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A utosomal dominant polycystic kidney disease (AD-PKD) is the most common inherited renal disease and is the fourth-leading cause of end-stage renal disease (1-3). ADPKD is progressive in nature, but the rate of progression is variable (4); in light of this variability, a readily available tool to determine individualized rate of progression is valuable in ADPKD management (5). Increases in renal cyst number and size leading to observable enlargement of the kidneys (4) precedes renal dysfunction in ADPKD, often by many years to decades (4). Therefore, quantifying renal enlargement emerged as a robust marker of progression in ADPKD (6,7). This concept was extended to imaging-based classifications (6) used to individualize prognosis and make treatment decisions (8-10). It is now recommended that all patients with ADPKD have an assessment of renal size as part of their initial evaluation (8,10,11). Whereas various methods of renal size assessment have been reported (6,7,12), total kidney volume (TKV) has emerged as the most accurate assessment method and is most strongly associated with clinical outcomes (5). MRIderived TKV is accurate and reproducible but the reference standard method of manual planimetry is time consuming (11,13,14), which limits translation into clinical practice. Alternative methods have been developed that estimate TKV on the basis of a more rapidly obtained series of measurements, although familiarity with these methods is limited in many clinical settings (6,14-16). In addition, image acquisition can be a challenge for clinicians who practice in settings where MRI access is limited (17). CT is known to help provide accurate TKV assessment (6,18), but there are concerns regarding radiation exposure; however, this has not been re-evaluated in the context of modern dosereducing imaging techniques (19).

Background: Recent years have witnessed an encouraging expansion of knowledge and management tools in the care of patients with autosomal dominant polycystic kidney disease (ADPKD), including measurement of total kidney volume as a biomarker of disease progression, stringent blood pressure targets to slow cyst growth, and targeted treatments such as tolvaptan. Objectives: We sought to evaluate clinicians’ familiarity with, and usage of, novel evidence-based management tools for ADPKD. Design: On-line survey. Setting: British Columbia, Canada. Participants: Nephrologists in academic and community practice (excluding clinicians who practice exclusively in transplantation). Measurements: Participants answered multiple-choice questions in 6 domains: sources of information, self-identified needs for optimal care delivery, prognostication, imaging tests, blood pressure targets, and use of tolvaptan. Methods: An online survey was developed and disseminated via email to 65 nephrologists engaged in current clinical practice in British Columbia. Results: A total of 29 nephrologists (45%) completed the questionnaire. The most popular source of information was the primary literature (83% of respondents). While 86% of respondents reported assessing the risk of disease progression before the onset of kidney function decline, most were using traditional metrics such as blood pressure and proteinuria rather than validated prediction tools such as the Mayo Classification. Although 90% of respondents obtained additional imaging after diagnosis in some or all of their ADPKD patients, only 1 in 5 reported being confident in their ability to interpret kidney size. The recommended blood pressure (BP) target of <110/75 mmHg was sought by 17% of respondents. All respondents reported being familiar with the literature regarding tolvaptan; however, only half were confident in their ability to identify suitable patients for treatment. The top 3 needs identified by clinicians were better access to medications (69%), clear management protocols (66%), and easier access to imaging tests (59%). Limitations: Funding mechanisms for tolvaptan can vary; therefore, clinicians’ experience with the drug may not be generalizable. Although the response rate was acceptable, the survey is nonetheless subject to responder bias. Conclusion: This survey indicates that there is substantial variability in the usage of, and familiarity with, evidence-based ADPKD management tools among contemporary nephrologists, contributing to incomplete translation of evidence into clinical practice. Providing greater access to tolvaptan or imaging tests is unlikely to improve patient care without enhancing knowledge translation and education. Trial Registration: Not applicable as this was a survey.

Non‐adherence to medications is a critical challenge in the management of people with chronic kidney disease (CKD). This review explores the complexities of adherence in this population, the unique barriers and enablers of good adherence behaviours, and the role of emerging digital health technologies in bridging the gap between evidence‐based treatment plans and the real‐world standard of care. We present the current evidence supporting the use of digital health interventions among CKD populations, identifying the key research questions that remain unanswered, and providing practical strategies for clinicians to support medication adherence in a digital age.

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Background: The canagliflozin and renal endpoints in diabetes with established nephropathy clinical evaluation (CREDENCE) and dapagliflozin and prevention of adverse outcomes in chronic kidney disease (DAPA-CKD) trials have demonstrated significant kidney benefits with sodium-glucose cotransporter-2 (SGLT2) inhibitors. SGLT2 inhibitors are now standard of care for patients with diabetic kidney disease and have also been shown to be effective in those with albuminuric CKD with or without diabetes. Objective: We sought to determine how many patients in nephrology care in British Columbia, Canada, would have been eligible for those trials, to compare rates of outcomes, and to estimate cost avoidance arising from widespread use of SGLT2 inhibitors in this cohort. Study design: Retrospective cohort study. Setting: British Columbia, Canada. Participants: CKD patients followed in the Kidney Care Clinics in British Columbia. Measurements: We compared the outcomes of kidney failure, sustained estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2, dialysis, transplant, death from any cause, and doubling of serum creatinine. We also compared the composite outcome of kidney failure and doubling of serum creatinine. Methods: The cohort was derived using a provincial database by combining the inclusion criteria of CREDENCE and DAPA-CKD trials. We included adult patients aged ≥18 years, urine albumin to creatinine ratio (UACR) ≥20 mg/mmol, and eGFR between 25 and 90 mL/min/1.73 m2, between April 1, 2014 and March 31, 2017. The primary outcome was compared with the outcomes experienced in the placebo arms of CREDENCE and DAPA-CKD. The composite outcome stratified by eGFR categories were compared in the British Columbia cohort and the CREDENCE trial. Cost avoidance was estimated based on the number needed to treat to prevent one instance of kidney failure. Results: A total of 17.5% (3138/17 963) of patients were eligible, resulting in a cohort with a mean age of 69.7 years and 38% women. The eGFR slope of the British Columbia cohort was −4.21 ± 0.47 mL/min. The mean eGFR was 37.0 mL/min/1.73 m2, median UACR was 55.3 mg/mmol, and use of renin-angiotensin-aldosterone system inhibitors was 56.6%. The British Columbia cohort experienced nearly double the outcomes of kidney failure, death from any cause, and doubling of serum creatinine than the placebo arms of CREDENCE and DAPA-CKD. When stratified by eGFR, the British Columbia cohort and the CREDENCE placebo arm had similar event rates for those with an eGFR <45 mL/min but there were still higher rates of outcome in the greater than 45 mL/min eGFR groups in the British Columbia cohort. Treating the British Columbia cohort with canagliflozin could lead to net cost avoidance of $2.31 million over 2.6 years. Limitations: The database only captures those referred to the Kidney Care Clinics by nephrologists, which may lead to selection bias of higher risk patients in the British Columbia cohort. The cost avoidance analysis was a limited high-level analysis. Conclusions: The British Columbia cohort represents a high-risk group in whom implementation of the use of SGLT2 inhibitors may well improve outcomes and reduce health care system costs.