Stephanie Thompson

Background: Microvascular dysfunction contributes to PAD progression, and its detection may facilitate earlier recognition and risk stratification. People with advanced chronic kidney disease (CKD) have a high burden of PAD, yet early detection is limited by disease‐related changes, such as medial calcification. Near‐infrared spectroscopy (NIRS) is a candidate microvascular tool for early PAD detection, but its feasibility in CKD is unknown. Purpose: To evaluate NIRS feasibility for assessing lower limb microvascular function in participants with CKD Stage 5 (dialysis and non‐dialysis) versus controls. Methods: Using an ischaemic challenge, lower limb reperfusion kinetics of the tibialis anterior were assessed by NIRS in CKD participants and controls. Feasibility was defined as acceptability, technical limitations, interpretability, and safety; a priori analyses examined associations between participant characteristics and feasibility within CKD. NIRS indices were compared with brachial and popliteal hyperaemic velocity–time integral (VTI). Results: Thirty‐eight CKD and 20 controls were included. Among CKD participants, 79% of tests were acceptable versus 100% of controls, linked to higher ankle systolic blood pressure and BMI. Interpretability was reduced in 39% of CKD tests, unrelated to these characteristics. Popliteal VTI correlated moderately with NIRS reperfusion time from nadir to baseline ( r = −0.64) and hyperemic AUC ( r = 0.63); brachial VTI did not. Conclusions: NIRS was feasible when tolerated, but acceptability and interpretability limited its use in advanced CKD. Acceptability, but not interpretability, was limited by markers of vascular severity consistent with a calcified, poorly compressible vasculature. Moderate correlations with popliteal VTI support the potential utility of NIRS in this population.

Purpose of Program: People receiving dialysis experience a high burden of mental health challenges. Few dialysis-specific resources exist to support their mental well-being. The Can-SOLVE CKD Network ‘Mind the Gap’ project team identified mental health care challenges for the dialysis population and explored strategies to integrate relevant support and resources into practice. Sources of Information: Candidate interventions were a Dialectical Behavioural Therapy (DBT) Skills Training program implemented for people receiving hemodialysis in Manitoba and a provincial pathway for mental health care for people receiving all dialysis modalities at a system-level in Alberta. For this reason, we refer to both hemodialysis and dialysis in this report. Methods: Mind the Gap’s two interventions were identified after input from diverse interest-holders including people with lived dialysis experience, their caregivers, and kidney and mental health care providers and leaders. Emphasis was placed on patient engagement, Equity, Diversity, Inclusion and Accessibility (EDI-A), and Indigenous cultural safety. The Knowledge to Action Framework informed implementation. Key Findings: Looking across both interventions, at the person-level, barriers included stigma around asking about and accessing mental health resources, and the perspective that mental health care does not belong in dialysis care. To empower people on dialysis to advocate for their mental health needs, we developed resource lists of freely accessible, online mental health supports for Canadians receiving dialysis. From the DBT project, Indigenous patients and patient partners were more engaged when the Mind the Gap Indigenous Research Coordinator was involved in team interactions. At the healthcare provider-level, the importance of mental health care in dialysis populations was recognized but there was uncertainty as to who was responsible to address this. Champions in various roles, including patient partners, healthcare providers, and leaders, have been a constant strategic facilitator. Intervention-level facilitators for DBT included holding DBT sessions at a location away from the hemodialysis unit and obtaining funding for allied healthcare providers to complete DBT Skills training. Intervention-level facilitators for the provincial pathway for mental health care for people receiving dialysis included engaging hundreds of knowledge users in its development. At both the intervention and system-levels, barriers included the impact of interventions on clinical care resources or workflow and high turnover of program leadership. Limitations: Our work reflects the perspectives of interest-holders in two Canadian provinces. Transferability of findings about mental healthcare challenges, available supports, and interventions to diverse dialysis populations across Canadian contexts requires further investigation. Conclusion: All interest-holders expressed a compelling call to attend to mental health support needs in dialysis patients. The process involves numerous challenges, including stigma associated with people receiving dialysis accessing and healthcare providers engagement in mental health supports, time constraints, lack of relevant training among dialysis staff, and inflexible, siloed structures within healthcare systems. Blending mental health care with dialysis care is culturally novel and an important step to meaningfully support the emotional and mental well-being of people on dialysis.

Background: Anxiety, depression, and fatigue affect >50% of adults across a range of chronic medical conditions, leading to reductions in quality of life. Digital symptom management interventions may address this burden, but clinical trial evidence across diverse conditions is limited, and the added value of human support remains uncertain. This study aimed to determine whether a multicomponent digital intervention, delivered with or without human support, reduces anxiety and depression compared with usual care at 12 weeks in adults with chronic medical conditions, and whether human-supported delivery outperforms self-directed delivery. Methods and findings: A three-arm parallel-group open-label randomized controlled trial was conducted from February 2023 to December 2024, with online recruitment and delivery across 13 countries. 825 adults (≥18 years) with self-reported chronic medical conditions and internet access were allocated by computer-generated stratified block randomization (1:1:1) to: (i) waitlist control ( n = 274); (ii) eMPower, a self-directed digital program integrating video-guided movement, breathwork, and meditation practices, a psychology-based coping skills curriculum, and disease education ( n = 275); or (iii) eMPower + human support consisting of weekly telephone check-ins (≤15 min) from trained nonclinicians ( n = 276). The primary outcome was change in Hospital Anxiety and Depression Scale (HADS) total score from baseline to 12 weeks in the eMPower + human support arm compared with the control arm, adjusted for baseline score, chronic condition type, age, and sex. Secondary outcomes included HADS anxiety and depression subscales, fatigue (Modified Fatigue Impact Scale [MFIS]), and health-related quality of life (Short Form-12 [SF-12] mental and physical component scores and EQ-5D-5L index score). Twelve-week assessments were completed by 695 participants (84.2%). Primary outcome data were available for 222 participants in the eMPower + human support arm, 214 in the self-directed eMPower arm, and 259 in the control arm. Analyses followed the intention-to-treat principle. In the prespecified primary comparison, eMPower + human support improved HADS total score by 2.9 points (95% CI [2.0, 3.8]; p < 0.001). In prespecified exploratory analyses, the self-directed eMPower arm also significantly improved HADS total score, compared with control (mean difference 2.6 points; 95% CI [1.8, 3.5]; p < 0.001). No significant differences were observed between intervention arms for any outcome (all p > 0.05). Both intervention arms were associated with improvements across prespecified secondary outcomes compared with control. No intervention-related adverse events were reported in any arm. Key limitations include the use of a waitlist control design, which does not control for nonspecific intervention effects; reliance on self-reported diagnoses for most participants; the 12-week follow-up period; and a predominantly female and highly educated sample, which may limit generalizability. Additional registered process-oriented secondary outcomes and exploratory outcomes will be reported in companion publications. Conclusions: A multicomponent digital intervention with human support significantly reduced anxiety and depression symptoms compared with usual care in adults with chronic medical conditions. Comparable effects between self-directed and human-supported delivery in exploratory analyses highlight potential for scalable, low-resource implementation. Longer-term follow-up and cost-effectiveness analyses are warranted. Trial registration: ClinicalTrials.gov: NCT05786482.

Background: People with hearing loss may have difficulty communicating with health care providers if not properly supported. Hearing loss is common among people with kidney failure. Outpatient hemodialysis centers may present communication barriers due to noisy machines and overlapping conversations. Tools, such as assistive listening devices, exist to help people with hearing loss communicate. If and how they should be used in the outpatient hemodialysis setting is unclear. Understanding the patient perspective is an important first step before implementing such solutions. Objective: Describe the communication-related experiences of patients with hearing loss when conversing with health care providers during hemodialysis treatment, focusing on perceptions about communication tools. Design: Qualitative descriptive. Setting: Outpatient hemodialysis centers in Calgary and Edmonton, Alberta, Canada. Participants: Adults with kidney failure receiving maintenance hemodialysis with self-reported hearing loss. Methods: Semi-structured individual interviews. Interviews were audio-recorded, transcribed, and abductively coded using a validated communication framework, a strategy to guide communication access in practice, and participants’ experiences. Results: Fourteen patients participated between October 2023 and January 2024. Patient perceptions about communication tools varied. We identified three themes that describe these differences: (1) communication tools may be needed in transitional or clinically complex situations, (2) patients with their own resources may rely less on center-provided tools, and (3) awareness and self-advocacy for support varies across patients. Limitations: The major limitation of this study is the lack of representation from patients with language barriers and those belonging to the Deaf community or with overlooked hearing difficulties. Consequently, results may not be transferable to all patients with hearing loss in Alberta or elsewhere. Conclusions: Communication support needs are both person-specific and context-dependent, varying across and within patients. Not all patients that may benefit from communication tools will be comfortable asking or accepting help. Clinicians should routinely check in with patients about their communication needs and offer a variety of tools to accommodate as needed.

Purpose of review: Cardiovascular disease (CVD) accounts for nearly half of deaths among people receiving maintenance hemodialysis. Observational and interventional data suggest that higher serum magnesium, achieved through higher dialysate magnesium concentrations or oral supplementation, may improve cardiovascular outcomes and survival. This review synthesizes current evidence and provides context for an ongoing cluster-randomized trial that is testing whether a center-wide dialysate magnesium concentration of 0.75 mmol/L, versus ≤0.50 mmol/L, delivered as a policy and sustained for up to four years, reduces the risk of major cardiovascular-related hospitalizations. Sources of information: Peer-reviewed articles. Methods: We searched MEDLINE and EMBASE for observational and interventional studies evaluating serum or dialysate magnesium concentrations and cardiovascular outcomes in patients with chronic kidney disease and/or kidney failure. We appraised the methodological quality of interventional trials. This review is divided into four sections: (1) epidemiological associations between serum magnesium concentrations and CVD outcomes, (2) the impact of a higher concentration of dialysate magnesium on CVD outcomes, (3) the impact of oral magnesium supplementation on CVD outcomes, and (4) ongoing trials. Key findings: Twenty studies, including 10 randomized controlled trials, were reviewed. Systematic reviews and meta-analyses show that hypomagnesemia is associated with higher risks of cardiovascular events and all-cause mortality in hemodialysis. Interventional studies indicate that higher dialysate magnesium concentrations or oral supplementation can improve surrogate markers of vascular health, including less vascular calcification and stiffness. Higher dialysate concentrations may also lower cardiovascular mortality. Given encouraging but predominantly surrogate-based evidence, adequately powered randomized trials are warranted. Limitations: Most trials were small, single-center, and of short duration. They relied on surrogate endpoints, and there was heterogeneity in interventions and outcome measures.

Higher pulmonary microvascular function may contribute to higher rest and exercise diffusing capacity (DL _CO ), pulmonary capillary blood volume (V _C ) and membrane diffusing capacity (D _M ) in trained individuals. We hypothesized that pulmonary vasodilatation with sildenafil would increase resting and exercise DL _CO , V _C and D _M in untrained (UT) individuals, whereas trained (T) individuals would have a smaller response. This double‐blind randomized crossover trial recruited n = 24 healthy participants (nine females) into UT and T groups ( n = 12 each) based on (mean ± SD = 37.5 ± 3.8 and 65.3 ± 6.7 mL ^. kg ^{−1 .} min ⁻¹ , respectively). Rest and exercise DL _CO (cycle ergometry; 60 W, 30%, 60% and 90% of ) was measured following oral sildenafil (50 mg) or placebo (block randomized) and evaluated using one‐way ANOVA and linear mixed effects modelling. At rest, right ventricular systolic pressure was reduced with sildenafil across groups (mean ∆ = −2.1 mmHg; P = 0.01), indicating effective pulmonary vasodilatation. No group, drug or drug by group interaction effect was detected in resting DL _CO , V _C or D _M (all P _group > 0.058). T had higher exercise DL _CO during all workloads (all P _group < 0.031) and higher V _C in relative workloads ( P _group = 0.006). Sildenafil did not impact exercise DL _CO , V _C or D _M at any workload (all P _drug > 0.395), with no significant drug by group interaction (all P _interaction > 0.086). As sildenafil did not impact rest or exercise DL _CO , V _C or D _M in either group, there was no evidence that improved nitric oxide‐mediated pulmonary vasodilatory function would explain the greater DL _CO observed in trained individuals. image Key points: Higher pulmonary vascular function may explain why trained individuals have higher pulmonary diffusing capacity for carbon monoxide (DL _CO ) compared to untrained individuals. This double‐blind randomized crossover trial investigated whether pulmonary vasodilatation with sildenafil would elucidate changes in resting and exercise DL _CO within trained and untrained groups. Trained individuals had higher DL _CO , but sildenafil did not elicit alterations in DL _CO in either group. Our findings suggest that improved nitric oxide‐mediated pulmonary vasodilatation is not likely the primary mechanism responsible for the greater DL _CO observed in trained individuals. Future work should investigate which mechanism(s) are responsible for the higher DL _CO in trained individuals.

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.

Introduction: People with hemodialysis-dependent kidney failure experience significantly higher cardiovascular (CV) morbidity, mortality, symptom burden, and cognitive impairment compared to the general population. Hemodialysis-induced ischemia contributes to myocardial stunning, which worsens CV outcomes. Intradialytic cycling has the potential to mitigate cardiac stunning, but its effects have not been assessed in randomized controlled trials (RCTs). Methods: This multicenter RCT evaluates the impact of 12 weeks of intradialytic cycling on hemodialysis-induced myocardial stunning. The study will recruit 160 adults (80 intervention and 80 control) receiving maintenance hemodialysis at five Canadian centers and one Australian center. Outcome assessments are conducted at baseline, 12 weeks, and 16 weeks. An intervention implementation process evaluation is part of this study. Outcomes: The primary outcome is change in number of regional wall motion abnormalities (RWMAs) at peak hemodialysis stress from baseline to 12 weeks. Secondary outcomes include changes in cognitive function, hemodialysis recovery time, and symptom burden. Statistical Analysis: Change in number of RWMAs at peak hemodialysis stress from baseline to 12 weeks are compared between study groups using an independent 2-tailed t test and using a Poisson generalized linear mixed model with study group as a fixed effect, and time and mean ultrafiltration rate as random effects. Conclusion: Compared with standard care, we anticipate that intradialytic cycling will decrease myocardial stunning, resulting in improved symptom burden, and functional and cognitive status. This trial provides critical evidence regarding the benefits and feasibility of exercise during hemodialysis, potentially informing clinical practice, and guidelines for hemodialysis care. Trial registration number: NCT04877041

Background: In individuals receiving hemodialysis, lower serum magnesium concentrations are associated with a higher risk of death and cardiovascular disease and more discomfort from muscle cramps. Small trials suggest that increasing serum magnesium by using a higher concentration of dialysate magnesium may be beneficial. This protocol outlines a large, randomized trial examining the effects of adopting a high versus low concentration of dialysate magnesium as a hemodialysis center-wide policy on the risk of mortality, major adverse cardiovascular events, and the burden of muscle cramps. Objective: To determine whether implementing a dialysate magnesium concentration of 0.75 mmol/L versus ≤ 0.5 mmol/L as a hemodialysis center-wide policy, for up to 4 years, affects (1) the rate of all-cause mortality or major cardiovascular-related hospitalizations or (2) the level of discomfort individuals experience from muscle cramps. Design: Pragmatic, 2-arm, parallel-group, registry-based, open-label, 2-sided superiority cluster randomized trial. Hemodialysis centers were randomly allocated (1:1) to one of the 2 arms. The assignment was constrained by five center-level prognostic factors and stratified by province. Setting: 137 hemodialysis centers in four Canadian provinces—Ontario, British Columbia, Alberta, and Manitoba. The trial period is from April 4, 2022, to March 31, 2026. Outcomes will be analyzed after March 31, 2026, using provincial health care databases and self-reported questionnaires. Participants: Individuals who received maintenance hemodialysis at participating centers during the trial period. Intervention: Use of a dialysate magnesium concentration of either 0.75 mmol/L or ≤ 0.5 mmol/L as a center-wide policy during the trial period. Measurements: The two primary outcomes are (1) a composite of all-cause mortality or major cardiovascular-related hospitalization (a hospital admission with myocardial infarction, congestive heart failure, or ischemic stroke) recorded in large health care databases and (2) self-reported muscle cramps collected from questionnaires. Methods: Using an intent-to-treat approach, the intervention effect on the instantaneous rate of the primary composite outcome will be analyzed using a stratified Cox proportional hazards model accounting for center-level clustering. The observation time will be censored for provincial emigration or the trial end date. Self-reported muscle cramps will be analyzed using a cumulative link (proportional odds) model. All models will be stratified by province and adjusted for the covariates used to constrain randomization. Limitations: The trial start date was delayed in some centers due to post-pandemic supply disruptions (including discontinued dialysate formulations); however, all centers secured dialysate concentrates in alignment with the trial-allocated magnesium level. Conclusions: The results of this pragmatic trial will inform center-wide policy on the optimal dialysate magnesium concentration for patient health. Trial Registration: www.clinicaltrials.gov ; identifier: NCT04079582

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.