Purpose of Program:The best treatment option for most patients with kidney failure is a transplant from a living kidney donor, yet multiple barriers prevent most patients from receiving one. The Living Donor Kidney Transplantation project within the Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) Network aims to improve access to living donor kidney transplantation across Ontario and beyond by enhancing our understanding of the living kidney donor and kidney transplant processes and by implementing and evaluating patient-informed, evidence-based solutions.Sources of Information:To achieve our goal of improving access to living donor kidney transplantation, our research draws on multiple sources, including (1) insights from patients, health care professionals, provincial and national kidney agencies, and researchers; (2) Ontario’s administrative health care databases; (3) clinical trials; and (4) qualitative methodology (surveys, interviews, consensus meetings, Delphi process).Methods:Our research activities in Phase 2 (2022-2026) focus on four key projects:(1) High-quality living kidney donor evaluation: A national consensus conference to define a high-quality living kidney donor evaluation and associated metrics.(2) One-day donor assessment clinic: A streamlined donor evaluation clinic to improve the efficiency of the living kidney donor evaluation.(3) Transplant Ambassador Program: A peer-support program led by patient volunteers to support patients with kidney failure and living kidney donors.(4) Collaboration and equitable access to transplant: Collaboration with patients, health care professionals, and health system leaders to develop, implement, and evaluate solutions with a focus on equity.Key Findings:Engaging with patients and knowledge users at every stage of our research has enabled the creation of high-quality research, resulting in actionable change. Our work has established 35 national consensus standards for a high-quality living kidney donor evaluation, demonstrated the scalability of a one-day living kidney donor evaluation clinic, expanded a peer-support program, and developed strong system partnerships.Limitations:Our work has primarily focused on improving access to living donor kidney transplantation in the province of Ontario. Equitable access to living donor kidney transplants remains a challenge, which we plan to continue focusing on in future iterations of our work.Implications:Our work highlights the vital role of patient-oriented research and the importance of involving patient volunteers in enhancing access to living kidney donation. Together, we remain committed to creating a Canadian system where everyone who needs a living donor kidney transplant can receive one fairly and without delay.

Rationale: Kidney transplantation (KT) is the treatment of choice for end-stage kidney disease (ESKD) in all age groups. However, KT in octogenarians is a rare and unique event. We describe the evaluation and clinical course of the world’s oldest kidney transplant recipient at 87 years, 262 days, as recognized by the Guinness Book of World Records. Presenting Concern of Patient: An 84-year-old Canadian retired real estate agent of Indian origin with ESKD due to diabetic nephropathy on hemodialysis presented to our center as a potential kidney transplant candidate. Comorbidities included hypertension, coronary artery disease, benign prostatic hyperplasia, and bilateral knee replacements. He was functional, independent, and extremely keen to undergo KT to further improve his quality of life. Diagnosis: Extensive pretransplant investigation revealed a reasonable state of health for all major organ systems. Multiple specialists were consulted prior to listing. Interventions: After 5 years on hemodialysis, he received a standard neurological determination of death donor kidney transplant. Outcomes: Graft function was immediate. Complications experienced in the first posttransplant year included two urinary tract infections—one with bacteremia; uncontrolled blood pressure and blood glucose, cytomegalovirus and BK viremia, and an inferior wall non-ST segment elevation myocardial infarction. In the second year, he developed a scrotal abscess. However, graft function remained stable with a serum creatinine concentration of 82 µmol/L at two years posttransplant. Teaching Points: Successful KT in advanced octogenarians is possible. Appropriate patient selection is crucial. Extended screening for infection, cardiac and vascular disease, malignancy, and frailty including cognitive deficits is required. Plans for diabetes care and ensuring adequate social support including home care may mitigate complications. Willingness to investigate identified illnesses and seek assistance from other specialists may reduce but not necessarily prevent posttransplant complications. Neurological determination of death donor organs might be preferable for advanced octogenarian KT recipients even if those organs meet expanded criteria.

Background:Kidney transplantation is the most effective treatment for patients with end-stage kidney disease. Modern immunosuppressive treatment has prolonged graft survival and reduced transplant rejection. However, these immunosuppressive regimens are associated with multiple side effects, including increased infections and cancer risk, nephrotoxicity, and metabolic complications. Attaining transplant tolerance with minimal reliance on immunosuppressive drugs is considered the ultimate goal in transplantation. Regulatory T cells (Tregs) adoptive immunotherapy has been proposed as a strategy to achieve transplant tolerance. However, this approach is labor-intensive and expensive, limiting its large-scale applicability. There is, therefore, a need to develop methods that promote Treg-mediated tolerance in vivo. Treg function and numbers are influenced by dietary components, and dietary interventions could provide a new therapeutic opportunity. Recently, our group demonstrated that sucralose supplementation, a commonly used sugar substitute (sweetener), reduces proinflammatory T-cell function and unpublished data indicating enhanced Treg frequencies. Building on this discovery, we propose to investigate the impact of sucralose on modulating T-cell populations and function in humans.Objective:To determine whether sucralose supplementation increases circulating Treg frequencies and alters T-cell function and populations in healthy adults.Design:This is a randomized, double-blind, placebo-controlled, crossover pilot trial.Setting:The study will be monocentric, at the Maisonneuve-Rosemont Hospital.Patients:Twelve healthy adult volunteers (>18 years of age), of both sexes, with no prior history of autoimmune disease or current treatments of immunomodulatory drugs. In addition, pregnant women will also be excluded from this study.Measurements:The primary outcome will be an alteration in circulating Treg frequency after sucralose supplementation. The secondary outcomes include modulation in the frequency of CD45+ cells, the frequency of CD4+ T-cell subsets, the differentiation of both CD4+ and CD8+ T cells, and T-cell function after antigen-specific and alloreactive challenges. Feasibility will also be evaluated, including adherence to visits, blood draw, ease of recruitment, percentage of study completion, and adherence to supplements. Exploratory outcomes in response to sucralose supplementation include changes in circulating metabolites and gut microbiome composition.Methods:Participants will be randomly assigned to receive either a placebo or sucralose (5–7 mg/kg/day) for four weeks, separated by a two-week washout period. This will be followed by a crossover phase, where patients receiving sucralose will receive the placebo and vice versa for an additional four weeks. Capsules will be prepared and blinded by a licensed pharmacy. Blood will be collected at baseline, after four weeks of treatment or placebo, after washout and after four weeks of crossover for Peripheral Blood Mononuclear Cell (PBMC) isolation, flow cytometry, functional assays, and metabolomics. Stool samples will be collected for microbiome sequencing.Limitations:This will be a small, single-center, short-duration trial in healthy volunteers. Findings might not apply to transplant recipients.Conclusion:The SWEET trial will provide first-in-human data on sucralose as a potential, inexpensive oral immunomodulator to promote Tregs.Trial Registration:NCT06997133 (2025-06-05)

Kidney transplantation is the best treatment for chronic kidney failure, but antibody-mediated rejection (AMR) is a major cause of kidney transplant loss. Human leukocyte antigen (HLA) molecular-compatibility-based organ allocation aims to reduce the risk of donor-specific antibody formation and thereby lower the risk of AMR. However, integrating molecular compatibility in organ allocation could introduce barriers to access, consequently raising ethical concerns. The objective of this study was to gather perspectives of HLA professionals on molecular matching in kidney transplantation. Individual semi-structured interviews. Canadian HLA laboratories. HLA laboratory directors or HLA professionals. Seven participants took part in semi-structured interviews between January and June 2024. The interviews were digitally recorded, transcribed, and analyzed using the qualitative description approach. Participants reported positive feelings regarding the current allocation system but highlighted that HLA matching could be improved. They differed on whether kidney allocation should prioritize medical utility or fairness. While acknowledging the potential benefits of precision medicine in improving transplant outcomes, experts emphasized that its implementation confronts both scientific uncertainties and practical challenges, identifying logistical, financial, technological, and occupational barriers. They expressed concerns regarding decreased access to kidney transplantation for marginalized groups, recommending the adoption of mitigation measures. Regarding the kidney-paired donation program, experts supported integrating molecular matching as an optimizing tool to complement the current algorithm. Participants recommended that future implementation of molecular matching in Canada should involve nationwide collaboration, establishing a maximum wait time and appropriate selection criteria, additional research, adequate staffing and funding for HLA laboratories, as well as education of transplant professionals and patients. The major limitation of this study is the small number of participants, all of whom were Canadian HLA professionals. Consequently, results may not be generalizable to transplant contexts in other countries. This study highlights the complexities of integrating molecular matching into organ allocation, raising concerns about equity, feasibility, and implementation. While HLA experts agree on the importance of ensuring equity and timely access, their perspectives also underscore the challenges of implementation, such as the availability of timely high-resolution HLA typing, stakeholder buy-in, and the need for dedicated tools and applications. To ensure an ethical and equitable implementation, future efforts must address access disparities through targeted mitigation strategies, such as the introduction of a maximum waiting time for a molecular-matched kidney.

Chronic kidney disease (CKD) is a resource-intensive and complex challenge to sustainable health care. The purpose of this narrative review is to describe how person-centered integrated care can support sustainable health care for this population, the strategies currently in place, and the gaps to consider. The findings may support the delivery and improvement of comprehensive support. Original peer-reviewed articles, website information, and Google Analytics were used to describe the current state of sustainable care strategies for CKD. We reviewed the available strategies to support sustainable care through a person-centered approach in Alberta, specifically examining strategies to support care for CKD. These strategies were mapped onto the Centre for Sustainable Healthcare's four principles of sustainable health care. In Alberta, there are several strategies to support person-centered integrated care. These include resources for health care providers that support prevention and lean service delivery, as well as patient-facing tools to support patient self-care. Person-centered integrated care and sustainability within health care are mutually supportive; however, strategies are often created in silos. There is an opportunity to improve sustainability of kidney care with a comprehensive approach and planning around outcome measures. While these strategies may have significant benefits, there is limited knowledge of direct impacts on outcomes. We used the data that were available and highlighted the need to measure the impact of health care strategies.

Youth living with type 2 diabetes (T2D) have high rates of early kidney disease and progression to kidney failure in early adulthood. Pediatric diabetes clinical practice guidelines have focused on screening for albuminuria and have not included recommendations for estimated glomerular filtration rate (eGFR) evaluation in children. In partnership with patients, families, and community partners, we are implementing a novel eGFR equation for youth with T2D into their diabetes care, with the aim of detecting youth with early kidney disease and providing appropriate interventions to slow disease progression. The development of such a tool aligned with a priority-setting workshop in 2016, where early detection and prevention of kidney disease were identified as a key priority by people living with kidney disease. In response, our team developed the novel Improving renal Complications in Adolescents with type 2 diabetes through Research (iCARE) eGFR equation, which estimates kidney function over time in youth with T2D, and validated it in a cohort of youth in Colorado (US) and a secondary group of youth in Manitoba (Canada). To integrate the tool into clinical care, this study includes 4 separate phases. Phase 1: External validation of the iCARE eGFR equation in a cohort of children with obesity and T2D from Colorado, US, to assess the generalizability of the equation. Phase 2: Readiness Assessment of pediatric endocrinologists (a) quantitative survey in Canada (n = 40) and the United States (n = 75) to assess current practice for screening youth with T2D for diabetic kidney disease (DKD) and (b) qualitative focus groups (4 groups; 2 in Canada [n = 8] and 2 in the United States [n = 5]) to explore barriers and facilitators to implementation of the iCARE eGFR equation into the care for youth with T2D. Focus groups of youth living with T2D are underway and explore how youth and families wish to be educated regarding kidney health and what sources of information would be helpful to empower youth to ask about kidney health in clinical settings. Phase 3: Development and implementation of an iCARE eGFR equation toolkit, which will include the resources for providers and patient education materials and the inclusion of the novel eGFR equation into an app and local electronic medical record systems at 3 sites (Vancouver, Winnipeg, Toronto). Phase 4: Evaluation of the iCARE eGFR implementation toolkit, including audits at 3 centers in Canada, as well as patient and provider satisfaction surveys. Phase 1: The validation study confirmed that the iCARE eGFR performed better than previously published eGFR equations in youth living with obesity and T2D. Relevant metrics were the highest P30 (% of eGFR values that fall within 30% of the measured glomerular filtration rate [GFR]) and the lowest bias. Phase 2: Survey results suggest that providers have strong adherence to existing T2D clinical practice guidelines, focused on albuminuria, but have limited experience and comfort with eGFR equations in general. Focus group discussions identified concerns about insufficient evidence indicating that eGFR metrics in childhood are associated with long-term outcomes and questions about generalizability and external validity. Key facilitators for improving uptake included development of a more comprehensive app or platform that presents eGFR findings in an accessible way for endocrinologists and development of clinical pathway guidelines to support follow-up treatment. Findings from phases 1 and 2 will be incorporated into the iCARE eGFR implementation toolkit, such that care providers and patients are able to utilize the most up-to-date evidence to screen for DKD and implement care strategies that will optimize the long-term kidney health of youth living with T2D.

The purpose of this commentary is to address the challenges of implementing the evolving Kidney Disease Improving Global Outcomes (KDIGO) glomerulonephritis (GN) guidelines within the Canadian health care context, highlighting barriers to adoption of the guidelines and discussing contextual issues unique to Canada. The KDIGO 2021 guidelines with 2024 updates in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis and lupus nephritis, as well as the 2025 updated guideline for immunoglobulin A (IgA) nephropathy. A Canadian Society of Nephrology (CSN) working group with expertise in GN was formed, representing nephrologists, pathologists, pharmacists, and patient partners with geographic representation from across Canada. Recommendations and practice points were reviewed by member surveys, with discussions to reach consensus and frame the commentary. The commentary highlights diagnostic investigations, the role of immune treatments for primary glomerular diseases, and the growing role of conservative kidney therapies. A review of the quality of evidence was not undertaken. Implementation and uptake of the guidelines will vary across each province given drug availability and cost. The commentary aims to provide tailored guidance to enhance the care of Canadians living with glomerular disease.

Patients with chronic kidney disease (CKD) at times must decide whether to take an invasive approach to management of coronary artery disease (CAD), which involves procedures such as angiography, angioplasty, and surgery, versus attempt management with medications alone. My Heart and CKD is a decision aid to support shared decision-making (SDM) between patients and their care providers in these situations. This report describes the pathway to implement My Heart and CKD , and key learnings that have emerged through this process. Human-centered design was used to develop the decision aid while concurrently identifying design features that could facilitate its incorporation within patient-physician clinical encounters. Interviews exploring use of the decision aid with patients and care providers were qualitatively analyzed according to the theoretical domains framework to identify barriers and facilitators to implementation. Simulated encounters between patient and physicians were used for pre-clinical testing and to identify additional training and resources that could support effective implementation. Implementation insights overlapped with decision-aid design input and influenced key design elements of My Heart and CKD as well as the development of implementation strategies to facilitate its clinical use. An overarching theme that influenced development and implementation was the concept that the decision aid be designed for use by patients and physicians together, to support the bidirectional communication and relationship building intended with SDM. This influenced design features to support varying use preferences and contexts, encompassing both digital and paper-based forms for use. Implementation considerations also influenced order and arrangement of content in My Heart and CKD to enhance integration of all stages of SDM into varying clinical environments. Additional training and implementation resources, including an accredited continuous medical education program for care providers, were identified as additional facilitators necessary to support implementation. Clinical evaluation has not yet been completed. My Heart and CKD is intended to support personalized, patient-centered care by providing patients with CKD and CAD and their care providers with tools to engage in SDM. Further research will evaluate the effectiveness of its implementation and impact on the quality of decision-making.

Children with chronic kidney disease (CKD) experience significant physical and psychological symptoms, necessitating patient-reported outcome (PRO) measurement tools to quantify symptoms, and to improve communication between children with CKD and their health care providers. This study aimed to implement the novel PRO-Kid tool into pediatric CKD and dialysis programs in Canada. The PRO-Kid tool is a novel 14-item questionnaire that was developed and validated by our research team, in partnership with patients living with childhood-onset CKD and caregivers for children with G3-G5 CKD, including dialysis. PRO-Kid measures both the frequency and impact of CKD symptoms in children ages eight to 18 years. It showed strong internal consistency and validity, as demonstrated by a Cronbach alpha of .83 (95% confidence interval [CI], 0.78-0.88) for the frequency scale, and .84 (95% CI, 0.80-0.89) on the impact scale. The PRO-Kid tool is being implemented in seven Pediatric Nephrology Programs across Canada. Guided by the Consolidated Framework for Implementation Research (CFIR), organizational readiness at each of the sites was assessed via surveys and focus groups. To date, the PRO-Kid tool (eight- to 18-year-old version) and site-specific toolkits have been implemented at three sites that were ready to launch (HSC, Winnipeg; BC Children's Hospital, Vancouver; and McMaster Children's Hospital, Hamilton). Implementation outcomes, such as the number of patients reached and patient and provider satisfaction, were evaluated using audits, surveys, and focus groups guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The organizational readiness assessment identified different electronic medical records and preferences for paper-based data collection methods across sites as well as the need to translate the PRO-Kid tool into other languages. Preliminary evaluation revealed that PRO-Kid is easy to use and is satisfactory to both patients and health care providers. Local champions were identified as key facilitators of implementation efforts. PRO-Kid can help improve communication between children with CKD and their health care providers in identifying symptoms that may not otherwise come up (be disclosed) during clinical encounters. However, language and low reading levels are barriers for some children, and unavailability of clinical staff can limit the use of the tool at some sites. Local teams will be required to play crucial roles in integrating the use of the tool in clinical settings. To ensure the tool can be applied across diverse populations, the validation of PRO-Kid tool two to four years old, five to seven years old, and French versions are ongoing. The availability of different versions of the tool will ensure equitable access and promote sustainability of the tool.

Diabetes mellitus is increasingly common among deceased donors and may signal donor-derived kidney injury that affects post-transplant outcomes. To evaluate whether donor proteinuria is associated with graft and patient outcomes after kidney transplantation from deceased donors with diabetes. Retrospective cohort study using a national transplant registry. United States; Scientific Registry of Transplant Recipients (SRTR), February 28, 2013-2023. 9486 kidney-alone transplant recipients from deceased donors with diabetes in whom a pre-implantation (procurement) biopsy was performed and donor proteinuria status was available. Primary outcome: death-censored graft failure (DCGF). Secondary outcomes: all-cause graft failure (ACGF), death with graft function (DWGF), and delayed graft function (DGF). Exposure: donor proteinuria (present vs absent). Kaplan-Meier analyses and multivariable Cox models (a priori covariables from a directed acyclic graph) assessed associations between donor proteinuria and time-to-event outcomes. Because proportional hazards were violated for DCGF, analyses were performed in two periods: an "early" cohort up to 2.5 years post-transplant and a landmarked cohort of recipients with functioning grafts at 2.5 years. Logistic regression evaluated DGF. Sensitivity analyses adjusted for donor insulin dependence (proxy for diabetes severity) and recipient characteristics; exploratory effect modification by biopsy glomerulosclerosis (GS) was assessed. Donor proteinuria was present in 54.9% of cases. In adjusted Cox models, donor proteinuria was not associated with early DCGF (<2.5 years; HR 1.14, 95% CI: 0.99, 1.32) but was associated with increased risk of late DCGF >2.5 years post-transplant (HR 1.36, 95% CI: 1.15, 1.62), with similar findings for ACGF. No associations were observed with DWGF or DGF. Results were consistent after adjustment for donor insulin dependence as a proxy for severity and recipient factors including diabetes status. The association between proteinuria and late graft failure was more pronounced in kidneys with lower GS, suggesting proteinuria may reflect chronic injury not well-captured by biopsy. Observational design with potential residual confounding. Because the cohort includes only kidneys that were actually transplanted, findings reflect outcomes among accepted organs and are not intended to guide offer acceptance or decline decisions. Donor proteinuria was recorded only as present or absent, without standardized measurement. This may have led to misclassification, prevented assessment of dose-response relationships, and likely made it harder to detect true associations. Registry constraints limited histologic detail beyond GS. Among diabetic deceased donors, the presence of proteinuria is a time-dependent marker of increased long-term graft-failure risk, complementing biopsy and clinical data. Standardized, quantitative proteinuria assessment may improve risk stratification and post-transplant management while supporting judicious utilization of diabetic donor kidneys.