Since December of 2012, the ICES Kidney, Dialysis & Transplantation (KDT) Program has supported health care providers in their use of linked health and health-related databases to conduct research on kidney disease and solid organ transplantation. This support has led to 37 publications and seven reports over the last year, addressing complex and important questions and providing data-based evidence for patients, policy makers, and health care providers to apply in real-world settings, improving the health and health care of Ontarians and beyond.
Over the years, KDT has developed valuable partnerships, which have aided in the advancement of quality research conducted at KDT. We greatly value these partnerships, including ones with the Ontario Renal Network (ORN), the Trillium Gift of Life Network (TGLN), the Can-SOLVE CKD Network, and others, which continue to evolve and improve the services that ICES KDT provides to researchers.
This past year has been a busy but successful year for KDT. Our 14 staff, 16 ICES scientists, and 12 trainees have continued their ardent work to further medical understanding of kidney disease and its effects. Our researchers have started 46 new projects, published 37 studies, completed 7 reports, and been awarded nearly $5 million in grant funds to complete this important research with one goal in mind: Improve patient health across the spectrum of kidney disease and solid organ transplantation. Thank you to everyone who participated in the program’s leadership review, where Dr. Garg’s position as ICES KDT program lead was renewed through March 31, 2024.
In the years to come, KDT will continue to provide the support so that our researchers can continue to accomplish their remarkable work.
ICES Kidney, Dialysis & Transplantation scientist Dr. Rahul Chanchlani has been driven by his passion to care for children with kidney disease for years. His hope, and the focus of most of his research, is to improve the care and outcomes of children living with kidney disease. He is meeting this goal in part by accessing the vast array of health administrative data housed at ICES.
Dr. Chanchlani is an associate professor and clinician investigator program lead for the Division of Nephrology in the Department of Pediatrics at McMaster Children’s Hospital. He is also a scientist for the Population Health Research Institute (PHRI) at McMaster University. In 2020, Dr. Chanchlani was appointed an ICES adjunct scientist, affiliated with ICES McMaster and the ICES KDT Research Program.
Dr. Chanchlani has been using ICES administrative healthcare data dating back to his MSc thesis at the University of Toronto in 2014, which focused on determining the risk of diabetes among children with a solid organ transplant. Since 2017, his work with the KDT Program has focused on knowledge gaps for key kidney diseases such as acute kidney injury (AKI), kidney transplantation, hypertension and nephrotic syndrome among pediatric patients. Currently, he focuses on understanding the epidemiology, risk factors, and outcomes of pediatric patients who suffer from AKI and hypertension. AKI is common among hospitalized pediatric patients and can be associated with adverse short- and long-term kidney outcomes. However, data regarding long-term outcomes of children with episodes of dialysis-treated AKI are limited.
To address this knowledge gap, Dr. Chanchlani decided to conduct a research project focusing on the epidemiology and long-term outcome of pediatric patients with dialysis-treated AKI, for which he received grant funding from Hamilton Health Sciences and the Kidney Foundation of Canada. Through these funding opportunities, he recently published a couple of studies looking at the temporal trends in dialysis-treated AKI. The first study published found an increase in the incidence of dialysis-treated AKI among children in Ontario over the last 2 decades.
Dr. Chanchlani and his team continued this line of research in a study published in the Journal of American Society of Nephrology, focusing on the long-term outcomes of these children. In this study, Dr. Chanchlani and his team utilized ICES health administrative data to identify almost 1700 pediatric patients who had been hospitalized and treated with dialysis for AKI episodes from 1996 to 2017 and compared outcomes with matched hospitalized comparators. They showed that dialysis-treated AKI survivors were at significantly increased risk of long-term kidney failure or death. The team also observed higher long-term rates of chronic kidney disease (CKD) and hypertension among the dialysis-treated AKI survivors, suggesting the need for enhanced surveillance of kidney function and blood pressure following episodes of severe childhood AKI to improve long-term kidney and patient survival.
The study’s findings have a real-world impact on the care of children who suffer from dialysis-treated AKI, showing that higher levels of surveillance among this patient population could result in better long-term outcomes and save lives. Dr. Chanchlani’s next research project furthers this study by taking the next logical step, creating risk stratification tools to help establish criteria for targeted follow-up and CKD prevention strategies.
Dr. Chanchlani’s research has been driven by his passion to advance healthcare for children living with kidney disease, which he has succeeded in doing during his tenure with ICES KDT. The impact of his research improves the quality of life for children living with kidney disease across Canada and shows how a dedicated researcher can use ICES health administrative data to better the lives of patients living with kidney disease.
Ms. Sarah Bota, MSc, is a foundational member of the ICES KDT team. After receiving her undergraduate degree in psychology from Simon Fraser University, she started at ICES Central as a research assistant with the Ontario Stroke Registry (formally the Registry of the Canadian Stroke Network) and was promoted to project manager of the Ontario Stroke Audit. She joined the ICES KDT team when ICES Western opened in 2013. Since then, Ms. Bota has participated in numerous research projects, KDT program initiatives and obtained her MSc in epidemiology from Western University.
Most of the research she does with the KDT team focuses on cardiovascular diseases across the kidney disease spectrum. However, over the past eight years she has participated in several studies that have expanded her kidney disease-related research knowledge. The topics of these studies include infections following solid organ transplant, inappropriate prescribing practices in patients with kidney disease, palliative care for those on chronic dialysis, primary care after chronic dialysis initiation, and many more topics that affect patients living with kidney disease.
In her role, Ms. Bota develops project protocols in coordination with the primary investigator and study team, in order to answer their questions about patient populations and the health care system. In addition to providing her epidemiological and ICES database knowledge, Ms. Bota assists in the coordination of the research projects, maintaining timelines, connecting team members, and helping them comply with ICES policies. In short, she assists in moving projects through the entire process, from inception to publication.
One such project Ms. Bota coordinated was focused on the association of sodium polystyrene sulfonate (SPS) with adverse gastrointestinal outcomes. In 2017, Dr. Manish Sood connected with Ms. Bota hoping to investigate whether SPS, a drug commonly prescribed to treat hyperkalemia (high blood levels of potassium), was associated with a risk of adverse gastrointestinal (GI) events. In collaboration with Dr. Sood, Ms. Bota assisted in formalizing the objectives and designing the study protocol using ICES health administrative databases.
The team compiled a cohort of adults 66 years-of-age or older who took SPS to treat hyperkalemia between April 1, 2003 and September 30, 2015, matching 20,000 SPS users with 20,000 non-users. The study team found that SPS users experienced a higher incidence and risk of adverse GI events in the 30 days after prescription dispensation compared to non-users. The team concluded that physicians should exercise caution when prescribing the ongoing use of SPS until replication of these results could be completed. The study was published in JAMA Internal Medicine and has been cited in the clinical decision support tool UpToDate.
This study is just one of many that Ms. Bota has helped move through the research process, illustrating how her hard work and diligence result in a smooth research process and impactful findings that improve the provision of healthcare in Ontario for the better.
Several hemodialysis centres in Ontario have standardized approaches to collecting clinical data electronically using NephroCare® software, a renal information system that enables caregivers to electronically manage and report a patient’s dialysis session-level data.
This software integrates with other hospital and clinical systems, allowing caregivers access at patient bedsides to enable point-of-care charting in the electronic patient record. This provides for remote access to patient data containing detailed information, such as patient demographics, data elements collected during the hemodialysis session, type of vascular access used for hemodialysis, missed hemodialysis sessions, and hospitalizations.
We are currently in the process of linking NephroCare® data from 10 centres, to enrich ICES data with information that can better help researchers understand factors which influence hemodialysis treatments and care, and how various aspects of hemodialysis treatments associate with outcomes and costs. Because NephroCare® data is the most accurate record of hemodialysis treatments received, researchers will also be able to use the data to better understand the validity of other data on dialysis treatments available at ICES.
Linked Data Projects
Researchers at KDT also link datasets (new data) to ICES regularly to expand the scope and breadth of the research they conduct. The following is a list of KDT projects where ICES data is being linked with other data sets to improve and refine research findings:
- Stephanie Dixon linked the ORN COVID-19 Tracker data in her project titled “Impact of COVID-19 on outcomes of patients with kidney disease.”
- Richard Kim linked personal pharmaco-genomics data from his personalized medicine clinic in his project titled “Implementation of pharmacogenomics-based personalized medicine: 5- fluorouracil and capecitabine (personalized medicine- 5-FU and capecitabine)”
- KDT researchers linked data from the College of Physicians and Surgeons of Ontario (CPSO) to understand the impact of COVID-19 on physicians in Ontario.
- Chirag Parikh at John’s Hopkins University linked peri-operative data, biomarker measurements, and follow-up data of participants for his TRIBE-AKI study, which found associations between post-operative blood biomarkers and risk of chronic kidney disease after cardiac surgery.
KDT has a long history of collaborating with researchers in other jurisdictions to improve the quality and scope of their research, as well as expand the impact and reach of the findings. As a result of this collaboration, researchers use ICES administrative health data to develop a growing knowledge base that better informs health care and policy worldwide.
This past year, KDT has been happy to support researchers in the following interjurisdictional collaborations:
- Matthew James, at University of Calgary, used ICES data to perform an “External validation of a post-surgery acute kidney injury risk prediction model with Ontario data” regarding findings for creating a risk-prediction tool to identify high risk patients following hospitalization with acute kidney injury.
- Min Jun, at the George Institute in Australia, with his project titled “Kidney function and the effectiveness and safety of direct oral anticoagulant therapy in atrial fibrillation.”
- Wai Lim, at University of Sydney, Australia, in his project “Outcomes of kidney transplant recipients with and without diabetes” which resulted in two studies, one focused on cardiovascular events in transplant recipients, and the other focused on the relationship between cardiovascular events and pretransplant diabetes and new onset diabetes after transplant.
- Germaine Wong, at Centre for Kidney Research, Kids Research Institute, The Children’s Hospital at Westmead, in her project “Cancer screening and mortality among patients across the spectrum of kidney disease.”
The findings from these collaborations offers multiple examples of how to expand the reach of our local datasets. We hope to continue supporting our researchers in their endeavors to answer questions that improve health care and policy for patients world-wide.
We understand that the health of staff has a direct impact on the quality of services that we can provide to researchers and, as a result, can impact the quality and scope of the research being conducted. That is why we focus on the processes and concerns that affect the capacity and performance of our staff and the program as a whole. This is exemplified in some of our metrics.
KDT’s organizational health ensures high-quality support for researchers and promotes a high-value work environment for staff. To this end, KDT has taken the following steps to guarantee the organization’s ongoing health:
- Develop and empower our staff to do outstanding work:
- Up to 4 paid-days off and $1500 per annum offered towards professional development (PD)
- Quarterly PD sessions from local leaders and professionals
- Create best practices to increase staff autonomy
- Foster an environment that attracts and retains qualified people:
- Provide excellent benefits, a pension plan, and competitive compensation
- Allow for flexible schedules, including work-from-home arrangements
- Consistent growth that offers opportunity for promotions and organic growth
- Enhance efficiency, reduce roadblocks and demonstrate value for money:
- Implement project management structure (e.g. intake and analytic-kick-off meetings, analytic oversight)
- Train subject matter experts for more complex and frequently used datasets (e.g. Ontario Renal Reporting System)
- Improve operations while ensuring compliance:
- Monthly invoicing to provide PIs with greater awareness regarding the correlation between payments and specific activities
- Implement project closeouts to ensure proper compliance
Organizational Health During COVID-19
Our research program has been put to the test over the last 18 months, as COVID-19 forced the world to restructure how things are done while still maintaining the vibe in our unit. We have worked hard to ensure that our staff had the tools and support they needed to weather this storm. In March 2020, staff transitioned to a work-from-home (WFH) model and have not yet returned to the office in a full capacity.
We’ve always trusted our staff to support our researchers. When COVID-19 arrived, our staff illustrated that this trust was not misplaced. In fact, they stepped up and worked even harder, diligently supporting our researchers and moving their work forward despite the many new challenges that COVID-19 posed. As you can tell from our Counting the Beans infographic above, they have not disappointed, rewarding our trust by meeting deadlines, encouraging each other, and exceeding KDT’s already high expectations.
But we wanted to know how they were doing during the pandemic. In staff surveys conducted 6 and 12 months after moving to a WFH model, almost all indicated they were very satisfied working from home, citing increased flexibility with schedules and reduced commutes as personally beneficial and positively impacting productivity levels during this high-stress time. All combined, this has increased productivity and ensured that KDT researchers were able to succeed in completing their valuable work.
Please help us thank our staff for their diligent work: Kathleen Blake-Brown, Sarah Bota, Steph Dixon, Christina Frederiksen, Nivi Jeyakumar, Greg Kang, Shane Kilburn, Lauren Killin, Bin Luo, Eric McArthur, Danielle Nash, Kyla Naylor, and Graham Smith.
KDT has grown a lot over nine years, celebrating many highs and overcoming several challenges. As the program continues to mature, individual contributions from our staff, researchers and scientists are paramount to the ongoing success of the program. With the focus of improving the already high quality of work done at KDT, we felt it was important to share a rare misstep.
In early 2017, KDT was approached to support an investigation of the incidence and severity of certain events in a particular group. While considered a standard project, it ended up running significantly past the funding deadline and ran well over budget. We’ve identified here some of the triggers: (a) long communication gaps which tend to increase the likelihood of forgetting something important, (b) limited attempts at scoping which has led to concerns in how accurately the available data supports the objective, (c) poor budgeting and communication regarding timelines and costs, (d) scope creep to explore tangential interests and, (e) rushed work which increases the likelihood of mistakes.
By further understanding the triggers that cause these issues, we can eliminate such challenges in future projects. We’re asking that everyone involved in future research share in the responsibility of flagging triggers and actively adopting processes as they come along.
We are asking PIs to review your PI responsibilities.
We are asking scientists to review your scientist responsibilities.
Please log in to the intranet to review these documents. Go to Research and Data – Resources – Faculty and Student Resources or you can request a copy from firstname.lastname@example.org.
In recognition of KDT’s responsibilities regarding our projects, we have implemented the following best practices:
- Project management plans, with defined administrative checkpoints that include project intake forms to scope, an analytic kick-off meeting, and a project close-out meeting
- Oversight from senior analytic staff throughout DCP development
- PAW amendments following any large change in scope or addition of objectives
- Transition plans when a new/replacement staff is assigned
Further, for general awareness, other best practices include:
- Respond to communication inquiries within ~72 hours
- Properly scope objectives early on and work to limit all scope creep
- Consider initiating a new project rather than adding new objectives
- Limit rapid requests by communicating deadlines in advance
Strengthening Partnerships for a Healthier Ontario
Ontario Renal Network
Over the past year, KDT continued its seven-year relationship with ORN (part of Ontario Health), collaborating on projects such as:
- Describing the relationship between mental health service use and CKD;
- Exploring CKD quality indicators for First Nations People;
- Refining estimates of people who are transplant eligible;
- Defining possible pathways of pre-dialysis care for end-stage kidney disease patients starting on chronic dialysis;
- Impact of the COVID-19 pandemic on patients receiving chronic dialysis.
In addition, KDT leadership successfully grew this partnership with the goal of directly informing the care of patients with CKD by integrating knowledge translation and patient oriented research to address knowledge gaps in 10 patient identified priority research areas. Over the next five years we plan to partner with the ORN to address gaps in:
- Mental health in kidney disease
- Drug safety for patients with kidney disease
- Kidney disease in First Nations communities
- Kidney transplantation
- Geography effects on kidney care: improving the coordination between nephrology and primary care
- Women’s kidney health
- Improving care among vulnerable populations
- Enhancing access to multi-care kidney clinics
Trillium Gift of Life Network
In March 2021, TGLN (part of Ontario Health) awarded ICES KDT with funding to support a shared interest in research related to quality improvement innovation in donation, transplantation and donor registration over the next five years. This funding is overseen by a joint TGLN and KDT committee and has already been put to good use supporting a project focused on determining COVID-19 vaccine uptake and effectiveness in solid organ transplant recipients. This project is intended to provide important information to health care professionals and transplant recipients on the effectiveness of the SARS-CoV-2 vaccine.
COVID-19 Working Group
The emergence of COVID-19 on the international stage has shifted the focus of many researchers towards determining the extent of the virus’ impact, resulting in several projects on COVID-19 and its impacts over the past year. Because of this, we took steps towards making COVID-19-related projects more efficient and cohesive by instituting the ICES Western and KDT COVID-19 Working Group lead by Kyla Naylor. The goal of this working group is to discuss current COVID-19 projects, align key decisions related to COVID-19 work, and share resources to track COVID-19-related resources (e.g., peer-reviewed manuscripts).
There are several currently active COVID-19 related projects at KDT, including:
- Impact of COVID-19 on outcomes of patients with kidney disease, PI: Stephanie Dixon
- Impact of COVID-19 on patients receiving chronic dialysis, PI: Kyla Naylor
- The impact of the Novel 2019 Coronavirus (COVID-19) outbreak on physicians, PI: Amit Garg
- COVID-19 vaccine in the kidney disease population, PI: Matthew Oliver
- COVID-19 vaccine in solid organ transplant recipients, PI: Kyla Naylor
Our program remains dedicated to helping researchers navigate the possibilities of research related to COVID-19 and promoting their work to improve COVID-19 related health care and policy. If you would like more information regarding COVID-19 related research being conducted, please contact Kyla Naylor.
Lithium’s Connection with Kidney Function Decline
Lithium is an important tool in the treatment of various mood disorders, such as bipolar disorder and treatment-resistant depression. It can prevent or lessen intensity of episodes and improve the quality of life for individuals living with these disorders. However, there are many questions surrounding its benefits and risks in some patient populations, and previous studies indicate that lithium may pose a risk to older patients with chronic kidney disease (CKD).
Approximately half of patients treated for bipolar disorder and depression will be over the age of 60 by 2030, and between 35 to 45% of those patients will have pre-morbid moderate CKD. As time passes, the need to determine the risks of using lithium in this population grows.
That’s why Dr. Soham Rej and his team conducted a study to determine whether there was an association between the risk of kidney function decline and the use of lithium in older adults, compared to patients who use valproate. Valproate is a mood disorder medication used to treat conditions like those treated with lithium. The team also took a close look at serum lithium concentrations to determine whether these levels associate with greater kidney function decline.
Using data from multiple linked administrative health databases stored at ICES, Dr. Rej’s team conducted a population-based cohort study, focusing their cohort on patients who were older than 65-years-old and used lithium or valproate between January 1, 2007, and September 30, 2015. Valproate users were chosen as a comparator group because valproate is not associated with kidney decline.
A total of 3,857 patients that used lithium and 6,257 patients using valproate were identified for the study. To measure kidney function, Dr. Rej’s team looked at the cohort’s eGFR, or estimated glomerular filtration rate, which is a blood test used to determine the efficacy of kidney function. The test measures the amount of creatinine in the blood and, using a mathematical formula, estimates kidney function quality.
Dr. Rej’s team analyzed changes in eGFR for patients who used lithium and those who used valproate, comparing the two groups to determine whether the use of lithium had a greater effect on kidney function decline than valproate.
The study found that lithium users showed a statistically significant, but moderate, increased risk of kidney function loss when compared to similar valproate users.
Also, the team wanted to know whether a patient’s serum lithium concentration affected kidney function. To find out, using ICES data, the team compared kidney function in patients with lower lithium levels (<0.7mmol/L), indicating lower concentrations, with patients who had higher lithium levels (>0.7 mmol/L).
Looking closely at the lithium levels, Dr. Rej’s team found when baseline serum lithium concentrations were > 0.7 mmol/L, the risk of kidney function decline was significantly higher compared to valproate use. However, when baseline lithium concentrations were ≤ 0.7 mmol/L, the risk was not significantly different.
The study suggests that patients who respond well to lithium for bipolar disorder or depression may be able to remain on lithium and avoid kidney function decline. The study also indicates that kidney function decline may be less than previously reported.
Specifically, though, the study provides guidance for clinical care for such patients, indicating a higher risk of kidney function decline for patients on lithium, particularly those patients with a serum lithium concentration of greater than 0.7 mmol/L, and suggesting that, in the clinical setting, it may be safer to closely follow the patient’s serum lithium concentrations and target a value <0.7 mmol/L.
As our population ages and a growing number of CKD at-risk patients need lithium to improve or maintain their quality of life, studies such as this provide much-needed clinical guidance.
ICES KDT Scientists
Our expert researchers and scientists support and advance the valuable research conducted at ICES KDT. All ICES projects require active participation by an appointed ICES scientist to ensure that ICES policies and procedures are followed. Thus, our ICES scientists are an integral part of any project and the broader ICES KDT community.
The following 16 researchers have been appointed as ICES scientists affiliated with ICES KDT:
For information on how to become an ICES scientist or to collaborate with an ICES KDT scientist, go to https://www.ices.on.ca/Research/Information-for-researchers.
ICES KDT Researchers
Our researchers comprise of a widely varied community of research, data and clinical experts whose work results in high-quality and impactful evidence used by health care providers and policy makers to guide decision-making and improve health care services and health policy. With their expertise, these researchers produce work that changes health care and policy in new and exciting ways, leading to innovative solutions to complex health care problems.
Our research community has been integral in the development and success of the KDT program, and we wish to express a heartfelt thanks.
For information on how to conduct research with ICES, visit https://www.ices.on.ca/Research/Information-for-researchers.
ICES KDT Trainees
Since its inception in December 2012, KDT has supported the work of 27 students, of which 11 are currently active. The graduates who have completed their training include three doctoral students, one combination master’s/doctoral student, nine master’s students, and three doctoral/post-doctoral fellows, all whose projects were enabled through access to ICES’s data holdings.
We are proud to report that between April 1, 2020 and March 30, 2021, the following ICES students have made us aware of their completed degrees:
For information on becoming an ICES student, visit https://www.ices.on.ca/Research/Information-for-students.