A Canadian Commentary on the NKF-ASN Task Force Recommendations on Reassessing the Inclusion of Race in Diagnosing Kidney Disease.

In 2021, a committee was commissioned by the Canadian Society of Nephrology to comment on the 2021 National Kidney Foundation-American Society of Nephrology Task Force recommendations on the use of race in glomerular filtration rate estimating equations. The committee met on numerous occasions and agreed on several recommendations. However, the committee did not achieve unanimity, with a minority group disagreeing with the scope of the commentary. As a result, this report presents the viewpoint of the majority members. We endorsed many of the recommendations from the National Kidney Foundation-American Society of Nephrology Task Force, most importantly that race should be removed from the estimated glomerular filtration rate creatinine-based equation. We recommend an immediate implementation of the new Chronic Kidney Disease Epidemiology Collaboration equation (2021), which does not discriminate among any group while maintaining precision. Additionally, we recommend that Canadian laboratories and provincial kidney organizations advocate for increased testing and access to cystatin C because the combination of cystatin C and creatinine in revised equations leads to more precise estimates. Finally, we recommend that future research studies evaluating the implementation of the new equations and changes to screening, diagnosis, and management across provincial health programs be prioritized in Canada.

Five Things to Know About Incremental Peritoneal Dialysis.

Incremental peritoneal dialysis (PD) offers patients newly starting dialysis less than the standard "full dose" of PD, reducing treatment burden and intrusiveness while minimizing symptoms of renal failure. Incremental PD is a cost-effective approach that has been associated with slower rates of decline in residual kidney function. This approach also produces less waste and in turn reduces environmental footprint compared to standard PD prescriptions. It also aligns with the International Society of Peritoneal Dialysis (ISPD) Practice Recommendations for high-quality, goal-oriented therapy. Awareness of incremental PD along with its advantages and limitations provides practitioners with the tools to provide more patient-centered dialysis prescriptions in appropriate populations.

La dialyse péritonéale (DP) incrémentale propose un traitement à une dose moindre que la « dose complète ¼ habituelle aux patients qui amorcent la dialyse; ce qui contribue à réduire le fardeau du traitement et à en limiter le caractère intrusif, tout en minimisant les symptômes de l'insuffisance rénale. La DP incrémentale est une approche qui présente un bon rapport coût/efficacité, en plus d'avoir été associée à un ralentissement du déclin de la fonction rénale résiduelle. Elle produit également moins de déchets que la DP standard, ce qui, par conséquent, réduit l'empreinte environnementale du traitement. Enfin, la DP incrémentale est conforme aux recommandations de pratique de l'International Society of Peritoneal Dialysis (ISPD) pour une thérapie de haute qualité axée sur les objectifs. La sensibilisation à la DP incrémentale, ainsi qu'à ses avantages et à ses limites, fournit aux praticiens les outils nécessaires pour prescrire une modalité de dialyse davantage centrée sur le patient dans les populations appropriées.

Continuous quality improvement in peritoneal dialysis: Your questions answered.

Peritoneal dialysis (PD) uptake around the globe has steadily increased over the last several decades as a viable alternative to haemodialysis. Continued success of this technique for patients is contingent on the application of continuous quality improvement (CQI) principles in PD practice which can improve patient outcomes and in turn lead to more successful PD programmes worldwide. In this installation of 'Your Questions Answered', we will outline an approach to quality improvement initiatives and examine the importance of CQI principles in PD practice. We will also highlight common pitfalls and provide strategies to identify potential targets for improvement within your PD programme.

Five Things to Know About Volume Overload in Peritoneal Dialysis.

Volume overload in peritoneal dialysis (PD) is common and associated with significant morbidity and mortality. If left untreated, it can result in premature technique failure in patients receiving PD. Practitioners should be aware of common causes and formulate a stepwise approach in the management of volume overload.

La surcharge volumique est fréquente chez les patients traités par dialyse péritonéale (DP) et elle est associée à davantage de morbidité et de mortalité. Une surcharge volumique non traitée peut entraîner une défaillance technique prématurée chez les patients sous dialyse péritonéale. Il est important que les praticiens connaissent les causes communes de la surcharge volumique et qu'une approche par étapes soit formulée pour sa prise en charge.

A case of severe bleeding and deep inferior epigastric pseudoaneurysm after peritoneal dialysis catheter removal.

We present an unusual but severe complication of peritoneal dialysis (PD) catheter removal resulting in significant haemorrhage and hospitalisation. A patient presented for PD catheter removal under local anaesthesia in the interventional radiology suite and was noted to have a heavily calcified deep Dacron cuff. This cuff was intimately associated with a deep inferior epigastric perforating (DIEP) vessel. Removal of the catheter resulted in shearing of DIEP vessel and pseudoaneurysm formation. Despite attempted surgical management with ligation haemorrhage continued, requiring urgent angiographic embolisation to stop the bleeding. Intimate relationship between DIEP vessel and Dacron cuff due to calcification was the cause of this complication. This case report represents a rare but important complication associated with PD catheter removal, highlighting that when calcification is seen at the deep cuff, caution should be exercised and there should be access to angiography suite in case of complication.

Peritoneal Dialysis Prescription and Adequacy in Clinical Practice: Core Curriculum 2023.

As the global prevalence of peritoneal dialysis (PD) continues to grow, practitioners must be equipped with prescribing strategies that focus on the needs and preferences of patients. PD is an effective form of kidney replacement therapy that offers numerous benefits to patients, including more flexibility in schedules compared with in-center hemodialysis (HD). Additional benefits of PD include salt and water removal without significant changes in patient hemodynamics. This continuous yet gentle removal of solutes and fluid is associated with better-preserved residual kidney function. Unfortunately, sometimes these advantages are overlooked at the expense of an emphasis on achieving small solute clearance targets. A more patient-centered approach emphasizes the importance of individualized treatment, particularly when considering incremental PD and other prescriptions that align with lifestyle preferences. In shifting the focus from small solute clearance targets to patient needs and clinical goals, PD remains an attractive, patient-centered form of kidney replacement therapy.

Ambulatory Parathyroidectomy for Secondary Hyperparathyroidism at a Large Dialysis Program in Toronto: A Program Report.

Purpose of program: Operative wait times for non-oncology-related procedures continue to rise in Canada, and this was further exacerbated by the COVID-19 pandemic. These challenges will remain prevalent beyond the pandemic given the limited number of acute care beds and resources required to care for patients. As a result, the need for innovative approaches to optimize the utilization of health care resources while maintaining equitable and timely access is needed. In this report, we describe the development of a collaborative ambulatory parathyroidectomy program between two centers in Toronto, allowing for more expedient surgical treatment of secondary hyperparathyroidism among patients from a large dialysis program. Sources of information: The need for expanded access to surgical care for secondary hyperparathyroidism was identified through interdepartmental communication between referring nephrologists and surgeons at Sunnybrook Health Sciences Centre and Women's College Hospital, respectively. Methods: A multidisciplinary ambulatory parathyroidectomy planning team was formed that included nephrologists, endocrine surgeons, nurses, and patient care managers to conduct a needs assessment. It was identified that patients had long wait times, and to address that gap in care, a protocol was developed to identify suitable patients requiring treatment. The teams created a plan to coordinate patient care and transfers. A clinical tool and protocol for post-operative management of hypocalcemia was developed using a Delphi model, gathering input from many members of the care team. The Delphi process to finalize the protocol included a series of virtual meetings over a period of about 4 months with various stakeholders and included input from two departmental heads (medicine and surgery), three nephrologists, a nurse practitioner, a patient care manager, and two nurse educators. Meetings involved core members of the Nephrology Quality Improvement and Patient Safety at Sunnybrook Health Sciences Centre and finalized protocol was agreed upon by members of this group at a quarterly meeting. Key findings: In this article, we describe the development, initial deployment, and planned assessment of the ambulatory parathyroidectomy program at the Women's College Hospital and Sunnybrook Health Sciences Centre. The primary aim of the program is to increase accessibility to parathyroidectomy for secondary hyperparathyroidism. A secondary aim was to allow patients to have streamlined care with a team that is well versed with maintenance dialysis needs and optimizing treatment of post operative hypocalcemia through standardized protocols. Limitations: Ambulatory parathyroidectomy relies on effective communication, flow, and availability of acute care beds. It is anticipated that occasionally, unexpected hospital demands, and health care disruptions may occur, which can limit efficiency of the program. We will also need to examine the cost-effectiveness of this program as it may improve access but increase costs related to the procedure. As the program is implemented, useful adaptations and policies to our protocol to help mitigate these limitations will be documented and published in our outcomes report. Implications: Ontario residents with chronic kidney disease with secondary hyperparathyroidism who have failed medical management will have increased and timely access to parathyroidectomy.

Objectif du program: Les temps d'attente pour les interventions non oncologiques continuent d'augmenter au Canada, une situation qui s'est aggravée avec la pandémie de COVID-19. Ce problème persistera au-delà de la pandémie en raison du nombre limité de lits en soins aigus et de ressources pour soigner les patients. Par conséquent, l'adoption d'approches novatrices pour optimiser l'utilisation des ressources en santé, tout en maintenant un accès équitable et opportun, est nécessaire. Dans ce rapport, nous décrivons l'élaboration d'un programme collaboratif de parathyroïdectomie ambulatoire entre deux centres de Toronto, lequel permettra le traitement chirurgical plus rapide de l'hyperparathyroïdie secondaire chez les patients d'un important programme de dialyse. Sources: Le besoin d'élargir l'accès aux soins chirurgicaux pour l'hyperparathyroïdie secondaire a été révélé grâce à la communication interservices entre les néphrologues traitants du Sunnybrook Health Sciences Centre et les chirurgiens de l'Hôpital Women's College. Méthodologie: Une équipe multidisciplinaire de planification de la parathyroïdectomie ambulatoire composée de néphrologues, de chirurgiens-endocrinologues, d'infirmières et de gestionnaires de soins aux patients a été formée pour procéder à une évaluation des besoins. Il a été établi que les patients expérimentaient de longs temps d'attente et, pour combler cette lacune, un protocole a été mis au point pour identifier adéquatement les patients nécessitant un traitement. Les équipes ont créé un plan pour coordonner les soins aux patients et les transferts. Un outil clinique et un protocole de prise en charge postopératoire de l'hypocalcémie ont été mis au point à l'aide d'un modèle Delphi impliquant la participation plusieurs membres de l'équipe soignante. Le processus Delphi de finalisation du protocole a comporté, sur une période de quatre mois, une série de réunions virtuelles avec divers intervenants, ainsi que la participation de deux chefs de service (médecine et chirurgie), de trois néphrologues, d'une infirmière praticienne, d'un gestionnaire des soins aux patients et de deux formateurs en soins infirmiers. Ces rencontres ont réuni les principaux membres du Nephrology Quality Improvement and Patient Safety at Sunnybrook Health Sciences Centre, et ces derniers ont convenu d'un protocole finalisé lors d'une réunion trimestrielle. Principaux resultants: Cet article décrit l'élaboration, le déploiement initial et l'évaluation prévue du programme de parathyroïdectomie ambulatoire du Women's College Hospital et du Sunnybrook Health Sciences Centre. Le principal objectif du programme est d'accroître l'accessibilité à la parathyroïdectomie pour les patients souffrant d'hyperparathyroïdie secondaire. Les autres objectifs étaient de permettre aux patients de bénéficier de soins rationalisés, grâce à une équipe qui connaît parfaitement les besoins en dialyse d'entretien, et d'optimiser le traitement de l'hypocalcémie postopératoire grâce à des protocoles normalisés. Limites: La parathyroïdectomie ambulatoire repose sur l'efficacité du flux et de la communication, et sur la disponibilité des lits en soins aigus. Il est attendu que des demandes hospitalières inattendues et des perturbations se produiront de temps à autre, ce qui pourrait limiter l'efficacité du programme. Nous devrons également examiner la rentabilité du programme, car l'amélioration de l'accès pourrait se traduire par une augmentation des coûts liés à la procédure. Au fur et à mesure de la mise en œuvre du programme, des adaptations et politiques utiles à notre protocole seront documentées et publiées dans notre rapport sur les résultats, afin d'aider à atténuer ces limites. Conclusion: Les résidents de l'Ontario atteints d'insuffisance rénale chronique et d'hyperparathyroïdie secondaire dont la prise en charge médicale a échoué auront un accès accru et opportun à la parathyroïdectomie.

The Physician Leader: Teaching Leadership in Medicine.

An integral part of a physician's practice includes being a leader, especially as there is a strong need for skilled leaders to advocate and navigate patient-centered and organizational outcomes. Nephrologists undertake multiple leadership roles, but dedicated leadership training is lacking in medical and postgraduate education. Given the growing need for physician leaders, practitioners in nephrology and beyond must become better equipped in understanding the role of leadership skills in medical practice. Nephrology and the medical community as a whole should focus on intentional and dedicated leadership in medical education training to better groom physicians for leadership roles. In this paper, we define and discuss the components and styles of leadership. We further propose cognitive models that allow one to apply leadership theory in common practice.

Cardiovascular Effects of Home Dialysis Therapies: A Scientific Statement From the American Heart Association.

Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Currently, thrice-weekly in-center hemodialysis for 3 to 5 hours per session is the most common therapy worldwide for patients with treated kidney failure. Outcomes with thrice-weekly in-center hemodialysis are poor. Emerging evidence supports the overarching hypothesis that a more physiological approach to administering dialysis therapy, including in the home through home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and cardiovascular outcomes compared with thrice-weekly in-center hemodialysis. The Advancing American Kidney Health Initiative, which has a goal of increasing the use of home dialysis, is aligned with the American Heart Association's 2024 mission to champion a full and healthy life and health equity. We conclude that incorporation of interdisciplinary care models to increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.

Design and Development of a Digital Counseling Program for Chronic Kidney Disease.

Background: Self-management has shown to improve the quality of life in patients with chronic kidney disease (CKD). Readily accessible self-management tools are essential in promoting adherence to self-care behaviors. In recognizing that digital health facilitates efficient access to self-management programs, we developed a digital counseling program, ODYSSEE Kidney Health, to promote self-care behaviors while supporting health-related quality of life. Objective: To present the design and development of ODYSSEE Kidney Health for digital counseling for patients with CKD. Design: The study involved an iterative design process based on user-centered design principles to develop the digital counseling program, ODYSSEE Kidney Health. Setting: A sample of 10 to 15 participants were purposively sampled from nephrology clinics at the University Health Network, Toronto, Canada. Methods: Participants underwent 2 phases in the development process. In each phase, participants were presented with a component of the program, asked to perform goal-oriented tasks, and participate in the "think-aloud" process. Semi-structured interviews followed the first phase to identify feedback about the overall program. Thematic analysis of the interviews identified themes from the usability testing. Descriptive statistics were used to summarize patient demographic data. Results: We enrolled 11 participants (n = 7 males, n = 4 females, ages 30-82). The main themes generated anchored on (1) impact on nephrology care, (2) technical features, and (3) CKD content. Overall, participants reported positive satisfaction toward the navigation, layout, and content of the program. They cited the value of the program in their daily CKD care. Limitations: Study limitations included using a single center to recruit participants, most of the participants having prior technology use, and using one module as a representative of the entire digital platform. Conclusion: The acceptability of a digital counseling program for patients with CKD relies on taking the patients' perspective using a user-centered design process. It is vital in ensuring adoption and adherence to self-management interventions aimed at sustaining behavioral change.

Contexte: L'autogestion s'est avérée efficace pour améliorer la qualité de vie des patients atteints d'insuffisance rénale chronique (IRC). Des outils d'autogestion facilement accessibles sont essentiels pour favoriser l'adhésion aux comportements d'autogestion. Conscients que la santé numérique facilite l'accès efficace aux programmes d'autogestion, nous avons mis au point un programme de consultation numérique, ODYSSEE Kidney Health, afin de promouvoir les comportements d'autogestion tout en soutenant la qualité de vie liée à la santé. Objectif: Présenter la conception et le développement du programme de consultation numérique ODYSSEE Kidney Health, destiné aux patients atteints d'IRC. Conception: L'étude a impliqué un processus de conception itératif fondé sur des principes de conception axés sur l'utilisateur pour développer le programme de consultation numérique, ODYSSEE Kidney Health. Participants: Un échantillon de 10 à 15 participants choisis à dessein dans des cliniques de néphrologie du University Health Network de Toronto (Canada). Méthodologie: Les participants ont pris part à deux phases du processus de développement. À chaque phase, une composante du programme a été présentée aux participants et ceux-ci ont été invités à effectuer des tâches axées sur les objectifs et à participer à un processus de « réflexion à voix haute ¼. Des entretiens semi-structurés ont suivi la première phase pour fournir de la rétroaction sur le programme dans son ensemble. L'analyse thématique des entretiens a permis de dégager les thèmes des tests d'utilisabilité. Des statistiques descriptives ont servi à présenter les données démographiques des patients. Résultats: Nous avons inclus 11 participants (7 hommes, 4 femmes; de 30 à 82 ans). Les principaux thèmes générés sont ancrés sur: 1) l'impact sur les soins de néphrologie, 2) les caractéristiques techniques et 3) le contenu sur l'IRC. Dans l'ensemble, les participants étaient satisfaits de leur expérience de navigation, de la disposition des contenus et du contenu du programme. Ils ont mentionné la valeur du programme dans leurs soins quotidiens d'IRC. Limites: Un seul centre a été utilisé pour recruter des participants, la majorité des participants avait déjà utilisé la technologie et un seul module a été utilisé pour représenter l'ensemble de la plateforme numérique. Conclusion: L'acceptabilité d'un programme de consultation numérique destiné aux patients atteints d'IRC repose sur la prise en compte du point de vue des patients par le biais d'un processus de conception axé sur l'utilisateur. Ceci est essentiel pour garantir l'adoption et l'adhésion aux interventions d'autogestion visant à pérenniser les changements de comportement.

A review of the AURORA and BLISS trials: will it revolutionize the treatment of lupus nephritis?

PURPOSE OF REVIEW: Renal involvement in patients with systemic lupus erythematosus can lead to significant complications including end-stage renal disease. Treatment of lupus nephritis has evolved over the last several decades, but despite this evolution, many patients fail to achieve remission and often progress to end-stage kidney disease or carry a burden of adverse side effects related to treatment. RECENT FINDINGS: The recent findings from AURORA 1 and BLISS LN trials led the FDA to approve voclosporin and belimumab for the treatment of lupus nephritis. The AURORA 1 trial demonstrated that voclosporin, a second-generation calcineurin inhibitor, effectively lowers proteinuria in patients with lupus nephritis, when added to mycophenolate mofetil with a better safety profile, compared with other calcineurin inhibitors. The BLISS LN trial revealed better control of disease and lower risk of progression to end stage kidney disease (ESKD) and relapses in patients treated with belimumab in addition to standard therapy. SUMMARY: Both voclosporin and belimumab are costly and have not shown any early evidence to revolutionize practice in the management of lupus nephritis. Until more data are made available with future studies or other cost-effective treatment options become available, the widespread adoption and utility of these novel agents remains limited.

The need for individualizing teaching and assurance of knowledge transmission to patients training for home dialysis.

Patients have varied learning styles and this has implications for home haemodialysis (HHD). Assessment tools directed toward understanding these styles remains understudied. As a consequence, this may lead to substandard retention rates or adverse events in HHD programs. As part of a continuous quality improvement initiative we have aimed to improve our understanding of patient learning styles and consequently tailor home dialysis training to individuals. To objectively determine knowledge translation and comprehension, irrespective of learning styles, we have introduced an objective structured clinical examination (OSCE). This assessment tool allows for further refinement of educational priorities by highlighting both deficiencies and strengths. Thereafter, an exit OSCE ensures patients attain an acceptable standard to complete home haemodialysis independently. We hope this tool will help shape future training criteria for HHD programs and consequently reduce adverse event rates.