Increasing the uptake of exercise programs in the dialysis unit: A protocol for a realist synthesis

Background: For people with end-stage kidney disease on hemodialysis, exercise during the dialysis treatment ( intradialytic exercise ) may promote exercise adherence and enhance aspects of the dialysis treatment. However, intradialytic exercise programs are complex and how to adapt program components to local context so that the program is more likely to attain its intended health outcomes have not been well described. To increase the uptake of exercise in clinical practice, more evidence is needed on how contextual factors influence the program’s impact. Methods: Using the realist approach, we aim to understand how the processes and structures of intradialytic exercise programs work to influence patient participation according to different contextual factors. The focus of a realist review is explanatory and aims to develop and test theory on how contextual factors trigger specific processes or behaviors ( or “mechanisms” ) to produce outcomes. Using the realist context-mechanism-outcome configuration of theory development, we will use a range of sources to develop initial candidate theories: a scoping review of published papers and the gray literature, and discussion with stakeholders. To provide a theoretical basis for how contextual factors could work to influence patient participation in intradialytic exercise ( IDE ), several of our preliminary theories will be based on dominant theories of exercise adherence and behavior change. To support or refute these initial theories, we will synthesize data from a systematic literature review and semi-structured interviews with intradialytic exercise program stakeholders, sampled from a range of programs worldwide. Discussion: The complexity of intradialytic exercise programs poses challenges to their implementation. Using the “context, mechanism, outcome” approach, the knowledge gained from this study will be used to develop general recommendations for renal care providers and administration on how to adapt components of an intradialytic exercise programs according to different contextual factors in order to promote patient participation. Systematic review registration: PROSPERO CRD4201603333

Statin Use and Survival After Acute Kidney Injury

IntroductionThe incidence of acute kidney injury (AKI) in hospitalized patients is rising, and survivors are at high risk for cardiovascular events and mortality. Effective strategies that improve long-term outcomes of AKI are unknown.MethodsA retrospective cohort study was performed between 2008 and 2011. All subjects were followed until 31 March 2013, with a minimum follow-up of 2 years. Participants were adults 18 years of age or older, who developed AKI during a hospitalization and had chronic kidney disease (CKD) following discharge (n = 19,707 mean age 69.9 years, mean postdischarge estimated glomerular filtration rate (eGFR) 43.0 ml/min/1.73 m2). Exposure to statins was examined prior to the index hospitalization as well as within 2 years following hospital discharge. The primary outcome was mortality; secondary outcomes included all-cause re-hospitalization and cardiovascular events.ResultsWithin 2 years of discharge, only 38.3% of the participants were prescribed a statin. After adjustment for comorbidities, statin use prior to admission, demographics, baseline kidney function, and a number of other factors, statin use was associated with lower mortality (hazard ratio, 0.74; 95% confidence interval, 0.69, 0.79) in AKI survivors with CKD. Patients who received a statin also had a lower risk of all cause rehospitalization (adjusted hazarad ratio, 0.90; 95% confidence interval, 0.85, 0.94). Statin use was not associated with a reduction in cardiovascular events.DiscussionAmong AKI survivors with CKD, statin use was associated with a lower risk of mortality and rehospitalization rates. This finding suggests that there is an opportunity to improve postdischarge care in AKI survivors

The effects of nocturnal hemodialysis compared to conventional hemodialysis on change in left ventricular mass: Rationale and study design of a randomized controlled pilot study

BACKGROUND: Nocturnal hemodialysis (NHD) is an alternative to conventional three times per week hemodialysis (CvHD) and has been reported to improve several health outcomes. To date, no randomized controlled trial (RCT) has compared NHD and CvHD. We have undertaken a multi-center RCT in hemodialysis patients comparing the effect of NHD to CvHD on left ventricular (LV) mass, as measured by cardiac magnetic resonance imaging (cMR). METHODOLOGY/DESIGN: All patients in Alberta, Canada, expressing an interest in performing NHD are eligible for the study. Patients enrolled in the study will be randomized to either NHD or CvHD for a six month period. All patients will have a full clinical assessment, including collection of biochemical and cMR data at baseline and at 6 months. Both groups of patients will be monitored biweekly to optimize blood pressure (BP) to a goal of <130/80 mmHg post-dialysis using a predefined BP management protocol. The primary outcome is change in LV mass, a surrogate marker for cardiac mortality, measured at baseline and 6 months. The high sensitivity and reproducibility of cMR facilitates reduction of the required sample size and the time needed between measures compared with echocardiography. Secondary outcomes include BP control, anemia, mineral metabolism, health-related quality of life, and costs. DISCUSSION: To our knowledge, this study will be the first RCT evaluating health outcomes in NHD. The impact of NHD on LV mass represents a clinically important outcome which will further elucidate the potential benefits of NHD and guide future clinical endpoint studies

The impact of nocturnal hemodialysis on sexual function

BACKGROUND: Sexual dysfunction is common in patients with end stage renal disease (ESRD) and treatment options are limited. Observational studies suggest that nocturnal hemodialysis may improve sexual function. We compared sexual activity and responses to sexual related questions in the Kidney Disease Quality of Life Short Form questionnaire among patients randomized to frequent nocturnal or thrice weekly conventional hemodialysis. METHODS: We performed a secondary analysis of data from an RCT which enrolled 51 patients comparing frequent nocturnal and conventional thrice weekly hemodialysis. Sexual activity and responses to sexual related questions were assessed at baseline and six months using relevant questions from the Kidney Disease Quality of Life Short Form questionnaire. RESULTS: Overall, there was no difference in sexual activity, or the extent to which people were bothered by the impact of kidney disease on their sex life between the two groups between randomization and 6 months. However, women and patients age < 60 who were randomized to frequent nocturnal hemodialysis were less bothered by the impact of kidney disease on their sex life at 6 months, compared with patients allocated to conventional hemodialysis (p = 0.005 and p = 0.024 respectively). CONCLUSIONS: Our results suggest that frequent nocturnal hemodialysis is not associated with an improvement in sexual activity in all patients but might have an effect on the burden of kidney disease on sex life in women and patients less than 60 years of age. The validity of these subgroup findings require confirmation in future RCTs

Patient and allograft survival of Indo Asian and East Asian dialysis patients treated in Canada

Kidney failure is relatively common among Canadians of Asian origin. However, little is known about the health outcomes after initiation of renal replacement therapy in this population. Our study evaluates differences in the likelihood of renal transplantation and graft loss among Asian and white patients. We studied 21 523 adults of East Asian, Indo Asian or white ethnicity who had initiated dialysis in Canada from 1990–2000. Subjects were followed until death, loss to follow-up or end of study (2004). The proportion of the eligible subjects who were East Asian, Indo Asian, or white was 6, 3, and 91%, respectively. Compared to white patients, East Asian and Indo Asian patients were significantly less likely to receive a renal transplant after adjusting for potential confounding factors. This disparity is greater for transplants from living donors as compared to those from deceased donors. The adjusted death censored graft loss in transplant recipients was not significantly different between ethnic groups. The adjusted risk of death following transplantation, however, was significantly lower in Indo Asian than in white patients. Our findings show that in a Canadian population, patients of East Asian or Indo Asian origin had lower rates of renal transplantation than white patients, especially for living donor transplantation. These findings warrant further study, especially given the good graft outcomes in these individuals

Population based screening for chronic kidney disease: cost effectiveness study

Objective To determine the cost effectiveness of one-off population based screening for chronic kidney disease based on estimated glomerular filtration rate

Correction to:Methods for identifying 30 chronic conditions: application to administrative data

Following publication of the original manuscript [1], the authors noted several errors in Table 1. Details of the requested corrections are shown below

Reimbursing Live Organ Donors for Incurred Non-Medical Expenses: A Global Perspective on Policies and Programs

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75502/1/j.1600-6143.2009.02829.x.pd