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Birks P, Al-Zeer B, Holmes D, Elzayat R, Canney M, Djurdjev O, Shao TS, Zheng Y, Silver SA, Levin A. Assessing Discharge Communication and Follow-up of Acute Kidney Injury in British Columbia: A Retrospective Chart Review. Can J Kidney Health Dis 2024; 11:20543581231222064. [PMID: 38322506 PMCID: PMC10845986 DOI: 10.1177/20543581231222064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/21/2023] [Indexed: 02/08/2024] Open
Abstract
Background and objective Acute kidney injury (AKI) affects up to 20% of hospitalizations and is associated with chronic kidney disease, cardiovascular disease, increased mortality, and increased health care costs. Proper documentation of AKI in discharge summaries is critical for optimal monitoring and treatment of these patients once discharged. Currently, there is limited literature evaluating the quality of discharge communication after AKI. This study aimed to evaluate the accuracy and quality of documentation of episodes of AKI at a tertiary care center in British Columbia, Canada. Methods design setting patients and measurements This was a retrospective chart review study of adult patients who experienced AKI during hospital admission between January 1, 2018, and December 31, 2018. Laboratory data were used to identify all admissions to the cardiac and general medicine ward complicated by AKI defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. A random sample of 300 AKI admissions stratified by AKI severity (eg, stages 1, 2, and 3) were identified for chart review. Patients were excluded if they required ongoing renal replacement therapy after admission, had a history of kidney transplant, died during their admission, or did not have a discharge summary available. Discharge summaries were reviewed for documentation of the following: presence of AKI, severity of AKI, AKI status at discharge, practitioner and laboratory follow-up plans, and medication changes. Results A total of 1076 patients with 1237 AKI admissions were identified. Of the 300 patients selected for discharge summary review, 38 met exclusion criteria. In addition, AKI was documented in 140 (53%) discharge summaries and was more likely to be documented in more severe AKI: stage 1, 38%; stage 2, 51%; and stage 3, 75%. Of those with their AKI documented, 94 (67%) documented AKI severity, and 116 (83%) mentioned the AKI status or trajectory at the time of discharge. A total of 239 (91%) of discharge summaries mentioned a follow-up plan with a practitioner, but only 23 (10%) had documented follow-up with nephrology. Patients with their AKI documented were more likely to have nephrology follow-up than those without AKI documented (17% vs 1%). Regarding laboratory investigations, 92 (35%) of the summaries had documented recommendations. In summaries that included medications typically held during AKI, only about half made specific reference to those medications being held, adjusted, or documented a post-discharge plan for that medication. For those with nonsteroidal anti-inflammatory drugs (NSAIDs) listing, 64% of discharge summaries mentioned holding, and 9% mentioned a discharge plan. For those with angiotensin converting enzyme inhibitor (ACEi)/angiotensin II receptor blocker (ARB) listing, 38% mentioned holding these medications, and 46% mentioned a discharge plan. In summaries with diuretics listed, 35% mentioned holding, and 51% included a discharge plan. Conclusions and limitations We found suboptimal quality and completeness of discharge reporting in patients hospitalized with AKI. This may contribute to inadequate follow-up and post-hospitalization care for this patient population. Strategies are required for increasing the presence and quality of AKI reporting in discharge summaries. Limitations include our definition of AKI based on lab criteria, which may have missed some of the injuries that met the criteria based on urine output. Another limitation is that our definition of AKI based on the highest and lowest creatinine during admission may have led to some overclassification. In addition, without outpatient laboratories, it is possible that we have not captured the true baseline creatinine in some patients.
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Affiliation(s)
- Peter Birks
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - Bader Al-Zeer
- Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Daniel Holmes
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, Canada
| | - Rami Elzayat
- Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Mark Canney
- Department of Medicine, University of Ottawa, Ontario, Canada
| | | | | | | | - Samuel A. Silver
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Adeera Levin
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
- BC Renal, Vancouver, Canada
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Atiquzzaman M, Zhu B, Romann A, Er L, Djurdjev O, Bevilacqua M, Wong MMY, Birks P, Yi TW, Singh A, Tangri N, Levin A. Kidney Failure Risk Equation in vascular access planning: a population-based study supporting value in decision making. Clin Kidney J 2024; 17:sfae008. [PMID: 38327282 PMCID: PMC10847629 DOI: 10.1093/ckj/sfae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 12/13/2023] [Indexed: 02/09/2024] Open
Abstract
Background The Kidney Failure Risk Equation (KFRE) can play a better role in vascular access (VA) planning in patients with chronic kidney disease (CKD) requiring hemodialysis (HD). We described the VA creation and utilization pattern under existing estimated glomerular filtration rate (eGFR)-based referral, and investigated the utility of KFRE score as an adjunct variable in VA planning. Methods Patients with CKD aged ≥18 years with eGFR <20 mL/min/1.73 m2 who chose HD as dialysis modality from January 2010 to August 2020 were included from a population-based database in British Columbia, Canada. Modality selection date was the index date. Exposures were categorized as (i) current eGFR-based referral, (ii) eGFR-based referral plus KRFE 2-year risk score on index date (KFRE-2) >40% and (iii) eGFR-based referral plus KFRE-2 ≤40%. We estimated the proportion of patients who started HD on arteriovenous fistula/graft (AVF/G) within 2 years, indicating timely pre-emptive creation, and the proportion of patients in whom AVF/G was created but did not start HD within 2 years, indicating too-early creation. Results Study included 2581 patients, median age 71 years, 60% male. Overall, 1562(61%) started HD and 276 (11%) experienced death before HD initiation within 2 years. Compared with current referral, the proportion of patients who started HD on AVF/G was significantly higher when KFRE-2 was considered in addition to current referral (49% vs 58%, P-value <.001). Adjunct KFRE-2 significantly reduced too-early creation (31% vs 18%, P-value <.001). Conclusions KFRE in addition to existing eGFR-based referral for VA creation has the potential to improve VA resource utilization by ensuring more patients start HD on AVF/G and may minimize too-early/unnecessary creation. Prospective research is necessary to validate these findings.
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Affiliation(s)
- Mohammad Atiquzzaman
- BC Renal, Vancouver, Canada
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | | | | | - Lee Er
- BC Renal, Vancouver, Canada
| | - Ognjenka Djurdjev
- BC Renal, Vancouver, Canada
- Provincial Clinical Policy Analytics and Registry Initiatives, Data Analytics, Reporting and Evaluation, Provincial Health Services Authority, Vancouver, Canada
| | - Micheli Bevilacqua
- BC Renal, Vancouver, Canada
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Michelle M Y Wong
- BC Renal, Vancouver, Canada
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Peter Birks
- BC Renal, Vancouver, Canada
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Tae Won Yi
- BC Renal, Vancouver, Canada
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Anurag Singh
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Navdeep Tangri
- Division of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Adeera Levin
- BC Renal, Vancouver, Canada
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
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Giles C, Novakovic M, Hopman W, Barreto EF, Beaubien-Souligny W, Birks P, Neyra JA, Wald R, Silver SA. The Quality of Discharge Summaries After Acute Kidney Injury. Can J Kidney Health Dis 2023; 10:20543581231199018. [PMID: 37781153 PMCID: PMC10540581 DOI: 10.1177/20543581231199018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 03/26/2023] [Accepted: 07/12/2023] [Indexed: 10/03/2023] Open
Abstract
Background Acute kidney injury (AKI) increases the risk of hospital readmission, chronic kidney disease, and death. Therefore, effective communication in discharge summaries is essential for safe transitions of care. Objective The objectives of this study were to determine the quality of discharge summaries in AKI survivors and identify predictors of higher quality discharge summaries. Design Retrospective chart review. Setting Tertiary care academic center in Ontario, Canada. Patients We examined the discharge summary quality of 300 randomly selected adult patients who survived a hospitalization with AKI at our tertiary care hospital, stratified by AKI severity. We included 150 patients each from 2015 to 2016 and 2018 to 2019, before and after introduction of a post-AKI clinic in 2017. Measurements We reviewed charts for 9 elements of AKI care to create a composite score summarizing discharge summary quality. Methods We used multivariable logistic regression to identify predictors of discharge summary quality. Results The median discharge summary composite score was 4/9 (interquartile range, 2-6). The least frequently mentioned elements were baseline creatinine (n = 55, 18%), AKI-specific follow-up labs (n = 66, 22%), and medication recommendations (n = 80, 27%). The odds of having a higher quality discharge summary (composite score ≥4/9) was greater for every increase in baseline creatinine of 25 μmol/L (adjusted odds ratio [aOR]: 1.27; 95% confidence interval [CI]: 1.03, 1.56), intrarenal etiology (aOR: 2.32; 95% CI: 1.26, 4.27), and increased AKI severity (stage 2 aOR: 2.57; 95% CI: 1.35, 4.91 and stage 3 aOR: 3.36; 95% CI: 1.56, 7.22). There was no association between discharge summary quality and the years before and after introduction of a post-AKI clinic (aOR: 0.77; 95% CI: 0.46, 1.29). Limitations The single-center study design limits generalizability. Conclusions Most discharge summaries are missing key AKI elements, even in patients with severe AKI. These gaps suggest several opportunities exist to improve discharge summary communication following AKI.
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Affiliation(s)
- Cameron Giles
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Milica Novakovic
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Wilma Hopman
- Kingston General Hospital Research Institute, Kingston Health Sciences Centre, ON, Canada
| | | | | | - Peter Birks
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Javier A. Neyra
- Division of Nephrology, Department of Medicine, The University of Alabama at Birmingham, AL, USA
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital, University of Toronto, ON, Canada
| | - Samuel A. Silver
- Division of Nephrology, Department of Medicine, Queen’s University and Kingston Health Sciences Centre, ON, Canada
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Jun M, Scaria A, Andrade J, Badve SV, Birks P, Bota SE, Campain A, Djurdjev O, Garg AX, Ha J, Harel Z, Hemmelgarn B, Hockham C, James MT, Jardine MJ, Levin A, McArthur E, Ravani P, Shao S, Sood MM, Tan Z, Tangri N, Whitlock R, Gallagher M. Kidney function and the comparative effectiveness and safety of direct oral anticoagulants vs. warfarin in adults with atrial fibrillation: a multicenter observational study. Eur Heart J Qual Care Clin Outcomes 2023; 9:621-631. [PMID: 36302143 DOI: 10.1093/ehjqcco/qcac069] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 09/13/2023]
Abstract
AIMS The aim of this study was to determine the comparative effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in adults with atrial fibrillation (AF) by level of kidney function. METHODS AND RESULTS We pooled findings from five retrospective cohorts (2011-18) across Australia and Canada of adults with; a new dispensation for a DOAC or warfarin, an AF diagnosis, and a measure of baseline estimated glomerular filtration rate (eGFR). The outcomes of interest, within 1 year from the cohort entry date, were: (1) the composite of all-cause death, first hospitalization for ischaemic stroke, or transient ischaemic attack (effectiveness), and (2) first hospitalization for major bleeding defined as an intracranial, upper or lower gastrointestinal, or other bleeding (safety). Cox models were used to examine the association of a DOAC vs. warfarin with outcomes, after 1:1 matching via a propensity score. Kidney function was categorized as eGFR ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2. A total of 74 542 patients were included in the matched analysis. DOAC initiation was associated with greater or similar effectiveness compared with warfarin initiation across all eGFR categories [pooled HRs (95% CIs) for eGFR categories: 0.74(0.69-0.79), 0.76(0.54-1.07), 0.68(0.61-0.75) and 0.86(0.76-0.98)], respectively. DOAC initiation was associated with lower or similar risk of major bleeding than warfarin initiation [pooled HRs (95% CIs): 0.75(0.65-0.86), 0.81(0.65-1.01), 0.82(0.66-1.02), and 0.71(0.52-0.99), respectively). Associations between DOAC initiation, compared with warfarin initiation, and study outcomes were not modified by eGFR category. CONCLUSION DOAC use, compared with warfarin use, was associated with a lower or similar risk of all-cause death, ischaemic stroke, and transient ischaemic attack and also a lower or similar risk of major bleeding across all levels of kidney function.
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Affiliation(s)
- Min Jun
- The George Institute for Global Health, UNSW Sydney, Sydney, Newtown, NSW 2042, Australia
| | - Anish Scaria
- The George Institute for Global Health, UNSW Sydney, Sydney, Newtown, NSW 2042, Australia
| | - Jason Andrade
- University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| | - Sunil V Badve
- The George Institute for Global Health, UNSW Sydney, Sydney, Newtown, NSW 2042, Australia
| | - Peter Birks
- University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
| | | | - Anna Campain
- The George Institute for Global Health, UNSW Sydney, Sydney, Newtown, NSW 2042, Australia
| | | | - Amit X Garg
- ICES, ON, Canada
- Department of Medicine, Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Jeffrey Ha
- The George Institute for Global Health, UNSW Sydney, Sydney, Newtown, NSW 2042, Australia
| | - Ziv Harel
- Division of Nephrology, St. Michael's Hospital, Toronto, ON, Canada
| | - Brenda Hemmelgarn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Carinna Hockham
- The George Institute for Global Health, Imperial College London, London, UK
| | - Matthew T James
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Calgary AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Meg J Jardine
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Adeera Levin
- University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
- BC Renal, Vancouver, BC, Canada
| | | | - Pietro Ravani
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Calgary AB, Canada
| | | | - Manish M Sood
- The Ottawa Hospital Research Institute and Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Zhi Tan
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Calgary AB, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, MB, Canada
| | - Reid Whitlock
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, MB, Canada
| | - Martin Gallagher
- The George Institute for Global Health, UNSW Sydney, Sydney, Newtown, NSW 2042, Australia
- Liverpool Clinical School, UNSW Sydney, Sydney, NSWAustralia
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Ha JT, Scaria A, Andrade J, Badve SV, Birks P, Bota SE, Campain A, Djurdjev O, Garg AX, Harel Z, Hemmelgarn B, Hockham C, James MT, Jardine MJ, Lam D, Levin A, McArthur E, Ravani P, Shao S, Sood MM, Tan Z, Tangri N, Whitlock R, Gallagher M, Jun M. Safety and Effectiveness of Rivaroxaban Versus Warfarin Across GFR Levels in Atrial Fibrillation: A Population-Based Study in Australia and Canada. Kidney Med 2023; 5:100675. [PMID: 37492112 PMCID: PMC10363562 DOI: 10.1016/j.xkme.2023.100675] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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] [Indexed: 07/27/2023] Open
Abstract
Rationale & Objective The benefit-risk profile of rivaroxaban versus warfarin for atrial fibrillation (AF) in patients with chronic kidney disease is uncertain. We compared rivaroxaban with warfarin across the range of kidney function in adults with AF. Study Design Multicenter retrospective cohort. Setting & Participants Adults with AF and a measure of estimated glomerular filtration rate (eGFR); using administrative data from 5 jurisdictions across Australia and Canada (2011-2018). Kidney function was categorized as eGFR ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2. Patients receiving dialysis and kidney transplant recipients were excluded. Exposures New dispensation of either rivaroxaban or warfarin. Outcomes Composite (1) effectiveness outcome (all-cause death, ischemic stroke, or transient ischemic attack) and (2) major bleeding events (intracranial, gastrointestinal, or other) at 1 year. Analytical Approach Cox proportional hazards models accounting for propensity score matching were performed independently in each jurisdiction and then pooled using random-effects meta-analysis. Results 55,568 patients (27,784 rivaroxaban-warfarin user matched pairs; mean age 74 years, 46% female, 33.5% with eGFR <60 mL/min/1.73 m2) experienced a total of 4,733 (8.5%) effectiveness and 1,144 (2.0%) bleeding events. Compared to warfarin, rivaroxaban was associated with greater or similar effectiveness across a broad range of kidney function (pooled HRs of 0.72 [95% CI, 0.66-0.78], 0.78 [95% CI, 0.58-1.06], 0.70 [95% CI, 0.57-0.87], and 0.78 [95% CI, 0.62-0.99]) for eGFR ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2, respectively). Rivaroxaban was also associated with similar risk of major bleeding across all eGFR categories (pooled HRs of 0.75 [95% CI, 0.56-1.00], 1.01 [95% CI, 0.79-1.30], 0.87 [95% CI, 0.66-1.15], and 0.63 [95% CI, 0.37-1.09], respectively). Limitations Unmeasured treatment selection bias and residual confounding. Conclusions In adults with AF, rivaroxaban compared with warfarin was associated with lower or similar risk of all-cause death, ischemic stroke and transient ischemic attack and similar risk of bleeding across a broad range of kidney function. Plain-Language Summary This real-world study involved a large cohort of 55,568 adults with atrial fibrillation from 5 jurisdictions across Australia and Canada. It showed that the favorable safety (bleeding) and effectiveness (stroke or death) profile of rivaroxaban compared with warfarin was consistent across different levels of kidney function. This study adds important safety data on the use of rivaroxaban in patients with reduced kidney function, including those with estimated glomerular filtration rate <30 mL/min/1.73 m2 in whom the risks and benefits of rivaroxaban use is most uncertain. Overall, the study supports the use of rivaroxaban as a safe and effective alternative to warfarin for atrial fibrillation across differing levels of kidney function.
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Affiliation(s)
- Jeffrey T. Ha
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Anish Scaria
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Jason Andrade
- University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Sunil V. Badve
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Peter Birks
- University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Anna Campain
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | | | - Amit X. Garg
- ICES, Ontario, Canada
- Department of Medicine, Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ziv Harel
- Division of Nephrology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Brenda Hemmelgarn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Carinna Hockham
- The George Institute for Global Health, U.K., Imperial College London, London, United Kingdom
| | - Matthew T. James
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada
| | - Meg J. Jardine
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Dickson Lam
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Adeera Levin
- University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- BC Provincial Renal Agency, Vancouver, British Columbia, Canada
| | | | - Pietro Ravani
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada
| | - Selena Shao
- BC Provincial Renal Agency, Vancouver, British Columbia, Canada
| | - Manish M. Sood
- The Ottawa Hospital Research Institute and Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Zhi Tan
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada
| | - 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
| | - Reid Whitlock
- 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
| | - Martin Gallagher
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
- Liverpool Clinical School, UNSW Sydney, Sydney, NSW, Australia
| | - Min Jun
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
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Atiquzzaman M, Birks P, Bevilacqua M, Wong MMY, Zheng Y, Djurdjev O, Levin A. Prescription Pattern of Cation Exchange Resins and Their Efficacy in Treating Chronic Hyperkalemia Among Patients With Chronic Kidney Diseases: Findings From a Population-Based Analysis in British Columbia, Canada. Can J Kidney Health Dis 2022; 9:20543581221137177. [DOI: 10.1177/20543581221137177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Little was known about how chronic hyperkalemia (cHK) in patients with chronic kidney disease (CKD) is managed in British Columbia, Canada. Objective: To investigate the trend in sodium polystyrene sulfonate (SPS) and calcium polystyrene sulfonate (CPS) utilization and their efficacy in treating cHK in CKD patients from British Columbia, Canada. Study Design: Retrospective cohort. Setting & Patients: CKD patients aged ≥18 years, followed in Kidney Care Clinic (KCC), who had at least 2 potassium values ≥5.0 mmol/L separated by no more than 91 days during the period of June 1, 2015, to July 31, 2021, were included. Index date was the first date of the 2 potassium values ≥5.0 mmol/L. Patients who received SPS or CPS within 90 days before index date were excluded. Patients who were on dialysis or received kidney transplantation on or before index date were also excluded. Exposure: Continuous exposure to SPS and CPS. Outcome: SPS/CPS prescription utilization trend was described by the proportion of patients ever treated with SPS/CPS, median time in days between cHK diagnosis and initiating treatment with SPS/CPS, total and median number of SPS/CPS prescriptions dispensed. Change in mean serum potassium concentration before and after a 90-day continuous treatment with SPS/CPS was estimated. Analytical Approach: Descriptive. Results: This study included 10 495 patients with cHK (median age 74 years, 60% were male). Median follow-up time was 625 days. Only 2864 (27%) patients were dispensed at least 1 prescription of either SPS or CPS. A total 7300 prescriptions were dispensed; median prescriptions dispensed per patients were 2 (interquartile range [IQR]: 1-3). Median time from index date to the first prescription dispensing date was 154 days (IQR: 36-455). Continuous 90-day treatment with SPS/CPS decreased the mean serum potassium concentration by 0.60 mmol/L, from 5.58 to 4.98 mmol/L. Limitations: Descriptive observational study without control group. Conclusions: In British Columbia, only 1 in 4 CKD patients with cHK were dispensed with SPS/CPS, mostly with higher degrees of hyperkalemia. These medications appeared to be moderately effective in reducing the serum potassium concentration. Future research is necessary to evaluate the comparative effectiveness of newer generation medications.
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Affiliation(s)
| | - Peter Birks
- BC Renal, Vancouver, Canada
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - Micheli Bevilacqua
- BC Renal, Vancouver, Canada
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - Michelle M. Y. Wong
- BC Renal, Vancouver, Canada
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - Yuyan Zheng
- Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Ognjenka Djurdjev
- BC Renal, Vancouver, Canada
- Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Adeera Levin
- BC Renal, Vancouver, Canada
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
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Canney M, Birks P, Shao S, Parfrey P, Djurdjev O, Levin A. Temporal Trends in Hemoglobin, Use of Erythropoiesis Stimulating Agents, and Major Clinical Outcomes in Incident Dialysis Patients in Canada. Kidney Int Rep 2021; 6:1130-1140. [PMID: 33912762 PMCID: PMC8071619 DOI: 10.1016/j.ekir.2020.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 12/02/2020] [Accepted: 12/22/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Several jurisdictions have adopted a more conservative approach to anemia in patients receiving dialysis amid safety concerns from target hemoglobin studies. It is largely unknown if this has contributed to a change in clinical outcomes. Methods A national registry was used to identify 35,945 adult patients who initiated and were maintained on dialysis for ≥90 days in Canada from January 2007 to December 2015. Outcomes were ascertained until March 2017 via linkage with hospital discharge diagnoses. Cox proportional hazards models were used to investigate the association between the era of dialysis initiation and the primary composite outcome (acute myocardial infarction [AMI], stroke, or mortality). Results The mean hemoglobin at dialysis initiation decreased from 102.9 g/l in 2007 to 95.5 g/l in 2015, corresponding with a higher prevalence of hemoglobin <80 g/l (8% to 17%) and a reduction in erythropoiesis stimulating agent (ESA) use (49% to 44%). After multivariable adjustment, Era 3 (2013–2015) was associated with an 8% relative risk reduction in the primary outcome compared with Era 1 (2007–2009) (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.88–0.96), a 10% relative reduction in mortality (HR 0.90, 95% CI 0.85–0.94) but no significant change in AMI or stroke. In a model without era, neither hemoglobin nor ESA use was an independent predictor of outcome. Conclusion There have been modest declines in average hemoglobin values and ESA use among incident dialysis patients in Canada with no change in major cardiovascular outcomes. Patient survival has improved over time, likely for reasons other than anemia management.
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Affiliation(s)
- Mark Canney
- University of British Columbia, Division of Nephrology, Vancouver, British Columbia, Canada.,BC Renal, Provincial Health Services Authority, Vancouver, British Columbia, Canada.,Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter Birks
- BC Renal, Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Selena Shao
- BC Renal, Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Patrick Parfrey
- Memorial University Medical School, Department of Medicine, St. John's, Newfoundland, Canada
| | - Ognjenka Djurdjev
- BC Renal, Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Adeera Levin
- University of British Columbia, Division of Nephrology, Vancouver, British Columbia, Canada.,BC Renal, Provincial Health Services Authority, Vancouver, British Columbia, Canada
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Moghaddamjou A, Tashakkor AY, Birks P, Cheung WY. A risk stratification schema for predicting diabetes mellitus in cancer survivors. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.9052] [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: 11/20/2022] Open
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