Canadian Journal of Kidney Health and Disease最新文献

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.

Rationale: Hyperammonemia in patients receiving hemodialysis is uncommon but poses a significant clinical challenge due to the effective clearance of ammonia by dialysis, which can obscure the underlying cause. Recognizing atypical etiologies is crucial for appropriate management.

Presenting concerns of the patient: A 59-year-old man being treated with hemodialysis presented with altered level of consciousness and recurrent hyperammonemia. Despite previous episodes of hyperammonemia, the etiology of his intermittently elevated ammonia remained unclear and was initially attributed to his kidney failure.

Diagnoses: Initial assessments, including liver function tests, abdominal ultrasound, medication review, and genetic screening for urea cycle disorders, were unremarkable. Upon recurrence of symptoms with hyperammonemia, a computed tomography scan was performed which revealed a large portosystemic shunt between the splenic vein and right common iliac vein.

Interventions: The patient underwent embolization of the identified portosystemic shunt.

Outcomes: Following embolization of the shunt, the patient's hyperammonemia and encephalopathy resolved, with no further recurrences.

Novel findings: This case illustrates the challenges of determining the etiology of hyperammonemia in patients treated with hemodialysis due to the dialysis clearance of ammonia. Portosystemic shunts cause hyperammonemia by bypassing the liver's ammonia-detoxification pathways, and their effects may be paradoxically exacerbated immediately after dialysis due to dialysis-related hemodynamic changes. We emphasize the importance of investigating hyperammonemia as a cause of altered level of consciousness among patients being treated with hemodialysis and considering anatomical shunting in the differential diagnosis.

Acute kidney injury (AKI) in non-Hodgkin lymphoma has diverse etiologies. We report a case in which AKI due to light chain cast nephropathy was the initial manifestation of extranodal marginal zone lymphoma, occurring without systemic symptoms. A 64-year-old male presented with severe AKI without other symptoms. His physical examination and renal ultrasound were unremarkable. Renal biopsy revealed light chain cast nephropathy, and a subsequent bone marrow biopsy confirmed marginal zone lymphoma. The patient received R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) for a total of six cycles. The patient had a partial response to lymphoma. However, his renal function did not improve, and ultimately he progressed to end-stage kidney disease, requiring maintenance hemodialysis. This case highlights extranodal marginal zone lymphoma presenting as AKI, emphasizing its unique renal-limited manifestation in the absence of systemic symptoms and the critical role of renal biopsy in diagnosing unexplained AKI.

Background: The mineralocorticoid aldosterone may contribute to the risk of cardiovascular morbidity and mortality in patients receiving maintenance dialysis. Whether spironolactone, a mineralocorticoid receptor antagonist, improves outcomes for patients receiving maintenance dialysis is unclear.

Objective: To assess the efficacy and safety of spironolactone in patients receiving maintenance dialysis.

Design: Placebo-controlled, randomized controlled trial.

Setting: Dialysis units.

Patients: Patients receiving maintenance dialysis who are adherent to and able to tolerate spironolactone 25 mg daily during an open-label run-in period of at least 49 days were randomized to spironolactone 25 mg daily or matching placebo.

Measurements: Randomized participants were followed for the primary outcome of cardiovascular death or hospitalization due to heart failure. Secondary outcomes include cause specific deaths, hospitalization due to heart failure, all-cause death, all-cause hospitalizations, and severe hyperkalemia. All deaths and possible hospitalizations for heart failure were adjudicated.

Methods: Eligible participants received open-label spironolactone 25 mg daily for at least 7 weeks during a run-in period. Participants who tolerated and adhered to treatment were randomly allocated to continue spironolactone 25 mg daily or a matching placebo. We followed participants until trial close.

Results: The trial began recruitment in 2018 and concluded recruitment in December 2024. Despite a reduced rate of recruitment during the global COVID-19 pandemic 3565 eligible participants were enrolled of whom 2538 were randomized to spironolactone or placebo from 143 dialysis programs.

Limitations: Limited funding and the trial was stopped early due to futility to demonstrate an effect.

Conclusions: ACHIEVE was designed as a large, simple trial to determine if spironolactone 25 mg daily prevents cardiovascular mortality and heart failure hospitalizations in patients with kidney failure receiving maintenance dialysis. ACHIEVE demonstrates the possibility of conducting large, international, investigator initiated randomized controlled trials for patients with kidney failure receiving dialysis.NCT03020303.