Canadian Journal of Kidney Health and Disease最新文献

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.

Purpose of review: Depression and depressive symptoms are prevalent and disproportionally high among individuals undergoing hemodialysis. Depression has emerged as the most common mental health issue within the hemodialysis community. However, the characteristics related to sex and gender among individuals receiving hemodialysis and experiencing depression and depressive symptoms are not well known. The purpose of this review is to describe the characteristics of sex and/or gender in adults receiving hemodialysis and living with depression or depressive symptoms.

Sources of information: Electronic databases included Cochrane, Embase, Medline, CINAHL, and PsycINFO, when searching for peer-reviewed literature.

Methods: Systematic searches were conducted to identify peer-reviewed literature related to the characteristics of sex and gender factors among people treated with hemodialysis worldwide. Two reviewers screened 4036 titles, abstracts, and 37 full texts. Discrepancies were resolved by these same reviewers. Data from the studies that met the inclusion criteria were extracted according to the study objectives; characteristics of sex and/or gender were further analyzed by similarities and differences.

Key findings: We identified 25 peer-reviewed articles that addressed the characteristics of sex and/or gender. Of the 25 articles, 7 reported gender differences, 4 reported gender similarities, 13 reported sex differences, and 1 reported sex similarities in individuals with depression or depressive symptoms treated with hemodialysis. We found more differences than similarities in sex and gender related to depression among individuals with kidney failure undergoing hemodialysis, with notably higher rates of depressive symptoms observed in female individuals (sex) and women (gender). However, findings alert us to the possibility that due to contextual influences, male individuals may express depressive symptoms in different ways. There was substantial heterogeneity among the included papers, with nearly half of the studies conducted in Asia. In 76% of the studies, sex and gender were used interchangeably without a clear distinction; we used the term or the intention of the term used by the authors in their studies to inform our analysis. Studies further lacked any representation of gender-diverse individuals.

Limitations: It is possible that additional literature on depression in relation to the characteristics of sex and gender among adults undergoing home-based hemodialysis exists; our systematic search was limited to in-center and satellite settings. Our study primarily investigated populations in Asia. It is important to note that there may have been misclassification issues with the terms "sex" and "gender."

Purpose of review: Kidney transplantation is associated with survival benefit compared to dialysis. Yet, there is an unmet need for access to kidney transplantation within Canada and globally. Donation after death determined by circulatory criteria (DCC) has expanded access to kidney transplantation among the adult and pediatric population. However, there are concerns inherent to DCC kidneys, including warm ischemia time and ischemia-reperfusion injury (IRI). This narrative review aims to summarize relevant literature in this context, discuss potential opportunities to expand the use of DCC kidneys, and highlight knowledge gaps for further study.

Sources of information: PubMed (Medline), the Canadian Institute for Health Information, and regulatory bodies for organ donation and transplantation.

Methods: A focused review and critical appraisal of existing literature on the mechanisms of kidney IRI, consideration of sex in experimental studies relevant to DCC kidney transplantation, ex vivo perfusion strategies, and pediatric kidney transplant considerations.

Key findings: DCC kidneys confer a higher risk of delayed graft function (DGF) due to prolonged warm ischemic time. However, long-term graft survival is generally comparable to that of kidneys from donors with death determined by neurologic criteria (DNC). Key barriers to expansion include the paucity of sex-balanced experimental studies on DCC graft preservation and outcomes and existing protocols for DCC donor selection, including thresholds for warm ischemia time. Ex vivo strategies including non-oxygenated and oxygenated hypothermic machine perfusion and normothermic ex vivo kidney perfusion are promising research areas. Improving DCC protocols to reduce kidney IRI has the potential to further expand access to DCC transplantation, including to the pediatric population.

Limitations: This narrative review only included articles written in English. Study quality was not formally assessed. Discussion points were influenced by the author's areas of expertise.

The Cardiac and Renal Endocrine (C.a.R.E) clinic is an interdisciplinary clinic offering integrated care to complex patients with cardiovascular-kidney-metabolic syndrome. Previous data from the clinic demonstrated improvements in clinical parameters but provided limited information on the indicated usage of evidence-based therapies. We aimed to update baseline characteristics and clinical data of the C.a.R.E clinic cohort, with added information on the uptake of therapies and reasons for therapy non-use. We performed a retrospective chart review of patients seen in the C.a.R.E clinic between July 2014 and July 2024 with at least two documented clinic visits. Data from the first and last visits were compared to evaluate treatment uptake and changes in clinical parameters. A total of 125 patients met our inclusion criteria. There were significant improvements in low-density lipoprotein levels (1.61 mmol/L for last visit vs 1.82 mmol/L for first visit), blood pressure (BP) measurements, (median systolic BP of 126 mm Hg vs 130 mm Hg and median diastolic BP of 72 mm Hg vs 76 mm Hg), and proportion of patients achieving BP targets (60.0% vs 44.8%). Uptake of therapies significantly increased, including sodium-glucose cotransporter-2 inhibitors (59.2% vs 24.0%) and glucagon-like peptide-1 receptor agonists (30.4% vs 9.6%). The use of finerenone also increased (22.7% vs 3.0%) among the 66 patients whose last visit occurred after Health Canada approved finerenone. The C.a.R.E clinic demonstrates potential to improve therapy uptake and clinical outcomes in patients with cardiovascular-kidney-metabolic syndrome. However, consistent clinical documentation and innovative strategies are needed to further enhance the adoption of evidence-based therapies.