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Au EH, Wong G, Tong A, Teixeira-Pinto A, van Zwieten A, Dobrijevic E, Ahn C, Blosser CD, Davidson B, Francis A, Jhaveri KD, Malyszko J, Mena-Gutierrez A, Newell KA, Palmer S, Scholes-Robertson N, Silva Junior HT, Craig JC. Scope and Consistency of Cancer Outcomes Reported in Randomized Trials in Kidney Transplant Recipients. Kidney Int Rep 2022; 8:274-281. [PMID: 36815120 PMCID: PMC9939355 DOI: 10.1016/j.ekir.2022.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction Cancer is an important outcome in kidney transplantation, but the scope and consistency of how cancer is defined and reported in trials involving kidney transplant recipients has not been evaluated. This study aimed to assess the range and variability of cancer outcomes in trials involving kidney transplant recipients. Methods The ClinicalTrials.gov database was searched from February 2000 to July 2021 to identify all randomized controlled trials (RCTs) in adult kidney transplant recipients, and which included cancer as a specified outcome. The definition of cancer, types of cancer (if any), timepoint(s) of measurement and method of aggregation were extracted for each cancer outcome. Results Of the 819 trials in kidney transplantation, only 84 (10%) included 1 or more cancer outcomes. Of these, 72 of 84 (86%) trials included cancer as a secondary outcome and 12 of 84 (14%) considered cancer as a primary outcome. The most frequent description of cancer was "malignancy" (n = 44, 43%), without reference to diagnostic criteria, histology, grade, or stage. The 2 most common cancer types were posttransplant lymphoproliferative disorder (PTLD) (n = 20, 20%) and nonmelanoma skin cancer (n = 10, 10%). Several methods of aggregation were identified, including incidence or rate (n = 47, 46%), frequency or proportion (n = 30, 29%), and time to event (n = 5, 5%). Approximately half the cancer outcomes were measured at a single time point (n = 44, 52%). Conclusion Cancer is an infrequently reported outcome and is inconsistently defined in trials of kidney transplant recipients. Consistent reporting of cancer outcomes using standardized definitions would provide important information on the impact of cancer in patients after kidney transplantation.
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Affiliation(s)
- Eric H. Au
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia,Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia,Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia,Correspondence: Eric H. Au, Center for Kidney Research, The Children’s Hospital at Westmead, Corner Hawkesbury Road and Hainsworth Street, Westmead, New South Wales 2145, Australia.
| | - Germaine Wong
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia,Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia,Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia,Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia,Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Anita van Zwieten
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia,Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Ellen Dobrijevic
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia,Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Curie Ahn
- Division of Nephrology, National Medical Center, Seoul, Korea
| | - Christopher D. Blosser
- Division of Nephrology, Department of Medicine, University of Washington School of Medicine, and Division of Nephrology, Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Bianca Davidson
- Division of Nephrology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Anna Francis
- Queensland Children's Hospital, Queensland, Australia
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - Kenneth A. Newell
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sarah Palmer
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia,Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Nicole Scholes-Robertson
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia,Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | | | - Jonathan C. Craig
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Nicholls SG, Carroll K, Goldstein CE, Brehaut JC, Weijer C, Zwarenstein M, Dixon S, Grimshaw JM, Garg AX, Taljaard M. Patient Partner Perspectives Regarding Ethically and Clinically Important Aspects of Trial Design in Pragmatic Cluster Randomized Trials for Hemodialysis. Can J Kidney Health Dis 2021; 8:20543581211032818. [PMID: 34367647 PMCID: PMC8317238 DOI: 10.1177/20543581211032818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cluster randomized trials (CRTs) are trials in which intact groups such as hemodialysis centers or shifts are randomized to treatment or control arms. Pragmatic CRTs have been promoted as a promising trial design for nephrology research yet may also pose ethical challenges. While randomization occurs at the cluster level, the intervention and data collection may vary in a CRT, challenging the identification of research participants. Moreover, when a waiver of patient consent is granted by a research ethics committee, there is an open question as to whether and to what degree patients should be notified about ongoing research or be provided with a debrief regarding the nature and results of the trial upon completion. While empirical and conceptual research exploring ethical issues in pragmatic CRTs has begun to emerge, there has been limited discussion with patients, families, or caregivers of patients undergoing hemodialysis. OBJECTIVE To explore with patients and families with experience of hemodialysis research the challenges raised by different approaches to designing pragmatic CRTs in hemodialysis. Specifically, their perceptions of (1) the use of a waiver of consent, (2) notification processes and information provided to participants, and (3) any other concerns about cluster randomized designs in hemodialysis. DESIGN Focus group and interview discussions of hypothetical clinical trial designs. SETTING Focus groups and interviews were conducted in-person or via videoconference or telephone. PARTICIPANTS Patient partners in hemodialysis research, defined as patients with personal experience of dialysis or a family member who had experience supporting a patient receiving hemodialysis, who have been actively involved in discussions to advise a research team on the design, conduct, or implementation of a hemodialysis trial. METHODS Participants were invited to participate in focus groups or individual discussions that were audio recorded with consent. Recorded interviews were transcribed verbatim prior to analysis. Transcripts were analyzed using a thematic analysis approach. RESULTS Two focus groups, three individual interviews, and one interview involving a patient and family member were conducted with 17 individuals between February 2019 and May 2020. Participants expressed support for approaches that emphasized patient choice. Disclosure of patient-relevant risks and information were key themes. Both consent and notification processes served to generate trust, but bypassing patient choice was perceived as undermining this trust. Participants did not dismiss the option of a waiver of consent. They were, however, more restrictive in their views about when a waiver of consent may be acceptable. Patient partners were skeptical of claims to impracticability based on costs or the time commitments for staff. LIMITATIONS All participants were from Canada and had been involved in the design or conduct of a trial, limiting the degree to which results may be extrapolated. CONCLUSIONS Given the preferences of participants to be afforded the opportunity to decide about trial participation, we argue that investigators should thoroughly investigate approaches that allow participants to make an informed choice regarding trial participation. In keeping with the preference for autonomous choice, there remains a need to further explore how consent approaches can be designed to facilitate clinical trial conduct while meeting their ethical requirements. Finally, further work is needed to define the limited circumstances in which waivers of consent are appropriate.
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Affiliation(s)
- Stuart G. Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
| | | | - Jamie C. Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
| | - Charles Weijer
- Department of Philosophy, Western University, London, ON, Canada
- Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Western University, London, ON, Canada
- Department of Family Medicine, Western University, London, ON, Canada
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- ICES, Ontario, Canada
| | - Stephanie Dixon
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- ICES, Ontario, Canada
- Lawson Research Institute, London, ON, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
| | - Amit X. Garg
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- ICES, Ontario, Canada
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- Nephrology, London Health Sciences Centre, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
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Robison L, Cho Y, Viecelli AK, Johnson DW, Hawley CM, Valks A, Paul-Brent PA, Stastny R, Varghese J, Kiriwandeniya C, Pascoe EM, Vergara LA, Fahim MA, Boudville N, Krishnasamy R, Reidlinger D. Conducting clinical trials during the COVID-19 pandemic-a collaborative trial network response. Trials 2021; 22:278. [PMID: 33853661 PMCID: PMC8045567 DOI: 10.1186/s13063-021-05200-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/16/2021] [Indexed: 11/22/2022] Open
Abstract
The unprecedented demand placed on healthcare systems from the COVID-19 pandemic has forced a reassessment of clinical trial conduct and feasibility. Consequently, the Australasian Kidney Trials Network (AKTN), an established collaborative research group known for conducting investigator-initiated global clinical trials, had to efficiently respond and adapt to the changing landscape during COVID-19. Key priorities included ensuring patient and staff safety, trial integrity and network sustainability for the kidney care community. New resources have been developed to enable a structured review and contingency plan of trial activities during the pandemic and beyond.
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Affiliation(s)
- Laura Robison
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia.
| | - Yeoungjee Cho
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
- The Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Andrea K Viecelli
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
- The Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
- The Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- The Translational Research Institute, Brisbane, QLD, Australia
| | - Carmel M Hawley
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
- The Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- The Translational Research Institute, Brisbane, QLD, Australia
| | - Andrea Valks
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Peta-Anne Paul-Brent
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Ruth Stastny
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Julie Varghese
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Charani Kiriwandeniya
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Liza A Vergara
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Magid A Fahim
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
- The Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Metro North Hospital & Health Service, Brisbane, QLD, Australia
| | - Neil Boudville
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
- The Medical School, University of Western Australia, Perth, WA, Australia
| | - Rathika Krishnasamy
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
- Department of Nephrology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Donna Reidlinger
- Australasian Kidney Trials Network, The University of Queensland, Level 5, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
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Nicholls SG, Carroll K, Weijer C, Goldstein CE, Brehaut J, Sood MM, Al-Jaishi A, Basile E, Grimshaw JM, Garg AX, Taljaard M. Ethical Issues in the Design and Conduct of Pragmatic Cluster Randomized Trials in Hemodialysis Care: An Interview Study With Key Stakeholders. Can J Kidney Health Dis 2020; 7:2054358120964119. [PMID: 33194212 PMCID: PMC7597560 DOI: 10.1177/2054358120964119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pragmatic cluster randomized trials (CRTs) offer an opportunity to improve health care by answering important questions about the comparative effectiveness of treatments using a trial design that can be embedded in routine care. There is a lack of empirical research that addresses ethical issues generated by pragmatic CRTs in hemodialysis. OBJECTIVE To identify stakeholder perceptions of ethical issues in pragmatic CRTs conducted in hemodialysis. DESIGN Qualitative study using semi-structured interviews. SETTING In-person or telephone interviews with an international group of stakeholders. PARTICIPANTS Stakeholders (clinical investigators, methodologists, ethicists and research ethics committee members, and other knowledge users) who had been involved in the design or conduct of a pragmatic individual patient or cluster randomized trial in hemodialysis, or their role would require them to review and evaluate pragmatic CRTs in hemodialysis. METHODS Interviews were conducted in-person or over the telephone and were audio-recorded with consent. Recorded interviews were transcribed verbatim prior to analysis. Transcripts and field notes were analyzed using a thematic analysis approach. RESULTS Sixteen interviews were conducted with 19 individuals. Interviewees were largely drawn from North America (84%) and were predominantly clinical investigators (42%). Six themes were identified in which pragmatic CRTs in hemodialysis raise ethical issues: (1) patients treated with hemodialysis as a vulnerable population, (2) appropriate approaches to informed consent, (3) research burdens, (4) roles and responsibilities of gatekeepers, (5) inequities in access to research, and (6) advocacy for patient-centered research and outcomes. LIMITATIONS Participants were largely from North America and did not include research staff, who may have differing perspectives. CONCLUSIONS The six themes reflect concerns relating to individual rights, but also the need to consider population-level issues. To date, concerns regarding inequity of access to research and the need for patient-centered research have received less coverage than other, well-known, issues such as consent. Pragmatic CRTs offer a potential approach to address equity concerns and we suggest future ethical analyses and guidance for pragmatic CRTs in hemodialysis embed equity considerations within them. We further note the potential for the co-creation of health data infrastructure with patients which would aid care but also facilitate patient-centered research. These present results will inform planned future guidance in relation to the ethical design and conduct of pragmatic CRTs in hemodialysis. TRIAL REGISTRATION Registration is not applicable as this is a qualitative study.
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Affiliation(s)
- Stuart G. Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Charles Weijer
- Department of Philosophy, Western University, London, Canada
- Department of Medicine, Western University, London, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Canada
| | | | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Manish M. Sood
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Jindal Research Chair for the Prevention of Kidney Disease, The Ottawa Hospital, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ontario, Canada
| | - Ahmed Al-Jaishi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Erika Basile
- Research Ethics and Compliance, Western University, London, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Amit X. Garg
- Department of Epidemiology and Biostatistics, Western University, London, Canada
- Institute for Clinical Evaluative Sciences, Ontario, Canada
- Division of Nephrology- Department of Medicine, Western University, London, Canada
- Nephrology, London Health Sciences Centre, London, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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