Chronic kidney disease (CKD) affects approximately one in ten adults globally. Multiple studies have identified underuse of effective therapies in eligible patients with CKD despite guideline endorsement. Clinical decision support (CDS) may increase confidence in prescribing recommended medications, but how end-users perceive it is unknown. To evaluate clinician-reported perspectives and acceptability of CDS elements for ambulatory CKD management and inform the development of a CKD-specific CDS intervention. Eligible participants for this electronic cross-sectional study were prescribing clinicians from Alberta, Canada, that practiced in ambulatory care settings, including physicians, nurse practitioners, and pharmacists. The survey presented examples of a proposed CDS’ content and format, and collected information on clinician demographics, CKD workflows, perceptions of CDS design, perceived acceptability and clinical utility. Knowledge, comfort, and prescribing patterns were examined for renin-angiotensin system inhibitors (RASi), statins, sodium-glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1RA), and non-steroidal mineralocorticoid receptor agonists (nsMRA). Participant comfort prescribing each medication class was compared using mean paired differences before and after viewing the proposed CDS. Between May and June 2025, 137 clinicians engaged with the survey, 131 completed demographics and 111 completed all survey elements. Most were nephrologists (n = 42; 32

RATIONALE & OBJECTIVE:Patients seen by nephrologists are highly complex, and clinical experience suggests this complexity has increased over time. This study compared temporal trends in the complexity profiles of inpatients seen by nephrologists to those seen by other physicians. STUDY DESIGN:Retrospective-cohort study. SETTING & PARTICIPANTS:Adult inpatients hospitalized between 2011 and 2020 in Alberta, Canada. EXPOSURE:(1) Physician groups involved during hospitalization and (2) calendar time. OUTCOME:Ten markers of complexity were evaluated before hospital admission, and 2 outcomes (death and placement in long-term care) were assessed after hospitalization. ANALYTICAL APPROACH:Generalized linear models to estimate absolute changes over the study period. RESULTS:Between 2011 and 2020, there were 1,621,630 hospital admissions among 971,051 patients. The number of nephrology inpatients seen annually rose by 44%, an increase larger than observed with other specialties (95% CI, 28.9-59.8). The percentage of inpatients seen by nephrologists in 2020 with complexity markers related to the number of specialty caregivers, number of physician caregivers, number of prescriptions, emergency department visits, and number of drug reactions increased by 6.1% (95% CI, 5.0-7.1), 6.0% (95% CI, 4.9-7.1) 1.9% (95% CI, 1.0-2.8), 1.5% (95% CI, 0.9-2.1), and 1.2% (95% CI, 0.4-2.0), respectively. The percentage of inpatients with frailty seen by nephrologists and with low primary-care attachment increased by 5.1% (95% CI, 4.2-6.0) and 3.5% (95% CI, 2.4-4.6), respectively. Except for frailty and number of prescriptions, the magnitude of the increases in these markers was larger for nephrology inpatients than for those cared for by other physicians. Secular changes in complexity were largely due to increases in characteristics other than age. Risks of death or placement in long-term care within 1 year of discharge decreased to a greater extent for inpatients cared for by nephrologists than among those cared for by other physicians. LIMITATIONS:Various markers of patient complexity were not evaluated. CONCLUSIONS:Volume and complexity of inpatients cared for by nephrologists have increased over time, a trend not explained by the increasing age of the population. However, the risks of death or need for long-term care fell more among patients cared for by nephrologists. PLAIN-LANGUAGE SUMMARY:Patients seen by nephrologists are highly complex, and clinical experience suggests that this complexity has increased over time. This study evaluated changes in various markers of patient complexity among hospitalized patients seen by nephrologists in Alberta, Canada, between 2011 and 2020. This study found increasing clinical complexity among patients seen by nephrologists, with changes greater than those observed among patients seen by other physician groups. Despite these changes showing increasing complexity among patients cared for by nephrologists, the risks of death or placement in long-term care within a year of hospital discharge decreased over time, and the decrease was greater among patients seen by nephrologists.

Background People with non-dialysis-dependent chronic kidney disease (CKD) have identified sexual health as an important aspect of kidney care and a research priority, yet limited information is available on how sexual health is provided within multidisciplinary clinics. We aimed to explore the perceptions, needs, and practices of healthcare providers in Canadian multidisciplinary CKD clinics related to sexual health support for individuals with non-dialysis-dependent CKD. Methods We used a convergent mixed methods design involving a self-administered online survey and semi-structured interviews to collect information from healthcare providers working in CKD clinics. The survey included questions related to providers' understanding of sexual health, current practices, and perceived gaps in how sexual health is addressed in routine CKD care, and was analyzed using descriptive statistics. We undertook follow-up interviews with a subset of survey respondents to elaborate on perspectives about sexual health support, which we analyzed using inductive, content analysis. Results Thirty-three nurses, 23 nephrologists, 9 allied health professionals, and 8 administrators completed the survey between September and December 2023. Five survey respondents participated in an interview. Quantitative and qualitative results were integrated and summarized in four themes describing current perceptions and practices in the provision of sexual health support for patients with non-dialysis-dependent CKD: (1) Mismatch between perceived value and ability to respond; (2) Roles and processes for integrating sexual health into CKD care; (3) Insufficient knowledge and competence in sexual health provider practices; (4) Influence of patient and provider characteristics in sexual health discussions. Key barriers to integrating sexual health into routine care were lack of knowledge, experience, and training; insufficient time and competing priorities; lack of resources; need for clarity in scope of practice; and concern for patient discomfort. Providers suggested access to credible, appropriate resources and clear expectations and guidelines around sexual health care provision for providers working in CKD clinics and other specialty areas (e.g., primary care) to support sexual health care for those with non-dialysis-dependent CKD. Conclusions We identified variability in care practices among healthcare providers from multidisciplinary CKD clinics. Identified barriers will inform strategies to enhance sexual health supports for individuals with non-dialysis-dependent CKD.

Introduction:People on chronic hemodialysis identify fatigue and its negative impact on their life participation (i.e., ability to accomplish valued daily occupations) as central to their illness experience. We explored how fatigue, as experienced by people on hemodialysis, shaped their participation in daily occupations, and participants' experiences in the Personal Energy Planning programme. Method:This qualitative follow-up study to a pilot randomized controlled trial used an interpretive description approach with six participants who completed an energy management programme for people treated with hemodialysis in Calgary, Canada. Each participant completed one semistructured interview about their experiences with fatigue management, life participation and the programme. Data were analyzed using modified constant comparative analysis. Findings:Participants described moving from an illness experience to one of living, where they could envision participation in both activities of daily living and social leisure occupations. Participants also described how they felt supported by the programme with its focus on applying the learning from the programme to improve their participation. Conclusion:Fatigue has an extensive impact on various facets of life participation. For people treated with hemodialysis, the reconstruction of their occupational lives can be enabled through energy management education programmes focused on the development of personal metacognitive strategies.

Background: Care for mild to moderate chronic kidney disease (CKD) entails self-management from patients and clinical support from primary care and nephrology. To address the gap in self-management resources, My Kidneys My Health was codeveloped to support patients with CKD. Health care providers play a critical role in the implementation of patient resources; however, there is a gap in understanding providers' perspectives in this role. Objective: This study develops and evaluates strategies to implement My Kidneys My Health into routine primary care and general nephrology clinical care. Methods: Health care providers working in Alberta, Canada, who support patients with CKD were invited to participate in our multistep study, guided by the Quality Implementation Framework. In step 1, we followed qualitative descriptive methodology to identify barriers and enablers to implementation using a directed content analysis and a deductive coding approach. Participants were invited to complete semistructured interviews from October 2021 to May 2022. In step 2, we identified, prioritized, codeveloped, and launched implementation strategies based on step 1 results using behavior change theory. Participants were invited to use the materials during the implementation period (May to October 2022). Website engagement was tracked through Google Analytics and document distribution tracking. In step 3, we conducted follow-up interviews with participants (October to December 2022) to evaluate implementation based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, following the same qualitative approach as step 1. Effectiveness was out of the scope of this study. Results: A total of 16 health care providers participated in step 1 qualitative interviews (8 from nephrology clinics and 5 from primary care or nonambulatory care). Participants shared an individual-level readiness and interest in sharing My Kidneys My Health with their patients. The key barriers to implementation included awareness, memory, time, motivation, and innovation accessibility. Implementation strategies were co-designed and implemented by step 1 participants (ie, educational sessions and materials, reminders, and implementation coaching). Notably, 9 health care providers participated in step 3 qualitative interviews. Participants shared their approach to tailoring implementation based on their patients and integrating the resource into their current practices. The resources developed were highly used by participants, with positive feedback on their usability and accessibility. Participants expressed motivation to continue sharing My Kidneys My Health; however, awareness and accessibility require further adaptations that can improve sustainability of implementation. Our rigorous approach allowed us to address behavior change and sustainability of implementation of My Kidneys My Health, as well as identify appropriate and tailored implementation strategies. Conclusions: There is a readiness to implement self-management supports for patients with early-stage CKD. A theory-informed approach and strategic implementation strategies can support sustainability. International Registered Report Identifier (IRRID): RR2-10.1007/s43477-022-00038-3

Background:There are limited data on the outcomes following medical management alone versus revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) after coronary angiography in kidney transplant recipients. Objective:The objective was to compare survival and graft loss in kidney transplant recipients treated with medical therapy alone versus coronary revascularization following coronary angiography. Design:We conducted a retrospective, population-based cohort study using linked health care databases. Setting:This study was conducted in Alberta, Canada. Patients:We included adult, kidney-only transplant recipients between January 1997 and March 2015 who survived at least 1-year post-transplant with a functioning graft and had a coronary angiography during follow-up. Measurements:The outcomes were all-cause mortality, death-censored graft failure, death with a functioning graft, and all-cause graft failure. Methods:We ascertained baseline characteristics, covariate information, and outcome data from the Alberta Kidney Disease Network (AKDN) and Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) databases. We used Cox proportional hazards models to compare mortality and graft loss between recipients treated with medical management versus revascularization (PCI or CABG) following angiography. Results:We identified 142 kidney transplant recipients who received a coronary angiography: 69 (49%) were treated with medical management, and 73 (51%) were treated with revascularization (PCI n = 52, CABG n = 21). The median age was 60 years (interquartile range [IQR] 50-66), 76% were male, the median baseline estimated glomerular filtration rate (eGFR) was 54 mL/min/1.73 m2 (IQR 41-69), and the median follow-up was 5 years (IQR 2-8). Compared to medical management, recipients treated with revascularization did not have statistically higher risk of all-cause mortality (55% vs 62%; 80 vs 102 events/1000 person-years; adjusted hazard ratio [aHR] 1.32, 95% CI 0.86-2.02; P = .21). There was no significant difference in death-censored graft failure between the two treatment groups (20% vs 22%; 33 vs 40 events/1000 person-years; aHR 1.22, 95% CI 0.58-2.58; P = .60). Limitations:The clinical indications for medical management alone versus revascularization might influence the choice of these interventions. Due to the smaller sample size, we could not present the outcomes by PCI versus CABG. We also did not have complete data on blood pressure, body mass index, or medication usage which might have influenced our outcomes. Conclusions:In kidney transplant recipients undergoing coronary angiography, the rate of mortality was more than double that of graft failure, regardless of post-angiography management of coronary artery disease. The high overall risk for both groups requires further exploration in larger cohorts with longer follow-up.

This overview outlines the development and implementation of the Health System Impact Fellowship (HSIF) National Cohort Training Program (NCTP)-a national training program for embedded health services and policy research (HSPR) in Canada. The program aims to improve HSPR capacity and make a recognizable impact within health systems. The HSIF NCTP aimed to achieve three specific goals related to advancing the community of practice in health services research: (1) providing tools and learning opportunities in HSPR competency areas, enabling the CoP to advance learning health systems nationally; (2) creating deliberate, ongoing networking opportunities that encourage diverse HSIF members to engage meaningfully, thereby strengthening community of practice collaboration; and (3) laying the groundwork for the evolution and sustainability of the community of practice within Canada's integrated HSRP ecosystem. Analysis of the program's evolution reveals critical elements to its development and implementation, including but not limited to adaptive learning environments that respond to emerging needs, cross-sectoral collaboration fostered through mentorship, and balanced instructional formats that combine theoretical depth with practical application. The curriculum, co-developed by fellows and faculty, emphasizes critical analysis of complex health system challenges. Insights from implementing and refining the program offer valuable lessons for developing embedded research training initiatives in healthcare settings.

Purpose of Program: Our team co-developed My Kidneys My Health , an online platform designed with patients with non-dialysis-dependent chronic kidney disease and care partners to provide tailored education and self-management support. While My Kidneys My Health has seen increased use and positive user feedback since its development and launch in 2021, there are opportunities to improve its cultural relevance, accessibility, and usefulness for diverse populations. In this report, we describe our approach to addressing these elements by adapting My Kidneys My Health content and knowledge mobilization strategies. Sources of Information: Patients and care partners in Canada have identified the lack of accessible, person-centered resources as a major barrier to effective self-management for non-dialysis-dependent chronic kidney disease. Digital heath tools can meet this need by delivering consistent, evidence-based education and support in a user-friendly format. Through our program of research with Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD), we have co-developed My Kidneys My Health through a series of patient-oriented research studies. Methods: Our program objectives are to (1) understand and address gaps in sexual health support for individuals with non-dialysis-dependent chronic kidney disease; (2) build relationships with Indigenous communities in Alberta to understand and share self-management learnings; and (3) improve accessibility to My Kidneys My Health content for diverse populations. To guide the adaptation and implementation of My Kidneys My Health , our team adopted the following Can-SOLVE CKD phase 2 pillars: (1) Implementation Science and Knowledge Mobilization, (2) Indigenous Cultural Competency, (3) Incorporation of Equity, Diversity, and Inclusion principles in Knowledge Mobilization and Implementation Efforts, and (4) Patient Engagement and Capacity Building. We used the Can-SOLVE CKD Pathway to Implementation and applied the Map2Adapt framework. Key Findings: Primary care and nephrology providers expressed readiness to integrate My Kidneys My Health into clinical workflows, and collaborative partnerships with initiatives like Kidney Check enhanced knowledge sharing. We initiated relationship building with the Stoney Nakoda Tsuut’ina Tribal Council Ltd. Health Department (G4 Health), including in-person meetings with the health directors, and co-development of engagement packages and communications designed to reflect our culturally safe methodologies. We addressed accessibility barriers by updating website features and new printable materials on key self-management topics, with French translations. Results from our mixed methods sexual health study underscored the need for tailored, credible resources for people with non-dialysis-dependent chronic kidney disease. Findings from our ongoing environmental scan will inform a sexual health resource inventory for integration into My Kidneys My Health . Patient partners reported meaningful involvement that shaped project priorities, design, and knowledge mobilization. Limitations: Significant time and resources are required to support meaningful Indigenous engagement, which contributed to delays in the project timeline. In Alberta, we have had ongoing healthcare restructuring disrupting relationship building with key decision-makers and creating uncertainty around partner roles. Finally, a permanent solution to accommodate and maintain My Kidneys My Health will be needed after the research is completed. Implications: Our work exemplifies an integrated, patient-oriented approach that emphasizes implementation science, equity, cultural competency, and capacity-building. As we move forward, our focus will remain on enhancing accessibility, relevance, and sustainability to ensure that all people living with non-dialysis-dependent chronic kidney disease can access trusted, evidence-based support to live well with kidney disease.

Introduction:Person-centered integrated care (PC-IC) has been shown to improve health outcomes for individuals with chronic conditions. However, there is limited evidence measuring PC-IC delivery to people with mild to moderate chronic kidney disease and co-morbidities. We aimed to assess PC-IC delivery for this population in Alberta, Canada. Methods:We conducted a survey (May-December 2023) using the Rainbow Model of Integrated Care Measurement Tool via weblink or telephone to quantify PC-IC using a 5-point Likert agreement scale. Patients with chronic kidney disease (non-dialysis, non-transplant) and co-morbidities, caregivers, and health care providers in Alberta were invited to participate. Participants were recruited through various methods, including in-clinic posters and web-based posts. We assessed responses using descriptive and non-parametric analyses (e.g., Mann-Whitney U-test). Results:Ninety-seven eligible individuals completed the survey; 24 patients, 12 caregivers, and 61 health care providers. Caregivers rated PC-IC significantly lower than patients (overall score: 3.36/5 and 3.91/5, respectively, p < 0.05) and health care providers rated PC-IC moderately (3.56/5). The lowest scored domain was care coordination amongst patients and caregivers (3.43/5 and 3/5, respectively, p < 0.05) and regional health care laws/regulations amongst health care providers (2.94/5). Conclusion:Survey respondents recognized that the overall delivery of PC-IC is not optimal and identified key areas to address including improving care coordination (e.g., communication between providers) and tackling regional health care laws/regulations (e.g., funding models). Our study highlights the need for further exploration regarding why PC-IC is perceived as suboptimal, particularly among subgroups, and how it can be improved.

Introduction: One in ten Canadians face kidney disease. Both patients and providers have been calling for strategies to address the needs of individuals with early-stage chronic kidney disease. This population faces a high burden of multimorbidity (occurrence of two or more chronic conditions) and requires coordinated care across multiple providers and healthcare settings. However, there is a risk of fragmented care when coordinating across primary and nephrology care sectors, which may lead to poor access to and integration of services for patients. Person-centered integrated care (PC-IC) is a recognized approach for enhancing the management of chronic kidney disease and improving health outcomes. Nevertheless, there is limited evidence available to guide the delivery of PC-IC for this specific population. Audience: Our aim is to provide insight into the perspectives of patients with early-stage chronic kidney disease and multimorbodity, along with their caregivers and healthcare providers. Team: We have assembled a strong team of researchers, clinicians, and patient partners. Our team brings complementary skills for conducting the proposed research, including expertise in quantitative, qualitative, and mixed methods, patient-orientated research, primary care and nephrology research in remote, rural, and urban settings, integrated care, and health economics and service delivery. Two of our patient partners, Ms. Verdin and Ms. Russon, actively participate in the planning and execution of this study. They are actively involved in research team meetings and play a crucial role in promoting the dissemination of our research findings. Methods: We conducted a cross-sectional survey study using the Rainbow Model of Integrated Care Measurement Tools (RMIC-MTs). Our recruitment efforts targeted patients, caregivers, and healthcare providers through various channels, including networks, social media, and direct referrals from healthcare professionals within Health Services and Primary Care Networks in Alberta. We conducted descriptive analyses to detect variances tied to respondent roles and background characteristics. Additionally, the integrated case assessments were examined and compared to those of an international collaborative network of dialysis clinics in 23 different countries. Results: During the conference, we will present the preliminary findings regarding the perceptions of integrated renal care among patients and healthcare providers in Alberta. We will also provide a comparative analysis with an international renal care network. Furthermore, we will unveil and discuss variations in integrated care perspectives among subgroups, considering the roles and background characteristics of the participants. Discussion: This research enhances our understanding of the challenges and opportunities, both at the national and international levels, associated with delivering person-centered integrated renal care. The insights gained from this study will serve as a foundational element for a patient-oriented research initiative aimed at collaboratively devising an innovative approach to PC-IC. In the subsequent phase of our work, we will identify and prioritize barriers and facilitators that impact PC-IC in Alberta, Canada. This will be accomplished through qualitative interviews and the application of a modified Nominal Group Technique.

Rationale & Objective: People with advanced kidney disease undergo more noncardiac operations compared with the general population, with a higher risk of perioperative cardiac events and death. However, little is known about the associations between severity of preoperative kidney dysfunction with postoperative length of hospitalization and discharge disposition; these were the focus of this study. Study Design: Population-based retrospective cohort. Setting & Participants: Adults from Alberta, Canada, undergoing inpatient major noncardiac surgery between April 2005 and February 2019. Exposure: Categorical preoperative outpatient estimated glomerular filtration rate (eGFR) or kidney failure status. Outcome: Length of stay (LOS), days alive at home after surgery within 30 and 90 days, and discharge disposition location. Analytical Approach: Associations were estimated with unadjusted and adjusted generalized estimating equation models. Results: We identified 927,560 inpatient surgeries in 666,770 people (55.9% female; median age, 57.4 years). People receiving dialysis had the longest LOS (11 days [95% CI, 6-29]), 2 times greater than that among people with normal kidney function (adjusted incidence rate ratio [IRR], 2.21 [95% CI, 2.102.32]). This group also had the fewest days alive at home within the first 30 days after surgery, with an IRR of 0.69 (95% CI, 0.670.70) compared with people with normal eGFR. The majority of people (82.8%) were discharged home without nursing support after surgery, though people receiving dialysis were discharged to a facility with 24-hour nursing care nearly 4 times more often. There were graded increases in risks of these outcomes with lower levels of kidney function. Limitations: Many people did not have preoperative kidney function assessed, reflecting standard clinical practice in the general population. Conclusions: After major surgery, people with kidney disease spend more time recovering in hospital and have less independence from postdischarge nursing supports than otherwise similar patients who have normal or near normal kidney function. These differences were more pronounced for those with the most severe stages of kidney disease.

This real-world study involved a large cohort of 38,598 adults with atrial fibrillation from five jurisdictions across Australia and Canada. This study supports the use of apixaban as a safe and effective alternative to warfarin for atrial fibrillation across differing levels of kidney function. This study also adds important safety data on the use of apixaban in patients with reduced kidney function. Evidence to guide the use of apixaban in people with atrial fibrillation (AF) and CKD in routine clinical practice has been limited. We assessed comparative safety (major bleeding) and effectiveness (ischemic stroke and death) of apixaban versus warfarin in patients with AF across the spectrum of non–dialysis-dependent CKD using large, routinely collected data. We combined findings from five retrospective cohorts (2013–2018) across Australia and Canada. Adults with AF, new dispensation of apixaban or warfarin, and a recorded eGFR grouped as ≥60, 45–59, 30–44, and <30 ml/min per 1.73 m2 were included. Patients on dialysis or kidney transplant recipients were excluded. We assessed outcomes within 1 year of initiating either therapy: (1) composite of all-cause death, ischemic stroke, or transient ischemic attack and (2) first hospitalization for major bleeding (intracranial, gastrointestinal, or other). Cox models estimated hazard ratios (HRs; 95% confidence intervals) for outcomes across eGFR categories, after 1:1 matching using propensity scores. We summarized center-level data using random effects meta-analysis. Among 38,598 matched apixaban and warfarin users, there were 4130 (10.7%) ischemic and 697 (1.8%) bleeding events within 1 year. Apixaban was associated with lower or similar risk for the ischemic outcome compared with warfarin in all eGFR categories (pooled HRs [95% confidence interval]: 0.78 [0.64 to 0.94], 0.77 [0.62 to 0.97], 0.82 [0.68 to 0.98], and 0.99 [0.68 to 1.45] for eGFR ≥60, 45–59, 30–44, and <30 ml/min per 1.73 m2, respectively). Apixaban was associated with lower or similar risk of bleeding across the range of kidney function (pooled HRs: 0.55 [0.43 to 0.69], 0.73 [0.52 to 1.02], 0.55 [0.31 to 0.97], and 0.68 [0.47 to 0.99], respectively). There was no significant heterogeneity across jurisdictions or eGFR categories. In adults with AF and non–dialysis-dependent CKD, apixaban compared with warfarin was associated with lower or similar risk of ischemic and bleeding outcomes. Our results suggest that apixaban offers a favorable risk-benefit ratio in patients with AF independent of kidney function.

RATIONALE & OBJECTIVE:Cognitive impairment is commonly associated with chronic kidney disease (CKD. A number of intervention approaches have the potential to improve cognitive performance in CKD. Our objective was to characterize interventions studied to improve cognitive performance for adults with CKD across all categories of severity, including kidney failure. STUDY DESIGN:Scoping review following JBI methodology. SETTING AND STUDY POPULATIONS:Adults (≥18 years) with CKD or kidney failure. SELECTION CRITERIA FOR STUDIES:We searched 5 electronic databases for studies published up to April 5, 2024. Eligible sources were primary research studies that investigated any intervention targeting cognition in adults (≥18 years) with CKD or kidney failure. Full-text article screening was performed in duplicate. DATA EXTRACTION:Characteristics of interventions, populations studied, and outcomes investigated. ANALYTICAL APPROACH:Descriptive statistics and narrative syntheses. RESULTS:Seventy-one studies were included. Over half (n = 37, 52%) were conducted within the past five years, and most studies (n = 47, 66%) targeted people on maintenance hemodialysis therapy. Just over one-third of studies investigated pharmacological interventions, with much of the pharmacological or medical research focusing on anemia management or dialysis adequacy. Although recent research has expanded in focus, many other purported mechanisms of cognitive dysfunction in CKD remain understudied in interventional research. Exercise training (n = 14) was the most common nonpharmacological approach studied, but few studies have explored other promising nonpharmacological approaches such as cognitive rehabilitation interventions. LIMITATIONS:Abstract screening not performed in duplicate; non-English studies excluded. CONCLUSION:Research into cognitive interventions for people with kidney disease has primarily focused on the hemodialysis population and investigated erythropoietin stimulating agents, frequent or prolonged dialysis, and exercise, although there has been recent growth of research activity into other interventions. Future research should aim to address a broader range of purported pathophysiological mechanisms of cognitive impairment in CKD, investigate interventions for predialysis and peritoneal dialysis patients, and explore the impacts of established cognitive rehabilitation approaches.

BACKGROUND:Evidence to guide use of apixaban in people with atrial fibrillation (AF) and chronic kidney disease (CKD) in routine clinical practice has been limited. We assessed comparative safety (major bleeding) and effectiveness (ischemic stroke and death) of apixaban versus warfarin in patients with AF across the spectrum of non-dialysis-dependent CKD using large, routinely collected data. METHODS:We combined findings from 5 retrospective cohorts (2013-2018) across Australia and Canada. Adults with AF, new dispensation of apixaban or warfarin, and a recorded eGFR grouped as ≥60, 45-59, 30-44 and <30mL/min/1.73m2 were included. Patients on dialysis or kidney transplant recipients were excluded. We assessed outcomes within one year of initiating either therapy: (1) composite of all-cause death, ischemic stroke or transient ischemic attack and (2) first hospitalization for major bleeding (intracranial, gastrointestinal or other). Cox models estimated hazard ratios (HRs; 95% confidence intervals [CIs]) for outcomes across eGFR categories, after 1:1 matching using propensity scores. We summarized center-level data using random effects meta-analysis. RESULTS:Among 38,598 matched apixaban and warfarin users, there were 4130 (10.7%) ischemic and 697 (1.8%) bleeding events within one year. Apixaban was associated with lower or similar risk for the ischemic outcome compared with warfarin in all eGFR categories (pooled HRs [95% CI]: 0.78 [0.64-0.94]), 0.77 [0.62-0.97], 0.82 [0.68-0.98] and 0.99 [0.68-1.45] for eGFR >60, 45-59, 30-44 and <30mL/min/1.73m2 respectively). Apixaban was associated with lower or similar risk of bleeding across the range of kidney function (pooled HRs: 0.55 [0.43-0.69], 0.73 [0.52-1.02], 0.55 [0.31-0.97], 0.68 [0.47-0.99], respectively). There was no significant heterogeneity across jurisdictions or eGFR categories. CONCLUSIONS:In adults with AF and non-dialysis-dependent CKD, apixaban compared with warfarin was associated with lower or similar risk of ischemic and bleeding outcomes. Our results suggest apixaban offers a favorable risk-benefit ratio in patients with AF independent of kidney function.

Background: People with chronic kidney disease (CKD) and other chronic conditions commonly experience fragmented care. A person-centered integrated care (PC-IC) approach has shown to effectively address care delivery and health outcomes for other populations. However, evidence to guide the application of PC-IC in patients with early-stage CKD and multimorbidity remains limited.To understand challenges and opportunities to address PC-IC for early-stage CKD and multimorbidity we engaged people with lived experience, including patients, caregivers, healthcare providers, and organizational leaders in Alberta, Canada. Approach: Our diverse multidisciplinary team includes two patient partners with lived experience (a patient and caregiver). They supported the grant applications, project planning, material development, and recruitment. The patient partners continue to provide guidance on interpretation of results and knowledge mobilization. We partnered with Essenburgh, leaders in the study of integrated care who developed the Rainbow Model of Integrated Care (RMIC) Framework and continue to collaborate, incorporating their international experience. Various organizations including Alberta Strategy for Patient Oriented Research, Can-SOLVE CKD Network, Primary Health Care Integrated Network, and Alberta Health Services (via the Medicine Strategic Clinical Network) supported the project including recruitment and facilitating community connections.This is a multi-phase, multi-methods patient-oriented study to co-design a PC-IC model of care. Our initial phases of work included conducting an online survey, using the validated RMIC Measurement Tool (RMIC-MT; May to November 2023) to measure the delivery of integrated care. We invited patients, caregivers, healthcare providers (HCPs), and decision-makers over the age of 8 and living in Alberta, Canada. We conducted descriptive and comparative analyses based on background characteristics (e.g., roles, settings, health status complexity). Next, we interviewed this population to contextualize our survey findings (9 completed, anticipating total of 30 interviews). We will use the Framework Method of analysis based on the RMIC Framework. Results: A total of 97 participants completed the survey. Participants included people with early-stage CKD and at least one comorbidity (n=24, 25%), caregivers (n=2, 2%), and HCPs (n=6, 63%). Many participants live in urban (n=62, 70%) compared to rural settings (n=26, 30%), and most HCPs were nephrologists (n=23, 4%) and primary care physicians (n=2, 38%). Overall, patients/caregivers and HCPs rated their experience with person-centered care moderately (3.98/5 and 4.8/5, respectively). The lowest scored items were care coordination between different providers (patients/caregivers; 3.29/5) and regional healthcare laws and regulations (HCPs; 2.94/5). Overall, Alberta received lower integrated care scores than the international benchmark.Preliminary interview results indicate current successes (e.g., multidisciplinary teams, provider to patient/caregiver communication) and challenges (e.g., information sharing between specialty and primary care) to implementing PC-IC. Implications: This research adds to existing knowledge on understanding the current state of PC-IC for early-stage CKD and multimorbidity management through a validated measurement tool and supplementary interviews. Our findings demonstrate opportunities to co-create an innovative PC-IC approach that would align services and resources to meet patient needs.Simultaneously, we are conducting a scoping review to identify existing PC-IC strategies at the micro-, meso-, and macro-levels employed internationally for this population. We will use these findings to inform a pan-Canadian survey aimed at identifying feasible PC-IC strategies.Our results from this current work inform the next phases of work including prioritizing barriers to PC-IC and identifying and leveraging feasible strategies to reimagine a model of care that addresses identified gaps.

INTRODUCTION:Falls among older adults are a substantial concern, with considerable effects on health, service use and costs. Preventing falls is therefore an important goal. In our previous systematic review and network meta-analysis (NMA), several effective fall prevention interventions were identified, but their cost-effectiveness in Canada remains unknown. METHODS:A microsimulation model was used to conduct a cost-utility analysis from a public healthcare payer perspective and a lifetime time horizon. Data sources included the previous NMA, administrative datasets and published literature. Three interventions (exercise, exercise plus vision assessment [Ex + va], and Ex + va + environmental assessment) were compared to usual care in the primary analysis; a secondary analysis assessed four additional interventions. Uncertainty was characterised in scenario analyses. RESULTS:Ex + va had the lowest cost ($149 346, 95% confidence interval [CI] 147 985-150 706) and the highest quality-adjusted life years (QALYs) gained (7.35, 95% CI 7.34-7.37), dominating all other interventions. Differences in costs and QALYs between interventions were small (ranges: $149 346-152 691; 7.27-7.35); usual care was the costliest and least effective. Results were unchanged in the scenario analyses. DISCUSSION:Ex + va dominated all other interventions, and all primary interventions dominated usual care. Adoption of a societal perspective may affect these conclusions, as some costs for vision care and environmental modifications are borne by patients in our setting, which were not included. Uptake of interventions that reduce falls and costs is recommended. These findings demonstrate that in Canada, multiple forms of fall prevention interventions may reduce costs and improve outcomes.

BACKGROUND:Guidelines recommend regular serum creatinine testing to detect chronic kidney disease (CKD) among people with diabetes or hypertension, but the ideal frequency of testing is unknown. We determined the diagnostic yield for incident CKD as defined by ≥2 measures of eGFR <60 mL/min/1.73m2, based on testing frequencies of every 2, 3, 4 or 5 years as compared to annually. METHODS:We did a retrospective population-based cohort study of 3,515,163 adults aged >18 years with eGFR >60 mL/min/1.73m2 at baseline in Alberta, Canada. We assessed diagnostic yield overall, and in categories defined by age, sex, comorbidity, albuminuria, or levels of a multivariable risk score for CKD. RESULTS:Assuming annual testing, the number of tests needed (NTN) to detect one new CKD case was >67-fold higher among those aged <50 years (2149, [95%CI 2103,2196]) as compared to >70 years (32, [32,32]). NTN for annual testing were 50 (49,50) among people with diabetes, 57 (57, 58) in those with hypertension and 20 (20,21) among people with heart failure. When stratified by CKD risk score, the NTN for annual testing ranged from 7 (7,8) at a score of 9 (highest risk), to 5708 (5494,5930) at a score of 0 (lowest risk). Testing people with diabetes every three years instead of every year would delay the diagnosis of CKD by a mean of 1.5 years for 2, 12, and 32 per 1000 people with diabetes aged <50, 50-70 and >70 years respectively. Corresponding delays associated with testing people with hypertension every three years instead of every year would impact 2, 9, and 27 per 1000 people aged <50, 50-70 and >70 years respectively. If applied to all adult Albertans, these two changes in testing frequency would potentially avert more than 5.9 million laboratory assays over the next decade. CONCLUSIONS:Tailoring the frequency of serum creatinine testing according to age and the presence of other risk factors would decrease the number of tests needed to detect cases of incident CKD.