Welcome to the fifth edition of The Kidney Quarterly, a publication dedicated to stories that highlight the Can-SOLVE CKD Network’s impact on Canadian kidney health research.

March 10, 2022 is World Kidney Day, an opportunity to reflect on the global impact and human toll of chronic kidney disease. Roughly 850 million individuals worldwide are affected by kidney disease, including four million Canadians.

Despite this significant toll, many knowledge gaps persist at all levels of kidney care. The World Kidney Day Joint Steering Committee has declared 2022 to be the year of “Kidney Health for All.” Specifically, it calls on all of us to work to bridge the knowledge gaps to better kidney care.

For the Can-SOLVE CKD Network, everything we do is centred around generating new knowledge and using it to support better health outcomes and quality of life. We are proud to lead 18 patient-oriented research projects that are answering key questions about prevention, diagnosis, treatment, and care. These projects combined with our growing set of resources for patient engagement and cultural competency are bringing hope to those living with and at risk of kidney disease.

To mark World Kidney Day 2022, we are pleased to share highlights of our work that are bridging knowledge gaps in support of better kidney health.

Feature story

Treating kidney disease with precision

Over the past few decades, scientists have been able to tease apart the nuances of many diseases through genetic sequencing and analysis. The ability to study diseases in such detail has spurred a revolution in medicine – offering hundreds of thousands of patients more personalized care. But whereas genetic analysis has greatly improved our understanding of diseases such as cancer and opened the door to new treatments, similar breakthroughs for kidney disease have been lacking.

A Can-SOLVE CKD research team is striving to change this status quo. As part of the “Precision Medicine in Diabetic Kidney Disease” study, they have analyzed 50 kidney biopsies (tissue samples) taken from patients with diabetic kidney disease. Using a “molecular microscope” that can analyze roughly 14,000 genes, they have uncovered important findings that hint at which patients with diabetic kidney disease are at higher risk of disease progression.

Dr. Darren Yuen, an Associate Professor at the University of Toronto, is co-leading the study. He notes that a doctor assessing these 50 patients would have difficulty noticing any clinical differences among them without the genetic data. “But when we look with the molecular microscope, we can find that there’s two distinct subtypes of diabetic kidney disease,” explains Yuen.

Using these data, the research team has also identified a collection of genes that are associated with more aggressive progression of kidney disease. The results could help doctors identify patients who need earlier intervention and higher levels of care, to slow disease progression, and allow these patients and their care teams to prepare for more aggressive disease further down the road.

Yuen notes that thirty years ago there was only one known form of breast cancer – and now, thanks to molecular analyses, different subtypes of the disease have been identified, as well as more specialized treatments for many of these subtypes. His hope is that similar progress is made for treating kidney disease.

He also notes that these initial findings were made with just 50 biopsies at St. Michael’s Hospital in Toronto, and the national reach of the Can-SOLVE CKD Network will see the team receive an additional 75 kidney biopsies from Ottawa and British Columbia. “Now we’re going to be more than doubling [our sample size] because of this national network, which is amazing,” says Yuen, noting that this new data will be useful in helping to validate their initial findings.

As the study continues, the team will also be analyzing data on patient outcomes, comparing it to the genetic data. This may hint at which treatments are best for the different subtypes of diabetic kidney disease.

Yuen notes that this work has “truly been a team effort,” with patient partners, nephrologists and scientists from across the country contributing.

“We may not necessarily be able to come up with a new drug, but at least [this research will] be able to inform those new studies that could lead to new drugs. That’s how I feel that [this work] is actually making a difference.”

Dr. Darren Yuen

Co-Lead, Precision Medicine in Diabetic Kidney Disease

Feature story

New tool finds the right medicine for better kidney health

Medication can help save lives, but – like with all things – too much can be harmful. Hemodialysis patients have a very high pill burden (averaging 12 medications a day) and research suggests many of these medications may not be necessary, potentially leading to unnecessary hospitalizations and adverse drug reactions.

Medication can help save lives, but – like with all things – too much can be harmful. Hemodialysis patients have a very high pill burden (averaging 12 medications a day) and research suggests many of these medications may not be necessary, potentially leading to unnecessary hospitalizations and adverse drug reactions.

To help reduce this burden, a Can-SOLVE CKD research project developed a new tool to help care teams identify unnecessary medications being taken by hemodialysis patients. The STOP Med-HD research team has spent years developing and validating the tool – a set of “deprescribing” algorithms – and now the time has come to implement it in the clinic.

Dr. Marisa Battistella, a Pharmacy Clinician Scientist at the University of Toronto and University Health Network who is leading the study, says the new deprescribing tool will be implemented at the Toronto General Hospital – University Health Network first. The insights gained from this initial pilot will be used to implement the tool more broadly at three additional sites across Canada.

Although the deprescribing tool has the potential to significantly improve the lives of people on hemodialysis, the research team needs an effective way to help patients and their care teams understand the value in the tool and best way to use it.

Notably, some patients in the first phase of the project expressed concern about stopping medications they believed to be necessary. This prompted the STOP Med-HD team to develop strategic communications materials to help patients understand why certain medications can be stopped safely.

“I think that our tools will help to optimize medication use in hemodialysis patients, as well educate patients on medications and deprescribing,” says Battistella. “Our patient partners helped us to develop these tools as well as to validate them, so they are all ready for use in practice.”

As well, the team is exploring the possibility of patient partners talking one-on-one with other patients to explain the deprescribing tool. This peer support approach may help patients better understand deprescribing and feel more comfortable with stopping some of the medications, explains Battistella.

The pilot study in Toronto was launched in February. “It is exciting, as data from this pilot study will help other sites also implement our tools,” says Battistella. “The results could really ease the pill burden for many people living with kidney disease in Canada.”

“I think that our tools will help to optimize medication use in hemodialysis patients, as well educate patients on medications and deprescribing. Our patient partners helped us to develop these tools as well as to validate them, so they are all ready for use in practice.”

Dr. Marisa Battistella

Lead, STOP Med-HD

Feature story

Addressing the knowledge gaps that affect Indigenous peoples’ care

Imagine that you are feeling ill at home and your symptoms worsen to the point that you need medical care at a hospital. But rather than seeking the help you need, you are hesitant to go because you may be disregarded or treated poorly by the hospital staff. While this thought would not cross the minds of most white people living in Canada, it remains a major concern for many Indigenous people.

As we celebrate World Kidney Day, which this year embodies the theme of “Bridge the knowledge gap to better kidney care,” it’s important to not just focus on obvious knowledge gaps, such as the need for new therapies to treat kidney disease, but also the knowledge gap among non-Indigenous people – related to racial biases, anti-Indigenous racism and colonialism – that leaves many First Nations, Inuit and Métis individuals and communities with subpar levels of care.

Members of the Indigenous Peoples’ Engagement and Research Council (IPERC) at Can-SOLVE CKD have been taking important steps to help address these gaps in knowledge and bring Indigenous voices into the spotlight, both within the research network and beyond. This includes the development of the Wabishki Bizhiko Skaanj learning pathway, among many other initiatives.

The learning pathway is a series of programs and trainings that people in health research and care settings can take to learn more about the historical and ongoing impacts of colonialism on Indigenous Peoples in Canada. It also aims to highlight the unique cultures of First Nations, Inuit and Métis from coast to coast, as well as their respective ways of knowing, being and healing.

Craig Settee is Cree/Anishinaabe and a citizen of Fisher River Cree Nation (Treaty 5 Territory), Manitoba. He has been helping to develop the learning pathway for several years, and points to numerous reasons the pathway is helpful for improving the quality of care that Indigenous people experience.

“It’s important for non-Indigenous people to understand the social determinants of health that we [as Indigenous people] experience,” he explains. For example, colonialism altered the traditional foods systems of Indigenous people, making it harder to access healthy foods due to Nations’ access to their own traditional territories often hindered by private land ownership or being Crown Lands. As well, Indigenous people are still healing after centuries of harmful policies and imposed colonial systems, such as the Indian Act, Residential Schools and the Sixties Scoop.

Increasing non-Indigenous peoples’ awareness of colonial history and their own racial biases helps bring us one step closer to addressing the gaps in care between Indigenous people and the general public. Another critical step that needs to be taken is to ensure that Indigenous voices are present and heard within research and health care settings.

The formation of IPERC within Can-SOLVE CKD has helped to amplify Indigenous voices across the network, notes Settee. “It’s good to to support voices and share our experiences to help shape and re-shape research projects, and to shift the attitudes and beliefs of the people who take care of us in those hospital settings and in research settings,” he explains.

He points to a good analogy that he heard during a talk on Indigenous cultural safety, whereby Leslie Bonshor, Vice-President, Indigenous Health at Vancouver Coastal Health, noted that Indigenous voices should not be “sprinkled” on at the end of a research project. Rather, inclusion of Indigenous voices and knowledge should be a key ingredient of every project from the beginning. Settee emphasizes that inclusion needs to also be occurring at all level and especially at higher levels, for example among medical boards of directors and other leadership and decision-making positions.

“Hopefully [these leaders] use their platform and space to bring Indigenous people into those rooms as well, so that it’s not only allies speaking on behalf on Indigenous people, but there’s actually Indigenous people these leadership spaces speaking to Indigenous experiences, needs and recommendations to continue building cultural safety in the health care and research systems,” says Settee.

“As good as I feel about the work we’re doing here, I think there’s a long way to go, in continuing to advocate and continuing to call out our health care teams to continue learning on how to be culturally safe and embedding cultural humility and competency into policy, practice and care.”

Craig Settee

Cultural Competency Manager

Feature story

Demystifying knowledge translation

There are many great studies being done around the world to explore new therapies and improve the quality of care for patients. But making sure those new data and findings are applied to the real-world is a major challenge.

This is what knowledge translation (KT) is all about.

“I think there’s definitely a gap between creating evidence and using that evidence in decision-making,” says Louise Morrin, co-chair of Can-SOLVE CKD’s Knowledge User/Knowledge Translation (KU/KT) Committee. “So KT is really trying to bridge that gap and use the knowledge that has been created in research to actually improve treatment and care.”

She notes that although the initial concept of KT tended to only focus on disseminating the results of studies, it has since evolved to include many more facets. Now, KT is not just about informing patients, providers and policy-makers of new evidence, but also about helping them actually use the new information and implement it in practice.

Examples of KT tools include communication aids, clinical guidelines, webinars, KT templates, among others.

KT has been a key focus within the Can-SOLVE CKD Network, and for good reason. The network has 18 important research projects on the go, but our teams need tools and techniques to implement research findings in the clinic in a way that will truly transform kidney care. This requires a highly strategic KT approach.

To support research groups in developing effective KT approaches, the network’s KU/KT Committee has developed an Implementation Toolkit. Steven Soroka, a co-chair on the committee, says the toolkit is analogous to a prep meal kit, which provides all the “ingredients” that teams may need to translate their research into practice.

But, tailoring the implementation plans based on the unique project and targeted audience is important, Soroka and Morrin both note.

For these reasons, the implementation strategies used by each Can-SOLVE CKD’s research group can vary greatly.

Soroka notes that there are four overarching themes that KT could potentially target: improving the patient experience, providing better care, cost-efficiency of health care, and supporting health care providers. “That’s the quadruple aim,” he says. “If you can get one, two, three, or all of those, you can make a difference.”

As with all aspects of Can-SOLVE CKD, patients play a central role in shaping KT efforts within the network. Morrin points out that this helps keep the strategies focused on what matters most to patients, and leads to better KT practices. As a result, she says, “You have better outcomes for patients. You have better outcomes for the health system and you have a better patient experience at the end of the day.”

“We really want to see that the knowledge that is being created through these Can-SOLVE CKD projects is actually being taken up, whether that be [by the practitioners, patients or entire health care systems]. Those are all types of knowledge translation with different target audiences and strategies.”

Louise Morrin

Co-Chair, Knowledge User/Knowledge Translation Committee

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