End-stage Renal Disease In Canada Research Articles

Innovations in Hemodialysis Care: An Evaluation of Quality and the Patient Experience.

Hemodialysis (HD) performed in a tertiary care facility is the most prevalent and costly treatment for end-stage renal disease in Canada. This life-sustaining treatment is usually performed thrice weekly in an in-center facility. When people on HD also require a rehabilitation/complex care inpatient program, the burden of transportation for dialysis is immense to both the patient and health-care system. To improve the patient experience, create efficiency, and reduce travel costs, the renal team and a team from a rehabilitation/complex care center collaborated to provide HD services in the rehab/complex care setting. A patient/family representative was involved in all aspects of the design through to evaluation of this project. This study used realistic evaluation to examine the efficacy of this program from the perspective of the patient experience, HD staff, rehab/complex care staff and costs. The decreased travel with having dialysis on-site and adequate resources in the HD unit were the mechanisms for success in improved patient experience, quality of life and rehabilitation patient outcomes, decreased costs as well as increased communication and satisfaction.

The BC Glomerulonephritis Network: Improving Access and Reducing the Cost of Immunosuppressive Treatments for Glomerular Diseases

Glomerulonephritis (GN) is a common cause of end-stage renal disease in Canada and worldwide, and results in significant health care resource utilization and patient morbidity. However, GN has not been a traditional priority of provincial renal health care organizations, despite the known benefits to health services delivery and patient outcomes from integrated provincial care in other types of chronic kidney disease. To address this deficiency, the British Columbia (BC) Provincial Renal Agency created the BC GN Network in 2013 to coordinate provincial GN health services delivery informed by robust population-level data capture on all GN patients in the province via the BC GN Registry. This report describes the use of the BC GN Network infrastructure to systematically develop and evaluate a provincial GN drug formulary to improve patient and physician access to evidence-based immunosuppressive treatments for GN in a cost-efficient manner that successfully halted historical trends of increasing medication costs. An example is provided of using the provincial infrastructure to implement and subsequently evaluate an evidence-informed health policy of converting brand to generic tacrolimus for the treatment of GN. The BC GN Network, including the provincial drug formulary and data infrastructure, is an example of the benefits of expanding the mandate of provincial renal health administrative organizations to include the care of patients with GN, and constitutes a viable health delivery model that can be implemented in other Canadian provinces to achieve similar goals.

Opportunities and Challenges for Genetic Studies of End-Stage Renal Disease in Canada.

Purpose of review:Genetic testing can improve diagnostic precision in some patients with end-stage renal disease (ESRD) providing the potential for targeted therapy and improved patient outcomes. We sought to describe the genetic architecture of ESRD and Canadian data sources available for further genetic investigation into ESRD.Sources of information:We performed PubMed searches of English, peer-reviewed articles using keywords “chronic kidney disease,” “ESRD,” “genetics,” “sequencing,” and “administrative databases,” and searched for nephrology-related Mendelian diseases on the Online Mendelian Inheritance in Man database.Methods:In this narrative review, we discuss our evolving understanding of the genetic architecture of kidney disease and ESRD, the risks and benefits of using genetic data to help diagnose and manage patients with ESRD, existing public Canadian biobanks and databases, and a vision for future genetic studies of ESRD in Canada.Key findings:ESRD has a polygenic architecture including rare Mendelian mutations and common small effect genetic polymorphism contributors. Genetic testing will improve diagnostic accuracy and contribute to a precision medicine approach in nephrology. However, the risk and benefits of genetic testing needs to be considered from an individual and societal perspective, and further research is required. Merging existing health data, linking biobanks and administrative databases, and forming Canadian collaborations hold great potential for genetic research into ESRD. Large sample sizes are necessary to perform the suitably powered investigations required to bring this vision to reality.Limitations:This is a narrative review of the literature discussing future directions and opportunities. It reflects the views and academic biases of the authors.Implications:National collaborations will be required to obtain sample sizes required for impactful, robust research. Merging established datasets may be one approach to obtain adequate samples. Patient education and engagement will improve the value of knowledge gained.

Hypertension in dialysis and kidney transplant patients

For the first time, the Canadian Hypertension Education Program has studied the evidence supporting blood pressure control in people requiring renal replacement therapy for end-stage kidney disease, including those on dialysis and with renal transplants. According to the Canadian Organ Replacement Registry's 2008 annual report, there were an estimated 33,832 people with end-stage renal disease in Canada at the end of 2006, an increase of 69.7% since 1997. Of these, 20,465 were on dialysis and 13,367 were living with a functioning kidney transplant. Thus, it is becoming more likely that primary care practitioners will be helping to care for these complex patients. With the lack of large controlled clinical trials, the consensus recommendation based on interpretation of the existing literature is that blood pressure should be lowered to below 140/90 mmHg in hypertensive patients on renal replacement therapy and to below 130/80 mmHg for renal transplant patients with diabetes or chronic kidney disease.

The economic burden of end-stage renal disease in Canada

End-stage renal disease (ESRD) is a serious illness with significant health consequences and high-cost treatment options. This study estimates direct and indirect cost associated with ESRD from a societal perspective. A prevalence-based approach was used to estimate direct health-care costs and productivity losses from short- and long-term disability. An incident-based human capital approach was used to estimate mortality costs as the sum of the discounted present value of current and future productivity losses from premature deaths. Less than 0.1% of Canadians have ESRD; however, the disease generated direct health-care costs of $1.3 billion in the year 2000. The amount of direct spending per person with ESRD is much more than the average spending per person for all health-care conditions. Adding indirect morbidity and mortality cost brings the total burden associated with ESRD to $1.9 billion. This economic impact is higher than that for skin or infectious diseases, about the same as for genitourinary or endocrine diseases, but lower than that for conditions such as cancer or stroke. This economic weight is borne by a relatively small number of individuals. With the rapid increase in the incidence of ESRD, these findings may be useful in setting priorities for research, prevention programs, and in the planning of treatments. A better understanding of the scope and magnitude of the total economic burden of ESRD would help to inform those making policy decisions.

The economics of end-stage renal disease care in Canada: incentives and impact on delivery of care

Examining international differences in health outcomes for end-stage renal disease (ESRD) patients requires an understanding of ESRD funding structures. In Canada, funding for all aspects of dialysis and transplant care, with the exception of drugs (for which supplementary insurance can be purchased), is provided for all citizens. Although ESRD programs across Canada's 10 provinces differ in funding structure, they share important economic characteristics, including being publicly funded and universal, and providing most facets of ESRD care for free. This paper explains how ESRD care fits into the Canadian health care system, describes the epidemiology of ESRD in Canada, and offers economic explanations for international discrepancies.

Association between residence location and likelihood of kidney transplantation in Aboriginal patients treated with dialysis in Canada

For reasons that are not well understood, Aboriginal people with end-stage renal disease (ESRD) have lower rates of kidney transplantation. We hypothesized that distance between residence location and the closest transplant center was greater in Aboriginal dialysis patients and would partially explain the lower rate of transplantation in this population. We studied a random sample of 9905 patients initiating dialysis in Canada between 1990 and 2000. We calculated the distance between residence location at dialysis inception and the closest transplant center. Cox proportional hazards models were used to examine the relation between residence location and the likelihood of transplantation over a median period of 2.3 years. The proportion of Aboriginal participants living <or=50, 50.1-150, 150.1-300, and >300 km from the closest transplant center was 25, 18, 18, and 39% respectively, compared with 55, 19, 11, and 15% among white subjects. The relative likelihood of transplantation was significantly lower for Aboriginal compared to white participants across all four distance strata, with no apparent effect of residence location. For example, the relative likelihood of transplantation was hazard ratio (HR) 0.47, 95% confidence interval (CI) (0.31-0.72) in Aboriginal participants residing <or=50 and 0.55 (0.38-0.80) in those residing >300 km from the closest transplant center. Results were similar for transplants from deceased donors and living donors, and in all seven regions studied. In conclusion, remote location of residence does not explain the lower rate of kidney transplantation among Aboriginal people treated for ESRD in Canada.

Wait-Listing for Kidney Transplantation Among Aboriginal Hemodialysis Patients

Although there has been rapid growth in the global prevalence of Aboriginal patients with end-stage renal disease (ESRD), these individuals have markedly lower rates of kidney transplantation for reasons that are unclear. We investigated barriers to kidney transplantation for Aboriginal patients treated with hemodialysis for ESRD in Canada. All consenting adults in the province of Alberta, Canada, who had been established on hemodialysis therapy for 6 months or longer were interviewed by a physician. Data for transplantation referral, waiting list status, and the assessment process were determined from the regional transplant programs, with race defined by patient self-report. For purposes of this analysis, race was dichotomized as either Aboriginal or non-Aboriginal. Of 835 subjects, 100 (12%) were Aboriginal. Aboriginal patients were significantly younger and more likely to have diabetes mellitus as the cause of ESRD than non-Aboriginal patients. Although a greater proportion of Aboriginal patients were referred for transplantation assessment (60.6% versus 46.0%; P < 0.01), after adjustment, the likelihood of referral was similar for both racial groups (hazard ratio associated with Aboriginal race, 0.80; 95% confidence interval, 0.59 to 1.08). Aboriginal patients also were significantly less likely to be active on the transplant wait list than non-Aboriginal patients (adjusted hazard ratio, 0.46; 95% confidence interval, 0.27 to 0.78). Aboriginal subjects who had been referred for assessment were significantly more likely than non-Aboriginals to be in the process of completing the transplantation workup (69.6% versus 26.9%; P < 0.01) as opposed to being temporarily or permanently unsuitable for transplantation (30.4% versus 73.3%; P < 0.01). Although not statistically significant, median duration of the workup in progress in referred, but nonlisted, participants appeared longer in Aboriginal participants (954 versus 596 days; P = 0.07). The likelihood of referral for transplantation was similar between Aboriginal and non-Aboriginal people. However, Aboriginal people were approximately half as likely to be successfully activated to the transplant waiting list compared with non-Aboriginal people. These data suggest that the major barrier to transplantation in Aboriginal patients occurs after referral, but early in the course of evaluation for eligibility.

End-stage renal disease in Canada: prevalence projections to 2005

End-stage renal disease in Canada: prevalence projections to 2005

New and Prevalent Patients With End-Stage Renal Disease in Canada

The number of patients initiating treatment for end-stage renal disease (ESRD) has increased dramatically in Canada and other countries. To assist healthcare planners, the prevalence of ESRD in Canada has been projected to the year 2000 using a Markov modelling technique. Significant increases in ESRD are expected in Canada during the next decade, particularly among the elderly and diabetic populations: estimated increases in prevalence rates of ESRD between 1992 and the year 2000 were 78% and 154% for non diabetic and diabetic populations respectively. These expected increases did not differ significantly between the treatment groups, except among patients with diabetes, in whom projected increases in the prevalence of functioning transplant was smaller than for hemodialysis or peritoneal dialysis. Because the current Canadian prevalence rates are lower than those of some other countries, such as the United States and Japan, these expected trends in prevalence appear reasonable, and illustrate the growing healthcare needs of the ESRD population in Canada during the next decade.

New and Prevalent Patients With End-Stage Renal Disease in Canada

The number of patients initiating treatment for end-stage renal disease (ESRD) has increased dramatically in Canada and other countries. To assist healthcare planners, the prevalence of ESRD in Canada has been projected to the year 2000 using a Markov modelling technique. Significant increases in ESRD are expected in Canada during the next decade, particularly among the elderly and diabetic populations: estimated increases in prevalence rates of ESRD between 1992 and the year 2000 were 78% and 154% for non diabetic and diabetic populations respectively. These expected increases did not differ significantly between the treatment groups, except among patients with diabetes, in whom projected increases in the prevalence of functioning transplant was smaller than for hemodialysis or peritoneal dialysis. Because the current Canadian prevalence rates are lower than those of some other countries, such as the United States and Japan, these expected trends in prevalence appear reasonable, and illustrate the growing healthcare needs of the ESRD population in Canada during the next decade.ASAIO Journal1995; 41:230-233.

Treatment of End-Stage Renal Disease in Canada

Treatment of End-Stage Renal Disease in Canada