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Ghimire A, Shah S, Chauhan U, Ibrahim KS, Jindal K, Kazancioglu R, Luyckx VA, MacRae JM, Olanrewaju TO, Quinn RR, Ravani P, Shah N, Thompson S, Tungsanga S, Vachharanjani T, Arruebo S, Caskey FJ, Damster S, Donner JA, Jha V, Levin A, Malik C, Nangaku M, Saad S, Tonelli M, Ye F, Okpechi IG, Bello AK, Johnson DW. Global variations in funding and use of hemodialysis accesses: an international report using the ISN Global Kidney Health Atlas. BMC Nephrol 2024; 25:159. [PMID: 38720263 PMCID: PMC11080121 DOI: 10.1186/s12882-024-03593-z] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/29/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND There is a lack of contemporary data describing global variations in vascular access for hemodialysis (HD). We used the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) to highlight differences in funding and availability of hemodialysis accesses used for initiating HD across world regions. METHODS Survey questions were directed at understanding the funding modules for obtaining vascular access and types of accesses used to initiate dialysis. An electronic survey was sent to national and regional key stakeholders affiliated with the ISN between June and September 2022. Countries that participated in the survey were categorized based on World Bank Income Classification (low-, lower-middle, upper-middle, and high-income) and by their regional affiliation with the ISN. RESULTS Data on types of vascular access were available from 160 countries. Respondents from 35 countries (22% of surveyed countries) reported that > 50% of patients started HD with an arteriovenous fistula or graft (AVF or AVG). These rates were higher in Western Europe (n = 14; 64%), North & East Asia (n = 4; 67%), and among high-income countries (n = 24; 38%). The rates of > 50% of patients starting HD with a tunneled dialysis catheter were highest in North America & Caribbean region (n = 7; 58%) and lowest in South Asia and Newly Independent States and Russia (n = 0 in both regions). Respondents from 50% (n = 9) of low-income countries reported that > 75% of patients started HD using a temporary catheter, with the highest rates in Africa (n = 30; 75%) and Latin America (n = 14; 67%). Funding for the creation of vascular access was often through public funding and free at the point of delivery in high-income countries (n = 42; 67% for AVF/AVG, n = 44; 70% for central venous catheters). In low-income countries, private and out of pocket funding was reported as being more common (n = 8; 40% for AVF/AVG, n = 5; 25% for central venous catheters). CONCLUSIONS High income countries exhibit variation in the use of AVF/AVG and tunneled catheters. In low-income countries, there is a higher use of temporary dialysis catheters and private funding models for access creation.
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Affiliation(s)
- Anukul Ghimire
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Samveg Shah
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Utkarsh Chauhan
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Kwaifa Salihu Ibrahim
- Nephrology Unit, Department of Medicine, Wuse District Hospital, Abuja, Nigeria
- Department of Internal Medicine, College of Health Sciences, Federal Capital Territory, Nile University, Abuja, Nigeria
| | - Kailash Jindal
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | | | - Valerie A Luyckx
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | | | - Timothy O Olanrewaju
- Division of Nephrology, Department of Medicine, College of Health Sciences, University of Ilorin, Ilorin, Nigeria
- Julius Center for Health Sciences and Primary Care, Julius Global Health, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Robert R Quinn
- Departments of Medicine & Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Pietro Ravani
- Division of Nephrology, University of Calgary, Calgary, AB, Canada
| | - Nikhil Shah
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Stephanie Thompson
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Somkanya Tungsanga
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Division of General Internal Medicine-Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Tushar Vachharanjani
- Department of Medicine, John D. Dingell Veterans Affairs Medical Center, Wayne State University School of Medicine, Detroit, MI, USA
| | - Silvia Arruebo
- The International Society of Nephrology, Brussels, Belgium
| | - Fergus J Caskey
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Jo-Ann Donner
- The International Society of Nephrology, Brussels, Belgium
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales (UNSW), New Delhi, India
- School of Public Health, Imperial College, London, UK
- Manipal Academy of Higher Education, Manipal, India
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Charu Malik
- The International Society of Nephrology, Brussels, Belgium
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Syed Saad
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Canada and Pan-American Health Organization/World Health Organization's Collaborating Centre in Prevention and Control of Chronic Kidney Disease, University of Calgary, Calgary, AB, Canada
| | - Feng Ye
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ikechi G Okpechi
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Division of Nephrology and Hypertension, University of Cape Town, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Aminu K Bello
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - David W Johnson
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Centre for Kidney Disease Research, University of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, The University of Queensland, Woolloongabba, Queensland, Australia
- Translational Research Institue, University of Queensland, Queensland, Brisbane, Australia
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Ford E, Stewart K, Garcia E, Sharma M, Whitlock R, Getachew R, Rossum K, Duhamel TA, Verrelli M, Zacharias J, Komenda P, Tangri N, Rigatto C, MacRae JM, Bohm C. Randomized Controlled Trial of the Effect of an Exercise Rehabilitation Program on Symptom Burden in Maintenance Hemodialysis: A Clinical Research Protocol. Can J Kidney Health Dis 2024; 11:20543581241234724. [PMID: 38576769 PMCID: PMC10993676 DOI: 10.1177/20543581241234724] [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: 10/31/2023] [Accepted: 01/22/2024] [Indexed: 04/06/2024] Open
Abstract
Background People receiving hemodialysis experience high symptom burden that contributes to low functional status and poor health-related quality of life. Management of symptoms is a priority for individuals receiving hemodialysis but limited effective treatments exist. There is emerging evidence that exercise programming can improve several common dialysis-related symptoms. Objective The primary aim of this study is to evaluate the effect of an exercise rehabilitation program on symptom burden in individuals receiving maintenance hemodialysis. Design Multicenter, randomized controlled, 1:1 parallel, open label, prospective blinded end point trial. Setting Three facility-based hemodialysis units in Winnipeg, Manitoba, Canada. Participants Adults aged 18 years or older with end-stage kidney disease receiving facility-based maintenance hemodialysis for more than 3 months, with at least 1 dialysis-related symptom as indicated by the Dialysis Symptom Index (DSI) severity score >0 (n = 150). Intervention Supervised 26-week exercise rehabilitation program and 60 minutes of cycling during hemodialysis thrice weekly. Exercise intensity and duration were supervised and individualized by the kinesiologist as per participant baseline physical function with gradual progression over the course of the intervention. Control Usual hemodialysis care (no exercise program). Measurements Our primary outcome is change in symptom burden at 12 weeks as measured by the DSI severity score. Secondary outcomes include change in modified DSI severity score (includes 10 symptoms most plausible to improve with exercise), change in DSI severity score at 26 and 52 weeks; time to recover post-hemodialysis; health-related quality of life measured using EuroQol (EQ)-5D-5L; physical activity behavior measured by self-report (Godin-Shepherd questionnaire) and triaxial accelerometry; exercise capacity (shuttle walk test); frailty (Fried); self-efficacy for exercise; and 1-year hospitalization and mortality. Methods Change in primary outcome will be compared between groups by independent 2-tailed t test or Mann-Whitney U test depending on data distribution and using generalized linear mixed models, with study time point as a random effect and adjusted for baseline DSI score. Similarly, change in secondary outcomes will be compared between groups over time using appropriate parametric and nonparametric statistical tests depending on data type and distribution. Limitations The COVID-19 pandemic restrictions on clinical research at our institution delayed completion of target recruitment and prevented collection of accelerometry and physical function outcome data for 15 months until restrictions were lifted. Conclusions The application of an exercise rehabilitation program to improve symptom burden in individuals on hemodialysis may ameliorate common symptoms observed in individuals on hemodialysis and result in improved quality of life and reduced disability and morbidity over the long term. Importantly, this pragmatic study, with a standardized exercise intervention that is adaptable to baseline physical function, addresses an important gap in both clinical care of hemodialysis patients and our current knowledge.
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Affiliation(s)
- Emilie Ford
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | | | - Eric Garcia
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Manitoba Renal Program, Winnipeg, MB, Canada
| | - Monica Sharma
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Reid Whitlock
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Ruth Getachew
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Krista Rossum
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Todd A. Duhamel
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, MB, Canada
| | - Mauro Verrelli
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Manitoba Renal Program, Winnipeg, MB, Canada
| | - James Zacharias
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Manitoba Renal Program, Winnipeg, MB, Canada
| | - Paul Komenda
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- Manitoba Renal Program, Winnipeg, MB, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- Manitoba Renal Program, Winnipeg, MB, Canada
| | - Claudio Rigatto
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- Manitoba Renal Program, Winnipeg, MB, Canada
| | - Jennifer M. MacRae
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Clara Bohm
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- Manitoba Renal Program, Winnipeg, MB, Canada
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MacRae JM, Tam TA, Harrison T, Harasemiw O, Bohm C, Bennett PN, Verdin N, Scholes-Robertson N, Warren M, Thompson S. Exercise perceptions and practices of people receiving peritoneal dialysis: An international cross-sectional survey. Perit Dial Int 2024:8968608241237686. [PMID: 38562120 DOI: 10.1177/08968608241237686] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Low physical activity and functional impairment are prevalent and unaddressed in people receiving peritoneal dialysis (PD). Exercise has been shown to improve physical function and mental health for people with kidney disease. METHODS Cross-sectional descriptive survey aimed at identifying the exercise and physical activity perceptions and practice patterns of people receiving PD. The survey was developed and pretested with persons living with kidney disease, PD clinicians and exercise specialists. RESULTS There were 108 respondents (people receiving PD) with the majority from Canada (68%) and the United Kingdom (25%). Seventy-one per cent were engaged in physical activity two or more times per week. Most (91.8%) believed that physical activity is beneficial, and 61.7% reported healthcare provider discussion about physical activity. Perceptions regarding weightlifting restrictions varied: 76% were told not to lift weight with a maximum amount ranging from 2 kg to 45 kg. Few (28%) were instructed to drain PD fluid prior to physical activity. Mixed advice regarding swimming ability was common (44% were told they could swim and 44% were told they should not). CONCLUSIONS Knowledge gaps suggest that education for both healthcare providers and patients is needed regarding the practice of exercise for people living with PD. Common areas of confusion include the maximum weight a person should lift, whether exercise was safe with or without intrabdominal PD fluid in situ and whether swimming is allowed. Further research is needed to provide patients with evidence-based recommendations rather than defaulting to restricting activity.
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Affiliation(s)
| | - Trinity A Tam
- Department of Medicine, University of Calgary, AB, Canada
| | - Tyrone Harrison
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Oksana Harasemiw
- Chronic Disease Innovation Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Clara Bohm
- Chronic Disease Innovation Centre, University of Manitoba, Winnipeg, MB, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Paul N Bennett
- Griffith Health, Griffith University, Brisbane, QLD, Australia
| | - Nancy Verdin
- The Global Renal Exercise Network Patient Engagement Council, Calgary, AB, Canada
| | | | - Madeleine Warren
- Warren-Charnock Associates, Global Renal Exercise Network Patient Engagement Council, London, UK
| | - Stephanie Thompson
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Edmonton, AB, Canada
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Bhasin AA, MacRae JM, Manns B, Leung KCW, Molnar AO, Busse JW, Collister D, Brimble KS, Rabbat CG, Tyrwhitt J, Mazzetti A, Walsh M. The Association Between Intradialytic Symptom Clusters and Recovery Time in Patients Undergoing Maintenance Hemodialysis: An Exploratory Analysis. Can J Kidney Health Dis 2024; 11:20543581241237322. [PMID: 38532937 PMCID: PMC10964465 DOI: 10.1177/20543581241237322] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/09/2024] [Indexed: 03/28/2024] Open
Abstract
Background Individuals receiving hemodialysis often experience concurrent symptoms during treatment and frequently report feeling unwell after dialysis. The degree to which intradialytic symptoms are related, and which specific symptoms may impair health-related quality of life (HRQoL) is uncertain. Objectives To explore intradialytic symptoms clusters, and the relationship between intradialytic symptom clusters with dialysis treatment recovery time and HRQoL. Design/setting We conducted a post hoc analysis of a prospective cohort study of 118 prevalent patients receiving hemodialysis in two centers in Calgary, Alberta and Hamilton, Ontario, Canada. Participants Adults receiving hemodialysis treatment for at least 3 months, not scheduled for a modality change within 6 weeks of study commencement, who could provide informed consent and were able to complete English questionnaires independently or with assistance. Methods Participants self-reported the presence (1 = none to 5 = very much) of 10 symptoms during each dialysis treatment, the time it took to recover from each treatment, and weekly Kidney Disease Quality of Life 36-Item-Short Form (KDQoL-36) assessments. Principal component analysis identified clusters of intradialytic symptoms. Mixed-effects, ordinal and linear regression examined the association between symptom clusters and recovery time (categorized as 0, >0 to 2, >2 to 6, or >6 hours), and the physical component and mental component scores (PCS and MCS) of the KDQoL-36. Results One hundred sixteen participants completed 901 intradialytic symptom questionnaires. The most common symptom was lack of energy (56% of treatments). Two intradialytic symptom clusters explained 39% of the total variance of available symptom data. The first cluster included bone or joint pain, muscle cramps, muscle soreness, feeling nervous, and lack of energy. The second cluster included nausea/vomiting, diarrhea and chest pain, and headache. The first cluster (median score: -0.56, 25th to 75th percentile: -1.18 to 0.55) was independently associated with longer recovery time (odds ratio [OR] 1.62 per unit difference in score, 95% confidence interval [CI]: 1.23-2.12) and decreased PCS (-0.72 per unit difference in score, 95% CI: -1.29 to -0.15) and MCS scores (-0.82 per unit difference in score, 95% CI: -1.48 to -0.16), whereas the second cluster was not (OR 1.24, 95% CI: 0.97-1.58; PCS 0.19, 95% CI -0.46 to 0.83; MCS -0.72, 95% CI: -1.50 to 0.06). Limitations This was an exploratory analysis of a small data set from 2 centers. Further work is needed to externally validate these findings to confirm intradialytic symptom clusters and the generalizability of our findings. Conclusions Intradialytic symptoms are correlated. The presence of select intradialytic symptoms may prolong the time it takes for a patient to recover from a dialysis treatment and impair HRQoL.
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Affiliation(s)
- Arrti A. Bhasin
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Braden Manns
- Department of Medicine, University of Calgary, AB, Canada
| | | | - Amber O. Molnar
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- St. Joseph’s Healthcare Hamilton, ON, Canada
| | - Jason W. Busse
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - David Collister
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - K Scott Brimble
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- St. Joseph’s Healthcare Hamilton, ON, Canada
| | - Christian G. Rabbat
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- St. Joseph’s Healthcare Hamilton, ON, Canada
| | | | | | - Michael Walsh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- St. Joseph’s Healthcare Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
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James MT, Scory TD, Novak E, Manns BJ, Hemmelgarn BR, Bello AK, Ravani P, Kahlon B, MacRae JM, Ronksley PE. Nurse Practitioner Care Compared with Primary Care or Nephrologist Care in Early CKD. Clin J Am Soc Nephrol 2023; 18:1533-1544. [PMID: 38064305 PMCID: PMC10723919 DOI: 10.2215/cjn.0000000000000305] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/13/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Early interventions in CKD have been shown to improve health outcomes; however, gaps in access to nephrology care remain common. Nurse practitioners can improve access to care; however, the quality and outcomes of nurse practitioner care for CKD are uncertain. METHODS In this propensity score-matched cohort study, patients with CKD meeting criteria for nurse practitioner care were matched 1:1 on their propensity scores for ( 1 ) nurse practitioner care versus primary care alone and ( 2 ) nurse practitioner versus nephrologist care. Processes of care were measured within 1 year after cohort entry, and clinical outcomes were measured over 5 years of follow-up and compared between propensity score-matched groups. RESULTS A total of 961 (99%) patients from the nurse practitioner clinic were matched on their propensity score to 961 (1%) patients receiving primary care only while 969 (100%) patients from the nurse practitioner clinic were matched to 969 (7%) patients receiving nephrologist care. After matching to patients receiving primary care alone, those receiving nurse practitioner care had greater use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (82% versus 79%; absolute differences [ADs] 3.4% [95% confidence interval, 0.0% to 6.9%]) and statins (75% versus 66%; AD 9.7% [5.8% to 13.6%]), fewer prescriptions of nonsteroidal anti-inflammatory drugs (10% versus 17%; AD -7.2% [-10.4% to -4.2%]), greater eGFR and albuminuria monitoring, and lower rates of all-cause hospitalization (34.1 versus 43.3; rate difference -9.2 [-14.7 to -3.8] per 100 person-years) and all-cause mortality (3.3 versus 6.0; rate difference -2.7 [-3.6 to -1.7] per 100 person-years). When matched to patients receiving nephrologist care, those receiving nurse practitioner care were also more likely to be prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and statins, with no difference in the risks of experiencing adverse clinical outcomes. CONCLUSIONS Nurse practitioner care for patients with CKD was associated with better guideline-concordant care than primary care alone or nephrologist care, with clinical outcomes that were better than or equivalent to primary care alone and similar to those with care by nephrologists. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_12_08_CJN0000000000000305.mp3.
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Affiliation(s)
- Matthew T. James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Tayler D. Scory
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ellen Novak
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden J. Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Aminu K. Bello
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Pietro Ravani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Bhavneet Kahlon
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer M. MacRae
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Paul E. Ronksley
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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6
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Schneider AR, Ravani P, King-Shier KM, Quinn RR, MacRae JM, Love S, Oliver MJ, Hiremath S, James MT, Ortiz M, Manns BR, Elliott MJ. Alignment Among Patient, Caregiver, and Health Care Provider Perspectives on Hemodialysis Vascular Access Decision-Making: A Qualitative Study. Can J Kidney Health Dis 2023; 10:20543581231215858. [PMID: 38033483 PMCID: PMC10685780 DOI: 10.1177/20543581231215858] [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: 06/05/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Background Updates to the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access emphasize the "right access, in the right patient, at the right time, for the right reasons." Although this implies a collaborative approach, little is known about how patients, their caregivers, and health care providers engage in vascular access (VA) decision-making. Objective To explore how the perspectives of patients receiving hemodialysis, their caregivers, and hemodialysis care team align and diverge in relation to VA selection. Design Qualitative descriptive study. Setting Five outpatient hemodialysis centers in Calgary, Alberta. Participants Our purposive sample included 19 patients receiving maintenance hemodialysis, 2 caregivers, and 21 health care providers (7 hemodialysis nurses, 6 VA nurses, and 8 nephrologists). Methods We conducted semi-structured interviews with consenting participants. Using an inductive thematic analysis approach, we coded transcripts in duplicate and characterized themes addressing our research objective. Results While participants across roles shared some perspectives related to VA decision-making, we identified areas where views diverged. Areas of alignment included (1) optimizing patient preparedness-acknowledging decisional readiness and timing, and (2) value placed on trusting relationships with the kidney care team-respecting decisional autonomy with guidance. Perspectives diverged in the following aspects: (1) differing VA priorities and preferences-patients' emphasis on minimizing disruptions to normalcy contrasted with providers' preferences for fistulas and optimizing biomedical parameters of dialysis; (2) influence of personal and peer experience-patients preferred pragmatic, experiential knowledge, whereas providers emphasized informational credibility; and (3) endpoints for VA review-reassessment of VA decisions was prompted by access dissatisfaction for patients and a medical imperative to achieve a functioning access for health care providers. Limitations Participation was limited to individuals comfortable communicating in English and from urban, in-center hemodialysis units. Few informal caregivers of people receiving hemodialysis and younger patients participated in this study. Conclusions Although patients, caregivers, and healthcare providers share perspectives on important aspects of VA decisions, conflicting priorities and preferences may impact the decisional outcome. Findings highlight opportunities to bridge knowledge and readiness gaps and integrate shared decision-making in the VA selection process.
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Affiliation(s)
| | - Pietro Ravani
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Kathryn M. King-Shier
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Robert R. Quinn
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Jennifer M. MacRae
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Shannan Love
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Swapnil Hiremath
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Matthew T. James
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Mia Ortiz
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Braden R. Manns
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Meghan J. Elliott
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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MacRae JM, Harasemiw O, Lightfoot CJ, Thompson S, Wytsma-Fisher K, Koufaki P, Bohm C, Wilkinson TJ. Measurement properties of performance-based measures to assess physical function in chronic kidney disease: recommendations from a COSMIN systematic review. Clin Kidney J 2023; 16:2108-2128. [PMID: 37915888 PMCID: PMC10616478 DOI: 10.1093/ckj/sfad170] [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: 02/16/2023] [Indexed: 11/03/2023] Open
Abstract
Background There is wide heterogeneity in physical function tests available for clinical and research use, hindering our ability to synthesize evidence. The aim of this review was to identify and evaluate physical function measures that could be recommended for standardized use in chronic kidney disease (CKD). Methods MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, Scopus and Web of Science were searched from inception to March 2022, identifying studies that evaluated a clinimetric property (validity, reliability, measurement error and/or responsiveness) of an objectively measured performance-based physical function outcomes using the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) methodology and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) based recommendations. Studies with individuals of all ages and of any stage of CKD were included. Results In total, 50 studies with 21 315 participants were included. Clinimetric properties were reported for 22 different physical function tests. The short physical performance battery (SPPB), Timed-up-and-go (TUG) test and Sit-to-stand tests (STS-5 and STS-60) had favorable properties to support their use in CKD and should be integrated into routine use. However, the majority of studies were conducted in the hemodialysis population, and very few provided information regarding validity or reliability. Conclusion The SPPB demonstrated the highest quality of evidence for reliability, measurement error and construct validity amongst transplant, CKD and dialysis patients. This review is an important step towards standardizing a core outcome set of tools to measure physical function in research and clinical settings for the CKD population.
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Affiliation(s)
- Jennifer M MacRae
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Oksana Harasemiw
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | | | - Stephanie Thompson
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Pelagia Koufaki
- School of Health Sciences, Centre for Health, Activity and Rehabilitation Research, Queen Margaret University, Edinburgh, UK
| | - Clara Bohm
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
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Bohm C, Bennett P, Lambert K, Wilund K, Verdin N, Fowler K, Sumida K, Wang AYM, Tangri N, MacRae JM, Thompson S. Advancing Exercise Science for Better Health Outcomes Across the Spectrum of Chronic Kidney Disease. J Ren Nutr 2023; 33:S103-S109. [PMID: 37632512 DOI: 10.1053/j.jrn.2022.12.002] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/27/2022] [Accepted: 12/10/2022] [Indexed: 08/28/2023] Open
Abstract
Despite over 30 years of evidence for improvements in physical function, physical fitness, and health-related quality of life with exercise training in individuals with chronic kidney disease, access to dedicated exercise training programs remains outside the realm of standard of care for most kidney care programs. In this review, we explore possible reasons for this by comparing approaches in other chronic diseases where exercise rehabilitation has become the standard of care, identifying enablers and factors that need to be addressed for continued growth in this area, and discussing knowledge gaps for future research. For exercise rehabilitation to be relevant to all stakeholders and become a sustainable component of kidney care, a focus on the effect of exercise on clinically relevant outcomes that are prioritized by individuals living with kidney disease, use of evidence-based implementation strategies for diverse settings and populations, and approaching exercise as a medical therapy are required.
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Affiliation(s)
- Clara Bohm
- Department of Medicine, University of Manitoba, Winnipeg, Canada; Chronic Disease Innovation Centre, Winnipeg, Canada.
| | - Paul Bennett
- School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia
| | - Kelly Lambert
- School of Medical, Indigenous and Health Sciences, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Ken Wilund
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, Illinois
| | | | - Kevin Fowler
- The Voice of the Patient, Inc, Saint Louis, Missouri
| | - Keiichi Sumida
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Angela Yee-Moon Wang
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, SAR
| | - Navdeep Tangri
- Department of Medicine, University of Manitoba, Winnipeg, Canada; Chronic Disease Innovation Centre, Winnipeg, Canada
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Dumaine CS, Fox DE, Ravani P, Santana MJ, MacRae JM. Health related quality of life during dialysis modality transitions: a qualitative study. BMC Nephrol 2023; 24:282. [PMID: 37740177 PMCID: PMC10517513 DOI: 10.1186/s12882-023-03330-y] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/11/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Modality transitions represent a period of significant change that can impact health related quality of life (HRQoL). We explored the HRQoL of adults transitioning to new or different dialysis modalities. METHODS We recruited eligible adults (≥ 18) transitioning to dialysis from pre-dialysis or undertaking a dialysis modality change between July and September 2017. Nineteen participants (9 incident and 10 prevalent dialysis patients) completed the KDQOL-36 survey at time of transition and three months later. Fifteen participants undertook a semi-structured interview at three months. Qualitative data were thematically analyzed. RESULTS Four themes and five sub-themes were identified: adapting to new circumstances (tackling change, accepting change), adjusting together, trading off, and challenges of chronicity (the impact of dialysis, living with a complex disease, planning with uncertainty). From the first day of dialysis treatment to the third month on a new dialysis therapy, all five HRQoL domains from the KDQOL-36 (symptoms, effects, burden, overall PCS, and overall MCS) improved in our sample (i.e., those who remained on the modality). CONCLUSIONS Dialysis transitions negatively impact the HRQoL of people with kidney disease in various ways. Future work should focus on how to best support people during this time.
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Affiliation(s)
- Chance S Dumaine
- Division of Nephrology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Danielle E Fox
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Pietro Ravani
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Maria J Santana
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Jennifer M MacRae
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, Canada.
- Department of Cardiac Sciences, University of Calgary, Calgary, Canada.
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10
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Schick-Makaroff K, Klarenbach S, Kwon JY, Cohen SR, Czupryn J, Lee L, Pauly R, MacRae JM, Forde B, Sawatzky R. Electronic patient-reported outcomes in clinical kidney practice (ePRO Kidney): a process evaluation of educational support for clinicians. Ther Adv Chronic Dis 2023; 14:20406223231173624. [PMID: 37332391 PMCID: PMC10272664 DOI: 10.1177/20406223231173624] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/17/2023] [Indexed: 06/20/2023] Open
Abstract
Background Patient-reported outcomes (PROs) are increasingly mandated in kidney care to incorporate patients' perspectives. Objectives We assessed whether educational support for clinicians using electronic (e)PROs could enhance person-centered care. Design A process evaluation, using a mixed methods longitudinal comparative concurrent design was undertaken of educational support to clinicians on routine use of ePROs. In two urban home dialysis clinics in Alberta, Canada, patients completed ePROs. At the implementation site, clinicians were provided with ePROs and clinician-oriented education via voluntary workshops. At the non-implementation site, neither were provided. Person-centered care was measured using the Patient Assessment of Chronic Illness Care-20 (PACIC-20). Methods Longitudinal structural equation models (SEMs) compared change in overall PACIC scores. The interpretive description approach, using thematic analysis of qualitative data, further evaluated processes of implementation. Results Data were collected from questionnaires completed by 543 patients, 4 workshops, 15 focus groups, and 37 interviews. There was no overall difference in person-centered care throughout the study, including after delivery of workshops. The longitudinal SEMs revealed substantial individual-level variability in overall PACIC trajectories. However, there was no improvement at the implementation site and no difference between the sites during both the pre- and post-workshop periods. Similar results were obtained for each PACIC domain. Qualitative analysis provided insights into why there was no substantial difference between sites: (1) clinicians wanted to see kidney symptoms, not quality of life, (2) workshops were tailored to clinicians' educational needs, not patients' needs, and (3) variable use of ePRO data by clinicians. Conclusion Training clinicians on use of ePROs is complex and likely only part of what is required to enhance person-centered care. Registration NCT03149328. https://clinicaltrials.gov/ct2/show/NCT03149328.
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Affiliation(s)
- Kara Schick-Makaroff
- Faculty of Nursing, University of Alberta, 4-116 Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB T6G 1C9, Canada
| | - Scott Klarenbach
- Division of Nephrology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jae-Yung Kwon
- School of Nursing, University of Victoria, Victoria, BC, Canada
| | - S. Robin Cohen
- Departments of Oncology and Medicine, McGill University, Montreal, QC, Canada
- Lady Davis Research Institute of the Jewish General Hospital, Montreal, QC, Canada
| | - Joanna Czupryn
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Loretta Lee
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Robert Pauly
- Division of Nephrology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | | | - Bruce Forde
- Cambian Business Services, Surrey, BC, Canada
| | - Richard Sawatzky
- School of Nursing, Trinity Western University, Langley, BC, Canada
- Centre for Health Evaluation & Outcome Sciences, St. Paul’s Hospital, Vancouver, BC, Canada
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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11
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Kalenga CZ, Metcalfe A, Robert M, Nerenberg KA, MacRae JM, Ahmed SB. Association Between the Route of Administration and Formulation of Estrogen Therapy and Hypertension Risk in Postmenopausal Women: A Prospective Population-Based Study. Hypertension 2023. [PMID: 37272379 DOI: 10.1161/hypertensionaha.122.19938] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Hypertension is the leading global cause of cardiovascular disease and premature mortality in women. The effects of postmenopausal hormone therapy (HT) on blood pressure are uncertain but may be related to route of estrogen administration and formulation of estrogen. We sought to determine the association between route of administration and formulation of estrogen HT and hypertension risk in postmenopausal women. METHODS Population-based cohort study with women aged ≥45 years who filled ≥2 consecutive prescriptions for estrogen-only HT, identified from linked provincial health administrative data from Alberta, Canada, between 2008 and 2019. The primary outcome, incident hypertension, was identified using standardized International Classification of Diseases, Ninth and Tenth Revision. Cox proportional hazard models were used to calculate hazard ratios (HRs) for hypertension in women using oral HT compared with nonoral HT (transdermal, vaginal, or intramuscular). RESULTS In total, 112 240 women used an estrogen-only form of HT. Oral estrogen was associated with a higher risk of hypertension compared with both transdermal (HR, 1.14 [95% CI, 1.08-1.20]) and vaginal (HR, 1.19 [95% CI, 1.13-1.25]) estrogens. Conjugated equine estrogen was associated with an increased risk of hypertension compared with estradiol (HR, 1.08 [95% CI, 1.04-1.14]) but not estrone (HR, 1.00 [95% CI, 0.93-1.10]). Duration of estrogen exposure and cumulative dose of estrogen was positively associated with risk of hypertension. CONCLUSIONS Oral estrogen-only HT use was associated with an increased risk of hypertension in women. In women using estrogen-only HT, nonoral estradiol at the lowest dose and for the shortest time-period is associated with the lowest risk of hypertension.
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Affiliation(s)
- Cindy Z Kalenga
- Cumming School of Medicine, University of Calgary, Alberta, Canada. (C.Z.K., A.M., M.R., K.A.N., J.M.M., S.B.A.)
- Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada. (C.Z.K., A.M., K.A.N., J.M.M., S.B.A.)
| | - Amy Metcalfe
- Cumming School of Medicine, University of Calgary, Alberta, Canada. (C.Z.K., A.M., M.R., K.A.N., J.M.M., S.B.A.)
- Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada. (C.Z.K., A.M., K.A.N., J.M.M., S.B.A.)
- O'Brien Institute for Public Health, University of Calgary, Alberta, Canada. (A.M., K.A.N.)
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada (A.M.)
| | - Magali Robert
- Cumming School of Medicine, University of Calgary, Alberta, Canada. (C.Z.K., A.M., M.R., K.A.N., J.M.M., S.B.A.)
| | - Kara A Nerenberg
- Cumming School of Medicine, University of Calgary, Alberta, Canada. (C.Z.K., A.M., M.R., K.A.N., J.M.M., S.B.A.)
- Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada. (C.Z.K., A.M., K.A.N., J.M.M., S.B.A.)
- O'Brien Institute for Public Health, University of Calgary, Alberta, Canada. (A.M., K.A.N.)
| | - Jennifer M MacRae
- Cumming School of Medicine, University of Calgary, Alberta, Canada. (C.Z.K., A.M., M.R., K.A.N., J.M.M., S.B.A.)
- Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada. (C.Z.K., A.M., K.A.N., J.M.M., S.B.A.)
- Alberta Kidney Disease Network, Calgary, Alberta, Canada (J.M.M., S.B.A.)
| | - Sofia B Ahmed
- Cumming School of Medicine, University of Calgary, Alberta, Canada. (C.Z.K., A.M., M.R., K.A.N., J.M.M., S.B.A.)
- Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada. (C.Z.K., A.M., K.A.N., J.M.M., S.B.A.)
- Alberta Kidney Disease Network, Calgary, Alberta, Canada (J.M.M., S.B.A.)
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12
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Rossum K, Hancock E, Thompson S, Brar R, Riehl-Tonn V, Garcia E, Leon SJ, Sharma M, Ford E, Komenda P, Rigatto C, Tangri N, MacRae JM, Bohm C. A Randomized Trial Examining the Impact of Timing of Intradialytic Cycling on Intradialytic Hypotension. Kidney Int Rep 2023; 8:1002-1012. [PMID: 37180520 PMCID: PMC10166740 DOI: 10.1016/j.ekir.2023.02.1074] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/15/2023] [Accepted: 02/08/2023] [Indexed: 02/22/2023] Open
Abstract
Introduction Intradialytic cycling is often performed during the first half of hemodialysis because of concerns regarding increased frequency of intradialytic hypotension (IDH) late in hemodialysis. This increases exercise program resource needs and limits utility of intradialytic cycling to treat dialysis-related symptoms. Methods This multicenter, randomized, crossover trial compared IDH rate when cycling during the first half versus the second half of hemodialysis in 98 adults on maintenance hemodialysis. Group A cycled during the first half of hemodialysis for 2 weeks and subsequently during the second half for 2 weeks. In group B, the cycling schedule was reversed. Blood pressure (BP) was measured every 15 minutes throughout hemodialysis. Primary outcome was IDH rate (systolic BP [SBP] decrease of >20 mm Hg or SBP <90 mm Hg). Secondary outcomes included symptomatic IDH rate and time to recover post hemodialysis. Data were analyzed using negative binomial and gamma distribution mixed regression. Results Mean age 64.7 (SD 12.0) and 64.7 (SD 14.2) years in group A (n = 52) and group B (n = 46), respectively. Proportions of females were 33% in group A and 43% in group B. Median time on hemodialysis was 4.1 (interquartile range [IQR] 2.5, 6.1]) years in group A and 3.9 years (IQR 2.5, 6.7) in group B. IDH rate per 100 hemodialysis hours (95% confidence interval [CI]) was 34.2 (26.4, 42.0) and 36.0 (28.9, 43.1) during early and late intradialytic cycling, respectively (P = 0.53). Timing of intradialytic cycling was not associated with symptomatic IDH (relative risk [RR]: 1.07 [0.75-1.53]) or time to recover post hemodialysis (odds ratio: 0.99 [0.79-1.23]). Conclusion We found no association between the rate of overall or symptomatic IDH and the timing of intradialytic cycling in patients enrolled in an intradialytic cycling program. Increased use of cycling late in hemodialysis may optimize intradialytic cycling program resource use and should be studied as a possible treatment for symptoms common in late hemodialysis.
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Affiliation(s)
- Krista Rossum
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Evelyn Hancock
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stephanie Thompson
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ranveer Brar
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | | | - Eric Garcia
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Manitoba Renal Program, Winnipeg, Manitoba, Canada
| | - Silvia J. Leon
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Monica Sharma
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emilie Ford
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Claudio Rigatto
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Jennifer M. MacRae
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Clara Bohm
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Global Renal Exercise Network6
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Manitoba Renal Program, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
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13
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Harrison TG, Tam TA, Elliott MJ, Ahmed SB, Riehl-Tonn V, Swamy AKR, Benham JL, Peterson J, MacRae JM. Sex differences in COVID-19 symptoms and outcomes in people with kidney failure treated with dialysis: a prospective cohort study. J Nephrol 2023; 36:851-860. [PMID: 36087218 PMCID: PMC9463668 DOI: 10.1007/s40620-022-01448-0] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/20/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND People with kidney failure treated with dialysis are at increased risk of SARS-CoV-2 infection, and severe COVID-19 outcomes such as hospitalization and death. Though there are well-defined sex differences in outcomes for the general population with COVID-19, we do not know whether this translates into kidney failure populations. We aimed to estimate the differences in COVID-19 symptoms and clinical outcomes between males and females treated with maintenance dialysis. METHODS In this prospective observational cohort study, we included adults treated with maintenance dialysis in Southern Alberta, Canada that tested positive for COVID-19 between March 2020 and February 2022. We examined the association between sex (dichotomized as male and female) with COVID-19 symptoms including fever, cough, malaise, shortness of breath, muscle joints/aches, nausea and/or vomiting, loss of appetite, diarrhea, headache, sore throat, and loss of smell/taste using chi-square or Fisher's exact tests. Secondary outcomes included 30-day hospitalization, ICU admission, and death. RESULTS Of 1,329 cohort participants, 246 (18.5%) tested positive for SARS-CoV-2 and were included in our study, including 95 females (39%). Of 207 participants with symptoms assessed, females had less frequent fever (p = 0.003), and more nausea or vomiting (p = 0.003) compared to males, after correction for multiple testing. Males exhibited no symptoms 25% of the time, compared with 10% of females (p = 0.01, not significant when corrected for multiple testing). We did not identify statistically significant differences in clinical outcomes between the sexes, though vaccinated patients had lower odds of hospitalization. CONCLUSIONS Sex differences in COVID-19 symptoms were identified in a cohort of patients treated with maintenance dialysis, which may inform sex-specific screening strategies in dialysis units. Further work is necessary to examine mechanisms for identified sex differences.
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Affiliation(s)
- Tyrone G Harrison
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Trinity A Tam
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Meghan J Elliott
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Sofia B Ahmed
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Asha K R Swamy
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jamie L Benham
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | | | - Jennifer M MacRae
- Department of Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Departments of Medicine and Cardiac Sciences, Alberta Kidney Care South, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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Nicholl DDM, Hanly PJ, MacRae JM, Zalucky AA, Handley GB, Sola DY, Ahmed SB. Sex differences in body fluid composition in humans with obstructive sleep apnea before and after CPAP therapy. Physiol Rep 2023; 11:e15677. [PMID: 37078461 PMCID: PMC10116540 DOI: 10.14814/phy2.15677] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 03/24/2023] [Accepted: 03/31/2023] [Indexed: 04/21/2023] Open
Abstract
Obstructive sleep apnea (OSA) is common in heart and kidney disease, both conditions prone to fluid retention. Nocturnal rostral fluid shift contributes to the pathogenesis of OSA in men more than women, suggesting a potential role for sex differences in body fluid composition in the pathogenesis of OSA, with men having a predisposition to more severe OSA due to an underlying volume expanded state. Continuous positive airway pressure (CPAP) increases intraluminal pressure in the upper airway and mitigates the rostral fluid shift; this, in turn, may prevent fluid redistribution from other parts of the body to the upper airway. We sought to determine the impact of CPAP on sex differences in body fluid composition. Twenty-nine (10 women, 19 men) incident, sodium replete, otherwise healthy participants who were referred with symptomatic OSA (oxygen desaturation index >15/h) were studied pre- and post-CPAP (>4 h/night × 4 weeks) using bioimpedance analysis. Bioimpedance parameters including fat-free mass (FFM, %body mass), total body water (TBW, %FFM), extracellular and intracellular water (ECW and ICW, %TBW), and phase angle (°) were measured and evaluated for sex differences before and after CPAP. Pre-CPAP, despite TBW being similar between sexes (74.6 ± 0.4 vs. 74.3 ± 0.2%FFM, p = 0.14; all values women vs. men), ECW (49.7 ± 0.7 vs. 44.0 ± 0.9%TBW, p < 0.001) was increased, while ICW (49.7 ± 0.5 vs. 55.8 ± 0.9%TBW, p < 0.001) and phase angle (6.7 ± 0.3 vs. 8.0 ± 0.3°, p = 0.005) were reduced in women compared to men. There were no sex differences in response to CPAP (∆TBW -1.0 ± 0.8 vs. 0.7 ± 0.7%FFM, p = 0.14; ∆ECW -0.1 ± 0.8 vs. -0.3 ± 1.0%TBW, p = 0.3; ∆ICW 0.7 ± 0.4 vs. 0.5 ± 1.0%TBW, p = 0.2; ∆Phase Angle 0.2 ± 0.3 vs. 0.0 ± 0.1°, p = 0.7). Women with OSA had baseline parameters favoring volume expansion (increased ECW, reduced phase angle) compared to men. Changes in body fluid composition parameters in response to CPAP did not differ by sex.
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Affiliation(s)
- David D M Nicholl
- Division of Nephrology, Department of Medicine, Royal Inland Hospital, University of British Columbia, Kamloops, British Columbia, Canada
| | - Patrick J Hanly
- Division of Respirology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Sleep Centre, Foothills Medical Centre, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer M MacRae
- Division of Nephrology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Kidney Disease Network, Calgary, Alberta, Canada
| | - Ann A Zalucky
- Department of Critical Care, University of Calgary, Calgary, Alberta, Canada
| | | | - Darlene Y Sola
- Division of Nephrology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Sofia B Ahmed
- Division of Nephrology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Kidney Disease Network, Calgary, Alberta, Canada
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Bennett PN, Kohzuki M, Bohm C, Roshanravan B, Bakker SJL, Viana JL, MacRae JM, Wilkinson TJ, Wilund KR, Van Craenenbroeck AH, Sakkas GK, Mustata S, Fowler K, McDonald J, Aleamañy GM, Anding K, Avin KG, Escobar GL, Gabrys I, Goth J, Isnard M, Jhamb M, Kim JC, Li JW, Lightfoot CJ, McAdams-DeMarco M, Manfredini F, Meade A, Molsted S, Parker K, Seguri-Orti E, Smith AC, Verdin N, Zheng J, Zimmerman D, Thompson S. Global Policy Barriers and Enablers to Exercise and Physical Activity in Kidney Care. J Ren Nutr 2022; 32:441-449. [PMID: 34393071 PMCID: PMC10505947 DOI: 10.1053/j.jrn.2021.06.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 06/06/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Impairment in physical function and physical performance leads to decreased independence and health-related quality of life in people living with chronic kidney disease and end-stage kidney disease. Physical activity and exercise in kidney care are not priorities in policy development. We aimed to identify global policy-related enablers, barriers, and strategies to increase exercise participation and physical activity behavior for people living with kidney disease. DESIGN AND METHODS Guided by the Behavior Change Wheel theoretical framework, 50 global renal exercise experts developed policy barriers and enablers to exercise program implementation and physical activity promotion in kidney care. The consensus process consisted of developing themes from renal experts from North America, South America, Continental Europe, United Kingdom, Asia, and Oceania. Strategies to address enablers and barriers were identified by the group, and consensus was achieved. RESULTS We found that policies addressing funding, service provision, legislation, regulations, guidelines, the environment, communication, and marketing are required to support people with kidney disease to be physically active, participate in exercise, and improve health-related quality of life. We provide a global perspective and highlight Japanese, Canadian, and other regional examples where policies have been developed to increase renal physical activity and rehabilitation. We present recommendations targeting multiple stakeholders including nephrologists, nurses, allied health clinicians, organizations providing renal care and education, and renal program funders. CONCLUSIONS We strongly recommend the nephrology community and people living with kidney disease take action to change policy now, rather than idly waiting for indisputable clinical trial evidence that increasing physical activity, strength, fitness, and function improves the lives of people living with kidney disease.
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Affiliation(s)
- Paul N Bennett
- Medical and Clinical Affairs, Satellite Healthcare, San Jose, California; Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia.
| | - Masahiro Kohzuki
- Department of Internal Medicine and Rehabilitation Science, Tohoku University Graduate School of Medicine, Sendai City, Japan
| | - Clara Bohm
- University of Manitoba, Winnipeg, Canada
| | | | - Stephan J L Bakker
- Department of Internal Medicine, University Medical Center MC Groningen, University of Groningen, Groningen, the Netherlands
| | - João L Viana
- Research Center in Sports Sciences, Health Sciences and Human Development, University Institute of Maia, Maia, Portugal
| | - Jennifer M MacRae
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Kenneth R Wilund
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, Illinois
| | | | - Giorgos K Sakkas
- Cardiff Metropolitan University, Cardiff, UK and University of Thessaly, Volos, Greece
| | - Stefan Mustata
- Faculty of Medicine, University of Calgary, Calgary, Canada
| | | | - Jamie McDonald
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | | | - Kirsten Anding
- Nephrology, KfH Nierenzentrum Bischofswerda, Bischofswerda, Germany
| | - Keith G Avin
- Indiana University Department of Physical Therapy, Indianapolis, Indiana
| | - Gabriela Leal Escobar
- Department of Nephrology Instituto Nacional de Cardiologia Ignacio Chávez, Mexico City, Mexico
| | - Iwona Gabrys
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Jill Goth
- Programs & Public Policy, The Kidney Foundation of Canada, Montreal, Quebec, Canada
| | | | | | - Jun Chul Kim
- Division of Nephrology, Department of Internal Medicine, CHA Gumi Medical Center, CHA University, Gumi, Republic of Korea
| | - John Wing Li
- Renal Medicine, Nepean Hospital, Katoomba, New South Wales, Australia
| | | | | | - Fabio Manfredini
- Department of Biomedical Sciences and Surgical specialties, University of Ferrara, Ferrara, Italy
| | | | | | | | - Eva Seguri-Orti
- Department of Physiotherapy, Universidad Cardenal Herrera-CEU, Alfara del Patriarca, Valencia, Spain
| | - Alice C Smith
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - Jing Zheng
- School of Nursing, Guangdong Pharmaceutical University, Guangzhou, P.R. China
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16
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Kalenga CZ, Hay JL, Boreskie KF, Duhamel TA, MacRae JM, Metcalfe A, Nerenberg KA, Robert M, Ahmed SB. The Association Between Route of Post-menopausal Estrogen Administration and Blood Pressure and Arterial Stiffness in Community-Dwelling Women. Front Cardiovasc Med 2022; 9:913609. [PMID: 35757351 PMCID: PMC9226418 DOI: 10.3389/fcvm.2022.913609] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPostmenopausal hormone therapy (HT) is associated with increased cardiovascular risk. Although the route of estrogen administration may play a role in mediating risk, previous studies have not controlled for concomitant progestin use.ObjectiveTo investigate the association between the route of estrogen therapy (oral or non-oral) HT use, without concomitant progestin, and blood pressure and arterial stiffness in postmenopausal women.MethodsSystolic blood pressure [SBP], diastolic blood pressure [DBP]), arterial stiffness (aortic pulse wave velocity [aPWV] and augmentation index at 75 beats per minute [AIx]) were measured using a validated automated brachial cuff-based oscillometric approach (Mobil-O-Graph) in a community-dwelling sample of 328 women.ResultsFifty-five participants (16.8%) were ever users (current and past use) of estrogen-only HT (oral [n = 16], transdermal [n = 20], vaginal [n = 19]), and 223 were never HT users (control). Ever use of oral estrogen was associated with increased SBP and DBP (Oral: SBP: 137 ± 4 mmHg, DBP: 79 ± 2 mmHg) compared to use of non-oral estrogen (transdermal: SBP: 118 ± 2 mmHg, DBP: 73 ± 1 mmHg; p < 0.01 & p = 0.012, respectively; vaginal: SBP: 123 ± 2 mmHg DBP: 73 ± 2 mmHg; p = 0.02 & p = 0.01, respectively.) and controls (SBP: 124 ± 1 mmHg, DBP: 74 ± 1 mmHg, p = 0.03, p = 0.02, respectively) after adjustment for covariates. aPWV was higher in oral estrogen ever users (9.9 ± 1 m/s) compared to non-oral estrogen (transdermal: 8.6 ± 0.3 m/s, p < 0.01; vaginal: 8.8 ± 0.7 m/s, p = 0.03) and controls (8.9 ± 0.5 m/s, p = 0.03) but these associations were no longer significant after adjustment for covariates. AIx was higher in oral estrogen (29 ± 2 %) compared to non-oral estrogen (transdermal: 16 ± 2 %; vaginal: 22 ± 1.7 %) but this association was no longer significant after adjustment for covariates (p = 0.92 vs. non-oral; p = 0.74 vs. control).ConclusionEver use of oral estrogen was associated with increased SBP and DBP compared to non-oral estrogen use and no use. Given the cardiovascular risk associated with both menopause and increased blood pressure, further studies are required exploring the potential benefits of non-oral estrogen in postmenopausal women.
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Affiliation(s)
- Cindy Z. Kalenga
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Jacqueline L. Hay
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, MB, Canada
| | - Kevin F. Boreskie
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, MB, Canada
| | - Todd A. Duhamel
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, MB, Canada
| | - Jennifer M. MacRae
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- Alberta Kidney Disease Network, Calgary, AB, Canada
| | - Amy Metcalfe
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Kara A. Nerenberg
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Magali Robert
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sofia B. Ahmed
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- Alberta Kidney Disease Network, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- *Correspondence: Sofia B. Ahmed
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17
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Kalenga CZ, Dumanski SM, Metcalfe A, Robert M, Nerenberg KA, MacRae JM, Premji Z, Ahmed SB. The effect of non-oral hormonal contraceptives on hypertension and blood pressure: A systematic review and meta-analysis. Physiol Rep 2022; 10:e15267. [PMID: 35510324 PMCID: PMC9069167 DOI: 10.14814/phy2.15267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 06/14/2023] Open
Abstract
Oral contraceptives (OC) are associated with increased risk of hypertension and elevated blood pressure (BP). Whether non-oral hormonal contraceptives have similar associations is unknown. We sought to investigate the effect of non-oral hormonal contraceptive (NOHC) use on the risk of hypertension and changes in BP, compared to non-hormonal contraceptive and OC use. We searched bibliographic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) until August 2020. Studies reporting risk of hypertension or changes in systolic and diastolic BP with NOHC use compared with either non-hormonal contraceptive or OC use. Abstract screening, full-text review, data extraction, and quality assessment were completed in duplicate. For studies reporting dichotomous outcomes, we reported results as relative risk with 95% confidence intervals (CI). A random-effects model was used to estimate pooled weighted mean difference and 95% CI of change in BP. Twenty-five studies were included. A lower incidence of hypertension was observed with injectable contraceptive use compared to non-hormonal contraceptive and OC use, although it was unclear if this was statistically significant. Compared to non-hormonal contraceptive use, injectable contraceptive use was associated with increased BP (SBP: 3.24 mmHg, 95%CI 2.49 to 3.98 mmHg; DBP: 3.15 mmHg, 95%CI 0.09 to 6.20 mmHg), the hormonal intra-uterine device use was associated with reduced BP (SBP: -4.50 mmHg, 95%CI -8.44 to -0.57 mmHg; DBP: -7.48 mmHg, 95% -14.90 to -0.05 mmHg), and the vaginal ring was associated with reduced diastolic BP (-3.90 mmHg, 95%CI -6.67 to -1.13 mmHg). Compared to OC use, the injectable contraceptive use was associated with increased diastolic BP (2.38 mmHg, 95%CI 0.39 to 4.38 mmHg). NOHC use is associated with changes in BP which differ by type and route of administration. Given the strong association between incremental increases in BP and cardiovascular risk, prospective studies are required.
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Affiliation(s)
- Cindy Z. Kalenga
- Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Libin Cardiovascular InstituteUniversity of CalgaryCalgaryAlbertaCanada
| | - Sandra M. Dumanski
- Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Libin Cardiovascular InstituteUniversity of CalgaryCalgaryAlbertaCanada
- Alberta Kidney Disease NetworkCalgaryAlbertaCanada
| | - Amy Metcalfe
- Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Libin Cardiovascular InstituteUniversity of CalgaryCalgaryAlbertaCanada
- Alberta Children's Hospital Research InstituteCalgaryAlbertaCanada
| | - Magali Robert
- Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Kara A. Nerenberg
- Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Libin Cardiovascular InstituteUniversity of CalgaryCalgaryAlbertaCanada
| | - Jennifer M. MacRae
- Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Libin Cardiovascular InstituteUniversity of CalgaryCalgaryAlbertaCanada
| | - Zahra Premji
- University of VictoriaVictoriaBritish ColumbiaCanada
| | - Sofia B. Ahmed
- Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Libin Cardiovascular InstituteUniversity of CalgaryCalgaryAlbertaCanada
- Alberta Kidney Disease NetworkCalgaryAlbertaCanada
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18
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Kalenga CZ, Ramesh S, Dumanski SM, MacRae JM, Nerenberg K, Metcalfe A, Sola DY, Ahmed SB. Sex influences the effect of adiposity on arterial stiffness and renin‐angiotensin aldosterone system activity in young adults. Endocrinol Diabetes Metab 2022; 5:e00317. [PMID: 34954909 PMCID: PMC8917865 DOI: 10.1002/edm2.317] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/23/2021] [Accepted: 12/04/2021] [Indexed: 11/06/2022] Open
Abstract
Introduction Methods Results Conclusion
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Affiliation(s)
- Cindy Z. Kalenga
- Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Libin Cardiovascular Institute University of Calgary Calgary Alberta Canada
| | - Sharanya Ramesh
- Temerty Faculty of Medicine University of Toronto Toronto Ontario Canada
| | - Sandra M. Dumanski
- Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Libin Cardiovascular Institute University of Calgary Calgary Alberta Canada
- Alberta Kidney Disease Network Calgary Alberta Canada
| | - Jennifer M. MacRae
- Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Libin Cardiovascular Institute University of Calgary Calgary Alberta Canada
| | - Kara Nerenberg
- Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Libin Cardiovascular Institute University of Calgary Calgary Alberta Canada
- O’Brien Institute for Public Health University of Calgary Calgary Alberta Canada
| | - Amy Metcalfe
- Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Libin Cardiovascular Institute University of Calgary Calgary Alberta Canada
- O’Brien Institute for Public Health University of Calgary Calgary Alberta Canada
- Alberta Children's Hospital Research Institute Calgary Alberta Canada
| | - Darlene Y. Sola
- Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Libin Cardiovascular Institute University of Calgary Calgary Alberta Canada
| | - Sofia B. Ahmed
- Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Libin Cardiovascular Institute University of Calgary Calgary Alberta Canada
- Alberta Kidney Disease Network Calgary Alberta Canada
- O’Brien Institute for Public Health University of Calgary Calgary Alberta Canada
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19
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Castillo G, Presseau J, Wilson M, Cook C, Field B, Garg AX, McIntyre C, Molnar AO, Hogeterp B, Thornley M, Thompson S, MacRae JM, Bohm C. Addressing feasibility challenges to delivering intradialytic exercise interventions: A theory-informed qualitative study. Nephrol Dial Transplant 2021; 37:558-574. [PMID: 34415351 DOI: 10.1093/ndt/gfab228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Intradialytic exercise (IDE) may improve physical function and health-related quality of life. However, incorporating IDE into standard hemodialysis care has been slow due to feasibility challenges. We conducted a multicenter qualitative feasibility study to identify potential barriers and enablers to IDE and generate potential solutions to these factors. METHODS We conducted 43 semi-structured interviews with healthcare providers and patients across twelve hospitals in Ontario, Canada. We used the Theoretical Domains Framework and directed content analysis to analyze the data. RESULTS We identified eight relevant domains (knowledge, skills, beliefs about consequences, beliefs about capabilities, environmental context and resources, goals, social/professional role and identity, and social influences) represented by three overarching categories: 1) Knowledge, skills and expectations: lack of staff expertise to oversee exercise, uncertainty regarding exercise risks, benefits, and patient interest, lack of knowledge regarding exercise eligibility; 2) Human, material and logistical resources: staff concerns regarding workload, perception that exercise professionals should supervise IDE; space, equipment, and scheduling conflict concerns; 3) Social dynamics of the unit: local champions and patient stories contribute to IDE sustainability.We developed a list of actionable solutions by mapping barriers and enablers to behavior change techniques. We also developed a feasibility checklist of 47 questions identifying key factors to address prior to IDE launch. CONCLUSIONS Evidence-based solutions to identified barriers and enablers to IDE and a feasibility checklist may help recruit and support units, staff, and patients and address key challenges to the delivery of IDE in diverse clinical and research settings.
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Affiliation(s)
- Gisell Castillo
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario
| | - Mackenzie Wilson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Charles Cook
- Transplant Ambassador Program, Grand River Hospital, Kitchener, Ontario
| | - Bonnie Field
- Patient and Family Advisory Committee, London Health Sciences Centre, London, Ontario
| | - Amit X Garg
- Schulich School of Medicine and Dentistry, Division of Nephrology, Western University, London, Ontario
| | - Christopher McIntyre
- Schulich School of Medicine and Dentistry, Division of Nephrology, Western University, London, Ontario
| | - Amber O Molnar
- Department of Medicine, Division of Nephrology, McMaster University, Hamilton, Ontario
| | - Betty Hogeterp
- Department of Medicine, Division of Nephrology, Lakeridge Health, Oshawa, Ontario
| | - Michelle Thornley
- Department of Medicine, Division of Nephrology, Lakeridge Health, Oshawa, Ontario
| | - Stephanie Thompson
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta
| | - Jennifer M MacRae
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Calgary, Alberta
| | - Clara Bohm
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba
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20
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Paterson B, Fox DE, Lee CH, Riehl-Tonn V, Qirzaji E, Quinn R, Ward D, MacRae JM. Understanding Home Hemodialysis Patient Attrition: A Cohort Study. Can J Kidney Health Dis 2021; 8:20543581211022195. [PMID: 34178360 PMCID: PMC8207266 DOI: 10.1177/20543581211022195] [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: 02/18/2021] [Accepted: 05/01/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Home hemodialysis (HHD) offers a flexible, patient-centered modality for patients with kidney failure. Growth in HHD is achieved by increasing the number of patients starting HHD and reducing attrition with strategies to prevent the modifiable reasons for loss. Objective: Our primary objective was to describe a Canadian HHD population in terms of technique failure and time to exit from HHD in order to understand reasons for exit. Our secondary objectives include the following: (1) determining reasons for training failure, (2) reasons for early exit from HHD, and (3) timing of program exit. Design: A retrospective cohort study of incident adult HHD patients between January 1, 2013—June 30, 2020. Setting: Alberta Kidney Care South, AKC-S HHD program. Participants: Patients who started training for HHD in AKC-S. Methods: A retrospective, cohort study of incident adult HHD patients with primary outcome time on home hemodialysis, secondary outcomes include reason for train failure, time to and reasons for technique failure. Cox-proportional hazard model to determine associations between patient characteristics and technique failure. The cumulative probability of technique failure over time was reported using a competing risks model. Results: A total of 167 patients entered HHD. Training failure occurred in 20 (12%), at 3.1 [2.0, 5.5] weeks; these patients were older (P < .001) and had 2 or more comorbidities (P < .001). Reasons for HHD exit after training included transplant (35; 21%), death (8; 4.8%), and technique failure (24; 14.4%). Overall, the median time to HHD exit, was 23 months [11, 41] and the median time of technique failure was 17 months [8.9, 36]. Reasons for technique failure included: psychosocial reasons (37%) at a median time 8.9 months [7.7, 13], safety (12.5%) at 19 months [19, 36], and medical (37.5%) at 26 months [11, 50]. Limitations: Small patient population with quality of data limited by the electronic-based medical record and non-standardized definitions of reasons for exit. Conclusions: Training failure is a particularly important source of patient loss. Reasons for exit differ according to duration on HHD. Early interventions aimed at reducing train failure and increasing psychosocial supports may help program growth.
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Affiliation(s)
- Bailey Paterson
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Danielle E Fox
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Chel Hee Lee
- Department of Mathematics and Statistics, University of Calgary, AB, Canada
| | - Victoria Riehl-Tonn
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Elena Qirzaji
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Rob Quinn
- Department of Community Health Sciences, University of Calgary, AB, Canada.,Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - David Ward
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Jennifer M MacRae
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Cardiac Sciences, University of Calgary, AB, Canada
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21
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Dumaine CS, Ravani P, Parmar MK, Leung KCW, MacRae JM. In-center nocturnal hemodialysis improves health-related quality of life for patients with end-stage renal disease. J Nephrol 2021; 35:245-253. [PMID: 34050903 DOI: 10.1007/s40620-021-01066-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Conventional in-center hemodialysis (HD) is associated with significant symptom burden and reduced health-related quality of life (HRQOL). The HRQOL effects of conversion to in-center nocturnal hemodialysis (INHD) remain unclear, especially amongst those with poor HRQOL. METHODS Prospective cohort study of HD patients converting to INHD. Linear regression models summarized the mean score at baseline and at 12 months for the cohort. To assess whether patients with low baseline HRQOL derive greater benefit, we compared values before and after by levels of baseline score for each domain (below vs equal to or above the median) using a formal interaction test (t test). RESULTS 36 patients started INHD, 7 withdrew (5 transplanted, 1 death, 1 moved) and 5 declined follow-up. After 12 months the mental component score (MCS) increased by 7.1 points to a value of 51.0 (95% CI + 1.5 to 10.9, p = 0.01). Amongst patients with baseline scores below the median, improvements were seen in: Symptoms/Problems of Kidney Disease (+ 15.2, 95% CI + 5.5 to + 24.9, p = 0.003), Effects of Kidney Disease (+ 16.9, 95% CI + 2.2 to + 31.7, p = 0.026), Physical Component Score (+ 9.4, 95% CI + 1.69 to + 17.2, p = 0.018), MCS (+ 10.7, 95% CI + 2.4 to + 19.1, p = 0.013). Burden of Kidney Disease domain change was not significant (+ 15.1, 95% CI - 2.1 to + 32.3, p = 0.083). DISCUSSION INHD is a potential intervention for HD patients who struggle with reduced HRQOL, especially for those who struggle with poor mental health. Medical benefits of reduced pill burden and improved phosphate control occur with transition to INHD.
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Affiliation(s)
- Chance S Dumaine
- Division of Nephrology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Pietro Ravani
- Division of Nephrology, Cumming School of Medicine, University of Calgary, HRIC Building, 3230 Hospital Dr NW, Calgary, AB, T2N4Z6, Canada
| | | | - Kelvin C W Leung
- Division of Nephrology, Cumming School of Medicine, University of Calgary, HRIC Building, 3230 Hospital Dr NW, Calgary, AB, T2N4Z6, Canada
| | - Jennifer M MacRae
- Division of Nephrology, Cumming School of Medicine, University of Calgary, HRIC Building, 3230 Hospital Dr NW, Calgary, AB, T2N4Z6, Canada. .,Department of Cardiac Sciences, Libin Cardiovascular Institute, Calgary, AB, Canada.
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22
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Alabbas A, Harvey E, Kirpalani A, Teoh CW, Mammen C, Pederson K, Nemec R, Davis TK, Mathew A, McCormick B, Banks CA, Frenette CH, Clark DA, Zimmerman D, Qirjazi E, Mac-Way F, Vorster H, Antonsen JE, Kappel JE, MacRae JM, Hemmett J, Tennankore KK, Moist LM, Copland M, McCormick M, Suri RS, Singh RS, Davison SN, Lemaire M, Chanchlani R. Canadian Association of Paediatric Nephrologists COVID-19 Rapid Response: Home and In-Center Dialysis Guidance. Can J Kidney Health Dis 2021; 8:20543581211053458. [PMID: 34777841 PMCID: PMC8586166 DOI: 10.1177/20543581211053458] [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: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE PROGRAM This article provides guidance on optimizing the management of pediatric patients with end-stage kidney disease (ESKD) who will be or are being treated with any form of home or in-center dialysis during the COVID-19 pandemic. The goals are to provide the best possible care for pediatric patients with ESKD during the pandemic and ensure the health care team's safety. SOURCES OF INFORMATION The core of these rapid guidelines is derived from the Canadian Society of Nephrology (CSN) consensus recommendations for adult patients recently published in the Canadian Journal of Kidney Health and Disease (CJKHD). We also consulted specific documents from other national and international agencies focused on pediatric kidney health. Additional information was obtained by formal review of the published academic literature relevant to pediatric home or in-center hemodialysis. METHODS The Leadership of the Canadian Association of Paediatric Nephrologists (CAPN), which is affiliated with the CSN, solicited a team of clinicians and researchers with expertise in pediatric home and in-center dialysis. The goal was to adapt the guidelines recently adopted for Canadian adult dialysis patients for pediatric-specific settings. These included specific COVID-19-related themes that apply to dialysis in a Canadian environment, as determined by a group of senior renal leaders. Expert clinicians and nurses with deep expertise in pediatric home and in-center dialysis reviewed the revised pediatric guidelines. KEY FINDINGS We identified 7 broad areas of home dialysis practice management that may be affected by the COVID-19 pandemic: (1) peritoneal dialysis catheter placement, (2) home dialysis training, (3) home dialysis management, (4) personal protective equipment, (5) product delivery, (6) minimizing direct health care providers and patient contact, and (7) caregivers support in the community. In addition, we identified 8 broad areas of in-center dialysis practice management that may be affected by the COVID-19 pandemic: (1) identification of patients with COVID-19, (2) hemodialysis of patients with confirmed COVID-19, (3) hemodialysis of patients not yet known to have COVID-19, (4) management of visitors to the dialysis unit, (5) handling COVID-19 testing of patients and staff, (6) safe practices during resuscitation procedures in a pandemic, (7) routine hemodialysis care, and (8) hemodialysis care under fixed dialysis resources. We make specific suggestions and recommendations for each of these areas. LIMITATIONS At the time when we started this work, we knew that evidence on the topic of pediatric dialysis and COVID-19 would be severely limited, and our resources were also limited. We did not, therefore, do formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. Thus, this article's advice and recommendations are primarily expert opinions and subject to the biases associated with this level of evidence. To expedite the publication of this work, we created a parallel review process that may not be as robust as standard arms' length peer-review processes. IMPLICATIONS We intend these recommendations to help provide the best care possible for pediatric patients prescribed in-center or home dialysis during the COVID-19 pandemic, a time of altered priorities and reduced resources.
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Affiliation(s)
- Abdullah Alabbas
- Division of Nephrology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Elizabeth Harvey
- Division of Nephrology, Department of Paediatrics, University of Toronto, ON, Canada
| | - Amrit Kirpalani
- Division of Nephrology, Department of Paediatrics, Western University, London, ON, Canada
| | - Chia Wei Teoh
- Division of Nephrology, Department of Paediatrics, University of Toronto, ON, Canada
| | - Cherry Mammen
- Division of Nephrology, Department of Pediatrics, The University of British Columbia, Vancouver, Canada
| | - Kristen Pederson
- Division of Nephrology, Department of Pediatrics, University of Manitoba, Winnipeg, Canada
| | - Rose Nemec
- Division of Nephrology, Department of Paediatrics, University of Toronto, ON, Canada
| | - T. Keefe Davis
- Division of Nephrology, Department of Medicine & Pediatrics, University of Saskatchewan, Saskatoon, Canada
| | - Anna Mathew
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Cheryl A. Banks
- Prince Edward Island Provincial Renal Program, Summerside, Canada
| | - Charles H. Frenette
- Division of Infectious Diseases, Infection Prevention and Control, Department of Medicine, McGill University, Montreal, QC, Canada
| | - David A. Clark
- Division of Nephrology, Department of Medicine, Dalhousie University & Nova Scotia Health, Halifax, Canada
| | | | - Elena Qirjazi
- Division of Nephrology, Department of Medicine, Alberta Health Services, University of Calgary, Canada
| | - Fabrice Mac-Way
- Division of Nephrology, Department of Medicine, Hôtel-Dieu de Québec Hospital, CHU de Québec-Université Laval, Quebec City, Canada
| | | | - John E. Antonsen
- Hemodialysis Committee, British Columbia Renal Agency, Vancouver, Canada
| | - Joanne E. Kappel
- Division of Nephrology, Department of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Jennifer M. MacRae
- Division of Nephrology, Department of Medicine, Alberta Health Services, University of Calgary, Canada
| | - Juliya Hemmett
- Division of Nephrology, Department of Medicine, Alberta Health Services, University of Calgary, Canada
| | - Karthik K. Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University & Nova Scotia Health, Halifax, Canada
| | - Louise M. Moist
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | | | | | - Rita S. Suri
- Division of Nephrology, Department of Medicine, Research Institute, McGill University, Montreal, QC, Canada
- Centre de recherche du Centre hospitalier de l’Université de Montréal, QC, Canada
| | - Rajinder S. Singh
- Division of Nephrology, Department of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Sara N. Davison
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Mathieu Lemaire
- Division of Nephrology, Department of Paediatrics, University of Toronto, ON, Canada
- Mathieu Lemaire, Division of Nephrology, Department of Paediatrics, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children’s Hospital, Hamilton, ON, Canada
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23
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Labib M, Bohm C, MacRae JM, Bennett PN, Wilund KR, McAdams-DeMarco M, Jhamb M, Mustata S, Thompson S. An International Delphi Survey on Exercise Priorities in CKD. Kidney Int Rep 2020; 6:657-668. [PMID: 33732980 PMCID: PMC7938076 DOI: 10.1016/j.ekir.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Defining the role of exercise in chronic kidney disease (CKD) is a top research priority for people with CKD. We aimed to achieve consensus on specific research priorities in exercise and CKD among an international panel of stakeholders. Methods Using the Delphi method, patients/caregivers, researchers, clinicians, and policymakers submitted their top research priorities in round 1 and ranked their importance in rounds 2 and 3 using a 9-point Likert scale. The mean, median, and proportion of scores ranked 7 to 9 were calculated. Consensus was defined as priorities that scored above the overall mean and median score within each stakeholder panel. Qualitative description was used to understand participants’ rankings. Results Seventy participants (78% response) completed round 1: 15 (21.4%) clinicians, 33 (47.1%) researchers, 13 (18.6%) policymakers, and 9 (12.9%) patients; (85.7%) completed round 3. The top research priorities were defining exercise-related outcomes meaningful to patients, identifying patients’ motivation and perspective towards exercise, understanding the effect of exercise on the risk of institutionalization, mortality, and mobility, and understanding the effect of pre- and post-transplant exercise on postoperative recovery. Themes from the qualitative analysis were individualization, personal experience, and holistic approach to exercise (patients), the need to address common clinical problems (clinicians), developing targeted interventions (researchers), and the importance of evidence-based development versus implementation (policymakers). Conclusions Preventing physical disability was a common priority. Policymakers emphasized that more efficacy studies were needed. Other panels expressed the need for holistic and targeted exercise interventions and for outcomes that address common clinical problems.
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Affiliation(s)
- Mary Labib
- Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Clara Bohm
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jennifer M MacRae
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul N Bennett
- Medical Clinical Affairs, Satellite Healthcare, San Jose, California, USA.,Clinical & Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Kenneth R Wilund
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Manisha Jhamb
- Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stefan Mustata
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephanie Thompson
- Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
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24
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Clarke A, Ravani P, Oliver MJ, Mahsin M, Lam NN, Fox DE, Qirjazi E, Ward DR, MacRae JM, Quinn RR. Four steps to standardize reporting of peritoneal dialysis technique failure: A proposed approach. Perit Dial Int 2020; 42:270-278. [PMID: 33272118 DOI: 10.1177/0896860820976935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Technique failure is an important outcome measure in research and quality improvement in peritoneal dialysis (PD) programs, but there is a lack of consistency in how it is reported. METHODS We used data collected about incident dialysis patients from 10 Canadian dialysis programs between 1 January 2004 and 31 December 2018. We identified four main steps that are required when calculating the risk of technique failure. We changed one variable at a time, and then all steps, simultaneously, to determine the impact on the observed risk of technique failure at 24 months. RESULTS A total of 1448 patients received PD. Selecting different cohorts of PD patients changed the observed risk of technique failure at 24 months by 2%. More than one-third of patients who switched to hemodialysis returned to PD-90% returned within 180 days. The use of different time windows of observation for a return to PD resulted in risks of technique failure that differed by 16%. The way in which exit events were handled during the time window impacted the risk of technique failure by 4% and choice of statistical method changed results by 4%. Overall, the observed risk of technique failure at 24 months differed by 20%, simply by applying different approaches to the same data set. CONCLUSIONS The approach to reporting technique failure has an important impact on the observed results. We present a robust and transparent methodology to track technique failure over time and to compare performance between programs.
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Affiliation(s)
- Alix Clarke
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Pietro Ravani
- Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Matthew J Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Mohamed Mahsin
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Ngan N Lam
- Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Danielle E Fox
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Elena Qirjazi
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - David R Ward
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | - Robert R Quinn
- Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada
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25
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Suri RS, Antonsen JE, Banks CA, Clark DA, Davison SN, Frenette CH, Kappel JE, MacRae JM, Mac-Way F, Mathew A, Moist LM, Qirjazi E, Tennankore KK, Vorster H. Management of Outpatient Hemodialysis During the COVID-19 Pandemic: Recommendations From the Canadian Society of Nephrology COVID-19 Rapid Response Team. Can J Kidney Health Dis 2020; 7:2054358120938564. [PMID: 32963790 PMCID: PMC7488889 DOI: 10.1177/2054358120938564] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 04/17/2020] [Accepted: 06/04/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose: To collate best practice recommendations on the management of patients receiving in-center hemodialysis during the COVID-19 pandemic, based on published reports and current public health advice, while considering ethical principles and the unique circumstances of Canadian hemodialysis units across the country. Sources of information: The workgroup members used Internet search engines to retrieve documents from provincial and local hemodialysis programs; provincial public health agencies; the Centers for Disease Control and Prevention; webinars and slides from other kidney agencies; and nonreviewed preprints. PubMed was used to search for peer-reviewed published articles. Informal input was sought from knowledge users during a webinar. Methods: Challenges in the care of hemodialysis patients during the COVID-19 pandemic were highlighted within the Canadian Senior Renal Leaders Forum discussion group. The Canadian Society of Nephrology (CSN) developed the COVID-19 rapid response team (RRT) to address these challenges. They identified a pan-Canadian team of clinicians and administrators with expertise in hemodialysis to form the workgroup. One lead was chosen who drafted the initial document. Members of the workgroup reviewed and discussed all recommendations in detail during 2 virtual meetings on April 7 and April 9. Disagreements were resolved by consensus. The document was reviewed by the CSN COVID-19 RRT, an ethicist, an infection control expert, a community nephrologist, and a patient partner. Content was presented during an interactive webinar on April 11, 2020 attended by 269 kidney health professionals, and the webinar and first draft of the document were posted online. Final revisions were made based on feedback received until April 13, 2020. CJKHD editors reviewed the parallel process peer review and edited the manuscript for clarity. Key findings: Recommendations were made under the following themes: (1) Identification of patients with COVID-19 in the dialysis unit, (2) hemodialysis of patients with confirmed COVID-19, (3) hemodialysis of patients not yet known to have COVID-19, (4) visitors; (5) testing for COVID-19 in the dialysis unit; (6) resuscitation, (6) routine hemodialysis care, (7) hemodialysis care under fixed dialysis resources. Limitations: Because of limitations of time and resources, and the large number of questions, formal systematic review was not undertaken. The recommendations are based on expert opinion and subject to bias. The parallel review process that was created may not be as robust as the standard peer review process. Implications: We hope that these recommendations provide guidance for dialysis unit directors, clinicians, and administrators on how to limit risk from infection and adverse outcomes, while providing necessary dialysis care in a setting of finite resources. We also identify a number of resource allocation priorities, which we hope will inform decisions at provincial funding agencies.
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Affiliation(s)
- Rita S Suri
- Division of Nephrology, Department of Medicine/Research Institute, McGill University, Montreal, QC, Canada.,Centre de recherche de l'Université de Montréal, Montreal, QC, Canada
| | - John E Antonsen
- Hemodialysis Committee, British Columbia Renal Agency, Vancouver, Canada
| | - Cheryl A Banks
- Prince Edward Island Provincial Renal Program, Summerside, Canada
| | - David A Clark
- Division of Nephrology, Department of Medicine, Dalhousie University & Nova Scotia Health Authority, Halifax, Canada
| | - Sara N Davison
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Charles H Frenette
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Joanne E Kappel
- Division of Nephrology, Department of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Jennifer M MacRae
- Division of Nephrology, Department of Medicine, University of Calgary/Alberta Health Services, Canada
| | - Fabrice Mac-Way
- CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Division of Nephrology, Department of Medicine, Université Laval, QC, Canada
| | - Anna Mathew
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Louise M Moist
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Elena Qirjazi
- Division of Nephrology, Department of Medicine, University of Calgary/Alberta Health Services, Canada
| | - Karthik K Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University & Nova Scotia Health Authority, Halifax, Canada
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26
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MacRae JM, Clarke A, Ahmed SB, Elliott M, Quinn RR, James M, King-Shier K, Hiremath S, Oliver MJ, Hemmelgarn B, Scott-Douglas N, Ravani P. Sex differences in the vascular access of hemodialysis patients: a cohort study. Clin Kidney J 2020; 14:1412-1418. [PMID: 33959269 PMCID: PMC8087139 DOI: 10.1093/ckj/sfaa132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 05/18/2020] [Indexed: 11/14/2022] Open
Abstract
Background We describe differences for probability of receiving a fistula attempt, achieving fistula use, remaining catheter-free and the rate of access-related procedures as a function of sex. Methods Prospectively collected vascular access data on incident dialysis patients from five Canadian programs using the Dialysis Measurement Analysis and Reporting System to determine differences in fistula-related outcomes between women and men. The probability of receiving a fistula attempt and the probability of fistula use were determined using binary logistic regression. Catheter and fistula procedure rates were described using Poisson regression. We studied time to fistula attempt and time to fistula use, accounting for competing risks. Results We included 1446 (61%) men and 929 (39%) women. Men had a lower body mass index (P < 0.001) and were more likely to have coronary artery disease (P < 0.001) and peripheral vascular disease (p < 0.001). A total of 688 (48%) men and 403 (43%) women received a fistula attempt. Women were less likely to receive a fistula attempt by 6 months {odds ratio [OR] 0.64 [95% confidence interval (CI) 0.52-0.79]} and to achieve catheter-free use of their fistula by 1 year [OR 0.38 (95% CI 0.27-0.53)]. At an average of 2.30 access procedures per person-year, there is no difference between women and men [incidence rate ratio (IRR) 0.97 (95% CI 0.87-1.07)]. Restricting to those with a fistula attempt, women received more procedures [IRR 1.16 (95% CI 1.04-1.30)] attributed to increased catheter procedures [IRR 1.50 (95% CI 1.27-1.78)]. There was no difference in fistula procedures [IRR women versus men 0.96 (95% CI 0.85-1.07)]. Conclusion Compared with men, fewer women undergo a fistula attempt. This disparity increases after adjusting for comorbidities. Women have the same number of fistula procedures as men but are less likely to successfully use their fistula.
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Affiliation(s)
- Jennifer M MacRae
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Alix Clarke
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sofia B Ahmed
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Meghan Elliott
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rob R Quinn
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Matthew James
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kathryn King-Shier
- Faculty of Nursing and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Matthew J Oliver
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Brenda Hemmelgarn
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nairne Scott-Douglas
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Pietro Ravani
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
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27
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Ronksley PE, Wick JP, Elliott MJ, Weaver RG, Hemmelgarn BR, McRae A, James MT, Harrison TG, MacRae JM. Derivation and Internal Validation of a Clinical Risk Prediction Tool for Hyperkalemia-Related Emergency Department Encounters Among Hemodialysis Patients. Can J Kidney Health Dis 2020; 7:2054358120953287. [PMID: 32953128 PMCID: PMC7485157 DOI: 10.1177/2054358120953287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 04/17/2020] [Accepted: 07/16/2020] [Indexed: 01/28/2023] Open
Abstract
Background Approximately 10% of emergency department (ED) visits among dialysis patients are for conditions that could potentially be managed in outpatient settings, such as hyperkalemia. Objective Using population-based data, we derived and internally validated a risk score to identify hemodialysis patients at increased risk of hyperkalemia-related ED events. Design Retrospective cohort study. Setting Ten in-center hemodialysis sites in southern Alberta, Canada. Patients All maintenance hemodialysis patients (≥18 years) between March 2009 and March 2017. Measurements Predictors of hyperkalemia-related ED events included patient demographics, comorbidities, health-system use, laboratory measurements, and dialysis information. The outcome of interest (hyperkalemia-related ED events) was defined by International Classification of Diseases (10th Revision; ICD-10) codes and/or serum potassium [K+] ≥6 mmol/L. Methods Bootstrapped logistic regression was used to derive and internally validate a model of important predictors of hyperkalemia-related ED events. A point system was created based on regression coefficients. Model discrimination was assessed by an optimism-adjusted C-statistic and calibration by deciles of risk and calibration slope. Results Of the 1533 maintenance hemodialysis patients in our cohort, 331 (21.6%) presented to the ED with 615 hyperkalemia-related ED events. A 9-point scale for risk of a hyperkalemia-related ED event was created with points assigned to 5 strong predictors based on their regression coefficients: ≥1 laboratory measurement of serum K+ ≥6 mmol/L in the prior 6 months (3 points); ≥1 Hemoglobin A1C [HbA1C] measurement ≥8% in the prior 12 months (1 point); mean ultrafiltration of ≥10 mL/kg/h over the preceding 2 weeks (2 points); ≥25 hours of cumulative time dialyzing over the preceding 2 weeks (1 point); and dialysis vintage of ≥2 years (2 points). Model discrimination (C-statistic: 0.75) and calibration were good. Limitations Measures related to health behaviors, social determinants of health, and residual kidney function were not available for inclusion as potential predictors. Conclusions While this tool requires external validation, it may help identify high-risk patients and allow for preventative strategies to avoid unnecessary ED visits and improve patient quality of life. Trial registration Not applicable-observational study design.
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Affiliation(s)
- Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
| | - James P Wick
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Meghan J Elliott
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Robert G Weaver
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brenda R Hemmelgarn
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Andrew McRae
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Matthew T James
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Tyrone G Harrison
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Jennifer M MacRae
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
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28
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Thanh NX, Dmytruk K, O'Connell P, Rogers E, Fillier D, MacRae JM, Thomas C, Rennie C, Eitzenberger C, Newman C, Match B, Thompson C, Nhan J, Wasylak T. Return on investment of the diabetes foot care clinical pathway implementation in Alberta, Canada. Diabetes Res Clin Pract 2020; 165:108241. [PMID: 32502692 DOI: 10.1016/j.diabres.2020.108241] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/01/2020] [Accepted: 05/24/2020] [Indexed: 11/28/2022]
Abstract
AIMS Based on best practices, the diabetes foot care clinical pathway (DFCCP) has been developed and implemented in several clinics in Alberta, Canada. We performed a return on investment (ROI) analysis of this implementation. METHODS We used a cohort design comparing both cost and return (in terms of reduced health services utilization, HSU) between diabetes patients who were exposed and who were unexposed, to the intervention. We used a difference-in-difference approach and a propensity-score-matching technique to minimize biases due to differences in demographic and clinical characteristics between two cohorts. We used a 1-year time-horizon and converted all costs/savings to 2019 Canadian dollars (1 CA$ ~= 0.75 US$). RESULTS The intervention helped avoid $3500 in costs of HSU per patient-year. Subtracting the intervention cost of $500, the net benefit of intervention was $3000 (ranged $2400-$3700) per patient-year. The ROI ratio was estimated at 7.4 (ranged 6.1 to 8.8) meaning that every invested $1 returned $7.4 (ranged $6.1-$8.8) for the health system. The probability of intervention being cost-saving ranged from 99.5-100%. CONCLUSIONS The implementation of DFCCP in Alberta is cost-saving. A continuation of the pathway implementation at studied clinics and a spread to other clinics are recommended.
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Affiliation(s)
- Nguyen X Thanh
- Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alberta, Canada
| | - Kathy Dmytruk
- Diabetes, Obesity & Nutrition Strategic Clinical Network, Alberta Health Services, Edmonton and Calgary, Alberta, Canada
| | - Petra O'Connell
- Diabetes, Obesity & Nutrition Strategic Clinical Network, Alberta Health Services, Edmonton and Calgary, Alberta, Canada.
| | - Edwin Rogers
- Analytics (DIMR), Alberta Health Services, Calgary, Alberta, Canada
| | - Denise Fillier
- Alberta Kidney Care, Alberta Health Services, Edmonton, Calgary, Alberta, Canada
| | - Jennifer M MacRae
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chandra Thomas
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chantal Rennie
- Bigelow Fowler Medical Clinics, Lethbridge, Alberta, Canada
| | | | | | - Brian Match
- Kalyna Country Primary Care Network, Vegreville, Alberta, Canada
| | | | - Julie Nhan
- Alberta Kidney Care, Alberta Health Services, Edmonton, Calgary, Alberta, Canada
| | - Tracy Wasylak
- Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alberta, Canada
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29
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Copland M, Hemmett J, MacRae JM, McCormick B, McCormick M, Qirjazi E, Singh RS, Zimmerman D. Canadian Society of Nephrology COVID-19 Rapid Response Team Home Dialysis Recommendations. Can J Kidney Health Dis 2020; 7:2054358120928153. [PMID: 32523709 PMCID: PMC7262737 DOI: 10.1177/2054358120928153] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 04/14/2020] [Accepted: 04/29/2020] [Indexed: 11/16/2022] Open
Abstract
Purpose of program This paper will provide guidance on how to best manage patients with end-stage kidney disease who will be or are being treated with home dialysis during the COVID-19 pandemic. Sources of information Program-specific documents, pre-existing, and related to COVID-19; documents from national and international kidney agencies; national and international webinars, including webinars that we hosted for input and feedback; with additional information from formal and informal review of published academic literature. Methods Members of the Canadian Society of Nephrology (CSN) Board of Directors solicited a team of clinicians and administrators with expertise in home dialysis. Specific COVID-19-related themes in home dialysis were determined by the Canadian senior renal leaders community of practice, a group compromising medical and administrative leaders of provincial and health authority renal programs. We then developed consensus-based recommendations virtually by the CSN work-group with input from ethicists with nephrology training. The recommendations were further reviewed by community nephrologists and over a CSN-sponsored webinar, attended by 225 kidney health care professionals, for further peer input. The final consensus recommendations also incorporated review by the editors at the Canadian Journal of Kidney Health and Disease (CJKHD). Key findings We identified 7 broad areas of home dialysis practice management that may be affected by the COVID-19 pandemic: (1) peritoneal dialysis catheter placement, (2) home dialysis training, (3) home dialysis management, (4) personal protective equipment, (5) product delivery, (6) minimizing direct health care provider and patient contact, and (7) assisted peritoneal dialysis in the community. We make specific suggestions and recommendations for each of these areas. Limitations This suggestions and recommendations in this paper are expert opinion, and subject to the biases associated with this level of evidence. To expedite the publication of this work, a parallel review process was created that may not be as robust as standard arms' length peer-review processes. Implications These recommendations are intended to provide the best care possible during a time of altered priorities and reduced resources.
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Lee EJ, Patel A, Acedillo RR, Bachynski JC, Barrett I, Basile E, Battistella M, Benjamin D, Berry D, Blake PG, Chan P, Bohm CJ, Clemens KK, Cook C, Dember L, Dirk JS, Dixon S, Fowler E, Getchell L, Gholami N, Goldstein C, Hahn E, Hogeterp B, Huang S, Hughes M, Jardine MJ, Kalatharan S, Kilburn S, Lacson E, Leonard S, Liberty C, Lindsay C, MacRae JM, Manns BJ, McCallum J, McIntyre CW, Molnar AO, Mustafa RA, Nesrallah GE, Oliver MJ, Pandes M, Pandeya S, Parmar MS, Rabin EZ, Riley J, Silver SA, Sontrop JM, Sood MM, Suri RS, Tangri N, Tascona DJ, Thomas A, Wald R, Walsh M, Weijer C, Weir MA, Vorster H, Zimmerman D, Garg AX. Cultivating Innovative Pragmatic Cluster-Randomized Registry Trials Embedded in Hemodialysis Care: Workshop Proceedings From 2018. Can J Kidney Health Dis 2019; 6:2054358119894394. [PMID: 31903190 PMCID: PMC6933546 DOI: 10.1177/2054358119894394] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022] Open
Abstract
Hemodialysis is a life-sustaining treatment for persons with kidney failure. However, those on hemodialysis still face a poor quality of life and a short life expectancy. High-quality research evidence from large randomized controlled trials is needed to identify interventions that improve the experiences, outcomes, and health care of persons receiving hemodialysis. With the support of the Canadian Institutes of Health Research and its Strategy for Patient-Oriented Research, the Innovative Clinical Trials in Hemodialysis Centers initiative brought together Canadian and international kidney researchers, patients, health care providers, and health administrators to participate in a workshop held in Toronto, Canada, on June 2 and 3, 2018. The workshop served to increase knowledge and awareness about the conduct of innovative, pragmatic, cluster-randomized registry trials embedded into routine hemodialysis care and provided an opportunity to discuss and build support for new trial ideas. The workshop content included structured presentations, facilitated group discussions, and expert panel feedback. Partnerships and promising trial ideas borne out of the workshop will continue to be developed to support the implementation of future large-scale trials.
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Affiliation(s)
| | | | - Rey R. Acedillo
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
| | | | | | - Erika Basile
- Office of Human Research Ethics, Western
University, London, ON, Canada
| | - Marisa Battistella
- Department of Pharmacy, University
Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy,
University of Toronto, ON, Canada
| | - Derek Benjamin
- Royal Victoria Regional Health Centre,
Barrie, ON, Canada
| | - David Berry
- Algoma Regional Renal Program, Sault
Area Hospital, Sault Ste. Marie, ON, Canada
| | - Peter G. Blake
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
| | - Patricia Chan
- Division of Nephrology, Department of
Medicine, Michael Garron Hospital, Toronto, ON, Canada
| | - Clara J. Bohm
- Department of Internal Medicine, Max
Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Kristin K. Clemens
- ICES, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
- Division of Endocrinology and
Metabolism, Department of Medicine, Western University, London, ON, Canada
- St. Joseph’s Health Care London, ON,
Canada
| | - Charles Cook
- Transplant Ambassador Program, Grand
River Hospital, Kitchener, ON, Canada
| | - Laura Dember
- Renal, Electrolyte and Hypertension
Division, Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Stephanie Dixon
- ICES, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
| | | | | | | | - Cory Goldstein
- Rotman Institute of Philosophy,
Western University, London, ON, Canada
| | | | | | - Susan Huang
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
| | | | - Meg J. Jardine
- Innovation & Kidney Research, The
George Institute for Global Health, UNSW Sydney, Newtown, NSW, Australia
| | | | | | | | | | | | | | - Jennifer M. MacRae
- Division of Nephrology, Department of
Medicine, University of Calgary, AB, Canada
| | - Braden J. Manns
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Janice McCallum
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
- Renal Services, London Health Sciences
Centre, ON, Canada
| | - Christopher W. McIntyre
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
- Department of Medical Biophysics,
Schulich School of Medicine and Dentistry, Western University, London, ON,
Canada
| | - Amber O. Molnar
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
| | - Reem A. Mustafa
- Division of Nephrology and
Hypertension, Department of Internal Medicine, University of Kansas Medical Center,
Kansas City, USA
| | - Gihad E. Nesrallah
- Division of Nephrology, Department of
Medicine, Humber River Hospital, Toronto, ON, Canada
| | - Matthew J. Oliver
- Division of Nephrology, Department of
Medicine, University of Toronto, ON, Canada
| | | | | | | | | | | | - Samuel A. Silver
- Division of Nephrology, Kingston
Health Sciences Center, Queen’s University, Kingston, ON, Canada
| | - Jessica M. Sontrop
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
| | - Manish M. Sood
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, University of Ottawa, ON, Canada
| | - Rita S. Suri
- Division of Nephrology, Department of
Medicine, McGill University, Montreal, QC, Canada
- Canadian Nephrology Trials Network,
Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre,
Winnipeg, MB, Canada
- Department of Internal Medicine,
University of Manitoba, Winnipeg, Canada
| | - Daniel J. Tascona
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
- Orillia Soldiers’ Memorial Hospital,
ON, Canada
| | | | - Ron Wald
- St. Michael’s Hospital, Toronto, ON,
Canada
- Division of Nephrology, Department of
Medicine, University of Toronto, ON, Canada
| | - Michael Walsh
- Division of Nephrology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute,
Hamilton, ON, Canada
| | - Charles Weijer
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
- Rotman Institute of Philosophy,
Western University, London, ON, Canada
| | - Matthew A. Weir
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
| | - Hans Vorster
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
| | - Deborah Zimmerman
- Division of Nephrology, Department of
Medicine, University of Ottawa, ON, Canada
| | - Amit X. Garg
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
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Kalenga C, Dumanski S, Ramesh S, MacRae JM, Nerenberg K, Metcalfe A, Sola D, Ahmed SB. Abstract P1101: Hormonal Contraceptive Use, Arterial Stiffness and Renin Angiotensin System Activity in Women. Hypertension 2019. [DOI: 10.1161/hyp.74.suppl_1.p1101] [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] [Indexed: 11/16/2022]
Abstract
Background:
Oral contraceptive use is associated with increased CV risk. Whether non-oral hormonal contraceptive use poses a similar risk is unclear.
Objectives:
To evaluate the association between oral and non-oral hormonal and arterial stiffness and renin-angiotensin system (RAS) activity in premenopausal women.
Methods:
Healthy premenopausal women using non-oral hormonal contraception (NOHC), oral hormonal contraception (OC) (minimum duration of 3 months) and controls were studied in a fasting, high-salt state. Aortic augmentation index (AIx) and pulse wave velocity (PWV) were measured at baseline and in response to Angiotensin II (AngII) challenge, a validated marker of arterial RAS activity. Results from the 3 groups were compared using ANOVA and presented as mean and standard error.
Results:
Fifty-six women (6 OC, 8 NOHC, 42 controls) were studied. Women were similar in age (OC 29±7yvs NOHC 28±4yvs controls 32±2y, p=0.52)and BMI (OC 26.7±1vsNOHC 22.3±2vs controls25.3±4, p=0.12). No differences were observed amongst the groups with regards to baseline arterial stiffness measures (AIx: OC 4.08±1%; NOHC -2.75±2%; controls 9.01±3%; p =0.10; PWV: OC 6.94±3 m/s; NOHC 6.4±2 m/s; controls 8.04±5m/s; p=0.49). In response to AngII challenge, NOHC users had a greater change in AIx compared to OC after adjustment for age and blood pressure (NOHC 17.06±3%; controls 9.76±1%; p=0.048). No significant changes in PWV were observed among NOHC or OC and controls.
Conclusions:
Arterial RAS is lower in non-oral hormonal contraceptive users, suggesting this may be a safer contraception option in women at high risk of CVD.
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Kalenga CZ, Metcalfe A, Ahmed SB, Sharanya R, MacRae JM, Nerenberg K, Sola DY, Dumanski S. Abstract 031: Association Between Non-Oral Hormonal Contraceptives and Blood Pressure: A Systematic Review. Hypertension 2019. [DOI: 10.1161/hyp.74.suppl_1.031] [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] [Indexed: 11/16/2022]
Abstract
Background:
Combined oral contraceptives (COCs) are associated with increased blood pressure (BP) and hypertension. Whether non-oral forms of hormonal contraceptive (NOHC) have similar associations is unknown.
Methods:
We conducted a systematic review investigating the association between NOHC use and blood pressure compared to women using COC and non-hormonal contraception (NHC). Three databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) were searched for articles published from database inception through October 2018. Primary studies examining women using NOHC [transdermal, hormonal intrauterine device (IUD), implant, vaginal ring or injectables] compared with women using COC or NHC were included. Two independent investigators screened identified abstracts. Data on study population, hormonal exposure, outcomes, study quality and risk of bias were independently extracted from each eligible study. Primary outcomes were change in BP or prevalence of hypertension. Quality of case control and cohort studies was assessed using the Newcastle-Ottawa scale. Quality of randomized control trials was assessed using the Cochrane risk of bias tool.
Results:
Of 3981 studies reviewed, 22 met inclusion criteria (12 studies on injectables, 6 on implants, 4 on hormonal IUDs, 3 on the vaginal ring). Some studies examining the effect of IUD use showed a significantly lower BP compared to COC use, and no difference compared to NHC users. No differences in BP were reported with vaginal ring use compared to COC or NHC use. Conflicting results were presented with implant use compared to NHC use, but no change in BP compared to COC. Five studies reported increased BP with injectable use compared to COC and NHC, while seven studies showed no change in BP. All women remained in the normotensive range in all included studies.
Conclusion:
Non-oral hormonal contraceptive use is associated with increases in blood pressure, though the effects differ by route of administration. These results may inform contraceptive choices in women with or at risk of hypertension.
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Bohm C, Schick-Makaroff K, MacRae JM, Tan M, Thompson S. The role of exercise in improving patient-reported outcomes in individuals on dialysis: A scoping review. Semin Dial 2019; 32:336-350. [PMID: 31006928 DOI: 10.1111/sdi.12806] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Exercise improves objective measures of physical function in individuals on hemodialysis, but its effect on patient-reported outcomes (PROs) is largely unknown. We performed a scoping review to characterize the existing knowledge base on exercise and PROs in dialysis patients to make recommendations for future research. We searched Medline, Embase, Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials, CINAHL, and SPORT Discus from inception to November 28, 2018 and then screened results for randomized controlled trials comparing aerobic/resistance exercise, or both, with no exercise in individuals on dialysis that reported results of any PRO. Of 1374 eligible studies, 25 studies met inclusion criteria. Study interventions included aerobic exercise (11 intradialytic and 3 home-based trials); intradialytic resistance exercise (seven studies) and combined aerobic and resistance exercise (six intradialytic and one facility-based trial). The PROs measured included health-related quality of life (n = 19), depression (n = 6), anxiety (n = 3), symptom burden (n = 4), sleep quality (n = 2), restless legs syndrome (n = 2), disability (n = 2), and self-reported physical activity level (n = 4). Only five studies included a PRO as a primary outcome. Studies primarily used broad/generic measures of health-related quality of life and the effect of exercise on symptoms remains relatively unexplored, particularly in peritoneal dialysis populations. Although limited, the role of exercise in improving restless legs was consistent and is a promising outcome for future study. A critical step to improving the quality of the research on this topic includes the use of validated and consistent PRO measures.
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Affiliation(s)
- Clara Bohm
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Jennifer M MacRae
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Maria Tan
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
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Nicholl DDM, Hanly PJ, Zalucky AA, Mann MC, MacRae JM, Poulin MJ, Handley GB, Sola DY, Ahmed SB. CPAP Therapy Delays Cardiovagal Reactivation and Decreases Arterial Renin-Angiotensin System Activity in Humans With Obstructive Sleep Apnea. J Clin Sleep Med 2018; 14:1509-1520. [PMID: 30176965 DOI: 10.5664/jcsm.7326] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 05/18/2018] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is associated with increased cardiovascular risk. The effect of OSA treatment with continuous positive airway pressure (CPAP) on the cardiovascular response to a stressor is unknown. We sought to determine the effect of CPAP therapy on heart rate variability (HRV) and arterial stiffness, at baseline, in response to, and recovery from a physiological stressor, Angiotensin II (AngII), in humans with OSA. METHODS Twenty-five incident healthy subjects (32% female; 49 ± 2 years) with moderate-severe OSA and nocturnal hypoxia were studied in high-salt balance, a state of maximal renin-angiotensin system (RAS) suppression, before CPAP, and after 4 weeks of effective CPAP therapy (usage > 4 h/night) in a second identical study day. HRV was calculated by spectral power and time domain analysis. Aortic augmentation index (AIx) and carotid-femoral pulse-wave velocity (PWVcf) were measured by applanation tonometry. HRV and arterial stiffness were measured at baseline and in response to AngII challenge (3 ng/ kg/min·30 minutes, 6 ng/kg/min·30 minutes, recovery·30 minutes). The primary outcome was the association between CPAP treatment and HRV and arterial stiffness responses to, and recovery from, AngII challenge. In an exploratory analysis subjects were stratified by sex. RESULTS CPAP corrected OSA and nocturnal hypoxemia. CPAP treatment was associated with increased sensitivity and delayed recovery from AngII (Δln HF [high frequency; recovery: -0.09 ± 0.19 versus -0.59 ± 0.17 ms2, P = .042; ΔrMSSD [root mean successive differences; recovery: -0.4 ± 2.0 versus -7.2 ± 1.9 ms, P = .001], ΔpNN50 [percentage of normal waves differing ≥ 50 ms compared to the preceding wave; AngII: 1.3 ± 2.3 versus -3.0 ± 2.4%, P = .043; recovery: -0.4 ± 1.4 versus -6.0 ± 1.9%, P = .001], all values pre-CPAP versus post-CPAP treatment). No differences were observed by sex. There was increased AIx sensitivity to AngII after CPAP among men (8.2 ± 1.7 versus 11.9 ± 2.2%, P = .046), but not women (11.4 ± 1.5 versus 11.6 ± 2.1%, P = .4). No change in PWVcf sensitivity was observed in either sex. CONCLUSIONS CPAP therapy was associated with delayed cardiovagal reactivation after a stressor and down-regulation of the arterial RAS. These findings may have important implications in mitigating cardiovascular risk in both men and women with OSA.
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Affiliation(s)
- David D M Nicholl
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Patrick J Hanly
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Sleep Centre, Foothills Medical Centre, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ann A Zalucky
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michelle C Mann
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer M MacRae
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Kidney Disease Network, Canada
| | - Marc J Poulin
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Faculty of Kinesiology, University of Calgary, Alberta, Canada
| | | | - Darlene Y Sola
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Sofia B Ahmed
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Kidney Disease Network, Canada
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Dumaine C, Kiaii M, Miller L, Moist L, Oliver MJ, Lok CE, Hiremath S, MacRae JM. Vascular Access Practice Patterns in Canada: A National Survey. Can J Kidney Health Dis 2018; 5:2054358118759675. [PMID: 29511569 PMCID: PMC5833215 DOI: 10.1177/2054358118759675] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 10/12/2017] [Indexed: 12/21/2022] Open
Abstract
Background: One of the mandates of the Canadian Society of Nephrology’s (CSN) Vascular Access Working Group (VAWG) is to inform the nephrology community of the current status of vascular access (VA) practice within Canada. To better understand VA practice patterns across Canada, the CSN VAWG conducted a national survey. Objectives: (1) To inform on VA practice patterns, including fistula creation and maintenance, within Canada. (2) To determine the degree of consensus among Canadian clinicians regarding patient suitability for fistula creation and to assess barriers to and facilitators of fistula creation in Canada. Design: Development and implementation of a survey. Setting: Community and academic VA programs. Participants: Nephrologists, surgeons, and nurses who are involved in VA programs across Canada. Measurements: Practice patterns regarding access creation and maintenance, including indications and contraindications to fistula creation, as well as program-wide facilitators of and barriers to VA. Methods: A small group of CSN VAWG members determined the scope and created several VA questions which were then reviewed by 5 additional VAWG members (4 nephrologists and 1 VA nurse) to ensure that questions were clear and relevant. The survey was then tested by the remaining members of the VAWG and refinements were made. The final survey version was submitted electronically to relevant clinicians (nephrologists, surgeons, and nurses) involved or interested in VA across Canada. Questions centered around 4 major themes: (1) Practice patterns regarding access creation (preoperative assessment and maturation assessment), (2) Practice patterns regarding access maintenance (surveillance and salvage), (3) Indications and contraindications for arteriovenous (AV) access creation, and (4) Facilitators of and barriers to fistula creation and utilization. Results: Eighty-two percent (84 of 102) of invited participants completed the survey; the majority were nurses or VA coordinators (55%) with the remainder consisting of nephrologists (21%) and surgeons (20%). Variation in practice was noted in utility of preoperative Doppler ultrasound, interventions to assist nonmaturing fistulas, and procedures to salvage failing or thrombosed AV-access. Little consensus was seen regarding potential contraindications to AV-access creation (with the exception of limited life expectancy and poor vasculature on preoperative imaging, which had high agreement). Frequent barriers to fistula utilization were primary failure (77% of respondents) and long maturation times (73%). Respondents from centers with low fistula prevalence also cited long surgical wait times as an important barrier to fistula creation, whereas those from centers with high fistula prevalence cited access to multidisciplinary teams and interventional radiology as keys to successful fistula creation and utilization. Conclusions: There is significant variation in VA practice across Canada and little consensus among Canadian clinicians regarding contraindications to fistula creation. Further high-quality studies are needed with regard to appropriate fistula placement to help guide clinical practice.
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Affiliation(s)
- Chance Dumaine
- Division of Nephrology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Mercedeh Kiaii
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Lisa Miller
- Division of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Louise Moist
- Division of Nephrology, Schulich School of Medicine and Dentistry, Department of Medicine, Western University, London, Ontario, Canada
| | | | - Charmaine E Lok
- Faculty of Medicine, University Health Network, University of Toronto, Ontario, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa, Ontario, Canada
| | - Jennifer M MacRae
- Division of Nephrology, Department of Medicine, University of Calgary, Alberta, Canada
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Brown PDS, Rowed K, Shearer J, MacRae JM, Parker K. Impact of intradialytic exercise intensity on urea clearance in hemodialysis patients. Appl Physiol Nutr Metab 2018; 43:101-104. [DOI: 10.1139/apnm-2017-0460] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Intradialytic exercise (IDE) has been shown to benefit dialysis efficacy; however, the effect of IDE intensity is unknown. Dialyzer urea clearance (K urea, mL/min) was significantly greater during both IDE protocols (55% and 70% maximal heart rate, HRmax), compared with no IDE (p < 0.05). No significant difference in K urea was found between IDE protocols (55% vs. 70% HRmax) (p > 0.05). Results show that higher intensity IDE has no additional benefit on K urea.
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Affiliation(s)
| | - Kylie Rowed
- Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jane Shearer
- Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Biochemistry and Molecular Biology, Cumming School of Medicine, University of Calgary. Calgary, AB T2N 2T9, Canada
| | - Jennifer M. MacRae
- Department of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2T9, Canada
| | - Kristen Parker
- Southern Alberta Renal Program, South Calgary Hemodialysis, 31 Sunpark Plaza SE, Calgary, AB T2X 3W5, Canada
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Leung KC, Quinn RR, Ravani P, Duff H, MacRae JM. Randomized Crossover Trial of Blood Volume Monitoring-Guided Ultrafiltration Biofeedback to Reduce Intradialytic Hypotensive Episodes with Hemodialysis. Clin J Am Soc Nephrol 2017; 12:1831-1840. [PMID: 29018100 PMCID: PMC5672962 DOI: 10.2215/cjn.01030117] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 07/13/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Intradialytic hypotension (IDH) is associated with morbidity. The effect of blood volume-guided ultrafiltration biofeedback, which automatically adjusts fluid removal rate on the basis of blood volume parameters, on the reduction of IDH was tested in a randomized crossover trial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a 22-week, single blind, randomized crossover trial in patients receiving maintenance hemodialysis who had >30% of sessions complicated by symptomatic IDH in five centers in Calgary, Alberta, Canada. Participants underwent a 4-week run-in period to standardize dialysis prescription and dry weight on the basis of clinical examination. Those meeting inclusion criteria were randomized to best clinical practice hemodialysis (control) or best clinical practice plus blood volume-guided ultrafiltration biofeedback (intervention) for 8 weeks, followed by a 2-week washout and subsequent crossover for a second 8-week phase. The primary outcome was rate of symptomatic IDH. RESULTS Thirty-five participants entered, 32 were randomized, and 26 completed the study. The rate of symptomatic IDH with biofeedback was 0.10/h (95% confidence interval, 0.06 to 0.14) and 0.07/h (95% confidence interval, 0.05 to 0.10) during control (P=0.29). There were no differences in the rate or proportion of sessions with asymptomatic IDH or symptoms alone. Results remained consistent when adjusted for randomization order and study week. There were no differences between intervention and control in the last study week in interdialytic weight gain (difference [SD], -0.02 [0.8] kg), brain natriuretic peptide (1460 [19,052] ng/L), cardiac troponins (3 [86] ng/L), extracellular water-to-intracellular water ratio (0.05 [0.33]), ultrafiltration rate (1.1 [7.0] ml/kg per hour), and dialysis recovery time (0.43 [19.25] hours). CONCLUSION The use of blood volume monitoring-guided ultrafiltration biofeedback in patients prone to IDH did not reduce the rate of symptomatic IDH events.
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Affiliation(s)
| | | | - Pietro Ravani
- Departments of Medicine
- Community Health Sciences, and
| | - Henry Duff
- Departments of Medicine
- Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer M. MacRae
- Departments of Medicine
- Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
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Dumaine CS, Brown RS, MacRae JM, Oliver MJ, Ravani P, Quinn RR. Central venous catheters for chronic hemodialysis: Is "last choice" never the "right choice"? Semin Dial 2017; 31:3-10. [PMID: 29098715 DOI: 10.1111/sdi.12655] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Since the publication of the first vascular access clinical practice guidelines in 1997, the global nephrology community has dedicated significant time and resources toward increasing the prevalence of arteriovenous fistulas and decreasing the prevalence of central venous catheters for hemodialysis. These efforts have been bolstered by observational studies showing an association between catheter use and increased patient morbidity and mortality. To date, however, no randomized comparisons of the outcomes of different forms of vascular access have been conducted. There is mounting evidence that much of the difference in patient outcomes may be explained by patient factors, rather than choice of vascular access. Some have called into question the appropriateness of fistula creation for certain patient populations, such as those with limited life expectancy and those at high risk of fistula-related complications. In this review, we explore the extent to which catheters and fistulas exhibit the characteristics of the "ideal" vascular access and highlight the significant knowledge gaps that exist in the current literature. Further studies, ideally randomized comparisons of different forms of vascular access, are required to better inform shared decision making.
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Affiliation(s)
- Chance S Dumaine
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Robert S Brown
- Division of Nephrology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Jennifer M MacRae
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Matthew J Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Pietro Ravani
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Robert R Quinn
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
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40
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Miller LM, MacRae JM, Kiaii M, Clark E, Dipchand C, Kappel J, Lok C, Luscombe R, Moist L, Oliver M, Pike P, Hiremath S. Hemodialysis Tunneled Catheter Noninfectious Complications. Can J Kidney Health Dis 2017. [PMID: 28270922 DOI: 10.1177/2054358116669130.] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Noninfectious hemodialysis catheter complications include catheter dysfunction, catheter-related thrombus, and central vein stenosis. The definitions, causes, and treatment strategies for catheter dysfunction are reviewed below. Catheter-related thrombus is a less common but serious complication of catheters, requiring catheter removal and systemic anticoagulation. In addition, the risk factors, clinical manifestation, and treatment options for central vein stenosis are outlined.
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Affiliation(s)
- Lisa M Miller
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Jennifer M MacRae
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Mercedeh Kiaii
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Edward Clark
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | - Joanne Kappel
- Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Charmaine Lok
- Faculty of Medicine, University Health Network, University of Toronto, Ontario, Canada
| | - Rick Luscombe
- Department of Nursing, Providence Health Care, Vancouver, British Columbia, Canada
| | - Louise Moist
- Department of Medicine, University of Western Ontario, London, Canada
| | - Matthew Oliver
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Pamela Pike
- Department of Medicine, Memorial University, Saint John's, Newfoundland and Labrador, Canada
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41
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Ronksley PE, Tonelli M, Manns BJ, Weaver RG, Thomas CM, MacRae JM, Ravani P, Quinn RR, James MT, Lewanczuk R, Hemmelgarn BR. Emergency Department Use among Patients with CKD: A Population-Based Analysis. Clin J Am Soc Nephrol 2017; 12:304-314. [PMID: 28119410 PMCID: PMC5293336 DOI: 10.2215/cjn.06280616] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 10/19/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Although prior studies have observed high resource use among patients with CKD, there is limited exploration of emergency department use in this population and the proportion of encounters related to CKD care specifically. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We identified all adults (≥18 years old) with eGFR<60 ml/min per 1.73 m2 (including dialysis-dependent patients) in Alberta, Canada between April 1, 2010 and March 31, 2011. Patients with CKD were linked to administrative data to capture clinical characteristics and frequency of emergency department encounters and followed until death or end of study (March 31, 2013). Within each CKD category, we calculated adjusted rates of overall emergency department use as well as rates of potentially preventable emergency department encounters (defined by four CKD-specific ambulatory care-sensitive conditions: heart failure, hyperkalemia, volume overload, and malignant hypertension). RESULTS During mean follow-up of 2.4 years, 111,087 patients had 294,113 emergency department encounters; 64.2% of patients had category G3A CKD, and 1.6% were dialysis dependent. Adjusted rates of overall emergency department use were highest among patients with more advanced CKD; 5.8% of all emergency department encounters were for CKD-specific ambulatory care-sensitive conditions, with approximately one third resulting in hospital admission. Heart failure accounted for over 80% of all potentially preventable emergency department events among patients with categories G3A, G3B, and G4 CKD, whereas hyperkalemia accounted for almost one half (48%) of all ambulatory care-sensitive conditions among patients on dialysis. Adjusted rates of emergency department events for heart failure showed a U-shaped relationship, with the highest rates among patients with category G4 CKD. In contrast, there was a graded association between rates of emergency department use for hyperkalemia and CKD category. CONCLUSIONS Emergency department use is high among patients with CKD, although only a small proportion of these encounters is for potentially preventable CKD-related care. Strategies to reduce emergency department use among patients with CKD will, therefore, need to target conditions other than CKD-specific ambulatory care-sensitive conditions.
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Affiliation(s)
| | - Marcello Tonelli
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden J. Manns
- Departments of Community Health Sciences and
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert G. Weaver
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chandra M. Thomas
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer M. MacRae
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Departments of Community Health Sciences and
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert R. Quinn
- Departments of Community Health Sciences and
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T. James
- Departments of Community Health Sciences and
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Richard Lewanczuk
- Provincial Primary Health Care, Alberta Health Services, Edmonton, Alberta, Canada; and
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Departments of Community Health Sciences and
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Wick JP, Turin TC, Faris PD, MacRae JM, Weaver RG, Tonelli M, Manns BJ, Hemmelgarn BR. A Clinical Risk Prediction Tool for 6-Month Mortality After Dialysis Initiation Among Older Adults. Am J Kidney Dis 2016; 69:568-575. [PMID: 27856091 DOI: 10.1053/j.ajkd.2016.08.035] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 08/17/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Information on an individual's risk for death following dialysis therapy initiation may inform the decision to initiate maintenance dialysis for older adults. We derived and validated a clinical risk prediction tool for all-cause mortality among older adults during the first 6 months of maintenance dialysis treatment. STUDY DESIGN Prediction model using retrospective administrative and clinical data. SETTING & PARTICIPANTS We linked administrative and clinical data to define a cohort of 2,199 older adults (age ≥ 65 years) in Alberta, Canada, who initiated maintenance dialysis therapy (excluding acute kidney injury) in May 2003 to March 2012. CANDIDATE PREDICTORS Demographics, laboratory data, comorbid conditions, and measures of health system use. OUTCOMES All-cause mortality within 6 months of dialysis therapy initiation. ANALYTICAL APPROACH Predicted mortality by logistic regression with 10-fold cross-validation. RESULTS 375 (17.1%) older adults died within 6 months. We developed a 19-point risk score for 6-month mortality that included age 80 years or older (2 points), glomerular filtration rate of 10 to 14.9mL/min/1.73m2 (1 point) or ≥15mL/min/1.73m2 (3 points), atrial fibrillation (2 points), lymphoma (5 points), congestive heart failure (2 points), hospitalization in the prior 6 months (2 points), and metastatic cancer (3 points). Model discrimination (C statistic = 0.72) and calibration (Hosmer-Lemeshow χ2=10.36; P=0.2) were reasonable. As examples, a score < 5 equated to <25% of individuals dying in 6 months, whereas a score > 12 predicted that more than half the individuals would die in the first 6 months. LIMITATIONS The tool has not been externally validated; thus, generalizability cannot be assessed. CONCLUSIONS We used readily available clinical information to derive and internally validate a 7-variable tool to predict early mortality among older adults after dialysis therapy initiation. Following successful external validation, the tool may be useful as a clinical decision tool to aid decision making for older adults with kidney failure.
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Affiliation(s)
- James P Wick
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Tanvir C Turin
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Peter D Faris
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jennifer M MacRae
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Robert G Weaver
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Braden J Manns
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Brenda R Hemmelgarn
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada.
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43
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Rannelli LA, MacRae JM, Mann MC, Ramesh S, Hemmelgarn BR, Rabi D, Sola DY, Ahmed SB. Sex differences in associations between insulin resistance, heart rate variability, and arterial stiffness in healthy women and men: a physiology study. Can J Physiol Pharmacol 2016; 95:349-355. [PMID: 28099042 DOI: 10.1139/cjpp-2016-0122] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diabetes confers greater cardiovascular risk to women than to men. Whether insulin-resistance-mediated risk extends to the healthy population is unknown. Measures of insulin resistance (fasting insulin, homeostatic model assessment, hemoglobin A1c, quantitative insulin sensitivity check index, glucose) were determined in 48 (56% female) healthy subjects. Heart rate variability (HRV) was calculated by spectral power analysis and arterial stiffness was determined using noninvasive applanation tonometry. Both were measured at baseline and in response to angiotensin II infusion. In women, there was a non-statistically significant trend towards increasing insulin resistance being associated with an overall unfavourable HRV response and increased arterial stiffness to the stressor, while men demonstrated the opposite response. Significant differences in the associations between insulin resistance and cardiovascular physiological profile exist between healthy women and men. Further studies investigating the sex differences in the pathophysiology of insulin resistance in cardiovascular disease are warranted.
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Affiliation(s)
- Luke Anthony Rannelli
- a Faculty of Medicine, University of Calgary, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada
| | - Jennifer M MacRae
- a Faculty of Medicine, University of Calgary, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada.,b Alberta Kidney Disease Network, 1403-29th St. NW, C210, Calgary, AB T2N 2T9, Canada.,c Libin Cardiovascular Institute of Alberta, 1403-29th St. NW, Calgary, AB T2N 2T9, Canada
| | - Michelle C Mann
- a Faculty of Medicine, University of Calgary, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada.,c Libin Cardiovascular Institute of Alberta, 1403-29th St. NW, Calgary, AB T2N 2T9, Canada
| | - Sharanya Ramesh
- a Faculty of Medicine, University of Calgary, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada.,c Libin Cardiovascular Institute of Alberta, 1403-29th St. NW, Calgary, AB T2N 2T9, Canada
| | - Brenda R Hemmelgarn
- a Faculty of Medicine, University of Calgary, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada.,b Alberta Kidney Disease Network, 1403-29th St. NW, C210, Calgary, AB T2N 2T9, Canada.,c Libin Cardiovascular Institute of Alberta, 1403-29th St. NW, Calgary, AB T2N 2T9, Canada.,d Institute for Public Health, University of Calgary, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada
| | - Doreen Rabi
- a Faculty of Medicine, University of Calgary, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada.,c Libin Cardiovascular Institute of Alberta, 1403-29th St. NW, Calgary, AB T2N 2T9, Canada.,d Institute for Public Health, University of Calgary, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada
| | - Darlene Y Sola
- b Alberta Kidney Disease Network, 1403-29th St. NW, C210, Calgary, AB T2N 2T9, Canada.,c Libin Cardiovascular Institute of Alberta, 1403-29th St. NW, Calgary, AB T2N 2T9, Canada
| | - Sofia B Ahmed
- a Faculty of Medicine, University of Calgary, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada.,b Alberta Kidney Disease Network, 1403-29th St. NW, C210, Calgary, AB T2N 2T9, Canada.,c Libin Cardiovascular Institute of Alberta, 1403-29th St. NW, Calgary, AB T2N 2T9, Canada
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Mann MC, Exner DV, Hemmelgarn BR, Hanley DA, Turin TC, MacRae JM, Wheeler DC, Sola DY, Ramesh S, Ahmed SB. The VITAH Trial-Vitamin D Supplementation and Cardiac Autonomic Tone in Patients with End-Stage Kidney Disease on Hemodialysis: A Blinded, Randomized Controlled Trial. Nutrients 2016; 8:nu8100608. [PMID: 27690095 PMCID: PMC5083996 DOI: 10.3390/nu8100608] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 06/16/2016] [Revised: 08/27/2016] [Accepted: 09/20/2016] [Indexed: 12/12/2022] Open
Abstract
End-stage kidney disease (ESKD) patients are at increased cardiovascular risk. Vitamin D deficiency is associated with depressed heart rate variability (HRV), a risk factor depicting poor cardiac autonomic tone and risk of cardiovascular death. Vitamin D deficiency and depressed HRV are highly prevalent in the ESKD population. We aimed to determine the effects of oral vitamin D supplementation on HRV ((low frequency (LF) to high frequency (HF) spectral ratio (LF:HF)) in ESKD patients on hemodialysis. Fifty-six subjects with ESKD requiring hemodialysis were recruited from January 2013–March 2015 and randomized 1:1 to either conventional (0.25 mcg alfacalcidol plus placebo 3×/week) or intensive (0.25 mcg alfacalcidol 3×/week plus 50,000 international units (IU) ergocalciferol 1×/week) vitamin D for six weeks. The primary outcome was the change in LF:HF. There was no difference in LF:HF from baseline to six weeks for either vitamin D treatment (conventional: p = 0.9 vs. baseline; intensive: p = 0.07 vs. baseline). However, participants who remained vitamin D-deficient (25-hydroxyvitamin D < 20 ng/mL) after treatment demonstrated an increase in LF:HF (conventional: n = 13, ∆LF:HF: 0.20 ± 0.06, p < 0.001 vs. insufficient and sufficient vitamin D groups; intensive: n = 8: ∆LF:HF: 0.15 ± 0.06, p < 0.001 vs. sufficient vitamin D group). Overall, six weeks of conventional or intensive vitamin D only augmented LF:HF in ESKD subjects who remained vitamin D-deficient after treatment. Our findings potentially suggest that while activated vitamin D, with or without additional nutritional vitamin D, does not appear to improve cardiac autonomic tone in hemodialysis patients with insufficient or sufficient baseline vitamin D levels, supplementation in patients with severe vitamin D deficiency may improve cardiac autonomic tone in this higher risk sub-population of ESKD. Trial Registration: ClinicalTrials.gov, NCT01774812.
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Affiliation(s)
- Michelle C Mann
- Department of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada.
- Libin Cardiovascular Institute of Alberta, Calgary, AB T2N 4Z6, Canada.
| | - Derek V Exner
- Department of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada.
- Libin Cardiovascular Institute of Alberta, Calgary, AB T2N 4Z6, Canada.
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada.
- Libin Cardiovascular Institute of Alberta, Calgary, AB T2N 4Z6, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB T2N 4Z6, Canada.
| | - David A Hanley
- Department of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada.
- Osteoporosis and Metabolic Bone Disease Centre, Calgary, AB T2T 5C7, Canada.
| | - Tanvir C Turin
- Department of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada.
| | - Jennifer M MacRae
- Department of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada.
- Libin Cardiovascular Institute of Alberta, Calgary, AB T2N 4Z6, Canada.
| | - David C Wheeler
- Department of Medicine, University College London, London NW3 2PF, UK.
| | - Darlene Y Sola
- Department of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada.
| | - Sharanya Ramesh
- Department of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada.
- Libin Cardiovascular Institute of Alberta, Calgary, AB T2N 4Z6, Canada.
| | - Sofia B Ahmed
- Department of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada.
- Libin Cardiovascular Institute of Alberta, Calgary, AB T2N 4Z6, Canada.
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45
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Miller LM, MacRae JM, Kiaii M, Clark E, Dipchand C, Kappel J, Lok C, Luscombe R, Moist L, Oliver M, Pike P, Hiremath S. Hemodialysis Tunneled Catheter Noninfectious Complications. Can J Kidney Health Dis 2016; 3:2054358116669130. [PMID: 28270922 PMCID: PMC5332086 DOI: 10.1177/2054358116669130] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/04/2016] [Indexed: 12/19/2022] Open
Abstract
Noninfectious hemodialysis catheter complications include catheter dysfunction, catheter-related thrombus, and central vein stenosis. The definitions, causes, and treatment strategies for catheter dysfunction are reviewed below. Catheter-related thrombus is a less common but serious complication of catheters, requiring catheter removal and systemic anticoagulation. In addition, the risk factors, clinical manifestation, and treatment options for central vein stenosis are outlined.
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Affiliation(s)
- Lisa M Miller
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Jennifer M MacRae
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Mercedeh Kiaii
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Edward Clark
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | - Joanne Kappel
- Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Charmaine Lok
- Faculty of Medicine, University Health Network, University of Toronto, Ontario, Canada
| | - Rick Luscombe
- Department of Nursing, Providence Health Care, Vancouver, British Columbia, Canada
| | - Louise Moist
- Department of Medicine, University of Western Ontario, London, Canada
| | - Matthew Oliver
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Pamela Pike
- Department of Medicine, Memorial University, Saint John's, Newfoundland and Labrador, Canada
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46
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MacRae JM, Dipchand C, Oliver M, Moist L, Lok C, Clark E, Hiremath S, Kappel J, Kiaii M, Luscombe R, Miller LM. Arteriovenous Access Failure, Stenosis, and Thrombosis. Can J Kidney Health Dis 2016; 3:2054358116669126. [PMID: 28270918 PMCID: PMC5332078 DOI: 10.1177/2054358116669126] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/04/2016] [Indexed: 01/29/2023] Open
Abstract
Vascular access–related complications can lead to patient morbidity and reduced patient quality of life. Some of the common arteriovenous access complications include failure to mature, stenosis formation, and thrombosis.
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Affiliation(s)
- Jennifer M MacRae
- Cumming School of Medicine and Department of Cardiac Sciences, University of Calgary, Alberta, Canada
| | | | - Matthew Oliver
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Louise Moist
- Department of Medicine, University of Western Ontario, London, Canada
| | - Charmaine Lok
- Faculty of Medicine, University Health Network, University of Toronto, Ontario, Canada
| | - Edward Clark
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | - Joanne Kappel
- Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Mercedeh Kiaii
- Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Rick Luscombe
- Department of Nursing, Providence Health Care, Vancouver, British Columbia, Canada
| | - Lisa M Miller
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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47
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MacRae JM, Oliver M, Clark E, Dipchand C, Hiremath S, Kappel J, Kiaii M, Lok C, Luscombe R, Miller LM, Moist L. Arteriovenous Vascular Access Selection and Evaluation. Can J Kidney Health Dis 2016; 3:2054358116669125. [PMID: 28270917 PMCID: PMC5332074 DOI: 10.1177/2054358116669125] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/04/2016] [Indexed: 12/11/2022] Open
Abstract
When making decisions regarding vascular access creation, the clinician and vascular access team must evaluate each patient individually with consideration of life expectancy, timelines for dialysis start, risks and benefits of access creation, referral wait times, as well as the risk for access complications. The role of the multidisciplinary team in facilitating access choice is reviewed, as well as the clinical evaluation of the patient.
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Affiliation(s)
- Jennifer M MacRae
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Matthew Oliver
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Edward Clark
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | | | - Joanne Kappel
- Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Mercedeh Kiaii
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Charmaine Lok
- Faculty of Medicine, University Health Network, University of Toronto, Ontario, Canada
| | - Rick Luscombe
- Department of Nursing, Providence Health Care, Vancouver, British Columbia, Canada
| | - Lisa M Miller
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Louise Moist
- Department of Medicine, University of Western Ontario, London, Canada
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MacRae JM, Dipchand C, Oliver M, Moist L, Yilmaz S, Lok C, Leung K, Clark E, Hiremath S, Kappel J, Kiaii M, Luscombe R, Miller LM. Arteriovenous Access: Infection, Neuropathy, and Other Complications. Can J Kidney Health Dis 2016; 3:2054358116669127. [PMID: 28270919 PMCID: PMC5332082 DOI: 10.1177/2054358116669127] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/04/2016] [Indexed: 12/16/2022] Open
Abstract
Complications of vascular access lead to morbidity and may reduce quality of life. In this module, we review both infectious and noninfectious arteriovenous access complications including neuropathy, aneurysm, and high-output access. For the challenging patients who have developed many complications and are now nearing their last vascular access, we highlight some potentially novel approaches.
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Affiliation(s)
- Jennifer M MacRae
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | - Matthew Oliver
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Louise Moist
- Department of Medicine, University of Western Ontario, London, Canada
| | - Serdar Yilmaz
- Department of Surgery, University of Calgary, Alberta, Canada
| | - Charmaine Lok
- Faculty of Medicine, University Health Network, University of Toronto, Ontario, Canada
| | - Kelvin Leung
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Edward Clark
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | - Joanne Kappel
- Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Mercedeh Kiaii
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Rick Luscombe
- Department of Nursing, Providence Health Care, Vancouver, British Columbia, Canada
| | - Lisa M Miller
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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Leung KCW, Tai DJ, Ravani P, Quinn RR, Scott-Douglas N, MacRae JM. Citrate vs. acetate dialysate on intradialytic heparin dose: A double blind randomized crossover study. Hemodial Int 2016; 20:537-547. [DOI: 10.1111/hdi.12433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/29/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - Davina J. Tai
- Cumming School of Medicine; University of Saskatchewan
| | | | - Rob R. Quinn
- Cumming School of Medicine; University of Calgary
| | | | - Jennifer M. MacRae
- Cumming School of Medicine; University of Calgary
- Department of Cardiac Sciences; University of Calgary
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Ravani P, Quinn RR, Oliver MJ, Karsanji DJ, James MT, MacRae JM, Palmer SC, Strippoli GF. Preemptive Correction of Arteriovenous Access Stenosis: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Kidney Dis 2016; 67:446-60. [DOI: 10.1053/j.ajkd.2015.11.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 11/23/2015] [Indexed: 11/11/2022]
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