Project 1: Timing of Dialysis Initiation
Background: Over the past 10 years, research has shown that patients are starting dialysis at higher levels of Estimated Glomerular Filtration Rate (eGFR). This is consistent with existing guidelines, but may not be consistent with recent information from clinical trials. During the initial background work for the CIHR network catalyst grant, CANN-NET surveyed nephrology knowledge users and subsequently confirmed priorities at the knowledge user meeting at the world Congress of nephrology in Vancouver. Knowledge users noted that the timing of dialysis initiation would be an ideal first project given that the stakeholders are all nephron-centric, that the knowledge base is now relatively strong, and that there is variation in timing of dialysis initiation practice across the country. At the December 15, 2011 meeting of knowledge users, the knowledge users confirmed that this continues to be an important priority which is feasible and that work on this project will provide the framework through which other knowledge translation activities can follow.
The Ad-Hoc Guidelines Working Group is doing a systematic review to examine the issues of timing of dialysis initiation, and will come up with guidelines around timing of dialysis initiation
It was noted that there are some specific questions that the knowledge users would like addressed. Specifically what is the optimal timing of dialysis initiation for patients in different situation-for instance those starting on peritoneal dialysis, those of different age, patients with and without diabetes and those who live in remote geographic locations. It is possible that some of these answers might be identified within the systematic review. Finally whether there is a role for the use of prediction formula in identifying patients who are at high risk for progression to end stage renal disease.
The Knowledge User Committee (KU) has identified priorities and modified questions based on understanding and interactions with the larger medical community and infrastructure (policies and procedures). While many on this committee may have interest and abilities to be involved in direct development of research questions and knowledge translation activities, the goal of this group is to ensure focus and applicability of questions to clinical practice and policy. The initial priority that has been identified is timing of dialysis initiation. They have also identified topics for the guidelines which are of particular relevance for knowledge translation. Once the draft guidelines are available, they will confirm which of the draft guidelines are most relevant for knowledge translation. They will assist with the knowledge translation process by providing contacts to the knowledge translation committee within each of their programs.
The Knowledge Translation (KT) Committee will focus around the knowledge to action cycle and will refine the plan below. The role of the KT committee is to identify and implement those activities most likely to impact behavior, and to develop an evaluation plan to demonstrate those changes.
Rough work plan:
Determine current practice patterns (and predictors of care patterns):
- It is already established that there is variation in mean eGFR at dialysis initiation in Canadian centres-further work is needed to identify those centers where dialysis is initiated earliest (e.g. a survey of dialysis programs to determine the causes for variation in dialysis starts)
- An analysis using CORR (Canadian Organ Replacement Register) data; specifically patient and facility predictors of eGFR at dialysis initiation by region. The information will be sued to help identify optimal practice, gaps in best practice, data gaps and system barriers and to target geographic areas where knowledge translation is needed.
- A network of knowledge users will be developed
Determine KT activities:
- After identifying the main barriers to timely initiation appropriate KT activities will be implemented which may include:
- Guidelines, disseminating guidelines slide sets to be used by key messengers, posting guidelines, and key messages on a central website for locating Canadian Chronic Kidney Disease (CKD) guidelines, physician education, education of allied health professionals, writing a series of clinical and scientific summaries for various audiences (renal programs, primary care practitioners, patients with or at risk of kidney disease), rules around dialysis starts and other knowledge translation tools.
Determine whether the interventions have led to changes in care:
- Repeat step one i.e. evaluate mean eGFR at dialysis initiation, to determine if there has been a change in care patterns and outcomes.
Background: After discussion of CANN-NET priorities, knowledge users confirmed that choice of dialysis modality, given that this is closely linked with timing of dialysis, would be an important priority to take on at this point. There was a general discussion that the promotion of home therapies seems to be an important objective. It was noted that a better understanding of the variations and nuances in practice across the country would aid in changing practices. The framework for this would largely follow that identified about for timing of dialysis initiation.
Project 3: Pediatric Nephrotic Syndrome
Nephrotic syndrome is common acquired kidney disease in children. The syndrome is associated with significant morbidity due to severe and recurrent episodes of proteinuria, hypoalbuminemia and edema. Treatment of nephrotic syndrome involves prolonged high doses of steroids for initial presentation and subsequent relapses of proteinuria. Various steroid sparing drugs (both old and new) are used to decrease frequency of relapses and minimize toxicity from steroid use. However, the current approach for treatment of childhood nephrotic syndrome with prednisone is based on several decades' old evidence and the use of newer steroid sparing drugs is substantiated by limited evidence. The generalizability of these treatment protocols to the present cohort of affected patients in Canada is unknown.
Management of childhood nephrotic syndrome is highly variable between physicians and care centres both in Canada and other countries. Variability in practice may exist due to uncertainty in evidence or a lack of appropriate knowledge translation strategies to implement evidence. Using a survey of Canadian pediatric nephrologists, we determined that the management of childhood nephrotic syndrome was the top priority for knowledge generation and knowledge translation activities. We formed the Canadian Childhood Nephrotic Syndrome Project (CHILDNEPH) Project in response to this identified need.
We hypothesize that by assessing determinants of practice variation and related patient outcomes, using both qualitative and quantitative methods, we will improve use of best evidence in practice and ultimately improve patient outcomes. Therefore as a first step, we will study centre- , physician-, patient-level determinants of cumulative steroid exposure in children with steroid sensitive nephrotic syndrome.
Read more about The Canadian Childhood Nephrotic Syndrome Project (overview of design and methods) - CJKHD 2014
The Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) in partnership with the Canadian Society of Nephrology (CSN) and the Kidney Foundation of Canada (KFOC) aims to improve care and outcomes of people with kidney disease. Improving anemia management in Chronic Kidney Disease (CKD) patients has been identified as a priority by these organizations. As such, CANN-NET, working in collaboration with the CSN guidelines workgroup who recently published a commentary on the 2012 KDIGO clinical practice guidelines for anemia management in CKD patients, has taken on the task of updating a pre-existing and well-functioning anemia management protocol. CANN-NET seeks to make this nurse or pharmacist-led anemia management protocol available to all hemodialysis centres and provide the necessary tools for its implementation.
Why is a Nurse or Pharmacist-led Anemia Management Protocol important?
Several high quality randomized controlled trials of erythropoietin-stimulating agents (ESAs) have:
- Raised safety concerns regarding normalizing hemoglobin in patients with CKD
- Raised questions about when ESAs should be started
- Raised concerns about whether ESAs should be used in patients with cancer or recent strokes
- Raised questions about how best to use ESAs in patients with erythropoietin resistance
Has a Nurse or Pharmacist-led Anemia Management Protocol been noted to have significant benefits in the Canadian healthcare system?
Yes, several randomized trials have documented that nurse or pharmacist-led anemia protocols lead to similar or improved outcomes compared to anemia management by physicians. A prospective evaluation of a nurse /pharmacist-led anemia protocol in the British Columbia Provincial Renal program (British Columbia) has documented the following benefits:
- Reduced time to achieve anemia treatment targets and increased patient time within the hemoglobin target range
- Reduced within-patient variability in ESA dosing
- A decrease in time spent by nephrologists reviewing and prescribing anemia therapy
- Increased career satisfaction for registered nurses and pharmacists involved in the delivery of protocolized anemia management.
- Substantial cost savings (14%), translating to over $3 million in BC over the past five years
- Permits nurses and pharmacists to work to their scope of practice
Please note that several versions of the anemia protocol are available, differing based on the frequency of lab-work and the specific ESA and Iron preparations used in your hemodialysis unit. This Nurse or Pharmacist-led Anemia Management Protocol is available free of charge.
For units measuring hemoglobin levels every 4 weeks, please click here to download the 4-week version of the CANN-NET Anemia Management Protocol.
For units measuring hemoglobin levels every 6 weeks, please click here please click here to download the 6-week version of the CANN-NET Anemia Management Protocol.
In an effort to facilitate the introduction and implementation of the Nurse or Pharmacist-led Anemia Management Protocol, we have created several accompanying documents as follows:
A comprehensive educational package which moves step-by-step through the Anemia Management Protocol. This document also contains a draft set of policy and procedures that your hemodialysis unit may find helpful.
The supplementary documents include frequently asked questions for health care providers and case-study questions.
Finally, for hemodialysis units requiring an ESA dosing algorithm for patient-bought ESA or a modifiable version of the CANN-NET Nurse or Pharmacist-led Anemia Management Protocol, please contact our team lead at .
If your hemodialysis program is interested in implementing the CANN-NET Nurse or Pharmacist-led Anemia Management Protocol, or for more information about this important initiative, please contact our team lead at .