Purpose of Review: Chronic kidney disease (CKD)-associated pruritus is a common, persistent, and distressing itch experienced by patients across the CKD spectrum. Although the disorder is associated with adverse outcomes and poor health-related quality of life, it remains underdiagnosed and undertreated. The purpose of this narrative review is to offer health care providers guidance on how to effectively identify, assess, and treat patients with CKD-associated pruritus, with the goal of reducing symptom burden and improving patient-important outcomes, such as quality of life (QoL). Sources of Information: A panel of nephrologists and researchers from across Canada and the United States was assembled to develop this narrative review based on the best available data, current treatment guidelines, and their clinical experiences. Methods: A panel of nephrologists who actively care for patients with pruritus receiving dialysis from across Canada was assembled. Two researchers from the United States were also included based on their expertise in the diagnosis and management of CKD-associated pruritus. Throughout Spring 2023, the panel met to discuss key topics in the identification, assessment, and management of CKD-associated pruritus. Panel members subsequently developed summaries of the pertinent information based on the best available data, current treatment guidelines, and added information on their own clinical experiences. In all cases, approval of the article was sought and achieved through discussion. Key Findings: This narrative review provides pragmatic guidance addressing: (1) methods for screening CKD-associated pruritus, (2) assessing severity, (3) management of CKD-associated pruritus, and (4) suggested areas for future research. The panel developed a 3-pillar framework for proactive assessment and severity scoring in CKD-aP: systematic screening for CKD-associated pruritus (pillar 1), assessment of pruritus intensity (pillar 2), and understanding the impact of CKD-associated pruritus on the patient’s QoL (pillar 3). Management of CKD-associated pruritus can include ensuring optimization of dialysis adequacy, achieving mineral metabolism targets (ie, calcium, phosphate, and parathyroid hormone). However, treatment of CKD-associated pruritus usually requires additional interventions. Patients, regardless of CKD-associated pruritus severity, should be counseled on adequate skin hydration and other non-pharmacological strategies to reduce pruritus. Antihistamines should be avoided in favor of evidence-based treatments, such as difelikefalin and gabapentin. Limitations: A formal systematic review (SR) of the literature was not undertaken, although published SRs were reviewed. The possibility for bias based on the experts’ own clinical experiences may have occurred. Key takeaways are based on the current available evidence, of which head-to-head clinical trials are lacking. Funding: This work was funded by an arm’s length grant from Otsuka Canada Pharmaceutical Inc. (the importer and distributer of difelikefalin in Canada). LiV Medical Education Agency Inc. provided logistical and editorial support.

Background:Estimated glomerular filtration rate (eGFR) at dialysis initiation is increasingly recognized as a key quality indicator (QI) for patients with end-stage kidney disease (ESKD). Specifically, guidelines recommend assessing deferral of dialysis initiation until symptoms arise or if the eGFR is ≤6 mL/min/1.73 m2. Despite the recognition of the importance of this QI, how eGFR at the time of dialysis initiation is defined, collected, and tracked at dialysis centers across Canada remains unknown.Objectives:To identify how provincial renal programs define eGFR at dialysis initiation, to compare practice across Canadian provinces, and to determine if there is a consistent benchmark for deferred dialysis start.Design:Cross-sectional survey distributed to the medical leads of each provincial renal program, administered from July 2021 to November 2021. Quebec was not included given it did not yet participate in Canadian Organ Replacement Register (CORR) data submission.Setting:The survey was designed and distributed by the Canadian Society of Nephrology Quality Improvement & Implementation Science Committee (CSN-QUIS) Indicator Working Group.Methods:The survey asked respondents on how eGFR is defined, collected, reported, and perceived barriers to QI data collection. The National Senior Renal Leaders Forum helped identify the key provincial medical leads to disseminate the survey for completion.Results:Surveys were distributed to the medical leads of the 9 provincial renal programs that participate in CORR. In total, there were 8 responses. Five provinces submit eGFR for all new dialysis starts and 3 provinces only submit this information for chronic patients. There is variation in determining when a patient with acute kidney injury requiring dialysis is classified as a chronic patient. Four provinces use a 30-day trigger, 3 provinces use a 90-day trigger, and the patient's nephrologist makes this determination in 1 province. The creatinine used for the eGFR at dialysis initiation was the value measured on the first dialysis session (ie, day 0) for 5 provinces; the last outpatient clinic creatinine value in 2 provinces, and 1 province did not have a standard definition. Three provinces did not have a benchmark target for eGFR at dialysis initiation, 1 province had a target of <9.5 mL/min/1.73 m2, 3 provinces had a target of <10 mL/min/1.73 m2, 1 province had a target of <15 mL/min/1.73 m2. All 8 responding provincial medical leads support the establishment of a national benchmark for this measure.Limitations:This survey was restricted to provincial medical leads and therefore is unable to determine practice at individual dialysis sites. The survey was not anonymous, so it may be subject to conformity bias.Conclusions:There is wide variability in how eGFR at dialysis initiation is measured and reported across Canada. Additionally, there is no consensus on a benchmark target for an intent-to-defer dialysis strategy. Standardization of target eGFR at dialysis initiation may facilitate national reporting and quality improvement initiatives.

Abstract Background Potassium regulation in the body is primarily done in the kidney. In addition to this, hyperkalemia, occurs in approximately 10% of individuals with chronic kidney disease (CKD) and is associated with elevated all-cause mortality. Individuals with CKD are often told to restrict dietary potassium (K), however, this recommendation is based on low quality evidence. Reduced quality of life, limited dietary choices and nutritional deficiencies are all potential negative outcomes that may occur when restricting dietary K in CKD patients. There is a need for randomized controlled trials investigating the impact of dietary K modification on serum K concentrations in people with CKD. Methods A randomized 2-period crossover design comparing a liberalized K fruit and vegetable diet where participants will be required to consume ~ 3500 mg of dietary K daily, to a standard K restricted diet where participants will be required to consume < 2000 mg of dietary K daily. All participants will begin on a liberalized K run-in period for 2 weeks where they will receive fruit and vegetables home deliveries and for safety will have clinical chemistry, including serum potassium measurements taken after 1 week. Participants will then be randomized into either liberalized K or standard K diet for six weeks and then crossover to the other intervention for another 6 weeks after a 2-week washout period. Discussion 30 male and female CKD outpatients, ≥ 18 years of age, who have an estimated glomerular filtration rate (eGFR) between 15 and 45 ml/min/1.73m2 and serum K between 4.5 and 5.5 mEq/L. This design would have greater than 80% power to detect a difference of 0.35 mEq/L serum K between groups. Anthropometric measurements, clinical chemistry, dietary recalls, physical function assessments, as well as a quality of life assessments will also be measured in this trial. These findings will provide high quality evidence for, or against, recommendations for dietary K restriction in individuals living with CKD. The removal of K restriction could provide individuals living with CKD more dietary choice leading to improved dietary status and quality of life. Trial Registration This trial has received approval from the University of Manitoba Research Ethics board (HS25191 (B2021:104)).

Patients with advanced chronic liver disease have a complex symptom burden and many are not candidates for curative therapy. Despite this, provision of palliative interventions remains woefully inadequate, with an insufficient evidence base being a contributory factor. Designing and conducting palliative interventional trials in advanced chronic liver disease remains challenging for a multitude of reasons. In this manuscript we review past and ongoing palliative interventional trials. We identify barriers and facilitators and offer guidance on addressing these challenges. We hope that this will reduce the inequity in palliative care provision in advanced chronic liver disease.

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

PURPOSE OF REVIEW:Quality improvement (QI) work is a cornerstone of health care, and a growing area within nephrology. With such growth comes the need to ensure that QI activities are implemented in an ethically responsible manner. The existing institutional research board (IRB) framework has largely focused on reviewing the ethical suitability of traditional research projects, and it can be challenging to know if QI initiatives require formal ethics oversight. Several tools have been developed to assist in distinguishing between the two, such as the "A pRoject Ethics Community Consensus Initiative" tool. Our objective was to demonstrate how QI is distinct from research, to outline how QI-focused IRB process is used across Canada, and to develop a practical aid for clinicians embarking on QI-related projects.SOURCES OF INFORMATION:Publicly available institutional Web sites from academic and select nonacademic sites across Canada.METHODS:Institutional Web sites across all academic centers within Canada were examined to determine local QI-specific ethics review processes. We have provided examples of QI processes from select community sites. We have developed a tool to assist clinicians navigate the ethical challenges of QI projects and to determine whether their project may require ethics approval.KEY FINDINGS:This overview of the considerations of the research ethics approval process helps clinicians to determine whether IRB approval is required for QI studies. Examples of the current ethical processes employed in both academic and community institutions across Canada demonstrate the variability between centers. We have included examples of fictional nephrology-oriented QI initiatives to illustrate when ethics approval may be considered, along with a flowchart. This summary highlights the opportunity for QI-specific IRB review processes to be standardized across Canada, along with the need for creation of a separate stream with dedicated expertise for QI project review.LIMITATIONS:We did not do a formal environmental scan of the QI IRB review process in all hospital institutions across Canada.

Background: Quality indicators can be used to identify gaps in care and drive frontline improvement activities. These efforts are important to prevent adverse events in the increasing number of ambulatory patients with advanced kidney disease in Canada, but it is unclear what indicators exist and the components of health care quality they measure. Objective: We sought to identify, categorize, and evaluate quality indicators currently in use across Canada for ambulatory patients with advanced kidney disease. Design: Environmental scan of quality indicators currently being collected by various organizations. Setting: We assembled a 16-member group from across Canada with expertise in nephrology and quality improvement. Patients: Our scan included indicators relevant to patients with chronic kidney disease in ambulatory care clinics. Measurements: We categorized the identified quality indicators using the Institute of Medicine and Donabedian frameworks. Methods: A 4-member panel used a modified Delphi process to evaluate the indicators found during the environmental scan using the American College of Physicians/Agency for Healthcare Research and Quality criteria. The ratings were then shared with the full panel for further comments and approval. Results: The environmental scan found 28 quality indicators across 7 provinces, with 8 (29%) rated as “necessary” to distinguish high-quality from poor-quality care. Of these 8 indicators, 3 were measured by more than 1 province (% of patients on a statin, number of patients receiving a preemptive transplant, and estimated glomerular filtration rate at dialysis start); no indicator was used by more than 2 provinces. None of the indicators rated as necessary measured timely or equitable care, nor did we identify any measures that assessed the setting in which care occurs (ie, structure measures). Limitations: Our list cannot be considered as an exhaustive list of available quality indicators at hand in Canada. Our work focused on quality indicators for nephrology providers and programs, and not indicators that can be applied across primary and specialty providers. We also focused on indicator constructs and not the detailed definitions or their application. Last, our panel does not represent the views of other important stakeholders. Conclusions: Our environmental scan provides a snapshot of the scope of quality indicators for ambulatory patients with advanced kidney disease in Canada. This catalog should inform indicator selection and the development of new indicators based on the identified gaps, as well as motivate increased pan-Canadian collaboration on quality measurement and improvement. Trial registration: Not applicable as this article is not a systematic review, nor does it report results of a health intervention on human participants.

BACKGROUND:Quality metrics or indicators help guide quality improvement work by reporting on measurable aspects of health care upon which improvement efforts can focus. For recipients of in-center hemodialysis (ICHD) in Canada, it is unclear what ICHD quality indicators exist and whether they adequately cover different domains of health care quality.OBJECTIVES:To identify and evaluate current Canadian ICHD quality metrics to document a starting point for future collaborations and standardization of quality improvement in Canada.DESIGN:Environmental scan of quality metrics in ICHD, and subsequent indicator evaluation using a modified Delphi approach.SETTING:Canadian ICHD units.PARTICIPANTS:Sixteen-member pan-Canadian working group with expertise in ICHD and quality improvement.MEASUREMENTS:We classified the existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks.METHODS:Each metric was rated by a 5-person subcommittee using a modified Delphi approach based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for additional comments.RESULTS:We identified 27 metrics that are tracked across 8 provinces, with only 9 (33%) tracked by multiple provinces (ie, more than 1 province). We rated 9 metrics (33%) as "necessary" to distinguish high-quality from low-quality care, of which only 2 were tracked by multiple provinces (proportion of patients by primary access and rate of vascular access-related bloodstream infections). Most (16/27, 59%) indicators assessed the IOM domains of safe or effective care, and none of the "necessary" indicators measured the IOM domains of timely, patient-centered, or equitable care.LIMITATIONS:The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals, with more representation from academic sites.CONCLUSIONS:Quality indicators in Canada mainly focus on safe and effective care, with little provincial overlap. These results highlight current gaps in quality of care measurement for ICHD, and this initial work should provide programs with a starting point to combine highly rated indicators with newly developed indicators into a concise balanced scorecard that supports quality improvement initiatives across all aspects of ICHD care.TRIAL REGISTRATION:not applicable.

Background Dedicated care programs that provide increased support to patients starting dialysis are increasingly being used to reduce the risk of complications. The objectives of this systematic review were to determine the characteristics of existing programs and their effect on patient outcomes. Methods We searched Embase, MEDLINE, Web of Science, Cochrane CENTRAL, and CINAHL from database inception to November 20, 2019 for English-language studies that evaluated dedicated care programs for adults starting maintenance dialysis in the inpatient or outpatient setting. Any study design was eligible, but we required the presence of a control group and prespecified patient outcomes. We extracted data describing the nature of the interventions, their components, and the reported benefits. Results The literature search yielded 12,681 studies. We evaluated 66 full texts and included 11 studies (n=6812 intervention patients); eight of the studies evaluated hemodialysis programs. All studies were observational, and there were no randomized controlled trials. The most common interventions included patient education (n=11) and case management (n=5), with nurses involved in nine programs. The most common outcomes were mortality (n=8) and vascular access (n=4), with only three studies reporting on the uptake of home dialysis and none on transplantation. We identified four high-quality studies that combined patient education and case management; in these programs, the relative reduction in 90-day mortality ranged from 22% (95% CI, -3% to 41%) to 49% (95% CI, 33% to 61%). Pooled analysis was not possible due to study heterogeneity. Conclusions Few studies have evaluated dedicated care programs for patients starting dialysis, especially their effect on home dialysis and transplantation. Whereas multidisciplinary care models that combine patient education with case management appear to be promising, additional prospective studies that involve patients in their design and execution are needed before widespread implementation of these resource-intensive programs.

RATIONALE:Hypokalemia is a common finding. Typically asymptomatic presentations of neuromuscular weakness emerge at levels below 2.5 mmol/L. Causes include gastrointestinal losses, renal losses, or intracellular shift, with gastrointestinal losses and diuretics accounting for the majority. Although the cause is often apparent on clinical assessment, a systematic approach incorporating urine biochemistry can aid in narrowing the differential in obscure cases.PRESENTATION:We describe a case of a previously healthy 27-year-old man who presented with acute ascending paralysis, with an associated severe hypokalemia and metabolic acidosis. There were no apparent causes on clinical assessment.DIAGNOSIS:Based on analysis of urine biochemistry, we concluded that a pathologic kaluresis was present, and given his acidemia and transient pathology, we diagnosed the patient with hypokalemic paralysis secondary to toluene toxicity.INTERVENTIONS:We provided supportive care and electrolyte repletion for our patient; no specific therapies for toluene were required. Our patient was counseled regarding appropriate protective measures when handling toluene.OUTCOMES:Complete neurologic recovery and biochemical normalization occurred within 48 hours of presentation with supportive care. He continued to use proper precautions when handling toluene, and experienced no symptom relapse, or further abnormalities on both blood and urine chemistry.LESSONS LEARNED:Using this case, we review an algorithmic approach incorporating urine biochemistries to aid in the workup of hypokalemia. We review toluene as a toxicologic entity and highlight its role as a cause of hypokalemia.

Refractory non-malignant ascites is associated with significant morbidity. Serial, large-volume paracentesis is a common treatment. Tunneled peritoneal dialysis (PD) catheters are an effective treatment for refractory malignant ascites, but there are limited data on complications and effectiveness for non-malignant ascites. We reviewed all 13 PD catheter insertions between 2010 - 2015 for this indication at our center. The median catheter survival time was 146 days. No complications occurred during catheter insertion, and no mechanical complications occurred after catheter insertion. One case of peritonitis developed over 217 catheter months. Peritoneal dialysis catheters may be a safe and effective option to manage refractory non-malignant ascites. Prospective, randomized trials are needed to better evaluate potential risks and benefits.

Single-patient methanol intoxications are a common clinical presentation, but outbreaks are rare and usually occur in settings in which there is limited access to ethanol and methanol is consumed as a substitute. In this case report, we describe an outbreak of methanol intoxications that was challenging from a public health perspective and discuss strategies for managing such an outbreak.

BACKGROUND:In some jurisdictions, routine reporting of the estimated glomerular filtration rate (eGFR) has led to an increase in nephrology referrals and wait times.OBJECTIVE:We describe the use of the Kidney Failure Risk Equation (KFRE) as part of a triage process for new nephrology referrals for patients with chronic kidney disease stages 3 to 5 in a Canadian province.DESIGN:A quasi-experimental study design was used.SETTING:This study took place in Manitoba, Canada.MEASUREMENTS:Demographics, laboratory values, referral numbers, and wait times were compared between periods.METHODS:In 2012, we adopted a risk-based cutoff of 3% over 5 years using the KFRE as a threshold for triage of new referrals. Referrals who did not meet other prespecified criteria (such as pregnancy, suspected glomerulonephritis, etc) and had a kidney failure risk of <3% over 5 years were returned to primary care with recommendations based on diabetes and hypertension guidelines. The average wait time and number of consults seen between the pretriage (January 1, 2011, to December 31, 2011) and posttriage period (January 1, 2013, to December 31, 2013) were compared using a general linear model.RESULTS:In the pretriage period, the median number of referrals was 68/month (range: 44-76); this increased to 94/month (range: 61-147) in the posttriage period. In the posttriage period, 35% of referrals were booked as urgent, 31% as nonurgent, and 34% of referrals were not booked. The median wait times improved from 230 days (range: 126-355) in the pretriage period to 58 days (range: 48-69) in the posttriage period.LIMITATIONS:We do not have long-term follow-up on patients triaged as low risk. Our study may not be applicable to nephrology teams operating under capacity without wait lists. We did not collect detailed information on all referrals in the pretriage period, so any differences in our pretriage and posttriage patient groups may be unaccounted for.CONCLUSIONS:Our risk-based triage scheme is an effective health policy tool that led to improved wait times and access to care for patients at highest risk of progression to kidney failure.

Background: Patients with chronic kidney disease (CKD) are at risk to progress to kidney failure. We previously developed the Kidney Failure Risk Equation (KFRE) to predict progression to kidney failure in patients referred to nephrologists. Objective: The objective of this study was to determine the ability of the KFRE to discriminate which patients will progress to kidney failure in an unreferred population. Design: A retrospective cohort study was conducted using administrative databases. Setting: This study took place in Manitoba, Canada. Measurements: Age, sex, estimated glomerular filtration rate (eGFR), and urine albumin-to-creatinine ratio (ACR) were measured. Methods: We included patients from the Diagnostic Services of Manitoba database with an eGFR <60 mL/min/1.73 m2 and ACR measured between October 2006 and March 2007. Five-year kidney failure risk was predicted using the 4-variable KFRE and compared with treated kidney failure events from the Manitoba Renal Program database. Sensitivity and specificity for KFRE risk thresholds (3% and 10% over 5 years) were compared with eGFR thresholds (30 and 45 mL/min/1.73 m2). Results: Of 1512 included patients, 151 developed kidney failure over the 5-year follow-up period. The 4-variable KFRE showed a superior prognostic discrimination compared with eGFR alone (area under the receiver operating characteristic curve [AUROC] values, 0.90 [95% confidence interval {CI}: 0.88-0.92] for KFRE vs 0.78 [95% CI: 0.74-0.83] for eGFR). At a 3% threshold over 5 years, the KFRE had a sensitivity of 97% and a specificity of 62%. At 10% risk, sensitivity was 86%, and specificity was 80%. Limitations: Only 11.7% of stage 3-5 CKD patients had simultaneous ACR measurement. The KFRE does not account for other indications for referral such as suspected glomerulonephritis, polycystic kidney disease, and recurrent stone disease. Conclusions: The KFRE has been validated in a population with a demographic and referral profile heretofore untested and performs well at predicting 5-year risk of kidney failure in a population-based sample of Manitobans with CKD stages 3 to 5. Thresholds of 3% and 10% over 5 years are sensitive, specific, and can be used in clinical decision making. Further testing of the 4-variable KFRE and these thresholds in clinical practice should be considered.

BACKGROUND:It has been shown that in-center hemodialysis (HD) nurses prefer in-center HD for patients with certain characteristics; however it is not known if their opinions can be changed.OBJECTIVE:To determine if an education initiative modified the perceptions of in-center HD nurses towards home dialysis.DESIGN:Cross-sectional survey of in-center HD nurses before and after a three hour continuing nursing education (CNE) initiative. Content of the CNE initiative included a didactic review of benefits of home dialysis, common misconceptions about patient eligibility, cost comparisons of different modalities and a home dialysis patient testimonial video.SETTING:All in-center HD nurses (including those working in satellite dialysis units) affiliated with a single academic institution.MEASUREMENTS:Survey themes included perceived barriers to home dialysis, preferred modality (home versus in-center HD), ideal modality distribution in the local program, awareness of home dialysis and patient education about home modalities.METHODS:Paired comparisons of responses before and after the CNE initiative.RESULTS:Of the 115 in-center HD nurses, 100 registered for the CNE initiative and 89 completed pre and post surveys (89% response rate). At baseline, in-center HD nurses perceived that impaired cognition, poor motor strength and poor visual acuity were barriers to peritoneal dialysis and home HD. In-center HD was preferred for availability of multidisciplinary care and medical personnel in case of catastrophic events. After the initiative, perceptions were more in favor of home dialysis for all patient characteristics, and most patient/system factors. Home dialysis was perceived to be underutilized both at baseline and after the initiative. Finally, in-center HD nurses were more aware of home dialysis, felt better informed about its benefits and were more comfortable teaching in-center HD patients about home modalities after the CNE session.LIMITATIONS:Single-center study.CONCLUSIONS:CNE initiatives can modify the opinions of in-center HD nurses towards home modalities and should complement the multitude of strategies aimed at promoting home dialysis.

There is substantial variability at international, national, and regional levels in how effective dialysis providers are in the implementation of well-accepted interventions to deliver better health outcomes at reduced costs to payers. The growing number of dialysis patients within a finite pool of resources has led to searches for more efficient methods to provide patient care without compromising or diminishing quality. We review here some contemporary concepts surrounding quality improvement and operations research that may provide clinician administrators to both improve efficiency and quality in facility based hemodialysis units. The creation of balanced scorecards, utilization of process mapping techniques, and the application of LEAN principles may readily improve how hemodialysis care is delivered in an environment of increasing patient volumes and reduced operating resources.

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

Background Multiple benefits of arteriovenous fistulas (AVF) and arteriovenous grafts (AVGs) exist over catheters. As part of a strategy to preserve thoracic venous sites and reduce internal jugular (IJ) vein catheter use, we inserted tunneled femoral vein catheters in incident “urgent start” dialysis patients while facilitating a more appropriate definitive dialysis access. Methods “Urgent start” dialysis patients between January 15, 2013 and January 15, 2014 who required chronic dialysis, and did not have prior modality and vascular access plans, had tunneled femoral vein catheters inserted. We determined the femoral vein catheter associated infections rates, thrombosis, and subsequent dialysis access. Eligible patients were surveyed on their femoral vein catheter experience. Results Twenty-two femoral vein catheters were inserted without complications. Subsequently, one catheter required intraluminal thrombolytic locking, while all other catheters maintained blood flow greater than 300 ml/min. There were no catheter-related infections (exit site infection or bacteremia). Six patients continued to use their tunneled catheter at report end, one transitioned to peritoneal dialysis, thirteen to an arteriovenous graft, and two to a fistula. One patient received a tunneled IJ vein catheter. Of the patients who completed the vascular access survey, all indicated satisfaction with their access and that they had minimal complaints of bruising, bleeding, or swelling at their access sites. Pain/discomfort at the exit site was the primary complaint, but they did not find it interfered with activities of daily living. Conclusions Femoral vein tunneled catheters appear to be a safe, well tolerated, and effective temporary access in urgent start dialysis patients while they await more appropriate long-term access.

BACKGROUND:There is a paucity of information about the views of dialysis nurses towards dialysis modality selection, yet nurses often have the most direct contact time with patients. We conducted a survey to better understand nurses' attitudes and perceptions, and hypothesized that nurses with different areas of expertise would have differences in opinions.METHODS:We administered an electronic survey to all dialysis/predialysis nurses (n = 129) at a large, tertiary care center. The survey included questions about preferred therapy - in-center hemodialysis (CHD), versus home dialysis (home hemodialysis and peritoneal dialysis) and ideal modality mix. Responses were compared between nurses with home dialysis and CHD experience.RESULTS:The survey response rate was 69%. Both nursing groups ranked patient caregivers and dialysis nurses as having the least impact on patient modality selection. For most patient characteristics (including age > 70 years and presence of multiple chronic illnesses), CHD nurses felt that CHD was somewhat or strongly preferred, while home dialysis nurses preferred a home modality (p < 0.001 for all characteristics studied). Similar differences in responses were noted for patient/system factors such as patient survival, cost to patients and nursing job security. Compared to CHD nurses, a higher proportion of home dialysis nurses felt that CHD was over-utilized (85% versus 58%, p = 0.024).CONCLUSION:Dialysis nurses have prevailing views about modality selection that are strongly determined by their area of experience and expertise.

The incidence of end-stage renal disease is increasing, placing a tremendous burden on health care resources. Peritoneal dialysis (PD) is cheaper than hemodialysis and has many potential advantages and few contraindications as an initial modality selection. This study examined differences in patient PD attempt rates between nephrologists using technique survival and mortality as outcomes.We performed a retrospective review of the Manitoba Renal Program databases from January 2004 to January 2010. Analysis of 630 patients who commenced dialysis and had demographic data available was performed. A genetic matching algorithm was used to balance potential differences between patient characteristics. Each nephrologist was then compared against their peers to calculate a PD attempt rate. The highest attempt rate group was compared with the lowest.When comparing PD attempt rates between groups, all the results were significant. PD technique survival at 90 days showed no significant differences (P 0.42). Patient mortality at 90 days was also not significant when comparing groups (P 0.14).Our data suggest that when comparing the low- with high-attempt groups, the factors limiting PD utilization do not include on-site availability of PD, case mix, funding, patient location or reimbursement. Aggressive approaches of starting more patients on PD did not lead to lower technique survival or higher mortality rates. If the PD attempt rate was maximized, a significant amount of money and resources could be saved or directed toward helping a larger population without significant harm to patients.