Background Emergency department (ED) use is common among patients with end-stage kidney disease (ESKD) initiating hemodialysis (HD), but potentially modifiable predictors of these visits remain poorly defined. Objective To identify factors associated with ED visits among patients newly initiated on intermittent HD in Regina, Saskatchewan, Canada. Design Retrospective cohort study. Setting Regina General Hospital in Saskatchewan, Canada. Patients 360 incident adult patients who received at least 90 days of HD between January 1, 2018, and December 31, 2022. Measurements Patients were followed for one year from dialysis initiation to capture the number and causes of all-cause ED visits. Methods Multinomial logistic regression was used to examine associations between patient characteristics and ED utilization, categorized as no visits, a single visit, 2–3 visits, or >3 visits, with no visits as the reference group. Results Half of the cohort (n=180, 50%) had at least one ED visit during the first year, totaling 453 encounters. Gastrointestinal (GI) complaints were the most common reason for presentation (14.1%), followed by fluid overload (11.5%) and cardiovascular causes (8.3%). Dialysis non-adherence was independently associated with ED utilization across all categories, with the strongest association for >3 visits (RRR 7.34, 95% CI 2.81-19.20, p<0.001). Arteriovenous fistula use at dialysis initiation was associated with a lower risk of a single ED visit (RRR 0.28, 95% CI 0.09-0.90, p=0.033). In contrast, age, sex, diabetes, hypertension, and cardiovascular disease were not independently associated with ED utilization. Limitations This single-center, retrospective study is limited by generalizability and could not analyze non-adherence factors. ED visits were grouped broadly, without assessing severity or preventability. Although ED visits were more frequent during the winter months, we did not examine whether missed dialysis treatments also varied by season. The study period from 2018 to 2022 overlaps with the COVID-19 pandemic, which may have affected ED utilization, dialysis attendance, outpatient access, and patient health-seeking behavior. This limits direct comparison with studies conducted entirely before or after the pandemic. Conclusions Early ED utilization among incident HD patients may be reduced by improving dialysis adherence, ensuring timely permanent vascular access placement, and better management of GI symptoms.
Background Incremental hemodialysis (iHD), which adapts dialysis frequency to a patient’s residual kidney function, may ease the transition to dialysis, improve quality of life, and reduce costs. Objectives In our tertiary care center, we aimed to develop and implement an iHD protocol and to safely initiate 75% of eligible patients starting incident dialysis on iHD, defined as twice-weekly dialysis, over a two-year period. This project was a nephrology fellow–led quality improvement (QI) initiative conducted as part of the Canadian Society of Nephrology’s Quality Improvement and Implementation Science national curriculum. Methods We conducted a QI study from November 1, 2022, to December 31, 2024. An iHD protocol was developed with input from key stakeholders. It included a patient information sheet, routine 24-hour urine collections, a nursing safety checklist integrated into the electronic medical record, and an alert system to identify patients on iHD for physician review. Patients were eligible for iHD if medically stable without indications for thrice-weekly dialysis, and able to comply with physician recommendations and complete required 24-hour urine collections. The primary outcome measure was the proportion of incident patients initiated on iHD. Balancing measures included reasons for iHD discontinuation, hospitalization and mortality rates, and duration on iHD, while process measures included completion rates of nursing checklists and urine collections. Results Of 135 incident hemodialysis starts during the study period, 57 (42%) patients were deemed eligible for iHD, of which 44 (77%) were initiated on an incremental prescription (mean age 61 years). At the end of the study, 25% of patients remained on iHD, with a mean duration of 234 days on iHD. The most common reasons for transition to thrice-weekly hemodialysis were volume overload (54%) and inadequate clearance (33%). Five Plan–Do–Study–Act (PDSA) cycles led to refinements of the protocol, including increased frequency of nursing checklist, facilitated identification of patients on iHD, more frequent electrolyte monitoring, and multiple educational sessions with healthcare providers. Overall, the 24-hour urine collection completion rate by patients was 69%, while nursing checklist completion rates increased from 61% in the first 8 months to a 100% by study end. Mortality and dialysis-related hospitalization rates, excluding vascular access-related issues, were significantly lower in the incremental group than in the conventional group (mortality: 2.3% vs. 17.6%; hospitalization: 0.10 vs. 0.22 events per patient-year). Conclusion A structured iHD protocol, refined through iterative PDSA cycles, enabled safe initiation of iHD in 77% of eligible patients in our center. This study illustrates how a systematic, QI-driven approach can guide other centers in adopting incremental HD safely while promoting ongoing process improvement and patient-centred care.
Background: Obesity and chronic kidney disease (CKD) often coexist and compound the risk of adverse health outcomes including dysglycemia and accelerated CKD progression. Obesity also limits access to kidney transplantation. The objectives of this study were to (1) understand current weight-management practices in CKD centres across Canada and (2) describe the availability of weight-management services nationwide. Methods: We conducted a cross-sectional, quantitative, online survey of English-speaking nephrologists practicing in Canada in 2025. The 23-question survey was developed based on a literature review and the content expertise of investigators. It was reviewed by nephrologists to ensure clarity, appropriateness, and ease of completion. Survey questions focused on the availability of dietitian services, exercise supports, behavioural counselling, weight-management consultations, and use of weight-loss medications in kidney outpatient clinics and dialysis units (including hemodialysis and peritoneal dialysis). The survey was administered via Qualtrics and distributed through the Canadian Society of Nephrology to nephrologists who care for patients with advanced CKD. Results: Between April 7 and June 12, 2025, 56 valid and complete responses were received, an estimated 15% response rate. Respondents primarily practised in Ontario (36%), Quebec (20%), British Columbia (18%), and Alberta (14%), with fewer respondents from the Territories and Atlantic provinces. Clinicians reported initiating weight-management discussions with patients when they felt obesity was contributing to poor health or impacting eligibility for transplant. While almost all nephrologists reported having access to a dietitian, over 60% were uncertain about the specific role of the dietitian in weight management. Gaps in the availability and coordination of behavioural coaching, physiotherapy, and exercise services were frequently cited. Over 60% of nephrologists reported prescribing weight-loss medications despite limited evidence supporting their efficacy and safety in patients with advanced CKD. Conclusions: Weight management is a recognized health priority in patients with advanced CKD, yet there are gaps in management. The nephrology community would benefit from weight-management services that reduce morbidity and improve transplant access for patients with CKD.
Background Hyperkalemia affects more than one in five patients receiving maintenance hemodialysis and remains a major contributor to arrhythmias and sudden cardiac death. Traditional potassium restriction has centered on limiting fruits and vegetables, even as emerging evidence challenges the assumption that all high-potassium foods pose equal risk. Meanwhile, awareness of potassium additives has grown, and recommendations to avoid additive-containing processed foods have been layered onto existing restrictions. Together, the uncertainties around long-standing to newer recommendations create guidance that is difficult for many patients to navigate. Objective To describe the protocol for EvoKe-HD, a pilot randomised controlled trial evaluating the feasibility, acceptability and safety of a targeted dietary counselling strategy for potassium management in hemodialysis. Design Two-arm, 1:1 randomised, parallel-group feasibility trial. Setting Two dialysis units at the CIUSSS du Nord-de-l’Île-de-Montréal, Canada. Patients Adults receiving thrice-weekly maintenance hemodialysis with elevated pre-dialysis serum potassium levels or receiving regular potassium binder therapy. Measurements The primary feasibility outcome is the proportion of eligible patients who enrol and complete the 3-month assessment. The main exploratory clinical outcome is mean mid-week pre-dialysis serum potassium during follow-up. Secondary and exploratory outcomes include hyperkalemia events, potassium binder use, dialysate potassium adjustments, biochemical measures, dietary outcomes, patient-reported outcomes, and process evaluation measures. Methods Participants are randomised to monthly targeted dietary counselling focused on reducing potassium additives and selected high-impact foods, or to monthly standard potassium-restriction counselling based primarily on total potassium content. Feasibility outcomes will be summarized with 95% confidence intervals. Mean follow-up serum potassium will be analysed using linear mixed-effects model adjusted for baseline potassium and sex, with a random intercept for participant. Results Recruitment began in June 2025 and was completed in January 2026. The last study visit was completed in March 2026. Process evaluation interviews are expected to be completed in July 2026. Limitations As a single-centre pilot feasibility trial, EvoKe-HD is not powered to evaluate definitive effects on serum potassium, hyperkalemia events, or other clinical outcomes. Conclusions EvoKe-HD will assess whether a targeted potassium counselling strategy can be implemented in routine hemodialysis care and will provide feasibility and process evaluation data to inform the design of a larger trial.
Background Kidney care has increasingly understood environmental impacts, and patient transportation to care is recognized as one of its largest greenhouse gas (GHG) emissions sources. Objective Our health region aims to reduce the environmental impact of kidney services while providing equitable care, hence assessment of transportation distances and associated emissions was undertaken. Design A retrospective observational study was performed to determine round trip and yearly transportation distances from residence to corresponding kidney care setting. Setting All registered kidney care services throughout British Columbia. Patients All adult patients in a provincial registry who were receiving scheduled pre-dialysis, conservative management, and home and facility-based dialysis therapies, in 2023. Measurements Yearly GHG emissions by modality were calculated by multiplying distance travelled by locally sourced emissions factors by vehicle type, then by frequency of care, as defined by local best practices. Methods Transportation distances and emissions data were reported in median with interquartile range, for a base scenario of travel via gas car, and for four alternate hypothetical emissions lowering scenarios. Results The cohort included 15,772 adult patients, with distance travelled to care in 2023 exceeding 17 million kilometres, and corresponding annual GHG emissions of 3873 tonnes of carbon dioxide equivalents. Significant variability existed in transportation distance and emissions both within and between care modalities. Home dialysis patients had the longest median round trip distances (and corresponding emissions) for home hemodialysis and peritoneal dialysis of 52.4 and 27.3 kilometres (11.5 and 6.0 kilograms carbon dioxide equivalents, respectively); whereas facility hemodialysis patients had the greatest annual median distances of 2265.2 kilometres and annual emissions of 498.1 kilograms. Combining all transportation to care emissions reductions scenarios resulted in a 62% reduction in GHG emissions. Limitations Staff transportation was not considered, including that for supported home dialysis modalities, and public transit by light transport vehicle was assumed to follow the most direct road distance from residence to dialysis treatment facility. Conclusions Patient transportation to kidney therapies in British Columbia has climate change impact considerations, and appropriate use of virtual care, home dialysis therapies, and various low emissions transportation options offer significant improvement opportunities.
Background Accurate prognostic classification in autosomal dominant polycystic kidney disease is important for risk stratification and treatment decisions, including tolvaptan eligibility. Although the ellipsoid method has shown good performance for kidney volume measurement in magnetic resonance imaging cohorts, data from cohorts imaged predominantly with computed tomography remains limited. Objective To evaluate the agreement between the ellipsoid and manual segmentation methods for kidney volume measurement in a computed tomography-heavy cohort of patients with autosomal dominant polycystic kidney disease, with a focus on prognostic classification and identification of high-risk disease. Design Retrospective observational cohort study. Setting The Ottawa Hospital Cystic Kidney Disease Clinic, a tertiary academic center in Ottawa, Ontario, Canada. Patients One hundred fifty-one patients with autosomal dominant polycystic kidney disease who underwent cross-sectional abdominal imaging suitable for volumetric assessment between January 2018 and February 2022, including 107 computed tomography studies and 44 magnetic resonance imaging studies. Measurements Height-adjusted total kidney volume, Mayo Clinic Imaging Classification, and classification of high-risk disease (classes 1C-1E). Methods Height-adjusted total kidney volume was measured using both manual segmentation, the reference standard, and the ellipsoid method. Agreement in kidney volume measurement was assessed using intraclass correlation coefficients, Bland-Altman analysis, and mean percent difference. Agreement in Mayo Clinic Imaging Classification was assessed using weighted Cohen kappa. Diagnostic performance of the ellipsoid method for identifying high-risk disease was evaluated using sensitivity, specificity, positive predictive value, and McNemar testing. Results The ellipsoid method showed good concordance with manual segmentation height-adjusted total kidney volume measurement, with an intraclass correlation coefficient of 0.93 overall, 0.92 in the computed tomography subgroup, and 0.96 in the magnetic resonance imaging subgroup. The ellipsoid method underestimated kidney volume by a mean of 12.7%. Agreement in Mayo Clinic Imaging Classification was high, with a weighted Cohen kappa of 0.87, although 25.8% of cases were misclassified, most often to a lower risk class. For identification of high-risk disease, the ellipsoid method had a sensitivity of 83.0% and a specificity of 98.0% overall; in the computed tomography subgroup, sensitivity was 85.5% and specificity was 97.4%. Limitations Single-center design, use of a single reader, and cross-sectional analysis without longitudinal follow-up. Discussion In this computed tomography-heavy cohort, the ellipsoid method showed good concordance with manual segmentation for kidney volume measurement and high specificity for identifying high-risk disease. However, systematic underestimation may lead to downward misclassification, particularly in borderline cases.
Diabetes is a leading cause of chronic kidney disease, yet gaps in the use of guideline-directed therapies persist in primary care. In 2025, our group developed and validated community pharmacist-led prescribing algorithms for individuals with an estimated glomerular filtration rate ≥30 mL/min/1.73 m 2 , targeting angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, sodium-glucose cotransporter-2 inhibitors, and nonsteroidal mineralocorticoid receptor antagonists. To address the evolving therapeutic landscape, we developed and validated a semaglutide-specific algorithm to complement this approach. Algorithm development and validation followed Lynn’s method. A two-part questionnaire per algorithm item assessed content and face validity, with nephrology clinicians (nephrologists and kidney pharmacists) and community pharmacists rating items using Likert scales. Content validity was measured using item-level (I-CVI) and scale-level (S-CVI/Ave) indices, while face validity was assessed by level of agreement to five statements per round. The algorithm was iteratively revised between rounds. Ten nephrology clinicians (five per round for three rounds) and 12 community pharmacists (six per round for two rounds) participated. For clinicians, the I-CVI ranged from 0.6 to 1.0, with an overall S-CVI/Ave of 0.89 across three rounds. Among pharmacists, all items met the prespecified content validity threshold for both rounds (I-CVI ≥0.83; P < 0.05). Face validity exceeded the 70% consensus threshold for both validator groups. This study adds a validated semaglutide-specific algorithm to our existing pharmacist-led care model, expanding a suite of algorithms to support uptake of disease-modifying therapies for individuals with type 2 diabetes and chronic kidney disease in primary care. Implementation and evaluation in Nova Scotia community pharmacy clinics are underway.
Introduction An understanding of perspectives toward kidney transplant amongst individuals with kidney failure is integral to supporting treatment-related decision-making and preparing for life post-transplant, yet this has not been studied in a Canadian context. Therefore, the objective of this study was to examine the perspectives of individuals with kidney failure in Canada regarding kidney transplant. Methods Adults (18-75y) from four Canadian provinces who either had initiated dialysis within the prior 6 months or were preemptively referred for kidney transplantation within the prior 3 months were recruited to participate in focus group discussions (FGDs) or individual interviews. Data were analyzed using inductive thematic analysis. Results Fifteen individuals participated in one of four FGDs (n=13) or a semi-structured interview (n=2). Seven were on dialysis and eight were pre-dialysis (four and six of whom had been referred for transplant, respectively). Overall, participants expressed a clear preference for transplant compared to dialysis. Participants’ willingness to consider transplant was influenced by their (1) relationship with the healthcare team , recognition of (2) the necessity of treatment , the (3) potential to live a “normal” life , and knowledge of (4) others’ experiences with transplant . Despite a preference for transplant, participants expressed (5) concerns regarding securing a living donor and a sense of having (6) a lack of control over the transplant referral process. Conclusion In this study, we evaluated perceptions towards kidney transplantation amongst individuals with kidney failure in Canada. Understanding potential concerns regarding future transplant may lead to improved patient-centered education, communication and psychosocial support strategies to empower patients to confidently make treatment-related decisions.
The use of Janus Kinase (JAK) inhibitors with concomitant maintenance immunosuppressive therapy (IST) for the solid organ transplant (SOT) population presents significant challenges due to intensified immunosuppression resulting in an increased risk of opportunistic infections and malignancies coupled with limited clinical experience among transplant providers. A 48-year-old man presented with end-stage kidney disease secondary to IgA nephropathy requiring commencement of haemodialysis. He had a concurrent diagnosis of primary myelofibrosis (PMF), which did not require treatment at presentation. A year later, he underwent a living-donor kidney transplant from an HLA-identical sibling. The patient received induction IST with basiliximab and methylprednisolone, followed by standard maintenance therapy with tacrolimus and mycophenolate mofetil. The latter was reduced in dose due to underlying PMF. In the months following transplantation, he experienced worsening PMF parameters and was commenced on the JAK2 inhibitor, ruxolitinib. This was complicated by development of detectable BK Polyomavirus DNA (BKPyV-DNAemia), prompting adjustment of his immunosuppression regimen and dose reduction of ruloxlitinib. His course was further complicated by renal allograft rejection. Ruxolitinib was subsequently discontinued, and he transitioned to the second-generation JAK inhibitor fedratinib, which led to improvement in PMF parameters and stabilization of both graft function and BKPyV-DNAemia. This case highlights the therapeutic challenges inherent in integrating JAK inhibitors into established immunosuppression regimens in solid organ transplantation. It underscores the difficult balance between preserving graft tolerance and mitigating the risk of opportunistic infections such as BKPyV-DNAemia, while emphasising the need for close monitoring of net immunosuppression in this setting.
Purpose of program This conference report describes findings from activities to reposition the Canadian Chronic Kidney Disease (CKD) Clinic Network by identifying research priorities and actionable steps aligned with the 2024 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. The initiative aimed to identify priority actions to integrate clinical research and care through collaborative dialogue and community-driven planning. Sources of information The 2024 KDIGO Clinical Practice Guideline for CKD served as the foundation to assess and prioritize relevant research areas. Insights were gathered through a national survey and a participatory workshop using World Café methodology. Methods An anonymized online semi-structured survey was distributed to members of the Canadian CKD Clinic Network from April 4-14, 2025 to assess the perceived relevance and importance of the 2024 KDIGO CKD guideline research recommendations. This was followed by an in-person World Café workshop in May 2025 involving patients, clinicians, researchers, and administrators. Data collection included live graphic recording, table notes, and Post-it reflections, which were thematically analyzed. Key findings The survey yielded responses from 80 network members, representing a 24% response rate. Survey results prioritized the need for research on: the impact of newer medications (SGLT2i, non-steroidal mineralocorticoid receptor antagonists) in patients intolerant of ACEi/ARB, implementation science to ensure uptake of proven therapies and symptom management, essential components for transition clinics for young people, tools for health literacy in different populations, strategies to prevent hyperkalemia, impact of medication deprescribing, effects of dietary restriction, and symptom identification, classification, and control. Attendees of the World Café (n=19) identified several network strengths, including its established relationships that drive national collaboration, willingness in knowledge sharing, and inclusion of the patient voice. Feedback emphasized the need for collaborative implementation and context-sensitive application of guidelines. The workshop also aligned the network’s future direction with Learning Health System principles, which embed research into routine care delivery, supporting goals with provincial and national CKD strategies, deepening patient engagement, shared measurement tools, and local-to-national learning loops. Actionable steps identified included enhancing visibility through a public-facing website, anchoring activities to sustainable national platforms, and exploring additional partnerships and collaborative research opportunities. Limitations Only 24% of the CKD Clinic Network responded to the survey, and 19 members were present at the World Café, reflecting perspectives from only a small portion of the network. Therefore, the results may overlook key challenges or opportunities that did not surface due to missing perspectives of others within the kidney care community. Implications This initiative demonstrates how engaging diverse perspectives can inform network transformation and future strategic research directions. The CKD Clinic Network is well-positioned to evolve into a responsive, patient-centred platform that drives learning and improvement in health care delivery across Canada’s kidney care system.
Background An underappreciated complication of laparoscopic nephrectomy in male living kidney donors is testicular pain, swelling, and hydrocele development. A recent cohort study in Ontario, Canada, found that male donors had a higher rate of hydrocelectomy (7.7 vs. 0.1 events/1000 person-years) and scrotal ultrasounds (25.6 vs. 6.9 events/1000 person-years) than nondonors, when followed for a median of 9 years. Objective To conduct a replication study in Alberta, Canada, examining the long-term risk of hydrocelectomy after laparoscopic living donor nephrectomy, comparing male donors to nondonors from the general population matched on baseline health indicators. Design Population-based matched cohort study using linked healthcare databases. Setting Alberta, Canada (April 1, 2002, to March 31, 2021). Patients We matched 115 male kidney donors who underwent a laparoscopic nephrectomy with 1150 nondonors. The matching characteristics were age at cohort entry, date of cohort entry, rural residence, income, prior vasectomy, and prior inguinal hernia repair. Measure ments: The primary outcome was a hydrocelectomy, and the secondary outcome was receipt of a scrotal ultrasound. Methods Males were followed for a median of eight years, with a maximum follow-up of 19 years. Results The rate of hydrocelectomy was higher in donors than in nondonors (3 of 115 [2.6%] vs. 1 of 1150 [0.1%]; 3.3 vs. 0.1 events/1000 person-years; P < 0.001). The rate of scrotal ultrasounds was also higher among donors than among nondonors (23.4 vs. 7.5 events/1000 person-years; P < 0.001). Limitations A low event rate impeded a precise estimation of the risk of hydrocelectomy attributable to donation. Conclusions In this population-based cohort study from Alberta, Canada, rates of hydrocelectomy and receipt of a scrotal ultrasound were significantly higher in males who underwent laparoscopic living donor nephrectomy than in male nondonors matched for age and other factors. Males considering living kidney donation should be informed of the risk of developing a symptomatic ipsilateral scrotal hydrocele in the years following laparoscopic nephrectomy.
Background Guidelines for anemia management in chronic kidney disease (CKD) adopted a conservative approach in response to landmark clinical trials demonstrating lack of benefit and potential harm associated with higher hemoglobin targets. Although the findings have been applied to all CKD populations, the concordance between trial populations and those being treated in clinical practice has not been well described. Objective We sought to evaluate trends in hemoglobin distribution and erythropoiesis stimulating agent (ESA) use among adult patients with CKD, and compare their characteristics to those of participants from landmark hemoglobin target trials. Design Retrospective observational cohort study. Setting A provincial clinical information system was used to identify patients with CKD under the care of a nephrologist in British Columbia between April 1, 2007 and March 31, 2018. Patients Adult patients (over 18 years) with estimated glomerular filtration rate (eGFR) less than 45 mL/min/1.73m 2 and a minimum of three hemoglobin values during follow-up. Patients were censored if they left the province, died, or started kidney replacement therapy. Measurements Hemoglobin was measured in grams per litre (g/L) and treated as both a continuous and categorical variable. ESA use was defined as the proportion of patients who received at least one prescription for ESA therapy. The dose of ESA was quantified as an average monthly dose of epoetin alfa or darbepoetin alfa. Methods Descriptive statistics were used to compare characteristics of patients in the study population to those of trial participants including Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT), Correction of Hemoglobin and Outcomes in Renal Insufficiency (CHOIR), and Cardiovascular Risk Reduction by Early Anemia Treatment with Epoetin Beta trial (CREATE). Polytomous logistic regression was used to estimate odds ratios (OR) of different hemoglobin levels across cohort years. The model was adjusted for age, sex, race, comorbid conditions, eGFR, proteinuria, etiology of CKD and iron parameters. Results A total of 29,033 patients were included in the analysis (mean age 71 years, 45% female, median eGFR 29 mL/min/1.73m 2 ). Average hemoglobin declined from 122 g/L in 2007 to 112.9 g/L in 2017 with a reduction in ESA use from 35% to 18%. The likelihood of patients having a hemoglobin below 90 g/L (versus 110-124 g/L) increased progressively over time (OR 5.3 in 2008; OR 16.2 in 2017). The proportion of patients meeting inclusion criteria for landmark trials ranged from 9% (TREAT) to 27% (CHOIR). Compared to trial participants, the study population had less comorbidities and received lower doses of ESA therapy. Limitations Measurement of hemoglobin may have been subject to confounding by indication, for example due to a bleeding episode. Physicians may have elected not to treat certain patients with ESA therapy, introducing selection bias. Data regarding blood transfusions were not available. Conclusions Despite a minority of patients meeting criteria for prior hemoglobin target trials, the universal adoption of guidelines favoring a conservative approach to anemia has culminated in a higher likelihood of patients experiencing severe anemia. The implications of this, particularly patient-reported outcomes, warrant further investigation.
Background Many living kidney donors (LKDs) describe their evaluation process as the most difficult part of donating a kidney. The process is often lengthy, complex and inefficient, frequently requiring several months to complete. A more efficient and donor-centered evaluation may improve LKD experiences, reduce attrition, and encourage more individuals to donate. Methods We employed a Delphi approach to define and select metrics of a high-quality LKD evaluation. Four multidisciplinary working groups were created in which LKDs (n=8), healthcare professionals (n=11), and administrators (n=3) collaborated to develop evidence and experience informed recommendations. Results This work culminated in a national consensus conference held virtually in September 2024, which brought together over 100 LKDs, nurses, nephrologists, surgeons, researchers, and representatives from transplant organizations. Of the 42 recommendations evaluated through the e-Delphi process, 35 achieved consensus (≥75% agreement) across four domains. Ninety-two percent were supported by moderate-quality evidence, while 8% had no supporting evidence, reflecting the limited empirical data available for several aspects of donor evaluation processes. The recommendations clustered into four overarching themes included: (1) increasing donor numbers and evaluation efficiency (e.g., eligibility for donation determined within three to six months), (2) enhancing program resources and donor reimbursement (e.g., metrics on donor financial neutrality), (3) ensuring a donor-centered evaluation process (e.g., donor-centered metrics such as donor satisfaction), and (4) promoting consistency and evidence-based practice across programs (e.g., consistent evaluation nationally). Conclusion Collectively, these recommendations provide a framework to guide quality improvement, benchmarking, and policy development, with implications for strengthening the LKD evaluation process worldwide.
Background A prior study of living kidney donors demonstrated a substantially higher long-term risk of hydrocelectomy among male living kidney donors who underwent laparoscopic nephrectomy compared with nondonors. Given the potential shared anatomical pathways between hydrocele and indirect inguinal hernia formation, we aimed to evaluate the donation-attributable risk of inguinal hernia repair. Objective To evaluate long-term rates of inguinal hernia repair in male living kidney donors compared to nondonors. Design and Setting Population-based, retrospective matched cohort study using linked health administrative databases from Ontario, Canada. Patients 848 male living kidney donors aged ≥18 years who underwent laparoscopic donor nephrectomy between April 1, 2002, and March 31, 2023, were matched (1:10) to 8480 healthy male nondonors based on age, cohort entry date, rurality, neighbourhood income, and prior vasectomy. Individuals with prior scrotal conditions or previous inguinal hernia repair were excluded. Measurements The primary outcome was inguinal hernia repair. Methods Risk was assessed using Cox proportional hazards models with robust variance. Cumulative incidence was estimated at key time points using Aalen–Johansen methods, treating death as a competing event. To contextualize the findings, incidence rates were also examined after other renal (e.g., nondonor nephrectomy, pyeloplasty) and abdominal surgeries. Results Over a median follow-up of 8.8 years, 4.7% of donors (40 of 848) and 3.4% of nondonors (287 of 8480) underwent inguinal hernia repair. Donors had a modestly higher risk of undergoing inguinal hernia repair than nondonors (4.9 vs. 3.5 events per 1000 person-years; hazard ratio (HR) 1.40; 95% CI, 1.01–1.93; P = 0.043). The cumulative incidence of inguinal hernia repair after laparoscopic donor nephrectomy was comparable to that observed after other renal and abdominal surgeries. Limitations This study relied on administrative data, which lacked information on hernia type (direct or indirect), laterality, pre-existing asymptomatic hernias, and key confounders such as body mass index and occupation. Donors may differ from nondonors in care-seeking behaviours and lifestyle factors, which could influence the observed risk. Conclusions In contrast to the markedly higher risk of hydrocele repair, the donation-attributable risk of inguinal hernia repair in the years following laparoscopic donor nephrectomy appears modest, and in some comparisons was not evident. These findings support current counselling and selection practices for prospective donors, for which this outcome does not warrant specific consideration.
Background While sodium-glucose cotransporter-2 (SGLT2) inhibitors provide major benefits across multiple chronic diseases, clinician prescription and patient adherence rates remain low. Objective To explore perspectives of clinician and patient stakeholders regarding barriers and facilitators for SGLT2 inhibitor use. Design Semi-structured interviews, conducted as part of a larger project examining the type 2 diabetes mellitus (T2DM) standard of care. Setting Australia. Participants Clinicians involved in the care of people with T2DM, including primary care clinicians, endocrinologists, nephrologists, cardiologists, diabetes educators, and pharmacists; and adults with T2DM. Methods Barriers and facilitators of SGLT2 inhibitor implementation were explored through the Consolidated Framework for Implementation Research. Analysis of interview transcripts was conducted in duplicate using a combination of framework and thematic analysis. Results A total of 24 clinicians, and four people with T2DM, were interviewed between November 2021 and August 2023, including four primary care clinicians, four endocrinologists, four nephrologists, four cardiologists, four diabetes educators, and four pharmacists. Key findings included that clinicians miss opportunities to prescribe due to competing priorities and therapeutic inertia, and may find it difficult to educate and engage patients about SGLT2 inhibitor use. Patients require detailed education to understand benefits and adverse effect prevention, ideally with multimodal resources and staggered over time, and would benefit from general adherence coaching. Some clinicians were concerned about the risk of urinary tract infections despite reassuring safety data, and few provided genital hygiene advice to reduce SGLT2 inhibitor-associated genital mycotic infections. Better health system support could be achieved through additional cost reimbursement and support for multidisciplinary care access. Limitations Most participants were from a single Australian state, New South Wales, which may not fully reflect experiences across Australia. Participation bias may under-represent those less engaged in SGLT2 inhibitor use. Conclusions Clinicians are convinced about SGLT2 inhibitor benefits but require support to deliver evidence-based care, including effective patient education and engagement. These insights can help inform the design of interventions to maximise societal benefit from these effective medications.
Background Canadian regulatory standards require the label increased risk donor (IRD) be applied to donors with risk factors for hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus infection (HIV). This study aimed to assess trends in the rate of IRD and specific donor risk factors over time as well as the association with donor screening results for HBV, HCV and HIV. Methods This was a retrospective study of deceased organ donors at 2 Canadian centers (University of Alberta Hospital and Transplant Manitoba) encompassing an overlapping period between 2013 and 2022. The proportion of IRD donations over time were analyzed with trend analysis. Trends for risk factors and their association with donor screening results were explored. Results Overall, 332 of 1491 (22.3%) donors were categorized as IRD. A significant rising trend of IRD donors was documented for Alberta. Any donor drug use and overdose as cause of death increased during the study period and were strongly associated with HCV infection (OR 18.03 (6.34-51.2) p<0.001 and OR 6.48 (3.32-12.65) p<0.001). Donors classified as men who had sex with men (MSM) did not have an increased risk of HBV, HCV or HIV. Answers to some questions on the donor risk history were “I don’t know” in up to 20% of specific questionnaire items. Conclusions Our study demonstrates a rising proportion of IRD organ donations in 2 Canadian transplant centers. The regulatory requirements include variables not associated with HBV/HCV/HIV and do not capture others associated with risk in this cohort. The proportion of “I don’t know” responses on the donor risk assessment highlights its limitations. This data may inform donor risk assessment in the Canadian setting and highlights the changing epidemiology of HBV/HCV/HIV in organ donors.
Background: People with hearing loss may have difficulty communicating with health care providers if not properly supported. Hearing loss is common among people with kidney failure. Outpatient hemodialysis centers may present communication barriers due to noisy machines and overlapping conversations. Tools, such as assistive listening devices, exist to help people with hearing loss communicate. If and how they should be used in the outpatient hemodialysis setting is unclear. Understanding the patient perspective is an important first step before implementing such solutions. Objective: Describe the communication-related experiences of patients with hearing loss when conversing with health care providers during hemodialysis treatment, focusing on perceptions about communication tools. Design: Qualitative descriptive. Setting: Outpatient hemodialysis centers in Calgary and Edmonton, Alberta, Canada. Participants: Adults with kidney failure receiving maintenance hemodialysis with self-reported hearing loss. Methods: Semi-structured individual interviews. Interviews were audio-recorded, transcribed, and abductively coded using a validated communication framework, a strategy to guide communication access in practice, and participants’ experiences. Results: Fourteen patients participated between October 2023 and January 2024. Patient perceptions about communication tools varied. We identified three themes that describe these differences: (1) communication tools may be needed in transitional or clinically complex situations, (2) patients with their own resources may rely less on center-provided tools, and (3) awareness and self-advocacy for support varies across patients. Limitations: The major limitation of this study is the lack of representation from patients with language barriers and those belonging to the Deaf community or with overlooked hearing difficulties. Consequently, results may not be transferable to all patients with hearing loss in Alberta or elsewhere. Conclusions: Communication support needs are both person-specific and context-dependent, varying across and within patients. Not all patients that may benefit from communication tools will be comfortable asking or accepting help. Clinicians should routinely check in with patients about their communication needs and offer a variety of tools to accommodate as needed.
Anti-neutrophil cytoplasmic antibody (ANCA)–associated vasculitis (AAV) and primary focal segmental glomerulosclerosis (FSGS) are distinct glomerular diseases that rarely occur together. When present concurrently, they may produce overlapping nephritic and nephrotic features that complicate diagnosis and management. We report a case of a 63-year-old man who presented with four weeks of progressive anasarca and several months of cognitive changes, blurry vision, and paresthesia. Investigations demonstrated nephrotic-range proteinuria (8.25 g per day), hypoalbuminemia, hematuria, acute kidney injury, and hypertension. Kidney biopsy demonstrated two concurrent pathologies: FSGS with complete podocyte foot process effacement and pauci-immune glomerulonephritis with focal active crescents. Serology confirmed proteinase 3 antibody (PR3)-ANCA positivity, establishing active AAV alongside primary FSGS. Treatment included pulse intravenous methylprednisolone followed by oral prednisone and rituximab for induction and maintenance of AAV. Because nephrotic syndrome persisted, calcineurin inhibitor therapy was initiated for steroid-resistant FSGS (cyclosporine followed by tacrolimus). Adjunctive antiproteinuric therapies included renin-angiotensin system blockade, sodium-glucose cotransporter-2 inhibition, and later a nonsteroidal mineralocorticoid antagonist. The patient eventually achieved partial remission with resolution of his nephrotic syndrome and undetectable PR3 titers. After 2.5 years of follow-up, kidney function stabilized at an estimated glomerular filtration rate (eGFR) of 29 mL/min/1.73 m 2 with persistent urine albumin-to-creatinine ratio (ACR) of 163 mg/mmol despite maximal antiproteinuric therapy. Long-term complications included diabetes mellitus related to immunosuppression. This case illustrates the rare coexistence of primary FSGS and PR3-positive AAV requiring simultaneous treatment, with differing responses to therapy. It highlights the challenges of assessing treatment response in dual glomerular pathology while balancing aggressive immunosuppression against systemic toxicity. Incorporation of the patient perspective in this case report highlights the lived experience and burden of managing concurrent FSGS and AAV.
Purpose of review: Cardiovascular disease (CVD) accounts for nearly half of deaths among people receiving maintenance hemodialysis. Observational and interventional data suggest that higher serum magnesium, achieved through higher dialysate magnesium concentrations or oral supplementation, may improve cardiovascular outcomes and survival. This review synthesizes current evidence and provides context for an ongoing cluster-randomized trial that is testing whether a center-wide dialysate magnesium concentration of 0.75 mmol/L, versus ≤0.50 mmol/L, delivered as a policy and sustained for up to four years, reduces the risk of major cardiovascular-related hospitalizations. Sources of information: Peer-reviewed articles. Methods: We searched MEDLINE and EMBASE for observational and interventional studies evaluating serum or dialysate magnesium concentrations and cardiovascular outcomes in patients with chronic kidney disease and/or kidney failure. We appraised the methodological quality of interventional trials. This review is divided into four sections: (1) epidemiological associations between serum magnesium concentrations and CVD outcomes, (2) the impact of a higher concentration of dialysate magnesium on CVD outcomes, (3) the impact of oral magnesium supplementation on CVD outcomes, and (4) ongoing trials. Key findings: Twenty studies, including 10 randomized controlled trials, were reviewed. Systematic reviews and meta-analyses show that hypomagnesemia is associated with higher risks of cardiovascular events and all-cause mortality in hemodialysis. Interventional studies indicate that higher dialysate magnesium concentrations or oral supplementation can improve surrogate markers of vascular health, including less vascular calcification and stiffness. Higher dialysate concentrations may also lower cardiovascular mortality. Given encouraging but predominantly surrogate-based evidence, adequately powered randomized trials are warranted. Limitations: Most trials were small, single-center, and of short duration. They relied on surrogate endpoints, and there was heterogeneity in interventions and outcome measures.
Purpose of review 1) Provide a Canadian perspective on the 2025 Kidney Disease Improving Global Outcomes (KDIGO) Autosomal Dominant Polycystic Kidney Disease (ADPKD) guidelines; 2) identify challenges and nuances in applying these guidelines in Canada; 3) highlight shifts in expert practice points for Canadian care providers; 4) outline opportunities for research, knowledge translation, and quality improvement in Canada. Sources of information The KDIGO 2025 Clinical Practice Guideline Update for the management of ADPKD, as well as a survey and discussion by Canadian experts in ADPKD. Methods The co-chairs invited stakeholders from the Canadian ADPKD community to ensure national representation, including adult and pediatric clinicians, trainees, a genetic counselor, and a patient partner with an Indigenous perspective. Members were surveyed to identify key practice points. Subgroups reviewed issues and drafted discussion topics. All members reviewed the final draft. Key Findings The committee commented on recommendations with nuance for Canadian practitioners, especially on multidisciplinary care, challenges with genetic testing, and the use of CKD therapies like sodium-glucose transport protein 2 (SGLT2) inhibitors in ADPKD. Limitations The committee relied on the evidence summaries produced by KDIGO and the experience and knowledge of committee members. The committee did not replicate or update the systematic reviews.
