Canadian Journal of Kidney Health and Disease最新文献

Purpose of review: People living with chronic kidney disease (CKD), individuals receiving dialysis therapies, and those with both native and transplant kidneys undergo routine blood testing for regular follow-up and monitoring of CKD and its complications. There is a lack of evidence supporting the established frequency and utility of testing, which is largely based on historical practice and expert consensus. While early identification and correction of critical laboratory values can lead to improved clinical outcomes, surveillance bloodwork does not always lead to changes or improvements in patient care. As with all investigations, bloodwork has implications for patients, health care providers and our health care system, impacting costs and the environment. Frequent monitoring of highly variable laboratory values may also lead to overtreatment or undertreatment. The purpose of this review is to synthesize the existing evidence pertaining to current blood testing frequencies across the spectrum of patients with CKD to fully inform the appropriateness of care.

Sources of information: The sources included published studies and available guidelines regarding the frequency of routine surveillance bloodwork in patients with CKD G3-5, including those receiving all types of dialysis therapies, and recipients of a kidney transplant.

Methods: Information was gathered from database searches using a search strategy that included keywords related to bloodwork, lab work, frequency, chronic kidney disease, kidney transplant, and dialysis modalities. Reference lists of relevant studies were also screened.

Key findings: There is a paucity of evidence underpinning monthly routine lab testing across the spectrum of patients with CKD. Five observational studies compared outcomes between in-center hemodialysis patients undergoing monthly bloodwork and those receiving less frequent bloodwork (every six weeks). Of those five studies, four demonstrated that it is safe to undergo less frequent testing. The totality of current data, while limited, suggests that for in-center hemodialysis patients, less frequent testing is a safe strategy. No such data exist for other dialysis or non-dialysis CKD populations. Evidence is needed to inform an appropriate testing frequency across the spectrum of patients with CKD to optimize care at the patient, provider, system, and planetary levels.

Limitations: A formal systematic review was not undertaken, and therefore, there is a possibility of bias in the included studies.

Background: Patients with chronic kidney disease (CKD) at times must decide whether to take an invasive approach to management of coronary artery disease (CAD), which involves procedures such as angiography, angioplasty, and surgery, versus attempt management with medications alone. My Heart and CKD is a decision aid to support shared decision-making (SDM) between patients and their care providers in these situations. This report describes the pathway to implement My Heart and CKD , and key learnings that have emerged through this process.

Methods: Human-centered design was used to develop the decision aid while concurrently identifying design features that could facilitate its incorporation within patient-physician clinical encounters. Interviews exploring use of the decision aid with patients and care providers were qualitatively analyzed according to the theoretical domains framework to identify barriers and facilitators to implementation. Simulated encounters between patient and physicians were used for pre-clinical testing and to identify additional training and resources that could support effective implementation.

Key findings: Implementation insights overlapped with decision-aid design input and influenced key design elements of My Heart and CKD as well as the development of implementation strategies to facilitate its clinical use. An overarching theme that influenced development and implementation was the concept that the decision aid be designed for use by patients and physicians together, to support the bidirectional communication and relationship building intended with SDM. This influenced design features to support varying use preferences and contexts, encompassing both digital and paper-based forms for use. Implementation considerations also influenced order and arrangement of content in My Heart and CKD to enhance integration of all stages of SDM into varying clinical environments. Additional training and implementation resources, including an accredited continuous medical education program for care providers, were identified as additional facilitators necessary to support implementation.

Limitations: Clinical evaluation has not yet been completed.

Implications: My Heart and CKD is intended to support personalized, patient-centered care by providing patients with CKD and CAD and their care providers with tools to engage in SDM. Further research will evaluate the effectiveness of its implementation and impact on the quality of decision-making.

Purpose of review: Chronic kidney disease (CKD) is a resource-intensive and complex challenge to sustainable health care. The purpose of this narrative review is to describe how person-centered integrated care can support sustainable health care for this population, the strategies currently in place, and the gaps to consider. The findings may support the delivery and improvement of comprehensive support.

Sources of information: Original peer-reviewed articles, website information, and Google Analytics were used to describe the current state of sustainable care strategies for CKD.

Methods: We reviewed the available strategies to support sustainable care through a person-centered approach in Alberta, specifically examining strategies to support care for CKD. These strategies were mapped onto the Centre for Sustainable Healthcare's four principles of sustainable health care.

Key findings: In Alberta, there are several strategies to support person-centered integrated care. These include resources for health care providers that support prevention and lean service delivery, as well as patient-facing tools to support patient self-care. Person-centered integrated care and sustainability within health care are mutually supportive; however, strategies are often created in silos. There is an opportunity to improve sustainability of kidney care with a comprehensive approach and planning around outcome measures.

Limitations: While these strategies may have significant benefits, there is limited knowledge of direct impacts on outcomes. We used the data that were available and highlighted the need to measure the impact of health care strategies.

Rationale: Kidney transplantation (KT) is the treatment of choice for end-stage kidney disease (ESKD) in all age groups. However, KT in octogenarians is a rare and unique event. We describe the evaluation and clinical course of the world's oldest kidney transplant recipient at 87 years, 262 days, as recognized by the Guinness Book of World Records.

Presenting concern of patient: An 84-year-old Canadian retired real estate agent of Indian origin with ESKD due to diabetic nephropathy on hemodialysis presented to our center as a potential kidney transplant candidate. Comorbidities included hypertension, coronary artery disease, benign prostatic hyperplasia, and bilateral knee replacements. He was functional, independent, and extremely keen to undergo KT to further improve his quality of life.

Diagnosis: Extensive pretransplant investigation revealed a reasonable state of health for all major organ systems. Multiple specialists were consulted prior to listing.

Interventions: After 5 years on hemodialysis, he received a standard neurological determination of death donor kidney transplant.

Outcomes: Graft function was immediate. Complications experienced in the first posttransplant year included two urinary tract infections-one with bacteremia; uncontrolled blood pressure and blood glucose, cytomegalovirus and BK viremia, and an inferior wall non-ST segment elevation myocardial infarction. In the second year, he developed a scrotal abscess. However, graft function remained stable with a serum creatinine concentration of 82 µmol/L at two years posttransplant.

Teaching points: Successful KT in advanced octogenarians is possible. Appropriate patient selection is crucial. Extended screening for infection, cardiac and vascular disease, malignancy, and frailty including cognitive deficits is required. Plans for diabetes care and ensuring adequate social support including home care may mitigate complications. Willingness to investigate identified illnesses and seek assistance from other specialists may reduce but not necessarily prevent posttransplant complications. Neurological determination of death donor organs might be preferable for advanced octogenarian KT recipients even if those organs meet expanded criteria.

Purpose of review: The purpose of this commentary is to address the challenges of implementing the evolving Kidney Disease Improving Global Outcomes (KDIGO) glomerulonephritis (GN) guidelines within the Canadian health care context, highlighting barriers to adoption of the guidelines and discussing contextual issues unique to Canada.

Sources of information: The KDIGO 2021 guidelines with 2024 updates in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis and lupus nephritis, as well as the 2025 updated guideline for immunoglobulin A (IgA) nephropathy.

Methods: A Canadian Society of Nephrology (CSN) working group with expertise in GN was formed, representing nephrologists, pathologists, pharmacists, and patient partners with geographic representation from across Canada. Recommendations and practice points were reviewed by member surveys, with discussions to reach consensus and frame the commentary.

Key findings: The commentary highlights diagnostic investigations, the role of immune treatments for primary glomerular diseases, and the growing role of conservative kidney therapies.

Limitations: A review of the quality of evidence was not undertaken. Implementation and uptake of the guidelines will vary across each province given drug availability and cost.

Implications: The commentary aims to provide tailored guidance to enhance the care of Canadians living with glomerular disease.