Background: Improving interactions between people receiving hemodialysis and health care providers of facility-based hemodialysis care is a top priority for patients, caregivers, and health care providers.
Objective: To identify challenges for high-quality clinical interactions in facility-based hemodialysis care as well as potential solutions.
Design: Multicentre qualitative study using focus groups and semi-structured interviews to elicit the perspectives of patients, caregivers, and health care providers.
Setting: Five Canadian facility-based hemodialysis centers.
Participants: English-speaking adults receiving facility-based hemodialysis for longer than 6 months, their caregivers, and hemodialysis health care providers.
Methods: Between May 2017 and August 2018, focus groups and interviews with patients and their caregivers subsequently informed semi-structured interviews with providers. Data were analyzed using inductive thematic analysis with application of a grounded theory approach.
Results: A total of 8 focus groups and 44 interviews were completed. Participants included 64 people receiving hemodialysis, 18 caregivers, and 31 health care providers. Communication between health care providers and patients was often characterized as intersections of care (unidirectional) rather than interactions (bidirectional). Challenges were grouped into 4 main themes as follows: (1) culture of care provision; (2) mistrust between patients and health care providers; (3) time constraints for clinical interactions, and (4) lack of collaboration and care coordination among health care team. Potential solutions were identified for each challenge.
Limitations: Findings were limited to Canadian context, English-speaking adults, and individuals receiving facility-based hemodialysis in urban centers.
Conclusions: Interactions between health care providers and people receiving dialysis are often unidirectional, where the patient is a passive recipient of ideas and information from the health care provider. To promote improved bidirectional interactions, team-based care that includes better tools to improve information transfer, better information regarding roles, and identity of health care team members and opportunities for all members of the health care team, including the people receiving dialysis, to provide input on care plans is required.
Trial registration: Not applicable.
Rationale: Infection-related glomerulonephritis (IRGN) is an immune-mediated glomerulonephritis caused by extra-renal infectious diseases. There has been an important shift in epidemiology in recent years, with a significant proportion of adults affected. The incidence of IRGN is higher amongst Indigenous populations and especially in those with multiple comorbidities. Beginning in 2019, we observed several IRGN cases amongst adult Indigenous peoples referred to the McGill University Health Center (MUHC). The aim of this article is to describe the demographic, clinical, and outcome data of these individuals and highlight the heterogeneity of IRGN in this population through 2 illustrative cases.
Presenting concerns of the patient: In total, 8 cases of IRGN were identified between 2019 and 2022. All patients presented with features of acute glomerulonephritis.
Diagnoses: All patients had documented evidence of an infection that preceded their diagnosis of IRGN. IRGN was not the initial clinical diagnosis in all cases.
Interventions: Half the patients received immunosuppression while the others received supportive care only.
Outcomes: Four patients required initiation of hemodialysis at time of presentation and at 2 years of follow-up, 3 of the 4 remained hemodialysis-dependent.
Teaching points: Our case series emphasizes the heterogenous clinical, laboratory, and pathological presentations that make the diagnosis of IRGN quite challenging. A high index of suspicion should be present when a patient presents with acute kidney injury, features of a glomerulonephritis, and an infection, especially those with multiple comorbidities and a preceding history of chronic kidney disease.
Background: In 2013, the British Columbia (BC) Childhood Nephrotic Syndrome Clinical Pathway (CNSCP) was developed to standardize the care of children with nephrotic syndrome (NS). In BC, children access nephrology care at BC Children's Hospital (BCCH) and multiple regional clinics.
Objective: The primary objective was to compare induction therapy and clinical outcomes between BCCH and regional clinics since implementation of the CNSCP.
Design setting and patients: This was a retrospective cohort study of children with NS in BC.
Measurements and methods: We conducted a retrospective cohort study of children 1 to 17 years old with new-onset NS from 2013 to 2019 inclusive with minimum 12 months of follow-up. Children with non-minimal change disease, steroid resistance, incomplete induction therapy, or less than 6 months of pathway treatment within their first year post-diagnosis were excluded. Clinics were categorized as BCCH or regional (Surrey, Prince George, or Kelowna).
Results: Sixty-nine patients were included, with 52 (75%) at BCCH and 17 (25%) at regional clinics. There were no significant between-group differences in age, sex, or clinical characteristics at time of diagnosis. Comparing BCCH and regional clinics, there was no difference in induction prednisone exposure (median 3400, interquartile range [IQR] 3331-3585 mg/m2 vs 3492, IQR 3397-3644 mg/m2, P = .167), annualized relapse rate (median 3.3, IQR 1.1-5.3 vs 2.3, IQR 0.5-4.2, P = .575), or development of frequently relapsing courses (50% vs 62%, P = .475). There was a similar number of first-year clinic visits (4.2 ± 1.2 vs 4.0 ± 1.8, P = .655) and dietitian-reviewed food records (67% vs 47%, P = .135, BCCH vs regional). More children at BCCH had a recommended ophthalmology surveillance visit (87% vs 59%, P = .01, BCCH vs regional).
Limitations: Study limitations include small sample size and exclusion of children with complicated NS (ie, relapse during induction, steroid resistance).
Conclusion: Since we implemented the CNSCP, children with NS received comparable care and had similar outcomes at BCCH and regional clinics without significant practice variation.
Background: Frailty and functional decline are being recognized as important conditions in kidney transplant candidates. However, the ideal measures of functional status and frailty remain unknown as there is not a complete understanding of the relationship between these conditions and important post-transplant outcomes.
Objective: The objective was to examine the association between different measures of frailty and functional status evaluated before or at the time of transplant with adverse clinical outcomes post-transplantation.
Design: This study is a systematic review.
Setting: Observational studies including cohort, case-control, or cross-sectional studies examining the effect of frailty and functional status on clinical outcomes. There were no restrictions on type of setting or country of origin.
Patients: Adults who were waitlisted for kidney transplant or had received a kidney transplant.
Measurements: Data including demographic information (eg, sample size, age, country), assessments of frailty or functional status and their domains, and outcomes including mortality, transplantation, graft loss, delayed graft function and hospital readmission were extracted.
Methods: A search was performed in Medline, Embase, and Cochrane Central Register for Controlled Trials. Studies were included from inception to February 7, 2023. The eligibility of studies was screened by 2 independent reviewers. Data were presented by frailty/functional status instrument and clinical outcome. Point estimates and 95% confidence intervals from fully adjusted statistical models were reported or calculated from the raw data.
Results: A total of 50 studies were identified, among which 36 unique instruments were found. Measurements of these instruments occurred mostly at time of kidney transplant, transplant evaluation, and waitlisting. The median sample size of studies was 457 patients (interquartile range = 183-1760). Frailty and lower functional status were associated with an increased risk for mortality. Similar trends were observed among other clinical outcomes such as graft loss and rehospitalization.
Limitations: The heterogeneity in measurement instruments, study designs, and outcome definitions prevents pooling of the data. Selection bias and the validity of data collection could not be ascertained for some studies.
Conclusion: Frailty and functional status measures are important predictors of post-kidney transplant outcomes. Further studies are needed to evaluate the best instruments to assess frailty and functional status, and importantly, interventional studies are needed to determine whether prehabilitation strategies can improve post-transplant outcomes.
Registration prospero: CRD42016045251.
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