Establishing a clinical trials network in nephrology: experience of the Australasian Kidney Trials Network

Building a National Clinical Trials Network in child and youth mental health: Growing Minds Australia

Many fields of medicine have benefitted from the formation of clinical trials networks, whereby researchers come together on a large scale to identify high-priority questions and implement coordinated clinical trials. Clinical trials networks in the field of mental health, however, have been rare and largely absent from the Australian context. Here, we present an overview of the newly formed Growing Minds Australia Clinical Trials Network, which represents the first comprehensive clinical trials network in child and youth mental health in Australia. The 60 principal members of the Growing Minds Australia Clinical Trials Network represent teams across 19 diverse areas related to specific forms of psychopathology (e.g. internalising, externalising, neurodevelopmental disorders, early psychosis, substance use), specific research methods and processes (e.g. health economics, eHealth, implementation science) and specialised areas of practice (e.g. school-based systems, parenting interventions, Indigenous mental health, refugee families). Core functions of the Growing Minds Australia Clinical Trials Network include collaborative trial protocol development; peer review, prioritisation and endorsement of proposed trials; training; development of clinical guidelines; and consumer representation. The research by the clinical trials network will encompass the populations typically accessing youth mental health services, while placing a key emphasis on the early periods of life, and the role of parents and caregivers as critical partners in the co-design of research and the delivery of intervention and prevention strategies. The structures and processes built into the network are designed to coordinate collaboration between diverse stakeholders and ensure that provisions for translation are integrated into research from the outset. In this paper, we examine the potential for a dedicated clinical trials network to initiate fundamental improvement in child and youth mental health systems, and discuss the unique and complex challenges associated with establishing such an initiative.

Research Activities in General Medicine: A Scoping Survey by the Internal Medicine Society of Australia and New Zealand (IMSANZ)

Background

In developing an effective framework for a collaborative research network (RN) that supports members involved in research, the Internal Medicine Society of Australia and New Zealand (IMSANZ) required a better understanding of the current level of research activity and engagement by general physicians, and factors influencing such engagement.

Aims

To explore the current research landscape amongst general physicians in Australia and Aotearoa New Zealand.

Methods

A questionnaire exploring research participation, scope, research enablers and barriers was disseminated to IMSANZ members over a 3‐month period. Core functions of IMSANZ‐RN, research priorities, potential solutions to perceived barriers and required level of support were also evaluated.

Results

A total of 82 members, mostly senior medical staff (74.4%), responded to the survey (11.8% response rate). More than 70% were involved in impactful research across multiple disciplines, encompassing a wide range of research themes and topics. However, there is limited support and resources available to conduct research, with most projects being self‐instigated and self‐funded. There is overwhelming support to increasing the profile of research in general medicine through the establishment of IMSANZ‐RN, whose principal purposes, as identified by respondents, are to foster collaboration, promote research, provide research education and training, and share information among general physicians. Quality improvement studies (56.1%) and clinical trials (41.5%) were also identified as priority research types.

Conclusions

This study has profiled the constraints faced by general physicians in conducting high‐quality collaborative research and provides insights into what is needed to support greater research engagement, through development of a discipline‐specific clinical RN.

Activities supporting the growth of Clinical Trial Networks in Australia

Clinical Trial Networks in which trialists work collaboratively enable multi-site, large-scale, high-quality clinical trials to be efficiently run. Although the benefits of Clinical Trial Networks are largely known, establishing a Clinical Trial Network can be complex. There are many factors for clinicians and researchers to consider, and there is currently a paucity of information on how to form a Clinical Trial Network. This article provides a suggested roadmap on how to establish a Clinical Trial Network. The Australian Clinical Trials Alliance (ACTA) is the peak body for Clinical Trial Networks, Coordinating Centres and Registries in Australia, and has produced several resources to support the effective and efficient running of clinical trials. This guide has come about through discussions with members of the ACTA Clinical Trial Network Sector Expansion Reference Group consisting of clinical trialists, clinicians, researchers, and consumers.

Conducting clinical trials during the COVID-19 pandemic-a collaborative trial network response

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.

Recruitment and retention in clinical trials in chronic kidney disease: report from national workshops with patients, caregivers and health professionals

BACKGROUND

Slow recruitment and poor retention jeopardize the reliability and statistical power of clinical trials, delaying access to effective interventions and increasing costs, as commonly observed in nephrology trials. Involving patients in trial design, recruitment and retention is infrequent but potentially transformational.

METHODS

We conducted three workshops involving 105 patients/caregivers and 43 health professionals discussing patient recruitment and retention in clinical trials in chronic kidney disease.

RESULTS

We identified four themes. 'Navigating the unknown'-patients described being unaware of the research question, confused by technical terms, sceptical about findings and feared the risk of harm. 'Wary of added burden'-patients voiced reluctance to attend additional appointments, were unsure of the commitment required or at times felt too unwell and without capacity to participate. 'Disillusioned and disconnected'-some patients felt they were taken for granted, particularly if they did not receive trial results. Participants believed there was no culture of trial participation in kidney disease and an overall lack of awareness about opportunities to participate. To improve recruitment and retention, participants addressed 'Building motivation and interest'.

CONCLUSIONS

Investigators should establish research consciousness from the time of diagnosis, consider optimal timing for approaching patients, provide comprehensive information in an accessible manner, emphasize current and future relevance to them and their illness, involve trusted clinicians in recruitment and minimize the burden of trial participation. Participation in clinical trials was seen as an opportunity for people to give back to the health system and for future people in their predicament.

Clinical trials in end-stage renal disease-priorities and challenges

Patients with end-stage renal disease (ESRD) experience extremely high morbidity and mortality and there are virtually no therapeutic interventions besides dialysis treatment that are proven in properly designed randomized controlled trials (RCTs) to improve patients' outcomes. Historically, the number of RCTs performed in the ESRD population has been very low compared with other medical subspecialties, and several of the few large RCTs have yielded inconclusive or negative results, dampening enthusiasm for future investment in similar trials. Recent initiatives promoting a focus on patient-centered outcomes and more active patient and caregiver involvement in the planning and conduct of clinical trials may result in more clinically relevant RCTs and broader participation from patients representing the diversity of the ESRD population. The adoption of novel clinical trial design elements characteristic of pragmatic clinical trials and platform trials could help improve both the internal and external validity of RCTs in ESRD, ultimately resulting in the adoption of therapeutic interventions that can be rapidly translated to clinical practice.

Improving the prognosis of patients with severely decreased glomerular filtration rate (CKD G4+): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Patients with severely decreased glomerular filtration rate (GFR) (i.e., chronic kidney disease [CKD] G4+) are at increased risk for kidney failure, cardiovascular disease (CVD) events (including heart failure), and death. However, little is known about the variability of outcomes and optimal therapeutic strategies, including initiation of kidney replacement therapy (KRT). Kidney Disease: Improving Global Outcomes (KDIGO) organized a Controversies Conference with an international expert group in December 2016 to address this gap in knowledge. In collaboration with the CKD Prognosis Consortium (CKD-PC) a global meta-analysis of cohort studies (n = 264,515 individuals with CKD G4+) was conducted to better understand the timing of clinical outcomes in patients with CKD G4+ and risk factors for different outcomes. The results confirmed the prognostic value of traditional CVD risk factors in individuals with severely decreased GFR, although the risk estimates vary for kidney and CVD outcomes. A 2- and 4-year model of the probability and timing of kidney failure requiring KRT was also developed. The implications of these findings for patient management were discussed in the context of published evidence under 4 key themes: management of CKD G4+, diagnostic and therapeutic challenges of heart failure, shared decision-making, and optimization of clinical trials in CKD G4+ patients. Participants concluded that variable prognosis of patients with advanced CKD mandates individualized, risk-based management, factoring in competing risks and patient preferences.

The establishment and validation of novel therapeutic targets to retard progression of chronic kidney disease

The focus of this article is to define goals and resulting action plans that can be collectively embraced by interested stakeholders to facilitate new therapeutic approaches to mitigate chronic kidney disease progression. The specific goals include identifying druggable targets, increasing the capacity for preclinical and early clinical development, broadening the availability of new therapeutic approaches, and increasing investment in the development of new therapies to limit chronic kidney disease. Key deliverables include the establishment of new regional, national, and global consortia; development of clinical trial networks; and creation of programs to support the temporary mutual movement of scientists between academia and the biotechnology and pharmaceutical sector. Other deliverables include cataloging and maintaining up-to-date records to collate progress in renal research and development, inventorying the capacity of research and clinical networks, and describing methods to ensure novel drug development.

Practice of Peritoneal Dialysis Catheter Flushing in Australia and New Zealand: Multi-Center Cross-Sectional Survey

Background

Evidence of effective interventions to prevent peritoneal dialysis (PD) catheter malfunction before first use is presently insufficient to guide clinical care. Regular flushing of the PD catheter (e.g. before PD commencement) has been adopted by some practitioners in the belief that it will prevent catheter obstruction and/or malfunction. The aim of this study was to characterize and evaluate PD catheter flushing practices across Australian and New Zealand PD units.

Methods

An on-line survey was distributed to all 62 PD units in Australia (12 August 2016; n = 51) and New Zealand (2 February 2017; n = 11), with questions relating to PD catheter flushing practices, audit, and outcomes.

Results

Forty-nine units of variable size (< 16 to > 100 patients) completed the survey (79% response rate). All centers flushed PD catheters at some stage after insertion as routine unit practice. Forty-one units (84%) routinely flushed during periods of PD rest at varying intervals ranging from alternate daily to monthly. The type and volume of solution used to flush varied between units. Units that practised routine flushing of PD catheters were almost twice as likely to audit their catheter-related outcomes (66% vs 38%, p = 0.23) and more likely to have reported blocked catheters in the preceding 12 months (84% vs 0%, p = 0.01) compared with those units that did not routinely flush PD catheters. Thirty units (61%) regularly audited and monitored catheter-related outcomes.

Conclusions

This study identified a wide variation in center practices relating to PD catheter flushing. Drawing conclusions about any relationship between flushing practices and clinical outcomes was impeded by the relatively low uptake of regular auditing and monitoring of catheter-related outcomes across surveyed units. Evaluation of the benefits and harms of standardized PD catheter flushing practices on patient outcomes in a randomized trial is needed to guide practice.

Changes in the worldwide epidemiology of peritoneal dialysis

As the global burden of chronic kidney disease continues to increase, so does the need for a cost-effective renal replacement therapy. In many countries, patient outcomes with peritoneal dialysis are comparable to or better than those with haemodialysis, and peritoneal dialysis is also more cost-effective. These benefits have not, however, always led to increased utilization of peritoneal dialysis. Use of this therapy is increasing in some countries, including China, the USA and Thailand, but has proportionally decreased in parts of Europe and in Japan. The variable trends in peritoneal dialysis use reflect the multiple challenges in prescribing this therapy to patients. Key strategies for facilitating peritoneal dialysis utilization include implementation of policies and incentives that favour this modality, enabling the appropriate production and supply of peritoneal dialysis fluid at a low cost, and appropriate training for nephrologists to enable increased utilization of the therapy and to ensure that rates of technique failure continue to decline. Further growth in peritoneal dialysis use is required to enable this modality to become an integral part of renal replacement therapy programmes worldwide.

Optimizing Enrollment of Patients into Nephrology Research Studies

Advances in medical care and biomedical research depend on the participation of human subjects. Poor patient enrollment in research has limited past clinical and translational research endeavors in nephrology. Simultaneously, patients and their caregivers are seeking better diagnostic, monitoring, and therapeutic approaches to improve or restore kidney and overall health. This manuscript will discuss a framework and strategies to optimize patient enrollment within nephrology research and provide examples of success from existing nephrology research programs.

Hurdles to the introduction of new therapies for immune-mediated kidney diseases

Innovative immunotherapies continue to markedly benefit many disciplines in clinical medicine but disappointingly, these benefits have not translated to the treatment of kidney diseases despite encouraging findings from preclinical models of kidney dysfunction. This lack of progress in nephrology might relate to the unique biology of the kidney. More likely, this lack of progress relates to conceptual hurdles in the application of newer therapies to renal disease. In this Review we discuss seven hurdles that must be addressed in order to appropriately assess and introduce immunologic therapies for immune-mediated kidney disease: the use of appropriate criteria to define disease categories; issues relating to the heterogeneity of kidney diseases and how this heterogeneity affects approaches to treatment; issues related to the rarity of most kidney diseases; the paucity of good animal models of human kidney disease; issues relating to trial design; problems with current approaches to the identification and use of appropriate and feasible study end points; and a lack of adequate biomarkers of intrarenal inflammation and parenchymal injury. We suggest that overcoming these hurdles, in addition to searching for better therapeutic targets, will be necessary to progress the treatment of immune-mediated kidney disease into a new age of drug therapy.

Glomerular filtration rate decline as a surrogate end point in kidney disease progression trials

Chronic kidney disease (CKD) is strongly associated with increased risks of progression to end-stage kidney disease (ESKD) and mortality. Clinical trials evaluating CKD progression commonly use a composite end point of death, ESKD or serum creatinine doubling. However, due to low event rates, such trials require large sample sizes and long-term follow-up for adequate statistical power. As a result, very few interventions targeting CKD progression have been tested in randomized controlled trials. To overcome this problem, the National Kidney Foundation and Food and Drug Administration conducted a series of analyses to determine whether an end point of 30 or 40% decline in estimated glomerular filtration rate (eGFR) over 2-3 years can substitute for serum creatinine doubling in the composite end point. These analyses demonstrated that these alternate kidney end points were significantly associated with subsequent risks of ESKD and death. However, the association between, and consistency of treatment effects on eGFR decline and clinical end points were influenced by baseline eGFR, follow-up duration and acute hemodynamic effects. The investigators concluded that a 40% eGFR decline is broadly acceptable as a kidney end point across a wide baseline eGFR range and that a 30% eGFR decline may be acceptable in some situations. Although these alternate kidney end points could potentially allow investigators to conduct shorter duration clinical trials with smaller sample sizes thereby generating evidence to guide clinical decision-making in a timely manner, it is uncertain whether these end points will improve trial efficiency and feasibility. This review critically appraises the evidence, strengths and limitations pertaining to eGFR end points.

Translational nephrology: what translational research is and a bird's-eye view on translational research in nephrology

The ultimate aim of biomedical research is to preserve health and improve patient outcomes. However, by a variety of measures, preservation of kidney health and patient outcomes in kidney disease are suboptimal. Severe acute kidney injury has been treated solely by renal replacement therapy for over 50 years and mortality still hovers at around 50%. Worldwide deaths from chronic kidney disease (CKD) increased by 80% in 20 years--one of the greatest increases among major causes of death. This dramatic data concur with huge advances in the cellular and molecular pathophysiology of kidney disease and its consequences. The gap appears to be the result of sequential roadblocks that impede an adequate flow from basic research to clinical development [translational research type 1 (T1), bench-to-bed and back] and from clinical development to clinical practice and widespread implementation (translational research T2) that supported by healthcare policy-making reaches all levels of society throughout the globe (sometimes called translational research T3). Thus, it is more than 10 years since the introduction of the last new-concept drug for CKD patients, cinacalcet; and 30 years since the introduction of reninangiotensin system (RAS) blockade, the current mainstay to prevent progression of CKD, illustrating the basic science-clinical practice disconnect. Roadblocks from clinical advances to widespread implementation, together with lag time-to-benefit may underlie the 20 years since the description of the antiproteinuric effect of RAS blockade to the observation of decreased age-adjusted incidence of endstage renal disease due to diabetic kidney disease. Only a correct understanding of the roadblocks in translational medicine and a full embracement of a translational research culture will spread the benefits of the biomedical revolution to its ultimate destinatary, the society.