Pietro Ravani

Background: An underappreciated complication of laparoscopic nephrectomy in male living kidney donors is testicular pain, swelling, and hydrocele development. A recent cohort study in Ontario, Canada, found that male donors had a higher rate of hydrocelectomy (7.7 vs. 0.1 events/1000 person-years) and scrotal ultrasounds (25.6 vs. 6.9 events/1000 person-years) than nondonors, when followed for a median of 9 years. Objective: To conduct a replication study in Alberta, Canada, examining the long-term risk of hydrocelectomy after laparoscopic living donor nephrectomy, comparing male donors to nondonors from the general population matched on baseline health indicators. Design: Population-based matched cohort study using linked healthcare databases. Setting: Alberta, Canada (April 1, 2002, to March 31, 2021). Patients: We matched 115 male kidney donors who underwent a laparoscopic nephrectomy with 1150 nondonors. The matching characteristics were age at cohort entry, date of cohort entry, rural residence, income, prior vasectomy, and prior inguinal hernia repair. Measure: ments: The primary outcome was a hydrocelectomy, and the secondary outcome was receipt of a scrotal ultrasound. Methods: Males were followed for a median of eight years, with a maximum follow-up of 19 years. Results: The rate of hydrocelectomy was higher in donors than in nondonors (3 of 115 [2.6%] vs. 1 of 1150 [0.1%]; 3.3 vs. 0.1 events/1000 person-years; P < 0.001). The rate of scrotal ultrasounds was also higher among donors than among nondonors (23.4 vs. 7.5 events/1000 person-years; P < 0.001). Limitations: A low event rate impeded a precise estimation of the risk of hydrocelectomy attributable to donation. Conclusions: In this population-based cohort study from Alberta, Canada, rates of hydrocelectomy and receipt of a scrotal ultrasound were significantly higher in males who underwent laparoscopic living donor nephrectomy than in male nondonors matched for age and other factors. Males considering living kidney donation should be informed of the risk of developing a symptomatic ipsilateral scrotal hydrocele in the years following laparoscopic nephrectomy.

Background: 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.

Key Points: People with CKD are at high risk of unplanned readmission and death due to multimorbidity and health care complexity. Lower eGFR is strongly associated with 30-day unplanned readmission or death, with congestive heart failure as the most common cause. Targeted, risk-based discharge strategies are needed to reduce readmissions and improve outcomes in CKD populations. Background: People with CKD have higher risk of repeated hospitalization and mortality than the general population. Given many unplanned readmissions may be avoidable, examining risks and reasons for readmission across CKD categories may inform targeted interventions and safer discharge planning. Thus, we estimated the association between eGFR and both readmission and mortality and identified diagnoses for readmission. Methods: Adults discharged from hospitals in Alberta, Canada, from 2005 to 2021 were included. Preadmission eGFR was categorized into eight groups (in ml/min per 1.73 m ² ): ≥60 (G1–2), 45–59 (G3a), 30–44 (G3b), 15–29 (G4), <15 not on dialysis (G5ND), on dialysis (G5D), prevalent kidney transplant recipients (G1T–5T), and unknown. The primary outcome was unplanned readmission or death within 30 days of discharge. Multivariable logistic regression, accounting for multiple admissions per participant, was used to estimate unadjusted and adjusted odds ratios (aOR) of the primary outcome, using G1–2 as the reference. The results were stratified by age and sex. The type and frequency of each unplanned readmission was also determined. Results: The cohort comprised 2,992,810 admissions among 1,249,248 participants (median [interquartile range] admission per participant: 1 [1–3] admission; age: 61 [47–74] years). Among lower eGFR categories, heart failure was the most common readmission diagnosis, followed by AKI. Relative to G1–2, more impaired eGFR groups had significantly higher odds of the primary outcome, with the highest adjusted odds experienced by the G1T–5T group (aOR, 1.47; 95% confidence interval, 1.12 to 1.93) and G5ND group (aOR, 1.40; 95% confidence interval, 1.34 to 1.47). Stratified analyses showed that individuals younger than 65 years and females with reduced eGFR had higher odds compared with counterparts in the G1–2 reference group. Conclusions: People with severe CKD had the highest risk of hospital readmission, suggesting the need to test interventions in this group to target volume and hemodynamic related readmissions such as postdischarge AKI and heart failure.

IntroductionChronic diseases are linked to high rates of hospitalization and mortality, which disproportionately affect populations experiencing social disadvantage. Social determinants of health are also known as equity-stratifying variables and can be categorized using the PROGRESS-Plus framework (e.g., social capital, race/ethnicity, occupation, etc.). The accuracy and applicability of case definitions to identify these variables from administrative and clinical health data is unknown.ObjectiveWe conducted a systematic review to explore how equity-stratifying variables, as categorized by the PROGRESS-Plus framework, have been defined and validated in epidemiologic studies using administrative health, population-level, or electronic health record (EHR) data.MethodsMedline, EMBASE, CINAHL, Web of Science, and Google Scholar were searched from the inception of the databases to 2024 for validation studies of equity-stratifying variables in adults using administrative health datasets, health registries, or EHR data. Titles and abstracts, followed by relevant full-text articles, were screened in duplicate by two reviewers for eligibility. The data sources utilized, algorithms employed, and their associated performance measures were extracted and synthesized from included studies. Given substantial heterogeneity in study design, equity-stratifying variable definition, and performance metrics, meta-analysis was not possible.ResultsOf the 9099 unique citations screened, 201 full texts were reviewed and 116 were included in this review. Most studies were validation studies of race/ethnicity definitions that used race/ethnicity codes or surname list algorithms. No studies examined religion. Regarding the performance measures of these algorithms, the race/ethnicity/culture/language equity-stratifying variables category had the largest variability across sensitivity, positive predictive value (PPV), and Cohen’s Kappa. Occupation validation studies had the lowest variation in sensitivity and PPV.ConclusionDespite an increasing number of publications reporting on the validation of equity-stratifying variables relevant to the PROGRESS-PLUS framework, performance measures varied widely across studies. The significant heterogeneity in equity-stratifying variable definitions and methods used to validate them support the need for further rigorous validation of equity stratifying variables in administrative and clinical health data.

Background: Current guidelines recommend that living kidney donors should avoid non-steroidal anti-inflammatory drugs due to their potential nephrotoxic effects. It is unclear if physicians are adhering to this recommendation. Objective: Our aim was to determine the proportion of living kidney donors that filled a non-steroidal anti-inflammatory drug prescription post-donation and the proportion with measurement of kidney function post-prescription. Design: We conducted a population-based, retrospective cohort study. Setting: We identified kidney donors in Alberta, Canada that had accessed the healthcare system in the outpatient, emergency department, or inpatient setting. Patients: Adult living kidney donors in Alberta, Canada who donated between 2002 and 2019. Measurements: We measured the number of non-steroidal anti-inflammatory drug prescriptions, type of prescribing physician, and evidence of post-prescription measurement of creatinine and potassium. Methods: We identified the proportion of donors who filled a non-steroidal anti-inflammatory drug prescription at least 1 year post-donation. We also assessed how many donors underwent laboratory testing for kidney function and potassium within 14 days following the first prescription. Results: Of the 759 living kidney donors included in our study, 273 (36%) had at least one non-steroidal anti-inflammatory drug prescription over a median follow-up of 7.2 years (interquartile range 3.5-11.5). The proportion of donors with at least one prescription in follow-up remained stable over time (~10% per year). Family physicians accounted for 66% of all non-steroidal anti-inflammatory drug prescriptions. Approximately, 10% of donors had measurements of serum creatinine or potassium post-prescription. Limitations: This study was limited by the inability to capture over-the-counter non-steroidal anti-inflammatory drug use, indication for the prescriptions, and indication for bloodwork being completed in the post-prescription period. Conclusions: Over one-third of living kidney donors are prescribed non-steroidal anti-inflammatory drugs despite current guideline recommendations, with only a minority undergoing post-prescription laboratory testing. Further research assessing outcomes following non-steroidal anti-inflammatory drug use is recommended to better inform optimal pain-management strategies for living kidney donors.

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 m ² (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.