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Swanepoel CR, McCulloch MI, Abraham G, Donner JA, Alrukhaimi MN, Blake PG, Bunnag S, Claus S, Dreyer G, Ghnaimat MA, Ibhais FM, Liew A, McKnight M, Mengistu YT, Naicker S, Niang A, Obrador GT, Perl J, Rashid HU, Tonelli M, Tungsanga K, Vachharajani T, Zakharova E, Zuniga C, Finkelstein FO. Challenges for sustainable end-stage kidney disease care in low-middle-income countries: the problem of the workforce. Kidney Int Suppl (2011) 2020; 10:e49-e54. [PMID: 32149008 DOI: 10.1016/j.kisu.2019.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/11/2019] [Accepted: 11/07/2019] [Indexed: 11/30/2022] Open
Abstract
Prevention and early detection of kidney diseases in adults and children should be a priority for any government health department. This is particularly pertinent in the low-middle-income countries, mostly in Asia, Africa, Latin America, and the Caribbean, where up to 7 million people die because of lack of end-stage kidney disease treatment. The nephrology workforce (nurses, technicians, and doctors) is limited in these countries and expanding the size and expertise of the workforce is essential to permit expansion of treatment for both chronic kidney disease and end-stage kidney disease. To achieve this will require sustained action and commitment from governments, academic medical centers, local nephrology societies, and the international nephrology community.
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Oliver MJ, Perl J, McQuillan R, Blake PG, Jain AK, McCormick B, Yang R, Pirkle JL, Fissell RB, Golper TA, Shen JI, Hu SL, Pellegrino B, Liebman SE, Krishna VN, Ravani P, Clarke A, Quinn RR. Quantifying the risk of insertion-related peritoneal dialysis catheter complications following laparoscopic placement: Results from the North American PD Catheter Registry. Perit Dial Int 2020; 40:185-192. [PMID: 32063191 DOI: 10.1177/0896860819893813] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Peritoneal dialysis (PD) is a more cost-effective therapy to treat kidney failure than in-center hemodialysis, but successful therapy requires a functioning PD catheter that causes minimal complications. In 2015, the North American Chapter of the International Society for Peritoneal Dialysis established the North American PD Catheter Registry to improve practices and patient outcomes following PD catheter insertion. AIMS The objective of this study is to propose a methodology for defining insertion-related complications that lead to significant adverse events and report the risk of these complications among patients undergoing laparoscopic PD catheter insertion. METHODS Patients undergoing laparoscopic PD catheter insertion were enrolled at 14 participating centers in Canada and the United States and followed using a Web-based registry. Insertion-related complications were defined as flow restriction, exit-site leak, or abdominal pain at any point during follow-up. We also included infections or bleeding within 30 days of insertion, and any immediate postoperative complications. Adverse events were categorized as PD never starting or termination of PD therapy, delay in the start of PD therapy or interruption of PD therapy, an emergency department visit or hospitalization, or need for invasive procedures. Cause-specific cumulative incidence functions were used to estimate risk. RESULTS Five hundred patients underwent laparoscopic PD catheter insertion between 10 November 2015 and 24 July 2018. The cumulative risk of insertion-related complications 6 months from the date of insertion that led to an adverse event was 24%. The risk of flow restriction, exit-site leak, and pain at 6 months was 10.2%, 5.7%, and 5.3%, respectively. PD was never started or terminated in 6.4% of patients due to an insertion-related complication. Leaks and flow restrictions were most likely to delay or interrupt PD therapy. Flow restrictions were the primary cause of invasive procedures. Fifty percent of the complications occurred before the start of PD therapy. CONCLUSIONS Insertion-related complications leading to significant adverse events following laparoscopic placement of PD catheters are common. Many complications occur before the start of PD. Insertion-related complications are an important area of focus for future research and quality improvement efforts.
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Brimble KS, Boll P, Grill AK, Molnar A, Nash DM, Garg A, Akbari A, Blake PG, Perkins D. Impact of the KidneyWise toolkit on chronic kidney disease referral practices in Ontario primary care: a prospective evaluation. BMJ Open 2020; 10:e032838. [PMID: 32066603 PMCID: PMC7044871 DOI: 10.1136/bmjopen-2019-032838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Chronic kidney disease (CKD) is common; therefore, coordination of care between primary care and nephrology is important. Ontario Renal Network's KidneyWise toolkit was developed to provide guidance on the detection and management of people with CKD in primary care (www.kidneywise.ca). The aim of this study was to evaluate the impact of the April 2015 KidneyWise toolkit release on the characteristics of primary care referrals to nephrology. DESIGN AND SETTING The study was a prospective pre-post design conducted at two nephrology sites (community site: Trillium Health Partners in Mississauga, Ontario, Canada, and academic site: St Joseph's Healthcare in Hamilton, Ontario, Canada). Referrals were compared during the 3-month time period immediately prior to, and during a 3-month period 1 year after, the toolkit release. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the change in proportion of referrals for CKD that met the KidneyWise criteria. Additional secondary referral and quality of care outcomes were also evaluated. Multivariable logistic regression was used to evaluate preselected variables for their independent association with referrals that met the KidneyWise criteria. RESULTS The proportion of referrals for CKD among people who met the KidneyWise referral criteria did not significantly change from pre-KidneyWise to post-KidneyWise implementation (44.7% vs 45.8%, respectively, adjusted OR 1.16, 95% CI 0.85 to 1.59, p=0.36). The proportion of referrals for CKD that provided a urine albumin-creatinine ratio significantly increased post-KidneyWise (25.8% vs 43.8%, adjusted OR 1.45, 95% CI 1.06 to 1.97, p=0.02). The significant independent predictors of meeting the KidneyWise referral criteria were academic site, increased age and use of the KidneyWise referral form. CONCLUSIONS We did not observe any change in the proportion of appropriate referrals for CKD at two large nephrology centres 1 year after implementation of the KidneyWise toolkit.
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Al-Jaishi AA, McIntyre CW, Sontrop JM, Dixon SN, Anderson S, Bagga A, Benjamin D, Berry D, Blake PG, Chambers L, Chan PCK, Delbrouck N, Devereaux PJ, Ferreira-Divino LF, Goluch R, Gregor L, Grimshaw JM, Hanson G, Iliescu E, Jain AK, Lok CE, Mustafa RA, Nathoo B, Nesrallah GE, Oliver MJ, Pandeya S, Parmar MS, Perkins D, Presseau J, Rabin E, Sasal J, Shulman T, Sood MM, Steele A, Tam P, Tascona D, Wadehra D, Wald R, Walsh M, Watson P, Wodchis W, Zager P, Zwarenstein M, Garg AX. Major Outcomes With Personalized Dialysate TEMPerature (MyTEMP): Rationale and Design of a Pragmatic, Registry-Based, Cluster Randomized Controlled Trial. Can J Kidney Health Dis 2020; 7:2054358119887988. [PMID: 32076569 PMCID: PMC7003172 DOI: 10.1177/2054358119887988] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/23/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Small randomized trials demonstrated that a lower compared with higher dialysate temperature reduced the average drop in intradialytic blood pressure. Some observational studies demonstrated that a lower compared with higher dialysate temperature was associated with a lower risk of all-cause mortality and cardiovascular mortality. There is now the need for a large randomized trial that compares the effect of a low vs high dialysate temperature on major cardiovascular outcomes. OBJECTIVE The purpose of this study is to test the effect of outpatient hemodialysis centers randomized to (1) a personalized temperature-reduced dialysate protocol or (2) a standard-temperature dialysate protocol for 4 years on cardiovascular-related death and hospitalizations. DESIGN The design of the study is a pragmatic, registry-based, open-label, cluster randomized controlled trial. SETTING Hemodialysis centers in Ontario, Canada, were randomized on February 1, 2017, for a trial start date of April 3, 2017, and end date of March 31, 2021. PARTICIPANTS In total, 84 hemodialysis centers will care for approximately 15 500 patients and provide over 4 million dialysis sessions over a 4-year follow-up. INTERVENTION Hemodialysis centers were randomized (1:1) to provide (1) a personalized temperature-reduced dialysate protocol or (2) a standard-temperature dialysate protocol of 36.5°C. For the personalized protocol, nurses set the dialysate temperature between 0.5°C and 0.9°C below the patient's predialysis body temperature for each dialysis session, to a minimum dialysate temperature of 35.5°C. PRIMARY OUTCOME A composite of cardiovascular-related death or major cardiovascular-related hospitalization (a hospital admission with myocardial infarction, congestive heart failure, or ischemic stroke) captured in Ontario health care administrative databases. PLANNED PRIMARY ANALYSIS The primary analysis will follow an intent-to-treat approach. The hazard ratio of time-to-first event will be estimated from a Cox model. Within-center correlation will be considered using a robust sandwich estimator. Observation time will be censored on the trial end date or when patients die from a noncardiovascular event. TRIAL REGISTRATION www.clinicaltrials.gov; identifier: NCT02628366.
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Brown EA, Blake PG, Boudville N, Davies S, de Arteaga J, Dong J, Finkelstein F, Foo M, Hurst H, Johnson DW, Johnson M, Liew A, Moraes T, Perl J, Shroff R, Teitelbaum I, Wang AYM, Warady B. International Society for Peritoneal Dialysis practice recommendations: Prescribing high-quality goal-directed peritoneal dialysis. Perit Dial Int 2020; 40:244-253. [PMID: 32063219 DOI: 10.1177/0896860819895364] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Blake PG, Brown EA. Person-centered peritoneal dialysis prescription and the role of shared decision-making. Perit Dial Int 2020; 40:302-309. [DOI: 10.1177/0896860819893803] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Person-centered care has become a dominant paradigm in modern health care. It needs to be applied to people with end-stage kidney disease considering the initiation of dialysis and to peritoneal dialysis (PD) prescription and care delivery. It is relevant to their decisions about goals of care, transplantation, palliative care, and discontinuation of dialysis. It is also relevant to decisions about how PD is delivered, including options such as incremental PD. Shared decision-making is the essence of this process and needs to become a standard principle of care. It requires engagement, education, and empowerment of patients. Patient-reported outcomes and patient-reported experience are also central to person-centered care in PD.
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Abstract
Incremental peritoneal dialysis (PD) has been variably defined. It involves taking advantage of the residual renal function that is usually present at initiation of dialysis to initially prescribe less onerous lower doses of PD while still achieving individualized clearance goals. We propose that incremental PD be defined as a strategy, rather than a particular regime, in which: (1) less than standard “full-dose” PD is initially prescribed in recognition of the value of residual renal function; (2) peritoneal clearance is initially less than the individualized clearance goal but the combination of peritoneal plus renal clearance achieves or exceeds that goal clearance; and (3) there is a clear intention to increase dose of PD as renal clearance declines and/or symptoms appear.Incremental PD by its nature lessens the workload of dialysis for those doing PD, reduces cost and exposure of the peritoneal membrane to glucose, and may lessen mechanical symptoms. Evidence that incremental PD improves clinical outcomes compared to the use of full-dose PD is lacking but one randomized controlled trial, multiple observational studies, and a systematic review all suggest that outcomes are at least as good. Given that incremental PD costs less and is inherently less onerous, it is reasonable, pending larger randomized trials, to adopt this strategy.
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Gutman T, Manera KE, Baumgart A, Johnson DW, Wilkie M, Boudville N, Craig JC, Dong J, Jesudason S, Mehrotra R, Neu A, Shen JI, Van Biesen W, Blake PG, Brunier G, Cho Y, Jefferson N, Lenga I, Mann N, Mendelson AA, Perl J, Sanabria RM, Scholes-Roberston N, Schwartz D, Teitelbaum I, Tong A. “Can I go to Glasgow?” Learnings from patient involvement at the 17th Congress of the International Society for Peritoneal Dialysis (ISPD). Perit Dial Int 2020; 40:12-25. [DOI: 10.1177/0896860819880101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Recognition of the discrepancy between the research priorities of patients and health professionals has prompted efforts to involve patients as active contributors in research activities, including scientific conferences. However, there is limited evidence about the experience, challenges, and impacts of patient involvement to inform best practice. This study aims to describe patient and health professional perspectives on patient involvement at the Congress of the International Society for Peritoneal Dialysis (ISPD). Methods: Semi-structured interviews were conducted with 14 patients/caregivers and 15 health professionals from six countries who attended ISPD. Interviews were recorded and transcribed verbatim, and transcripts were analyzed thematically. Results: We identified four themes: protecting and enhancing scientific learning (grounding science in stories, sharing and inspiring new perspectives, distilling the key messages of research presentations, striking a balance between accommodating patients and presenting the science); democratizing access to research (redistributing power, challenging the traditional ownership of knowledge, cultivating self-management through demystifying research); inadequate support for patient/caregiver delegates (lacking purposeful inclusion, challenges in interpreting research findings, soliciting medical advice, difficulty negotiating venue and program, limited financial assistance in attending); and amplifying impact beyond the room (sparking innovation in practice, giving patients and families hope for the future). Conclusions: Patient involvement at the ISPD Congress clarified the applicability of research to patient care and self-management, democratized science, and strengthened the potential impact of research. More structured support for patients to help them purposefully articulate their experience in relation to session objectives may enhance their contribution and their own learning experience.
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Lee EJ, Patel A, Acedillo RR, Bachynski JC, Barrett I, Basile E, Battistella M, Benjamin D, Berry D, Blake PG, Chan P, Bohm CJ, Clemens KK, Cook C, Dember L, Dirk JS, Dixon S, Fowler E, Getchell L, Gholami N, Goldstein C, Hahn E, Hogeterp B, Huang S, Hughes M, Jardine MJ, Kalatharan S, Kilburn S, Lacson E, Leonard S, Liberty C, Lindsay C, MacRae JM, Manns BJ, McCallum J, McIntyre CW, Molnar AO, Mustafa RA, Nesrallah GE, Oliver MJ, Pandes M, Pandeya S, Parmar MS, Rabin EZ, Riley J, Silver SA, Sontrop JM, Sood MM, Suri RS, Tangri N, Tascona DJ, Thomas A, Wald R, Walsh M, Weijer C, Weir MA, Vorster H, Zimmerman D, Garg AX. Cultivating Innovative Pragmatic Cluster-Randomized Registry Trials Embedded in Hemodialysis Care: Workshop Proceedings From 2018. Can J Kidney Health Dis 2019; 6:2054358119894394. [PMID: 31903190 PMCID: PMC6933546 DOI: 10.1177/2054358119894394] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022] Open
Abstract
Hemodialysis is a life-sustaining treatment for persons with kidney failure. However, those on hemodialysis still face a poor quality of life and a short life expectancy. High-quality research evidence from large randomized controlled trials is needed to identify interventions that improve the experiences, outcomes, and health care of persons receiving hemodialysis. With the support of the Canadian Institutes of Health Research and its Strategy for Patient-Oriented Research, the Innovative Clinical Trials in Hemodialysis Centers initiative brought together Canadian and international kidney researchers, patients, health care providers, and health administrators to participate in a workshop held in Toronto, Canada, on June 2 and 3, 2018. The workshop served to increase knowledge and awareness about the conduct of innovative, pragmatic, cluster-randomized registry trials embedded into routine hemodialysis care and provided an opportunity to discuss and build support for new trial ideas. The workshop content included structured presentations, facilitated group discussions, and expert panel feedback. Partnerships and promising trial ideas borne out of the workshop will continue to be developed to support the implementation of future large-scale trials.
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Muanda FT, Weir MA, Bathini L, Blake PG, Chauvin K, Dixon SN, McArthur E, Sontrop JM, Moist L, Garg AX. Association of Baclofen With Encephalopathy in Patients With Chronic Kidney Disease. JAMA 2019; 322:1987-1995. [PMID: 31705755 PMCID: PMC6865230 DOI: 10.1001/jama.2019.17725] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE At least 30 case reports have linked the muscle relaxant baclofen to encephalopathy in patients with chronic kidney disease (CKD). OBJECTIVE To compare the 30-day risk of encephalopathy in patients with CKD and newly prescribed baclofen at greater than or equal to 20 mg per day vs less than 20 mg per day. The secondary objective was to compare the risk of encephalopathy in baclofen users vs nonusers. DESIGN, SETTING, AND PARTICIPANTS Retrospective population-based cohort study in Ontario, Canada (2007-2018) using linked health care data. Participants comprised 15 942 older adults (aged 66 years or older) with CKD (defined as an estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2 but not receiving dialysis). The primary cohort was restricted to patients who were newly prescribed baclofen; participants in the secondary cohort were new users and nonusers. EXPOSURES Prescription for oral baclofen greater than or equal to 20 mg per day vs less than 20 mg per day. MAIN OUTCOMES AND MEASURES Hospital admission with encephalopathy, defined as a main diagnosis of delirium, disorientation, transient alteration of awareness, transient cerebral ischemic attack, or unspecified dementia within 30 days of starting baclofen. Inverse probability of treatment weighting on the propensity score was used to balance comparison groups on indicators of baseline health. Weighted risk ratios (RRs) were obtained using modified Poisson regression and weighted risk differences (RDs) using binomial regression. Prespecified subgroup analyses were conducted by eGFR category. RESULTS The primary cohort comprised 15 942 patients with CKD (9699 [61%] women; median age, 77 years [interquartile range, 71-82]; 9707 [61%] patients started baclofen at ≥20 mg/d and 6235 [39%] at <20 mg/d). The primary outcome, hospitalization with encephalopathy, occurred in 108/9707 (1.11%) patients who started baclofen at greater than or equal to 20 mg per day and in 26/6235 (0.42%) who started baclofen at less than 20 mg per day; weighted RR, 3.54 (95% CI, 2.24 to 5.59); weighted RD, 0.80% (95% CI, 0.55% to 1.04%). In subgroup analysis, the absolute risk increased progressively at lower eGFR (weighted RD eGFR 45-59, 0.42% [95% CI, 0.19%-0.64%]; eGFR 30-44, 1.23% [95% CI, 0.62%-1.84%]; eGFR <30, 2.90% [95% CI, 1.30%-4.49%]; P for interaction, <.001]). In the secondary comparison with 284 263 nonusers, both groups of baclofen users had a higher risk of encephalopathy (<20 mg/d weighted RR, 5.90 [95% CI, 3.59 to 9.70] and ≥20 mg/d weighted RR, 19.8 [95% CI, 14.0 to 28.0]). CONCLUSIONS AND RELEVANCE Among older patients with CKD who were newly prescribed baclofen, the 30-day incidence of encephalopathy was increased among those prescribed higher doses compared with lower doses. If verified, these risks should be balanced against the benefits of baclofen use.
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Krahn MD, Bremner KE, de Oliveira C, Dixon SN, McFarlane P, Garg AX, Mitsakakis N, Blake PG, Harvey R, Pechlivanoglou P. Home Dialysis Is Associated with Lower Costs and Better Survival than Other Modalities: A Population-Based Study in Ontario, Canada. Perit Dial Int 2019; 39:553-561. [PMID: 31582466 DOI: 10.3747/pdi.2018.00268] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/05/2019] [Indexed: 12/19/2022] Open
Abstract
Background:How and where to initiate dialysis are policy challenges with enormous economic and health consequences. Initiating with home hemodialysis (HD) or peritoneal dialysis (PD) may reduce costs and improve outcomes but evidence is conflicting.Methods:We conducted a population-based study in patients aged ≥ 18 years who initiated chronic dialysis in the province of Ontario, Canada from 2006 to 2014 (N = 12,691) using linked administrative data. Patients were grouped by initial modality: facility HD, facility short daily or slow nocturnal (SD/SN) HD, PD, home HD. We estimated publicly-paid healthcare costs (2015 Canadian dollars; 1 = 0.947 US dollar) and survival, from dialysis initiation to March 2015.Results:By 5 years after dialysis initiation, mean 30-day costs (as-treated) for patients receiving PD and home HD were 50% and 64% lower, respectively, than for facility HD patients ($11,011). Approximately 50% of costs were unrelated to dialysis, reflecting high comorbidity in these patients. With covariate adjustment, mean 5-year cumulative costs were similar for initiators of home HD and PD ($304,178 and $349,338) and higher for facility HD initiators ($410,981). The highest 5-year unadjusted survival was for home HD patients (80%), followed by PD (52%), SD/SN HD (50%), and facility HD (42%).Conclusions:This study in a large cohort over 9 years provides new population-based evidence suggesting that initiating dialysis at home is cost-effective, with lower costs and better survival, than starting with facility HD. Survival differences persisted after adjustment for baseline characteristics but we could not adjust for functional status or severity of comorbidities.
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Clarke A, Ravani P, Oliver MJ, Hiremath S, Blake PG, Moist LM, Garg AX, Lam NN, Quinn RR. Timing of Fistula Creation and the Probability of Catheter-Free Use: A Cohort Study. Can J Kidney Health Dis 2019; 6:2054358119843139. [PMID: 31105964 PMCID: PMC6506926 DOI: 10.1177/2054358119843139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 02/15/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Fistula creation is recommended to avoid the use of central venous catheters
for hemodialysis. The extent to which timing of fistula creation minimizes
catheter use is unclear. Objective: To compare patient outcomes of 2 fistula creation strategies: fistula attempt
prior to the initiation of dialysis (“predialysis”) or fistula attempt after
starting dialysis (“postinitiation”). Design: Cohort study. Setting: Five Canadian dialysis programs. Patients: Patients who started hemodialysis between 2004 and 2012, who underwent
fistula creation, and were tracked in the Dialysis Measurement Analysis and
Reporting (DMAR) system. Measurements: Catheter-free fistula use within 1 year of hemodialysis start, probability of
catheter-free fistula use during follow-up, and rates of access-related
procedures. Methods: Retrospective data analysis: logistic regression; negative binomial
regression. Results: Five hundred and eight patients had fistula attempts predialysis and 583
postinitiation. At 1 year, 80% of those with predialysis attempts achieved
catheter-free use compared to 45% with post-initiation attempts (adjusted
odds ratio [OR]preVSpost = 4.67; 95% confidence interval [CI] =
3.28-6.66). The average of all patient follow-up time spent catheter-free
was 63% and 28%, respectively (probability of use per unit time,
ORpreVSpost = 2.90; 95% CI = 2.18-3.85). This finding was
attenuated when accounting for maturation time and when restricting the
analysis to those who achieved catheter-free use. Predialysis fistula
attempts were associated with lower procedure rates after dialysis
initiation—1.61 procedures per person-year compared with 2.55—but had 0.65
more procedures per person prior to starting dialysis. Limitations: Observational design, unknown indication for predialysis and postinitiation
fistula creation, and unknown reasons for prolonged catheter use. Conclusions: Predialysis fistula attempts were associated with a higher probability of
catheter-free use and remaining catheter-free over time, and also resulted
in fewer procedures compared with postinitiation attempts, which could be
due to timing of attempt or patient factors. Catheter use and procedures
were still common for all patients, regardless of the timing of fistula
creation.
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Poinen K, Quinn RR, Clarke A, Ravani P, Hiremath S, Miller LM, Blake PG, Oliver MJ. Complications From Tunneled Hemodialysis Catheters: A Canadian Observational Cohort Study. Am J Kidney Dis 2019; 73:467-475. [DOI: 10.1053/j.ajkd.2018.10.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/24/2018] [Indexed: 11/11/2022]
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Blake PG, Jain AK. Urgent Start Peritoneal Dialysis: Defining What It Is and Why It Matters. Clin J Am Soc Nephrol 2018; 13:1278-1279. [PMID: 30018049 PMCID: PMC6086705 DOI: 10.2215/cjn.02820318] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Nesrallah GE, Dixon SN, MacKinnon M, Jassal SV, Bota SE, Dirk JS, Arthurs E, Blake PG, Sood MM, Garg AX, Davison SN. Home Palliative Service Utilization and Care Trajectory Among Ontario Residents Dying on Chronic Dialysis. Can J Kidney Health Dis 2018; 5:2054358118783761. [PMID: 30083365 PMCID: PMC6073817 DOI: 10.1177/2054358118783761] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 04/18/2018] [Indexed: 11/16/2022] Open
Abstract
Background: Many patients who receive chronic hemodialysis have a limited life expectancy comparable to that of patients with metastatic cancer. However, patterns of home palliative care use among patients receiving hemodialysis are unknown. Objectives: We aimed to undertake a current-state analysis to inform measurement and quality improvement in palliative service use in Ontario. Methods: We conducted a descriptive study of outcomes and home palliative care use by Ontario residents maintained on chronic dialysis using multiple provincial healthcare datasets. The period of study was the final year of life, for those died between January 2010 and December 2014. Results: We identified 9611 patients meeting inclusion criteria. At death, patients were (median [Q1, Q3] or %): 75 (66, 82) years old, on dialysis for 3.0 (1.0-6.0) years, 41% were women, 65% had diabetes, 29.6% had dementia, and 13.9% had high-impact neoplasms, and 19.9% had discontinued dialysis within 30 days of death. During the last year of life, 13.1% received ⩾1 home palliative services. Compared with patients who had no palliative services, those who received home palliative care visits had fewer emergency department and intensive care unit visits in the last 30 days of life, more deaths at home (17.1 vs 1.4%), and a lower frequency of deaths with an associated intensive care unit stay (8.1 vs 37.8%). Conclusions: Only a small proportion of patients receiving dialysis in Ontario received support through the home palliative care system. There appears to be an opportunity to improve palliative care support in parallel with dialysis care, which may improve patient, family, and health-system outcomes.
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Manns B, Agar JWM, Biyani M, Blake PG, Cass A, Culleton B, Kleophas W, Komenda P, Lobbedez T, MacRae J, Marshall MR, Scott-Douglas N, Srivastava V, Magner P. Can economic incentives increase the use of home dialysis? Nephrol Dial Transplant 2018; 34:731-741. [DOI: 10.1093/ndt/gfy223] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Indexed: 11/14/2022] Open
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McCudden C, Akbari A, White CA, Biyani M, Hiremath S, Brown PA, Tangri N, Brimble S, Knoll G, Blake PG, Sood MM. Individual patient variability with the application of the kidney failure risk equation in advanced chronic kidney disease. PLoS One 2018; 13:e0198456. [PMID: 29894480 PMCID: PMC5997334 DOI: 10.1371/journal.pone.0198456] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 05/18/2018] [Indexed: 12/28/2022] Open
Abstract
The Kidney Failure Risk Equation (KFRE) predicts the need for dialysis or transplantation using age, sex, estimated glomerular filtration rate (eGFR), and urine albumin to creatinine ratio (ACR). The eGFR and ACR have known biological and analytical variability. We examined the effect of biological and analytical variability of eGFR and ACR on the 2-year KFRE predicted kidney failure probabilities using single measure and the average of repeat measures of simulated eGFR and ACR. Previously reported values for coefficient of variation (CV) for ACR and eGFR were used to calculate day to day variability. Variation was also examined with outpatient laboratory data from patients with an eGFR between 15 and 50 mL/min/1.72 m2. A web application was developed to calculate and model day to day variation in risk. The biological and analytical variability related to ACR and eGFR lead to variation in the predicted probability of kidney failure. A male patient age 50, ACR 30 mg/mmol and eGFR 25, had a day to day variation in risk of 7% (KFRE point estimate: 17%, variability range 14% to 21%). The addition of inter laboratory variation due to different instrumentation increased the variability to 9% (KFRE point estimate 17%, variability range 13% to 22%). Averaging of repeated measures of eGFR and ACR significantly decreased the variability (KFRE point estimate 17%, variability range 15% to 19%). These findings were consistent when using outpatient laboratory data which showed that most patients had a KFRE 2-year risk variability of ≤ 5% (79% of patients). Approximately 13% of patients had variability from 5–10% and 8% had variability > 10%. The mean age (SD) of this cohort was 64 (15) years, 36% were females, the mean (SD) eGFR was 32 (10) ml/min/1.73m2 and median (IQR) ACR was 22.7 (110). Biological and analytical variation intrinsic to the eGFR and ACR may lead to a substantial degree of variability that decreases with repeat measures. Use of a web application may help physicians and patients understand individual patient’s risk variability and communicate risk (https://mccudden.shinyapps.io/kfre_app/). The web application allows the user to alter age, gender, eGFR, ACR, CV (for both eGFR and ACR) as well as units of measurements for ACR (g/mol versus mg/g).
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Liu P, Quinn RR, Oliver MJ, Ronksley PE, Hemmelgarn BR, Quan H, Hiremath S, Bello AK, Blake PG, Garg AX, Johnson J, Verrelli M, Zacharias JM, Abd ElHafeez S, Tonelli M, Ravani P. Association between Duration of Predialysis Care and Mortality after Dialysis Start. Clin J Am Soc Nephrol 2018; 13:893-899. [PMID: 29507006 PMCID: PMC5989670 DOI: 10.2215/cjn.11951017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/27/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Early nephrology referral is recommended for people with CKD on the basis of observational studies showing that longer nephrology care before dialysis start (predialysis care) is associated with lower mortality after dialysis start. This association may be observed because predialysis care truly reduces mortality or because healthier people with an uncomplicated course of disease will have both longer predialysis care and lower risk for death. We examined whether the survival benefit of longer predialysis care exists after accounting for the potential confounding effect of disease course that may also be affected by predialysis care. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a retrospective cohort study and used data from 3152 adults with end stage kidney failure starting dialysis between 2004 and 2014 in five Canadian dialysis programs. We obtained duration of predialysis care from the earliest nephrology outpatient visit to dialysis start; markers of disease course, including inpatient or outpatient dialysis start and residual kidney function around dialysis start; and all-cause mortality after dialysis start. RESULTS The percentages of participants with 0, 1-119, 120-364, and ≥365 days of predialysis care were 23%, 8%, 10%, and 59%, respectively. When we ignored markers of disease course as in previous studies, longer predialysis care was associated with lower mortality (hazard ratio120-364 versus 0-119 days, 0.60; 95% confidence interval, 0.46 to 0.78]; hazard ratio≥365 versus 0-119 days, 0.60; 95% confidence interval, 0.51 to 0.71; standard Cox model adjusted for demographics and laboratory and clinical characteristics). When we additionally accounted for markers of disease course using the inverse probability of treatment weighted Cox model, this association was weaker and no longer significant (hazard ratio120-364 versus 0-119 days, 0.84; 95% confidence interval, 0.60 to 1.18; hazard ratio≥365 versus 0-119 days, 0.88; 95% confidence interval, 0.69 to 1.13). CONCLUSIONS The association between longer predialysis care and lower mortality after dialysis start is weaker and imprecise after accounting for patients' course of disease.
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Naylor KL, Dixon SN, Garg AX, Kim SJ, Blake PG, Nesrallah GE, McCallum MK, D'Antonio C, Li AH, Knoll GA. Variation in Access to Kidney Transplantation Across Renal Programs in Ontario, Canada. Am J Transplant 2017; 17:1585-1593. [PMID: 28068455 DOI: 10.1111/ajt.14133] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 11/10/2016] [Accepted: 11/12/2016] [Indexed: 01/25/2023]
Abstract
In the United States, kidney transplant rates vary significantly across end-stage renal disease (ESRD) networks. We conducted a population-based cohort study to determine whether there was variability in kidney transplant rates across renal programs in a health care system distinct from the United States. We included incident chronic dialysis patients in Ontario, Canada, from 2003 to 2013 and determined the 1-, 5-, and 10-year cumulative incidence of kidney transplantation in 27 regional renal programs (similar to U.S. ESRD networks). We also assessed the cumulative incidence of kidney transplant for "healthy" dialysis patients (aged 18-50 years without diabetes, coronary disease, or malignancy). We calculated standardized transplant ratios (STRs) using a Cox proportional hazards model, adjusting for patient characteristics (maximum possible follow-up of 11 years). Among 23 022 chronic dialysis patients, the 10-year cumulative incidence of kidney transplantation ranged from 7.4% (95% confidence interval [CI] 4.8-10.7%) to 31.4% (95% CI 16.5-47.5%) across renal programs. Similar variability was observed in our healthy cohort. STRs ranged from 0.3 (95% CI 0.2-0.5) to 1.5 (95% CI 1.4-1.7) across renal programs. There was significant variation in kidney transplant rates across Ontario renal programs despite patients having access to the same publicly funded health care system.
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Ankawi GA, Woodcock NI, Jain AK, Garg AX, Blake PG. The Use of Incremental Peritoneal Dialysis in a Large Contemporary Peritoneal Dialysis Program. Can J Kidney Health Dis 2016; 3:2054358116679131. [PMID: 28781885 PMCID: PMC5518964 DOI: 10.1177/2054358116679131] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 09/23/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The use of an incremental peritoneal dialysis (PD) strategy in a large contemporary patient population has not been described. OBJECTIVE We report the use of this strategy in clinical practice, the prescriptions required, and the clearances achieved in a large center which has routinely used this approach for more than 10 years. DESIGN This is a cross-sectional observational study. SETTING A single large Canadian academic center. PATIENTS This study collected data on 124 prevalent PD patients at a single Canadian academic center. METHODS AND MEASUREMENTS The proportion of patients who achieve the clearance target on a low clearance or incremental PD prescription; the actual PD prescriptions and consequent total, peritoneal, and renal urea clearances [Kt/V] achieved; and patient and technique survival and peritonitis rate in comparison with national and international reports. RESULTS Of the 124 prevalent PD patients in this PD unit, 106 (86%) were achieving the Kt/V target, and of these, 54 (44% of all patients) were doing so using incremental PD prescriptions. Fifty of these incremental PD patients were using automated PD (APD) with either no day dwell (68%) or less than 7 days a week treatment (12%) or both (20%). Patient survival in our PD unit was not different from that reported in Canada as a whole. Peritonitis rates were better than internationally recommended standards. LIMITATIONS This is an observational study with no randomized control group. CONCLUSIONS Incremental PD is feasible in a contemporary PD population treated mainly with APD. Almost half of the patients were able to achieve clearance targets while receiving less onerous and less costly low clearance prescriptions. We suggest that incremental PD should be widely used as a cost-effective strategy in PD.
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Woodward GL, Iverson A, Harvey R, Blake PG. Implementation of an agency to improve chronic kidney disease care in Ontario: lessons learned by the Ontario Renal Network. ACTA ACUST UNITED AC 2016; 17 Spec No:44-7. [PMID: 25562134 DOI: 10.12927/hcq.2014.24009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In 2009, Ontario's Ministry of Health and Long-Term Care initiated the transfer of oversight and coordination of chronic kidney disease (CKD) care to the Ontario Renal Network (ORN) under the auspices of Cancer Care Ontario (CCO). The aim was to replicate the quality improvement and change management practices used for cancer control within CKD. Much of the ORN's first three years were dedicated to building the infrastructure necessary to bridge the gap between provincial policy and clinical practice. This article explores the accomplishments, challenges and lessons learned over that period. The results, which are applicable to the management of chronic diseases in Ontario, Canada, and internationally, confirm that sustainable change takes time and requires strong leadership, transparency, accountability and communication, supported by a solid foundation of data and evidence.
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Vargas E, Blake PG, Sanabria M, Bunch A, López P, Vesga J, Buitrago A, Astudillo K, Devia M, Sánchez R. Early Peritonitis in a Large Peritoneal Dialysis Provider System in Colombia. Perit Dial Int 2016; 37:30-34. [PMID: 27605683 DOI: 10.3747/pdi.2016.00030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 04/03/2016] [Indexed: 11/15/2022] Open
Abstract
♦ BACKGROUND: Peritonitis is the most important complication of peritoneal dialysis (PD), and early peritonitis rate is predictive of the subsequent course on PD. Our aim was to calculate the early peritonitis rate and to identify characteristics and predisposing factors in a large nationwide PD provider network in Colombia. ♦ METHODS: This was a historical observational cohort study of all adult patients starting PD between January 1, 2012, and December 31, 2013, in 49 renal facilities in the Renal Therapy Services in Colombia. We studied the peritonitis rate in the first 90 days of treatment, its causative micro-organisms, its predictors and its variation with time on PD and between individual facilities. ♦ RESULTS: A total of 3,525 patients initiated PD, with 176 episodes of peritonitis during 752 patient-years of follow-up for a rate of 0.23 episodes per patient year equivalent to 1 every 52 months. In 41 of 49 units, the rate was better than 1 per 33 months, and in 45, it was better than 1 per 24 months. Peritonitis rates did not differ with age, ethnicity, socioeconomic status, or PD modality. We identified high incidence risk periods at 2 to 5 weeks after initiation of PD and again at 10 to 12 weeks. ♦ CONCLUSION: An excellent peritonitis rate was achieved across a large nationwide network. This occurred in the context of high nationwide PD utilization and despite high rates of socioeconomic deprivation. We propose that a key factor in achieving this was a standardized approach to management of patients.
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Blake PG. Sodium Levels in Peritoneal Dialysis Solution: How Low Should We Go? Am J Kidney Dis 2016; 67:719-21. [PMID: 27091013 DOI: 10.1053/j.ajkd.2016.02.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/03/2016] [Indexed: 11/11/2022]
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