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

Refereed/Peer-reviewed Introduction: Low activity levels and poor physical function are associated with technique failure and mortality in people receiving peritoneal dialysis (PD). Adequate levels of physical function are required to maintain independence for people choosing this predominantly home-based therapy. The objective of this study was to identify the exercise-related perceptions and practices of PD clinicians globally. Methods: We conducted a cross-sectional survey of PD clinicians from English-, Thai-, Spanish-, and Portuguese-speaking PD-prevalent countries exploring clinicians’ perceptions and practices of swimming, activity following PD catheter insertion, lifting, and falls prevention. This study was convened by the International Society of Peritoneal Dialysis and Global Renal Exercise Network between July and December 2021. Results: Of 100 of the highest PD-prevalent countries, 85 responded and were represented in the findings. A total of 1125 PD clinicians (448 nephrologists, 558 nephrology nurses, 59 dietitians, and 56 others) responded from 61% high-income, 32% upper middle-income and 7% lower middle-income countries. The majority (n = 1054, 94%) agreed that structured exercise programs would be beneficial for people receiving PD. Most respondents believed people on PD could perform more exercise (n = 907, 81%) and that abdominal strengthening exercises could be safely performed (n = 661, 59%). Compared to clinicians in high-income countries, clinicians from lower middle-income status (odds ratio [OR], 5.57; 1.64 to 18.9) are more likely to promote participation in physical activity. Conclusion: Clinicians know the importance of physical activity in people receiving PD. Exercise counseling and structured exercise plans could be included in the standard care of people receiving PD to maintain independence.

Background Cognitive impairment is common among persons with chronic kidney disease (CKD), due in part to reduced kidney function. Given that physical activity (PA) is known to mitigate cognitive decline, we examined whether associations between CKD stage and global/domain-specific cognitive function differ by PA. Methods We leveraged 3223 participants (≥60 years of age) enrolled in National Health and Nutrition Examination Survey (NHANES, 2011–2014), with at least one measure of objective cognitive function [immediate recall (CERAD-WL), delayed recall (CERAD-DR), verbal fluency (AF), executive function/processing speed (DSST), global (average of four tests) or self-perceived memory decline (SCD)]. We quantified the association between CKD stage {no CKD: estimated glomerular filtration rate [eGFR] ≥60 mL/min/1.73 m2 and albuminuria [albumin:creatinine ratio (ACR)] Results Among NHANES participants, 34.9% had CKD stages G1–G3, 2.6% had stages G4 and G5 and 50.7% had low PA. CKD stages G4 and G5 were associated with lower global cognitive function {difference = −0.38 standard deviation [SD] [95% confidence interval (CI) −0.62 to −0.15]}. This association differed by PA (Pinteraction = 0.01). Specifically, among participants with low PA, those with CKD stages G4 and G5 had lower global cognitive function [difference = −0.57 SD (95% CI −0.82 to −0.31)] compared with those without CKD. Among those with high PA, no difference was found [difference = 0.10 SD (95% CI −0.29–0.49)]. Similarly, the CKD stage was only associated with immediate recall, verbal fluency, executive function and processing speed among those with low PA; no associations were observed for delayed recall or self-perceived memory decline. Conclusions CKD is associated with lower objective cognitive function among those with low but not high PA. Clinicians should consider screening older patients with CKD who have low PA for cognitive impairment and encourage them to meet PA guidelines.

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

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

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

Purpose of review People with chronic kidney disease have a high prevalence of poor physical function, which in turn is associated with poor health-related quality of life, and an increased risk of adverse events, including hospitalizations and all-cause mortality. Implementing early interventions may prove to be effective for preventing decline in physical function; however, it is imperative that clinicians screen patients to identify those at the highest risk of decline. In this review, we present subjective and objective screening tools that can easily and cost-effectively be implemented into routine nephrology practice to assess physical function. Recent findings Physical function can be assessed using commonly used physical performance tests that include objective measures, such as tests measuring gait speed, balance, chair-stand ability, and handgrip strength, as well as tests that include subjective self-reported measures. Summary The validated tools summarized in this review offer clinicians the ability to identify people at risk of poor physical function, in turn affording the opportunity to implement interventions for optimum management of risk of physical decline, preventing adverse health outcomes, and encouraging independence.

Life participation requiring physical activity and physical function is a key patient-reported outcome for people receiving peritoneal dialysis (PD). Clinician guidance is required from multidisciplinary sources regarding exercise and activity advice to address the specific needs of this group. From August 2020 through to June 2021, the Global Renal Exercise Network and the International Society for Peritoneal Dialysis reviewed the published literature and international clinical experience to develop a set of clinical practice points. A set of questions relevant to physical activity and exercise were developed from the perspective of a person receiving PD and were the basis for the practice point development. The GRADE framework was used to evaluate the quality of evidence and to guide clinical practice points. The review of the literature found sparse quality evidence, and thus the clinical practice points are generally based on the expert consensus of people receiving PD, PD exercise expert clinicians and experienced PD exercise researchers. Clinical practice points address timing of exercise and activity (post-catheter insertion, peritoneal space empty or full), the uptake of specific activities (work, sex, swimming, core exercise), potential adverse outcomes related to activity and exercise (exit site care, perspiration, cardiovascular compromise, fatigue, intra-abdominal pressure), the effect of exercise and activity on conditions of interest (mental health, obesity, frailty, low fitness) and exercise nutrition. (Figure presented.). Refereed/Peer-reviewed

BACKGROUND AND OBJECTIVES: Although progressive declines in physical activity and function are common in individuals with worsening chronic kidney disease (CKD), little is known about the impact of dialysis initiation. We assessed for any association of progression to dialysis in people with advanced CKD with temporal rates of change in physical activity and function. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Canadian Frailty Observation and Interventions Trial (CanFIT) participants with eGFR

Although Chronic Kidney Disease is common, only a relatively small proportion of individuals will reach kidney failure requiring dialysis or transplantation. Validated risk equations using routine laboratory tests have been developed that can easily be used at the bedside to help clinicians accurately predict the risk of kidney failure in their patient population, in turn informing patient-centered conversations, guiding appropriate nephrology referrals, improving the timing of dialysis treatment planning, and identifying individuals who are most likely to benefit from interventions. In this article, individuals living with kidney disease share why access to individualized prediction of kidney failure risk can help patients manage their disease and why it should be considered an essential component of kidney care.

Although renin-angiotensin aldosterone system (RAAS) inhibitors have become the mainstay treatment for patients with chronic diseases, hyperkalemia is a major contributory deterrent to their use in patients with chronic kidney disease (CKD) and heart failure. For the first time in 50 years, two new therapies (patiromer and ZS-9) have recently emerged for the concomitant treatment of hyperkalemia in these patients. The objective of this review is to discuss the efficacy and safety of these new agents.Patiromer effectively reduces serum potassium in patients with CKD and heart failure, even with the concomitant use of RAAS inhibitors. The most common adverse events in clinical trials were gastrointestinal events. ZS-9 (Lokelma) rapidly reduces serum potassium levels and to a greater magnitude, and has a role in the acute management of hyperkalemia. Despite having more adverse events than patiromer, ZS-9 is overall well tolerated.These new therapies show promising results for the chronic management of hyperkalemia, whilst also potentially allowing for the concomitant use of RAAS inhibitors at optimal doses. More research is needed to examine the benefits of continuation of RAAS inhibitors after an episode of hyperkalemia in patients with CKD and heart failure.

Introduction: Rural and remote indigenous individuals have a high burden of chronic kidney disease (CKD) when compared to the general population. However, it has not been previously explored how these rates compare to urban-dwelling indigenous populations. Methods: In a recent cross-sectional screening study, 1346 adults 18 to 80 years of age were screened for CKD and diabetes across 11 communities in rural and remote areas in Manitoba, Canada, as part of the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) program. An additional 284 Indigenous adults who resided in low-income areas in the city of Winnipeg, Manitoba, Canada were screened as part of the NorWest Mobile Diabetes and Kidney Disease Screening and Intervention Project. Results: Our findings indicate that a gradient of CKD and diabetes prevalence exists for Indigenous individuals living in different geographic areas. Compared to urban-dwelling Indigenous individuals, rural-dwelling individuals had more than a 2-fold (2.1, 95% CI = 1.4−3.1) increase in diabetes whereas remote-dwelling individuals had a 4-fold (4.1, 95% CI = 2.8−6.0) increase, and more than a 3-fold (3.1, 95% CI = 2.2−4.5) increase in CKD prevalence. Conclusion: Although these results highlight the relative importance of geography in determining the prevalence of diabetes and CKD in Indigenous Canadians, geography is but an important surrogate of other determinants, such as poverty and access to care. Keywords: chronic kidney disease, Indigenous Canadians, remoteness, rurality, screening, social determinants of health

A risk-based model of care for managing patients with chronic kidney disease (CKD) using the Kidney Failure Risk Equation (KFRE) has been successfully integrated into nephrology care pathways in several jurisdictions. However, as most patients with CKD can be managed in primary care, the next pertinent steps would be to integrate the KFRE into primary care pathways.Using a risk-based approach for guiding CKD care in the primary care setting, the objective of the study is to develop, implement, and evaluate tools that can be used by patients and providers.This study is a multicenter cluster randomized control trial.Thirty-two primary care clinics belonging to the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) across Manitoba and Alberta.All patients at least 18 years old or older with CKD categories G3-G5 attending the participating clinics; we estimate each clinic will have an average of 185 patients with CKD.Thirty-two primary care clinics will be randomized to receive either an active knowledge translation intervention or no intervention. The intervention involves the addition of the KFRE and decision aids to clinics' Data Presentation Tool (DPT), as well as patient-facing visual aids, a medical detailing visit, and sentinel feedback reports. Control clinics will only be exposed to current guidelines for CKD management, without active dissemination.Data from the CPCSSN repository will be used to assess whether a risk-based care approach affected management of CKD. Primary outcomes are as follows: the proportion of patients with measured urine albumin-to-creatinine ratio, and the proportion of patients being appropriately treated with angiotensin-converting enzyme inhibitor or angiotensin receptor blockers. Secondary outcomes are as follows: the optimal management of diabetes (hemoglobin A1C8.5%, and the use of sodium-glucose cotransporter-2 inhibitors in CKD G3 patients), hypertension (office blood pressure130/80 for patients with diabetes, 140/90 for those without), and cardiovascular risk (statin prescription); prescriptions of nonsteroidal anti-inflammatory drugs; and decline in estimated glomerular filtration rate (eGFR). In addition, in a substudy, we will measure CKD-specific health literacy and trust in physician care via surveys administered in the clinic post-visit. At the provider level, we will measure satisfaction with the risk prediction tools. Lastly, at the health system level, outcomes include cost of CKD care, and appropriate referrals for patients at high risk of kidney failure based on provincial guidelines. Primary and secondary outcomes will be measured at the patient level and enumerated at the clinic level 1 year after the intervention implementation, except for decline in eGFR, which will be measured 2 years postintervention.Limitations include scalability of the proposal in other health care systems.If successful, this intervention has the potential to improve the management of patients with CKD within Canadian primary care settings, leading to health and economic benefits, and influencing practice guidelines.ClinicalTrials.gov identifier: NCT03365063.Un modèle de soins intégrant la prévision du risque d’évolution vers l’insuffisance rénale par la KFRE (Avec une approche intégrant la prévision des risques dans les soins en IRC, l’étude vise à élaborer, mettre en œuvre et évaluer les outils qui pourraient être utilisés par les patients et les fournisseurs de soins en contexte de soins de première ligne.Il s’agit d’un essai multicentrique, contrôlé et à répartition aléatoire en grappes.L’étude se tiendra dans trente-deux cliniques de soins de première ligne du Manitoba et de l’Alberta faisant partie du Réseau canadien de surveillance sentinelle en soins primaires (RCSSSP).Tous les patients adultes atteints d’IRC de stades G3-G5 fréquentant les cliniques participantes. Nous estimons que chaque clinique fournira une moyenne de 185 patients à l’étude.Les trente-deux cliniques seront réparties aléatoirement pour recevoir ou non une intervention active de transmission des connaissances. L’intervention comprendra l’ajout de la KFRE et d’outils d’aide à la décision à l’outil actuel de présentation des données de la clinique; de même que du support visuel pour les patients, une consultation médicale détaillée et des rapports de rétroaction sentinelle. Les cliniques contrôles, quant à elles, ne seront exposées qu’aux lignes directrices actuelles pour la prise en charge de l’IRC, sans diffusion active.Les données du registre du RCSSSP seront employées pour évaluer l’impact de l’approche intégrant la prévision du risque sur la gestion de l’IRC. Les critères de jugement principaux seront la proportion de patients pour lesquels on aura une mesure du rapport albumine/créatinine urinaire (RAC) et la proportion de patients traités adéquatement avec un inhibiteur de l’enzyme de conversion de l’angiotensine ou d’antagonistes des récepteurs de l’angiotensine. Les critères de jugement secondaires incluront la gestion optimale du diabète (hémoglobine A1C8,5 %, et l’emploi d’inhibiteurs de SGLT2 chez les patients de stade G3), de l’hypertension (pression sanguine en cabinet à130/80 pour les diabétiques et à140/90 pour les non-diabétiques) et du risque de maladies cardiovasculaires (prescription de statines); ainsi que la prescription d’anti-inflammatoires non stéroïdiens et un déclin du débit de filtration glomérulaire estimé (DFGe). Parallèlement, dans une étude secondaire, nous examinerons les connaissances des patients sur l’IRC et leur confiance envers les soins médicaux par le biais de sondages menés à la clinique après la consultation. Nous mesurerons également la satisfaction des fournisseurs de soins à l’égard des outils de prévention du risque. Enfin, du point de vue du système de santé, nous examinerons les coûts associés aux soins en IRC et l’aiguillage adéquat des patients dont le risque d’évolution vers l’insuffisance rénale est jugé élevé selon les lignes directrices provinciales. Les critères de jugement primaires et secondaires seront mesurés du point de vue des patients et recensés à l’échelle de la clinique un an après la mise en œuvre de l’intervention, à l’exception du déclin du DFGe qui sera mesuré deux ans après l’intervention.Les limites de l’étude incluent notamment l’extensibilité de la proposition à d’autres systèmes de santé.Si elle réussit, cette intervention pourrait améliorer la prise en charge des patients atteints d’IRC dans les établissements canadiens de première ligne, et ainsi entraîner des retombées positives en matière de santé et d’économie en plus d’influencer les lignes directrices de pratique.

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

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

Objectives: The objectives of this study were to examine: 1) whether the relationship between social network types, depressive symptoms and life satisfaction is mediated by different types ...

It is well-documented that social isolation is detrimental to health and well-being. What is less clear is what types of social networks allow older adults to get the social support they need to promote health and well-being. In this study, we identified social network types in a national sample of older Canadians and explored whether they are associated with perceived availability of different types of social support (affectionate, emotional, or tangible, and positive social interactions). Data were drawn from the baseline questionnaire of the Canadian Longitudinal Study on Aging for participants aged 65–85 (unweighted n = 8,782). Cluster analyses revealed six social network groups. Social support generally declined as social networks became more restricted; however, different patterns of social support availability emerged for different social network groups. These findings suggest that certain types of social networks place older adults at risk of not having met specific social support needs.