Presenters:

Charlene Salmon, NP, Windsor Regional Hospital, Windsor ON

Learning Objectives:

• Discuss optimal therapies that prevent or slow the progression of kidney disease and the need for dialysis in patients with Type 2 Diabetes
• Review the safe integration of SGLTi inhibitors in appropriate patients in your practice
• Recognize the impact of homelessness and mental health issues as barriers to the delivery of care in patients who have T2DM and high renal/cardiac risk

Presenter:
Danielle E. Fox, RN, MN, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
Nancy Verdin, BScOT(ret), PaCER, patient partner, Patient and Community Engagement Research (PaCER) Program, O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada

Abstract

Authors:

Danielle E. Fox¹ , RN, MN

Nancy Verdin², BScOT(ret), PaCER, patient partner

David J. T. Campbell^1,3, MD, PhD, FRCPC

Kathryn King-Shier^1,4, RN, PhD, FESC

Pietro Ravani^1,3, MD, PhD, FRCPC

Robert R. Quinn^1,3, MD, PhD, FRCPC

¹Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

²Patient and Community Engagement Research (PaCER) Program, O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada

³Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

⁴Faculty of Nursing, University of Calgary, Calgary, AB, Canada

Purpose: As the prevalence of chronic kidney disease rises, many Canadians will progress to kidney failure and will start dialysis. Home dialysis is promoted in Canada as it is cost-effective compared to in-centre dialysis therapies. Home dialysis can be challenging as individuals must learn to perform a complex procedure while also managing other factors related to their kidney failure and its associated comorbidities. A person-centered approach to care is required to adequately support someone on home dialysis, as challenges will vary based on the unique characteristics and experiences of the individual. Unfortunately, little is known about how to effectively deliver person-centered home dialysis care.

Description: We performed a narrative review of the literature pertaining to person-centered care (PCC) and identified key components of delivering it in the context of home dialysis.

Evaluation: The dimensions of PCC varied between the theories and frameworks presented, but a multi-faceted approach was universally regarded as a foundational element. The integration of individual perspectives, values, and the needs of all stakeholders was integral to success but was often difficult to achieve due to a multitude of barriers. PCC in the context of home dialysis was not well-studied.

Implications: The implementation of person-centered home dialysis care may address many challenges faced by individuals on home dialysis and may be an important model of care for kidney programs. We plan to implement a collaborative research approach to understand and develop person-centered home dialysis care in Canada.

 

 

Presenters

Jarrin D. Penny, BSN, RN, CNeph(C), PhD Candidate^1,2 – Research Associate, Lilibeth Caberto Kidney Clinical Research Unit, London Health;  Sciences Centre, London, ON, Department of Medical Biophysics, Western University, London, ON

Abstract

Authors:

Jarrin D. Penny, BSN, RN, CNeph(C), PhD Candidate^1,2 – Research Associate

Patricia Jarosz, MMASc¹ – Clinical Research Coordinator

Christopher W. McIntyre, MD, PhD^1,2,3

¹Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON

²Department of Medical Biophysics, Western University, London, ON

³Department of Medicine – Division of Nephrology, London Health Sciences Centre, London, ON

Purpose:  Current hemodialysis (HD) treatments have limited ability to clear larger molecular weight uremic toxins. Retention is associated with increased symptom burden, low health-related quality of life (HR-QOL) and high mortality. Improved clearance, using novel medium cut-off dialyzers, known as expanded dialysis (HDx) may be associated with improved HR-QOL. The London Evaluation of Illness (LEVIL), a dynamic patient reported outcome measure instrument allows iterative recordings to understand overall burden of disease and assess the impact of therapy.

Methods: Initial study consisting of two-week observation (baseline with high flux membrane), followed by 12-weeks HDx therapy (Theranova-Baxter). HR-QOL was assessed using dynamic PROM LEVIL instrument thrice weekly.  Extension phase – two-week baseline with 24-weeks HDx and eight-week wash-out. Principal aim was to establish if HDx therapy was associated with changes in HR-QOL utilizing LEVIL.

Results: Patients with lower LEVIL scores (<70/100) at baseline showed improvement in overall HR-QOL after eight-weeks of therapy.  General wellbeing, energy and sleep quality were improved significantly as a consequence of HDx therapy.  There were no detrimental effects in patients with higher baseline HR-QOL.

Conclusion: Dynamic PROM assessment effectively identified patients with lower HR-QOL and higher symptom burden, demonstrating durable time/dose-dependent improvements across a range of symptom domains.

Implications for nephrology care:  Improving HR-QOL in the HD population is an essential priority from a patient experience perspective and as a surrogate for longer term outcomes.  Additionally, the ability to systematically identify patients that may benefit from therapy in a constrained healthcare system is paramount.

Presented by Dr Louis Girard

Objectives:

• Discuss the Importance of Assessing Renal Function and (Kidney) Damage; Discuss the KDGO Heat Map;
• Provide an Overview of the Evolution of CKD Management;
• Review SGLT2i therapy and the benefits to CKD patients, with or without T2DM;
• Discuss the role of other novel agents in the management of CKD with T2DM

Presented by Daniel Schwartz, Medical Director, Fraser Health Renal Program; Program Lead, Fraser Health Peritoneal Dialysis Program

Objectives:

• Understand the latest data regarding nephroprotection with RAAS inhibitors & SGLT2 inhibitors in patients with and without diabetes
• Recognize the indications for discontinuation & restarting of RAAS inhibitors & SGLT2 inhibitors in patients with CKD
• Risk stratification in CKD
• Review practical tips in managing your patients with CKD

Presenters:

Patty Quinan, MN, RN, CNeph(C), Vascular Access Coordinator, Humber River Hospital, Toronto, Ontario, Canada
Dr. Allan Yee, MD, FRCPC, Vascular/Interventional Radiologist, Humber River Hospital, Toronto, Ontario, Canada
Balraj Panesar, Data Integrity Analyst, Medical Imaging, Humber River Hospital, Toronto, Ontario, Canada

Abstract

Authors:
Patty Quinan, MN, RN, CNeph(C), Vascular Access Coordinator¹
Dr. Allan Yee, MD, FRCPC, Vascular/Interventional Radiologist¹
Balraj Panesar, Data Integrity Analyst, Medical Imaging¹

¹Humber River Hospital, Toronto, Ontario, Canada

Purpose of the project: Preservation of arteriovenous (AV) access is key to avoiding central venous catheter placement. Central venous catheters have been associated with complications such as infection, thrombosis and central vein stenosis which can limit future vascular access options. We describe percutaneous thrombolysis with overnight systemic thrombolysis to treat clotted AV accesses (fistulae and grafts).

Description: An environmental scan in Canada identified that the majority of nephrology programs perform a combination of percutaneous and surgical procedures, without overnight thrombolysis.
Our percutaneous treatment of thrombosed AV accesses includes duplex ultrasound to identify extent of thrombus; request inpatient bed; fistulogram and angioplasty with pharmacological and mechanical thrombolysis; overnight systemic thrombolysis (suitability determined by the interventional radiologist); and fistulogram with/without angioplasty the following day to determine patency.

Evaluation/Outcomes: Thrombolysis data from January 2015 to May 2021 (77 months) identified 128 cases (average 1.6 per month). Seven cases did not undergo a procedure (unsuitable/patient refusal) and were excluded from the data. Of the 121 cases remaining, 75 (65%) were successful; 29 (24%) underwent overnight systemic thrombolysis (22 (76%) successful and 7 (24%) unsuccessful); and 17 (14%) were deemed not salvageable by the interventional radiologist (multiple procedures, age of access, aneurysms, and failed surgeries). Adverse events were observed in two cases (1.7%); urticaria and angioedema (1), and oxygen desaturation (1). Inpatient beds unavailable 20% of the time, however this did not lead to AV access loss.

Implications for nephrology practice/education: Our unique approach with overnight systemic thrombolysis for the treatment of thrombosed AV accesses may be considered by other programs as a strategy to improve AV access patency.

Presenters:

Gerard K. Barlow, RN, MN, CNeph(c), Clinical Educator, Hemodialysis, Unity Health Toronto, Toronto, Ontario, Canada
Fiona Harrington, RN, Clinical Leader Manager, Hemodialysis, Unity Health Toronto, Toronto, Ontario, Canada
Kathleen McIntosh, RN, MN, Vascular Access Nurse, Hemodialysis, Unity Health Toronto, Toronto, Ontario, Canada
Sadie Webster, RN, Vascular Access Nurse, Hemodialysis, Unity Health Toronto, Toronto, Ontario, Canada

Abstract

Authors:
Gerard K. Barlow, RN¹, MN, CNeph(c) – Clinical Educator
Fiona A. Harrington, RN¹, MN – Clinical Leader Manager
Kathleen McIntosh, RN¹ – Vascular Access Nurse
Sadie Webster, RN¹ – Vascular Access Nurse

¹Kidney & Metabolism Program, Hemodialysis Unit, Unity Health Toronto, Toronto, Ontario, Canada

Purpose of the project: Infections are common complications among patients on chronic hemodialysis. Patients with a hemodialysis central venous catheter (CVC) are two to three times more at risk of increased hospitalizations for infection and death compared to patients with an arteriovenous fistula or graft (Miller et al., 2016; Farrington & Allon, 2019).

In the spring of 2020, the vascular access team noticed an unexplained increase in dialysis central catheter-related bloodstream infections (CRBSIs) from 0.20 to 0.81 per 1000 catheter days. Many of these infections were noted several days post interventional radiology insertion.

Description: The aim of this project was to identify the cause of our increased rates and develop solutions to address this problem. Using a ‘Plan, Do, Study, Act’ methodology, each step of the process was reviewed. This included: hand hygiene, vascular access insertion, care and maintenance audits, cleansing agents, dressings, CVC cuff exposure practices, engagement of stakeholders, and current best practices.

Evaluation and Outcomes:  A multifaceted approach to this problem was implemented which included a review of basic catheter care, standardized education including changes to our protocol and procedures, and innovation in this vulnerable patient population. The overall outcome was a reduction in line infection rates to 0.18 cases per 1000 catheter days.

Implications for nephrology practice/education:   It was evident through this quality improvement initiative, that surveillance programs require dedicated teams and resources which closely monitor CRBSI rates, continuously monitor for improvement opportunities, standardization and engagement of both staff and patients in prevention and management of CRBSIs.

References:

Farrington, C. & Allon, M., 2019. Complications of hemodialysis catheter bloodstream infections: Impact of infecting organism. American Journal of Nephrology, 50, 126-132.
https://www.karger.com/Article/Pdf/501357

Miller, L., Clark, E., Dipchand, C., Hiremath, S., Kappel, J., Kiaii, M., Lok, C., Luscombe, R., Moist, L., Oliver, & O., MacRae, J. (2016). Hemodialysis tunneled catheter-related infections. Canadian Journal of Kidney Health and Disease, 3, 1-11.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5332080/pdf/10.1177_2054358116669129.pdf

Presenter:

Dr. Robert Ting, Staff Nephrology/Internist, Scarborough Health Network
Alison Thomas, RN (EC), MN, CNeph(C), Hemodialysis Nurse Practitioner, Unity Health Toronto, St. Michael’s Hospital

Overview:

Hyperphosphatemia in advanced CKD is associated with increased risk of morbidity and mortality. Patients should be educated on dietary restriction of phosphate, with special attention on avoidance of high-phosphorus food additives. However, phosphate-binding agents are necessary in most patients with advanced CKD. Importantly, patients are best managed when the multidisciplinary team participates in their care, of which nurses play a pivotal role coordinating care.

In this presentation, a nurse practitioner and a nephrologist will discuss best practices and optimal approaches for the management and education of CKD patients with hyperphosphatemia.

Program Objectives

The objectives of the webinar are to:

• Increase awareness of the consequences of hyperphosphatemia
• Enhance knowledge of best practices to optimize management of hyperphosphatemia
• Foster communication between the multidisciplinary team that manages patients with hyperphosphatemia

Presenters:

Marjan Kasirlou¹, RN, BScN, MBA, Home Dialysis Coordinator, Humber River Hospital

Abstract:

Marjan Kasirlou¹, RN, BScN, MBA, Home Dialysis Coordinator, Humber River Hospital
Zahra Rajaeiramsheh¹, RN, BScN, Dialysis Nurse, Humber River Hospital
Vlad Padure¹, MScN, NP-PHC, MBA, Nephrology Program Director, Humber River Hospital

¹Department of Nephrology, Humber River Hospital, Toronto, Ontario, Canada

Purpose: Considering growing population of seniors with multiple comorbidities in long-term care (LTC), we expect an increase in population of dialysis patients. The provision of dialysis in LTC is effective and economic model (Beaudry, 2018; Hager, 2019; Klarenbach, 2014; Pierratos 2016).

Methods: Microsimulation cost analysis used calculating cost of dialysis in LTC-HD. Study performed on cohort of dialysis patients residing in LTC (Nov 2020-April 2021). Two types of dialysis machines and modality selected as per feasibility. 12 patients on short daily dialysis (SDD) (833 patient-day) using NxStage and 14 patients on conventional (613 patient-day).

Results: Cost of dialysis in LTC calculated based on patient-day for supplies and caregiver.
Supplies per day on conventional dialysis cost 49 whereas 168 on SDD. The caregiver cost per treatment for conventional and SDD is 158 and 178 respectively. Overall 315,629 spend on caregivers in LTC.

Transportation cost evaluated for the same period and population. Considering these patients received ICHD, the healthcare would incurred 252,327 for transportation. The LTC-HD demonstrated cost saving on transportation that cover caregivers cost.

To illustrate the efficacy of this model, percentage of death and COVID contraction reviewed in LTC patients during pandemic. No COVID positive reported in LTC-HD compared to 26% in ICHD. Percentage of death is 43% in ICHD while 31% in LTC-HD.

Conclusions: Considering saving on transportation in LTC-HD, caregiver cost is justifiable.
It is recommended the funding model for transportation be reviewed. This funding could be redirected to nephrology programs to facilitate provision of dialysis in LTCs.

Reference

Alain Beaudry, et al. (2018). Cost of Dialysis Therapy by Modality in Manitoba. CJASN. 13 (8) 1197-1203; DOI: 10.2215/CJN.10180917

Hager, D., Ferguson, T. W., & Komenda, P. (2019). Cost Controversies of a “Home Dialysis First” Policy.  Canadian Journal of Kidney Health and Disease, 6, 205435811987154. https://doi.org/10.1177/2054358119871541

Klarenbach, S., Tonelli, M., Chui, B. et al. Economic evaluation of dialysis therapies. Nat Rev Nephrol 10, 644–652 (2014). https://doi.org/10.1038/nrneph.2014.145

Pierratos, A., Tremblay, M., Kandasamy, G., Woodward, G., Blake, P., Graham, J., Hebert, M., & Harvey, R. (2016, August 22). Personal Support Worker (PSW)‐supported home hemodialysis: A paradigm shift. Wiley Online Library. https://onlinelibrary.wiley.com/doi/full/10.1111/hdi.12476#citedby-section.

Presenters:

Michael J. Davis, Department of Nephrology, Memorial University of Newfoundland, St. John’s, NL

Abstract: Michael J. Davis_{a a}Department of Nephrology, Memorial University of Newfoundland, St. John’s, NL Peritoneal dialysis (PD) provides renal replacement therapy by diffusion of solutes, and ultrafiltration of solute and fluid across the peritoneal membrane.   While many physicians, nurses, and patients are familiar and comfortable with hemodialysis, PD is a less well understood, but attractive alternative. It provides a survival equivalence to hemodialysis¹ and has been shown to better maintain residual renal function (RRF)² and maintaining RRF conveys a survival advantage³. While surgical access is required to perform hemodialysis and PD, the arteriovenous fistula, when compared to the PD catheter, has a higher primary failure and intervention rate⁴. The traditional risks involved with the hemodialysis, including catheter-related infection, and higher mortality from hemodialysis intermittency, are avoided in PD. There is also no difference in outcomes when transitioning to transplant, between PD and hemodialysis⁵.   One of the most important advantages of PD is its lifestyle advantage. PD can be performed at home, increasing independence and quality of life. Additionally, in the last decade, there has been a shift toward incremental PD⁶. When RRF is maintained, a small amount of PD can provide symptomatic improvement and decrease the rate of GFR decline³, while being less burdensome. This is especially important in certain populations like heart and liver failure, and patients with cognitive decline. This talk will describe the advantages of PD and the basics of providing PD and troubleshooting problems. It will outline a model of incremental PD that can be provided to patients to optimize quantity and quality of life.   References

1. Perl, J., Wald, R., McFarlane, P., Bargman, J. M., Vonesh, E., Na, Y., Jassal, S. V., & Moist, L. (2011). Hemodialysis Vascular Access Modifies the Association between Dialysis Modality and Survival. Journal of the American Society of Nephrology, 22(6), 1113–1121. https://doi.org/10.1681/asn.2010111155
2. Lysaght, M. J. (1996). Preservation of Residual Renal Function in Maintenance Dialysis Patients. Peritoneal Dialysis International: Journal of the International Society for Peritoneal Dialysis, 16(2), 126–127. https://doi.org/10.1177/089686089601600207
3. BARGMAN, J. M., THORPE, K. E., & CHURCHILL, D. N. (2001). Relative Contribution of Residual Renal Function and Peritoneal Clearance to Adequacy of Dialysis: A Reanalysis of the CANUSA Study. Journal of the American Society of Nephrology, 12(10), 2158–2162. https://doi.org/10.1681/asn.v12102158
4. Oliver, M. J., Verrelli, M., Zacharias, J. M., Blake, P. G., Garg, A. X., Johnson, J. F., Pandeya, S., Perl, J., Kiss, A. J., & Quinn, R. R. (2011). Choosing peritoneal dialysis reduces the risk of invasive access interventions. Nephrology Dialysis Transplantation, 27(2), 810–816. https://doi.org/10.1093/ndt/gfr289
5. Snyder, J. J. (2003). A comparison of transplant outcomes in peritoneal and hemodialysis patients. Kidney International, 63(5), 1956–1957. https://doi.org/10.1046/j.1523-1755.2002.00563.x
6. Paniagua, R., Amato, D., Vonesh, E., Correa-Rotter, R., Ramos, A., Moran, J., & Mujais, S. (2002). Effects of Increased Peritoneal Clearances on Mortality Rates in Peritoneal Dialysis: ADEMEX, a Prospective, Randomized, Controlled Trial. Journal of the American Society of Nephrology, 13(5), 1307–1320. https://doi.org/10.1681/asn.v1351307

 

Presenters:

Hassan Akhoond, RPN, Toronto, ON
Beata Pszczolkowski, RN, BScN, Toronto ON

Learning Objectives:

• Explore the challenges patients face in making a modality selection if they are eligible for peritoneal dialysis but hesitant
• Discuss solutions and strategies to reduce hesitancy in selecting a peritoneal dialysis for eligible patients
• Understand the benefits of remote patient monitoring as a tool during the initiation of a patient on PD and throughout therapy

Adam Burwash, Project Manager, Canadian Water Technologies, Calgary

Learning Objectives:

• Two levels: Standard versus Ultrapure dialysis water
• Water sampling requirements and methods
• Surveillance of water treatment equipment

Danielle Boucher, IPSN, M.SC., D.E.S.S, CNeph(C)

Le potassium est un électrolyte intervenant dans la contraction musculaire plus particulièrement celle du muscle cardiaque. Ainsi, une concentration sérique de potassium trop élevé lors hyperkaliémie est à l’origine de faiblesses musculaires et de troubles du rythme cardiaque pouvant provoquer un arrêt cardiaque.

Les patients en insuffisance rénale sont particulièrement exposés à un risque d’hyperkaliémie puisque le rein joue un rôle majeur dans la régulation du potassium. En effet, l’hyperkaliémie résulte généralement d’une diminution de l’excrétion de potassium rénal ou d’un déplacement anormal de potassium hors des cellules. En général, plusieurs facteurs favorisants simultanés concourent à l’hyperkaliémie.

La mortalité, notamment cardiovasculaire, du patient hémodialysé est nettement plus élevée que celle observée dans la population générale. La mort subite en est une des causes principales. Le rôle des variations de la kaliémie induites pendant la dialyse et l’accumulation du potassium dans la période inter-dialytique font partis des explications à cette surmortalité.

Pour les patients en hémodialyse les traitements de l’hyperkaliémie sont ordres nutritionnel et pharmacologique. À travers le temps ces derniers ont évolué. De nouvelles stratégies ont faits leurs apparitions. Nous brosserons un tableau de ces dernières et présenterons les nouvelles molécules chélateur de potassium, soit le Lokelma (Cyclosilicate de ziconium sodique) et Veltassa (Patiromer).

Objectifs 

À l’aide d’un cas clinique

• Regarder les risques associés de l’hyperkaliémie chez les patients hémodialysés
• Connaître les recommandations actuelles
• Faire une réflexion sur les options thérapeutiques dont les nouvelles molécules chélateur de potassium, soit le Lokelma et Veltassa.

Presented by Philip McFarlane MD, FRCP(C), PhD, Clinical-Investigator, Division of Nephrology, St. Michael’s Hospital, Toronto; Assistant Professor, University of Toronto; Medical Director, Home Dialysis, Chief Nephrologist, Live Kidney Donor Program , St. Michael’s Hospital, Toronto Overview: Explore the benefits of promoting an HHD program first over an In-centre conventional treatment. Learning Objectives: 1) Discuss in-practice advanced treatment options for HHD patients, such as sodium profiling, HDF and online priming. 3) Recognize the shift in HHD during the Global pandemic. Review the implications and benefits. 4) Hear a patient perspective—an interview with an HHD patient about how they fit Home dialysis into their lifestyle to thrive independently.