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Bakari AI, Yahaya JJ, Matobogolo BM, Abraham ZS, Mpondo B. Adequacy of haemodialysis and associated factors among patients with end-stage kidney disease in Tanzania. J Taibah Univ Med Sci 2024; 19:287-295. [PMID: 38283378 PMCID: PMC10821596 DOI: 10.1016/j.jtumed.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 12/07/2023] [Accepted: 12/25/2023] [Indexed: 01/30/2024] Open
Abstract
Objectives Adequate haemodialysis helps maintain normal renal function by removing toxins and other waste products in patients with end-stage kidney disease. This study was aimed at determining the prevalence and predictors of adequacy of haemodialysis and outcomes in patients with end-stage kidney disease. Methods This longitudinal analytical hospital-based study was conducted at two dialysis centres in Dodoma city, Tanzania, between February and July of 2020. Adequacy of haemodialysis was measured with single-pool (sp) Kt/V and urea reduction rate (URR) formulae. Binary logistic regression and multivariable analysis were used to assess the independent predictors of adequacy of haemodialysis. Results The analysis included 100 patients with a mean age of 50.6 ± 15.0 years. The prevalence of adequacy of haemodialysis according to URR and sp-Kt/V was 72 % and 75 %, respectively. Having <12 months since dialysis initiation (AOR = 7.3, 95 % CI = 0.11-0.90, p = 0.032), fewer than three dialysis sessions per week (AOR = 6.9, 95 % CI = 1.52-31.49, p = 0.013) and severe anaemia (AOR = 2.2, 95 % CI = 0.26-0.93, p = 0.033) were predictors of inadequate haemodialysis, according to the URR formula. Having fewer than three dialysis sessions per week was significantly associated with inadequate haemodialysis (AOR = 5.6, 95 % CI = 1.47-19.66, p = 0.011), according to the sp-Kt/V formula. The mortality rate was 11.2 %, and cardiovascular disease and uremic syndrome were responsible for most deaths. Conclusion This study indicated a high percentage of adequacy of haemodialysis among patients with end-stage kidney disease. Having fewer than three dialysis sessions per week, late initiation of dialysis after diagnosis of end-stage kidney disease and severe anaemia were predictors of inadequate haemodialysis among patients.
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Affiliation(s)
- Abilah I. Bakari
- Department of Internal Medicine, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
| | - James J. Yahaya
- Department of Pathology, School of Health Sciences, Soroti University, Soroti, Uganda
| | - Boaz M. Matobogolo
- Department of Internal Medicine, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
| | - Zephania S. Abraham
- Department of Surgery, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
| | - Bonaventura Mpondo
- Department of Internal Medicine, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
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Downie ML, Foster BJ. Secular Trends in Incidence of Treated Kidney Failure in the United States. J Am Soc Nephrol 2024; 35:392-394. [PMID: 38557786 PMCID: PMC11000724 DOI: 10.1681/asn.0000000000000332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Affiliation(s)
- Mallory L. Downie
- Division of Nephrology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Bethany J. Foster
- Division of Nephrology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
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Escamilla-Cabrera B, Luis-Lima S, Gallego-Valcarce E, Sánchez-Dorta NV, Negrín-Mena N, Díaz-Martín L, Cruz-Perera C, Hernández-Valles AM, González-Rinne F, Rodríguez-Gamboa MJ, Estupiñán-Torres S, Miquel-Rodríguez R, Cobo-Caso MÁ, Delgado-Mallén P, Fernández-Suárez G, González-Rinne A, Hernández-Barroso G, González-Delgado A, Torres-Ramírez A, Jiménez-Sosa A, Ortiz A, Gaspari F, Hernández-Marrero D, Porrini EL. The error of estimated GFR in predialysis care. Sci Rep 2024; 14:5219. [PMID: 38433228 PMCID: PMC10909958 DOI: 10.1038/s41598-024-55022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/19/2024] [Indexed: 03/05/2024] Open
Abstract
The error of estimated glomerular filtration rate (eGFR) and its consequences in predialysis are unknown. In this prospective multicentre study, 315 predialysis patients underwent measured GFR (mGFR) by the clearance of iohexol and eGFR by 52 formulas. Agreement between eGFR and mGFR was evaluated by concordance correlation coefficient (CCC), total deviation index (TDI) and coverage probability (CP). In a sub-analysis we assessed the impact of eGFR error on decision-making as (i) initiating dialysis, (ii) preparation for renal replacement therapy (RRT) and (iii) continuing clinical follow-up. For this sub-analysis, patients who started RRT due to clinical indications (uremia, fluid overload, etc.) were excluded. eGFR had scarce precision and accuracy in reflecting mGFR (average CCC 0.6, TDI 70% and cp 22%) both in creatinine- and cystatin-based formulas. Variations -larger than 10 ml/min- between mGFR and eGFR were frequent. The error of formulas would have suggested (a) premature preparation for RTT in 14% of stable patients evaluated by mGFR; (b) to continue clinical follow-up in 59% of subjects with indication for RTT preparation due to low GFRm and (c) to delay dialysis in all asymptomatic patients (n = 6) in whom RRT was indicated based on very low mGFR. The error of formulas in predialysis was frequent and large and may have consequences in clinical care.
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Affiliation(s)
- Beatriz Escamilla-Cabrera
- Nephrology Department, Complejo Hospitalario Universitario de Canarias, La Laguna, Spain
- Facultad de Medicina, Universidad de La Laguna, La Laguna, Spain
| | - Sergio Luis-Lima
- Department of Laboratory Medicine, Complejo Hospitalario Universitario de Canarias, Tenerife, Spain
- Laboratory of Renal Function (LFR), Faculty of Medicine, Complejo Hospitalario Universitario de Canarias, University of La Laguna, La Laguna, Spain
| | | | | | - Natalia Negrín-Mena
- Laboratory of Renal Function (LFR), Faculty of Medicine, Complejo Hospitalario Universitario de Canarias, University of La Laguna, La Laguna, Spain
| | - Laura Díaz-Martín
- Laboratory of Renal Function (LFR), Faculty of Medicine, Complejo Hospitalario Universitario de Canarias, University of La Laguna, La Laguna, Spain
| | - Coriolano Cruz-Perera
- Laboratory of Renal Function (LFR), Faculty of Medicine, Complejo Hospitalario Universitario de Canarias, University of La Laguna, La Laguna, Spain
| | | | - Federico González-Rinne
- Laboratory of Renal Function (LFR), Faculty of Medicine, Complejo Hospitalario Universitario de Canarias, University of La Laguna, La Laguna, Spain
| | | | - Sara Estupiñán-Torres
- Nephrology Department, Complejo Hospitalario Universitario de Canarias, La Laguna, Spain
| | - Rosa Miquel-Rodríguez
- Nephrology Department, Complejo Hospitalario Universitario de Canarias, La Laguna, Spain
| | | | | | | | - Ana González-Rinne
- Nephrology Department, Complejo Hospitalario Universitario de Canarias, La Laguna, Spain
| | | | | | - Armando Torres-Ramírez
- Nephrology Department, Complejo Hospitalario Universitario de Canarias, La Laguna, Spain
- Facultad de Medicina, Universidad de La Laguna, La Laguna, Spain
| | | | - Alberto Ortiz
- Faculty of Medicine, Universidad Autónoma de Madrid. IIS-Fundación Jiménez Díaz. RICORS, Madrid, Spain
| | - Flavio Gaspari
- Laboratory of Renal Function (LFR), Faculty of Medicine, Complejo Hospitalario Universitario de Canarias, University of La Laguna, La Laguna, Spain
| | - Domingo Hernández-Marrero
- Nephrology Department, Complejo Hospitalario Universitario de Canarias, La Laguna, Spain
- Instituto de Tecnologías Biomédicas (ITB), Faculty of Medicine, University of La Laguna, La Laguna, Spain
- Facultad de Medicina, Universidad de La Laguna, La Laguna, Spain
| | - Esteban Luis Porrini
- Laboratory of Renal Function (LFR), Faculty of Medicine, Complejo Hospitalario Universitario de Canarias, University of La Laguna, La Laguna, Spain.
- Instituto de Tecnologías Biomédicas (ITB), Faculty of Medicine, University of La Laguna, La Laguna, Spain.
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Pieroni D, Leon SJ, Krueger AL, Burton L, Tremblay-Savard O, Tangri N, Komenda P, Bohm C, Rigatto C. Use of Wearable and Wireless Technology in Real-World Clinical Settings to Improve Patient Outcomes in Chronic Kidney Disease: A Mixed Methods Pilot Prospective Trial. Can J Kidney Health Dis 2023; 10:20543581231212125. [PMID: 38020485 PMCID: PMC10666721 DOI: 10.1177/20543581231212125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/06/2023] [Indexed: 12/01/2023] Open
Abstract
Background During the 30-day period prior to initiating dialysis, there is a 10-fold rise in emergency department visits and hospitalizations related to kidney failure. Objective The Virtual Ward Incorporating Electronic Wearables (VIEWER) trial implemented a home telemonitoring system to track changes in patients' vitals and assess their adherence and the acceptability of telemonitoring in a chronic kidney disease (CKD) population. Design A pilot prospective clinical trial using a mixed methods approach was performed. Setting The research was conducted in Winnipeg, Manitoba. Participants There were 2 phases: Phase 1 was a 2-week-long pilot trial consisting of 10 participants. Phase 2 was a 3-month-long trial with a total of 26 participants. Patients with an estimated glomerular filtration rate <15 and a >40% risk of beginning dialysis in the next 2 years according to the kidney failure risk equation were eligible to participate in the study. Methods The primary quantitative outcome was adherence, defined as the proportion of daily self-assessments completed using VIEWER over the follow-up period. The usability and acceptability of VIEWER was assessed qualitatively at the end of the trial through structured questionnaires and focus groups. Results Phase 1 participants (n = 10) had a median adherence of 77.17% for the 2-week observation period. Phase 2 participants (n = 26) showed a lower median adherence of 36% for the 3-month period. Focus group participants (n = 11) identified many positive aspects of VIEWER, including increased awareness and empowerment over health, simplicity of the data platform, and the ability to show clinical staff their health trends. Some challenges identified with VIEWER were connectivity issues with the Bluetooth, perceived inconvenience, and negative thoughts toward their health. Limitations Limitations of the study include a small sample size, which limited our ability to measure quantitative outcomes. In addition, patients agreeing to participate in any trial are generally more highly motivated and engaged in their care than those declining participation. Therefore, our results may not be generalizable to individuals who are not interested in self-management of their health. Conclusion Our results suggest that home telemonitoring in patients with advanced CKD is feasible using a CKD-specific platform like VIEWER. We anticipate that improved functionality with incorporation of feedback from this study will result in greater long-term adherence. A future randomized clinical trial is planned.
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Affiliation(s)
- Domenic Pieroni
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Silvia J. Leon
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Amanda L Krueger
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Lauren Burton
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Navdeep Tangri
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Paul Komenda
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Clara Bohm
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Claudio Rigatto
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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Larkins NG, Lim W, Goh C, Francis A, McCarthy H, Kim S, Wong G, Craig JC. Timing of Kidney Replacement Therapy among Children and Young Adults. Clin J Am Soc Nephrol 2023; 18:1041-1050. [PMID: 37279903 PMCID: PMC10564350 DOI: 10.2215/cjn.0000000000000204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/23/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND No randomized trials exist to guide the timing of the initiation of KRT in children. We sought to define trends and predictors of the eGFR at initiation of KRT, center-related clinical practice variation, and any association with patient survival. METHODS Children and young adults (1-25 years) commencing KRT (dialysis or kidney transplantation) between 1995 and 2018 were included using data from the Australia and New Zealand Dialysis and Transplant Registry. The associations between eGFR on commencing KRT and covariates were estimated using quantile regression. Cox regression was used to estimate the association between eGFR and patient survival. Logistic regression, categorizing eGFR about a value of 10 ml/min per 1.73 m 2 , was used in conjunction with a random effect by center to quantify clinical practice variation. RESULTS Overall, 2274 participants were included. The median eGFR at KRT initiation increased from 7 to 9 ml/min per 1.73 m 2 over the study period and the 90th centile from 11 to 17 ml/min per 1.73 m 2 . The effect of era on median eGFR was modified by modality, with a greater increase among those receiving a preemptive kidney transplant (1.0 ml/min per 1.73 m 2 per 5 years; 95% confidence interval [CI], 0.6 to 1.5) or peritoneal dialysis (0.7 ml/min per 1.73 m 2 per 5 years; 95% CI, 0.4 to 0.9) compared with hemodialysis (0.1 ml/min per 1.73 m 2 per 5 years; 95% CI, -0.1 to 0.3). There were 252 deaths (median follow-up 8.5 years, interquartile range 3.7-14.2) and no association between eGFR and survival (hazard ratio, 1.01 per ml/min per 1.73 m 2 ; 95% CI, 0.98 to 1.04). Center variation explained 6% of the total variance in the odds of initiating KRT earlier. This rose to over 10% when comparing pediatric centers alone. CONCLUSIONS Children and young adults progressively commenced KRT earlier. This change was more pronounced for children starting peritoneal dialysis or receiving a preemptive kidney transplant. Earlier initiation of KRT was not associated with any difference in patient survival. A substantial proportion of clinical practice variation was due to center variation alone. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_08_08_CJN0000000000000204.mp3.
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Affiliation(s)
- Nicholas G. Larkins
- Department of Nephrology and Hypertension, Perth Children's Hospital, Nedlands, Western Australia, Australia
- School of Medicine, University of Western Australia, Australia, Crawley, Western Australia, Australia
| | - Wai Lim
- School of Medicine, University of Western Australia, Australia, Crawley, Western Australia, Australia
- Department of Nephrology, Sir Charles Gardiner Hospital, Nedlands, Western Australia, Australia
| | - Carrie Goh
- Department of Nephrology and Hypertension, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Anna Francis
- Department of Nephrology, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Hugh McCarthy
- Department of Nephrology, Sydney Children's Hospital, Randwick, New South Wales, Australia
- Nephrology Department, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Centre for Kidney Research, Westmead, New South Wales, Australia
| | - Siah Kim
- Nephrology Department, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Centre for Kidney Research, Westmead, New South Wales, Australia
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Germaine Wong
- Centre for Kidney Research, Westmead, New South Wales, Australia
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Jonathan C. Craig
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Laham G, Pujol GS, Guzman J, Boccia N, Abib A, Diaz CH. Early start hemodialysis with a catheter may be associated with greater mortality: A propensity score analysis. Semin Dial 2023; 36:294-302. [PMID: 37088891 DOI: 10.1111/sdi.13157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/30/2022] [Accepted: 04/10/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Deciding when and how to initiate hemodialysis (HD) is still controversial. An early start (ES) seems to show a lack of benefit. "Lead time bias" and comorbidities have been associated with different outcomes in ES groups. On the other hand, it is well accepted that the impact the type of vascular access (VA) has on patient survival. Our aim was to evaluate survival with early start (ES) versus late start (LS) on HD, taking into account the vascular access (VA) used. METHODS Between 01/1995 and 06/2018, 503 incidental patients initiated HD at our Dialysis Unit. eGFR was estimated by the CKD-EPI equation. Diabetes mellitus (DM), coronary disease (CD), and peripheral vascular disease (PVD) were considered comorbid conditions. According to eGFR and VA, patients were divided into four groups: G1: ES (eGFR > 7 mL/min) with catheter (ES + C), G2: ES with fistula or graft (F/G) (ES + F/G), G3: LS (eGFR< 7 mL/min) with catheter (LS + C), and G4: LS with F/G (LS + F/G). The cut-off value to define ES or LS was based on median eGFR for these 503 patients. We compared patient's survival rates by Kaplan-Meier and log-rank test. The four groups were compared before and after matching with propensity scores (PS). Cox analysis was performed to determine the impact of predictors of mortality. RESULTS Median eGFR was 7 (5.3-9.5) mL/min/1.73 m2 , median follow-up time was 30.9 (13-50) months, 52.1% had F/G access at entry, and 46.9% died during the observation period. Among the four groups, the ES + C were significantly older, and there were more diabetics and comorbid conditions, while phosphatemia, iPTH, albumin, and hemoglobin were significantly higher in the LS groups. Before propensity score (PS) matching, the ES + C group had a poor survival rate (p < 0.0001), while LS + F/G access had the best survival. After PS, a total of 180 patients were selected in the same four groups and ES + C kept showing a statistically significant poorer survival. Multivariate analysis revealed that ES + C was an independent predictor of mortality. CONCLUSION In this retrospective study, ES + C on HD was associated with a higher mortality rate than LS. This association persisted after PS matching.
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Affiliation(s)
- Gustavo Laham
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Gervasio Soler Pujol
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Jenny Guzman
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Natalia Boccia
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Anabel Abib
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Carlos H Diaz
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
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Chen S, Yang F, Xu T, Wang Y, Zhang K, Fu G, Zhang W. Smoking and coronary artery disease risk in patients with diabetes: A Mendelian randomization study. Front Immunol 2023; 14:891947. [PMID: 36776880 PMCID: PMC9910331 DOI: 10.3389/fimmu.2023.891947] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 01/09/2023] [Indexed: 01/27/2023] Open
Abstract
Background Previous observational studies have shown an association between smoking and coronary artery disease (CAD) in patients with diabetes. Whether this association reflects causality remains unestablished. This study aimed to explore the causal effect of smoking on CAD in patients with diabetes. Methods Genetic signatures for smoking were extracted from a large genome-wide association study (GWAS), consisted of up to 1.2 million participants. Four smoking phenotypes were included: smoking initiation, cigarettes per day, age at initiation of regular smoking, and smoking cessation. Genetic associations with CAD in patients with diabetes were extracted from another GWAS, which included 15,666 participants (3,968 CAD cases and 11,696 controls). The analyses were performed using the univariable and multivariable Mendelian randomization (MR) method. Results MR analysis revealed that smoking initiation was positively related to CAD risk in patients with diabetes (OR = 1.322, 95% CI = 1.114 - 1.568, P = 0.001), but this association was attenuated when adjusted for cardiovascular risk factors (OR = 1.212, 95% CI = 1.008 - 1.457, P = 0.041). Age at initiation of regular smoking was negatively related to CAD in patients with diabetes (OR = 0.214, 95% CI = 0.070 - 0.656, P = 0.007), but this association became insignificant when adjusted for cardiovascular risk factors. Conclusions This study supported the effect of smoking initiation on the risk of CAD in patients with diabetes.
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Affiliation(s)
- Songzan Chen
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Fangkun Yang
- Department of Cardiology, Ningbo First Hospital, Ningbo, China
| | - Tian Xu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Yao Wang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Kaijie Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Wenbin Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China,*Correspondence: Wenbin Zhang,
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Lee TW, Bae W, Choi J, Bae E, Jang HN, Chang SH, Park DJ. The neutrophil-to-lymphocyte ratio may indicate when to start hemodialysis. Ren Fail 2022; 44:1401-1408. [PMID: 35969022 PMCID: PMC9397444 DOI: 10.1080/0886022x.2022.2110894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We evaluated whether the neutrophil-to-lymphocyte ratio (NLR) could aid dialysis decision-making in combination with the clinical presentation and biochemical findings. We retrospectively evaluated the medical records of 279 patients who commenced chronic maintenance hemodialysis. We compared the laboratory findings at 6 months before dialysis to those at dialysis initiation. NLR cutoffs and risk factors for each of six uremic symptoms were determined. Mean age was 60.7 years and mean estimated glomerular filtration rate (eGFR) was 5.7 ± 2.5 mL/min/1.73 m2 at the time of hemodialysis and 7.7 ± 3.8 mL/min/1.73 m2 6 months earlier (p < 0.001). The mean NLR increased significantly from 2.5 ± 1.0 to 4.9 ± 2.8 (p < 0.001). The NLR was positively correlated with the C-reactive protein level (r = 0.202, p = 0.009) and negatively correlated with those of albumin (r = −0.192, p = 0.001) and total CO2 (r = −0.134, p = 0.023). The NLR cutoffs for neurological and gastrointestinal symptoms as determined using receiver operator curve analysis were 2.4 (area under the curve [AUC] 0.976; 95% confidence interval [CI] 0.960–0.993; sensitivity 92.2%; specificity 94.7%) and 3.6 (AUC 0.671; 95% CI 0.588–0.755; sensitivity 68.1%; specificity 63.5%), respectively. On multiple linear regression analysis of neurological symptoms, the NLR was a significant predictor (β = −0.218, p = 0.017), as was age (β = 0.314, p = 0.037). In conclusion, the NLR may serve as a supplementary marker predicting uremic symptoms and a need for hemodialysis in stage 5 CKD patients.
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Affiliation(s)
- Tae Won Lee
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Wooram Bae
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Jungyoon Choi
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Eunjin Bae
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea.,Department of Internal Medicine, Gyeongsang National University College of Medicine, Jinju, South Korea.,Institute of Health Science, Gyeongsang National University, Jinju, South Korea
| | - Ha Nee Jang
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, South Korea
| | - Se-Ho Chang
- Department of Internal Medicine, Gyeongsang National University College of Medicine, Jinju, South Korea.,Institute of Health Science, Gyeongsang National University, Jinju, South Korea.,Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, South Korea
| | - Dong Jun Park
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea.,Department of Internal Medicine, Gyeongsang National University College of Medicine, Jinju, South Korea.,Institute of Health Science, Gyeongsang National University, Jinju, South Korea
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Nakano Y, Mandai S, Genma T, Akagi Y, Fujiki T, Ando F, Susa K, Mori T, Iimori S, Naito S, Sohara E, Uchida S, Fushimi K, Rai T. Nationwide mortality associated with perioperative acute dialysis requirement in major surgeries. Int J Surg 2022; 104:106816. [DOI: 10.1016/j.ijsu.2022.106816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/22/2022] [Accepted: 07/30/2022] [Indexed: 02/07/2023]
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10
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The Failed Kidney. PHYSICIAN ASSISTANT CLINICS 2022. [DOI: 10.1016/j.cpha.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Does delivering more dialysis improve clinical outcomes? What randomized controlled trials have shown. J Nephrol 2022; 35:1315-1327. [PMID: 35041196 DOI: 10.1007/s40620-022-01246-8] [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: 11/03/2021] [Accepted: 01/01/2022] [Indexed: 10/19/2022]
Abstract
Some randomized controlled trials (RCTs) have sought to determine whether different dialysis techniques, dialysis doses and frequencies of treatment are able to improve clinical outcomes in end-stage kidney disease (ESKD). Virtually all of these RCTs were enacted on the premise that 'more' haemodialysis might improve clinical outcomes compared to 'conventional' haemodialysis. Aim of the present narrative review was to analyse these landmark RCTs by posing the following question: were their intervention strategies (i.e., earlier dialysis start, higher haemodialysis dose, intensive haemodialysis, increase in convective transport, starting haemodialysis with three sessions per week) able to improve clinical outcomes? The answer is no. There are at least two main reasons why many RCTs have failed to demonstrate the expected benefits thus far: (1) in general, RCTs included relatively small cohorts and short follow-ups, thus producing low event rates and limited statistical power; (2) the designs of these studies did not take into account that ESKD does not result from a single disease entity: it is a collection of different diseases and subtypes of kidney dysfunction. Patients with advanced kidney failure requiring dialysis treatment differ on a multitude of levels including residual kidney function, biochemical parameters (e.g., acid base balance, serum electrolytes, mineral and bone disorder), and volume overload. In conclusion, the different intervention strategies of the RCTs herein reviewed were not able to improve clinical outcomes of ESKD patients. Higher quality studies are needed to guide patients and clinicians in the decision-making process. Future RCTs should account for the heterogeneity of patients when considering inclusion/exclusion criteria and study design, and should a priori consider subgroup analyses to highlight specific subgroups that can benefit most from a particular intervention.
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Chen S, Yang F, Xu T, Wang Y, Zhang K, Fu G, Zhang W. The impact of serum 25-hydroxyvitamin D, calcium, and parathyroid hormone levels on the risk of coronary artery disease in patients with diabetes: a Mendelian randomization study. Nutr J 2021; 20:82. [PMID: 34602077 PMCID: PMC8489084 DOI: 10.1186/s12937-021-00735-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 08/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the causal association between serum 25-hydroxyvitamin D (25OHD), calcium (Ca), and parathyroid hormone (PTH) levels and the risk of coronary artery disease (CAD) in patients with diabetes using a Mendelian randomization approach. METHODS Genetic signatures associated with serum 25OHD, Ca, and PTH levels were extracted from recently published genome-wide association study (GWAS), including 79,366, 39,400, 29,155 individuals, respectively. Genetic association estimates for CAD in patients with diabetes were obtained from a GWAS of 15,666 individuals with diabetes (3,968 CAD cases, 11,696 controls). The inverse-variance-weighted method was employed for the primary analysis, and other robust methods were applied for sensitivity analyses. RESULTS Six, seven and five single nucleotide polymorphisms were identified as instrumental variables for serum 25OHD, Ca and PTH levels, respectively. There was no significant association between genetically predicted serum 25OHD levels and the risk of CAD in patients with diabetes (odds ratio (OR) = 1.04, 95% confidence interval (CI): 0.58 - 1.87, P = 0.888). Similarly, genetically predicted serum Ca (OR = 1.83, 95% CI: 0.62 - 5.35, P = 0.273) and PTH levels (OR = 1.27, 95% CI: 0.67 - 2.44, P = 0.464) were not significantly associated with the risk of CAD in patients with diabetes. These findings were robust in sensitivity analyses. CONCLUSIONS/INTERPRETATION Serum 25OHD, Ca and PTH levels may not be causally associated with the risk of CAD in patients with diabetes.
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Affiliation(s)
- Songzan Chen
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Fangkun Yang
- Department of Cardiology, Ningbo First Hospital, School of Medicine, Zhejiang University, Ningbo, 315010, China
| | - Tian Xu
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Yao Wang
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Kaijie Zhang
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Guosheng Fu
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China.
| | - Wenbin Zhang
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China.
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13
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Chen S, Yang F, Xu T, Wang Y, Zhang K, Fu G, Zhang W. Genetically predicted serum uric acid levels and the risk of coronary artery disease in patients with diabetes: A Mendelian randomization study. Nutr Metab Cardiovasc Dis 2021; 31:1832-1839. [PMID: 33975736 DOI: 10.1016/j.numecd.2021.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/05/2021] [Accepted: 03/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Serum uric acid (SUA) levels have been reported to be associated with an increased risk of coronary artery disease (CAD) among patients with diabetes in observational study. Whether this relationship is causal remains unclear. The current study aimed to explore the causal association between SUA and the risk of CAD in patients with diabetes. METHODS AND RESULTS A two-sample Mendelian randomization (MR) approach was employed to evaluate the causal effect of SUA on the risk of CAD in patients with diabetes. A total of 28 single nucleotide polymorphisms (SNPs) related to SUA were identified as instruments. Genetic association with CAD were obtained from a recently published genome-wide association study (GWAS) of 15,666 patients with diabetes (3968 CAD cases and 11,696 controls). The fixed-effects inverse variance-weighted method was employed to estimate the causal effect for the primary analysis, and other robust methods were employed for sensitivity analyses. In addition, the whole analyses were repeated using 9 non-pleiotropic SNPs. Genetic determined SUA levels were not significantly associated with the risk of CAD in patients with diabetes in the primary analysis (odds ratio = 1.13, 95% confidence interval: 0.98-1.16, P = 0.09). Consistent results were observed in the sensitivity analyses using various robust methods. In addition, this finding was confirmed by the repeated analyses using 9 non-pleiotropic SNPs. CONCLUSIONS This two-sample MR study does not support a causal effect of genetically predicted SUA levels on the risk of CAD in patients with diabetes.
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Affiliation(s)
- Songzan Chen
- Department of Cardiology, Key laboratory of biotherapy of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Fangkun Yang
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Tian Xu
- Department of Cardiology, Key laboratory of biotherapy of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Yao Wang
- Department of Cardiology, Key laboratory of biotherapy of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Kaijie Zhang
- Department of Cardiology, Key laboratory of biotherapy of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Guosheng Fu
- Department of Cardiology, Key laboratory of biotherapy of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China.
| | - Wenbin Zhang
- Department of Cardiology, Key laboratory of biotherapy of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China.
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Hsu CY, Parikh RV, Pravoverov LN, Zheng S, Glidden DV, Tan TC, Go AS. Implication of Trends in Timing of Dialysis Initiation for Incidence of End-stage Kidney Disease. JAMA Intern Med 2020; 180:1647-1654. [PMID: 33044519 PMCID: PMC7551228 DOI: 10.1001/jamainternmed.2020.5009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE In the last 2 decades, there have been notable changes in the level of estimated glomerular filtration rate (eGFR) at which patients initiate long-term dialysis in the US and around the world. How changes over time in the likelihood of dialysis initiation at any given eGFR level in at-risk patients are associated with the population burden of end-stage kidney disease (ESKD) has not been not well defined. OBJECTIVE To examine temporal trends in long-term dialysis initiation by level of eGFR and to quantify how these patterns are associated with the number of patients with ESKD. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study analyzing data obtained from a large, integrated health care delivery system in Northern California from 2001 to 2018 in successive 3-year intervals. Included individuals, ranging in number from as few as 983 122 (2001-2003) to as many as 1 844 317 (2016-2018), were adult members with 1 or more outpatient serum creatinine levels determined in the prior year. MAIN OUTCOMES AND MEASURES One-year risk of initiating long-term dialysis stratified by eGFR levels. Multivariable logistic regression was performed to assess temporal trends in each 3-year cohort with adjustment for age, sex, race, and diabetes status. The potential change in dialysis initiation in the final cohort (2016-2018) was estimated using the relative difference between the standardized risks in the initial cohort (2001-2003) and the final cohort. RESULTS In the initial 3-year cohort, the mean (SD) age was 55.4 (16.3) years, 55.0% were women, and the prevalence of diabetes was 14.9%. These characteristics, as well as the distribution of index eGFR, were stable across the study period. The likelihood of receiving dialysis at eGFR levels of 10 to 24 mL/min/1.73 m2 generally increased over time. For example, the 1-year odds of initiating dialysis increased for every 3-year interval by 5.2% (adjusted odds ratio, 1.052; 95% CI, 1.004-1.102) among adults with an index eGFR of 20 to 24 mL/min/1.73 m2, by 6.6% (adjusted odds ratio, 1.066; 95% CI, 1.007-1.130) among adults with an eGFR of 16 to 17 mL/min/1.73 m2, and by 5.3% (adjusted odds ratio, 1.053; 95% CI, 1.008-1.100) among adults with an eGFR of 10 to 13 mL/min/1.73 m2, adjusting for age, sex, race, and diabetes. The incidence of new cases of ESKD was estimated to have potentially been 16% (95% CI, 13%-18%) lower if there were no changes in system-level practice patterns or other factors besides timing of initiating long-term dialysis from the initial 3-year interval (2001-2003) to the final interval (2016-2018) assessed in this study. CONCLUSIONS AND RELEVANCE The present results underscore the importance the timing of initiating long-term dialysis has on the size of the population of individuals with ESKD.
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Affiliation(s)
- Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco.,Division of Research, Kaiser Permanente Northern California, Oakland
| | - Rishi V Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Leonid N Pravoverov
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Sijie Zheng
- Division of Research, Kaiser Permanente Northern California, Oakland.,Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California.,Division of Medical Education, Department of Medicine, University of California, San Francisco, San Francisco
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Thida C Tan
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Alan S Go
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco.,Division of Research, Kaiser Permanente Northern California, Oakland.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco.,Department of Medicine, Stanford University, Stanford, California.,Department of Health Research and Policy, Stanford University, Stanford, California
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Almajed MR, Ali Jan SJ. Initiation of Hemodialysis After Eight Years Following the Diagnosis of Stage 5 Chronic Kidney Disease: A Case Report. Cureus 2020; 12:e11357. [PMID: 33178542 PMCID: PMC7651776 DOI: 10.7759/cureus.11357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 11/05/2022] Open
Abstract
With the growing global rates of diabetes and hypertension, chronic kidney disease (CKD) appears to be a major contributor to morbidity and all-cause mortality. In recent years, there has been growing controversy regarding the optimal timing for the initiation of hemodialysis in this patient cohort. In this report, we present the case of a 52-year-old female with a 15-year history of CKD who was admitted to the hospital with clinical manifestations of uremia, volume overload, and symptomatic anemia. The patient presented with fatigue, nausea, progressive shortness of breath, and lightheadedness for two weeks, which had limited the activities of daily living. For the past eight years, her estimated glomerular filtration rate (GFR) had ranged from 5 to 15 mL/min/1.73 m2, consistent with kidney failure seen in stage 5 CKD. Prior to her recent admission, the patient had been grossly asymptomatic and had been responsive to medical therapy. After appropriate management with hemodialysis, a transfusion of packed red blood cells, and medication adjustment, the patient was scheduled for maintenance dialysis through an arteriovenous fistula. She had no further complaints and her laboratory abnormalities were found normalized at the six-month follow-up. This case report presents the survival and outcome of a patient with stage 5 CKD, who was only initiated on hemodialysis eight years after her diagnosis.
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Affiliation(s)
- Mohamed R Almajed
- Medicine, Salmaniya Medical Complex, Manama, BHR
- Medicine, Royal College of Surgeons in Ireland - Medical University of Bahrain, Busaiteen, BHR
| | - Salman J Ali Jan
- Medicine, King Hamad University Hospital, Muharraq, BHR
- Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
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16
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Should we abandon GFR in the decision to initiate chronic dialysis? Pediatr Nephrol 2020; 35:1593-1600. [PMID: 31418062 DOI: 10.1007/s00467-019-04333-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/31/2019] [Accepted: 08/06/2019] [Indexed: 12/20/2022]
Abstract
The best time to start chronic dialysis during the course of CKD stage 5 is controversial. The first randomised control trial of dialysis initiation either in early or late CKD stage 5 in adults (IDEAL study), and 3 studies from the two largest paediatric registries, the U.S. Renal Data System (USRDS) and the European Society of Paediatric Nephrology (ESPN) Registry, have now provided us with evidence to guide us in this important decision-making process. The message 'no benefit from early start of dialysis' is the conclusion from all four studies. However, what are the limitations of these studies? Can GFR be assessed at CKD stages 4 and 5? What are the factors used to assess the benefit of early or late start? These issues are discussed in this review.
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Moore C, Carter LA, Mitra S, Skevington S, Wearden A. Quality of life improved for patients after starting dialysis but is impaired, initially, for their partners: a multi-centre, longitudinal study. BMC Nephrol 2020; 21:185. [PMID: 32423378 PMCID: PMC7236460 DOI: 10.1186/s12882-020-01819-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 04/19/2020] [Indexed: 02/07/2023] Open
Abstract
Background Quality of life (QOL) is important to patients with end stage renal disease and their partners. Despite the first 12 weeks being a critical time in the treatment pathway, limited research exists which examines how the transition onto dialysis impacts QOL. In this study we measured QOL in patients and their partners at pre-dialysis and over the first 12 weeks on dialysis to investigate QOL during this crucial period. Methods Patients and their partners, recruited from 10 renal units in England, completed questionnaires at pre-dialysis (n = 166 participants, 83 couples), 6 weeks (n = 90 participants, 45 couples) and 12 weeks (n = 78, 39 couples) after starting dialysis. On each occasion participants completed a QOL questionnaire (WHOQOL-BREF). Multilevel modelling accommodated the nested structure of couples with repeated measures within participants. Three-level random intercept models estimated changes in WHOQOL general QOL and its four domains (Physical, Psychological, Social and Environment). Two-level random intercept models assessed the relationship between baseline clinical and socio-demographic variables with changes in general QOL. Results Patients reported positive changes in general QOL from pre-dialysis to 6 weeks (β = 0.42, p < 0.001, 95% CI 0.19, 0.65) and from pre-dialysis to 12 weeks (β = 0.47, p < 0.001, 95% CI 0.24, 0.71). Partners’ general QOL decreased significantly from pre-dialysis to 6 weeks (β = − 0.24, p = 0.04, 95% CI -0.47, − 0.01) but returned to its original level at 12 weeks. Patients reported improvements in the physical domain between pre-dialysis and 12 weeks (β = 6.56, p < 0.004, 95% CI 2.10, 11.03). No other domains changed significantly in patients or partners. Only in patients were there significant associations between moderator variables and general QOL. High comorbidity risk level and diabetes were associated with poorer QOL at pre-dialysis whereas being female and having an arteriovenous fistula were linked with improvements in general QOL. Conclusions Patients reported significant improvements in their general and physical QOL after starting dialysis. Partners’ general QOL worsened after patients started dialysis but improved by 12 weeks. Both patients and partners may benefit from additional educational and counselling services in the lead up to, and immediately after starting dialysis, which could facilitate the transition onto dialysis and improve QOL in both. Study registration This study was adopted on the NIHR Clinical Research Network (UK). The details of this study are registered on the Research Registry website (www.researchregistry.com). The identifier for this study is researchregistry2574.
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Affiliation(s)
- Currie Moore
- School of Health Sciences, Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, UK. .,Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Lesley-Anne Carter
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Sandip Mitra
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK.,NIHR Devices for Dignity MedTech Cooperative, Sheffield, UK
| | - Suzanne Skevington
- School of Health Sciences, Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Alison Wearden
- School of Health Sciences, Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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18
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Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach. Nutrients 2020; 12:nu12030785. [PMID: 32188148 PMCID: PMC7146606 DOI: 10.3390/nu12030785] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/11/2020] [Accepted: 03/13/2020] [Indexed: 12/11/2022] Open
Abstract
Dialysis and nutrition are two sides of the same coin—dialysis depurates metabolic waste that is typically produced by food intake. Hence, dietetic restrictions are commonly imposed in order to limit potassium and phosphate and avoid fluid overload. Conversely, malnutrition is a major challenge and, albeit to differing degrees, all nutritional markers are associated with survival. Dialysis-related malnutrition has a multifactorial origin related to uremic syndrome and comorbidities but also to dialysis treatment. Both an insufficient dialysis dose and excessive removal are contributing factors. It is thus not surprising that dialysis alone, without proper nutritional management, often fails to be effective in combatting malnutrition. While composite indexes can be used to identify patients with poor prognosis, none is fully satisfactory, and the definitions of malnutrition and protein energy wasting are still controversial. Furthermore, most nutritional markers and interventions were assessed in hemodialysis patients, while hemodiafiltration and peritoneal dialysis have been less extensively studied. The significant loss of albumin in these two dialysis modalities makes it extremely difficult to interpret common markers and scores. Despite these problems, hemodialysis sessions represent a valuable opportunity to monitor nutritional status and prescribe nutritional interventions, and several approaches have been tried. In this concept paper, we review the current evidence on intradialytic nutrition and propose an algorithm for adapting nutritional interventions to individual patients.
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Liu Y, Wang L, Han X, Wang Y, Sun X, Jiang H, Shi W, Liu W, Fu P, Ding X, Lin H, Chen X. The Profile of Timing Dialysis Initiation in Patients with End-stage Renal Disease in China: A Cohort Study. Kidney Blood Press Res 2020; 45:180-193. [PMID: 32000162 DOI: 10.1159/000504671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/12/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hemodialysis is the main approach for renal replacement therapy in patients with end-stage renal disease (ESRD) in China. The timing of dialysis initiation is one of the key factors influencing patient survival and prognosis. Over the past decade, the relationship between the timing of dialysis initiation and mortality has remained unclear in patients with ESRD in China. METHODS Patients who commenced maintenance hemodialysis from 2009 to 2014 from 24 hemodialysis centers in Mainland China were enrolled in the study (n = 1,674). Patients were divided into 2 groups based on the year they started hemodialysis (patients who started hemodialysis from 2009 to 2011, and patients who started hemodialysis from 2012 to 2014). Analysis of the yearly change in the estimated glomerular filtration rate (eGFR) at the initiation of dialysis was performed for the 2 groups. Meanwhile, the patients were divided into 3 groups based on their eGFR at the initiation of dialysis (<4, 4-8, and >8 mL/min/1.73 m2). For these 3 groups, the relationship between the eGFR at the start of dialysis and mortality were analyzed. RESULTS The average eGFRs were 5.68 and 5.94 mL/min/1.73 m2 for 2009-2011 and 2012-2014, respectively. Compared with the 2009-2011 group, the proportion of patients with diabetes in 2012-2014 increased from 26.7 to 37.7%. The prognosis of patients with different eGFRs at the start of dialysis was analyzed using Kaplan-Meier survival curves. After adjusting for confounding factors through a Cox regression model, no significant difference was demonstrated among the 3 groups (<4 mL/min/1.73 m2 was used as the reference, in comparison with 4-8 mL/min/1.73 m2 [p = 0.681] and >8 mL/min/1.73 m2 [p = 0.403]). CONCLUSION In Mainland China, the eGFR at the start of dialysis did not change significantly over time from 2008 to 2014 and had no association with the mortality of patients with ESRD.
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Affiliation(s)
- Ying Liu
- Graduate School of Dalian Medical University, Dalian, China.,Department of Nephrology, The First Affiliated Hospital, Institute for Nephrology Research of Dalian Medical University, Center for Kidney Diseases Translational Medicine of Liaoning Province, Dalian, China
| | - Luping Wang
- Department of Nephrology, The First Affiliated Hospital, Institute for Nephrology Research of Dalian Medical University, Center for Kidney Diseases Translational Medicine of Liaoning Province, Dalian, China
| | - Xianfeng Han
- Department of Nephrology, The First Affiliated Hospital, Institute for Nephrology Research of Dalian Medical University, Center for Kidney Diseases Translational Medicine of Liaoning Province, Dalian, China
| | - Yang Wang
- Medical Research and Biometrics Center, Cardiovascular Institute and Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuefeng Sun
- Department of Nephrology, Chinese PLA General Hospital, National Clinical Research Center for Kidney Diseases, State Key Laboratory of Kidney Diseases, Chinese PLA Institute of Nephrology, Beijing, China
| | - Hongli Jiang
- Blood Purification Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wei Shi
- Division of Nephrology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wenhu Liu
- Division of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ping Fu
- Kidney Research Institute, Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoqiang Ding
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hongli Lin
- Graduate School of Dalian Medical University, Dalian, China, .,Department of Nephrology, The First Affiliated Hospital, Institute for Nephrology Research of Dalian Medical University, Center for Kidney Diseases Translational Medicine of Liaoning Province, Dalian, China,
| | - Xiangmei Chen
- Department of Nephrology, Chinese PLA General Hospital, National Clinical Research Center for Kidney Diseases, State Key Laboratory of Kidney Diseases, Chinese PLA Institute of Nephrology, Beijing, China
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Zhao X, Wang P, Wang L, Chen X, Huang W, Mao Y, Hu R, Cheng X, Wang C, Wang L, Zhang P, Li D, Wang Y, Ye W, Chen Y, Jia Q, Yan X, Zuo L. Protocol for a prospective, cluster randomized trial to evaluate routine and deferred dialysis initiation (RADDI) in Chinese population. BMC Nephrol 2019; 20:455. [PMID: 31818266 PMCID: PMC6902500 DOI: 10.1186/s12882-019-1627-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 11/15/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The timing of when to initiate dialysis for progressive chronic kidney disease (CKD) patients has not been well established. There has been a strong trend for early dialysis initiation for these patients over the past decades. However, the perceived survival advantage of early dialysis has been questioned by a series of recent observational studies. The only randomized controlled trial (RCT) research on this issue found the all-cause mortality, comorbidities, and quality of life showed no difference between early and late dialysis starters. To better understand optimal timing for dialysis initiation, our research will evaluate the efficacy and safety of deferred dialysis initiation in a large Chinese population. METHODS The trial adopts a multicenter, cluster randomized, single-blind (outcomes assessor), and endpoint-driven design. Eligible participants are 18-80 years old, in stable CKD stages 4-5 (eGFR > 7 ml/min /1.73 m2), and with good heart function (NYHA grade I or II). Participants will be randomized into a routine or deferred dialysis group. The reference eGFR at initiating dialysis for asymptomatic patients is 7 ml/min /1.73 m2 (routine dialysis group) and 5 ml/min/1.73 m2 or less (deferred dialysis group) in each group. The primary endpoint will be the difference of all-cause mortality and acute nonfatal cerebro-cardiovascular events between the two groups. The secondary outcomes include hospitalization rate and other safety indices. The primary and secondary outcomes will be analyzed by appropriate statistical methods. DISCUSSION This study protocol represents a large, cluster randomized study evaluating deferred and routine dialysis intervention for an advanced CKD population. The reference eGFR to initiate dialysis for both treatment groups is targeted at less than 7 ml/min/1.73m2. With this design, we aim to eliminate lead-time and survivor bias and avoid selection bias and confounding factors. We acknowledge that the study has limitations. Even so, given the low-targeted eGFR values of both arms, this study still has potential economic, health, and scientific implications. This research is unique in that such a low targeted eGFR value has never been studied in a clinical trial. TRIAL REGISTRATION The trial has been approved by ClinicalTrials.gov (Trial registration ID NCT02423655). The date of registration was April 22, 2015.
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Affiliation(s)
- Xinju Zhao
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Pei Wang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lining Wang
- Department of Nephrology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xiaonong Chen
- Department of Nephrology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Wen Huang
- Department of Nephrology, Beijing Tongren Hospital Capital Medical University, Beijing, China
| | - Yonghui Mao
- Department of Nephrology, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Rihong Hu
- Department of Nephrology, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, China
| | - Xiaohong Cheng
- Department of Nephrology, Shaanxi Hospital of Traditional Chinese Medicine, Shaanxi, China
| | - Caili Wang
- Department of Nephrology, The First Affiliated Hospital of Baotou Medical College, Baotou, China
| | - Li Wang
- Department of Nephrology, Sichuan Academy of Medical Sciences, Chengdu, China
| | - Ping Zhang
- Kidney disease center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Detian Li
- Department of Nephrology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yuzhu Wang
- Department of Nephrology, Beijing Haidian Hospital (Beijing Haidian Section of Peking University Third Hospital), Beijing, China
| | - Wenling Ye
- Department of Nephrology, Peking Union Medical College Hospital, Beijing, China
| | - Yuqing Chen
- Renal Division, Peking University First Hospital, Beijing, China
| | - Qiang Jia
- Department of Nephrology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Xiaoyan Yan
- Peking University Clinical Research Institute, Beijing, China
| | - Li Zuo
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
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21
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Affiliation(s)
- Nicholas G Larkins
- Department of Nephrology and Hypertension, Perth Children's Hospital, Perth, Australia; .,School of Paediatrics and Child Health, University of Western Australia, Perth, Australia; and
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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22
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Chen T, Lee VW, Harris DC. When to initiate dialysis for end-stage kidney disease: evidence and challenges. Med J Aust 2019; 209:275-279. [PMID: 30208820 DOI: 10.5694/mja18.00297] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/12/2018] [Indexed: 11/17/2022]
Abstract
The decision about when to start dialysis for end-stage kidney disease (ESKD) is complex and is influenced by many factors. ESKD-related symptoms and signs are the most common indications for dialysis initiation. Creatinine-based formulae to estimate glomerular filtration rate (GFR) are inaccurate in patients with ESKD and, thus, the decision to start dialysis should not be based solely on estimated GFR (eGFR). Early dialysis initiation (ie, at an eGFR > 10 mL/min/1.73 m<sup>2</sup>) is not associated with a morbidity and mortality benefit, as shown in the Initiating Dialysis Early and Late (IDEAL) study. This observation has been incorporated into the latest guidelines, which place greater emphasis on the assessment of patients' symptoms and signs rather than eGFR. It is suggested that in asymptomatic patients with stage 5 chronic kidney disease, dialysis may be safely delayed until the eGFR is at least as low as 5-7 mL/min/1.73 m<sup>2</sup> if there is careful clinical follow-up and adequate patient education. The decision on when to start dialysis is even more challenging in older patients. Due to their comorbidities and frailty, dialysis initiation may be associated with worse outcomes and quality of life. Therefore, the decision to start dialysis in these patients should be carefully weighed against its risks, and conservative care should be considered in appropriate cases. To optimise the decision-making process for dialysis initiation, patients need to be referred to a nephrologist in a timely fashion to allow adequate pre-dialysis care and planning. Dialysis initiation and its timing should be a shared decision between physician, patients and family members, and should be tailored to the individual patient's needs.
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Nehus E, Mitsnefes MM. When to Initiate Dialysis in Children and Adolescents: Is Waiting Worthwhile? Am J Kidney Dis 2019; 73:762-764. [DOI: 10.1053/j.ajkd.2019.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 02/09/2019] [Indexed: 11/11/2022]
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24
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Liu Y, Wang D, Chen X, Sun X, Song W, Jiang H, Shi W, Liu W, Fu P, Ding X, Chang M, Yu X, Cao N, Chen M, Ni Z, Cheng J, Sun S, Wang H, Wang Y, Gao B, Wang J, Hao L, Li S, He Q, Liu H, Shao F, Li W, Wang Y, Szczech L, Lv Q, Han X, Wang L, Fang M, Odeh Z, Sun X, Lin H. An Equation Based on Fuzzy Mathematics to Assess the Timing of Haemodialysis Initiation. Sci Rep 2019; 9:5871. [PMID: 30971708 PMCID: PMC6458145 DOI: 10.1038/s41598-018-37762-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 12/05/2018] [Indexed: 02/05/2023] Open
Abstract
In order to develop an equation that integrates multiple clinical factors including signs and symptoms associated with uraemia to assess the initiation of dialysis, we conducted a retrospective cohort study including 25 haemodialysis centres in Mainland China. Patients with ESRD (n = 1281) who commenced haemodialysis from 2008 to 2011 were enrolled in the development cohort, whereas 504 patients who began haemodialysis between 2012 and 2013 were enrolled in the validation cohort comprised. An artificial neural network model was used to select variables, and a fuzzy neural network model was then constructed using factors affecting haemodialysis initiation as input variables and 3-year survival as the output variable. A logistic model was set up using the same variables. The equation’s performance was compared with that of the logistic model and conventional eGFR-based assessment. The area under the bootstrap-corrected receiver-operating characteristic curve of the equation was 0.70, and that of two conventional eGFR-based assessments were 0.57 and 0.54. In conclusion, the new equation based on Fuzzy mathematics, covering laboratory and clinical variables, is more suitable for assessing the timing of dialysis initiation in a Chinese ESRD population than eGFR, and may be a helpful tool to quantitatively evaluate the initiation of haemodialysis.
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Affiliation(s)
- Ying Liu
- Dalian Medical University Graduate School, Dalian, China.,Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Liaoning Province Translational Medicine Research Center of Kidney Disease, Dalian, China.,Kidney Research Institute of Dalian Medical University, Dalian, China
| | - Degang Wang
- School of Control Science and Engineering, Dalian University of Technology, Dalian, China
| | - Xiangmei Chen
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Xuefeng Sun
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Wenyan Song
- School of Economics, Dongbei University of Finance and Economics, Dalian, China
| | - Hongli Jiang
- Blood Purification Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wei Shi
- Division of Nephrology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wenhu Liu
- Division of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ping Fu
- Kidney Research Institute, Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoqiang Ding
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming Chang
- Division of Nephrology, Dalian Municipal Central Hospital, Dalian, China
| | - Xueqing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangzhou, China
| | - Ning Cao
- Blood Purification Center, General Hospital of Shenyang Military Area Command, Shenyang, China
| | - Menghua Chen
- Department of Nephrology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Zhaohui Ni
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jing Cheng
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Huimin Wang
- Division of Nephrology, General Hospital of Benxi Iron and Steel Co., Ltd, Benxi, China
| | - Yunyan Wang
- Blood Purification Center, Daping Hospital & Surgery Institute, the Third Military Medical University, Chongqing, China
| | - Bihu Gao
- Division of Nephrology, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - Jianqin Wang
- Division of Nephrology, Lanzhou University Second Hospital, Lanzhou, China
| | - Lirong Hao
- Division of Nephrology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Suhua Li
- Division of Nephrology, the First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Qiang He
- Division of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Hongmei Liu
- Division of Nephrology, An Steel Group Hospital, Anshan, China
| | - Fengmin Shao
- Blood Purification Center, The People's Hospital of Zhengzhou University & Henan Provincial People's Hospital, Zhengzhou, China
| | - Wei Li
- Medical Research & Biometrics Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Wang
- Medical Research & Biometrics Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | | | - Qiuxia Lv
- School of Control Science and Engineering, Dalian University of Technology, Dalian, China
| | - Xianfeng Han
- Dalian Medical University Graduate School, Dalian, China.,Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Liaoning Province Translational Medicine Research Center of Kidney Disease, Dalian, China
| | - Luping Wang
- Dalian Medical University Graduate School, Dalian, China.,Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Liaoning Province Translational Medicine Research Center of Kidney Disease, Dalian, China
| | - Ming Fang
- Dalian Medical University Graduate School, Dalian, China.,Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Liaoning Province Translational Medicine Research Center of Kidney Disease, Dalian, China.,Kidney Research Institute of Dalian Medical University, Dalian, China
| | - Zach Odeh
- Dalian Medical University Graduate School, Dalian, China.,Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Liaoning Province Translational Medicine Research Center of Kidney Disease, Dalian, China
| | - Ximing Sun
- School of Control Science and Engineering, Dalian University of Technology, Dalian, China
| | - Hongli Lin
- Dalian Medical University Graduate School, Dalian, China. .,Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Liaoning Province Translational Medicine Research Center of Kidney Disease, Dalian, China. .,Kidney Research Institute of Dalian Medical University, Dalian, China.
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25
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Okuda Y, Soohoo M, Tang Y, Obi Y, Laster M, Rhee CM, Streja E, Kalantar-Zadeh K. Estimated GFR at Dialysis Initiation and Mortality in Children and Adolescents. Am J Kidney Dis 2019; 73:797-805. [PMID: 30833086 DOI: 10.1053/j.ajkd.2018.12.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/17/2018] [Indexed: 12/27/2022]
Abstract
RATIONALE & OBJECTIVE The association of estimated glomerular filtration rate (eGFR) at dialysis therapy initiation with mortality among adult dialysis patients has been greatly debated, with some studies showing no benefit from early dialysis therapy initiation. However, this association has not been well investigated in pediatric dialysis patients. The objective of this study was to evaluate the mortality risk associated with eGFR at dialysis therapy initiation in children and adolescents with kidney failure. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 9,963 incident dialysis patients aged 1 to 17 years in the US Renal Data System registry (1995-2016). PREDICTOR eGFRs at dialysis therapy initiation calculated using the pediatric-specific bedside Schwartz equation (<5, 5-<7, 7-<9, 9-<12, and ≥12mL/min/1.73m2). OUTCOME Time to all-cause death. ANALYTICAL APPROACH Cox proportional hazards regression adjusted for case-mix variables, height, body mass index, hemoglobin level, and serum albumin level. RESULTS Median eGFR was 7.8 (IQR, 5.6-10.5) mL/min/1.73m2 and median age was 13 (IQR, 9-16) years. 696 deaths were observed during the median follow-up of 1.4 (IQR, 0.7-2.7) years, and overall crude mortality rate was 31 per 1,000 patient-years. There appeared to be a trend toward higher mortality risk across higher eGFRs at dialysis therapy initiation. Compared with eGFRs of 7 to <9mL/min/1.73m2, eGFRs <5 and ≥12mL/min/1.73m2 were associated with lower and higher mortality, with adjusted HRs of 0.57 (95% CI, 0.43-0.74) and 1.31 (95% CI, 1.05-1.65), respectively. In age-stratified analysis, there were consistent relationships among patients 6 years and older while the eGFR-mortality association was attenuated among patients younger than 6 years (Pinteraction = 0.002). LIMITATIONS Possible errors in eGFRs due to methods for serum creatinine measurement. Unmeasured confounders related to eGFR at dialysis therapy initiation. CONCLUSIONS Higher eGFR at dialysis therapy initiation was associated with higher mortality risk. Further studies of eGFR at initiation are needed in pediatric dialysis patients, especially among those younger than 6 years.
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Affiliation(s)
- Yusuke Okuda
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA
| | - Ying Tang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Department of Pediatric Nephrology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA
| | - Marciana Laster
- David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Pediatric Nephrology, Mattel Children's Hospital at UCLA, Los Angeles, CA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA.
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26
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Nannan Panday R, Haan Y, Diemer F, Punwasi A, Rommy C, Heerenveen I, van Montfrans GA, Brewster LM. Chronic kidney disease and kidney health care status: the healthy life in Suriname (HeliSur) study. Intern Emerg Med 2019; 14:249-258. [PMID: 30361850 PMCID: PMC6394460 DOI: 10.1007/s11739-018-1962-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 09/26/2018] [Indexed: 01/13/2023]
Abstract
The high cardiovascular risk burden in low- and middle-income countries is expected to lead to an explosive increase in chronic kidney disease (CKD). However, population data on CKD from these countries are scarce. Therefore, we assessed kidney health in Suriname. In the Healthy Life in Suriname (HeliSur) study, a random sample of the adult population, we collected data with standardized questionnaires, physical examination, and blood and urine samples analysed in a central laboratory. Prevalent CKD was graded with KDIGO guidelines. In addition, we assessed national data on prevalent renal replacement therapy (RRT), estimated the future need for RRT, and evaluated national kidney health work force and policies. We include 1117 participants (2.0‰ of the population), 63% women, 40% of African ancestry and 43% of Asian ancestry, with a mean age of 42.2 (SE 0.4) years. Blood pressure is elevated in 72% of the participants, 26% have diabetes or prediabetes, and 78% are obese or overweight. The prevalence of CKD is 5.4%, and around 0.3% have kidney failure, translating to approximately 1500 patients nationally (2690 per million population, pmp), with currently 516 patients (920 pmp) on dialysis. Based on the participants from the random population sample in CKD stage G3 or G4, we estimate that 6750-10,750 pmp may develop kidney failure within the next 10 years. However, specialized kidney health workforce is currently very limited, and specific national or local policies for CKD management are lacking. Since the large majority of the general population has one or more risk factors for CKD including elevated blood pressure, urgent action is needed to strengthen kidney health care and prevent a catastrophic rise in need for RRT in the coming years.
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Affiliation(s)
- Rani Nannan Panday
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Yentl Haan
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Frederieke Diemer
- Department of Cardiology, Academic Hospital of Paramaribo, Paramaribo, Suriname
| | - Amar Punwasi
- Department of Internal Medicine, Academic Hospital of Paramaribo, Paramaribo, Suriname
- Surrenal Dialysis Center, Paramaribo, Suriname
| | - Chantal Rommy
- Faculty of Medicine, Anton de Kom University, Paramaribo, Suriname
| | | | - Gert A van Montfrans
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Lizzy M Brewster
- Amsterdam Institute for Global Health and Development, AHTC, Tower C4, Paasheuvelweg 25, BP 1105, Amsterdam, The Netherlands.
- Creatine Kinase Foundation, Amsterdam, The Netherlands.
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27
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Previously-initiated hemodialysis as prognostic factor for in-hospital mortality in pneumonia patients with stage 5 chronic kidney disease: Retrospective database study of Japanese hospitals. PLoS One 2019; 14:e0213105. [PMID: 30818331 PMCID: PMC6394945 DOI: 10.1371/journal.pone.0213105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/14/2019] [Indexed: 11/24/2022] Open
Abstract
Background Some clinicians keep patients in stage 5 chronic kidney disease (CKD) without hemodialysis for a while. This study investigated whether previously-initiated hemodialysis in stage 5 CKD patients may become a prognostic factor for in-hospital mortality due to pneumonia. Methods Patient data were obtained from the multi-institutional diagnosis procedure combination database between April 1, 2012 and March 31, 2016. The patients had records of pneumonia as both trigger and major diagnoses and records of end stage renal disease (ESRD) or stage 5 CKD as a comorbidity or other diagnoses on admission and aged 18 years or older. The following factors were adjusted: age, sex, body mass index, Barthel index, orientation disturbance, arterial oxygen saturation, systolic blood pressure, C-reactive protein level or the extent of consolidation on chest radiography, ambulance use, hospitalization within 90 days, and comorbidities upon admission. The primary outcome measure was all-cause in-hospital mortality obtained via multivariable logistic regression analysis using four Models. Model 1 involved complete case analysis with overlapping; one hospitalization per patient was counted as one. Model 2 involved a complete case analysis without overlapping; only the first hospitalization per patient was counted. Model 3 involved multilevel analysis clustered by hospital codes. Model 4 was created after multiple imputation for lacking adjusted factors. Results A total of 907 hospitals and 7,726 patients were identified. Hemodialysis was significantly associated with lower in-hospital mortality in all models (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.54–0.87 in Model 1; OR = 0.71, 95% CI: 0.55–0.91 in Model 2; OR = 0.67, 95% CI: 0.52–0.86 in Model 3; and OR = 0.68, 95% CI: 0.54–0.87 in Model 4). Conclusion Previously-initiated hemodialysis may be an independent prognostic factor for in-hospital mortality in pneumonia patients with end-stage renal disease. This should be borne in mind when considering the time of initiation of dialysis.
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28
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Moderate Protein Restriction in Advanced CKD: A Feasible Option in An Elderly, High-Comorbidity Population. A Stepwise Multiple-Choice System Approach. Nutrients 2018; 11:nu11010036. [PMID: 30586894 PMCID: PMC6356994 DOI: 10.3390/nu11010036] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 12/08/2018] [Accepted: 12/17/2018] [Indexed: 02/07/2023] Open
Abstract
Background: Protein restriction may retard the need for renal replacement therapy; compliance is considered a barrier, especially in elderly patients. Methods: A feasibility study was conducted in a newly organized unit for advanced kidney disease; three diet options were offered: normalization of protein intake (0.8 g/kg/day of protein); moderate protein restriction (0.6 g/kg/day of protein) with a “traditional” mixed protein diet or with a “plant-based” diet supplemented with ketoacids. Patients with protein energy wasting (PEW), short life expectancy or who refused were excluded. Compliance was estimated by Maroni-Mitch formula and food diary. Results: In November 2017–July 2018, 131 patients started the program: median age 74 years (min–max 24-101), Charlson Index (CCI): 8 (min-max: 2–14); eGFR 24 mL/min (4–68); 50.4% were diabetic, BMI was ≥ 30 kg/m2 in 40.4%. Normalization was the first step in 75 patients (57%, age 78 (24–101), CCI 8 (2–12), eGFR 24 mL/min (8–68)); moderately protein-restricted traditional diets were chosen by 24 (18%, age 74 (44–91), CCI 8 (4–14), eGFR 22 mL/min (5–40)), plant-based diets by 22 (17%, age 70 (34–89), CCI 6.5 (2–12), eGFR 15 mL/min (5–46)) (p < 0.001). Protein restriction was not undertaken in 10 patients with short life expectancy. In patients with ≥ 3 months of follow-up, median reduction of protein intake was from 1.2 to 0.8 g/kg/day (p < 0.001); nutritional parameters remained stable; albumin increased from 3.5 to 3.6 g/dL (p = 0.037); good compliance was found in 74%, regardless of diets. Over 1067 patient-months of follow-up, 9 patients died (CCI 10 (6–12)), 7 started dialysis (5 incremental). Conclusion: Protein restriction is feasible by an individualized, stepwise approach in an overall elderly, high-comorbidity population with a baseline high-protein diet and is compatible with stable nutritional status.
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29
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Xiong CZ, Su M, Jiang Z, Jiang W. Prediction of Hemodialysis Timing Based on LVW Feature Selection and Ensemble Learning. J Med Syst 2018; 43:18. [PMID: 30547238 DOI: 10.1007/s10916-018-1136-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 12/03/2018] [Indexed: 11/30/2022]
Abstract
We propose an improved model based on LVW embedded model feature extractor and ensemble learning for improving prediction accuracy of hemodialysis timing in this paper. Due to this drawback caused by feature extraction models, we adopt an enhanced LVW embedded model to search the feature subset by stochastic strategy, which can find the best feature combination that are most beneficial to learner performance. In the model application, we present an improved integrated learners for model fusion to reduce errors caused by overfitting problem of the single classifier. We run several state-of-the-art Q&A methods as contrastive experiments. The experimental results show that the ensemble learning model based on LVW has better generalization ability (97.04%) and lower standard error (± 0.04). We adopt the model to make high-precision predictions of hemodialysis timing, and the experimental results have shown that our framework significantly outperforms several strong baselines. Our model provides strong clinical decision support for physician diagnosis and has important clinical implications.
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Affiliation(s)
- Chang-Zhu Xiong
- Department of electronic information, Sichuan University, Chengdu, China.
| | - Minglian Su
- West China School of clinical medicine, Sichuan University, Chengdu, China
| | - Zitao Jiang
- Department of electronic information, Sichuan University, Chengdu, China
| | - Wei Jiang
- Department of electronic information, Sichuan University, Chengdu, China
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30
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Piccoli GB, Nielsen L, Gendrot L, Fois A, Cataldo E, Cabiddu G. Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status. J Clin Med 2018; 7:E331. [PMID: 30297628 PMCID: PMC6210736 DOI: 10.3390/jcm7100331] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022] Open
Abstract
There is no simple way to prescribe hemodialysis. Changes in the dialysis population, improvements in dialysis techniques, and different attitudes towards the initiation of dialysis have influenced treatment goals and, consequently, dialysis prescription. However, in clinical practice prescription of dialysis still often follows a "one size fits all" rule, and there is no agreed distinction between treatment goals for the younger, lower-risk population, and for older, high comorbidity patients. In the younger dialysis population, efficiency is our main goal, as assessed by the demonstrated close relationship between depuration (tested by kinetic adequacy) and survival. In the ageing dialysis population, tolerance is probably a better objective: "good dialysis" should allow the patient to attain a stable metabolic balance with minimal dialysis-related morbidity. We would like therefore to open the discussion on a personalized approach to dialysis prescription, focused on efficiency in younger patients and on tolerance in older ones, based on life expectancy, comorbidity, residual kidney function, and nutritional status, with particular attention placed on elderly, high-comorbidity populations, such as the ones presently treated in most European centers. Prescription of dialysis includes reaching decisions on the following elements: dialysis modality (hemodialysis (HD) or hemodiafiltration (HDF)); type of membrane (permeability, surface); and the frequency and duration of sessions. Blood and dialysate flow, anticoagulation, and reinfusion (in HDF) are also briefly discussed. The approach described in this concept paper was developed considering the following items: nutritional markers and integrated scores (albumin, pre-albumin, cholesterol; body size, Body Mass Index (BMI), Malnutrition Inflammation Score (MIS), and Subjective Global Assessment (SGA)); life expectancy (age, comorbidity (Charlson Index), and dialysis vintage); kinetic goals (Kt/V, normalized protein catabolic rate (n-PCR), calcium phosphate, parathyroid hormone (PTH), beta-2 microglobulin); technical aspects including vascular access (fistula versus catheter, degree of functionality); residual kidney function and weight gain; and dialysis tolerance (intradialytic hypotension, post-dialysis fatigue, and subjective evaluation of the effect of dialysis on quality of life). In the era of personalized medicine, we hope the approach described in this concept paper, which requires validation but has the merit of providing innovation, may be a first step towards raising attention on this issue and will be of help in guiding dialysis choices that exploit the extraordinary potential of the present dialysis "menu".
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Affiliation(s)
- Giorgina Barbara Piccoli
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, Ospedale san Luigi, Regione Gonzole, 10100 Torino, Italy.
| | - Louise Nielsen
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Lurilyn Gendrot
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Antioco Fois
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Emanuela Cataldo
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Nefrologia, Università Aldo Moro, Piazza Umberto I, 70121 Bari, Italy.
| | - Gianfranca Cabiddu
- Nefrologia Ospedale Brotzu, Piazzale Alessandro Ricchi, 1, 09134 Cagliari, Italy.
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31
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Rifkin DE. Now or Later? Understanding Timing of Dialysis Initiation beyond IDEAL. J Am Soc Nephrol 2018; 29:2033-2035. [PMID: 29914873 DOI: 10.1681/asn.2018050534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Dena E Rifkin
- Division of Nephrology, Veterans Affairs Healthcare System, San Diego, California; and Divisions of Nephrology and Preventive Medicine, University of California, San Diego, California
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