Jennifer M. MacRae

Background: Fistulas are the preferred form of vascular access and historically, have been recommended by guidelines because they were associated with improved clinical outcomes and costs. However, there has never been a randomized comparison of catheters to fistulas and the evidence on which recommendations were based is observational with potential for bias. Methods: A pilot randomized controlled trial was conducted in 12 hemodialysis centers in Canada and Australia. Individuals aged 55 years and older who started hemodialysis using a tunneled or non-tunneled central venous catheter for vascular access were randomized to an attempt at fistula creation or continued use of a tunneled, central venous hemodialysis catheter. The primary outcome was feasibility, as measured by the proportion of eligible patients who consented to randomization and the proportion of patients randomized to the fistula group who underwent fistula placement within 90 days. Secondary outcomes included invasive access-related procedures, hospitalizations, access-related infections, tissue plasminogen activator usage, and death. Results: A total of 1287 patients were screened and 67 patients underwent randomization. A total of 25% of eligible patients agreed to randomization and 71% randomized to the fistula arm underwent fistula placement within 90 days. The most common reason patients declined to participate in the trial was that they preferred to continue to dialyze with their catheter. Patients randomized to fistulas had nominally more access-related interventions, hospitalizations, and bacteremia (the majority of which were catheter-related), while the catheter group experienced greater reliance on thrombolytic therapy. Conclusions: Findings from this trial suggest that conducting a definitive randomized trial of fistulas versus catheters is not feasible in the current climate. There was no signal of harm associated with randomization to the catheter strategy and most outcomes favored the catheter group. Patients exhibited strong preferences regarding choice of vascular access.

Background: People with kidney failure have complex care needs and frequently access care using the emergency department (ED). Little is known about how continuity of care (CoC) relates to ED care seeking for people with kidney failure. To understand the experiences of CoC among adults with kidney failure in relation to their recent ED encounter. Methods: Using a qualitative descriptive methodology, we purposively sampled adults with kidney failure (defined as eGFR <15 mL/min/1.73m2 and/or receipt of maintenance dialysis) from Alberta who accessed the ED for a non-life-threatening indication within the preceding six weeks between May 2024 and January 2025. We conducted individual semi-structured interviews and analyzed transcripts in duplicate using a framework analysis approach with reference to an established framework defining CoC according to 3 types (i.e., relational, management, and informational). Thematic development involved both inductive and deductive techniques. Results: 29 patients were included (12 in-center hemodialysis, 1 in-center nocturnal hemodialysis, 7 peritoneal dialysis, 5 home hemodialysis, and 4 without kidney replacement therapy). Themes were identified within CoC types and across settings of before, during, and after the acute care encounter. Key relational continuity themes included: stability and trust in care teams, disrupted therapeutic relationships, and re-establishing engagement in circles of care. Management continuity themes included: safeguarding kidney supports and kidney care fragmentation in the ED. Informational continuity themes included: patients as continuity self-advocates, bridging care through information sharing, and extending continuity beyond the ED. Conclusions: Patients with kidney failure expressed varied experiences of CoC and identified important gaps relevant to the emergency care context. Strategies that bridge these perceived gaps across outpatient and acute care settings may help to mitigate the burden of ED use in this population.

Key Points: The term, frailty, had unclear meaning for most participants but was commonly explained as weakness, dependence, and unmodifiable. Knowledge of frailty assessment tools and the evidence to support their prognostic utility was low among clinicians. Though patients and caregivers saw value in discussing frailty, the label of frailty was often viewed as pejorative. Background: Frailty is highly prevalent among individuals with kidney failure and independently associated with poor health outcomes. Identifying and managing frailty can inform prognosis and care but stakeholders' understanding of frailty and their perspectives on how to detect and manage it in routine kidney care are unknown. Methods: We recruited participants from four Canadian kidney programs in Alberta, Manitoba, and Nova Scotia from January 2021 to June 2023. We conducted focus groups and semistructured interviews with patients (50 years or older with dialysis-dependent or nondependent kidney failure), caregivers, allied health care professionals, and nephrologists. We used qualitative description and inductive thematic analysis to describe their perspectives. Results: Ninety-one people participated: patients ( N =31), caregivers ( N =8), kidney allied health care professionals ( N =38), and nephrologists ( N =14). We identified three themes, each with subthemes: ( 1 ) What is frailty? All groups expressed uncertainty, but frailty was commonly described as physical, visible, inevitable, and fixed; ( 2 ) discussing frailty: the value of knowing what to expect with frailty, and frailty as a difficult topic to discuss; ( 3 ) frailty assessment and management: skepticism from patients and caregivers that frailty is measurable; support from clinicians for a systematic approach to identifying frailty but a lack of knowledge on multidisciplinary roles and potential interventions. For all groups, having actionable solutions after identifying frailty was key for acceptability and successful implementation. Conclusions: Education on the nature and potentially modifiable aspects of frailty as well as the scope and potential benefits of frailty interventions is necessary for successful implementation of frailty detection and management in kidney care.

Background: Assisted peritoneal dialysis (PD), where trained health care providers assist individuals with PD in their home, allows individuals, who would otherwise be ineligible, to pursue home dialysis. Alberta Kidney Care South started an assisted PD program in 2011 using licensed practical nurses (LPNs) and switched to health care aids (HCA) July 2018. Methods: A retrospective chart review to describe characteristics of assisted PD patients and their outcomes for each of the models of health care. The primary outcome was the duration of assisted PD from initiation to exit. Secondary outcomes included reasons for exit and the proportion of patients who performed independent PD. Results: A total of 135 patients received assisted PD, mean age 70.7 ± 11.2 years and 44.4% (60/135) women. The average time to exit from assisted PD was 366.2 ± 378.1 days. There was no difference between time in PD between LPN (1.89 [1.02, 3.85] years) and HCA (2.09 [0.89, 3.26] years), p = 0.98. Main reasons for exit from assisted PD included death 30.4% (41/135) and switching to hemodialysis 26.7% (36/135). Total of 29 patients (21.5%) continued PD independently for an additional 495 ± 399 days. There was no difference in reasons for exit, p = 0.90 or peritonitis rates between the two care models, p = 0.60. Conclusion: Assisted PD allows patients to maintain independence in the community and facilitates the uptake of independent PD in a significant proportion. Utilizing an HCA model offers a cost-effective alternative while still providing high-quality care.

Exercise and physical activity have been shown to improve health outcomes among people receiving peritoneal dialysis (PD), however, little is known about PD clinicians’ perceptions and practices regarding exercise counselling. To inform exercise program design and implementation, we distributed a cross-sectional online questionnaire to PD clinicians between July and December 2021 through professional nephrology societies and networks. As part of this survey, participants were asked, “What are the most important aspects you would like to see incorporated in an exercise program for PD patients?” Six hundred and nine respondents provided 1249 unique perspectives. Responses were coded using summative content analysis and grouped into themes. The overarching theme identified was the need for individualized and accessible programming. Under this umbrella, the four main sub-themes identified were: promotion of specific exercises, overcoming common barriers to exercise, perceived cornerstones of exercise prescriptions, and program design to address patient-relevant outcomes. Overall, PD clinicians believed that PD does not preclude exercise participation and recognized the potential for exercise to improve physical, mental, and social well-being. The involvement of exercise professionals was valued in PD clinical programs. However, additional education for practitioners and patients regarding safety and the benefits of exercise is required to assist in widespread implementation and acceptance of exercise programming in the PD population.

Introduction: There is little evidence on the ideal frequency of routine blood work in maintenance dialysis patients to manage complications, including anemia, mineral bone disease (MBD), and hyperkalemia. Recent quality improvement studies from Ontario showed no negative impacts when decreasing the frequency from monthly to every 6 weeks in conventional in-center hemodialysis (ICHD) patients. In December 2020, Alberta Kidney Care–South (AKC-S) reduced the frequency of routine blood work from every 6 weeks to every 8 weeks for ICHD patients. Objective: We aimed to assess the impact of reducing blood work frequency on patient outcomes. Methods: We compared prevalent AKC-S ICHD patients in 2 cohorts: (1) retrospective control (October 31, 2019-October 31, 2020) and (2) prospective intervention (December 1, 2020-December 1, 2021). Primary outcomes were true frequency of routine blood work, odds of patients being within target for anemia and MBD, and proportion of lab values of hyperkalemia. Furthermore, we compared hospitalizations and mortality. Results: A total of 972 patients in Calgary’s ICHD program were included, 787 in each period (with 602 patients overlapping both cohorts). The frequency of routine blood work decreased from every 39.5 days in the control period to every 54.2 days in the intervention period ( P < .01). There was a reduction in the odds of phosphate values in targets ( P = .02), and an increase in the odds of labs with hyperkalemia (>6.0 mmol/L) during the intervention period ( P = .01). There was no significant change in the odds of being within the accepted targets during the intervention period compared with the control period for hemoglobin, Tsat, calcium, or parathyroid hormone (PTH). Fewer patients were hospitalized during the intervention period and the risk of death decreased as well, although additional factors such as the COVID-19 pandemic may have affected this. A cost-savings of $32 962 occurred from the reduced anemia and MBD blood work during the intervention period. Conclusions: When ICHD units in Calgary reduced routine blood work frequency from every 6 weeks to 8 weeks, there were no negative impacts on hospitalizations or deaths. A slightly lower proportion of phosphate values were within target, and a 0.7% increase in potassium values greater than 6 mmol/L was demonstrated. Our study suggests that blood work frequency in ICHD dialysis patients may be further reduced to every 8 weeks safely. Ultimately, additional pragmatic trials are needed to identify the optimal frequency of routine blood work.

Background: Low physical activity and functional impairment are prevalent and unaddressed in people receiving peritoneal dialysis (PD). Exercise has been shown to improve physical function and mental health for people with kidney disease. Methods: Cross-sectional descriptive survey aimed at identifying the exercise and physical activity perceptions and practice patterns of people receiving PD. The survey was developed and pretested with persons living with kidney disease, PD clinicians and exercise specialists. Results: There were 108 respondents (people receiving PD) with the majority from Canada (68%) and the United Kingdom (25%). Seventy-one per cent were engaged in physical activity two or more times per week. Most (91.8%) believed that physical activity is beneficial, and 61.7% reported healthcare provider discussion about physical activity. Perceptions regarding weightlifting restrictions varied: 76% were told not to lift weight with a maximum amount ranging from 2 kg to 45 kg. Few (28%) were instructed to drain PD fluid prior to physical activity. Mixed advice regarding swimming ability was common (44% were told they could swim and 44% were told they should not). Conclusions: Knowledge gaps suggest that education for both healthcare providers and patients is needed regarding the practice of exercise for people living with PD. Common areas of confusion include the maximum weight a person should lift, whether exercise was safe with or without intrabdominal PD fluid in situ and whether swimming is allowed. Further research is needed to provide patients with evidence-based recommendations rather than defaulting to restricting activity.

Background: Modality transitions represent a period of significant change that can impact health related quality of life (HRQoL). We explored the HRQoL of adults transitioning to new or different dialysis modalities. Methods: We recruited eligible adults (≥ 18) transitioning to dialysis from pre-dialysis or undertaking a dialysis modality change between July and September 2017. Nineteen participants (9 incident and 10 prevalent dialysis patients) completed the KDQOL-36 survey at time of transition and three months later. Fifteen participants undertook a semi-structured interview at three months. Qualitative data were thematically analyzed. Results: Four themes and five sub-themes were identified: adapting to new circumstances (tackling change, accepting change), adjusting together, trading off, and challenges of chronicity (the impact of dialysis, living with a complex disease, planning with uncertainty). From the first day of dialysis treatment to the third month on a new dialysis therapy, all five HRQoL domains from the KDQOL-36 (symptoms, effects, burden, overall PCS, and overall MCS) improved in our sample (i.e., those who remained on the modality). Conclusions: Dialysis transitions negatively impact the HRQoL of people with kidney disease in various ways. Future work should focus on how to best support people during this time.

Background: There is wide heterogeneity in physical function tests available for clinical and research use, hindering our ability to synthesize evidence. The aim of this review was to identify and evaluate physical function measures that could be recommended for standardized use in chronic kidney disease (CKD). Methods: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, Scopus and Web of Science were searched from inception to March 2022, identifying studies that evaluated a clinimetric property (validity, reliability, measurement error and/or responsiveness) of an objectively measured performance-based physical function outcomes using the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) methodology and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) based recommendations. Studies with individuals of all ages and of any stage of CKD were included. Results: In total, 50 studies with 21 315 participants were included. Clinimetric properties were reported for 22 different physical function tests. The short physical performance battery (SPPB), Timed-up-and-go (TUG) test and Sit-to-stand tests (STS-5 and STS-60) had favorable properties to support their use in CKD and should be integrated into routine use. However, the majority of studies were conducted in the hemodialysis population, and very few provided information regarding validity or reliability. Conclusion: The SPPB demonstrated the highest quality of evidence for reliability, measurement error and construct validity amongst transplant, CKD and dialysis patients. This review is an important step towards standardizing a core outcome set of tools to measure physical function in research and clinical settings for the CKD population.