Estimating renal function before and during pregnancy has clinical importance: kidney dysfunction can affect maternal and perinatal health. Glomerular hyperfiltration is a typical physiological adaptation to pregnancy, reflected by a decrease in levels of serum creatinine (SCr) with advancing gestational age. Creatinine-based equations used to estimate glomerular filtration may misclassify renal function during pregnancy, 1 as they depend on a steady state of creatinine balance. Moreover, a 24-hour collection of urine to measure cre-atinine clearance is impractical. 2 Accordingly, physicians typically rely on SCr level. Previous studies attempted to define a normal SCr level in pregnancy, but they had few participants and may have been confounded by sampling bias. 3,4 The current study was undertaken to generate gestational age-specific estimates of renal function-before, during, and after pregnancy-among women without antecedent kidney disease.

Childhood transplant recipients have a 30-times greater cancer incidence versus the general population. Further investigation is needed to guide screening strategies in this at-risk population.

Background. This is the first time deemed consent, where the entire population of a jurisdiction is considered to have consented for donation unless they have registered otherwise, will be implemented in North America. While relatively common in other regions of the world-notably Western Europe-it is uncertain how this practice will influence deceased donation practices and attitudes in Canada. Methods. We describe a Health Canada funded program of research that will evaluate the implementation process and full impact of the deceased organ donation legislation and the health system transformation in Nova Scotia that includes opt-out consent. Results. There is a need to evaluate the impact of these changes to inform not only Nova Scotia and Atlantic Canada, but also other provincial, national, and international stakeholders. Conclusions. We establish a rigorous academic framework that we will use to evaluate this significant health system transformation.

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Background:Many patients who receive chronic hemodialysis have a limited life expectancy comparable to that of patients with metastatic cancer. However, patterns of home palliative care use among patients receiving hemodialysis are unknown.Objectives:We aimed to undertake a current-state analysis to inform measurement and quality improvement in palliative service use in Ontario.Methods:We conducted a descriptive study of outcomes and home palliative care use by Ontario residents maintained on chronic dialysis using multiple provincial healthcare datasets. The period of study was the final year of life, for those died between January 2010 and December 2014.Results:We identified 9611 patients meeting inclusion criteria. At death, patients were (median [Q1, Q3] or %): 75 (66, 82) years old, on dialysis for 3.0 (1.0-6.0) years, 41% were women, 65% had diabetes, 29.6% had dementia, and 13.9% had high-impact neoplasms, and 19.9% had discontinued dialysis within 30 days of death. During the last year of life, 13.1% received ⩾1 home palliative services. Compared with patients who had no palliative services, those who received home palliative care visits had fewer emergency department and intensive care unit visits in the last 30 days of life, more deaths at home (17.1 vs 1.4%), and a lower frequency of deaths with an associated intensive care unit stay (8.1 vs 37.8%).Conclusions:Only a small proportion of patients receiving dialysis in Ontario received support through the home palliative care system. There appears to be an opportunity to improve palliative care support in parallel with dialysis care, which may improve patient, family, and health-system outcomes.

Prepregnancy kidney dysfunction may perturb the normal physiologic adaptations of pregnancy, predisposing a woman and her fetus to adversity, at least partly mediated by placental and endothelial dysfunction. 1 Complications such as preeclampsia 2 and poor fetal growth 3 may necessitate provider-initiated preterm birth. Preterm birth of any form before 37 weeks' gestation occurs in 6% to 11% of viable pregnancies and is the leading cause of infant death. 4 Prepregnancy kidney dysfunction has been associated with preterm birth. [5][6][7] Prior studies of the relation between prepregnancy kidney dysfunction and preterm birth were primarily case series and thus had inadequate statistical power to differentiate between the outcomes of spontaneous versus providerinitiated preterm birth. In addition, arbitrary cut points were used in these studies to define prepregnancy kidney dysfunction, and there was no accounting for important confounders. 5,[8][9][10][11][12][13][14] In an effort to overcome the aforementioned limitations, we completed a large cohort study in a setting where prenatal and obstetric care is covered under a provincial health insurance plan. Using population-derived cut points for prepregnancy serum creatinine to define kidney dysfunction, we examined the risk of preterm birth and other related outcomes. Methods Study design and data sourcesIn this population-based cohort study, we considered all live births and stillbirths that occurred in hospital in Ontario, Canada, from April 2007 to October 2016. Obstetric care is covered for Ontario residents through the Ontario Health Insurance Plan, and nearly all women undergo ultrasonography during the first or second trimester to enable accurate dating of the pregnancy.

Hemodialysis is a life-sustaining treatment for persons with kidney failure. However, those on hemodialysis still face a poor quality of life and a short life expectancy. High-quality research evidence from large randomized controlled trials is needed to identify interventions that improve the experiences, outcomes, and health care of persons receiving hemodialysis. With the support of the Canadian Institutes of Health Research and its Strategy for Patient-Oriented Research, the Innovative Clinical Trials in Hemodialysis Centers initiative brought together Canadian and international kidney researchers, patients, health care providers, and health administrators to participate in a workshop held in Toronto, Canada, on June 2 and 3, 2018. The workshop served to increase knowledge and awareness about the conduct of innovative, pragmatic, cluster-randomized registry trials embedded into routine hemodialysis care and provided an opportunity to discuss and build support for new trial ideas. The workshop content included structured presentations, facilitated group discussions, and expert panel feedback. Partnerships and promising trial ideas borne out of the workshop will continue to be developed to support the implementation of future large-scale trials.

Background: Patients with acute kidney injury (AKI) may require inter-hospital transfer in order to receive renal replacement therapy (RRT). Inter-hospital transfer may lead to delays in therapy resulting in poor patient outcomes. There is minimal data comparing outcomes among patients undergoing transfer for RRT versus those who receive RRT at the hospital to which they first present. Methods: We conducted a population-based cohort study of all adult patients (19 years and older) who received acute dialysis within 14 days of admission to an acute care hospital between April 1, 2004 and March 31, 2015. The transferred group included all patients who presented to a hospital without a dialysis program and underwent interhospital transfer (with the start of dialysis ≤3 days of transfer and within 14 days of initial admission). All other patients were considered non-transferred. The primary outcome was time to 90-day all-cause mortality adjusting for demographics, comorbidities and measures of acute illness severity. We also assessed chronic dialysis dependence as a secondary outcome using Fine and Gray proportional hazards model to account for the competing risks of death. In a secondary post-hoc analysis, we assessed these outcomes in a propensity-score matched cohort, matching on age, sex and prior chronic kidney disease status. Results: We identified 27,270 individuals initiating acute RRT within 14 days of a hospital admission, of whom 2,113 underwent inter-hospital transfer. Inter-hospital transfer was associated with lower rate of mortality [adjusted hazard ratio (aHR) 0.90 (95%CI: 0.84-0.97)]. Chronic dialysis dependence was not significantly different between groups [aHR 0.98 (0.91-1.06)]. In the propensity score matched analysis, interhospital transfer remained associated with a lower risk of death [HR 0.88 (0.80-0.96)]. Conclusions: Inter-hospital transfer for receipt of RRT does not confer higher mortality or worse kidney outcomes.