieure par l'hépatite B avec immunité. Une biopsie rénale avait montré un résultat compatible avec une GIP. Une deuxième biopsie rénale effectuée deux ans plus tard a également montré des résultats caractéristiques d'une GIP et une aggravation de l'épanchement des podocytes, mais aucun changement d'intervalle en terme de chronicité. INTERVENTIONS: La patiente a été traitée par maîtrise de la tension artérielle et blocage du SRAA avec irbésartan et spironolactone. Elle a également reçu une dose de 1 mg/kg de prednisone pendant deux mois, qui a par la suite été progressivement réduite. Le traitement à la prednisone s'est étalé sur un total de sept mois. RÉSULTATS: La patiente a répondu partiellement au traitement à la prednisone. Mais depuis l'arrêt des stéroïdes, une aggravation de la protéinurie et une altération de la fonction rénale progressives ont été observées. ENSEIGNEMENTS TIRÉS: La GIP affecte principalement des patients originaires de l'Asie de l'Est. Cette maladie se présente sous la forme d'une protéinurie et elle est souvent associée à une maladie auto-immune, bien qu'elle puisse aussi être idiopathique. À la biopsie rénale, la GIP se caractérise par un repli ou une protrusion du cytoplasme des podocytes dans la membrane basale glomérulaire, de même que par des microsphérules ou des microtubules cytoplasmiques intramembranaires. Une néphropathie membranaire atypique doit être exclue avant de poser le diagnostic. Contrairement à la néphropathie membranaire, la GIP répond généralement, au moins partiellement, aux stéroïdes en monothérapie. À notre connaissance, il s'agit du premier cas signalé de GIP en Amérique du Nord. Il s'agit en outre du premier cas de GIP avec biopsie répétée montrant une aggravation de la maladie pendant l'intervalle plutôt qu'une résolution ou une transformation de la maladie en un diagnostic différent.

Maintaining the Uptake of Peritoneal Dialysis During the COVID-19 Pandemic: A Research Letter.

BACKGROUND: Due to inherent challenges in maintaining physical distancing in hemodialysis units, the Canadian Society of Nephrology has recommended peritoneal dialysis as the preferred modality for patients requiring maintenance dialysis during the coronavirus disease 19 (COVID-19) pandemic. However, pursuing peritoneal dialysis is not without risk due to the requirement for in-person contact during catheter insertion and training, and there is a paucity of data regarding the experience of peritoneal dialysis during the early phases of the pandemic. OBJECTIVE: To examine the incidence and outcomes of peritoneal dialysis between March 17 and June 01, 2020 compared to the same time period in preceding years. DESIGN: Retrospective observational study. SETTING: British Columbia, Canada. After the pandemic was declared on March 17, 2020, patients continued to be trained in peritoneal dialysis. In an effort to limit time spent in hospital, patients were preferentially trained in continuous ambulatory peritoneal dialysis, training times were truncated for some patients, and peritoneal dialysis catheters were inserted by a physician at the bedside whenever feasible. PATIENTS: All patients aged >18 years who started chronic maintenance dialysis during the period March 17 to June 01 in the years 2018 to 2020 inclusive. The time period was extended to include the years 2010 to 2020 inclusive to evaluate longer term trends in dialysis incidence. MEASUREMENTS: A provincial clinical information system was used to capture the date of commencing dialysis, dialysis modality, and complications including peritonitis. Overall uptake of peritoneal dialysis included new starts and transitions to peritoneal dialysis from in-center hemodialysis during the observation period. METHODS: The incidence of dialysis during the specified time period, overall and by modality, was calculated per million population using census figures for the population at risk. Patients were followed for a minimum of 30 days from the start of peritoneal dialysis to capture episodes of peritonitis and COVID-19. RESULTS: A total of 211 patients started maintenance dialysis between March 17 and June 01, 2020. The incidence dialysis rate (41.3 per million population) was lower than that expected based on the 10-year trend from 2010 to 2019 inclusive (expected rate 45.7 per million population, 95% confidence interval 41.7 to 50.1). A total of 93 patients started peritoneal dialysis, including 32 patients who transitioned from in-center hemodialysis, contributing to a higher overall uptake of peritoneal dialysis compared to preceding years. The incidence rate for peritoneal dialysis of 18.2 per million population was higher than that expected (16.3 per million population, 95% confidence interval 14.0 to 19.0). Half of patients (48%) underwent a bedside peritoneal dialysis catheter insertion by a physician. During 30 days of follow-up, 2 (2.2%) patients experienced peritonitis and no patients were diagnosed with COVID-19. LIMITATIONS: Results are short term and generalizable only to regions with similarly low community rates of transmission of severe acute respiratory syndrome coronavirus 2. CONCLUSIONS: These preliminary findings indicate that peritoneal dialysis can be safely started and perhaps expanded as a means of mitigating the anticipated surge in in-center hemodialysis during the COVID-19 pandemic. Important contributors to the uptake of peritoneal dialysis in British Columbia were bedside catheter insertions and expediting transitions from in-center hemodialysis to peritoneal dialysis.

Quantifying Missed Opportunities for Recruitment to Home Dialysis Therapies.

BACKGROUND: Despite the recognized benefits of home therapies for patients and the health care system, most individuals with kidney failure in Canada continue to be initiated on in-center hemodialysis. To optimize recruitment to home therapies, there is a need for programs to better understand the extent to which potential candidates are not successfully initiated on these therapies. OBJECTIVE: We aimed to quantify missed opportunities to recruit patients to home therapies and explore where in the modality selection process this occurs. DESIGN: Retrospective observational study. SETTING: British Columbia, Canada. PATIENTS: All patients aged >18 years who started chronic dialysis in British Columbia between January 01, 2015, and December 31, 2017. The sample was further restricted to include patients who received at least 3 months of predialysis care. All patients were followed for a minimum of 12 months from the start of dialysis to capture any transition to home therapies. METHODS: Cases were defined as a "missed opportunity" if a patient had chosen a home therapy, or remained undecided about their preferred modality, and ultimately received in-center hemodialysis as their destination therapy. These cases were assessed for: (1) documentation of a contraindication to home therapies; and (2) the type of dialysis education received. Differences in characteristics among patients classified as an appropriate outcome or a missed opportunity were examined using Wilcoxon rank-sum test or χ2 test, as appropriate. RESULTS: Of the 1845 patients who started chronic dialysis during the study period, 635 (34%) were initiated on a home therapy. A total of 320 (17.3%) missed opportunities were identified, with 165 (8.9%) having initially chosen a home therapy and 155 (8.4%) being undecided about their preferred modality. Compared with patients who chose and initiated or transitioned to a home therapy, those identified as a missed opportunity tended to be older with a higher prevalence of cardiovascular disease. A contraindication to both peritoneal dialysis and home hemodialysis was documented in 8 "missed opportunity" patients. General modality orientation was provided to most (71%) patients who had initially chosen a home therapy but who ultimately received in-center hemodialysis. These patients received less home therapy-specific education compared with patients who chose and subsequently started a home therapy (20% vs 35%, P < .001). LIMITATIONS: Contraindications to home therapies were potentially under-ascertained, and the nature of contraindications was not systematically captured. CONCLUSIONS: Even within a mature home therapy program, we discovered a substantial number of missed opportunities to recruit patients to home therapies. Better characterization of modality contraindications and enhanced education that is specific to home therapies may be of benefit. Mapping the recruitment pathway in this way can define the magnitude of missed opportunities and identify areas that could be optimized. This is to be encouraged, as even small incremental improvements in the uptake of home therapies could lead to better patient outcomes and contribute to significant cost savings for the health care system. TRIAL REGISTRATION: Not applicable as this was a qualitative study.

CONTEXTE: Les avantages de la dialyse à domicile pour les patients et le système de santé sont reconnus. Pourtant, la majorité des personnes atteintes d'insuffisance rénale au Canada continue de recevoir des traitements d'hémodialyse en centre. Pour recruter davantage de patients sur les thérapies à domicile, il est nécessaire d'instaurer des programmes qui permettent d'établir dans quelle mesure les candidats potentiels n'y sont pas initiés avec succès. OBJECTIF: Nous souhaitions quantifier les occasions manquées de recruter des patients pour les modalités à domicile et déterminer où ces occasions manquées se produisent dans le processus de sélection de la modalité. CONCEPTION: Étude de cohorte rétrospective. CADRE: Colombie-Britannique (Canada). SUJETS: Tous les adultes ayant amorcé des traitements de dialyse chronique en Colombie-Britannique entre le 1er janvier 2015 et le 31 décembre 2017. L'échantillon a été davantage restreint pour inclure les patients ayant reçu au moins trois mois de soins prédialyse. Le suivi s'est étalé sur un minimum de douze mois à compter de l'amorce de la dialyse afin de capter toute transition vers une modalité à domicile. MÉTHODOLOGIE: Les cas ont été définis comme une « occasion manquée ¼ si la personne avait d'emblée choisi une modalité à domicile ou si elle était demeurée indécise quant à sa modalité préférée et avait finalement reçu des traitements d'hémodialyse en centre de façon permanente. Les occasions manquées ont été examinées pour: i) une contre-indication aux thérapies à domicile et; ii) le type de formation reçue pour la dialyse. L'évaluation des différences dans les caractéristiques des patients, selon que leur cas était classé comme un résultat favorable ou une occasion manquée, a été effectuée à l'aide du test de Wilcoxon ou du test du Chi-carré. RÉSULTATS: Des 1 845 patients ayant débuté des traitements de dialyse chronique au cours de la période étudiée, 635 (34 %) avaient amorcé la dialyse à domicile. En tout, 320 cas (17,3 %) ont été classés comme « occasions manquées ¼, soit 165 patients (8,9 %) ayant d'emblée choisi une thérapie à domicile et 155 (8,4 %) indécis quant à leur modalité préférée. Comparativement aux patients qui avaient choisi et amorcé un traitement à domicile ou qui avaient fait une transition (hémodialyse en centre vers une modalité à domicile), les patients classés « occasion manquée ¼ tendaient à être plus âgés avec une prévalence plus élevée de maladies cardiovasculaires. Une contre-indication à la fois à la dialyse péritonéale et à l'hémodialyse à domicile était documentée pour huit patients classés « occasion manquée ¼. Une orientation générale sur la modalité avait été fournie à la majorité des patients (71 %) qui avaient initialement choisi une thérapie à domicile, mais qui avaient finalement reçu une hémodialyse en centre. Ces patients avaient reçu moins d'information spécifique aux modalités pratiquées à domicile que les patients qui avaient d'emblée choisi et poursuivi leurs traitements à domicile (20 % contre 35 %, p < 0,001). LIMITES: Les contre-indications aux modalités à domicile pourraient avoir été sous-évaluées et leur nature n'était pas systématiquement prise en compte. CONCLUSION: Un nombre significatif d'occasions manquées de recruter des patients pour les modalités de dialyse à domicile a été observé, bien que le programme étudié soit solidement établi. Une meilleure caractérisation des contre-indications à ces modalités et davantage de formation spécifique à ces thérapies pourraient s'avérer bénéfiques. De plus, une cartographie du processus de recrutement pourrait contribuer à mieux définir l'ampleur des occasions manquées et à cerner les domaines susceptibles d'être optimisés. Cette démarche est à encourager, car toute amélioration progressive dans l'adoption des thérapies à domicile, aussi infime soit-elle, est susceptible d'améliorer les résultats des patients et de générer des économies importantes pour le système de santé. ENREGISTREMENT DE L'ESSAI: Sans objet, il s'agit d'une étude qualitative.

Balancing the Needs of Acute and Maintenance Dialysis Patients during the COVID-19 Pandemic: A Proposed Ethical Framework for Dialysis Allocation.

The COVID-19 pandemic continues to strain health care systems and drive shortages in medical supplies and equipment around the world. Resource allocation in times of scarcity requires transparent, ethical frameworks to optimize decision making and reduce health care worker and patient distress. The complexity of allocating dialysis resources for both patients receiving acute and maintenance dialysis has not previously been addressed. Using a rapid, collaborative, and iterative process, BC Renal, a provincial network in Canada, engaged patients, doctors, ethicists, administrators, and nurses to develop a framework for addressing system capacity, communication challenges, and allocation decisions. The guiding ethical principles that underpin this framework are (1) maximizing benefits, (2) treating people fairly, (3) prioritizing the worst-off individuals, and (4) procedural justice. Algorithms to support resource allocation and triage of patients were tested using simulations, and the final framework was reviewed and endorsed by members of the provincial nephrology community. The unique aspects of this allocation framework are the consideration of two diverse patient groups who require dialysis (acute and maintenance), and the application of two allocation criteria (urgency and prognosis) to each group in a sequential matrix. We acknowledge the context of the Canadian health care system, and a universal payer in which this framework was developed. The intention is to promote fair decision making and to maintain an equitable reallocation of limited resources for a complex problem during a pandemic.

Canadian Association of Paediatric Nephrologists COVID-19 Rapid Response: Home and In-Center Dialysis Guidance.

PURPOSE OF THE PROGRAM: This article provides guidance on optimizing the management of pediatric patients with end-stage kidney disease (ESKD) who will be or are being treated with any form of home or in-center dialysis during the COVID-19 pandemic. The goals are to provide the best possible care for pediatric patients with ESKD during the pandemic and ensure the health care team's safety. SOURCES OF INFORMATION: The core of these rapid guidelines is derived from the Canadian Society of Nephrology (CSN) consensus recommendations for adult patients recently published in the Canadian Journal of Kidney Health and Disease (CJKHD). We also consulted specific documents from other national and international agencies focused on pediatric kidney health. Additional information was obtained by formal review of the published academic literature relevant to pediatric home or in-center hemodialysis. METHODS: The Leadership of the Canadian Association of Paediatric Nephrologists (CAPN), which is affiliated with the CSN, solicited a team of clinicians and researchers with expertise in pediatric home and in-center dialysis. The goal was to adapt the guidelines recently adopted for Canadian adult dialysis patients for pediatric-specific settings. These included specific COVID-19-related themes that apply to dialysis in a Canadian environment, as determined by a group of senior renal leaders. Expert clinicians and nurses with deep expertise in pediatric home and in-center dialysis reviewed the revised pediatric guidelines. KEY FINDINGS: We identified 7 broad areas of home dialysis practice management that may be affected by the COVID-19 pandemic: (1) peritoneal dialysis catheter placement, (2) home dialysis training, (3) home dialysis management, (4) personal protective equipment, (5) product delivery, (6) minimizing direct health care providers and patient contact, and (7) caregivers support in the community. In addition, we identified 8 broad areas of in-center dialysis practice management that may be affected by the COVID-19 pandemic: (1) identification of patients with COVID-19, (2) hemodialysis of patients with confirmed COVID-19, (3) hemodialysis of patients not yet known to have COVID-19, (4) management of visitors to the dialysis unit, (5) handling COVID-19 testing of patients and staff, (6) safe practices during resuscitation procedures in a pandemic, (7) routine hemodialysis care, and (8) hemodialysis care under fixed dialysis resources. We make specific suggestions and recommendations for each of these areas. LIMITATIONS: At the time when we started this work, we knew that evidence on the topic of pediatric dialysis and COVID-19 would be severely limited, and our resources were also limited. We did not, therefore, do formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. Thus, this article's advice and recommendations are primarily expert opinions and subject to the biases associated with this level of evidence. To expedite the publication of this work, we created a parallel review process that may not be as robust as standard arms' length peer-review processes. IMPLICATIONS: We intend these recommendations to help provide the best care possible for pediatric patients prescribed in-center or home dialysis during the COVID-19 pandemic, a time of altered priorities and reduced resources.

The cost of starting and maintaining a large home hemodialysis program.

Home extended hours hemodialysis improves some measurable biological and quality-of-life parameters over conventional renal replacement therapies in patients with end-stage renal disease. Published small studies evaluating costs have shown savings in terms of ongoing operating costs with this modality. However, all estimates need to include the total costs, including infrastructure, patient training, and maintenance; patient attrition by death, transplantation, technique failure; and the necessity of in-center dialysis. We describe a comprehensive funding model for a large centrally administered but locally delivered home hemodialysis program in British Columbia, Canada that covered 122 patients, of which 113 were still in the program at study end. The majority of patients performed home nocturnal hemodialysis in this 2-year retrospective study. All training periods, both in-center and in-home dialysis, medications, hospitalizations, and deaths were captured using our provincial renal database and vital statistics. Comparative data from the provincial database and pricing models were used for costing purposes. The total comprehensive costs per patient-incorporating startup, home, and in-center dialysis; medications; home remodeling; and consumables-was $59,179 for years 2004-2005 and $48,648 for 2005-2006. The home dialysis patients required multiple in-center dialysis runs, significantly contributing to the overall costs. Our study describes a valid, comprehensive funding model delineating reliable cost estimates of starting and maintaining a large home-based hemodialysis program. Consideration of hidden costs is important for administrators and planners to take into account when designing budgets for home hemodialysis.