Canadian Journal of Kidney Health and Disease最新文献

Background: Chronic kidney disease (CKD) represents a global health concern, with particular significance in Latin America due to socioeconomic inequalities and heterogeneous health care systems.

Objective: To determine the prevalence of CKD in Latin American populations through a systematic review with meta-analysis.

Design: Systematic review and meta-analysis of observational studies following the PRISMA guidelines.

Setting: Twelve Latin American countries (Argentina, Brazil, Chile, Colombia, Cuba, Ecuador, El Salvador, Haiti, Mexico, Nicaragua, Panama, and Peru).

Patients: A total of 72 486 participants from 21 observational studies reporting CKD prevalence in Latin American populations.

Measurements: The CKD prevalence according to Kidney Disease: Improving Global Outcomes (KDIGO) or Kidney Disease Outcomes Quality Initiative (K/DOQI) criteria, stratified by age groups (<60-65 vs ≥60-65 years), sex, CKD categories (G1-G5), and country.

Methods: Systematic search in PubMed, SCOPUS, Web of Science, and EMBASE databases. Observational studies using standardized CKD diagnostic criteria were included without language restrictions. A meta-analysis was conducted using random-effects models with a Freeman-Tukey double arcsine transformation. The risk of bias was assessed using the Munn et al tool. Meta-regressions examined temporal trends and the effects of sample size.

Results: The pooled CKD prevalence was 17.14% (95% confidence interval [CI] = 13.40-21.23%) with high heterogeneity (I² = 99.5%). Age-stratified analysis revealed a prevalence of 11.66% (95% CI = 8.09%-15.79%) in younger adults and 28.29% (95% CI = 22.34%-34.64%) in older adults. Women showed a higher prevalence (19.23%) compared to men (16.75%). Country-specific estimates ranged from 7.26% in Ecuador to 27.14% in Haiti. Meta-regression showed no significant temporal trend (P = .178).

Limitations: High between-study heterogeneity, most studies used single measurements rather than confirming chronicity, potential publication bias favoring higher prevalence studies, and limited representation from certain countries, which restricts generalizability.

Conclusions: The prevalence of CKD in Latin America exhibits marked age-related differences, with consistently higher rates in older adults. These findings support the need for age-specific prevention strategies and standardized diagnostic approaches across the region.

Trial registration: Not registered prospectively (limitation acknowledged).

Background: Severe acute kidney injury (AKI) in the intensive care unit (ICU) is complicated by fluid accumulation, making fluid removal a central component of kidney replacement therapy (KRT). However, the optimal fluid management strategy in patients receiving KRT remains unknown, and practice varies widely.

Objective: To assess the feasibility of conducting a multicentre randomized controlled trial comparing a protocol-based fluid-removal strategy with usual care in critically ill adult patients receiving KRT. The primary objective is to determine whether the intervention results in a difference in cumulative fluid balance from randomization to day five.

Design: Open-label, multicentre, pilot randomized controlled trial.

Setting: Centers in Canada, the United States, and Australia.

Patients: We are enrolling 150 adults admitted to the ICU with AKI who have been receiving KRT for ≤48 hours or who are anticipated to commence KRT within the next 12 hours.

Measurements: The primary outcome is the difference in cumulative fluid balance (mL) between treatment arms from randomization (day zero) to the end of day five. Secondary outcomes include feasibility metrics, patient outcomes, resource use, safety outcomes, and process measures.

Methods: Participants are randomized 1:1 to receive either protocol-based fluid management or usual care. The intervention consists of a prescription template updated at least once daily by the attending care team, specifying a 24-hour fluid balance target, a prescription for fluid removal using KRT, and daily re-evaluation of fluid intake. The intervention is continued until day five post-randomization, KRT discontinuation due to kidney recovery, or ICU discharge.

Limitations: The application of the intervention relies on the clinical judgment of the attending care team, which may affect the fidelity of the intervention. Usual care may differ between institutions, which may lead to variability. The treatment teams are unblinded, however the statistician will be blinded to group allocation.

Conclusions: The Probe-Fluid pilot trial will provide important groundwork toward a future definitive multicentre randomized controlled trial comparing a protocol-based fluid management strategy with usual care in critically ill patients receiving KRT.

Purpose of program: In 2018, Ontario Health (Ontario Renal Network) established a new multidisciplinary model of glomerulonephritis care to be available to all 27 Regional Renal Programs. This model of care was designed to fill existing gaps and ensure individuals with glomerulonephritis access to standardized, timely, and high-quality treatment close to home. This report describes the characteristics of individuals who received this care since it was established.

Sources of information: Provincial administrative health care databases.

Methods: This is a descriptive study of the characteristics of adults with a registered glomerulonephritis visit provided by a multidisciplinary care team in Ontario, Canada between April 1, 2019, and March 31, 2023. Individuals were excluded if they had evidence of a kidney transplant prior to their first registered visit.

Key findings: A total of 6,926 individuals were included in the cohort. Every year since 2019, approximately 1,200 new individuals had a registered multidisciplinary visit. IgA nephropathy was the most common reported diagnosis at the first registered visit (1,407 of 6,926 [20.5%]). Over a median follow-up period of 2.7 years (interquartile range = 1.3-3.7) since their first registered visit, 420 individuals (6%) received kidney replacement therapy (maintenance dialysis or kidney transplant).

Limitations: This description of individuals with registered visits underestimates the true prevalence of adults with glomerulonephritis in Ontario, as it does not capture those who did not register or who received more advanced disease management in other settings.

Implications: The use of a new model of multidisciplinary glomerulonephritis care in Ontario, Canada is becoming well established. Ongoing analysis of administrative data will guide future healthcare planning and delivery.

Desmopressin is a vasopressin analogue. In addition to its antidiuretic effects, it is also a procoagulant. While it is indicated to reduce bleeding in a variety of situations, it is not currently being utilized broadly for kidney biopsies, a procedure where bleeding is the most common complication.

Purpose of review: To discuss the evidence surrounding use of desmopressin for kidney biopsy.

Sources of information: We conducted a search of MEDLINE (Ovid), Embase (Ovid), CENTRAL (Wiley), International Pharmaceutical Abstracts (Ovid), and Scopus databases.

Methods: All identified trials were reviewed. Trials since the last systematic review in 2020 were organized in color-coded tables by efficacy, neutral results, or harm.

Key findings: Studies are generally favorable in terms of efficacy data for reduced bleeding during kidney biopsies, with some safety concerns. More studies are still needed, but we believe desmopressin can be justified to reduce bleeding complications of kidney biopsy in the setting of chronic kidney disease (CKD).

Limitations: Trials involved small sample sizes, single-center data, and were largely observational in nature.

Background: The process for kidney transplant listing is often lengthy and fragmented, contributing to delayed access to transplantation.

Objective: At our center, we aimed to reduce time to listing by 25% within 12 months through a quality improvement (QI) initiative.

Design: We conducted a mixed-method QI study.

Setting: Tertiary care academic transplant center.

Participants: Adult patients listed for transplantation from January 1, 2019, to July 31, 2023.

Methods: Quantitative data were collected through chart review and qualitative data were gathered from semi-structured interviews with health care providers. Outcome measure was time from evaluation start to transplant listing and process measures included time to obtaining specific consultations and tests. Findings informed a multifaceted intervention, which included (1) improved documentation guidelines, (2) expedited access for delayed investigations, (3) a dedicated transplant nurse for Indigenous patients, and (4) an informatic-enabled coordination tool. Outcomes were then compared to those of patients listed from January 1 to July 31, 2024.

Results: Among 109 patients in the preintervention cohort, the median time from evaluation to listing was 437 days, with only 9 patients listed predialysis. Indigenous patients, who represent over 25% of our population, accounted for only 11% of those listed. Key delays were identified in cardiology testing, colonoscopies, and mammograms. Ten health care providers were interviewed, and the main themes identified were: lack of resources, confusing task responsibilities, coordination of informatic systems and inequities affecting Indigenous patients. Following preliminary interventions, 22 patients were listed for transplant in just over 6 months-nearly one fifth of the total listed over the prior 4 years-demonstrating a marked acceleration in the listing process. Furthermore, median time to listing improved by 17% to 362 days, with a higher proportion of Indigenous patients (23%) listed and modest reductions in cardiology-related delays. Plan-Do-Study-Act cycles continue to optimize these interventions.

Limitations: Conducted at a single center which limits the generalizability of findings to other health care centers. Furthermore, the timeline included the COVID-19 pandemic, which may have caused delays and influenced results independent of the QI initiative.

Conclusions: A multifaceted intervention addressing local challenges showed early signs of success in reducing time to transplant listing and improving access for Indigenous patients. This highlights the critical role of data-driven QI initiatives in optimizing processes and improving patient care.