Impact of the 2021 CKD-EPI eGFR Equation on Kidney Care Referral Criteria in Ontario, Canada: A Population-based Cross-sectional Study

Background

In some jurisdictions, individuals become eligible or recommended for referral for different types of kidney care using criteria based on their estimated glomerular filtration rate (eGFR). Historically, GFR was estimated with an equation developed in 2009, which included a Black race term. An updated, race-free equation was developed in 2021. It is unclear how adoption of the 2021 equation will influence the number of individuals meeting referral criteria to receive different types of kidney care.

Objective

To develop population-based estimates on how the number of individuals meeting the eGFR-based referral criteria to receive three different types of kidney care (nephrologist consultation, care in a multi-care specialty clinic, kidney transplant evaluation) changes when the 2021 versus 2009 equation is used to calculate eGFR.

Design

Population-based, cross-sectional study.

Setting

Ontario, Canada's most populous province with 14.2 million residents as of 2021. Less than 5% of Ontario's residents self-identify as being of Black race.

Patients

Adults with at least one outpatient serum creatinine measurement in the 2 years prior to December 31, 2021.

Measurements

Referral criteria to 3 different types of kidney care: nephrologist consultation, multi-care specialty clinic, and evaluation for a kidney transplant. The eGFR thresholds used to define referral eligibility or recommendation for these kidney health services were based on guidelines from Ontario's provincial renal agency.

Methods

The number of individuals meeting referral criteria for the 3 different healthcare services was compared between the 2009 and 2021 equations, restricted to individuals not yet receiving that level of care. As individual-level race data were not available, estimates were repeated, randomly assigning a Black race status to 1%, 5%, and 10% of the population.

Results

We had an outpatient serum creatinine measurement available for 1 048 110 adults. Using the 2009 equation, 37 345 individuals met the criteria to be referred to a nephrologist, 10 019 met the criteria to receive care in a multi-care specialty clinic, and 10 178 met the criteria to be referred for kidney transplant evaluation. Corresponding numbers with the 2021 equation (and the percent relative to the 2009 equation) were 26 645 (71.3%), 9009 (89.9%), and 8615 (84.6%) individuals, respectively. These numbers were largely unchanged when Black race was assumed in up to 10% of the population.

Limitations

Referral criteria based solely on urine albumin-to-creatinine ratio were not assessed. Self-reported race data were unavailable.

Conclusions

For healthcare planning, in regions where a minority of the population is Black, a substantial number of individuals may no longer meet referral criteria for different types of kidney healthcare following adoption of the new 2021 eGFR equation.

Comparison of Acute Health Care Utilization Between Patients Receiving In-Center Hemodialysis and the General Population: A Population-Based Matched Cohort Study From Ontario, Canada

Background

Patients receiving maintenance hemodialysis have multiple comorbidities and are at high risk of presenting to the hospital. However, the incidence and cost of acute health care utilization in the in-center hemodialysis population and how this compares with other populations is poorly understood.

Objective

To determine the rate, pattern, and cost of emergency department visits and hospitalizations in patients receiving in-center hemodialysis compared with a matched general population.

Design

Population-based matched cohort study.

Setting

We used linked administrative health care databases from Ontario, Canada.

Patients

We included 25 379 patients (incident and prevalent) receiving in-center hemodialysis between January 1, 2010, and December 31, 2018. Patients were matched on birth date (±2 years), sex, and cohort entry date using a 1:4 ratio to 101 516 individuals from the general population.

Measurements

Our primary outcomes were emergency department visits (allowing for multiple visits per individual) and hospital admissions from the emergency department. We also assessed all-cause hospitalizations, all-cause readmissions within 30 days of discharge from the original hospitalization, length of stay for hospital admissions (including multiple visits per individual), and the financial cost of these admissions.

Methods

We presented the rate, percentage, median (25th, 75th percentiles), and incidence rate per 1000 person-years for emergency department visits and hospitalizations. Individual-level health care costs for emergency department visits and all-cause hospitalization were estimated using resource intensity weights multiplied by the cost per weighted case.

Results

Patients receiving in-center hemodialysis had substantially more comorbidities (eg, diabetes) than the matched general population. Eighty percent (n = 20 309) of patients receiving in-center hemodialysis had at least 1 emergency department visit compared with 56% (n = 56 452) of individuals in the matched general population, over a median follow-up of 1.8 years (25th, 75th percentiles: 0.7, 3.6) and 5.2 (2.5, 8.4) years, respectively. The incidence rate of emergency department visits, allowing for multiple visits per individual, was 2274 per 1000 person-years (95% confidence interval [CI]: 2263, 2286) for patients receiving in-center hemodialysis, which was almost 5 times as high as the matched general population (471 per 1000 person-years; 95% CI: 469, 473). The rate of hospital admissions from the emergency department and the rate of all-cause hospital admissions in the in-center hemodialysis population was more than 7 times as high as the matched general population (hospital admissions from the emergency department: 786 vs 101 per 1000 person-years; all-cause hospital admissions: 1056 vs 139 per 1000 person-years). The median number of all-cause hospitalization days per patient year was 4.0 (0, 16.5) in the in-center hemodialysis population compared with 0 (0, 0.5) in the matched general population. The cost per patient-year for emergency department visits in the in-center hemodialysis population was approximately 5.5 times as high as the matched general population while the cost of hospitalizations in the in-center hemodialysis population was approximately 11 times as high as the matched general population (emergency department visits: CAN$ 1153 vs CAN$ 209; hospitalizations: CAN$ 21 151 vs CAN$ 1873 [all costs in 2023 CAN$]).

Limitations

External generalizability and we could not determine whether emergency department visits and hospitalizations were preventable.

Conclusions

Patients receiving in-center hemodialysis have high acute health care utilization. These results improve our understanding of the burden of disease and the associated costs in the in-center hemodialysis population, highlight the need to improve acute outcomes, and can aid health care capacity planning. Additional research is needed to address the risk of hospitalization after controlling for patient comorbidities.

Trial registration

This is not applicable as this is a population-based matched cohort study and not a clinical trial.

System-Level Strategies to Improve Home Dialysis: Policy Levers and Quality Initiatives

Advocacy and policy change are powerful levers to improve quality of care and better support patients on home dialysis. While the kidney community increasingly recognizes the value of home dialysis as an option for patients who prioritize independence and flexibility, only a minority of patients dialyze at home in the United States. Complex system-level factors have restricted further growth in home dialysis modalities, including limited infrastructure, insufficient staff for patient education and training, patient-specific barriers, and suboptimal physician expertise. In this article, we outline trends in home dialysis use, review our evolving understanding of what constitutes high-quality care for the home dialysis population (as well as how this can be measured), and discuss policy and advocacy efforts that continue to shape the care of US patients and compare them with experiences in other countries. We conclude by discussing future directions for quality and advocacy efforts.

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

Importance

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

Objectives

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

Design, Setting, and Participants

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

Interventions

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT03329521.

Mental health and addiction service utilization among people living with chronic kidney disease

BACKGROUND

Mental health problems, particularly anxiety and depression, are common in patients with chronic kidney disease (CKD), and negatively impact quality of life, treatment adherence, and mortality. However, the degree to which mental health and addictions services are utilized by those with CKD is unknown. We examined the history of mental health and addictions service use of individuals across levels of kidney function.

METHODS

We performed a population-based cross-sectional study using linked healthcare databases from Ontario, Canada from 2009 to 2017. We abstracted the prevalence of individuals with mental health and addictions service use within the previous 3 years across levels of kidney function (eGFR$\ \ge $60, 45 to < 60, 30 to < 45, 15 to < 30, <15 mL/min per 1.73m2 and maintenance dialysis). We calculated prevalence ratios (PR) to compare prevalence across kidney function strata, while adjusting for age, sex, year of cohort entry, urban versus rural location, area-level marginalization, and Charlson comorbidity scores.

RESULTS

Of 5 956 589 adults, 9% (n = 534 605) had an eGFR<60 mL/min per 1.73m2 or were receiving maintenance dialysis. Fewer individuals with eGFR < 60 had a history of any mental health and addictions service utilization (crude prevalence range 28% to 31%), compared to individuals with eGFR ≥ 60 (35%). Compared to eGFR ≥ 60, the lowest prevalence of individuals with any mental health and addictions service utilization was among those with eGFR 15 to < 30 (adjusted PR 0.86, 95% CI 0.85 to 0.88), eGFR < 15 (adjusted PR 0.81, 95% CI 0.76 to 0.86) and those receiving maintenance dialysis (adjusted PR 0.83, 95% CI 0.81 to 0.84). Less use of outpatient services accounted for differences in service utilization.

CONCLUSIONS

Mental health and addictions service utilization is common but less so in individuals with advanced CKD in Ontario, Canada.

Patient Care Gaps Prior to Maintenance Dialysis Initiation: A Population-Based Retrospective Study

Background

Guidelines in Ontario, Canada, recommend timely referral for multidisciplinary kidney care to facilitate planned dialysis initiation. Many patients do not receive recommended multidisciplinary kidney care prior to dialysis.

Objective

To better understand why this gap in pre-dialysis care exists, we conducted a study to describe the pathways by which patients initiate maintenance dialysis.

Design

A retrospective cohort study.

Setting

Population-based, using health care administrative databases from Ontario, Canada.

Patients

Adults initiating maintenance dialysis from April 2016 to March 2019.

Measurements and methods

Patients were grouped based on whether they received recommended multidisciplinary kidney care prior to dialysis initiation (at least 1 year of care with at least 2 visits). For those who did not receive recommended care, we grouped patients as having no identified care gap or into the following groups: (1) lack of timely chronic kidney disease (CKD) screening, (2) late nephrology referral (<1 year), or (3) late or no referral for multidisciplinary kidney care among patients followed by a nephrologist for at least 1 year.

Results

A total of 9216 patients were included with a mean (standard deviation) age of 66 (15) years, and 61.5% were male. Of the total, 896 (9.7%) patients died, 7671 (83.2%) remained on dialysis at 90 days, and 649 (7.0%) had stopped dialysis due to kidney function recovery within 90 days. Of the 9216 patients, 5434 (59%) had not received recommended multidisciplinary kidney care. Among those without recommended care, there were 2251 (41.4%) patients with no identified care gaps, 1351 (24.9%) patients with a lack of timely CKD screening, 359 (6.6%) patients with late nephrology referral, and 1473 (27.1%) patients with late or no referral for multidisciplinary kidney care.

Limitations

We could not determine if patients were referred but declined multidisciplinary kidney care.

Conclusions

More than half of patients had not received recommended multidisciplinary kidney care. Many patients experienced an acute decline in kidney function, which may not be preventable, but in others, there were missed opportunities for CKD screening or early referral to nephrology, or at the level of nephrology practice for early referral for multidisciplinary care. This work could be used to inform policies aimed at improving increased uptake of multidisciplinary kidney care prior to dialysis.

Low-Dose Methotrexate and Serious Adverse Events Among Older Adults With Chronic Kidney Disease

Importance

Low-dose methotrexate is used to treat rheumatoid arthritis and psoriasis. Due to its kidney elimination, better evidence is needed to inform its safety in adults with chronic kidney disease (CKD).

Objectives

To compare the 90-day risk of serious adverse events among adults with CKD who started low-dose methotrexate vs those who started hydroxychloroquine and to compare the risk of serious adverse events among adults with CKD starting 2 distinct doses of methotrexate vs those starting hydroxychloroquine.

Design, Setting, and Participants

This retrospective, population-based, new-user cohort study was conducted in Ontario, Canada (2008-2021) using linked administrative health care data. Adults aged 66 years or older with CKD (defined as an estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2 but not receiving dialysis) who started low-dose methotrexate (n = 2309) were matched 1:1 with those who started hydroxychloroquine.

Exposure

Low-dose methotrexate (5-35 mg/wk) vs hydroxychloroquine (200-400 mg/d).

Main Outcome and Measure

The primary outcome was a composite of serious adverse events: a hospital visit with myelosuppression, sepsis, pneumotoxic effects, or hepatotoxic effects within 90 days of starting the study drug. Prespecified subgroup analyses were conducted by eGFR category. Propensity score matching was used to balance comparison groups on indicators of baseline health. Risk ratios (RRs) were obtained using modified Poisson regression, and risk differences (RDs) using binomial regression.

Results

In a propensity score-matched cohort of 4618 adults with CKD (3192 [69%] women; median [IQR] age, 76 [71-82] years), the primary outcome was higher in patients who started low-dose methotrexate vs those who started hydroxychloroquine (82 of 2309 [3.55%] vs 40 of 2309 [1.73%]; RR, 2.05 (95% CI, 1.42-2.96); RD, 1.82% [95% CI, 0.91%-2.73%]). In subgroup analysis, the risks increased progressively at lower eGFR (eg, eGFR <45 mL/min/1.73 m2: RR, 2.79 [95% CI, 1.51-5.13]). In the secondary comparison with hydroxychloroquine, methotrexate users at 15 to 35 mg/wk had a higher risk of the primary outcome.

Conclusions and Relevance

In this cohort of 4618 older patients with CKD, the 90-day risk of serious adverse events was higher among those who started low-dose methotrexate than those who started hydroxychloroquine. If verified, these risks should be balanced against the benefits of low-dose methotrexate use.

Variation in Kidney Transplant Referral Across Chronic Kidney Disease Programs in Ontario, Canada

Background

Eligible patients with kidney failure should have equal access to kidney transplantation. Transplant referral is the first crucial step toward receiving a kidney transplant; however, studies suggest substantial variation in the rate of kidney transplant referral across regions. The province of Ontario, Canada, has a public, single-payer health care system with 27 regional chronic kidney disease (CKD) programs. The probability of being referred for kidney transplant may not be equal across CKD programs.

Objective

To determine whether there is variability in kidney transplant referral rates across Ontario's CKD programs.

Design

Population-based cohort study using linked administrative health care databases from January 1, 2013, to November 1, 2016.

Setting

Twenty-seven regional CKD programs in the province of Ontario, Canada.

Patients

Patients approaching the need for dialysis (advanced CKD) and patients receiving maintenance dialysis (maximum follow-up: November 1, 2017).

Measurements

Kidney transplant referral.

Methods

We calculated the 1-year unadjusted cumulative probability of kidney transplant referral for Ontario's 27 CKD programs using the complement of Kaplan-Meier estimator. We calculated standardized referral ratios (SRRs) for each CKD program, using expected referrals from a 2-staged Cox proportional hazards model, adjusting for patient characteristics in the first stage. Standardized referral ratios with a value less than 1 were below the provincial average (maximum possible follow-up of 4 years 10 months). In an additional analysis, we grouped CKD programs according to 5 geographic regions.

Results

Among 8641 patients with advanced CKD, the 1-year cumulative probability of kidney transplant referral ranged from 0.9% (95% confidence interval [CI]: 0.2%-3.7%) to 21.0% (95% CI: 17.5%-25.2%) across the 27 CKD programs. The adjusted SRR ranged from 0.2 (95% CI: 0.1-0.4) to 4.2 (95% CI: 2.1-7.5). Among 6852 patients receiving maintenance dialysis, the 1-year cumulative probability of transplant referral ranged from 6.4% (95% CI: 4.0%-10.2%) to 34.5% (95% CI: 29.5%-40.1%) across CKD programs. The adjusted SRR ranged from 0.2 (95% CI: 0.1-0.3) to 1.8 (95% CI: 1.6-2.1). When we grouped CKD programs according to geographic region, we found that patients residing in Northern regions had a substantially lower 1-year cumulative probability of transplant referral.

Limitations

Our cumulative probability estimates only captured referrals within the first year of advanced CKD or maintenance dialysis initiation.

Conclusions

There is marked variability in the probability of kidney transplant referral across CKD programs operating in a publicly funded health care system.

Clinical Outcomes and Vaccine Effectiveness for SARS-CoV-2 Infection in People Attending Advanced CKD Clinics: A Retrospective Provincial Cohort Study

BACKGROUND

People with advanced CKD are at high risk of mortality and morbidity from coronavirus disease 2019 (COVID-19). We measured rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe outcomes in a large population attending advanced CKD clinics during the first 21 months of the pandemic. We examined risk factors for infection and case fatality, and we assessed vaccine effectiveness in this population.

METHODS

In this retrospective cohort study, we analyzed data on demographics, diagnosed SARS-CoV-2 infection rates, outcomes, and associated risk factors, including vaccine effectiveness, for people attending a province-wide network of advanced CKD clinics during the first four waves of the pandemic in Ontario, Canada.

RESULTS

In a population of 20,235 patients with advanced CKD, 607 were diagnosed with SARS-CoV-2 infection over 21 months. The case fatality rate at 30 days was 19% overall but declined from 29% in the first wave to 14% in the fourth. Hospitalization and intensive care unit (ICU) admission rates were 41% and 12%, respectively, and 4% started long-term dialysis within 90 days. Significant risk factors for diagnosed infection on multivariable analysis included lower eGFR, higher Charlson Comorbidity Index, attending advanced CKD clinics for more than 2 years, non-White ethnicity, lower income, living in the Greater Toronto Area, and long-term care home residency. Being doubly vaccinated was associated with lower 30-day case fatality rate (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.03 to 0.52). Older age (OR, 1.06 per year; 95% CI, 1.04 to 1.08) and higher Charlson Comorbidity Index (OR, 1.11 per unit; 95% CI, 1.01 to 1.23) were associated with higher 30-day case fatality rate.

CONCLUSIONS

People attending advanced CKD clinics and diagnosed with SARS-CoV-2 infection in the first 21 months of the pandemic had high case fatality and hospitalization rates. Fatality rates were significantly lower in those who were doubly vaccinated.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_04_10_CJN10560922.mp3.

Effectiveness of Three Doses of mRNA COVID-19 Vaccines in the Hemodialysis Population during the Omicron Period

BACKGROUND

Coronavirus disease 2019 (COVID-19) vaccine effectiveness studies in the hemodialysis population have demonstrated that two doses of mRNA COVID-19 vaccines are effective against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe complications when Alpha and Delta were predominant variants of concern. Vaccine effectiveness after a third dose versus two doses for preventing SARS-CoV-2 infection and severe COVID-19 in the hemodialysis population against Omicron is not known.

METHODS

We conducted a retrospective cohort study in Ontario, Canada, between December 1, 2021, and February 28, 2022, in the maintenance hemodialysis population who had received two versus three doses of mRNA COVID-19 vaccines. COVID-19 vaccination, SARS-CoV-2 infection, and related hospitalization and death were determined from provincial databases. The primary outcome was the first RT-PCR confirmed SARS-CoV-2 infection, and the secondary outcome was a SARS-CoV-2-related severe outcome, defined as either hospitalization or death.

RESULTS

A total of 8457 individuals receiving in-center hemodialysis were included. At study initiation, 2334 (28%) individuals received three doses, which increased to 7468 (88%) individuals by the end of the study period. The adjusted hazard ratios (aHR) for SARS-CoV-2 infection (aHR, 0.58; 95% confidence interval [CI], 0.50 to 0.67) and severe outcomes (hospitalization or death) (aHR, 0.40; 95% CI, 0.28 to 0.56) were lower after three versus two doses of mRNA vaccine. Prior infection, independent of vaccine status, was associated with a lower risk of reinfection, with an aHR of 0.44 (95% CI, 0.27 to 0.73).

CONCLUSIONS

Three-dose mRNA COVID-19 vaccination was associated with lower incidence of SARS-CoV-2 infection and severe SARS-CoV-2-related outcomes during the Omicron period compared with two doses.

Early Experience with Modified Dose Nirmatrelvir/Ritonavir in Dialysis Patients with Coronavirus Disease 2019

BACKGROUND

Nirmatrelvir/ritonavir was approved for use in high-risk outpatients with coronavirus disease 2019 (COVID-19). However, patients with severe CKD were excluded from the phase 3 trial, and the drug is not recommended for those with GFR <30 ml/min per 1.73 m 2 . On the basis of available pharmacological data, we developed a modified low-dose regimen of nirmatrelvir/ritonavir 300/100 mg on day 1, followed by 150/100 mg daily from day 2 to 5. In this study, we report our experience with this modified dose regimen in dialysis patients in the Canadian province of Ontario.

METHODS

We included dialysis patients who developed COVID-19 and were treated with the modified dose nirmatrelvir/ritonavir regimen during a 60-day period between April 1 and May 31, 2022. Details of nirmatrelvir/ritonavir use and outcomes were captured manually, and demographic data were obtained from a provincial database. Data are presented with descriptive statistics. The principal outcomes we describe are 30-day hospitalization, 30-day mortality, and required medication changes with the modified dose regimen.

RESULTS

A total of 134 dialysis patients with COVID-19 received nirmatrelvir/ritonavir during the period of study. Fifty-six percent were men, and the mean age was 64 years. Most common symptoms were cough and/or sore throat (60%). Medication interactions were common with calcium channel blockers, statins being the most frequent. Most patients (128, 96%) were able to complete the course of nirmatrelvir/ritonavir, and none of the patients who received nirmatrelvir/ritonavir died of COVID-19 in the 30 days of follow-up.

CONCLUSIONS

A modified dose of nirmatrelvir/ritonavir use was found to be safe and well tolerated, with no serious adverse events being observed in a small sample of maintenance dialysis patients.

Infection Control Practices in In-Center Hemodialysis Units During Wave 1 of the COVID-19 Pandemic in Ontario, Canada: Research Letter

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a virus that caused coronavirus disease 2019 (COVID-19), the multisystem disease central to the COVID-19 pandemic. As patients receiving in-center maintenance hemodialysis require treatment 3 times weekly, they were unable to fully isolate. It was important for in-center hemodialysis units to implement robust infection control practices to ensure patient safety and minimize risk of transmitting SARS-CoV-2 among patients and staff. There are 27 renal programs within Ontario, Canada, providing care for about 9000 people across about 100 in-center hemodialysis units. These units are funded by the Ontario Renal Network (ORN), which is part of the provincial agency Ontario Health.

Objective

The objective was to track infection control practices that were implemented by in-center hemodialysis units and be able to provide a descriptive narrative of the COVID-19 pandemic response of Ontario's hemodialysis units between March and September 2020.

Methods

Between May and September 2020, data were collected from Ontario's 27 renal programs on the implementation of key infection control practices, including symptom screening, use of personal protective equipment, testing, practices specifically related to patients from congregate living settings, other prevention practices, and outbreak management. There were 4 data collection cycles, each approximately 1 month apart. The results were compiled and shared across the province, and infection control practices were also discussed at provincial COVID-19 teleconferences hosted by the ORN.

Results

By March 2020, all but one renal program had implemented one or more forms of symptom screening, all renal programs had implemented physical distancing in waiting rooms and restricted visitors, and 74% of renal programs had implemented universal masking for all staff. By April 2020, 89% of renal programs had implemented universal masking for all patients, 52% had implemented enhanced contact and droplet precautions for suspected or positive cases, and 59% of renal programs tested all patients from congregate living settings regularly (with a low symptom threshold for testing). Infection control practices became more homogeneous across renal programs over time, and most practices were in place as of the last data collection.

Conclusions

The renal system in Ontario was able to respond quickly within the first 2 months of the pandemic to minimize the spread of COVID-19 within in-center hemodialysis units. Through provincial teleconferences, infection control practices were shared across the province as the pandemic and hemodialysis unit responses evolved. This supported renal programs to advocate locally if their hospital was lagging in practices felt to be of value in other hemodialysis units. Although no direct correlation can be made regarding the implementation of infection control practices within in-center hemodialysis units and the number of COVID-19 cases in this population, the limited number of outbreaks in hemodialysis units may have been influenced by the proactive response of renal programs. Practices described in this article may support management and response to subsequent waves of COVID-19 or future similar infectious diseases.

Initiation Dose of Allopurinol and the Risk of Severe Cutaneous Reactions in Older Adults With CKD: A Population-Based Cohort Study

RATIONALE & OBJECTIVE

Allopurinol should be started at lower doses in patients with chronic kidney disease (CKD) to avoid adverse effects. We examined the risk of severe cutaneous reactions in older adults with CKD who were newly prescribed allopurinol at varied doses.

STUDY DESIGN

Population-based cohort study using linked health care databases.

SETTING & PARTICIPANTS

Patients in Ontario, Canada (2008-2019) aged ≥66 years, with an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m², and who were new users of allopurinol.

EXPOSURE

A new prescription for allopurinol >100 mg/d versus a dose ≤100 mg/d.

OUTCOME

The primary outcome was a hospital visit with a severe cutaneous reaction within 180 days of starting allopurinol. Secondary outcomes included all-cause hospitalization and all-cause mortality.

ANALYTICAL APPROACH

The exposure and referent groups were balanced on indicators of baseline health using inverse probability of treatment weighting on the propensity score. Weighted risk ratios (RR) were obtained using modified Poisson regression and weighted risk differences (RD) using binomial regression.

RESULTS

Of 47,315 patients (median age, 76 years; median eGFR, 45 mL/min/1.73 m²), 55% started allopurinol at >100 mg/d. Starting allopurinol at >100 versus ≤100 mg/d was associated with an increased risk of a severe cutaneous reaction: number of events (weighted), 103 of 25,802 (0.40%) versus 46 of 25,816 (0.18%), respectively (weighted RR, 2.25 [95% CI, 1.50-3.37]; weighted RD, 0.22% [95% CI, 0.12%-0.32%]. Starting allopurinol at >100 versus ≤100 mg/d was associated with an increased risk of all-cause hospitalization but not with all-cause mortality.

LIMITATIONS

This study was underpowered to detect risk differences in the association of allopurinol dose with outcomes across eGFR categories (ie, 45-59, 30-44, and <30 mL/min/1.73 m²).

CONCLUSIONS

Older patients with CKD who started allopurinol at >100 mg/d versus ≤100 mg/d were twice as likely to visit a hospital with a severe cutaneous reaction in the next 180 days.

Impact of unplanned peritoneal dialysis start on patients' outcomes-A multicenter cohort study

Background

Patients with end-stage kidney disease (ESKD) who start unplanned dialysis therapy are more likely to be treated with hemodialysis (HD) using a central venous catheter, which has been associated with a greater risk of infections and other complications, as well as with a higher long-term risk of death. Urgent-start PD is an alternative that has been suggested as an option for starting dialysis in these cases, with potentially better patient outcomes. However, the definition of urgent-start PD is not homogeneous, and no study, to our knowledge, has compared clinical outcomes among urgent start, early start, and conventional start of PD. In this study, we aimed to compare these types of initiation of dialysis therapy in terms of a composite outcome of patient survival and technique failure.

Methods

This is a retrospective, multicenter, cohort study, involving data from 122 PD clinics in Brazil. We used the following: Urgent-start groups refer to patients who initiated PD within 72 h after the PD catheter insertion; early-start groups are those starting PD from 72 h to 2 weeks after the catheter insertion; and conventional-start groups are those who used the PD catheter after 2 weeks from its insertion. We analyzed the composite endpoint of all causes of patient's mortality and technique failure (within the initial 90 days of PD therapy) using the following three different statistical models: multivariate Cox, Fine and Gay competing risk, and a multilevel model.

Results

We included 509 patients with valid data across 68 PD clinics. There were 38 primary outcomes, comprising 25 deaths and 13 technique failures, with a total follow-up time of 1,393.3 months. Urgent-start PD had no association with the composite endpoint in all three models.

Conclusion

Unplanned PD seems to be a safe and feasible option for treatment for patients with non-dialysis ESKD in urgent need of dialysis.

Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD): Statistical Analysis Plan of a Registry-Based, Cluster-Randomized Clinical Trial

BACKGROUND

Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) is a quality improvement intervention designed to enhance access to kidney transplantation and living kidney donation. We conducted a cluster-randomized clinical trial to evaluate the effect of the intervention versus usual care on completing key steps toward receiving a kidney transplant.

OBJECTIVE

To prespecify the statistical analysis plan for the EnAKT LKD trial.

DESIGN

The EnAKT LKD trial is a pragmatic, 2-arm, parallel-group, registry-based, open-label, cluster-randomized, superiority, clinical trial. Randomization was performed at the level of the chronic kidney disease (CKD) programs (the "clusters").

SETTING

Twenty-six CKD programs in Ontario, Canada.

PARTICIPANTS

More than 10 000 patients with advanced CKD (ie, patients approaching the need for dialysis or receiving maintenance dialysis) with no recorded contraindication to receiving a kidney transplant.

METHODS

The trial data (including patient characteristics and outcomes) will be obtained from linked administrative health care databases (the "registry"). Stratified covariate-constrained randomization was used to allocate the 26 CKD programs (1:1) to provide the intervention or usual care from November 1, 2017, to December 31, 2021 (4.17 years). CKD programs in the intervention arm received the following: (1) support for local quality improvement teams and administrative needs; (2) tailored education and resources for staff, patients, and living kidney donor candidates; (3) support from kidney transplant recipients and living kidney donors; and (4) program-level performance reports and oversight by program leaders.

OUTCOMES

The primary outcome is completing key steps toward receiving a kidney transplant, where up to 4 unique steps per patient will be considered: (1) patient referred to a transplant center for evaluation, (2) a potential living kidney donor begins their evaluation at a transplant center to donate a kidney to the patient, (3) patient added to the deceased donor transplant waitlist, and (4) patient receives a kidney transplant from a living or deceased donor.

ANALYSIS PLAN

Using an intent-to-treat approach, the primary outcome will be analyzed using a patient-level constrained multistate model adjusting for the clustering in CKD programs.

TRIAL STATUS

The EnAKT LKD trial period is November 1, 2017, to December 31, 2021. We expect to analyze and report the results once the data for the trial period is available in linked administrative health care databases.

TRIAL REGISTRATION

The EnAKT LKD trial is registered with the U.S. National Institute of Health at clincaltrials.gov (NCT03329521 available at https://clinicaltrials.gov/ct2/show/NCT03329521).

STATISTICAL ANALYTIC PLAN

Version 1.0 August 26, 2022.

Personalised cooler dialysate for patients receiving maintenance haemodialysis (MyTEMP): a pragmatic, cluster-randomised trial

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.

Protocol for a Process Evaluation of the Quality Improvement Intervention to Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) Cluster-Randomized Clinical Trial

Background:

Many patients who would benefit from a kidney transplant never receive one. The Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) pragmatic, cluster-randomized clinical trial is testing whether a multi-component quality improvement intervention, provided in chronic kidney disease (CKD) programs (vs. usual care), can help patients with CKD with no recorded contraindications to kidney transplant complete more steps toward receiving a transplant (primary outcome of the trial). The EnAKT LKD intervention has 4 components: (1) quality Improvement teams and administrative support, (2) improved transplant education for patients and healthcare providers, (3) access to support and (4) program-level performance monitoring.

Objective:

To conduct a process evaluation of the EnAKT LKD quality improvement intervention to determine if the components were delivered, received, and enacted as designed (fidelity), and if the intervention addressed intended barriers (mechanisms of change).

Design:

A mixed-methods process evaluation informed by new practice implementation and theories of behavior change.

Setting:

Chronic kidney disease programs in Ontario, Canada, began receiving the EnAKT LKD intervention on November 1, 2017 and will continue to receive it until December 31, 2021. The process evaluation (interviews and surveys) will occur alongside the trial, between December 2020 to May 2021.

Participants:

Healthcare providers (eg, dialysis nurses, nephrologists, members of the multi-care kidney clinic team) at Ontario’s 27 CKD programs.

Methods:

We will survey and interview healthcare providers at each CKD program, and complete an intervention implementation checklist. Quantitative data from the surveys and the intervention implementation checklist will assess fidelity to the intervention, while quantitative and qualitative data from surveys and interviews will provide insight into the mechanisms of change.

Limitations:

The long trial period may result in poor participant recall.

Conclusion:

This process evaluation will enhance interpretation of the trial findings, guide improvements in the intervention components, and inform future implementation.

Trial registration:

Clinicaltrials.gov; identifier: NCT03329521.

Vaccine Effectiveness Against SARS-CoV-2 Infection and Severe Outcomes in the Maintenance Dialysis Population in Ontario, Canada

BACKGROUND

Vaccination studies in the hemodialysis population have demonstrated decreased antibody response compared with healthy controls, but vaccine effectiveness for preventing SARS-CoV-2 infection and severe disease is undetermined.

METHODS

We conducted a retrospective cohort study in the province of Ontario, Canada, between December 21, 2020, and June 30, 2021. Receipt of vaccine, SARS-CoV-2 infection, and related severe outcomes (hospitalization or death) were determined from provincial health administrative data. Receipt of one and two doses of vaccine were modeled in a time-varying cause-specific Cox proportional hazards model, adjusting for baseline characteristics, background community infection rates, and censoring for non-COVID death, recovered kidney function, transfer out of province, solid organ transplant, and withdrawal from dialysis.

RESULTS

Among 13,759 individuals receiving maintenance dialysis, 2403 (17%) were unvaccinated and 11,356 (83%) had received at least one dose by June 30, 2021. Vaccine types were BNT162b2 (n=8455, 74%) and mRNA-1273 (n=2901, 26%); median time between the first and second dose was 36 days (IQR 28-51). The adjusted hazard ratio (HR) for SARS-CoV-2 infection and severe outcomes for one dose compared with unvaccinated was 0.59 (95% CI, 0.46 to 0.76) and 0.54 (95% CI, 0.37 to 0.77), respectively, and for two doses compared with unvaccinated was 0.31 (95% CI, 0.22 to 0.42) and 0.17 (95% CI, 0.1 to 0.3), respectively. There were no significant differences in vaccine effectiveness among age groups, dialysis modality, or vaccine type.

CONCLUSIONS

COVID-19 vaccination is effective in the dialysis population to prevent SARS-CoV-2 infection and severe outcomes, despite concerns about suboptimal antibody responses.

Differences in mRNA-1273 (Moderna) and BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 vaccine immunogenicity among patients undergoing dialysis

BACKGROUND

Differences in immunogenicity between mRNA SARS-CoV-2 vaccines have not been well characterized in patients undergoing dialysis. We compared the serologic response in patients undergoing maintenance hemodialysis after vaccination against SARS-CoV-2 with BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna).

METHODS

We conducted a prospective observational cohort study at 2 academic centres in Toronto, Canada, from Feb. 2, 2021, to July 20, 2021, which included 129 and 95 patients who received the BNT162b2 and mRNA-1273 SARS-CoV-2 vaccines, respectively. We measured SARS-CoV-2 immunoglobulin G antibodies to the spike protein (anti-spike), receptor binding domain (anti-RBD) and nucleocapsid protein (anti-NP) at 6-7 and 12 weeks after the second dose of vaccine and compared those levels with the median convalescent serum antibody levels from 211 controls who were previously infected with SARS-CoV-2.

RESULTS

At 6-7 weeks after 2-dose vaccination, we found that 51 of 70 patients (73%) who received BNT162b2 and 83 of 87 (95%) who received mRNA-1273 attained convalescent levels of anti-spike antibody (p < 0.001). In those who received BNT162b2, 35 of 70 (50%) reached the convalescent level for anti-RBD compared with 69 of 87 (79%) who received mRNA-1273 (p < 0.001). At 12 weeks after the second dose, anti-spike and anti-RBD levels were significantly lower in patients who received BNT162b2 than in those who received mRNA-1273. For anti-spike, 70 of 122 patients (57.4%) who received BNT162b2 maintained the convalescent level versus 68 of 71 (96%) of those who received mRNA-1273 (p < 0.001). For anti-RBD, 47 of 122 patients (38.5%) who received BNT162b2 maintained the anti-RBD convalescent level versus 45 of 71 (63%) of those who received mRNA-1273 (p = 0.002).

INTERPRETATION

In patients undergoing hemodialysis, mRNA-1273 elicited a stronger humoral response than BNT162b2. Given the rapid decline in immunogenicity at 12 weeks in patients who received BNT162b2, a third dose is recommended in patients undergoing dialysis as a primary series, similar to recommendations for other vulnerable populations.

Higher-Dose Gabapentinoids and the Risk of Adverse Events in Older Adults With CKD: A Population-Based Cohort Study

RATIONALE & OBJECTIVE

Gabapentinoids are an opioid substitute whose elimination by the kidneys is reduced as kidney function declines. To inform their safe prescribing in older adults with chronic kidney disease (CKD), we examined the 30-day risk of serious adverse events according to the prescribed starting dose.

STUDY DESIGN

Population-based cohort study.

SETTING & PARTICIPANTS

74,084 older adults (64% women; median age 79 [interquartile range 73-85]) with CKD (defined as an estimated glomerular filtration rate [eGFR] <60 mL/min/1.73m2 while not receiving dialysis) and a newly prescribed a gabapentinoid between 2008-2020 in Ontario, Canada.

EXPOSURE

Higher-dose gabapentinoids (gabapentin >300 mg/day or pregabalin >75 mg/day) vs lower-dose gabapentinoids (gabapentin ≤300 mg/day or pregabalin ≤75 mg/day).

OUTCOMES

The primary composite outcome was the 30-day risk of a hospital visit with encephalopathy, a fall, a fracture, or a hospitalization with respiratory depression.

ANALYTICAL APPROACH

Comparison groups were balanced on indicators of baseline health using inverse probability of treatment weighting using propensity score analysis that generated a pseudo-sample for the reference group with a distribution of measured covariates similar to the exposed group. Weighted risk ratios (RR) were estimated using modified Poisson regression, and weighted risk differences (RD) estimated using binomial regression. Pre-specified subgroup analyses were conducted by eGFR category and type of gabapentinoid.

RESULTS

Among 74,084 patients were identified with CKD and a new prescription for gabapentin or pregabalin 41% started at >300 mg/day and >75 mg/day, respectively. From this set of patients a weighted study population with a size of 61,367 was generated. Patients who started at a higher dose had a 30-day risk of the primary outcome higher than the risk among with patients who started at lower dose. Within the weighted population, the numbers of events for higher vs. lower dose were 585/30,660 [1.9%] vs 462/30,707 [1.5%], respectively. The weighted RR was 1.27 [95% CI, 1.13 to 1.42] and the weighted RD was 0.40% [95% CI, 0.21% to 0.60%]). In subgroup analyses, neither multiplicative nor additive interactions were statistically significant.

LIMITATIONS

Residual confounding.

CONCLUSIONS

In this population-based study, starting a gabapentinoid at a higher vs lower dose was associated with a slightly higher risk of a hospital stay with encephalopathy, a fall, or a fracture, or hospitalization with respiratory depression. If verified, these risks should be balanced against the benefits of using a higher-dose gabapentinoid.

Acute kidney injury requiring renal replacement therapy in people with COVID-19 disease in Ontario, Canada: a prospective analysis of risk factors and outcomes

Background

Severely ill people with coronavirus disease 2019 (COVID-19) are at risk of acute kidney injury treated with renal replacement therapy (AKI-RRT). The understanding of the risk factors and outcomes for AKI-RRT is incomplete.

Methods

We prospectively collected data on the incidence, demographics, area of residence, time course, outcomes and associated risk factors for all COVID-19 AKI-RRT cases during the first two waves of the pandemic in Ontario, Canada.

Results

There were 271 people with AKI-RRT, representing 0.1% of all diagnosed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases. These included 10% of SARS-CoV-2 admissions to intensive care units (ICU). Median age was 65 years, with 11% &lt;50 years, 76% were male, 47% non-White and 48% had diabetes. Overall, 59% resided in the quintile of Ontario neighborhoods with the greatest ethnocultural composition and 51% in the two lowest income quintile neighborhoods. Mortality was 58% at 30 days after RRT initiation, and 64% at 90 days. By 90 days, 20% of survivors remained RRT-dependent and 31% were still hospitalized. On multivariable analysis, people aged &gt;70 years had higher mortality (odds ratio 2.4, 95% confidence interval 1.3, 4.6). Cases from the second versus the first COVID-19 wave were older, had more baseline comorbidity and were more likely to initiate RRT  &gt;2 weeks after SARS-CoV-2 diagnosis (34% versus 14%; P &lt; 0.001).

Conclusions

AKI-RRT is common in COVID-19 ICU admissions. Residency in areas with high ethnocultural composition and lower socioeconomic status are strong risk factors. Late-onset AKI-RRT was more common in the second wave. Mortality is high and 90-day survivors have persisting high morbidity.

What do end-users want to know about managing the performance of healthcare delivery systems? Co-designing a context-specific and practice-relevant research agenda

Background

Despite increasing interest in joint research priority-setting, few studies engage end-user groups in setting research priorities at the intersection of the healthcare and management disciplines. With health systems increasingly establishing performance management programmes to account for and incentivize performance, it is important to conduct research that is actionable by the end-users involved with or impacted by these programmes. The aim of this study was to co-design a research agenda on healthcare performance management with and for end-users in a specific jurisdictional and policy context.

Methods

We undertook a rapid review of the literature on healthcare performance management (n = 115) and conducted end-user interviews (n = 156) that included a quantitative ranking exercise to prioritize five directions for future research. The quantitative rankings were analysed using four methods: mean, median, frequency ranked first or second, and frequency ranked fifth. The interview transcripts were coded inductively and analysed thematically to identify common patterns across participant responses.

Results

Seventy-three individual and group interviews were conducted with 156 end-users representing diverse end-user groups, including administrators, clinicians and patients, among others. End-user groups prioritized different research directions based on their experiences and information needs. Despite this variation, the research direction on motivating performance improvement had the highest overall mean ranking and was most often ranked first or second and least often ranked fifth. The research direction was modified based on end-user feedback to include an explicit behaviour change lens and stronger consideration for the influence of context.

Conclusions

Joint research priority-setting resulted in a practice-driven research agenda capable of generating results to inform policy and management practice in healthcare as well as contribute to the literature. The results suggest that end-users are keen to open the “black box” of performance management to explore more nuanced questions beyond “does performance management work?” End-users want to know how, when and why performance management contributes to behaviour change (or fails to) among front-line care providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-021-00779-x.

Province-Wide Prevalence Testing for SARS-CoV-2 of In-Center Hemodialysis Patients and Staff in Ontario, Canada: A Cross-Sectional Study

Background:

People receiving in-center hemodialysis face a high risk for contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and experience poor outcomes. During the first wave of the coronavirus disease 2019 (COVID-19) pandemic in Ontario (between March and June 2020), it was unclear whether asymptomatic or presymptomatic cases were common and whether widespread testing of all dialysis patients and staff would identify cases earlier and prevent transmission. Ontario has a population of about 14.5 million. Approximately 8900 people receive dialysis across 102 in-center dialysis units.

Objective:

The objective of this study was to determine participation rates for patients and staff in point prevalence testing in dialysis units across the province and to determine the prevalence of asymptomatic or presymptomatic infection.

Design:

Cross-sectional study design.

Setting:

In-center hemodialysis units at 27 renal programs across Ontario.

Participants:

Patients and staff in in-center dialysis units in Ontario.

Measurements:

Participation rates, demographic data, SARS-CoV-2 positivity rates, and COVID-19-related symptom data.

Methods:

From June 8 to 30, 2020, all in-center dialysis patients and staff in the Province of Ontario were requested to undergo a symptom screening assessment and nasopharyngeal swab. Testing was done using polymerase chain reaction to detect SARS-CoV-2. A standardized questionnaire of atypical and typical COVID-19-related symptoms was administered to patients, to assess for new or worsening COVID-19-related symptoms.

Results:

Patient participation was 83% (7155 of 8612) of which 15 tests were positive: less than 5 (<0.07%) were new positive cases, 7 were false positive, and the remaining were recovered positives. Half of the new positive cases had symptoms. Common symptoms reported included fatigue (4%), falls (4%), runny nose (3%), dyspnea (3%), and cough (3%). Staff participation was 49% (2109 of 4325), and less than 5 (<0.24%) were asymptomatic positive.

Limitations:

As point prevalence testing was voluntary, not all patients and staff participated. Lower participation rate may be due to decreasing new cases in Ontario, and testing or pandemic fatigue, among other factors. This study did not use serology to identify prior infections because it was not widely available in Ontario. With respect to the standardized symptom questionnaire, it was only available in English and French and could not be tested due to the urgency of the initiative.

Conclusions:

Participation among patients in point prevalence testing was good, but participation among staff was relatively low. Asymptomatic positivity in the dialysis patient and staff population was rare during the first wave of the COVID-19 pandemic in Ontario.

Growing home dialysis: The Ontario Renal Network Home Dialysis Initiative 2012-2019

The Ontario Renal Network (ORN), a provincial government agency in Ontario, Canada, launched an initiative in 2012 to increase home dialysis use province-wide. The initiative included a new modality-based funding formula, a standard mandatory informatics system, targets for prevalent home dialysis rates, the development of a 'network' of renal programmes with commitment to home dialysis and a culture of accountability with frequent meetings between ORN and each renal programme leadership to review their results. It also included funding of home dialysis coordinators, encouragement and funding of assisted peritoneal dialysis (PD), and support for catheter insertion and urgent start PD. Between 2012 and 2017, home dialysis use rose from 21.9% to 26.5% and then between 2017 and 2019 stabilised at 26% to 26.5%. Over 7 years, the absolute number of people on home dialysis increased 40% from 2222 to 3105, while the number on facility haemodialysis grew 11% from 7935 to 8767. PD prevalence rose from 16.6% to 20.9%, a relative increase of 25%. The initiative showed that a sustained multifaceted approach can increase home dialysis utilisation.

COVID-19 chez les patients ontariens sous dialyse à long terme

CONTEXTE:

Les patients sous dialyse à long terme pourraient avoir un risque accru d’infection par le coronavirus du syndrome respiratoire aigu sévère 2 (SRAS-CoV-2), et de maladie et de mortalité associées. Nous avons voulu décrire l’incidence, les facteurs de risque et les issues de l’infection chez ces patients en Ontario (Canada).

MÉTHODES:

Nous avons utilisé des ensembles de données reliées pour comparer les caractéristiques de la maladie et la mortalité chez les patients sous dialyse à long terme en Ontario qui ont testé positif pour le SRAS-CoV-2 et ceux qui n’ont pas développé d’infection, entre le 12 mars et le 20 août 2020. Nous avons recueilli des données sur l’infection par le SRAS-CoV-2 de manière prospective. Nous avons évalué les facteurs de risque d’infection et de mortalité par des analyses de régression logistique multivariées.

RÉSULTATS:

Pendant la période à l’étude, 187 patients dialysés sur 12 501 (1,5 %) ont reçu un diagnostic d’infection par le SRAS-CoV-2. Parmi eux, 117 (62,6 %) ont été hospitalisés, et le taux de mortalité était de 28,3 %. Les facteurs prédictifs significatifs associés à l’infection incluaient l’hémodialyse dans un centre plutôt que la dialyse à domicile (rapport de cotes [RC] 2,54; intervalle de confiance [IC] à 95 % 1,59–4,05), le fait de vivre dans un établissement de soins de longue durée (RC 7,67; IC à 95 % 5,30–11,11), le fait d’habiter la région du Grand Toronto (RC 3,27; IC à 95 % 2,21–4,80), les ethnicités Noire (RC 3,05; IC à 95 % 1,95–4,77), du sous-continent indien (RC 1,70; IC à 95 % 1,02–2,81) et autres non blanches (RC 2,03; IC à 95 % 1,38–2,97) et les quintiles de revenu inférieurs (RC 1,82; IC à 95 % 1,15–2,89).

INTERPRÉTATION:

Les patients sous dialyse à long terme sont exposés à un risque accru d’infection par le SRAS-CoV-2 et de mortalité due à la maladie à coronavirus 2019. Il faudra travailler à éliminer les facteurs de risque d’infection et vacciner ces patients en priorité.

A Quality Improvement Intervention to Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) in Patients With Chronic Kidney Disease: Clinical Research Protocol of a Cluster-Randomized Clinical Trial

Background:

Many patients with kidney failure will live longer and healthier lives if they receive a kidney transplant rather than dialysis. However, multiple barriers prevent patients from accessing this treatment option.

Objective:

To determine if a quality improvement intervention provided in chronic kidney disease (CKD) programs (vs. usual care) enables more patients with no recorded contraindications to kidney transplant to complete more steps toward receiving a kidney transplant.

Design:

This protocol describes a pragmatic 2-arm, parallel-group, open-label, registry-based, cluster-randomized clinical trial—the Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) trial.

Setting:

All 26 CKD programs in Ontario, Canada, with a trial start date of November 1, 2017. The original end date of March 31, 2021 (3.4 years) has been extended to December 31, 2021 (4.1 years) due to the COVID-19 pandemic.

Participants:

During the trial, the 26 CKD programs are expected to care for more than 10 000 adult patients with CKD (including patients approaching the need for dialysis and patients receiving dialysis) with no recorded contraindications to a kidney transplant.

Intervention:

Programs were randomly allocated to provide a quality improvement intervention or usual care. The intervention has 4 main components: (1) local quality improvement teams and administrative support; (2) tailored education and resources for staff, patients, and living kidney donor candidates; (3) support from kidney transplant recipients and living kidney donors; and (4) program-level performance reports and oversight by program leaders.

Primary Outcome:

The primary outcome is the number of key steps completed toward receiving a kidney transplant analyzed at the cluster level (CKD program). The following 4 unique steps per patient will be counted: (1) patient referred to a transplant center for evaluation, (2) at least one living kidney donor candidate contacts a transplant center for an intended recipient and completes a health history questionnaire to begin their evaluation, (3) patient added to the deceased donor transplant wait list, and (4) patient receives a kidney transplant from a living or deceased donor.

Planned Primary Analysis:

Study data will be obtained from Ontario’s linked administrative healthcare databases. An intent-to-treat analysis will be conducted comparing the primary outcome between randomized groups using a 2-stage approach. First stage: residuals are obtained from fitting a regression model to individual-level variables ignoring intervention and clustering effects. Second stage: residuals from the first stage are aggregated at the cluster level as the outcome.

Limitations:

It may not be possible to isolate independent effects of each intervention component, the usual care group could adopt intervention components leading to contamination bias, and the relatively small number of clusters could mean the 2 arms are not balanced on all baseline prognostic factors.

Conclusions:

The EnAKT LKD trial will provide high-quality evidence on whether a multi-component quality improvement intervention helps patients complete more steps toward receiving a kidney transplant.

Trial registration:

Clinicaltrials.gov; identifier: NCT03329521.

COVID-19 in patients undergoing long-term dialysis in Ontario

BACKGROUND

Patients undergoing long-term dialysis may be at higher risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and of associated disease and mortality. We aimed to describe the incidence, risk factors and outcomes for infection in these patients in Ontario, Canada.

METHODS

We used linked data sets to compare disease characteristics and mortality between patients receiving long-term dialysis in Ontario who were diagnosed SARS-CoV-2 positive and those who did not acquire SARS-CoV-2 infection, between Mar. 12 and Aug. 20, 2020. We collected data on SARS-CoV-2 infection prospectively. We evaluated risk factors for infection and death using multivariable logistic regression analyses.

RESULTS

During the study period, 187 (1.5%) of 12 501 patients undergoing dialysis were diagnosed with SARS-CoV-2 infection. Of those with SARS-CoV-2 infection, 117 (62.6%) were admitted to hospital and the case fatality rate was 28.3%. Significant predictors of infection included in-centre hemodialysis versus home dialysis (odds ratio [OR] 2.54, 95% confidence interval [CI] 1.59-4.05), living in a long-term care residence (OR 7.67, 95% CI 5.30-11.11), living in the Greater Toronto Area (OR 3.27, 95% CI 2.21-4.80), Black ethnicity (OR 3.05, 95% CI 1.95-4.77), Indian subcontinent ethnicity (OR 1.70, 95% CI 1.02-2.81), other non-White ethnicities (OR 2.03, 95% CI 1.38-2.97) and lower income quintiles (OR 1.82, 95% CI 1.15-2.89).

INTERPRETATION

Patients undergoing long-term dialysis are at increased risk of SARS-CoV-2 infection and death from coronavirus disease 2019. Special attention should be paid to addressing risk factors for infection, and these patients should be prioritized for vaccination.

Implementing a Patient-Reported Outcome Measure for Hemodialysis Patients in Routine Clinical Care: Perspectives of Patients and Providers on ESAS-r:Renal

BACKGROUND AND OBJECTIVES

The Edmonton Symptom Assessment System Revised: Renal is a patient-reported outcome measure used to assess physical and psychosocial symptom burden in patients treated with maintenance dialysis. Studies of patient-reported outcome measures suggest the need for deeper understanding of how to optimize their implementation and use. This study examines patient and provider perspectives of the implementation process and the influence of the Edmonton Symptom Assessment System Revised: Renal on symptom management, patient-provider communication, and interdisciplinary communication.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Eight in-facility hemodialysis programs in Ontario, Canada, assessed patients using the Edmonton Symptom Assessment System Revised: Renal every 4-6 weeks for 1 year. Screening and completion rates were tracked, and pre- and postimplementation surveys and midimplementation interviews were conducted with patients and providers. A chart audit was conducted 12 months postimplementation.

RESULTS

In total, 1459 patients completed the Edmonton Symptom Assessment System Revised: Renal; 58% of eligible patients completed the preimplementation survey (n=718), and 56% of patients who completed the Edmonton Symptom Assessment System Revised: Renal at least once completed the postimplementation survey (n=569). Provider survey response rates were 71% (n=514) and 54% (n=319), respectively. Nine patients/caregivers from three sites and 48 providers from all sites participated in interviews. A total of 1207 charts were audited. Seven of eight sites had mean screening rates over 80%, suggesting that routine use of the Edmonton Symptom Assessment System Revised: Renal in clinical practice is feasible. However, the multiple data sources painted an inconsistent picture of the value and effect of the Edmonton Symptom Assessment System Revised: Renal. The Edmonton Symptom Assessment System Revised: Renal standardized symptom screening processes across providers and sites; improved patient and provider symptom awareness, particularly for psychosocial symptoms; and empowered patients to raise issues with providers. Yet, there was little, if any, statistically significant improvement in the metrics used to assess symptom management, patient-provider communication, and interdisciplinary communication.

CONCLUSIONS

The Edmonton Symptom Assessment System Revised: Renal patient-reported outcome measure may be useful to standardize symptom screening, enhance awareness of psychosocial symptoms among patients and providers, and empower patients rather than to reduce symptom burden.

International Society for Peritoneal Dialysis Practice Recommendations: The view of the person who is doing or who has done peritoneal dialysis

The 2019 International Society for Peritoneal Dialysis (ISPD) Practice Recommendations were prepared by a committee invited by the ISPD to develop new practice recommendations for prescribing high-quality, goal-directed peritoneal dialysis (PD). Further input was sought at the stage of the first draft of the proposed recommendations by circulating drafts of the recommendations and articles to an international selection of people who were either actively doing PD or who were previously treated with PD, as well as caregivers, to ask for their feedback. A diverse group of 22 people from 8 countries across 5 continents provided their feedback covering the main recommendations as well as the accompanying articles. Much of the feedback has been acted upon at the revision stages, however, the responses are published here in summary form to underscore the commitment to hearing the voice of those doing PD or caring for them. A key change that arose from the feedback has been the shift of language from “patient-centred” to “person-centered,” reflecting the desire of these recommendations to address the patient as a person with needs and preferences beyond just the medical perspective, along with the need for the person doing PD to be central to the process of shared decision-making. Notwithstanding the challenges of an international, multi-lingual population, with people doing PD in highly diverse geographic and economic environments, the next iteration of ISPD guidelines should consider the role of people doing PD and their carers in evidence-based coproduced guidelines, from the inception of the guidelines.

Is Total Creatinine Clearance a Good Predictor of Clinical Outcomes in Continuous Ambulatory Peritoneal Dialysis?

The measurement of the adequacy of dialysis in continuous ambulatory peritoneal dialysis (CAPD) is controversial. The use of weekly total creatinine clearance (TCC) has been recommended, but not validated. We analyzed data from our recent urea kinetics in a CAPD study to investigate TCC and its relationship to patient outcomes. TCC was measured over 24 hours by adding residual renal and peritoneal creatinine clearance, correcting for 1.73 m2 surface area and converting to a weekly value. Seventy-six patients had 218 measurements, on starting CAPD and then at 6–month intervals, with mean follow-up of 20 months (range 1–57 months). The mean TCC was 73.62±32.11 L/week. Due mainly to the loss of residual renal function, the TCC decreased with time (r=-0.40, p<0.0001), from 88.65 L/week initially to 66.11 at one year, 59.84 at two years, and 50.47 at three years. Dialysate-to-plasma creatinine concentration ratios (DIP Cr) increased with time (r=0.28, p<0.0001) from 0.62 initially to 0.66 at one year and 0.73 at two years. The TCC correlated significantly with serum levels of creatinine (r=-0.46, p<0.0001), urea (r=-0.21, p<0.001), potassium (r=-0.14, p<0.05), phosphate (r=-0.25, p<0.001), and hemoglobin (r=0.16, p<0.01), but not with serum albumin or with clinical outcomes including technique failure, hospital days, transfusions, peritonitis rate, nerve conduction velocity, or subjective indices of well-being, except for a weak correlation with the fatigue index (r=0.19, p<0.05). However, of 13 deaths 6 occurred in patients with TCC under 48 L/week (p<0.05). There is little evidence of a proportionality relationship between TCC and clinical outcomes in CAPD, but a TCC of 48 L/week may usefully define a lower limit below which excess mortality occurs.

How Much Extra Does “Adequa Te” Peritoneal Dialysis Cost?

Our objective was to investigate the extra cost associated with implementing an adequacy program in peritoneal dialysis (PO) and to evaluate the cost effectiveness of a variety of PO prescriptions. This was a cross-sectional study of all 37 patients attending the PO clinic at a university teaching hospital. Extra costs incurred on dialysate, tubing, and cyclers as a consequence of implementing an adequacy program in PO were measured. Costs per unit KT/V for a variety of PO prescriptions were also calculated. Thirteen patients (35%) required an alteration in prescription for adequacy reasons. The average extra costs incurred for all patients was Cdn. $2,323 per annum, which represents a 16% increase per patient. The most costeffective prescriptions were high volume continuous ambulatory peritoneal dialysis (CAPO) and automated peritoneal dialysis (APO) with two daytime dwells. The least cost-effective prescriptions were day dry APO and high volume APO with only one daytime dwell. Significant extra expense is incurred when an adequacy program is implemented in PO. This is mainly due to the requirement to put more patients on APO. An alternative pricing policy for PO is suggested.

Individualized Prescription of Peritoneal Dialysis Therapy

Prescribing PD has become more challenging, but also more rewarding and stimulating in recent years. The number of technical aids and strategies has increased, and a potential exists to optimize clearances and ultrafiltration in a way that has not been seen before and that will, it is to be hoped, translate into better patient outcomes. It is crucial, however, that the technologies and strategies be applied with an awareness of the individual patient's particular lifestyle, aspirations, and social circumstances. A failure to consider these factors may lead to noncompliance and, ultimately, to “burnout” and technique failure. Patients must be educated about the importance of clearance targets so that they will accept the alterations in, or the onerous aspects of, the prescriptions they require. Successful prescribing of PD requires an awareness of both clearance and lifestyle factors so that the two can be integrated to give an effective and acceptable regimen. Finally, cost factors should also be considered.

Answers to All Your Questions about Peritoneal Urea Clearance and Nutrit Ion in Capd Patients

In summary, SA and a number of other indices related to nutritional status have been identified as being strongly predictive of outcome in CAPD patients. Evidence connecting these indices to KTN urea, or even to protein intake, remains limited, however. Increased dialytic dose may well increase protein intake, but neither of these parameters have been shown prospectively to raise SA, total body nitrogen, or SGA status on a consistent basis. Studies addressing this issue, however, have been few and small, and more data are required. For now, we will likely continue to deal with malnutrition by attempting to raise small solute clearance and protein intake, but we should be aware that such measures will frequently be unsuccessful, and we must pay attention to other factors, particularly comorbidity.

It is clear from this review that there are many unanswered questions relating to this topic and that, in particular, the effect of prospective increases in the dialytic dose needs to be further elucidated.

Changes in Peritoneal Dialysis Practices in Canada 1996 – 1999

← Objective

Over the past decade, clinical studies and clinical practice guidelines have suggested the use of higher small solute clearance targets for patients on peritoneal dialysis (PD). This study asks whether these recommendations have translated into changes in clinical prescription of PD.

← Study Design

Data were collected annually from 1996 to 1999 on all prevalent dialysis patients in 24 Canadian centers, accounting for approximately 40% of the Canadian chronic dialysis population. Approximately a third of these patients were on PD. Full details of each patient's prescription were recorded, with particular attention to dwell volumes and frequency of exchanges for continuous ambulatory PD (CAPD) and to total treatment volumes and day dwells for automated PD (APD). The most recent Kt/V and creatinine clearance values available were recorded for each patient and the overall results for each year were compared to present treatment recommendations.

← Setting

24 university- and community-based hospitals.

← Results

From 1996 to 1999, the use of APD, relative to CAPD, grew from 14% to 28% of all PD patients. Among CAPD patients, the proportion using dwell volumes greater than 2 L rose from 14% to 32%, and the proportion doing more than 4 dwells per day rose from 16% to 28%. The mean daily volume of prescribed fluid for CAPD patients increased from 8.3 to 9.1 L. As a result, the proportion of patients achieving a weekly Kt/V above 2.0 rose from 54% to 72%, and those receiving a Kt/V less than 1.7 fell from 22% to 10%. For creatinine clearance, those exceeding 60 L per week rose from 63% to 73%. For APD, the mean treatment volume rose from 11.8 L in 1996 to plateau at about 13.4 L in 1998 and 1999. However, the proportion of patients receiving more than 1 day dwell grew from 31% in 1998 to 40% in 1999, and the proportion that were “day dry” fell from 25% to 17%. For APD, the proportion of patients with a Kt/V above 2.0 rose from 67% to 77%, and with a creatinine clearance above 60 L, from 62% to 70%. The proportion with no recent clearance value recorded fell during the course of the study, from 45% to 27%.

← Conclusion

There was a marked change in PD prescription practices in Canada during the second half of the 1990s. This occurred in response to clinical studies and publication of guidelines. There is room for further improvement, especially with respect to the proportion of patients that did not have regular clearance measurements made.