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Abstract Background Physical inactivity is common among older adults and is associated with poor health outcomes. Medical fitness facilities provide a medically focused approach to physical fitness and can improve physical activity in their communities. This study aimed to assess the relationship between membership in the medical fitness model and all-cause mortality, health care utilization, and major adverse cardiac events in older adults. Methods A propensity weighted retrospective cohort study linked individuals that attended medical fitness facilities to provincial health administrative databases. Older adults who had at least 1 year of health coverage from their index date between January 1st, 2005 to December 31st 2015 were included. Controls were assigned a pseudo-index date at random based on the frequency distribution of index dates in members. Members were stratified into low frequency attenders ( 1 Weekly Visits). Time to event models estimated the hazard ratios (HRs) for risk of all-cause mortality and major adverse cardiac event. Negative binomial models estimated the risk ratios (RRs) for risk of hospitalizations, outpatient primary care visits and emergency department visits. Results Among 3,029 older adult members and 91,734 controls, members had a 45% lower risk of all-cause mortality (HR: 0.55, 95% CI: 0.50 – 0.61), 20% lower risk of hospitalizations (RR: 0.80, 95% CI: 0.75 – 0.84), and a 27% (HR: 0.72, 95% CI: 0.66 – 0.77), lower risk of a major adverse cardiovascular event. A dose–response effect with larger risk reductions was associated with more frequent attendance as regular frequency attenders were 4% more likely to visit a general practitioner for a routine healthcare visit (RR: 1.04, 95% CI: 1.01 – 1.07), but 23% less likely to visit the emergency department (RR: 0.87, 95% CI: 0.82 – 0.92). Conclusions Membership at a medical fitness facility was associated with a decreased risk of mortality, health care utilization and cardiovascular events. The medical fitness model may be an alternative approach for public health strategies to promote positive health behaviors in older adult populations.

Background: People receiving hemodialysis experience high symptom burden that contributes to low functional status and poor health-related quality of life. Management of symptoms is a priority for individuals receiving hemodialysis but limited effective treatments exist. There is emerging evidence that exercise programming can improve several common dialysis-related symptoms. Objective: The primary aim of this study is to evaluate the effect of an exercise rehabilitation program on symptom burden in individuals receiving maintenance hemodialysis. Design: Multicenter, randomized controlled, 1:1 parallel, open label, prospective blinded end point trial. Setting: Three facility-based hemodialysis units in Winnipeg, Manitoba, Canada. Participants: Adults aged 18 years or older with end-stage kidney disease receiving facility-based maintenance hemodialysis for more than 3 months, with at least 1 dialysis-related symptom as indicated by the Dialysis Symptom Index (DSI) severity score >0 (n = 150). Intervention: Supervised 26-week exercise rehabilitation program and 60 minutes of cycling during hemodialysis thrice weekly. Exercise intensity and duration were supervised and individualized by the kinesiologist as per participant baseline physical function with gradual progression over the course of the intervention. Control: Usual hemodialysis care (no exercise program). Measurements: Our primary outcome is change in symptom burden at 12 weeks as measured by the DSI severity score. Secondary outcomes include change in modified DSI severity score (includes 10 symptoms most plausible to improve with exercise), change in DSI severity score at 26 and 52 weeks; time to recover post-hemodialysis; health-related quality of life measured using EuroQol (EQ)-5D-5L; physical activity behavior measured by self-report (Godin-Shepherd questionnaire) and triaxial accelerometry; exercise capacity (shuttle walk test); frailty (Fried); self-efficacy for exercise; and 1-year hospitalization and mortality. Methods: Change in primary outcome will be compared between groups by independent 2-tailed t test or Mann-Whitney U test depending on data distribution and using generalized linear mixed models, with study time point as a random effect and adjusted for baseline DSI score. Similarly, change in secondary outcomes will be compared between groups over time using appropriate parametric and nonparametric statistical tests depending on data type and distribution. Limitations: The COVID-19 pandemic restrictions on clinical research at our institution delayed completion of target recruitment and prevented collection of accelerometry and physical function outcome data for 15 months until restrictions were lifted. Conclusions: The application of an exercise rehabilitation program to improve symptom burden in individuals on hemodialysis may ameliorate common symptoms observed in individuals on hemodialysis and result in improved quality of life and reduced disability and morbidity over the long term. Importantly, this pragmatic study, with a standardized exercise intervention that is adaptable to baseline physical function, addresses an important gap in both clinical care of hemodialysis patients and our current knowledge.

Background Cardiovascular disease remains the leading cause of disease burden and death in the world. The medical fitness model may be an alternative public health strategy to address cardiovascular risk factors with medical integrated programming. Methods and Results We performed a retrospective cohort study between January 1, 2005, and December 31, 2015. Adults (aged ≥18 years) who did not have a prior major adverse cardiovascular event were included. Controls were assigned a pseudo‐index date at random on the basis of the frequency distribution of start dates in the medical fitness facility group. Multivariate Cox proportional hazards regression models were adjusted for age, sex, socioeconomic status, comorbidities, and year of index date. We stratified the medical fitness facility group into low‐frequency attenders (≤1 weekly visit) and regular‐frequency attenders (>1 weekly visit). Our primary outcome was a hospitalization for nonfatal myocardial infarction and stroke, heart failure, or cardiovascular death. We included 11 319 medical fitness facility members and 507 400 controls in our study. Compared with controls, members had a lower hazard risk of a major adverse cardiovascular event‐plus (hazard ratio [HR], 0.88 [95% CI, 0.81–0.96]). Higher weekly attendance was associated with a lower hazard risk of a major adverse cardiovascular event‐plus compared with controls, but the effect was not significant for lower weekly attendance (low‐frequency attenders: HR, 0.94 [95% CI, 0.85–1.04]; regular‐frequency attenders: HR, 0.77 [95% CI, 0.67–0.89]). Conclusions Medical fitness facility membership and attendance at least once per week may lower the risk of a major adverse cardiovascular event‐plus. The medical fitness model should be considered as a public health intervention, especially for individuals at risk for cardiovascular disease.

Introduction: Intradialytic cycling is often performed during the first half of hemodialysis because of concerns regarding increased frequency of intradialytic hypotension (IDH) late in hemodialysis. This increases exercise program resource needs and limits utility of intradialytic cycling to treat dialysis-related symptoms. Methods: This multicenter, randomized, crossover trial compared IDH rate when cycling during the first half versus the second half of hemodialysis in 98 adults on maintenance hemodialysis. Group A cycled during the first half of hemodialysis for 2 weeks and subsequently during the second half for 2 weeks. In group B, the cycling schedule was reversed. Blood pressure (BP) was measured every 15 minutes throughout hemodialysis. Primary outcome was IDH rate (systolic BP [SBP] decrease of >20 mm Hg or SBP

Background: During the 30-day period prior to initiating dialysis, there is a 10-fold rise in emergency department visits and hospitalizations related to kidney failure. Objective: The Virtual Ward Incorporating Electronic Wearables (VIEWER) trial implemented a home telemonitoring system to track changes in patients’ vitals and assess their adherence and the acceptability of telemonitoring in a chronic kidney disease (CKD) population. Design: A pilot prospective clinical trial using a mixed methods approach was performed. Setting: The research was conducted in Winnipeg, Manitoba. Participants: There were 2 phases: Phase 1 was a 2-week-long pilot trial consisting of 10 participants. Phase 2 was a 3-month-long trial with a total of 26 participants. Patients with an estimated glomerular filtration rate 40% risk of beginning dialysis in the next 2 years according to the kidney failure risk equation were eligible to participate in the study. Methods: The primary quantitative outcome was adherence, defined as the proportion of daily self-assessments completed using VIEWER over the follow-up period. The usability and acceptability of VIEWER was assessed qualitatively at the end of the trial through structured questionnaires and focus groups. Results: Phase 1 participants (n = 10) had a median adherence of 77.17% for the 2-week observation period. Phase 2 participants (n = 26) showed a lower median adherence of 36% for the 3-month period. Focus group participants (n = 11) identified many positive aspects of VIEWER, including increased awareness and empowerment over health, simplicity of the data platform, and the ability to show clinical staff their health trends. Some challenges identified with VIEWER were connectivity issues with the Bluetooth, perceived inconvenience, and negative thoughts toward their health Limitations: Limitations of the study include a small sample size, which limited our ability to measure quantitative outcomes. In addition, patients agreeing to participate in any trial are generally more highly motivated and engaged in their care than those declining participation. Therefore, our results may not be generalizable to individuals who are not interested in self-management of their health. Conclusion: Our results suggest that home telemonitoring in patients with advanced CKD is feasible using a CKD-specific platform like VIEWER. We anticipate that improved functionality with incorporation of feedback from this study will result in greater long-term adherence. A future randomized clinical trial is planned.

Background: Fabry disease is a rare disorder caused by the deficient activity of α-galactosidase A (GLA) that often leads to organ damage. Fabry disease can be treated with enzyme replacement or pharmacological therapy, but due to its rarity and nonspecific manifestations, it often goes undiagnosed. Mass screening for Fabry disease is impractical; however, a targeted screening program for high-risk individuals may uncover previously unknown cases. Objective: Our objective was to use population-level administrative health databases to identify patients at high risk of Fabry disease. Design: Retrospective cohort study. Setting: Population-level health administrative databases housed at the Manitoba Centre for Health Policy. Patients: All residents of Manitoba, Canada, between 1998 and 2018. Measurements: We ascertained the evidence of GLA testing in a cohort of patients at high risk of Fabry disease. Methods: Individuals without a hospitalization or prescription indicative of Fabry disease were included if they had evidence of 1 of 4 high-risk conditions for Fabry disease: (1) ischemic stroke

Rationale & Objective: To what degree and how patient navigators improve clinical outcomes for patients with chronic kidney disease (CKD) and kidney failure is uncertain. We performed a systematic review to summarize patient navigator program design, evidence, and implementation in kidney disease. Study Design: A search strategy was developed for randomized controlled trials and observational studies that evaluated the impact of navigators on outcomes in the setting of CKD and kidney failure. Articles were identified from various databases. Two reviewers independently screened the articles and identified those meeting the inclusion criteria. Setting & Participants: Patients with CKD or kidney failure (in-center hemodialysis, peritoneal dialysis, home hemodialysis, or kidney transplantation). Selection Criteria for Studies: Studies that compared patient navigators with a control, without limits on size, duration, setting, or language. Studies focusing solely on patient education were excluded. Data Extraction: Data were abstracted from full texts and risk of bias was assessed. Analytical Approach: No meta-analysis was performed. Results: Of 3,371 citations, 17 articles met the inclusion criteria including 14 original studies. Navigators came from various healthcare backgrounds including nursing (n=6), social worker (n=2), medical interpreter (n=1), research (n=1), and also included kidney transplant recipients (n=2) and non-medical individuals (n=2). Navigators focused mostly on education (n=9) and support (n = 6). Navigators were used for patients with CKD (n=5), peritoneal dialysis (n=2), in-center hemodialysis (n=4), kidney transplantation (n=2), but not home hemodialysis. Navigators improved transplant workup and listing, peritoneal dialysis utilization, and patient knowledge. Limitations: Many studies did not show benefits across other outcomes, were at a high risk of bias, and none reported cost-effectiveness or patient-reported experience measures. Conclusions: Navigators improve some health outcomes for CKD but there was heterogeneity in their structure and function. High-quality randomized controlled trials are needed to evaluate navigator program efficacy and cost-effectiveness.

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

Background: Home-based peritoneal dialysis (PD) is an alternative to facility-based hemodialysis and has lower costs and greater freedom for patients with kidney failure. For a patient to undergo PD, a safe and reliable method of accessing the peritoneum is needed. However, different catheter insertion techniques may affect patient health outcomes. Objective: To compare the risk of infectious and mechanical complications between surgical (open and laparoscopic) PD catheter insertion and percutaneous catheter insertion. Design: Systematic review and meta-analysis. Setting: We searched for observational studies and randomized controlled trials (RCTs) in CENTRAL, EMBASE, MEDLINE, PubMed, and SCOPUS from inception until June 2018. Data were extracted by 2 independent reviewers based on a preformed template. Patients: Adult (aged 18+) patients with kidney failure who underwent a PD catheter insertion procedure. Measurements: We analyzed leak, malfunction, and bleed as early complications (occurring within 1 month of catheter insertion). Infectious complications (exit-site infections, tunnel infections, and peritonitis) were presented as both early complications and with the longest duration of follow-up. Methods: Random effects meta-analyses with the generic inverse variance method to estimate pooled rate ratios and 95% confidence intervals. We quantified heterogeneity by using the I2 statistic for inconsistency and assessed heterogeneity using the χ 2 test. Sensitivity analysis was performed by removing studies at high risk of bias as measured with the Newcastle-Ottawa Scale and the Cochrane Risk of Bias tool. Results: Twenty-four studies (22 observational, 2 RCTs) with 3108 patients and 3777 catheter insertions were selected. Data from 2 studies were unable to be extracted and were qualitatively assessed. In the remaining 22 studies, percutaneous insertion was associated with a lower risk of both exit-site infections (risk ratio [RR] = 0.36, 95% confidence interval [CI] = 0.24-0.53, I 2 = 0%) and peritonitis (RR = 0.52, 95% CI = 0.36-0.77, I 2 = 3%) within 1 month of the procedure. There was no difference in mechanical complication rates between the 2 techniques. Limitations: Lack of consistency in the time periods for the various outcomes reported, risk of bias concerns with respect to population comparability, and the inability to analyze individual component causes of primary nonfunction (catheter obstruction, catheter migration, and leak). Conclusions: Our meta-analysis suggests differences in early infectious complications in favor of percutaneous insertion and no significant differences in mechanical complications compared with surgical insertion. These findings have implications on the direction of PD programs in terms of maximizing operating room resources.

Rationale & Objective: The prevalence of kidney failure is increasing globally. Most of these patients will require life-sustaining dialysis at a substantial cost to the health care system. Assisted peritoneal dialysis (PD) and assisted home hemodialysis (HD) are potential alternatives to in-center HD and have demonstrated equivalent outcomes with respect to mortality and morbidity. We aim to describe the costs associated with assisted continuous cycling PD (CCPD) and assisted home HD. Study Design: Cost minimization model. Setting & Population: Adult incident maintenance dialysis patients in Manitoba, Canada. Intervention: Full- and partial-assist home HD and CCPD. Full-assist modalities were defined as nurse-assisted dialysis setup and takedown performed by a health care aide, whereas partial-assist modalities only included nurse-assisted setup. Additionally, full-assist home HD was evaluated under a complete care scenario with the inclusion of a health care aide remaining with the patient throughout the duration of treatment. Outcomes: Annual per-patient maintenance and training costs related to assisted and self-care home HD and CCPD, presented in 2019 Canadian dollars. Model, Perspective, & Time Frame: This model took the perspective of the Canadian public health payer using a 1-year time frame. Results: Annual total per-patient maintenance (and training) costs by modality were the following: full-assist CCPD, $75.717 (initial training costs, $301); partial-assist CCPD, $67,765 ($4,385); full-assist home HD, $47,862 ($301); partial-assist home HD, $44,650 ($14,813); and full-assist home HD (complete care), $64,659 ($301). Limitations: This model did not account for costs taken from the societal perspective or costs related to PD failure and modality switching. Additionally, this analysis reflects only costs experienced by a single center. Conclusions: Assisted home-based dialysis modalities are viable treatment options for patients from a cost perspective. Future studies to consider graduation rates to full self-care from assisted dialysis and the cost implications of respite care are needed.

Abstract Background Chronic Kidney Disease (CKD) is common and its prevalence has increased steadily over several decades. Monitoring of rates and severity of CKD across populations is critical for policy development and resource planning. Administrative health data alone has insufficient sensitivity for this purpose, therefore utilizing population level laboratory data and novel methodology is required for population-based surveillance. The aims of this study include a) develop the Manitoba CKD Cohort, b) estimate CKD prevalence, c) identify individuals at high risk of progression to kidney failure and d) determine rates of comorbid health conditions. Methods Administrative health and laboratory data from April 1996 to March 2012 were linked from the data repository at the Manitoba Centre for Health Policy. Prevalence was estimated using three methods: a) all CKD cases in administrative and laboratory databases; b) all CKD cases captured only through the laboratory data; c) and the capture-recapture method. Patients were stratified by risk by estimated Glomerular Filtration Rate (eGFR) and albuminuria based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. For comorbid health conditions, the counts were modelled using a Generalized Linear Model (GLM). Results The Manitoba CKD Cohort consisted of 55,876 people with CKD. Of these, 18,342 were identified using administrative health data, 27,393 with laboratory data, and 10,141 people were identified in both databases. The CKD prevalence was 5.6% using the standard definition, 10.6% using only people captured by the laboratory data and 10.6% using the capture-recapture method. Of the identified cases, 46% were at high risk of progression to end-stage kidney disease (ESKD), 41% were at low risk and 13% were not classified, due to unavailable laboratory data. High risk cases had a higher burden of comorbid conditions. Conclusion This study reports a novel methodology for population based CKD surveillance utilizing a combination of administrative health and laboratory data. High rates of CKD at risk of progression to ESKD have been identified with this approach. Given the high rates of comorbidity and associated healthcare costs, these data can be used to develop a targeted and comprehensive public health surveillance strategy that encompass a range of interrelated chronic diseases.

Purpose of program: Access to health care services remains a significant barrier for many Indigenous people’s living in rural and remote regions of Canada. Driven by geographical isolation and compounded by socioeconomic and environmental disparities, individuals living under these circumstances face disproportionately poor health outcomes. Kidney Check is a comprehensive screening, triage, and treatment initiative working to bring culturally safe preventive care to rural and remote Indigenous communities across Manitoba, Ontario, BC, Alberta, and Saskatchewan. The project’s patient-oriented approach addresses concerns raised by kidney patients and their caregivers using culturally safe practices. Using the various expertise of their multidisciplinary team, Kidney Check seeks to further collaborative efforts to improve access to preventive health care for these groups. Meaningful engagement with patients, communities, and local health care stakeholders ensures Indigenous voices are heard and incorporated into the project in a way that promotes shared decision-making and sustainability. Sources of information: As an affiliate program of the Can-SOLVE CKD Network, Kidney Check’s guiding priorities were developed over 3 years of patient consultation and finalized during 2 workshops held with more than 30 patients, caregivers, Indigenous peoples, researchers, and policy makers using a modified Delphi process. Today, patients continue to participate in project development via 2 governing bodies: The Patient Governance Circle and the Indigenous Peoples Engagement and Research Council (IPERC). Methods: Modeled after the Indigenous-led 2015 FINISHED project in Manitoba, Kidney Check employs point-of-care testing to identify diabetes, hypertension, and chronic kidney disease (CKD) in individuals, ages 10 and above, regardless of pre-existing risk factors. The Kidney Check team consists of 4 working groups: project leadership, provincial management, local community partners, and patient partners. By using and building on existing relationships between local and provincial health care stakeholders and various Indigenous communities, the program furthers collaborative efforts to bridge gaps in health equity. Key findings: The Kidney Check program has established an infrastructure that integrates patient engagement at all stages of the program from priority setting to deployment and dissemination strategies. Limitations: While we encourage and offer screening services to all, many still choose not to attend for a variety of reasons which may introduce selection bias. Kidney Check uses patient engagement as a foundational component of the program; however, there is currently a limited amount of research documenting the benefits of patient engagement in health care settings. More formal qualitative evaluations of these activities are needed. In addition, as the COVID-19 pandemic has halted screening procedures in most communities, we currently do not have quantitative data to support the efficacy of the Kidney Check program. Implications: For many Indigenous people, lack of accessibility to health care services is compounded by sociopolitical barriers that disrupt relationships between patients and providers. Meaningful engagement presents one opportunity to ensure the voices and perspectives of Indigenous patients and communities are incorporated into health services. In addition, this screening paradigm has shown to be cost effective as shown by analyses done on the FINISHED screening program.

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

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

Background: The StatSensor is a point-of-care device which measures creatinine in capillary whole blood. Previous studies reported an underestimation of the creatinine measurements at high creatinine concentrations and were performed in the prestandardization era for creatinine. Objective: This accuracy-based study evaluates the use of this device in kidney-transplanted patients and those with chronic kidney disease (CKD). Design: Cross-sectional diagnostic accuracy study. Setting: Nephrology outpatient clinic in an urban tertiary center. Participants: Adults with CKD or a functioning kidney transplant. Measurements: Duplicate StatSensor creatinine measurements were performed on capillary whole blood samples collected by direct fingerstick and SAFE-T-FILL collection device. Results were compared with simultaneous venous blood sampling for serum and plasma creatinine measured by an enzymatic method on the Roche Integra 400 mainframe analyzer with traceability to the ID-GC-MS (isotope dilution gas chromatography mass spectrometry) reference method. Methods: Deming regression, Pearson correlation coefficient, and Bland-Altman analysis were used to assess accuracy and comparability between capillary whole blood measured by StatSensor and plasma creatinine measured by routine analyzer with traceability to the reference method. Estimated glomerular filtration (eGFR) rates were calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and concordance with Kidney Disease Improving Global Outcomes (KDIGO) CKD stage classification was evaluated. Results: There were 60 participants (mean age = 61.9 ± 15.0 years, 55% men, 33% transplant, mean plasma creatinine = 137 ± 59 µmol/L). Bland-Altman analysis indicated a positive mean bias of 12.7 µmol/L between StatSensor fingerstick creatinine measurement and plasma creatinine. Comparison of eGFR (CKD-EPI) calculated from the StatSensor fingerstick creatinine versus plasma creatinine showed misclassification across all KDIGO CKD stages. Postanalytical correction of the bias did not improve misclassifications. The use of mean of duplicate StatSensor creatinine results did not improve performance compared with the use of singlet results. Limitations: Single center, limited participant numbers. Conclusions: The results of our study suggest that the limiting characteristics of the StatSensor device are not only bias, but also imprecision. The level of imprecision observed may influence clinical decision-making and limit the usefulness of StatSensor as a CKD screening tool. If choosing to utilize it for either screening for or monitoring CKD, it is essential that clinicians understand the limitations of point-of-care devices and apply this knowledge to test interpretation.

Background: There is an increasing demand to incorporate patient-reported outcome measures (PROMs) such as quality of life (QOL) in decision-making when selecting a chronic dialysis modality. Objective: To compare the change in QOL over time among similar patients on different dialysis modalities to provide unique and novel insights on the impact of dialysis modality on PROMs. Design: Systematic reviews, randomized controlled trials, and nonrandomized controlled trials were examined via a comprehensive search strategy incorporating multiple bibliographic databases. Setting: Data were extracted from relevant studies from January 1, 2000 to December 31, 2019 without limitations on country of study conduction. Patients: Eligible studies included adults (≥18 years) with end-stage kidney disease of any cause who were prescribed dialysis treatment (either as lifetime treatment or bridge to transplant). Measurements: The 5 comparisons were peritoneal dialysis (PD) vs in-center hemodialysis (ICHD), home hemodialysis (HHD) vs ICHD, HHD modalities compared with one another, HHD vs PD, and self-care ICHD vs traditional nurse-based ICHD. Methods: Included studies compared adults on different dialysis modalities with repeat measures within individuals to determine changes in QOL between dialysis modalities (in-center or home dialysis). Methodological quality was assessed by the Scottish Intercollegiate Guidelines Network (SIGN 50) checklist. A narrative synthesis was conducted, synthesizing the direction and size of any observed effects across studies. Results: Two randomized controlled trials and 9 prospective cohort studies involving a combined total of 3711 participants were included. Comparing PD and ICHD, 5 out of 9 studies found significant differences ( P < .05) favoring PD in the change of multiple QOL domains, including “physical component score,” “role of social component score,” “cognitive status,” “role limitation due to emotional function,” “role limitation due to physical function,” “bodily pain,” “burden of kidney disease,” “effects of kidney disease on daily life,” “symptoms/problems,” “sexual function,” “finance,” and “patient satisfaction.” Conversely, 3 of these studies demonstrated statistically significant differences ( P < .05) favoring ICHD in the domains of “role limitation due to physical function,” “general health,” “support from staff,” “sleep quality,” “social support,” “health status,” “social interaction,” “body image,” and “overall health.” Comparing HHD and ICHD, significant differences ( P < .05) favoring HHD for the QOL domains of “general health,” “burden of kidney disease,” and the visual analogue scale were reported. Limitations: Our study is constrained by the small sample sizes of included studies, as well as heterogeneity among both study populations and validated QOL scales, limiting inter-study comparison. Conclusions: We identified differences in specific QOL domains between dialysis modalities that may aid in patient decision-making based on individual priorities. Trial registration: PROSPERO Registration Number: CRD42016046980. Primary funding source: The original research for this study was derived from the Canadian Agency for Drugs and Technologies in Health (CADTH) 2017 optimal use report, titled “Dialysis Modalities for the Treatment of End-Stage Kidney Disease: A Health Technology Assessment.” The CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.

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

Ineffective healing and treatment of foot ulcers can lead to an infection and gangrene of the wound area that ultimately results in the loss of the limb. The incidence of foot ulcers is higher in patients with diabetes, peripheral vascular disease and kidney disease. Accordingly, this study was undertaken to assess the ability of foot bathing in CO2-enriched water to heal foot ulcers. The design was a double-blinded, randomized, placebo-controlled study. Patients with at least one foot ulcer were randomized to receive either a treatment with bath therapy at 37 ± 0.5 °C containing either 1000–1200 ppm CO2-enriched tap water (the intervention) or non-carbonated tap water at 37 ± 0.5 °C (the control group). Treatment was conducted three times/week for 15 min per session for up to 16 weeks for a total of 48 treatment sessions. Before and at the end of every treatment month, wound size, wound area oxygenation and the ankle brachial index were measured. In addition, the McGill pain questionnaire was conducted. Blood was also collected at these time points (for a total of five collections) for the measurement of different biomarkers. While no significant differences (p < 0.05) in the group/time interaction effect were observed, a clear separation within the wound area reduction/wound area/oxygenated Hb outcomes was seen between placebo (control) and treatment (CO2) group. This pilot study is suggestive that bathing in CO2-enriched water may accelerate the healing of foot ulcers.

Acute kidney injury (AKI) is a potentially fatal complication of cardiac surgery. The inability to predict cardiac surgery-associated AKI is a major barrier to prevention and early treatment. Current clinical risk models for the prediction of cardiac surgery-associated AKI are insufficient, particularly in patients with preexisting kidney dysfunction. Methods: To identify intraoperative variables that might improve the performance of a validated clinical risk score (Cleveland Clinic Score, CCS) for the prediction of cardiac surgery-associated AKI, we conducted a prospective cohort study in 289 consecutive elective cardiac surgery patients at a tertiary care center. We compared the area under the receiver operator characteristic curve (AUC) of a base model including only the CCS with models containing additional selected intraoperative variables including mean arterial pressure, hematocrit, duration of procedure, blood transfusions, and fluid balance. AKI was defined by the Kidney Disease Improving Global Outcomes 2012 criteria. Results: The CCS alone gave an AUC of 0.72 (95% confidence interval, 0.62–0.82) for postoperative AKI. Nadir intraoperative hematocrit was the only variable that improved AUC for postoperative AKI when added to the CCS (AUC = 0.78; 95% confidence interval, 0.70–0.87; P = 0.002). In the subcohort of patients without preexisting chronic kidney disease (n = 214), where the CCS underperformed (AUC, 0.60 [0.43–0.76]), the improvement with the addition of nadir hematocrit was more marked (AUC, 0.74 [0.62–0.86]). Other variables did not improve discrimination. Discussion: Nadir intraoperative hematocrit is useful in improving discrimination of clinical risk scores for AKI, and may provide a target for intervention.

Purpose of review: Kidney Failure is highly prevalent and uses a disproportionate amount of health care funding. In Canada (excluding Quebec), 37 647 people were living with kidney failure in 2016. The single-payer Canadian health care system spends approximately 1.2% of their annual budget on kidney failure. In 2016, 58.4% of patients with kidney failure in Canada (excluding Quebec) were on dialysis as opposed to living with a functioning kidney transplant. Home dialysis modalities including peritoneal dialysis (PD) and home hemodialysis (HD) were used by 18.9% and 4.7% of these patients, respectively. In-center HD and home dialysis (PD and home HD) are often considered equally efficacious and have similar impacts on quality of life. Despite cost minimization analyses suggesting that home dialysis offers cost savings over in-center HD, there has been a slow uptake of home dialysis in developed nations over time, suggesting that controversies and barriers to implementation currently exist. The primary objective of this health policy briefing article is to introduce and address some of the major controversies surrounding the cost effectiveness in supporting advocacy for a “Home Dialysis First” policy with a primary focus on single-payer systems in a developed nation such as Canada. Sources of information: Canadian Agency for Drugs and Technologies in Health (CADTH), Canadian and US epidemiologic databases, national/international conference presentations, primary literature review, and discussion with experts within the field of home dialysis. Methods: We have conducted a focused primary literature review alongside individuals with expertise in the field of home dialysis to discuss the cost controversies surrounding the implementation of a “Home Dialysis First” policy. Key findings: First, the primary literature is limited to mostly observational studies which are highly variable in study design and content. Local economic assessments, however, have provided convincing data for home dialysis cost savings in Canada. Second, the cost of delivering dialysis differs significantly throughout the world, explained by differing costs of labor and supplies in developing nations. Third, the indirect patient costs of water, energy, and home modifications are often barriers to implementation and may be overcome by introducing cost reimbursement programs. Fourth, home dialysis requires upfront training costs. We explore the impact of premature switches from home dialysis to in-center HD or a functioning kidney transplant on overall cost savings. Fifth, we discuss the effect of physician financial incentives and program funding on the uptake of home dialysis. Finally, we introduce the controversial topic of comparing the societal value of freedom of modality choice against the societal cost savings of a “Home Dialysis First” policy. Limitations: Narrative reviews, due to their inherently reduced methodological quality in comparison with systematic reviews, may expose our collected literature to selection bias. We have attempted to compose a diverse collection of available literature alongside consensus expertise to provide a fair and concise review of home dialysis cost controversies. Implications: Implementation of a “Home Dialysis First” policy would be a disruptive change to kidney failure care in Canada. To make informed policy decisions, we should recognize the cost savings associated with home dialysis in developed nations, the significance of patient-borne costs as a barrier to implementation, the impact of training costs and early modality switching in home dialysis, the lack of evidence regarding physician financial incentives, and the importance of program funding. Ultimately, we must consider the societal value of freedom of patient modality choice in comparison with the potential cost savings of a “Home Dialysis First” policy.

Background: 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. Objective: 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. Design: This study is a multicenter cluster randomized control trial. Setting: Thirty-two primary care clinics belonging to the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) across Manitoba and Alberta. Patients: 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. Methods: 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. Measurements: 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 A1C

Purpose: The purpose of this article is to update the previously published consensus recommendations from March 2017 discussing the optimal management of adult patients with autosomal dominant polycystic kidney disease (ADPKD). This document focuses on recent developments in genetic testing, renal imaging, assessment of risk regarding disease progression, and pharmacological treatment options for ADPKD. Sources of information: Published literature was searched in PubMed, the Cochrane Library, and Google Scholar to identify the latest evidence related to the treatment and management of ADPKD. Methods: All pertinent articles were reviewed by the authors to determine if a new recommendation was required, or if the previous recommendation needed updating. The consensus recommendations were developed by the authors based on discussion and review of the evidence. Key findings: The genetics of ADPKD are becoming more complex with the identification of new and rarer genetic variants such as GANAB . Magnetic resonance imaging (MRI) and computed tomography (CT) continue to be the main imaging modalities used to evaluate ADPKD. Total kidney volume (TKV) continues to be the most validated and most used measure to assess disease progression. Since the publication of the previous consensus recommendations, the use of the Mayo Clinic Classification for prognostication purposes has been validated in patients with class 1 ADPKD. Recent evidence supports the benefits of a low-osmolar diet and dietary sodium restriction in patients with ADPKD. Evidence from the Replicating Evidence of Preserved Renal Function: an Investigation of Tolvaptan Safety and Efficacy in ADPKD (REPRISE) trial supports the use of ADH (antidiuretic hormone) receptor antagonism in patients with ADPKD 18 to 55 years of age with eGFR (estimated glomerular filtration rate) of 25 to 65 mL/min/1.73 m 2 or 56 to 65 years of age with eGFR of 25 to 44 mL/min/1.73 m 2 with historical evidence of a decline in eGFR >2.0 mL/min/1.73 m 2 /year. Limitations: Available literature was limited to English language publications and to publications indexed in PubMed, the Cochrane Library, and Google Scholar. Implications: Advances in the assessment of the risk of disease progression include the validation of the Mayo Clinic Classification for patients with class 1 ADPKD. Advances in the pharmacological management of ADPKD include the expansion of the use of ADH receptor antagonism in patients 18 to 55 years of age with eGFR of 25 to 65 mL/min/1.73 m 2 or 56 to 65 years of age with eGFR of 25 to 44 mL/min/1.73 m 2 with historical evidence of a decline in eGFR >2.0 mL/min/1.73 m 2 /year, as per the results of the REPRISE study.

Purpose of review This article serves to describe the Can-SOLVE CKD network, a program of research projects and infrastructure that has excited patients and given them hope that we can truly transform the care they receive. Issue Chronic kidney disease (CKD) is a complex disorder that affects more than 4 million Canadians and costs the Canadian health care system more than $40 billion per year. The evidence base for guiding care in CKD is small, and even in areas where evidence exists, uptake of evidence into clinical practice has been slow. Compounding these complexities are the variations in outcomes for patients with CKD and difficulties predicting who is most likely to develop complications over time. Clearly these gaps in our knowledge and understanding of CKD need to be filled, but the current state of CKD research is not where it needs to be. A culture of clinical trials and inquiry into the disease is lacking, and much of the existing evidence base addresses the concerns of the researchers but not necessarily those of the patients. Program overview The Canadian Institutes of Health Research (CIHR) has launched the national Strategy for Patient-Oriented Research (SPOR), a coalition of federal, provincial, and territorial partners dedicated to integrating research into care. Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) is one of five pan-Canadian chronic kidney disease networks supported through the SPOR. The vision of Can-SOLVE CKD is that by 2020 every Canadian with or at high risk for CKD will receive the best recommended care, experience optimal outcomes, and have the opportunity to participate in studies with novel therapies, regardless of age, sex, gender, location, or ethnicity. Program objective The overarching objective of Can-SOLVE CKD is to accelerate the translation of knowledge about CKD into clinical research and practice. By focusing on the patient’s voice and implementing relevant findings in real time, Can-SOLVE CKD will transform the care that CKD patients receive, and will improve kidney health for future generations.

Patients on dialysis are often elderly and frail, with multiple comorbid conditions, and are heavy users of Emergency Department (ED) services. However, objective data on the frequency and pattern of ED utilization by dialysis patients are sparse. Such data could identify periods of highest risk for ED visits and inform health systems interventions to mitigate these risks and improve outcomes.To describe the pattern and frequency of presentation to ER by dialysis patients.Retrospective cohort study using administrative data collected over ten years (2000-2009) in the Province of Manitoba, Canada.Patients presenting to any of 9 ED's in Winnipeg and Brandon Manitoba. These departments serve >90% of the population of Manitoba, Canada (population 1.2 million).All patients presenting to an ED in any of 9 emergency departments in Manitoba, Canada.Dialysis status.Presentation to the ED.Over 2.1 million ED visits by more than 1.2 million non-dialysis patients and 17,782 ED visits by 3257 dialysis patients were included. Dialysis patients presented 8.5 times more frequently to the ED than the general population (age and sex adjusted, p

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

Background: In some jurisdictions, routine reporting of the estimated glomerular filtration rate (eGFR) has led to an increase in nephrology referrals and wait times. Objective: We describe the use of the Kidney Failure Risk Equation (KFRE) as part of a triage process for new nephrology referrals for patients with chronic kidney disease stages 3 to 5 in a Canadian province. Design: A quasi-experimental study design was used. Setting: This study took place in Manitoba, Canada. Measurements: Demographics, laboratory values, referral numbers, and wait times were compared between periods. Methods: In 2012, we adopted a risk-based cutoff of 3% over 5 years using the KFRE as a threshold for triage of new referrals. Referrals who did not meet other prespecified criteria (such as pregnancy, suspected glomerulonephritis, etc) and had a kidney failure risk of

Background: Patients with chronic kidney disease (CKD) are at risk to progress to kidney failure. We previously developed the Kidney Failure Risk Equation (KFRE) to predict progression to kidney failure in patients referred to nephrologists. Objective: The objective of this study was to determine the ability of the KFRE to discriminate which patients will progress to kidney failure in an unreferred population. Design: A retrospective cohort study was conducted using administrative databases. Setting: This study took place in Manitoba, Canada. Measurements: Age, sex, estimated glomerular filtration rate (eGFR), and urine albumin-to-creatinine ratio (ACR) were measured. Methods: We included patients from the Diagnostic Services of Manitoba database with an eGFR

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal disorder worldwide. The disease is characterized by renal cysts and progressive renal failure due to progressive enlargement of cysts and renal fibrosis. An estimated 45% to 70% of patients with ADPKD progress to end-stage renal disease by age 65 years. Although both targeted and nontargeted therapies have been tested in patients with ADPKD, tolvaptan is currently the only pharmacological therapy approved in Canada for the treatment of ADPKD. The purpose of this consensus recommendation is to develop an evidence-informed recommendation for the optimal management of adult patients with ADPKD. This document focuses on the role of genetic testing, the role of renal imaging, predicting the risk of disease progression, and pharmacological treatment options for ADPKD. These areas of focus were derived from 2 national surveys that were disseminated to nephrologists and patients with ADPKD with the aim of identifying unmet needs in the management of ADPKD in Canada. Specific recommendations are provided for the treatment of ADPKD with tolvaptan.

Myocardial infarction (MI) is associated with high morbidity and mortality, particularly in the first 12 months post-event. Interventions such as dual antiplatelet therapy can reduce the risk of major adverse cardiovascular events (MACE), but the duration of the high-risk time interval and the optimal prescription time frame for these interventions remains unknown.We performed a retrospective cohort study using data from medical services and hospitalizations in Manitoba, Canada for patients admitted with a MI between April 2006 and March 2010, and followed until Nov 30, 2014. We used survival analysis to determine the cumulative incidence of death, subsequent MI, or stroke, and used Cox proportional hazards models to assess factors associated with these endpoints.There were 8,493 patients in Manitoba admitted to hospital for a MI during the study period. Of those, 6,749 (79.5%) survived for at least 1 year without a recurrent MI or stroke. In the following year, this population remained at high risk, with 372 (5.5%) of the remaining patients dying in the next twelve months (48.1% cardiovascular deaths), 244 (3.6%) having a recurrent MI, and 74 (1.1%) having a stroke. Older age, male sex, diabetes, prior stroke, prior heart failure, prior unstable angina, and absence of revascularization were associated with worse long-term prognosis.The risk of MACE remains elevated among post-MI patients after the first year. Interventions to more intensively monitor, evaluate, and treat these patients should be considered beyond the first year following myocardial infarction.

Background: Reactivation of latent Mycobacterium tuberculosis infection (LTBI) is a health concern for patients on dialysis or receiving a kidney transplant, as these patients are often immunosuppressed. The most frequently used test for LTBI screening in this population is the tuberculin skin test (TST). The diagnostic accuracy (sensitivity and specificity) of the TST in a contemporary North American or Western European dialysis population is unknown. Objectives: Our objective was to determine the diagnostic accuracy and clinical utility of the two-step TST in patients receiving dialysis. Design: This is a retrospective cohort study. Setting: This study is set at four tertiary dialysis units across Winnipeg, Manitoba. Patients: There are 483 chronic hemodialysis and peritoneal dialysis patients in the study. Measurements: The measurements are sensitivity and specificity of the TST with respect to abnormal chest X-ray. Methods: All patients received a two-step TST and assessment of risk factors for prior tuberculosis (TB) infection between February 2008 and December 2008. This cohort was retrospectively linked to our tuberculosis registry to ascertain if prophylaxis was received for LTBI. Results: At an induration cutoff of 5 mm, 62 (13 %) patients had a positive two-step TST. Patients with a known Bacillus Calmette-Guérin (BCG) vaccination were more likely to test positive (50 % of those with a positive TST had a BCG versus 34 % with a negative TST, p = 0.05). Using a diagnostic gold standard of an abnormal chest X-ray as a proxy for LTBI, the sensitivity of the TST was only 14 % and the specificity was 88 %. Only 8 of 62 patients with a positive TST (13 %) received prophylaxis for LTBI. None of the patients who tested negative were treated. Limitations: There is a lack of a truly accurate gold standard for LTBI. Conclusions: The TST has limited diagnostic and clinical utility for LTBI screening in patients on dialysis. Further research into the diagnostic accuracy of interferon-gamma release assays and a revision of LTBI screening guidelines in patients on dialysis should be considered.

Background: Frailty, a manifestation of unsuccessful aging, is highly prevalent in people with chronic kidney disease (CKD) and is associated with comorbid conditions in cross-sectional studies. Longitudinal studies investigating the progression of frailty in those with advanced non-dialysis CKD are lacking. Objectives: Can adian F railty Observation and I nterventions T rial (CanFIT). To determine the natural history, prevalence of perceived and measured frailty and its association with dialysis treatment choices and adverse outcomes in patients with advanced CKD. Design: Longitudinal observational study, designed to collect data from 600 participants over 2 years. Setting: Interprofessional non-dialysis CKD clinics at four tertiary health care centres in central Canada. Patients: People with CKD stage 4 and 5 (eGFR

Background: Screening the general population for Chronic Kidney Disease is not currently recommended. Rural and remote Canadian First Nations people suffer a disproportionate burden of Kidney Failure. The Fi rst N at i ons Community Based S creening to Improve Kidney He alth and Prevent D ialysis ( FINISHED ) project intends to test the hypothesis that a mobile, mass screening initiative available to all First Nations people 10 years of age and older residing in rural and/or remote communities, is feasible, will improve health outcomes and is cost effective. Objectives: The objective of this manuscript is to describe the key elements required to design, implement and evaluate such a program and describe key characteristics of our screened cohort. Design: Methods and cohort description. Setting: 11 First Nations communities within 2 Tribal Councils in Manitoba, Canada. Patients: All First Nations individuals between the ages of 10–80 living in the 11communities were eligible for the screening initiative. Measurements: Screening Rates achieved within communities. Methods: An interdisciplinary team partnership was established between the Diabetes Integration Project and the Manitoba Renal Program. Stakeholder consultation was obtained and protocols developed to mass screen community members using point of care testing equipment. All people screened were risk stratified, counselled and referred to nephrologists as required in real time, based on risk. Results: As of August 31, 2014, 1480 people in 11 communities over 2 Tribal Councils have been successfully screened. A mean screening rate of 21% of all community members eligible (aged 10–80) has been achieved. All patients at intermediate or high risk of kidney failure have been seen by nephrologists within 1 month of screening. Limitations: Long term outcomes of kidney failure rates not assessed for at least 5 years. Alternative public health initiatives to reduce kidney failure not investigated. Conclusions: Point of care mass screening, real time risk prediction and counselling of First Nations people at high risk of Kidney Failure is feasible in rural and remote communities. Further analysis of this cohort will describe theepidemiology of CKD in these communities, and test the cost effectiveness of this strategy.

Chronic Obstructive Pulmonary Disease (COPD) is a common lung disease characterized by breathing difficulty as a consequence of narrowed airways. Previous studies have shown that COPD is correlated with neutrophil infiltration into the airways through chemotactic migration. However, whether neutrophil chemotaxis can be used to characterize and diagnose COPD is not well established. In the present study, we developed a microfluidic platform for evaluating neutrophil chemotaxis to sputum samples from COPD patients. Our results show increased neutrophil chemotaxis to COPD sputum compared to control sputum from healthy individuals. The level of COPD sputum induced neutrophil chemotaxis was correlated with the patient's spirometry data. The cell morphology of neutrophils in a COPD sputum gradient is similar to the morphology displayed by neutrophils exposed to an IL-8 gradient, but not a fMLP gradient. In competing gradients of COPD sputum and fMLP, neutrophils chemotaxis and cell morphology are dominated by fMLP.

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

Background: Previous reports have demonstrated similar survival for men and women on hemodialysis, despite women's increased survival in the general population. Objectives: To examine the effect of age on mortality in women undergoing chronic hemodialysis. Design: A retrospective cohort study using an administrative data registry, the Canadian Organ Replacement Registry (CORR) from Jan. 2001 and Dec. 2009. Setting: Canada. Patients: 28,971 (Women 11,792 (40.7%), Men 17,179 (59.3%)) incident chronic hemodialysis patients who survived greater than 90 days on dialysis. Measurements: All-cause mortality. Methods: Cox proportional hazards and competing risks models were employed to determine the independent association between sex, age and likelihood of all-cause mortality with renal transplantation as the competing outcome. Results: During the study period, 6060 (51.4%) of women and 8650 (50.4%) of men initiating dialysis died. Younger women experienced higher mortality (Age < 45: Women 22.5%, Men 18.2%, hazard ratio (HR) 1.31 (1.12–1.52)) whereas elderly women experience lower mortality (Age 75–85: Women 65%, Men 67.3%, HR 0.94 95% CI 0.88–0.99, Age > 85: Women 66%, Men 70.2%, HR 0.83 95% CI 0.71–0.97) compared to men. This relationship persisted after accounting for the competing risk of transplantation. Limitations: The cause of death was unknown. Conclusions: Women's survival on chronic hemodialysis varies by age compared to men with a significantly higher mortality in women younger than 45 years old and lower mortality in woman older than 75 years of age.

Background: Over 40% of patients with end stage renal disease in the United States were treated with home hemodialysis (HHD) in the early 1970's. However, this number declined rapidly over the ensuing decades so that the overwhelming majority of patients were treated in-centre 3 times per week on a 3–4 hour schedule. Poor outcomes for patients treated in this fashion led to a renewed interest in home hemodialysis, with more intensive dialysis schedules including short daily (SDHD) and nocturnal (NHD). The relative infancy of these treatment schedules means that there is a paucity of data on ‘how to do it’. Objective: We undertook a systematic survey of home hemodialysis programs in Canada to describe current practice patterns. Design: Development and deployment of a qualitative survey instrument. Setting: Community and academic HHD programs in Canada. Participants: Physicians, nurses and technologists. Measurements: Programmatic approaches to patient selection, delivery of dialysis, human resources available, and follow up. Methods: We developed the survey instrument in three phases. A focus group of Canadian nephrologists with expertise in NHD or SDHD discussed the scope the study and wrote questions on 11 domains. Three nephrologists familiar with all aspects of HHD delivery reviewed this for content validity, followed by further feedback from the whole group. Multidisciplinary teams at three sites pretested the survey and further suggestions were incorporated. In July 2010 we distributed the survey electronically to all renal programs known to offer HHD according to the Canadian Organ Replacement Registry. We compiled the survey results using qualitative and quantitative methods, as appropriate. Results: Of the academic and community programs that were invited to participate, 80% and 63%, respectively, completed the survey. We observed wide variation in programmatic approaches to patient recruitment, human resources, equipment, water, vascular access, patient training, dialysis prescription, home requirements, patient follow up, medications, and the approach to non-adherent patients. Limitations: Cross-sectional survey, unable to link variation to outcomes. Competition for patients between HHD and home peritoneal dialysis means that case mix for HHD may also vary between centres. Conclusions: There is wide variation between programs in all domains of HHD delivery in Canada. We plan further study of the extent to which differences in approach are related to outcomes.

Background: Chronic kidney disease screening using estimated glomerular filtration rate (eGFR) reporting is standard in many regions. With its implementation, many centres have had higher referral rates and increased wait times to see nephrologists. Objective: Manitoba began eGFR reporting in October 2010. We measured the effect of eGFR reporting on referral rates, wait times, and appropriateness of referrals after an educational intervention. Design: An interrupted time series design was used. Setting: This study took place in Manitoba, Canada. Patients: All referrals to the Manitoba Renal Program in the period prior to eGFR reporting between April 1, 2010 and September 30, 2010 were compared with a post period between January 1, 2011 and June 30, 2011. Measurements: Data on demographics, co-morbidities, referral numbers and wait times were compared between periods. Appropriateness of consults was also measured after eGFR implementation. Methods: Prior to eGFR reporting, primary care physicians underwent educational interventions on eGFR interpretation and referral guidelines. Referral rates and wait times were compared between periods using generalized linear models. Chart audits of a random sample of 232 patients in the pre period and 239 patients in the post period were performed. Results: The pre and post eGFR reporting referral rate was 116 and 152 referrals/month, respectively. Average wait times in the pre and post eGFR reporting was 113 and 115 days, respectively. Non-urgent referral wait times increased by 40 days immediately post reporting, while urgent median referral wait times had a more gradual increase. Despite our intervention, inappropriate consultations post eGFR reporting was 495/790 (62.7%). Limitations: Our study did not measure the intervention's success on primary care providers, which may have affected our appropriateness data. Our time series design was not powered to find a statistically significant difference in referral numbers. Residual confounding of our results was possible given the retrospective nature of our study. Conclusion: Despite our educational intervention, the inappropriate referrals remained high, and wait times increased. Other systemic interventions should be considered to attenuate the potential negative effects of eGFR reporting and ensure timely access for patients needing specialist consultation.