Variability in Reporting eGFR at Dialysis Initiation in Canada: A Research Letter.

Background: Estimated glomerular filtration rate (eGFR) at dialysis initiation is increasingly recognized as a key quality indicator (QI) for patients with end-stage kidney disease (ESKD). Specifically, guidelines recommend assessing deferral of dialysis initiation until symptoms arise or if the eGFR is ≤6 mL/min/1.73 m2. Despite the recognition of the importance of this QI, how eGFR at the time of dialysis initiation is defined, collected, and tracked at dialysis centers across Canada remains unknown. Objectives: To identify how provincial renal programs define eGFR at dialysis initiation, to compare practice across Canadian provinces, and to determine if there is a consistent benchmark for deferred dialysis start. Design: Cross-sectional survey distributed to the medical leads of each provincial renal program, administered from July 2021 to November 2021. Quebec was not included given it did not yet participate in Canadian Organ Replacement Register (CORR) data submission. Setting: The survey was designed and distributed by the Canadian Society of Nephrology Quality Improvement & Implementation Science Committee (CSN-QUIS) Indicator Working Group. Methods: The survey asked respondents on how eGFR is defined, collected, reported, and perceived barriers to QI data collection. The National Senior Renal Leaders Forum helped identify the key provincial medical leads to disseminate the survey for completion. Results: Surveys were distributed to the medical leads of the 9 provincial renal programs that participate in CORR. In total, there were 8 responses. Five provinces submit eGFR for all new dialysis starts and 3 provinces only submit this information for chronic patients. There is variation in determining when a patient with acute kidney injury requiring dialysis is classified as a chronic patient. Four provinces use a 30-day trigger, 3 provinces use a 90-day trigger, and the patient's nephrologist makes this determination in 1 province. The creatinine used for the eGFR at dialysis initiation was the value measured on the first dialysis session (ie, day 0) for 5 provinces; the last outpatient clinic creatinine value in 2 provinces, and 1 province did not have a standard definition. Three provinces did not have a benchmark target for eGFR at dialysis initiation, 1 province had a target of <9.5 mL/min/1.73 m2, 3 provinces had a target of <10 mL/min/1.73 m2, 1 province had a target of <15 mL/min/1.73 m2. All 8 responding provincial medical leads support the establishment of a national benchmark for this measure. Limitations: This survey was restricted to provincial medical leads and therefore is unable to determine practice at individual dialysis sites. The survey was not anonymous, so it may be subject to conformity bias. Conclusions: There is wide variability in how eGFR at dialysis initiation is measured and reported across Canada. Additionally, there is no consensus on a benchmark target for an intent-to-defer dialysis strategy. Standardization of target eGFR at dialysis initiation may facilitate national reporting and quality improvement initiatives.

Contexte: Le débit de filtration glomérulaire estimé (DFGe) à l'amorce de la dialyse est de plus en plus reconnu comme un indicateur clé de la qualité (IQ) chez les patients atteints d'insuffisance rénale terminale (IRT). Plus précisément, les lignes directrices recommandent d'évaluer la possibilité de reporter l'initiation de la dialyse jusqu'à l'apparition des symptômes ou l'atteinte d'un DFGe égal ou inférieur à 6 ml/min/1,73 m2. Bien qu'on reconnaisse l'importance de cet IQ, on ignore encore comment le DFGe est défini, mesuré et suivi au moment de l'initiation de la dialyse dans les centres de dialyse canadiens. Objectifs: Déterminer la façon dont les programmes rénaux provinciaux définissent le DFGe à l'initiation de la dialyse, comparer les pratiques en cours dans les différentes provinces canadiennes et déterminer s'il existe une cible de référence commune pour une initiation différée de la dialyse. Conception: Un sondage transversal distribué entre juillet et novembre 2021 aux directeurs médicaux de chaque programme provincial de soins rénaux. Le Québec n'a pas été inclus puisque la province n'a pas encore participé au Registre canadien des insuffisances et des transplantations d'organes (RCITO). Cadre: Le sondage a été conçu et distribué par le Groupe de travail sur les indicateurs du Quality Improvement & Implementation Science Committee de la Société canadienne de néphrologie (CSN-QUIS). Méthodologie: Les répondants au sondage devaient décrire la façon dont le DFGe est défini, mesuré et rapporté, ainsi que les obstacles perçus à la collecte de données sur les IQ. Le sondage a été distribué aux directeurs médicaux provinciaux identifiés par le biais du National Senior Renal leaders Forum. Résultats: Le sondage a été distribué aux directeurs médicaux des neuf programmes provinciaux de soins rénaux participant au RCITO; huit ont répondu. Cinq provinces soumettent le DFGe pour toute nouvelle initiation d'un traitement de dialyse; trois provinces ne soumettent cette information que pour les patients atteints d'insuffisance rénale chronique. Il existe des différences entre les provinces dans la détermination du moment où un patient passe de l'insuffisance rénale aiguë nécessitant une dialyse à l'insuffisance rénale chronique. Quatre provinces utilisent un délai de 30 jours, trois provinces utilisent un délai de 90 jours et dans la dernière province, cette détermination est faite par le néphrologue du patient. Dans cinq des huit provinces sondées, le taux de créatinine utilisé pour établir le DFGe à l'initiation de la dialyse est la valeur mesurée à la première séance de dialyse (au jour 0); deux provinces utilisent la valeur de créatinine mesurée lors de la dernière visite en ambulatoire, et une province n'a pas de définition normalisée. Trois provinces n'ont pas de cible de référence pour le DFGe à l'initiation de la dialyse; cette cible est de moins de 9,5 ml/min/1,73 m2 dans une province, de moins de 10 ml/min/1,73 m2 dans trois provinces, et de moins de 15 ml/min/1,73 m2 dans une province. Les huit responsables médicaux provinciaux ayant répondu au sondage appuient l'établissement d'une valeur de référence nationale pour cette mesure. Limites: Ce sondage n'a été envoyé qu'aux directions médicales provinciales, par conséquent, il ne permet pas de déterminer les pratiques en cours dans chaque site de dialyse. Le sondage n'étant pas anonyme, il pourrait comporter un biais de conformité. Conclusion: Il existe une grande variabilité au Canada dans la façon dont le DFGe est mesuré et rapporté au début de la dialyse. On observe en outre une absence de consensus quant à une cible de référence pour une stratégie d'initiation différée de la dialyse. La normalisation de la valeur cible de DFGe au début de la dialyse pourrait faciliter les initiatives nationales de déclaration et d'amélioration de la qualité.

Efficacy of emergency department-based interventions designed to reduce repeat visits and other adverse outcomes for older patients after discharge: A systematic review.

AIM: There is an urgent need for effective geriatric interventions to meet the health service demands of the growing older population. In this paper, we systematically review and update existing literature on interventions within emergency departments (ED) targeted towards reducing ED re-visits, hospitalizations, nursing home admissions and deaths in older patients after initial ED discharge. METHODS: Databases Medline, CINAHL, Embase and Web of Science were searched to identify all articles published up to June 2012 that focused on older adults in the ED, included a comparison group, and reported quantitative results in four primary outcomes: ED re-visits, hospitalizations, nursing home admissions and death after initial ED discharge. RESULTS: Of the 2826 titles screened, just nine studies met our inclusion criteria. The studies varied in their design and outcome measurements such that results could not be combined. Two trends surfaced: (i) more intensive interventions more frequently resulted in reduced adverse outcomes than did simple referral intervention types; and (ii) among the lowest intensity, referral-based interventions, studies that used a validated prediction tool to identify high-risk patients more frequently reported improved outcomes than those that did not use such a tool. CONCLUSION: Of the few studies that met the inclusion criteria, there was a lack of consistency and clarity in study designs and evaluative outcomes. Despite this, more intensive interventions that followed patients beyond a referral and the use of a clinical risk prediction tool appeared to be associated with improved outcomes. The dearth of rigorous evaluations with standardized methodologies precludes further recommendations.

The role of genetic variants in genes regulating the oxytocin-vasopressin neurohumoral system in childhood-onset aggression.

OBJECTIVE: The genetic etiology of aggressive behaviors remains elusive, but growing evidence suggests that they are heritable, and certain genetic variants have been implicated as contributing factors. The oxytocin-vasopressin (OXT-AVP) neurohumoral system has recently been implicated in social behaviors. Oxytocin, especially, has been linked to prosocial behaviors such as trust and social bonds. Hence, the aim of this study was to determine whether genes regulating this system were also associated with childhood-onset aggressive behaviors. METHODS: Our sample included 182 White children showing extreme, persistent, and pervasive aggressive behavior. These cases were matched with 182 White controls on the basis of sex and age. We used PCR to determine the genotype for 28 single nucleotide polymorphisms within eight genes regulating the OXT-AVP system, including CD38 polymorphisms. Genotypic analyses were carried out using STATA, whereas differences in haplotypic and allelic frequencies were analyzed using Unphased. RESULTS: None of the results reached significance after correction for multiple testing. However, nominally significant allelic effects were observed for OXTR rs6770632T (P=0.028) and AVPR1A rs11174811G (P=0.040) in females, and OXTR rs237898A (P=0.006), rs237902C (P=0.007), and AVP rs3761249A (P=0.008) in males. CONCLUSION: Genetic variants regulating the OXT-AVP system may be associated with childhood-onset aggression.

Possible genetic association between vasopressin receptor 1B and child aggression.

BACKGROUND: Studies on animal models have implicated arginine vasopressin signalling pathway in aggressive behaviour. The role of arginine vasopressin in childhood onset aggression is unclear. METHODS: We investigated 11 single-nucleotide polymorphisms in the genes coding for arginine vasopressin and its receptors in our sample of 177 aggressive child cases paired with adult controls matched for sex and ethnicity. RESULTS: We found the non-synonymous polymorphism AVPR1B_rs35369693 to be associated with child aggression in our sample (P=0.007). We also found two-marker haplotype window containing AVPR1B_rs35369693 and AVPR1B_rs28676508 to be associated (P=0.003). The haplotype findings survived multiple-testing adjusted significance threshold of 0.0063. CONCLUSIONS: This is the first report of a genetic association between vasopressin receptor 1B and child aggression. Replication in independent samples are required to confirm these findings.

Childhood aggression, callous-unemotional traits and oxytocin genes.

Given the known behavior effects of oxytocin,and in particular its putative effect on trust, affiliation and anxiety, we hypothesized that oxytocin may be involved in the development and expression of callous-unemotional traits in children with aggressive antisocial behavior. We recruited 162 children between the ages of 6 and 16. The majority of subjects were Caucasian (84.0%) compared to African-Canadian (4.9%) and others (11.1%). The oxytocin and oxytocin receptor gene polymorphisms were genotyped and analyzed for possible association with child aggression in a case­control study design as well as with callous-unemotional traits in a within cases analysis. We did not have significant findings with our tested OXTR markers in the case­control analysis. We found the OXTR_rs237885 AA genotype carriers to score higher than AC or CC genotype carriers on the callous-unemotional traits. This result remained significant following correction for multiple testing. No other markers were found to be significant. However, the haplotype consisting of the OXTR_rs237885 A allele and OXTR_rs2268493 A allele was associated with significantly higher callous-unemotionals cores than other haplotypes. This is the first known study to show a significant association between callous unemotional traits in children and adolescents with extreme, persistent pervasive aggression and a polymorphism on the oxytocin receptor. Given the small sample size and the possibility of false positive effects, the need to replicate and verify these findings is required.