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In the United States, kidney transplant rates vary significantly across end-stage renal disease (ESRD) networks. We conducted a population-based cohort study to determine whether there was variability in kidney transplant rates across renal programs in a health care system distinct from the United States. We included incident chronic dialysis patients in Ontario, Canada, from 2003 to 2013 and determined the 1-, 5-, and 10-year cumulative incidence of kidney transplantation in 27 regional renal programs (similar to U.S. ESRD networks). We also assessed the cumulative incidence of kidney transplant for "healthy" dialysis patients (aged 18-50 years without diabetes, coronary disease, or malignancy). We calculated standardized transplant ratios (STRs) using a Cox proportional hazards model, adjusting for patient characteristics (maximum possible follow-up of 11 years). Among 23 022 chronic dialysis patients, the 10-year cumulative incidence of kidney transplantation ranged from 7.4% (95% confidence interval [CI] 4.8-10.7%) to 31.4% (95% CI 16.5-47.5%) across renal programs. Similar variability was observed in our healthy cohort. STRs ranged from 0.3 (95% CI 0.2-0.5) to 1.5 (95% CI 1.4-1.7) across renal programs. There was significant variation in kidney transplant rates across Ontario renal programs despite patients having access to the same publicly funded health care system.

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The need to improve the dialysis outcomes, the negative results from the HEMO and ADEMEX studies as well reports of clinical benefits have rekindled the interest in daily hemodialysis. Although no randomized controlled studies have been published, a large number of manuscripts have described significant benefits from both the short or nocturnal forms of daily (quotidian) dialysis or hemo(dia)filtration. They include improved quality of life, hemodynamic stability, blood pressure control with minimal number of medications, anemia control, regression of cardiac hypertrophy and improved nutrition. Furthermore, quotidian nocturnal hemodialysis provides higher dialysis dose, and has been described to improve endothelial as well as endothelial progenitor cell function, heart rate variability, sleep and phosphate control while it offers unrestricted diet. Several studies have pointed to a lower overall cost and improved cost utility when treating patients using quotidian hemodialysis at home. The obstacles to widespread use are the reimbursement structure in most countries, the willingness and ability of the patients to do home hemodialysis and the availability of user-friendly machines. A prospective randomized controlled study sponsored by the National Institutes of Health (NIH) and US Centers for Medicare and Medicaid services (CMS) currently underway will be pivotal in confirming these benefits and convincing the stakeholders to promote the use of daily hemodialysis.

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BACKGROUND/AIMS: To evaluate the effect of plasma exchange on renal function in patients with rapidly progressive renal failure secondary to multiple myeloma. METHODS: The study was done through a retrospective chart review using a standardized form at a tertiary care centre in southwestern Ontario. Patients were included in the study if they had a diagnosis of multiple myeloma and rapidly progressive renal failure. Multiple myeloma was defined by a bone marrow aspirate >15% plasma cells plus one of the following: serum monoclonal paraproteins, monoclonal light-chain excretion, or lytic lesions. Patients were excluded if they had evidence of chronic renal failure or failed to complete three plasma exchanges. Twenty-six patients were reviewed; of these 24 were followed up to 1 year. All patients received hydration, standard chemotherapy, and plasma exchange. The plasma exchange volume was 50 ml/kg of 50% normal saline and 50% human serum albumin. Primary outcome measures included (1) prevention of acute dialysis and (2) prevention of progression from acute to chronic dialysis; secondary end points included (1) a decrease in creatinine of 25% or more within 3 months of the last plasma exchange and (2) survival at 1 year. RESULTS: Sixteen of 24 patients, followed up to 1 year, did not require dialysis. Two patients required dialysis initially, but were able to come off dialysis after 3 months. Fourteen patients were alive at 1 year, 13 of whom were dialysis independent. Twelve of 13 dialysis-independent patients had a >25% reduction in creatinine at 3 months. Two patients were lost to follow-up after discharge and were not included in the analysis. CONCLUSIONS: This retrospective study suggests that plasma exchange may offer some benefit in preventing the initiation or continuation of dialysis in patients with rapidly progressive renal failure secondary to multiple myeloma. A randomized controlled prospective study is needed to determine whether plasma exchange should be recommended as a standard treatment for patients with rapidly progressive renal failure due to multiple myeloma.

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AIMS: A study was designed to assess the effects of a standardized instructional videotape on training senior medical students to acceptable levels of reliability in performing several commonly used obsever dependent outcome measures in patients with ankylosing spondylilis (AS). METHODS: During a single day, six third-year medical students independently examined five patients with AvS in predetermined order using a Latin Square design, before and after viewing a standardized videotape demonstrating 14 examination techniques. Reliability coefficients were calculated based on the variance components of the analysis of variance (ANOVA) table. RESULTS: Prestandardization reliability coefficients were < 0.80 for three measures. Following standardization 12 reliability coefficients exceeded 0.80. For the majority of measures prestandardization reliability coefficients were high and no further improvement in reliability could be demonstrated. CONCLUSIONS: High levels of interobserver agreement were noted prior to viewing the instructional videotape. This may represent the success of undergraduate clinical skills training programmes, or it may be the result of having reviewed an illustrated instructional text just prior to the initial patient examinations. With the exception of chest excursion, high levels of prestandardization reliability, by necessity, precluded the demonstration of significant effects from viewing the videotape. Nevertheless, the data indicate that senior medical students arc capable of reliably performing quantitative measurement in AS. Recent surveys in Canada and Australia, showing a general lack of quantitative clinical measurement in the longitudinal follow up of AS outpatients by rheumatologists, suggest that the lack of quantitation is not due to inability to reliably perform the measurements.