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Gholizadeh Ghozloujeh Z, Singh T, Jhaveri KD, Shah S, Lerma E, Abdipour A, Norouzi S. Lupus nephritis: management challenges during pregnancy. FRONTIERS IN NEPHROLOGY 2024; 4:1390783. [PMID: 38895665 PMCID: PMC11183321 DOI: 10.3389/fneph.2024.1390783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
Lupus nephritis (LN), a severe complication of systemic lupus erythematosus (SLE), leads to significant kidney inflammation and damage and drastically increases mortality risk. Predominantly impacting women in their reproductive years, LN poses specific risks during pregnancy, including pre-eclampsia, growth restrictions, stillbirth, and preterm delivery, exacerbated by lupus activity, specific antibodies, and pre-existing conditions like hypertension. Effective management of LN during pregnancy is crucial and involves carefully balancing disease control with the safety of the fetus. This includes pre-conception counseling and a multidisciplinary approach among specialists to navigate the complexities LN patients face during pregnancy, such as distinguishing LN flare-ups from pregnancy-induced conditions. This review focuses on exploring the complex dynamics between pregnancy and LN, emphasizing the management difficulties and the heightened risks pregnant women with LN encounter.
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Affiliation(s)
- Zohreh Gholizadeh Ghozloujeh
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Tripti Singh
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Kenar D. Jhaveri
- Department of Medicine, Division of Kidney Diseases and Hypertension, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, United States
| | - Silvi Shah
- Department of Medicine, Division of Nephrology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Edgar Lerma
- Department of Medicine, Division of Nephrology, Advocate Christ Medical Center, University of Illinois at Chicago, Oak Lawn, IL, United States
| | - Amir Abdipour
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Sayna Norouzi
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
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Nili F, Farahani E, Moghimian M, Jahanzad I, Minoo FS, Salarvand S, Abdollahi A, Mirshahvalad SA. Spectrum and Distribution of Biopsy-proven Kidney Diseases: A 12-year Survey of a Single Center in Iran. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2023; 34:346-354. [PMID: 38345590 DOI: 10.4103/1319-2442.395451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Data about the prevalence of biopsy-proven kidney diseases in Iran are rare, and none of the previous studies used electron microscopy for diagnosis. This study aimed to analyze the prevalence of biopsy-proven kidney diseases in Iran's primary referral center. To the best of our knowledge, this is the most extensive study carried out in Iran. Reports of kidney biopsy samples from patients referred to our center in 2007-2018 were reviewed for demographic data, clinical presentation, and final diagnosis. Statistical analyses were performed. Among the 3455 samples received, 2975 were analyzed. Nephrotic syndrome (39%) was the most common cause of biopsy, followed by subnephrotic proteinuria (18%), hematuria in association with proteinuria (15%), renal failure (9%), isolated hematuria (6%), and lupus nephritis (LN) (4%). The most common diagnoses were membranous glomerulonephritis (17.9%), focal segmental glomerulosclerosis (FSGS) (15.9%), LN (13.7%), minimal histopathological findings (unsampled FSGS vs. minimal change disease, 12.1%), Immunoglobin A nephropathy (IgAN) (6.5%) and Alport syndrome (6.1%). NS and proteinuria were the most common indications for a kidney biopsy. IgAN and LN were the most common causes of primary and secondary glomerulonephritis, presenting with hematuria and proteinuria, respectively. Although membranous glomerulonephritis was the most common disease, it has been replaced by FSGS in recent years.
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Affiliation(s)
- Fatemeh Nili
- Department of Pathology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Farahani
- Department of Radiology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehran Moghimian
- Department of Urology, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
| | - Issa Jahanzad
- Department of Pathology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Samaneh Salarvand
- Department of Pathology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Abdollahi
- Department of Pathology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Farahani E, Nili F, Moghimian M, Jahanzad I, Minoo FS, Abdollahi A, Salarvand S. Analysis of Prevalence and Trends in the Biopsy-Proven Native Kidney Diseases in Iranian Population: A 12-year Survey from a Referral Center. IRANIAN JOURNAL OF PATHOLOGY 2023; 18:202-209. [PMID: 37600578 PMCID: PMC10439747 DOI: 10.30699/ijp.2023.2000827.3104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/03/2023] [Indexed: 08/22/2023]
Abstract
Background & Objective The prevalence of glomerular diseases, as the leading cause of chronic kidney disease, is increasing. Renal biopsy is still the gold standard for diagnosis of the most kidney disorders. Data on prevalence of the biopsy-proven kidney diseases in Iran is limited and none of the previously reported studies used electron microscopic (EM) evaluation for the diagnosis. This study was conducted to analyze the prevalence of biopsy-proven kidney diseases in a referral center in Iran. Methods The reports of kidney biopsy samples from 2006 to 2018 referred to a pathology center, affiliated with Tehran University of Medical Sciences were reviewed. The prevalence of different disorders was assessed based on the clinical presentation in 3 age categories, including childhood, adulthood, and elderly. Results Among 3455 samples, 2975 were analyzed after excluding transplant-related specimens, suboptimal specimens, and those with uncertain diagnoses. Nephrotic syndrome (NS) (39%) was the most common cause of biopsy followed by subnephrotic proteinuria (18%), hematuria in association with proteinuria (15%), renal failure (9%), isolated hematuria (6%), lupus (4%) and the other non-specific manifestations such as hypertetion or malaise (each one less than 2%). The most common diagnoses included membranous nephropathy (MGN) (17.9%), focal segmental glomerulosclerosis (FSGS) (15.9%), lupus nephritis (LN) (13.7%), minimal histopathological findings (unsampled FSGS versus Minimal Change Disease, 12.1%), Immunoglobulin-A (IgA) nephropathy (6.5%) and Alport syndrome (6.1%). MGN was the most frequent disease before 2013, but FSGS became more frequent after that. Conclusion NS and proteinuria were the most indications for kidney biopsy. Although MGN was the most common disease, the prevalence of FSGS has been increasing in recent years and making it the most common disease after 2013. LN and IgA nephropathy are the most common causes of secondary and primary GN presenting with proteinuria and hematuria, respectively.
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Affiliation(s)
- Elham Farahani
- Department of Radiology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Nili
- Department of Pathology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Nephrology Research Center, Tehran University of Medical Science, Tehran, Iran
| | - Mehran Moghimian
- Department of Urology, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
| | - Issa Jahanzad
- Department of Pathology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzaneh-Sadat Minoo
- Nephrology Research Center, Tehran University of Medical Science, Tehran, Iran
- Center of Excellence in Nephrology, Tehran University of Medical Science, Tehran, Iran
| | - Alireza Abdollahi
- Department of Pathology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Samaneh Salarvand
- Department of Pathology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Bergmann M, Nguyen TN, Segal CC, Jaber BL. Cerebral venous thrombosis in an adult with relapsing minimal change disease. Am J Med Sci 2023; 365:538-544. [PMID: 36933861 DOI: 10.1016/j.amjms.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/27/2023] [Accepted: 03/10/2023] [Indexed: 03/18/2023]
Abstract
Minimal change disease (MCD) is a well-known cause of fulminant acute nephrotic syndrome (NS) and has been associated with thrombotic complications. We report the case of a 51-year-old woman with previously biopsy-proven MCD in remission who presented with headache and encephalopathy shortly after a relapse of the NS and was diagnosed with cerebral venous thrombosis (CVT) complicated by intracranial hemorrhage and midline shift. One month prior, she had been initiated on an oral contraceptive agent during remission of the NS. After initiation of systemic anticoagulation, her condition rapidly deteriorated, and she passed away before being able to undergo catheter-based venous thrombectomy. We conducted a systematic literature review and identified 33 case reports of adults with NS-associated CVT. The most common symptoms were headache (83%), nausea or vomiting (47%), and altered mental status (30%). 64% of patients presented at time of initial diagnosis of the NS and 32% during a relapse. Mean urinary protein excretion was 9.32 g/day and mean serum albumin was 1.8 g/dL. 91% of patients received systemic anticoagulation, and 19% died. The outcome in the remaining cases was favorable with only one report (5%) of residual neurological deficit. Of the available kidney biopsy results, MCD was the most common diagnosis (70%), raising the hypothesis that the fulminant acute onset of the NS might be a predisposing factor for this serious thrombotic complication. Clinicians should have a high index of suspicion for CVT in patients with the NS who present with new-onset neurological symptoms, including headache and nausea.
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Affiliation(s)
- Matthias Bergmann
- Division of Nephrology, Department of Medicine, St. Elizabeth's Medical Center, Boston, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, MA, USA; Department of Neurology, St. Elizabeth's Medical Center, Boston, MA, USA
| | - Christine C Segal
- Department of Radiology, St. Elizabeth's Medical Center, Boston, MA, USA
| | - Bertrand L Jaber
- Division of Nephrology, Department of Medicine, St. Elizabeth's Medical Center, Boston, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.
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Female Reproductive and Gynecologic Considerations in Chronic Kidney Disease: Adolescence and Young Adulthood. Kidney Int Rep 2022; 7:152-164. [PMID: 35155855 PMCID: PMC8820991 DOI: 10.1016/j.ekir.2021.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 10/27/2021] [Accepted: 11/01/2021] [Indexed: 11/21/2022] Open
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 733] [Impact Index Per Article: 244.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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Gleeson S, Lightstone L. Glomerular Disease and Pregnancy. Adv Chronic Kidney Dis 2020; 27:469-476. [PMID: 33328063 DOI: 10.1053/j.ackd.2020.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 12/28/2022]
Abstract
Nephrologists are routinely involved in the care of pregnant women with glomerulonephritis. Prepregnancy counseling is vital to inform women of the potential risks of pregnancy and to reduce those risks by optimizing clinical status and medications. In general, for all glomerulonephritides, the best pregnancy outcomes are achieved when the disease is in remission and the woman has preserved renal function with no proteinuria or hypertension. Each glomerulonephritis has specific considerations, for example in lupus nephritis, mycophenolate is teratogenic and must be stopped at least 6 weeks before conception, hydroxychloroquine is recommended for all pregnant women, and flares are frequently encountered and must be treated appropriately. De novo glomerulonephritis should be considered when significant proteinuria is found early in pregnancy or an acute kidney injury with active urine is encountered. Biopsy can be safely undertaken in the first trimester. Treatment is often with corticosteroids, azathioprine, and/or tacrolimus. Rituximab is increasingly used for severe disease. Women with glomerulonephritis should ideally be managed in a joint renal-obstetric clinic. This review details the approach to the care of women with glomerulonephritis from prepregnancy counseling, through antenatal care and delivery, to the postpartum period. Special attention is given to medications and treatment of glomerulonephritis in pregnancy.
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Haninger-Vacariu N, Herkner H, Lorenz M, Säemann M, Vychytil A, Jansen M, Marculescu R, Kramar R, Sunder-Plassmann G, Schmidt A. Exclusion of pregnancy in dialysis patients: diagnostic performance of human chorionic gonadotropin. BMC Nephrol 2020; 21:70. [PMID: 32111190 PMCID: PMC7049197 DOI: 10.1186/s12882-020-01729-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/19/2020] [Indexed: 12/19/2022] Open
Abstract
Background A positive pregnancy test in acute or chronically ill patients has implications for the use of potentially mutagenic or teratogenic products in urgent medical therapies such as the use of chemotherapies or therapies with immunosuppressants, for anesthesia, and for time-sensitive indications like urgent surgery or organ Transplantation. Despite a lack of evidence, it is currently believed that human chorionic gonadotropin serum concentrations are always elevated in female dialysis patients even without pregnancy. It is also believed that human chorionic gonadotropin cannot be used to confirm or exclude pregnancy. Methods Human chorionic gonadotropin was examined in female dialysis patients (18–50 years of age), and was classified as positive above 5 mlU/ml. In addition, fertility status was determined. For an enhanced index test, the cut-off of 5 mIU/ml was used for potentially fertile patients and 14 mIU/ml for infertile patients to calculate diagnostic test accuracy. The ideal cut-off for human chorionic gonadotropin was estimated using Liu’s method with bootstrapped 95% confidence intervals. Predictors of human chorionic gonadotropin increase were analyzed using multivariable linear regression. Results Among 71 women, two (2.8%) were pregnant, 46 (64.8%) potentially fertile, and 23 (32.4%) infertile. We observed human chorionic gonadotropin concentrations > 5 mIU/ml in 10 patients, which had a sensitivity of 100% (95% confidence interval: 100 to 100), a specificity of 86% (95% confidence interval: 77 to 94), a positive predictive value of 17% (95% confidence interval: 8 to 25) and a negative predictive value of 100% (95% confidence interval: 100 to 100) for the diagnosis of pregnancy. Using a cut-off > 14 mIU/ml for infertile patients or the exclusion of infertile patients increased specificity to 93% or 98%, respectively. The ideal cut-off was 25 mIU/ml (95% confidence interval: 17 to 33). Pregnancy and potential fertility, but not age, were independent predictors of human chorionic gonadotropin. Conclusion Human chorionic gonadotropin is elevated > 5mIU/ml in 14.5% of non-pregnant dialysis patients of child-bearing age. In potentially fertile women, this cut-off can be used to exclude pregnancy. In case of an unknown fertility status, the ideal human chorionic gonadotropin cut-off was 25 mIU/ml.
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Affiliation(s)
- Natalja Haninger-Vacariu
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria.
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, 1090, Vienna, Austria
| | | | - Marcus Säemann
- Department of Medicine VI, Wilhelminenspital, 1160, Vienna, Austria.,Sigmund Freud Private University, Medical School, 1020, Vienna, Austria
| | - Andreas Vychytil
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
| | - Martin Jansen
- Division of Gastroenterology and Nephrology, Department of Medicine I, Hospital St. John of God, 1020, Vienna, Austria
| | - Rodrig Marculescu
- Department of Laboratory Medicine, Medical University of Vienna, 1090, Vienna, Austria
| | - Reinhard Kramar
- Austrian Dialysis and Transplant Registry, 4532, Rohr im Kremstal, Austria
| | - Gere Sunder-Plassmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
| | - Alice Schmidt
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
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Pillay C, Clark K. Postpartum care of women with renal disease. Best Pract Res Clin Obstet Gynaecol 2019; 57:89-105. [PMID: 31122756 DOI: 10.1016/j.bpobgyn.2019.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/25/2019] [Indexed: 10/26/2022]
Abstract
Twenty-three percent of women with known chronic kidney disease (CKD) have been reported to demonstrate the first decline in kidney function between giving birth and six-weeks postpartum. As such, these women warrant close monitoring during the postpartum period irrespective of their pregnancy journey. Substantial haemodynamic variability during pregnancy and postpartum renders estimated glomerular filtration rate inaccurate, and poorly defined normal ranges of markers of kidney function at this time pose challenges for accurate assessment of renal complications. Multi-disciplinary specialist care is therefore essential, with consideration of specific implications of any known renal diagnosis and with observation for the development of postpartum complications of pregnancy. Furthermore, the postpartum period affords time to further investigate and diagnose kidney disease revealed by pregnancy. Good care planning and communication in the postpartum period has the potential to improve long-term health outcomes for women with known or new CKD and will be discussed in this review.
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Affiliation(s)
- Camilla Pillay
- Department of Renal Medicine, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - Katherine Clark
- Antental Hypertension Clinic, King's College Hospital, 16-20, Windsor Walk, London, SE5 8BB, UK.
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Dumanski SM, Ahmed SB. Fertility and reproductive care in chronic kidney disease. J Nephrol 2019; 32:39-50. [PMID: 30604149 DOI: 10.1007/s40620-018-00569-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 12/12/2018] [Indexed: 12/20/2022]
Abstract
In both women and men, chronic kidney disease (CKD) is associated with decreased fertility. Though a multitude of factors contribute to the reduction in fertility in this population, progressively impaired function of the hypothalamic-pituitary-gonadal axis appears to play a key role in the pathophysiology. There is limited research on strategies to manage infertility in the CKD population, but intensive hemodialysis, kidney transplantation, medication management and assisted reproductive technologies (ART) have all been proposed. Though fertility and reproductive care are reported as important elements of care by CKD patients themselves, few nephrology clinicians routinely address fertility and reproductive care in clinical interactions. Globally, the average age of parenthood is increasing, with concurrent growth and expansion in the use of ART. Coupled with an increasing prevalence of CKD in women and men of reproductive age, the importance of understanding fertility and reproductive technologies in this population is highlighted. This review endeavors to explore the female and male factors that affect fertility in the CKD population, as well as the evidence supporting strategies for reproductive care.
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Affiliation(s)
- Sandra Marie Dumanski
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada. .,Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada. .,Libin Cardiovascular Institute of Alberta, 1403 29th St NW, Calgary, AB, T2N 2T9, Canada. .,Alberta Kidney Disease Network, 1403 29th St NW, Calgary, AB, T2N 2T9, Canada.
| | - Sofia Bano Ahmed
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.,Libin Cardiovascular Institute of Alberta, 1403 29th St NW, Calgary, AB, T2N 2T9, Canada.,Alberta Kidney Disease Network, 1403 29th St NW, Calgary, AB, T2N 2T9, Canada
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