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Purpose of the Program: This article provides guidance on optimizing the management of pediatric patients with end-stage kidney disease (ESKD) who will be or are being treated with any form of home or in-center dialysis during the COVID-19 pandemic. The goals are to provide the best possible care for pediatric patients with ESKD during the pandemic and ensure the health care team's safety., Sources of Information: The core of these rapid guidelines is derived from the Canadian Society of Nephrology (CSN) consensus recommendations for adult patients recently published in the Canadian Journal of Kidney Health and Disease ( CJKHD ). We also consulted specific documents from other national and international agencies focused on pediatric kidney health. Additional information was obtained by formal review of the published academic literature relevant to pediatric home or in-center hemodialysis., Methods: The Leadership of the Canadian Association of Paediatric Nephrologists (CAPN), which is affiliated with the CSN, solicited a team of clinicians and researchers with expertise in pediatric home and in-center dialysis. The goal was to adapt the guidelines recently adopted for Canadian adult dialysis patients for pediatric-specific settings. These included specific COVID-19-related themes that apply to dialysis in a Canadian environment, as determined by a group of senior renal leaders. Expert clinicians and nurses with deep expertise in pediatric home and in-center dialysis reviewed the revised pediatric guidelines., Key Findings: We identified 7 broad areas of home dialysis practice management that may be affected by the COVID-19 pandemic: (1) peritoneal dialysis catheter placement, (2) home dialysis training, (3) home dialysis management, (4) personal protective equipment, (5) product delivery, (6) minimizing direct health care providers and patient contact, and (7) caregivers support in the community. In addition, we identified 8 broad areas of in-center dialysis practice management that may be affected by the COVID-19 pandemic: (1) identification of patients with COVID-19, (2) hemodialysis of patients with confirmed COVID-19, (3) hemodialysis of patients not yet known to have COVID-19, (4) management of visitors to the dialysis unit, (5) handling COVID-19 testing of patients and staff, (6) safe practices during resuscitation procedures in a pandemic, (7) routine hemodialysis care, and (8) hemodialysis care under fixed dialysis resources. We make specific suggestions and recommendations for each of these areas., Limitations: At the time when we started this work, we knew that evidence on the topic of pediatric dialysis and COVID-19 would be severely limited, and our resources were also limited. We did not, therefore, do formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. Thus, this article's advice and recommendations are primarily expert opinions and subject to the biases associated with this level of evidence. To expedite the publication of this work, we created a parallel review process that may not be as robust as standard arms' length peer-review processes., Implications: We intend these recommendations to help provide the best care possible for pediatric patients prescribed in-center or home dialysis during the COVID-19 pandemic, a time of altered priorities and reduced resources., 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.)

Purpose of Program: This article will provide guidance on how to best manage patients with glomerulonephritis (GN) during the COVID-19 pandemic., Sources of Information: We reviewed relevant published literature, program-specific documents, and guidance documents from international societies. An informal survey of Canadian nephrologists was conducted to identify practice patterns and expert opinions. We hosted a national webinar with invited input and feedback after webinar., Methods: The Canadian Society of Nephrology (CSN) Board of Directors invited physicians with expertise in GN to contribute. Specific COVID-19-related themes in GN were identified, and consensus-based recommendations were made by this group of nephrologists. The recommendations received further peer input and review by Canadian nephrologists via a CSN-sponsored webinar. This was attended by 150 kidney health care professionals. The final consensus recommendations also incorporated review by Editors of the Canadian Journal of Kidney Health and Disease ., Key Findings: We identified 9 areas of GN management that may be affected by the COVID-19 pandemic: (1) clinic visit scheduling, (2) clinic visit type, (3) provision of multidisciplinary care, (4) blood and urine testing, (5) home-based monitoring essentials, (6) immunosuppression, (7) other medications, (8) patient education and support, and (9) employment., Limitations: These recommendations are expert opinion, and are subject to the biases associated with this level of evidence. To expedite the publication of this work, a parallel review process was created that may not be as robust as standard arm's length peer review processes., Implications: These recommendations are intended to provide optimal care during the COVID-19 pandemic. Our recommendations may change based on the evolving evidence., 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: To collate best practice recommendations on the management of patients receiving in-center hemodialysis during the COVID-19 pandemic, based on published reports and current public health advice, while considering ethical principles and the unique circumstances of Canadian hemodialysis units across the country., Sources of Information: The workgroup members used Internet search engines to retrieve documents from provincial and local hemodialysis programs; provincial public health agencies; the Centers for Disease Control and Prevention; webinars and slides from other kidney agencies; and nonreviewed preprints. PubMed was used to search for peer-reviewed published articles. Informal input was sought from knowledge users during a webinar., Methods: Challenges in the care of hemodialysis patients during the COVID-19 pandemic were highlighted within the Canadian Senior Renal Leaders Forum discussion group. The Canadian Society of Nephrology (CSN) developed the COVID-19 rapid response team (RRT) to address these challenges. They identified a pan-Canadian team of clinicians and administrators with expertise in hemodialysis to form the workgroup. One lead was chosen who drafted the initial document. Members of the workgroup reviewed and discussed all recommendations in detail during 2 virtual meetings on April 7 and April 9. Disagreements were resolved by consensus. The document was reviewed by the CSN COVID-19 RRT, an ethicist, an infection control expert, a community nephrologist, and a patient partner. Content was presented during an interactive webinar on April 11, 2020 attended by 269 kidney health professionals, and the webinar and first draft of the document were posted online. Final revisions were made based on feedback received until April 13, 2020. CJKHD editors reviewed the parallel process peer review and edited the manuscript for clarity., Key Findings: Recommendations were made under the following themes: (1) Identification of patients with COVID-19 in the dialysis unit, (2) hemodialysis of patients with confirmed COVID-19, (3) hemodialysis of patients not yet known to have COVID-19, (4) visitors; (5) testing for COVID-19 in the dialysis unit; (6) resuscitation, (6) routine hemodialysis care, (7) hemodialysis care under fixed dialysis resources., Limitations: Because of limitations of time and resources, and the large number of questions, formal systematic review was not undertaken. The recommendations are based on expert opinion and subject to bias. The parallel review process that was created may not be as robust as the standard peer review process., Implications: We hope that these recommendations provide guidance for dialysis unit directors, clinicians, and administrators on how to limit risk from infection and adverse outcomes, while providing necessary dialysis care in a setting of finite resources. We also identify a number of resource allocation priorities, which we hope will inform decisions at provincial funding agencies., 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 Program: To provide guidance on the management of patients with advanced chronic kidney disease (CKD) not requiring kidney replacement therapy during the COVID-19 pandemic., Sources of Information: Program-specific documents, pre-existing, and related to COVID-19; documents from national and international kidney agencies; national and international webinars, including webinars that we hosted for input and feedback; with additional information from formal and informal review of published academic literature., Methods: Challenges in the care of patients with advanced CKD during the COVID-19 pandemic were highlighted within the Canadian Senior Renal Leaders Forum discussion group. The Canadian Society of Nephrology (CSN) developed the COVID-19 rapid response team (RRT) to address these challenges. They identified a lead with expertise in advanced CKD who identified further nephrologists and administrators to form the workgroup. A nation-wide survey of advanced CKD clinics was conducted. The initial guidance document was drafted and members of the workgroup reviewed and discussed all suggestions in detail via email and a virtual meeting. Disagreements were resolved by consensus. The document was reviewed by the CSN COVID-19 RRT, an ethicist and an infection control expert. The suggestions were presented at a CSN-sponsored interactive webinar, attended by 150 kidney health care professionals, for further peer input. The document was also sent for further feedback to experts who had participated in the initial survey. Final revisions were made based on feedback received until April 28, 2020. Canadian Journal of Kidney Health and Disease (CJKHD) editors reviewed the parallel process peer review and edited the manuscript for clarity., Key Findings: We identified 11 broad areas of advanced CKD care management that may be affected by the COVID-19 pandemic: (1) clinic visit scheduling, (2) clinic visit type, (3) provision of multidisciplinary care, (4) bloodwork, (5) patient education/support, (6) home-based monitoring essentials, (7) new referrals to multidisciplinary care clinic, (8) kidney replacement therapy, (9) medications, (10) personal protective equipment, and (11) COVID-19 risk in CKD. We make specific suggestions for each of these areas., Limitations: The suggestions in this paper are expert opinion, and subject to the biases associated with this level of evidence. To expedite the publication of this work, a parallel review process was created that may not be as robust as standard arms' length peer-review processes., Implications: These suggestions are intended to provide guidance for advanced CKD directors, clinicians, and administrators on how to provide the best care possible during a time of altered priorities and reduced resources., 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.)

Background: Chronic kidney disease is more prevalent among First Nations people than in non-First Nations people. Emerging research suggests that First Nations people are subject to greater disease burden than non-First Nations people., Objective: We aimed to identify the severity of chronic kidney disease and quantify the geographical challenges of obtaining kidney care by Saskatchewan's First Nations people., Design: This study is a retrospective analysis of the provincial electronic medical record clinical database from January 2012 to December 2013., Setting: The setting involved patients followed by the Saskatchewan provincial chronic kidney care program, run out of two clinics, one in Regina, SK, and one in Saskatoon, SK., Patients: The patients included 2478 individuals (379 First Nations and 2099 non-First Nations) who were older than 18 years old, resident in Saskatchewan, and followed by the provincial chronic kidney care program. First Nations individuals were identified by their Indigenous and Northern Affairs Canada (INAC) Number., Measurements: The demographics, prevalence, cause of end-stage renal disease, severity of chronic kidney disease, use of home-based therapies, and distance traveled for care among patients are reported., Methods: Data were extracted from the clinical database used for direct patient care (the provincial electronic medical record database for the chronic kidney care program), which is prospectively managed by the health care staff. Actual distance traveled by road for each patient was estimated by a Geographic Information System Analyst in the First Nations and Inuit Health Branch of Health Canada., Results: Compared with non-First Nations, First Nations demonstrate a higher proportion of end-stage renal disease (First Nations = 33.0% vs non-First Nations = 21.4%, P < .001), earlier onset of chronic kidney disease (M FN = 56.4 years, SD = 15.1; M NFN = 70.6 years, SD = 14.7, P < .001), and higher rates of end-stage renal disease secondary to type 2 diabetes (First Nations = 66.1% vs non-First Nations = 39.0%, P < .001). First Nations people are also more likely to be on dialysis (First Nations = 69.7% vs non-First Nations = 40.2%, P < .001), use home-based therapies less frequently (First Nations = 16.2% vs non-First Nations = 25.7%; P = 003), and must travel farther for treatment ( P < .001), with First Nations being more likely than non-First Nations to have to travel greater than 200 km., Limitations: Patients who are followed by their primary care provider or solely through their nephrologist's office for their chronic kidney disease would not be included in this study. Patients who self-identify as Aboriginal or Indigenous without an INAC number would not be captured in the First Nations cohort., Conclusions: In Saskatchewan, First Nations' burden of chronic kidney disease reveals higher severity, utilization of fewer home-based therapies, and longer travel distances than their non-First Nations counterparts. More research is required to identify innovative solutions within First Nations partnering communities., 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.

Background: Nephrology was previously identified as a subspecialty with few Canadian employment opportunities, and in recent years, fewer trainees are choosing nephrology., Objective: The objective of this study is to better understand the current Canadian adult nephrology workforce and the expected workforce trends over the next 5 years., Design: This is an online self-administered survey., Setting: This study is set in Canada., Survey Participants: Survey participants are Canadian adult nephrologists, including self-identified division heads., Measurements: The measurements of this study are demographics, training, current practice characteristics, work hours, and projected workforce needs., Methods: Survey questions were based on previous workforce surveys. Ethics approval was obtained through the University of Saskatchewan. The survey was piloted in both English and French and modified based on the feedback to ensure that responses accurately reflected the information desired. It was circulated to all identified Canadian nephrologists via an anonymous e-mail link for self-administration. Categorical data was aggregated, and free-text answers were thematically analyzed. Additional descriptive analysis was conducted by all authors., Results: Five hundred ninety-two Canadian nephrologists were contacted and 48 % responded, with representation from all Canadian provinces. One third of the respondents were female, and the largest age cohort was 41-50 years. Most nephrologists are trained in Canada and 61 % completed additional training. The majority of the respondents (69.1 %) began working as a nephrologist immediately upon completion of fellowship training. Younger nephrologists reported more challenges in finding a job. Eighty percent of responding nephrologists were satisfied with their current work hours, 13.1 % will reduce work hours within 3 years, an additional 8.2 % will reduce work hours within 5 years, and a further 14.2 % will reduce work hours within 10 years. Nephrology division heads forecasted the number of clinical and academic nephrologists needed for the next 3 and 5 years., Limitations: The response rate was 48 %. Forecasted workforce needs are not indicative of guaranteed future positions., Conclusions: This Canadian Society of Nephrology workforce survey demonstrated the current workforce demographics, individual nephrologist future workforce plans, and projected nephrology division requirements for the next 3 and 5 years. Further work will need to be done to refine Canadian nephrology workforce planning with the development of a robust strategy that encompasses both societal and nephrologists' needs with the realities of employment.

Introduction: The Canadian Organ Replacement Register (CORR) is the only Canadian information system on kidney and extra-kidney organ failure and transplantation in Canada. CORR's mandate is to record and analyze the level of activity and outcomes of vital organ transplantation and treatment of end stage kidney disease using dialysis, either hemodialysis or peritoneal dialysis, activities across Canada. The Canadian Organ Replacement Register was officially launched in 1987, and it included transplantation of extra-renal vital organs (liver, heart, lung, pancreas, bowel), in addition to renal transplantation and replacement therapy, with new financial support from the provinces., Objective: This manuscript describes the process of data acquisition and reporting, focusing on the patients with end stage kidney disease on dialysis, with data reported from the 2014 CORR Annual Data Report and the Center-Specific Reports on Clinical Measures., Methods: CORR is currently housed in the Canadian Institute for Health Information and collects data from hospital dialysis programs, regional transplant programs, organ procurement organizations and kidney dialysis services offered at independent health facilities. Data on patients is collected by completion of survey forms for each patient at the start of dialysis or receiving a transplant, using the Initial Registration form, and yearly follow up forms, which collects data on the status of the patient as of October 31(st)., Results: The incident rate per million population (RPMP) has remained stable with the exception of the 65+ age group with has experience a modest decrease since 2001. However, there has been an increasing prevalence of ESKD diagnoses, with the highest rate per million population (RPMP) amongst the age group 65+ years. This is likely attributed to gradual improving patient survival. Between 2003 and 2012, nearly 90% of dialysis patients younger than <18 and 26% of patients 75+ years survived for at least five years., Conclusion: As the number of people treated for end-stage organ failure grows, so does the importance of understanding their treatment and outcomes. In 2014, CORR continues to evolve and support the important information need to advance ESRD research and clinical practice.

There is not yet a universally accepted protocol for the recovery of microorganisms causing peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD). We prospectively analyzed 343 peritoneal effluent specimens by three protocols: 1) 10 ml of effluent centrifuged and the pellet plated onto blood, MacConkey agars, and into thioglycolate broth (routine method); 2) 5 ml and 10 ml inoculated at the bedside into Bactec 16A and 26A aerobic resin-containing blood culture bottles, respectively; and 3) 5 ml and 10 ml inoculated in the laboratory into Bactec 16A and 26A media, respectively. One hundred and forty (41%) peritoneal effluent specimens had microorganisms recovered, and, of these, 101 were recovered by routine culture compared to 117 (p < .021), 125 (p < .0001), 115 (p < .047), and 116 (p < .032) for bedside-inoculated 16A and 26A and for laboratory-inoculated 16A and 26A, respectively. Bedside-inoculated bottles were not significantly better than laboratory-inoculated bottles, and high-volume bottles were not significantly better than low-volume bottles for detection of patients positive for microorganisms; however, the number of total microorganisms recovered were significantly better from all inoculated blood culture bottles compared to routine culture. Bedside- and laboratory-inoculated resin-containing blood culture bottles are superior to the routine method for recovery of microorganisms causing peritonitis in CAPD patients.

Background: Previously, we identified an antimitogenic IgG antibody separated from sera of patients with known kidney transplant chronic rejection. This antibody inhibits individual patients' own unprimed T helper cell responses to alloantigens as well as a third-party mixed lymphocyte response, but does not inhibit autologous unprimed T helper cell proliferation to adherent anti-CD3 antibody. We suggest that the mechanism of inhibitory action is allogeneic-dependent., Methods: We used a series of similar experimental designs to test the presence of this antibody in uremic, sensitized patients and have studied its relationship to sensitization as defined by the presence of lymphocytotoxins in four uremic groups: highly sensitized with or without previous graft loss, moderately sensitized with or without graft loss, nonsensitized without previous graft loss, and nonsensitized with graft loss., Results: (1) Sensitization is associated with the presence of a potent antibody that blocks primary mixed lymphocyte response. Primed cells are less susceptible to its antimitogenic action. (2) The blocking antibody activity is present only in sensitized patients who have IgG lymphocytotoxic activity against the same HLA class I antigens. (3) The blocking activity is unequal in the following order: IgG 3 > IgG 1 > IgG 2. (4) Although IgG 1 and 2 fractions contain lymphocytotoxic activity against HLA class I antigens, the IgG 3 fraction does not., Conclusions: The differential effect of IgG antibodies on naive and memory T cells may explain why humeral responses to alloantigens can be maintained in the presence of blocking antibodies.

Recovery of microorganisms causing peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD) continues to be problematic. To date, there is no universally accepted protocol. We prospectively analyzed 430 peritoneal effluent specimens by three protocols: (a) 3 ml of effluent was centrifuged and the pellet plated onto blood and MacConkey agars and into thioglycolate broth (routine method), (b) 3 ml of each was inoculated at the bedside into Bactec 6A aerobic and 16A aerobic resin-containing media, and (c) 3 ml of each was inoculated in the laboratory into Bactec 6A and 16A media. Of the peritoneal effluent specimens, 104 (24%) had microorganisms recovered; 63 were positive by the routine method compared with 86 (P < .001) by bedside-inoculated 16A. Bedside-inoculated 16A (86) recovered more microorganisms than bedside-inoculated 6A (70) (P < .05). Laboratory-inoculated 16A (78) recovered more organisms than the routine method (63) (P < .05). Of 42 positive peritoneal effluent specimens delayed in transit > or = 1 day, 23 were positive by the routine method compared with 34 bedside inoculated 16A (P < .01) and 30 laboratory-inoculated 16A (P > .114). Bedside-inoculated 16A media is superior to the routine method for the recovery of microorganisms causing peritonitis in CAPD patients.

From January 1989 to June 1994 we examined the success rate of fluoroscopically guided stiff wire manipulation of malfunctioning peritoneal dialysis catheters (PDCs) at St. Paul's Hospital, Saskatoon. There were 341 (201 male, 140 female) patients with a PDC. There were 118 manipulations (70 initial, 48 remanipulations) for malposition, fibrin clot, or kinked catheter. Single-cuff Tenckhoff catheters accounted for 95% of manipulated PDCs. No complications including peritonitis, exit-site infections, ruptured catheter, or bowel perforation were reported postmanipulation. A successful manipulation was defined as a functional PDC at 30 days postmanipulation. There was an overall success rate of 64%-67% for initial manipulations (IM) and 48% for remanipulations (RM). Ninety percent of those PDCs requiring IM occurred within 42 days of surgical insertion. RM occurred on average 55 days after IM. There were no risk factors identified that predisposed patients for PDC manipulation. This success rate for combined IM and RM of PDCs is higher than those rates quoted in the literature (27%-42%). We conclude that fluoroscopically guided stiff wire manipulation of PDCs, including repeated attempts, is a safe and effective way of prolonging PDC life, thus avoiding the risks of repeated surgery, improving quality of life, and decreasing health care costs.

Objective: To report a case of trimethoprim/sulfamethoxazole (TMP/SMX)-induced hypoglycemia in an immunosuppressed renal transplant patient., Data Source: English-language journal articles and reference texts identified via a MEDLINE search and a bibliographic review of pertinent data sources., Data Synthesis: Hypoglycemia resulting from the combination of sulfonylureas and sulfonamides is a recognized drug interaction. Hypoglycemia induced by sulfonamides alone may be encountered less frequently. Previously reported cases of TMP/SMX-induced hypoglycemia postulated that the sulfonamide mimics hypoglycemic sulfonylurea agents and stimulates pancreatic islet cells to secrete insulin. We report a case of hypoglycemia following the administration of high-dose TMP/SMX in a renal transplant patient. Elevated C-peptide concentrations following the hypoglycemic episode indicate that hypoglycemia resulted from increased endogenous insulin secretion., Conclusions: Hypoglycemia has been a rarely encountered result of TMP/SMX use. Patients receiving TMP/SMX, particularly those with impaired renal function and those receiving high doses, should be monitored closely for hypoglycemia.

Studies have suggested that oral quinolones may be useful in the treatment of peritonitis in peritoneal dialysis. We undertook a study of organisms causing peritonitis in our IPD and CAPD populations to determine if these organisms would be susceptible in vitro to Cipro. We determined the minimal inhibitory concentrations (MIC) of 62 non-duplicate isolates from episodes of peritonitis to Cipro by standard broth microdilution. Serial dilutions were done with Cipro and MIC50 and MIC90 were determined. The isolates were as follows: S, epidermidis (17), S. aureus (14), coliforms (11), Pseudomonas (8), Enterococci (8), Diphtheroids (4). The MIC50 and MIC90 for each of the isolate groups and overall are shown below.