Background and objectivesPatients with CKD exhibit heterogeneity in their rates of progression to kidney failure. The kidney failure risk equation (KFRE) has been shown to accurately estimate progression to kidney failure in adults with CKD. Our objective was to determine health care utilization patterns of patients on the basis of their risk of progression.Design, setting, participants, & measurementsWe conducted a retrospective cohort study of adults with CKD and eGFR of 15–59 ml/min per 1.73 m2 enrolled in multidisciplinary CKD clinics in the province of Saskatchewan, Canada. Data were collected from January 1, 2004 to December 31, 2012 and followed for 5 years (December 31, 2017). We stratified patients by eGFR and risk of progression and compared the number and cost of hospital admissions, physician visits, and prescription drugs.ResultsIn total, 1003 adults were included in the study. Within the eGFR of 15–29 ml/min per 1.73 m2 group, the costs of hospital admissions, physician visits, and drug dispensations over the 5-year study period comparing high-risk patients with low-risk patients were (Canadian dollars) $89,265 versus $48,374 (P=0.008), $23,423 versus $11,231 (P<0.001), and $21,853 versus $16,757 (P=0.01), respectively. Within the eGFR of 30–59 ml/min per 1.73 m2 group, the costs of hospital admissions, physician visits, and prescription drugs were $55,944 versus $36,740 (P=0.10), $13,414 versus $10,370 (P=0.08), and $20,394 versus $14,902 (P=0.02) in high-risk patients in comparison with low-risk patients, respectively, for progression to kidney failure.ConclusionsIn patients with CKD and eGFR of 15–59 ml/min per 1.73 m2 followed in multidisciplinary clinics, the costs of hospital admissions, physician visits, and drugs were higher for patients at higher risk of progression to kidney failure by the KFRE compared with patients in the low-risk category. The high-risk group of patients with CKD and eGFR of 15–29 ml/min per 1.73 m2 had stronger association with hospitalizations costs, physician visits, and drug utilizations.

Hepatocellular cancer (HCC) is a common cancer and an important cause of cancer-related death globally. Although surgery is the primary curative treatment, most patients at diagnosis are not surgical candidates and are treated with liver-directed therapy and or systemic therapy. Over the past decade, the systemic treatment options for patients with advanced HCC have evolved. This paper reviews recent progress in systemic therapy and the results of major clinical trials involving novel compounds in patients with HCC. A literature search was performed using keywords related to HCC and systemic therapy. The evidence shows that at the present time an effective adjuvant systemic therapy is not available for patients with early-stage HCC following surgery. In patients with advanced HCC, in addition to sorafenib at least four other targeted agents and several immune checkpoint inhibitors, alone or in combination have been shown to be associated with improved progression-free and overall survival. The optimal sequence of agents, is currently not known, and is determined by patient characteristics, toxicities profile, patients and physicians preference. The future identification of novel active agents and predictive biomarkers are vital to personalize systemic therapy in HCC.

Immune checkpoint inhibitors are novel oncological medications, current classes of which include monoclonal antibodies that target inhibitory receptors cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), programmed death 1 protein (PD-1) and programmed death-ligand 1. While they are novel in their ability to treat cancer, they also have a unique spectrum of immune-related adverse events. Renal-related immune adverse events, though rare, are an increasingly recognised clinical entity. We present the case of a 67-year-old man with acute kidney injury (AKI) after the second cycle of combination anti-CTLA-4 and anti-PD-1 antibodies for metastatic cutaneous melanoma. He presented with vomiting and diarrhoea, and AKI secondary to dehydration was treated with aggressive rehydration. After failing to recover biochemically, a renal biopsy was performed, which demonstrated severe acute interstitial nephritis. The culprit medications were held and he was treated with steroids. With immunosuppression, creatinine improved to pretreatment values.

Background and Aims: Multidisciplinary clinics (MDC’s) were established in Canada to offer a variety of support systems (diabetes care, social support, easy access to pharmacists, dietitians, specialty trained nurses), to monitor and delay progression through timed lab investigations and visits in conjunction with the Nephrologist. The reasons for better outcomes have been identified as better education, focus on self-care, dietary interventions, timely transplant referrals, modality education, lower hospitalizations and mortality. Treating all patients with chronic kidney disease (CKD) as part of a multidisciplinary care team runs the risk of adding unwarranted labs, interventions, polypharmacy and costs. Kidney Failure Risk Equation (KFRE) uses routine laboratory and clinical data, to stratify patients into three risk categories (low, medium, and high risk) of progression. KFRE has been shown to accurately estimate progression to kidney failure in adults with CKD. The objectives of the study were to i) validate the KFRE in our CKD patients, ii) evaluate health care utilization of patients based on the risk of progression in our province, Saskatchewan. iii) identify the subgroup of patients that benefit most from follow up in MDC. Methods: We conducted a retrospective study on 1007 patients with CKD stages G3 and G4 in two CKD multidisciplinary clinics in the province of Saskatchewan, Canada (January 2004-December 2012). The predicted risk of kidney failure (low, medium high) for each patient was calculated using the 8-variable KFRE. Patients were followed for five years to validate the KFRE; data on initiation of dialysis or death was collected. Cost of delivery of care per patient per year in the CKD clinic was determined. Health care utilization was evaluated by measuring the number/cost of hospital admissions, cardiovascular and thoracic (CVT) surgery, non-nephrology specialist appointments, and medications. Results: There were more patients in G 3 (n= 533) than in G 4 (n=474). 313 (59%), 150 (28%), and 70 (13%) were in low, medium and high-risk categories for G 3 CKD. 275 (58%), 86 (18%), and 113 (24%) were in similar categories for G 4. The mean age (SD) was 71 (12.8) years. The number of patients &gt; 65 years of age was 75%. 57% were men, mean GFR (mls/min/1.73m2) for G3 was 40 (7.8) and 23 (4) for G4. Of the G3 patients, 4% of low risk, 11% of the medium risk and 26% of the high risk progressed to dialysis by 5 years. In G 4 patients, 7% of low risk, 17% of medium risk and 48% of high risk progressed to dialysis over 2 years. These results validate the KFRE in our population. The cost of care per patient in MDC was $ 3800 (CAD) per year. There was a difference in the cost of medications, number and cost of (inpatient hospitalizations, cardiovascular surgeries, non-Nephrology specialist visits, and day surgeries) between low risk patients vs high risk patients in G4 patients. Conclusion: We performed a cost-effectiveness analysis of our MDC’s and show that very few patients at low-risk of progression advance to ESRD. They are also unlikely to benefit from intensive care management and better managed in primary care with advice from tertiary centres. Individual programs have significant opportunity to improve health care delivery by identifying the sub- groups that benefit the most from MDC based on the risk of progression to allow optimal utilization of resources. At $ 3800 (CAD) per patient, we suggest that MDC’s are best utilized by patients with medium and high risk of progression. Further, we show that patients that the low-risk patients were older, had fewer inpatient visits, had lesser drug costs, underwent fewer cardiovascular surgeries, had fewer day surgery visits, and fewer non-nephrology specialist visits. This is the first study to our knowledge that focuses on health care utilization based on the risk of disease progression rather than the stage of CKD.