Manitoba has one of the highest rates of Chronic Kidney Disease and End Stage Renal Disease of any province in Canada. Here are some recent websites and articles on the topic. If you are looking for more information on this topic please request a literature search from us and MHIKNET Library Services.

Websites:

• Manitoba Renal Program – Year in Review 2012-2013
• Chronic Kidney Disease in Diabetes – Clinical Practice Guidelines [2013; Canadian Diabetes Association]
• End-Stage Renal Disease Among Aboriginal Peoples in Canada: Treatment and Outcomes [2013; Canadian Institute for Health Information]

Articles:

1. CMAJ. 2013 Jun 11;185(9):E417-23. doi: 10.1503/cmaj.120833. Epub 2013 May 6.
   Prevalence estimates of chronic kidney disease in Canada: results of a nationally representative survey.
   Arora P, Vasa P, Brenner D, Iglar K, McFarlane P, Morrison H, Badawi A.BACKGROUND: Chronic kidney disease is an important risk factor for death and cardiovascular-related morbidity, but estimates to date of its prevalence in Canada have generally been extrapolated from the prevalence of end-stage renal disease. We used direct measures of kidney function collected from a nationally representative survey population to estimate the prevalence of chronic kidney disease among Canadian adults. METHODS: We examined data for 3689 adult participants of cycle 1 of the Canadian Health Measures Survey (2007-2009) for the presence of chronic kidney disease. We also calculated the age-standardized prevalence of cardiovascular risk factors by chronic kidney disease group. We cross-tabulated the estimated glomerular filtration rate (eGFR) with albuminuria status. RESULTS: The prevalence of chronic kidney disease during the period 2007-2009 was 12.5%, representing about 3 million Canadian adults. The estimated prevalence of stage 3-5 disease was 3.1% (0.73 million adults) and albuminuria 10.3% (2.4 million adults). The prevalence of diabetes, hypertension and hypertriglyceridemia were all significantly higher among adults with chronic kidney disease than among those without it. The prevalence of albuminuria was high, even among those whose eGFR was 90 mL/min per 1.73 m(2) or greater (10.1%) and those without diabetes or hypertension (9.3%). Awareness of kidney dysfunction among adults with stage 3-5 chronic kidney disease was low (12.0%). INTERPRETATION: The prevalence of kidney dysfunction was substantial in the survey population, including individuals without hypertension or diabetes, conditions most likely to prompt screening for kidney dysfunction. These findings highlight the potential for missed opportunities for early intervention and secondary prevention of chronic kidney disease.
2. Am J Kidney Dis. 2014 Feb 12. pii: S0272-6386(14)00024-9. doi: 10.1053/j.ajkd.2013.12.012. [Epub ahead of print]
   Cost-effectiveness of Primary Screening for CKD: A Systematic Review. [order for free]
   Komenda P(1), Ferguson TW(2), Macdonald K(3), Rigatto C(4), Koolage C(2), Sood MM(5), Tangri N(4).
   PMID: 24529536BACKGROUND: Chronic kidney disease (CKD) is a major health problem with an increasing incidence worldwide. Data on the cost-effectiveness of CKD screening in the general population have been conflicting. STUDY DESIGN: Systematic review. SETTING & POPULATION: General, hypertensive, and diabetic populations. No restriction on setting. SELECTION CRITERIA FOR STUDIES: Studies that evaluated the cost-effectiveness of screening for CKD. INTERVENTION: Screening for CKD by proteinuria or estimated glomerular filtration rate (eGFR). OUTCOMES: Incremental cost-effectiveness ratio of screening by proteinuria or eGFR compared with either no screening or usual care. RESULTS: 9 studies met criteria for inclusion. 8 studies evaluated the cost-effectiveness of proteinuria screening and 2 evaluated screening with eGFR. For proteinuria screening, incremental cost-effectiveness ratios ranged from $14,063-$160,018/quality-adjusted life-year (QALY) in the general population, $5,298-$54,943/QALY in the diabetic population, and $23,028-$73,939/QALY in the hypertensive population. For eGFR screening, one study reported a cost of $23,680/QALY in the diabetic population and the range across the 2 studies was $100,253-$109,912/QALY in the general population. The incidence of CKD, rate of progression, and effectiveness of drug therapy were major drivers of cost-effectiveness. LIMITATIONS: Few studies evaluated screening by eGFR. Performance of a quantitative meta-analysis on influential assumptions was not conducted because of few available studies and heterogeneity in model designs. CONCLUSIONS: Screening for CKD is suggested to be cost-effective in patients with diabetes and hypertension. CKD screening may be cost-effective in populations with higher incidences of CKD, rapid rates of progression, and more effective drug therapy.
3. BMC Nephrol. 2013 Oct 22;14:228. doi: 10.1186/1471-2369-14-228.
   Association of frailty and physical function in patients with non-dialysis CKD: a systematic review. 
   Walker SR, Gill K, Macdonald K, Komenda P, Rigatto C, Sood MM, Bohm CJ, Storsley LJ, Tangri N.
   PMID: 24148266BACKGROUND: Frailty is a condition characterized by a decline in physical function and functional capacity. Common symptoms of frailty, such as weakness and exhaustion, are prevalent in patients with chronic kidney disease (CKD). The increased vulnerability of frail patients with coexisting CKD may place them at a heightened risk of encountering additional health complications. The purpose of this systematic review was to explore the link between frailty, CKD and clinical outcomes. METHODS: We searched for cross sectional and prospective studies in the general population and in the CKD population indexed in EMBASE, Pubmed, Web of Science, CINAHL, Cochrane and Ageline examining the association between frailty and CKD and those relating frailty in patients with CKD to clinical outcomes. RESULTS: We screened 5,066 abstracts and retrieved 108 studies for full text review. We identified 7 studies associating frailty or physical function to CKD. From the 7 studies, we identified only two studies that related frailty in patients with CKD to a clinical outcome. CKD was consistently associated with increasing frailty or reduced physical function [odds ratios (OR) 1.30 to 3.12]. In patients with CKD, frailty was associated with a greater than two-fold higher risk of dialysis and/or death [OR from 2.0 to 5.88]. CONCLUSIONS: CKD is associated with a higher risk of frailty or diminished physical function. Furthermore, the presence of frailty in patients with CKD may lead to a higher risk of mortality. Further research must be conducted to understand the mechanisms of frailty in CKD and to confirm its association with clinical outcomes.
4. Am J Kidney Dis. 2014 Jan 28. pii: S0272-6386(13)01637-5. doi: 10.1053/j.ajkd.2013.12.008. [Epub ahead of print]
   CKD Stage at Nephrology Referral and Factors Influencing the Risks of ESRD and Death. [order for free]
   Sud M(1), Tangri N(2), Levin A(3), Pintilie M(4), Levey AS(5), Naimark DM(6).
   PMID: 24485146BACKGROUND: Patients with chronic kidney disease (CKD) stages 3-5 are at increased risk of progressing to end-stage renal disease (ESRD) or dying prior to the development of ESRD compared with patients with less severe CKD. The magnitude of these risks may vary by stage, which has important implications for therapy. Our objective was to apply a competing risk analysis in order to estimate these risks in a referred cohort of patients with CKD by stage at referral and identify risk factors associated with each outcome. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 3,273 patients with CKD stages 3-5 who were referred to the nephrology clinic at Sunnybrook Health Sciences Centre, Toronto, prior to December 31, 2008, with follow-up data available prior to December 31, 2008. PREDICTORS: CKD stage at time of referral; demographic, laboratory, and clinical characteristics. OUTCOMES: ESRD, defined as the initiation of dialysis therapy or pre-emptive kidney transplantation, and death from any cause prior to ESRD. MEASUREMENTS: Baseline laboratory data. RESULTS: Over a median follow-up of 2.98 years, 459 patients (14%) developed ESRD and 540 (16%) died. Rates per 100 patient-years of ESRD versus death prior to ESRD for CKD stage 3A were 0.6 (95% CI, 0.1-1.0) versus 2.2 (95% CI, 1.2-3.1; P<0.001); for CKD stage 3B, 1.4 (95% CI, 0.8-2.1) versus 4.4 (95% CI, 3.3-5.6; P<0.001); for CKD stage 4, 7.7 (95% CI, 5.9-9.4) versus 8.0 (95% CI, 6.2-9.8; P=0.6); and for CKD stage 5, 41.4 (95% CI, 34.4-48.4) versus 9.4 (95% CI, 5.2-13.4; P<0.001). For those with CKD stage 4, we identified 12 variables associated with higher risk of ESRD and 7 variables associated with higher risk of death prior to ESRD. LIMITATIONS: A cohort analyzed retrospectively. CONCLUSIONS: ESRD and death prior to ESRD incidence was most similar in CKD stage 4. We identified variables easily assessed at the time of referral that could discriminate between these risks.

When it comes to evidence informed practice everyone agrees that it sounds like a good idea but to many people are not sure what articles they should be considering. There is a great deal of variety in what the experts consider to be evidence based information but in the Library when you ask me for an evidence based literature search I focus my searching on looking for Randomized Controlled Trials, Meta-Analysis and Systematic Reviews. Here are some great descriptions on what you can expect from each of these different types of articles.

Types of Articles

• Bastian, Hilda. 5 key things to know about meta-analysis. Scientific American Blogs. 2014
• Study Design 101: Randomized Controlled Trial [Himmelfarb Health Sciences Library; 2011]
• J R Soc Med. 2003 March; 96(3): 118–121. Five steps to conducting a systematic review. Khalid S Khan, Regina Kunz, Jos Kleijnen, and Gerd Antes

Reviewing the articles

This article and websites might help you in reviewing the results I send you from my literature searches.

• CMAJ. 2004 Aug 17;171(4):353-8. Tips for learners of evidence-based medicine: 1. Relative risk reduction, absolute risk reduction and number needed to treat. Barratt A, Wyer PC, Hatala R, McGinn T, Dans AL, Keitz S, Moyer V, For GG; Evidence-Based Medicine Teaching Tips Working Group.
• 11 questions to help you make sense of a trial [Critical Appraisal Skills Program; 2013]
• 10 questions to help you make sense of a review [Critical Appraisal Skills Program; 2013]

With the latest windchill alerts questions may be coming in from your patients about frostbite injuries, hypothermia and other concerns relating to windchill. Here are a few  recent articles which may be of interest to those treating or who might be advising people.  We’ve also selected a few web sites about windchill and frostbite from the Government of Canada and Professor Popsicle [G.G. Giesbrecht]. Two articles are not freely available but we can order them for you through MHIKNET Library Services.

1. N Engl J Med. 2011 Jan 13;364(2):189-90. doi: 10.1056/NEJMc1000538.
   A controlled trial of a prostacyclin and rt-PA in the treatment of severe frostbite.
   Cauchy E, Cheguillaume B, Chetaille E.
2. Wilderness Environ Med. 2011 Jun;22(2):156-66. doi: 10.1016/j.wem.2011.03.003.
   Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite.
   McIntosh SE, Hamonko M, Freer L, Grissom CK, Auerbach PS, Rodway GW, Cochran A, Giesbrecht G, McDevitt M, Imray CH, Johnson E, Dow J, Hackett PH; Wilderness Medical Society. PMID: 21664561The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for the prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens for each modality according to methodology stipulated  by the American College of Chest Physicians.
3. Crit Care Nurs Q. 2012 Jan-Mar;35(1):50-63. doi: 10.1097/CNQ.0b013e31823d3e9b.
   Evidence-based thermoregulation for adult trauma patients.
   Block J, Lilienthal M, Cullen L, White A. PMID: 22157492The purpose of this project was to develop a staff nurse-led initiative to
   implement and evaluate evidence-based thermoregulation care for adult trauma
   patients. An evidence-based practice protocol was developed and implemented,
   addressing varying patient needs across the spectrum of hypothermia seen in
   practice, serving as a guide for improving thermoregulation care in trauma
   patients. There were 2 key pieces to the evidence-based practice protocol. The
   first piece consisted of an interdisciplinary thermoregulation flowchart to
   provide focused care based on patient temperatures. The flowchart outlined
   progressive interventions for increasing hypothermia. The second piece outlined
   the nursing assistant role, preparing the care area before patient arrival and
   assisting nursing staff during trauma care. Data from staff questionnaires and
   patient documentation were used in a pre- and postevaluation of the practice
   change. Improvements were demonstrated in staff feeling better prepared to
   identify patients with hypothermia, treat hypothermia, and document thermal care
   of trauma patients. Clinically important improvement in temperature control
   during emergency treatment in both moderate and severe hypothermic patients were
   observed. Ongoing monitoring is underway to promote integration of the practice
   change.
4. Scand J Trauma Resusc Emerg Med. 2011 Jun 23;19:41. doi: 10.1186/1757-7241-19-41.
   Comparison of three different prehospital wrapping methods for preventing hypothermia–a crossover study in humans.
   Thomassen Ø, Færevik H, Østerås Ø, Sunde GA, Zakariassen E, Sandsund M, Heltne JK, Brattebø G.BACKGROUND: Accidental hypothermia increases mortality and morbidity in trauma patients. Various methods for insulating and wrapping hypothermic patients are used worldwide. The aim of this study was to compare the thermal insulating effects and comfort of bubble wrap, ambulance blankets / quilts, and Hibler’s method, a low-cost method combining a plastic outer layer with an insulating layer. METHODS: Eight volunteers were dressed in moistened clothing, exposed to a cold and windy environment then wrapped using one of the three different insulation methods in random order on three different days. They were rested quietly on their back for 60 minutes in a cold climatic chamber. Skin temperature, rectal temperature, oxygen consumption were measured, and metabolic heat production was calculated. A questionnaire was used for a subjective evaluation of comfort, thermal sensation, and shivering. RESULTS: Skin temperature was significantly higher 15 minutes after wrapping using Hibler’s method compared with wrapping with ambulance blankets / quilts or bubble wrap. There were no differences in core temperature between the three insulating methods. The subjects reported more shivering, they felt colder, were more uncomfortable, and had an increased heat production when using bubble wrap compared with the other two methods. Hibler’s method was the volunteers preferred method for preventing hypothermia. Bubble wrap was the least effective insulating method, and seemed to require significantly higher heat production to compensate for increased heat loss. CONCLUSIONS: This study demonstrated that a combination of vapour tight layer and an additional dry insulating layer (Hibler’s method) is the most efficient wrapping method to prevent heat loss, as shown by increased skin temperatures, lower metabolic rate and better thermal comfort. This should then be the method of choice when wrapping a wet patient at risk of developing hypothermia in prehospital environments.

Web sites:

• Canada’s Windchill Index [Environment Canada; 2014]
• It’s Your Health – Extreme Cold [Health Canada; 2013]
• Accidental Hypothermia [Gordon G. Giesbrecht]

With MHIKNET staff contemplating a well-deserved holiday break, we thought you’d be interested in a few web sites and articles on health and the holidays. Most of the sites are from the Government of Canada’s Healthy Canadians web site and might be good for your patients and family. The Statistics Canada page is a wealth of information and facts that will stagger and amaze you. Definitely worth the long read. We’ve also selected articles on a variety of topics from the health effects of holidays; toxic holiday plants; energy expenditure; a holiday wish for Canadian children and an interesting case of Christmas giving a small population Hay Fever! Hope you enjoy reading them as much as we enjoyed selecting them!

Web sites

• Stress, depression and the holidays: Tips for coping [Mayo Clinic]
• Healthy Holiday Eating [Healthy Canadians; 2013]
• Holiday food safety [Healthy Canadians; 2013]
• Toy safety during the holidays [Healthy Canadians; 2013]
• Holiday Safety [Healthy Canadians; 2013]

Statistics Canada

Christmas… by the numbers 2013 [Statistics Canada]
You’ll be amazed!

Articles [freely available]

1. Cook CM, Subar AF, Troiano RP, Schoeller DA. Relation between holiday weight
   gain and total energy expenditure among 40- to 69-y-old men and women (OPEN study). Am J Clin Nutr. 2012 Mar;95(3):726-31.
2. de Bloom J, Kompier M, Geurts S, de Weerth C, Taris T, Sonnentag S. Do we recover from vacation? Meta-analysis of vacation effects on health and well-being. J Occup Health. 2009;51(1):13-25.
3. Eagle K. Hypothesis: holiday sudden cardiac death: food and alcohol inhibition of SULT1A enzymes as a precipitant. J Appl Toxicol. 2012 Oct;32(10):751-5.
4. Evens ZN, Stellpflug SJ. Holiday plants with toxic misconceptions. West J Emerg Med. 2012 Dec;13(6):538-42.
5. Gassner M, Gehrig R, Schmid-Grendelmeier P. Hay fever as a Christmas gift. N Engl J Med. 2013 Jan 24;368(4):393-4.
6. Sansone RA, Sansone LA. The christmas effect on psychopathology. Innov Clin Neurosci. 2011 Dec;8(12):10-3.
7.  Tonelo D, Providência R, Gonçalves L. Holiday heart syndrome revisited after 34 years. Arq Bras Cardiol. 2013 Aug;101(2):183-9.
8. Trepanowski JF, Bloomer RJ. The impact of religious fasting on human health. Nutr J. 2010 Nov 22;9:57. doi: 10.1186/1475-2891-9-57.
9. Williams R, Goel V. A holiday wish list for Canada’s Early Years System. Paediatr Child Health. 2012 Dec;17(10):541-543.