Dr. Peter Blake is a Professor of Medicine at the University of Western Ontario and a renowned expert in peritoneal dialysis, having published over 100 papers and served as Editor-in-Chief of Peritoneal Dialysis International. In addition to his academic and editorial contributions, he has held significant leadership roles, including Provincial Medical Director of the Ontario Renal Network and Chair of the Canadian Society of Nephrology Work Group on Peritoneal Dialysis. His career is distinguished by extensive international speaking engagements and active service on the boards of several major nephrology journals.
A study of dialysis patients in Ontario, Canada, found that those starting low-dose methotrexate had a more than threefold higher risk of death or serious hospitalization compared to those starting hydroxychloroquine. Nearly 30 percent of patients taking methotrexate experienced severe complications such as sepsis, lung toxicity, or bone marrow suppression within 90 days. These findings suggest that methotrexate should be avoided in the dialysis population in favour of safer alternative medications.
Researchers evaluated the impact of changing the eligibility rules for multidisciplinary kidney care in Ontario, Canada, which shifted from a simple kidney function threshold to a risk-based model. While the change led to fewer patients receiving specialized clinic care and a slight increase in late referrals before starting dialysis, there were no significant negative effects on long-term clinical outcomes like dialysis initiation methods or mortality. These findings suggest that using risk-based criteria can help focus resources on high-risk patients without compromising overall patient safety.
Dial-Mag Investigator Writing Committee*, Killin L, Bohm C, Harris C, MacRae JM, Shah N, Thompson S, Tonelli M, Luo B, Sontrop JM, Acedillo RR, Al-Jaishi AA, Anderson S, Antonsen J, Bagga A, Beaubien E, Berry D, Blake PG, Brown PA, Bueti J, Chan CT, Cote B, Cowan AC, Cuerden MS, Day NE, Dev V, Dhruve M, Djurdjev O, Gregor L, Hiremath S, Joseph G, Kammila S, Kiaii M, Kumar Kolusu E, Lacson E Jr, Mazurat A, Molnar AO, Nathoo B, Nistico A, Oliver MJ, Pandeya S, Parmar MS, Perkins D, Quinn K, Romann A, Sasal J, Shulman T, Silver SA, Singh A, Louis IS, Steele A, Tangri N, Ting RH, Vorster H, Wadehra DB, Wald R, Walters J, Whitlock RH, Yao S, Zacharias J, Garg AX
This protocol describes an ongoing study across 137 Canadian hemodialysis centres to determine if using a higher concentration of magnesium in dialysis fluid reduces the risk of death, heart disease, and muscle cramps. Researchers are comparing a centre-wide policy of high magnesium dialysis fluid against a lower concentration over a four-year period. The study uses provincial health databases and patient questionnaires to track long-term cardiovascular outcomes and patient comfort.
In 2018, Ontario established a new multidisciplinary care model to provide standardized and timely treatment for individuals with glomerulonephritis. An analysis of provincial administrative databases showed that nearly 7,000 patients accessed this care model over a four-year period, with IgA nephropathy being the most common diagnosis and six percent of patients eventually requiring dialysis or a kidney transplant. This new model of care is becoming well established in the province and will help guide future healthcare planning.
This study followed patients receiving maintenance dialysis in Ontario, Canada, to determine if surviving COVID-19 led to worse health outcomes over the following two years. Researchers found that those who survived the first 90 days after infection did not have a higher risk of death, hospitalization, or heart disease compared to similar patients who were never infected. However, experiencing a second COVID-19 infection later on was linked to an increased risk of death.
Wang C, Kang Y, Dixon SN, Jeyakumar N, Scott Brimble K, Garg AX, Blake PG, Stukel TA, Oliver MJ, Al-Jaishi A, Clemens KK, Fu L, Ip J, McKenzie S, Moist L, Molnar AO, Muanda-Tsobo F, Reich M, Roshanov P, Silver SA, Wald R, Weir MA, Yau K, Young A, Naylor KL
Researchers in Ontario, Canada, found that deaths among people with advanced chronic kidney disease increased by eight per cent during the first 21 months of the COVID-19 pandemic. Despite this increase in mortality, hospital admissions and emergency room visits for these patients actually decreased, suggesting a significant disruption in how they accessed medical care. Interestingly, visits to kidney specialists remained stable throughout the pandemic, and there was no significant change in the number of patients needing to start urgent dialysis.
In a study of 125 adults aged 50 and older with chronic kidney disease, researchers found that genetic testing identified a specific cause of disease in 38% of patients. The highest success rate for diagnosis occurred in those aged 50 to 54, with various forms of glomerular disease being the most common findings. These genetic results led to changes in medical treatment and clinical management, suggesting that age alone should not be a barrier to accessing genetic testing for kidney disease.
Naylor KL, Jeyakumar N, Kang Y, Dixon SN, Garg AX, Al-Jaishi A, Blake PG, Chanchlani R, Fu L, Harel Z, Ip J, Kitchlu A, Kwong JC, Nesrallah G, Oliver MJ, Stukel TA, Wald R, Weir M, Yau K
Researchers in Ontario, Canada, compared the health outcomes of over 31,000 dialysis patients before and during the first three years of the COVID-19 pandemic. While death rates were significantly higher during specific months of the pandemic, the overall mortality rate over the entire 36-month period was not substantially higher than expected. Interestingly, hospitalizations and emergency room visits decreased during the pandemic, yet there was no corresponding increase in deaths unrelated to COVID-19.
Researchers conducted a process evaluation using surveys and interviews with healthcare providers to understand why a recent program failed to increase patient access to kidney transplantation in Ontario. They found that while many parts of the program were successfully integrated into daily routines, staff felt the intervention was too complex and lacked sufficient resources and frontline buy-in. These insights into implementation challenges will help guide the design of future strategies to improve transplant rates.
Researchers analyzed health records from three large groups of patients in Ontario to estimate how many people with kidney failure die without starting dialysis or receiving a transplant. The study found that approximately one in six individuals with kidney failure dies without these treatments, highlighting a significant group that likely receives conservative medical management. These findings are important for health care planning and ensuring that resources are available for patients who choose not to pursue intensive kidney replacement therapies.
This report summarizes a conference dedicated to developing six new pragmatic clinical trials designed to improve the quality of care for patients receiving hemodialysis. Researchers, health care providers, and patient partners collaborated on study designs that will test interventions such as different blood pressure targets and dialysis fluid compositions within routine clinical settings. The initiative aims to increase the number of high-quality randomized trials in nephrology to better support evidence-based treatment decisions.
This study followed nearly 800 patients on maintenance dialysis in Ontario who survived the first 30 days of a COVID-19 infection to understand their long-term health outcomes. Researchers found that these survivors faced high rates of death, reinfection, and hospitalizations for heart-related issues for more than a year following their initial illness. Patients who required intensive care during their first infection or who later became reinfected were at a significantly higher risk of death.
A population-based study in Ontario, Canada, examined the use of mental health and addiction services among nearly six million adults with varying levels of kidney function. Researchers found that while mental health and addiction service use was common overall, individuals with advanced chronic kidney disease and those receiving maintenance dialysis were less likely to access these services compared to individuals with normal kidney function. This lower rate of service use was primarily driven by a lower utilization of outpatient mental health and addiction care.
This study examined whether tailoring the bicarbonate levels in dialysis fluid to individual patients or using a standard concentration affected their pre-dialysis blood bicarbonate levels. Analyzing data from over 5,000 hemodialysis patients in Ontario, Canada, researchers found no significant difference in blood bicarbonate levels between the individualized and standardized approaches. However, using very high standard bicarbonate concentrations in the dialysis fluid did slightly increase patients' blood bicarbonate levels compared to lower standard concentrations.
This study evaluated how adopting the newer, race-free 2021 equation for estimating kidney function would affect eligibility for specialized kidney care in Ontario, Canada, compared to the older 2009 equation. Researchers found that using the 2021 equation substantially reduced the number of individuals meeting the criteria for nephrologist consultations, multidisciplinary specialty clinic care, and kidney transplant evaluations. These findings suggest that in regions with a small Black population, transitioning to the newer equation could significantly decrease the number of patients eligible for specialized kidney services.
A study in Ontario, Canada, found that patients receiving in-centre hemodialysis visit the emergency department five times more often and are hospitalized seven times more frequently than the general population. These patients also face significantly higher healthcare costs, with annual hospitalization expenses being approximately eleven times higher than those of matched individuals without kidney failure. These findings highlight the substantial burden of illness in the dialysis population and the importance of health system planning to manage these high acute care needs.
Researchers tested a new program across 26 kidney care centres in Ontario to see if providing extra administrative support, education, and peer storytelling could help more patients receive a kidney transplant. Although the program was successfully put into practice, it did not significantly increase the rate at which patients completed the necessary steps toward transplantation compared to those receiving standard care. These findings highlight the ongoing challenge of overcoming barriers to kidney transplantation and the need for different strategies to improve patient access.
A retrospective study in Ontario, Canada, found that fifty-nine percent of patients did not receive recommended multidisciplinary kidney care before starting maintenance dialysis. While some patients experienced an unpreventable, rapid decline in kidney function, others missed opportunities for early chronic kidney disease screening, timely referral to a kidney specialist, or referral to multidisciplinary care clinics. These findings highlight specific gaps in the healthcare system that could be targeted to improve pre-dialysis care.
A study of older adults in Ontario, Canada, found that those with chronic kidney disease who started low-dose methotrexate had double the risk of serious adverse events, such as sepsis or lung and liver toxicity, compared to those starting hydroxychloroquine. This risk was even higher for individuals with more advanced kidney impairment, particularly those with an estimated glomerular filtration rate below 45. These findings suggest that the potential for severe complications should be carefully weighed against the benefits when prescribing methotrexate to patients with reduced kidney function.
This review examines system-level barriers that limit the adoption of home dialysis in the United States, such as infrastructure gaps, staffing shortages for patient training, and limited physician expertise. The authors discuss evolving quality measures for home dialysis care and compare American policy and advocacy initiatives with international experiences. They conclude by outlining future directions for policy levers and quality improvement initiatives to better support patients who choose home therapies.
Researchers examined kidney transplant referral rates across 27 regional chronic kidney disease programs in Ontario and found significant geographic disparities. Even after accounting for patient characteristics, the likelihood of being referred for a transplant within one year varied widely between programs, with patients in Northern regions facing substantially lower referral rates. These findings highlight inconsistent access to the first step of transplantation within a single-payer health care system.
Yau K, Enilama O, Levin A, Romney MG, Singer J, Blake P, Perl J, Leis JA, Kozak R, Tsui H, Bolotin S, Tran V, Chan CT, Tam P, Dhruve M, Kandel C, Estrada-Codecido J, Brown T, Siwakoti A, Abe KT, Hu Q, Colwill K, Gingras AC, Oliver MJ, Hladunewich MA
This protocol describes the design of an ongoing prospective study tracking the long-term immune response to COVID-19 vaccination in patients across the spectrum of kidney disease, including those on dialysis and transplant recipients. Researchers will measure antibody levels and cellular immunity from blood samples collected at multiple intervals up to one year after vaccination. The findings are intended to help shape public health guidelines and optimize immunization strategies for Canadians living with chronic kidney disease.
Wing S, Thomas D, Balamchi S, Ip J, Naylor K, Dixon SN, McArthur E, Kwong JC, Perl J, Atiquzzaman M, Yeung A, Yau K, Hladunewich MA, Leis JA, Levin A, Blake PG, Oliver MJ
Researchers in Ontario, Canada, studied the effectiveness of a third dose of mRNA COVID-19 vaccines compared to two doses in over 8,000 patients receiving maintenance hemodialysis during the Omicron wave. The study found that a third dose significantly reduced the risk of both infection and severe outcomes, such as hospitalization or death, compared to receiving only two doses. Additionally, patients who had a previous COVID-19 infection were found to have a lower risk of being reinfected regardless of their vaccination status.
Hiremath S, Blake PG, Yeung A, McGuinty M, Thomas D, Ip J, Brown PA, Pandes M, Burke A, Sohail QZ, To K, Blackwell L, Oliver M, Jain AK, Chagla Z, Cooper R
Researchers evaluated a modified, low-dose regimen of the antiviral medication nirmatrelvir/ritonavir in 134 dialysis patients with COVID-19 in Ontario, Canada. The study found that the treatment was safe and well-tolerated, with 96% of patients completing the full course and no COVID-19-related deaths occurring within 30 days. While many patients required adjustments to their other medications due to drug interactions, this modified dosing provides a potential treatment option for a high-risk group originally excluded from clinical trials.
A study of over 20,000 patients attending advanced chronic kidney disease clinics in Ontario, Canada, found that those diagnosed with COVID-19 during the first 21 months of the pandemic faced high rates of hospitalization and death. Risk factors for infection included lower kidney function, non-White ethnicity, lower income, and living in long-term care homes. However, receiving two doses of the COVID-19 vaccine was associated with a significant reduction in the risk of death within 30 days of infection.
Perl J, Brown EA, Chan CT, Couchoud C, Davies SJ, Kazancioğlu R, Klarenbach S, Liew A, Weiner DE, Cheung M, Jadoul M, Winkelmayer WC, Wilkie ME, for Conference Participants
An international controversies conference convened by Kidney Disease: Improving Global Outcomes examined the barriers to home dialysis and proposed strategies to expand its use. Experts highlighted that while clinical outcomes are similar across dialysis modalities, home therapies offer greater patient autonomy and satisfaction. To increase adoption, health systems must align policy, funding, and education, while clinical teams should use shared decision-making to match dialysis options with patient preferences and lifestyle goals.
This study compared three different research designs to estimate the effectiveness of mRNA COVID-19 vaccines in patients with stage 5 chronic kidney disease in Ontario, Canada. While all three methods showed that two vaccine doses were effective at preventing infection and severe outcomes like hospitalization or death, the 'pseudo-test-negative' design was identified as a practical and reliable approach for this specific population. This finding is important because it suggests that researchers can accurately measure vaccine effectiveness in kidney disease patients using administrative data even when specific symptom records are missing.
This study tracked the implementation of infection control practices across all 27 renal programs in Ontario, Canada, during the first wave of the COVID-19 pandemic. Researchers found that most programs rapidly adopted measures such as symptom screening, physical distancing, and universal masking for staff and patients within the first two months of the pandemic. These proactive and increasingly standardized practices, shared through provincial teleconferences, likely helped minimize virus transmission and limit outbreaks in in-centre hemodialysis units.
This study compared the outcomes of patients with end-stage kidney disease who started peritoneal dialysis at different times after catheter insertion: urgent-start (within 72 hours), early-start (between 72 hours and two weeks), or conventional-start (after two weeks). Analyzing data from 68 clinics in Brazil, researchers found no significant differences in the combined rates of death or treatment failure within the first 90 days across the three groups. The findings suggest that starting peritoneal dialysis urgently is a safe and feasible option for patients who need to begin dialysis without delay.
This protocol describes the statistical analysis plan for an ongoing study evaluating a program designed to help patients with advanced kidney disease access transplantation and living donation. Researchers are using health registry data from Ontario, Canada, to compare whether patients in kidney programs receiving extra education and administrative support complete more steps toward transplantation than those receiving standard care. The study tracks progress through four key stages, including specialist referral, donor evaluation, waitlist addition, and the successful receipt of a kidney transplant.
The authors clarify that their previous publication was not suggesting that patients should be forced into conservative kidney management to meet policy targets. Instead, they express concern that the aggressive targets set by the Advancing American Kidney Health Initiative might unintentionally pressure healthcare providers to limit patient choice and steer individuals away from in-centre dialysis. They advocate for shared decision-making and caution that performance measures must be carefully designed to avoid negatively affecting patient care.
Patients with advanced chronic kidney disease, including those on dialysis or with a kidney transplant, are at high risk for severe COVID-19 but are often excluded from clinical trials evaluating therapies like nirmatrelvir/ritonavir. This article reviews the pharmacology, efficacy, and safety of nirmatrelvir/ritonavir, proposing specific reduced-dosing regimens for patients with severe kidney impairment. The authors emphasize the need to carefully manage significant drug-drug interactions, particularly with immunosuppressive medications in transplant recipients, to safely offer this beneficial antiviral therapy.
This study examines the clinical utility of COVID-19 vaccination in patients undergoing maintenance hemodialysis, a population that has been disproportionately affected by the pandemic. The researchers evaluated the real-world effectiveness of the vaccine in preventing severe infection and mortality in these high-risk individuals. The findings highlight the critical role of vaccination in reducing COVID-19-related complications and death in the hemodialysis population.
A study of older adults with chronic kidney disease in Ontario, Canada, found that starting the gout medication allopurinol at a dose higher than 100 milligrams per day was associated with a more than twofold increased risk of hospitalisation for severe skin reactions compared to starting at a lower dose. This higher starting dose was also linked to an increased risk of overall hospitalisation, though not to a higher risk of death. These findings support the practice of initiating allopurinol at lower doses in patients with reduced kidney function to prevent serious adverse events.
This commentary examines the Advancing American Kidney Health Initiative, which aims to have eighty percent of patients with kidney failure treated with home dialysis or transplantation by 2025. The authors argue that this target is mathematically implausible to reach solely by increasing the absolute numbers of home therapies and transplants because of the large overall number of patients receiving renal replacement therapy in the United States. They suggest that the current metric may incentivize strategies that restrict patient choice or limit access to therapy, and recommend that the measure of success be reconsidered to better align with the goal of person-centred care.
This protocol describes an ongoing study to evaluate how a quality improvement program is being delivered across kidney care centres in Ontario to increase access to transplantation. Researchers will use surveys and interviews with healthcare providers to determine if the program components, such as patient education and performance monitoring, are being implemented as intended. The findings will help explain the results of the main clinical trial and provide guidance for improving transplant access in the future.
Oliver MJ, Thomas D, Balamchi S, Ip J, Naylor K, Dixon SN, McArthur E, Kwong J, Perl J, Atiquzzaman M, Singer J, Yeung A, Hladunewich M, Yau K, Garg AX, Leis JA, Levin A, Krajden M, Blake PG
A study of over 13,000 dialysis patients in Ontario, Canada, found that COVID-19 vaccines were highly effective at preventing infection and severe outcomes like hospitalization or death. While a single dose provided significant protection, receiving two doses further reduced the risk of severe illness by 83 per cent compared to being unvaccinated. These protective benefits were consistent across different age groups, dialysis types, and vaccine brands, despite earlier concerns about weaker immune responses in this population.
Yau K, Chan CT, Abe KT, Jiang Y, Atiquzzaman M, Mullin SI, Shadowitz E, Liu L, Kostadinovic E, Sukovic T, Gonzalez A, McGrath-Chong ME, Oliver MJ, Perl J, Leis JA, Bolotin S, Tran V, Levin A, Blake PG, Colwill K, Gingras AC, Hladunewich MA
This study compared the immune response of patients undergoing maintenance hemodialysis in Toronto, Canada, after receiving either the Pfizer-BioNTech or Moderna COVID-19 vaccine. Researchers found that patients who received the Moderna vaccine had significantly higher antibody levels and maintained them better at 12 weeks after their second dose compared to those who received the Pfizer-BioNTech vaccine. The rapid decline in antibody levels among those who received the Pfizer-BioNTech vaccine supports the recommendation for a third vaccine dose in this vulnerable population.
