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Rationale: Kidney transplant (KT) recipients have an increased risk of malignancy due to chronic immunosuppression. The emerging use of immune checkpoint inhibitors (ICIs) has been a promising development for the treatment of malignancy, but their use adds to the complexity of immunosuppression management for KT recipients. This case report describes 2 cases of acute rejection in KT recipients following ICI initiation and discusses the balance of malignancy treatment with adequate immunosuppression., Presenting Concerns of Patients: The first patient is a 44-year-old male KT recipient with a diagnosis of metastatic renal cell carcinoma presenting with acute kidney injury 6 days following initiation of an ICI. The second patient is a 73-year-old male KT recipient with a diagnosis of squamous cell carcinoma presenting with acute kidney injury 2 weeks following initiation of an ICI., Diagnoses: Both patients were diagnosed with acute rejection in the setting of reduced immunosuppression and initiation of an ICI., Interventions: Both cases received an increased dose of steroid without improvement of graft function. The first patient subsequently underwent a delayed graft nephrectomy due to complications of acute rejection, whereas the second patient did not undergo nephrectomy., Outcomes: The first patient experienced complications including perioperative bleeding requiring multiple operations, but ultimately stabilized on hemodialysis and showed a durable response to ICI. The second patient remained dialysis-dependent post-ICI treatment and was readmitted with allograft complications leading to his eventual death., Teaching Points: This study underscores the complexity of managing KT recipients diagnosed with malignancy and receiving ICIs. The balance between immunosuppression reduction to treat malignancy and preventing allograft rejection presents a significant challenge. Key considerations include the risk of acute allograft rejection and patient-centered decision-making. These cases highlight the need for further research to develop evidence-based guidelines for managing this patient population. In addition, the patient perspective in this study highlights the importance of careful risk-benefit analysis and the impact of treatment decisions on patient-focused outcomes., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: The relationship between post-operative urine output (UO) following kidney transplantation and long-term graft function has not been well described., Objective: In this study, we examined the association between decreased UO on post-operative day 1 (POD1) and post-transplant outcomes., Design: This is a retrospective cohort study., Setting: Atlantic Canada., Patients: Patients from the 4 Atlantic Canadian provinces (Nova Scotia, New Brunswick, Newfoundland, and Prince Edward Island) who received a live or deceased donor kidney transplant from 2006 through 2019 through the multiorgan transplant program at the Queen Elizabeth II Health Sciences Centre (QEII) hospital in Halifax, Nova Scotia., Measurements: Using multivariable Cox proportional hazards models, we assessed the association of low POD1 UO (defined as ≤1000 mL) with death-censored graft loss (DCGL). In secondary analyses, we used adjusted logistic regression or Cox models as appropriate to assess the impact of UO on delayed graft function (DGF), prolonged length of stay (greater than the median for the entire cohort), and death., Results: Of the 991 patients included, 151 (15.2%) had a UO ≤1000 mL on POD1. Low UO was independently associated with DCGL (hazard ratio [HR] = 4.00, 95% confidence interval [CI] = 95% CI = 1.55-10.32), DGF (odds ratio [OR] = 45.25, 95% CI = 23.00-89.02), and prolonged length of stay (OR = 5.06, 95% CI = 2.95-8.69), but not death (HR = 0.81, 95% CI = 0.31-2.09)., Limitations: This was a single-center, retrospective, observational study and therefore has inherent limitations of generalizability, data collection, and residual confounding., Conclusions: Overall, reduced post-operative UO following kidney transplantation is associated with an increased risk of DCGL, DGF, and prolonged hospital length of stay., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: A.J.V. has received consultancy and fellowship grant funding through Paladin Labs Inc, and K.T. has received advisory board and CME support from Astra Zeneca, Baxter, Bayer, GSK, Otsuka, and Vifor Pharmaceuticals. However, the authors of this manuscript have no conflicts of interest to declare as described by the International Committee of Medical Journal Editors that are relevant to the current submission., (© The Author(s) 2024.)

Purpose of the Conference: The 2022 Banff-Canadian Society of Transplantation Meeting in Banff, Alberta, brought together transplant professionals to review new developments across various aspects of solid organ transplantation (SOT) in Canada., Sources of Information: Presentations included consensus recommendations from expert-led forums; experiences with new procedures and legislation; reports from public health data repositories; original clinical and laboratory research; and industry updates regarding novel technologies. Speakers referenced articles and reports published in peer-reviewed journals and online, and unpublished data and preliminary findings., Methods: All authors attended presentations in-person or virtually. Recordings of select presentations were available for later review. Summaries emphasize concepts indicated by speakers as new and clinically relevant., Key Findings: The COVID-19 pandemic disproportionately affected solid organ transplant recipients (SOTRs), who experience worse outcomes of COVID-19 infection than the general population. Vaccinations demonstrate an attenuated immunological response in SOTRs yet provide meaningful protection. Monoclonal antibodies are effective for both passive immunization and treatment of COVID-19 in SOTRs. Infection control protocols have driven the development of virtual methods for clinical research, such as using home blood draws and virtual follow-up to evaluate vaccine efficacy in SOTRs; and patient care delivery, such as employing telerehabilitation post transplant. Access to living kidney donation is limited by various disincentives experienced by potential donors, which may be overcome by more efficient evaluations including a One-Day Living Kidney Donor Assessment Clinic. The International Donation and Transplantation Legislative and Policy Forum provided a means of establishing consensus guidance for organ donation and transplantation (ODT) program policy to standardize delivery across jurisdictions. The implementation of a deemed consent model for organ and tissue donation in Nova Scotia may provide insight as to whether this model indeed improves access to organs. Canada's Indigenous population experiences unique barriers to transplantation, prompting efforts for more inclusive ODT policy-making. The Pan-Canadian ODT Data and Performance Reporting System Project has defined performance quality indicators, of which iTransplant and other point-of-care software solutions may facilitate collection; however, these endeavors ultimately require information technology infrastructure that exceeds the capabilities of the existing Canadian Organ Replacement Register and Canadian Transplant Registry. Pig-to-human xenotransplantation requires genetic modification of pigs and xenoantibody testing in recipients but may yet prove viable. Serum cell-free DNA, urine biomarkers, and genetic markers offer an alternative to routine biopsy for identifying subclinical rejection. Modified perfusion temperatures and perfusion solutions with hydrogen sulfide donor compounds may improve organ preservation. Molecular compatibility tools provide another means of improving SOTR outcomes, and the Genome Canada Transplant Consortium has been examining important considerations of their implementation., Limitations: We were unable to capture all presentations and topics at the meeting due to the sizable quantity and variety. Topics ultimately excluded from this summary include those in pathology including Banff Classification updates; those unique to extra-renal SOT; as well as numerous abstract and poster presentations, allied health provider forums, and business meetings. A portion of the material was presented by speakers prior to peer-review or publication., Implications: The various conference presentations summarized in this report identify methods by which individual clinicians and provincial ODT programs may improve access, delivery, and quality of SOT care in Canada, while additionally identifying gaps in the literature that investigators are encouraged to pursue., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: Prolonged warm ischemia time (WIT) and cold ischemia time (CIT) are independently associated with post-transplant graft failure; their combined impact has not been previously studied. We explored the effect of combined WIT/CIT on all-cause graft failure following kidney transplantation., Methods: The Scientific Registry of Transplant Recipients was used to identify kidney transplant recipients from January 2000 to March 2015 (after which WIT was no longer separately reported), and patients were followed until September 2017. A combined WIT/CIT variable (excluding extreme values) was separately derived for live and deceased donor recipients using cubic splines; for live donor recipients, the reference group was WIT 10 to <23 minutes and CIT >0 to <0.42 hours, and for deceased donor recipients the WIT was 10 to <25 minutes and CIT 1 to <7.75 hours. The adjusted association between combined WIT/CIT and all-cause graft failure (including death) was analyzed using Cox regression. Secondary outcomes included delayed graft function (DGF)., Results: A total of 137 125 recipients were included. For live donor recipients, patients with prolonged WIT/CIT (60 to ≤120 minutes/3.04 to ≤24 hours) had the highest adjusted hazard ratio (HR) for graft failure (HR = 1.61, 95% confidence interval [CI] = 1.14-2.29 relative to the reference group). For deceased donor recipients, a WIT/CIT of 63 to ≤120 minutes/28 to ≤48 hours was associated with an adjusted HR of 1.35 (95% CI = 1.16-1.58). Prolonged WIT/CIT was also associated with DGF for both groups although the impact was more driven by CIT., Conclusions: Combined WIT/CIT is associated with graft loss following transplantation. Acknowledging that these are separate variables with different determinants, we emphasize the importance of capturing WIT and CIT independently. Furthermore, efforts to reduce WIT and CIT should be prioritized., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: KKT has conducted CME/Advisory board activities for Baxter, Bayer, Astra Zeneca, Outsuka, and GlaxoSmith Kline. AJV has accepted investigator-initiated fellowship grant funding and consultancy funding from Paladin Labs Inc., (© The Author(s) 2023.)

Background: Significant variability in organ acceptance thresholds have been demonstrated across the United States, but data regarding the rate and rationale for kidney donor organ decline in Canada are lacking., Objective: To examine decision making regarding deceased kidney donor acceptance and non-acceptance in a population of Canadian transplant professionals., Design: A survey study of theoretical deceased donor kidney cases of increasing complexity., Setting: Canadian transplant nephrologists, urologists, and surgeons making donor call decisions responding to an electronic survey between July 22 and October 4, 2022., Participants: Invitations to participate were distributed to 179 Canadian transplant nephrologists, surgeons, and urologists through e-mail. Participants were identified by contacting each transplant program and requesting a list of physicians who take donor call., Measurements: Survey respondents were asked whether they would accept or decline a given donor, assuming there was a suitable recipient. They were also asked to cite reasons for donor non-acceptance., Methods: Donor scenario-specific acceptance rates (total acceptance divided by total number of respondents for a given scenario and overall) and reasons for decline were determined and presented as a percentage of the total cases declined., Results: In all, 72 respondents from 7 provinces completed at least one question of the survey, with considerable variability between acceptance rates for centers; the most conservative center declined 60.9% of donor cases, whereas the most aggressive center declined only 28.1%, P -value < .001. There was an increased risk of non-acceptance with advancing age, donation after cardiac death, acute kidney injury, chronic kidney disease, and comorbidities., Limitations: As with any survey, there is the potential for participation bias. In addition, this study examines donor characteristics in isolation, however, asks respondent to assume there is a suitable candidate available. In reality, whenever donor quality is considered, it should be considered in the context of the intended recipient., Conclusion: In a survey of increasingly medically complex deceased kidney donor cases, there was significant variability in donor decline among Canadian transplant specialists. Given relatively high rates of donor decline and apparent heterogeneity in acceptance decisions, Canadian transplant specialists may benefit from additional education regarding the benefits achieved from even medically complex kidney donors for appropriate candidates relative to remaining on dialysis on the transplant waitlist., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: Patients receiving maintenance hemodialysis frequently require ambulance transport to the emergency department (ambulance-ED transport). Identifying predictors of outcomes after ambulance-ED transport, especially the need for timely dialysis, is important to health care providers., Objective: The purpose of this study was to derive a risk-prediction model for urgent dialysis after ambulance-ED transport., Design: Observational cohort study., Setting and Patients: All ambulance-ED transports among incident and prevalent patients receiving maintenance hemodialysis affiliated with a regional dialysis program (catchment area of approximately 750 000 individuals) from 2014 to 2018., Measurements: Patients' vital signs (systolic blood pressure, oxygen saturation, respiratory rate, and heart rate) at the time of paramedic transport and time since last dialysis were utilized as predictors for the outcome of interest. The primary outcome was urgent dialysis (defined as dialysis in a monitored setting within 24 hours of ED arrival or dialysis within 24 hours with the first ED patient blood potassium level >6.5 mmol/L) for an unscheduled indication. Secondary outcomes included, hospitalization, hospital length of stay, and in-hospital mortality., Methods: A logistic regression model to predict outcomes of urgent dialysis. Discrimination and calibration were assessed using the C-statistic and Hosmer-Lemeshow test., Results: Among 878 ED visits, 63 (7.2%) required urgent dialysis. Hypoxemia (odds ratio [OR]: 4.04, 95% confidence interval [CI]: 1.75-9.33) and time from last dialysis of 24 to 48 hours (OR: 3.43, 95% CI: 1.05-11.9) and >48 hours (OR: 9.22, 95% CI: 3.37-25.23) were strongly associated with urgent dialysis. A risk-prediction model incorporating patients' vital signs and time from last dialysis had good discrimination (C-statistic 0.8217) and calibration (Hosmer-Lemeshow goodness of fit P value .8899). Urgent dialysis patients were more likely to be hospitalized (63% vs 34%), but there were no differences in inpatient mortality or length of stay., Limitations: Missing data, requires external validation., Conclusion: We derived a risk-prediction model for urgent dialysis that may better guide appropriate transport and care for patients requiring ambulance-ED transport., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: Kidney transplantation is the optimal treatment for an individual requiring kidney replacement therapy, resulting in improved survival and quality of life while costing the health care system less than maintenance dialysis. Achieving and maintaining a kidney transplant requires extensive coordination of several different health care services. To improve the quality of kidney transplant care, quality metrics or indicators that encompass all aspects of the individual's journey to transplant should be measured in a standardized fashion., Objective: To identify, categorize, and evaluate strengths and weaknesses of kidney transplant quality indicators currently being used across Canada., Design: An environmental scan of quality indicators being used by kidney organizations and programs., Setting: A 16-member volunteer pan-Canadian panel with expertise in nephrology, transplant, and quality improvement., Sample: Transplant programs, as well as provincial transplant and kidney agencies across Canada., Methods: Indicators were first categorized based on the period of transplant care and then using the Institute of Medicine and Donabedian frameworks. A 4-member subcommittee rated each indicator using a modified version of the Delphi consensus technique based on the American College of Physician/Agency for Healthcare Research and Quality criteria. Consensus ratings were subsequently shared with the entire 16-member panel for additional comments., Results: We identified 46 measures related to transplant care across 7 Canadian provinces (9 referral and evaluation, 9 waitlist activity and outcomes, 6 hospitalization for transplant surgery, 12 posttransplant care, 6 organ utilization, 4 living donor). We rated 24 indicators (52%) as necessary to distinguish high-quality from low-quality care, most of which measured effective (n = 10) or efficient (n = 6) care. Only 7 (15%) of 46 indicators evaluated person-centered or equitable care. Fourteen common indicators were measured by 5 of 7 provinces, 10 of which were deemed "necessary," measuring safe (n = 2), effective (n = 5), efficient (n = 2), and equitable (n = 1) care., Limitations: The panel lacked patient and allied health representation., Conclusions: There are a large number of kidney transplant quality indicators currently being used in Canada, some of which are common across provinces and focus primarily on measuring effective care. Person-centered and equitable care indicators were lacking, and only half of these indicators were deemed "necessary" for quality improvement. Our results should complement ongoing work to achieve national consensus on the standardization of quality indicators in kidney transplantation., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: T.G. has participated in consultancy for Paladin Labs Inc. A.V. has participated in advisory boards/consultancy work for Paladin Labs Inc. S.A.S. has received speaking fees from Sanofi and Baxter Canada. S.Y. has no conflicts of interest relevant to this study. All authors approved the final version of the submitted manuscript. We certify that this manuscript nor one with substantially similar content has been published or is being considered for publication elsewhere., (© The Author(s) 2021.)

Background: Live donor (LD) kidney transplantation is the best option for patients with end-stage kidney disease (ESKD). However, this may not be the best option if a patient's donor is older and considerably smaller in weight. Patient (A) with a less than ideal donor (Donor A) might enter into a live donor paired exchange (LDPE) program with the hopes of swapping for a better-quality organ. A second patient (B) who is in the LDPE may or may not benefit from this exchange with Donor A., Methods: This medical decision analysis examines the conditions that favor Patient A entering into the LDPE compared to directly accepting a kidney from their intended donor, as well as the circumstances where Patient B also benefits by accepting a lower-quality organ., Results: Under select circumstances, a paired exchange could benefit both Patients A and B. For example, a 30-year-old Patient A with a lower-quality donor might gain 1.20 1.52 1.84 quality adjusted life years (QALYs) by entering into a LDPE for a better-quality kidney, whereas a 60-year-old Patient B might gain 0.93 1.03 1.13 QALYs by accepting Donor A's kidney rather than waiting longer in the LDPE. The net benefit (or loss) of entering the LDPE differs by recipient age, donor organ quality, likelihood of Patient B being transplanted in LDPE, and likelihood of Patient A finding an ideal donor in the LDPE., Conclusion: This study shows there are ways to increase live donor utilization and effectiveness that require further research and potentially changes to the LDPE process., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Background: Routine testing of hemodialysis patients for COVID-19 (outside of those identified as "at risk" based on regional practice) is not universally recommended. However, there is variability in the clinical presentation of COVID-19; patients may experience symptoms that do not meet regional criteria for testing and some patients with active infection may be asymptomatic. To avoid missing individuals who are infected, consideration could be made for regular screening, particularly among those residing in areas with evidence of community spread., Objective: To describe the clinical characteristics, symptom burden, and COVID-19 status in a cross-section of hemodialysis patients residing in areas with evidence of community spread., Design: Cross-sectional study., Setting: Three hemodialysis units in a large tertiary care facility in Nova Scotia, Canada., Patients: In-center hemodialysis patients who resided in areas with evidence of community transmission at the time of the study., Methods: All dialysis patients (irrespective of whether or not they resided in areas with community spread) completed a standard "at-risk" questionnaire for COVID-19 based on (1) 2 or more of new or worsening cough, fever greater than 38°C, sore throat, headache, runny nose/new or acute respiratory illness consistent with infection or (2) any one of close contact with a known/suspected case, travel outside of the province or residence in a facility with an outbreak prior to entry into the dialysis unit at each treatment. Patients residing in areas with evidence of community spread were swabbed for SARS-CoV-2 over a 1-week period (May 1-7, 2020) using a combined oropharyngeal/nares swab irrespective of whether or not they were identified as "at-risk.", Measurements: Baseline characteristics of patients were acquired using electronic records. In addition to the "at-risk" questionnaire, patients answered "yes" or "no" to any of the following symptoms at the time of the swab (sneeze, fatigue, myalgia, nausea/vomiting, diarrhea, malaise, abdominal pain, loss of taste, and loss of smell)., Results: Of the 334 patients receiving dialysis at the time of the study, 133 resided in areas with evidence of community transmission and 104 consented for the study. No patients met our regional criteria for being "at-risk" and no patients reported cough, sore throat or fever at the time of swab. Many other symptoms were noted, including sneezing (24%), fatigue (16%), myalgias (11%), nausea/vomiting (11%), loss of taste (4%), and loss of smell (4%). Overall, 100% of swabs performed for this study were negative for SARS-CoV-2., Limitations: Single-center study, and the daily new case rate was exceedingly low (4-14) at the time of the study, emphasizing that the findings are not generalizable to areas of higher prevalence of SARS-CoV-2., Conclusions: In this study of hemodialysis patients residing in areas with community spread who otherwise did not meet symptom criteria for being "at-risk," we did not identify any individual who tested positive for SARS-CoV-2. Future studies are needed to examine the utility of routine testing for COVID-19 (outside of those who are "at-risk") in areas of higher disease prevalence., Trial Registration: Not applicable as this is not a clinical trial., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Purpose of Review: (1) To provide commentary on the 2017 update to the Kidney Disease Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD); (2) to apply the evidence-based guideline update for implementation within the Canadian health care system; (3) to provide comment on the care of children with chronic kidney disease (CKD); and (4) to identify research priorities for Canadian patients., Sources of Information: The KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD., Methods: The commentary committee co-chairs selected potential members based on their knowledge of the Canadian kidney community, aiming for wide representation from relevant disciplines, academic and community centers, and different geographical regions., Key Findings: We agreed with many of the recommendations in the clinical practice guideline on the diagnosis, evaluation, prevention, and treatment of CKD-MBD. However, based on the uncommon occurrence of abnormalities in calcium and phosphate and the low likelihood of severe abnormalities in parathyroid hormone (PTH), we recommend against screening and monitoring levels of calcium, phosphate, PTH, and alkaline phosphatase in adults with CKD G3. We suggest and recommend monitoring these parameters in adults with CKD G4 and G5, respectively. In children, we agree that monitoring for CKD-MBD should begin in CKD G2, but we suggest measuring ionized calcium, rather than total calcium or calcium adjusted for albumin. With regard to vitamin D, we suggest against routine screening for vitamin D deficiency in adults with CKD G3-G5 and G1T-G5T and suggest following population health recommendations for adequate vitamin D intake. We recommend that the measurement and management of bone mineral density (BMD) be according to general population guidelines in CKD G3 and G3T, but we suggest against routine BMD testing in CKD G4-G5, CKD G4T-5T, and in children with CKD. Based on insufficient data, we also recommend against routine bone biopsy in clinical practice for adults with CKD or CKD-T, or in children with CKD, although we consider it an important research tool., Limitations: The committee relied on the evidence summaries produced by KDIGO. The CSN committee did not replicate or update the systematic reviews., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: R.M.H. has received investigator-initiated research funding from OPKO Health, Inc (OPKO Renal Division) and Sanofi. R.A.M. has received research funding from the Patient-Centered Outcomes Research Institute (PCORI), the American Society of Hematology (ASH), and the American College of Rheumatology (ACR). R.T.A. has received consulting honoraria from Ardelyx, Inc and from Advicenne. M.B. has received honoraria for advisory board membership with Otsuka Canada Pharmaceutical Inc (OCPI) and AstraZeneca. M.U.B. has received honoraria for consultation, advisory board membership, speaking engagements, or research funding from Janssen, OCPI, and Sanofi. G.K. declared no conflicts of interest. F.M.-W. has received honoraria for conferences, advisory board membership, or research funding from Amgen Inc, Otsuka Canada Pharmaceutical Inc, and Sanofi. M.R. declared no conflicts of interest. R.W. declared no conflicts of interest. P.D.A. declared no conflicts of interest. P.F. has no conflicts of interest. A.G. declared no conflicts of interest. K.K.J. has received honoraria for consultation or advisory board membership from Boehringer Ingelheim, Baxter, Amgen Inc, Sanofi, Eli Lilly and Company, LEO Pharma Inc Canada, and AstraZeneca. M.K. declared no conflicts of interest. B.A.K. declared no conflicts of interest. S.M. has received honoraria for consultation, advisory board membership, research funding, unrestricted grants, and educational grants from the Ontario Ministry of Health, NGX, Health Canada, Nutrigenomix Inc, Mitacs, Central East Local Health Integration Network, Ontario Renal Network (ORN), Sanofi, Shire, Amgen Inc, Sanofi Genzyme, Boehringer Ingelheim, and Baxter. K.M. declared no conflicts of interest. A.M. declared no conflicts of interest. M.P. declared no conflicts of interest. C.R. declared no conflicts of interest. S.D.S. has received honoraria for consultation, advisory board membership, and Canadian Medical Education (CME) lectures from the, Sanofi, Pfizer Inc, Janssen Inc, Amgen Inc, and Otsuka Canada Pharmaceutical Inc. A.J.V. has received honoraria for consultation from Paladin Labs Inc. D.Z. has received investigator-initiated research funding from Sanofi and has been a member of advisory boards for Otsuka Canada Pharmaceutical Inc, and Amgen Inc. C.M.C. has received honoraria for consultation, advisory board membership, or research funding from the Ontario Ministry of Health, Sanofi, Pfizer Inc, LEO Pharma Inc Canada, Astellas, Janssen Inc, Amgen Inc, Boehringer Ingelheim, and Baxter., (© The Author(s) 2020.)

Background: Dialysis patients have reduced moderate to vigorous physical activity, and light physical activity. This has been shown in self-reported surveys and objective accelerometer studies. Less attention has been directed toward sedentary behavior, which is characterized by low energy expenditure (≤1.5 metabolic equivalents). Furthermore, locations where physical activity and sedentary behavior occur are largely unknown for dialysis patients., Objectives: The objectives of this study were (1) to determine the minutes per day of moderate to vigorous physical activity, light physical activity, and sedentary behavior for hemodialysis patients; (2) to describe differences in moderate to vigorous physical activity, light physical activity, and sedentary behavior comparing dialysis versus nondialysis days; and (3) to describe the locations where moderate to vigorous physical activity, light physical activity, and sedentary behavior occur using global positioning system (GPS) data., Design: Cross-sectional study., Setting: The study was performed at a tertiary care hospital in Nova Scotia, Canada., Patients: A total of 50 adult in-center hemodialysis patients consented to the study., Measurements: Physical activity and sedentary behavior were measured with an Actigraph-GT3X accelerometer. Location was determined using a Qstarz BT-Q1000X GPS receiver., Methods: Minutes of daily activity were described as was percentage of wear time for each activity level across different locations during waking hours. Physical activity intensity, quantity, and location were also analyzed according to dialysis vs nondialysis days., Results: Forty-three patients met requirements for accelerometer analysis, of whom 42 had GPS data. Median wear time was 836.5 min/day (interquartile range [IQR]: 788.3-918.3). Median minutes of daily wear time spent in sedentary behavior, light physical activity, and moderate to vigorous physical activity was 636 minutes (IQR: 594.1-730.1), 178 minutes (IQR: 144-222.1), and 1.6 minutes (IQR: 0.6-7.7), respectively. Proportion of daily wear time spent in sedentary behavior, light physical activity, and moderate to vigorous physical activity was 78.4% (IQR: 70.7-84.0), 21.5% (IQR: 16.0-26.9), and 0.2% (IQR: 0.1-1.1), respectively. Home was the dominant location for total linked accelerometer-GPS time (59.4%, IQR: 46.9-69.5) as well as for each prespecified level of activity. Significantly more sedentary behavior and less light physical activity occurred on dialysis days compared with nondialysis days ( P ≤ .01, respectively). Moderate to vigorous physical activity did not differ significantly between dialysis and nondialysis days., Limitations: Small sample size from a single academic center may limit generalizability. Difficult to engage population as less than half of eligible dialysis patients provided consent. Physical activity may have been underestimated as devices were not worn for all waking hours or aquatic activities, and hip-based accelerometers may not capture stationary exercise., Conclusions: Ambulatory, in-center hemodialysis patients exhibit substantial sedentary behavior and minimal physical activity across a limited range of locations. Given the sedentary tendencies of this population, focus should be directed on increasing physical activity at any location frequented. Home-based exercise programs may serve as a potential adjunct to established intradialytic-based therapies given the amount of time spent in the home environment., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose of Review: Many observational studies have demonstrated a survival benefit with home dialysis compared with in-center dialysis; however, results have been conflicting. The purpose of this review was to identify pitfalls and limitations in existing literature and examine the challenges of studying home and in-center dialysis populations., Sources of Information: Original research articles were identified from MEDLINE using search terms "in-center hemodialysis," "home hemodialysis," "conventional hemodialysis," "nocturnal hemodialysis," and "short daily hemodialysis.", Methods: A focused review and critical appraisal of existing home versus in-center hemodialysis survival literature was conducted to identify potential causes for variability in the observed survival outcomes., Key Findings: The controversy in existing literature stems from the challenges of randomizing patients to home versus in-center hemodialysis modalities, and therefore a reliance on observational comparisons for study. In many cases, these observational analyses have been limited by selection bias (variabilities in populations included, inclusion of both incident and prevalent cohorts, and variabilities in dialysis intensity), as well as residual confounding. Furthermore, the studies that do exist lack generalizability in many cases., Limitations: There are few randomized controlled trials examining the survival benefit of home versus in-center hemodialysis and existing observational studies are often limited by bias and reduced generalizability. These limitations comprise the body of this review., Implications: This review examines challenges surrounding survival comparisons with home versus in-center hemodialysis and identify important directions for future study., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.P. has received speaking honoraria from Baxter Healthcare, Amgen Canada, and DaVita Healthcare Partners and has consulting fees from Amgen, Boehringer Ingelheim Canada, Baxter Healthcare, Otsuka, Janssen Ortho Shire, and Takeda, as well as research support from Baxter Healthcare and salary support from Arbor Research Collaborative for Health. K.K.T. has received unrestricted grant funding from Astellas, Canada, and Otsuka, Canada, and has done consulting work for Otsuka and Astra Zeneca.

Background: Dialysis patients who require ambulance transport to the emergency department ("ambulance-ED") may subsequently require timely dialysis in a monitored setting ("urgent dialysis")., Objective: The purpose of this study was to develop and internally validate a risk prediction model for urgent dialysis based on patient characteristics at the time of paramedic assessment before ambulance-ED., Design: Cohort Study., Setting: Region of Nova Scotia, Canada, covered by a single emergency medical services provider., Patients: Thrice-weekly hemodialysis patients who initiated dialysis between 2009 and 2013 (follow-up to 2015) and experienced one or more ambulance-ED events., Measurements: The primary outcome ("urgent dialysis") was defined as dialysis within 24 hours of an ambulance-ED in a monitored setting or dialysis within 24 hours of an ambulance-ED with an initial ED potassium of >6.5 mmol/L. Predictors of urgent dialysis based on paramedic assessment before ambulance-ED included presenting complaint, vital signs and time from last dialysis to ambulance dispatch., Methods: Associations with urgent dialysis were analyzed using logistic regression from which a risk prediction model was created. The model was internally validated using bootstrapping and model performance was assessed by discrimination and calibration., Results: Among 197 patients, there were 624 ambulance-ED events and 87 episodes of urgent dialysis. Weakness as a presenting complaint (odds ratio [OR]: 4.62, 95% confidence interval [CI]: 1.23-17.29), >24 hours since last dialysis (OR: 2.09, 95% CI: 1.15-3.81), and vital signs, including heart rate <60 beats/minute (OR: 3.06, 95% CI: 1.09-8.61), oxygen saturation <90% (OR: 3.04, 95% CI: 1.55-5.94), elevated respiratory rate (≥20 breaths/min), and systolic blood pressure>160 mmHg, were associated with urgent dialysis after ambulance-ED. A risk prediction model incorporating these variables had very good discrimination (C-statistic: 0.81, 95% CI: 0.76-0.86). The negative predictive value was 93.6% using the optimal cut point. Of patients who were predicted to need urgent dialysis but were transported to a facility incapable of providing it, 31% were re-transported for urgent dialysis., Limitations: Findings of our study may not be generalizable to other centers where the practice of ambulance transfer and availability of monitored dialysis may differ, and data were lacking for potential missed dialysis sessions or changes in routine dialysis scheduling., Conclusions: Patient characteristics at the time of paramedic assessment are associated with urgent dialysis after ambulance-ED. This risk prediction model has the potential to guide dialysis patient transport to dialysis-capable facilities when needed., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: KT has no direct conflicts of interest relevant to the current area of research. KT has done advisory work for AstraZeneca and Otsuka, Canada. All other authors have no conflicts of interest to declare.