Background:Individuals with chronic kidney disease (CKD) can develop metabolic acidosis which, in turn, is associated with faster progression of CKD and an increased need for dialysis. Oral sodium bicarbonate (the current standard of care therapy for metabolic acidosis) is poorly tolerated leading to low adherence. Base-producing or alkalizing Fruit and vegetables have potential as an alternative treatment for metabolic acidosis as they have been shown to reduce acid load arising from the diet.Objective:This trial will evaluate the feasibility of providing base-producing fruit and vegetables as a dietary treatment for metabolic acidosis, compared with oral sodium bicarbonate.Design:A 2-arm, open-label, dual-center, randomized controlled feasibility trial.Setting:Two Canadian sites: a nephrology clinic in Winnipeg, Manitoba, and a nephrology clinic in Halifax, Nova Scotia.Participants:Adult participants with G3-G5 CKD and metabolic acidosis.Measurements:Participants will undergo baseline measurements and attend 5 study visits over 12 months at which they will have a measurement of feasibility criteria as well as blood pressure, blood and urine biochemistry, 5-repetition chair stand test (STS5), and questionnaires to assess quality of life and symptoms. Furthermore, participants fill out Automated Self-Administered 24-hour recalls (ASA-24) in the beginning, middle, and end of trial.Methods:A total of 40 eligible participants will be randomized 1:1 to either base-producing fruit and vegetables (experimental) group or sodium bicarbonate (control) group, beginning from a daily dose of 1500 mg.Limitations:Using self-administered dietary assessments, lack of supervision over the consumption of study treatments and the possible disappointment of the control group for not receiving fruit and vegetables would be considered as limitations for this study. However, we are planning to undertake proper practices to overcome the possible limitations. These practices are discussed throughout the article in detail.Conclusions:This study will generate data on base-producing fruit and vegetables consumption as a dietary treatment for metabolic acidosis in CKD. The data will be used to design a future multi-center trial looking at slowing CKD progression in people with metabolic acidosis.Trial Registration:This study is registered on clinicaltrials.gov with the identifier NCT05113641.

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

The health status of First Nations, Inuit and Metis peoples reflects a disparate sociopolitical and environmental context inextricably linked to Canada’s colonial history. This health inequity is exemplified by the disproportionate burden of chronic diseases such as diabetes, hypertension, and chronic kidney disease (CKD) affecting Indigenous communities. Frequently diagnosed at a younger age and greater severity than non-Indigenous groups, the increasing prevalence of these conditions is of particular concern in rural and remote Indigenous communities (1, 2). Often marginalized from mainstream healthcare services (geographically, economically, or culturally), many of these communities lack the preventive health benefits associated with continuity of care (3). Consequently, the detection and treatment of these conditions is often delayed, resulting in an increased risk of adverse outcomes that impact quality of life and strain healthcare systems. In 2015, the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) program in Manitoba highlighted the efficacy of mobile point-of-care testing among adults and children in 11 rural and remote First Nations communities. Importantly, the program reported that a majority (87%) of CKD cases identified by albuminuria or a decreased estimated glomerular rate were early-stage and potentially treatable, representing an opportunity to prevent or delay kidney failure (4). As the lifetime health and economic burden of CKD is dependent on the severity of the disease, early detection and management represents a crucial opportunity to reduce this burden through risk factor modification including blood pressure control, diabetes management and the use of reno-protective medications, such as Renin-Angiotensin-Aldosterone System (RAAS) and Sodium-glucose co-transporter-2 (SGLT2) inhibitors (5). Modelled after FINISHED, Kidney Check is an Indigenous-led screen and treat program working to bring early detection and preventive kidney care to rural and remote Indigenous communities across Canada (Manitoba, Ontario, British Columbia, Alberta, Saskatchewan) [Table 1]. Using portable diagnostic equipment, specialized Kidney Check health teams screen participating adults and children ages 10 and up for CKD, diabetes, and hypertension. True to its name, point-of care testing (POCT) is designed for use at the site of patient care, presenting an opportunity to expand preventive healthcare to regions with diminished access. Following screening, participants are triaged according to their individualized kidney failure risk prediction scores and are referred to additional resources accordingly. An affiliate of the patient-oriented Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) research network, the programs design and implementation is guided by foundational research priorities set by patient partners. These and other collaborative partnerships between Kidney Check, Indigenous healthcare providers, adult and pediatric clinician specialists and engaged policy makers contribute to the programs sustainability and success. Table 1 Kidney Check screening communities for British Columbia, Alberta and Manitoba

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.

Indigenous peoples often endure significant health disparities fueled by historic and ongoing marginalizing policies and practices. In many cases, Indigenous groups are isolated from mainstream health care services (geographically, economically, or culturally) and lack the preventive health benefits associated with continuity of care.1 In Canada, this manifests in disproportionately high rates of chronic disease, often diagnosed at a younger age and greater severity than non-Indigenous groups. Of these, chronic kidney disease (CKD), diabetes, and hypertension are highly prevalent, reaching epidemic levels in many communities.