Canadian Journal of Kidney Health and Disease最新文献

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.

Background: Point of care ultrasound (POCUS) has become increasingly integrated into routine clinical care, though its adoption in nephrology remains limited.

Objective: This pilot study evaluated a program to train nephrology fellows to perform POCUS to detect small kidney size and hydronephrosis.

Design and setting: We performed a quality improvement initiative at a single academic center (St. Michael's Hospital).

Patients: 63 patients were included.

Measurements: Pre- and post-workshop surveys assessed trainees' comfort level with kidney POCUS imaging. Patient satisfaction was also measured using a questionnaire. Time to kidney imaging, radiologic diagnosis and kidney POCUS diagnostic accuracy were also assessed.

Methods: Nephrology fellows participated in two 1-hour workshops featuring didactic and hands-on training using POCUS machines, after which they scanned hospitalized patients.

Results: Sixty-two native kidneys and 32 transplant kidneys were scanned. Patient surveys indicated high satisfaction with POCUS, with 71% preferring bedside ultrasound in future care. Trainee confidence with using POCUS improved post-workshop. Trainee-performed POCUS demonstrated a specificity of 1.00 (95% CI 0.94-1.00) and 0.96 (95% CI 0.80-1.00) for the detection of hydronephrosis in native and transplant kidneys, respectively. Nephrology trainees demonstrated a specificity of 0.75 (95% CI 0.53-0.90) [left native kidneys], 0.81 (95% CI 0.61-0.93) [right native kidneys] and 0.97 (95% CI 0.84-1.00) [transplant kidneys] for the detection of small kidney size.

Limitations: The prevalence of hydronephrosis and small kidneys was too low in this pilot study to draw conclusions about sensitivity. Additionally, a majority of the kidneys underwent POCUS imaging after an ultrasound had been performed in the medical imaging department.

Conclusions: Despite the increasing demand for POCUS training in nephrology, a significant gap persists in its clinical integration. Our study demonstrates that a structured workshop improves trainee confidence in kidney POCUS, with high patient satisfaction. Preliminary findings suggest that nephrology fellow-performed POCUS is feasible and promising, though further large-scale studies are needed to validate its clinical utility.

Background: Sex-disaggregated data demonstrate that there are more female than male living kidney donors (LKDs), and this is widely thought to be a manifestation of gender inequities. A better understanding of how gender norms, roles, and relations influence the living kidney donation process is needed.

Objective: We aimed to develop an analytical tool that can be used to conduct a systematic gender analysis of the living kidney donation process.

Design: A participatory research approach was used.

Setting: Canada.

Participants: Canadian living kidney donors and health care professionals.

Methods: Using a participatory research approach, we co-designed a gender analysis matrix (GAM) applicable to the context of living kidney donation. This tool is the first step into conducting a gender analysis of the living kidney donation process. Participants included 11 healthcare professionals, 6 LKDs, 1 patient partner, and a core methodology team (3 qualitative researchers and a gender analysis expert).

Results: Following an iterative process, a final LKD-GAM with 4 columns and 4 rows was created. The gender-specific domains are access to resources, division of labor and everyday practices, social norms and beliefs, and decision-making power and autonomy. Context-specific domains are the decision to donate, physical and mental wellbeing, experiences with health services, and broader social and economic impacts of (non-)donation. Key insights for our future work include diversity in our sample (include LKD candidates, men, and different life stages) and unpacking the notions of consent, constrained consent, and subtle coercion.

Limitations: The GAM's scope is likely limited to the Canadian context. The study was also limited by the recruitment of LKDs from a past list of participants and by the lack of cultural and linguistic diversity in the sample.

Conclusion: Using a participatory co-design approach, we have developed a robust tool that will inform a multinational qualitative study to better understand factors contributing to gender disparities in living kidney donation.

Case description: A 38-year-old man presented with NELL-1 positive membranous nephropathy (MN). Initial treatment with rituximab and later cyclosporine failed to result in sustained clinical improvement. Upon further review, the patient had been applying a skin fairness cream nightly for 2 years preceding diagnosis. The cream was discontinued, and follow-up testing confirmed markedly elevated serum mercury levels of 66.8 µg/L (normal less than 20 µg/L), and 24-hour urine mercury of 103.9 nmol/d. Two rounds of chelation therapy were arranged, the first with dimercaptosuccinic acid (DMSA) and the second with dimercaptopropane-1-sulfonic acid (DMPS) given cost and availability. Repeat mercury levels normalized but follow up kidney biopsy confirmed persistent immune complex glomerulonephritis. The patient was subsequently treated with prednisone followed by additional rituximab resulting in improvement of proteinuria and stabilization of kidney function.

Rationale/teaching points: This case reinforces the risk of mercury containing topicals and is the first to report systemic absorption of this magnitude. While chelation therapy is effective at improving systemic mercury levels, patients may require additional immunosuppression to treat immune complex-mediated MN following exposure.

Background: Obesity is a chronic disease which directly contributes to the onset and progression of chronic kidney disease (CKD). For patients with advanced CKD (CKD G4-5D), kidney transplantation is the optimal treatment to improve morbidity and quality of life. However, obesity is a barrier to transplantation, due to an associated risk of postoperative complications and decreased graft survival.

Objective: We sought to understand patient experiences with weight management and CKD to inform future studies in this area.

Design: Descriptive qualitative study.

Setting: London, Ontario, Canada.

Participants: Individuals with CKD G4-5D and experiences with obesity and weight management.

Methods: We interviewed 12 participants with CKD G4-5ND, using thematic analysis and a phenomenological framework. We explored their beliefs, experiences, and expectations of weight loss management. An inductive, open coding technique was used to generate themes that informed our understanding of their shared experiences.

Results: We identified 6 themes from our data: strengths and gaps in healthcare support, influence of social circles and systems, past experiences with weight loss, limitations of current health status, knowledge and motivation around weight management, and personal autonomy in treatment choices.

Limitations: Small homogenous population limits generalizability, self-report of weight loss attempts without numerical data.

Conclusions: Our study emphasizes opportunities for healthcare providers to identify and address potential unmet needs in weight management, while also guiding patient-centered conversations on this topic.