1
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Garg AX, Al-Jaishi AA, Dixon SN, Sontrop JM, Anderson SJ, Bagga A, Benjamin DS, Berry WAD, Blake PG, Chambers LC, Chan PCK, Delbrouck NF, Devereaux PJ, Goluch RJ, Gregor LH, Grimshaw JM, Hanson GJ, Illiescu EA, Jain AK, Killin L, Lok CE, Luo B, Mustafa RA, Nathoo BC, Nesrallah GE, Oliver MJ, Pandeya S, Parmar MS, Perkins DN, Presseau J, Rabin EZ, Sasal JT, Shulman TS, Smith DM, Sood M, Steele AW, Tam PYW, Tascona DJ, Wadehra DB, Wald R, Walsh M, Watson PA, Wodchis WP, Zager PG, Zwarenstein M, McIntyre CW. Personalised cooler dialysate for patients receiving maintenance haemodialysis (MyTEMP): a pragmatic, cluster-randomised trial. Lancet 2022; 400:1693-1703. [PMID: 36343653 DOI: 10.1016/s0140-6736(22)01805-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Haemodialysis centres have conventionally provided maintenance haemodialysis using a standard dialysate temperature (eg, 36·5°C) for all patients. Many centres now use cooler dialysate (eg, 36·0°C or lower) for potential cardiovascular benefits. We aimed to assess whether personalised cooler dialysate, implemented as centre-wide policy, reduced the risk of cardiovascular-related death or hospital admission compared with standard temperature dialysate. METHODS MyTEMP was a pragmatic, two-arm, parallel-group, registry-based, open-label, cluster-randomised, superiority trial done at haemodialysis centres in Ontario, Canada. Eligible centres provided maintenance haemodialysis to at least 15 patients a week, and the medical director of each centre had to confirm that their centre would deliver the assigned intervention. Using covariate-constrained randomisation, we allocated 84 centres (1:1) to use either personalised cooler dialysate (nurses set the dialysate temperature 0·5-0·9°C below each patient's measured pre-dialysis body temperature, with a lowest recommended dialysate temperature of 35·5°C), or standard temperature dialysate (36·5°C for all patients and treatments). Patients and health-care providers were not masked to the group assignment; however, the primary outcome was recorded in provincial databases by medical coders who were unaware of the trial or the centres' group assignment. The primary composite outcome was cardiovascular-related death or hospital admission with myocardial infarction, ischaemic stroke, or congestive heart failure during the 4-year trial period. Analysis was by intention to treat. The study is registered at ClinicalTrials.gov, NCT02628366. FINDINGS We assessed all of Ontario's 97 centres for inclusion into the study. Nine centres had less than 15 patients and one director requested that four of their seven centres not participate. 84 centres were recruited and on Feb 1, 2017, these centres were randomly assigned to administer personalised cooler dialysate (42 centres) or standard temperature dialysate (42 centres). The intervention period was from April 3, 2017, to March 31, 2021, and during this time the trial centres provided outpatient maintenance haemodialysis to 15 413 patients (about 4·3 million haemodialysis treatments). The mean dialysate temperature was 35·8°C in the cooler dialysate group and 36·4°C in the standard temperature group. The primary outcome occurred in 1711 (21·4%) of 8000 patients in the cooler dialysate group versus 1658 (22·4%) of 7413 patients in the standard temperature group (adjusted hazard ratio 1·00, 96% CI 0·89 to 1·11; p=0·93). The mean drop in intradialytic systolic blood pressure was 26·6 mm Hg in the cooler dialysate group and 27·1 mm Hg in the standard temperature group (mean difference -0·5 mm Hg, 99% CI -1·4 to 0·4; p=0·14). INTERPRETATION Centre-wide delivery of personalised cooler dialysate did not significantly reduce the risk of major cardiovascular events compared with standard temperature dialysate. The rising popularity of cooler dialysate is called into question by this study, and the risks and benefits of cooler dialysate in some patient populations should be clarified in future trials. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Renal Network, Ontario Strategy for Patient-Oriented Research Support Unit, Dialysis Clinic, Inc., ICES (formerly known as the Institute for Clinical Evaluative Sciences), Lawson Health Research Institute, and Western University.
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2
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Manns BJ, Garg AX, Sood MM, Ferguson T, Kim SJ, Naimark D, Nesrallah GE, Soroka SD, Beaulieu M, Dixon SN, Alam A, Allu S, Tangri N. Multifaceted Intervention to Increase the Use of Home Dialysis: A Cluster Randomized Controlled Trial. Clin J Am Soc Nephrol 2022; 17:535-545. [PMID: 35314481 PMCID: PMC8993468 DOI: 10.2215/cjn.13191021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/03/2022] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Braden J Manns
- Department of Medicine and Community Health Sciences, Libin Cardiovascular Institute and O'Brien Public Health Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Manish M Sood
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas Ferguson
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S Joseph Kim
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - David Naimark
- Division of Nephrology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | - Gihad E Nesrallah
- Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Steven D Soroka
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Monica Beaulieu
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie N Dixon
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ahsan Alam
- Division of Nephrology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Selina Allu
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
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3
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Tangri N, Garg AX, Ferguson TW, Dixon S, Rigatto C, Allu S, Chau E, Komenda P, Naimark D, Nesrallah GE, Soroka SD, Beaulieu M, Alam A, Kim SJ, Sood MM, Manns B. Effects of a Knowledge-Translation Intervention on Early Dialysis Initiation: A Cluster Randomized Trial. J Am Soc Nephrol 2021; 32:1791-1800. [PMID: 33858985 PMCID: PMC8425657 DOI: 10.1681/asn.2020091254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 02/19/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The Initiating Dialysis Early and Late (IDEAL) trial, published in 2009, found no clinically measurable benefit with respect to risk of mortality or early complications with early dialysis initiation versus deferred dialysis start. After these findings, guidelines recommended an intent-to-defer approach to dialysis initiation, with the goal of deferring it until clinical symptoms arise. METHODS To evaluate a four-component knowledge translation intervention aimed at promoting an intent-to-defer strategy for dialysis initiation, we conducted a cluster randomized trial in Canada between October 2014 and November 2015. We randomized 55 clinics, 27 to the intervention group and 28 to the control group. The educational intervention, using knowledge-translation tools, included telephone surveys from a knowledge-translation broker, a 1-year center-specific audit with feedback, delivery of a guidelines package, and an academic detailing visit. Participants included adults who had at least 3 months of predialysis care and who started dialysis in the first year after the intervention. The primary efficacy outcome was the proportion of patients who initiated dialysis early (at eGFR >10.5 ml/min per 1.73 m2). The secondary outcome was the proportion of patients who initiated in the acute inpatient setting. RESULTS The analysis included 3424 patients initiating dialysis in the 1-year follow-up period. Of these, 509 of 1592 (32.0%) in the intervention arm and 605 of 1832 (33.0%) in the control arm started dialysis early. There was no difference in the proportion of individuals initiating dialysis early or in the proportion of individuals initiating dialysis as an acute inpatient. CONCLUSIONS A multifaceted knowledge translation intervention failed to reduce the proportion of early dialysis starts in patients with CKD followed in multidisciplinary clinics. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER ClinicalTrials.gov, NCT02183987. Available at: https://clinicaltrials.gov/ct2/show/NCT02183987.
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Affiliation(s)
- Navdeep Tangri
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada,Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Amit X. Garg
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada,Department of Medicine, Western University, London, Ontario, Canada,Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Thomas W. Ferguson
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada,Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Stephanie Dixon
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada,Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Claudio Rigatto
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada,Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Selina Allu
- Department of Medicine and Community Health Sciences, Libin Cardiovascular Institute, Calgary, Canada,O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Elaine Chau
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada,Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada,Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - David Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gihad E. Nesrallah
- Institute for Clinical Evaluative Sciences, London, Ontario, Canada,Division of Nephrology, Humber River Hospital, Toronto, Ontario, Canada
| | - Steven D. Soroka
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada,Nova Scotia Health Authority Renal Program, Halifax, Nova Scotia, Canada
| | - Monica Beaulieu
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada,BC Renal Agency, Vancouver, British Columbia, Canada
| | - Ahsan Alam
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - S. Joseph Kim
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Manish M. Sood
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Braden Manns
- Department of Medicine and Community Health Sciences, Libin Cardiovascular Institute, Calgary, Canada,O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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4
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Parikh RV, Nash DM, Brimble KS, Markle-Reid M, Tan TC, McArthur E, Khoshniat-Rad F, Sood MM, Zheng S, Pravoverov L, Nesrallah GE, Garg AX, Go AS. Kidney Function and Potassium Monitoring After Initiation of Renin-Angiotensin-Aldosterone System Blockade Therapy and Outcomes in 2 North American Populations. Circ Cardiovasc Qual Outcomes 2020; 13:e006415. [PMID: 32873054 DOI: 10.1161/circoutcomes.119.006415] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical practice guidelines recommend routine kidney function and serum potassium testing within 30 days of initiating ACE (angiotensin-converting enzyme) inhibitor or angiotensin II receptor blocker therapy. However, evidence is lacking about whether follow-up testing reduces therapy-related adverse outcomes. METHODS AND RESULTS We conducted 2 population-based retrospective cohort studies in Kaiser Permanente Northern California and Ontario, Canada. Patients with outpatient serum creatinine and potassium tests in the 30 days after starting ACE inhibitor or angiotensin II receptor blocker therapy were matched 1:1 to patients without follow-up tests. We evaluated the association of follow-up testing with 30-day all-cause mortality and hospitalization with acute kidney injury or hyperkalemia using Cox regression. We also developed and externally validated a risk score to identify patients at risk of having abnormally high serum creatinine and potassium values in follow-up. We identified 75 251 matched pairs initiating ACE inhibitor or angiotensin II receptor blocker therapy between January 1, 2007, and December 31, 2017, in Kaiser Permanente Northern California. Follow-up testing was not significantly associated with 30-day all-cause mortality in Kaiser Permanente Northern California (hazard ratio, 0.75 [95% CI, 0.54-1.06]) and was associated with higher mortality in 84 905 matched pairs in Ontario (hazard ratio, 1.32 [95% CI, 1.07-1.62]). In Kaiser Permanente Northern California, follow-up testing was significantly associated with higher rates of hospitalization with acute kidney injury (hazard ratio, 1.66 [95% CI, 1.10-2.22]) and hyperkalemia (hazard ratio, 3.36 [95% CI, 1.08-10.41]), as was observed in Ontario. The risk score for abnormal potassium provided good discrimination (area under the curve [AUC], 0.75) and excellent calibration of predicted risks, while the risk score for abnormal serum creatinine provided moderate discrimination (AUC, 0.62) but excellent calibration. CONCLUSIONS Routine laboratory monitoring after ACE inhibitor or angiotensin II receptor blocker initiation was not associated with a lower risk of 30-day mortality. We identified patient subgroups in which targeted testing may be effective in identifying therapy-related changes in serum potassium or kidney function.
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Affiliation(s)
- Rishi V Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland (R.V.P., T.C.T., F.K.-R., A.S.G.)
| | - Danielle M Nash
- ICES, Ontario, Canada (D.M.N., E.M., M.M.S., A.X.G.).,Department of Health Research Methods, Evidence, and Impact (D.M.N., M.M.-R., A.X.G.), McMaster University, Hamilton, Ontario, Canada.,Ontario Renal Network, Toronto, Canada (D.M.N., G.E.N., A.X.G.)
| | - K Scott Brimble
- Department of Medicine (K.S.B.), McMaster University, Hamilton, Ontario, Canada
| | - Maureen Markle-Reid
- Department of Health Research Methods, Evidence, and Impact (D.M.N., M.M.-R., A.X.G.), McMaster University, Hamilton, Ontario, Canada.,School of Nursing (M.M.-R.), McMaster University, Hamilton, Ontario, Canada
| | - Thida C Tan
- Division of Research, Kaiser Permanente Northern California, Oakland (R.V.P., T.C.T., F.K.-R., A.S.G.)
| | - Eric McArthur
- ICES, Ontario, Canada (D.M.N., E.M., M.M.S., A.X.G.)
| | - Farzien Khoshniat-Rad
- Division of Research, Kaiser Permanente Northern California, Oakland (R.V.P., T.C.T., F.K.-R., A.S.G.)
| | - Manish M Sood
- ICES, Ontario, Canada (D.M.N., E.M., M.M.S., A.X.G.).,Division of Nephrology, University of Ottawa, Ontario, Canada (M.M.S.)
| | - Sijie Zheng
- Nephrology Service Line, The Permanente Medical Group (S.Z., L.P.).,Department of Nephrology, Kaiser Permanente Oakland Medical Center, CA (S.Z., L.P.)
| | - Leonid Pravoverov
- Nephrology Service Line, The Permanente Medical Group (S.Z., L.P.).,Department of Nephrology, Kaiser Permanente Oakland Medical Center, CA (S.Z., L.P.)
| | - Gihad E Nesrallah
- Ontario Renal Network, Toronto, Canada (D.M.N., G.E.N., A.X.G.).,Humber River Hospital, Toronto, Ontario, Canada (G.E.N.).,Department of Medicine, University of Toronto, Ontario, Canada (G.E.N.)
| | - Amit X Garg
- ICES, Ontario, Canada (D.M.N., E.M., M.M.S., A.X.G.).,Department of Health Research Methods, Evidence, and Impact (D.M.N., M.M.-R., A.X.G.), McMaster University, Hamilton, Ontario, Canada.,Ontario Renal Network, Toronto, Canada (D.M.N., G.E.N., A.X.G.).,Department of Medicine, Western University, London, Ontario, Canada (A.X.G.)
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland (R.V.P., T.C.T., F.K.-R., A.S.G.).,Departments of Epidemiology (A.S.G.).,Biostatistics (A.S.G.).,Medicine (A.S.G.).,University of California, San Francisco (A.S.G.).,Department of Medicine (Nephrology) and Health Research and Policy, Stanford University School of Medicine, CA (A.S.G.)
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5
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Al-Jaishi AA, McIntyre CW, Sontrop JM, Dixon SN, Anderson S, Bagga A, Benjamin D, Berry D, Blake PG, Chambers L, Chan PCK, Delbrouck N, Devereaux PJ, Ferreira-Divino LF, Goluch R, Gregor L, Grimshaw JM, Hanson G, Iliescu E, Jain AK, Lok CE, Mustafa RA, Nathoo B, Nesrallah GE, Oliver MJ, Pandeya S, Parmar MS, Perkins D, Presseau J, Rabin E, Sasal J, Shulman T, Sood MM, Steele A, Tam P, Tascona D, Wadehra D, Wald R, Walsh M, Watson P, Wodchis W, Zager P, Zwarenstein M, Garg AX. Major Outcomes With Personalized Dialysate TEMPerature (MyTEMP): Rationale and Design of a Pragmatic, Registry-Based, Cluster Randomized Controlled Trial. Can J Kidney Health Dis 2020; 7:2054358119887988. [PMID: 32076569 PMCID: PMC7003172 DOI: 10.1177/2054358119887988] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/23/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Small randomized trials demonstrated that a lower compared with higher dialysate temperature reduced the average drop in intradialytic blood pressure. Some observational studies demonstrated that a lower compared with higher dialysate temperature was associated with a lower risk of all-cause mortality and cardiovascular mortality. There is now the need for a large randomized trial that compares the effect of a low vs high dialysate temperature on major cardiovascular outcomes. OBJECTIVE The purpose of this study is to test the effect of outpatient hemodialysis centers randomized to (1) a personalized temperature-reduced dialysate protocol or (2) a standard-temperature dialysate protocol for 4 years on cardiovascular-related death and hospitalizations. DESIGN The design of the study is a pragmatic, registry-based, open-label, cluster randomized controlled trial. SETTING Hemodialysis centers in Ontario, Canada, were randomized on February 1, 2017, for a trial start date of April 3, 2017, and end date of March 31, 2021. PARTICIPANTS In total, 84 hemodialysis centers will care for approximately 15 500 patients and provide over 4 million dialysis sessions over a 4-year follow-up. INTERVENTION Hemodialysis centers were randomized (1:1) to provide (1) a personalized temperature-reduced dialysate protocol or (2) a standard-temperature dialysate protocol of 36.5°C. For the personalized protocol, nurses set the dialysate temperature between 0.5°C and 0.9°C below the patient's predialysis body temperature for each dialysis session, to a minimum dialysate temperature of 35.5°C. PRIMARY OUTCOME A composite of cardiovascular-related death or major cardiovascular-related hospitalization (a hospital admission with myocardial infarction, congestive heart failure, or ischemic stroke) captured in Ontario health care administrative databases. PLANNED PRIMARY ANALYSIS The primary analysis will follow an intent-to-treat approach. The hazard ratio of time-to-first event will be estimated from a Cox model. Within-center correlation will be considered using a robust sandwich estimator. Observation time will be censored on the trial end date or when patients die from a noncardiovascular event. TRIAL REGISTRATION www.clinicaltrials.gov; identifier: NCT02628366.
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Affiliation(s)
- Ahmed A. Al-Jaishi
- London Health Sciences Centre, ON, Canada
- ICES, ON, Canada
- McMaster University, Hamilton, ON, Canada
| | | | - Jessica M. Sontrop
- London Health Sciences Centre, ON, Canada
- Western University, London, ON, Canada
| | - Stephanie N. Dixon
- London Health Sciences Centre, ON, Canada
- ICES, ON, Canada
- Western University, London, ON, Canada
| | | | | | | | - David Berry
- Sault Area Hospital, Sault Ste. Marie, ON, Canada
| | - Peter G. Blake
- London Health Sciences Centre, ON, Canada
- Western University, London, ON, Canada
| | | | | | | | | | | | | | | | - Jeremy M. Grimshaw
- Ottawa Hospital Research Institute, ON, Canada
- University of Ottawa, ON, Canada
| | | | | | - Arsh K. Jain
- London Health Sciences Centre, ON, Canada
- ICES, ON, Canada
- Western University, London, ON, Canada
| | | | - Reem A. Mustafa
- McMaster University, Hamilton, ON, Canada
- University of Kansas Medical Center, Kansas City, USA
| | | | | | - Matthew J. Oliver
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- University of Toronto, ON, Canada
| | | | | | | | - Justin Presseau
- Ottawa Hospital Research Institute, ON, Canada
- University of Ottawa, ON, Canada
| | - Eli Rabin
- Niagara Health System, St. Catharines, ON, Canada
| | | | | | - Manish M. Sood
- ICES, ON, Canada
- Ottawa Hospital Research Institute, ON, Canada
- University of Ottawa, ON, Canada
| | | | - Paul Tam
- Scarborough Health Network, ON, Canada
| | | | | | - Ron Wald
- ICES, ON, Canada
- University of Toronto, ON, Canada
- St. Michael’s Hospital, Toronto, ON, Canada
| | - Michael Walsh
- McMaster University, Hamilton, ON, Canada
- St. Joseph’s Healthcare, Hamilton, ON, Canada
| | - Paul Watson
- Thunder Bay Regional Health Sciences Centre, ON, Canada
| | | | | | | | - Amit X. Garg
- London Health Sciences Centre, ON, Canada
- ICES, ON, Canada
- McMaster University, Hamilton, ON, Canada
- Western University, London, ON, Canada
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6
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Lee EJ, Patel A, Acedillo RR, Bachynski JC, Barrett I, Basile E, Battistella M, Benjamin D, Berry D, Blake PG, Chan P, Bohm CJ, Clemens KK, Cook C, Dember L, Dirk JS, Dixon S, Fowler E, Getchell L, Gholami N, Goldstein C, Hahn E, Hogeterp B, Huang S, Hughes M, Jardine MJ, Kalatharan S, Kilburn S, Lacson E, Leonard S, Liberty C, Lindsay C, MacRae JM, Manns BJ, McCallum J, McIntyre CW, Molnar AO, Mustafa RA, Nesrallah GE, Oliver MJ, Pandes M, Pandeya S, Parmar MS, Rabin EZ, Riley J, Silver SA, Sontrop JM, Sood MM, Suri RS, Tangri N, Tascona DJ, Thomas A, Wald R, Walsh M, Weijer C, Weir MA, Vorster H, Zimmerman D, Garg AX. Cultivating Innovative Pragmatic Cluster-Randomized Registry Trials Embedded in Hemodialysis Care: Workshop Proceedings From 2018. Can J Kidney Health Dis 2019; 6:2054358119894394. [PMID: 31903190 PMCID: PMC6933546 DOI: 10.1177/2054358119894394] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022] Open
Abstract
Hemodialysis is a life-sustaining treatment for persons with kidney failure. However, those on hemodialysis still face a poor quality of life and a short life expectancy. High-quality research evidence from large randomized controlled trials is needed to identify interventions that improve the experiences, outcomes, and health care of persons receiving hemodialysis. With the support of the Canadian Institutes of Health Research and its Strategy for Patient-Oriented Research, the Innovative Clinical Trials in Hemodialysis Centers initiative brought together Canadian and international kidney researchers, patients, health care providers, and health administrators to participate in a workshop held in Toronto, Canada, on June 2 and 3, 2018. The workshop served to increase knowledge and awareness about the conduct of innovative, pragmatic, cluster-randomized registry trials embedded into routine hemodialysis care and provided an opportunity to discuss and build support for new trial ideas. The workshop content included structured presentations, facilitated group discussions, and expert panel feedback. Partnerships and promising trial ideas borne out of the workshop will continue to be developed to support the implementation of future large-scale trials.
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Affiliation(s)
| | | | - Rey R. Acedillo
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
| | | | | | - Erika Basile
- Office of Human Research Ethics, Western
University, London, ON, Canada
| | - Marisa Battistella
- Department of Pharmacy, University
Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy,
University of Toronto, ON, Canada
| | - Derek Benjamin
- Royal Victoria Regional Health Centre,
Barrie, ON, Canada
| | - David Berry
- Algoma Regional Renal Program, Sault
Area Hospital, Sault Ste. Marie, ON, Canada
| | - Peter G. Blake
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
| | - Patricia Chan
- Division of Nephrology, Department of
Medicine, Michael Garron Hospital, Toronto, ON, Canada
| | - Clara J. Bohm
- Department of Internal Medicine, Max
Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Kristin K. Clemens
- ICES, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
- Division of Endocrinology and
Metabolism, Department of Medicine, Western University, London, ON, Canada
- St. Joseph’s Health Care London, ON,
Canada
| | - Charles Cook
- Transplant Ambassador Program, Grand
River Hospital, Kitchener, ON, Canada
| | - Laura Dember
- Renal, Electrolyte and Hypertension
Division, Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Stephanie Dixon
- ICES, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
| | | | | | | | - Cory Goldstein
- Rotman Institute of Philosophy,
Western University, London, ON, Canada
| | | | | | - Susan Huang
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
| | | | - Meg J. Jardine
- Innovation & Kidney Research, The
George Institute for Global Health, UNSW Sydney, Newtown, NSW, Australia
| | | | | | | | | | | | | | - Jennifer M. MacRae
- Division of Nephrology, Department of
Medicine, University of Calgary, AB, Canada
| | - Braden J. Manns
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Janice McCallum
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
- Renal Services, London Health Sciences
Centre, ON, Canada
| | - Christopher W. McIntyre
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
- Department of Medical Biophysics,
Schulich School of Medicine and Dentistry, Western University, London, ON,
Canada
| | - Amber O. Molnar
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
| | - Reem A. Mustafa
- Division of Nephrology and
Hypertension, Department of Internal Medicine, University of Kansas Medical Center,
Kansas City, USA
| | - Gihad E. Nesrallah
- Division of Nephrology, Department of
Medicine, Humber River Hospital, Toronto, ON, Canada
| | - Matthew J. Oliver
- Division of Nephrology, Department of
Medicine, University of Toronto, ON, Canada
| | | | | | | | | | | | - Samuel A. Silver
- Division of Nephrology, Kingston
Health Sciences Center, Queen’s University, Kingston, ON, Canada
| | - Jessica M. Sontrop
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
| | - Manish M. Sood
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, University of Ottawa, ON, Canada
| | - Rita S. Suri
- Division of Nephrology, Department of
Medicine, McGill University, Montreal, QC, Canada
- Canadian Nephrology Trials Network,
Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre,
Winnipeg, MB, Canada
- Department of Internal Medicine,
University of Manitoba, Winnipeg, Canada
| | - Daniel J. Tascona
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
- Orillia Soldiers’ Memorial Hospital,
ON, Canada
| | | | - Ron Wald
- St. Michael’s Hospital, Toronto, ON,
Canada
- Division of Nephrology, Department of
Medicine, University of Toronto, ON, Canada
| | - Michael Walsh
- Division of Nephrology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute,
Hamilton, ON, Canada
| | - Charles Weijer
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
- Rotman Institute of Philosophy,
Western University, London, ON, Canada
| | - Matthew A. Weir
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
| | - Hans Vorster
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
| | - Deborah Zimmerman
- Division of Nephrology, Department of
Medicine, University of Ottawa, ON, Canada
| | - Amit X. Garg
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
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7
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Ferguson TW, Garg AX, Sood MM, Rigatto C, Chau E, Komenda P, Naimark D, Nesrallah GE, Soroka SD, Beaulieu M, Alam A, Kim SJ, Dixon S, Manns B, Tangri N. Association Between the Publication of the Initiating Dialysis Early and Late Trial and the Timing of Dialysis Initiation in Canada. JAMA Intern Med 2019; 179:934-941. [PMID: 31135821 PMCID: PMC6547160 DOI: 10.1001/jamainternmed.2019.0489] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Published in 2010, the Initiating Dialysis Early and Late (IDEAL) randomized clinical trial, which randomized patients with an estimated glomerular filtration rate (GFR) between 10 and 15 mL/min/1.73 m2 to planned initiation of dialysis with an estimated GFR between 10 and 14 mL/min/1.73 m2 (early start) or an estimated GFR between 5 and 7 mL/min/1.73 m2 (late start), concluded that early initiation was not associated with improved survival or clinical outcomes. OBJECTIVE To assess the association between the IDEAL trial results and the proportion of early dialysis starts over time. DESIGN, SETTING, AND PARTICIPANTS This interrupted time series analysis used data from the Canadian Organ Replacement Register to study adult (≥18 years of age) patients with incident chronic dialysis between January 1, 2006, and December 31, 2015, in Canada, which has a universal health care system. Patients from the province of Quebec were excluded because its privacy laws preclude submission of deidentified data without first-person consent. The patients included in the study (n = 28 468) had at least 90 days of nephrologist care before starting dialysis and a recorded estimated GFR at dialysis initiation. Data analyses were performed from November 2016 to January 2019. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of early dialysis starts (estimated GFR >10.5 mL/min/1.73 m2), and the secondary outcomes included the proportions of acute inpatient dialysis starts, patients who started dialysis using a home modality, and patients receiving hemodialysis who started with an arteriovenous access. Measures included the trend prior to the IDEAL trial publication, the change in this trend after publication, and the immediate consequence of publication. RESULTS The final cohort comprised 28 468 patients, of whom 17 342 (60.9%) were male and the mean (SD) age was 64.8 (14.6) years. Before the IDEAL trial, a statistically significant increasing trend was observed in the monthly proportion of early dialysis starts (adjusted rate ratio, 1.002; 95% CI, 1.001-1.004; P = .004). After the IDEAL trial, an immediate decrease was observed in the proportion of early dialysis starts (rate ratio, 0.874; 95% CI, 0.818-0.933; P < .001), along with a statistically significant change in trend between the pretrial and posttrial periods (rate ratio, 0.994; 95% CI, 0.992-0.996; P < .001). No statistically significant differences were found in acute inpatient dialysis initiations, the proportion of patients receiving home dialysis as the initial modality, or the proportion of arteriovenous access creation at hemodialysis initiation after the IDEAL trial publication. CONCLUSIONS AND RELEVANCE The publication of the IDEAL trial appeared to be associated with an immediate and meaningful change in the timing of dialysis initiation in Canada.
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Affiliation(s)
- Thomas W Ferguson
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Amit X Garg
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Department of Medicine, Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Manish M Sood
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Claudio Rigatto
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Elaine Chau
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - David Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gihad E Nesrallah
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Humber River Hospital, Toronto, Ontario, Canada
| | - Steven D Soroka
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Monica Beaulieu
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,BC Renal Agency, Vancouver, British Columbia, Canada
| | - Ahsan Alam
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - S Joseph Kim
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie Dixon
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Braden Manns
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
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8
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Huang SHS, MacRae J, Ross D, Imtiaz R, Hollingsworth B, Nesrallah GE, Copland MA, McFarlane PA, Chan CT, Zimmerman D. Buttonhole versus Stepladder Cannulation for Home Hemodialysis: A Multicenter, Randomized, Pilot Trial. Clin J Am Soc Nephrol 2019; 14:403-410. [PMID: 30659057 PMCID: PMC6419275 DOI: 10.2215/cjn.08310718] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/12/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Canadian home hemodialysis guidelines highlight the potential differences in complications associated with arteriovenous fistula (AVF) cannulation technique as a research priority. Our primary objective was to determine the feasibility of randomizing patients with ESKD training for home hemodialysis to buttonhole versus stepladder cannulation of the AVF. Secondary objectives included training time, pain with needling, complications, and cost by cannulation technique. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS All patients training for home hemodialysis at seven Canadian hospitals were assessed for eligibility, and demographic information and access type was collected on everyone. Patients who consented to participate were randomized to buttonhole or stepladder cannulation technique. Time to train for home hemodialysis, pain scores on cannulation, and complications over 12 months was recorded. For eligible but not randomized patients, reasons for not participating in the trial were documented. RESULTS Patient recruitment was November 2013 to November 2015. During this time, 158 patients began training for home hemodialysis, and 108 were ineligible for the trial. Diabetes mellitus as a cause of ESKD (31% versus 12%) and central venous catheter use (74% versus 6%) were more common in ineligible patients. Of the 50 eligible patients, 14 patients from four out of seven sites consented to participate in the study (28%). The most common reason for declining to participate was a strong preference for a particular cannulation technique (33%). Patients randomized to buttonhole versus stepladder cannulation required a shorter time to complete home hemodialysis training. We did not observe a reduction in cannulation pain or complications with the buttonhole method. Data linkages for a formal cost analysis were not conducted. CONCLUSIONS We were unable to demonstrate the feasibility of conducting a randomized, controlled trial of buttonhole versus stepladder cannulation in Canada with a sufficient number of patients on home hemodialysis to be able to draw meaningful conclusions.
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Affiliation(s)
- Shih-Han S. Huang
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Jennifer MacRae
- Department of Medicine, Division of Nephrology, Foothills Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Dana Ross
- Ottawa Hospital, Ottawa, Ontario, Canada
| | - Rameez Imtiaz
- University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Brittany Hollingsworth
- Kidney Research Centre of the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Gihad E. Nesrallah
- Faculty of Medicine, Division of Nephrology, Humber River Hospital, Toronto, Ontario, Canada
| | - Michael A. Copland
- Department of Medicine, Division of Nephrology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and
| | | | - Christopher T. Chan
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Deborah Zimmerman
- Ottawa Hospital, Ottawa, Ontario, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
- Kidney Research Centre of the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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9
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McArthur E, Bota SE, Sood MM, Nesrallah GE, Kim SJ, Garg AX, Dixon SN. Comparing Five Comorbidity Indices to Predict Mortality in Chronic Kidney Disease: A Retrospective Cohort Study. Can J Kidney Health Dis 2018; 5:2054358118805418. [PMID: 30349730 PMCID: PMC6195002 DOI: 10.1177/2054358118805418] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/04/2018] [Indexed: 01/26/2023] Open
Abstract
Background: Several different indices summarize patient comorbidity using health care data. An accurate index can be used to describe the risk profile of patients, and as an adjustment factor in analyses. How well these indices perform in persons with chronic kidney disease (CKD) is not well known. Objective: Assess the performance of 5 comorbidity indices at predicting mortality in 3 different patient groups with CKD: incident kidney transplant recipients, maintenance dialysis patients, and individuals with low estimated glomerular filtration rate (eGFR). Design: Population-based retrospective cohort study. Setting: Ontario, Canada, between 2004 and 2014. Patients: Individuals at the time they first received a kidney transplant, received maintenance dialysis, or were confirmed to have an eGFR less than 45 mL/min per 1.73m2. Measurements: Five comorbidity indices: Charlson comorbidity index, end-stage renal disease-modified Charlson comorbidity index, Johns Hopkins’ Aggregated Diagnosis Groups score, Elixhauser score, and Wright-Khan index. Our primary outcome was 1-year all-cause mortality. Methods: Comorbidity indices were estimated using information in the prior 2 years. Each group was randomly divided 100 times into derivation and validation samples. Model discrimination was assessed using median c-statistics from logistic regression models, and calibration was evaluated graphically. Results: We identified 4111 kidney transplant recipients, 23 897 individuals receiving maintenance dialysis, and 181 425 individuals with a low eGFR. Within 1 year, 108 (2.6%), 4179 (17.5%), and 17 898 (9.9%) in each group had died, respectively. In the validation sample, model discrimination was inadequate with median c-statistics less than 0.7 for all 5 comorbidity indices for all 3 groups. Calibration was also poor for all models. Limitations: The study used administrative health care data so there is the potential for misclassification. Indices were modeled as continuous scores as opposed to indicators for individual conditions to limit overfitting. Conclusions: Existing comorbidity indices do not accurately predict 1-year mortality in patients with CKD. Current indices could be modified with additional risk factors to improve their performance in CKD, or a new index could be developed for this population.
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Affiliation(s)
- Eric McArthur
- Institute for Clinical Evaluative Sciences, London, ON, Canada
| | - Sarah E Bota
- Institute for Clinical Evaluative Sciences, London, ON, Canada
| | - Manish M Sood
- Institute for Clinical Evaluative Sciences, London, ON, Canada.,Division of Nephrology, University of Ottawa, ON, Canada
| | - Gihad E Nesrallah
- Ontario Renal Network, Toronto, Canada.,Department of Nephrology, Humber River Regional Hospital, Toronto, ON, Canada
| | - S Joseph Kim
- Institute for Clinical Evaluative Sciences, London, ON, Canada.,Division of Nephrology, University of Toronto, ON, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, London, ON, Canada.,Ontario Renal Network, Toronto, Canada.,Department of Medicine, Western University, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Stephanie N Dixon
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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10
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Kontos P, Grigorovich A, Colobong R, Miller KL, Nesrallah GE, Binns MA, Alibhai SMH, Parsons T, Jassal SV, Thomas A, Naglie G. Fit for Dialysis: a qualitative exploration of the impact of a research-based film for the promotion of exercise in hemodialysis. BMC Nephrol 2018; 19:195. [PMID: 30081845 PMCID: PMC6091204 DOI: 10.1186/s12882-018-0984-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Exercise improves functional outcomes and quality of life of older patients with end-stage renal disease undergoing hemodialysis. Yet exercise is not promoted as part of routine care. Health care providers and family carers rarely provide encouragement for patients to exercise, and the majority of older patients remain largely inactive. There is thus the need for a shift in the culture of hemodialysis care towards the promotion of exercise for wellness, including expectations of exercise participation by older patients, and encouragement by health care providers and family carers. Film-based educational initiatives hold promise to effect cultures of best practice, but have yet to be utilized in this population. METHODS We developed a research-based film, Fit for Dialysis, to promote exercise for wellness in hemodialysis care. Using a qualitative approach, we evaluated the effects that resulted from engagement with this film (e.g. knowledge/attitudes regarding the importance of exercise-based principles of wellness) as well as the generative mechanisms of these effects (e.g. realism, aesthetics). We also explored the factors related to patients, family carers, and health care providers that influenced engagement with the film, and the successful uptake of the key messages of Fit for Dialysis. We conducted qualitative interviews with 10 patients, 10 health care providers, and 10 family carers. Data were analyzed using thematic analysis. RESULTS The film was perceived to be effective in increasing patients', family carers' and health care providers' understanding of the importance of exercise and its benefits, motivating patients to exercise, and in increasing encouragement by family carers and health care providers of patient exercise. Realism (e.g. character identification) and aesthetic qualities of the film (e.g. dialogue) were identified as central generative mechanisms. CONCLUSIONS Fit for Dialysis is well-positioned to optimize the health and wellbeing of older adults undergoing hemodialysis. TRIAL REGISTRATION NCT02754271 ( ClinicalTrials.gov ), retroactively registered on April 21, 2016.
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Affiliation(s)
- Pia Kontos
- Toronto Rehabilitation Institute-University Health Network, 550 University Ave, Toronto, ON M5G 2A2 Canada
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7 Canada
| | - Alisa Grigorovich
- Toronto Rehabilitation Institute-University Health Network, 550 University Ave, Toronto, ON M5G 2A2 Canada
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7 Canada
| | - Romeo Colobong
- Toronto Rehabilitation Institute-University Health Network, 550 University Ave, Toronto, ON M5G 2A2 Canada
| | - Karen-Lee Miller
- Toronto Rehabilitation Institute-University Health Network, 550 University Ave, Toronto, ON M5G 2A2 Canada
| | - Gihad E. Nesrallah
- Department of Nephrology, Humber River Regional Hospital, 1235 Wilson Ave, Toronto, M3M 0B2 ON Canada
| | - Malcolm A. Binns
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7 Canada
- Rotman Research Institute, Baycrest Health Sciences, 3560 Bathurst St, Toronto, ON M6A 2E1 Canada
| | - Shabbir M. H. Alibhai
- Department of Medicine, University of Toronto, 1 King’s College Cir, Toronto, ON M5S 1A8 Canada
- Institute of Health Policy, Management and Evaluation, 155 College St, Toronto, ON M5T 3M7 Canada
- Institute of Medical Sciences, University of Toronto, 1 King’s College Cir, Toronto, ON M5S 1A8 Canada
- Department of Medicine, University Health Network, 200 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Trisha Parsons
- School of Rehabilitation Therapy, Queen’s University, 31 George St, Kingston, ON K7L 3N6 Canada
| | - Sarbjit Vanita Jassal
- Department of Medicine, University Health Network, 200 Elizabeth St, Toronto, ON M5G 2C4 Canada
- Division of Nephrology, University Health Network, 200 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Alison Thomas
- St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, ON M5T 1P8 Canada
| | - Gary Naglie
- Toronto Rehabilitation Institute-University Health Network, 550 University Ave, Toronto, ON M5G 2A2 Canada
- Rotman Research Institute, Baycrest Health Sciences, 3560 Bathurst St, Toronto, ON M6A 2E1 Canada
- Department of Medicine, University of Toronto, 1 King’s College Cir, Toronto, ON M5S 1A8 Canada
- Department of Medicine, Baycrest Health Sciences, 3560 Bathurst St, Toronto, ON M6A 2E1 Canada
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11
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Nesrallah GE, Dixon SN, MacKinnon M, Jassal SV, Bota SE, Dirk JS, Arthurs E, Blake PG, Sood MM, Garg AX, Davison SN. Home Palliative Service Utilization and Care Trajectory Among Ontario Residents Dying on Chronic Dialysis. Can J Kidney Health Dis 2018; 5:2054358118783761. [PMID: 30083365 PMCID: PMC6073817 DOI: 10.1177/2054358118783761] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 04/18/2018] [Indexed: 11/16/2022] Open
Abstract
Background: Many patients who receive chronic hemodialysis have a limited life expectancy comparable to that of patients with metastatic cancer. However, patterns of home palliative care use among patients receiving hemodialysis are unknown. Objectives: We aimed to undertake a current-state analysis to inform measurement and quality improvement in palliative service use in Ontario. Methods: We conducted a descriptive study of outcomes and home palliative care use by Ontario residents maintained on chronic dialysis using multiple provincial healthcare datasets. The period of study was the final year of life, for those died between January 2010 and December 2014. Results: We identified 9611 patients meeting inclusion criteria. At death, patients were (median [Q1, Q3] or %): 75 (66, 82) years old, on dialysis for 3.0 (1.0-6.0) years, 41% were women, 65% had diabetes, 29.6% had dementia, and 13.9% had high-impact neoplasms, and 19.9% had discontinued dialysis within 30 days of death. During the last year of life, 13.1% received ⩾1 home palliative services. Compared with patients who had no palliative services, those who received home palliative care visits had fewer emergency department and intensive care unit visits in the last 30 days of life, more deaths at home (17.1 vs 1.4%), and a lower frequency of deaths with an associated intensive care unit stay (8.1 vs 37.8%). Conclusions: Only a small proportion of patients receiving dialysis in Ontario received support through the home palliative care system. There appears to be an opportunity to improve palliative care support in parallel with dialysis care, which may improve patient, family, and health-system outcomes.
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Affiliation(s)
- Gihad E Nesrallah
- Faculty of Medicine, University of Toronto, Ontario, Canada.,Ontario Renal Network, Cancer Care Ontario, Toronto, Canada
| | - Stephanie N Dixon
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Faculty of Medicine and Dentistry, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | | | | | - Sarah E Bota
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Faculty of Medicine and Dentistry, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Jade S Dirk
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Erin Arthurs
- Ontario Renal Network, Cancer Care Ontario, Toronto, Canada
| | - Peter G Blake
- Ontario Renal Network, Cancer Care Ontario, Toronto, Canada.,Faculty of Medicine and Dentistry, Division of Nephrology and Immunology, Western University, London, Ontario, Canada
| | | | - Amit X Garg
- Faculty of Medicine and Dentistry, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Faculty of Medicine and Dentistry, Division of Nephrology and Immunology, Western University, London, Ontario, Canada
| | - Sara N Davison
- Division of Nephrology and Immunology, Faculty of Medicine, University of Alberta, Edmonton, Canada
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12
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Naylor KL, Dixon SN, Garg AX, Kim SJ, Blake PG, Nesrallah GE, McCallum MK, D'Antonio C, Li AH, Knoll GA. Variation in Access to Kidney Transplantation Across Renal Programs in Ontario, Canada. Am J Transplant 2017; 17:1585-1593. [PMID: 28068455 DOI: 10.1111/ajt.14133] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 11/10/2016] [Accepted: 11/12/2016] [Indexed: 01/25/2023]
Abstract
In the United States, kidney transplant rates vary significantly across end-stage renal disease (ESRD) networks. We conducted a population-based cohort study to determine whether there was variability in kidney transplant rates across renal programs in a health care system distinct from the United States. We included incident chronic dialysis patients in Ontario, Canada, from 2003 to 2013 and determined the 1-, 5-, and 10-year cumulative incidence of kidney transplantation in 27 regional renal programs (similar to U.S. ESRD networks). We also assessed the cumulative incidence of kidney transplant for "healthy" dialysis patients (aged 18-50 years without diabetes, coronary disease, or malignancy). We calculated standardized transplant ratios (STRs) using a Cox proportional hazards model, adjusting for patient characteristics (maximum possible follow-up of 11 years). Among 23 022 chronic dialysis patients, the 10-year cumulative incidence of kidney transplantation ranged from 7.4% (95% confidence interval [CI] 4.8-10.7%) to 31.4% (95% CI 16.5-47.5%) across renal programs. Similar variability was observed in our healthy cohort. STRs ranged from 0.3 (95% CI 0.2-0.5) to 1.5 (95% CI 1.4-1.7) across renal programs. There was significant variation in kidney transplant rates across Ontario renal programs despite patients having access to the same publicly funded health care system.
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Affiliation(s)
- K L Naylor
- Institute for Clinical Evaluative Sciences (ICES), London, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - S N Dixon
- Institute for Clinical Evaluative Sciences (ICES), London, Ontario, Canada.,Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - A X Garg
- Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada.,Division of Nephrology, Western University, London, Ontario, Canada
| | - S J Kim
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - P G Blake
- Division of Nephrology, Western University, London, Ontario, Canada
| | - G E Nesrallah
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Nephrology Program, Humber River Hospital, Toronto, Ontario, Canada
| | - M K McCallum
- Institute for Clinical Evaluative Sciences (ICES), London, Ontario, Canada
| | - C D'Antonio
- Ontario Renal Network, Toronto, Ontario, Canada
| | - A H Li
- Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada.,Division of Nephrology, Western University, London, Ontario, Canada
| | - G A Knoll
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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13
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Nash DM, Brimble S, Markle-Reid M, McArthur E, Tu K, Nesrallah GE, Grill A, Garg AX. Quality of Care for Patients With Chronic Kidney Disease in the Primary Care Setting: A Retrospective Cohort Study From Ontario, Canada. Can J Kidney Health Dis 2017; 4:2054358117703059. [PMID: 28616249 PMCID: PMC5461905 DOI: 10.1177/2054358117703059] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 01/25/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with chronic kidney disease may not be receiving recommended primary renal care. OBJECTIVE To use recently established primary care quality indicators for chronic kidney disease to determine the proportion of patients receiving recommended renal care. DESIGN Retrospective cohort study using administrative data with linked laboratory information. SETTING The study was conducted in Ontario, Canada, from 2006 to 2012. PATIENTS Patients over 40 years with chronic kidney disease or abnormal kidney function in primary care were included. MEASUREMENTS In total, 11 quality indicators were assessed for chronic kidney disease identified through a Delphi panel in areas of screening, monitoring, drug prescribing, and laboratory monitoring after initiating an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). METHODS We calculated the proportion and cumulative incidence at the end of follow-up of patients meeting each indicator and stratified results by age, sex, cohort entry, and chronic kidney disease stage. RESULTS Less than half of patients received follow-up tests after an initial abnormal kidney function result. Most patients with chronic kidney disease received regular monitoring of serum creatinine (91%), but urine albumin-to-creatinine monitoring was lower (70%). A total of 84% of patients age 66 and older did not receive a non-steroidal anti-inflammatory drug prescription of at least 2-week duration. Three quarters of patients age 66 and older were on an ACE inhibitor or ARB, and 96% did not receive an ACE inhibitor and ARB concurrently. Among patients 66 to 80 years of age with chronic kidney disease, 65% were on a statin. One quarter of patients age 66 and older who initiated an ACE inhibitor or ARB had their serum creatinine and potassium monitored within 7 to 30 days. LIMITATIONS This study was limited to people in Ontario with linked laboratory information. CONCLUSIONS There was generally strong performance across many of the quality of care indicators. Areas where more attention may be needed are laboratory testing to confirm initial abnormal kidney function test results and monitoring serum creatinine and potassium after initiating a new ACE inhibitor or ARB.
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Affiliation(s)
- Danielle M. Nash
- Institute for Clinical Evaluative Sciences Western, London, Ontario, Canada
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Scott Brimble
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- The Ontario Renal Network, Toronto, Canada
| | - Maureen Markle-Reid
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences Western, London, Ontario, Canada
| | - Karen Tu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
- Family Health Team, Toronto Western Hospital, University Health Network, Ontario, Canada
| | - Gihad E. Nesrallah
- The Ontario Renal Network, Toronto, Canada
- Department of Nephrology, Humber River Regional Hospital, Toronto, Ontario, Canada
| | - Allan Grill
- The Ontario Renal Network, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
- Department of Family Medicine, Markham Stouffville Hospital, Ontario, Canada
- Division of Long Term Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Amit X. Garg
- Institute for Clinical Evaluative Sciences Western, London, Ontario, Canada
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- The Ontario Renal Network, Toronto, Canada
- Department of Medicine, London Health Sciences Centre, Ontario, Canada
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Hayward JS, McArthur E, Nash DM, Sontrop JM, Russell SJ, Khan S, Walker JD, Nesrallah GE, Sood MM, Garg AX. Kidney Disease Among Registered Métis Citizens of Ontario: A Population-Based Cohort Study. Can J Kidney Health Dis 2017; 4:2054358117703071. [PMID: 28491337 PMCID: PMC5406217 DOI: 10.1177/2054358117703071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Indexed: 12/20/2022] Open
Abstract
Background: Indigenous peoples in Canada have higher rates of kidney disease than non-Indigenous Canadians. However, little is known about the risk of kidney disease specifically in the Métis population in Canada. Objective: To compare the prevalence of chronic kidney disease and incidence of acute kidney injury and end-stage kidney disease among registered Métis citizens in Ontario and a matched sample from the general Ontario population. Design: Population-based, retrospective cohort study using data from the Métis Nation of Ontario’s Citizenship Registry and administrative databases. Setting: Ontario, Canada; 2003-2013. Patients: Ontario residents ≥18 years. Measurements: Prevalence of chronic kidney disease and incidence of acute kidney injury and end-stage kidney disease. Secondary outcomes among patients hospitalized with acute kidney injury included non-recovery of kidney function and mortality within 1 year of discharge. Methods: Database codes and laboratory values were used to determine study outcomes. Métis citizens were matched (1:4) to Ontario residents on age, sex, and area of residence. The analysis included 12 229 registered Métis citizens and 48 916 adults from the general population. Results: We found the prevalence of chronic kidney disease was slightly higher among Métis citizens compared with the general population (3.1% vs 2.6%, P = 0.002). The incidence of acute kidney injury was 1.2 per 1000 person-years in both Métis citizens and the general population (P = 0.54). Of those hospitalized with acute kidney injury, outcomes were similar among Métis citizens and the general population except 1-year mortality, which was higher for Métis citizens (24.5% vs 15.3%, P = 0.03). The incidence of end-stage kidney disease did not differ between groups (<3.0 per 10 000 person-years, P = 0.73). Limitations: The Métis Nation of Ontario Citizenship Registry only captures about 20% of Métis people in Ontario. Administrative health care codes used to identify kidney disease are highly specific but have low sensitivity. Conclusions: Rates of kidney disease were similar or slightly higher for Métis citizens in Ontario compared with the matched general population.
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Affiliation(s)
- Jade S Hayward
- Institute for Clinical Evaluative Sciences Western, London, Ontario, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences Western, London, Ontario, Canada
| | - Danielle M Nash
- Institute for Clinical Evaluative Sciences Western, London, Ontario, Canada
| | - Jessica M Sontrop
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | | | - Saba Khan
- Institute for Clinical Evaluative Sciences Western, London, Ontario, Canada
| | - Jennifer D Walker
- Institute for Clinical Evaluative Sciences Western, London, Ontario, Canada.,School of Rural and Northern Health, Laurentian University, Sudbury, Ontario, Canada
| | - Gihad E Nesrallah
- Department of Nephrology, Humber River Regional Hospital, Toronto, Ontario, Canada
| | - Manish M Sood
- Institute for Clinical Evaluative Sciences Western, London, Ontario, Canada.,Division of Nephrology, Department of Medicine, The Ottawa Hospital and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences Western, London, Ontario, Canada.,Department of Medicine, London Health Sciences Centre, London, Ontario, Canada
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Chau EMT, Manns BJ, Garg AX, Sood MM, Kim SJ, Naimark D, Nesrallah GE, Soroka SD, Beaulieu M, Dixon S, Alam A, Tangri N. Knowledge Translation Interventions to Improve the Timing of Dialysis Initiation: Protocol for a Cluster Randomized Trial. Can J Kidney Health Dis 2016; 3:2054358116665257. [PMID: 28270916 PMCID: PMC5332084 DOI: 10.1177/2054358116665257] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 07/28/2016] [Accepted: 07/28/2016] [Indexed: 11/30/2022] Open
Abstract
Background: Early initiation of chronic dialysis (starting dialysis with higher vs lower kidney function) has risen rapidly in the past 2 decades in Canada and internationally, despite absence of established health benefits and higher costs. In 2014, a Canadian guideline on the timing of dialysis initiation, recommending an intent-to-defer approach, was published. Objective: The objective of this study is to evaluate the efficacy and safety of a knowledge translation intervention to promote the intent-to-defer approach in clinical practice. Design: This study is a multicenter, 2-arm parallel, cluster randomized trial. Setting: The study involves 55 advanced chronic kidney disease clinics across Canada. Patients: Patients older than 18 years who are managed by nephrologists for more than 3 months, and initiate dialysis in the follow-up period are included in the study. Measurements: Outcomes will be measured at the patient-level and enumerated within a cluster. Data on characteristics of each dialysis start will be determined by linkages with the Canadian Organ Replacement Register. Primary outcomes include the proportion of patients who start dialysis early with an estimated glomerular filtration rate greater than 10.5 mL/min/1.73 m2 and start dialysis in hospital as inpatients or in an emergency room setting. Secondary outcomes include the rate of change in early dialysis starts; rates of hospitalizations, deaths, and cost of predialysis care (wherever available); quarterly proportion of new starts; and acceptability of the knowledge translation materials. Methods: We randomized 55 multidisciplinary chronic disease clinics (clusters) in Canada to receive either an active knowledge translation intervention or no intervention for the uptake of the guideline on the timing of dialysis initiation. The active knowledge translation intervention consists of audit and feedback as well as patient- and provider-directed educational tools delivered at a comprehensive in-person medical detailing visit. Control clinics are only exposed to guideline release without active dissemination. We hypothesize that the clinics randomized to the intervention group will have a lower proportion of early dialysis starts. Limitations: Limitations include passive dissemination of the guideline through publication, and lead-time and survivor bias, which favors delayed dialysis initiation. Conclusions: If successful, this active knowledge translation intervention will reduce early dialysis starts, lead to health and economic benefits, and provide a successful framework for evaluating and disseminating future guidelines. Trial Registration: ClinicalTrials.gov, NCT02183987
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Affiliation(s)
- Elaine M T Chau
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Braden J Manns
- Department of Medicine, University of Calgary, Alberta, Canada
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Manish M Sood
- The Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - S Joseph Kim
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Medicine, Division of Nephrology, University of Toronto, Ontario, Canada
| | - David Naimark
- Division of Nephrology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | - Gihad E Nesrallah
- Li Ka Shing Knowledge Institute, Keenan Research Centre, St Michael's Hospital, and Nephrology Program, Humber River Hospital, Toronto, Ontario, Canada
| | - Steven D Soroka
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Monica Beaulieu
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Stephanie Dixon
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ahsan Alam
- Division of Nephrology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Nesrallah GE, Li L, Suri RS. Comparative effectiveness of home dialysis therapies: a matched cohort study. Can J Kidney Health Dis 2016; 3:19. [PMID: 27006781 PMCID: PMC4802626 DOI: 10.1186/s40697-016-0105-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 02/04/2016] [Indexed: 01/26/2023] Open
Abstract
Background Home dialysis is being increasingly promoted among patients with end-stage renal disease, but the comparative effectiveness of home hemodialysis and peritoneal dialysis is unknown. Objective To determine whether patients receiving home daily hemodialysis have reduced mortality risk compared with matched patients receiving home peritoneal dialysis. Design This study is an observational, propensity-matched, new-user cohort study. Setting Linked electronic data were from the United States Renal Data System (USRDS) and a large dialysis provider’s database. Patients The patients were adults receiving in-center hemodialysis in the USA between 2004 and 2011 and registered in the USRDS. Measurements Baseline comorbidities, demographics, and outcomes for both groups were ascertained from the United States Renal Data System. Methods We identified 3142 consecutive adult patients initiating home daily hemodialysis (≥5 days/week for ≥1.5 h/day) and matched 2688 of them by propensity score to 2688 contemporaneous US patients initiating home peritoneal dialysis. We used Cox regression to compare all-cause mortality between groups. Results After matching, the two groups were well balanced on all baseline characteristics. Mean age was 51 years, 66 % were male, 72 % were white, and 29 % had diabetes. During 10,221 patient-years of follow-up, 1493/5336 patients died. There were significantly fewer deaths among patients receiving home daily hemodialysis than those receiving peritoneal dialysis (12.7 vs 16.7 deaths per 100 patient-years, respectively; hazard ratio (HR) 0.75; 95 % CI 0.68–0.82; p < 0.001). Similar results were noted with several different analytic methods and for all pre-specified subgroups. Limitations We cannot exclude residual confounding in this observational study. Conclusions Home daily hemodialysis was associated with lower mortality risk than home peritoneal dialysis. Electronic supplementary material The online version of this article (doi:10.1186/s40697-016-0105-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gihad E Nesrallah
- The Li Ka Shing Knowledge Institute, Keenan Research Center, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8 Canada ; Nephrology Program, Humber River Regional Hospital, Toronto, Ontario Canada ; Division of Nephrology, Western University, London, Ontario Canada
| | - Lihua Li
- Division of Nephrology, Western University, London, Ontario Canada
| | - Rita S Suri
- Division of Nephrology, Western University, London, Ontario Canada ; Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Québec Canada
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Nesrallah GE. Pro: Buttonhole cannulation of arteriovenous fistulae. Nephrol Dial Transplant 2016; 31:520-3. [DOI: 10.1093/ndt/gfw031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 11/14/2015] [Indexed: 11/13/2022] Open
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Abstract
Creating and maintaining a healthy vascular access is a critical factor in successful home hemodialysis (HD). This article aims to serve as a "how-to manual" regarding vascular access issues for both patients and health-care providers in a home HD program. This document outlines cannulation options for patients with arteriovenous access and describes troubleshooting techniques for potential complications; strategies are suggested to help patients overcome fear of cannulation and address problems associated with difficult cannulation. Technical aspects of central venous catheter care, as well as a guide to troubleshooting catheter complications, are covered in detail. Monitoring for access-related complications of stenosis, infection, and thrombosis is a key part of every home HD program. Key performance and quality indicators are important mechanisms to ensure patient safety in home HD and should be used during routine clinic visits.
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Affiliation(s)
- Rose Faratro
- University Health Network, Toronto, Ontario, Canada
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19
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Suri RS, Li L, Nesrallah GE. The risk of hospitalization and modality failure with home dialysis. Kidney Int 2015; 88:360-8. [PMID: 25786099 PMCID: PMC4526768 DOI: 10.1038/ki.2015.68] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/20/2015] [Accepted: 01/22/2015] [Indexed: 12/13/2022]
Abstract
While home dialysis is being promoted, there are few comparative effectiveness studies of home-based modalities to guide patient decisions. To address this, we matched 1116 daily home hemodialysis (DHD) patients by propensity scores to 2784 contemporaneous USRDS patients receiving home peritoneal dialysis (PD), and compared hospitalization rates from cardiovascular, infectious, access-related or bleeding causes (prespecified composite), and modality failure risk. We performed similar analyses for 1187 DHD patients matched to 3173 USRDS patients receiving in-center conventional hemodialysis (CHD). The composite hospitalization rate was significantly lower with DHD than with PD (0.93 vs. 1.35/patient-year, hazard ratio=0.73 (95% CI=0.67–0.79)). DHD patients spent significantly fewer days in hospital than PD patients (5.2 vs. 9.2 days/patient-year), and significantly more DHD patients remained admission-free (52% DHD vs. 32% PD). In contrast, there was no significant difference in hospitalizations between DHD and CHD (DHD vs. CHD: 0.93 vs. 1.10/patient-year, hazard ratio 0.92 (0.85–1.00)). Cardiovascular hospitalizations were lower with DHD than with CHD (0.68 (0.61–0.77)), while infectious and access hospitalizations were higher (1.15 (1.04–1.29) and 1.25 (1.08–1.43), respectively). Significantly more PD than DHD patients switched back to in-center HD (44% vs. 15% 3.4 (2.9–4.0)). In this prevalent cohort, home DHD was associated with fewer admissions and hospital days than PD, and a substantially lower risk of modality failure.
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Affiliation(s)
- Rita S Suri
- 1] Department of Medicine, Section of Nephrology, Centre de Recherche, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada [2] Division of Nephrology, Western University, London, Ontario, Canada
| | - Lihua Li
- Division of Nephrology, Western University, London, Ontario, Canada
| | - Gihad E Nesrallah
- 1] Department of Nephrology, Humber River Regional Hospital, Toronto, Ontario, Canada [2] The Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
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Iansavichus AV, Hildebrand AM, Haynes RB, Wilczynski NL, Levin A, Hemmelgarn BR, Tu K, Nesrallah GE, Nash DM, Garg AX. High-performance information search filters for CKD content in PubMed, Ovid MEDLINE, and EMBASE. Am J Kidney Dis 2014; 65:26-32. [PMID: 25059221 DOI: 10.1053/j.ajkd.2014.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 06/02/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Finding relevant articles in large bibliographic databases such as PubMed, Ovid MEDLINE, and EMBASE to inform care and future research is challenging. Articles relevant to chronic kidney disease (CKD) are particularly difficult to find because they are often published under different terminology and are found across a wide range of journal types. STUDY DESIGN We used computer automation within a diagnostic test assessment framework to develop and validate information search filters to identify CKD articles in large bibliographic databases. SETTING & PARTICIPANTS 22,992 full-text articles in PubMed, Ovid MEDLINE, or EMBASE. INDEX TEST 1,374,148 unique search filters. REFERENCE TEST We established the reference standard of article relevance to CKD by manual review of all full-text articles using prespecified criteria to determine whether each article contained CKD content or not. We then assessed filter performance by calculating sensitivity, specificity, and positive predictive value for the retrieval of CKD articles. Filters with high sensitivity and specificity for the identification of CKD articles in the development phase (two-thirds of the sample) were then retested in the validation phase (remaining one-third of the sample). RESULTS We developed and validated high-performance CKD search filters for each bibliographic database. Filters optimized for sensitivity reached at least 99% sensitivity, and filters optimized for specificity reached at least 97% specificity. The filters were complex; for example, one PubMed filter included more than 89 terms used in combination, including "chronic kidney disease," "renal insufficiency," and "renal fibrosis." In proof-of-concept searches, physicians found more articles relevant to the topic of CKD with the use of these filters. LIMITATIONS As knowledge of the pathogenesis of CKD grows and definitions change, these filters will need to be updated to incorporate new terminology used to index relevant articles. CONCLUSIONS PubMed, Ovid MEDLINE, and EMBASE can be filtered reliably for articles relevant to CKD. These high-performance information filters are now available online and can be used to better identify CKD content in large bibliographic databases.
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Affiliation(s)
- Arthur V Iansavichus
- Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada
| | - Ainslie M Hildebrand
- Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada; Division of Nephrology, Western University, London, Ontario, Canada.
| | - R Brian Haynes
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Nancy L Wilczynski
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Karen Tu
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Gihad E Nesrallah
- Division of Nephrology, Humber Regional Hospital, Toronto, Ontario, Canada; The Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Danielle M Nash
- Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Amit X Garg
- Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada; Division of Nephrology, Western University, London, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Mustafa RA, Levin A, Akbari A, Foster BJ, Zimmerman D, Nesrallah GE, Knoll GA, Rioux JP, Barton J, Ruzicka M, Muirhead N, Moist L, Pannu N, McFarlane P, Klarenbach S, Samuel S, Clark WF, Hemmelgarn BR. The Canadian Society of Nephrology methods in developing and adapting clinical practice guidelines: a review. Can J Kidney Health Dis 2014; 1:5. [PMID: 25780600 PMCID: PMC4346300 DOI: 10.1186/2054-3581-1-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 03/26/2014] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The Canadian Society of Nephrology (CSN) was established to promote the highest quality of care for patients with renal diseases and to encourage research related to the kidney and its disorders. The CSN Clinical Practice Guideline (CPG) Committee develops guidelines with clear recommendations to influence physicians' practice and improve the health of patients with kidney disease in Canada. REVIEW In this review we describe the CSN process in prioritizing CPGs topics. We document the CSN experience using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We then detail the CSN process in developing de novo CPGs and in adapting existing CPGs and developing accompanying commentaries. We also discuss challenges faced during this process and suggest solutions. Furthermore, we summarize the CSN effort in disseminating and implementing their guidelines. Additionally, we describe recent development and partnerships that allow evaluation of the effect of the CSN guidelines and commentaries. CONCLUSION The CSN follows a comprehensive process in identifying priority areas to be addressed in CPGs. In 2010, the CSN adopted GRADE, which enhanced the rigor and transparency of guideline development. This process focuses on systematically identifying best available evidence and carefully assessing its quality, balancing benefits and harms, considering patients' and societies' values and preferences, and when possible considering resource implications. Recent partnership allows wider dissemination and implementation among end users and evaluation of the effects of CPG and commentaries on the health of Canadians.
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Affiliation(s)
- Reem A Mustafa
- />Department of Clinical Epidemiology and Biostatistics, McMaster University, CanadaHSC Room 2C15 1280 Main Street West, Hamilton, Ontario ON L8S 4 K1 Canada
- />Department of Internal Medicine, University of Missouri, Kansas City, USA
| | - Adeera Levin
- />Department of Medicine, University of British Columbia, Vancouver, British Columbia Canada
| | - Ayub Akbari
- />Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, Ontario Canada
| | - Bethany J Foster
- />Departments of Pediatrics and Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec Canada
| | - Deborah Zimmerman
- />Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, Ontario Canada
| | - Gihad E Nesrallah
- />Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michael’s Hospital, and Humber River Hospital, Toronto, Ontario Canada
| | - Greg A Knoll
- />Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario Canada
| | - Jean-Philippe Rioux
- />Department of Medicine, Nephrology Division, Hôpital du Sacré-Cœur de Montréal, University of Montreal, Montreal, Quebec Canada
| | - Jim Barton
- />Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan Canada
| | - Marcel Ruzicka
- />Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, Ontario Canada
| | - Norman Muirhead
- />Department of Medicine, Western University, London, Ontario Canada
| | - Louise Moist
- />Department of Medicine, Western University, London, Ontario Canada
| | - Neesh Pannu
- />Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta Canada
| | - Phil McFarlane
- />Department of Medicine, Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michael’s Hospital, University of Toronto, Toronto, Ontario Canada
| | - Scott Klarenbach
- />Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta Canada
| | - Susan Samuel
- />Department of Pediatrics, University of Calgary, Calgary, Alberta Canada
| | - William F Clark
- />Department of Medicine, Western University, London, Ontario Canada
| | - Brenda R Hemmelgarn
- />Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta Canada
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Nesrallah GE, Mustafa RA, Clark WF, Bass A, Barnieh L, Hemmelgarn BR, Klarenbach S, Quinn RR, Hiremath S, Ravani P, Sood MM, Moist LM. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. CMAJ 2014; 186:112-7. [PMID: 24492525 DOI: 10.1503/cmaj.130363] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Affiliation(s)
- Louise M. Moist
- Schulich School of Medicine and Dentistry and
- Department of and Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada
| | - Gihad E. Nesrallah
- The Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michael’s Hospital, Toronto, Ontario, Canada; and
- Department of Nephrology, Humber River Hospital, Toronto, Ontario, Canada
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Zimmerman DL, Nesrallah GE, Lindsay RM. In Reply to ‘Dialysate Calcium Concentration and Mineral Metabolism in Long and Long-Frequent Hemodialysis’. Am J Kidney Dis 2013; 62:1019-20. [DOI: 10.1053/j.ajkd.2013.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 08/27/2013] [Indexed: 11/11/2022]
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Nesrallah GE, Mustafa RA, MacRae J, Pauly RP, Perkins DN, Gangji A, Rioux JP, Steele A, Suri RS, Chan CT, Copland M, Komenda P, McFarlane PA, Pierratos A, Lindsay R, Zimmerman DL. Canadian Society of Nephrology Guidelines for the Management of Patients With ESRD Treated With Intensive Hemodialysis. Am J Kidney Dis 2013; 62:187-98. [DOI: 10.1053/j.ajkd.2013.02.351] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 02/14/2013] [Indexed: 11/11/2022]
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Mustafa RA, Zimmerman D, Rioux JP, Suri RS, Gangji A, Steele A, MacRae J, Pauly RP, Perkins DN, Chan CT, Copland M, Komenda P, McFarlane PA, Lindsay R, Pierratos A, Nesrallah GE. Vascular Access for Intensive Maintenance Hemodialysis: A Systematic Review for a Canadian Society of Nephrology Clinical Practice Guideline. Am J Kidney Dis 2013; 62:112-31. [DOI: 10.1053/j.ajkd.2013.03.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 03/27/2013] [Indexed: 11/11/2022]
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Zimmerman DL, Nesrallah GE, Chan CT, Copland M, Komenda P, McFarlane PA, Gangji A, Lindsay R, MacRae J, Pauly RP, Perkins DN, Pierratos A, Rioux JP, Steele A, Suri RS, Mustafa RA. Dialysate calcium concentration and mineral metabolism in long and long-frequent hemodialysis: a systematic review and meta-analysis for a Canadian Society of Nephrology clinical practice guideline. Am J Kidney Dis 2013; 62:97-111. [PMID: 23591289 DOI: 10.1053/j.ajkd.2013.02.357] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 02/01/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients treated with conventional hemodialysis (HD) develop disorders of mineral metabolism that are associated with increased morbidity and mortality. More frequent and longer HD has been associated with improvement in hyperphosphatemia that may improve outcomes. STUDY DESIGN Systematic review and meta-analysis to inform the clinical practice guideline on intensive dialysis for the Canadian Society of Nephrology. SETTING & POPULATION Adult patients receiving outpatient long (≥5.5 hours/session; 3-4 times per week) or long-frequent (≥5.5 hours/session, ≥5 sessions per week) HD. SELECTION CRITERIA FOR STUDIES We included clinical trials, cohort studies, case series, case reports, and systematic reviews. INTERVENTIONS Dialysate calcium concentration ≥1.5 mmol/L and/or phosphate additive. OUTCOMES Fragility fracture, peripheral arterial and coronary artery disease, calcific uremic arteriolopathy, mortality, intradialytic hypotension, parathyroidectomy, extraosseous calcification, markers of mineral metabolism, diet liberalization, phosphate-binder use, and muscle mass. RESULTS 21 studies were identified: 2 randomized controlled trials, 2 reanalyses of data from the randomized controlled trials, and 17 observational studies. Dialysate calcium concentration ≥1.5 mmol/L for patients treated with long and long-frequent HD prevents an increase in parathyroid hormone levels and a decline in bone mineral density without causing harm. Both long and long-frequent HD were associated with a reduction in serum phosphate level of 0.42-0.45 mmol/L and a reduction in phosphate-binder use. There was no direct evidence to support the use of a dialysate phosphate additive. LIMITATIONS Almost all the available information is related to changes in laboratory values and surrogate outcomes. CONCLUSIONS Dialysate calcium concentration ≥1.5 mmol/L for most patients treated with long and long-frequent dialysis prevents an increase in parathyroid hormone levels and decline in bone mineral density without increased risk of calcification. It seems prudent to add phosphate to the dialysate for patients with a low predialysis phosphate level or very low postdialysis phosphate level until more evidence becomes available.
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Affiliation(s)
- Deborah L Zimmerman
- Division of Nephrology, Kidney Research Centre of the Ottawa Hospital Research Institute, Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada.
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Suri RS, Lindsay RM, Bieber BA, Pisoni RL, Garg AX, Austin PC, Moist LM, Robinson BM, Gillespie BW, Couchoud CG, Galland R, Lacson EK, Zimmerman DL, Li Y, Nesrallah GE. A multinational cohort study of in-center daily hemodialysis and patient survival. Kidney Int 2013; 83:300-7. [DOI: 10.1038/ki.2012.329] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Nesrallah GE, Suri RS, Guyatt G, Mustafa RA, Walter SD, Lindsay RM, Akl EA. Biofeedback dialysis for hypotension and hypervolemia: a systematic review and meta-analysis. Nephrol Dial Transplant 2012. [PMID: 23197678 DOI: 10.1093/ndt/gfs389] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Intradialytic hypotension (IDH) is associated with morbidity and mortality. We conducted a systematic review to determine whether biofeedback hemodialysis (HD) can improve IDH and other outcomes, compared with HD without biofeedback. METHODS Data sources included the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and ISI Web of Science. We included randomized trials that enrolled adult patients (>18 years) with IDH or extracellular fluid expansion and that used biofeedback to guide ultrafiltration and/or dialysate conductivity. Two authors assessed trial quality and independently extracted data in duplicate. We assessed heterogeneity using I(2). We applied the GRADE framework for rating the quality of evidence. RESULTS We found two parallel-arm randomized controlled clinical trials and six randomized crossover trials meeting inclusion criteria. All trials were open-label and at least four were industry-sponsored. Studies were small (median n = 27). No study evaluated hospitalization and the evidence for effect on mortality was of very low quality. Three studies assessed quality of life (QoL); none demonstrated benefit or harm, and quality of evidence was very low. Biofeedback significantly reduced IDH (risk ratio 0.61, 95% confidence interval 0.44-0.86; I(2)= 0%). Quality of evidence for this outcome was low due to risk of bias and potential publication bias. CONCLUSIONS Biofeedback dialysis significantly reduces the frequency of IDH. Large and well-designed randomized trials are needed to assess the effects on survival, hospitalization and QoL.
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Affiliation(s)
- Gihad E Nesrallah
- Department of Medicine, The University of Western Ontario, London, Canada.
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Nesrallah GE, Lindsay RM, Cuerden MS, Garg AX, Port F, Austin PC, Moist LM, Pierratos A, Chan CT, Zimmerman D, Lockridge RS, Couchoud C, Chazot C, Ofsthun N, Levin A, Copland M, Courtney M, Steele A, McFarlane PA, Geary DF, Pauly RP, Komenda P, Suri RS. Intensive hemodialysis associates with improved survival compared with conventional hemodialysis. J Am Soc Nephrol 2012; 23:696-705. [PMID: 22362910 DOI: 10.1681/asn.2011070676] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Patients undergoing conventional maintenance hemodialysis typically receive three sessions per week, each lasting 2.5-5.5 hours. Recently, the use of more intensive hemodialysis (>5.5 hours, three to seven times per week) has increased, but the effects of these regimens on survival are uncertain. We conducted a retrospective cohort study to examine whether intensive hemodialysis associates with better survival than conventional hemodialysis. We identified 420 patients in the International Quotidian Dialysis Registry who received intensive home hemodialysis in France, the United States, and Canada between January 2000 and August 2010. We matched 338 of these patients to 1388 patients in the Dialysis Outcomes and Practice Patterns Study who received in-center conventional hemodialysis during the same time period by country, ESRD duration, and propensity score. The intensive hemodialysis group received a mean (SD) 4.8 (1.1) sessions per week with a mean treatment time of 7.4 (0.87) hours per session; the conventional group received three sessions per week with a mean treatment time of 3.9 (0.32) hours per session. During 3008 patient-years of follow-up, 45 (13%) of 338 patients receiving intensive hemodialysis died compared with 293 (21%) of 1388 patients receiving conventional hemodialysis (6.1 versus 10.5 deaths per 100 person-years; hazard ratio, 0.55 [95% confidence interval, 0.34-0.87]). The strength and direction of the observed association between intensive hemodialysis and improved survival were consistent across all prespecified subgroups and sensitivity analyses. In conclusion, there is a strong association between intensive home hemodialysis and improved survival, but whether this relationship is causal remains unknown.
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Affiliation(s)
- Gihad E Nesrallah
- Division of Nephrology, University of Western Ontario, London, Ontario, Canada.
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Nesrallah GE. ACP Journal Club. Increased frequency of hemodialysis reduced adverse clinical outcomes. Ann Intern Med 2011; 154:JC4-6. [PMID: 21502644 DOI: 10.7326/0003-4819-154-8-201104190-02006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Pauly RP, Maximova K, Coppens J, Asad RA, Pierratos A, Komenda P, Copland M, Nesrallah GE, Levin A, Chery A, Chan CT. Patient and technique survival among a Canadian multicenter nocturnal home hemodialysis cohort. Clin J Am Soc Nephrol 2010; 5:1815-20. [PMID: 20671218 DOI: 10.2215/cjn.00300110] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES As a result of improved clinical and quality-of-life outcomes compared with conventional hemodialysis, interest in nocturnal home hemodialysis (NHD) has steadily increased in the past decade; however, little is known about the flow of patients through NHD programs or about patient-specific predictors of mortality or technique failure associated with this modality. This study addressed this gap in knowledge. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study included 247 NHD patients of the Canadian Slow Long nightly ExtEnded dialysis Programs (CAN-SLEEP) cohort from 1994 through 2006 inclusive. The association between program- and patient-specific variables and risk for adverse outcomes was determined using uni- and multivariable Cox regression. RESULTS A total of 14.6% of the cohort experienced death or technique failure. Unadjusted 1- and 5-year adverse event-free survival was 95.2 and 80.1%, respectively. Significant predictors of a composite of mortality and technique failure included advanced age (P < 0.001), diabetes (P < 0.001), central venous catheter use (P = 0.01), and inability to perform NHD independently (P = 0.009) and were adjusted for center effect. Weekly frequency of NHD was not predictive. Age and diabetes remained significant with multivariable analysis (hazard ratio 1.07 and 2.64, respectively). Unadjusted 1- and 5-year technique survival was 97.9 and 95.2%, respectively. Only age was a significant predictor of technique failure. CONCLUSIONS NHD is associated with excellent adverse event-free survival. This study underscores the importance of modality-specific predictors in the success of home hemodialysis, as well as favorable baseline characteristics such as younger age and the absence of diabetes.
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Affiliation(s)
- Robert P Pauly
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
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Nesrallah GE, Cuerden M, Wong JHS, Pierratos A. Staphylococcus aureus bacteremia and buttonhole cannulation: long-term safety and efficacy of mupirocin prophylaxis. Clin J Am Soc Nephrol 2010; 5:1047-53. [PMID: 20413438 DOI: 10.2215/cjn.00280110] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Buttonhole (constant-site) cannulation (BHC) continues to gain popularity with home and in-center dialysis programs worldwide. However, long-term safety data are lacking. This paper reports the authors' single-center experience with Staphylococcus aureus bacteremia (SAB) and the efficacy of topical mupirocin prophylaxis (MP). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study was a retrospective prepost comparison of SAB rates after establishing MP. Fifty-six consecutive patients on home nocturnal hemodialysis via arteriovenous fistulae, mean age 51.5 +/- 10.6 years, 38% women, and vintage 44.5 +/- 34.5 months were observed for a total of 93.4 (pre-MP) and 193.5 (post-MP) patient-years. RESULTS Ten episodes of SAB were observed, with metastatic complications in four cases, including pneumonia (n = 2), septic arthritis, and a fatal C3 epidural abscess. When analyzed by observation period, the odds ratio (OR) for SAB before versus after the introduction of MP was 6.4 [95% confidence interval (CI) = 1.3 to 32.3; P = 0.02]. Two SAB episodes occurred after the MP started. Both patients had discontinued the MP for 3 weeks (nonadherent) preceding infection; hence, no SAB episodes were observed on treatment. In an as-treated analysis, the OR for SAB in the absence of MP was 35.3 (95% CI = 2.0 to 626.7; P = 0.01). CONCLUSIONS BHC is associated with a significant risk of SAB with metastatic complications. In this prepost comparison of SAB rates, no infections were observed with MP. While awaiting more definitive studies, this simple intervention should be considered for patients using BHC.
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Affiliation(s)
- Gihad E Nesrallah
- Division of Nephrology, The University of Western Ontario, London, Ontario, Canada.
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Nesrallah GE, Suri RS, Moist LM, Cuerden M, Groeneweg KE, Hakim R, Ofsthun NJ, McDonald SP, Hawley C, Caskey FJ, Couchoud C, Awaraji C, Lindsay RM. International Quotidian Dialysis Registry: annual report 2009. Hemodial Int 2010; 13:240-9. [PMID: 19703054 DOI: 10.1111/j.1542-4758.2009.00391.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The International Quotidian Dialysis Registry (IQDR) is a global initiative designed to study practices and outcomes associated with the use of hemodialysis regimens of increased frequency and/or duration. Several small studies suggest that compared with conventional hemodialysis (HD), short-daily, nocturnal, and long conventional HD regimens may improve surrogate endpoints and quality of life. However, methodologically robust comparisons on hard outcomes are sorely lacking. The IQDR represents the first-ever attempt to aggregate long-term follow-up data from centers utilizing alternative HD regimens worldwide, and will have adequate statistical power to examine the effects of these regimens on multiple clinical endpoints, including mortality. To date, the IQDR has enrolled patients from Canada, the United States, Australia, and New Zealand, with plans in place to begin linking with additional commercial databases and national registries. This fifth annual report of the IQDR describes (1) a proposed governance structure that will facilitate international collaboration, stakeholder input and funding; (2) data sources and participating registries; (3) recruitment to date and patient baseline characteristics; and (4) an agenda for future research.
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Affiliation(s)
- Gihad E Nesrallah
- Department of Nephrology, Humber River Regional Hospital, Toronto, ON, Canada
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Nesrallah GE, Suri RS, Moist LM, Ofsthun NJ, Hakim R, McDonald SP, Marshall MR, Carter ST, Lindsay RM. The International Quotidian Dialysis Registry: Annual report 2008. Hemodial Int 2008; 12:281-9. [PMID: 18638080 DOI: 10.1111/j.1542-4758.2008.00268.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Alternative hemodialysis (HD) schedules, including short-daily and nocturnal HD, continue to proliferate, with the hope of offering improved patient outcomes. Three nights per week and every other night, nocturnal HD are now being provided to more patients worldwide, both at home and in-center. However, alternative HD schedules are still experimental in most centers, and studies establishing the efficacy of these therapies with respect to major clinical outcomes are needed. Endorsed by the National Institutes of Health, the International Quotidian Dialysis Registry is an international collaboration that was established in 2002 to prospectively study large numbers of patients treated with alternate HD schedules. The Registry will ultimately allow alternate HD modalities to be compared to conventional thrice-weekly HD with respect to clinical endpoints, including mortality, using a prospective cohort study. To date, the Registry has enrolled 182, 1193, and 740 subjects from Canada, the United States, and Australia, respectively. This report is the fourth annual update and describes recruitment progress, baseline characteristics of enrolled patients, and worldwide prescription patterns.
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Affiliation(s)
- Gihad E Nesrallah
- Department of Nephrology, Humber River Regional Hospital, Toronto, Ontario, Canada.
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Abstract
In view of the need to study both intermediate and definitive outcomes associated with daily and extended-hours hemodialysis (HD), our group has undertaken the design and implementation of an international registry to collect data describing the treatments and outcomes of patients treated with these regimens. The International Quotidian Dialysis Registry began recruiting patients in June 2004. There are currently 229 patients enrolled in the registry, up from 199 last year. The projected growth is 2000 patients by 2008. This paper constitutes the third annual report of progress of patient and center recruitment, and includes descriptive data drawn from the 3 primary patient groups currently tracked by the registry: home nocturnal, home short-daily, and in-center short-daily HD. As the cohort grows, patients will be compared with control subjects drawn from their respective national registries, and comparative analyses will follow.
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Affiliation(s)
- Gihad E Nesrallah
- Department of Nephrology, Humber River Regional Hospital, Toronto, Canada.
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Lebner AC, Nesrallah GE, Mendelssohn DC. Experience and evidence: is there enough to support funding daily in-center dialysis? Nephrol News Issues 2007; 21:42-47. [PMID: 18038752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The dialysis community has increasingly shown the health benefits of short daily hemodialysis (sDHD) at home. While this appears mainly suitable for younger and more independent patients, it seems likely that older and frailer patients would benefit from short daily dialysis as well. Humber River Regional Hospital has an in-center daily dialysis program in Canada, offering services to 31 patients. The experiences of patients, challenges for the health care team, and funding issues are discussed and point toward a promising future for in-center daily dialysis. However, a need for studies of greater quality and quantity is outlined as a major obstacle in gaining widespread support for in-center daily dialysis from the funders of dialysis care.
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Abstract
Interest in short daily and nocturnal hemodialysis (HD) regimens continues to grow worldwide. Despite growing optimism that these therapies will afford better patient outcomes over conventional HD, the current literature has not been viewed as sufficiently compelling to affect widespread implementation in most jurisdictions. Before these therapies can gain wider acceptance, larger and more rigorous studies will likely be needed. In June 2004, the Quotidian Dialysis Registry, based at the Lawson Health Research Institute at the University of Western Ontario, Canada, began recruiting patients across North America. By using an Internet-based data entry platform, patients from various centers worldwide will eventually be recruited, and studied prospectively. This paper constitutes the second annual update on patient and center recruitment, patient and treatment characteristics, and future directions for the registry.
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Nesrallah GE, Lindsay RM. The international quotidian dialysis registry. Nephrol News Issues 2006; 20:41-2, 44. [PMID: 16499174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Affiliation(s)
- Gihad E Nesrallah
- Division of Nephrology, Humber River Regional Hospital, Toronto, Ontario, Canada
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Abstract
Several studies have reported improved outcomes with daily hemodialysis (DHD), but the strength of this evidence has not been evaluated. The published evidence on DHD was synthesized and its quality rated to inform need and sample size calculations for a randomized trial. Citations were identified in MEDLINE and EMBASE using validated search strategies. Dialysis journals that were not indexed and bibliographies of relevant articles were hand-searched. Two authors reviewed all citations. Articles that reported original data on five or more adults who were receiving DHD (1.5 to 3 h, 5 to 7 d/wk) for > or = 3 mo were included. Twenty-five articles reporting 14 unique populations with 268 patients (five to 72 per study) met inclusion criteria. Of the 14 cohorts, 13 were studied with an observational design, 10 were studied prospectively, and four had parallel control groups. Mean age ranged form 41 to 64 yr, mean time on dialysis was 2 to 11 yr, 0 to 28% of patients had diabetes, > 90% had arteriovenous fistulae, and > 50% were dialyzed at home. Most data were described at < or = 12 mo of follow-up. Outcomes included quality of life, cardiovascular disease, erythropoiesis, nutritional status, hospitalizations, and vascular access failures. Reporting was too heterogeneous to allow pooling of data. Ten of 11 studies suggested improvements in blood pressure; findings for other outcomes varied. Discontinuation of DHD occurred in 0 to 57% in-center and 0 to 15% home patients. Studies of DHD are limited by small sample size, nonideal control groups, selection and dropout biases, and paucity of data on potential risks. Randomized trials with adequate statistical power are required to establish the efficacy and the safety of DHD.
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Affiliation(s)
- Rita S Suri
- Division of Nephrology, University of Western Ontario, London, Ontario, Canada.
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Nesrallah GE, Suri RS, Garg AX, Moist LM, Awaraji C, Lindsay RM. The International Quotidian Hemodialysis Registry: Rationale and methods. Hemodial Int 2004; 8:354-9. [DOI: 10.1111/j.1492-7535.2004.80411.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nesrallah GE, Moist LM, Awaraji C, Lindsay RM. An international registry to compare quotidian dialysis regimens with conventional thrice-weekly hemodialysis: why, how, and potential pitfalls. Semin Dial 2004; 17:131-5. [PMID: 15043615 DOI: 10.1111/j.0894-0959.2004.17210.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thrice-weekly hemodialysis is the most commonly used form of renal replacement therapy, yet it is associated with unacceptably high morbidity and mortality. Attempts to improve outcomes for hemodialysis patients by increasing their per-session dose of dialysis have recently proven unsatisfactory in the multicentered Hemodialysis (HEMO) study. Interest has thus turned to increasing dialysis frequency. Short daily and long nocturnal dialysis, which are typically performed 6 days per week, are gaining acceptance and are associated with significant improvements in secondary outcomes, including nutrition, left ventricular hypertrophy, hypertension, anemia, and calcium-phosphorus balance. Studies to date have not been adequately powered to detect the survival benefits that these changes may confer. Large-scale randomized studies are planned, but will likely not answer the survival question for several years. Until this issue is resolved, funding policies are unlikely to change, confining current dialysis patients to potentially suboptimal therapy. By capturing data from current and future daily dialysis patients using an international registry, a survival benefit might be demonstrated more quickly. Such a project will soon be undertaken by the London Daily/Nocturnal Study Group with endorsement from the International Society for Hemodialysis and the U.S. National Institutes of Health. This database will also provide useful descriptive data that will help develop methodologies in this growing field. Historically the interpretation of dialysis registry data has been plagued with various methodological problems. These are briefly reviewed, and some potential solutions and necessary precautions are discussed.
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Affiliation(s)
- Gihad E Nesrallah
- Department of Medicine, University of Western Ontario and London Health Sciences Center, London, Ontario, Canada
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Nesrallah GE, Pierratos A. Short Daily and Long-hours Daily Nocturnal Hemodialysis: Methods, Outcomes and Future Directions. Int J Organ Transplant Med 2004. [DOI: 10.1016/s1561-5413(09)60121-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Nesrallah GE, Chan CT, Buoncristiani U. Cardiovascular Risk Factor Modification with Quotidian Hemodialysis. CONTRIBUTIONS TO NEPHROLOGY 2004; 145:55-62. [PMID: 15496791 DOI: 10.1159/000081667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- Gihad E Nesrallah
- Division of Nephrology, Humber River Regional Hospital, and The University of Western Ontario, London, Ont., Canada
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