2023 Program

*Subject to Change

THURSDAY OCTOBER 26
0700-0800	Registration and Continental Breakfast
0800-0830	Opening Remarks
0830-1000	Opening Keynote – Bridging the Gap — How to Get to Where You Need to Go Presented by Michael Gardam MSc, MD, CM, MSc, FRCPC, CHE, Chief Executive Officer, Health PEIMichael is the Chief Executive Officer at Health PEI, the health authority that delivers publicly funded healthcare in the Prince Edward Island. He is also the Chair of the Board of Directors of HealthCareCAN, the national voice for healthcare organizations and hospitals across Canada. Michael is a pioneer of using complexity science-based approaches to improve patient safety, system transformation, staff engagement and other complex challenges. He has advised organizations in Canada and internationally, including the World Health Organization, the Centers for Disease Control and Prevention, Excellus Blue Cross Blue Shield, Hand Hygiene New Zealand, the Irish Health Services Executive and the Maryland Patient Safety Center, the Canadian Foundation for Healthcare Improvement, the Canadian Patient Safety Institute, as well as numerous hospitals across Canada. His interest in physician leadership and organizational culture led him to become Chair of the Medical Advisory Committee at UHN (2015-2017) and Chief of Staff and Humber River Hospital in Toronto (2018-2020). He is also currently the Program Director of the York University Schulich School of Business Healthcare Leadership Development Program, and an instructor for the Physician Leadership Institute of Joule (Canadian Medical Association). Michael is an Associate Professor of Medicine at the University of Toronto. He holds Master’s degrees from McGill University (Biochemistry) and the University of Toronto (Health policy, management and evaluation), and is a Fellow of the Royal College of Physicians and Surgeons of Canada in infectious diseases.
1000-1015	Refreshment Break
1015-1215	From Awareness to Action: Empowering Nurses in Managing Hyperphosphatemia and CKD Associated Pruritus – Sponsored by Otsuka Pharmaceuticals
1215-1300	Lunch – includes update from CANNT Journal Editors
1300-1400	Plenary – Ethical issues in Nephrology Presented by Dr. Timothy Christie
1400-1445	Concurrent Sessions 1A – 1
1A	Collaborating with an Adult Program to Establish a Pediatric Hemodialysis Vascular Access Program
1B	Nephrology Mythology 2.0
1C	The Effect of Taurolidine-based Lock Solutions as Prophylaxis and Antithrombotic in Central Venous Access Device: An Integrative Review
1445-1500	Refreshment Break
1500-1545	Concurrent Sessions 2A – 2C
2A	The Beginning of the End: A Case Scenario of an Infected Graft
2B	Insights into current practices and unmet needs relating to chronic kidney disease-associated pruritus: Results from a Canadian nephrologist survey
2C	Supporting hemodialysis patients through nursing-technologist collaborative education
1545-1600	Transition Break
1600-1645	Concurrent Sessions 3A – 3C
3A	Nurse practitioner led initiative implementing bedside POCUS to assess fluid status in the in-centre hemodialysis unit at London Health Science Centre
3B	Significance of Choosing Right Solution for Peritoneal Dialysis Therapy
3C	Bridging the Gap: Implementing the Transitional Care Approach for New Hemodialysis Patients
1645-1845	Opening Reception in Exhibit Hall
1930	Evening Activity: Bowling Night at The Alley You look STRIKING! On Thursday evening, following the Opening Reception in the exhibit hall, delegates can make their way to the bowling alley up the street!Eat. Drink. Bowl. At the Alley! Tickets are available online when you register for the Conference.
FRIDAY OCTOBER 27
0630-0730	Rise and Shine! Morning Wellness Yoga with Shripal Parikh
0730-0830	Breakfast in Exhibit Hall
0830-0900	Sponsor Recognition and Award Presentations
0900-1000	Calciphylaxis: Like a Thief in the Night Presented by Dr. Chaudhary
1000-1045	Refreshment Break in Exhibit Hall and Poster Q&A
1045-1145	Plenary – Personality-Informed Medical Care Presented by Joseph Rasmias The person who has a disease is often much more important to understand than the disease a person has. Psychiatrists who consult to medical practices attempt to make useful sense of that reality. The the demand for psychiatric expertise in a variety of settings, including inpatient medical settings, primary care clinics, outpatient specialty clinics has grown exponentially. The ability to provide psychiatric expertise is significantly enhanced through the understanding of psychodynamic principles by allowing the patient to be understood on a deeper level. Understanding patients through a psychodynamic lens allows treaters to establish a deeper connection with their patients, allowing the patients to feel better understood and the treaters to feel more empowered, leading to lower burnout — even when outcomes are non-ideal.
1145-1245	Lunch in Exhibit Hall
1245-1330	Concurrent Sessions 4A – 4D
4A	Patient-Centered Hemodialysis Nursing Care
4B	Staying connected: helping you manage multiple patients with a few clicks!
4C	Guiding Best Practise using ultrasound
4D	Critical incident during dialysis treatment: Protocols followed by Technologists in AKC-S
1330-1400	Refreshment Break and Exhibit Hall Draw Prizes
1400-1445	Concurrent Sessions 5A – 5D
5A	Halton Best Start Unit-A New Approach to Transition
5B	Utilizing artificial intelligence to predict admission risk among in-center hemodialysis patients
5C	The secret ingredient to preserving an arteriovenous graft: Honey
5D	Secrets of Communicating in Serious Illness
1445-1600	Plenary – The Role of the Transplant Urologist Presented by Dr. McGregor
1830-2300	Evening of Entertainment – Kitchen Party with the Ross Family Band
	Get ready for a kitchen party to remember! There will be music, seafood – an east coast party! Celebrating PEI’s traditional and contemporary roots music, the Ross Family will present a taste of real Island culture through song and story, bolstered by driving fiddle sets and outstanding stepdancing! Tickets are extra and available online when you register for the Conference.
SATURDAY OCTOBER 28
0630-0730	Rise and Shine! Morning Wellness Activity Yoga with Shripal Parikh
0730-0900	Breakfast and CANNT Annual General Meeting
0900-1000	Plenary – Patient Empowerment Panel
1000-1015	Refreshment Break
1015-1100	Concurrent Sessions 6A – 6C
6A	Chest pain on hemodialysis: What are the causes? A review of the literature, cases and treatment
6B	The Association Between Food Insecurity and Hypertension: A Narrative Review
6C	Assessing risk factors of non-adherence and post-Transplant outcomes in kidney transplant recipients
1100-1115	Stretch Break
1115-1200	Concurrent Sessions 7A – 7D
7A	Analyzing the impact of nurse practitioner- based collaborative care model within hemodialysis outpatient settings
7B	Goals of Care for the renal patient
7C	Transplant Ambassador Program (TAP)
7D	Interventional Nephrology – Dr. Girsberger
1200-1245	Lunch
1245-1330	Closing Keynote: J.D. Gilmour
1330-1430	Closing Ceremonies and Passing of Banner to CANNT 2024

The beginning of the end: a case scenario of a failing graft

Kevin Barlow, RN, MN, CNeph(C), Clinical Nurse Educator
Elizabeth Poisson, RN, Vascular Access Coordinator
Unity Health – St. Michael’s Hospital, Toronto, Ontario

Background: Arteriovenous grafts (AVG) are constructed by interposing graft material between an artery and a vein for hemodialysis.  Their usage is dependent on vascular anatomy and can be preferred over central venous catheters (CVC) in many cases. Intimal hyperplasia is the most common complication followed by thrombosis. Infection, however, can have detrimental effects on the continued usage of the AVG. Staff assessments and reporting have not always reflected the level of urgency with potential vascular access emergencies. Earlier intervention of the patient’s AVG infection may not have changed the outcome, however, the drastic extent of complications may have been limited. A vascular access clinical assessment tool was developed and made available for nursing staff to document and communicate with the health care team.

This format will ensure pertinent and high-risk findings are reported such as the risk of bleeding, dysfunction, or infection. Clinical staff will also receive education on vascular access complications and the use of the tool. This process was evaluated by the frequency of its use with the number of vascular access consults requested and analysis of high-risk reports.

Evaluation/Outcome: Staff struggled with using the tool consistently but appreciated the systematic approach to reporting a potential problem. Regardless of utilization, staff had better awareness of vascular access health and communicated in a more proactive approach.

Implications for nephrology practice: Consistent and timely nursing observation and intervention is key to managing the health of a hemodialysis vascular access.

---

Nephrology Mythology 2.0

Sylvia D. Zuidema,^a MSc, NP
Sandeep K. Chahal,^b, BScPharm, ACPR

^aAlberta Kidney Care – North, University of Alberta Hospital, Edmonton, AB
^bDepartment of Pharmacy, Royal Alexandra Hospital, Edmonton, Alberta

Background: As healthcare providers it is important to engage in continuous education and re-evaluate our understanding of existing medical procedures and practices. Practice in medicine can be continued because of history, previous experience, or simply because celebrities endorse a claim on social media. If evidence cannot support the medicine, the practice may be a medical myth!

Purpose: The purpose of this oral presentation will be to critically examine several nephrology myths and to encourage the questioning of widely accepted practices and beliefs.

Description: We will discuss several nephrology-related concepts including indications for utilizing albumin, mechanisms of action for metolazone and furosemide, eating on hemodialysis, and drinking water as a renal protective strategy.

Evaluation/Outcome: Participants will be able to understand the evidence, or lack thereof, behind commonly identified nephrology practices.

Implications for nephrology practice: It is our hope that participants will reflect upon controversial topics, understand the available literature, and facilitate discussion in their respective fields to potentially promote practice change.

---

Insights into current practices and unmet needs relating to chronic kidney disease-associated pruritus: Results from a Canadian nephrologist survey

Daniel Schwartz,^a MD
Gerald Miciak,^b MSc, BSc Pharm
Arthur Magnaye,^b  MSc

^aThe University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
^bOtsuka Canada Pharmaceutical Inc., Saint-Laurent, Quebec, Canada.

Background: Chronic kidney disease-associated pruritus (CKD-aP) is a common but under-recognized condition in patients with CKD undergoing hemodialysis (HD).

Purpose: In this real-world study, Canadian nephrologists were surveyed to gain insight into current practices and unmet needs related to the treatment of CKD-aP.

Description: Quantitative data regarding the perception of current treatment practices for CKD-aP were collected in December 2021 by a 20-minute survey completed by 62 nephrologists across Canada. Respondents’ level of agreement was assessed using a 7-point scale, from 1 (do not agree at all) to 7 (strongly agree).

Results: In current practice, the mean perceived prevalence of CKD-aP in HD patients was 30.5%. Of these, 33.6% and 18.3% experience moderate or severe CKD-aP, respectively. CKD-aP was most frequently identified (75.8% of cases) through patients complaining of itch to the multidisciplinary health care team. The first conversation about CKD-aP was most often with a nephrologist (55%) or renal nurse (34%).  In clinical practice, 63% of respondents currently do not use a formal scale to diagnose and assess CKD-aP.  Nephrologists used topical moisturizers / emollients (85%), oral antihistamines (14%), and gabapentinoids (2%) as first-line treatments. Nephrologists reported 42% of patients with severe CKD-aP and 41% with moderate CKD-aP do not respond to treatment. Most nephrologists (94%) agreed there is a need for new treatments specifically designed to address CKD-aP and 69% agreed there is a need for guidelines for the treatment of CKD-aP.

Conclusion: This Canadian study showed that systematic identification processes are not in place to identify CKD-aP, and the majority of patients are only diagnosed after the patients complain about itch to a member of the multidisciplinary team.  There is an urgent unmet need for better identification, more effective treatments, and for guidelines to aid in the identification and selection of therapy to manage CKD-aP.

 

---

Supporting hemodialysis patients through nursing-technologist collaborative education

Melissa G. Triemstra, RN
Luke P. Adamcewicz, CNT
Hemodialysis Program, St. Joseph’s Healthcare Hamilton, Hamilton, Ontario

Background: At St. Joseph’s Healthcare Hamilton (SJHH), specific hemodialysis (HD) patients have been assigned to a collaborative model of care. This patient care area is staffed by a registered nurse (RN) and a clinical nephrology technologist (CNT). Staff have witnessed HD patients experiencing anxiety in response to foreign equipment, changes in physical symptoms, and lack of general knowledge of their HD treatment. A great deal of these concerns, especially with patients who are new to HD, can be supported through effective patient education.

Purpose: The purpose of this project is to explore the positive influence of combining clinical and technical knowledge within an interprofessional team to support patient education.

Description: Staff have noticed patients who are more knowledgeable and engaged with their HD treatment seem to display better self-care. This can be further supported by the patient having exposure to both clinical and technical resources during each HD session. In addition to patients learning about their own health and kidney disease management from the RN, patients can become capable of learning about the dialysis machine and the basic technical attributes of their treatments from the CNT. A portion of our analysis on this education model will include a patient feedback survey to determine the effect on the outcomes listed below.

Outcomes: Using this specialized educational approach, we hope patients become empowered, leading to increased comfort and assurance around their HD treatments, treatment efficiency, and confidence to potentially transition into our home program.

Implications for nephrology practice: Although the RN-CNT collaborative model is unique to SJHH, there is an opportunity for other HD programs to utilize all staff to support their HD patients. In addition to this specialized educational approach better serving our patients, this model can also assist with the current nursing shortage.

---

 A Nurse practitioner-led initiative implementing point of care ultrasonography to assess fluid status in the in-center hemodialysis units.

Julia Petrakis, BScN, NP
Lyndsay Beker, BScN, NP
Renal Care, London Health Science Centre, London, Ontario

Background: Fluid assessment and establishment of dry target weight have been topics of discussion in a Canada-wide nurse practitioner (NP) platform. Fluid assessment is an important part of the NP role when caring for patients in the dialysis units across Canada.  Conventional point of care ultrasonography (POCUS) may enhance the reliable assessment of fluid status when used in adjunct with a physical examination.

Purpose: The purpose of this project is to determine: (1) if the NPs in an in-centre hemodialysis unit have an interest in learning how to perform a POCUS and fluid assessments; (2) if it is a practical skill to utilize in our clinical role; and (3) if the NPs felt the use of POCUS had an impact on patient clinical outcomes regarding fluid assessments and dry weight. A survey revealed there were seven NPs interested in learning POCUS. A description of this process includes providing an educational curriculum developed in collaboration with key physician partners that included one educational video and two hands-on learning opportunities to practice, followed by implementing POCUS into practice.

Evaluation: Qualitative feedback on the learning process will be sought from each NP. By gathering this data, we will determine if the NPs felt that utilizing POCUS was useful in determining fluid status and dry target weight in the in-centre hemodialysis unit. We will also assess if the NPs were able to integrate the new skill into their practice, and finally, assess if the NPs felt the practice change of implementing POCUS had an impact on patient care with regards to fluid assessments.

Implications for nephrology practice: Nurse practitioners across Canada have expressed interest in utilizing POCUS to enhance fluid assessment on hemodialysis patients. We are hopeful that this project will help establish strategies for education and implementation of POCUS and determine the impact on patient care as perceived by the NP.

---

Staying connected: Helping you manage multiple patients with a few clicks!

Alba Marin, MD
Isabelle Darrach, RN, CNeph(C)
Baxter Healthcare, Mississauga, Ontario

Background: Remote patient management (RPM) is now available for patients on automated peritoneal dialysis (APD). RPM technology allows nurses to utilize therapy data to identify adherence patterns, potential catheter issues, and inadequate dialysis. The ability to manage patients remotely also helps health care professionals (HCPs) to be more proactive with patient care utilizing therapy information and to act quickly to mitigate any potential challenges. Evidence also suggests that RPM may also decrease hospitalization rates of patient on APD by 39%. Utilization of technologies such as remote patient management (RPM) may further support access to patient therapy information and allow for patients to minimize clinic visits. RPM can be an integral part of pandemic planning supporting HCP and patient comfort with patient self-care at home.

Purpose: This presentation provides a brief navigation of treatment data that is available to HCPs that may assist in proactive case management of patients. Case scenarios will also be presented that highlight data analysis and troubleshooting.

Evaluation/Outcome: We identified four themes: (1) gaining knowledge and triggering actions (tracking and responding to change, prompting timely and accessible care, supporting self-management and shared decision-making); (2) reassurance and security (safety in being alone, peace of mind); (3)  concern about additional burden (reluctance to learn something new, lack of trust in technology, avoiding additional out-of-pocket costs), and (4) jeopardizing interpersonal connections (fear of being lost in data, losing face to face contact).

Implications for nephrology practice: Remote patient management (RPM) has the potential to help clinicians detect early issues, allowing intervention prior to development of more significant problems.

---

Patient-Centered Hemodialysis Nursing Care

 Billie Hilborn, RN
York University, Toronto, Ontario

Background: Patient-centered care originated in the 1950s, gained popularity in the 1990’s, and is expected to be provided by all nurses in Canada. The term is used liberally on the Health Canada website, and in 2011 the Canadian Institutes of Health Research launched the Strategy for Patient-Oriented Research, and the Canadian Nurses Association (CNA) and Canadian Medical Association (CMA) jointly identified patient-centred care as the first principle to guide healthcare transformation. In 2018, patient-centred care was adopted by Accreditation Canada through the addition of patient surveyors. Patient-centred nursing care could benefit people with end-stage kidney disease (ESKD) however the philosophical ideals of the approach may not consistently align with the everyday reality of hemodialysis nursing.

Purpose of Study: To describe the experiences and perspectives of hemodialysis nurses in their provision of patient-centred care.

Methods: A qualitative interpretive description design was used, with purposive sampling of hemodialysis nurses from hospital and satellite hemodialysis units in urban and rural areas registered with the College of Nurses of Ontario and currently employed full or part-time for more than three months. Semi-structured interviews were held, and transcripts were analyzed.

Results: Ten registered nurses (RNs) participated, and five themes were constructed through interpretation of their comments during interviews: (1) Knowing, (2) Applying, (3) Sustaining, (4) Promoters, and (5) Detours of Patient-Centred Hemodialysis Nursing Care.

Conclusions: Patient-centred hemodialysis nursing care is occurring in a complex, multi-layered, dynamic matrix with multiple promoters such as therapeutic relationships, reflective nursing practice, collaboration, the satellite unit context, and effective communication. Nurses needed to navigate detours that interfered with the provision of patient-centred care, such as a lack of support and respect for nurses, heavy workload, and managerial and organizational processes.

Implications for nephrology care: Patient-centred hemodialysis nursing care should be prioritized in the education, practice, and policy domains.

---

Significance of choosing the right solution for peritoneal dialysis

Shyalini Jeevakaran, MN, RN, Advanced Practice Nurse Educator, Multi-organ Transplant and Nephrology
University Health Network, Toronto, Ontario

Background: Sufficient knowledge of peritoneal dialysis (PD) therapy and the appropriate care required have a high potential for improving patient outcomes. However, when an inappropriate PD solution is chosen, it can lead to dehydration or fluid overload. The PD unit should continuously assess the quality of PD patients receive and evaluate the patient’s treatment outcomes.

Purpose: My project was to improve PD therapy by enabling nurses to identify the ideal solution for patients’ symptoms. This quality improvement project aimed to improve and standardize PD practice and provide nurses with a PD update via curriculum development, policy reviews, and flow sheet redesign.

Project description: Furthermore, nurses empowered with evidence-based knowledge about choosing the right solution for PD therapy would allow nurses to work with the medical team to influence solution selection, ensuring patients receive the appropriate treatment. The curriculum is evidence-based, context-relevant, and unified, and encompasses educating staff nurses on identifying the right solution to improve the patient’s condition and documenting 24-hour ultrafiltration on the flowsheet. Nurses received a pocket card about identifying the right solution for PD according to patients’ condition. Flow sheet redesign allowed documenting 24-hour ultrafiltration, which identified the effectiveness of the recommended PD therapy. The curriculum also taught nurses how to teach PD patients about the care and management of PD catheters, choosing the correct PD solution, and complications related to PD. This reduced PD complications such as peritonitis, fluid overload, and dehydration and, most importantly, reduced hospital readmission.

Implications for nephrology practice: Knowledge about incorporating evidence-informed practice when clarifying the orders will contribute to effective treatment, ultimately improving patient care. Moreover, the performance in turn, gives nurses job satisfaction.

---

Halton Best Start Unit – A new approach to transition

Aman Sandhu, RN
Olga Zhdanova, RN
Maria Doyle, RN
Gail Burns, Director
Oakville Trafalgar Memorial Hospital, Oakville, Ontario

Background: Our nephrology program has grown tremendously over the years; however, the rate of home dialysis patients remained low. There was a lack of communication, education, and continuity of care, which created a barrier for patients to fully understand the options they had.

In 2019, The Best Start Unit (BSU) initiative was created to help patients be more independent in their lives and incorporate dialysis into their life instead of working around dialysis.

Purpose: The purpose of the initiative is to empower our patients and help them choose the right modality that best suits their lifestyle. In the BSU, we have patients coming from all walks of life including patients with prior education or who were considered “acute starts.” The BSU helps to inform those patients, answer questions, and give them the modality education they lacked.

Description: All patients new to dialysis would come through the BSU. Here they would stay for three weeks, which would allow for patient education or navigation to take place. The allied health care team would visit and build a therapeutic relationship with the patients. Once the patient has chosen a modality, the nurse will help them navigate through the program. They are also educated about transplant. A TAP (Transplant Ambassador Program) ambassador is available for family or patient education.

Outcomes: Since the opening of the BSU, patients have stated they feel better about their health, are aware of the progression of disease, and know the “nephrology language.” They feel like they are more in control of their situation.

Implications for nephrology practice: Since the program, we have seen an increase in the number of home dialysis patients and kidney transplants, decreased stress on the in-center hemodialysis unit, and patients feel more supported with their choices and health concerns. We are now one of the top five programs in the provision of home dialysis care provincially.

---

Secrets of communicating in serious illness 

Dawn Frizzell, BSW, RSW, Nephrology Social Worker
PEI Renal Program, Charlottetown, Prince Edward Island

Background: Knowing how to engage in end-of-life (EOL) conversations is a crucial skill when caring for our chronic kidney disease (CKD) patient population. A recent Canadian audit showed only 30% agreement between patient preferences and prescribed goals of care. This presentation aims to allow opportunity to engage in conversation about how we can improve our communication skills thereby bridging that gap.

Purpose: The purpose of this presentation is to provide information to renal staff regarding the importance of conducting difficult conversations, and how they can positively impact end of life care in our patient population.

Description: This presentation outlines the importance of having difficult conversations in EOL care. Tips and tricks to help facilitate these conversations and improve the quality of life for your patient and their family will be provided. It is crucial that we learn how to help bridge the gap between patient/family preferences and the care they are receiving. Tools utilized in Health PEI such as “The serious illness conversation guide” have been helpful in facilitating these conversations and will be outlined in this presentation.

Evaluation/Outcomes: By the end of the presentation, attendees will have gained an

understanding of what patients want when it comes to EOL communication and why this is so important, and increased knowledge of the critical elements that are part of a “serious illness conversation.” Attendees will be more familiar with tools that may be helpful in their own workplace.

Implications for nephrology practice: By increasing knowledge and comfort level on having EOL conversations, patients and families will have better EOL conversations with their nephrology team, improved quality of life, care that is more closely aligned with their values, and better outcomes in terms of the dying process.

---

The Association Between Food Insecurity and Hypertension: Reviewing the Literature

Judy Ukrainetz, RN, AHS
Branko Braam, MD, PhD
Alberta Kidney Care – North, Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada

Introduction: Hypertension (HTN) and dietary choices are closely related. HTN is a leading cause of chronic kidney disease (CKD), and a poor diet contributes to about 80% of HTN. Food insecurity (FI) is defined as the lack of secure access to sufficient amounts of safe and nutritious food for normal growth and development of an active and healthy life, and it is prevalent and determines dietary choices. The prevalence of FI for adults has increased by 84% in the last 20 years and the mortality rate from CKD has also increased by over 40% in the same time frame, making this a relevant issue to address. We wanted to explore the relationship between the modifiable risk factors of FI and HTN in the context of CKD.

Method: A narrative review was performed using a systematic search in PubMed. Search terms included: food insecurity, chronic disease, hypertension, and social determinants of health. The search was limited to 2004-2023.  A PubMed search yielded 147 peer-reviewed articles, and findings were narrowed down to exclude other literature or systematic reviews. Data synthesis was conducted according to a thematic synthesis approach.

Results: Out of a total of 147 articles, 26 studies were included in the final review. The thematic synthesis enabled the construction of four themes: (1) low income negatively affects diet and is associated with food insecurity and HTN; (2) education and health literacy affect diet and the correlation between food insecurity and HTN; (3) access to healthy food feeds into the association between food insecurity and HTN; and (4) poor diet aggravates other adverse health conditions and is correlated to food insecurity and HTN.

Conclusion: FI is correlated to poor nutrition and HTN. Both FI and HTN together are an increasing global public health concern. The literature indicated how diet and health behavior are modifiable by addressing low income, limited access to healthy food, and poor education, thereby, making it relevant to mitigate the negative dietary consequences of food insecurity on HTN and cardiovascular disease at the local and global scales. This is a threat also for the development of CKD.

Implications for nephrology practice: Globally, HTN is a leading non-communicable risk factor for cardiovascular morbidity and mortality. Hypertension is one of the leading causes of CKD. FI is associated with HTN, and these global health threats beg for urgent attention to improve health outcomes on a worldwide scale.

---

The secret ingredient to preserving an arteriovenous graft: Honey

Rosaleen Nemec, MAEd, BScN, RN, CNeph(C)
Usha Dinesh, BScN, RN
Dialysis/Apheresis Unit, The Hospital for Sick Children, Toronto, Ontario

Background: A peritoneal dialysis (PD) pediatric patient with rapidly deteriorating function, was in need of urgent hemodialysis (HD). The patient had an extensive history of poor access on PD and HD.  Exploratory surgery indicated that a central venous catheter, or lower and upper arm fistula or graft would not be possible due to prior clots and stenosis. A leg arteriovenous loop graft was created.  One year after use, an emergency scab formed and required a graft revision. After the sutures were removed, the wound became infected. Several weeks of antibiotics were administered and the wound care team became involved. The wound increased in size and there were concerns that the infection would seed onto the graft. The patient was switched to single needle dialysis to avoid the tissue around the site. It was becoming more painful to needle, which led to inadequate dialysis.

Purpose: An opportunity presented itself to try medical grade manuka honey dressings to heal the wound over the graft site.

Description: Pure manuka honey has natural anti-bacterial properties. Based on the stage of the wound, different applications of the product were used. After nine weeks of failed treatments, the manuka honey products contributed to rapid improvement of the wound. No irritation to surrounding tissue was noted.

Evaluation/Outcomes: The wound healing progress has been documented, and surgical revision of the wound and graft has been avoided. With limited HD access, the honey-based product was the last option before surgery. Rapid wound healing and improved skin condition have enabled the dialysis team to continue to use of the graft while it heals. Double needling of the graft below and above the wound allows for adequate dialysis.

Implications for nephrology practice/education: Natural honey-based products have facilitated wound healing and preservation of the graft.

---

Collaborating with an adult program to establish a pediatric hemodialysis vascular access program

Rosaleen Nemec, MAEd, BScN, RN, CNeph(C)¹
Frank Shih, RN, BHSc²
Gary Manzanilla, RN^2
1The Hospital for Sick Children, Toronto, ON, ² University Health Network, Toronto, ON

Background: Kidney Disease Outcomes Quality Initiative (KDOQI) have recommended that arteriovenous fistulas (AVFs) should be the preferred vascular access choice for children on hemodialysis. In order to establish and maintain such a program, the following are required: (a) specialized surgeons to place and revise AVFs and arteriovenous grafts (AVGs); (2) an interventional radiology or vascular surgery department to mitigate complications; and (3) nephrologist, trainees, and a strong nursing team to access, and identify trends and complications.

Purpose: For many years in a large pediatric hospital, patients with simple AVF, placed externally, came to the unit and experienced limited complications. No guidelines were established for complications.  Unexpectedly, there was an urgent need to place an AVG for a pediatric patient with limited access options. Surgical expertise was offered by the adult vascular team to create the AVG.  The pediatric nursing team had limited knowledge, skill, and judgement in caring for the newly created AVG.

Description: Collaborating with the adult vascular access team provided the support needed to help the staff understand the principles and gain comfort in accessing and using the AVG.

Evaluation/Outcomes: From here, an ongoing partnership developed between the adult and pediatric sites to help develop pediatric-focused policies and practices, guides to troubleshooting complications, pathways to navigate complications, and appropriate teams to intervene.

Implications for nephrology practice/education: Collaborating with the adult vascular access team enabled the pediatric dialysis program to develop their own program with support and guidance. From this experience, other pediatric patients have benefited from the development of the AVF and AVG program in a safe and methodical manner.

---

Goals of care for the renal patient

Steve Gobran, RN(EC)
Melinda Daamen, RN
Grand River Hospital, Kitchener, Ontario

Background: Healthcare continues to move in a direction that values patient centered decision making.  Goals of care conversations are an important tool for determining care plans, and these conversations start with an understanding of illness and disease outcomes. These conversations can assist the patient and their family to understand their renal failure and identify important priorities for their care.

Purpose: This presentation will spotlight how our organization implemented goals of care conversations throughout the renal program. Together we will explore how to prepare ourselves and our patients for these conversations, how to navigate the discussions, and how to apply the patient’s goals to their kidney care. We will also share the successes and barriers that were encountered as we implemented this practice across the program.

---

Chest pain on hemodialysis: What are the causes? A review of the literature, cases, and treatment. 

Leora H. Wanounou, NP, CCN(C)
Kidney and Metabolism Program, St. Michael’s Hospital, Toronto, Ontario
Adjunct Lecturer, Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario

Background: In the hemodialysis unit nurses frequently come to assess patients with chest pain. This review of the literature will provide an overview of the various causes of chest pain on dialysis and how to manage and treat the patient.

Purpose: The purpose of the project is to provide nursing education to the hemodialysis nurses in order to better manage patients with chest pain on dialysis.

Description: The author conducted a literature review using the terms “hemodialysis” and “chest pain” in humans and limiting to English articles.  In total, 148 articles were found and then narrowed down to 37 articles of interests. The articles described various reasons for chest pain.  Common causes were cardiac-related such as myocardial infarction, pericarditis, and Takotsubo syndrome. Other common causes were related to dialysis access and included steal syndrome, broken central venous catheters or lacerations as well as catheter-related emboli. Chest pain could also be secondary to dialyzer or membrane reactions, intravenous iron infusions, or air emboli. One of the most common causes of chest pain was hypovolemia.

Evaluation/Outcome: The author then plans to provide nurses education in May of 2023 to review the different causes of chest pain on dialysis and then conduct an evaluation from the nurses to receive feedback on their learning.

Implications for nephrology practice: It is important to provide nephrology nursing education to bedside nurses, especially on practical topics. This presentation will help nurses to better understand chest pain on dialysis and improve the overall care for hemodialysis patients.

---

Analyzing the impact of a nurse practitioner-based collaborative care model within hemodialysis settings

Chrystal S. Dias, MN, NP-PHC
Hemodialysis Program, St. Joseph’s Healthcare Hamilton, Hamilton, Ontario

Background: The integration of nurse practitioners (NP) has significantly improved the management of chronic diseases and enhanced timely access to care. NPs are autonomous healthcare providers who incorporate the nursing lens, as well as, medical knowledge to prevent disease and manage illness. Today, a number of outpatient hemodialysis (HD) centres utilize an NP collaborative care model (CCM) with the nephrologist to address the complex care needs of HD patients.

Description: In February 2020, the outpatient HD program at St Joseph’s Healthcare Hamilton integrated five NPs across three sites to oversee the care of HD patients. The incorporation of NPs across the sites has contributed to timely follow-up in addressing HD-related complications, prompt intervention for foot ulcers, admission avoidance to hospital, and increased continuity of care.

Purpose: The purpose of this presentation is to discuss the quality improvement project on analyzing the effect of the NP-CCM on addressing the ongoing care needs within the HD setting.

Evaluation/ Outcome: Anecdotal evidence in the form of a voluntary questionnaire will be captured from 50 patients, dialysis staff and nephrologists across all sites. Preliminary consultation with colleagues and patients suggests that the addition of NPs has resulted in positive patient care outcomes, improved access to timely care and greater interprofessional collaboration. Common themes will be extrapolated and explored in more detail.

Implications for nephrology practice: The implications of this project are three-fold. First, it will raise awareness on the NP scope of practice and their contributions on HD units. Second, it will identify areas in which NPs can better respond to patient care needs. Finally, it will highlight ways that NPs can continue to collaborate within the interprofessional team to improve quality of care.

---

Bridging the gap: Implementing the transitional care approach for new hemodialysis patients

Prachi Khanna, BSc^1,2
Jill Hidalgo, BSN, RN, CNeph(C)¹Nikki Craig, BSN, RN, CNeph(C)¹
Elina Barsky, BSN, RN, CNeph(C)¹
Betty Sung, BSc, RD¹
Daisy Lin, BSc, RD¹
Brittaney Walker, RN¹
Paulina Iturra, RN¹

¹St. Paul’s Dialysis Unit, Providence Health Care, Vancouver, British Columbia
²University of British Columbia, Vancouver, British Columbia

Background: Education plays a key role in helping patients adjust to chronic kidney disease and adhere to treatment, especially in the high-risk period while patients are transitioning to dialysis. Patient education and psychosocial support can lead to the achievement of long-lasting changes in behaviour through the provision of knowledge and skills to empower patients to make informed decisions about their care and take ownership of their health.

Description: New hemodialysis (HD) patients receive comprehensive care from the interdisciplinary care team but feel overwhelmed during their transition. In a previous study, we investigated the learning needs of new HD patients by exploring patient and nurse clinician perspectives on strategies to address these needs. We adapted the four-week Transitional Care Program (TCP) in collaboration with nurses, patient partners, departmental leadership, and other members of the renal interdisciplinary team including staff in other renal replacement modality areas for a six-month pilot implementation. We mapped workflows, identified gaps, and designed strategies to build capacity of existing infrastructure to streamline the care of new patients with five key TCP components: (1) peer support; (2) an online patient-oriented resource hub; (3) staff education; (4) a communication tool to coordinate care and a dedicated space for patients to create safety and predictability.

Evaluation/Outcome: Preliminary results from our mixed-methods evaluation indicate improvements in patient self-management. Patients report positive relationships with their care team and peer support. Staff report that TCP patients are receptive to information, experience less anxiety and are more open to being approached by team members. Despite communication and staffing challenges, the TCP has provided the framework necessary to track new patients and better address their needs.

Implications for nephrology practice: The TCP demonstrates that investing time to educate staff and providing them with the necessary tools to support their work significantly impacts dialysis care, preventing patients from falling through the cracks.

---

Assessing risk factors of non-adherence and post-transplant outcomes in kidney transplant recipients

Olusegun Famure, MPH, MEd
Kateryna Maksyutynskya, BHSc
Benedict Batoy, BHSc
Yanhong Li, MSc
Joseph Kim, MD, PhD, MHS, FRCPC, MBA
University Health Network, Toronto, Ontario

Background: Kidney transplant recipients’ (KTR) adherence to prescribed regimens is vital for optimal recovery and long-term graft function.

Purpose: The objective of this study was to identify risk factors of KTR non-adherence and their impact on post-transplant outcomes.

Description: A retrospective single-centre cohort study was conducted among KTR transplanted between January 1, 2003-December 31, 2017. Non-adherence was defined as one or more of the following in the first year post transplant: (1) at least one missed clinic visit; (2) > 30% missed laboratory visits; and/or (3) > 40% coefficient of variation of calcineurin inhibitor levels. Univariable and multivariable logistic and Cox proportional hazards models were fitted to identify adherence risk factors and outcomes, respectively. From a total of 2,714 patients, 1,803 (66.4%) were included in the analysis. The mean recipient age was 51.7 (± 13.4) years, and 60.7% were male. Overall non-adherence was identified in 34.9% patients; 11.2% patients were non-adherent to clinic visits, 5.4% to laboratory tests, and 25.2% to medication. Recipient history of psychiatric disorders (OR 1.57 [95% CI: 1.22, 2.02]) or non-adherence (OR 1.82 [95% CI: 1.31, 2.54]) were independent risk factors for non-adherence. Private (vs. public) drug coverage reduced the risk for non-adherence (OR 0.62 [95% CI: 0.48, 0.80]). Any episode of non-adherence over the first-year after transplant was associated with total graft failure (HR 1.52 [95% CI: 1.20, 1.91]), death with graft function (HR 1.51 [95% CI: 1.11, 2.05]), and biopsy-proven acute rejection (HR 2.35 [95% CI: 1.38, 3.99]). A trend toward an increased risk of death-censored graft failure was observed (HR 1.39 [95% CI: 0.96, 2.01]).

Implications for practice: KTR adherence is influenced by both psychosocial and socioeconomic determinants, which impact post-transplant outcomes. Our results emphasize the need for multifaceted interventions to improve patient adherence and further investigation to determine if our results are generalizable to younger patient populations.

---

Critical incident during dialysis treatment: Protocols followed by technologists in AKC-S

Ed Doppler, BSc, EET, CET, Technical Manager, AKC-S
Shripal Parikh, cdt, AScT, Dialysis Tech 2, AKC-S
Clinical Engineering, Alberta Health Services

Hemodialysis treatment is generally considered safe and effective option for managing ESRD.  However, critical incidents can happen resulting in adverse reaction or, in very rare cases, even death of a patient.  It is very important to follow certain protocols post incident to manage risks and to investigate and get to the root of the problem. These protocols also help in protecting patient rights to know and manage risks for the organization. An incident can happen in the dialysis facility or home dialysis setting. In both cases, technologists are involved from the onset as they are responsible for safe and accurate operation of dialysis equipment. The presentation will include an in-depth discussion of protocols followed by technologists at Alberta Kidney Care–South in managing such critical incidents. It will conclude with the importance of documentation and following recommended manufacturers’ guidelines for the repair and maintenance of hemodialysis and related equipment as well as following strict protocols post critical incidents to manage risks.

---

Utilizing artificial intelligence to predict admission risk among in-center hemodialysis patients
Samiksha Singh, MN, NP
Lesley Donovan, MScN, NP
Department of Nephrology, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario

Background: Patients with end-stage kidney disease (ESKD) requiring hemodialysis (HD) have multiple comorbidities and a higher risk of mortality than their age-matched general population. At St. Michael’s Hospital, 280 patients receive HD, and 25% of these patients are admitted to hospital or visit the Emergency Department (ED) in an average month. Many hospitalizations and ED visits may be preventable but are often difficult to anticipate. Early identification of acute medical issues in HD patients is imperative. Collaborating with the Li-Ka Shing Center for Health Care Analytics and Research & Training (LKS-CHART), a prediction tool is being created using artificial intelligence to stratify HD patients’ risk level of hospital admission or ED visit in the subsequent seven days. A standardized clinical pathway will then be implemented prompting closer surveillance and further investigations and interventions for those identified at the highest risk. Hospitalization may be inevitable in some cases; however, this prediction tool could assist us to avoid hospitalization or, if inevitable, bypass ED by directing admission through the inpatient ward.  In conclusion, by utilizing artificial intelligence, we aim to address one of the most vexing challenges in the care of maintenance HD recipients. By enabling HD unit clinicians to target the highest risk patients, we hypothesize that the application of this prediction tool will enhance care delivery to HD patients, increase the efficiency with which resources are utilized, and ultimately help reduce the burden of ED visits and inpatient stays.

---

The effect of taurolidine-based lock solutions as prophylaxis and antithrombotic in central venous access device: An integrative review

Kay Sunshine Acar, Nephrology Nurse
McGill University Health Centre-Royal Victoria Hospital, Montréal, Quebec

Background: To achieve adequate dialysis, suitable vascular access is needed. For elderly patients who have a high prevalence of comorbid conditions, a central line catheter may be a viable option. Central line-associated bloodstream infection (CLABSI) is the most serious and potentially fatal problem. Locking solutions are currently used in practice. Taurolidine is a novel non-toxic substance with no adverse effects or microbial resistance. It reduces catheter-related infections (CRIs) and dysfunction in all hemodialysis patients, including children.

Objectives: To assess the effectiveness of taurolidine-based and combined locking solutions in preventing thrombus formation and infections associated with catheters in adult hemodialysis patients.

Methods: Using Whittemore and Knafl’s (2005) framework for integrative review, an electronic search was conducted using Google Scholar, Springer, Elsevier, Science Direct, Crossref, Cochrane Library, and PubMed databases to find articles from 2012 to 2022. Qualified articles randomized clinical trials that compared the efficacy of taurolidine-based lock (TBL) versus control for prophylaxis and antithrombotic purposes. Nine studies were considered eligible.

Results: The selected studies demonstrated the efficiency of TBL solutions in removing biofilm, thereby, significantly reducing CLABSI and CRIs. The use of taurolidine-urokinase once weekly over a weekend in conjunction with the taurolidine-citrate-heparin solution twice weekly (known as the 2+1 protocol) maximizes this result. TBL is a remarkably cost-efficient in reducing catheter dysfunction and as equally effective as antibiotic prophylaxis. This may be a viable antibiotic alternative. Moreover, the use of high-concentrate citrate over low-dose citrate solutions provides no additional benefits as upheld by the current guidelines. Taurolidine has also been demonstrated to have antineoplastic properties that induce apoptosis. Its use in cancer treatment is plausible in the future.

Conclusions: The use of TBL as a prophylactic and antithrombotic agent is promising, but the studies included have poor quality designs that likely introduce bias.

Implications for nephrology practice: Nurses play a critical part in decreasing the likelihood of infection. TBL as a cost-effective locking solution targets catheter-related infections and dysfunction, which improves the quality of care. Further research should be conducted with large double-blind trials to validate these findings. Hence, the results should be interpreted with prudence.

---

Guiding Best Practise II: Establishing Routine Point of Care Use of Ultrasound in a Haemodialysis Unit
Christine Morton
Carrie Ellis-Driscoll

This presentation will review the experiences and outcomes learned from a hemodialysis unit who implemented point of care ultrasound guided cannulation.
We will look at what teaching techniques were used to promote staff training, what created learning curves, analyse the benefits to routine clinical practise, review troubleshooting enhancements and other discoveries learned along the way of the implementation. This dialysis program did not have ultrasound guided technology readily available to them until the handheld ultrasound was introduced in May 2023. Staff training was smooth and efficient, and provided at the patient chairside thanks to the simplicity and ease of use of the small handheld ultrasound device.

As nurses practicing in units with pre-existing ultrasound technology or those who are yet to experience this technology you will benefit from a comprehensive discussion on vascular health. Learned experiences regarding ultrasound guided cannulation implementation will be reviewed. You will have the opportunity to review training tools which promote vascular access management and health. The importance of effective and safe fistula cannulation will be discussed as well as the benefits of ultrasound guided technology to visualize the integrity and aspects of a patient’s fistula. This extra safety measure encouraged the development of needling plans, a change in staff orientation plans, vascular access documentation/follow-up, and nurse competency and accountability in fistula assessment.