Search

Background: The buttonhole technique is an alternative method of cannulating the arteriovenous fistula (AVF) in hemodialysis (HD), frequently used for home HD patients. However, the balance of risks and benefits of the buttonhole compared with the rope-ladder technique is uncertain., Study Design: A systematic review of randomized trials and observational studies (case reports, case series, studies without a control group, non-English studies, and abstracts were excluded)., Setting & Population: HD patients (both in-center conventional HD and home HD) using an AVF for vascular access., Selection Criteria for Studies: We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL from the earliest date in the databases to March 2014 for studies comparing clinical outcomes of the buttonhole versus rope-ladder technique., Intervention: Buttonhole versus rope-ladder cannulation technique., Outcomes: The primary outcomes of interest were patient-reported cannulation pain and rates of AVF-related local and systemic infections. Secondary outcomes included access survival, intervention, hospitalization, and mortality, as well as hematoma and aneurysm formation, time to hemostasis, and all-cause hospitalization and mortality., Results: Of 1,044 identified citations, 23 studies were selected for inclusion. There was equivocal evidence with respect to cannulation pain: pooled observational studies yielded a statistical reduction in pain with buttonhole cannulation (standardized mean difference, -0.76 [95%CI, -1.38 to -0.15] standard deviations), but no difference in cannulation pain was found among randomized controlled trials (standardized mean difference, 0.34 [95%CI, -0.76 to 1.43] standard deviations). Buttonhole, as compared to rope-ladder, technique appeared to be associated with increased risk of local and systemic infections., Limitations: Overall poor quality and substantial heterogeneity among studies precluded pooling of most outcomes., Conclusions: Evidence does not support the preferential use of buttonhole over rope-ladder cannulation in either facility-based conventional HD or home HD. This does not preclude buttonhole cannulation as being appropriate for some patients with difficult-to-access AVFs., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: The Canadian Organ Replacement Register (CORR) is the only Canadian information system on kidney and extra-kidney organ failure and transplantation in Canada. CORR's mandate is to record and analyze the level of activity and outcomes of vital organ transplantation and treatment of end stage kidney disease using dialysis, either hemodialysis or peritoneal dialysis, activities across Canada. The Canadian Organ Replacement Register was officially launched in 1987, and it included transplantation of extra-renal vital organs (liver, heart, lung, pancreas, bowel), in addition to renal transplantation and replacement therapy, with new financial support from the provinces., Objective: This manuscript describes the process of data acquisition and reporting, focusing on the patients with end stage kidney disease on dialysis, with data reported from the 2014 CORR Annual Data Report and the Center-Specific Reports on Clinical Measures., Methods: CORR is currently housed in the Canadian Institute for Health Information and collects data from hospital dialysis programs, regional transplant programs, organ procurement organizations and kidney dialysis services offered at independent health facilities. Data on patients is collected by completion of survey forms for each patient at the start of dialysis or receiving a transplant, using the Initial Registration form, and yearly follow up forms, which collects data on the status of the patient as of October 31(st)., Results: The incident rate per million population (RPMP) has remained stable with the exception of the 65+ age group with has experience a modest decrease since 2001. However, there has been an increasing prevalence of ESKD diagnoses, with the highest rate per million population (RPMP) amongst the age group 65+ years. This is likely attributed to gradual improving patient survival. Between 2003 and 2012, nearly 90% of dialysis patients younger than <18 and 26% of patients 75+ years survived for at least five years., Conclusion: As the number of people treated for end-stage organ failure grows, so does the importance of understanding their treatment and outcomes. In 2014, CORR continues to evolve and support the important information need to advance ESRD research and clinical practice.

Background: Kidney transplant improves quality of life and survival compared with dialysis. Despite advances in immunosuppressant regimens and the prevention and treatment of acute rejection, graft survival rates have not improved significantly in the past decade. Although the clinical effectiveness of these regimens has been studied, the impact of changes over time on cost has not., Methods: Costs of kidney transplant were compared between 2 periods demarcated by a programmatic change from cyclosporine (early) to tacrolimus (late) and from nonroutine induction (early) to routine induction (late) therapy in adult patients receiving a first kidney-only transplant in Calgary, Alberta, Canada, in an 8-year period., Results: Complete costs for 3 years after transplant was available for 344 patients, including 161 adult recipients in the early period (April 1, 1998-December 31, 2001) and 183 adult recipients in the late period (January 1, 2002-March 31, 2006). The mean total 3-year cost of transplant for recipients was Can$100 034 in the early period and Can$144 712 in the late period largely attributed to increases in the cost of immunosuppressants (P< .001)., Conclusions: Given that the cost of transplant has increased significantly over time, the cost-effectiveness of these and other immunosuppressive regimens should be evaluated carefully.

Background: Elucidation of the relationship between age, kidney function, and absolute coronary risk would facilitate efforts to promote chronic kidney disease (CKD) as a high-risk state for future vascular events and justify current recommendations for statin treatment in CKD., Study Design: Population-based study., Setting & Participants: 1,268,538 people with data for estimated glomerular filtration rate and albuminuria who were treated in a single Canadian province., Predictors: CKD risk groups (G1, G2, G3a, G3b, and G4 had estimated glomerular filtration rate ≥90, 60-89.9, 45-59.9, 30-44.9, and 15-29.9 mL/min/1.73 m2, respectively; A1, A2, and A3 had albuminuria with albumin-creatinine ratio [ACR]<30 mg/g or dipstick urinalysis negative, ACR of 30-300 mg/g or dipstick trace or 1+, and ACR >300 mg/g or dipstick ≥ 2+, respectively) and age (<40, 40-49, ≥50 years)., Outcomes: Rates of coronary death or nonfatal myocardial infarction (expressed per 1,000 person-years), stratified by age, sex, and CKD stage., Measurements: The first available serum creatinine value and the corresponding date were set as the index serum creatinine value and index date, respectively. ACR or dipstick urinalysis data were obtained from the periods defined by 6 months before and after the index creatinine value., Results: Absolute rates of coronary death or nonfatal myocardial infarction were consistently greater than 10 per 1,000 person-years for people with CKD and 50 years or older, regardless of CKD stage. However, absolute rates of the composite outcome were consistently less than 10 per 1,000 person-years for those younger than 50 years., Limitations: Single Canadian province, median follow-up only 4.0 years., Conclusions: People with CKD who are 50 years or older should be considered at the highest risk of coronary events. In contrast, consideration of other risk factors will be required when assessing future risk among people with CKD who are younger than 50 years., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Provision of in-centre nocturnal hemodialysis (ICNHD; 6-8 hours thrice weekly) is associated with health benefits, but the economic implications of providing this treatment are unclear., Objective: We conducted a health care costing study comparing ICNHD to in-centre thrice-weekly conventional hemodialysis (CvHD)., Design: Micro-costing of both ICNHD and CvHD as practiced at our centre., Setting: Hemodialysis unit at a tertiary-care hospital in Edmonton., Participants: An informal survey of 2 other Canadian ICNHD programs was conducted to inform practices that may deviate from ours to guide sensitivity analysis., Measurements: Resources consumed for each strategy were determined, and the cost of each unit (CAN $2012) was used to calculate incremental costs of ICNHD and CvHD., Methods: We focused on resources that differ between strategies (staffing, dialysis materials, and utilities). The reference case considered 1:3 staff to patient ratio; alternate scenarios explored nursing pay grade and ratio, full care vs. self-care dialysis (including training costs), and medication costs., Results: In the reference case, ICNHD was $61 more costly per dialysis treatment compared with CvHD ($9,538 per patient per year). Incremental annual costs for staffing, dialysis materials, and utilities were $8,201, $1,193, and $144, respectively. If ICNHD reduces medication use (anti-hypertensives, bone mineral metabolism medications), the incremental cost of ICNHD decreases to $8,620 per patient per year. In a scenario of self-care ICNHD utilizing a staff-to-patient ratio of 1:10, ICNHD is more costly in year 1 ($15,196), but results in cost savings of $2,625 in subsequent years compared with CvHD., Limitations: The findings of this cost analysis may not be generalizable to other health care systems, including other parts of Canada., Conclusions: Compared to CvHD, provision of ICNHD is more expensive, largely driven by increased staffing costs as patients dialyze longer. Alternate staffing models, including self-care ICNHD with minimal staff, may lead to net cost savings. The incremental cost of treatment should be considered in the context of impact on patient health outcomes, staffing model, and pragmatic factors, such as current capacity for daytime CvHD and the capital costs of new dialysis stations.

Purpose of Review: To date, there has been little analysis of the degree to which emerging incentive initiatives are permissible under Canadian law. The purpose of this review is to examine the relevant law - including legislation and case law - in order to clarify the legality of existing proposed incentive schemes., Sources of Information: Legislation and case law., Findings: Organ donation is governed by provincial legislation that, in general, bans the exchange of any "benefit" or any form of "valuable consideration" in return for an organ. As such, these laws are tremendously restrictive and could have significant implications for emerging and proposed procurement policy., Implications: Given the need for innovative, ethically appropriate policies to increase donation rates, we suggest that the time is right to rethink the potentially restrictive nature of Canada's organ donation laws.

Introduction: The Canadian Society of Nephrology (CSN) was established to promote the highest quality of care for patients with renal diseases and to encourage research related to the kidney and its disorders. The CSN Clinical Practice Guideline (CPG) Committee develops guidelines with clear recommendations to influence physicians' practice and improve the health of patients with kidney disease in Canada., Review: In this review we describe the CSN process in prioritizing CPGs topics. We document the CSN experience using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We then detail the CSN process in developing de novo CPGs and in adapting existing CPGs and developing accompanying commentaries. We also discuss challenges faced during this process and suggest solutions. Furthermore, we summarize the CSN effort in disseminating and implementing their guidelines. Additionally, we describe recent development and partnerships that allow evaluation of the effect of the CSN guidelines and commentaries., Conclusion: The CSN follows a comprehensive process in identifying priority areas to be addressed in CPGs. In 2010, the CSN adopted GRADE, which enhanced the rigor and transparency of guideline development. This process focuses on systematically identifying best available evidence and carefully assessing its quality, balancing benefits and harms, considering patients' and societies' values and preferences, and when possible considering resource implications. Recent partnership allows wider dissemination and implementation among end users and evaluation of the effects of CPG and commentaries on the health of Canadians.

Patients with chronic kidney disease (CKD) do not always receive care consistent with guidelines, in part due to complexities in CKD management, lack of randomized trial data to inform care, and a failure to disseminate best practice. At a 2007 conference of key Canadian stakeholders in kidney disease, attendees noted that the impact of Canadian Society of Nephrology (CSN) guidelines was attenuated given limited formal linkages between the CSN Clinical Practice Guidelines Group, kidney researchers, decision makers and knowledge users, and that further knowledge was required to guide care in patients with kidney disease. The idea for the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) developed from this meeting. CANN-NET is a pan-Canadian network established in partnership with CSN, the Kidney Foundation of Canada and other professional societies to improve the care and outcomes of patients with and at risk for kidney disease. The initial priority areas for knowledge translation include improving optimal timing of dialysis initiation, and increasing the appropriate use of home dialysis. Given the urgent need for new knowledge, CANN-NET has also brought together a national group of experienced Canadian researchers to address knowledge gaps by encouraging and supporting multicentre randomized trials in priority areas, including management of cardiovascular disease in patients with kidney failure.

Background: Publicly-funded drug plans vary in strategies used and policies employed to reduce continually increasing pharmaceutical expenditures. We systematically reviewed the utilization of cost-sharing strategies and physician-directed prescribing regulations in publicly-funded formularies within member nations of the Organization of Economic Cooperation and Development (OECD)., Methods & Findings: Using the OECD nations as the sampling frame, a search for cost-sharing strategies and physician-directed prescribing regulations was done using published and grey literature. Collected data was verified by a system expert within the prescription drug insurance plan in each country, to ensure the accuracy of key data elements across plans. Significant variation in the use of cost-sharing mechanisms was seen. Copayments were the most commonly used cost-containment measure, though their use and amount varied for those with certain conditions, most often chronic diseases (in 17 countries), and by socio-economic status (either income or employment status), or with age (in 15 countries). Caps and deductibles were only used by five systems. Drug cost-containment strategies targeting physicians were also identified in 24 countries, including guideline-based prescribing, prescription monitoring and incentive structures., Conclusions: There was variable use of cost-containment strategies to limit pharmaceutical expenditures in publicly funded formularies within OECD countries. Further research is needed to determine the best approach to constrain costs while maintaining access to pharmaceutical drugs.

Provider and patient enthusiasm for frequent home nocturnal hemodialysis (FHNHD) has been renewed; however, the cost-effectiveness of this technique is unknown. We performed a cost-utility analysis of FHNHD compared with conventional hemodialysis (CvHD; 4 hours three times per week) from a health payer perspective over a lifetime horizon using patient information from the Alberta NHD randomized controlled trial. Costs, including training costs, were obtained using microcosting and administrative data (CAN$2012). We determined the incremental cost per quality-adjusted life year (QALY) gained. Robustness was assessed using scenario, sensitivity, and probabilistic sensitivity analyses. Compared with CvHD (61% in-center, 14% satellite, and 25% home dialysis), FHNHD led to incremental cost savings (-$6700) and an additional 0.38 QALYs. In sensitivity analyses, when the annual probability of technique failure with FHNHD increased from 7.6% (reference case) to ≥19%, FHNHD became unattractive (>$75,000/QALY). The cost/QALY gained became $13,000 if average training time for FHNHD increased from 3.7 to 6 weeks. In scenarios with alternate comparator modalities, FHNHD remained dominant compared with in-center CvHD; cost/QALYs gained were $18,500, $198,000, and $423,000 compared with satellite CvHD, home CvHD, and peritoneal dialysis, respectively. In summary, FHNHD is attractive compared with in-center CvHD in this cohort. However, the attractiveness of FHNHD varies by technique failure rate, training time, and dialysis modalities from which patients are drawn, and these variables should be considered when establishing FHNHD programs.

Background: Multidisciplinary bariatric care is increasingly being delivered in Canada within publicly funded regional programs. Demand is high, wait lists are long, and clinical effectiveness is unknown., Objective: To examine the "real-world" outcomes associated with a publicly funded, population-based regional bariatric (medical and surgical) program., Research Design: Prospective observational cohort., Subjects: Five hundred consecutive patients (150 wait-listed, 200 medically treated, 150 surgically treated) from the Edmonton Weight Wise program were enrolled., Measures: The primary outcome was weight change (kg). Between-group changes were analyzed using multivariable regression adjusted for age, sex, and baseline weight and "last-observation-carried-forward" was used for missing data. Subjects transitioning between groups (wait-list to medical or medical to surgery) were censored when crossing over., Results: At baseline, mean age was 43.7 ± 9.6 years, mean body mass index was 47.9 ± 8.1 kg/m, and 88% were female. A total of 412 subjects (82%) completed 2-year follow-up and 143 (29%) subjects crossed over to the next treatment phase. Absolute and relative (% of baseline) mean weight reductions were 1.5 ± 8.5 kg (0.9 ± 6.1%) for wait-listed, 4.1 ± 11.6 kg (2.8 ± 8.1%) for medically treated, and 22.0 ± 19.7 kg (16.3 ± 13.5%) for surgically treated (P<0.001) subjects. For surgery, weight reductions were 7.0 ± 9.7 kg (5.8 ± 7.9%) with banding, 21.4 ± 16.0 kg (16.4 ± 11.6%) with sleeve gastrectomy, and 36.6 ± 19.5 kg (26.1 ± 12.2%) with gastric bypass (P<0.001). Rates of hypertension, diabetes, and dyslipidemia decreased to a significantly greater degree with surgery than medical management (P<0.001) and stayed the same or increased in wait-listed subjects., Conclusions: Population-based bariatric care, particularly bariatric surgery, was clinically effective. Weight and cardiometabolic risk was relatively stable wait-listed patients receiving "usual care."

Background: Studies linking low serum testosterone concentration to adverse clinical outcomes in hemodialysis patients have been relatively small. We investigated the role of testosterone in adverse outcomes and quality of life in an incident cohort of male Canadian hemodialysis patients., Study Design: A prospectively designed multicenter observational study using data from the Canadian Kidney Disease Cohort Study (CKDCS)., Setting & Participants: Male patients initiating hemodialysis therapy since February 14, 2005, in 3 Canadian centers serving ethnically diverse populations were studied (N = 623)., Predictor: Serum testosterone levels using the International Society of Andrology, International Society for the Study of the Aging Male, and European Association of Urology cutoffs (low, <231 ng/dL; borderline, 231-346 ng/dL; normal, >346 ng/dL)., Outcomes: All-cause mortality, fatal and nonfatal cardiovascular (CV) events, and Health Utility Index (HUI)-assessed health-related quality of life., Measurements: Participants completed a structured interview on demographics and medical history and an HUI questionnaire (version 3). Routine laboratory test results captured into the study database, and serum testosterone measured within 3 months after initiation of the baseline hemodialysis session., Results: During a median follow-up of 20 (range, 1-81) months, 166 (27%) died and 98 (20%) had a CV event. Mean serum testosterone level was 234.1 ± 146.1 (SD) ng/dL. Higher serum testosterone levels were associated with significantly decreased unadjusted risk of death (HR per 10-ng/dL increase, 0.58; 95% CI, 0.37-0.90). There was a statistically significant trend for higher all-cause mortality with low serum testosterone levels in adjusted analyses (P < 0.001). Higher levels of log-transformed testosterone were associated with significantly higher HUI scores (P for trend <0.001), and low levels of serum testosterone were associated significantly with lower HUI scores (P for trend <0.001). Although there was a significant trend in the unadjusted risk of CV events among participants with low serum testosterone levels (P < 0.001), the risk was no longer significant after adjustment for age. There was no significant interaction with age and serum testosterone level tested as continuous variables (P = 0.07)., Limitations: A short follow-up period and serum testosterone measured on a single occasion., Conclusions: Low serum testosterone concentration may be a modifiable risk factor for adverse outcomes and poor quality of life in male hemodialysis patients. This hypothesis should be tested in randomized controlled trials., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: There has been resurgent interest in home hemodialysis (HD) in recent years because of the reported benefits and its excellent safety record. However, the potential for adverse events, including potentially catastrophic ones, exists when patients are performing HD in their homes without supervision. There is a lack of literature on this important topic., Study Design: Quality improvement report., Setting & Participants: We present the experience of 2 adult home HD programs in Canada from 2001 to 2012, including a total of 190 patients and approximately 500 patient-years of treatments., Quality Improvement Plan: We retrospectively reviewed all life-threatening adverse events occurring in our programs and re-examined our approach to patient training, retraining, and safety monitoring., Results: We report 1 death and 6 potentially fatal adverse events, yielding a crude rate of 0.060 events/1,000 dialysis treatments. Six of 7 events involved significant blood loss (including 1 exsanguination); 5 of 7 events involved human error with lapses in protocol adherence. Because such events are rare, evaluation of specific intervention strategies will require much longer follow-up., Limitations: Retrospective identification of cases. A specific quality improvement initiative was not undertaken., Conclusions: Life-threatening adverse events in home HD are uncommon; however, when one does occur, this should prompt review of home HD-related policies and procedures to make this therapy even safer., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The use of a restrictive formulary, with placement determined through a drug-reimbursement decision-making process, is one approach to managing drug expenditures., Objective: To describe the processes in drug reimbursement decision-making systems currently used in national publicly funded outpatient prescription drug insurance plans., Methods: By using the Organisation for Economic Co-operation and Development (OECD) nations as the sampling frame, a search was done in the published literature, followed by the gray literature. Collected data were verified by a system expert within the prescription drug insurance plan in each country to ensure the accuracy of key data elements across countries., Results: All but one country provided at least one publicly funded prescription drug formulary. Many systems have adopted similar processes of drug reimbursement decision making. All but three systems required additional consideration of clinical evidence within the decision-making process. Transparency of recommendations varied between systems, from having no information publicly available (three systems) to all information available and accessible to the public (16 systems). Only four countries did not consider cost within the drug reimbursement decision-making process., Conclusions: There were similarities in the decision-making process for drug reimbursement across the systems; however, only five countries met the highest standard of transparency, requirement of evidence, and ability to appeal. Future work should focus on examining how these processes may affect formulary listing decisions for drugs between countries., (© 2013 International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Published by International Society for Pharmacoeconomics and Outcomes Research (ISPOR) All rights reserved.)

Unlike the United States, the potential to increase organ donation in Canada may be sufficient to meet the need for transplantation. However, there has been no national coordinated effort to increase organ donation. Strategies that do not involve payment for organs, such as investment in health care resources to support deceased donor organ donation and introduction of a remuneration framework for the work of deceased organ donation, should be prioritized for implementation. Financial incentives that may be permitted under existing legislation and that pose little risk to existing donation sources should be advanced, including the following: payment of funeral expenses for potential donors who register their decision on organ donation during life (irrespective of the decision to donate or actual organ donation) and removal of disincentives for directed and paired exchange living donation, such as payment of wages, payment for pain and suffering related to the donor surgery, and payment of directed living kidney donors for participation in Canada's paired exchange program. In contrast, it would be premature to contemplate a regulated system of organ sales that would require a paradigm shift in the current approach to organ donation and legislative change to implement., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: For eligible candidates, transplantation is considered the optimal treatment compared with dialysis for patients with ESRD. The growing number of patients with ESRD requires new strategies to increase the pool of potential donors., Design, Setting, Participants, & Measurements: Using decision analysis modeling, this study compared a strategy of paying living kidney donors to waitlisted recipients on dialysis with the current organ donation system. In the base case estimate, this study assumed that the number of donors would increase by 5% with a payment of $10,000. Quality of life estimates, resource use, and costs (2010 Canadian dollars) were based on the best available published data., Results: Compared with the current organ donation system, a strategy of increasing the number of kidneys for transplantation by 5% by paying living donors $10,000 has an incremental cost-savings of $340 and a gain of 0.11 quality-adjusted life years. Increasing the number of kidneys for transplantation by 10% and 20% would translate into incremental cost-savings of $1640 and $4030 and incremental quality-adjusted life years gain of 0.21 and 0.39, respectively., Conclusion: Although the impact is uncertain, this model suggests that a strategy of paying living donors to increase the number of kidneys available for transplantation could be cost-effective, even with a transplant rate increase of only 5%. Future work needs to examine the feasibility, legal policy, ethics, and public perception of a strategy to pay living donors.

Both obesity and chronic kidney disease (CKD) are associated with adverse periprocedural outcomes, but it is unknown how these two common conditions interact to influence risk. We examined the feasibility of combining a new procedure-related, obesity-specific flag with administrative and laboratory data and assessed the joint association between obesity and CKD with mortality. Since 2007, Alberta physicians may claim a fee supplement for performing eligible surgical and non-surgical procedures on patients with documented BMI ≥ 35 kg/m(2). We linked this information to the Alberta Kidney Disease Network registry. Participants were classified into four mutually exclusive groups based on the presence/absence of both obesity (BMI ≥ 35 kg/m(2)) and CKD (eGFR < 60 mL/min/1.73 m(2)). Mortality was assessed at 30 days following the index procedure. Of 393 659 participants, 9% were obese. Overall, 8% had obesity only, 78% neither obesity nor CKD, 13% CKD only and 1% both obesity and CKD. Unadjusted risks of mortality at 30 days were 0.3, 0.4, 2.0 and 2.1%, respectively--but decreased to 0.1, 0.2, 0.3 and 0.3%, respectively, after adjustment for age, sex, socioeconomic status, procedure type and other comorbidities. Administrative data can be feasibly combined with disease registries to study obesity-related outcomes. Results from the linked dataset demonstrated face validity--subjects with both obesity and CKD were at increased risk of periprocedural mortality, and this was driven in part by differences in age and comorbidity.

Proteinuria identifies patients at risk for adverse clinical outcomes, but it is unclear whether proteinuria correlates with the rate of renal decline. We examined the association between proteinuria and rate of change in estimated GFR (eGFR) in a cohort of 638,150 adults from a province-wide registry in Alberta, Canada, who had a measure of proteinuria and three or more outpatient serum creatinine measurements over a period of ≥1 year. An adjusted sex-specific linear mixed-effects model was used to determine the rate of change in eGFR per year for patients with normal, mild, and heavy proteinuria, stratified by baseline kidney function (eGFR ≥90, 60-89.9, 45-59.9, 30-44.9, and 15-29.9 ml/min per 1.73 m(2)). In men, heavy proteinuria and a baseline eGFR of 45-59.9 ml/min per 1.73 m(2) correlated with a change in eGFR of -2.16 (95% confidence interval [CI], -2.37 to -1.95) ml/min per 1.73 m(2) per year, whereas mild proteinuria and a baseline eGFR of 30-44.9 ml/min per 1.73 m(2) correlated with a change in eGFR of -0.51 (95% CI, -0.70 to -0.32) ml/min per 1.73 m(2) per year. Similar trends were observed for female, elderly, and diabetic patients. Notably, normal protein levels and a lower baseline eGFR (15-29.9 ml/min per 1.73 m(2)) correlated with stable or improved renal function. In conclusion, our results suggest that proteinuria of increasing severity is associated with a faster rate of renal decline, regardless of baseline eGFR, and the combined effect should be considered in patients with CKD.

Background: In Canada, demand for multidisciplinary bariatric (obesity) care far outstrips capacity. Consequently, prolonged wait times exist and contribute to substantial health impairments.A supportive, educational intervention (with in-person and web-based versions) designed to enhance the self-management skills of patients wait-listed for multidisciplinary bariatric medical and surgical care has been variably implemented across Alberta, Canada. However, its effectiveness has not been evaluated. Our objectives were: 1. To determine if this program improves clinical and humanistic outcomes and is cost-effective compared to a control intervention; and 2. To compare the effectiveness and cost-effectiveness of in-person group-based versus web-based care. We hypothesize that both the web-based and in-person programs will reduce body weight and improve outcomes compared to the control group. Furthermore, we hypothesize that the in-person version will be more effective but more costly than the web-based version., Methods/design: This pragmatic, prospective controlled trial will enrol 660 wait-listed subjects (220 per study arm) from regional bariatric programs in Alberta and randomly assign them to: 1. an in-person, group-based intervention (9 modules delivered over 10 sessions); 2. a web-based intervention (13 modules); and 3. controls who will receive mailed literature. Subjects will have three months to review the content assigned to them (the intervention period) after which they will immediately enter the weight management clinic. Data will be collected at baseline and every 3 months for 9 months (study end), including: 1. Clinical [5% weight loss responders (primary outcome), absolute and % weight losses, changes in obesity-related comorbidities]; 2. Humanistic (health related quality of life, patient satisfaction, depression, and self-efficacy); and 3. Economic (incremental costs and utilities and cost per change in BMI assessed from the third party health care payor perspective) outcomes. Covariate-adjusted baseline-to-nine-month change-scores will be compared between groups for each outcome using linear regression for continuous outcomes and logistic regression for dichotomous ones., Discussion: Our findings will determine whether this intervention is effective and cost-effective compared to controls and if online or in-person care delivery is preferred. This information will be useful for clinicians, health-service providers and policy makers and should be generalizable to similar publically-funded bariatric care programs., Trial Registration: Trial Identifier: NCT01860131.

Background: We hypothesized that the higher mortality for hemodialysis patients who live farther from the closest attending nephrologist compared with patients living closer might be due to lower quality of care., Study Design: Population-based longitudinal study., Setting & Participants: All adult maintenance hemodialysis patients with measurements of quality-of-care indicators initiating hemodialysis therapy between January 2001 and June 2010 in Northern Alberta, Canada., Predictors: Hemodialysis patients were classified into categories based on the distance by road from their residence to the closest nephrologist: ≤50 (referent), 50.1-150, 150.1-300, and >300 km., Outcomes: Quality-of-care indicators were based on published guidelines., Measurements: Quality-of-care indicators at 90 days following initiation of hemodialysis therapy and, in a secondary analysis, at 1 year., Results: Measurements were available for 1,784 patients. At baseline, the proportions of patients residing in each category were 69% for ≤50 km to closest nephrologist; 17%, 50.1-150 km; 7%, 150.1-300 km; and 7%, >300 km. Those who lived farther away from the closest nephrologist were less likely to have seen a nephrologist 90 days prior to the initiation of hemodialysis therapy (P for trend = 0.008) and were less likely to receive Kt/V of 1.2 (adjusted OR, 0.50; 95% CI, 0.30-0.84; P for trend = 0.01). Remote location also was associated with suboptimal levels of phosphate control (P for trend = 0.005). There were no differences in the prevalence of arteriovenous fistulas or grafts or hemoglobin levels across distance categories., Limitations: Registry data with limited data for non-guideline-based quality indicators., Conclusions: Although several quality-of-care indicators were less common in remote-dwelling hemodialysis patients, these differences do not appear sufficient to explain the previously noted disparities in clinical outcomes by residence location., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Patients with kidney failure sometimes do not receive chronic renal replacement therapy (RRT), even though this may reduce their life expectancy. This study aimed to identify factors associated with initiation of chronic RRT., Design, Setting, Participants, & Measurements: This cohort study was conducted with Albertans aged >18 years between May 2002 and March 2009, using linked data from the provincial renal programs, clinical laboratories, and provincial health ministry. This study focused on those who developed kidney failure, defined by an estimated GFR (eGFR) <15 ml/min per 1.73 m(2) at last measurement during follow-up, together with prior CKD (eGFR <60 ml/min per 1.73 m(2) at least 90 days earlier). Multivariable Cox proportional hazards models were used to determine factors significantly associated with initiation of chronic RRT., Results: In total, 7901 participants had eGFR <15 ml/min per 1.73 m(2) at last measurement. After adjustment, older participants were less likely to initiate chronic RRT. Remote residence location, dementia, and metastatic cancer also decreased the likelihood of initiating RRT. The cumulative probability of initiating RRT during follow-up was 76.8% for urban-dwelling men aged <50 years without comorbidity, but was only 3.2% among remote-dwelling women aged ≥70 years with dementia and metastatic cancer. In contrast, patients with diabetes and heavy/severe proteinuria were more likely to initiate chronic RRT., Conclusions: There is substantial variability in the likelihood of RRT initiation for patients with eGFR <15 ml/min per 1.73 m(2). Further studies are needed to delineate factors that influence this outcome.

LDL cholesterol (LDL-C) is an important marker of coronary risk in the general population, but its utility in people with CKD is unclear. We studied 836,060 adults from the Alberta Kidney Disease Network with at least one measurement of fasting LDL-C, estimated GFR (eGFR), and proteinuria between 2002 and 2009. All participants were free of stage 5 CKD at cohort entry. We followed participants from first eGFR measurement to March 31, 2009; we used validated algorithms applied to administrative data to ascertain primary outcome (hospitalization for myocardial infarction) and Cox regression to calculate adjusted hazard ratios (HRs) for myocardial infarction by LDL-C categories within eGFR strata. During median follow-up of 48 months, 7762 patients were hospitalized for myocardial infarction, with incidence highest among participants with the lowest eGFR. Compared with 2.6-3.39 mmol/L (referent), the risk associated with having LDL-C above 4.9 mmol/L seemed greatest for GFR≥90 ml/min per 1.73 m(2) and least for eGFR=15-59.9 ml/min per 1.73 m(2). Specifically, the adjusted HRs (95% confidence intervals) of myocardial infarction associated with LDL-C of ≥4.9 compared with 2.6-3.39 mmol/L in participants with eGFR=15-59.9, 60-89.9, and ≥90 ml/min per 1.73 m(2) were 2.06 (1.59, 2.67), 2.30 (2.00, 2.65), and 3.01 (2.46, 3.69). In conclusion, the association between higher LDL-C and risk of myocardial infarction is weaker for people with lower baseline eGFR, despite higher absolute risk of myocardial infarction. Increased LDL-C may be less useful as a marker of coronary risk among people with CKD than the general population.

Background and Objectives: This study aimed to determine if recovery of kidney function after AKI modifies the association between AKI during hospitalization and adverse outcomes after discharge., Design, Setting, Participants, & Measurements: The effect of renal recovery after AKI was evaluated in a population-based cohort study (n=190,714) with participants identified from a provincial claims registry in Alberta, Canada, between November 1, 2002 and December 31, 2007. AKI was identified by a two-fold increase between prehospital and peak in-hospital serum creatinine (SCr). Recovery was assessed using SCr drawn closest to 90 days after the AKI event. All-cause mortality and a combined renal outcome of sustained doubling of SCr or progression to kidney failure were evaluated., Results: Overall, 3.7% of the participants (n=7014) had AKI, 62.7% of whom (n=4400) survived 90 days. In the 3231 patients in whom recovery could be assessed over a median follow-up of 34 months, 30.8% (n=1268) of AKI survivors died and 2.1% (n=85) progressed to kidney failure. Participants who did not recover kidney function had a higher risk for mortality and adverse renal outcomes when AKI participants who recovered to within 25% of baseline SCr were used as the reference group (adjusted mortality hazard ratio (HR), 1.26; 95% confidence interval, 1.10, 1.43) (adjusted renal outcomes HR, 4.13; 95% confidence interval, 3.38, 5.04). Mortality HR was notably higher when participants failed to recover within 55% of baseline., Conclusions: Renal recovery after AKI is associated with a lower risk of death or adverse renal outcomes after hospital discharge.

Background and Objective: The acceptability of financial incentives for organ donation is contentious. This study sought to determine (1) the acceptability of expense reimbursement or financial incentives by the general public, health professionals involved with organ donation and transplantation, and those with or affected by kidney disease and (2) for the public, whether financial incentives would alter their willingness to consider donation., Design, Setting, Participants, & Measurements: Web-based survey administered to members of the Canadian public, health professionals, and people with or affected by kidney disease asking questions regarding acceptability of strategies to increase living and deceased kidney donation and willingness to donate a kidney under various financial incentives., Results: Responses were collected from 2004 members of the Canadian public October 11-18, 2011; responses from health professionals (n=339) and people with or affected by kidney disease (n=268) were collected during a 4-week period commencing October 11, 2011. Acceptability of one or more financial incentives to increase deceased and living donation was noted in >70% and 40% of all groups, respectively. Support for monetary payment for living donors was 45%, 14%, and 27% for the public, health professionals, and people with or affected by kidney disease, respectively. Overall, reimbursement of funeral expenses for deceased donors and a tax break for living donors were the most acceptable., Conclusion: The general public views regulated financial incentives for living and deceased donation to be acceptable. Future research needs to examine the impact of financial incentives on rates of deceased and living donors.

Background: Computer-based clinical decision support aims to improve the quality of patient care. The utility of decision support for improving blood pressure control in hemodialysis patients is unknown., Methods: This was a nonrandomized controlled trial of adult patients receiving chronic in-center hemodialysis during the period of April 1, 2005, to September 30, 2006, in 1 of the 2 major university-based renal programs in Alberta, Canada. Physicians in the intervention center were provided with twice-monthly audits and printed management suggestions based on guideline-recommended blood pressure targets. The same data were available to physicians in the control group but without audit and feedback decision support., Results: Eight hundred and thirty hemodialysis patients were receiving dialysis treatment at the time the study was initiated. Preintervention and postintervention blood pressure data were available for 361 patients. The primary outcome, the proportion of postdialysis systolic blood pressures at target over 12 months, did not differ between the intervention and the control programs (unadjusted odds ratio 0.59; 95% confidence interval [95% CI], 0.34-1.02, p = 0.06; adjusted odds ratio 0.62; 95% CI, 0.35-1.11, p = 0.11). There was no significant difference between the intervention and control groups in other measures of blood pressure such as the mean change in postdialysis systolic blood pressures (unadjusted mean difference 4 mm Hg, 95% CI, -1 to 9, p = 0.36; adjusted mean difference 2 mm Hg, 95% CI, -1 to 5, p = 0.19)., Conclusions: In this population of chronic hemodialysis patients, a computer-based clinical decision support system was not associated with improved blood pressure control.

For health scientists, knowledge translation refers to the process of facilitating uptake of knowledge into clinical practice or decision making. Since high-quality clinical research that is not applied cannot improve outcomes, knowledge translation is critical for realizing the value and potential for all types of health research. Knowledge translation is particularly relevant for areas within health care where gaps in care are known to exist, which is the case for some areas of management for people with chronic kidney disease (CKD), including assessment of proteinuria. Given that proteinuria is a key marker of cardiovascular and renal risk, forthcoming international practice guidelines will recommend including proteinuria within staging systems for CKD. While this revised staging system will facilitate identification of patients at higher risk for progression of CKD and mortality who benefit from intervention, strategies to ensure its appropriate uptake will be particularly important. This article describes key elements of effective knowledge translation strategies based on the knowledge-to-action cycle framework and describes options for effective knowledge translation interventions related to the new CKD guidelines, focusing on recommendations related to assessment for proteinuria specifically. The article also presents findings from a multidisciplinary meeting aimed at developing knowledge translation intervention strategies, with input from key stakeholders (researchers, knowledge users, decision makers and collaborators), to facilitate implementation of this guideline. These considerations are relevant for dissemination and implementation of guidelines on other topics and in other clinical settings.

Background: Canadians with chronic diseases often live far away from healthcare facilities, which may compromise their level of care. We used a new method for selecting optimal locations for new healthcare facilities in remote regions., Methods: We used a provincial laboratory database linked to data from the provincial health ministry. From all patients with serum creatinine measured at least once between 2002 and 2008 in Alberta, Canada, we selected those with diabetes and an estimated glomerular filtration rate (eGFR) of 15-60 mL/min/1.73 m(2). We then used two methods to select potential locations for new clinics that would serve the greatest number of remote-dwelling patients: plots showing the unadjusted density of such patients per 100 km(2) and SatScan analysis presenting the prevalent clusters of patients on the basis of chronic kidney disease (CKD) rates (adjusted for population size)., Results: We studied 32,278 patients with concomitant diabetes and CKD. A substantial number of patients (8%) resided >200 km from existing nephrologists' clinics. Density plots mapped with ArcGIS were useful for localizing a large cluster of underserved patients. However, objective assessment with SatScan technique and ArcGIS permitted us to detect additional clusters of patients in the northwest and southeast regions of Alberta--and suggested potential locations for new clinics in these areas., Conclusions: Objective techniques such as SatScan can identify clusters of underserved patients with CKD and identify potential new facility locations for consideration by decision-makers. Our findings may also be applicable to patients with other chronic diseases.

Background: To investigate the relation of residence location, markers of good quality healthcare and adverse clinical outcomes in patients with diabetes and chronic kidney disease (CKD)., Methods: We identified 31 337 individuals with diabetes and estimated glomerular filtration rate (eGFR) 15-59 mL/min/1.73 m(2) from a population-based cohort (n= 1 278 375) of adults with serum creatinine measured at least once during 2005 or 2006 in Alberta, Canada. The study population was classified into categories based on travel distance by road from residence location to the closest nephrologist: (0-50, 50.1-100, 100.1-200 and >200 km)., Results: At follow-up, compared with those living within 50 km, remote dwellers were less likely to visit a nephrologist, less likely to have hemoglobin A1c and urinary albumin measured within 1 year of the index eGFR, and less likely to receive an angiotensin converting enzyme inhibitor, angiotensin receptor blocker or statin (all P < 0.0001). In adjusted models, compared with those with CKD (Stage 3 or 4) living within 50 km, the adjusted likelihood of all-cause hospitalization was [1.4 (95% confidence interval, CI, 1.3-1.6)], [1.3 (95% CI, 1.1-1.6)] and [1.3 (95% CI, 1.2-1.5)]-fold higher for patients living 50.1-100, 100.1-200 and >200 km away from a nephrologist, respectively (P < 0.0001). The hazard ratio of all-cause mortality increased with increasing distance: [1.07 (95% CI, 0.9-1.2)], [1.1 (95% CI, 0.9-1.2)] and [1.2 (95% CI, 1.0-1.4)], respectively (P < 0.0001)., Conclusions: Compared with those living closer to a nephrologist, remote dwellers with diabetes and CKD were less likely to receive recommended quality care, and more likely to experience adverse health outcomes.

Background: Bariatric surgery is the most effective current treatment for severe obesity. Capacity to perform surgery within Canada's public health system is limited and potential candidates face protracted wait times. A better understanding of the gaps between demand for surgery and the capacity to provide it is required. The purpose of this study was to quantify and characterize the bariatric surgery-eligible population in Canada in comparison to surgery-ineligible subjects and surgical recipients., Methods: Data from adult (age > 20) respondents of the 2007-09 nationally representative Canadian Health Measures Survey (CHMS) were analyzed to estimate the prevalence and characteristics of the surgery-eligible and ineligible populations. Federally mandated administrative healthcare data (2007-08) were used to characterize surgical recipients., Results: In 2007-09, an estimated 1.5 million obese Canadian adults met eligibility criteria for bariatric surgery. 19.2 million were surgery-ineligible (3.4 million obese and 15.8 million non-obese). Surgery-eligible Canadians had a mean BMI of 40.1 kg/m2 (95% CI 39.3 to 40.9 kg/m2) and, compared to the surgery-ineligible obese population, were more likely to be female (62 vs. 44%), 40-59 years old (55 vs. 48%), less educated (43 vs. 35%), in the lowest socioeconomic tertile (41 vs. 34%), and inactive (73 vs. 59%). Self-rated mental health and quality of life were lower and comorbidity was higher in surgery-eligible respondents compared with the ineligible populations. The annual proportion of Canadians eligible for surgery that actually underwent a publicly funded bariatric surgery between 2007-09 was 0.1%. Surgical recipients (n = 847) had a mean age of 43.6 years (SD 11.1) and 82% were female. With the exception of type 2 diabetes, obesity-related comorbidity prevalence was much lower in surgical recipients compared to those eligible for surgery., Conclusions: The proportion of bariatric surgery-eligible Canadians that undergo publicly funded bariatric surgery is very low. There are notable differences in sociodemographic profiles and prevalence of comorbidities between surgery-eligible subjects and surgical recipients.

Living far away from specialized care centers is a potential barrier to the delivery of quality health care and has been associated with adverse outcomes. To assess mortality as a function of distance from the closest hemodialysis unit, and as a function of rural rather than urban residence, we analyzed prospectively collected data on 726,347 adults initiating chronic hemodialysis in the United States over a 13-year period. Participants were classified into categories of 0-10 (referent), 11-25, 26-45, 46-100, and remote living over 100 miles from the closest hemodialysis unit. After a median follow-up of 2.7 years (range 0 to 12.7 years), 368,569 patients died. Compared to the referent group, the adjusted hazard ratio of death was 1.01, 0.99, 0.96, and 1.21, respectively. When residence location was classified using rural-urban commuter areas, 16.5, 66.8, and 16.7% of patients lived in urban, micropolitan, and metropolitan areas, respectively. Compared with those living in metropolitan areas, the adjusted hazard ratio of mortality among patients residing in micropolitan and rural communities was 1.02 and 1.01, respectively. Thus, remote but not rural residence was associated with increased mortality among patients initiating chronic hemodialysis treatment in the United States.

Background: Sexual dysfunction is common in patients with end stage renal disease (ESRD) and treatment options are limited. Observational studies suggest that nocturnal hemodialysis may improve sexual function. We compared sexual activity and responses to sexual related questions in the Kidney Disease Quality of Life Short Form questionnaire among patients randomized to frequent nocturnal or thrice weekly conventional hemodialysis., Methods: We performed a secondary analysis of data from an RCT which enrolled 51 patients comparing frequent nocturnal and conventional thrice weekly hemodialysis. Sexual activity and responses to sexual related questions were assessed at baseline and six months using relevant questions from the Kidney Disease Quality of Life Short Form questionnaire., Results: Overall, there was no difference in sexual activity, or the extent to which people were bothered by the impact of kidney disease on their sex life between the two groups between randomization and 6 months. However, women and patients age < 60 who were randomized to frequent nocturnal hemodialysis were less bothered by the impact of kidney disease on their sex life at 6 months, compared with patients allocated to conventional hemodialysis (p = 0.005 and p = 0.024 respectively)., Conclusions: Our results suggest that frequent nocturnal hemodialysis is not associated with an improvement in sexual activity in all patients but might have an effect on the burden of kidney disease on sex life in women and patients less than 60 years of age. The validity of these subgroup findings require confirmation in future RCTs.

Background: Protracted, multi-year wait times exist for bariatric care in Canada. Our objective was to examine wait-listed patients' health status and perceptions regarding the consequences of prolonged wait times using a cross-sectional study design nested within a prospective cohort., Methods: 150 consecutive consenting subjects wait-listed for multi-disciplinary bariatric assessment in a population-based medical/surgical bariatric program were surveyed. Health status was measured using a visual analogue scale (VAS). A Waiting List Impact Questionnaire (WLIQ) examined employment, physical stress, social support, frustration, quality of life, and satisfaction with care. Multivariable linear regression analysis adjusted for age, sex and BMI identified independent predictors of lower VAS scores., Results: 136 (91%) subjects were women, mean age was 43 years (SD 9), mean BMI was 49.4 (SD 8.3) kg/m2 and average time wait-listed was 64 days (SD 76). The mean VAS score was 53/100 (SD 22). According to the WLIQ, 47% of subjects agreed/strongly agreed that waiting affected their quality of life, 65% described wait times as 'concerning' and 81% as 'frustrating'. 86% reported worsening of physical symptoms over time. Nevertheless, only 31% were dissatisfied/very dissatisfied with their overall medical care. Independent predictors of lower VAS scores were higher BMI (beta coefficient 0.42; p = 0.03), unemployment (13.7; p = 0.01) and depression (10.3; p = 0.003)., Conclusions: Patients wait-listed for bariatric care self-reported very impaired health status and other adverse consequences, attributing these to protracted waits. These data may help benchmark the level of health impairment in this population, understand the physical and mental toll of waiting, and assist with wait list management., Trial Registration: Clinicaltrials.gov NCT00850356.

Background: Living kidney donation offers a unique setting to study changes in phosphate and vitamin D homeostasis attributable to mild isolated decreases in estimated glomerular filtration rate (eGFR)., Study Design: Cross-sectional study., Setting & Participants: 198 living kidney donors and 98 nondonor controls from 9 transplant centers across 3 countries. For donors, median time after donation was 5.3 years. At assessment, donors had a lower eGFR than controls (73 vs 98 mL/min/1.73 m(2))., Predictor: Living kidney donation (mildly decreased eGFR)., Outcomes: Biochemical markers of chronic kidney disease-mineral and bone disorder., Measurements: Serum creatinine, total serum calcium, serum and urine inorganic phosphate, plasma intact parathyroid hormone, serum calcidiol and calcitriol, renal fractional excretion of inorganic phosphate, and intact serum fibroblast growth factor 23 (FGF-23)., Results: Serum FGF-23 levels were significantly higher in donors (38.1 vs 29.7 pg/mL; P < 0.001). For every 10-mL/min/1.73 m(2) decrease in eGFR, FGF-23 level was higher by 3.2 (95% CI, 2.0-4.4) pg/mL. Compared with controls, donors showed higher renal tubular fractional excretion of inorganic phosphate (17.8% vs 12.3%; P < 0.001), lower serum phosphate (0.97 vs 1.02 mmol/L; P = 0.03), and lower serum calcitriol values (63 vs 77 pmol/L; P < 0.001). Serum calcium levels were not significantly different between the 2 groups. Plasma intact parathyroid hormone levels were significantly higher in donors (5.7 vs 5.0 pmol/L; P = 0.03), but were not correlated with FGF-23 or calcitriol levels., Limitations: Enrollment of a small proportion of past donors at participating centers; assessment of only postdonation values; unable to assess seasonal variation or other temporal patterns in biochemical markers; assessment of kidney function was based on eGFR, not measured GFR., Conclusions: The FGF-23 pathway may be activated in living kidney donors who show early biochemical changes compatible with chronic kidney disease-mineral and bone disorder. Whether these changes influence bone mineral density and fracture rates warrants consideration., (Copyright © 2012 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The association of proteinuria and adverse clinical outcomes is well established. The optimal method of classifying proteinuria status for study participants in whom it is measured multiple times is unknown, especially when the frequency of measurement varies between participants., Study Design: Population-based longitudinal study., Setting & Participants: All adults with at least one outpatient serum creatinine measurement in the province of Alberta, Canada., Factor: Proteinuria (dipstick, albumin-creatinine ratio [ACR])., Outcomes: All-cause mortality, end-stage renal disease, or doubling of serum creatinine level., Measures: All outpatient urine dipstick and ACR measurements in the 6-month period before and after the first (index) estimated glomerular filtration rate were used to establish baseline proteinuria. Dipstick measures were analyzed as ceiling (median value up to the next integer), floor (median value down to the next integer), high (single highest dipstick value), low (single lowest dipstick value), and first (first available dipstick value only). Measurements of ACR were evaluated similarly and a median (median of all ACR measurements) value was added., Results: Of 920,985 participants, 17% (n = 160,548) had multiple dipstick urinalysis measurements and 22% (n = 22,814) had multiple ACR measurements. With single measurements, absolute rates of mortality and renal outcomes were lower in every proteinuria category compared with multiple measurements. In contrast, the relative increase in rate ratio was greater with increasing proteinuria in patients with single measurements compared with those with multiple measurements. In all classification systems evaluated, more severe proteinuria was associated with significantly higher rates of both outcomes (all P for trend <0.001)., Limitations: Lack of a gold standard for choosing between methods., Conclusions: Rates of adverse outcomes related to multiple baseline proteinuria/albuminuria measurements were similar, independent of the measure of baseline proteinuria that was used to combine results. In contrast, discarding follow-up measurements and relying on only the first measurement led to lower estimates of absolute and relative risk for each proteinuria category., (Copyright © 2012 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether people who donate a kidney have an increased risk of cardiovascular disease., Design: Retrospective population based matched cohort study., Participants: All people who were carefully selected to become a living kidney donor in the province of Ontario, Canada, between 1992 and 2009. The information in donor charts was manually reviewed and linked to provincial healthcare databases. Matched non-donors were selected from the healthiest segment of the general population. A total of 2028 donors and 20,280 matched non-donors were followed for a median of 6.5 years (maximum 17.7 years). Median age was 43 at the time of donation (interquartile range 34-50) and 50 at the time of follow-up (42-58)., Main Outcome Measures: The primary outcome was a composite of time to death or first major cardiovascular event. The secondary outcome was time to first major cardiovascular event censored for death., Results: The risk of the primary outcome of death and major cardiovascular events was lower in donors than in non-donors (2.8 v 4.1 events per 1000 person years; hazard ratio 0.66, 95% confidence interval 0.48 to 0.90). The risk of major cardiovascular events censored for death was no different in donors than in non-donors (1.7 v 2.0 events per 1000 person years; 0.85, 0.57 to 1.27). Results were similar in all sensitivity analyses. Older age and lower income were associated with a higher risk of death and major cardiovascular events in both donors and non-donors when each group was analysed separately., Conclusions: The risk of major cardiovascular events in donors is no higher in the first decade after kidney donation compared with a similarly healthy segment of the general population. While we will continue to follow people in this study, these interim results add to the evidence base supporting the safety of the practice among carefully selected donors.

Background: Metformin is widely accepted as first-line pharmacotherapy for patients with type 2 diabetes mellitus when glycemic control cannot be achieved by lifestyle interventions alone. However, uncertainty exists regarding the optimal second-line therapy for patients whose diabetes is inadequately controlled by metformin monotherapy. Increased use of newer, more costly agents, along with the rising incidence of type 2 diabetes, carries significant budgetary implications for health care systems. We conducted this analysis to determine the relative costs, benefits and cost-effectiveness of options for second-line treatment of type 2 diabetes., Methods: We used the United Kingdom Prospective Diabetes Study Outcomes Model to forecast diabetes-related complications, quality-adjusted life-years and costs of alternative second-line therapies available in Canada for adults with type 2 diabetes inadequately controlled by metformin. We obtained clinical data from a systematic review and mixed treatment comparison meta-analysis, and we obtained information on costs and utilities from published sources. We performed extensive sensitivity analyses to test the robustness of results to variation in inputs and assumptions., Results: Sulphonylureas, when added to metformin, were associated with the most favourable cost-effectiveness estimate, with an incremental cost of $12 757 per quality-adjusted life-year gained, relative to continued metformin monotherapy. Treatment with other agents, including thiazolidinediones and dipeptidyl peptidase-4 inhibitors, had unfavourable cost-effectiveness estimates compared with sulphonylureas. These results were robust to extensive sensitivity analyses., Interpretation: For most patients with type 2 diabetes that is inadequately controlled with metformin monotherapy, the addition of a sulphonylurea represents the most cost-effective second-line therapy.

Context: Use of bariatric surgery for severe obesity has increased dramatically., Objective: To systematically review 1. the clinical efficacy and safety, 2. cost-effectiveness of bariatric surgery, and 3. the association between number of surgeries performed (surgical volume) and outcomes., Data Sources: MEDLINE (from 1950), EMBASE (from 1980), CENTRAL, EconLit, EURON EED, Harvard Center for Risk Analysis, trial registries and HTA websites were searched to January 2011., Study Selection: 1. Randomized controlled trials (RCTs) and 2. cost-utility and cost-minimisation studies comparing a contemporary bariatric surgery (i.e., adjustable gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy) to another contemporary surgical comparator or a non-surgical treatment or 3. Any study reporting the association between surgical volume and outcome., Data Extraction: Outcomes included changes in weight and obesity-related comorbidity, quality of life and mortality, surgical complications, resource utilization, and incremental cost-utility., Results: RCT data evaluating mortality and obesity-related comorbidity endpoints were lacking. A small RCT of 16 patients reported that adjustable gastric banding reduced weight by 27% (p < 0.01) compared to diet-treated controls over 40 weeks. Six small RCTs reported comparisons of commonly used, contemporary procedures. Gastric banding reduced weight to a lower extent than gastric bypass and sleeve gastrectomy and resulted in shorter operating times, fewer serious complications, lower weight loss efficacy, and more frequent reoperations compared to gastric bypass. Sleeve gastrectomy and gastric bypass reduced weight to a similar extent. A 2-year RCT in 50 adolescents reported that gastric banding substantially reduced weight compared to lifestyle modification (35 kg vs. 3 kg; p <0.001). Based on findings of 14 observational studies, higher volume centers and surgeons had lower mortality and complication rates. Surgery resulted in long-term incremental cost-utility ratios of $ <1.000-$40,000 (2009 USD) per quality-adjusted-life-year compared with non-surgical treatment., Conclusions: Contemporary bariatric surgery appears to result in sustained weight reduction with acceptable costs but rigorous, longer-term (≥5 year) data are needed and a paucity of RCT data on mortality and obesity related comorbidity is evident. Procedure-specific variations in efficacy and risks exist and require further study to clarify the specific indications for and advantages of different procedures.

Background and Objectives: Travel distance to healthcare facilities affects healthcare access and utilization. Using the example of patients with kidney disease and nephrology services, we investigated the feasibility and utility of using geographic information system (GIS) techniques to identify the ideal location for new clinics to improve care for patients with kidney disease, on the basis of systematically minimizing travel time for remote dwellers., Design, Setting, Participants, & Measurements: Using a provincial laboratory database to identify patients with kidney disease and where they lived, we used GIS techniques of buffer and network analysis to determine ideal locations for up to four new nephrology clinics. Service-area polygons for different travel-time intervals were generated and used to determine the best locations for the four new facilities that would minimize the number of patients with kidney disease who were traveling >2 hours., Results: We studied 31,452 adults with living in Alberta, Canada. Adding the four new facilities would increase the number of patients living <30 minutes from a clinic by 2.2% and reduce the number living >120 minutes away by 72.5%. Different two- and three-clinic scenarios reduced the number of people living >120 minutes away by as much as 65% or as little as 32%, emphasizing the importance of systematic evaluation., Conclusions: GIS techniques are an attractive alternative to the current practice of arbitrarily locating new facilities on the basis of perceptions about patient demand. Optimal location of new clinical services to minimize travel time might facilitate better patient care.

The clinical efficacy and safety of bariatric surgery trials were systematically reviewed. MEDLINE, EMBASE, CENTRAL were searched to February 2009. A basic PubCrawler alert was run until March 2010. Trial registries, HTA websites and systematic reviews were searched. Manufacturers were contacted. Randomized trials comparing bariatric surgeries and/or standard care were selected. Evidence-based items potentially indicating risk of bias were assessed. Network meta-analysis was performed using Bayesian techniques. Of 1838 citations, 31 RCTs involving 2619 patients (mean age 30-48 y; mean BMI levels 42-58 kg/m(2) ) met eligibility criteria. As compared with standard care, differences in BMI levels from baseline at year 1 (15 trials; 1103 participants) were as follows: jejunoileal bypass [MD: -11.4 kg/m(2) ], mini-gastric bypass [-11.3 kg/m(2) ], biliopancreatic diversion [-11.2 kg/m(2) ], sleeve gastrectomy [-10.1 kg/m(2) ], Roux-en-Y gastric bypass [-9.0 kg/m(2) ], horizontal gastroplasty [-5.0 kg/m(2) ], vertical banded gastroplasty [-6.4 kg/m(2) ], and adjustable gastric banding [-2.4 kg/m(2) ]. Bariatric surgery appears efficacious compared to standard care in reducing BMI. Weight losses are greatest with diversionary procedures, intermediate with diversionary/restrictive procedures, and lowest with those that are purely restrictive. Compared with Roux-en-Y gastric bypass, adjustable gastric banding has lower weight loss efficacy, but also leads to fewer serious adverse effects., (© 2011 The Authors. obesity reviews © 2011 International Association for the Study of Obesity.)

Background: Acute kidney injury (AKI) in hospitalized patients is associated with poor outcomes; however, it is unclear how relationships between AKI and clinical outcomes vary with baseline kidney function., Study Design: Population-based cohort., Setting & Participants: Adults in Alberta, Canada, who were hospitalized between January 1, 2003, and December 31, 2006, with at least 1 serum creatinine measurement during hospitalization and 1 outpatient creatinine measurement within 6 months preceding admission., Predictor: Baseline kidney function, defined as mean estimated glomerular filtration rate (eGFR) of all outpatient creatinine measurements within 6 months before the index hospitalization, and AKI, defined using consensus criteria., Outcomes: Death during the index hospitalization and death or end-stage renal disease (ESRD) after hospitalization., Results: AKI occurred in 18.3% of the 43,008 hospitalized patients in the cohort. Risk of AKI increased with decreasing eGFR (8.9% with eGFR ≥60 mL/min/1.73 m(2) vs 68.9% with eGFR <30 mL/min/1.73 m(2)). In multivariable Cox models, AKI of any severity was associated with death during the index hospitalization across all levels of eGFR, with an HR of 2.99 (95% CI, 2.59-3.44) in patients who had the least severe AKI across all eGFR strata up to an HR of 10.62 (95% CI, 8.78-12.82) in patients with baseline eGFR >60 mL/min/1.73 m(2) and the most severe AKI. The risk of death or ESRD decreased after discharge, with the highest risk of ESRD after AKI noted in patients with eGFR <30 mL/min/1.73 m(2) (17.0% in the AKI group vs 5.6% in the non-AKI group; P < 0.01)., Limitations: The study cohort is restricted to patients who had outpatient serum creatinine values available., Conclusions: AKI of any severity increases the risk of death both during hospitalization and after discharge. Although the risk of developing ESRD after AKI is greatest in patients with baseline eGFR <30 mL/min/1.73 m(2), this is exceeded by the risk of death., (Copyright © 2011 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Most studies of chronic kidney disease (CKD) and outcomes focus on mortality and ESRD, with limited data on other adverse outcomes. This study examined the associations among proteinuria, eGFR, and adverse cardiovascular (CV) events., Design, Setting, Participants, & Measurements: This was a population-based longitudinal study with patients identified from province-wide laboratory data from Alberta, Canada, between 2002 and 2007. Selected for this study from a total of 1,526,437 patients were 920,985 (60.3%) patients with at least one urine dipstick measurement and 102,701 patients (6.7%) with at least one albumin-creatinine ratio (ACR) measurement. Time to hospitalization was considered for one of four indications: congestive heart failure (CHF), coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI), peripheral vascular disease (PVD), and stroke/transient ischemic attacks [TIAs] (cerebrovascular accident [CVA]/TIA)., Results: After a median follow-up of 35 months, in fully adjusted models and compared with patients with estimated GFR (eGFR) of 45 to 59 ml/min per 1.73 m(2) and no proteinuria, patients with heavy proteinuria by dipstick and eGFR ≥ 60 ml/min per 1.73 m(2) had higher rates of CABG/PCI and CVA/TIA. Similar results were obtained in patients with proteinuria measured by ACR., Conclusions: Risks of major CV events at a given level of eGFR increased with higher levels of proteinuria. The findings extend current data on risk of mortality and ESRD. Measurement of proteinuria is of incremental prognostic benefit at every level of eGFR. The data support use of proteinuria measurement with eGFR for definition and risk stratification in CKD.

Objective: More frequent dialysis may improve nutrition and remove dietary restrictions in hemodialysis (HD) patients. We present results from a trial comparing nutritional parameters between nocturnal hemodialysis (NHD) and conventional HD patients., Methods: Patients were randomized to conventional thrice weekly HD or NHD for a 6-month study period. Dietary intake was recorded by patients using a 3-day food record at baseline and study exit., Results: Of 51 patients, 23 completed baseline and exit food records and were included in the analysis. Although dietary intake of calcium, potassium, and lipids increased in the NHD group, serum levels of calcium and potassium remained within target limits. The majority of NHD subjects were able to reduce or discontinue their phosphate binders and maintain serum phosphate levels within target limits. Serum albumin improved among the NHD group (0.7 g/L) and declined for the conventional group (-1.6 g/L). None of the between group differences achieved statistical significance., Conclusions: As compared with conventional dialysis, NHD was associated with a nonstatistically significant increase in dietary intake for some nutrients, with maintenance of serum levels for potassium, calcium, and phosphorus. Whether increased dietary intake translates into improvement in morbidity and mortality remains to be determined., (Copyright © 2011 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The risks associated with using an angiotensin-converting-enzyme (ACE) inhibitor and an angiotensin-receptor blocker together are unclear. This study was designed to determine the safety of combination therapy with these two drugs in clinical practice., Methods: We conducted a population-based longitudinal analysis using linked administrative and laboratory data for elderly patients who were new users of an ACE inhibitor, an angiotensin-receptor blocker or a combination of both medications between May 1, 2002, and Dec. 31, 2006. We compared outcomes in patients given combination therapy versus patients given monotherapy using Cox proportional hazards analyses with adjustment for baseline characteristics., Results: Of the 32,312 new users of either medication (mean age 76.1 years, median creatinine level 92 μmol/L), 1750 (5.4%) received combination therapy. However, 1512 (86.4%) of the patients who were given combination therapy did not have trial-established indications such as heart failure or proteinuria. Renal dysfunction was more common among patients given combination therapy (5.2 [95% confidence interval (CI) 3.4 to 7.9] events per 1000 patients per month) than among patients given monotherapy (2.4 [95% CI 2.2 to 2.7] events per 1000 patients per month) (adjusted hazard ratio [HR] 2.36, 95% CI 1.51 to 3.71). Hyperkalemia was also more common among patients given combination therapy (2.5 [95% CI 1.4 to 4.3] events per 1000 patients per month) than among patients given monotherapy (0.9 [95% CI 0.8 to 1.0] events per 1000 patients per month) (adjusted HR 2.42, 95% CI 1.36 to 4.32). Most patients took combination therapy for only a short time (median three months before at least one agent was stopped)., Interpretation: Combination therapy was frequently prescribed for patients without established indications and was associated with an increased risk of adverse renal outcomes when compared with monotherapy. These results mirrored data from randomized controlled trials.

Background: There has been increasing interest in determining renal outcomes after nephrectomy for renal tumors. Previous studies have not assessed all relevant risk factors, including proteinuria., Objective: We sought to determine the risk and predictors for the development of adverse renal outcomes in a population-based cohort of subjects undergoing partial or complete nephrectomy., Design, Setting, and Participants: A large population-based data set was used to identify all subjects undergoing nephrectomy in Alberta, Canada, from 2002 to 2007 using administrative codes. Comorbid conditions were determined using validated algorithms, and baseline estimated glomerular filtration rate (eGFR) and proteinuria status were determined., Measurements: Postsurgical outcomes of end-stage renal disease, acute dialysis, chronic kidney disease (CKD) (eGFR <30 ml/min per 1.73 m(2)), and rapidly progressive CKD (eGFR <60 ml/min per 1.73 m(2) and eGFR loss ≥4 ml/min per 1.73 m(2) per year) were assessed. The risk and risk factors for developing the composite renal outcome were determined using a multivariable Cox proportional hazards model., Results and Limitations: Of 1151 subjects, 10.5% developed an adverse renal outcome over a mean of 32 mo. Complete (vs partial) nephrectomy was associated with a hazard ratio (HR) of 1.75 (95% confidence interval [CI], 1.02-2.99) for the primary outcome, as was lower baseline eGFR. Subjects with proteinuria were more likely to experience the primary outcome (42% vs 9%), conferring an adjusted HR of 2.40 (95% CI, 1.47-3.88)., Conclusions: Clinically important adverse renal outcomes are common in patients undergoing nephrectomy for renal tumors. In addition to baseline eGFR and the extent of the renal mass removed, proteinuria is a strong independent risk factor. Assessment of proteinuria, in addition to other risk factors, should be performed to inform prognosis and the optimal treatment strategy., (Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Previous studies that described the long-term quality of life of living kidney donors were conducted in single centers, and lacked data on a healthy nondonor comparison group. We conducted a retrospective cohort study to compare the quality of life of 203 kidney donors with 104 healthy nondonor controls using validated scales (including the SF36, 15D and feeling thermometer) and author-developed questions. Participants were recruited from nine transplant centers in Canada, Scotland and Australia. Outcomes were assessed a median of 5.5 years after the time of transplantation (lower and upper quartiles of 3.8 and 8.4 years, respectively). 15D scores (scale of 0 to 1) were high and similar between donors and nondonors (mean 0.93 (standard deviation (SD) 0.09) and 0.94 (SD 0.06), p = 0.55), and were not different when results were adjusted for several prognostic characteristics (p = 0.55). On other scales and author-developed questions, groups performed similarly. Donors to recipients who had an adverse outcome (death, graft failure) had similar quality of life scores as those donors where the recipient did well. Our findings are reassuring for the practice of living transplantation. Those who donate a kidney in centers that use routine pretransplant donor evaluation have good long-term quality of life., (©2011 The Authors Journal compilation©2011 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Context: Many transplant candidates have concerns about living donation., Objective: To determine whether a structured educational session increased eligible kidney transplant candidates' pursuit of living donation., Design and Intervention: Eligible transplant candidates were randomized to standard of care (n = 50) or to the educational intervention (n = 50), which included both written materials and a 2-hour education session. The primary outcome was having a living donor contact the transplant program to express interest in donation for a patient, and a secondary outcome was the candidates' preference for treatment of end-stage renal disease; both outcomes were determined at 3 months after enrollment., Results: Of the 100 patients randomized, 4 in the intervention group and 2 in the standard of care group had a living donor contact the program (P = .45). Within-group changes in treatment preference from baseline were seen in the education intervention group (P = .02), but not in the standard of care group (P = .37)., Conclusions: This educational intervention did not increase the likelihood of a potential donor contacting the transplant program, compared with standard care. However, patients who received the educational intervention were more likely to change their treatment preference to living donation at study completion. Research investigating other methods of increasing living transplant rates is urgently required.

Kidney transplantation improves quality of life and survival and is associated with lower health care costs compared with dialysis. We described and compared the costs of living and standard criteria for deceased donor kidney transplantation. Patients included adult recipients of a first kidney-only transplant between April 1, 1998, and March 31, 2006, as well as their donor information. All costs (outpatient care, diagnostic imaging, inpatient care, physician claims, laboratory tests and transplant medications) for 2 years after transplant for recipients and transplant-related costs prior to transplant (donor workup and management) were included. Complete cost information was available for 357 recipients. The mean total 2-year cost of transplantation, including donor costs, for recipients of living and deceased donors was $118 347 (95% confidence interval [CI], 110 395-126 299) and $121 121 (95% CI 114 287-127 956), respectively (p = 0.7). The mean cost for a living donor was $18 129 (95% CI 16 845-19 414) and for a deceased donor was $36 989 (95% CI 34 421-39 558). Living donor kidney transplantation has similar costs at 2 years compared with deceased donor transplantation. These results can be used by health care decision makers to inform strategies to increase donation., (©2011 The Authors Journal compilation©2011 The American Society of Transplantation and the American Society of Transplant Surgeons.)