Protection against Incidences of Serious Cardiovascular Events Study with daily fish oil supplementation in dialysis patients (PISCES): protocol for a randomised controlled trial.

INTRODUCTION: Patients with kidney failure with replacement therapy (KFRT) suffer premature cardiovascular (CV) mortality and events with few proven pharmacological interventions. Omega-3 polyunsaturated essential fatty acids (n-3 PUFAs) are associated with a reduced risk of CV events and death in non-dialysis patients and in patients with established CV disease but n-3 PUFAs have not been evaluated in the high risk KFRT patient population. METHODS AND ANALYSIS: This multicentre randomised, placebo controlled, parallel pragmatic clinical trial tests the hypothesis that oral supplementation with n-3 PUFA, when added to usual care, leads to a reduction in the rate of serious CV events in haemodialysis patients when compared with usual care plus matching placebo. A target sample size of 1100 KFRT patients will be recruited from 26 dialysis units in Canada and Australia and randomised to n-3 PUFA or matched placebo in a 1:1 ratio with an expected intervention period of at least 3.5 years. The primary outcome to be analysed and compared between intervention groups is the rate of all, not just the first, serious CV events which include sudden and non-sudden cardiac death, fatal and non-fatal myocardial infarction, stroke, and peripheral vascular disease events. ETHICS AND DISSEMINATION: This study has been approved by all institutional ethics review boards involved in the study. Participants could only be enrolled following informed written consent. Results will be published in peer-reviewed journals and presented at scientific and clinical conferences. TRIAL REGISTRATION NUMBER: ISRCTN00691795.

A Quantitative and Qualitative Study on Patient and Physician Perceptions of Nephrology Telephone Consultation During COVID-19.

BACKGROUND: COVID-19 required rapid adoption of virtual modalities to provide care for patients with a chronic disease. Care was initially provided by telephone, which has not been evaluated for its effectiveness by patients and providers. This study reports patients' and nephrologists' perceptions and preferences surrounding telephone consultation in a chronic kidney disease (CKD) clinic. OBJECTIVE: To evaluate patient and physician perspectives on the key advantages and disadvantages of telephone consultations in a nephrology out-patient clinic setting. DESIGN: Cross-sectional observational survey study. SETTING: General nephrology clinic and a multidisciplinary kidney care clinic in London, Ontario, Canada. PARTICIPANTS: Patients with CKD who were fluent in English and participated in at least one telephone consultation with a nephrologist during the COVID-19 pandemic. METHODS AND MEASUREMENTS: Nephrologists' and participants' input facilitated the development of both patient and nephrologist surveys. Participants provided self-reported measures in 5 domains of satisfaction: user experience, technical quality, perceived effectiveness on well-being, perceived usefulness, and effect on interaction. Nephrologists provided self-reported measures within 6 categories: general experience, time management, medication changes, quality of care, job satisfaction, and challenges/strengths. Descriptive statistics were used to present data. Content analysis was performed on 2 open-ended responses. RESULTS: Of the 372 participants recruited, 235 participated in the survey (63% response). In all, 79% of the participants were ≥65 years old and 91% were white. Telephone consultation was a comfortable experience for 68%, and 73% felt it to be a safer alternative during the pandemic. Although 65% perceived no changes to health care access, most reported spending less time and fewer resources on transit and parking. Disadvantages to telephone consultation included a lack of physical examination and reduced patient-physician rapport. Eleven of 14 nephrologists were surveyed, with most reporting confidence in the use of telephone consultation. Physician barriers to telephone consultation included challenges with communications and lack of technology to support telephone clinics. LIMITATIONS: Our survey included a majority of older, white participants, which may not be generalizable to other participants particularly those of other ages and ethnicity. CONCLUSION: Although both patients and nephrologists adapted to telephone consultations, there remain opportunities to further explore populations and situations that would be better facilitated with an in-person visit. Future research in virtual care will require measurement of health care outcomes and economics. TRIAL REGISTRATION: Not applicable as this was a survey.

Can Additional Water a Day Keep the Cysts Away, in Patients with Polycystic Kidney Disease?

Can Additional Water a Day Keep the Cysts Away, in Patients with Polycystic Kidney Disease? If a patient with autosomal dominant polycystic kidney disease could drink enough water to suppress arginine vasopressin release, would cyst growth be attenuated, thereby reducing the decline in kidney function over time? Louise M. Moist, M.D. discusses this randomized controlled trial.

Canadian Association of Paediatric Nephrologists COVID-19 Rapid Response: Home and In-Center Dialysis Guidance.

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.

Management of Outpatient Hemodialysis During the COVID-19 Pandemic: Recommendations From the Canadian Society of Nephrology COVID-19 Rapid Response Team.

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.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update.

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

KDOQI Clinical Practice Guideline for vascular access: 2019 update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidencebased guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research

The Influence of Age on the Likelihood of Catheter-Free Fistula Use in Hemodialysis Patients.

BACKGROUND: Clinical practice guidelines recommend arteriovenous fistulas as the preferred form of vascular access for hemodialysis. However, some studies have suggested that older age is associated with poorer fistula outcomes. OBJECTIVE: We assessed the impact of age on the outcomes of fistula creation and access-related procedures. DESIGN: This was a prospective cohort study using data collected as part of the Dialysis Measurement Analysis and Reporting (DMAR) system. SETTING: Participating Canadian dialysis programs, including Southern Alberta Renal Program, Manitoba Renal Program, Sunnybrook Health Sciences Centre (Toronto, Ontario), London Health Sciences Centre (London, Ontario), and The Ottawa Hospital (Ottawa, Ontario). PATIENTS: Incident hemodialysis patients aged 18 years and older who started dialysis between January 1, 2004, and May 31, 2012. MEASUREMENTS: The primary outcome was the proportion of all first fistula attempts that resulted in catheter-free fistula use, defined as independent use of a fistula for hemodialysis (ie, no catheter in place). Secondary outcomes included the time to catheter-free fistula use among patients with a fistula creation attempt, total number of days of catheter-free fistula use, and the proportion of a patient's hemodialysis career spent with an independently functioning fistula (ie, catheter-free fistula use). METHODS: We compared patient characteristics by age group, using t tests or Wilcoxon rank sum tests, and chi-square or Fisher exact tests, as appropriate. Logistic and fractional logistic regression were used to estimate the odds of achieving catheter-free fistula use by age group and the proportion of dialysis time spent catheter-free, respectively. RESULTS: A total of 1091 patients met our inclusion criteria (567 age ≥ 65; 524 age < 65). Only 57% of first fistula attempts resulted in catheter-free fistula use irrespective of age (adjusted odds ratio [OR]≥65vs<65: 1.01; P = .93). The median time from hemodialysis start to catheter-free use of the first fistula did not differ by age when grouped into fistulas attempted pre- and post-dialysis initiation. The adjusted rates of access-related procedures were comparable (incidence rate ratio [IRR]≥65vs<65: 0.95; P = .32). The median percentage of follow-up time spent catheter-free was similar and low in patients who attempted fistulas (<65 years: 19% vs ≥65 years: 21%; P = .85). LIMITATIONS: The relatively short follow-up time may have underestimated the benefits of fistula creation and the observational study design precludes inferences about causality. CONCLUSIONS: In our study, older patients who underwent a fistula attempt were just as likely as younger patients to achieve catheter-free fistula use, within a similar time frame, and while requiring a similar number of access procedures. However, the minority of dialysis time was spent catheter-free.

CONTEXTE: Les lignes directrices cliniques recommandent de privilégier la fistule artérioveineuse comme accès vasculaire pour l'hémodialyse. Certaines études suggèrent toutefois que les résultats seraient moins bons chez les patients âgés. OBJECTIF: Nous avons examiné l'effet de l'âge du patient sur l'issue de la création d'une fistule et sur les procédures liées à l'accès. TYPE D'ÉTUDE: Il s'agit d'une étude de cohorte prospective utilisant les données colligées par le système DMAR (Dialysis Measurement Analysis and Reporting). CADRE: Les programmes de dialyse canadiens participants, soit le Southern Alberta Renal Program, le Manitoba Renal Program, le Sunnybrook Health Sciences Centre (Toronto, Ontario), le London Health Sciences Centre (London, Ontario), et l'hôpital d'Ottawa (Ottawa, Ontario). SUJETS: Les patients adultes incidents ayant amorcé une hémodialyse entre le 1er janvier 2004 et le 31 mai 2012. MESURES: La principale mesure était la proportion de premières fistules créées ayant mené à une utilisation sans cathéter, soit à un usage indépendant pour l'hémodialyse. Les mesures secondaires incluaient le temps écoulé jusqu'à l'utilisation d'une fistule sans cathéter pour les patients ayant subi une première tentative, le nombre total de jours d'utilisation d'une fistule sans cathéter, et la proportion du temps de dialyse passé avec une fistule indépendante fonctionnelle (sans cathéter). MÉTHODOLOGIE: Nous avons comparé les caractéristiques des patients par groupe d'âge à l'aide de tests t ou de tests de somme des rangs de Wilcoxon, et de tests chi-deux ou de tests exacts de probabilité de Fisher, selon le cas. Une régression logistique et une régression logistique fractionnée ont été employées pour estimer respectivement, selon le groupe d'âge, les chances d'utiliser une fistule sans cathéter et la proportion du temps de dialyse passé sans cathéter. RÉSULTATS: Au total, 1 091 patients satisfaisaient nos critères d'inclusion (n=567 [≥65 ans]; n=524 [<65 ans]). Seulement 57 % des premières tentatives de création d'une fistule ont mené à une utilisation sans cathéter, indépendamment de l'âge (rapport de cote corrigé [RC]≥65contre<65: 1,01; p=0,93). Le temps médian jusqu'à l'utilisation sans cathéter de la première fistule créée n'a pas varié en fonction de l'âge lorsque les patients ont été groupés selon que la fistule avait été créée avant ou après l'amorce de la dialyse. Les taux corrigés de procédures liées à l'accès vasculaire étaient similaires (rapport des taux d'incidence [RTI]≥65contre<65 0,95; p=0,32); tout comme le pourcentage médian de temps de dialyse passé sans cathéter qui s'est avéré faible pour tous les patients (19 % [<65 ans] contre 21 % [≥65 ans]; p=0,85). LIMITES: La période de suivi relativement courte pourrait avoir sous-estimé les avantages de créer une fistule, et la nature observationnelle de l'étude ne permet pas de tirer de conclusions sur la causalité. CONCLUSION: Selon notre étude, les patients âgés avaient autant de chance que les plus jeunes d'utiliser la fistule sans cathéter, et ce, dans un délai semblable et avec sensiblement le même nombre de procédures liées à l'accès vasculaire. Néanmoins, la proportion du temps de dialyse passé sans cathéter était faible.

Timing of Fistula Creation and the Probability of Catheter-Free Use: A Cohort Study.

BACKGROUND: Fistula creation is recommended to avoid the use of central venous catheters for hemodialysis. The extent to which timing of fistula creation minimizes catheter use is unclear. OBJECTIVE: To compare patient outcomes of 2 fistula creation strategies: fistula attempt prior to the initiation of dialysis ("predialysis") or fistula attempt after starting dialysis ("postinitiation"). DESIGN: Cohort study. SETTING: Five Canadian dialysis programs. PATIENTS: Patients who started hemodialysis between 2004 and 2012, who underwent fistula creation, and were tracked in the Dialysis Measurement Analysis and Reporting (DMAR) system. MEASUREMENTS: Catheter-free fistula use within 1 year of hemodialysis start, probability of catheter-free fistula use during follow-up, and rates of access-related procedures. METHODS: Retrospective data analysis: logistic regression; negative binomial regression. RESULTS: Five hundred and eight patients had fistula attempts predialysis and 583 postinitiation. At 1 year, 80% of those with predialysis attempts achieved catheter-free use compared to 45% with post-initiation attempts (adjusted odds ratio [OR]preVSpost = 4.67; 95% confidence interval [CI] = 3.28-6.66). The average of all patient follow-up time spent catheter-free was 63% and 28%, respectively (probability of use per unit time, ORpreVSpost = 2.90; 95% CI = 2.18-3.85). This finding was attenuated when accounting for maturation time and when restricting the analysis to those who achieved catheter-free use. Predialysis fistula attempts were associated with lower procedure rates after dialysis initiation-1.61 procedures per person-year compared with 2.55-but had 0.65 more procedures per person prior to starting dialysis. LIMITATIONS: Observational design, unknown indication for predialysis and postinitiation fistula creation, and unknown reasons for prolonged catheter use. CONCLUSIONS: Predialysis fistula attempts were associated with a higher probability of catheter-free use and remaining catheter-free over time, and also resulted in fewer procedures compared with postinitiation attempts, which could be due to timing of attempt or patient factors. Catheter use and procedures were still common for all patients, regardless of the timing of fistula creation.

CONTEXTE: La création d'une fistule est recommandée pour l'hémodialyse afin d'éviter l'utilisation de cathéters veineux centraux. On ignore toutefois à quel point le moment choisi pour la créer minimise l'utilisation d'un cathéter. OBJECTIF: Comparer les résultats des patients selon que la fistule est créée avant (pré-dialyse) ou après (post-initiation) l'initiation de la dialyse. TYPE D'ÉTUDE: Étude de cohorte. CADRE: Cinq centres canadiens de dialyse. SUJETS: Des patients repérés dans le système DMAR (Dialysis Measurement Analysis and Reporting) ayant amorcé un traitement d'hémodialyse et subi une tentative de création de fistule entre 2004 et 2012. MESURES: L'utilisation d'une fistule sans cathéter dans l'année suivant le début de l'hémodialyse, la probabilité d'utiliser une fistule sans cathéter au cours de la période de suivi, et les taux de procédures liées à l'accès vasculaire. MÉTHODOLOGIE: Analyse rétrospective des données, régression logistique et régression binomiale négative. RÉSULTATS: Cinq cent huit patients ont eu une création de fistule pré-dialyse et 583 patients ont eu une création de fistule après l'initiation de la dialyse. Après un an, 80 % des patients avec une fistule pré-dialyse l'utilisaient sans cathéter contre 45 % des patients avec une fistule post-initiation (rapport de cotes corrigé [RC] préVSpost: 4,67; IC 95 %: 3,28 ­ 6,66). Les patients ont respectivement passé 63 % et 28 % (probabilité d'utilisation par unité de temps, RCpréVSpost: 2,90; IC 95 %: 2,18 ­ 3,85) de leur temps de suivi sans cathéter. Ce résultat s'est atténué en tenant compte du temps de maturation de la fistule et en limitant l'analyse aux patients ayant utilisé la fistule sans cathéter. La création d'une fistule pré-dialyse a été associée à de plus faibles taux de procédures après l'initiation de la dialyse (1,61 procédure par année-personne contre 2,55), mais avait demandé 0,65 procédure de plus par personne avant le début de la dialyse. LIMITES: Étude observationnelle; manque d'information sur les motifs justifiant la création d'une fistule avant ou après le début de la dialyse et sur les raisons de l'utilisation prolongée d'un cathéter. CONCLUSION: La création d'une fistule pré-dialyse a été associée à une plus grande probabilité d'éviter l'utilisation d'un cathéter et que cela se poursuive dans le temps. Elle s'est également traduite par un taux réduit de procédures comparativement aux tentatives post-initiation, ce qui pourrait être lié au moment de la tentative de création de fistule ou à des facteurs propres aux patients. L'utilisation d'un cathéter et les procédures liées à l'accès vasculaire sont toutefois demeurées fréquentes pour tous les patients, peu importe le moment où la fistule avait été créée.

Barriers to Education and Shared Decision Making in the Chronic Kidney Disease Population: A Narrative Review.

PURPOSE OF REVIEW: Provision of education to inform decision making for renal replacement therapy (RRT) is a key component in the management of chronic kidney disease (CKD), yet patients report suboptimal satisfaction with the process of selecting a dialysis modality. Our purpose is to review the influencers of RRT decision making in the CKD population, which will better inform the process of shared decision making between clinicians and patients. SOURCES OF INFORMATION: PubMed and Google Scholar. METHODS: A narrative review was performed using the main terms "chronic kidney disease," "CKD," "dialysis," "review," "decision-making," "decision aids," "education," and "barriers." Only articles in English were accessed. The existing literature was critically analyzed from a theoretical and contextual perspective and thematic analysis was performed. KEY FINDINGS: Eight common themes were identified as influencers for decision making. "Patient-focused" themes including social influence, values and beliefs, comprehension, autonomy and sociodemographics, and "clinician-focused" themes including screening, communication, and engagement. Early predialysis education and decision aids can effectively improve decision making. Patient-valued outcomes need to be more fully integrated into clinical guidelines. LIMITATIONS: This is not a systematic review; therefore, no formal tool was utilized to evaluate the rigor and quality of studies included and findings may not be generalizable. IMPLICATIONS: Standardized comprehensive RRT education programs through multidisciplinary health teams can help optimize CKD patient education and shared decision making. Involving patients in the research process itself and implementing patient values and preferences into clinical guidelines can help to achieve a patient-centered model of care.

CONTEXTE MOTIVANT LA REVUE: La transmission d'informations en vue d'éclairer la prise de décision en matière de thérapie de remplacement rénal (TRR) est un élément clé de la prise en charge des patients atteints d'insuffisance rénale chronique (IRC). Malgré cela, les patients rapportent des niveaux sous-optimaux de satisfaction en regard du processus de sélection d'une modalité de dialyse. Notre objectif est d'examiner les facteurs influençant la prise de décision dans le choix d'une TRR chez une population de patients atteints d'IRC, ce qui aura pour effet de mieux guider le processus de prise de décision partagée entre les cliniciens et les patients. SOURCES: Les bases de données PubMed et Google Scholar. MÉTHODOLOGIE: On a procédé à un examen narratif de la littérature à l'aide des principaux termes suivants : insuffisance rénale chronique (chronic kidney disease), IRC (CKD), dialyse (dialysis), revue (review), prise de décision (decision making), aides à la décision (decision aids), éducation (education), et obstacles (barriers). Seuls les articles en anglais ont été consultés. La littérature existante a fait l'objet d'une critique rigoureuse d'un point de vue théorique et contextuel, et une analyse thématique a été réalisée. PRINCIPAUX RÉSULTATS: Nous avons relevé huit thèmes communs influençant la prise de décision. Ces thèmes se divisent en deux catégories : i) les thèmes liés au patient, soit l'influence sociale, ses valeurs et croyances, sa compréhension, son autonomie et ses caractéristiques socio-démographiques, et; ii) les thèmes liés au clinicien, soit le dépistage, la communication et son implication. Informer le patient et lui fournir des aides à la décision tôt dans le processus pré-dialyse s'avère efficace pour faciliter la prise de décision. Les résultats attendus par les patients devraient être mieux intégrés aux protocoles cliniques. LIMITES: Cet examen ne constitue pas une revue systématique. Dès lors, aucun outil officiel n'a été employé pour évaluer la rigueur et la qualité des études retenues. Les résultats pourraient ne pas être généralisables. IMPLICATIONS: En matière de TRR, des programmes informatifs complets et normalisés, offerts par l'entremise d'équipes pluridisciplinaires en santé, pourraient contribuer à optimiser la transmission d'informations aux patients atteints d'IRC et éclairer la prise de décision partagée. La participation des patients au processus de recherche et l'intégration de leurs valeurs et de leurs préférences dans les protocoles cliniques pourraient favoriser l'élaboration d'un modèle de soins mieux axé sur le patient.

Educational Support Around Dialysis Modality Decision Making in Patients With Chronic Kidney Disease: Qualitative Study.

BACKGROUND: Patients with chronic kidney disease (CKD) are asked to choose a renal replacement therapy or conservative management. Education and knowledge transfer play key roles in this decision-making process, yet they remain a partially met need. OBJECTIVE: We sought to understand the dialysis modality decision-making process through exploration of the predialysis patient experience to better inform the educational process. DESIGN: Qualitative descriptive study. SETTING: Kidney Care Centre of London Health Sciences Centre in London, Ontario, Canada. PATIENTS: Twelve patients with CKD, with 4 patients on in-center hemodialysis, home hemodialysis, and peritoneal dialysis, respectively. MEASUREMENTS: Not applicable. METHODS: We conducted semistructured interviews with each participant, along with any family members who were present. Interviews were transcribed verbatim. Conventional content analysis was used to analyze the transcripts for common themes. Representative quotes were decided via team consensus. A patient collaborator was part of the research team. RESULTS: Three themes influenced dialysis modality decision making: (i) Patient Factors: individualization, autonomy, and emotions; (ii) Educational Factors: tailored education, time and preparation, and available resources; and (iii) Support Systems: partnership with health care team, and family and friends. LIMITATIONS: Sample not representative of wider CKD population. Limited number of eligible patients. Poor recall may affect findings. CONCLUSIONS: Modality decision making is a complex process, influenced by the patient's health literacy, willingness to accept information, predialysis lifestyle, support systems, and values. Patient education requires the flexibility to individualize the delivery of a standardized CKD curriculum in partnership with a patient-health care team, to fulfill the goal of informed, shared decision making.

CONTEXTE: Les patients atteints d'insuffisance rénale chronique (IRC) sont appelés à choisir entre une thérapie de remplacement rénal ou un traitement conservateur. La transmission d'informations et le transfert des connaissances jouent un rôle de premier plan dans ce processus de prise de décision, mais ces éléments demeurent à ce jour des besoins partiellement comblés. OBJECTIF: Nous avons cherché à comprendre le processus de prise de décision dans le choix d'une modalité de dialyse en explorant l'expérience des patients pré-dialyse, de façon à mieux éclairer la démarche éducative. TYPE D'ÉTUDE: Une étude qualitative et descriptive. CADRE: Le Kidney Care Centre du London Health Sciences Centre de London en Ontario (Canada). SUJETS: Un total de douze patients atteints d'IRC, soit quatre patients pour chacune des modalités de dialyse : hémodialyse en centre, hémodialyse à domicile et dialyse péritonéale. MESURES: Ne s'applique pas. MÉTHODOLOGIE: Nous avons procédé à des entretiens semi-structurés avec chacun des participants, de même qu'avec les membres de leur famille qui étaient présents. Les entrevues ont été transcrites textuellement. L'analyse de contenu a été employée pour retracer les thèmes communs dans les transcriptions. Les extraits représentatifs ont été établis par consensus des membres de l'équipe. Un patient collaborateur faisait partie de l'équipe de recherche. RÉSULTATS: Trois grands thèmes ont influencé la prise de décision quant au choix d'une modalité de dialyse : (i) des facteurs liés au patient : la personnalisation, l'autonomie et les émotions; (ii) des facteurs liés à l'information : information personnalisée, exigence en temps et en préparation, ressources disponibles, et; (iii) le réseau de soutien : la collaboration avec l'équipe de soins, la famille et les ami(e)s. LIMITES: L'échantillon n'est pas représentatif de l'ensemble de la population des patients atteints d'IRC. Les résultats pourraient également être affectés par le nombre limité de patients admissibles et par de possibles défaillances de mémoire de la part des répondants. CONCLUSION: La prise de décision quant au choix d'une modalité de remplacement rénal est un processus complexe influencé par les connaissances du patient en matière de santé, de même que par sa disposition à accepter l'information, son mode de vie pré-dialyse, son réseau de soutien et ses valeurs. L'éducation des patients demande la flexibilité nécessaire pour personnaliser la prestation d'un programme informatif normalisé sur l'IRC en partenariat avec l'équipe de soins; de manière à réaliser l'objectif d'une prise de décision éclairée et partagée.

Validity of administrative database code algorithms to identify vascular access placement, surgical revisions, and secondary patency.

BACKGROUND:: We assessed the validity of physician billing codes and hospital admission using International Classification of Diseases 10th revision codes to identify vascular access placement, secondary patency, and surgical revisions in administrative data. METHODS:: We included adults (≥18 years) with a vascular access placed between 1 April 2004 and 31 March 2013 at the University Health Network, Toronto. Our reference standard was a prospective vascular access database (VASPRO) that contains information on vascular access type and dates of placement, dates for failure, and any revisions. We used VASPRO to assess the validity of different administrative coding algorithms by calculating the sensitivity, specificity, and positive predictive values of vascular access events. RESULTS:: The sensitivity (95% confidence interval) of the best performing algorithm to identify arteriovenous access placement was 86% (83%, 89%) and specificity was 92% (89%, 93%). The corresponding numbers to identify catheter insertion were 84% (82%, 86%) and 84% (80%, 87%), respectively. The sensitivity of the best performing coding algorithm to identify arteriovenous access surgical revisions was 81% (67%, 90%) and specificity was 89% (87%, 90%). The algorithm capturing arteriovenous access placement and catheter insertion had a positive predictive value greater than 90% and arteriovenous access surgical revisions had a positive predictive value of 20%. The duration of arteriovenous access secondary patency was on average 578 (553, 603) days in VASPRO and 555 (530, 580) days in administrative databases. CONCLUSION:: Administrative data algorithms have fair to good operating characteristics to identify vascular access placement and arteriovenous access secondary patency. Low positive predictive values for surgical revisions algorithm suggest that administrative data should only be used to rule out the occurrence of an event.

In-center hemodialysis education: Challenges and innovations in training of fellows in nephrology.

The in-center dialysis unit and practice of dialysis, in the current multi-team approach, requires knowledge and skills in all the domains including medical expert, communicator, collaborator, scholar, health advocate, and leader. We are tasked as a community, to embrace and incentivize new innovations and technology to address these needs for our post graduate trainees. These innovations must address the basic principles of dialysis, quality improvement, technical and procedural skills as well as leadership and administration skills. The teaching methods and innovations must also be challenged to demonstrate the translation into adoption and improvements in practice to demonstrate success. This article will review the current state of the training curriculum in Nephrology for in-center hemodialysis and address some of the recent innovations.

Incident Dialysis Access in Patients With End-Stage Kidney Disease: What Needs to Be Improved.

The initiation of dialysis is a challenging time of transition for patients, families, and their supporters. Patients with exposure to a comprehensive chronic kidney disease clinic may have had education and subsequent decision making regarding dialysis modality and access; however, many patients with or without prior education will require an urgent start to dialysis, requiring quick decisions regarding dialysis modality and access. In many countries, hemodialysis (HD) using a central venous catheter (CVC) is the most common initial renal replacement modality and dialysis access. Multiple factors, both remedial and nonremedial, contribute to this including late referral, rapid decrease in kidney function, delay in delivery or acceptance of education, and decision making and other system delays. Recent use of urgent peritoneal dialysis as the initial dialysis modality has resulted in decreased exposure to CVCs and in-center HD. This article addresses the current state of incident dialysis access, recent trends toward urgent peritoneal dialysis start, and opportunities to avoid the use of CVCs for HD when appropriate, with a focus on considering dialysis access as a critical component of the end-stage kidney disease life-plan, which requires consideration of future modalities and access when making the choice of the initial dialysis access.

The Effect of Predialysis Fistula Attempt on Risk of All-Cause and Access-Related Death.

Whether the lower risk of mortality associated with arteriovenous fistula use in hemodialysis patients is due to the avoidance of catheters or if healthier patients are simply more likely to have fistulas placed is unknown. To provide clarification, we determined the proportion of access-related deaths in a retrospective cohort study of patients aged ≥18 years who initiated hemodialysis between 2004 and 2012 at five Canadian dialysis programs. A total of 3168 patients initiated dialysis at the participating centers; 2300 met our inclusion criteria. Two investigators independently adjudicated cause of death using explicit criteria and determined whether a death was access-related. We observed significantly lower mortality in individuals who underwent a predialysis fistula attempt than in those without a predialysis fistula attempt in patients aged <65 years (hazard ratio [HR], 0.49; 95% confidence interval [95% CI], 0.29 to 0.82) and in the first 2 years of follow-up in those aged ≥65 years (HR0-24 months, 0.60; 95% CI, 0.43 to 0.84; HR24+ months, 1.83; 95% CI, 1.25 to 2.67). Sudden deaths that occurred out of hospital accounted for most of the deaths, followed by deaths due to cardiovascular disease and infectious complications. We found only 2.3% of deaths to be access-related. In conclusion, predialysis fistula attempt may associate with a lower risk of mortality. However, the excess mortality observed in patients treated with catheters does not appear to be due to direct, access-related complications but is likely the result of residual confounding, unmeasured comorbidity, or treatment selection bias.

Complications of the Arteriovenous Fistula: A Systematic Review.

The implementation of patient-centered care requires an individualized approach to hemodialysis vascular access, on the basis of each patient's unique balance of risks and benefits. This systematic review aimed to summarize current literature on fistula risks, including rates of complications, to assist with patient-centered decision making. We searched Medline from 2000 to 2014 for English-language studies with prospectively captured data on ≥100 fistulas. We assessed study quality and extracted data on study design, patient characteristics, and outcomes. After screening 2292 citations, 43 articles met our inclusion criteria (61 unique cohorts; n>11,374 fistulas). Median complication rates per 1000 patient days were as follows: 0.04 aneurysms (14 unique cohorts; n=1827 fistulas), 0.11 infections (16 cohorts; n>6439 fistulas), 0.05 steal events (15 cohorts; n>2543 fistulas), 0.24 thrombotic events (26 cohorts; n=4232 fistulas), and 0.03 venous hypertensive events (1 cohort; n=350 fistulas). Risk of bias was high in many studies and event rates were variable, thus we could not present pooled results. Studies generally did not report variables associated with fistula complications, patient comorbidities, vessel characteristics, surgeon experience, or nursing cannulation skill. Overall, we found marked variability in complication rates, partly due to poor quality studies, significant heterogeneity of study populations, and inconsistent definitions. There is an urgent need to standardize reporting of methods and definitions of vascular access complications in future clinical studies to better inform patient and provider decision making.

International Society of Nephrology-Hydration and Kidney Health Initiative - Expanding Research and Knowledge.

The purpose of this manuscript is to describe a collaborative research initiative to explore the role of hydration in kidney health. Our understanding of the effects of hydration in health and disease is surprisingly limited, particularly when we consider the vital role of hydration in basic human physiology. Recent initiatives and research outcomes have challenged the global medical community to expand our knowledge about hydration, including the differences between water, sugared beverages and other consumables. Identification of the potential mechanisms contributing to the benefits of hydration has stimulated the global nephrology community to advance research regarding hydration for kidney health. Hydration and kidney health has been a focus of research for several research centers with a rapidly expanding world literature and knowledge. The International Society of Nephrology has collaborated with Danone Nutricia Research to promote development of kidney research initiatives, which focus on the role of hydration in kidney health and the global translation of this new information. This initiative supports the use of existing data in different regions and countries to expand dialogue among experts in the field of hydration and health, and to increase scientific interaction and productivity with the ultimate goal of improving kidney health.