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BACKGROUND: Longer travel time to the dialysis unit creates a substantial burden for many patients. This study evaluated the effect of self-reported 1-way travel time to hemodialysis on mortality, health-related quality of life (HR-QOL), adherence, withdrawal from dialysis therapy, hospitalization, and transplantation. STUDY DESIGN: Prospective observational cohort. SETTING & PARTICIPANTS: Patients enrolled in the Dialysis Outcomes and Practices Patterns Study who completed a patient questionnaire (n = 20,994). PREDICTOR: One-way travel time to hemodialysis treatment, categorized as 15 or less, 16 to 30, 31 to 60, and longer than 60 minutes. Covariates included demographics, comorbid conditions, serum albumin level, time on dialysis therapy, and country. OUTCOME & MEASUREMENT: HR-QOL was examined by using a linear mixed model. Cox proportional hazards regression was used to examine associations with mortality, withdrawal from dialysis therapy, hospitalization, and transplantation. RESULTS: Longer travel time was associated with greater adjusted relative risk (RR) of death (P = 0.05 for overall trend). Adjusted HR-QOL subscales were significantly lower for those with longer travel times compared with those traveling 15 minutes or less. There were no associations of travel time with withdrawal from dialysis therapy (P = 0.6), hospitalization (P = 0.4), or transplantation (P = 0.7). LIMITATIONS: The questionnaire nonresponse rate was substantial, and nonresponders were older, with more comorbid conditions. Travel time was assessed by using a single nonvalidated question. CONCLUSIONS: Longer travel time is associated significantly with greater mortality risk and decreased HR-QOL. Exploring opportunities to decrease travel time should be incorporated into the dialysis clinical routine. Copyright © 2008 by the National Kidney Foundation, Inc. [ABSTRACT FROM AUTHOR]

BACKGROUND: Australia historically has been recognized for its high fistula use. STUDY DESIGN: Observational study using registry data. SETTING & PARTICIPANTS: Adult patients registered in the Australia and New Zealand Dialysis and Transplant Association Registry on hemodialysis in Australia. PREDICTOR: Cohort year. OUTCOMES & MEASUREMENT: Hemodialysis access trends were examined from 2000 to 2005 for incident patients (within 60 days of hemodialysis therapy start), patients on hemodialysis therapy for 6 to 8 months, and prevalent hemodialysis patients. Multivariate analyses were performed to examine the relationship between access type and cohort year for each group, with adjustment for age, sex, race, body mass index, late referral, smoking status, cause of end-stage renal disease, comorbidities, and dialysis vintage. RESULTS: During 2000 to 2005, catheter use increased from 39% to 53% in incident patients, 10% to 22% in the 6- to 8-month groups, and 6% to 13% in prevalent patients. Fistula use decreased from 56% to 43% in incident patients and 78% to 67% in the 6- to 8-month group and remained at 73% to 75% in prevalent patients. Graft use decreased in all groups. Adjustment for factors associated with access type did not significantly change these results. LIMITATIONS: The registry collects only the access in use at the end of the survey period; thus, it was not possible to determine whether another access had failed or was present, but not in use. The small number of incident numbers prevented separate analysis of arteriovenous fistulas and arteriovenous grafts. CONCLUSION: Incident use of fistulas and grafts decreased, with an unexpected increase in both incident and prevalent catheters between 2000 and 2005. Adjustment for factors associated with access type did not significantly alter the trends. Changes in unidentified practice patterns, attitudes, or preferences are contributing to these trends. Ongoing evaluation of data and investigation into processes of care are required to increase functioning fistulas, together with reevaluation of the role of grafts in patients without a fistula. Copyright © 2007 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

Introduction: Patients with kidney failure with replacement therapy (KFRT) suffer premature cardiovascular (CV) mortality and events with few proven pharmacological interventions. Omega-3 polyunsaturated essential fatty acids (n-3 PUFAs) are associated with a reduced risk of CV events and death in non-dialysis patients and in patients with established CV disease but n-3 PUFAs have not been evaluated in the high risk KFRT patient population., Methods and Analysis: This multicentre randomised, placebo controlled, parallel pragmatic clinical trial tests the hypothesis that oral supplementation with n-3 PUFA, when added to usual care, leads to a reduction in the rate of serious CV events in haemodialysis patients when compared with usual care plus matching placebo. A target sample size of 1100 KFRT patients will be recruited from 26 dialysis units in Canada and Australia and randomised to n-3 PUFA or matched placebo in a 1:1 ratio with an expected intervention period of at least 3.5 years. The primary outcome to be analysed and compared between intervention groups is the rate of all, not just the first, serious CV events which include sudden and non-sudden cardiac death, fatal and non-fatal myocardial infarction, stroke, and peripheral vascular disease events., Ethics and Dissemination: This study has been approved by all institutional ethics review boards involved in the study. Participants could only be enrolled following informed written consent. Results will be published in peer-reviewed journals and presented at scientific and clinical conferences., Trial Registration Number: ISRCTN00691795., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Background: COVID-19 required rapid adoption of virtual modalities to provide care for patients with a chronic disease. Care was initially provided by telephone, which has not been evaluated for its effectiveness by patients and providers. This study reports patients' and nephrologists' perceptions and preferences surrounding telephone consultation in a chronic kidney disease (CKD) clinic., Objective: To evaluate patient and physician perspectives on the key advantages and disadvantages of telephone consultations in a nephrology out-patient clinic setting., Design: Cross-sectional observational survey study., Setting: General nephrology clinic and a multidisciplinary kidney care clinic in London, Ontario, Canada., Participants: Patients with CKD who were fluent in English and participated in at least one telephone consultation with a nephrologist during the COVID-19 pandemic., Methods and Measurements: Nephrologists' and participants' input facilitated the development of both patient and nephrologist surveys. Participants provided self-reported measures in 5 domains of satisfaction: user experience, technical quality, perceived effectiveness on well-being, perceived usefulness, and effect on interaction. Nephrologists provided self-reported measures within 6 categories: general experience, time management, medication changes, quality of care, job satisfaction, and challenges/strengths. Descriptive statistics were used to present data. Content analysis was performed on 2 open-ended responses., Results: Of the 372 participants recruited, 235 participated in the survey (63% response). In all, 79% of the participants were ≥65 years old and 91% were white. Telephone consultation was a comfortable experience for 68%, and 73% felt it to be a safer alternative during the pandemic. Although 65% perceived no changes to health care access, most reported spending less time and fewer resources on transit and parking. Disadvantages to telephone consultation included a lack of physical examination and reduced patient-physician rapport. Eleven of 14 nephrologists were surveyed, with most reporting confidence in the use of telephone consultation. Physician barriers to telephone consultation included challenges with communications and lack of technology to support telephone clinics., Limitations: Our survey included a majority of older, white participants, which may not be generalizable to other participants particularly those of other ages and ethnicity., Conclusion: Although both patients and nephrologists adapted to telephone consultations, there remain opportunities to further explore populations and situations that would be better facilitated with an in-person visit. Future research in virtual care will require measurement of health care outcomes and economics., Trial Registration: Not applicable as this was a survey., 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) 2022.)

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: 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.)

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research., (Copyright © 2019. Published by Elsevier Inc.)

Background: Clinical practice guidelines recommend arteriovenous fistulas as the preferred form of vascular access for hemodialysis. However, some studies have suggested that older age is associated with poorer fistula outcomes., Objective: We assessed the impact of age on the outcomes of fistula creation and access-related procedures., Design: This was a prospective cohort study using data collected as part of the Dialysis Measurement Analysis and Reporting (DMAR) system., Setting: Participating Canadian dialysis programs, including Southern Alberta Renal Program, Manitoba Renal Program, Sunnybrook Health Sciences Centre (Toronto, Ontario), London Health Sciences Centre (London, Ontario), and The Ottawa Hospital (Ottawa, Ontario)., Patients: Incident hemodialysis patients aged 18 years and older who started dialysis between January 1, 2004, and May 31, 2012., Measurements: The primary outcome was the proportion of all first fistula attempts that resulted in catheter-free fistula use, defined as independent use of a fistula for hemodialysis (ie, no catheter in place). Secondary outcomes included the time to catheter-free fistula use among patients with a fistula creation attempt, total number of days of catheter-free fistula use, and the proportion of a patient's hemodialysis career spent with an independently functioning fistula (ie, catheter-free fistula use)., Methods: We compared patient characteristics by age group, using t tests or Wilcoxon rank sum tests, and chi-square or Fisher exact tests, as appropriate. Logistic and fractional logistic regression were used to estimate the odds of achieving catheter-free fistula use by age group and the proportion of dialysis time spent catheter-free, respectively., Results: A total of 1091 patients met our inclusion criteria (567 age ≥ 65; 524 age < 65). Only 57% of first fistula attempts resulted in catheter-free fistula use irrespective of age (adjusted odds ratio [OR] ≥65vs<65 : 1.01; P = .93). The median time from hemodialysis start to catheter-free use of the first fistula did not differ by age when grouped into fistulas attempted pre- and post-dialysis initiation. The adjusted rates of access-related procedures were comparable (incidence rate ratio [IRR] ≥65vs<65: 0.95; P = .32). The median percentage of follow-up time spent catheter-free was similar and low in patients who attempted fistulas (<65 years: 19% vs ≥65 years: 21%; P = .85)., Limitations: The relatively short follow-up time may have underestimated the benefits of fistula creation and the observational study design precludes inferences about causality., Conclusions: In our study, older patients who underwent a fistula attempt were just as likely as younger patients to achieve catheter-free fistula use, within a similar time frame, and while requiring a similar number of access procedures. However, the minority of dialysis time was spent catheter-free., 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) 2019.)

Background: Fistula creation is recommended to avoid the use of central venous catheters for hemodialysis. The extent to which timing of fistula creation minimizes catheter use is unclear., Objective: To compare patient outcomes of 2 fistula creation strategies: fistula attempt prior to the initiation of dialysis ("predialysis") or fistula attempt after starting dialysis ("postinitiation")., Design: Cohort study., Setting: Five Canadian dialysis programs., Patients: Patients who started hemodialysis between 2004 and 2012, who underwent fistula creation, and were tracked in the Dialysis Measurement Analysis and Reporting (DMAR) system., Measurements: Catheter-free fistula use within 1 year of hemodialysis start, probability of catheter-free fistula use during follow-up, and rates of access-related procedures., Methods: Retrospective data analysis: logistic regression; negative binomial regression., Results: Five hundred and eight patients had fistula attempts predialysis and 583 postinitiation. At 1 year, 80% of those with predialysis attempts achieved catheter-free use compared to 45% with post-initiation attempts (adjusted odds ratio [OR] preVSpost = 4.67; 95% confidence interval [CI] = 3.28-6.66). The average of all patient follow-up time spent catheter-free was 63% and 28%, respectively (probability of use per unit time, OR preVSpost = 2.90; 95% CI = 2.18-3.85). This finding was attenuated when accounting for maturation time and when restricting the analysis to those who achieved catheter-free use. Predialysis fistula attempts were associated with lower procedure rates after dialysis initiation-1.61 procedures per person-year compared with 2.55-but had 0.65 more procedures per person prior to starting dialysis., Limitations: Observational design, unknown indication for predialysis and postinitiation fistula creation, and unknown reasons for prolonged catheter use., Conclusions: Predialysis fistula attempts were associated with a higher probability of catheter-free use and remaining catheter-free over time, and also resulted in fewer procedures compared with postinitiation attempts, which could be due to timing of attempt or patient factors. Catheter use and procedures were still common for all patients, regardless of the timing of fistula creation., 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: Drs Oliver and Quinn disclose they are co-inventors of the Dialysis Measurement Analysis and Reporting system.

Purpose of Review: Provision of education to inform decision making for renal replacement therapy (RRT) is a key component in the management of chronic kidney disease (CKD), yet patients report suboptimal satisfaction with the process of selecting a dialysis modality. Our purpose is to review the influencers of RRT decision making in the CKD population, which will better inform the process of shared decision making between clinicians and patients., Sources of Information: PubMed and Google Scholar., Methods: A narrative review was performed using the main terms "chronic kidney disease," "CKD," "dialysis," "review," "decision-making," "decision aids," "education," and "barriers." Only articles in English were accessed. The existing literature was critically analyzed from a theoretical and contextual perspective and thematic analysis was performed., Key Findings: Eight common themes were identified as influencers for decision making. "Patient-focused" themes including social influence, values and beliefs, comprehension, autonomy and sociodemographics, and "clinician-focused" themes including screening, communication, and engagement. Early predialysis education and decision aids can effectively improve decision making. Patient-valued outcomes need to be more fully integrated into clinical guidelines., Limitations: This is not a systematic review; therefore, no formal tool was utilized to evaluate the rigor and quality of studies included and findings may not be generalizable., Implications: Standardized comprehensive RRT education programs through multidisciplinary health teams can help optimize CKD patient education and shared decision making. Involving patients in the research process itself and implementing patient values and preferences into clinical guidelines can help to achieve a patient-centered model of care., 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:: We assessed the validity of physician billing codes and hospital admission using International Classification of Diseases 10th revision codes to identify vascular access placement, secondary patency, and surgical revisions in administrative data., Methods:: We included adults (≥18 years) with a vascular access placed between 1 April 2004 and 31 March 2013 at the University Health Network, Toronto. Our reference standard was a prospective vascular access database (VASPRO) that contains information on vascular access type and dates of placement, dates for failure, and any revisions. We used VASPRO to assess the validity of different administrative coding algorithms by calculating the sensitivity, specificity, and positive predictive values of vascular access events., Results:: The sensitivity (95% confidence interval) of the best performing algorithm to identify arteriovenous access placement was 86% (83%, 89%) and specificity was 92% (89%, 93%). The corresponding numbers to identify catheter insertion were 84% (82%, 86%) and 84% (80%, 87%), respectively. The sensitivity of the best performing coding algorithm to identify arteriovenous access surgical revisions was 81% (67%, 90%) and specificity was 89% (87%, 90%). The algorithm capturing arteriovenous access placement and catheter insertion had a positive predictive value greater than 90% and arteriovenous access surgical revisions had a positive predictive value of 20%. The duration of arteriovenous access secondary patency was on average 578 (553, 603) days in VASPRO and 555 (530, 580) days in administrative databases., Conclusion:: Administrative data algorithms have fair to good operating characteristics to identify vascular access placement and arteriovenous access secondary patency. Low positive predictive values for surgical revisions algorithm suggest that administrative data should only be used to rule out the occurrence of an event.

Background: Patients with chronic kidney disease (CKD) are asked to choose a renal replacement therapy or conservative management. Education and knowledge transfer play key roles in this decision-making process, yet they remain a partially met need., Objective: We sought to understand the dialysis modality decision-making process through exploration of the predialysis patient experience to better inform the educational process., Design: Qualitative descriptive study., Setting: Kidney Care Centre of London Health Sciences Centre in London, Ontario, Canada., Patients: Twelve patients with CKD, with 4 patients on in-center hemodialysis, home hemodialysis, and peritoneal dialysis, respectively., Measurements: Not applicable., Methods: We conducted semistructured interviews with each participant, along with any family members who were present. Interviews were transcribed verbatim. Conventional content analysis was used to analyze the transcripts for common themes. Representative quotes were decided via team consensus. A patient collaborator was part of the research team., Results: Three themes influenced dialysis modality decision making: (i) Patient Factors: individualization, autonomy, and emotions; (ii) Educational Factors: tailored education, time and preparation, and available resources; and (iii) Support Systems: partnership with health care team, and family and friends., Limitations: Sample not representative of wider CKD population. Limited number of eligible patients. Poor recall may affect findings., Conclusions: Modality decision making is a complex process, influenced by the patient's health literacy, willingness to accept information, predialysis lifestyle, support systems, and values. Patient education requires the flexibility to individualize the delivery of a standardized CKD curriculum in partnership with a patient-health care team, to fulfill the goal of informed, shared decision making., 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 in-center dialysis unit and practice of dialysis, in the current multi-team approach, requires knowledge and skills in all the domains including medical expert, communicator, collaborator, scholar, health advocate, and leader. We are tasked as a community, to embrace and incentivize new innovations and technology to address these needs for our post graduate trainees. These innovations must address the basic principles of dialysis, quality improvement, technical and procedural skills as well as leadership and administration skills. The teaching methods and innovations must also be challenged to demonstrate the translation into adoption and improvements in practice to demonstrate success. This article will review the current state of the training curriculum in Nephrology for in-center hemodialysis and address some of the recent innovations., (© 2018 Wiley Periodicals, Inc.)

The implementation of patient-centered care requires an individualized approach to hemodialysis vascular access, on the basis of each patient's unique balance of risks and benefits. This systematic review aimed to summarize current literature on fistula risks, including rates of complications, to assist with patient-centered decision making. We searched Medline from 2000 to 2014 for English-language studies with prospectively captured data on ≥100 fistulas. We assessed study quality and extracted data on study design, patient characteristics, and outcomes. After screening 2292 citations, 43 articles met our inclusion criteria (61 unique cohorts; n >11,374 fistulas). Median complication rates per 1000 patient days were as follows: 0.04 aneurysms (14 unique cohorts; n =1827 fistulas), 0.11 infections (16 cohorts; n >6439 fistulas), 0.05 steal events (15 cohorts; n >2543 fistulas), 0.24 thrombotic events (26 cohorts; n =4232 fistulas), and 0.03 venous hypertensive events (1 cohort; n =350 fistulas). Risk of bias was high in many studies and event rates were variable, thus we could not present pooled results. Studies generally did not report variables associated with fistula complications, patient comorbidities, vessel characteristics, surgeon experience, or nursing cannulation skill. Overall, we found marked variability in complication rates, partly due to poor quality studies, significant heterogeneity of study populations, and inconsistent definitions. There is an urgent need to standardize reporting of methods and definitions of vascular access complications in future clinical studies to better inform patient and provider decision making., (Copyright © 2017 by the American Society of Nephrology.)

The initiation of dialysis is a challenging time of transition for patients, families, and their supporters. Patients with exposure to a comprehensive chronic kidney disease clinic may have had education and subsequent decision making regarding dialysis modality and access; however, many patients with or without prior education will require an urgent start to dialysis, requiring quick decisions regarding dialysis modality and access. In many countries, hemodialysis (HD) using a central venous catheter (CVC) is the most common initial renal replacement modality and dialysis access. Multiple factors, both remedial and nonremedial, contribute to this including late referral, rapid decrease in kidney function, delay in delivery or acceptance of education, and decision making and other system delays. Recent use of urgent peritoneal dialysis as the initial dialysis modality has resulted in decreased exposure to CVCs and in-center HD. This article addresses the current state of incident dialysis access, recent trends toward urgent peritoneal dialysis start, and opportunities to avoid the use of CVCs for HD when appropriate, with a focus on considering dialysis access as a critical component of the end-stage kidney disease life-plan, which requires consideration of future modalities and access when making the choice of the initial dialysis access., (Copyright © 2017. Published by Elsevier Inc.)

Whether the lower risk of mortality associated with arteriovenous fistula use in hemodialysis patients is due to the avoidance of catheters or if healthier patients are simply more likely to have fistulas placed is unknown. To provide clarification, we determined the proportion of access-related deaths in a retrospective cohort study of patients aged ≥18 years who initiated hemodialysis between 2004 and 2012 at five Canadian dialysis programs. A total of 3168 patients initiated dialysis at the participating centers; 2300 met our inclusion criteria. Two investigators independently adjudicated cause of death using explicit criteria and determined whether a death was access-related. We observed significantly lower mortality in individuals who underwent a predialysis fistula attempt than in those without a predialysis fistula attempt in patients aged <65 years (hazard ratio [HR], 0.49; 95% confidence interval [95% CI], 0.29 to 0.82) and in the first 2 years of follow-up in those aged ≥65 years (HR 0-24 months , 0.60; 95% CI, 0.43 to 0.84; HR 24+ months , 1.83; 95% CI, 1.25 to 2.67). Sudden deaths that occurred out of hospital accounted for most of the deaths, followed by deaths due to cardiovascular disease and infectious complications. We found only 2.3% of deaths to be access-related. In conclusion, predialysis fistula attempt may associate with a lower risk of mortality. However, the excess mortality observed in patients treated with catheters does not appear to be due to direct, access-related complications but is likely the result of residual confounding, unmeasured comorbidity, or treatment selection bias., (Copyright © 2017 by the American Society of Nephrology.)

Patients with Stages 4 and 5 CKD are optimally managed within a multidisciplinary care setting. This provides an opportunity to create a "patient centered" approach to renal replacement modality options and conservative care. The care team engages with the patient and caregivers to assist with the understanding of their health status, modality and vascular access selection, and overall living with the comorbidity of chronic illness. A systematic approach to provision of education, modality, and access selection, are in part, driven by the patient's expected survival and need for dialysis, the risks and benefits with different modalities, and access and adaptation to their preferences and home situations. Dialysis access education should be included in all education programs so that patients can consider risks and benefits of all modalities. Decision support interventions have been effective in reducing decisional conflict and informed values-based decision-making. For both hemodialysis and peritoneal dialysis, timing of the surgical referral and access creation should be individualized based on the rate of CKD progression, risk of complications, and ease of access to surgical services. The health care team should support the patients' decision balancing risks and benefits, as well as their lifestyle, values, beliefs, and preferences., (Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: A critical feature of any continuing medical education (CME) program is the inclusion of a needs assessment for its target audience. This assessment must identify both perceived and unperceived needs, so as to best capture the entire spectrum of learning opportunities for the group., Objective: We describe the process developed by the Canadian Society of Nephrology (CSN) to enhance the educational effectiveness of its Annual General Meeting program., Design: The design of this study is the analysis of a survey questionnaire and of the Canadian Organ Replacement Registry (CORR) database., Participants: We surveyed members of the CSN and analyzed patient data from CORR aggregated by center., Measurements: We tabulated votes in the survey by topic. We assessed the extent to which centers achieved CSN guideline targets on the clinical management of patients on dialysis., Methods: Perceived needs: a CSN panel constructed a list of topics, which was amplified by the inclusion of topics based on members' text responses to open-ended questions during previous iterations of this process. CSN members specified their top five choices, using an online survey instrument. Unperceived needs: an expert panel determined achievable thresholds for a number of quality metrics associated with dialysis. The quality metrics were identified from CSN guidelines. Using patient data in the CORR database, we generated center-specific performance estimates for each quality metric and constructed ratios comparing the performance of each center with the achievable threshold. We triangulated the results of the two assessments., Results: The response rate for the perceived needs assessment survey was 16 %. This assessment identified "Primary and Secondary Glomerulonephritis" as the non-dialysis topics and "Infectious Complications of Dialysis Access" and "Volume Status and Hypertension on Dialysis" as the dialysis topics with the highest perceived learning needs. In the unperceived needs assessment, "Vascular Access Type" and "Vascular Access Monitoring" were identified as having the highest learning needs. Triangulation identified "Vascular Access Type" and "Vascular Access Monitoring" as high needs topics., Limitations: Perceived needs assessment: Some topics were much more general than others, which could have led to over-selection. The response rate of 16 % limits the robustness of generalization to the membership as a whole or to all meeting attendees. Unperceived needs assessment: The assessment was limited by the data that CORR actually collects; many aspects of general nephrology practice, including glomerulonephritis, are not covered. The level of evidence underlying the various guidelines was variable, and in some cases, poor. A validated approach to data analysis in this area is lacking., Conclusions: To our knowledge, this is the first published example of a needs assessment for a nephrology CME event that considers both the perceived and unperceived needs of the membership. The results of this exercise are currently being used to assist in the development of a more responsive CME program.

Background: Non-tunneled (temporary) hemodialysis catheters (NTHCs) are the least-optimal initial vascular access for incident maintenance hemodialysis patients yet little is known about factors associated with NTHC use in this context. We sought to determine factors associated with NTHC use and examine regional and facility-level variation in NTHC use for incident maintenance hemodialysis patients., Methods: We analyzed registry data collected between January 2001 and December 2010 from 61 dialysis facilities within 12 geographic regions in Canada. Multi-level models and intra-class correlation coefficients were used to evaluate variation in NTHC use as initial hemodialysis access across facilities and geographic regions. Facility and patient characteristics associated with the lowest and highest quartiles of NTHC use were compared., Results: During the study period, 21,052 patients initiated maintenance hemodialysis using a central venous catheter (CVC). This included 10,183 patients (48.3 %) in whom the initial CVC was a NTHC, as opposed to a tunneled CVC. Crude variation in NTHC use across facilities ranged from 3.7 to 99.4 % and across geographic regions from 32.4 to 85.1 %. In an adjusted multi-level logistic regression model, the proportion of total variation in NTHC use explained by facility-level and regional variation was 40.0 % and 34.1 %, respectively. Similar results were observed for the subgroup of patients who received greater than 12 months of pre-dialysis nephrology care. Patient-level factors associated with increased NTHC use were male gender, history of angina, pulmonary edema, COPD, hypertension, increasing distance from dialysis facility, higher serum phosphate, lower serum albumin and later calendar year., Conclusions: There is wide variation in NTHC use as initial vascular access for incident maintenance hemodialysis patients across facilities and geographic regions in Canada. Identifying modifiable factors that explain this variation could facilitate a reduction of NTHC use in favor of more optimal initial vascular access.

Background: While central venous catheter (CVC) use has expanded home hemodialysis (HHD) eligibility to many patients who may be unable to self-cannulate an arteriovenous (AV) access, the association between CVC use and mortality has not been directly examined among HHD patients., Study Design: Registry-based retrospective observational cohort study., Setting & Participants: Incident HHD patients in The Canadian Organ Replacement Register who had information for vascular access type (CVC vs AV access) within the first year of HHD therapy initiation., Predictor: Use of a CVC versus an AV access (AV fistula or graft) within the first year of HHD therapy initiation., Outcome: The composite of all-cause mortality and technique failure (long-term transfer to an alternate dialysis modality). A Cox proportional hazards model was used to evaluate the adjusted composite outcome and each outcome separately., Results: 1,869 patients initiated HHD therapy in Canada in 1996 to 2012, of whom 1,217 had an access type recorded within the first year of HHD therapy initiation. Compared to CVC use (n=523) and during a median follow-up of 513 and 427 days for AV access and CVC patients, respectively, AV access use (n=694) was associated with lower risk for the composite event of death and technique failure (490 events; adjusted HR, 0.78; 95% CI, 0.64-0.94) and lower adjusted all-cause mortality (129 deaths; adjusted HR, 0.63; 95% CI, 0.43-0.91); the risk for technique failure was nominally lower, but this result was not statistically significant (361 events; adjusted HR, 0.84; 95% CI, 0.67-1.05). Results were robust to sensitivity analyses and after missing data imputation., Limitations: Missing information for vascular access type (n=659[35% of patients]) and lack of information for longitudinal changes in vascular access type., Conclusions: Compared to CVC use, AV access use was associated with superior survival. Minimizing CVC use and maximizing AV access use while addressing barriers to their placement and self-cannulation may improve HHD outcomes., (Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

The purpose of this manuscript is to describe a collaborative research initiative to explore the role of hydration in kidney health. Our understanding of the effects of hydration in health and disease is surprisingly limited, particularly when we consider the vital role of hydration in basic human physiology. Recent initiatives and research outcomes have challenged the global medical community to expand our knowledge about hydration, including the differences between water, sugared beverages and other consumables. Identification of the potential mechanisms contributing to the benefits of hydration has stimulated the global nephrology community to advance research regarding hydration for kidney health. Hydration and kidney health has been a focus of research for several research centers with a rapidly expanding world literature and knowledge. The International Society of Nephrology has collaborated with Danone Nutricia Research to promote development of kidney research initiatives, which focus on the role of hydration in kidney health and the global translation of this new information. This initiative supports the use of existing data in different regions and countries to expand dialogue among experts in the field of hydration and health, and to increase scientific interaction and productivity with the ultimate goal of improving kidney health., (© 2016 The Author(s) Published by S. Karger AG, Basel.)

Background: Little is known about vascular access in patients starting hemodialysis therapy after kidney transplant failure., Study Design: Retrospective cohort study., Setting & Participants: Adult patients (aged ≥18 years) who started hemodialysis therapy in Ontario, Canada, from January 1, 2001, through December 31, 2010, after kidney transplant failure., Predictor: Patient clinical and demographic characteristics., Outcomes: Proportion and timing of arteriovenous (AV) vascular access creation (fistula or graft) 12 months prior and up to 24 months after starting hemodialysis therapy., Measurements: Event rates and outcome predictors., Results: Our cohort included 683 patients with a mean age of 48 years and >50% with comorbidity index score < 3. In the 12 months predialysis and 24 months postdialysis, 16% and 47% of patients had an AV access created, respectively. In the postdialysis period, 13%, 26%, and 38% of patients had an AV access creation at 3, 6, and 12 months, respectively. History of coronary artery disease, diabetes mellitus, and peritoneal dialysis use prior to transplantation were associated with a lower likelihood of AV access creation., Limitations: Residual selection bias from unmeasured variables beyond the data elements., Conclusions: In Ontario, AV access creation, both before and after starting hemodialysis therapy, is low in patients with kidney transplant failure despite their being younger and healthier compared to the overall hemodialysis population. This highlights the need for a predialysis care pathway in the transplantation clinic and an active strategy to identify this patient cohort receiving hemodialysis to align modality and access choices., (Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: In Canada, approximately 17% of patients use an arteriovenous access (fistula or arteriovenous graft) at commencement of hemodialysis, despite guideline recommendations promoting its timely creation and use. It is unclear if this low pattern of use is attributable to the lack of surgical creation or a high nonuse rate., Design, Setting, Participants, & Measurements: Using large health care databases in Ontario, Canada, a population-based cohort of adult patients (≥18 years old) who initiated hemodialysis as their first form of RRT between 2001 and 2010 was studied. The aims were to (1) estimate the proportion of patients who had an arteriovenous access created before starting hemodialysis and the proportion who successfully used it at hemodialysis start, (2) test for secular trends in arteriovenous access creation, and (3) estimate the effect of late nephrology referral and patient characteristics on arteriovenous access creation., Results: There were 17,183 patients on incident hemodialysis. The mean age was 65.8 years, 60% were men, and 40% were referred late to a nephrologist; 27% of patients (4556 of 17,183) had one or more arteriovenous accesses created, and the median time between arteriovenous access creation and hemodialysis start was 184 days. When late referrals were excluded, 39% of patients (4007 of 10,291) had one or more arteriovenous accesses created, and 27% of patients (2724 of 10,291) used the arteriovenous access. Since 2001, there has been a decline in arteriovenous access creation before hemodialysis initiation. Women, higher numbers of comorbidities, and rural residence were consistently associated with lower rates of arteriovenous access creation. These results persisted even after removing patients with <6 months nephrology care or who had AKI 6 months before starting hemodialysis., Conclusions: In Canada, arteriovenous access creation before hemodialysis initiation is low, even among patients followed by a nephrologist. Better understanding of the barriers and influencers of arteriovenous access creation is needed to inform both clinical care and guidelines., (Copyright © 2015 by the American Society of Nephrology.)

Purpose of Review: To provide an overview of the transplant component of the Canadian Organ Replacement Register (CORR)., Findings: CORR is the national registry of organ failure in Canada. It has existed in some form since 1972 and currently houses data on patients with end-stage renal disease and solid organ transplants (kidney and/or non-kidney). The transplant component of CORR receives data on a voluntary basis from individual transplant centres and organ procurement organizations across the country. Coverage for transplant procedures is comprehensive and complete. Long-term outcomes are tracked based on follow-up reports from participating transplant centres. The longitudinal nature of CORR provides an opportunity to observe the trajectory of a patient's journey with organ failure over their life span. Research studies conducted using CORR data inform both practitioners and health policy makers alike., Implications: The importance of registry data in monitoring and improving care for Canadian transplant candidates/recipients cannot be over-stated. This paper provides an overview of the transplant data in CORR including its history, data considerations, recent findings, new initiatives, and future directions.

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.

Background: We previously reported a reduction in central venous catheter (CVC) malfunction when using once-weekly recombinant tissue-plasminogen activator (rt-PA) as a locking solution, compared with thrice-weekly heparin., Objectives: To identify risk factors for CVC malfunction to inform a targeted strategy for rt-PA use., Design: Retrospective analysis., Setting: Canadian hemodialysis (HD) units., Patients: Adults with newly placed tunnelled upper venous system CVCs randomized to a locking solution of rt-PA(1 mg/mL) mid-week and heparin (5000 u/ml) on the other HD sessions, or thrice-weekly heparin (5000 u/ml)., Measurements: CVC malfunction (the primary outcome) was defined as: peak blood flow less than 200 mL/min for thirty minutes during a HD session; mean blood flow less than 250 mL/min for two consecutive HD sessions; inability to initiate HD., Methods: Cox regression was used to determine the association between patient demographics, HD session CVC-related variables and the outcome of CVC malfunction., Results: Patient age (62.4 vs 65.4 yr), proportion female sex (35.6 vs 48.4%), and proportion with first catheter ever (60.7 vs 61.3%) were similar between patients with and without CVC malfunction. After multivariate analysis, risk factors for CVC malfunction were mean blood processed < 65 L when compared with ≥ 85 L in the prior 6 HD sessions (HR 4.36; 95% CI, 1.59 to 11.95), and mean blood flow < 300 mL/min, or 300 - 324 mL/min in the prior 6 HD sessions (HR 7.65; 95% CI, 2.78 to 21.01, and HR 5.52; 95% CI, 2.00 to 15.23, respectively) when compared to ≥ 350 mL/min., Limitations: This pre-specified post-hoc analysis used a definition of CVC malfunction that included blood flow, which may result in an overestimate of the effect size. Generalizability of results to HD units where trisodium citrate locking solution is used may also be limited., Conclusions: HD session characteristics including mean blood processed and mean blood flow were associated with CVC malfunction, while patient characteristics were not. Whether targeting these patients at greater risk of CVC malfunction with rt-PA as a locking solution improves CVC longevity remains to be determined.

Optimal vascular access in elderly patients requires consideration of the benefits and risks in a population with increased comorbidity and mortality. Our objective was to examine the association between vascular access type and patient mortality by age category among incident adult hemodialysis patients registered in the Canadian Organ Replacement Register between 2001 and 2010. We also describe the secular trend in incident and prevalent vascular access use. We used a Cox proportional hazards model to evaluate the overall mortality in patients aged less than 65, 65-74, 75-85, and greater than 85 years who initiated hemodialysis using a central venous catheter (catheter) or arteriovenous (AV)-access (fistula or graft) using an intention-to-treat approach. The cohort of 39,721 patients consisted of 42%, 27%, 26%, and 5% of patients aged <65, 65-74, 75-85, and >85, respectively. Patients who initiated hemodialysis using an AV-access constituted 21%, 22%, 20%, and 15% of each age category. AV access use was associated with lower adjusted mortality compared with catheter use in each age category (Hazard Ratios [HR], 0.67; 95% Confidence Interval [0.62-0.72]; HR, 0.76 [0.63-0.91]; HR, 0.77 [0.64-0.93], HR, 0.73 [0.56-0.96], respectively). In Canada, use of an AV-access is associated with lower mortality across all age categories, even in the very elderly. Further studies are required to understand the patient preference, complications, and resource use when selecting access type in the elderly., (© 2014 International Society for Hemodialysis.)

Background: Several observational studies of hemodialysis patients show an association between early dialysis therapy initiation and increased mortality. Few studies have examined this association among peritoneal dialysis patients., Study Design: Retrospective cohort study., Setting & Participants: A cohort of 8,047 incident peritoneal dialysis patients who started dialysis therapy in 2001-2009 and were treated in Canada., Predictor: Estimated glomerular filtration rate (eGFR) at dialysis therapy initiation. Defined early, mid, and late starts as eGFR>10.5, 7.5-10.5, and <7.5mL/min/1.73m(2), respectively., Outcomes: Time to death., Measurements: Proportional piecewise exponential survival models to compare mortality (overall and early) for the 3 predictor groups., Results: Between 2001 and 2009, the proportion of patients starting peritoneal dialysis therapy as early starts increased from 29% (95% CI, 26%-32%) to 44% (95% CI, 41%-47%). Compared with the late-start group, the overall mortality rate was not higher for the early- (adjusted HR, 1.08; 95% CI, 0.96-1.23) or mid-start (adjusted HR, 0.96; 95% CI, 0.86-1.09) groups. However, when examined yearly, patients in the early-start group were significantly more likely to die within the first year of dialysis therapy compared with those in the late-start group (adjusted HR, 1.38; 95% CI, 1.10-1.73), but not in subsequent years., Limitations: Bias and residual confounding may have influenced the observed relationship between predictor and outcome., Conclusions: Patients are initiating peritoneal dialysis therapy at increasingly higher eGFRs. Contrary to most observational studies assessing hemodialysis, the early initiation of peritoneal dialysis therapy, at eGFR>10.5mL/min/1.73m(2), is not associated with increased mortality., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

The saying "drink at least 8 glasses of water per day to be healthy" has had little supporting evidence. The purpose of this article was to briefly introduce the role of hydration in health in order to explore in more detail recent observational studies of hyperhydration in chronic kidney disease (CKD) in man. The Modification of Diet in Renal Disease study initially noted a negative association between increasing urine output and progression of CKD that was absent when corrected for baseline variables. Recently, data from 2 different cross-sectional populations found those with the highest fluid intake had a significantly lower risk of CKD. In a longitudinal, community-based cohort study adjusted for baseline variables, decline in kidney function was significantly slower in those with higher versus lower baseline urine volume. These new and contradictory results underline the need for a randomized controlled study to test the hypothesis that increased fluid intake will slow renal decline.

Effective hemodialysis requires a reliable vascular access. Clinical practice guidelines strongly recommend the fistula as the preferred option followed by arteriovenous (AV) grafts, with central venous catheters being least preferred. Recently, there has been a growing awareness of the limitations of the fistula, its high rate of primary failure and that a fistula may not be appropriate for all patients initiating or on hemodialysis. However, determinates for fistula eligibility have not been clearly defined. The creation and use of a fistula requires the complex integration of patient, biological, and surgical factors, none of which can be easily predicted or planned. There have been several successful initiatives over the last decade addressing patient suitability for AV access, but none have validated defined criteria for fistula eligibility. We discuss these initiatives by addressing: 1) process of care, 2) radiological and nonradiological tests and procedures, and 3) alternative surgical approaches. Careful clinical judgment, appropriate vascular access assessment and placement, and an individualized approach to the risks and benefits will optimize patient health outcomes while minimizing prolonged catheter dependence among hemodialysis patients., (© 2014 Wiley Periodicals, Inc.)

Background: Advantages of the arteriovenous fistula (AVF), including long patency and few complications, were ascertained more than 2 decades ago and may not apply to the contemporary dialysis population., Study Design: Systematic review and meta-analysis. Estimates were pooled using a random-effects model and sources of heterogeneity were explored using metaregression., Setting & Population: Patients treated with long-term hemodialysis using an AVF., Selection Criteria for Studies: English-language studies indexed in MEDLINE between 2000 and 2012 using prospectively collected data on 100 or more AVFs., Predictor: Age, AVF location, and study location., Outcomes: Outcomes of interest were primary AVF failure and primary and secondary patency at 1 and 2 years., Results: 7,011 citations were screened and 46 articles met eligibility criteria (62 unique cohorts; n = 12,383). The rate of primary failure was 23% (95% CI, 18%-28%; 37 cohorts; 7,393 AVFs). When primary failures were included, the primary patency rate was 60% (95% CI, 56%-64%; 13 studies; 21 cohorts; 4,111 AVFs) at 1 year and 51% (95% CI, 44%-58%; 7 studies; 12 cohorts; 2,694 AVFs) at 2 years. The secondary patency rate was 71% (95% CI, 64%-78%; 10 studies; 11 cohorts; 3,558 AVFs) at 1 year and 64% (95% CI, 56%-73%; 6 studies; 11 cohorts; 1,939 AVFs) at 2 years. In metaregression, there was a significant decrease in primary patency rate in studies that started recruitment in more recent years., Limitations: Low quality of studies, variable clinical settings, and variable definitions of primary AVF failure., Conclusions: In recent years, AVFs had a high rate of primary failure and low to moderate primary and secondary patency rates. Consideration of these outcomes is required when choosing a patient's preferred access type., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

The population of elderly patients with end-stage renal disease (ESRD) is growing rapidly worldwide. The high prevalence of comorbidities, limited life expectancy and complex quality of life issues associated with this population pose substantial challenges for clinicians in terms of clinical decision-making and providing optimal care. The first dilemma encountered in the management of an elderly patient with ESRD is deciding whether to initiate renal replacement therapy and, if so, selecting the most-suitable dialysis modality. Planning vascular access for haemodialysis is associated with additional challenges. Several clinical practice guidelines recommend an arteriovenous fistula, rather than a central venous catheter or arteriovenous graft, as the preferred access for maintenance haemodialysis therapy. However, whether this recommendation is applicable to elderly patients with ESRD and a limited life expectancy is unclear. Selection and planning of the most appropriate vascular access for an elderly patient with ESRD requires careful consideration of several factors and ultimately should lead to an improvement in the patient's quality of life.

The recent trend to early initiation of dialysis (at eGFR >10 ml/min/1.73 m(2) ) appears to have been based on conventional wisdoms that are not supported by evidence. Observational studies using administrative databases report worse comorbidity-adjusted dialysis survival with early dialysis initiation. Although some have concluded that the IDEAL randomized controlled trial of dialysis start provided evidence that patients become symptomatic with late dialysis start, there is no definitive support for this view. The potential harms of early start of dialysis, including the loss of residual renal function (RRF), have been well documented. The rate of RRF loss (renal function trajectory) is an important consideration for the timing of the dialysis initiation decision. Patients with low glomerular filtration rate (GFR) may have sufficient RRF to be maintained off dialysis for years. Delay of dialysis start until a working arterio-venous access is in place seems prudent in light of the lack of harm and possible benefit of late dialysis initiation. Prescribing frequent hemodialysis is not recommended when dialysis is initiated early. The benefits of early initiation of chronic dialysis after episodes of congestive heart failure or acute kidney injury require further study. There are no data to show that early start benefits diabetics or other patient groups. Preemptive start of dialysis in noncompliant patients may be necessary to avoid complications. The decision to initiate dialysis requires informed patient consent and a joint decision by the patient and dialysis provider. Possible talking points for obtaining informed consent are provided., (© 2013 Wiley Periodicals, Inc.)

The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for anemia management in patients with chronic kidney disease provides the structural and evidence base for the Canadian Society of Nephrology commentary on this guideline's relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 11 of the 61 KDIGO guideline statements. Specifically, we agreed that a therapeutic trial of iron is appropriate in cases in which a reduction in erythropoiesis-stimulating agent (ESA) dosage or avoidance of ESA and transfusion is desired, transferrin saturations are >30%, and ferritin concentrations are >500 μg/L. However, we concluded that there is insufficient evidence to support an upper target or threshold for ferritin and transferrin saturation levels. We agree with the initiation of ESA treatment when hemoglobin (Hb) level is 90-100 g/L; however, we specifically state that an acceptable range for Hb level is 95-115 g/L, with a target of 100-110 g/L, and add caution to individualization above this range due to concerns regarding the safety of ESAs. We agree that ESAs should be used with considerable caution in patients with active malignancy, history of stroke, or history of malignancy, and we suggest initiating ESA therapy at Hb level of 90 g/L and to aim for a Hb level in the range of 90-105 g/L. The reader is encouraged to note the level of evidence and review the entire KDIGO anemia guideline to interpret the guideline statements and commentary appropriately., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Understanding healthcare providers' preferences, values, and beliefs around AVF eligibility is important to explain variability in practice. We conducted a survey of international surgeons, using hypothetical patient scenarios, to assess resources used, variables, perceived barriers, and absolute contraindications to access creation. A total of 134 surgeons completed the survey. Venous duplex ultrasound mapping (VDUM) was offered to all patients by 90% of US, 68% Canadian, and 63% European respondents. VDUM altered clinical decision less than 25% of the time for 33% American, 48% Canadian, and 85% European surgeons. Increased comorbidities and previous failed access were deterrents to AVF creation as was vessel size. Second choice access was the AV graft in the US and Europe and the catheter in Canada. Absolute contraindications to AVF creation included patient life expectancy <1 year, left ventricular ejection fraction (LVEF) <15%, and a history of dementia, while 42% surgeons reported no absolute contraindications. Perceived barriers included patient preferences, long wait times for surgery, and late referral to a Nephrologist. Significant variability exists in the surgical preoperative assessment of patients, and the eligibility criteria used for fistula creation. Understanding surgeons' preferences can aid in establishing standardization for VA access eligibility, including surgical assessment., (© 2013 Wiley Periodicals, Inc.)