Canadian chronic kidney disease clinics: a national survey of structure, function and models of care

Effect of a Novel Multicomponent Intervention to Improve Patient Access to Kidney Transplant and Living Kidney Donation: The EnAKT LKD Cluster Randomized Clinical Trial

Importance

Patients with advanced chronic kidney disease (CKD) have the best chance for a longer and healthier life if they receive a kidney transplant. However, many barriers prevent patients from receiving a transplant.

Objectives

To evaluate the effect of a multicomponent intervention designed to target several barriers that prevent eligible patients from completing key steps toward receiving a kidney transplant.

Design, Setting, and Participants

This pragmatic, 2-arm, parallel-group, open-label, registry-based, superiority, cluster randomized clinical trial included all 26 CKD programs in Ontario, Canada, from November 1, 2017, to December 31, 2021. These programs provide care for patients with advanced CKD (patients approaching the need for dialysis or receiving maintenance dialysis).

Interventions

Using stratified, covariate-constrained randomization, allocation of the CKD programs at a 1:1 ratio was used to compare the multicomponent intervention vs usual care for 4.2 years. The intervention had 4 main components, (1) administrative support to establish local quality improvement teams; (2) transplant educational resources; (3) an initiative for transplant recipients and living donors to share stories and experiences; and (4) program-level performance reports and oversight by administrative leaders.

Main Outcomes and Measures

The primary outcome was the rate of steps completed toward receiving a kidney transplant. Each patient could complete up to 4 steps: step 1, referred to a transplant center for evaluation; step 2, had a potential living donor contact a transplant center for evaluation; step 3, added to the deceased donor waitlist; and step 4, received a transplant from a living or deceased donor.

Results

The 26 CKD programs (13 intervention, 13 usual care) during the trial period included 20 375 potentially transplant-eligible patients with advanced CKD (intervention group [n = 9780 patients], usual-care group [n = 10 595 patients]). Despite evidence of intervention uptake, the step completion rate did not significantly differ between the intervention vs usual-care groups: 5334 vs 5638 steps; 24.8 vs 24.1 steps per 100 patient-years; adjusted hazard ratio, 1.00 (95% CI, 0.87-1.15).

Conclusions and Relevance

This novel multicomponent intervention did not significantly increase the rate of completed steps toward receiving a kidney transplant. Improving access to transplantation remains a global priority that requires substantial effort.

Trial Registration

ClinicalTrials.gov Identifier: NCT03329521.

Priorities for peer support delivery among adults living with chronic kidney disease: a patient-oriented consensus workshop

BACKGROUND

Peer support can address the informational and emotional needs of people living with chronic kidney disease (CKD) and enable self-management. We aimed to identify preferences and priorities for content, format and processes of peer support delivery for patients with non-dialysis CKD and their loved ones.

METHODS

Using a patient-oriented research approach, we conducted a half-day, virtual consensus workshop with stakeholder participants from across Canada, including patients, caregivers, peer mentors and clinicians. Using personas (fictional characters), participants discussed and voted on preferences for delivery of peer support across format, content and process categories. We analyzed transcripts from small- and large-group discussions inductively using content analysis.

RESULTS

Twenty-one stakeholders, including 9 patients and 4 caregivers, participated in the workshop. In the voting exercise on format, participants prioritized peer mentor matching, programming for both patients and caregivers, and flexible scheduling. For content, participants prioritized informational and emotional support focus, and for process, they prioritized leveraging kidney care programs and alternative sources (e.g., social media) for promotion and referral. Analysis of workshop transcripts complemented prioritization results and emphasized tailoring of peer support delivery to accommodate the diversity of people living with CKD and their support needs. This concept was elaborated in 3 themes, namely alignment of program features with needs, inclusive peer support options and multiple access points.

INTERPRETATION

We identified preferences for peer support delivery for people living with CKD and underscore the importance of tailored, flexible programming in this context. Findings could be used to develop, adapt or study CKD-focused peer support interventions.

Healthcare provider perspectives on integrating peer support in non-dialysis-dependent chronic kidney disease care: a mixed methods study

BACKGROUND

Peer support complements traditional models of chronic kidney disease (CKD) care through sharing of peer experiences, pragmatic advice, and resources to enhance chronic kidney disease self-management and decision-making. As peer support is variably offered and integrated into multi-disciplinary CKD care, we aimed to characterize healthcare providers' experiences and views on peer support provision for people with non-dialysis-dependent CKD within Canada.

METHODS

In this concurrent mixed methods study, we used a self-administered online survey to collect information from multi-disciplinary CKD clinic providers (e.g., nurses, nephrologists, allied health professionals) on peer support awareness, program characteristics and processes, perceived value, and barriers and facilitators to offering peer support in CKD clinics. Results were analyzed descriptively. We undertook semi-structured interviews with a sample of survey respondents to elaborate on perspectives about peer support in CKD care, which we analyzed using inductive, content analysis.

RESULTS

We surveyed 113 providers from 49 clinics. Two thirds (66%) were aware of formal peer support programs, of whom 19% offered in-house peer support through their clinic. Peer support awareness differed by role and region, and most referrals were made by social workers. Likert scale responses suggested a high perceived need of peer support for people with CKD. Top cited barriers to offering peer support included lack of peer support access and workload demands, while facilitators included systematic clinic processes for peer support integration and alignment with external programs. Across 18 interviews, we identified themes related to peer support awareness, logistics, and accessibility and highlighted a need for integrated support pathways.

CONCLUSIONS

Our findings suggest variability in awareness and availability of peer support among Canadian multi-disciplinary CKD clinics. An understanding of the factors influencing peer support delivery will inform strategies to optimize its uptake for people with advanced CKD.

Multifaceted Intervention to Increase the Use of Home Dialysis: A Cluster Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Home dialysis therapies (peritoneal and home hemodialysis) are less expensive and provide similar outcomes to in-center hemodialysis, but they are underutilized in most health systems. Given this, we designed a multifaceted intervention to increase the use of home dialysis. In this study, our objective was to evaluate the effect of this intervention on home dialysis use in CKD clinics across Canada.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a cluster randomized controlled trial in 55 CKD clinic clusters in nine provinces in Canada between October 2014 and November 2015. Participants included all adult patients who initiated dialysis in the year following the intervention. We evaluated the implementation of a four-component intervention, which included phone surveys from a knowledge translation broker, a 1-year center-specific audit/feedback on home dialysis use, delivery of an educational package (including tools aimed at both providers and patients), and an academic detailing visit. The primary outcome was the proportion of patients using home dialysis at 180 days after dialysis initiation.

RESULTS

A total of 55 clinics were randomized (27 in the intervention and 28 in the control), with 5312 patients initiating dialysis in the 1-year follow-up period. In the primary analysis, there was no difference in the use of home dialysis at 180 days in the intervention and control clusters (absolute risk difference, 4%; 95% confidence interval, -2% to 10%). Using a difference-in-difference comparison, the use of home dialysis at 180 days was similar before and after implementation of the intervention (difference of 0% in intervention clinics; 95% confidence interval, -2% to 3%; difference of 0.8% in control clinics; 95% confidence interval, -1% to 3%; P=0.84).

CONCLUSIONS

A multifaceted intervention did not increase the use of home dialysis in adults initiating dialysis.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

A Cluster Randomized Trial to Assess the Impact of Patient and Provider Education on Use of Home Dialysis, NCT02202018.

Nephrologists' Attitudes Regarding Psychosocial Care in Hemodialysis Units

Background:

There is a high prevalence of psychosocial issues affecting patients with kidney failure.

Objective:

We sought to examine Canadian nephrologists’ attitudes and opinions regarding the importance of renal patient psychosocial care, nephrologists’ roles, and experience with psychosocial care in addition to what barriers, if any, prevent these physicians from providing psychosocial care to their patients.

Design:

A self-administered, survey questionnaire.

Setting:

Online.

Sample:

Canadian Society of Nephrology members who predominantly work in clinical care with adult, in-center hemodialysis patients.

Measurements:

Measurements of the survey include demographics, training, and nephrologists’ opinions regarding their role in administering psychosocial care, potential administrative and patient time constraints, accessibility of other health care workers for this activity, and factors that influence or impede physicians’ ability to address their patients’ psychosocial needs.

Methods:

A self-administered survey was sent to almost 500 members of the Canadian Society of Nephrology between November 2018 and December 2018. The survey questionnaire was designed to gather opinions and attitudes on psychosocial care delivery as well as potential influencing factors on nephrologists’ ability to provide this care. A univariate statistical analysis was used to analyze survey responses.

Results:

A total of 30 nephrologists responded to the survey, generating a 6% response rate. Respondents varied across provinces, with the majority being staff nephrologists (80%). While over 94% of respondents either agreed or strongly agreed that focus on psychosocial care improves patient outcomes, only 43% felt that staff nephrologists were suited to provide this care to patients; 97% of respondents believed social workers to be the most suited to provide this. Lack of additional supporting health care members, the need for additional training, too many administrative duties, and empathy fatigue were some of the predominant barriers respondents felt prevented them from addressing the psychosocial care of their patients.

Limitations:

A low response rate for the survey was obtained, roughly 6%, limiting our ability to draw definitive conclusions. Survey answers by respondents may be different from those by nonrespondents. Answers may be subject to social desirability and/or selection bias.

Conclusion:

Nephrologists believe that the current psychosocial care of patients in hemodialysis units is inadequate. However, further research is necessary to elucidate the barriers nephrologists face in providing psychosocial care and the changes required to most effectively implement optimal psychosocial care for patients with kidney failure in hemodialysis units.

The WISHED Randomized Controlled Trial: Impact of an Interactive Health Communication Application on Home Dialysis Use in People With Chronic Kidney Disease

Background:

While home dialysis therapies are more cost effective and may offer improved health-related quality of life, uptake compared to in-center hemodialysis remains low.

Objective:

To test whether a web-based interactive health communication application (IHCA) compared to usual care would increase home dialysis use.

Design:

Randomized control trial

Setting:

Patients were recruited from 3 multidisciplinary kidney clinics across Ontario, Canada (Hamilton, Kingston, London).

Patients:

We included adults with advanced chronic kidney disease (CKD) followed in multidisciplinary kidney clinics. Patients who had not completed dialysis modality education, who did not have access to a home computer or the internet, who had significant hearing or vision impairment, who could not read/write/speak English, who had a medical contraindication for home dialysis, or who had selected conservative kidney care were excluded.

Measurements:

The primary outcome was any use of home dialysis (peritoneal dialysis or home hemodialysis) within 90 days of dialysis initiation. Secondary outcomes were social support, decision conflict and dialysis knowledge measured at baseline, 6 months and 1 year.

Methods:

Eligible patients were randomized to either usual care or the IHCA in addition to usual care in a 1:1 ratio. As part of usual care, all patients received education about dialysis modalities and kidney transplantation delivered by clinic nurses according to local practices. Randomization was performed using a computer-generated sequence in randomly permuted block sizes, stratified by site, and allocation occurred using sequentially numbered sealed, opaque envelopes. Participants, care providers, and outcome assessors were not blinded to the intervention. All analyses were performed blinded using an intention to treat approach. We estimated the effect of the ICHA on the odds of the primary outcome using unadjusted logistic regression models. Linear mixed models for repeated measures over time were used to analyze the impact of the IHCA on the secondary outcomes of interest.

Results:

We randomized 140 (usual care, n = 71; IHCA, n = 69) out of a planned 264 patients (mean [SD] age 61 [14.5] years, 65% men). Among patients randomized to the IHCA group that completed 6-month and 1-year follow-up visits, 56.8% and 71.4%, respectively, had not accessed the IHCA website within the past month. There were 23 (32.4%) and 26 (37.7%) patients in the usual care and IHCA groups who received a home dialysis therapy within 90 days of dialysis initiation (odds ratio, OR = 1.3, 95% CI = [0.6-2.5], P = .5). Among the 78 patients who initiated dialysis (n = 38 usual care, n = 40 IHCA), 60.5% and 65% in the usual care and IHCA groups received a home therapy within 90 days of dialysis initiation (OR = 1.2, 95% CI = [0.5-3.0], P = .7). Secondary outcomes did not differ by intervention group over time.

Limitations:

The trial was underpowered due to poor recruitment and use of the IHCA was low.

Conclusions:

We did not find evidence of a difference in home dialysis uptake with IHCA use, but our analyses were notably underpowered. The incorporation of greater patient engagement, qualitative research and design research, and pilot implementation may help future evaluations of strategies to improve home dialysis uptake.

Trial Registration:

ClinicalTrials.gov #NCT01403454, registration date: Jul 21, 2011

An Environmental Scan of Ambulatory Care Quality Indicators for Patients With Advanced Kidney Disease Currently Used in Canada

Background:

Quality indicators can be used to identify gaps in care and drive frontline improvement activities. These efforts are important to prevent adverse events in the increasing number of ambulatory patients with advanced kidney disease in Canada, but it is unclear what indicators exist and the components of health care quality they measure.

Objective:

We sought to identify, categorize, and evaluate quality indicators currently in use across Canada for ambulatory patients with advanced kidney disease.

Design:

Environmental scan of quality indicators currently being collected by various organizations.

Setting:

We assembled a 16-member group from across Canada with expertise in nephrology and quality improvement.

Patients:

Our scan included indicators relevant to patients with chronic kidney disease in ambulatory care clinics.

Measurements:

We categorized the identified quality indicators using the Institute of Medicine and Donabedian frameworks.

Methods:

A 4-member panel used a modified Delphi process to evaluate the indicators found during the environmental scan using the American College of Physicians/Agency for Healthcare Research and Quality criteria. The ratings were then shared with the full panel for further comments and approval.

Results:

The environmental scan found 28 quality indicators across 7 provinces, with 8 (29%) rated as “necessary” to distinguish high-quality from poor-quality care. Of these 8 indicators, 3 were measured by more than 1 province (% of patients on a statin, number of patients receiving a preemptive transplant, and estimated glomerular filtration rate at dialysis start); no indicator was used by more than 2 provinces. None of the indicators rated as necessary measured timely or equitable care, nor did we identify any measures that assessed the setting in which care occurs (ie, structure measures).

Limitations:

Our list cannot be considered as an exhaustive list of available quality indicators at hand in Canada. Our work focused on quality indicators for nephrology providers and programs, and not indicators that can be applied across primary and specialty providers. We also focused on indicator constructs and not the detailed definitions or their application. Last, our panel does not represent the views of other important stakeholders.

Conclusions:

Our environmental scan provides a snapshot of the scope of quality indicators for ambulatory patients with advanced kidney disease in Canada. This catalog should inform indicator selection and the development of new indicators based on the identified gaps, as well as motivate increased pan-Canadian collaboration on quality measurement and improvement.

Trial registration:

Not applicable as this article is not a systematic review, nor does it report results of a health intervention on human participants.

Advanced Chronic Kidney Disease Units in Spain: a national survey on standards of structure, resources, results and patient safety

BACKGROUND AND OBJECTIVE

Recently, the Advanced Chronic Kidney Disease Units (UERCA, in Spanish) have been developed in Spain to offer a better quality of life to patients with advanced chronic kidney disease (ACKD), improving their survival and reducing morbidity in this phase of the disease. Nowadays, there is not much evidence in the Spanish and international literature regarding the structure and how to achieve these objectives in the UERCA. From the ERCA working group of the Spanish Society of Nephrology (SEN), this project is promoted to improve care for ERCA patients through the definition of quality standards for the operation of the UERCA.

MATERIAL AND METHODS

An initial proposal for quality standards concerning the operation of the UERCA was configured through consultation with the main sources of references and the advice of an expert working group through face-to-face and telematic meetings. Base on this initial proposal of standards, a survey was conducted and sent it via email to 121 nephrology specialist and nursing professionals with experience in Spanish UERCA to find out, among others, the suitability of each standards, that is, its mandatory nature or recommendation as standards. The access to the survey was allowed between July 16^th, 2018, until September 26^th, 2018.

RESULTS

A total of 95 (78.5%) professionals participated out of the 121 who were invited to participate. Of these, 80 of the participants were nephrology specialists and 15 nursing professionals, obtaining a varied representation of professionals from the Spanish geography. After analyzing the opinions of these participants, the standards were defined to a total of 68, 37 of them (54.4%) mandatory and 31 of them (45.5%) recommended. Besides, it was observed that the volume of patients attended in the UERCA is usually above 100 patients, and the referral criteria is generally below 25-29 mL/min/1.73 m² of glomerular filtration.

CONCLUSIONS

This work constitutes a first proposal of quality standards for the operation of UERCA in Spain. The definition of these standards has made it possible to establish the bases for the standardization of the organization of UERCA, and to subsequently work on the configuration of a standards manual for the accreditation of ERCA Units.

The Impact of a New Triage and Booking System on Renal Clinic Wait Times

Background:

Prolonged wait times are known barriers to accessing nephrology care for patients needing more urgent specialist services. Improved process and standardized triage systems are known to minimize wait times of urgent or semi-urgent care in health care disciplines. In Central Zone (CZ) renal clinic, mean wait times for urgent (P1) and semi-urgent (P2) referrals were prolonged before 2014. We also observed prolonged wait times for elective (P3-P5) categories. Improving wait times was identified as an access to care quality improvement focus in CZ renal clinic of the Nova Scotia Health Authority (NSHA).

Objectives:

To describe our new referral process and new triage system, and to examine their effect on number of referrals wait-listed and mean wait times.

Design:

A quasi-experimental design was used.

Setting:

Halifax, Nova Scotia, Canada.

Participants:

Patients referred to Central Zone Renal Clinic between 2012 and 2018.

Measurements:

A time series of referral counts and wait times for each triage category were measured before our interventions and after implementing our interventions.

Methods:

We reviewed our referral processes to identify gaps leading to prolonged wait times. On January 1, 2014, we implemented new administrative procedures: pretriage (standardized referral information form and staff training), triage (standardized clinic intake criteria and new triage guidelines), posttriage (protecting clinic spots for urgent and semi-urgent referrals, wait-list maintenance, and increasing new referral clinic capacity). Data were collected prospectively. Descriptive analysis on mean wait times was done using run charts.

Results:

A 33% reduction in total number of referrals wait-listed was observed over 4.5 years after intervention. Descriptive analysis of the urgent and semi-urgent categories (P1 and P2) revealed a significant shift of mean wait times on run charts after the interventions. Target wait time was achieved in 94% of P1 category and 78% of P2 category.

Limitations:

This type of study design does not exclude confounding variables influencing results. We did not explore stakeholder satisfaction or whether the new referral process presented barriers to resending referrals that had insufficient triage data. The long-term sustainability of adding demand-responsive surge clinics and opportunity cost were not assessed. Our referral process and triage system have not been externally validated and may not be applicable in settings without wait-lists or settings that use electronic, telephone or telemedicine consults.

Conclusion:

Our selective intake of referrals with adequate triage information and referrals needing nephrology consult as defined by our clinic intake criteria reduced number of referrals wait-listed. We saw improved wait times for urgent and semi-urgent referrals with these categories now falling within target wait times for the vast majority of patients. The work of this improvement initiative continues especially for the lower-risk triage categories.

Trial registration:

Not applicable as this was a Quality improvement initiative.

Multidisciplinary Chronic Kidney Disease Clinic Practices: A Scoping Review

Background:

Multidisciplinary chronic kidney disease (CKD) clinics improve patient outcomes but their optimal design is unclear.

Objective:

To perform a scoping review to identify and describe current practices (structure, function) associated with multidisciplinary CKD clinics.

Design:

Scoping review.

Setting:

Databases included Medline, EMBASE, Cochrane, and CINAHL.

Patients:

Patients followed in multidisciplinary CKD clinics globally.

Measurements:

Multidisciplinary CKD clinic composition, entry criteria, follow-up, and outcomes.

Methods:

We systematically searched the literature to identify randomized controlled trials, non-randomized interventional studies, or observational studies of multidisciplinary CKD clinics defined by an outpatient setting where two or more allied health members (with or without a nephrologist) provided longitudinal care to 50 or more adult or pediatric patients with CKD. Included studies were from 2002 to present. Searches were completed on August 10, 2018. Title, abstracts, and full texts were screened independently by two reviewers with disagreements resolved by a third. We abstracted data from included studies to summarize multidisciplinary CKD clinic team composition, entry criteria, follow-up, and processes.

Results:

40 studies (8 randomized controlled trials and 32 non-randomized interventional studies or observational studies) involving 23 230 individuals receiving multidisciplinary CKD care in 12 countries were included. Thirty-eight focused on adults (27 with CKD, 10 incident dialysis patients, one conservative therapy) while two studies focused on adolescents or children with CKD. The multidisciplinary team included a mean of 4.6 (SD 1.5) members consisting of a nephrologist, nurse, dietician, social worker, and pharmacist in 97.4%, 86.8%, 84.2%, 57.9%, and 42.1% of studies respectively. Entry criteria to multidisciplinary CKD clinics ranged from glomerular filtration rates of 20 to 70 mL/min/1.73m² or CKD stages 1 to 5 without any proteinuria or risk equation-based criteria. Frequency of follow-up was variable by severity of kidney disease. Team member roles and standardized operating procedures were infrequently reported.

Limitations:

Unstandardized definition of multidisciplinary CKD care, studies limited to CKD defined by glomerular filtration rate, and lack of representation from countries other than Canada, Taiwan, the United States, and the United Kingdom.

Conclusions:

There is heterogeneity in multidisciplinary CKD team composition, entry criteria, follow-up, and processes with inadequate reporting of this complex intervention. Additional research is needed to determine the best model for multidisciplinary CKD clinics.

Trial registration:

Not applicable.

Capacity of Kidney Care in Canada: Identifying Barriers and Opportunities

BACKGROUND

Chronic kidney disease (CKD) is a significant health problem in Canada. Understanding the capacity of the Canadian health-care system to deliver kidney care is important to provide optimal care.

OBJECTIVE

To compare Canada's position in relation to countries of similar economic standing.

DESIGN

Cross-sectional electronic survey.

SETTING

Member countries of the Organisation for Economic Co-operation and Development (OECD) that participated in the survey.

PARTICIPANTS

Nephrologists, other physicians, policymakers, and other professionals with relevant expertise in kidney care.

MEASUREMENTS

Not applicable.

METHODS

A survey administered by the International Society of Nephrology assessed the global capacity of kidney care delivery. Data from participating OECD countries were analyzed using descriptive statistics to compare Canada's position.

RESULTS

Of the participating countries, most funded kidney care services (non-medication) by government (transplantation: 85%, dialysis: 81%, acute kidney injury (AKI): 77%). Most countries covered medication. Canada reported a public funding model for kidney services and a mix of public and private sources for medication. Nephrologists and nephrology trainee densities were lower in Canada compared to the median (15.33 vs. 25.82 and 1.74 vs. 3.94, respectively). CKD was recognized as a health priority in five countries, but not in Canada. Registries for CKD did not exist in most (24/26) countries. Canada followed a national strategy for noncommunicable diseases, but this was not specific to CKD care, dialysis, or transplantation.

LIMITATIONS

Risks of recall bias or social desirability bias are present. Differences in a number of factors could influence discrepancies among countries and were not explored. Responses reflected the existence of practices, policies, and strategies, and may not necessarily describe action or impact. Capacity of care is not equal across all regions and provinces within Canada; however, the findings are reported on a national level and therefore may not appropriately address variability.

CONCLUSIONS

This study describes the capacity for kidney care at a national level within the context of the Canadian health system. The Canadian health-care system is well funded by the government; however, there are areas that could be improved to increase the optimization of kidney care provided.

Referral for Kidney Transplantation in Canadian Provinces

BACKGROUND

Patient referral to a transplant facility, a prerequisite for dialysis-treated patients to access kidney transplantation in Canada, is a subjective process that is not recorded in national dialysis or transplant registries. Patients who may benefit from transplant may not be referred.

METHODS

In this observational study, we prospectively identified referrals for kidney transplant in adult patients between June 2010 and May 2013 in 12 transplant centers, and linked these data to information on incident dialysis patients in a national registry.

RESULTS

Among 13,184 patients initiating chronic dialysis, the cumulative incidence of referral for transplant was 17.3%, 24.0%, and 26.8% at 1, 2, and 3 years after dialysis initiation, respectively; the rate of transplant referral was 15.8 per 100 patient-years (95% confidence interval, 15.1 to 16.4). Transplant referral varied more than three-fold between provinces, but it was not associated with the rate of deceased organ donation or median waiting time for transplant in individual provinces. In a multivariable model, factors associated with a lower likelihood of referral included older patient age, female sex, diabetes-related ESKD, higher comorbid disease burden, longer durations (>12.0 months) of predialysis care, and receiving dialysis at a location >100 km from a transplant center. Median household income and non-Caucasian race were not associated with a lower likelihood of referral.

CONCLUSIONS

Referral rates for transplantation varied widely between Canadian provinces but were not lower among patients of non-Caucasian race or with lower socioeconomic status. Standardization of transplantation referral practices and ongoing national reporting of referral may decrease disparities in patient access to kidney transplant.

Physical Activity In Renal Disease (PAIRED) and the effect on hypertension: study protocol for a randomized controlled trial

BACKGROUND

The prevalence of hypertension among people with chronic kidney disease is high with over 60% of people not attaining recommended targets despite taking multiple medications. Given the health and economic implications of hypertension, additional strategies are needed. Exercise is an effective strategy for reducing blood pressure in the general population; however, it is not known whether exercise would have a comparable benefit in people with moderate to advanced chronic kidney disease and hypertension.

METHODS

This is a parallel-arm trial of adults with hypertension (systolic blood pressure greater than 130 mmHg) and an estimated glomerular filtration rate of 15-45 ml/min 1.73 m2. A total of 160 participants will be randomized, with stratification for estimated glomerular filtration rate, to a 24-week, aerobic-based exercise intervention or enhanced usual care. The primary outcome is the difference in 24-h ambulatory systolic blood pressure after 8 weeks of exercise training. Secondary outcomes at 8 and 24 weeks include: other measurements of blood pressure, aortic stiffness (pulse-wave velocity), change in the Defined Daily Dose of anti-hypertensive drugs, medication adherence, markers of cardiovascular risk, physical fitness (cardiopulmonary exercise testing), 7-day accelerometry, quality of life, and adverse events. The effect of exercise on renal function will be evaluated in an exploratory analysis. The intervention is a thrice-weekly, moderate-intensity aerobic exercise supplemented with isometric resistance exercise delivered in two phases. Phase 1: supervised, facility-based, weekly and home-based sessions (8 weeks). Phase 2: home-based sessions (16 weeks).

DISCUSSION

To our knowledge, this study is the first trial designed to provide a precise estimate of the effect of exercise on blood pressure in people with moderate to severe CKD and hypertension. The findings from this study should address a significant knowledge gap in hypertension management in CKD and inform the design of a larger study on the effect of exercise on CKD progression.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03551119 . Registered on 11 June 2018.

Overview of Self-Management Resources Used by Canadian Chronic Kidney Disease Clinics: A National Survey

BACKGROUND

Chronic kidney disease (CKD) clinics across Canada provide tailored care for patients with CKD with an aim to slow progression and prevent complications. These clinics provide CKD self-management resources; however, there is limited information about what resources are being used by clinics. We undertook a survey of CKD clinics across Canada to identify self-management resources for adults aged 18 years and over with CKD categories 1 to 5 and not requiring dialysis or transplant.

OBJECTIVE

To identify and collate self-management resources (eg, strategies, tools, educational materials) used by CKD clinics across Canada for adults with CKD (categories 1 to 5, not requiring kidney replacement therapy).

DESIGN

Self-administered, semistructured electronic survey.

SETTING PARTICIPANTS

Canadian CKD clinics with previously identified contact information.

METHODS AND MEASUREMENTS

We contacted 57 CKD English-speaking clinics and invited them to complete an online survey. The survey was available from October 2016 to January 2017 and consisted of 17 questions regarding the use and attributes of self-management resources including topic, delivery format, provider, target population, where the intervention was provided, and resource languages.

RESULTS

Forty-four clinics (77%) completed the survey. The most common topic was modality education provided in print format, by nurses. The most frequently used resource was the Kidney Foundation of Canada (KFOC) Living With Kidney Disease manual. We also identified that the majority of resources were available in English, targeting both patients and caregivers in the outpatient setting.

LIMITATIONS

Our survey included Canadian adult CKD clinics, which may not be generalizability to other settings, such as care of people with CKD in primary care.

CONCLUSIONS

Adult CKD clinics across Canada provide some similar resources, but also provide many different self-management resources. Even though some of the same resources were used by multiple clinics, the way they were provided them (ie, provider, location, delivery format) varied by the individual clinics. Knowledge of self-management resources currently provided in CKD clinics, along with synthesis of the literature and patient preferred self-management strategies, will inform the design and development of a novel self-management intervention that is patient-centric and adheres to the principles of self-management.

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.

Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD): Form and Function

PURPOSE OF REVIEW

This article serves to describe the Can-SOLVE CKD network, a program of research projects and infrastructure that has excited patients and given them hope that we can truly transform the care they receive.

ISSUE

Chronic kidney disease (CKD) is a complex disorder that affects more than 4 million Canadians and costs the Canadian health care system more than $40 billion per year. The evidence base for guiding care in CKD is small, and even in areas where evidence exists, uptake of evidence into clinical practice has been slow. Compounding these complexities are the variations in outcomes for patients with CKD and difficulties predicting who is most likely to develop complications over time. Clearly these gaps in our knowledge and understanding of CKD need to be filled, but the current state of CKD research is not where it needs to be. A culture of clinical trials and inquiry into the disease is lacking, and much of the existing evidence base addresses the concerns of the researchers but not necessarily those of the patients.

PROGRAM OVERVIEW

The Canadian Institutes of Health Research (CIHR) has launched the national Strategy for Patient-Oriented Research (SPOR), a coalition of federal, provincial, and territorial partners dedicated to integrating research into care. Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) is one of five pan-Canadian chronic kidney disease networks supported through the SPOR. The vision of Can-SOLVE CKD is that by 2020 every Canadian with or at high risk for CKD will receive the best recommended care, experience optimal outcomes, and have the opportunity to participate in studies with novel therapies, regardless of age, sex, gender, location, or ethnicity.

PROGRAM OBJECTIVE

The overarching objective of Can-SOLVE CKD is to accelerate the translation of knowledge about CKD into clinical research and practice. By focusing on the patient's voice and implementing relevant findings in real time, Can-SOLVE CKD will transform the care that CKD patients receive, and will improve kidney health for future generations.

Global Kidney Health Atlas (GKHA): design and methods

There has been considerable effort within individual countries to improve the care of patients with kidney disease. There has been no concerted attempt to summarize these efforts, and therefore little is known about structuring health systems to facilitate acute kidney injury and chronic kidney disease (CKD) care and integration with national and international noncommunicable disease strategies. As part of the "Closing the Gaps Initiative," the International Society of Nephrology will conduct for the first time a survey of the current state of global kidney care covering both acute kidney injury and CKD and present the results in a Global Kidney Health Atlas. Data will be collected via an online questionnaire and targeted at national nephrology societies, policymakers, and consumer organizations. Individual country information will be provided by at least 3 stakeholders. The Global Kidney Health Atlas will provide concise, relevant, and synthesized information on the delivery of care across different health systems to facilitate understanding of performance variations over time and between countries. First, it will provide an overview of existing CKD care policy and context in the health care system. Second, it will provide an overview of how CKD care is organized in individual countries and a description of relevant CKD epidemiology between countries and regions, focusing on elements that are most germane to service delivery and policy development. Finally, synthesis, comparison, and analysis of individual country/regional data will be provided as a platform for recommendations to policymakers, practitioners, and researchers.

Perspectives on optimizing care of patients in multidisciplinary chronic kidney disease clinics

Purpose of review

To summarize a jointly held symposium by the Canadian Society of Nephrology (CSN), the Canadian Association of Nephrology Administrators (CANA), and the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) entitled “Perspectives on Optimizing Care of Patients in Multidisciplinary Chronic Kidney Disease (CKD) Clinics” that was held on April 24, 2015, in Montreal, Quebec.

Sources of information

The panel consisted of a variety of members from across Canada including a multidisciplinary CKD clinic patient (Randall Russell), nephrology fellow (Dr. David Collister), geriatrician (Dr. Josee Verdon), and nephrologists (Dr. Monica Beaulieu, Dr. Adeera Levin).

Findings

The objectives of the symposium were (1) to gain an understanding of the goals of care for CKD patients, (2) to gain an appreciation of different perspectives regarding optimal care for patients with CKD, (3) to examine the components required for optimal care including education strategies, structures, and tools, and (4) to describe a framework and metrics for CKD care which respect patient and system needs. This article summarizes the key concepts discussed at the symposium from a patient and physician perspectives. Key messages include (1) understanding patient values and preferences is important as it provides a framework as to what to prioritize in multidisciplinary CKD clinic and provincial renal program models, (2) barriers to effective communication and education are common in the elderly, and adaptive strategies to limit their influence are critical to improve adherence and facilitate shared decision-making, (3) the use of standardized operating procedures (SOPs) improves efficiency and minimizes practice variability among health care practitioners, and (4) CKD scorecards with standardized system processes are useful in approaching variability as well as measuring and improving patient outcomes.

Limitations

The perspectives provided may not be applicable across centers given the differences in patient populations including age, ethnicity, culture, language, socioeconomic status, education, and multidisciplinary CKD clinic structure and function.

Implications

Knowledge transmission by collaborative interprovincial and interprofessional networks may play a role in facilitating optimal CKD care. Validation of system and clinic models that improve outcomes is needed prior to disseminating these best practices.

Educating Patients about CKD: The Path to Self-Management and Patient-Centered Care

Patient education is associated with better patient outcomes and supported by international guidelines and organizations, but a range of barriers prevent widespread implementation of comprehensive education for people with progressive kidney disease, especially in the United States. Among United States patients, obstacles to education include the complex nature of kidney disease information, low baseline awareness, limited health literacy and numeracy, limited availability of CKD information, and lack of readiness to learn. For providers, lack of time and clinical confidence combine with competing education priorities and confusion about diagnosing CKD to limit educational efforts. At the system level, lack of provider incentives, limited availability of practical decision support tools, and lack of established interdisciplinary care models inhibit patient education. Despite these barriers, innovative education approaches for people with CKD exist, including self-management support, shared decision making, use of digital media, and engaging families and communities. Education efficiency may be increased by focusing on people with progressive disease, establishing interdisciplinary care management including community health workers, and providing education in group settings. New educational approaches are being developed through research and quality improvement efforts, but challenges to evaluating public awareness and patient education programs inhibit identification of successful strategies for broader implementation. However, growing interest in improving patient-centered outcomes may provide new approaches to effective education of people with CKD.

Trends in Arteriovenous Fistula Use at Dialysis Initiation After Automated eGFR Reporting

The purpose of this study was to examine trends in the presence of an arteriovenous fistula (AVF) at dialysis initiation before and after eGFR reporting. All incident dialysis patients from four Canadian provinces that implemented province-wide, automated laboratory reporting of eGFR with known vascular access at dialysis initiation were included in the study (N = 25,201) from 2001 to 2010. The primary outcome was the change in proportion of patients with an AVF at dialysis initiation using an interrupted time series and adjusted multilevel logistic regression models. AVF usage at dialysis initiation decreased gradually over the study period from 19.0% to 14.6%. After implementation of automated eGFR reporting, there was attenuation in the decline in AVF usage in models adjusted for case-mix, facility, and the downward trajectory in AVF use over time. The adjusted odds ratio for initiating dialysis with an AVF 1 year post-eGFR reporting compared to pre-eGFR reporting was more pronounced in older patients (age tertile >73; OR: 1.40; 95% CI: 1.04-1.90). Laboratory-based eGFR reporting was associated with a possible attenuation in the decline of AVF at dialysis initiation and this was more pronounced in older patients.