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Dissertations completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest dissertations.
The risk of cancer and its associated risk factors in patients with glomerular disease. A population-based study. (2026)
Patients with Glomerulonephritis (GN) may be at increased risk of developing de novo malignancies due to a combination of chronic immune system activation, tissue inflammation, immunosuppression use and as a consequence of the progression to end stage kidney disease (ESKD). However, there are limited epidemiologic data to accurately quantify cancer risk in GN and to determine the contributions of traditional and GN-specific risk factors including estimated glomerular filtration rate (eGFR), proteinuria and immunosuppressive therapies. This thesis intends to bridge these gaps.Chapter 1 introduces GN, its background, epidemiology, and the hypothesized relationship with cancer. Chapter 2 presents a narrative review summarizing existing observational studies and highlighting their limitations and methodological challenges. In Chapter 3, we assembled one of the largest cohorts of biopsy-proven GN patients by linking provincial GN registry with the Cancer Registry and other administrative databases spanning twenty years to conduct robust investigation of cancer risk and its associated factors in patients with GN. We showed that patients with GN have a substantially increased risk of cancer compared to the general population. This excessive risk was mostly observed for lymphoma, colorectal, kidney, and lung cancers, and was present both before and after the onset of ESKD, particularly among patients younger than 40 years. In Chapters 4 and 5, we found that cancer risk accumulates gradually with ongoing kidney dysfunction rather than being triggered solely by the onset of ESKD. To study the effect of immunosuppression on cancer risk in patients with GN, we used a data-driven approach to identify the most etiologically relevant exposure metrics for each immunosuppressive agent in relation to cancer risk. High cumulative exposure over years to immunosuppressive therapies, including antimetabolites, corticosteroids, and cyclophosphamide, was associated with increased cancer risk. The dosing thresholds linked to increased risk could be readily reached with conventional treatment protocols. Findings of this thesis highlight that while immunosuppression remains central to GN management, treatment decisions should involve shared decision-making, with a preference for low-dose agents that are not associated with increased cancer risk when possible, and careful reassessment as cumulative doses approach identified thresholds.
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Master's Student Supervision
Theses completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest theses.
A systematic review of medication adherence tools and measures in chronic kidney disease (2025)
Background: Patients with chronic kidney disease (CKD) are usually on multiple pharmacotherapies. It is crucial to properly understand and measure the levels of patients’ medication adherence due to negative health effects and economic burden of non-adherence. There is no gold standard tool for assessment of medication adherence in CKD patients and the extent of adherence among patients with CKD is poorly understood. Objective: The aim of this systematic review is to 1) Identify validated medication adherence measurement tools/methods that are used in clinical practice in the context of CKD patients. 2) Identify and synthesize key features of medication adherence methods and validated tools as an assessment of clinical applicability and feasibility in CKD patients. Methods: We systematically reviewed MEDLINE via Ovid, Embase via Ovid, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL (via EBSCO) from inception to August 08, 2023. All abstracts were screened by pairs of reviewers independently, followed by a full-text review identifying the tool/method used for measuring medication adherence. General study and medication adherence method/tool-specific characteristics were summarized. Results: The 32 articles which were included originated from 18 countries. The median of the sample size was 372.5 (3695), ranging from 31 to 559,865 with the age range varying between 14 and 76 years and an overall median age of 63.5 (15.5) years. Three (9.3%) studies were conducted on children and adolescents aged ≤18 years and the rest (n=29 ) were conducted on adult patients aged ≥18 years. The most common measures used for evaluating medication adherence were Medication Possession Ratio (MPR) (n= 9 ), Proportion of Days Covered (PDC) (n=8 ), Eight-Item Morisky Medication Adherence Scale (MMAS-8) (n=5 ), and Medication Events Monitoring System (MEMS) (n=5 ). Five (15.6%) studies used more than one method to measure medication adherence. Conclusion: There is no accepted reference tool available to measure medication adherence in CKD patients. However, some tools were used with increased frequency in the context of patients with CKD. The choice of an appropriate method/tool or a combination of methods depends on the clinician/researcher’s goals, study setting, availability of data and other resources, and patients’ characteristics.
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COVID-19 vaccination in patients with chronic kidney disease: exploring humoral immunity, perceptions, and health information-seeking behavior (2024)
Background: People living with chronic kidney disease (CKD) face an increased risk of severe illness from COVID-19, making vaccination a key strategy to reduce hospitalization and death in this population. There is limited information regarding the humoral immune response over time to COVID-19 vaccination in non-dialysis-dependent CKD (NDD-CKD) patients, particularly after the third dose, and whether this response varies by kidney function, assessed by estimated glomerular filtration rate (eGFR). Information on factors that shape COVID-19 vaccine uptake, including health information-seeking behavior (HISB) and perceptions, within the CKD population are also undefined. Methods: This thesis consists of two studies (Chapter 2 and 3), conducted within British Columbia and Ontario, Canada, between Aug 2021 – April 2023. Chapter 2: A prospective observational study that investigated the serologic response after a third mRNA COVID-19 vaccine dose in NDD-CKD patients over a 9-month follow-up period. Chapter 3: A mixed methods cross-sectional web-based survey that investigated perceptions, HISB, comprehension, and trust in information on COVID-19 in CKD patients (including dialysis and transplant). Results: Anti-spike and Anti-RBD antibody levels peaked 2 months after the third dose (1131 and 1672 BAU/mL, respectively), and high seropositivity rates (above 93% and 85%, respectively) were seen over the 9-month follow up period. There was no association found between eGFR and mounting a robust antibody response or on the magnitude of antibody levels over time. Chapter 3: A majority (65%) of CKD patients sought out information on COVID-19 and those with a higher number of COVID-19 vaccine doses were associated with having sought out (P =.017), comprehended (P .001), and trusted (P =.005) COVID-19 related information. Most CKD patients strongly agreed to statements regarding the benefits of COVID-19 vaccination. Questions posed by survey respondents about COVID-19 centered on four major categories: vaccination strategy, vaccine effectiveness, vaccine safety, and the impact of COVID-19 on kidney health. Conclusion: NDD-CKD patients had a strong humoral immune response following a third mRNA COVID-19 vaccine dose and there were no observed differences in this response by eGFR. CKD patients exhibited high HISB, trust, and comprehension on COVID-19 information, and perceptions towards the COVID-19 vaccines were mostly favorable.
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Evaluation of the Kidney Check project using an applied two-eyed seeing approach (2021)
Indigenous people in Canada experience rates of chronic kidney disease (CKD) higher than those of non-Indigenous Canadians as a direct result of colonization. Early detection and prevention through screening is a critical public health strategy in optimizing patient outcomes and reducing burden to the health care system. As such, a screen, triage and treat initiative called Kidney Check is currently offering point of care kidney health screening in sixteen First Nations in British Columbia (BC). One of the important aims of the Kidney Check project in its current iteration is to assess the value, acceptance, and sustainability of the project, with the aim of making a case for expansion and continuity. This thesis describes a culturally safe and respectful framework to understand these parameters from the perspective of Kidney Check team members responsible for organization and implementation of the program in community. A two-eyed seeing evaluation approach combining principles from Indigenous evaluation frameworks with qualitative approaches to evaluation was used to ensure a respectful, relational, and academically rigorous evaluation. Specifically, a narrative approach was taken to honor the tradition of oral knowledge sharing and to ensure that the evaluation priorities were set by community members themselves. Ten members of the Kidney Check screening team told their stories through conversational interviews. Interviews were transcribed verbatim and then thematically analyzed in collaboration with an Indigenous Knowledge Holder to maintain an Indigenous perspective throughout. Themes relating to value are described within the framework of the 4R’s; Respect, Relevance, Reciprocity and Responsibility. Themes around sustainability include levers and barriers. Levers to sustainability are intimately connected to the value of Kidney Check. Subthemes around barriers to sustainability include cost, staffing and logistics. The Indigenous metaphor of cedar bark weaving is described as an appropriate visual representation of how the themes illuminated by participants are interconnected and woven together, creating a wholistic evaluation. The results of this evaluation have important implications for both the field of public health as it relates to Indigenous communities and health policy in BC.
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