Canadian Journal of Kidney Health and Disease最新文献

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.].

Background: Individuals with advanced chronic kidney disease benefit from an integrated palliative approach to care through timely advance care planning and discussions about their goals of care. Despite literature and guidelines emphasizing the need for advance care planning in chronic kidney disease management, treatment-focused approach remains the norm, partly due to provider reluctance and discomfort in engaging in advance care planning conversations. In British Columbia (BC), the Integrated Palliative Nephrology (IPN) project was launched to enhance kidney health care provider engagement in advance care planning and goals of care discussions, to train kidney health care providers in the province to initiate serious illness conversations, and to develop standardized resources for patients and providers across a provincial renal network.

Objective: As part of the quality improvement, this study highlights the barriers/challenges and enablers to engage in advance care planning for health care providers of adult patients with chronic kidney disease.

Design: A multi-methods approach was used.

Setting: British Columbia, Canada.

Participants: Kidney health care providers who worked in nondialysis and dialysis care settings.

Methods: Data were collected through semistructured surveys, individual interviews, and focus groups with health care providers across the province who care for patients with chronic kidney disease.

Results: The results of a kidney health care provider survey (n = 90) showed self-reported improvements in knowledge of the integrated palliative approach and competency and comfort engaging in advance care planning discussions. The results of one-on-one interviews (n = 15) and focus groups (n = 32) with kidney health care providers showed that taking a relational approach with patients, enhancing provider comfort and competency with advance care planning, clarifying roles and responsibilities around who should engage in advance care planning conversation was beneficial to patient care. Supporting cohesion among care teams around the goal of advancing an integrated palliative approach, and offering mentorship and targeted education and resources for the kidney care team, can enable effective advance care planning discussions.

Limitations: The study was limited by purposive sampling, a small sample size, and potential bias due to participant interests and settings.

Conclusions: For kidney health care providers, targeted education and resources, clarity around roles and responsibilities, and long-term relationships with patients may help advance the cultural shift from treatment focus to integrating palliative care across the continuum of the illness journey.

Trial registration: Not registered.

Background: The growing emphasis on low-carbon, sustainable health care systems is driving the integration of environmental sustainability into clinical practice and research. This shift necessitates clinician literacy in health care sustainability, particularly in methodologies for assessing environmental impacts.

Objective: To introduce health care professionals to life cycle assessment (LCA) as a tool for evaluating environmental impacts in clinical contexts and to illustrate its application through a case study on hemodialysis therapies.

Design: A qualitative assessment of LCA methodology, including its fundamental principles, stages, and applications in health care.

Setting: Hemodialysis materials were collected from In-Centre and Home Dialysis units at Vancouver General Hospital.

Patients/sample/participants: No patients are directly involved in this work; samples of unused hemodialysis materials were collected for process assessment. The target audience is health care professionals, particularly those involved in kidney care, who need to interpret LCA results for informed decision-making.

Methods: Overview of LCA, an internationally standardized methodology that evaluates the environmental impacts of products and processes over their entire life cycle, is presented. The 4 stages of LCA, the key environmental impact categories it assesses, and guidelines for appropriate interpretation and use are explored.

Results: Life cycle assessment provides numerous midpoint data, mechanisms by which damages occur to endpoints, including human health and environments. The case study comparing home versus in-center hemodialysis demonstrates how LCA findings can inform decision-making in kidney care.

Limitations: The interpretation of LCA results requires an understanding of its methodology and limitations. The accuracy of LCA outcomes depends on the quality and scope of data used in the assessment.

Conclusions: As LCA is increasingly applied in clinical settings, health care professionals must develop the skills to critically evaluate and apply its findings. This primer equips kidney care professionals with essential knowledge of LCA methodology, supporting the integration of environmental sustainability into clinical practice.

Trial registration: Not applicable.

Purpose of the review: In this article, we provide an update on the Canadian Society of Nephrology's (CSN) process of identifying candidate topics and subsequent development of guidelines and commentaries using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-ADOLOPMENT methodology. We revise the process of adapting existing guidelines with the inclusion of Kidney Disease Improving Global Outcomes (KDIGO) practice points. We also describe challenges of implementing guidelines and suggest solutions to address this with description of the CSN approach to disseminating and implementing guidelines.

Sources of information: The update reflects internal CSN documentation, stakeholder consultation for topic prioritization, and integration of methodological guidance from GRADE-ADOLOPMENT and international sources such as KDIGO.

Methods: We reviewed and synthesized the CSN's current guideline-development process, which includes a detailed examination of internal documentation, meeting summaries, and publicly available methodological frameworks with specific focus on the application of the GRADE-ADOLOPMENT approach. We analyzed how recommendations and practice points from KDIGO are assessed for relevance, updated based on Canadian context, and integrated into the final commentary using GRADE Evidence-to-Decision (EtD) frameworks. We also examined how conflict of interest is managed, how working groups are structured, and how recommendations are prioritized. In addition, we explored the CSN's evolving strategies for dissemination and implementation, including stakeholder engagement, survey feedback, and use of knowledge-translation tools.

Key findings: The CSN follows a transparent and rigorous process in guideline and commentary development. This comprehensive process considers the best-available evidence, balancing desirable and undesirable effects and patients' values, perspectives, and implications for the Canadian health care system including resources, equity, acceptability, and feasibility to maximize guideline implementation and advance the health of Canadians.

Limitations: The CSN updated methods reflect the current process and may not be generalizable to other guideline organizations. The impact of CSN commentaries on clinical practice, decision-making, and policy uptake has not been formally evaluated, limiting our understanding of their contribution to health system improvement and patient outcomes.

Implications: This review updates the CSN's processes for commentary working groups to identify relevant international guidelines, establish the level of agreement on included recommendations, incorporate perspectives of people with lived experience, and adjust the final product to the Canadian healthcare system before dissemination.