Canadian Journal of Kidney Health and Disease最新文献

Background: Transplanting less-than-ideal (LTI) kidneys could help optimize organ utilization, but little is known about how patients and caregivers perceive the allocation process, waitlist, or LTI kidneys.

Objective: To explore the perspectives of patients and caregivers on the Canadian kidney transplant allocation process, waitlist, and LTI kidneys.

Design: Electronic survey.

Setting: Canada.

Patients: Transplant recipients, candidates, and caregivers.

Methods: A bilingual electronic national survey was administered from January to March 2024. The questionnaire contained sections on demographics, perceptions of organ allocation and acceptance, LTI kidneys, and educational preferences. Descriptive analysis was performed.

Results: Two hundred fifty-one responses were analyzed, including patients (63%, n = 159), and caregivers (37%, n = 92), from 11 provinces and territories. Three-quarters (74%, n = 186) understood how patients are placed on the waiting list, and 65% (n = 162) understood how donor kidneys are allocated, but 72% (n = 181) and 68% (n = 171) wanted more information about the waitlist and donor kidney allocation criteria, respectively. Approximately 20% felt that the waitlist and allocation processes were not transparent. Awareness about the option to refuse a deceased donor kidney offer was high (69%, n = 174), yet nearly half of respondents (46%, n = 115) expressed concern about being disadvantaged if an offer for a deceased donor kidney was refused. One-third of participants (33%, n = 83) were open to accepting an LTI kidney.

Limitations: Compared to the general population, more study participants were white, and the majority were educated and financially at ease. This limits the generalizability of the results.

Conclusion: Enhanced communication is required to improve transparency and information about the allocation system and waitlist in Canada.

Introduction: Tracking the evaluation process of living kidney donor candidates facilitates benchmarking and can inform process redesign to improve experiences with the evaluation and enable more living donor kidney transplantation.

Methods: We reviewed the medical records for all living donor candidates who were actively undergoing evaluation at any time between January 1, 2013, and December 31, 2016, at the London Health Sciences Centre in London, Ontario, Canada. We abstracted information on demographic factors, the evaluation process, reasons for a delayed evaluation, reasons for an evaluation termination (eg, donation, decline, withdrawal, loss to follow-up), frequency and timing of evaluation testing, and recipient dialysis status.

Results: Over time, the number of living donor kidney transplants increased from 22 in 2013 to 32 in 2016 (18% and 34% of which were pre-emptive, respectively). The median number of candidates coming forward doubled from 167 in 2013 (2 candidates per recipient) to 348 in 2016 (4 candidates per recipient). Median time from first contact until donation decreased from 12.8 months in 2013 to 7.1 months in 2016 (a 45% reduction). The time from computed tomography (CT) angiography until donation (n = 74) was a median of 75 (interquartile range [IQR] = 36, 180) days, the longest single step in the evaluation. Common reasons for delay included waiting for the referral of their intended recipient for transplant evaluation (11% of candidates) and a need for the donor candidate to lose weight (8% of candidates). Donors completed the main evaluation tests on a median of 5 different dates. Thirty-six recipients started dialysis after their living donor candidates' evaluation had been underway for at least 3 months.

Conclusion: Tracking the steps and reasons for an inefficient living kidney donor evaluation process can be used for quality improvement, and efficiency improvements are expected to translate into improved outcomes and experiences.

Background: Some men who donate a kidney have reported testicular pain after donation; however, attribution to donation is not clear as no prior studies included a comparison group of nondonors.

Objective: To examine the proportion of male donors who reported testicular pain in the years after nephrectomy compared to male nondonors with similar baseline health characteristics.

Design participants and setting: We enrolled 1042 living kidney donors (351 male) before nephrectomy from 17 transplant centers (12 in Canada and 5 in Australia) from 2004 to 2014. A concurrent sample of 396 nondonors (126 male) was enrolled. Follow-up occurred until November 2021.

Measurements: Donors and nondonors completed the same schedule of measurements at baseline (before nephrectomy) and follow-up. During follow-up, participants completed a questionnaire asking whether they had experienced new pain in their eyes, hands, or testicles; those who experienced pain were asked to indicate on which side of the body the pain occurred (left or right). The pain questionnaire was completed by 290 of 351 male donors (83%) and 97 of 126 male nondonors (77%) a median of 3 years after baseline (interquartile range = 2-6).

Methods: Inverse probability of treatment weighting on a propensity score was used to balance donors and nondonors on baseline characteristics. After weighting, the nondonor sample increased to a pseudo sample of 295, and most baseline characteristics were similar between donors and nondonors.

Results: At baseline, donors (n = 290) were a mean age of 49 years; 83% were employed, and 80% were married; 246 (84.8%) underwent laparoscopic surgery and 44 (15.2%) open surgery; 253 (87.2%) had a left-sided nephrectomy and 37 (12.8%) a right-sided nephrectomy. In the weighted analysis, the risk of testicular pain was significantly greater among donors than nondonors: 51/290 (17.6%) vs 7/295 (2.3%); weighted risk ratio, 7.8 (95% confidence interval [CI] = 2.7 to 22.8). Donors and nondonors did not differ statistically in terms of self-reported eye pain or hand pain. Among donors, the occurrence of testicular pain was most often unilateral (92.2%) and on the same side as the nephrectomy (90.2%). Testicular pain occurred more often in donors who had laparoscopic vs open surgery: 48/246 (19.5%) vs 3/44 (6.8%) but was similar in those who had a left-sided vs right-sided nephrectomy: 44/253 (17.4%) vs 7/37 (18.9%).

Limitations: Participants recalled their symptoms several years after baseline, and we did not assess the timing, severity, or duration of pain or any treatments received for the pain.

Conclusion: Unilateral testicular pain on the same side of a nephrectomy is a potential complication of living kidney donation that warrants further investigation.

Background: Quality indicators are required to identify gaps in care and to improve equitable access to kidney transplants. Referral to a transplant center for an evaluation is the first step toward receiving a kidney transplant, yet widespread reporting on this metric is lacking.

Objective: The objective was to use administrative health care databases to examine multiple ways to define referral for a kidney transplant evaluation by varying clinical inclusion criteria, definitions for end of follow-up, and statistical methodologies.

Design: This is a population-based cohort study.

Setting: This study linked administrative health care databases in Ontario, Canada.

Patients: Adults from Ontario, Canada, with advanced chronic kidney disease (CKD) between April 1, 2017, and March 31, 2018.

Measurements: The primary outcome was the 1-year cumulative incidence of kidney transplant referral.

Methods: We created several patient cohort definitions, varying patient transplant eligibility by health status (eg, whether patients had a recorded contraindication to transplant). We presented results by advanced CKD status (ie, patients approaching the need for dialysis vs receiving maintenance dialysis) and by method of cohort entry (ie, incident only vs prevalent and incident patients combined), resulting in 12 unique cohorts.

Results: Sample size varied substantially from 414 to 4128 depending on the patient cohort definition, with the largest reduction in cohort size occurring when we restricted to a "healthy" (eg, no evidence of cardiovascular disease) group of patients. The 1-year cumulative incidence of transplant referral varied widely across cohorts. For example, in the incident maintenance dialysis population, the cumulative incidence varied more than 2-fold from 16.3% (95% confidence interval [CI] = 15.0%-17.7%) using our most inclusive cohort definition to 40.0% (95% CI = 36.0%-44.5%) using our most restrictive "healthy" cohort of patients.

Limitations: Administrative data may have misclassified individuals' eligibility for kidney transplant.

Conclusions: These results can be used by jurisdictions to measure transplant referral, a necessary step in kidney transplantation that is not equitable for all patients. Adoption of these indicators should drive quality improvement efforts that increase the number of patients referred for transplantation and ensure equitable access for all patient groups.

Background: In a cluster-randomized trial, we learned that a novel multicomponent intervention designed to improve access to kidney transplantation did not significantly increase the rate of completed steps toward receiving a kidney transplant. Alongside the trial, we conducted a process evaluation to help interpret our findings.

Objective: To determine whether the intervention addressed targeted barriers to transplant and whether the implementation occurred as planned.

Design: Mixed-methods process evaluation informed by implementation science theories.

Setting: Chronic kidney disease (CKD) programs in Ontario, Canada. These programs, providing care to patients with advanced CKD, participated in the trial from November 1, 2017 to December 31, 2021 (either in the intervention or usual care group).

Participants: Health care providers (eg, nurses, managers) at Ontario's 27 CKD programs.

Methods: We conducted surveys (n = 114/162 [70.4%]) and semi-structured interviews (n = 17/26 [65.4%]) with providers in CKD programs in Ontario, Canada. In both the intervention-group and control-group surveys, using the Theoretical Domains Framework, we assessed perceived barriers to transplant and how barriers changed throughout the trial period. In the intervention-group surveys and interviews, using the normalization process theory, we assessed the extent to which the intervention was embedded into daily routines. In the intervention-group surveys, and by completing an implementation checklist, we assessed fidelity of implementation.

Results: Perceived barriers to transplant did not substantially differ between providers in the intervention and usual care groups, and both groups reported disagreeing or feeling neutral that the targeted barriers impeded transplant access. Intervention-group providers reported that intervention activities were becoming a regular part of their work and that they engaged with its components. However, they also felt the intervention was complex and described needing more resources, a better execution plan, and more buy-in from frontline staff. Fidelity was high for administrative support, quality improvement teams, delivery of educational resources, and patient peer support. The use of performance reports was low.

Conclusions: We identified several possible reasons why the intervention was unsuccessful. Improving access to kidney transplantation remains a high priority for health care systems. We will continue to foster a quality improvement culture, and our results will guide future interventions.

Limitations: Two of the 13 intervention-group CKD programs did not participate in this evaluation.

Trial registration: ClinicalTrials.gov Identifier: NCT03329521.

Background: Obesity can be an issue for renal transplant eligibility. Semaglutide constitutes an interesting choice for obesity treatment, but little data exist regarding its efficacy and security among dialysis patients.

Objectives: The co-primary endpoints of this study were to describe the change in body weight (%) and in body mass index (BMI) from the beginning and after 3, 6, and 12 months of treatment for participants who used semaglutide compared with a control group of non-users. Secondary endpoints included description of dosages used and reported adverse events.

Design: Multicenter cross-sectional descriptive study.

Setting: Seven hemodialysis centers in Quebec and New Brunswick, Canada.

Patients: Adults receiving hemodialysis treatment with BMI of at least 30 kg/m² were included.

Measurements: Weight as defined by the target body weight (kg) at the end of dialysis. Body mass index is defined by weight, kg/m².

Methods: As a primary objective, we collected in records the body weights and calculated BMI at months 0, 3, 6, and 12 for participants with BMI of 30 kg/m² or greater. The dosages of semaglutide and the mention of any adverse events were also collected from questionnaire to participants, to community drug stores, and from records.

Results: A total of 1286 patients received hemodialysis treatments in June 2023. Of these, 396 (31%) had a BMI of 30 kg/m² or greater. Two hundred fifty-one participants were included in the study and 41 (16%) received semaglutide. The estimated treatment differences for the percentage change in body weight from baseline to 3, 6, and 12 months for semaglutide compared with the control group were -2.26%, 95% confidence interval (CI), -3.68 to -0.84, P = .002; -0.94%, 95% CI, -2.17 to 0.29, P = 0.135; and -0.64%; 95% CI, -2.04 to 0.76, P = .370, respectively. The estimated treatment differences at 3, 6, and 12 months for BMI were -0.87 kg/m², 95% CI, -1.38 to -0.36, P < .001; -0.35 kg/m², 95% CI, -0.79 to 0.09, P = .119; and -0.23 kg/m², 95% CI, -0.72 to 0.27, P = .371, respectively. The estimated treatment difference in body weight and BMI change between the 2 groups was statistically significant at 3 months. A sensitivity analysis was carried out with all the participants of the semaglutide group who continued the treatment for 12 months (N = 15). The estimated treatment differences for the percentage change in body weight between this group and the control group were -3.04%, 95% CI, -5.18 to -0.89, P = .006; -1.97%, 95% CI, -3.79 to -0.14, P = .035; and -2.83%, 95% CI, -4.66 to -1.00, P = .003 at 3, 6, and 12 months, respectively. The average body weight change between months 0 and 12 wa