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Background Guidelines recommend treatment of metabolic acidosis (MA) in patients with chronic kidney disease (CKD), but the diagnosis and treatment rates in real-world settings are unknown. We investigated the frequency of MA treatment and diagnosis in patients with CKD. Methods In this retrospective cohort study, we examined administrative health data from two US databases [Optum's de-identified Integrated Claims + Clinical Electronic Health Record Database (US EMR cohort; 1 January 2007 to 30 June 2019) and Symphony Health Solutions IDV® (US claims cohort; 1 May 2016 to 30 April 2019)] and population-level databases from Manitoba, Canada (1 April 2006 to 31 March 2018). Patients who met laboratory criteria indicative of CKD and chronic MA were included: two consecutive estimated glomerular filtration results Results A total of 96 184 patients were included: US EMR, 6179; Manitoba, 3223; US Claims, 86 782. Sodium bicarbonate treatment was prescribed for 17.6%, 8.7% and 15.3% of patients, and a diagnosis was found for 44.7%, 20.9% and 20.9% of patients, for the US EMR, Manitoba and US Claims cohorts, respectively. Conclusions This analysis of 96 184 patients with laboratory-confirmed MA from three independent cohorts of patients with CKD and MA highlights an important diagnosis and treatment gap for this disease-modifying complication.

Metabolic acidosis in patients with chronic kidney disease (CKD) results from a loss of kidney function. It has been associated with CKD progression, all-cause mortality, and other adverse outcomes. We aimed to determine whether metabolic acidosis is associated with a higher risk of acute kidney injury (AKI).This was a retrospective cohort study. Using electronic health records and administrative data, we enrolled 2 North American cohorts of patients with CKD Stages G3-G5 as follows: (i) 136,067 patients in the US electronic medical record (EMR) based cohort; and (ii) 34,957 patients in the Manitoba claims-based cohort. The primary exposure was metabolic acidosis (serum bicarbonate between 12 mEq/l and 22 mEq/l). The primary outcome was the development of AKI (defined using ICD-9 and 10 codes at hospital admission or a laboratory-based definition based on Kidney Disease: Improving Global Outcomes guidelines). We applied Cox proportional hazards regression models adjusting for relevant demographic and clinical characteristics.In both cohorts, metabolic acidosis was associated with AKI: hazard ratio (HR) 1.57 (95% confidence interval [CI] 1.52-1.61) in the US EMR cohort, and HR 1.65 (95% CI 1.58-1.73) in the Manitoba claims cohort. The association was consistent when serum bicarbonate was treated as a continuous variable, and in multiple subgroups, and sensitivity analyses including those adjusting for albuminuria.Metabolic acidosis is associated with a higher risk of AKI in patients with CKD. AKI should be considered as an outcome in studies of treatments for patients with metabolic acidosis.

The comparative effectiveness of radical prostatectomy (RP) versus radiation therapy (RT) for prostate cancer remains a largely debated topic. Utilizing a provincial population-based linked data set from an equal-access, universal health care system, we sought to compare outcomes among patients treated with either radiation or prostatectomy for nonmetastatic prostate cancer.We performed a retrospective cohort study by linking several administrative data sets to identify patients who were diagnosed with prostate cancer between 2004 and 2016 in Manitoba, Canada and who were subsequently treated with either RP or RT. Cox proportional hazard models with inverse probability of treatment weighting were used to compare rates of all-cause mortality, as well as prostate cancer specific mortality (PCSM) between patients who underwent RP vs RT.During the study period, 2,540 patients underwent RP and 1,895 underwent RT for prostate cancer. Unadjusted overall survival was higher for RP vs RT (5-year overall survival 95.52% for RP compared with 84.55% for RT, p0.0001). In inverse probability of treatment weighting-adjusted Cox regression analysis, compared to patients in the RP groups, patients in the RT group had an increased rate of all-cause mortality (HR 1.93, 95% CI 1.65-2.26, p0.0001), and PCSM (HR 3.98, 95% CI 2.89-5.49; p0.0001).RT was associated with higher all-cause mortality and PCSM rates compared with RP. These findings highlight the importance of comparative effectiveness research to identify treatment disparities and warrant further investigation.

Background The risk of adverse geriatric outcomes such as falls and fractures is high among patients with chronic kidney disease (CKD). Metabolic acidosis is associated with protein catabolism and bone loss in experimental animal and human studies. We sought to quantify the independent association of metabolic acidosis with adverse muscle, bone and functional outcomes in a large US community-based cohort. Methods The Optum's de-identified Integrated Claims-Clinical dataset of US patients (2007–2017) was used to generate a cohort of patients with nondialysis-dependent CKD who had estimated glomerular filtration rate >10 to Results A total of 51 558 patients qualified for the study, with a median [Interquartile Range (IQR)] follow-up time of 4.2 (2.5–5.8) years. Over a ≤10-year period, for each 1 mmol/L increase in serum bicarbonate, the hazard ratios (adjusted for age, sex, race, estimated glomerular filtration rate, serum albumin, hemoglobin, diabetes and cardiovascular comorbidities) for failure to thrive, protein-calorie malnutrition and fall or fracture were 0.91 [95% confidence interval (CI): 0.90–0.92], 0.91 (95% CI: 0.90–0.92) and 0.95 (95% CI: 0.95–0.96), all P < 0.001, respectively. Conclusions The presence and severity of metabolic acidosis was a significant, independent risk factor for failure to thrive, protein-calorie malnutrition and fall or fracture in this large community cohort of patients with stage 3–5 CKD.

Purpose:Treatment selection for localized prostate cancer is guided by risk stratification and patient preferences. While socioeconomic status (SES) disparities exist for access to care, less is kn...

Background: The First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis project was a point-of-care screening program in rural and remote First Nations communities in Manitoba that aimed to identify and treat hypertension, diabetes and chronic kidney disease. The program identified chronic disease in 20% of children screened. We aimed to characterize clinical screening practices before and after intervention in children aged 10–17 years old and compare outcomes with those who did not receive the intervention. Methods: This observational, prospective cohort study started with community engagement and followed the principles of ownership, control, access and possession (OCAP). We linked participant data to administrative data at the Manitoba Centre for Health Policy to assess rates of primary care and nephrology visits, disease-modifying medication prescriptions and laboratory testing (i.e., glycosylated hemoglobin [HbA1c], estimated glomerural filtration rate [eGFR] and urine albumin- or protein-to-creatinine ratio). We analyzed the differences in proportions in the 18 months before and after the intervention. We also conducted a 1:2 propensity score matching analysis to compare outcomes of children who were screened with those who were not. Results: We included 324 of 353 children from the screening program (43.8% male; median age 12.3 yr) in this study. After the intervention, laboratory testing increased by 5.8% (95% confidence interval [CI] 1.1% to 10.1%) for HbA1c, by 9.9% (95% CI 4.2% to 15.5%) for eGFR and by 6.2% (95% CI 2.3% to 10.0%) for the urine albumin- or protein-to-creatinine ratio. We observed significant improvements in laboratory testing in screened patients in the group who were part of the program, compared with matched controls. Interpretation: Chronic disease surveillance and care increased significantly in children after the implementation of a point-of-care screening program in rural and remote First Nation communities. Interventions such as active surveillance programs have the potential to improve the chronic disease care being provided to First Nations children.

BACKGROUND: In 2013–2015, we conducted point-of-care screening for hypertension, diabetes and chronic kidney disease in rural and remote Indigenous communities in Manitoba, Canada. In this study, we aimed to determine whether optimal follow-up care was provided, defined as proportion of individuals with appropriate kidney disease laboratory testing, medication prescriptions and physician visits. METHODS: We linked screening data from participants to provincial administrative data sets to evaluate whether frequencies of laboratory testing, prescriptions of disease-modifying medications, and primary care and nephrology visits differed in the 18 months before and after screening. We also conducted a propensity score matching analysis to compare outcomes between screened and unscreened adults. RESULTS: Of 1353 adults who received the screening intervention and who had complete administrative data available, 44% were at risk of kidney failure at screening. Among these individuals, frequencies of comprehensive laboratory testing (estimated glomerular filtration rate and urine albumin to creatinine ratio) improved by 17.0% (95% confidence interval [CI] 11.5 to 22.5), anti-hyperglycemic medications improved by 4.4% (95% CI 1.0 to 7.8), and nephrology visits for participants meeting referral criteria improved by 5.9% (95% CI 3.4 to 8.5). We observed significant improvements in laboratory testing, antihyperglycemic medications and nephrology visits in the screened group compared with the 1:1 matched comparison group. INTERPRETATION: Point-of-care screening programs in rural and remote Indigenous communities are adaptable methods for increasing awareness, monitoring risk and treating chronic diseases. Interventions such as the development of a national screening program could improve chronic disease care in high-risk populations.

Objective Lower limb complications are major adverse events in patients with peripheral artery disease (PAD) and chronic kidney disease (CKD). These complications can lead to morbidity, disability, reduced quality of life, and higher health care costs. We sought to determine how interim lower limb complications modify the subsequent risk of progression to kidney failure, all-cause mortality before kidney failure, and cardiovascular (CV) events in a cohort of patients with CKD stages G3 to G5. Methods We performed a retrospective cohort study using patient-level data obtained by linking several administrative databases from Manitoba, Canada. We used Fine and Gray regression models for the primary outcomes of (1) kidney failure adjusted for the competing risk of all-cause mortality, (2) death before kidney failure, and (3) cardiovascular-related hospitalization with the competing risk of non-CV death. Results A total of 92,618 patients were included in the final cohort, with a median follow-up time of 2.56 years. Compared with patients who did not experience an interim lower limb complication, there was a higher risk of kidney failure (adjusted hazard ratio [HR] 2.51, 95% confidence interval [CI] 2.10–3.00), all-cause mortality before kidney failure (adjusted HR 2.73, 95% CI 2.55–2.92), and CV events (adjusted HR 2.12, 95% CI 1.90–2.38). Conclusions Interim lower limb complications are associated with an increased risk of kidney failure, all-cause mortality before kidney failure, and cardiovascular-related hospitalization. Clinical trials of screening and treatment strategies for patients with CKD at risk for lower limb complications may help determine optimal strategies to manage this risk., Graphical abstract

Introduction Interventions are needed to improve early detection of indications for dialysis before development of severe symptoms or complications. This may reduce suboptimal dialysis starts, prevent hospitalizations, and decrease costs. Our objectives were to explore assumptions around a nurse-led virtual case management intervention for patients with late-stage chronic kidney disease (CKD) with a 2-year Kidney Failure Risk Equation (KFRE) estimated risk of kidney failure ≥80% and to estimate how these assumptions affect potential cost savings. Methods We performed a cost-minimization analysis by developing a decision analytic microsimulation model constructed from the perspective of the health payer. Our primary outcome was the break-even point, defined as the maximum amount a health payer could spend on the intervention without incurring any net financial loss or gain. The intervention group received remote telemonitoring, including daily measurement of several health metrics (blood pressure, oxygen saturation, and weight), and a validated symptom questionnaire accompanied by nurse-led case management, whereas the comparator group received usual care. We assumed patients received the intervention for a maximum of 2 years. Results The break-even point was $7339 per late-stage CKD patient enrolled in the intervention. Based on the distribution of time receiving the intervention, we determined a maximum monthly intervention cost of $703.37. In probabilistic sensitivity analyses, we found that 75% of simulations produced break-even points between $3929 and $9460. Conclusion Nurse-led virtual home monitoring interventions in patients with CKD at high risk of kidney failure have the potential for significant cost savings from the perspective of the health payer., Graphical abstract

Chronic kidney disease (CKD) and acute kidney injury (AKI) are global public health problems associated with a significant burden of morbidity, healthcare resource use, and all-cause mortality. This review explores recently published studies that take a machine learning approach to the diagnosis, management, and prognostication in patients with AKI or CKD.The release of novel therapeutics for CKD has highlighted the importance of accurately identifying patients at the highest risk of progression. Many models have been constructed with reasonable predictive accuracy but have not been extensively externally validated and peer reviewed. Similarly, machine learning models have been developed for prediction of AKI and have found sufficient accuracy. There are issues to implementing these models, however, with conflicting results with respect to the relationship between prediction of an AKI outcome and improvements in the occurrence of other adverse events, and in some circumstances potential harm.Artificial intelligence models can help guide management of CKD and AKI, but it is important to ensure that they are broadly applicable and generalizable to various settings and associated with improved clinical decision-making and outcomes.

INTRODUCTION AND OBJECTIVE:Effective therapy to reduce risk of RCC relapse after surgery remains an unmet need. Adjuvant immune therapy is a potential strategy for these pts. The KEYNOTE-564 trial ...

Home-based peritoneal dialysis (PD) is an alternative to facility-based hemodialysis and has lower costs and greater freedom for patients with kidney failure. For a patient to undergo PD, a safe and reliable method of accessing the peritoneum is needed. However, different catheter insertion techniques may affect patient health outcomes.To compare the risk of infectious and mechanical complications between surgical (open and laparoscopic) PD catheter insertion and percutaneous catheter insertion.Systematic review and meta-analysis.We searched for observational studies and randomized controlled trials (RCTs) in CENTRAL, EMBASE, MEDLINE, PubMed, and SCOPUS from inception until June 2018. Data were extracted by 2 independent reviewers based on a preformed template.Adult (aged 18+) patients with kidney failure who underwent a PD catheter insertion procedure.We analyzed leak, malfunction, and bleed as early complications (occurring within 1 month of catheter insertion). Infectious complications (exit-site infections, tunnel infections, and peritonitis) were presented as both early complications and with the longest duration of follow-up.Random effects meta-analyses with the generic inverse variance method to estimate pooled rate ratios and 95% confidence intervals. We quantified heterogeneity by using the I2 statistic for inconsistency and assessed heterogeneity using the χTwenty-four studies (22 observational, 2 RCTs) with 3108 patients and 3777 catheter insertions were selected. Data from 2 studies were unable to be extracted and were qualitatively assessed. In the remaining 22 studies, percutaneous insertion was associated with a lower risk of both exit-site infections (risk ratio [RR] = 0.36, 95% confidence interval [CI] = 0.24-0.53, ILack of consistency in the time periods for the various outcomes reported, risk of bias concerns with respect to population comparability, and the inability to analyze individual component causes of primary nonfunction (catheter obstruction, catheter migration, and leak).Our meta-analysis suggests differences in early infectious complications in favor of percutaneous insertion and no significant differences in mechanical complications compared with surgical insertion. These findings have implications on the direction of PD programs in terms of maximizing operating room resources.La dialyse péritonéale à domicile (DPD) est une alternative plus économique à l’hémodialyse en centre et offre une plus grande liberté aux patients atteints d’insuffisance rénale. Or, pour qu’un patient soit traité par DPD, il est essentiel de recourir à une méthode d’accès au péritoine qui soit fiable et sûre. Les techniques existantes pour l’insertion du cathéter sont toutefois susceptibles d’affecter les résultats de santé du patient.Comparer le risque de complications mécaniques et infectieuses entre l’insertion chirurgicale (incision et laparoscopie) et percutanée d’un cathéter de DP.Revue systématique et méta-analyse.Nous avons consulté les bases de données CENTRAL, EMBASE, MEDLINE, PubMed et SCOPUS à la recherche d’études observationnelles et d’essais contrôlés à répartition aléatoire (ECRA) de la création à juin 2018. Deux réviseurs indépendants ont procédé à l’extraction des données en suivant un modèle préformé.Des adultes atteints d’insuffisance rénale ayant subi une procédure d’insertion d’un cathéter de DP.Nous avons analysé les fuites, le dysfonctionnement et les saignements comme des complications précoces (survenant dans le mois suivant l’insertion du cathéter). Les complications infectieuses (infections au point de sortie, infections des tunnels, péritonite) ont été présentées comme complications précoces et avec la plus longue durée de suivi.Nous avons procédé à des méta-analyses selon la méthode générique de l’inverse de la variance avec effets aléatoires pour estimer les rapports des taux combinés et les intervalles de confiance à 95 %. L’hétérogénéité a été quantifiée en utilisant la statistique I2 pour l’incohérence et a été évaluée par le test du Chi-Deux. L’analyse de sensibilité a été réalisée en retirant les études présentant un risque élevé de biais, lesquelles ont été définies à l’aide de l’échelle Newcastle-Ottawa et de l’outil Cochrane sur le risque de biais.En tout, 24 études (22 études observationnelles, 2 ECRA) ont été sélectionnées, ce qui représente 3 108 patients et 3 777 insertions de cathéters. Les données de deux études n’ont pu être extraites et ont été évaluées qualitativement. Dans les 22 autres études, l’insertion percutanée a été associée, dans le mois suivant la procédure, à un risque plus faible d’infections au site de sortie (RR = 0,36; IC à 95 %: 0,24-0,53; ILes résultats sont limités par le manque de cohérence dans les périodes associées aux divers résultats signalés, le risque de biais quant à la comparabilité des populations et l’incapacité d’analyser les causes individuelles du non-fonctionnement primaire (obstruction du cathéter, migration du cathéter, fuite).Notre méta-analyse suggère des différences en faveur de l’insertion percutanée par rapport à l’insertion chirurgicale pour les complications infectieuses précoces, mais aucune différence significative en ce qui concerne les complications mécaniques. Ces résultats ont des implications sur l’orientation des programmes de DP relativement à l’optimisation des ressources du bloc opératoire.

Interventions that increase physical activity behavior can reduce morbidity and prolong life, but long-term effects in large populations are unproven. This study investigates the association of medical fitness facility membership and frequency of attendance with all-cause mortality and rate of hospitalization.A propensity weighted retrospective cohort study was conducted by linking individuals who attended medical fitness facilities in Winnipeg, Canada to provincial health administrative databases. Members aged ≥18 years who had ≥1 year of provincial health coverage from their index date between January 1, 2005 and December 31, 2015 were included. Controls were assigned a pseudo-index date at random on the basis of the frequency distribution of index dates in the intervention group. Members were stratified into low-frequency attenders (1 weekly visit), moderate-frequency attenders (1-3 weekly visits), and high-frequency attenders (3 weekly visits). The primary outcomes were time to all-cause mortality and rate of hospitalizations. Statistical analyses were performed between 2018 and 2020.Among 19,300 adult members and 515,810 controls, members had a 60% lower risk of all-cause mortality during the first 651 days and 48% after 651 days. Membership was associated with a 13% lower risk of hospitalizations. A dose-response effect was apparent because higher weekly attendance was associated with a lower risk of hospitalizations (low frequency: 9%, moderate frequency: 20%, high frequency: 39%).Membership at a medical fitness facility was associated with a reduced risk of all-cause mortality and hospitalizations. Healthcare systems should consider the medical fitness model as a preventative public health strategy to encourage physical activity participation.

Background and Aims The number of patients receiving dialysis is increasing in the United Kingdom, costing the National Health Service (NHS) over 500 million GBP annually. New personal haemodialysis systems are being developed, such as the Quanta SC+, that are smaller and simpler to use by patients while providing the clearances of conventional systems. Increasing uptake of lower intensity assistance and full self-care dialysis may provide economic benefits to the public health payer. In addition, promotion of every other day dialysis (3.5x weekly) may improve costs to the health system by helping to close the “post-weekend effect” with increased emergency department use and hospitalisations following the long interdialytic gap. As such, we aimed to describe the annual therapy costs of using SC+ in the UK for 3x weekly and 3.5x weekly dialysis regimens, both for self-care haemodialysis provided in-centre and at home in comparison to dialysis provided with conventional machines from the perspective of the health care system. Method Cost minimisation approach. Costs for human resources, equipment, and consumables were sourced from the dialysis machine developer (Quanta Dialysis Technologies). Other costs, such as facility expenses, dialysis-related drugs, avoided emergency department and hospitalisation events, and utilities were taken from a review of the literature. Costs are provided in 2018 GBP. Results Therapy provided as self-care in-centre or full self-care at home were found to have similar costs (£33,721 in-centre versus £33,836 at home for the 3x weekly regimen). Costs increased to £37,238 for self-care in-centre and £35,557 at home for the 3.5x weekly regimen. A comparator cost of £39,416 was established for dialysis provided with conventional machines in-hospital 3x weekly. For each dialysis patient, the health care system is anticipated to save £3,666 in costs associated with excess hospital stays and £2,176 in costs associated with excess emergency department visits. Conclusion In the UK, SC+ offers cost savings when used both for self-care in-centre and full self-care at home in comparison to dialysis provided in the clinic using conventional machines.

Background and Aims Chronic Kidney Disease (CKD) is a potent risk factor for kidney failure, cardiovascular events and all cause hospitalizations. In addition to higher outpatient resource use, patients with CKD may present more frequently to the emergency department (ED) and may be more likely to be admitted for hospitalization. In Manitoba, we previously demonstrated an 8-fold increase in the frequency of ED presentations by patients on dialysis as compared to a non-dialysis population. Comparable data on ED visits remain sparse for patients with CKD G3-G5, not on dialysis. Here, we aim to describe the frequency of ED visits and highlight differences in reasons for visit in patients with CKD stages G3-G5 and Those on dialysis when compared to a non-renal population. Method We performed a retrospective cohort study using administrative health data from the Winnipeg Regional Health Authority, Canada. We included all adults (≥ 18 years) with CKD stages G3-G5 and patients undergoing dialysis between January 1st, 2010 and December 31, 2014. Secular trends in the in the rates of ED visits were calculated for those with CKD, those on dialysis and in the non-renal population. Results Over the study period, patients undergoing dialysis had the highest incidence of ED visits, followed by patients with CKD and those with normal kidney function (150 vs 106 vs 34 per 100 persons per year respectively). These rates were stable over the period studied. Among the non-renal population, the most common reasons for an ED visit were musculoskeletal complaints (25.6%), followed by gastrointestinal (11.04%) and cardiovascular complaints (10.26%). In the CKD and dialysis cohort, ED visits were more commonly secondary to cardiovascular complaints (21.54% and 18.99% respectively), followed by respiratory and gastrointestinal complaints. Admission to hospital was higher in CKD and dialysis populations than in the non-renal population (29.56%, 26.07% vs 10.61%, respectively). Conclusion Patients with CKD present frequently to the ED, and are often admitted after presentation. Cardiovascular and respiratory complaints are more common in the CKD population.

Rationale & Objective Sedentary behavior and low physical activity are associated with incident diabetes, cardiovascular disease, and early mortality. Previous studies have examined associations between chronic kidney disease (CKD) and physical activity, but little is known about the role of sedentary time. Study Design Cross-sectional national survey. Setting & Participants A nationally representative sample of adults (n=8,444) participating in the Canadian Health Measures Survey's (CHMS) activity monitoring component (2007-2013). Predictor Estimated glomerular filtration rate (eGFR). Outcomes Sedentary time (total sedentary minutes/total wear time) measured using triaxial accelerometry. Analytical Approach Multivariable ordinal logistic regression for quartiles of sedentary time and linear regression for sedentary time measured on a continuous scale were performed in the entire study population and in the subgroup with CKD. Results Mean proportion of sedentary time ranged from 58% (least sedentary quartile: Q1) to 81% (most sedentary quartile: Q4). Lower eGFR, older age, lower serum albumin level, higher blood pressure, cardiovascular disease, diabetes, and higher body mass index were independently associated with a higher proportion of sedentary time. Patients with eGFRs Limitations Cross-sectional design precluded evaluation of longitudinal outcomes and establishment of the causal nature of observed associations. Small sample of individuals with advanced CKD. Conclusions In this cross-sectional survey, reduced eGFR was strongly and independently associated with greater sedentary time. This risk was further heightened by the presence of diabetes and arthritis. Studies to determine causes for sedentary behavior and assess the feasibility and value of interventions to reduce sedentary time in CKD are needed.

BACKGROUND: Indigenous populations are disproportionately affected by kidney failure at younger ages than other ethnic groups in Canada. As symptoms do not occur until disease is advanced, early kidney disease risk is often unrecognized. OBJECTIVES: We sought to evaluate the yield of community-based screening for early risk factors for kidney disease in youth from rural Indigenous communities in Canada. METHODS: The FINISHED project screened 11 rural First Nations communities in Manitoba, Canada after community and school engagement. The results for the 10- to 17-year olds are reported here. Body mass index (BMI), blood pressure, estimated glomerular filtration rate (eGFR), hemoglobin A1c’s (HbA1c) and urine albumin-to-creatinine ratios (ACR) were assessed. All children were triaged and referred to either primary or tertiary care, depending on risk. RESULTS: A total of 353 were screened (estimated 22.4% of population). The median age was 12 years (IQR 10 to 13), 55% were female and 55% were overweight or obese. Overall, 21.8% of children had at least one abnormality. Hypertension was identified in 5.4% and 11.9% had prehypertension. None of the children had an eGFR < 60 ml/min/1.73 m(2) however 10.5% had an ACR > 3 mg/mmol and 6.2% had an eGFR < 90 ml/min/1.73 m(2) suggestive of early kidney disease. Diabetes was identified in 1.4%, and 1.4% had HbA1c’s between 6.1% and 6.49%. CONCLUSIONS: Risk factors for chronic kidney disease are highly prevalent in rural Indigenous children. More research is required to confirm the persistence of these findings, and to evaluate the efficacy of screening children to prevent or delay progression to kidney failure.

Rationale & Objective Metabolic acidosis related to chronic kidney disease (CKD) is associated with an accelerated decline in glomerular filtration rate (GFR) and the development of end-stage kidney disease. Whether metabolic acidosis is associated with cardiovascular (CV) events in patients with CKD is unclear. Study Design Retrospective cohort study. Setting & Participants The Optum De-identified Electronic Health Records Dataset, 2007–2017, was used to generate a cohort of patients with non-dialysis-dependent CKD who had at least 3 estimated GFR < 60 mL/min/1.73 m2. Patients with metabolic acidosis (serum bicarbonate 12 to, Graphical abstract

Accurate risk prediction for chronic kidney disease (CKD) progression can inform the patient-provider dialogue, and provide actionable thresholds for key clinical decisions. In 2011, we developed the kidney failure risk equations (KFREs) to predict the risk of kidney failure requiring dialysis or transplant in patients with CKD. Subsequently, the KFREs have been extensively validated, and have now been proven accurate in multiple continents, ethnicities and disease-specific subpopulations. They can discriminate progressors from non-progressors, and are well calibrated and easy to use. We believe that current and future studies should now focus on clinical implementation of the KFREs, through quality improvement initiatives and cluster randomized trials. A risk-based care paradigm for CKD care can be achieved through knowledge translation and implementation research.

Background: Chronic kidney disease (CKD) is common in patients with type 2 diabetes mellitus (T2DM) and limits therapeutic options. Dipeptidyl peptidase-4 (DPP-4) inhibitors represent a novel class of oral glucose-lowering agents and are known to be safe and effective in the general population. Methods: We searched Cochrane, EMBASE, and PubMed from the time of their inception until March 2015. We included randomized controlled trials analyzing the efficacy (change in hemoglobin A1C [HbA1C]) and safety of DPP-4 agents in individuals with reduced kidney function (estimated glomerular filtration rate 2). We extracted study characteristics, participants' baseline characteristics, and safety outcomes from eligible studies. We performed a random effects meta-analysis to summarize the change in HbA1C and the relative risk of cardiovascular events in patients with T2DM and CKD. We also collected data on hypoglycemia, other serious adverse events, and mortality. Results: We reviewed 12 studies with 4,403 patients with CKD and 239 on dialysis, finding a mean weighted decline in HbA1C of -0.48 (95% CI -0.61 to -0.35) with DPP-4 inhibitor therapy compared to placebo. DPP-4 inhibitors did not result in any additional adverse events, hypoglycemic episodes, or increased mortality. Restricting to studies with low risk of bias did not alter these findings. Conclusions: DPP-4 inhibitors can lower HbA1C without increasing the risk of cardiovascular or other major adverse events in patients with CKD. Few studies reported critical adverse events such as heart failure and hypersensitivity. If compared with other oral antiglycemic drugs, the effect of DPP-4 inhibitors is limited; however, their low risk of hypoglycemia may favor their use in patients with CKD. Summary: This systematic review of DPP-4 inhibitors in CKD suggests that they reduce HbA1C by about 0.5%. Furthermore, there was not any increase in the risk for significant adverse events. More research is needed to determine the safety and efficacy of DPP-4 inhibitors in CKD.

IMPORTANCE: Published in 2010, the Initiating Dialysis Early and Late (IDEAL) randomized clinical trial, which randomized patients with an estimated glomerular filtration rate (GFR) between 10 and 15 mL/min/1.73 m(2) to planned initiation of dialysis with an estimated GFR between 10 and 14 mL/min/1.73 m(2) (early start) or an estimated GFR between 5 and 7 mL/min/1.73 m(2) (late start), concluded that early initiation was not associated with improved survival or clinical outcomes. OBJECTIVE: To assess the association between the IDEAL trial results and the proportion of early dialysis starts over time. DESIGN, SETTING, AND PARTICIPANTS: This interrupted time series analysis used data from the Canadian Organ Replacement Register to study adult (≥18 years of age) patients with incident chronic dialysis between January 1, 2006, and December 31, 2015, in Canada, which has a universal health care system. Patients from the province of Quebec were excluded because its privacy laws preclude submission of deidentified data without first-person consent. The patients included in the study (n = 28 468) had at least 90 days of nephrologist care before starting dialysis and a recorded estimated GFR at dialysis initiation. Data analyses were performed from November 2016 to January 2019. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of early dialysis starts (estimated GFR >10.5 mL/min/1.73 m(2)), and the secondary outcomes included the proportions of acute inpatient dialysis starts, patients who started dialysis using a home modality, and patients receiving hemodialysis who started with an arteriovenous access. Measures included the trend prior to the IDEAL trial publication, the change in this trend after publication, and the immediate consequence of publication. RESULTS: The final cohort comprised 28 468 patients, of whom 17 342 (60.9%) were male and the mean (SD) age was 64.8 (14.6) years. Before the IDEAL trial, a statistically significant increasing trend was observed in the monthly proportion of early dialysis starts (adjusted rate ratio, 1.002; 95% CI, 1.001-1.004; P = .004). After the IDEAL trial, an immediate decrease was observed in the proportion of early dialysis starts (rate ratio, 0.874; 95% CI, 0.818-0.933; P

Introduction: Uptake rates of home hemodialysis are the lowest among all modality types, despite providing patients with clinical and quality of life benefits at a lower cost to providers. Currently, there is a need to develop dialysis systems that are appealing to patients while also being suitable for use across the continuum of care. The SC+ hemodialysis system was developed by Quanta Dialysis Technologies Ltd. to provide patients with a dialysis system that is small, simple to use, and powerful enough to deliver acceptable dialysis adequacy. Methods: As part of the SC+ design validation, human factors testing was performed with 17 Healthcare Professionals (nephrology nurses and healthcare assistants) and 15 Home Users (patients and caregivers). To assess usability and safety, the human factors testing involved between 4.5 and 6 hours of training and, after a period of training decay, a subsequent test session in which participants independently performed tasks on SC+. Findings: Between the two user groups, there were only 29 errors observed out of 1216 opportunities for errors, despite minimal training. Errors that did occur were minor and attributed to an initial lack of familiarity with the device; none were safety related. Discussion: Among prevalent dialysis patients and healthcare professionals, the SC+ hemodialysis system was easy to use, even with minimal training and a learning decay period, and had a high level of use safety. By taking into account human factors to optimize the user experience, SC+ has the potential to address systemic and patient barriers, allowing for wider self‐care and home hemodialysis adoption.

Background Readmission following hospital discharge is common and is a major financial burden on healthcare systems. Objectives Our objectives were to 1) identify studies describing post-discharge interventions and their efficacy with respect to reducing risk of mortality and rate of hospital readmission; and 2) identify intervention characteristics associated with efficacy. Methods A systematic review of the literature was performed. We searched MEDLINE, PubMed, Cochrane, EMBASE and CINAHL. Our selection criteria included randomized controlled trials comparing post-discharge interventions with usual care on rates of hospital readmission and mortality in high-risk chronic disease patient populations. We used random effects meta-analyses to estimate pooled risk ratios for all-cause and cause-specific mortality as well as all-cause and cause-specific hospitalization. Results We included 31 randomized controlled trials encompassing 9654 patients (24 studies in CHF, 4 in COPD, 1 in both CHF and COPD, 1 in CKD and 1 in an undifferentiated population). Meta-analysis showed post-discharge interventions reduced cause-specific (RR = 0.71, 95% CI = 0.63–0.80) and all cause (RR = 0.90, 95% CI = 0.81–0.99) hospitalization, all-cause (RR = 0.73, 95% CI = 0.65–0.83) and cause-specific mortality (RR = 0.68, 95% CI = 0.54–0.84) in CHF studies, and all-cause hospitalization (RR = 0.52, 95% CI = 0.32–0.83) in COPD studies. The inclusion of a cardiac nurse in the multidisciplinary team was associated with greater efficacy in reducing all-cause mortality among patients discharged after heart failure admission (HR = 0.64, 95% CI = 0.54–0.75 vs. HR = 0.87, 95% CI = 0.73–1.03). Conclusions Post-discharge interventions reduced all-cause mortality, cause-specific mortality, and cause-specific hospitalization in CHF patients and all-cause hospitalization in COPD patients. The presence of a cardiac nurse was associated with greater efficacy in included studies. Additional research is needed on the impact of post-discharge intervention strategies in COPD and CKD patients.

Rationale & Objective The kidney failure population is growing, necessitating the expansion of dialysis programs. These programs are costly and require a substantial amount of health care resources. Tools that accurately forecast resource use can aid efficient allocation. The objective of this study is to describe the development of an economic simulation model that incorporates treatment history and detailed modality transitions for patients with kidney disease using real-world data to estimate associated costs, utility, and survival by initiating modality. Study Design Cost-utility model with microsimulation. Setting & Population Adult incident maintenance dialysis patients in Canada who initiated facility-based hemodialysis (HD) or home peritoneal dialysis (PD) between 2004 and 2013. Intervention HD and PD. Outcomes Costs (related to dialysis, transplantation, infections, and hospitalizations), survival, utility, and dialysis modality mix over time. Model, Perspective, & Timeframe The model took the perspective of the health care payer. Patients were followed up for 10 years from initiation of dialysis. Our cost-utility analysis compared the intervention with receiving no treatment. Results During a 10-year time horizon, the cost-utility ratio for all patients initiating dialysis was $103,779 per quality-adjusted life-year (QALY) in comparison to no treatment. Patients who initiated with facility-based HD were treated at a cost-utility ratio of $104,880/QALY and patients who initiated with home PD were treated at a cost-utility ratio of $83,762/QALY. During this time horizon, the total mean cost and QALYs per patient were estimated at $350,774 ± $204,704 and 3.38 ± 2.05) QALYs respectively. Limitations The results do not include costs from the societal perspective. Rare patient trajectories were unable to be assessed. Conclusions This model demonstrates that patients who initiated dialysis with PD were treated more cost-effectively than those who initiated with HD during a 10-year time horizon., Graphical abstract

A Rapid Bedside Screen to Predict Unplanned Hospitalization and Death in Outpatients With Cirrhosis: A Prospective Evaluation of the Clinical Frailty Scale

Introduction: Chronic Kidney Disease (CKD) is a potent risk factor for kidney failure, cardiovascular events and all cause hospitalizations. In addition to higher outpatient resource use, patients with CKD may present more frequently to the emergency department (ED) and may be more likely to be admitted for hospitalization. In Manitoba, we previously demonstrated an 8-fold increase in the frequency of ED presentations by patients on dialysis as compared to a non-dialysis population. Comparable data on ED visits remain sparse for patients with CKD G3-G5, not on dialysis. Here, we aim to describe the frequency of ED visits and highlight differences in reasons for visit in patients with CKD stages G3-G5 and those on dialysis when compared to a non-CKD population. Methods: We performed a retrospective cohort study using administrative health data from the Winnipeg Regional Health Authority, Canada. We included all adults (≥ 18 years) with CKD stages G3-G5 and patients undergoing dialysis between January 1st, 2010 and December 31, 2014. Secular trends in the in the rates of ED visits were calculated for those with CKD, those on dialysis and in the non-CKD population. Results: Over the study period, patients undergoing dialysis had the highest incidence of ED visits, followed by patients with CKD and those with normal kidney function (150 vs 106 vs 34 per 100 persons per year respectively). These rates were stable over the period studied. Among the non-CKD population, the most common reasons for an ED visit were musculoskeletal complaints (25.6%), followed by gastrointestinal (11.04%) and cardiovascular complaints (10.26%). In the CKD and dialysis cohort, ED visits were more commonly secondary to cardiovascular complaints (21.54% and 18.99% respectively), followed by respiratory and gastrointestinal complaints. . Admission to hospital was higher in CKD and dialysis populations than in the non-CKD population (29.56%, 26.07% vs 10.61%, respectively). Conclusion: Patients with CKD present frequently to the ED, and are often admitted after presentation. Cardiovascular and respiratory complaints are more common in the CKD population when compared to the general population.

361 Background: A large body of research has shown that there are strong socioeconomic disparities in access to cancer treatment. However, whether these inequalities persist among men with prostate cancer has not been previously explored in the equal-access, universal Canadian health care system. The aim of this study is to compare whether socioeconomic status is associated with the type of treatment received (radical prostatectomy (RP) versus radiation therapy (RT)) for men diagnosed with nonmetastatic prostate cancer in Manitoba, Canada. Methods: Men who were diagnosed with non-metastatic prostate cancer between 2004 and 2016 and subsequently treated with RP or RT were identified using the CancerCare Manitoba Registry and linked to provincial databases. SES was defined as neighbourhood income by postal code and divided into income quintiles (Q1-Q5, with Q1 the lowest quintile and Q5 the highest). Multivariable logistic regression nested models were used to compare whether socioeconomic status was associated with treatment type received. Results: We identified 4,560 individuals between 2004-2016 who were diagnosed with non-metastatic prostate cancer. 2,554 men were treated with RP and 2,006 with RT.As income quintile increased, men were more likely to undergo RP than RT (Q3 vs Q1: aOR 1.45 (1.09-1.92); Q5 vs. Q1: aOR 2.17, 95% CI 1.52-2.86). Conclusions: Despite a universal health care system, socioeconomic inequities are present for men seeking primary treatment for prostate cancer. Further investigation into the decision making process among patients diagnosed with prostate cancer may inform decision making to ameliorate these disparities.

Predicting allograft failure in kidney transplant recipients can help plan renal replacement therapy and guide patient-provider communication. The kidney failure risk equation (KFRE) accurately predicts the need for dialysis in patients with chronic kidney disease (CKD), but has not been validated in kidney transplant recipients.We sought to validate the 4-variable KFRE (age, sex, estimated glomerular filtration rate [eGFR], and urine albumin-to-creatinine ratio [ACR]) for prediction of 2- and 5-year death-censored allograft failure.Retrospective cohort study.Four independent North American Cohorts from Ontario, Canada; Alberta, Canada; Manitoba, Canada; and Wisconsin, United States, between January 1999 and December 2017.Adult kidney transplant patients at 1-year posttransplantation.Kidney failure risk as measured by the KFRE (eGFR, urine ACR, age, and sex).We included all adult patients who had at least 1 serum creatinine and at least 1 urine ACR measurement approximately 1 year following kidney transplantation. The performance of the KFRE was evaluated using the area under the receiver operating characteristic curve (C-statistic). C-statistics from the 4 cohorts were meta-analyzed using random-effects models.A total of 3659 patients were included. Pooled C-statistics were good in the entire population, at 0.81 (95% confidence interval: 0.72-0.91) for the 2-year KFRE and 0.73 (0.67-0.80) for the 5-year KFRE. Discrimination improved among patients with poorer kidney function (eGFR45 mL/min/1.73 mThe KFRE does not predict episodes of acute rejection and there was heterogeneity between cohorts.The KFRE accurately predicts kidney failure in kidney transplant recipients at 1-year posttransplantation. Further validation in larger cohorts with longer follow-up times can strengthen the case for clinical implementation.En transplantation rénale, la capacité de prévoir la défaillance du greffon permet de planifier une thérapie de remplacement rénal et de guider la communication entre le patient et son soignant. L’équation KFRE (Nous souhaitions valider le pouvoir prédictif de l’équation KFRE à 4 variables (âge, sexe, débit de filtration glomérulaire estimé [DFGe] et rapport albumine-créatine urinaire [RAC]) quant à la défaillance du greffon après deux ans et cinq ans.Étude de cohorte rétrospective.Quatre cohortes indépendantes d’Amérique du Nord : trois provinces canadiennes (Ontario, Alberta et Manitoba) et un état américain (Wisconsin) entre janvier 1999 et décembre 2017.Des adultes receveurs d’une greffe rénale, un an après l’intervention.Le risque d’évolution vers l’insuffisance rénale, tel que mesuré par l’équation KFRE (DFGe, RAC urinaire, âge et sexe).Ont été inclus tous les patients adultes ayant eu au moins une mesure de la créatinine sérique et du RAC urinaire environ un an après la greffe. La performance de la KFRE a été évaluée par la surface sous la courbe ROC (statistique C). Des modèles à effets aléatoires ont été employés pour la méta-analyse des statistiques C pour les quatre cohortes.Un total de 3 659 patients a été inclus. Les statistiques C regroupées ont été bonnes dans l’ensemble de la population étudiée, avec des valeurs de 0,81 (intervalle de confiance à 95 % : 0,72-0,91) pour la prédiction sur deux ans et de 0,73 (0,67-0,80) pour la prédiction sur cinq ans. La discrimination s’est avérée encore meilleure pour les patients qui présentaient une plus faible fonction rénale (DFGe45 ml/min/1,73 mLa KFRE ne peut prédire les épisodes de rejet aigu et les cohortes étudiées comportaient une grande hétérogénéité.L’équation KFRE prédit avec exactitude le risque de défaillance du greffon dans notre population de receveurs d’une greffe rénale, un an après l’intervention. Poursuivre la validation dans de plus vastes cohortes et pour des temps de suivi prolongés viendrait appuyer le cas en vue de son application clinique.

Rationale & Objectives Chronic kidney disease (CKD) is a potent risk factor for macrovascular disease and death. Peripheral artery disease (PAD) is more common in patients with CKD and is associated with lower-limb complications and mortality. We sought to compare the prevalence of PAD in and outside the setting of kidney disease and examine how PAD affects the risk for adverse health outcomes, specifically lower-limb complications, cardiovascular events, and survival. Study Design Retrospective cohort study. Setting & Participants 453,573 adult residents of Manitoba with at least 1 serum creatinine measurement between 2007 and 2014. Exposure PAD defined by hospital discharge diagnosis codes and medical claims. Outcomes All-cause mortality, cardiovascular events, and lower-limb complications, including foot ulcers and nontraumatic amputations. Analytical Approach Survival analysis using Cox proportional hazards models. Results The prevalence of PAD in our study population was 4.5%, and patients with PAD were older, were more likely to be male, and had a higher burden of comorbid conditions, including diabetes and CKD. PAD was associated with higher risks for all-cause mortality, cardiovascular events, and lower-limb complications in patients with estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73 m2, those with CKD GFR categories 3 to 5 (G3-G5), and those treated by dialysis (CKD G5D). Although HRs for PAD were lower in the CKD population, event rates were higher as compared with those with eGFR ≥ 60 mL/min/1.73 m2. In particular, compared with patients with eGFR ≥ 60 mL/min/1.73 m2 and without PAD, patients with CKD G5D had 10- and 12-fold higher risks for lower-limb complications, respectively (adjusted HRs of 10.36 [95% CI, 8.83-12.16] and 12.02 [95% CI, 9.58-15.08] for those without and with PAD, respectively), and an event rate of 75/1,000 patient-years. Limitations Potential undercounting of PAD and complications using administrative codes and the limited ability to examine quality-of-care indicators for PAD. Conclusions PAD is more common in patients with CKD G3-G5 and G5D compared with those with eGFR ≥ 60 mL/min/1.73 m2 and frequently leads to lower-limb complications. Medical interventions and care pathways specifically designed to slow or prevent the development of lower-limb complications in this population are urgently needed.

Recent studies have demonstrated that measurement of areal bone mineral density by dual-energy x-ray absorptiometry (DXA) predicts fractures in patients with chronic kidney disease (CKD). However, whether fracture risk prediction through bone mineral density (BMD) is enhanced due to the assessment of biochemical markers of chronic kidney disease and mineral and bone disease (CKD-MBD) or clinical risk factors is not clear. We hypothesized that in a select cohort of patients managed in a CKD clinic, that combiningTo examine the relationships among BMD, biochemical markers of CKD-MBD, and fracture risk across Kidney Disease Improving Global Outcomes (KDIGO) glomerular filtration rate (GFR) categories G3a to G5.Retrospective study.Patients were recruited from the multidisciplinary CKD clinic, Regina General Hospital, Canada.A total of 374 patients who received a DXA scan upon initial referral to Regina Multidisciplinary CKD Program from January 31, 2001 to January 31, 2010, were included in this study. The patients were followed for a total of 5 years.We conducted a retrospective review of 374 consecutive patients who underwent DXA imaging at the point of entry into our multidisciplinary CKD program. Areal BMD,In our cohort, 14.3% of GFR categories G3a and G3b, 15.7% of GFR category G4, and 19.7% of GFR category G5 experienced a clinical fracture during the study period. On multivariate analysis, each decline of 1.0 SD in total hip BMDSelf-reporting by patients and administrative records were used to identify fractures. We did not perform spine imaging to ascertain morphometric vertebral fractures. We were unable to gather all 11 variables of FRAX score and information on ethnicity. We were unable to capture site of fracture (hips, spine, etc) from billing records. Albumin excretion rates were not collected at baseline. Treatment of the underlying bone disease with pharmacotherapeutic agents may have attenuated patients' fracture risk and thus underestimated the association between BMD and future fracture.Our findings confirm that BMD predicts fracture. The addition of cross-sectional CKD-MBD parameters and clinical risk factors to BMD did not add to fracture prediction. Prospective studies should investigate the utility of longitudinal biochemical markers on improving fracture risk assessment.Des études récentes ont démontré qu’il était possible de prédire les fractures chez les patients atteints d’insuffisance rénale chronique (IRC) avec une mesure de la densité minérale osseuse (DMO) surfacique par absorptiométrie biénergétique à rayons X (DXA). On ignore cependant si la valeur prédictive de la DMO est améliorée par l’analyze des biomarqueurs des troubles minéraux et osseux associés à l’IRC (TMO-IRC) ou des facteurs de risque cliniques. Nous avons émis l’hypothèse que, dans une cohorte choisie de patients suivis en clinique d’IRC, la combinaison des scores T et des marqueurs biochimiques optimiserait la discrimination des fractures par rapport à l’utilization de la DXA seule.L’étude visait à établir un lien entre la DMO, les biomarqueurs des TMO-IRC et le risque de fractures chez les patients présentant un débit de filtration glomérulaire (DFG) de catégories G3a à G5 selon la classification du KDIGO (Étude rétrospective.Les patients ont été recrutés à la clinique multidisciplinaire d’IRC de l’hôpital général de Régina (Canada).Ont été inclus les 374 patients ayant passé un test d’imagerie DXA entre le 31 janvier 2001 et le 31 janvier 2010 lors de leur aiguillage vers le program multidisciplinaire d’IRC de Régina. Les patients ont été suivis sur une période de cinq ans.Nous avons mené une étude rétrospective portant sur 374 patients consécutifs examinés par DXA à leur admission au program. La DMO surfacique et les scores T et Z ont été mesurés au rachis lombaire, à la hanche totale, à la moyenne des cols fémoraux droit et gauche, et au tiers du radius. On a recueilli les caractéristiques démographiques des patients, les données sur les marqueurs biochimiques transversaux du métabolisme minéral et les fractures subies (recensées à l’aide d’un questionnaire d’auto-déclaration et par consultation des dossiers médicaux électroniques et des registres de facturation des médecins). Nous sommes parvenus à rassembler des données sur huit variables des onze de l’outil FRAX (Dans notre cohorte, 14,3 % des patients avec un DFG de catégorie G3a-G3b, 15,7 % des patients avec un DFG de catégorie G4 et 19,7 % des patients avec un DFG de catégorie G5 ont subi une fracture clinique au cours de la période d’étude. Dans l’analyze multivariée, chaque déclin d’un point d’écart-type au score T de la DMO à la hanche a été associé à une augmentation significative du risque de fracture (RR = 1,46; IC 95 %: 1,12-1,89). L’ajout des marqueurs des TMO-IRC et des facteurs de risque cliniques n’a pas contribué davantage au modèle. Une faible DMO s’est avérée le seul facteur de risque indépendant de subir une fracture chez les patients atteints d’IRC.Les fractures ont été identifiées à partir des dossiers administratifs et par auto-déclaration des patients. Nous n’avons pas procédé à l’imagerie de la colonne vertébrale pour confirmer les fractures vertébrales morphométriques. Nous n’avons pas été en mesure de rassembler les onze variables du score FRAX ni les informations sur l’origine ethnique des patients. Les registres de facturation ne nous ont pas permis d’établir le site de la fracture (hanche, rachis ou autre). Les taux initiaux d’excrétion de l’albumine n’ont pas été mesurés. Le traitement de l’ostéopathie sous-jacente à l’aide d’agents pharmacothérapeutiques pourrait avoir atténué le risque de fracture des patients et ainsi, sous-évalué l’association entre la DMO et de futures fractures.Nos résultats confirment que la DMO est prédictive du risque de fractures. L’ajout des paramètres transversaux des TMO-IRC et des facteurs de risque cliniques à la mesure de DMO n’en a pas amélioré la valeur prédictive. Des études prospectives devraient examiner l’intérêt des marqueurs biochimiques longitudinaux pour améliorer l’évaluation du risque de fracture.

Background Exercise rehabilitation may help maintain physical function in chronic kidney disease (CKD), but long-term clinical effectiveness is unknown. We evaluated the effect of an exercise rehabilitation program on physical function over 1 year in individuals with CKD. Methods This clinical program evaluation included adults with CKD (any stage) registered in a provincial renal program from 1 January 2011 to 31 March 2016. Attenders were referred to and attended a 10-week exercise rehabilitation program (n = 117). Nonattenders were referred, but did not attend the program (n = 133). Individuals enrolled in a longitudinal frailty study (n = 318) composed a second control group. Primary outcome: Change in physical function [short physical performance battery (SPPB) score]. Secondary outcomes included change in health-related quality of life, physical activity, exercise behaviour, hospitalization over 1 year. Predictors of improved SPPB were assessed using logistic regression. Results In sum, 53, 40 and 207 participants completed 1-year follow-up in attender, nonattender and second control groups, respectively. Baseline median SPPB [interquartile range (IQR)] scores were 10.5 (9–12), 10 (8–12) and 9 (7–11) in attender, nonattender and second control groups, respectively (P = 0.02). Mean change in SPPB score over 1 year was not significantly different between groups (P = 0.7). Attenders with baseline SPPB score Conclusions The impact of clinical exercise rehabilitation programs on physical function at 1 year needs further delineation. However, our observation of improved exercise behaviour at 1 year suggests sustained benefits with such programs in CKD.

Hepatic encephalopathy (HE) is the most common potentially modifiable reason for admission in patients with cirrhosis. Cognitive and physical components of frailty have pathophysiologic rationale as risk factors for HE. We aimed to assess the utility of a composite score (MoCA–CFS) developed using the Montreal Cognitive Assessment (MoCA) and the Clinical Frailty Scale (CFS) for predicting HE admissions within 6 months. Consecutive adult patients with cirrhosis were followed for 6 months or until death/transplant. Patients with overt HE and dementia were excluded. Primary outcome was the prediction of HE-related admissions at 6 months. A total of 355 patients were included; mean age 55.9 ± 9.6; 62.5% male; Hepatitis C and alcohol etiology in 64%. Thirty-six percent of patients had cognitive impairment according to the MoCA (≤24) and 14% were frail on the CFS (>4). The MoCA–CFS independently predicted HE hospitalization within 6 months, a MoCA–CFS score of 1 and 2 respectively increasing the odds of hospitalization by 3.3 (95% CI:1.5–7.7) and 5.7 (95% CI:1.9–17.3). HRQoL decreased with increasing MoCA–CFS. Depression and older age were independent predictors of a low MoCA. Cognitive and physical frailty are common in patients with cirrhosis. In addition to being an independent predictor of HE admissions within 6 months, the MoCA-CFS composite score predicts impaired HRQoL and all-cause admissions within 6 months. These data support the predictive value of a “multidimensional” frailty tool for the prediction of adverse clinical outcomes and highlight the potential for a multi-faceted approach to therapy targeting cognitive impairment, physical frailty and depression.

Glomerular filtration rate (GFR) is rarely measured in clinical practice because of the complexity of the measurement. As such, kidney function is typically estimated using validated study equations, which use readily available data including age, sex, race, and serum creatinine as filtration marker. Contemporary research suggests that cystatin C may be an improved alternative to creatinine for inclusion in GFR estimating equations. The purpose of this article is to evaluate the benefits and limitations of using cystatin C as a biomarker of filtration.Cystatin C has fewer non-GFR determinants, when compared with serum creatinine. Use of serum cystatin C avoids the limitations related to both diet and muscle mass that affect serum creatinine. Cystatin C may be more accurate than serum creatinine in estimating GFR, and is more strongly associated with all-cause mortality and cardiovascular events.Cystatin C has some advantages over serum creatinine in estimating GFR. The use of cystatin C as a confirmatory biomarker in deciding medication dosages or as a confirmatory test in patients with an uncertain diagnosis of chronic kidney disease may be beneficial.

Background: Anemia is a common complication associated with kidney failure and is marked by poor health and increased risk of morbidity and mortality. There are ongoing concerns with the use of Erythropoietin Stimulating Agents (ESAs) to treat anemia in patients with kidney failure on dialysis. Questions as to their benefits, harms and overall effect on quality of life are still relevant today. Our objective was to systematically review studies evaluating the cost-effectiveness of ESAs in patients with kidney failure on dialysis. Methods: We performed a systematic review of studies determining the cost-effectiveness of ESAs in adult patients on dialysis. Databases, including PubMed, EMBASE, and Cochrane Database of Systematic Reviews, were searched from their establishment until June 2013. Studies that reported an incremental cost-effectiveness ratio of hemoglobin correction strategies based on ESA treatments in comparison to red blood cell transfusions, lower hemoglobin targets, or no ESA treatment were included. Results: Seven studies met inclusion criteria. Reported cost/quality-adjusted life-year (QALY) ratios ranged from USD 931-677,749/QALY across five studies comparing ESAs to red blood cell transfusions. There was heterogeneity in results when considering higher hemoglobin targets, with studies finding higher targets to be both dominant and dominated. Mortality, hospitalization, and utility estimates were major drivers. Conclusions: There is substantial variability in the estimates of the cost-effectiveness of using ESAs in the dialysis population. New models incorporating recent meta-analyses for estimates of utility, mortality, and hospitalization changes would allow for a more comprehensive answer to this question.

Background and objectives The safety of intravenous iron dosing in dialysis is uncertain. Higher-dose intravenous iron may be associated with a higher risk of infections, cardiovascular events, hospitalizations, and mortality. This systematic review aimed to determine the safety of higher-dose versus lower-dose intravenous iron, oral iron, or no iron supplementation in adult patients treated with dialysis. Design, setting, participants, & measurements We searched Medline, EMBASE, Cochrane library, and CINAHL from inception to January 6, 2017 for randomized, controlled trials and observational studies comparing higher-dose intravenous iron with lower-dose intravenous iron, oral iron, or no iron in patients treated with dialysis that had all-cause mortality, infection, cardiovascular events, or hospitalizations as outcomes. Results Of the 2231 eligible studies, seven randomized, controlled trials and 15 observational studies met inclusion criteria. The randomized, controlled trials showed no association between higher-dose intravenous iron (>400 mg/mo for most studies) and mortality (six studies; n =970; pooled relative risk, 0.93; 95% confidence interval, 0.47 to 1.84; follow-up ranging from 35 days to 26 months) or infection (four studies; n =743; relative risk, 1.02; 95% confidence interval, 0.74 to 1.41). The observational studies showed no association between higher-dose intravenous iron (>200 mg/mo for most studies) and mortality (eight studies; n =241,408; hazard ratio, 1.09; 95% confidence interval, 0.98 to 1.21; follow-up ranging from 3 to 24 months), infection (eight studies; n =135,532; pooled hazard ratio, 1.13; 95% confidence interval, 0.99 to 1.28), cardiovascular events (seven studies; n =135,675; hazard ratio, 1.18; 95% confidence interval, 0.90 to 1.56), or hospitalizations (five studies; n =134,324; hazard ratio, 1.08; 95% confidence interval, 0.97 to 1.19). Conclusions Higher-dose intravenous iron does not seem to be associated with higher risk of mortality, infection, cardiovascular events, or hospitalizations in adult patients on dialysis. Strength of this finding is limited by small numbers of participants and events in the randomized, controlled trials and statistical heterogeneity in observational studies.

Background There is little certainty as to the prevalence of frailty in Canadians in younger adulthood. This study examines and compares the prevalence of frailty in Canadians 18–79 years old using the Accumulation of Deficits and Fried models of frailty. Methods The Canadian Health Measures Study data were used to estimate the prevalence of frailty in adults 18–79 years old. A 23-item Frailty Index using the Accumulation of Deficits Model (cycles 1–3; n = 10,995) was developed; frailty was defined as having the presence of 25% or more indices, including symptoms, chronic conditions, and laboratory variables. Fried frailty (cycles 1–2; n = 7,353) included the presence of ≥3 criteria: exhaustion, physical inactivity, poor mobility, unintentional weight loss, and poor grip strength. Results The prevalence of frailty was 8.6 and 6.6% with the Accumulation of Deficits and the Fried Model. Comparing the Fried vs. the Accumulation of Deficits Model, the prevalence of frailty was 5.3% vs. 1.8% in the 18–34 age group, 5.7% vs. 4.3% in the 35–49 age group, 6.9% vs. 11.6% in the 50–64 age group, and 7.8% vs. 20.2% in the 65+ age group. Some indices were higher in the younger age groups, including persistent cough, poor health compared to a year ago, and asthma for the accumulation of deficits model, and exhaustion, unintentional weight loss, and weak grip strength for the Fried model, compared to the older age groups. Conclusions These data show that frailty is prevalent in younger adults, but varies depending on which frailty tool is used. Further research is needed to determine the health impact of frailty in younger adults. Electronic supplementary material The online version of this article (doi:10.1186/s12877-017-0423-6) contains supplementary material, which is available to authorized users.

Kidney Failure is highly prevalent and uses a disproportionate amount of health care funding. In Canada (excluding Quebec), 37 647 people were living with kidney failure in 2016. The single-payer Canadian health care system spends approximately 1.2% of their annual budget on kidney failure. In 2016, 58.4% of patients with kidney failure in Canada (excluding Quebec) were on dialysis as opposed to living with a functioning kidney transplant. Home dialysis modalities including peritoneal dialysis (PD) and home hemodialysis (HD) were used by 18.9% and 4.7% of these patients, respectively. In-center HD and home dialysis (PD and home HD) are often considered equally efficacious and have similar impacts on quality of life. Despite cost minimization analyses suggesting that home dialysis offers cost savings over in-center HD, there has been a slow uptake of home dialysis in developed nations over time, suggesting that controversies and barriers to implementation currently exist. The primary objective of this health policy briefing article is to introduce and address some of the major controversies surrounding the cost effectiveness in supporting advocacy for a "Home Dialysis First" policy with a primary focus on single-payer systems in a developed nation such as Canada.Canadian Agency for Drugs and Technologies in Health (CADTH), Canadian and US epidemiologic databases, national/international conference presentations, primary literature review, and discussion with experts within the field of home dialysis.We have conducted a focused primary literature review alongside individuals with expertise in the field of home dialysis to discuss the cost controversies surrounding the implementation of a "Home Dialysis First" policy.First, the primary literature is limited to mostly observational studies which are highly variable in study design and content. Local economic assessments, however, have provided convincing data for home dialysis cost savings in Canada. Second, the cost of delivering dialysis differs significantly throughout the world, explained by differing costs of labor and supplies in developing nations. Third, the indirect patient costs of water, energy, and home modifications are often barriers to implementation and may be overcome by introducing cost reimbursement programs. Fourth, home dialysis requires upfront training costs. We explore the impact of premature switches from home dialysis to in-center HD or a functioning kidney transplant on overall cost savings. Fifth, we discuss the effect of physician financial incentives and program funding on the uptake of home dialysis. Finally, we introduce the controversial topic of comparing the societal value of freedom of modality choice against the societal cost savings of a "Home Dialysis First" policy.Narrative reviews, due to their inherently reduced methodological quality in comparison with systematic reviews, may expose our collected literature to selection bias. We have attempted to compose a diverse collection of available literature alongside consensus expertise to provide a fair and concise review of home dialysis cost controversies.Implementation of a "Home Dialysis First" policy would be a disruptive change to kidney failure care in Canada. To make informed policy decisions, we should recognize the cost savings associated with home dialysis in developed nations, the significance of patient-borne costs as a barrier to implementation, the impact of training costs and early modality switching in home dialysis, the lack of evidence regarding physician financial incentives, and the importance of program funding. Ultimately, we must consider the societal value of freedom of patient modality choice in comparison with the potential cost savings of a "Home Dialysis First" policy.L’insuffisance rénale (IR) est très répandue et occupe une part disproportionnée du financement des soins de santé; le système de santé canadien à payeur unique y consacre environ 1,2 % de son budget annuel. En 2016, au Canada (excluant le Québec), 37 647 personnes vivaient avec une IR, desquelles 58,4 % suivaient des traitements de dialyse plutôt que de vivre avec une greffe fonctionnelle. Les modalités de dialyse à domicile, soit la dialyse péritonéale (DP) et l’hémodialyse à domicile (HD), étaient respectivement employées par 18,9 % et 4,7 % de ces patients. L’hémodialyse en centre (HC) et l’hémodialyse à domicile (HD) sont souvent considérées tout aussi efficaces et leurs répercussions sur la qualité de vie sont semblables. Bien que les analyses de minimisation des coûts suggèrent que l’HD soit plus économique que l’HC, on a observé au fil du temps une tendance à la baisse du choix de l’HD comme modalité dans les pays développés, ce qui suggère l’existence de controverses et d’obstacles à sa mise en œuvre. L’objectif principal de ce document d’information sur les politiques en matière de santé est de présenter et d’aborder certaines des principales controverses entourant la rentabilité et le plaidoyer en faveur d’une politique « HD en priorité » axée principalement sur les systèmes de santé à payeur unique des pays développés comme le Canada.L’Agence canadienne des médicaments et des technologies de la santé (ACMTS), les bases de données épidémiologiques canadiennes et étasuniennes, les présentations faites lors de conférences nationales et internationales, la revue primaire de la littérature et des discussions avec des experts de l’HD.Nous avons procédé à une revue primaire et ciblée de la littérature aux côtés de personnes possédant une expertise en HD afin de discuter des controverses entourant les coûts liés à la mise en œuvre d’une politique « HD en priorité ».(1) La revue primaire de la littérature est limitée principalement à des études observationnelles dont la conception et le contenu sont très variables. Les évaluations économiques locales ont cependant fourni des données convaincantes quant aux économies réalisées avec l’HD au Canada.(2) Le coût de la dialyse varie de façon significative à travers le monde, ce qui s’explique par les différences de coûts pour la main-d’œuvre et l’équipement dans les pays en développement.(3) Les coûts indirects (eau, énergie et aménagements requis) assumés par le patient constituent souvent un obstacle à la mise en œuvre qui pourrait être surmonté par la mise sur pied d’un programme de remboursement.(4) L’HD entraîne des coûts de formation à l’implantation. Nous explorons les conséquences d’un passage précoce de l’HD à l’HC ou à une transplantation fonctionnelle sur les économies globales.(5) Nous discutons de l’effet d’incitatifs financiers auprès des médecins et du financement de programmes encourageant l’HD.(6) Enfin, nous abordons le sujet controversé de la comparaison de la valeur sociétale du libre choix par rapport aux économies sociétales d’une politique « HD en priorité ».Les revues narratives, en raison de leur qualité méthodologique intrinsèquement réduite comparativement aux revues systématiques, peuvent exposer la documentation recueillie à des biais de sélection. Nous avons tenté de constituer un éventail diversifié de documents disponibles parallèlement à une expertise consensuelle de façon à fournir un examen juste et concis des controverses entourant les coûts liés à l’HD.La mise en œuvre d’une politique « HD en priorité » constituerait un virage majeur dans les pratiques en insuffisance rénale au Canada. Pour prendre des décisions éclairées, nous devons reconnaître: (1) les économies associées à l’HD dans les pays développés, (2) l’importance des coûts assumés par les patients comme obstacle à la mise en œuvre, (3) l’incidence des coûts incitatifs financiers aux médecins et, (4) l’importance de financer les programmes. Enfin, nous devons examiner la valeur sociétale du libre choix du patient par rapport aux potentielles économies d’une politique « HD en priorité ».

Canadian indigenous (First Nations) have rates of kidney failure that are 2- to 4-fold higher than the non-indigenous general Canadian population. As such, a strategy of targeted screening and treatment for CKD may be cost-effective in this population. Our objective was to assess the cost utility of screening and subsequent treatment for CKD in rural Canadian indigenous adults by both estimated glomerular filtration rate and the urine albumin-to-creatinine ratio. A decision analytic Markov model was constructed comparing the screening and treatment strategy to usual care. Primary outcomes were presented as incremental cost-effectiveness ratios (ICERs) presented as a cost per quality-adjusted life-year (QALY). Screening for CKD was associated with an ICER of $23,700/QALY in comparison to usual care. Restricting the model to screening in communities accessed only by air travel (CKD prevalence 34.4%), this ratio fell to $7,790/QALY. In road accessible communities (CKD prevalence 17.6%) the ICER was $52,480/QALY. The model was robust to changes in influential variables when tested in univariate sensitivity analyses. Probabilistic sensitivity analysis found 72% of simulations to be cost-effective at a $50,000/QALY threshold and 93% of simulations to be cost-effective at a $100,000/QALY threshold. Thus, targeted screening and treatment for CKD using point-of-care testing equipment in rural Canadian indigenous populations is cost-effective, particularly in remote air access–only communities with the highest risk of CKD and kidney failure. Evaluation of targeted screening initiatives with cluster randomized controlled trials and integration of screening into routine clinical visits in communities with the highest risk is recommended.

Observational studies are common in the nephrology literature, particularly given the lack of large randomized trials. While these studies have identified important associations, potential biases, if unrecognized, can result in misinterpreted conclusions. In this review, we present an example of four potentially important biases (lead time bias, survivor bias, immortal time bias, and index event bias) that can result in inaccurate estimates of association between risk factors or treatments and outcomes. Recognition of these potential biases can help improve study design and interpretation.

Chronic kidney disease (CKD) is a global public health problem that is associated with excess morbidity, mortality, and health resource utilization. The progression of CKD is defined by a decrease in glomerular filtration rate and leads to a variety of metabolic abnormalities including acidosis, hypertension, anemia, and mineral bone disorder. Lower glomerular filtration rate also bears a strong relationship with an increased risk of cardiovascular events, end-stage renal disease, and death. Patterns of CKD progression include linear and nonlinear trajectories, but kidney function can remain stable for years in some individuals. Addressing modifiable risk factors for the progression of CKD is needed to attenuate its associated morbidity and mortality. Developing effective risk prediction models for CKD progression is critical to identify patients who are more likely to benefit from interventions and more intensive monitoring. Accurate risk-prediction algorithms permit systems to best align health care resources with risk to maximize their effects and efficiency while guiding overall decision making.

Estimated glomerular filtration rate (eGFR) is important in the diagnosis and prognostication of chronic kidney disease (CKD). The current standards for CKD progression in clinical trials are kidney failure and the doubling of serum creatinine (∼57% decline in eGFR). These endpoints have limitations as they are only applicable to patients with later stages of CKD and often require large sample sizes to achieve adequate power.Lesser declines in eGFR (30% and 40%) have been evaluated as potential endpoints in recent studies. These endpoints are more common and show a strong association with the risk of end-stage renal disease and mortality. These findings have been shown to be consistent across different causes of CKD and for different interventions. A particular limitation of reduced thresholds is an elevated risk of type I errors in the presence of acute treatment effects, particularly with a 30% eGFR decline cut off.Surrogate endpoints for kidney failure and mortality are needed in clinical trials to allow for the reasonable management of timelines and resources, and the achievement of adequate sample sizes. Lesser eGFR decline thresholds should be considered to aid in the design and conduct of more randomized controlled trials in nephrology.

Background Unplanned hospital admissions in high-risk patients are common and costly in an increasingly frail chronic disease population. Virtual Wards (VW) are an emerging concept to improve outcomes in these patients. Purpose To evaluate the effect of post-discharge VWs, as an alternative to usual community based care, on hospital readmissions and mortality among heart failure and non-heart failure populations. Data sources Ovid MEDLINE, EMBASE, PubMed, the Cochrane Database of Systematic Reviews, SCOPUS and CINAHL, from inception through to Jan 31, 2017; unpublished data, prior systematic reviews; reference lists. Study selection Randomized trials of post-discharge VW versus community based, usual care that reported all-cause hospital readmission and mortality outcomes. Data extraction Data were reviewed for inclusion and independently extracted by two reviewers. Risk of bias was assessed using the Cochrane Collaboration risk of bias tool. Data synthesis In patients with heart failure, a post-discharge VW reduced risk of mortality (six trials, n = 1634; RR 0.59, 95% CI = 0.44–0.78). Heart failure related readmissions were reduced (RR 0.61, 95% CI = 0.49–0.76), although all-cause readmission was not. In contrast, a post-discharge VW did not reduce death or hospital readmissions for patients with undifferentiated high-risk chronic diseases (four trials, n = .3186). Limitations Heterogeneity with respect to intervention and comparator, lacking consistent descriptions and utilization of standardized nomenclature for VW. Some trials had methodologic shortcomings and relatively small study populations. Conclusions A post-discharge VW can provide added benefits to usual community based care to reduce all-cause mortality and heart failure-related hospital admissions among patients with heart failure. Further research is needed to evaluate the utility of VWs in other chronic disease settings.

Background Indigenous Canadians have high rates of risk factors for chronic kidney disease (CKD), in particular diabetes. Furthermore, they have increased rates of complications associated with CKD, such as kidney failure and vascular disease. Our objective was to describe the prevalence of CKD in this population. Study Design Cross-sectional cohort. Setting & Participants Indigenous (First Nations) Canadians 18 years or older screened as part of the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) project, an initiative completed in 2015 that accomplished community-wide screening in 11 rural communities in Manitoba, Canada. Predictors Indigenous ethnicity and geographic location (communities accessible by road compared with those accessible only by air). Outcome Prevalence of CKD, presumed based on a single ascertainment of urine albumin-creatinine ratio (UACR) ≥ 30mg/g and/or estimated glomerular filtration rate (eGFR) 2 . Measurements Kidney function measured by eGFR (CKD-EPI creatinine equation) and UACR. Results 1,346 adults were screened; 25.5% had CKD, defined as UACR≥30mg/g or eGFR 2 . Communities accessible by road had a lower prevalence of CKD (17.6%) than more remote communities accessible only by air (34.4%). Of those screened, 3.3% had reduced kidney function (defined as eGFR 2 ). Severely increased albuminuria was present in 5.0% of those screened. Limitations Presumption of chronicity based on a single ascertainment. There is a possibility of sampling bias, the net direction of which is uncertain. Conclusions We found a 2-fold higher prevalence of CKD in indigenous Canadians in comparison to the general population and a prevalence of severely increased albuminuria that was 5-fold higher. This is comparable to patients with diabetes and/or hypertension. Public health strategies to screen, triage, and treat all Canadian indigenous peoples with CKD should be considered.

Chronic kidney disease (CKD) is a worldwide health problem with increasing prevalence and incidence. Guidelines suggest that early referral to a nephrologist to manage advanced stage (4+) patients with CKD is an effective treatment strategy, with earlier stage patients best managed through primary care physicians. Should patients with CKD progress to total kidney failure, several therapies are available that vary widely in costs. Kidney transplantation offers the lowest costs and highest quality of life, followed in ascending order of costs by peritoneal dialysis, home hemodialysis and facility-based hemodialysis. Earlier detection of CKD may prevent progression to kidney failure, and accurate risk prediction of end-stage kidney failure may improve clinical planning, outcomes and resource allocation.

Background Kidney Failure is epidemic in many remote communities in Canada. In-centre hemodialysis is provided within these settings in satellite hemodialysis units. The key cost drivers of this program have not been fully described. Such information is important in informing the design of programs aimed at optimizing efficiency in providing dialysis and preventative chronic kidney disease care in remote communities. Design, Setting, Participants, and Measurements We constructed a cost model based on data derived from 16 of Manitoba, Canada’s remote satellite units. We included all costs for operation of the unit, transportation, treatment, and capital costs. All costs were presented in 2013 Canadian dollars. Results The annual per-patient cost of providing hemodialysis in the satellite units ranged from $80,372 to $215,918 per patient, per year. The median per patient, per year cost was $99,888 (IQR $89,057—$122,640). Primary cost drivers were capital costs related to construction, human resource expenses, and expenses for return to tertiary care centres for health care. Costs related to transport considerably increased estimates in units that required plane or helicopter transfers. Conclusions Satellite hemodialysis units in remote areas are more expensive on a per-patient basis than hospital hemodialysis and satellite hemodialysis available in urban areas. In some rural, remote locations, better value for money may reside in local surveillance and prevention programs in addition support for home dialysis therapies over construction of new satellite hemodialysis units.