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Reddy S, Scholes-Robertson N, Raj JM, Pais P. Catastrophic healthcare expenditure and caregiver burden in pediatric chronic kidney disease - a mixed methods study from a low resource setting. Pediatr Nephrol 2024; 39:3079-3093. [PMID: 38856776 DOI: 10.1007/s00467-024-06420-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Caregivers of children with chronic kidney disease (CKD) in low resource settings must provide complex medical care at home while being burdened by treatment costs often paid out-of-pocket. We hypothesize that caregiver burden in our low resource setting is greater than reported from high income countries and is associated with frequent catastrophic healthcare expenditure (CHE). METHODS We conducted a mixed-methods study of primary caregivers of children with advanced CKD (stage 3b-5) in our private-sector referral hospital in a low resource setting. We assessed caregiver burden using the Pediatric Renal Caregiver Burden Scale (PRCBS) and measured financial burden by calculating the proportion of caregivers who experienced CHE (monthly out-of-pocket healthcare expenditure exceeding 10% of total household monthly expenditure). We performed a qualitative reflexive thematic analysis of caregiver interviews to explore sources of burden. RESULTS Of the 45 caregivers included, 35 (78%) had children on maintenance dialysis (25 PD, 10 HD). Mean caregiver burden score was 141 (± 17), greater than previously reported. On comparative analysis, PRCBS scores were higher among caregivers of children with kidney failure (p = 0.005), recent hospitalization (p = 0.03), non-earning caregivers (p = 0.02), caring for > 2 dependents (p = 0.009), and with high medical expenditure (p = 0.006). CHE occurred in 43 (96%) caregivers of whom 37 (82%) paid out-of-pocket. The main themes derived relating to caregiver burden were severe financial burden, mental stress and isolation, and perpetual burden of concern. CONCLUSION Parents of children with CKD experienced severe caregiver burden with frequent CHE and relentless financial stress indicating an imminent need for social support interventions.
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Affiliation(s)
- Soumya Reddy
- Department of Paediatric Nephrology, St Johns Medical College Hospital, St Johns National Academy of Health Sciences, Sarjapur Road, Bangalore, 560034, India
| | - Nicole Scholes-Robertson
- Rural and Remote Health, College of Medicine and Public Health, Flinders University, Bedford Park, Australia
| | - John Michael Raj
- Department of Biostatistics, St Johns Medical College, St Johns National Academy of Health Sciences, Bangalore, India
| | - Priya Pais
- Department of Paediatric Nephrology, St Johns Medical College Hospital, St Johns National Academy of Health Sciences, Sarjapur Road, Bangalore, 560034, India.
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Ritschl V, Stamm T, Selzer A, Boesendorfer A, Eibensteiner F, Kaltenegger L, Mosor E, Omara M, Vachuda N, Sperl L, Masel EK, Aufricht C, Boehm M. Life outcomes after paediatric kidney transplantation: a qualitative, biographical study in long-term survivors. Arch Dis Child 2024; 109:240-246. [PMID: 38212079 PMCID: PMC10894829 DOI: 10.1136/archdischild-2023-326432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/06/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE The objective of this study was to analyse the narrative life stories of children with end-stage kidney disease (ESKD) and their families to determine how health professionals can effectively support these children to achieve better life outcomes. DESIGN Qualitative narrative biographic study. SETTING We invited every long-term survivor of paediatric kidney transplants and their families at the Medical University of Vienna between 2008 and 2013 to participate in this study. PARTICIPANTS Nineteen patients (women: n=8, 42%) and 34 family members (women: n=22, 65%) were interviewed. The patients had a mean age of 7.6 (SD±5.6) years at the time of transplantation and 22.2 (SD±5.4) at the time of interview. MAIN OUTCOMES MEASURES A qualitative narrative biographical analysis was combined with computational structured topic models using the Latent Dirichlet Allocation. RESULTS The overarching finding was the desire for normality in daily life in long-term survivors and their families but with different perceptions of what normality looks like and predominance of this aspect evolving. Different strategies were used by patients (focused on their advancement) and caregivers (normality for all family members). Siblings played a major role in supporting survivors' social inclusion. CONCLUSIONS The strong desire for normality confirms recent findings of the Standardised Outcomes in Nephrology Group initiative, which proposes survival and life participation as core outcomes in children with chronic kidney disease. Our study should be a starting point for an international effort to identify typologies and stratified interventions for children with ESKD and their families, particularly siblings.
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Affiliation(s)
- Valentin Ritschl
- Institute for Outcomes Research, Centre for Medical Data Science, Medical University of Vienna, Wien, Austria
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Tanja Stamm
- Institute for Outcomes Research, Centre for Medical Data Science, Medical University of Vienna, Wien, Austria
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Axana Selzer
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Wien, Austria
| | - Anna Boesendorfer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Wien, Austria
| | - Fabian Eibensteiner
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Wien, Austria
| | - Lukas Kaltenegger
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Wien, Austria
| | - Erika Mosor
- Institute for Outcomes Research, Centre for Medical Data Science, Medical University of Vienna, Wien, Austria
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Maisa Omara
- Institute for Outcomes Research, Centre for Medical Data Science, Medical University of Vienna, Wien, Austria
| | - Natalie Vachuda
- Institute for Outcomes Research, Centre for Medical Data Science, Medical University of Vienna, Wien, Austria
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Lisa Sperl
- Institute for Outcomes Research, Centre for Medical Data Science, Medical University of Vienna, Wien, Austria
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Eva K Masel
- Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, Wien, Austria
| | - Christoph Aufricht
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Wien, Austria
| | - Michael Boehm
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Wien, Austria
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Seephom S, Jittanoon P, Balthip K. Muslim caregivers' experiences in caring for patients receiving peritoneal dialysis. J Ren Care 2023; 49:6-14. [PMID: 34971469 DOI: 10.1111/jorc.12408] [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: 03/20/2021] [Revised: 12/18/2021] [Accepted: 12/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fulfilling the role of a family caregiver has a substantial effect on the lives of those involved. However, existing information on family caregivers of patients receiving peritoneal dialysis is insufficient-especially Muslim caregivers, whose practice is unique. OBJECTIVES The aim of this study was to understand the experiences of Muslim family caregivers looking after patients receiving peritoneal dialysis in an Islamic context. DESIGN A descriptive qualitative approach was employed. PARTICIPANTS Thirteen Muslim family caregivers who have cared for patients undergoing peritoneal dialysis for at least 1 month. APPROACH Data were collected through face-to-face in-depth interviews and a focus group discussion. Content analysis was used to analyse the data with initial codes grouped into sub-categories, generic categories, and main categories. FINDINGS The experiences of Muslim family caregivers looking after patients receiving peritoneal dialysis generated two main categories: overwhelmed with suffering and learning to live as a caregiver. CONCLUSIONS Caregiving has a substantial impact on Muslim family caregivers. They need to be cared for holistically. The recognition of Islamic beliefs, doctrine of Allah, and religious practices are clear spiritual anchors for caregiving. The findings provide a deeper understanding of the experiences of Muslim family caregivers looking after patients receiving peritoneal dialysis. These findings could serve as the basis for developing a specific nursing intervention for such caregivers.
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Affiliation(s)
- Sunisa Seephom
- Division of Adult and Gerontological Nursing, The Srisavarindhira Thai Red Cross Institute of Nursing, Pathumwan, ฺBangkok, Thailand
| | - Piyanuch Jittanoon
- Division of Community Nurse Practitioner, Faculty of Nursing, Prince of Songkla University, Hat Yai, Thailand
| | - Karnsunaphat Balthip
- Division of Community Nurse Practitioner, Faculty of Nursing, Prince of Songkla University, Hat Yai, Thailand
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Levy Erez D, Meyers MR, Raman S, Thomas M, Furth S, Forrest CB, Denburg M. When Dialysis "Becomes Life": Pediatric Caregivers' Lived Experiences Obtained From Patient-Reported Outcomes Measures. Front Pediatr 2022; 10:864134. [PMID: 35676900 PMCID: PMC9168233 DOI: 10.3389/fped.2022.864134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Qualitative research reveals significant caregiver impact resulting from managing children requiring chronic dialysis but offers few quantitative measures of their lived experiences. Materials and Methods This cross-sectional study included 25 caregivers of children on chronic peritoneal dialysis (PD) and hemodialysis (HD) enrolled from 2018 to 2019 at a large pediatric dialysis program in the U.S.Patient Reported Outcomes Measures Information System (PROMIS) measures and free text commentary were collected and analyzed to evaluate the self-reported impact and wellbeing of these caregivers. Results Among all dialysis modalities, caregivers' positive affect (43.4 ± 10) and general life satisfaction (45.1 ± 11.5) were significantly lower than the general adult population. Compared with HD caregivers, PD caregivers demonstrated significantly more fatigue and sleep disturbance and less positive affect and life satisfaction. Amongst HD caregivers, sleep disturbance, positive affect, and meaning/purpose differed significantly from the general population. Analyses of text commentary revealed that caregivers also expressed the feelings of loss, importance of knowing the impact of dialysis prior to initiation, need for a support group, and value of home nursing. Conclusions Caregivers of children on chronic dialysis had significantly poorer self-rated health and wellbeing compared with the general adult population. This may be due in part to their feelings of social isolation. Our findings highlight opportunities to improve caregivers' lived experiences.
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Affiliation(s)
- Daniella Levy Erez
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Schneider Children's Medical Center, Petah Tikva, Israel
| | - Melissa R. Meyers
- Division of Nephrology, Children's National Medical Center, Washington, DC, United States
- George Washington University School of Medicine, Washington, DC, United States
| | - Swathi Raman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Melissa Thomas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Susan Furth
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Christopher B. Forrest
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Michelle Denburg
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Pais P, Wightman A. Addressing the Ethical Challenges of Providing Kidney Failure Care for Children: A Global Stance. Front Pediatr 2022; 10:842783. [PMID: 35359883 PMCID: PMC8963107 DOI: 10.3389/fped.2022.842783] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/10/2022] [Indexed: 01/10/2023] Open
Abstract
Children with kidney failure require kidney replacement therapy (KRT), namely maintenance dialysis and kidney transplant. Adequate kidney failure care consists of KRT or conservative treatment with palliative care. In the context of kidney failure, children depend on parents who are their surrogate decision-makers, and the pediatric nephrology team for taking decisions about KRT or conservative care. In this paper, we discuss the ethical challenges that arise relating to such decision-making, from a global perspective, using the framework of pediatric bioethics. While many ethical dilemmas in the care of children with KRT are universal, the most significant ethical dilemma is the inequitable access to KRT in low & middle income countries (LMICs) where rates of morbidity and mortality depend on the family's ability to pay. Children with kidney failure in LMICs have inadequate access to maintenance dialysis, timely kidney transplant and palliative care compared to their counterparts in high income countries. Using case vignettes, we highlight how these disparities place severe burdens on caregivers, resulting in difficult decision-making, and lead to moral distress among pediatric nephrologists. We conclude with key action points to change this status-quo, the most important being advocacy by the global pediatric nephrology community for better access to affordable kidney failure care for children.
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Affiliation(s)
- Priya Pais
- Department of Pediatric Nephrology, St. John's Medical College, St. John's National Academy of Health Sciences, Bangalore, India
| | - Aaron Wightman
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States
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Experiences and Needs of Families Caring for Children and Adolescents With Chronic Kidney Disease: A meta-Synthesis. J Pediatr Nurs 2022; 63:52-63. [PMID: 35007849 DOI: 10.1016/j.pedn.2021.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 12/23/2021] [Accepted: 12/28/2021] [Indexed: 11/21/2022]
Abstract
PROBLEM Families struggle to care for children and adolescents with chronic kidney disease (CKD). They face extensive burden of care and altered family dynamics. ELIGIBILITY CRITERIA A meta-synthesis review was conducted to explore the experiences and needs of families caring for children and adolescents with CKD using seven electronic databases (CINAHL, EMBASE, ProQuest Dissertations and Theses, PsycINFO, PubMed, Scopus, and Web of Science). The inclusion criteria are (1) qualitative English studies from January 2010 to December 2020 that (2) report personal experiences or needs of (3) family members caring for children and adolescents aged 19 years and below who have been diagnosed with CKD of any stage (4) across all settings. Quality appraisal was done using the Critical Appraisal Skill Program checklist. Data was synthesised using Sandelowski & Barroso's (2007) method. SAMPLE 2,236 records were identified and 13 eligible studies were included. Family members involved mothers (n = 190), fathers (n = 83), siblings (n = 5), and grandparents (n = 2). RESULTS Three themes emerged: (1) demands of caregiving, (2) support systems, and (3) defining and making sense of new reality. CONCLUSIONS Family caregivers experience overwhelming demands of caregiving and unmet support needs to cope. Appropriate interventions are needed to alleviate their burden. IMPLICATIONS Knowledge of learning and support needs of families caring for children with CKD may shape nursing education and practice to cultivate more effective communication for better psychosocial family support.
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Coexisting with the Life of Patients with Hemodialysis: Qualitative Meta-Synthesis Study of Life of Caregivers of Patients with Hemodialysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042163. [PMID: 35206351 PMCID: PMC8871738 DOI: 10.3390/ijerph19042163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/04/2022] [Accepted: 02/09/2022] [Indexed: 02/04/2023]
Abstract
As the number of patients with hemodialysis (HD) continues to increase, so too does the number of people depending on caregivers. There is need to pay attention to the lives of caregivers of patients with HD, where sacrifices are forced. This study systematically reviewed and synthesized qualitative studies that explored the experiences of caregivers caring for patients with HD using the meta-synthesis method. We searched literature using four databases (i.e., PubMed, Excerpta Medica dataBASE, Cumulated Index to Nursing and Allied Health Literature, and Web of Science), and finally ten publications were selected. Four themes and nine subtopics were derived from analyzing and synthesizing the research results. The synthesized themes were: “bearing the burden of life as a caregiver,” “reconstructing life to maintain hemodialysis”, “the fading of caregiver’s own life,” and “effort to relieve the burden.” The results of this study can contribute to the development of interventional studies to improve the quality of life of HD patients. These studies provide an integrated and in-depth perspective on the experiences of caregivers who care for HD patients.
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Ong ZH, Ng CH, Tok PL, Kiew MJX, Huso Y, Shorey S, Ng YPM. Sources of Distress Experienced by Parents of Children with Chronic Kidney Disease on Dialysis: A Qualitative Systematic Review. J Pediatr Nurs 2021; 57:11-17. [PMID: 33207303 DOI: 10.1016/j.pedn.2020.10.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 10/19/2020] [Accepted: 10/19/2020] [Indexed: 10/23/2022]
Abstract
PROBLEM Parents of children with chronic kidney disease face tremendous burdens of care, having to adopt dual roles as parents and informal healthcare providers, delivering home-based clinical care, despite lacking proper qualification and training. ELIGIBILITY CRITERIA A systematic review of qualitative studies was conducted to identify sources of distress among parents caring for children with chronic kidney disease undergoing dialysis, excluding children who have had renal transplants. Guided by PRISMA guidelines, six electronic databases (PubMed, Embase, PsycINFO, Scopus, Cochrane, Google Scholar) were searched for relevant articles published in English. A three-step inductive thematic synthesis method outlined by Thomas and Harden (2018) was used to form descriptive themes and the Critical Appraisal Skill Program (CASP) qualitative checklist was utilised to appraise the quality of included articles. SAMPLE A total of 23,129 title and abstracts were reviewed; 161 full texts were reviewed. Thirteen papers, with the experiences of 183 parents, met the inclusion criteria. Most included studies were conducted in Western countries, which may limit the applicability of this review to other countries. RESULTS Five themes emerged: disease-related distress, personal struggles, family structure, lack of resources and unrealistic social expectations. CONCLUSION Parents of children with chronic kidney disease undergoing dialysis experienced distress at multiple levels. IMPLICATION Healthcare professionals caring for children with chronic kidney disease could screen parents early for distress, and refer them to relevant psychosocial and community services.
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Affiliation(s)
- Zhi Hao Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Pei Loo Tok
- Division of Nephrology, National University Hospital, Singapore
| | - Megan Jia Xuan Kiew
- School of Life Sciences and Chemical Technology, Ngee Ann Polytechnic, Singapore
| | - Yi Huso
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Shefaly Shorey
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Yvonne Peng Mei Ng
- Department of Neonatology, Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Singapore; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Wightman A. Caregiver burden in pediatric dialysis. Pediatr Nephrol 2020; 35:1575-1583. [PMID: 31435726 DOI: 10.1007/s00467-019-04332-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/08/2019] [Accepted: 08/06/2019] [Indexed: 12/28/2022]
Abstract
In spite of improvements in expected survival, neurodevelopmental outcome, and quality of life, decision-making in neonatal dialysis remains controversial in high-resource countries. In part, this may be based upon the significant burdens experienced by the child, and also those experienced by the parents as caregivers. Emerging research offers a clearer description of the burdens experienced by dialysis caregivers worldwide. Caregiver burden represents an important area for nephrologists to advocate for patients and their families; however, nephrologists must also recognize the realities caregivers currently experience. Incorporation of caregiver burden into medical decision-making for children with end-stage kidney disease is necessary, but raises several ethical concerns.
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Affiliation(s)
- Aaron Wightman
- Divisions of Nephrology, Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA. .,Division of Nephrology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98115, USA. .,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA, USA.
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