Canadian Journal of Kidney Health and Disease最新文献

Background: Traditional markers modestly predict chronic kidney disease progression in Aboriginal and Torres Strait Islander people. Therefore, we assessed associations of cardiometabolic and inflammatory clinical biomarkers with kidney disease progression among Aboriginal and Torres Strait Islander people with and without diabetes.

Objectives: To identify cardiometabolic and inflammatory clinical biomarkers that predict kidney disease progression in Aboriginal and Torres Strait Islander people.

Design: Prospective observational cohort study.

Setting: Northern Territory, Australia.

Participants: Aboriginal and Torres Strait Islander participants of the estimated glomerular filtration rate (eGFR) study with (n = 218) and without diabetes (n = 278).

Measurements: Baseline biomarkers (expressed as 1 standard deviation increase in logarithmic scale), plasma kidney injury molecule-1 (pKIM-1) (pg/ml), high-sensitivity troponin-T (hs-TnT) (ng/L), troponin-I (hs-TnI) (ng/L), and soluble tumor necrosis factor receptor-1 (sTNFR-1) (pg/ml) were assessed in 496 adults. Annual change in eGFR (ml/min/1.73 m²) and a composite kidney outcome (first of ≥30% eGFR decline with follow-up eGFR <60 ml/min/1.73 m², initiation of kidney replacement therapy or kidney disease-related death) over a median of 3 years.

Methods: Linear regression estimated annual change in eGFR (ml/min/1.73 m²). Cox proportional hazards regression estimated hazard ratio (HR) and 95% CI for developing a combined kidney health outcome.

Results: In individuals with diabetes, but not those without diabetes, higher baseline hs-TnT (-2.1 [-4.1 to -0.2], P = .033) and sTNFR-1 (-1.8 [-3.5 to -0.1], P = .039) predicted mean (95% CI) eGFR change, after adjusting for age, gender, baseline eGFR, and urinary albumin-to-creatinine ratio. Baseline variables explained 11% of eGFR decline variance; increasing to 27% (P < .001) with biomarkers. In diabetes, hs-TnT and hs-TnI were significantly associated with increased risk of kidney health outcomes.

Limitations: Limitations included potential chronic kidney disease misclassification from single creatinine and albumin measurements, limited adjustment for covariates due to a small sample size, and short follow-up restricting long-term outcome assessment.

Conclusions: Cardiovascular, kidney, and inflammatory biomarkers are likely associated with kidney function loss in diabetes, with particularly prominent associations for cardiac injury markers.

This program report describes the development and implementation of the Hemodialysis Emergency Support Team (HEST) in British Columbia, an initiative led by BC Renal in partnership with the province's 5 health authorities. The HEST was created in response to the growing risk of climate-related emergencies such as wildfires, floods, and water shortages, with the goal of ensuring continuity of care for patients receiving maintenance dialysis during service disruptions. The report outlines the provincial strategy behind HEST, including capacity building during non-emergency periods, strengthening of routine operations, and insights gained through simulation-based evaluations. Key outcomes include the achievement of provincial consensus, development of standardized staffing models, integration with existing emergency response frameworks, and the creation of rapid mobilization protocols. Beyond emergency response, HEST nurses also serve as mentors and clinical resources during non-emergency times, supporting local teams, sharing best practices, and helping build capacity within the hemodialysis unit. This dual role contributes to both emergency preparedness and long-term workforce sustainability.

Background: Hyperkalemia is a potentially life-threatening condition, with guidelines recommending urgent treatment when the serum potassium level is greater than 6.0 mmol/L. However, these recommendations are inconsistent, leading to diverse approaches to patient care.

Objectives: The primary objectives were to use population-based datasets to determine how often outpatient hyperkalemia (K > 6.2 mmol/L) occurs and how frequently patients present to the emergency department (ED) within 24 hours of the hyperkalemia report. Secondary objectives were to compare the characteristics of patients who had an ED encounter to those who did not, assess clinical outcomes within 7 days of the hyperkalemia report, and describe the initial potassium result within 24 hours of an ED encounter.

Design: Retrospective cohort study using linked population-based datasets at ICES.

Setting: Ontario, Canada from January 1, 2007, to December 24, 2021.

Patients: Adult patients (≥18 years) not on dialysis with an outpatient hyperkalemia result >6.2 mmol/L who were identified through flagged and urgently communicated results from outpatient laboratories.

Measurements: Emergency department encounters within 24 hours following an outpatient serum potassium report >6.2 mmol/L. Outcomes included all-cause mortality, cardiovascular mortality, arrhythmias, cardiac arrest in the ED, hospitalizations, and new dialysis starts within 7 days of the hyperkalemia report.

Methods: Administrative healthcare data were linked with laboratory results to compare baseline characteristics, medication use, healthcare utilization, and clinical outcomes for all patients. Standardized differences were used for comparisons.

Results: There were over 65 million serum potassium measurements and 57 607 individuals with an outpatient hyperkalemia value >6.2 mmol/L. Of these, 7469 (13.0%) individuals had an ED encounter within 24 hours. Individuals with an ED encounter had more comorbidities, higher medication use, and more prior healthcare utilization. Within 7 days of the hyperkalemia report, 675 of the 57 607 individuals (1.2%) had died. Where data were available, the first potassium value within 24 hours of an ED encounter was 1.5 mmol/L (± SD 1.3) lower, on average, than the initial outpatient potassium value.

Limitations: All-cause mortality may not be attributable to the hyperkalemia result. Sudden cardiac death, which is more specific to hyperkalemia, is not completely captured in our data sources. Data for medications are limited to patients 65 years of age and older.

Conclusions: Outpatient hyperkalemia is common. Despite guidelines recommending urgent treatment for patients with serum potassium levels >6.2 mmol/L, most are not referred to the ED.

Introduction: The goal of this study was to investigate the association between worsening renal function (WRF) and central venous pressure, right ventricular function, and lung fluid overload assessed by point-of-care ultrasound (POCUS) in hospitalized patients with acute heart failure (AHF).

Methods: This was a prospective cohort study including AHF adult inpatients, conducted in Geneva University Hospitals from October 2019 to March 2020. The primary outcome was WRF, defined by an increase in creatinine of ≥1.5 times from baseline value or an increase of ≥0.3 mg/dL between admission and day 4 to 6. Expert ultrasonographers used POCUS to examine lungs, inferior vena cava during spontaneous expiration (IVCe), and tricuspid annular plane systolic excursion (TAPSE) at admission.

Results: A total of 43 patients were included in the study. A total of 8 patients (19%) developed WRF during the study period (between October 8, 2019 and March 16, 2020), of whom 4 were in the higher quartile of lung fluid overload, 2 had TAPSE <14 mm, and 4 had IVCe ≥ 21 mm. In uni- and multi-variate logistic regression model, neither admission IVCe nor TAPSE was associated with WRF. However, lung congestion, as assessed by the number of B-lines, was significantly associated with WRF (odds ratio [OR] per quartile = 2.47, 95% confidence interval [CI] = 1.01 to 5.86, P = .04). This result remained statistically significant after adjustment for daily diuretic dose in mg/kg (OR = 2.98, 95% CI = 1.11 to 8.00, P = .03).

Conclusion: This study showed that lung congestion as assessed by POCUS was associated with WRF in AHF patients, whereas IVCe and TAPSE were not. Due to the small number of participants, our results need to be prospectively validated in future adequately powered clinical trials.

Purpose of review: Patients with both diabetes and kidney failure requiring dialysis are a complex population that is at risk of diabetes-related complications, hospitalizations, and mortality. Due to the significant illness burden, self-management of diabetes becomes challenging. The purpose of this review was to identify and synthesize the literature on barriers to, and facilitators of, diabetes self-management among patients with both diabetes and kidney failure requiring dialysis.

Sources of information: We conducted a search of health care databases (CINAHL, PubMed, OVID Medline) to find studies that were focused on exploring barriers to, and facilitators of, diabetes self-management in this population. We included English-language qualitative, quantitative, and mixed-methods studies.

Methods: We performed a focused narrative review assessing barriers and facilitators to diabetes management among patients with chronic kidney disease. The literature was critically analyzed using various appraisal tools, and thematic analysis was performed.

Key findings: A total of 134 articles were identified. Eight articles met inclusion criteria. A review of the articles revealed barriers in diabetes self-management covering 5 themes: financial limitations, limited access to healthcare services, siloed and fragmented care, increased complexity of the dietary regimen, and the higher burden of health. Three themes were revealed pertaining to facilitators of diabetes self-management: self-management support and education, coordinated care between healthcare providers, and family support.

Limitations: The literature search was in-depth and comprehensive, but not exhaustive. Also, we restricted our search criteria to articles published in the English language.

Implications: There can be challenges living with multiple chronic conditions, especially for those with comorbid diabetes and kidney failure requiring dialysis. This study underscores the urgent need for quality improvement and research initiatives to support these individuals. In addition, conducting further qualitative research to explore the perspectives of dialysis patients, their health care professionals, and caregivers would be beneficial.

Background: The COVID-19 pandemic significantly disrupted health care delivery; however, limited research attention has addressed the impacts of the pandemic specifically on renal-based health care.

Objective: The aim of the study was to understand the health and psychosocial impacts of the COVID-19 pandemic on care delivery as well as on health care providers (HCPs).

Design: A qualitative Interpretive Description approach was used.

Setting: Participants were recruited from kidney care units in Alberta and Ontario, Canada.

Participants: 46 interdisciplinary HCPs providing kidney care during the pandemic participated in the study. Participants comprised pediatric (n=9) and adult (n=37) HCPs.

Methods: Qualitative focus groups were facilitated. They were conducted using Zoom (Version 6.3.11).

Results: Research results indicated substantial strain on patients and HCPs during the COVID-19 pandemic, including mental health difficulties. For HCPs, moral distress was experienced from witnessing negative impacts of the pandemic and care shifts on patients. HCPs were further deleteriously affected by staffing shortages, facility limitations due to care interruptions and resource gaps in health and community systems. Conversely, participants identified concurrent benefits from pandemic-related shifts such as the rapid transition to virtual care. While virtual care imposed challenges for physical assessment of patients, patient convenience and increased access to HCPs were noted. With training, support and experience, HCPs and patients reported an appreciation for communication offered by virtual care where appropriate. Supportive unit leaders and peer support from HCP colleagues were viewed to make this difficult experience of the pandemic more manageable. HCPs drew strength in being able to support their patients despite the difficulties of the pandemic.

Limitations: Firsthand experiences of patients and families were not offered in this article, although their perspectives were elicited in another arm of this study. A more specific focus on pediatric versus adult systems of care, and the impacts of the pandemic on various disciplines, would add depth to understanding the unique impacts of the pandemic on various areas of care and across disciplines.

Conclusions: Study results call for the advancement of clinical care and heightened consideration of HCP needs in a pandemic. Included recommendations are ensuring sufficient resources, prudent use of communication technology, and optimizing support to HCPs.

[This corrects the article DOI: 10.1177/20543581251322571.].