Identification and Prioritization of Canadian Society of Nephrology Clinical Practice Guideline Topics With Multidisciplinary Stakeholders and People Living With Kidney Disease: A Clinical Research Protocol.

Background: Despite efforts to provide evidence-based care for people living with kidney disease, health care provider goals and priorities are often misaligned with those of individuals with lived experience of disease. Coupled with competing interests of time, resources, and an abundance of suitable guideline topics, identifying and prioritizing areas of focus for the Canadian nephrology community with a patient-oriented perspective is necessary and important. Similar priority-setting exercises have been undertaken to establish research priorities for kidney disease and to standardize outcomes for kidney disease research and clinical care; however, research priorities are distinct from priorities for guideline development. Inclusion of people living with health conditions in the selection and prioritization of guideline topics is suggested by patient engagement frameworks, though the process to operationalizing this is variable. We propose that the Canadian Society of Nephrology Clinical Practice Guideline Committee (CSN CPGC) takes the opportunity at this juncture to incorporate evidence-based prioritization exercises with involvement of people living with kidney disease and their caregivers to inform future guideline activities. In this protocol, we describe our planned research methods to address this. Objective: To establish consensus-based guideline topic priorities for the CSN CPGC using a modified Delphi survey with involvement of multidisciplinary stakeholders, including people living with kidney disease and their caregivers. Study design: Protocol for a Modified Delphi Survey. Setting: Pilot-tested surveys will be distributed via email and conducted using the online platform SurveyMonkey, in both French and English. Participants: We will establish a group of multidisciplinary clinical and research stakeholders (both within and outside CSN membership) from Canada, in addition to people living with kidney disease and/or their caregivers. Methods: A comprehensive literature search will be conducted to generate an initial list of guideline topics, which will be organized into three main categories: (1) International nephrology-focused guidelines that may require Canadian commentary, (2) Non-nephrology specific guidelines from Canada that may require CSN commentary, and (3) Novel topics for guideline development. Participants will engage in a multi-round Modified Delphi Survey to prioritize a set of "important guideline topics." Measures: Consensus will be reached for an item based on both median score on the Likert-type scale (≥ 7) and the percentage agreement (≥ 75%); the Delphi process will be complete when consensus is reached on each item. Guideline topics will then be given a priority score calculated from the total Likert ratings across participants, adjusted for the number of participants. Limitations: Potential limitations include participant response rates and compliance to survey completion. Conclusions: We propose to incorporate evidence-based prioritization exercises with the engagement of people living with kidney disease and their caregivers to establish consensus-based guideline topics and inform future guidelines activities of the CSN CPGC.

Contexte: Malgré les efforts déployés pour fournir aux personnes atteintes de néphropathies des soins fondés sur les données probantes, il s'avère que les objectifs et priorités des prestataires de soins de santé sont souvent mal alignés avec ceux des personnes qui ont une expérience concrète de la maladie. Compte tenu des intérêts concurrents en matière de temps et de ressources, et de l'abondance de sujets pertinents pour l'élaboration de lignes directrices, il est nécessaire et important d'identifier et de hiérarchiser les domaines prioritaires pour la communauté néphrologique canadienne dans une perspective orientée vers le patient. Des exercices semblables pour la définition des priorités ont été entrepris afin d'établir les priorités de la recherche sur les maladies rénales et normaliser les soins cliniques et les résultats de la recherche sur les maladies rénales. Or, les priorités de la recherche diffèrent des priorités pour l'élaboration des lignes directrices. Bien que les façons de procéder varient, les cadres d'engagement des patients suggèrent que des personnes vivant avec des problèmes de santé soient incluses dans la sélection et la hiérarchisation des sujets des lignes directrices. À cet égard, nous proposons que le Comité sur les lignes directrices de pratique clinique de la Société canadienne de néphrologie (CSN CPGC ­ Canadian Society of Nephrology Clinical Practice Guideline Committee) profite de l'occasion pour intégrer des exercices d'établissement des priorités fondés sur des données probantes et impliquer des personnes vivant avec une néphropathie et des soignants afin de guider les futures activités d'élaboration de lignes directrices. Dans ce protocole, nous décrivons la méthodologie de recherche que nous suivrons pour y remédier. Objectif: Établir des priorités consensuelles en matière de sujets de lignes directrices pour le CSN CPGC à l'aide d'une enquête Delphi modifiée et avec la participation d'intervenants multidisciplinaires, notamment des personnes vivant avec une néphropathie et leurs soignants. Conception: Protocole pour une enquête Delphi modifiée. Cadre: Des sondages pilotes, en anglais et en français, seront distribués par courriel et réalisés à l'aide de la plateforme en ligne SurveyMonkey. Participants: Nous créerons un groupe d'intervenants multidisciplinaires canadiens œuvrant en clinique et en recherche (à la fois des membres et des non membres de la SCN) auquel s'ajouteront des personnes atteintes d'une néphropathie et/ou leurs soignants. Méthodologie: Une recherche exhaustive sera effectuée dans la littérature afin de constituer une première liste de sujets de lignes directrices, laquelle sera divisée en trois catégories principales: (1) lignes directrices internationales axées sur la néphrologie et pouvant nécessiter des commentaires canadiens, (2) lignes directrices canadiennes non spécifiquement liées à la néphrologie et pouvant nécessiter des commentaires de la SCN, (3) nouveaux sujets pour l'élaboration de lignes directrices. Les participants s'engageront dans une enquête Delphi modifiée à plusieurs tours afin de hiérarchiser un ensemble de « sujets importants pour l'élaboration de lignes directrices ¼. Mesures: Un consensus sera atteint pour un énoncé s'il atteint à la fois un score médian (≥7) sur l'échelle de Likert et le pourcentage d'accord établi (≥ 75 %); le processus Delphi sera terminé lorsque le consensus sera atteint pour chaque énoncé. Les sujets pour l'élaboration de lignes directrices recevront ensuite une cote de priorité calculée à partir du total des scores des participants sur l'échelle Likert et ajustée en fonction du nombre de participants. Limites: L'étude pourrait être limitée par le taux de réponse des participants et leur engagement à compléter toutes les étapes de l'enquête. Conclusion: Nous proposons d'intégrer des exercices de définition des priorités fondés sur des données probantes et impliquant la participation de personnes vivant avec une néphropathie et de leurs soignants afin de déterminer des sujets consensuels pour l'élaboration de lignes directrices et de guider les futures activités du CSN CPGC en lien avec ce processus.

Changing Dialysis Modality during Pregnancy: A Case Report.

Pregnancy in patients with end-stage renal disease is rare, with a paucity of management guidelines in the literature. Various hemodialysis (HD) and peritoneal dialysis (PD) protocols have been used to successfully manage pregnancy in this population; however, there is a growing body of evidence that the best maternal and fetal outcomes are associated with intensified, high-dose HD. The optimal timing of transition from PD to HD is not known for prevalent PD patients who become pregnant. We report the case of a 32-year-old aboriginal female who became pregnant while being treated with chronic PD. She was converted to intensive HD early in the second trimester and underwent a planned caesarian section at 36 weeks with excellent outcomes for mother and child.

ANCA Associated Vasculitis Secondary to Levamisole-Adultered Cocaine with Associated Membranous Nephropathy: A Case Series.

BACKGROUND: Cocaine is a risk factor for acute kidney injury and chronic kidney disease with progression to end-stage renal disease. Levamisole is an adulterant that is added to cocaine to enhance its euphoric effects. Levamisole-adulterated cocaine (LAC) is associated with the distinct clinical syndromes of agranulocytosis, leukocytoclastic vasculitis, cocaine-induced midline destructive lesions (CIMDL), and ANCA-associated vasculitis (AAV) with pauci-immune necrotizing glomerulonephritis. METHODS: We reviewed all cases of AAV secondary to LAC at our institution. RESULTS: We report 3 cases of AAV secondary to LAC and associated membranous nephropathy (MN). The first and second cases are concurrent AAV secondary to LAC and associated MN while the third case involves the development of MN after AAV secondary to LAC. CONCLUSIONS: Clinicians should be aware of this novel association of LAC with MN.

A before and after cross-sectional analysis of a public health campaign to increase kidney health awareness in a Canadian province.

BACKGROUND: Chronic kidney disease (CKD) has a major impact on patient health and health system resources. The prevalence of kidney disease is increasing, with Manitoba being one of the provinces in Canada with the highest per capita rate of CKD and end stage renal disease (Anonymous, Canadian organ replacement register annual report: treatment of end-stage organ failure in Canada, 2001-2010, 2011). In 2011, a public health campaign to promote kidney health, by increasing awareness of CKD and its risk factors, was created to target high-risk individuals such as First Nations and those with hypertension and diabetes in urban and rural/remote Manitoba. In this study, we aimed to determine the effectiveness of this public health campaign on increasing the awareness of CKD. METHODS: Our public health campaign ran in March 2011, and employed a multifaceted approach with radio, television, internet, and print advertisements. Campaign awareness and understanding of the public health message were assessed with a telephone omnibus survey of randomly selected individuals with a Manitoba area code during February and April 2011. A before and after cross-sectional analysis was utilized to measure the effect of exposure to the campaign in telephone respondents. RESULTS: 1606 individuals participated in the survey (804 pre and 802 post). Overall awareness of the campaign messaging increased from 7% pre campaign to 25% in the post campaign period. Approximately two-thirds of respondents correctly identified a main theme message of the campaign. Awareness improved across most subgroups surveyed aside from those with lower education and income. CONCLUSIONS: Our study demonstrates the effective reach of our campaign and its relative effectiveness at raising awareness of chronic kidney disease and its risk factors.