Publications by authors named "Amanda J Vinson"

17 Publications

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COVID-19 in Solid Organ Transplantation: Results of the National COVID Cohort Collaborative.

Transplant Direct 2021 Nov 6;7(11):e775. Epub 2021 Oct 6.

Division of Nephology, Department of Medicine, University of Nebraska Medical Center, Omaha, NE.

Coronavirus disease 2019 (COVID-19) has resulted in significant morbidity and mortality in solid organ transplant (SOT) recipients. The National COVID Cohort Collaborative was developed to facilitate analysis of patient-level data for those tested for COVID-19 across the United States.

Methods: In this study, we identified a cohort of SOT recipients testing positive or negative for COVID-19 (COVID+ and COVID-, respectively) between January 1, 2020, and November 20, 2020. Univariable and multivariable logistic regression were used to determine predictors of a positive result among those tested. Outcomes following COVID-19 diagnosis were also explored.

Results: Of 18 121 SOT patients tested, 1925 were positive (10.6%). COVID+ SOT patients were more likely to have a kidney transplant and be non-White race. Comorbidities were common in all SOT patients but significantly more common in those who were COVID+. Of COVID+ SOT, 42.9% required hospital admission. COVID+ status was the strongest predictor of acute kidney injury (AKI), rejection, and graft failure in the 90 d after testing. A total of 40.9% of COVID+ SOT experienced a major adverse renal or cardiac event, 16.3% experienced a major adverse cardiac event, 35.3% experienced AKI, and 1.5% experienced graft loss.

Conclusions: In the largest US cohort of COVID+ SOT recipients to date, we identified patient factors associated with the diagnosis of COVID-19 and outcomes following infection, including a high incidence of major adverse renal or cardiac event and AKI.
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http://dx.doi.org/10.1097/TXD.0000000000001234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8500600PMC
November 2021

Sex and Organ-Specific Risk of Major Adverse Renal or Cardiac Events in Solid Organ Transplant Recipients with COVID-19.

Am J Transplant 2021 Oct 12. Epub 2021 Oct 12.

Division of Nephology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA.

While older males are at highest risk for poor COVID-19 outcomes, it is not known if this applies to the immunosuppressed recipient of a solid organ transplant (SOT), nor how the type of allograft transplanted may impact outcomes. In a cohort study of adult (>18 years) patients testing positive for COVID-19 (Jan 01, 2020-June 21, 2021) from 56 sites across the United States identified using the National COVID Cohort Collaborative (N3C) Enclave, we used multivariable Cox proportional hazards models to assess time to MARCE after COVID-19 diagnosis in those with and without SOT. We examined the exposure of age-stratified recipient sex overall and separately in kidney, liver, lung, and heart transplant recipients. 3,996 (36.4%) SOT and 91,646 (4.8%) non-SOT patients developed MARCE. Risk of post-COVID outcomes differed by transplant allograft type with heart and kidney recipients at highest risk. Males with SOT were at increased risk of MARCE, but to a lesser degree than the non-SOT cohort (HR 0.89, 95% CI 0.81-0.98 for SOT and HR 0.61, 95% CI 0.60-0.62 for non-SOT (females versus males)). This represents the largest COVID-19 SOT cohort to date and the first-time sex-age stratified and allograft-specific COVID-19 outcomes have been explored in those with SOT.
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http://dx.doi.org/10.1111/ajt.16865DOI Listing
October 2021

Incorporation of sex and gender guidelines into transplantation literature.

Transplantation 2021 Sep 28. Epub 2021 Sep 28.

Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada. Department: Surgery, University of Chicago, Chicago, Illinois, USA. College of Nursing and Health Professionals, Drexel University, Philadelphia, Pennsylvania, USA. Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany. Department of Pediatrics, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada; Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada. Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada; Department of Laboratory Medicine, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Alberta Precision Laboratories, Edmonton, Alberta, Canada; Alberta Transplant Institute, Edmonton, Alberta, Canada. Department of Medicine/Nephrology, University of Nebraska Medical Center, Omaha, Nebraska, USA. Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands. Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA. Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada; Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada. Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada; Alberta Transplant Institute, Edmonton, Alberta, Canada; Department of Pediatrics and Surgery, University of Alberta, Edmonton, Alberta, Canada; Department of Medical Microbiology/Immunology, University of Alberta, Edmonton, Alberta, Canada; Department of Laboratory Medicine/Pathology, University of Alberta, Edmonton, Alberta, Canada. School of Public Health, University of Sydney, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1097/TP.0000000000003967DOI Listing
September 2021

Successful Use of Kidneys from a Deceased Donor with Active Herpes Zoster Infection.

Case Rep Transplant 2021 16;2021:7719041. Epub 2021 Aug 16.

Division of Nephrology, Department of Medicine, Nova Scotia Health, Halifax, NS, Canada.

Background: The limited donor pool and increasing recipient wait list require a reevaluation of kidney organ suitability for transplantation. Use of higher infectious risk organs that were previously discarded may help improve access to transplantation and reduce patient mortality without placing patients at a higher risk of poor posttransplant outcomes. There is very little data available regarding the safe use of kidney organs from deceased donors with varicella zoster virus infection at the time of organ retrieval. . Here, we report a case of successful transplantation of both kidneys from a deceased donor with active herpes zoster infection at the time of organ retrieval. Recipients were treated preemptively with acyclovir. At 4 months posttransplant, both kidney recipients experienced no infectious complications and were off dialysis with functioning transplant grafts.

Conclusions: The use of kidney organs from donors with active herpes zoster infection appears to be a safe option to expand the kidney donor pool.
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http://dx.doi.org/10.1155/2021/7719041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8382547PMC
August 2021

COVID-19 Disease Severity among People with HIV Infection or Solid Organ Transplant in the United States: A Nationally-representative, Multicenter, Observational Cohort Study.

medRxiv 2021 Jul 28. Epub 2021 Jul 28.

Background: Individuals with immune dysfunction, including people with HIV (PWH) or solid organ transplant recipients (SOT), might have worse outcomes from COVID-19. We compared odds of COVID-19 outcomes between patients with and without immune dysfunction.

Methods: We evaluated data from the National COVID-19 Cohort Collaborative (N3C), a multicenter retrospective cohort of electronic medical record (EMR) data from across the United States, on. 1,446,913 adult patients with laboratory-confirmed SARS-CoV-2 infection. HIV, SOT, comorbidity, and HIV markers were identified from EMR data prior to SARS-CoV-2 infection. COVID-19 disease severity within 45 days of SARS-CoV-2 infection was classified into 5 categories: asymptomatic/mild disease with outpatient care; mild disease with emergency department (ED) visit; moderate disease requiring hospitalization; severe disease requiring ventilation or extracorporeal membrane oxygenation (ECMO); and death. We used multivariable, multinomial logistic regression models to compare odds of COVID-19 outcomes between patients with and without immune dysfunction.

Findings: Compared to patients without immune dysfunction, PWH and SOT had a greater likelihood of having ED visits (adjusted odds ratio [aOR]: 1.28, 95% confidence interval [CI] 1.27-1.29; aOR: 2.61, CI: 2.58-2.65, respectively), requiring ventilation or ECMO (aOR: 1.43, CI: 1.43-1.43; aOR: 4.82, CI: 4.78-4.86, respectively), and death (aOR: 1.20, CI: 1.19-1.20; aOR: 3.38, CI: 3.35-3.41, respectively). Associations were independent of sociodemographic and comorbidity burden. Compared to PWH with CD4>500 cells/mm , PWH with CD4<350 cells/mm were independently at 4.4-, 5.4-, and 7.6-times higher odds for hospitalization, requiring ventilation, and death, respectively. Increased COVID-19 severity was associated with higher levels of HIV viremia.

Interpretation: Individuals with immune dysfunction have greater risk for severe COVID-19 outcomes. More advanced HIV disease (greater immunosuppression and HIV viremia) was associated with higher odds of severe COVID-19 outcomes. Appropriate prevention and treatment strategies should be investigated to reduce the higher morbidity and mortality associated with COVID-19 among PWH and SOT.
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http://dx.doi.org/10.1101/2021.07.26.21261028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328066PMC
July 2021

An Environmental Scan and Evaluation of Quality Indicators Across Canadian Kidney Transplant Centers.

Can J Kidney Health Dis 2021 28;8:20543581211027969. Epub 2021 Jun 28.

Department of Medicine, Division of Nephrology, St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada.

Background: Kidney transplantation is the optimal treatment for an individual requiring kidney replacement therapy, resulting in improved survival and quality of life while costing the health care system less than maintenance dialysis. Achieving and maintaining a kidney transplant requires extensive coordination of several different health care services. To improve the quality of kidney transplant care, quality metrics or indicators that encompass all aspects of the individual's journey to transplant should be measured in a standardized fashion.

Objective: To identify, categorize, and evaluate strengths and weaknesses of kidney transplant quality indicators currently being used across Canada.

Design: An environmental scan of quality indicators being used by kidney organizations and programs.

Setting: A 16-member volunteer pan-Canadian panel with expertise in nephrology, transplant, and quality improvement.

Sample: Transplant programs, as well as provincial transplant and kidney agencies across Canada.

Methods: Indicators were first categorized based on the period of transplant care and then using the Institute of Medicine and Donabedian frameworks. A 4-member subcommittee rated each indicator using a modified version of the Delphi consensus technique based on the American College of Physician/Agency for Healthcare Research and Quality criteria. Consensus ratings were subsequently shared with the entire 16-member panel for additional comments.

Results: We identified 46 measures related to transplant care across 7 Canadian provinces (9 referral and evaluation, 9 waitlist activity and outcomes, 6 hospitalization for transplant surgery, 12 posttransplant care, 6 organ utilization, 4 living donor). We rated 24 indicators (52%) as necessary to distinguish high-quality from low-quality care, most of which measured effective (n = 10) or efficient (n = 6) care. Only 7 (15%) of 46 indicators evaluated person-centered or equitable care. Fourteen common indicators were measured by 5 of 7 provinces, 10 of which were deemed "necessary," measuring safe (n = 2), effective (n = 5), efficient (n = 2), and equitable (n = 1) care.

Limitations: The panel lacked patient and allied health representation.

Conclusions: There are a large number of kidney transplant quality indicators currently being used in Canada, some of which are common across provinces and focus primarily on measuring effective care. Person-centered and equitable care indicators were lacking, and only half of these indicators were deemed "necessary" for quality improvement. Our results should complement ongoing work to achieve national consensus on the standardization of quality indicators in kidney transplantation.
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http://dx.doi.org/10.1177/20543581211027969DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8243101PMC
June 2021

In Search of a Better Outcome: Opting Into the Live Donor Paired Kidney Exchange Program.

Can J Kidney Health Dis 2021 26;8:20543581211017412. Epub 2021 May 26.

Department of Medicine, Dalhousie University, Halifax, NS, Canada.

Background: Live donor (LD) kidney transplantation is the best option for patients with end-stage kidney disease (ESKD). However, this may not be the best option if a patient's donor is older and considerably smaller in weight. Patient (A) with a less than ideal donor (Donor A) might enter into a live donor paired exchange (LDPE) program with the hopes of swapping for a better-quality organ. A second patient (B) who is in the LDPE may or may not benefit from this exchange with Donor A.

Methods: This medical decision analysis examines the conditions that favor Patient A entering into the LDPE compared to directly accepting a kidney from their intended donor, as well as the circumstances where Patient B also benefits by accepting a lower-quality organ.

Results: Under select circumstances, a paired exchange could benefit both Patients A and B. For example, a 30-year-old Patient A with a lower-quality donor might gain 1.52 quality adjusted life years (QALYs) by entering into a LDPE for a better-quality kidney, whereas a 60-year-old Patient B might gain 1.03 QALYs by accepting Donor A's kidney rather than waiting longer in the LDPE. The net benefit (or loss) of entering the LDPE differs by recipient age, donor organ quality, likelihood of Patient B being transplanted in LDPE, and likelihood of Patient A finding an ideal donor in the LDPE.

Conclusion: This study shows there are ways to increase live donor utilization and effectiveness that require further research and potentially changes to the LDPE process.
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http://dx.doi.org/10.1177/20543581211017412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8161848PMC
May 2021

Panic in the Pandemic: When Should Kidney Transplant Programs Close?

Kidney Int Rep 2021 May 26;6(5):1232-1241. Epub 2021 Feb 26.

Department of Medicine, Division of Nephrology, Nova Scotia Health, Halifax, Nova Scotia, Canada.

Background: Pandemics greatly interfere with overall health care delivery as resources are diverted to combat the crisis. Kidney transplantation programs were closed temporarily during the COVID-19 pandemic. Given the critical shortage of organs, their short shelf life, and their overall importance to improving length and quality of life for those with kidney disease, this analysis examines the impact of discarding deceased donor organs.

Methods: The net benefit (or harm) of discarding deceased donor organs was measured in projected life years from a societal and individual perspective using a Markov model. A wide range of infection rates, pandemic durations, and case fatality rates associated with infection in wait listed and transplant recipients were examined.

Results: Overall, patient life expectancy fell for both wait listed and transplant recipients as the pandemic conditions became more unfavorable. However, the overall net benefit of a transplant during the pandemic was preserved. For example, prior to the pandemic, the net benefit of a kidney transplant over dialysis was calculated to be 6.25 life years (LYs) or 8.24 quality-adjusted life years (QALYs) in a 40-year old recipient. This fell to 5.86 LYs (7.78 QALYs) during the pandemic. Even assuming plausible but higher relative case fatality rates and risks of nosocomial and donor transmission in transplant recipients compared to wait listed patients, the net benefit remained >4 years for most deceased donor organs.

Conclusion: As long as hospitals have adequate resources to deal with the pandemic and can limit nosocomial infection, kidney transplantation should not be curtailed.
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http://dx.doi.org/10.1016/j.ekir.2021.02.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8116904PMC
May 2021

Survival comparisons in home hemodialysis: Understanding the present and looking to the future.

Nephrol Ther 2021 Apr;17S:S64-S70

Dalhousie University/Nova Scotia Health Authority, 5082 Dickson Building, 5820, University Avenue, NS B3H 1V8 Halifax, Canada.

A number of studies have compared relative survival for home hemodialysis patients (including longer hours/more frequent schedules) and other forms of renal replacement therapy. While informative, many of these studies have been limited by issues pertaining to their observational design including selection bias and residual confounding. Furthermore the few randomized controlled trials that have been conducted have been underpowered to detect a survival difference. Finally, in the face of a growing recognition of the value of patient-important outcomes beyond survival, the focus of comparisons between dialysis modalities may be changing. In this review, we will discuss the determinants of survival for patients receiving home hemodialysis and address the various studies that have compared relative survival for differing home hemodialysis schedules to each of in-center hemodialysis, peritoneal dialysis and transplantation. We will conclude this review by discussing whether there is an ongoing role for survival analyses in home hemodialysis.
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http://dx.doi.org/10.1016/j.nephro.2020.02.008DOI Listing
April 2021

Sex matters: COVID-19 in kidney transplantation.

Kidney Int 2021 03 5;99(3):555-558. Epub 2021 Jan 5.

Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada; Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.kint.2020.12.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783460PMC
March 2021

Canadian Society of Nephrology Commentary on the Kidney Disease Improving Global Outcomes 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder.

Can J Kidney Health Dis 2020 4;7:2054358120944271. Epub 2020 Aug 4.

Division of Nephrology, Department of Medicine, Department of Health Research, Evidence and Impact, McMaster University, Hamilton, ON, Canada.

Purpose Of Review: (1) To provide commentary on the 2017 update to the Kidney Disease Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD); (2) to apply the evidence-based guideline update for implementation within the Canadian health care system; (3) to provide comment on the care of children with chronic kidney disease (CKD); and (4) to identify research priorities for Canadian patients.

Sources Of Information: The KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD.

Methods: The commentary committee co-chairs selected potential members based on their knowledge of the Canadian kidney community, aiming for wide representation from relevant disciplines, academic and community centers, and different geographical regions.

Key Findings: We agreed with many of the recommendations in the clinical practice guideline on the diagnosis, evaluation, prevention, and treatment of CKD-MBD. However, based on the uncommon occurrence of abnormalities in calcium and phosphate and the low likelihood of severe abnormalities in parathyroid hormone (PTH), we recommend against screening and monitoring levels of calcium, phosphate, PTH, and alkaline phosphatase in adults with CKD G3. We suggest and recommend monitoring these parameters in adults with CKD G4 and G5, respectively. In children, we agree that monitoring for CKD-MBD should begin in CKD G2, but we suggest measuring ionized calcium, rather than total calcium or calcium adjusted for albumin. With regard to vitamin D, we suggest against routine screening for vitamin D deficiency in adults with CKD G3-G5 and G1T-G5T and suggest following population health recommendations for adequate vitamin D intake. We recommend that the measurement and management of bone mineral density (BMD) be according to general population guidelines in CKD G3 and G3T, but we suggest against routine BMD testing in CKD G4-G5, CKD G4T-5T, and in children with CKD. Based on insufficient data, we also recommend against routine bone biopsy in clinical practice for adults with CKD or CKD-T, or in children with CKD, although we consider it an important research tool.

Limitations: The committee relied on the evidence summaries produced by KDIGO. The CSN committee did not replicate or update the systematic reviews.
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http://dx.doi.org/10.1177/2054358120944271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7412914PMC
August 2020

Prolonged Cold Ischemia Time Offsets the Benefit of Human Leukocyte Antigen Matching in Deceased Donor Kidney Transplant.

Transplant Proc 2020 Apr 20;52(3):807-814. Epub 2020 Feb 20.

Nova Scotia Health Authority Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.

Background: The consequences of prolonging cold ischemia time (CIT) to facilitate HLA matching in kidney transplantation are not known.

Methods: Patients with a history of kidney transplant in the United States (2000-2016) with 0 HLA mismatch (MM) were categorized based on CIT (< 10; 10 to < 15; 15 to < 20; 20 to < 25; 25 to < 30; and ≥ 30 hours). Time to graft loss was compared for each CIT category to a reference group of individuals with > 0 HLA MM and short CIT (< 10 hours) using a multivariable Cox proportional hazards model.

Results: The adjusted risk of graft failure was significantly lower for 0 HLA MM with the shortest CIT compared to the reference group (hazard ratio, 0.82; 95% confidence interval, 0.72-0.94), and this survival advantage persisted to a threshold of < 20 hours of CIT. No survival advantage was observed for the 0 HLA MM group once CIT was > 20 hours. This trend persisted after excluding highly sensitized recipients (panel reactive antibody > 98%) where shipping of organs occurs to achieve more equitable access to organs rather than optimize HLA match.

Conclusions: CIT > 20 hours offsets the benefit of 0 HLA MM in kidney transplantation. This may have implications in organ shipping to facilitate immunologic match.
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http://dx.doi.org/10.1016/j.transproceed.2019.12.049DOI Listing
April 2020

A Location-Based Objective Assessment of Physical Activity and Sedentary Behavior in Ambulatory Hemodialysis Patients.

Can J Kidney Health Dis 2019 28;6:2054358119872967. Epub 2019 Aug 28.

Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada.

Background: Dialysis patients have reduced moderate to vigorous physical activity, and light physical activity. This has been shown in self-reported surveys and objective accelerometer studies. Less attention has been directed toward sedentary behavior, which is characterized by low energy expenditure (≤1.5 metabolic equivalents). Furthermore, locations where physical activity and sedentary behavior occur are largely unknown for dialysis patients.

Objectives: The objectives of this study were (1) to determine the minutes per day of moderate to vigorous physical activity, light physical activity, and sedentary behavior for hemodialysis patients; (2) to describe differences in moderate to vigorous physical activity, light physical activity, and sedentary behavior comparing dialysis versus nondialysis days; and (3) to describe the locations where moderate to vigorous physical activity, light physical activity, and sedentary behavior occur using global positioning system (GPS) data.

Design: Cross-sectional study.

Setting: The study was performed at a tertiary care hospital in Nova Scotia, Canada.

Patients: A total of 50 adult in-center hemodialysis patients consented to the study.

Measurements: Physical activity and sedentary behavior were measured with an Actigraph-GT3X accelerometer. Location was determined using a Qstarz BT-Q1000X GPS receiver.

Methods: Minutes of daily activity were described as was percentage of wear time for each activity level across different locations during waking hours. Physical activity intensity, quantity, and location were also analyzed according to dialysis vs nondialysis days.

Results: Forty-three patients met requirements for accelerometer analysis, of whom 42 had GPS data. Median wear time was 836.5 min/day (interquartile range [IQR]: 788.3-918.3). Median minutes of daily wear time spent in sedentary behavior, light physical activity, and moderate to vigorous physical activity was 636 minutes (IQR: 594.1-730.1), 178 minutes (IQR: 144-222.1), and 1.6 minutes (IQR: 0.6-7.7), respectively. Proportion of daily wear time spent in sedentary behavior, light physical activity, and moderate to vigorous physical activity was 78.4% (IQR: 70.7-84.0), 21.5% (IQR: 16.0-26.9), and 0.2% (IQR: 0.1-1.1), respectively. Home was the dominant location for total linked accelerometer-GPS time (59.4%, IQR: 46.9-69.5) as well as for each prespecified level of activity. Significantly more sedentary behavior and less light physical activity occurred on dialysis days compared with nondialysis days ( ≤ .01, respectively). Moderate to vigorous physical activity did not differ significantly between dialysis and nondialysis days.

Limitations: Small sample size from a single academic center may limit generalizability. Difficult to engage population as less than half of eligible dialysis patients provided consent. Physical activity may have been underestimated as devices were not worn for all waking hours or aquatic activities, and hip-based accelerometers may not capture stationary exercise.

Conclusions: Ambulatory, in-center hemodialysis patients exhibit substantial sedentary behavior and minimal physical activity across a limited range of locations. Given the sedentary tendencies of this population, focus should be directed on increasing physical activity at any location frequented. Home-based exercise programs may serve as a potential adjunct to established intradialytic-based therapies given the amount of time spent in the home environment.
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http://dx.doi.org/10.1177/2054358119872967DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716178PMC
August 2019

Survival Comparisons of Home Dialysis Versus In-Center Hemodialysis: A Narrative Review.

Can J Kidney Health Dis 2019 13;6:2054358119861941. Epub 2019 Jul 13.

Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Canada.

Purpose Of Review: Many observational studies have demonstrated a survival benefit with home dialysis compared with in-center dialysis; however, results have been conflicting. The purpose of this review was to identify pitfalls and limitations in existing literature and examine the challenges of studying home and in-center dialysis populations.

Sources Of Information: Original research articles were identified from MEDLINE using search terms "in-center hemodialysis," "home hemodialysis," "conventional hemodialysis," "nocturnal hemodialysis," and "short daily hemodialysis."

Methods: A focused review and critical appraisal of existing home versus in-center hemodialysis survival literature was conducted to identify potential causes for variability in the observed survival outcomes.

Key Findings: The controversy in existing literature stems from the challenges of randomizing patients to home versus in-center hemodialysis modalities, and therefore a reliance on observational comparisons for study. In many cases, these observational analyses have been limited by selection bias (variabilities in populations included, inclusion of both incident and prevalent cohorts, and variabilities in dialysis intensity), as well as residual confounding. Furthermore, the studies that do exist lack generalizability in many cases.

Limitations: There are few randomized controlled trials examining the survival benefit of home versus in-center hemodialysis and existing observational studies are often limited by bias and reduced generalizability. These limitations comprise the body of this review.

Implications: This review examines challenges surrounding survival comparisons with home versus in-center hemodialysis and identify important directions for future study.
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http://dx.doi.org/10.1177/2054358119861941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628511PMC
July 2019

Optimizing Ambulance Transport of Hemodialysis Patients to the Emergency Department: A Cohort Study.

Can J Kidney Health Dis 2019 18;6:2054358119848127. Epub 2019 Jun 18.

Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada.

Background: Dialysis patients who require ambulance transport to the emergency department ("ambulance-ED") may subsequently require timely dialysis in a monitored setting ("urgent dialysis").

Objective: The purpose of this study was to develop and internally validate a risk prediction model for urgent dialysis based on patient characteristics at the time of paramedic assessment before ambulance-ED.

Design: Cohort Study.

Setting: Region of Nova Scotia, Canada, covered by a single emergency medical services provider.

Patients: Thrice-weekly hemodialysis patients who initiated dialysis between 2009 and 2013 (follow-up to 2015) and experienced one or more ambulance-ED events.

Measurements: The primary outcome ("urgent dialysis") was defined as dialysis within 24 hours of an ambulance-ED in a monitored setting or dialysis within 24 hours of an ambulance-ED with an initial ED potassium of >6.5 mmol/L. Predictors of urgent dialysis based on paramedic assessment before ambulance-ED included presenting complaint, vital signs and time from last dialysis to ambulance dispatch.

Methods: Associations with urgent dialysis were analyzed using logistic regression from which a risk prediction model was created. The model was internally validated using bootstrapping and model performance was assessed by discrimination and calibration.

Results: Among 197 patients, there were 624 ambulance-ED events and 87 episodes of urgent dialysis. Weakness as a presenting complaint (odds ratio [OR]: 4.62, 95% confidence interval [CI]: 1.23-17.29), >24 hours since last dialysis (OR: 2.09, 95% CI: 1.15-3.81), and vital signs, including heart rate <60 beats/minute (OR: 3.06, 95% CI: 1.09-8.61), oxygen saturation <90% (OR: 3.04, 95% CI: 1.55-5.94), elevated respiratory rate (≥20 breaths/min), and systolic blood pressure>160 mmHg, were associated with urgent dialysis after ambulance-ED. A risk prediction model incorporating these variables had very good discrimination (C-statistic: 0.81, 95% CI: 0.76-0.86). The negative predictive value was 93.6% using the optimal cut point. Of patients who were predicted to need urgent dialysis but were transported to a facility incapable of providing it, 31% were re-transported for urgent dialysis.

Limitations: Findings of our study may not be generalizable to other centers where the practice of ambulance transfer and availability of monitored dialysis may differ, and data were lacking for potential missed dialysis sessions or changes in routine dialysis scheduling.

Conclusions: Patient characteristics at the time of paramedic assessment are associated with urgent dialysis after ambulance-ED. This risk prediction model has the potential to guide dialysis patient transport to dialysis-capable facilities when needed.
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http://dx.doi.org/10.1177/2054358119848127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582295PMC
June 2019

Minding the Missing Link: The Effect of Donor-Recipient Pairing on Kidney Transplant Outcomes.

Clin J Am Soc Nephrol 2018 10 25;13(10):1581-1583. Epub 2018 Jul 25.

Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.

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http://dx.doi.org/10.2215/CJN.03730318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6218811PMC
October 2018

Factors Associated With Prolonged Warm Ischemia Time Among Deceased Donor Kidney Transplant Recipients.

Transplant Direct 2018 May 18;4(5):e342. Epub 2018 Apr 18.

Division of Nephrology, Department of Medicine, Dalhousie University, Nova Scotia, Canada.

Background: Prolonged warm ischemia time (WIT) is associated with graft failure and mortality, however less is known about factors associated with prolonged WIT.

Methods: In a cohort of United States deceased donor kidney transplant recipients identified using the Scientific Registry of Transplant Recipients (Jan 2005-Dec 2013), we identified factors associated with prolonged WIT (defined as ≥ 30 minutes versus 10-30 minutes) using hierarchical multilevel models adjusting for center effect, and WIT as a continuous variable using multiple linear regression of log-transformed data.

Results: Among 55 829 patients, potentially modifiable risk factors associated with prolonged WIT included increased recipient body mass index (BMI) (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.44-1.72 for BMI > 35), right donor kidney (OR, 1.14; 95% CI, 1.08-1.19), and a prolonged cold ischemic time (OR, 1.23; 95% CI, 1.13-1.33 for cold ischemia time > 24 hours). Transplanting a right kidney into an obese recipient further prolonged WIT (OR, 1.75; 95% CI, 1.55-1.98; for BMI > 35), increasing overall WIT by 11.0%. There was no correlation between median WIT for a given center and annual center transplant rate (pairwise correlation coefficient, 0.0898).

Conclusions: In conclusion, several modifiable factors are associated with prolonged WIT and may represent strategies to improve WIT and subsequent posttransplant outcomes.
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http://dx.doi.org/10.1097/TXD.0000000000000781DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5959340PMC
May 2018
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