Search

Background: Many patients with end-stage kidney disease (ESKD) have valvular heart disease requiring surgery. The optimal prosthetic valve is not established in this population. We performed a systematic review and meta-analysis to assess outcomes of patients with dialysis-dependent ESKD who received mechanical or bioprosthetic valves. Methods: We searched Cochrane Central, Medline and Embase from inception to January 2020. We performed screening, full-text assessment, risk of bias and data collection, independently and in duplicate. Data were pooled using a random-effects model. Results: We identified 28 observational studies (n = 9857 patients, including 6680 with mechanical valves and 3717 with bioprosthetic valves) with a median follow-up of 3.45 years. Twenty-two studies were at high risk of bias and 1 was at critical risk of bias from confounding. Certainty in evidence was very low for all outcomes except bleeding. Mechanical valves were associated with reduced mortality at 30 days (relative risk [RR] 0.79, 95% confidence interval [CI] 0.65-0.97, [I.sup.2] = 0, absolute effect 27 fewer deaths per 1000) and at 6 or more years (mean 9.7 yr, RR 0.83, 95% CI 0.72-0.96, [I.sup.2] = 79%, absolute effect 145 fewer deaths per 1000), but increased bleeding (incidence rate ratio [IRR] 2.46, 95% CI 1.41-4.27, [I.sup.2] = 59%, absolute effect 91 more events per 1000) and stroke (IRR 1.63, 95% CI 1.21-2.20, [I.sup.2] = 0%, absolute effect 25 more events per 1000). Conclusion: Mechanical valves were associated with reduced mortality, but increased rate of bleeding and stroke. Given very low certainty for evidence of mortality and stroke outcomes, patients and clinicians may choose prosthetic valves based on factors such as bleeding risk and valve longevity. Study registration: PROSPERO no. CRD42017081863 Contexte : De nombreux patients souffrant d'insuffisance renale terminale (IRT) presentent une valvulopathie necessitant une intervention chirurgicale. On ignore quelle est la valve prothetique optimale chez cette population. Nous avons effectue un examen systematique et une meta-analyse pour evaluer les resultats des patients atteints d'IRT dialyses ayant recu une valvule mecanique ou une bioprothese valvulaire. Methodes : Nous avons interroge les bases de donnees Cochrane Central, Medline et Embase, de leur date de creation jusqu'a janvier 2020. Nous avons procede a la selection, a l'evaluation des textes integraux, a l'evaluation des risques de biais et a la collecte de donnees, independamment et en double. Les donnees ont ete regroupees a l'aide d'un modele a effets aleatoires. Resultats : Nous avons cible 28 etudes d'observation (n = 9857 patients, dont 6680 avec une valvule mecanique et 3717 avec une bioprothese valvulaire), avec un suivi d'une duree mediane de 3,45 ans. Vingt-deux etudes presentaient un risque eleve de biais et 1 etude presentait un risque critique de biais resultant de variables de confusion. La certitude des donnees etait tres faible pour tous les resultats, a l'exception des hemorragies. Les valvules mecaniques ont ete associees a une reduction de la mortalite a 30 jours (risque relatif [RR] de 0,79, intervalle de confiance [IC] de 95 % 0,65-0,97, [I.sup.2] = 0, effet absolu de 27 deces de moins pour 1000 patients) et a 6 ans ou plus (moyenne de 9,7 ans, RR de 0,83, IC de 95 % 0,72-0,96, [I.sup.2] = 79 %, effet absolu de 145 deces de moins pour 1000 patients), mais egalement a une augmentation des hemorragies (rapport des taux d'incidence [RTI] de 2,46, IC de 95 % 1,41-4,27, [I.sup.2] = 59 %, effet absolu de 91 evenements supplementaires pour 1000 patients) et des AVC (IRR de 1,63, IC de 95 % 1,21-2,20, [I.sup.2] = 0 %, effet absolu de 25 evenements supplementaires pour 1000 patients). Conclusion : Les valvules mecaniques ont ete associees a une reduction de la mortalite, mais a une augmentation du taux d'evenements hemorragiques et d'AVC. Compte tenu du tres faible degre de certitude des donnees sur la mortalite et les AVC, les patients et les cliniciens peuvent choisir les bioprotheses valvulaires selon des facteurs comme le risque d'hemorragie et la durabilite de la prothese. Numero d'enregistrement de la recherche : PROSPERO no CRD42017081863, In 2010, more than 2.6 million people worldwide were receiving dialysis for end-stage kidney disease (ESKD), a prevalence that is likely to increase to more than 5.4 million people by [...]

Background The Coronavirus Disease 2019 (COVID-19) pandemic has exacerbated mental health challenges among physicians and non-physicians. However, it is unclear if the worsening mental health among physicians is due to specific occupational stressors, reflective of general societal stressors during the pandemic, or a combination. We evaluated the difference in mental health and addictions health service use between physicians and non-physicians, before and during the COVID-19 pandemic. Methods and findings We conducted a population-based cohort study in Ontario, Canada between March 11, 2017 and August 11, 2021 using data collected from Ontario's universal health system. Physicians were identified using registrations with the College of Physicians and Surgeons of Ontario between 1990 and 2020. Participants included 41,814 physicians and 12,054,070 non-physicians. We compared the first 18 months of the COVID-19 pandemic (March 11, 2020 to August 11, 2021) to the period before COVID-19 pandemic (March 11, 2017 to February 11, 2020). The primary outcome was mental health and addiction outpatient visits overall and subdivided into virtual versus in-person, psychiatrists versus family medicine and general practice clinicians. We used generalized estimating equations for the analyses. Pre-pandemic, after adjustment for age and sex, physicians had higher rates of psychiatry visits (aIRR 3.91 95% CI 3.55 to 4.30) and lower rates of family medicine visits (aIRR 0.62 95% CI 0.58 to 0.66) compared to non-physicians. During the first 18 months of the COVID-19 pandemic, the rate of outpatient mental health and addiction (MHA) visits increased by 23.2% in physicians (888.4 pre versus 1,094.7 during per 1,000 person-years, aIRR 1.39 95% CI 1.28 to 1.51) and 9.8% in non-physicians (615.5 pre versus 675.9 during per 1,000 person-years, aIRR 1.12 95% CI 1.09 to 1.14). Outpatient MHA and virtual care visits increased more among physicians than non-physicians during the first 18 months of the pandemic. Limitations include residual confounding between physician and non-physicians and challenges differentiating whether observed increases in MHA visits during the pandemic are due to stressors or changes in health care access. Conclusions The first 18 months of the COVID-19 pandemic was associated with a larger increase in outpatient MHA visits in physicians than non-physicians. These findings suggest physicians may have had larger negative mental health during COVID-19 than the general population and highlight the need for increased access to mental health services and system level changes to promote physician wellness., Author(s): Daniel T. Myran 1,2,3,*, Rhiannon Roberts 1, Eric McArthur 4, Nivethika Jeyakumar 4, Jennifer M. Hensel 5, Claire Kendall 1,2,3,6, Caroline Gerin-Lajoie 7,8, Taylor McFadden 7, Christopher Simon 7, [...]

Key Points: Question: Do normotensive living kidney donors, compared with nondonors, have a higher risk of hypertension in the first 7 years following donation? Findings: In this 17-center prospective cohort study that included 924 living kidney donors and 396 nondonors, there were no significant between-group differences in the risk of hypertension and no significant between-group differences in mean blood pressure or the change in blood pressure during a median follow-up of 7.3 years. Meaning: After accounting for differences in baseline risk, living donors had a similar risk of hypertension as nondonors in the 7 years following donation and no significant difference in mean blood pressure. Importance: Recent guidelines call for better evidence on health outcomes after living kidney donation. Objective: To determine the risk of hypertension in normotensive adults who donated a kidney compared with nondonors of similar baseline health. Their rates of estimated glomerular filtration rate (eGFR) decline and risk of albuminuria were also compared. Design, Setting, and Participants: Prospective cohort study of 924 standard-criteria living kidney donors enrolled before surgery and a concurrent sample of 396 nondonors. Recruitment occurred from 2004 to 2014 from 17 transplant centers (12 in Canada and 5 in Australia); follow-up occurred until November 2021. Donors and nondonors had the same annual schedule of follow-up assessments. Inverse probability of treatment weighting on a propensity score was used to balance donors and nondonors on baseline characteristics. Exposure: Living kidney donation. Main Outcomes and Measures: Hypertension (systolic blood pressure [SBP] ≥140 mm Hg, diastolic blood pressure [DBP] ≥90 mm Hg, or antihypertensive medication), annualized change in eGFR (starting 12 months after donation/simulated donation date in nondonors), and albuminuria (albumin to creatinine ratio ≥3 mg/mmol [≥30 mg/g]). Results: Among the 924 donors, 66% were female; they had a mean age of 47 years and a mean eGFR of 100 mL/min/1.73 m2. Donors were more likely than nondonors to have a family history of kidney failure (464/922 [50%] vs 89/394 [23%], respectively). After statistical weighting, the sample of nondonors increased to 928 and baseline characteristics were similar between the 2 groups. During a median follow-up of 7.3 years (IQR, 6.0-9.0), in weighted analysis, hypertension occurred in 161 of 924 donors (17%) and 158 of 928 nondonors (17%) (weighted hazard ratio, 1.11 [95% CI, 0.75-1.66]). The longitudinal change in mean blood pressure was similar in donors and nondonors. After the initial drop in donors' eGFR after nephrectomy (mean, 32 mL/min/1.73 m2), donors had a 1.4-mL/min/1.73 m2 (95% CI, 1.2-1.5) per year lesser decline in eGFR than nondonors. However, more donors than nondonors had an eGFR between 30 and 60 mL/min/1.73 m2 at least once in follow-up (438/924 [47%] vs 49/928 [5%]). Albuminuria occurred in 132 of 905 donors (15%) and 95 of 904 nondonors (11%) (weighted hazard ratio, 1.46 [95% CI, 0.97-2.21]); the weighted between-group difference in the albumin to creatinine ratio was 1.02 (95% CI, 0.88-1.19). Conclusions and Relevance: In this cohort study of living kidney donors and nondonors with the same follow-up schedule, the risks of hypertension and albuminuria were not significantly different. After the initial drop in eGFR from nephrectomy, donors had a slower mean rate of eGFR decline than nondonors but were more likely to have an eGFR between 30 and 60 mL/min/1.73 m2 at least once in follow-up. Trial Registration: ClinicalTrials.gov Identifier: NCT00936078 This cohort study aims to determine the risk of hypertension in normotensive adults who donated a kidney compared with nondonors of similar baseline health. [ABSTRACT FROM AUTHOR]

Importance: Trimethoprim‐sulfamethoxazole (TMP‐SMX) may increase digoxin concentration, a medication with a narrow therapeutic index. Small changes in digoxin concentration could predispose individuals to the risk of toxicity. Objective: To characterize the risk of digoxin toxicity in older adults taking digoxin following co‐prescription of TMP‐SMX compared with co‐prescription of amoxicillin. Design, Settings, and Participants: Retrospective population‐based cohort study in Ontario, Canada (2002–2020) using linked health care data. Participants comprised 47,961 older adults taking digoxin (58% women; median age 80 years [interquartile range 74–86]) who were newly treated with TMP‐SMX (n = 10,273) compared with those newly treated with amoxicillin (n = 37,688). Exposure: Co‐prescription of TMP‐SMX versus amoxicillin in older adults concurrently taking digoxin. Main Outcome and Measure: The primary outcome was a hospital encounter (i.e., hospital admission or emergency department visit) with digoxin toxicity within 30 days of the antibiotic prescription. Inverse probability of treatment weighting on the propensity score was used to balance comparison groups on indicators of baseline health. Weighted risk ratios (RR) were obtained using modified Poisson regression and weighted risk differences (RD) using binomial regression. The number needed to harm (NNH) was calculated as 1/RD. Results: A hospital encounter with digoxin toxicity occurred in 49/10,273 (0.48%) patients treated with TMP‐SMX versus 32/37,688 (0.08%) in those treated with amoxicillin (weighted RR, 5.71 [95% confidence interval (CI), 3.19 to 10.24]; weighted RD, 0.39% [95% CI, 0.25% to 0.53%]; NNH 256 [95% CI, 233 to 400]). Conclusion and Relevance: In older adults taking digoxin, the 30‐day risk of a hospital encounter with digoxin toxicity was nearly 6 times higher in those co‐prescribed TMP‐SMX versus amoxicillin, although the absolute risk difference was low (0.4%). Physicians should prescribe an alternative antibiotic when clinically appropriate. If TMP‐SMX must be co‐prescribed with digoxin (if the benefit is believed to outweigh the risk), digoxin should be dose‐reduced on an individual basis. [ABSTRACT FROM AUTHOR]

Background Mental health problems, particularly anxiety and depression, are common in patients with chronic kidney disease (CKD) and negatively impact quality of life, treatment adherence and mortality. However, the degree to which mental health and addiction services are utilized by those with CKD is unknown. We examined the history of mental health and addiction service use of individuals across levels of kidney function. Methods We performed a population-based cross-sectional study using linked healthcare databases from Ontario, Canada from 2009 to 2017. We abstracted the prevalence of individuals with mental health and addiction service use within the previous 3 years across levels of kidney function [estimated glomerular filtration rate (eGFR) ≥60, 45 to <60, 30 to <45, 15 to <30, <15 ml/min/1.73 m2 and maintenance dialysis]. We calculated prevalence ratios (PRs) to compare prevalence across kidney function strata, while adjusting for age, sex, year of cohort entry, urban versus rural location, area-level marginalization and Charlson comorbidity index. Results Of 5 956 589 adults, 9% (n  = 534 605) had an eGFR <60 ml/min/1.73 m2 or were receiving maintenance dialysis. Fewer individuals with an eGFR <60 ml/min/1.73 m2 had a history of any mental health and addiction service utilization (crude prevalence range 28–31%) compared with individuals with an eGFR ≥60 ml/min/1.73 m2 (35%). Compared with an eGFR ≥60 ml/min/1.73 m2, the lowest prevalence of individuals with any mental health and addiction service utilization was among those with an eGFR of 15 to <30 ml/min/1.73 m2 {adjusted PR 0.86 [95% confidence interval (CI) 0.85 to 0.88]}, an eGFR <15 ml/min/1.73 m2 [adjusted PR 0.81 (95% CI 0.76–0.86)] and those receiving maintenance dialysis [adjusted PR 0.83 (95% CI 0.81–0.84)]. Less use of outpatient services accounted for differences in service utilization. Conclusions Mental health and addiction service utilization is common but less so in individuals with advanced CKD in Ontario, Canada. [ABSTRACT FROM AUTHOR]

For decades, researchers have used linkable administrative health data for evaluating the health care system, subject to local privacy legislation. In Ontario, Canada, the relevant privacy legislation permits some organizations (prescribed entities) to conduct this kind of research but is silent on their ability to identify and contact individuals in those datasets. Following consultation with the Office of the Information and Privacy Commissioner of Ontario, we developed a pilot study to identify and contact by mail a sample of people at high risk for kidney failure within the next 2 years, based on laboratory and administrative data from provincial datasets held by ICES, to ensure they receive needed kidney care. Before proceeding, we conducted six focus groups to understand the acceptability to the public and people living with chronic kidney disease of direct mail outreach to people at high risk of developing kidney failure. While virtually all participants indicated they would likely participate in the study, most felt strongly that the message should come directly from their primary care provider or whoever ordered the laboratory tests, rather than from an unknown organization. If this is not possible, they felt the health care provider should be made aware of the concern related to their kidney health. Most agreed that, if health authorities could identify people at high risk of a treatable life-threatening illness if caught early enough, there is a social responsibility to notify people. While privacy laws allow for free flow of health information among health care providers who provide direct clinical care, the proposed case-finding and outreach falls outside that model. Enabling this kind of information flow will require greater clarity in existing laws or revisions to these laws. This also requires adequate notification and culture change for health care providers and the public around information uses and flows. [ABSTRACT FROM AUTHOR]