Canadian Journal of Kidney Health and Disease最新文献

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.

Background: Much of the literature on kidney transplant education focuses on educating recipients prior to transplant or in the early postoperative period. It is unknown whether the information provided is meaningful to patients or whether the importance of education topics changes with time.

Objective: We sought to identify the learning needs of patients post-kidney transplant.

Design: Our multidisciplinary team conducted a mixed-method study to better understand the learning needs of patients; what is important to them in the early postoperative period and a year after transplant.

Setting: One urban academic hospital performing kidney transplant in Ontario, Canada. Data were collected between September 2019 and March 2021, including during the COVID-19 pandemic.

Participants: A convenience sample of 20 participants in the post-kidney transplant clinic. Participants' mean age was 56 (SD ± 11) with 75% of participants male gender.

Methods: Twenty kidney transplant patients were recruited between 3 and 6 months post-transplant. Participants completed an initial demographic questionnaire. They completed the Learning Needs Inventory (LNI) and a one-on-one semi-structured interview at 2 time points: 3 to 6 months post-transplant and 12 to 18 months post-transplant.

Results: Patient interviews revealed that their access to a trustworthy health care team, support system, and reported challenges post-transplant shaped their ability to engage in learning. Patients shared that each aspect influences when and what topics were important to them, which allowed patients to obtain personalized education. A multidisciplinary team extending beyond physicians and nurses to include professionals such as pharmacists, dietitians, and social workers can best address patient-specific education needs post-transplant was highlighted in patients' comments. Patients revealed that their support system helps to develop self-reliance and support their transition after transplant to allow them to recover and manage challenges after transplant. Support systems varied from family, friends, colleagues and included social media and community organizations were helpful. Our study identified 3 realms of challenges post-transplant including: emotional, physical, and financial. Quantitative data showed significant findings on the level of importance regarding the use of alcohol, demonstrating a shift in median rating of "not important at all" to "not very important" (P = .016). A significant effect (P = .031) shifting the median rating of post-transplant dental care from of "a little important" to "very important."

Limitations: The small convenience sample with only English-speaking patients used in this study may have affected our ability for generalizable results. Part of this study was com

Background: Organ and tissue donation and transplantation (OTDT) policies and practices lead to differential care for sexual and gender minorities (SGMs). The experiences of SGM patients and caregivers in the transplantation system have not been published. The perspectives of SGMs on how to best address existing inequities are not understood.

Objective: To characterize the lived experiences of SGM patients and caregivers in solid-organ transplant health systems, as well as the perspectives and priorities of these individuals regarding SGM-relevant policies, practices and targets for system improvements.

Methods: We conducted a series (N = 12) of one-on-one semi-structured interviews with a convenience sample of SGMs with lived experience of the OTDT system. We transcribed interviews verbatim and performed a formal qualitative analysis combining a best-fit framework synthesis and inductive thematic analysis.

Results: We revealed novel targets for action to improve inclusive care in the transplantation system directly informed by the lived experiences of SGM patients and caregivers. Targets for improvement included (1) enhancements to shared decision-making between OTDT providers and patients, (2) transparent communication from OTDT organizations, (3) data-driven donor risk assessments, (4) expanded healthcare worker training, (5) inclusive physical care spaces, (6) recommendations for transgender and gender-diverse health system planning, (7) integrated sexual and reproductive healthcare services for transplant recipients, (8) increased SGM representation in medical education and care settings, (9) SGM and OTDT intersectional support networks, and (10) structural facilitation of SGM community advocacy efforts.

Limitations: While thematic saturation was achieved with our sample, we recognize that not all SGM identities were represented. It remains likely that additional experiences, beliefs, and priorities exist in the SGM community.

Conclusions: The emergent priorities and perspectives of SGMs with lived experience of transplant systems should inform patient-centered equitable health system advancements.

Background: Urinary tract infections (UTI) are common in kidney transplant recipients (KTR). Although risk factors for UTI are well described, predicting symptomatic UTI with positive urine cultures in the first posttransplant year is challenging.

Objective: Our clinic routinely monitors serum highly sensitive C-reactive protein (CRP) as part of posttransplant care. We sought to define the role of CRP in identifying symptomatic UTI in KTR.

Design: Nested case control study.

Setting: A large adult single-organ kidney transplant center in Toronto, Canada.

Patients: We identified a nested cohort of 78 KTR who experienced a symptomatic UTI with positive urine cultures (cases) and compared them to a cohort of 78 KTR controls matched by time elapsed posttransplant.

Measurements: Patient demographics, urine cultures, CRP, and kidney function during the first posttransplant year.

Methods: We identified a cohort of KTR transplanted between January 1, 2016, and December 31, 2019. A positive urine culture ordered only for clinical indication in the first posttransplant year identified KTR with a UTI defined >10 ⁵ colony forming units/mL. UTI cases were matched 1:1 to non-UTI controls transplanted immediately preceding or succeeding the UTI case. Bivariate comparisons were performed by t test, Wilcoxon 2-sample test for continuous variables, chi-square, or Fisher's exact test as appropriate, with clinically significant variables entered into multivariable logistic regression models to determine associations.

Results: Older age, female sex, and the presence of a stent were each associated with a UTI. Immediately preceding UTI, eGFR (P = .019), serum albumin (P < .0001), and hemoglobin (P = .002) were lower, while serum CRP (P < .0001) and absolute neutrophils (P = .03) were higher in cases than controls. However, in several multivariable models, only absolute CRP (P = .001), change in CRP (P = .005), female sex (P < .0001), and ureteric stent (P = .008) consistently predicted a UTI. Each 5 mg/dL change between the 2 preceding CRP values predicted a 15% increased likelihood of UTI, while each 1 mg/dL in absolute CRP concentration was associated with a 5% risk.

Limitations: Retrospective case-control design, single-center, small sample size. Hospital inpatients and patients with other infections, acute inflammatory conditions, or rejection were excluded. Urine infections may more easily be detected when patients visit the clinic frequently.

Conclusions: Routine ambulatory CRP monitoring in the first year may help identify subsequent symptomatic UTI in KTR, allow for the initiation of earlier therapy, and reduce patient morbidity.

What was known