The BC Glomerulonephritis Network: Improving Access and Reducing the Cost of Immunosuppressive Treatments for Glomerular Diseases

Knowledge Translation in Glomerulonephritis: Successes in Translational Research From the Bench to Bedside

Purpose of review

Glomerulonephritis refers to a rare group of diseases characterized by glomerular inflammation, which collectively are a common cause of kidney failure. Until recently, there was a lack of high-quality clinical trials to inform the care of patients with glomerulonephritides. We identified examples of successful translational research spanning from basic science to clinical applications, and highlight gaps in implementation science.

Sources of information

The focus of our review was derived from discussions between health care professionals, researchers, and patient partners. We also performed literature searches pertaining to the treatment of glomerulonephritis in PubMed and Google Scholar.

Methods

Examples of successful knowledge translation were generated through review of new evidence in the past 5 years and by iterative discussions by the authors. We then conducted a narrative review of several themes related to knowledge translation in glomerulonephritis. This was complemented by an interview with a patient partner to provide an example of a patient's perspective living with glomerulonephritis.

Key findings

We summarized selected recent advances in glomerulonephritis and its knowledge translation in the following domains: (1) identification of auto-antibodies in membranous nephropathy and minimal change disease; (2) clinical trials of novel targeted therapies for IgA nephropathy and lupus nephritis, which have led to approval of new treatments; (3) developments in research networks and clinical trials in glomerulonephritis; (4) recognition of the importance in developing standardized patient reported outcome measures in clinical trials; and (5) barriers in knowledge translation including access to medication.

Limitations

A systematic search of the literature and formal assessment of quality of evidence were beyond the scope of this review.

Focused Jurisdictional Scan of Glomerulonephritis Medication Access in Canada: A Program Report

Purpose of Program

Glomerulonephritis (GN) is a group of rare kidney diseases that is increasingly being managed with higher cost immunosuppressive (IS) agents in Canada. Ontario Health's Ontario Renal Network (ORN) oversees the management and delivery of GN services in the province. Stakeholder surveys previously conducted by ORN identified that both clinicians and patients do not perceive access to GN medications as comprehensive or timely. The program conducted a focused jurisdictional scan among 7 provinces to inform ORN initiatives to improve access to GN medications. Specifically, the program examined clinician experience with GN access, public drug coverage criteria, and timelines for public coverage for select IS agents (ie, tacrolimus, cyclosporine, mycophenolate mofetil [MMF], mycophenolate sodium, rituximab, and eculizumab) used to manage GN in adults who live in Canada.

Methods

For the selected IS agents, a focused jurisdictional scan on medication access was conducted by ORN in 2018 and updated in July 2022. Information was obtained by searching the gray literature and/or credible online sources for public funding policies and eligibility criteria. Findings were supplemented by personal communications with provincial drug programs and consulting GN clinical experts from 7 provinces (ie, Alberta, British Columbia, Saskatchewan, Manitoba, Ontario, Nova Scotia, and Quebec).

Key Findings

Clinicians from different provinces prescribe IS agents similarly for GN indications, despite distinctions in public drug funding policies. While patients can obtain public funding for many IS agents, for GN, most provinces rely on case-by-case review processes. In addition, provinces can vary in their funding criteria and which IS agents are listed on the public formulary. For IS agents that require prior authorization or case-by-case review, timelines vary by province with decisions taking a few days to weeks. British Columbia, with a GN-specific drug formulary, had the most integrated and efficient system for patients and prescribers.

Limitations

This scan primarily relied on publicly available information for drug coverage criteria and clinician experience with access in their province. Since this scan was conducted, public drug coverage criteria and/or application processes may have changed.

Implications

While patients in most provinces have similar needs and nephrologists similar prescribing patterns, gaps still exist for publicly funded GN medications. Interprovincial differences in the drugs funded, funding criteria, and application process may affect timely and equitable access to GN medications across Canada. Given the rarity of GN, a pan-Canadian funding approach may be warranted to improve the current state.

Structure and Function of a Provincial Renal Pharmacy Program: Applying the Chronic Care Model to Address Equitable Access to Medication and Pharmacy Services

Purpose

We described the rationale, structure, design, and components of a provincial pharmacy services network for patients with kidney disease as a model for enabling equitable access and universal care to pharmacy services and medications across a wide range of clinical conditions, and geographic expanse in British Columbia (BC).

Sources of Information

These include minutes from 53 Pharmacy Services and Formulary (PS&F) Committee meetings held from 1999 to November 2022, documentation available on the British Columbia Renal (BCR) website, direct observation and participation in committee meetings, as well as interviews with key individuals involved in different aspects of the program.

Methods

We reviewed documents and data describing the evolution, rationale, and functioning of the BCR provincial pharmacy services system and used a variety of sources as mentioned above. In addition, a qualitative thematic synthesis of reports of chronic care models (CCMs) was conducted to map the program components into the chronic disease management models.

Key Findings

The components of the provincial pharmacy program (PPP) include (1) a PS&F committee, with interdisciplinary and geographical representation; (2) a community of dispensing pharmacies with standardized protocols and information; (3) a dedicated medication and pharmacy services budget, and regular evaluation of budget, outcomes, and performance; (4) provincial contracts for specific medications; (5) communication and education; and (6) information management system. Program components are described in the context of chronic disease management models. The PPP includes dedicated formularies for people with kidney disease at different points in the disease trajectory, including those on and off dialysis. Equitable access to medications is supported across the province. All medications and counseling services are provided to all patients registered in the program, through a robust distributed model, including community- and hospital-based pharmacies. Provincial contracts managed centrally ensure best economic value, and centralized education and accountability structures ensure sustainability.

Limitations

Limitations of the current report include lack of formal evaluation of the program on patient outcomes, but this is relative as the intention of this article is to describe the program which has existed for over 20 years and is fully functional. Formal evaluation of a complex system would include by costs, cost avoidance, provider, and patients' satisfaction. We are developing a formal plan for this reason.

Implications

The PPP is embedded in the provincial infrastructure of BCR and enables the provision of essential medications and pharmacy services for patients with kidney disease throughout the spectrum. The leveraging of local and provincial resources, knowledge, and expertise to implement a comprehensive PPP, ensures transparency and accountability and may serve as a model for other jurisdictions.

Rituximab for Adults With Multi-Drug Resistant Focal Segmental Glomerulosclerosis: A Case Series and Review of the Literature

Background:

Adults with primary focal segmental glomerulosclerosis (FSGS) are frequently resistant to multiple immunosuppressive agents, which is associated with ongoing complications of nephrotic syndrome and a high risk of progression to end-stage renal disease (ESRD). Rituximab, a monoclonal antibody against the B cell CD20 antigen, has shown some preliminary evidence in treating nephrotic syndrome.

Objectives:

Describe the usage and the efficacy of rituximab for adults with FSGS in British Columbia (BC) (Canada) and perform a literature review of multi-immunosuppressive drug resistant FSGS in adult patients treated with rituximab to estimate the overall response rate.

Design:

Case series report and a literature review.

Patients:

For the case-series, all BC patients who received rituximab for a diagnosis of primary FSGS were included. The literature review included all cases of immunosuppressive-resistant FSGS patients treated with rituximab. We excluded transplant and pediatric patients in both groups.

Methods:

We describe all cases of adults with native-kidney FSGS resistant to conventional immunosuppressive medications from our provincial health database who were treated with rituximab from 2014 to 2018. A review of the existing literature was performed via PubMed, MEDLINE, and Embase using the following keywords: rituximab, focal segmental glomerulosclerosis, and FSGS up to August 2019.

Results:

We characterize four immunosuppressive-resistant FSGS patients who were treated with rituximab as part of our provincial program, all of whom showed a response to rituximab with a sustained remission. We found 29 specific cases in the literature of adults with native-kidney FSGS treated with rituximab after being resistant to other immunosuppressive medications, of whom 15 cases showed a response to rituximab. This has increased the total response rate from 15/29 (52%) to 19/33 (58%).

Limitations:

Literature on this topic is coming predominantly from case series. Prospective trials are needed to confirm efficacy, tolerability, and duration of remission.

Conclusions:

Due to the low number of currently reported cases and variable response rates, these four cases provide critical data to generate a more accurate understanding of the role of rituximab in adults with resistant FSGS. Adding these results to the confirmed literature cases of multiple-immunosuppressive-resistant FSGS patients treated with rituximab results in a total remission rate of 19/33 cases.

Provincial Needs Assessment to Determine the Current State of Glomerulonephritis Care in Ontario

Background:

Despite its relative rarity, glomerulonephritis (GN) accounts for 20% of prevalent end-stage renal disease patients in Ontario. Early identification and appropriate management of GN to delay progression of disease can reduce patient morbidity and health system costs. As such, a provincial GN needs assessment was conducted to inform on the development of the provincial GN strategic framework in Ontario.

Objective:

To understand the current state of GN care in Ontario from nephrologist, hospital administrator, and patient and family perspectives.

Design:

Cross-sectional.

Settings:

26 regional renal programs in Ontario.

Patients:

23 patients and family members living with GN who do not require renal replacement therapy.

Measurements:

Patient and family member interviews as well as a survey of nephrologists.

Methods:

The study included 3 components: (1) interviews with patients and family members, (2) a survey of nephrologists, and (3) interviews with regional renal programs. The Ontario Renal Network provincial office developed the needs assessment questions and the physician survey questions after consultation with practicing nephrologists and hospital administrators. Thematic analysis was used to assess interview data and descriptive statistics to assess survey data.

Results:

Interviews with patients and family members (n = 23) identified gaps in care related to diagnosis and referral to nephrology care, education and decision-making, and psychosocial supports. The survey of nephrologists (n = 74) identified various issues that contribute to unstandardized GN care across Ontario, including a lack of provincial expertise in providing complex GN care, access to medication, multidisciplinary team support as well as patient education, and psychosocial supports. Interviews with regional renal programs aligned with interview and survey findings (n = 11).

Limitations:

Interviews with patients and family members were facilitated by 1 interviewer and limited to 20 interviews due to resource limitations. All nephrologists, patients, and family members who participated in the survey and interviews were volunteers and English-speaking, which may have resulted in self-selection bias.

Conclusions:

The provincial GN needs assessment emphasized the necessity to develop and implement a provincial GN strategy. The strategic framework includes 4 objectives: (1) ensure patients are supported to make informed decisions, (2) establish a provincial model of care, (3) leverage data to enable planning, decision-making, and monitoring of outcomes, and (4) ensure appropriate access to medication. This is the first Ontario strategy to address provincial gaps in GN care.